Sunday, August 17, 2008

Casualty days... casualty nights...

The next casualty will be my baby. 24 hours from 7am Thursday to 7am Friday, I will handle all the emergency surgical admissions (wince...). It doesn't end there though... I do the post casualty round on Friday morning, and if I'm lucky, get off around 3 or 4 pm to snooze and recharge as I will also be doing the weekend.

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.


Indunil said...

""Explaratory laparotomy" is pretty self-explanatory."

Oh yeah, i went thru four whole years of Engineering faculty. Why WOULDN'T i know what a explaratory laparo-what?-amy is?!

On a serious note tho, sorry abt the patient! :-(

Middle Child said...

wow. u write with such detached tone and yet the story got me hooked. so u the devil is a doctor? sorry, first time in ur blog :) cheers.

Bawa said...

hmmm.. lucky tht u did manage to get an ICU be bed for a 57 year old..
.normally dusnt happen with much younger patients being on the list..

In any case guess the guy had lived his life etc.

And about the detached tone.. I guess you get used to it after seeing a few patients die.. whats important is that u did everyhing u culd!

tc.. and gud luck with the rest of ur medical career.

p.s. maybe surgery wuld be a gud option for u.. not many female surgeons arnd LOL

Angel said...

Indunil : my bad, even if it was tongue in cheek. laparatomy = opening up the abdominal cavity. exploratory = to explore and see what's going on. I'm sorry too...

MC : well, detachment helps... often it's only the tone, and the attachment is still there... at least on a doctor-patient level. I've got a whole blog post incubating on that topic! thanks for dropping by!

Bawa : the only reason we got a bed was because someone else had died a nd we managed to get first booking. For routine cases, sometimes we go to the CU at 5.45am just so that "our" patient gets the first booking for that day. And we have to wait till 7am till the booking dude turns up, so we usually remember to take a good novel along! :)

Me, a surgeion... not really a good option as I have a pretty bad physiological tremor. Also wonder about the dearth of lady surgeons... does anyone have an explanation?