*bleep* holder – First Anaesthetic on-Call

So I have just come back from my first call as an anaesthetic doctor (or more specifically, an emergency medicine trainee rotating in anaesthetics who is holding the dreaded anaesthetic bleep very much reminiscent of a hand held grenade with the pin taken out. It may go off any second, heralding news which may be good or bad, usually bad).

So, I started the day taking a handover from my colleague who was the previous bleep holder. Or, I should rephrase that and tell you what actually happened. I waited for them to turn up to the operating theater for emergencies, and when they didn’t turn up after 20 minutes, I bleeped them. I found out they were in the middle of trying to help out a consultant with a dodgy arterial line for an elderly patient (who apparently at 92 had everything under the sun going wrong with her, and having managed to break her femur, was getting it surgically corrected), they rushed to meet me, handed me the bleep and a quick handover of the patients on the list (none!) and 2 patients that might require some analgesia maintenance sorting out later, and headed out the door. My first port of call was the consultant currently in the trauma theater dealing with the dodgy 92 year old. Old lady with CCF, AF on warfarin, small bilateral pleural effusions, past history of CVA (just last year) and a CABG 9 years back. She currently was using a frame to walk, and had tripped over an overturned edge of her carpet and ended up (long story short) on the operating table that evening. Anyway, the procedure went swimmingly, and she landed in recovery wihout any significant problems. My presence, though not directly helpful to the case, was atleast helpful in the sense that my consultant was able to grab a quick meal and some semblance of a hot beverage, and she mentioned she appreciated the chance to talk to someone. So far, so good, the call was going.

I was then bleeped about a potential appendix that was rumoured to have surfaced in A&E and the surgeons were contemplating taking it out. Young male, fit and well I was told. I took the opportunity to go round and see the patient myself, but as I was walking out of the recovery room, Cardiac arrest bleep goes off. In the heart centre (yes, ironic, isn’t it? I couldn’t make this up if I tried!) Apparently just a vasovagal syncopal episode though, as I ran down to the heart centre I saw the ITU registrar motioning me to relax as he seemed to have it under control.

Phew! On to the appendix…but first…ANOTHER CARDIAC ARREST BLEEP! Where is it? Second floor you say, oh the ward FURTHEST FROM WHERE I AM CURRENTLY STANDING? THANKS! I run to said ward, find CPR in full action on a what I understand is a 70 something year old gentleman found unresponsive on the ward (it is an orthopedic ward) and the rest of the history is a little late in coming, so CPR is in full progress, the ITU Reg enters almost at the same time as I do, he asks me if I have control of the airway, I reply in the negative as I am finding it difficult to bag mask ventilate. He chucks an I-gel towards me, which I insert successfully and ventilation is now adequate, as evidenced by the now rising saturations. CPR still ongoing, and there is now return of spontaneous circulation. He is intubated in the interim and post-resuscitative conversations/management are taking place (all this happens within the first 90 seconds of our arrival!) and someone then pipes up with the history (finally) that this patient is a known epileptic, admitted with multiple c-spine and other fractures, s/p corrective surgery for the spinal fractures 5 days back, was last seen alright 3-4 hours prior to being discovered unresponsive/in cardiopulmonary arrest. Based on the absence of pupillary reflexes, absence of any respiratory effort on the patient’s part, and cardiac function likely in response to the drugs given by us during the CPR, as well as the pre-morbid situation of the patient, it was the collective decision of the whole team involved to withdraw treatment. This was also agreed upon by the ITU consultant who we telephoned to ask for advice. The ITU reg offered to write up the notes as I took the tube out, and I went to see the appendix.

Very straightforward appendix – never had any anaesthetic, no family history of anaesthetic complications, last eaten/drunk something 11 hours back and that too vomitted up. Allergic to penicillin, otherwise fit and well young male with a slight language barrier, through which I discerned straightaway that he wasn’t happy about the surgery. He did not wish to proceed with the surgery for now. I stepped out of the room and let the surgical resident handle the situation. They would let me know if he still wanted the surgery. For now I would keep him on our list with an almost question mark. The staff in theaters would know what that code meant!

Bleeped again, this time from A&E RE an elderly female, Hmeatemesis with massive hemorrhage protocol in place, could we rush them into theaters for an urgent endoscopy +/- surgery? Her HB had dropped from a last known reading of 125 a few months prior to 49 on today’s blood gas. She already had a couple of IV lines secure, and the ED team had been excellent in pushing fluids, arranging blood and 2 units PRBC had already been given to her as well as 4 units of FFPs. I quickly pre-op assessed her, gave my consultant a quick phone call: he was happy to drive in (20 mins away) and assured me he would be ready and waiting by the time we got to the theaters. We did, and he was there, and it was an RSI, 4 more units of blood went into her, her last Hb was 98 and they found the bleeding point and treated it endoscopically, there was no need to open. Out into recovery where the ITU consultant also eyeballed her quickly, deemed to have no need for ITU support at that time and then moved to the ward after stable. He did ask me to give her the rest of the blood/FFPs booked for her, and afterwards send off clotting and FBC profile whenever transfusions over. Crisis averted (this took 2.5 minutes to write and around 2.5 hours to manage from start to finish, in which time I was bleeped 4 more times!)

One of those bleeps was from the surgical reg – appendix guy was agreeable and we would proceed for the surgery next. The consultant offered to do the RSI for this next one as well, I drew up the drugs for the case, and left to deal with the 2 pain patients from the handover (which seemed such a long time ago now!) and also deal with the 4 other bleeps that I had while we were dealing with PR bleed lady. 2 were urology cases apparently cystoscopies needed to be done for 2 elderly males, both with long term urinary catheters in place but unable to be taken out as the ballons werent deflating – eerily similar weird cases that were as much of an embarassment for the urology registrar as they were a hassle for the rest of the theater staff. Also while dealing with the bleeding lady, another consultant who was running the trauma list and who is now going home after his procedure has ended hands over 2 of his patients who are in recovery “shouldn’t be a problem but if there is just so you know about them” and walked out. I quickly scribble down their details so they don’t fall out of the back of my mind.

During my assessments of those 2 cystoscopies I got bleeped to remind me to do the bloods for the previous lady. I added it to my growing list of things to do.

I get called back to the theater because one of the other post-op patients in recovery (that the trauma consultant handed over) was being a bit…ummm…difficult. I quickly go see them. One of the other consultants prescribes some haloperidol. He is an elderly gentleman who has had a hip DHS, no prior known comorbids but slight cognitive impairment previously. But nothing as dramatic as how aggressive he was being right now. he was trying to get out of bed, he accused me of stealing his clothes and he accused the blushing nurse of having an affair with his wife, and he had quite a few choice words for how we were treating him. The halloperidol seemed to not do anything at all. It took all of our combined efforts (and a little bit of his analgesia) to calm him down and he went off into a deeply snoring snooze. Sigh. Phew.

9th bleep (or is it the 11th?) Urology registrar (sounding to be at the end of her thether, bless her) calling to tell me the first urology case cancelled as they were able to remove the catheter successfully, but the second case (similar) added to list, yet the consultant urologist was coming in to try to deal with it – should he fail, this was to be done cystoscopically so could we please keep the patient on our emergency list.

Another bleep – another story. A new bleeding patient, this time an esophagael variceal rupture potentially? Has not been booked on to the list but this is the theater staff calling to tell me there is a potential case – and to await further instructions. I swear I stared at the reciever of the phone to register my incredulity. At the end of the conversation I still wasn’t sure if there was or wasn’t a patient with a bleeding/hematemesis situation that needed to be urgently anaesthetized for their procedure. *DEEP BREATHS*

Another lap. appendix. Another x2 bleeps from pain relief point of view: something about a rectus sheath catheter that had dislodged, and another about someone who’s pain wasn’t being controlled despite adequate analgesia (problem was solved by a simple look at the drug chart which informed me that they WEREN’T in fact adequately analgesed!). 3 bleeps from various wards about cannulation difficulties. And finally, the last bleep of the day:

“Oh Hi there, it’s XYZ, coming to take handover – whereabouts are you?” I could have screamed in relief, but I managed to restrain myself till she got to the office where I handed over my bits and pieces. She was more senior than me, and asked how my first on call went, and then looked a more thorough look at me and said, “you know what? I know exactly how it must have gone – go home and get some rest. See you tomorrow!” Uncanny how she could discern from my expression and my hair and the overall dishevelled look and the stains on my OR shoes exactly how my first on call shift as an anaesthetic SHO went.

Just as I was stepping out of the office, I heard the bleep go off. And I was reminded of my own favourite pearl of wisdom: There is nothing worse than the sound of a bleep going off. And there is nothing better than realizing that it is someone else’s bleep that has gone off. I was smiling as I exited the office, and the hospital.

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….

Nightlife in ED: A series of ‘night’-mares – Part 1

I arrive at the night shift, change into scrubs and proceed on to shop floor – it’s not too bad – we get handed over 3-4 patients from the evening team, and I pick up my first patient – basically a minors patient, but since there is no ENP for the night: 40something male, no prior known comorbids, was playing football (yes, in this weather, and don’t get me started on the age!) went in for a kick with his right foot, all his weight on his left leg, and he suddenly heard a ‘pop’ in his left knee, since then has had difficulty walking or even bearing weight on the limb. Very swollen and tender anterior part of the leg (just 3 hours after this ‘injury’) but the mechanism isn’t direct trauma, so do I x-ray it? do I let it go? He is unable to weight bear, so I request one – would you believe he had an avulsion fracture of the patella! I am so glad I x-rayed it! Sent him home with a cricket pad splint (controversial, but that was our only option at the time) and a fracture clinic followup the next day. (More about this patient in one of my future blog posts)  My second patient is a young female who comes in septic (with septic observations – raised heart rate and a fever in this particular case), and I start figuring out the focus for her infection, which isn’t too difficult to ascertain: an infected surgical wound from a recent C-section she had, which looks (and smells) like it isn’t healing very well. Very quick and easy – antibiotics/fluids/sepsis 6 ticked off, and referred to the obstetricians (which was the Gynae SHO at this lovely hour), before moving on to my third patient: A young male who presented 6 hours after (yes, SIX HOURS AFTER!) being in an accident. He was stopped at a red light, and a car at unknown speed crashed into the back of his van. (yes, car … into THE BACK OF HIS VAN!) and then someone decided to crash into the back of that second car so he was jarred a second time. So he waited 6 whole hours before coming to ED at 2 am to be checked out. He complained of some shoulder pain, but had full range of motion and the mechanism wasn’t significant. I advised him to have some analgesia and go home. It was pointed out to me later on that he may only have been there for A) insurance reasons or B) so he could call in sick the next morning from work – being that he had been in hospital the previous night, or C) all of the above. Likely C. Anyway, the fourth: Elderly female, diagnosed with shingles 7 days ago started on treatment (which she had not taken!) and presented to ED because the pain was unbearable. I asked her if she had taken any pain-killers (she had not) and why she hadn’t been taking the amitriptyline (because it said on the leaflet ‘do not take if you have heart failure’ – even though her GP knew she had heart failure and had prescribed it for her and this warning is for people who usually take over the counter medications on their own) Bless her, the pain was more excruciating because the shingles rash was in her lower back, and the rash went into a skin fold, and everytime the skin folds rubbed onto themselves (as they usually do) or clothing touched it, it would burn. I empathised with her, told her how sorry I was that she was in this situation, but to expect that the pain will go away with time and that she needs to use her medication regularly, the rash itself was dry and not infected or anything, there was no other treatment for it. She didn’t like it, but that was unfortunately just the way shingles was. Unfortunately. Fifth: Barndoor chest pain, cardiac-sounding, first troponin 38 – started on ACS treatment, referred to medical specialty/cardiology for repeat troponin and further management/investigations – The sixth one was not really a patient I had seen, but was being handed over to me by one of my colleagues who was going off shift, and needed to hand over this patient to me to chase their CT scan report – if normal to be sent home with advice, if abnormal to be managed accordingly – the story will be unnecessary to relate here as the report came back 2 seconds later and he very kindly dealt with it himself (I did the discharge summary). Number Seven (or 6th?) was the cutest little old man, pleasantly confused dementia patient who had had an unwitnessed fall in his nursing home, and even though he denied any pain in his hips, there was a distinct grimace when you palpated his left hip, and his mobility had declined suddenly following to fall – Pelvic x-rays were requested, yet they appeared grossly normal. I gave him some analgesia and decided to refer him to the medical team because of his significantly reduced mobility following the fall, even though we could not find any significant injury, nor any significant cause for his fall (atleast not medically correctable in ED) – the medical team very kindly accepted the referral, understanding that this late hour meant he couldn’t go back home anyway, but also that he was unsafe till he was functionally fit to go back home as well. I then took a break (much-awaited) had some lunch (?dinner? breakfast?) at 4 AM – and felt exhausted, but the list went on: Eight – 74 year old female, known to have atrial fibrillation, who was brought in with palpitations and a fast heart rate – went through the mental checklist of things that may cause your heart to go fast – ruled it as infection as her WBC was 13 something, but her CRP was over 300! Very likely the focus was chest as she had reported a dry cough for the last week, that had x2 days back become quite phlegmy. CXR/bloods, including cultures/antibiotics and fluids prescribed – referred to medics.  Patient counselled at length because she was quite upset at having to be admitted (‘Doctor, can’t you just give me something to calm my nerves, and my heart will settle – I need to be home, it’s my daughter-in-law’s birthday tomorrow and I have to bring the cake!) and moving on…ninth on my list was my most interesting case of the night – middle aged female no prior known comorbids, with no personal or family history of epilepsy, brought in by paramedics and concerned family following what was very likely a generalised toniclonic seizure that she suffered in her sleep (she woke her husband up when he felt her shaking violently). The night before she was at her daughter’s wedding reception, and reportedly never drank alcohol. All her blood tests came back negative and her ECG and urine was fine (a urine pregnancy test was also negative). She had no focal neurology or anything else significant on her examination either. I discussed it with my seniors, and they agreed that something seemed very off about the whole case – we referred her to the medical specialty for inpatient observation as well as an inpatient MRI of the head, fearing the worst. The medical team agreed with the assessment, and were happy to admit the patient (usually patient with first seizures if their investigations in ED are ok and they are back to normal/usual baseline, and they have someone who can stay with them – we send them home with a followup to be seen in the ‘first-fit clinic’ as an outpatient). I counselled the patient and her family who understandably were very worried (they were very worried to begin with, but being admitted to be worked up for something sinister like what you would require an MRI head for worried them even more) – I answered all their questions and then once the patient was moved to the ward, I took a few minutes in the back room to compose myself. You do things on autopilot for so long, start of the shift to the very end, and you just keep moving forward from one patient to the next (often more than one) and there are times when one of those cases (or maybe all of them combined?) hits you right where it matters, because you are only human. I drank some water, took a deep breath – and moved on to number ten, very likely my last patient as there was about 50 minutes left till the end of my shift and all but one of the morning team had arrived. And I regretted picking up this patient at once: middle-aged male, admitted following an alleged overdose of 50 (yes. five. zero) grams of diazepam. I say alleged because reportedly he had taken them 3 hours back – and he was literally more awake than I was. Also, when I began to ask him what brought him to ED, he … just…started! Went on and on and on about everything under the sun – His divorce. His occupation. How he worked with the police. How he was a trauma surgeon for the past 26 years, how he knew the side effects of the medications he had taken. How he was also a scuba diving instructor. How he knew a certain celebrity. How he had been kicked out of his own house because his housekeeper had taken up residence there and had forged his signature on the papers and how he had a gun permit and not a gun but how he was framed for trying to murder his housekeeper who was still alive and the police won’t arrest him coz he worked with them and taught them scuba diving….*eyes going rolling backwards into their sockets* I interrupted about 5 times politely – but he went on. And on. And on. Not how you want to end your night shift (or any shift at any time!) Dealing with him felt like dealing with 5 different patients! And the alleged diazepam wasn’t making him sleepy or any less talkative either! I literally extricated myself from the encounter and almost ran to the phone to refer him to the medical specialty – not because I believed he had indeed overdosed on the amount he mentioned – but because he clearly needed psychiatric input/help (and now thanks to him, so did I!) I ran out of that shift like a bat out of hell – and as I exited the premises, one of my nursing colleagues, fresh as a daisy for her morning shift, yelled out ‘Bye darling, see you in a few hours!’ – reminding me that I was back again tonight, for the second of four consecutive nights. *Facepalm*