Rat-Bite Fever

You really do learn something new everyday!

So today I had a patient – 4 year old male with a 24 hour history of abdominal pain which woke him up in the middle of the previous night (he kept crying and pointing to his tummy, saying ‘ouch’ over and over again), associated with 1 episode of vomiting, and this morning when he woke up he had a fever (40 degrees) and was off his food and drink – Mum took him to the doctors, who diagnosed him (provisionally, I guess) with tonsillitis and sent him home with oral antibiotics (phenoxymethylpenicillin) the child had as yet only had 1 dose od this antibiotic but Mum felt he was being very difficult to feed/keep fluids down so was concerned, child still had an ongoing fever of 39.4. There was no history of any rashes, no cough but had a sniffly nose the last couple of days. Wetting nappies as per usual (a sure sign he was taking in enough fluids) but no dirty nappies today (not unusual for this patient to go x2 days without pooing) Upon my review he was a bit upset, and seemed to be in discomfort, despite having had some sickly sweet paracetamol a while ago to counter the fever.

He had a background of some degree of developmental delay due to a disorder that I do not want to disclose here, for patient confidentiality so this story is untraceable back to them. There were no other comorbidities.

On examination, the child was sitting in Mum’s lap, crying but was settling down when soothed. ENT exam revealed a slightly hyperaemic throat with enlarged tonsils, no exudate or discharge. He kept sticking his tongue out and wincing when he swallowed – pointing towards the possibility of odynophagia or painful swallowing. May explain the ‘off food and drink’ as may be too painful for him to swallow. The mother was giving him regular round the clock calpol though, so difficult to say. Ears were wax-laden and I could not visualise a tympanic membrane in either. Chest was clear to auscultation, no heart murmurs or other weird sounds on listening to the chest. Tummy was nice and soft with no palpable masses and child did not appear to be in discomfort when tummy was examined. He was moving all four limbs, neck seemed soft and his observations (vitals – heart rate, capillary refill/BP, respiratory rate, oxygen saturation on room air – were all within normal limits; all except the temperature, which was still high despite the calpol. I prescribed some ibuprofen. There were no rashes (did I already say that? Yes, that was history, this is examination) – Moving on…

I asked mum if he had been unwell prior to the waking up with the ‘ouches’ in the abdomen? She reported he had spent the weekend with Dad, where he had been bitten by a rat (!!!) on the right index finger – sure enough, on examining, his right index finger had a blackened almost shiny minuscule raised bit – an unmistakeable bite mark, on the distal end of the finger. Surrounding area was a bit reddened and slightly inflamed looking. On movement of the finger, hand, wrist etc, he did not seem to be in a lot of discomfort, though he wasn’t exactly happy I was poking and prodding him so much. There were no palpable axillary etc lymph nodes either – but he was a bit warm to the touch still, and when the temperature was rechecked it was 40 again! We quickly started some antipyretic measures while I quickly listed the differentials in my mind. A) It seemed very likely that the tonsillitis was not bacterial (probably) as a sniffly nose and the acuity and high grade of the fever pointed towards a viral upper respiratory tract infection. It could still be a bacterial infection, though, so I wasn’t going to stop the antibiotics. B) I could potentially/probably send the patient home, as even though they did not seem to be drinking too much, they seemed to be weeing as per usual, according to their wet nappies frequency, with advice to sort of force fluids, along with some adequate antipyretic advice and analgesia advice, with followup in the GP surgery, and that if situation worsens or any of the red flag signs appears, to come to A&E instead. C) could it be an infection spread by the bite of the rat? This last bit I honestly did not know – I had heard and studied about (and mcqsed!) about cat scratch disease and dog bites and human bites and tick bites, but I had never in the course of my 5 year study or almost 10 years as a doctor come across a rat bite – my curiosity piqued. I did what everyone does when they are confused about something – I want to say something impressive like ‘I discussed it with my seniors etc etc’ but in reality I … googled it! (I discussed it with my seniors after that, though, who very kindly reviewed the patient, and discussed it with the paeds registrar and admitted this patient to the hospital – the rationale being they still had a fever despite significant attempts by Mum and A&E staff.) But my google search was very fruitful, and I present to you a few bits and pieces about RAT-BITE FEVER (yes, sounds very impressive and a little icky, and it is!): (this information is courtesy of the CDC website, which is probably the most reliable and authentic information out there as it is so aptly named the Centres for Disease Control and Prevention!)

It is a bacterial infection, has two types of bacteria implicated in it: the spirilary (spirillum minus bacteria) type and the streptobacillary (caused by streptobacillus moniliformis) type. It is transmitted by either being bitten or scratched by infected rodents, or with regular handling of infected rodents even without being bitten, or due to ingestion of the pathogens in food/water that is laced with rat urine/feces. It is not contagious. Symptoms include invariably a combination of any or all of the following: fever, vomiting, headache, joint pains, muscle aches, headache, rash, ulcer at bite wound, swelling around the wound and swollen lymph nodes. Can we agree we are ticking off a lot of the boxes for rat-bite fever? Symptoms may begin within a few days of being bitten by a rodent, or may present a few weeks after the bite. Rash is usually maculopapular. There are certain people at risk – like if you have a rat fetish or handle them or keep them as pets or if your local rat population lives alongside your local human population. Penicillin is the treatment of choice – don’t ask me what it is when you are allergic to penicillin! Complications include meningitis, myocarditis, pneumonia and rarely death. *cue ominous music* Prevention is a) avoid rats! duh b)practise good hygiene c) do not put infected fingers into the mouth.

AND THIS IS WHERE IT ALL CLICKED FOR ME WITH REGARD TO THIS PATIENT – HE PROBABLY PUT HIS INFECTED RAT-BITTEN FINGER INTO HIS MOUTH – AND INGESTED SOME OF THE PATHOGENS – AND HE WAS CURRENTLY AN IDEAL CANDIDATE FOR TREATMENT FOR RAT BITE FEVER! Fortunately he was already on the treatment for it – the Paeds registrar concurred with our assessment and the patient was moved to the pads unit.

I reiterate: Learn something new everyday!

An interesting lump, courtesy of Warfarin – a dilemma in clinical management

59 Year old female came in to ED due to a painful lump that she had noticed overnight in the right side of her abdomen, associated with pain in the right half of her abdomen, back and upper part of her hip. This was the vague and slightly confusing history on the card as I went to review her. She was a very pleasant lady, who walked into the cubicle without assistance, no support required – and clearly no hip pain?

She reported she had had a cough x 6 weeks – not continuous, but had had a chest infection initially, and was still recovering from that about 3 weeks back when she began to have productive cough and fevers again – and had to complete a second lot of antibiotics, the last of which finished yesterday. She still had bouts of cough though, even though it had improved considerably – one of which had happened last night just as she was going to bed. She couldn’t sleep all night due to the continuous coughing, but this wasn’t the reason why she was here that morning. She woke up in the morning feeling quite sore in her upper abdomen, and put that down to her constant coughing. She tried to ignore it, and took some paracetamol, but as she tried to dress herself, she felt that she required help with undressing and dressing, which was a concern. To top it off, she also noticed in the shower that morning that she had a palpable tender lump under her ribs, in the upper part of her abdomen on the right side. This concerned her enough to come to the hospital. Oh, and she was on warfarin – that lovely blood thinning medication that’s given for clots in the lungs or in the legs, or if you have a heart rhythm disturbance that makes you prone to throw clots to your brain – for recurrent PEs (clots on the lung) and her last INR was 2.6 (a test to see if the warfarin is doing what it is supposed to be doing, and whether it was doing more or less than it was supposed to be doing – recommended range for her condition was between 2.5-3.5)

When I examined her there appeared to be no bruising to the area in question, and her abdomen was soft, though there was definitely a palpable tender firm swelling in the right upper quadrant, sort of jutting out of the lateral aspect of her liver – my thoughts immediately went to a spontaneous hepatoma/bleed into her liver because of her being on the warfarin – I quickly ticked off in my mind a checklist of things that would signify severe ongoing bleeding internally, like pulse and blood pressure (both within normal ranges for her) and she appeared nice and ‘hemoglobin-y’ – adequately perfused! I decided to request a quick ECG (which was normal sinus rhythm) and did some baseline bloods on her including a clotting screen (to check her haemoglobin and INR today – both were normal, though a slightly raised white cell count and CRP) as well as a chest x-ray (I felt there were two reasons for this: 1) cough for 6 weeks gradually worsening, warranted radiographic evidence and 2) in someone presenting with tenderness of right upper quadrant, it is very relevant to be thinking about problems with the lower part of the lung above, rather than just focussing on the abdominal complaint – she may well have a pneumonia sitting in her right lung base, causing pain in her right upper quadrant! In this case, however there was nothing nasty on the chest x-ray on the right, though you could argue the left lung base looked slightly more hazy than I would have liked; at any rate, she needed treatment for an LRTI)

I spoke to my consultant, who quickly magicked an ultrasound machine within the ED and did what is called a ‘FAST’ scan, an ultrasound to quickly rule out free fluid within the abdominal cavity, usually done for patients of abdominal trauma to look for bleeding, etc. The scan was negative for free fluid within the abdominal cavity (we both breathed sighs of relief!), however we did find what seemed to be a collection of blood within the abdominal wall in the area of pain – she seemed to have bled into her abdominal wall, probably due to the coughing, which caused a tear within the muscle wall, and due to her being on the warfarin, caused her to bleed internally but contained within the wall of the abdomen – causing her presentation of a tender painful lump in her abdomen. Mystery solved. Now to the management of said mystery.

The dilemma we faced was this: We couldn’t stop her Warfarin due to the indication for which she was taking it in the first place – it could prove fatal if she had a clot on the lungs again. We couldn’t just leave her bleeding on the warfarin and do nothing. We needed to treat her cough as well, because even if it wasn’t life-threatening at this point, if she went on coughing, who knew how much worse this bleeding might get? And we had limited treatment options for her cough-slash-chest-infection, because many drugs including some antibiotics interfere with the action of warfarin, and the patient was allergic to penicillin (of course, we wouldn’t want this to be too easy!)

So we requested a formal ultrasound from the radiology department – much more detailed than our very ‘FAST’ scan. They agreed with our preliminary findings, with the very valuable additional information that there seemed to be no evidence of ongoing bleeding – the hematoma was contained and was not likely to worsen. Her INR was within the limits appropriate for her, maybe slightly on the higher side, so we decided to advise her to skip the next dose of her warfarin, and to liaise with the anticoagulant monitoring service to monitor her INR in the next few days to make sure it was still within the prescribed limits for her. We sent a sample of her sputum for culture and sensitivity, and based on the haziness in the left lung base and the raised inflammatory markers (CRP and white cells) we decided to start her on some antibiotics – she was allergic to penicillin, and so the next best option was clarithromycin which unfortunately interacted with warfarin so we couldn’t go down that route; we decided on doxycycline being the best line of treatment for her. We explained to her any of the red flag signs, if she experienced any concerning symptoms, to come straight back for review. We advised some analgesia, and some cough medication as well, and the patient was very happy to go home. Fingers crossed, she has neither returned nor have I heard of any problems coming to light following her ED visit.

This served as a learning experience for me – coming to a diagnosis in this case when the presentation was completely different from what was actually going on, and then connecting all the dots in the history (warfarin, chronic cough) and the physical examination (presence of a tender palpable lump in the absence of trauma) and ultimately finding out the mystery of the sudden lump, and then reaching a management plan that should have been so easy and straightforward, but really wasn’t due to the patient’s unique situation.

Document!

If there is one thing I can not stress enough, it is that wherever you are (as in whichever country you work in, not your present location of the bathroom or the grocery store!), whatever you do (whether its emergency medicine or you’re a newly born FY1), whoever you are, always remember: DOCUMENT!

If you do something or say something or let the patient know, or if you don’t do something, or don’t say something or don’t let the patient know, DOCUMENT the conversation or the deed (or the lack thereof) and the pertinent details of the interaction – for your own good. I always try to tell my juniors (and anyone else for that matter!) that always think of your notes as someday standing up in court as a means of defending yourself; at times the ONLY means. Will you remember the 3rd patient on your 57th day of work in your 4th year of training, 3 years ago? Well, you may. But will you remember exact details? Not likely. So think of it this way, whatever you write down, or don’t write down, will always end up saving you. Or screwing you over, whichever way you want to look at it.

If you see a patient who, let’s say has epilepsy or you are working them up for a possible or probable seizure, sometime during this interaction it is your duty to tell them very clearly that they are not allowed to drive. And then also DOCUMENT that in your notes. If this patient then decides to continue driving, and ends up in an accident, it is very likely someone will pick up on the fact that he had a similar episode sometime back, and they will then look at your notes of the interaction. Now suddenly, every word you have written down (and also not written down) becomes significant. If this patient then goes on to say in court that he was not told he could not drive, and your notes do not mention you giving this advice, not only will you have aided him in escaping punishment for his poor judgement and from an unpleasant fine-slash-jail situation, but also it now becomes your fault, your poor judgement under scrutiny, your job at stake, your medical degree in question and your license in danger of being revoked. DOCUMENT!

If you use a chaperone for an intimate examination, DOCUMENT their name clearly in the notes. If you offered a chaperone and the patient declined, DOCUMENT that as well.

Always date and time your notes; always DOCUMENT your name (I prefer using my last name) instead of your signature. At the start of writing anything on a clinical document, look at the time and just put the time and date in right then and there; make it a habit to avoid problems. Any further changes or updates to the plan, document beneath it, with the new time (and the new date if applicable). When continuing to the next page, just remember, this page may at some point become lose and be put back in the wrong order, so always make some mention of the date time and who you are on the new page as well. Granted that sometimes when you are too busy to update notes continuously and in time order, you can go back and document your findings, but always do so by documenting clearly that these notes were written in retrospective. People understand; you’re a doctor. No one’s going to go ‘Right, can you intubate this patient with one hand and write up the information with your other hand? Thanks!’ and if they do, you can punch them and document why. But always document. (Ignore that last part. Do NOT punch them. Please)

You bleeped the cardiology registrar. They haven’t responded. DOCUMENT that. You bleep again 10 minutes later. Someone calls back, and tells you the cardiology registrar is busy because she is passing a critical line into a critical blood vessel in a critical patient (you see what I did there?) and you reassure them that you just wanted some non urgent advice and to ring back when free. DOCUMENT that as well. It’s not just helpful for whoever reads the notes as to why the cardiology consult took so much time, it’s also just common courtesy.

You have just broken the bad news of your 88 year old patient’s new diagnosis of metastases to the liver, unknown primary for which you give them a plan for workup. You offer your help; you offer tissues, water, a hug. You listen to their questions. You offer them to take their time digesting this information, and that you will come back when they are ready and answer any further questions and even repeat anything that they want repeated. You have the ward nurse present with you during this interaction, and the patient granddaughter and granddaughter’s boyfriend (with the patient’s permission) are also present. Your patient says she does not want to proceed with further investigation and treatment, that she has lived a long full life and is quite satisfied. You still offer your support and offer to re-address this at a later point. And any specialty that can come in offer their opinion on this situation. What do you write in the notes? EXACTLY ALL OF THIS INFORMATION. WITH THE DATE. AND THE TIME. AND YOUR NAME. And the granddaughter’s name, and her boyfriend’s if you have remembered to ask him, and the ward nurse’s.

Bottom line: Document every pertinent aspect of patient care; whether it’s your interaction with them, information from investigations, information from colleagues and staff on the ward or care staff from the patient’s nursing home, or even if it is to say that you came in to see the patient but the patient was not in her bed, or that she had gone for a CT scan. Trust me, you do not want to learn the art of documenting the hard way: when you fail to document something and it comes back and haunts you. Not just haunts you, but bites you in the ass. DOCUMENT!

A Day in the life of an A&E doctor

6:14 am – Eyes open. It’s still dark. Baby is asleep today, has not yet woken me up. Surely I still have enough time before to go back to sleep before I have to get up at 6:15am? Looks at mobile phone – an addiction – and an instant regret (along with a wave of anger) as I realise – I bloody woke up 1 bloody minute before my alarm went off. SH*T! *sigh* *longer sigh* Trudge off to get ready. I only slept 4 and a half hours ago, studying till almost 2 am! I should shave, but I am so angry, I decide not to.
6:43 am – sitting in the car with my cup of tea, trying to warm it up enough to hold on to the steering wheel without my fingers freezing off. And we’re off. *music coming from an unknown radio station – ‘keep bleeding’ aaaah keep keep bleeding’ in lurrrvvvveeee..’* It’s too early in the morning for Leona Lewis. oh. right. It’s Valentine’s day. Sheesh. Gotta remember to …do something or other. Flowers? Dinner out? Make dinner at home? hmm… *yawwwn*
7:00 am – walk onto shop floor (what the A&E centre of gravity is called, basically the work space) and find 7 patients waiting (OH SH*T!) and the night registrar dealing with a critical patient from before my shift started. There is a good overlap of shifts so I have started and the night team haven’t yet finished – well, in a manner of speaking, officially they still have an hour to go, but they have had a horrible night (I stifle another yawn) apparently from the looks on their faces, so I start seeing patients in time order. So…
7:01 am – Paeds! Start off the day with a kiddie, usually they’re cute and adorable, but  being sick isn’t how you want to picture them. Oh well. I go into the paediatric area of our ED – the nurse informs me my patient is in cubicle 2. I put my name on the board against the patient’s name so they know to hunt me down should I dilly-dally or skive in any way, God forbid! And then I go see Coughing Allnight (not her real name), an almost  3 year old female known to have asthma who was playing gleefully in the play area, talking to the nurse and what I assumed to be mum but was informed was her godmother. Play and talk was interspersed with bouts of horrible chesty sounding cough, that I agreed sounded bad enough to come to hospital with. Godmum reported that the child had been staying with her overnight since child’s mum was at work, and patient had been “coughin’ something’ nasty!” She had been unable to sleep, which basically translated to everyone in the house not being able to sleep. I probed a bit further – when did the cough first start? Oh about a year ago. It took me willpower than I would have expected to not walk out the door. I persevered, and figured out that for the past year she has had several bouts of sore throat and lower respiratory tract infections, that set off her asthma, ends up with her having a cough more often than not, and last night seemed to be particularly bad. Child is not febrile, her observations are all within normal limits for her. Most importantly, she is eating and drinking normally, interacting appropriately and seems (on my review) a happy child, preferring to play with all the various toys in the toyroom. I examine her fully, look for a rash, listen to her chest for a wheeze or crepts or anything sinister, like whether or not she is having increased work of breathing (she is not) and look at the back of her throat, ears and nose (and head and shoulders knees and toes, knees and toes!). She is able to speak in full sentences, and tummy is nice and soft. I reassure mum…no GODMUM. Monitor her inhaler/spacer technique, and give her my opinion regarding it being very likely a viral URTI – I do hasten to add that I would still like to discuss it with my seniors and if they agree with me then I will be sending her home. There was no need for antibiotics, something godmum wasn’t happy about. I told her to avoid very cold water to drink for her, and she reassured me that the patient gets bottled water to go to the daycare with her. I discuss the case with the night reg, who by this time looks like she is about to pull her hair out (but she doesn’t) and listens to me calmly and rationally, asks a few questions, and agrees with my assessment, and I hurry to bid the patient adieu. The nurse repeats a set of observations, and off she goes, while I hunker down to write up my patient’s notes (so tedious so early in the morning, I think I have arthritic fingers early mornings, so difficult to hold the pen – yes, we have to write everything by hand, followed by, wait for it….) and also an online discharge summary that will go to her GP. Basically a quick summary of what she presented with, what my review found, what we did and what we recommended. And I leave the pads area go back out into the majors area, to pick up my next patient.
7:29 am – ANOTHER PAEDS! love it. As I walk back to the Pads area – I notice 2 things: one, I remember how I used to be scared of paeds having no idea about how to assess babies and children, and what’s normal and what’s abnormal (everything seems to be a possible diagnosis or a symptom, or it can be normal! that’s not confusing at all) but now that I had had my son, I had gone through almost all the things parents go through from newly born to infant to screaming toddler. PS: I love my child, believe me. two the nursing shifts are changing, and there is an onslaught of all levels of staff and fresh faces and wafts of coffee and mint as I walk towards paeds. Still half an hour to go before the doctors morning shifts arrive. I shake my head and go see Wokeup WithaRash (not her real name), an 11 year old who woke up at 3am and felt quite itchy over her abdomen and flanks. Saw that she had a rash, texted mommy who was at work with a picture of the rash, mommy rushed home, found the rash had worsened to involve more body parts, and her lips were swollen, so rushed to ED, where she was given some antiallergic meds and some steroids for a presumed allergic reaction as soon as she came in, so that unfortunately (or fortunately, whichever way you want to look at it) by the time I saw her at 3 hours and 20 minutes, her rash had disappeared and so had the swelling. She looked completely normal to me, but I went through the motions of taking a history (it transpired she had had a sandwich at a popular sandwich shop the evening before, and tried out some new bread that had nuts and seeds in it) there was no shortness of breath, I asked mum whether she thought daughter’s voice had changed (it had not) I examined her fully with mum and a nurse being present in the room as a chaperone; I sent her home with advice and counselled mum about any red flag signs to look out for. I rushed to complete the written notes as well as the discharge summary. *that’s two down, and not even an hour. good job, but don’t get complacent, these were quick and easy cases, I’m lucky*
7:51 am – Let’s see what’s next. As I am picking up the next card, Paeds nurse approaches me. Oh sh*t, what have I done (or not done?!) Coughing Allnight’s god mum wants a word with me, she is still waiting for a note from me, apparently having told the nurse that I had suggested the patient needs bottled water to take to her day care?! umm….no, not true. I took a deep breath, and explained to the nurse what had transpired. I then went and clarified to god mum who understood and finally left, and I returned (trying very hard not to roll my eyes!) to look at the list.
8:01 am – next on the docket – 80 something year old PR Bleed. Aaaaah, the joy. I mentally steeled myself for the task ahead, no way was I going to be able to get out of examining his back passage, when he was actually bleeding from his back passage. *sigh* As I put my name the board against the patient’s name, and note the time when I start seeing him (so important to know times – when the patient arrived in the department, when he was seen by one of us, if discharged or admitted what time the decision was made and when did the patient physically leave the building, along with the time of any review requested, or opinion sought, or advice asked or provided – you are against the clock from the time the patient enters the department, till they are no longer your responsibility (when they have left). As I walk in to his cubicle, I see the morning cavalry has arrived. Coffee. Mint. crispnessfreshnessmorningness. Eurgh. and if only I had waited a few more minutes, someone much fresher would have picked this one up. Sh*t!
9:00 am – Took me a long time, I know, but the man’s history was extensive! Was on warfarin for a long time, that had caused his diverticular disease to become prone to bleeding, had had 6 PR bleeds in the past, one requiring transfusion, the last one was when he was off the warfarin, and he had now recently started a new anticoagulant, apixaban. He had had x2 episodes of fresh blood instead of stools when he went to void this morning. He was quite stable, and it seemed like a straightforward surgical referral. I did the needful, arranged blood, sent off samples, after examining him and reassuring him. Discussed it with the consultant (who had just arrived on the shop floor), who agreed with a surgical referral ASAP, and I mentioned I had not done the PR (examination of the back passage) and was it necessary, since the patient was known to have this previously and unlikely for it to be anything else. But I knew, and he knew I knew, what his answer was going to be. Oh Sh*t. I hung my head and went to …do the needful. Took a chaperone along, even though the patient insisted he didn’t require one. Sure enough, as I knew, there was nothing new to be seen or felt except for the expected fresh blood. Moving on, bleeped surgical reg, kindly accepted, thankyouverymuch. I need a wee. quickly complete the written notes, and try to find a computer to complete the discharge summary. As I am waiting for a computer to be free…
9:15 am – *gasp* IT CAN’T BE! Dare I say it out loud? Excitement prevails as there are no patients currently waiting to be seen. That is no way means the department isn’t busy. No. It just means that temporarily, we seem to be on top of things, and the number of doctors in the department is equal to or greater than the number of patients waiting. This almost never happens, so I might just go to the loo… oh sh*t! red phone! *sigh* The consultant looks at me, and says “You look like you are almost done with that discharge summary, how about you take this next patient coming in to resus? Her name is SepsisLowGCS lady (not her real name).” “Sure!” Groan.
(red fone is the resus/critical case phone, paramedics and air ambulance etc ring up on this phone to give us pre-alerts about incoming patients that they are on the way to us with, so that we can prepare beforehand the adequate staff and resources to be allocated to the area. Sepsis is the body’s response to an infection, and a localised infection can cause widespread multiple organ effects; GCS is the Glasgow Coma score, which is a score given to all patients to indicate their neurological functioning or deficit – optimum for me and you would be 15 out of a possible 15, indicating alertness- well maybe less than 15 for me currently! and lowest is 3/15, indicating comatose states.)
10:35 am – Sepsis lady sorted. Focus was her lower limb cellulitis bilaterally as well as a chest infection as shown on her x-ray, as well as a urinary tract infection. Wowzers. It took me a while because a few things needed to be done. And since I was relatively new to the department I needed to ask for things and where they were kept and asking for help; discussed it with 2 of the morning registrars just so they could tell me whether or not they were happy with my management. Then also discussed it with the consultant who was loitering with intent wanting to know my plan. Appropriate antibiotics prescribed, iv fluids begun, patient was catheterised, bloods sent off and wounds re-dressed. Job well done, why thank you. Am I forgetting something? There was something I needed to do. Oh well, I need a wee, my bladder is about to burst. As if on cue – the SepsisLowGCS lady starts complaining of chest pain (GCS had now improved to 13) and so that entailed a further assessment(oh sh*t!), ECG, bloods being added on, medications added, re-assessed, stabilised, before being sent to the ward. Phew!
11:00 am – I look at my phone and there are 2 missed calls from my mother in law (unusual, at this time of day) and 17 new whatsapp msgs from my wife (usual at any time of day or night!).  But there are no signals for me to call anyone back while I am in the department – is that fortunate or unfortunate, I never know, so I text them both saying I am unable to chat right now, and is everything OK. Wife tells me an issue regarding a missed council tax payment, letter received this morning blah blah blah, court summons etc, and hadn’t I paid the tax? EVERYTHING SUDDENLY COMES TO A STANDSTILL FOR ME. Oh my god. I am going to jail. Sh*t! I looked at my wife’s messages again. She had sent a picture of the letter. Last date of payment was a month later. She had read the date wrong. And I had already paid it off, so why was I scared? I didn’t know why they had sent me a reminder then, and I needed to get to the bottom of it. I needed to get to the bottom of it BEFORE picking up a new patient. I looked around for the consultants (there were 2 by this time) one was dealing with a difficult chest drain in rests, and one was having a very detailed discussion with one of the other patient’s relatives about end of life treatment. Who do I interrupt for permission to go outside the department and make a few phone calls? As I am contemplating my options I see a third consultant, who gives me permission to leave for a few minutes, I don my coat and go outside, find out from the council what has happened, sort everything out, reassure my wife that all is well with the world, and order is restored. My legs feel like jelly as I go back to the department. Crisis averted
12:00 pm – COPD lady is my next one. Worsening shortness of breath and a cough despite being on antibiotics. I assess her quickly, feel that she is actually clinically not too bad, and may actually be at her usual baseline. I decide I will wait for her bloods to come back, request a chest x-ray and counsel her that if everything is alright on her bloods and CXR, I would be quite happy for her to go home. I quickly write up the notes (bladder is about to burst by this time!) and ask the consultant if I can take a break. They realise I should have gone earlier, and apologise for not sending me sooner for lunch. I mention I have a supervisor meeting at 1:30 pm, just for them to be aware. They remind me I also have teaching today at 2:00 pm, and to be back from my break in time for the consultant’s handover at 1:00pm. Sh*t. I rush off.
12:30 pmAaaaaaaaaaahhhhh….FINALLY relieve my bladder.
12:35 pm – Grab my sandwich that my wife (love her!) packed for me, and head out to meet a friend from another department for lunch. We go to the canteen nearby, shoot the breeze, and all too soon it is time for me to go back.
12:55 pm – walk back to the department so that I can be in time for the handover.
1:00 pm – waiting for handover to begin.
1:10 pm – Still waiting. Why did I have to rush back from my break when they are late themselves? In the meantime, my patient’s had her X-ray, and her bloods are back, both of which are unremarkable. I contemplate whether I should wait for handover, or just send the patient home. I decide to discuss it with the consultant, who agrees to send the patient home like I had planned, but with COPD outreach team input now, to see if they can tweak her inhalers or if she can be supported further in any way in the community. First change of plans regarding this patient. I decide to do this after handover.
1:15 pm – the new consultant finally arrives, out of breath – couldn’t find parking. Handover done – I discuss my patient again, new consultant advises COPD outreach won’t be available to come round to ED today – To arrange for community followup tomorrow, and to send home currently with antibiotics and steroids. Change of plans x 2
1:20 pm – I speak to the patient. Inform her about the x-ray and the bloods. reassure her. mention the plan by the consultant. she reports she does not want to see the COPD team, as they had come to see her 2 years ago, with a promise to see her again every 3 months, and had not seen her since then. She reported she felt well enough to go home, and the only reason she came in to ED was because her doctor sent her. She herself had no concerns. Change of plans x 3. I relayed this to the consultant, who agreed.
1:30pm – I quickly complete the patient’s notes, remove her cannula and let the nurses know. Am I forgetting something? No time to think about it though, I am a minute late for my supervisor meeting!
1:32 pm – Arrive for meeting at the consultant’s office – out of breath, and late. Sh*t. Talk talk talk. plans. aims. concerns. advice. yakkity yak yak. blah blah. more talk. exam. studies. competencies. good evaluation. don’t be complacent. blah blah blah.
2:07 pm – yikes! late for teaching, it was supposed to have begun 7 minutes ago! Sh*t! Run to the conference room. Arrive late. Arrive out of breath. And very confused as everyone is sitting there discussing head injuries and anticoagulants and various guidelines for various INR levels and various anticoagulants and who to observe and who to send home and who to scan and what to do after the scan if its normal etc etc. Missed the start of it so took me a while to get my bearings. This went on for an hour and a half. *yawn* *snore* *sigh*
3:30 pm – finally free. day over. change scrubs into day clothes. literally run out of the department. I realise as I reach the parking lot – sh*t! I didn’t complete the discharge summary for the COPD lady! As well as SepsisLowGCS lady! Oh well, will get to it tomorrow.
3:45 pm – arrive home. unlock the front door and wife is standing there with the biggest smile on her face, looking radiant and an expectant look on her face – “Happy Valentine’s Day!” OH SH*T!