Nightlife in ED – A series of ‘Night’-mares (Part 2)

Second of 4 nights-in-a-row. There seemed to be no light at the end of this very, very, very long tunnel. Oh, well…

1) first card says 40 -something Male, PR bleeding x 3 days. *sigh* And he waited for my night shift on the 3rd day to seek medical advice. So I see him, apparently has had bleeding AND a slightly painful swelling … there. Thinks its haemorrhoids, has been using haemorrhoid ointment, but the bleeding hasn’t stopped. I reassure him. Ask him if he is on any regular meds, anticoagulants in particular. Nope. No associated abdominal pain, no constipation, bowels opening normally (otherwise). No recent fevers. No prior history of any bleeding (PR or otherwise!) and not ever had haemorrhoids before. Hmmmm. I obtained consent for a PR examination (yep, back passage examination) – found the swelling to be NEXT TO, and NOT coming from INSIDE the rectum – which essentially meant it was not a haemorrhoid. Very likely it was a localised gland or hair follicle that had become infected initially, swollen up with debris and when it became too big (or with the pressure of wiping) it just burst and spewed forth bloody discharge. Now looked like it was settling, no surrounding erythema, and it wasn’t painful. Rectal examination was otherwise unremarkable. Sent home with advice, did not need to have blood tests – some sitz baths and just good hygiene practises and red flag signs explained, advised to seek medical advice if any further concerns.

2) Next card – picked up the patient, put my name against it, got the notes, took down the blood test results and stepped into the cubicle – introduced myself…and got told the patient had already been seen by another doctor. They had just forgotten to … pick up the notes, write in them, write their name against the patient’s name in the list – anyway, I apologised to them and went to look at the waiting list to pick up the next one.

3) Next patient was a very cute little old lady, walked into he cubicle to be assessed, with her daughter in attendance. Was in the parking lot of a grocery store, went to deposit the trolley after she was done, misjudged a kerb (?miscalculated her footing?) and tripped, fell face-first onto the concrete, came in with a nose injury and some facial abrasions. By the time I reviewed her her wounds had been tended to and she was no longer bleeding. She had a superficial cut on the end of her nose (steristripped) and a few scratches around the nose. She hadn’t lost consciousness, not actually hit her head (witnessed by daughter who had been present) and was not on any anticoagulants. It had been more than 3-4 hours, she had not experienced any nausea or vomiting. I examined her for bony facial tenderness anywhere (there was none, apart from slight tenderness of her nose, understandable, but not really helpful in deciding whether it was a fracture or just soft tissue swelling/injury) – did a neurological examination, and she was able to walk without any discomfort in her hips. She was, for all intents and purposes ‘good to go’. The rest of her history and examination were unremarkable; I sent her home with nose injury advice – no need to x-ray it, yes it could be a fracture, but nothing needs to be done about it. Wait for a few days, upto a week, if after the swelling dies down, it’s still painful or there is an obvious deformity, go to your GP, they will sort out an ENT outpatient review. Otherwise, just continue with your routine, just don’t blow your nose or wipe too hard for the next few days. I sent her home with some head injury advice as well (look out for nausea, vomitting, severe headache, visual disturbance or any weakness, LOC or unusual behaviour) and the daughter was happy to keep an eye on mum for the next 24 hours. Job done. Next!

4) 9 year old female with abdominal pain that she awoke with, while at grandmother’s house, called mum to pick her up as was ‘in a lot of pain’. No pain since mum picked her up, and very happily playing in the play area. All my instincts told me this was a young child just seeking attention to get mommy to pick her up and take her home, probably because she was bored. I went through the motions, but I knew what was up. Or atleast I thought I knew. Abdomen was soft, non – tender, no bruising. No fevers reported, and all her observations were within normal limits. Mum was very concerned as this had happened on quite a few prior occasions (red flag!) and only when the child was without the mum (further red flag!) but the child was never with the same person – so it wasn’t as much an avoidance of a single sinister person (s) as it was a ‘mommy-I-miss-you-can-you-please-come-get-me?’ I treated it as such. BUT…as part of the workup of children with abdominal pain, we did a urine dip, even though she didn’t really complain of any urinary problems – it came back positive for a UTI. *oops…almost missed it being judgemental and complacent* Sent home with antibiotics, advised to followup with the GP for culture results, etc. Also made sure GP was aware in my discharge letter to him, that she had complained of abdominal pain, and it had been a frequent thing previously, and only this first time she was found to have a UTI. And so could he be aware and be on the lookout for further such occurrences, in case…something needed to be done or …something else thought of. Sigh. Difficult jobs we have. And unpleasant to even think about.

5) middle-aged male, who came in with chest pain, and after my full assessment we found that he actually had severe pain in his right flank (don’t ask how it was translated into him having chest pain) – loin, going to groin, very typical of renal colic and coupled with a positive urine dip for blood, was very likely a kidney stone. He was pain-free after the PR diclofenac (always works wonders!), and his blood creatinine levels were normal, and there was no signs of an infection on his bloods or his urine. So I sent him home, analgesia advice and and outpatient CT KUB (gold standard, diagnostic) and to go back to his GP if any further concerns.

6) 8 week old infant, brought in by mum (and referred in by out of hours GP – or OOHGP) because of failure to thrive. He was formula fed, and unfortunately did not seem to be gaining any weight since 3rd week of life, and mum had switched 4 different formulas (formulae?) and was now on a 5th one, trying a lactose-free one. He was quite an adorable child, very responsive, happy, alert – but bring that bottle close to him and he cried. And cried. And cried. And the mom cried. And by the next 45 minutes of trying to coax him to drink something – I was about ready to cry myself! Examination – wise he was fine, no abdominal lumps etc, he was passing formed stools, still greenish, and his wet nappies, though decreased, were still ongoing. So he was getting his fluid intake from somewhere – and weighing him we found he had actually gained some weight. Not a lot, mind you, but some. We tried to counsel the mum. Me. The nurse. The registrar I called. But the mum was having none of it. She was convinced there was something wrong, this was her third child, she was not a novice at this, and she was absolutely distraught. I tried to explain to her…but no. So we spoke to the paediatric registrar, and she very happily (and very kindly) accepted to admit the patient – less for the patient’s sake, but more because of parental anxiety and ‘at-the-end-of-her-tetherness’ of the mum. She agreed the child was gaining weight and producing urine and not vomiting, and was alert and all his observations were normal, so while things weren’t absolutely perfect with his feeding, things weren’t quite as horrible as initially thought.

After I took a 30 minute break around 4 in the morning – things became a bit too haphazard to describe in too much details. Barndoor abdominal pain with normal examination/bloods/observations (sent home); Barndoor chest pain with a normal ECG but abnormal initial bloods (admitted) and 2 back-to-back rests patients concluded my shift. This last part was such a blur that I won’t be able to do justice to it on this post – I might do a day of rests patients and give you an idea of the resus type cases that we see. But that is a story for another day. I went home and almost collapsed into bed. Glad to be able to sleep but at the same time, knowing at the back of my mind that I would get up and go back to the old drawing board in a few hours. Lovely. ZzzzzzZzZZZzzzzz….