another life saved

it was the day after this particularly anxious personality was transferred from a private hospital. she had fallen over at home and spent two weeks in hospital with lower back pain radiating down the left leg. no fractures on plain films, but mri showed a smidgeon of narrowing of the left L5/S1 intervertebral foramen. she was put on tramadol and panadol osteo, and had the joint injected with local anaesthetics and steroids under ct guidance. so basically a typical story of lower back pain, not much to find on investigation, but having a drastic impact on her mobility. the private guys finally handball her to us for "slow stream rehab", ie out of their hair. whatever.

except, then she develps new right pelvic rim and hip pain. not much to find on examination except focal tenderness over the greater trochanter. full range of movement in the hip joint. nothing on the original x-rays. doesnt sound particularly radicular or neuropathic. hmm...

later in the evening, just as i was about to go home after three admissions, one of the nurses came up to me with a tinge of panic in her voice: "she's got a pale, pulseless right foot". uh-oh. turns out i could actually feel all the pulses: dorsalis pedis, posterior tibial, popliteal. the foot is pale and cool. tone is reduced, 3/5 strength, reflexes absent and absent plantars. what can it be? i was almost convinced it was neurological but the spectre of ischaemic limb loomed. i put the call through to the on-call consultant, who is also unconvinced but says "she sounds like she won't be happy until we get her back to the private hospital to see a vascular surgeon, but try and talk her out of it." i didn't try too hard - perhaps they could get a neurosurgeon to look at her this time? a letter and a call to the ambos, finally i leave work only three hours late.

the next morning, while getting handover in my day job back at the alfred icu, i get a phone call from my intern: emergency femoral embolectomy. phew! all i can say is, thank god she was a grumpy old fart...

half measures

the patient has been in hospital for three months, in and out of icu for most of that. a young bloke, he went for a drive on his birthday with his nephew and they smashed themselves up good: broken bits, burns, the works. he has been making slow slow gains, his grafts and regrafts are mostly not taking. he is on tpn and ng feeding but remains cachexic. he is withdrawn and rarely engages. he hasnt moved his right arm for weeks and his left fractured femur is held together by metalware but hasnt made any attempt to form a callus after all these weeks. looking at a double amputation, weeks more in icu, months of rehab and years of recovery, his family have decided to pull out.

my consultant told me he was a bit surprised because he felt the patient had been making gains. but he could understand where the family was coming from. so the plan is to withdraw treatment, and quickly. he told me he didnt like to do thing by half measures. the patient could die by a thousand cuts, slowly succumb to infections and malnutrition over days and weeks. or he could die with dignity. we would turn the sedation up to ten and ten of morph and midaz per hour initially, then titrate upwards freely. three days later, we'd turn the ventilator off, knowing he'd be comfortable and lapse into apnoea.

i don't know if i agree. this seems to go against everything i believe in about medicine, about palliative care, about my role as a doctor. and yet, there is something dangerously seductive in what he says. it feels both right and wrong...