just another afternoon in ed

massive eyebrows lady had a great murmur that you could almost hear without your stethoscope. her lungs were filled with crackles and her troponin was 15. but she also had a low ph, a bsl of 24 and a tongue as dry as the sahara. i gave her some fluids and she got better than she got worse. her family gathered around with frowns and said they wanted full resuscitation. palliative care fail.

gcs 4 man came in with a fever and a raised troponin. he had a shearer blue singlet on and a permanent trache thanks to a floor of mouth scc. he had no neck (dissected away long ago) and no blood pressure. he also had no massive intracranial haemorrhage or cerebral mets on ct, which we were rather hoping to find. so we had to take him to icu because the ward couldnt manage his sats of 78%. yet another palliative care fail.

bmi 40+ man had no neck either. but he did have a pco2 of 113. his family attempted to keep him awake while we put him on bipap and tried to reverse his warfarin so we could tap his pleural effusion. finally at 11pm we decided to bite the bullet and tube him. the anaesthetist didnt want to come in but in the end she relented. perhaps it was the confidence (or was it panic) in my voice. thankfully it only took her three goes to tube him with the bougie. she also left me to check the tube position, put in a ngt to decompress his stomach, make up the ventilator settings, write up sedation, work out which inotrope to use (i wasn't too thrilled with a sbp of 65) and talk to the family. fortunately, it seemed that i had learnt something from my icu rotation after all (entirely through osmosis of course). and the icu nurses were very patient. another life saved.

but now i have a cold. hooray!

just wing it

i can't believe it's only been five days since i started up here in mildura. those days have been filled with so many... decisions. big important urgent decisions that i feel unprepared for, but nevertheless have to be made and there is no one else to make them.

so i just wing it.

do i resuscitate this 85 year old man who's just dropped his gcs and blood pressure in the rehab ward? do i take him to icu and scan him head to toe? just wing it.

do i admit this apparently well (albeit slightly smelly) guy who collapsed between placing his bets at the local tab and drinking at the bar, but with no risk factors on history and no abnormal findings on physical examination? and after i send him home, what do i do when the lab rings me with a positive blood culture for staph aureus in 2/2 bottles? just wing it.

do i advise the gp that it's okay for his patient to stop taking his beta-blocker, even though he came in with ischaemic sounding chest pain, dynamic ecg changes and moderate cardiovascular risk factors, because his enzymes and stress test were negative? just wing it.

and to top it all off: i have a scary intern.