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.