the man looked pretty good for someone who had just had fifteen minutes of cpr.
out of hospital vf arrest. bystander cpr until the ambos arrived. four shocks to get back into sinus rhythm. there were massive tombstones on the ecg. we thrombolysed him but his chest discomfort and ecg changes persisted. time to get him out of here. fast.
if you live in mildura and have a cardiac arrest, on average your outcome will be worse than if you lived in melbourne. it's closer to adelaide but they'd rather you sent your patient to melbourne, even if its almost twice the distance, because after all mildura is in victoria. even if you always send your cardiac patients to adelaide because there is a more integrated, easier to navigate cardiology service there and your boss has mates there. even if the patient has already been accepted and has a bed waiting for them in adelaide. even if your patient has failed thrombolysis and is rapidly developing q waves.
sorry fellas, but i don't give a shit whether mildura is in victoria or south australia. it might as well be in afghanistan or on the moon if you are going to keep acting like dickheads. this man needs a hot plasty and he needs to be retrieved. end of story as far as im concerned. but in the end, it took as long to resuscitate and stabilise my patient, talk to the family and admit another two patients, as it took the retrieval guys to dick around and try and handball responsibility to each other, until finally they dumped it on the rfds.
it's just not good enough.
11.6.10
30.5.10
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!
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!
15.5.10
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.
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.
20.4.10
the english surgeon
"what are we if we don't try to help others? we are nothing. nothing at all." - http://www.theenglishsurgeon.com/
12.4.10
funk
some days i wake up and, after downing that first coffee to open my eyes, halfway through the morning routine, i catch myself - why am i even bothering with this? it's not like ive been getting a kick out of life lately. working nights suck. and when im not working, im supposed to be studying for this exam that, at eleven months away, seem more bogeyman than deadline. what's more, after the nice, principles-based, practical specialty of respiratory medicine, we're up to infectious diseases. is there a fluffier, more waffly subject? what causes fever and rash in a fifty-nine year old man? oh i dont know - theres only about seventeen gazillion. maybe his wife just caught him ogling their seventeen year old neighbour. who cares?
its generally at this point i try to console myself: what else would i rather be doing? but i quickly realise that this is a dangerous and seductive question: do you want the whole list or just the top three? no, perhaps what i mean is: what else should i be doing? but once again that wont do (see the entry on 21.3.10). it's just hopeless. am i doing this exam because it's what im supposed to do? am i doing it because i dont know what else to do? i used to laugh condescendingly at my friends who i felt were doing exactly these things. whos laughing now? *choke*
i went to donate blood again the other day and found that i've put on ten kilos since we finished travelling fourteen months ago. ridiculous. mum thinks its because of all the beer that im drinking. the truth is im drinking less beer. its the lack of activity and eating out of boredom thats doing it. picture this - jabba the hutt in a "i heart ny" hoodie, with potato chip stains around his lips, slouching in front of his macbook, alt-tabbing between wikipedia and the same question on parvovirus b19 for the last three hours. this is not a joke.
what is a joke, a really bad one, is my entire existence. o woe is me, to have seen what i have seen, see what i see!
you'd want to cry too if you've just spent forty minutes learning about secondary syphilis (Lali Chetwynd, An Evening with Jabba the Hut, 2004, http://www.gasworks.org.uk/)
its generally at this point i try to console myself: what else would i rather be doing? but i quickly realise that this is a dangerous and seductive question: do you want the whole list or just the top three? no, perhaps what i mean is: what else should i be doing? but once again that wont do (see the entry on 21.3.10). it's just hopeless. am i doing this exam because it's what im supposed to do? am i doing it because i dont know what else to do? i used to laugh condescendingly at my friends who i felt were doing exactly these things. whos laughing now? *choke*
i went to donate blood again the other day and found that i've put on ten kilos since we finished travelling fourteen months ago. ridiculous. mum thinks its because of all the beer that im drinking. the truth is im drinking less beer. its the lack of activity and eating out of boredom thats doing it. picture this - jabba the hutt in a "i heart ny" hoodie, with potato chip stains around his lips, slouching in front of his macbook, alt-tabbing between wikipedia and the same question on parvovirus b19 for the last three hours. this is not a joke.
what is a joke, a really bad one, is my entire existence. o woe is me, to have seen what i have seen, see what i see!
you'd want to cry too if you've just spent forty minutes learning about secondary syphilis (Lali Chetwynd, An Evening with Jabba the Hut, 2004, http://www.gasworks.org.uk/)
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