Sunday, August 31, 2008
My first unpleasant encounter was about 5 years ago, during my first clinical appointment. I was examining this guy for varicose veins, and he kept asking weird questions such as whether his VVs had been caused by too much sex, whether the surgery would affect his sex life and how he was very active in that department and how much his wife complained. Engrossed as I was with trying to figure out where exactly the incompetent veins were, I merely made several soothing comments such as "don't worry, no of course not" etc. My clinical train of thought was rudely interrupted when his erection became so obvious that I couldn't possibly miss it. Eeeeuw. Utterly flustered, I snapped "get your clothes back on" and fled the ward.
Since then I've been resigned to the fact that as a female in the medical profession I'm likely to have the random patient drop his pants / raise his sarong in the ward, in the clinic and occasionally even on the corridor, usually accompanied by the words "nona meka poddak balanna" (Ma'm, have a look at this). Last week though was more trying than usual, hence this post.
A well known drunkard from the outskirts of Colombo was in our ward, after being assaulted by a gang of equally inebriated fellow drinkers. So there he was, on a bed, trying to look pathetic and failing miserably... and everytime a female went by his bed, this guy would reach under his sarong and start wanking away. Now, since our ward has 3 lady doctors, 5 nurses and about half a dozen student nurses walking around, this would happen every 10 minutes or so. Finally, after the poor nurse who was giving him injections came back looking absolutely nauseated, I asked a couple of attendants to tie his hands to the bars of the bed. Soon afterwards, his family requested that he be transferred to a health facility close to his home and we were only too happy to comply. Good riddance!
The casualty also saw this guy who for some unexplained reason had tied what looked suspiciously like a pirith noola around his penis! By the time he came, that ridiculous piece of thread had been there for a couple of weeks and the organ was swollen, rotting and stinking to high heaven. Our conversation went something like this...
Me : why did you tie that piece of thread?
Patient : I just felt like it Nona
Me : were you trying to sustain an erection?
Patient : no no, I don't do those bad things Nona
Me : why didn't you come any sooner??
Patient : only now it began to hurt Nona
Me : (silent scream of frustration)
The Registrar took one look and said we'd have to amputate, but as the patient was not fasting, we were told to just take him to the OT and cut the thread off, and prepare for surgery the following day. The pleasant task of breaking the news to the patient and getting consent for amputation of the penis was allocated to me. The thread duly came off and P. Nonis, as he jokingly became known as to the senior doctors, (read - No Penis - pathetic medical joke but it did sound funny at that time), was told to be ready for surgery the next day. Morning dawned and the patient was missing from the ward. Much hullabaloo, calls to the hospital police post and paper work to be sent to the Director's office. Goodness knows what happened to the poor fellow. Hopefully, that thing would fall off because if it stays attached for much longer, he'd get blood poisoning and die.
Finally, a 17 year old kid was admitted in the wee hours of the morning, complaining of pain in his weewee. I came to the ward, bleary eyed and started clerking. Apparently he had had sex with his 16 year old girlfriend 2 days ago, forgotten to pull back the foreskin and was now having pain and swelling "down there". Of course, he had to wait till 2.30am to come to hospital. I was more concerned about the girl. Had they used a condom? No. Did he have any idea what part of the cycle she was in? No. Could she be pregnant? Shrug. Apparently "she is a poor girl and has lots of family problems... that's why I was with her". I failed to understand how a possible pregnancy would improve this girl's prospects.
Getting his foreskin back in place was no picnic. Liberal amounts of anaesthetic gel were used... he thrashed around, arms and legs flailing... reinforcements were called... but in a few minutes, things were back to normal. I waited till morning to give that boy a large and nasty piece of my mind. If he thinks he's old enough to screw around, then he's old enough to be responsible about it.
Hopefully, next week will be more routine and have less ickyness all around. All in all, even you guys out there must admit that I have some justification for my rants! :)
Sunday, August 17, 2008
The last casualty I did saw 48 admissions in 24 hours...average for NHSL, and thankfully most were not critically ill. It's usually the uncontrolled diabetic with a foot infection, the uncontrolled alcoholic with gastritis/pancreatitis/withdrawal or someone with kidney-stone colic. The latter is the only category I really feel sorry for, as the others, IMHO, ask for it.
Recently, there was this guy (let's call him P, for patient) who was admitted with a painful hernia... something that an ice pack cured. He was asked not to eat and drink and we inserted a nasal tube... just in case. He was doing fine that night, snoozing peacefully, and doing fine when the consultant saw him the next morning. There was just one x-ray that was faintly dodgy... nothing clear cut, but when we looked at one area... it just didn't seem right... it looked as if there was air in the abdominal cavity. Now, air has no business being in there, unless it is in a loop of bowel, i.e. bowel gas. What we saw could be just a bowel loop... and that's what I thought it was. Others just thought it was dodgy.
P suddenly started to deteriorate at about 8.30 in the morning... pulse shot up, BP kept dropping at an alarming rate in spite of the IV drips. Yet he was conscious and rational and talking fine. There was no abdominal pain even though 4-5 doctors of varying experience kept prodding him. He didn't vomit and wasn't running a fever. Blood counts were absolutely normal. The consultant however was taking no chances and P was rushed to the casualty theatre with delay only to order blood and plasma.
"Explaratory laparotomy" is pretty self-explanatory. That's what we do when we have no idea what the heck is going on and open up to have a look. So we opened up and I just couldn't help gasp in horror. What looked like the entirety of what P had for breakfast, lunch and dinner the previous day was inside his abdominal cavity... obviously, part of his bowel had perforated. There's something a little surreal about seeing bits of carrot, kankun and half digested karapincha floating around the liver and sticking to bowel loops.
We sucked nearly 2 liters of intestinal contents out of his abdominal cavity before locating the part of the bowel with the hole in it. A very suspicious lumpy area (? cancer) was resected out and the two free ends were sewn together. And then the washing began... warm saline was poured in and the surgeons patiently washed and rubbed loop after loop of bowel, in a way faintly reminiscent of a Sunlight ad. Thankfully there was an ICU bed available and he was getting the best care available to someone with such a condition. Unfortunately, I guess the stress of the surgery, the infection and the pathology inside his bowel was too much for his system. P went into cardiac arrest yesterday, and could not be resuscitated.
What surprises me was that even with such a lot of muck inside the normally sterile abdominal cavity, this guy was not in pain, had no fever and even joked with the doctors while on the operating table before being anaesthetised. I guess this underlines the fact that in a really old person (ok, he wasn't that old, 67 years), going purely by clinical signs can be misleading and a really high index of suspicion is needed.
It's terrible when we loose a patient... but somehow, it seems less bad when it happens in the ICU. The death happens in spite of the best in critical care, 24 hour one to one medical and nursing care and the monitors and the fancy drugs... there is some sense of inevitability. When it happens in the ward in the middle of the night... there's always sick underlying feeling that something more could have been done... even if the circumstances are such that nothing really could be done.
After the round, I was at the nurses station filling up some forms when Nurse W (possibly my favourite of them all) came running at me brandishing a large pin as if it were the Sword of Omens. "Look at you child!" she hissed, "Even I am embarrassed... that poor man, who knows what he will cut off when he gets to the theater!!"
I glanced down to realise with shock that the outer flap of my blouse had got ...um... displaced... and that I had done the ward round with the right side of my bosom, (bright purple inner-wear and all) sticking out like a traffic light!
Oh dear... I guess wardrobe malfunctions happen even to the best of us!
Sunday, August 10, 2008
I really don't like this intern business... and apologise to all my readers because this blog is turning into a long drawn out "I don't like my job" whine. Sigh...
A patient almost died on me the other day. The night on-call was seemingly uneventful, I had high hopes of finishing a little early and catching a bit of the Olympics on TV back at the flat. I was almost at the last bed when one of the nurses cam running "Doctor, bed 13 patient A is bad".
Now A was admitted to the last casualty with non specific abdominal pains and had been doing fine so far. The problem was that he was foreign, understood no English or Sinhala and had a "smattering" of Tamil. History was taken using one or two words, lots of arm and leg movements and he was treated on the findings of the physical examination and blood tests. He was a round, jolly looking fellow, eager to tell his story and apparently unfazed that none of us could understand a word he was saying. When I had examined him 30 minutes ago, his tummy was soft but his lungs were a little noisy. Discussed with my senior, who also examined his lungs and we decided to add an antibiotic. What could possibly go wrong in 20 minutes?
I reach the bed to see patient A wheezing, with his chest heaving in the most laboured respirations I had ever seen. Sweat was pouring down his body in streams, his eyes were blood shot and his whole body shaking as he desperately fought to get air into his system. The nurses had got out the nebulizer and the oxygen and we gave him a shot of steroids while I felt for a pulse. Damn... no pulse to be felt on either arm... blood pressure could not be recorded and frantic groping at his neck revealed only a faint carotid pulse. Phew, I thought... this means he at least has a BP of 60. Lungs where full of rales and wheezes.... and his tongue was blue with cyanosis.
A million things were running through my mind... acute severe asthma, ok, we were doing everything required, 20 minutes now, why wasn't he improving? And in the background of the cold clinical reasonings, the desperate voice of a panicked child, please please please, don't let anything bad happen, please don't die.
To make things worse, we don't have a cardiac monitor in our ward. The pulse oxymeter (which is usually held together with a piece of plaster) refused to work. I ran to the next ward to borrow theirs... and before I talked my way through the red tape, an attendant called out that a few good thumps had cause our machine to start working. The readings positively chilled me. Pulse was 210/minute and oxygen saturation was 88%. One look at that and I ran to phone the medical Registrar on call... the patient was dying in front of me and the condition wasn't something I could handle on my own. Dr. N answered the page... and listened patiently as I almost wailed down the line at him. Added one more drug as advised, but the message was "keep doing what you are doing, I will be there soon". My own racing heart slowed down a notch.
Dr. N turned up soon, by then 40 minutes since the attack had started. Patient A was still distressed, still gasping, but his saturation was up to 95% and his heart rate had slowed somewhat. We stood in front of the bed, debating whether to give mag-sulphate or not. This wasn't too safe given the absence of a proper cardiac monitor... but the other options hadn't made much of a difference. Then slowly, slowly, the saturation rose to 100%, his breathing slowed down and A started looking more himself. One hour and 15 minutes after the onset, he was back to his jovial, voluble (but totally unintelligible) self.
Dr. N wrote out what to do next and left instructions that if an attack occurs again, to rush the patient over to the medical casualty ward. Once he left, I went to the lecture room, locked the door and had a mini breakdown. After the dry retching had finished and my shaking hands had settled a bit, I washed my face and went to complete the rest of the ward round.
I didn't sleep that night. My mind was churning, trying to find out possible causes and I kept looking at my phone every 10 minutes just in case I had gone suddenly deaf and missed a call from the ward. I think I fell into an uneasy doze around 3 in the morning.
The next day the nurse told me that the attack had come soon after she had given the antibiotic. I went next to patient A (who was, thank goodness, looking hale and hearty) and after waving my hands about and yelling "penicillin ooshi" at him several times he started nodding and said that penicillin was "bad" for him.
OMG!!! The drug we gave him wasn't penicillin (only distantly related) but it easily could have been. If it had been penicillin, he would probably have died within minutes in spite of our best efforts. What I had dealt with was anaphylaxis, a retrospective diagnosis that gave absolutely no comfort. I should have given adrenaline but I didn't know his allergic history and for all intents and purposes what he had seemed like acute severe asthma. All that would have been inexcusable, to my own conscience if not anyone else, had the worst happened.
All in all, I'm really really happy that I'm not on-call this weekend. I think I need a little break.
Sunday, August 3, 2008
Greetings, gentle readers, after more than a month of silence, and sparse blogging before that. Not much time today, either - but just enough for a quick update. :) The past four weeks were hectic... many things going on... some nice, some nasty.
- My blog turned one year old last April. And I didn't even notice, till early July and couldn't blog about it till now. Happy Birthday Angel - my alter ego, my stress buster, and the only means I have of actually putting my thoughts down.
- Darling and I got a place of our own - sort of. We've officially moved from the nest, taking clothes, furniture and the 3 rice cookers we got (each a different size, as you never know when or how many guests you'll have to dinner). To be honest, it's not that much of a change, except that now I have to think up of innovative dinner ideas. So far we've been alternating between noodles and pasta. And bread, when I don't feel like boiling the said noodles / pasta. promises to darling of Darwin like cooking have not been fullfilled, yet!
- I started the dreaded internship... eeek! Day after day I question why the heck I'm in this field of work. I'm in the ward by 6.30am, sometimes don't get home till past 10pm. I feel constantly sleep deprived. My feet developed blisters, which cracked and bled, in spite of me wearing what I thought were my most comfortable shoes.
It's not that the work's not enjoyable... it is. But it's different from a clinical problem in a textbook that can be leisurely analyzed and solved. We work with living, breathing human beings, in a dynamic state of flux, who develop different, unique and occasionally mind boggling problems every day. It's also coupled with the horrible feeling knowing that you're responsible for someone else's life. Being responsible for one's own is bad enough. To be honest, it's not really a happy job. the "oh but you're making people better" argument is inherently weak as people who get better will do so anyway (natural history), and the people who don't, suffer unbelievably and then die. :(
I did my first solo casualty last week and got through it safely (with all patients alive and ticking, phew!) It doesn't seem so scary now, but still do feel apprehensive as the next one looms up.
The last 24 hours were like a scene from ER... with about half the staff and none of the fancy equipment. Three (three!!) emergency laparotomies, and rushing a patient to a theatre to be ventilated because there were no ICU beds available. Hours of running around organising blood and plasma and platelets and fancy drugs. The emotionless announcement that there had been a death at one ICU and that we had first booking for that bed. How pathetic. One man's death opens the door to life for another. One family's bereavement is the source of relief to another family.
- Theatre. The surgical type. At least 10 days of the 28 spent in icy cold, sterile surroundings, wearing draughty green scrubs, face hidden behind a mask that smells a little weird. The stench of the diathermy device as it cuts through tissue and fat. This is why I don't like BBQs... the smell reminds me of burning human flesh. Yech!
- Bad news. Something I hate to deliver. Over the last 4 weeks I had to tell 5 families that the situation of their loved one was serious and that while we were doing our best, chances are slim. I watched their eyes tear up, watched grown men cry and rant and rave. I had a lady 15 years older than me kneel at my feet and beg me to somehow save her father. I felt like yelling "there's nothing I can do... I'm only a house officer, the most ignorant and incompetent of the team... even the seniors have done all they can, I cannot do anything more, I am not God!". I felt like kneeling on the floor next to her with my my arms around her shaking shoulders and reassuring her, however untrue and hollow those reassurances would be. I didn't do either. Just followed the protocol we had been trained to follow : asked her kindly, yet clinically, to calm down, wash her face and not to let the patient see her distress.
I wrote out a death certificate for the first time that week. Not a nice experience.
- Off day. Much anticipated opportunity to put feet up and consider something other than bread and an omlette for dinner. Darling convinced me that Kung Fu Panda was worth the effort of dragging self out of bed. Totally loved the movie... cuteness re-defined! Cheese kottu from Pilawoo's and early to bed. Bliss!
I guess I can't complain that my life is uneventful... stay tuned for more rants... and take care, all!