FRCEM Intermediate (SAQ) – “Revisiting the recent past (recalling the nightmare!)”

  1. picture of a bruised foot. fallen off horse, foot stuck in stirrup and dragged upside down. now unable to weight bear. bruising evident on medial dorsal area and lateral plantar area of involved foot. what is the mechanism of injury? what is the injury?
  2. patient with small stab wound to epigastrium. X-ray (picture shown) shows air under diaphragm on right side. what is the finding on X-ray and what does it signify? what is the management plan for this condition? how will you investigate/comfirm diagnosis next?
  3. image of bilateral knees of a middle aged patient. presented with sudden swelling and painful left knee, which is shown as slightly swollen. cause? treatment/management?
  4. paeds patient, infant, barking cough every time they cough. sniffling viral like symptoms …diagnosis? management?
  5. anaesthetic machine shown with knobs for respiratory rate and tidal volume adjustment, rest rate set at 8/min. scenario given of patient with head injury, aside from other measures, what will you do to ventilator settings to help, and how will it help.
  6. picture of pneumothorax (right sided) shown. what are the 2 abnormalities in the radiograph? (i could only see the pneumothorax) management questions about where to insert the seldinger, and what common complication can happen and how will you avoid it (what measures will you take to ensure it doesn’t happen)
  7. elbow posterior dislocation image shown. how will you manage in ED (explain/summarise maneuver) and what nerve tends to be damaged and what will you look for on neurological examination. what x 2 steps will you do after reduction
  8. image of posterior dislocation of shoulder shown. radiological sign?
  9. young child, accidental ingestion of paracetamol syrup. asymptomatic. previous history of similar episode last year. what steps will you take? when will blood need to be drawn?
  10. wife presents to ED with injuries sustained from beating by husband. has minor children but are not currently living at home with her or husband and have not witnessed abuse. she self discharges and does not want to press charges. what steps do you need to take
  11. image of open mouth, what is the malampatti scoring?
  12. young male, fallen from 30 foot height, complaining of back pain. otherwise normal examination. what is the first reasonable investigation?
  13. head injury patient, subdural hematoma. gcs 13/15 initially, on revaluation, drops gcs to 10/15, what will be your next step in management? how will you proceed? if they initially are ventilating well, and then drop sats, how will you proceed further?
  14. transferring patient who is intubated and ventilated suddenly notice significant drop in sats, blood pressure OK, what is likely cause, how will you manage/proceed?
  15. sudden onset painful testicular swelling in young male – likely cause? management? what time frame? if not this, then what is the next likely cause
  16. young girl – dizziness and fainting spells. biochemistry shows hypoglycemia, borderline raised potassium, borderline low sodium. diagnosis? what investigation will you do?
  17. renal failure patient, sudden worsening. ecg shown, hyper acute t waves seen. diagnosis? management? mechanism of action of 1 drug that you will prescribe
  18. pregnancy 3rd trimester. abdominal trauma. abdominal pain, hypotension, diagnosis? management?
  19. middle aged female, found with suicide note and empty pill packets. low gcs. blood gas shows alkalosis, low co2, high bicarb. likely drug?
  20. paeds with sob, not eating, generally unwell but appears well, playing with toys, interacting, low sats but other jobs all normal no fever. cxr shown (normal looking?) ? diagnosis?
  21. elderly patient, hip fracture, fascia iliac block administered for pain relief. sudden dizziness, followed by cardiac arrest. cause? how will you manage? (dose and name of drug)
  22. how will you immobilize/pull femur on child with fracture femur? analgesia options?
  23. image of facial trauma during RTC – airway concerns? how will you manage complications/difficulty? what will you advise your colleagues to do or not do
  24. post vomiting, chest pain, car shown, findings? (subcutaneous emphysema)what 2 causes can be attributed to this condition? how will you investigate further to find out which cause this is
  25. ecg shown ? LBBB?
  26. ecg shown – VT – conscious patient with palpitations. shocks given x 3 not reverted, how will you manage further.
  27. epipen administered. what total dose in MG of adrenaline administered in single dose?
  28. seizure activity in epileptic patient, already on phenytoin. status epilepticus. diazemols/lorazepam 1 dose given. allergic to valproate. what is the next 2nd line drug to give?
  29. patient on warfarin, routine blood tests high INR of 8-9 no bleeding, recent antibiotics. what possible antibiotics would have been used? first step in management?
  30. female child from african country, returning from trip, feeling unwell, crying, not interacting. c/o ado pain etc. no fever, all obs normal. nurse noticed bloody discharge on underpants. likely diagnosis? who will you inform? how will you manage?
  31. hip pain, limping child, non traumatic? X-rays shown. what view is it? what is the diagnosis? what are x 2 common causes of hip pain without trauma in paediatric age group?
  32. renal colic clinical picture. analgesic of choice? investigation to confirm? complications?
  33. paracetamol overdose patient. what x2 investigations will you perform?
  34. elderly patient present with a fall. what bedside investigation can you do to rule out dehydration
  35. patient with ascites, fever, abdo pain. diagnosis? where will you put needle in for ascitic tap?
  36. patient with red eye shown (image) presents with sudden onset headache, vomiting. diagnosis? management? what topical drug will you administer in ED?
  37. elderly patient, agitated, needs cannula. what will you give to the patient? what will you tell the helping nurse to do?
  38. patient with chest pain. ecg shows inferior MI.
  39. IVDU. c/o back pain. tender lumbar region. diagnosis? investigation?
  40. question about intraosseous access
  41. young male with rectal bleeding and diarrhoea travelling from african/middle eastern country. cause? give non infectious/non inflammatory cause
  42. scenario is patient has ingested amyl nitrate. picture of patient’s wound site with swab on – showing bleeding, blood is ?darker color than usual? identify what the abnormality is, and how will you treat it
  43. high BMI (50) patient, unconscious/collapsed – what factors affect her airway and what makes it a difficult airway for her – what manoeuvres will you do to improve/mange these factors
  44. do not remember the question but size of cannula given and rate or time 1 litre of saline gets completely given through it

Interesting Observations on a mock OSCE Teaching Day

Hi all – so a few days back I had the unique opportunity to organize (OK who am I kidding? I helped to organise) a 1-day course for the FRCA OSCE exam in our deanery. We as the juniors of the department of anaesthetics/ITU/Theaters were called upon to help with various tasks: timekeeper for the different stations, be a patient for history taking, or be one of the relatives for counselling, be a mannequin for examinations, etc. I had a multitude of nominal tasks on the day, but what I found to be invaluable to me that day were a few observations that I made observing the various candidates as they filed through the different stations, and I list those observations here in no particular order to be taken as advice for all my colleagues who have OSCEs to take, bear these in mind:

– Be cognisant of time. As you walk up to the OSCE station, whether it gives you 30 seconds to read through an initial scenario or there is a piece of paper with questions written on it that you are expect to answer, get into the mental zone where you can mould yourself to give what is required of that particular station in the time provided. If there is one question that needs to be answered, you can be a bit relaxed, if there are 3 questions on the paper, make sure you are aware of the time you have to divide amongst them all to do justice to all. If the station requires an interaction with someone like a viva or a direct encounter, make sure you have a framework in mind, a mental checklist to check things off during the actual station so that you are not rambling on about your second point when there are 7 other things you need to be talking about.

–  When asked a question, don’t feel pressured to answer as soon as you sit down – take a breath, pause, ponder over the question for a few seconds, frame your answer for the next few, and then open your mouth to speak. Do not repeat the question back to the examiner in wonderment, as if puzzling it over, you may think you are buying time while you collect your thoughts, but it looks unprofessional. If you need time to answer, take it, but do not insult the examiners’ intelligence by repeating the question back word for word. It is a waste of time.

– When asked a question, avoid using pronouns like ‘you’ as a general term. “If you are on the floor for a long time, your creatinine kinase levels may rise.” While correct, it looks like you are addressing the examiner, whereas a more professional way to answer would be “Patients lying on the floor for extended periods of time may have elevated levels of creatinine kinase.”

– Following on from the previous point – when describing the anatomical location of anything, or a function, it is OK to use your hands to express yourself, but do not gesture towards your own body as a descriptor for your answer. In answer to the question Where can an IO needle be inserted? you may think it is the right answer to point to your sternum, your humerus or your tibial tuberosity, but it won’t score you any points. Also please practise certain expressions or gestures, gesturing towards your crotch for instance when talking about urinary catheterisation is inappropriate. And for goodness sake, it is even worse to point these things out on the examiners body.

– Use proper terminology, use buzzwords if you know them (we all know them) and specific things carry specific marks so make sure you attend some sort of course at least once in your life for OSCE practise so that you know what the examiner is looking for in a particular station when they ask you a particular question. Also, examiners know when you are beating about the bush and not getting to the point – so don’t waste their time (and yours), admit you do not know, and move on.

– Having done poorly in a previous station has no bearing on how you can or should perform in the next one – so do not let anything bother you. Yes, you may well have failed the previous station, but if you continue to mull over it or let it get to you, you may ruin your chances of passing the next one as well. Once you step out of one station, close that chapter, and open the next one with a clean slate.

–  Do not try to impress with big words and fancy terms – be simple, logical and just answer to the best of your knowledge. They are there to test your knowledge and see how good you are with using that knowledge. They are not there to ask for your hand in marriage.

–  If there is a written station, please write clearly. In our current professional examination climate, where usually there is a tick box or a fill-in-the-correct-circle type answer sheets, we forget how to answer the short answer type questions. Make sure it is legible. Your right answer is useless if no one can decipher it.

–  Read up on the simple things (in case of our anaesthetics colleagues, anatomy and physiology, undoubtedly – aside from the usual physics etc) – understand the concept behind why something is done or not done, and it will make it easier for you in these exams.

–  Study. I don’t know why it is so under-rated, that OSCE exams are interaction based and so I just don’t need to read up on how to take a history or do a pre-op assessment or perform a physical examination or test the cranial nerves – we do it everyday, and we get into a comfortable zone – but the exam might need for us to brush up on those skills and make sure we are not missing out on anything. MOST candidates missed an important part of the history taking station, as well as the counselling station – points were docked, valuable points, and for some that can mean the difference between passing and failing.

ECT – the conflict within

DISCLAIMER 1 – EXTRA-LONG POST. You have been warned.
DISCLAIMER 2 – More importantly – this is in no way supposed to be a ‘for’ or ‘against’ type of post regarding any particular therapy/treatment – it is just my opinion and my own feelings about this experience which was very new to me. Bear with me, before rushing to judgement or conclusion – and if you already have formed an opinion without prior knowledge/experience then please stop reading further!)

For those of you who do not know, I have recently started my 6 month rotation in Anesthesia as part of my emergency medicine training, and it has introduced me to a whole new weird and wonderful world that is equal parts unexpected and fun and slightly scary but mostly awesome. But more about that later. Today (and for the past few days) I have been wrestling with some inner demons (wow, that’s not melodramatic at all!) about a recent experience and the ensuing internal conflict broiling inside me. I will try to explain things in my usual way, which is to take you on that journey with me.

So the day usually starts at 7:30 AM, and the rota tells you it’s a different theater every morning – I checked the night before and all it said was that I was assigned to a particular consultant to shadow (read badger/annoy for the rest of the day!) and that we were supposed to be in the “ECT” area (theater?) in a completely different building from the one I had been going to for operations/procedures requiring anaesthetics in the past week. My first thought was ECT? It can’t be electroconvulsive therapy? That’s not still being done in this day and age? But I texted one of my friends in the same rotation as I am, and he said this area was in the building that houses the maternity block, and I thought it was probably some sort of gynaecological/obstetric procedure requiring anaesthesia which is why I am being assigned to this and I am sure I thought of ECV – external cephalic version! I reassured myself and went to bed, woke up the next day bright and early and headed to whatever this amazing day heralded. It was not amazing. Atleast, not initially.

ECT, as it turned out, did mean electroconvulsive therapy – a treatment for drug-resistant psychiatric conditions (please excuse the rough/non-medical language) – and I found out that what I was assigned to today was in fact the ECT suite, a separate entity from the rest of the hospital- where I was shown around while I was waiting for the consultant. There was a procedure room, with anaesthetic stuff and an OT table, and a separate recovery area. There were 4 nurses, a head nurse, 2 health care assistants and 1 psychiatrist/consultant – aside from my anaesthetics consultant and absolute-novice-baby me! The whole area was very peaceful and calm, and the staff were very friendly and spoke in calm, reassuring voices even when they asked me if I would like a cup of tea. I felt myself calm down a bit (I was nervous because A- I had no idea what to expect and B- I HAD NO IDEA WHAT TO EXPECT!)

There were 4 patients on the list for today. 3 of them (the first 2 and the last one) were regulars, here for their 7th, 3rd and 11th treatments, so they did not need pre-assessments doing from an anaesthetics point of view – just a confirmation of their consent for the current procedure (consent did not mean a blanket consent for all treatments, you could consent to the first treatment and revoke consent at any later treatment session, if you were deemed to have capacity. All 4 patients today had capacity) The 4th one had completed 12 sessions of the ECT previously and that usually meant their treatment was over. But their doctor had assessed them and had thought that despite the improvement the patient could benefit from further sessions, and so they had to give another detailed informed consent – because initially they had consented to the 12 sessions, and this was adding on to what they had initially consented for. But I digress – there was just so much to take in and learn that I do not want to miss out on any of the details/finer points that I came across.

So anyway – while we waited for the first patient to turn up, my consultant took pity on the incredulous expression that I had on my face (this was without me realising it) and explained a few things to me, and looked up a very good paper for me to read about ECT. He broke down what we needed to do here, which basically entailed: introducing ourselves; confirming patient details; confirming no changes to medical/pre-assessment history had taken place in the last week since last treatment; putting a cannula in; hooking them up to some monitoring (continuous ECG trace, pulse oximeter, blood pressure, an initial temperature reading) and also hooking them to an EEG machine which is basically just like an ECG of the brain – mapping the electrical activity of the brain; administering the induction agent (usually propofol) and/or a sedative, and supporting the patients breathing before, during and after the procedure till the anaesthetic wears off.  ECT is basically electric current that is run via two ports/electrodes placed at both temples while the patient is unconscious. The current causes your neutrons to fire in a way to cause a generalised toniclonic seizure, and your brain activity is mapped continuously to make sure it has worked, and that the seizure lasts a certain length of time (usually greater than 10 seconds but on average about 30seconds in duration). It is essentially equivalent to being ‘under’ for a surgical procedure, just like you don’t feel the surgeons scalpel or drill, you do not feel the actual shock. Your heart rate and oxygen levels and blood pressure and all that jazz is continuously monitored and in the event of any fluctuations, it is handled by the team of extremely qualified individuals in attendance, as it would be in any surgical procedure. But the actual procedure was what caused me to be so incredulous. Why, you may ask? I will explain, but first let me take you through the first patient’s treatment.

This was a 50-something female, with a history of depression, and she had become so depressed that she had stopped eating and drinking, and none of the medication or combinations of medications had seemed to work on her. I had all this information from her history sheet, and chatting with the consultant psychiatrist made it clear that this was sort of a last resort. She had become anorexic to the point that she didn’t really have the strength to lift up her head from where she lay in bed, to take a sip of water. She was initially medically rehabilitated, her caloric intake monitored and her strength returned, and while she had become medically fit, her depression was still strong. She began this prescribed treatment, and today was coming in for her 7th session. She had been almost a complete mute prior to the first treatment, and was markedly different today. She walked in to the room unsupported (I thought she would atleast be in a wheelchair). She made eye contact with all of us. She smiled at me when I said good morning, and replied shyly that it was indeed a good morning. As they hooked her up to the various monitors she looked around with that smile her face, and gave adequate responses to the questions and requests from the staff members, such as May I put these ECG stickers on you?, and can I put a cannula into the back of your hand? We walked her through the procedure, put her under and after she had drifted off to sleep and we were monitoring her airway and breathing, we put a rubber/foam type thing between her teeth so she wouldn’t end up biting her tongue or lips, and then they placed those electrodes on her temples and …I don’t know what I expected, probably that the patients arms would flail around and her legs would jerk up off the table and it would all be very violent and gruesome. It was certainly difficult to see, but nothing quite as dramatic as that. She just straightened out a bit, feet became a bit rigid and there was a generalise trembling, followed by some twitching. The continuous EEG trace showed she had had a seizure that lasted 34 seconds, and while she became tachycardiac during it, she settled down almost at once after the seizure ended. She began breathing spontaneously after a few minutes and was taken to recovery as she regained consciousness. And now for the crux of this post – the reason why I was so conflicted.

All my life, or at least the last 10 years when I have been a doctor (15 if you count medical school) I have been working with the idea that we need to minimize seizures and we work very hard to figure why someone may have had their first fit, to try and prevent it from happening again, and I have been involved in extensively counselling and reassuring family and patients and parents of toddlers etc on the subject – so the ‘inducing’ of a seizure as a treatment was a bit of a shock – no pun intended! I knew the patient came to no harm from the immediate procedure, the electric current and the anaesthesia, and they actually did not feel anything, much like any surgical procedure (with the added benefit of amnesia as a known side effect of propofol!) and much more importantly, the patients reportedly feel better and they don’t have memory of it etc etc. But having never actually witnessed it before, I had quite mixed feelings about it because it conflicted with my mindset of ‘how to manage a seizing patient’ – as opposed to this current situation – once again, no pun intended! The conflict I speak about is not of the “ohmygod I do not agree with this practise how dare they?!” type of reflection, and I apologise if it sounded that way. Rather it is more of a “everything I feel inherently about this situation is basically not true!” and I had to actively try and work towards not panicking when I saw this patient seize. And the one after that. And the one after that. It didn’t get any easier, and I didn’t get used to it and it really bothered me. I didn’t know what really was most bothersome for me. Was it the fact that I pride myself in being completely professional and see all sorts of unexpected medical scenarios and presentations as an emergency medicine trainee with the calm and focussed approach that is taught and cultivated in my specialty, but that in my almost 6 or so years of emergency medicine experience, I have never been this affected by any procedure or situation? In other words, was it the procedure that had bothered me, or my own reaction to it?

A few positive notes/observations from the day –
*Any patient who can consent because they are deemed to have capacity will be asked for their explicit consent for the treatment, and they will be given the full information regarding it. Out of the 4 patients scheduled for the day, the 3rd one who was coming in for her 13th treatment (having completed 12 previous ones and deemed to still be in requirement of a few further sessions) came in and then declined to give consent for the next one. And, even though she had consented for 12 sessions and had had them, AND she had the capacity to refuse at any time, we respected her decision and she went home. We didn’t just strap her down like a bunch of frankenstein-y mad doctors while cackling in high pitched laughter to administer jolts of voltage against her will – though I will be the first to admit this is what I thought when I first found out I was in the ECT suite, that this was my unfortunate concept of ECT, based on nothing but my (very vivid, it turns out) imagination.
*Also, it has been around since 1938 – there is tons of research on this topic and while it is all shrouded in controversy mostly due to preconceived notions and ideas, there is no denying the absolute faith people have in this treatment.
*The sons of the first patient who’s treatment I detailed earlier were sat outside in the relatives’ room and while the patient was being wheeled to recovery, I went and asked them how they felt the treatment was affecting their mum. They both agreed there was a distinct difference in Mum, that she had begun enjoying her meals – looking forward to what was on the menu for the day,  offering to go to the park with the grandchildren and making plans for one of the sons’ wedding that was supposed to be an out of country type thing. This was in stark contrast to her being in the throes of progressively worsening depression since their father had passed away a few years ago.
*They don’t just administer this treatment without trying anything else.
*It is not like touching a live wire; you don’t feel anything – you aren’t zapped like a Tom&Jerry cartoon situation. In fact, the voltage is so low that I was surprised that while the current was being administered, one of the nurses had their hands on the patient’s chin as a reinforcing/reassuring measure. They were clearly not feeling the effects of a transmitted significant voltage, unlike in a cardiac arrest situation if you administer an electrical shock, you have to be clear and not touching any part of the patient’s body lest you get a shock as well. It is all very professional and clean and protocol-oriented.
*There are a lot of good people working very hard to make the experience as comfortable and easy for the patient as possible.

At some point I will probably do some research into the subject. It has certainly piqued my interest – but I am ashamed to admit I won’t be looking forward to the next time I get assigned to this area, and I dread looking at the rota announcing when I am going to go there next. And at some point I may actually grow to appreciate the whole process. And look beyond the obvious conflict. But today is not that day. Sigh.

The Intestinal Obstruction That Wasn’t

84 year old male – known to have chronic constipation, and on warfarin for atrial fibrillation – referred in by his GP for ‘inability to open bowels for 2 weeks’ – yes you read that right folks, T-W-O W-E-E-K-S! – ‘increasing abdominal distension and abdominal pain, along with decreased appetite and a possible mass in the pelvis/abdomen going above the umbilical area’.
The nurse triaging him came to me, asking for some pain relief for the patient ‘and an enema because that’s what he usually has for his constipation’ – I decided to go see the patient myself. I stepped into the cubicle and the gentleman seemed to be in some discomfort, but he kept saying that he was in an uncomfortable position/posture rather than anything else causing him discomfort. I introduced myself and asked him what had brought him to ED – he replied by telling me he had not opened his bowels for 2 weeks now, and though was still passing wind and had passed some today, he was drinking very little and felt nauseous and omitted a few times in the past 3 days. I asked him if he had been passing urine normally, and he reported that yes he was peeing fine, but that he was drinking so less due to the nausea that only small amounts were trickling when he needed to go. I took that statement at face value and moved on. He was lying in a trolley, awake but lethargic and completely oriented. His observations were all within normal limits except for a systolic BP of 89, and his GP notes reported a background of chronically low blood pressure. I examine him, of particular note is his visibly very distended tummy – which assort but distended, feels like gaseous distention from the percussion notes, and with tinkling infrequent bowel sounds – and is quite sore particularly in the lower half of the abdomen, and I can also palpate a mass in the lower part of the abdomen – the patient reports that’s been going on for atleast 3-5 days, possibly when the vomitting began as well. This seemed very much to me to be a classic case of intestinal obstruction – and the management plan is – do baseline bloods (already very kindly done by the triage nurse), get venous access (also done), start some fluids, abdominal X-rays, nasogastric tube and surgical referral, and also catheterise patient, to monitor intake and output.
I speak to my registrar who agrees with said plan of action and while I request the X-rays and take the patient down for it, the lab apparently calls back and my registrar takes the call – the patient’s urea is 44, and the creatinine is 469, last creatinine 3 weeks ago was 141 – so he is going into renal failure, if not there already. While I seemingly faff around with the surgical consult, my registrar gets an ultrasound machine, and I assume it is to rule out a AAA, so I walk into the cubicle with him. And he explains to me a great pearl of wisdom that clearly comes with experience but is such a simple thing that I am left berating myself for not thinking about it earlier. He told me that if someone comes in with such significant renal function decline so acutely, always think of and rule out an obstructive cause for this presentation before moving on to other more sinister things. He was doing an ultrasound to look for hydronephrosis or hydroureter, which is basically the dilated urine collection channels in the kidney downwards and the reason they are dilated is due to an obstruction further down the channel. And that is exactly what he found. The left kidney was moderately enlarged but the right kidney was massive and its ureter was like a fire hydrant pipe rather than the small thin tube – and the mass in the lower part of the abdomen, going from pelvis and extending up from the umbilical area? His urinary bladder!!! I was in shock – as my registrar then gave me the second pearl of wisdom: never believe anything you are told, do not take it for granted until you have objective evidence. The patient felt he was peeing less and less because he wasn’t drinking enough. Yet he was peeing less because the channels beyond his bladder were so narrowed and obstructed that they did not allow emptying of the bladder and it just kept filling up till it was a massive huge thing floating in his belly. I at once made arrangement to catheterise the patient, whereby 2000 ml (that’s 2 litres!!!) of dark brownish urine poured forth out of him.

He had been in urinary retention for the better part of 3-4 days, possibly due to an enlarged prostate that had just gotten worse, and his constipation (though being chronic) was either a factor of his massive bladder pressing on his rectum/colon and not allowing the contents to move ahead; or (a bit like the chicken and egg thing, of which came first?) he was constipated, which gave him some abdominal pain (expected) and that pain had the added effect of causing urinary retention – anyways, after passing the catheter and draining all that urine the patient felt quite comfortable, and the surgeons took him away to do their wonderful things.

Sometimes it is the smallest things that make you the saddest

Ever notice how you can go on being an automaton, robotically engaging in work stuff, moving from one patient to the other, each one a statistic on your ever growing list of patients to see or having had seen – no interaction long enough to actually create a connection other than that of patient/doctor and you professionally enter and exit the cubicle and move on to the next job, next patient, or indeed next shift. And yet sometimes it does happen that something hits the mark, and there is a chink in the armour, the professionalism slips (not outwardly, but it surprises you that you feel something other than empathy towards the patient in front of you – you really look at the patient, not as just a patient but an actual human being with feelings, and thoughts start milling around your head – or your heart? – and you think of the patient’s feelings, their desires and weaknesses, the consequences of their actions – and you realise with a jolt that you are not an automaton, that you are, indeed, human.

I am usually a happy presence at work (if I may say so myself) but I was having a particularly ‘smiling-from-ear-to-ear’ day a few days back. A recent couple of professional achievements, along with being well rested from a full night’s sleep meant I was walking around with a bit more bounce in my step. I was working a late shift, but from the broad smile on my face you would have thought I was about to go home on a 2 week holiday! (I was not, but yes, I am a bit weird – I actually have fun at work!) – I was assigned to see paeds patients in ED, all the minors, majors, ENP ones etc – and I was going about my day when the consultant asked me to come out of Paeds for a bit and see the next adult patient, who was already at 3 hours (that much time had elapsed since she had come in to the hospital) – the brief note from triage nurse said that this was a young female between 25-35 years of age, who had come in with a self harm injury or injuries – she was categorised as a ‘yellow’ which meant there was no imminent threat to her life but she did warrant a thorough assessment.

Treatment/management of such cases is usually 2-pronged: one, manage the obvious injury or insult and treat the current presentation, and two (and more importantly) try to deal with and manage the longterm/shortterm psychological aspects of the presentation (not an ED thing but there are certainly specialist who are better equipped to deal with this and who very kindly assess and evaluate patients from that perspective after they have been treated from a physical ailment point of view. So anyway – I went in to see the patient – it had been mentioned in the notes that she was accompanied by her support worker – but the woman who stood up when I announced the name in the waiting area was alone. And she stood up at once and followed me into the cubicle to be assessed, along the way I introduced myself, and thanked her for her patience in waiting. She was extremely polite, and even offered me a smile, but she kept looking anywhere but at me directly. I asked her what had brought her to the ED that evening and she matter of factly stated that she was here because she had self-harmed. Again. She did not seem to be in any sort of pain, so I assumed (wrongly) that she had a superficial sort of wound that wouldn’t really require too much medical attention. I smiled at her and said something along the lines of ‘well, let’s see what we are dealing with here, and I will try to help you any way I can.” She exposed her left arm unto her shoulder, and I took off her temporary dressings from her upper arm (above her elbow) – while I was doing so, I kept making small talk, and registered the many, many scars from previous self harm attempts there before me were 4 very large, very long, and VERY gaping full thickness lacerations to her upper arm. In places where normally the skin/muscle sags a bit, it was really using the lacerated margins to gape quite widely. The patient had something like an hour left before they breached? NO WAY was I going to be able to administer local anaesthetic AND suture all 4 of these wounds in under an hour. Alone.

This patient completely threw me off my game. I have closed wounds in numerous ways, and in all sorts of weird and wonderful places – I have once years ago even raced my mentor consultant orthopaedic surgeon in bilateral knee replacements to see who closed up their respective knee first! – But this time was different. This patient was different. And the reason will become apparent up ahead.

I called my consultant because he may have been under the impression this was a quick ‘tape-wound-shut-refer-to-psych-move-on’ kind of situation – he stepped into the cubicle and hemmed and hawwed. I was silent throughout. This felt like an operating table scenario with a patient’s body cavity open up in front of me – The smell was exactly the same. Flesh. Blood. Sadness.

Right then, the consultant asked me to stitch the wounds up – I gave the wounds a good thorough clean with some saline and the patient did not flinch. She did however, apologise quite sincerely for wasting my time. I will not go into the details of why she thought she needed to do this today – absolutely no judgements to be passed here on that account. But I did assure her she was well within her rights to be there. I said I would go calculate the amount of local anaesthetic require and get it and get it all ready – and her polite demeanor stiffened up. She absolutely refused any local anesthetic. She said, and I quote: ‘ I am not here to waste any of your valuable resources. Please use them for someone who really deserves it – and anyway, I am not in pain and the stitching can’t hurt me more than I have done myself – also (and I was surprised that she knew this) the amount of local anaesthetic required would be a bit too much and wouldn’t be safe for me – and it would wear off by the time it was done being administered!” She was right on all counts – but I requested my consultant to give me an opinion, since she had me absolutely flummoxed. He agreed, no need for the anaesthesia – and that I would achieve better results with a skin stapler rather than suturing the wounds. I had never used skin staplers outside of an OR before, and never on a patient who was conscious and sitting up and talking to me and FEELING THE STAPLES GOING IN! I took a few deep breaths. Got the stuff ready. Took a few more deep breaths. And a few more. And dove in. I put in upwards of 45 or so staples (yes metallic pins sharp enough to stab through the superficial tissues of skin etc and pull them close to optimise wound healing) – did I mention the wounds were exceptionally gaping? Each staple gun comes with 30 or so staples – and I had to use a second one about halfway as well. Wow. My mind was already blown after the first 2-3 staples. But I went on putting more in. I did my best – and to her credit she did not flinch. There was silence. And that smell. And sometimes she would talk to me.

She kept thanking me, and apologising to me, and kept pushing her other hand through her hair as if berating herself mentally. She told me she had a masters degree in something (I forget what – my ears still start ringing everytime I think back to that cubicle) and we chatted about how I wanted to pursue another degree, maybe a masters of some sort and hadn’t quite decided what. She guided me about which staple to remove because it had been bent at an awkward angle due to how gaping the wound was initially, and so when I had ‘scaffolded’ it with staples next to it either side, I removed the offending staple and put another one in. Like I said, she didn’t flinch. At all. She kept that small polite smile in place, was very respectful and I learnt something new about myself that day. That this had gotten to me beyond what I can express here or anywhere. I had seen dead and dying people almost on a daily basis. People in pain, people vomiting with pain, people trying to process bad news or loss or a shock. I have been the villain in so many stories in peoples lives – the bringer or the news that someone they loved had passed away, or what the reports had shown or why we feel that further aggressive measures would be futile – But I had not been affected by those things as much as this calm young woman had affected me. What about her affected me? Nothing about her situation. It was sad, no doubt. But what really affected me was what I realised about myself: I judge people, I am cynical about them, about their diagnoses, about their mental health problems – I never fully appreciated that when someone comes in to hospital following an overdose or some deliberate attempt at self harm, I focus solely on the physical aspect of the case, and let someone else deal with the mental/psychological/psychiatric aspect of it. But this time, I was metaphorically chained to the situation I usually avoid and judge as a spectator – and I could not escape how normal this young woman appeared. She was well read, had a grace and calm in her manner that belied a good upbringing – yet she was obviously in this mental pain and it got so severe sometimes that like this day, the thought of cutting herself and so brutally was her only way to cope with it, and possibly caused her less pain that she was already in. And to be able to get sutures or staples without any anaesthesia on board – how remarkably strong a pain threshold would you have to bear that? Or that you were so used to it that this was all just commonplace occurrence to her. And this wasn’t even the worst part. The worst part was that this was neither the first time, nor (we both knew) the last time that she went down this route. I could help her physically, suture/staple everything – but did I actually do anything at all to really, truly help her?

So like I said – we are usually automatons, going about our daily drudgery – and then one day a patient really opens our eyes and makes us sit back – and question …absolutely everything we know and believe in and understand. Or don’t understand.

(Edit: The rest of the shift went by in a blur or a haze, I don’t know if it was all too fast or all too slow for me. I am I think back to my usual self now – albeit with one difference. I am maybe not so quick to judge – and maybe not so quick to dismiss mental anguish based upon my perception of the physical consequences of that mental anguish. I admit to not knowing enough – and hope I can change my practise in a way makes all of this worthwhile.)