... and 47 to go.
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.