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 he is withdrawn and rarely engages.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...

bitch and moan

when im with others i feel irritated. yet when im finally alone im bored. listless, i turn to comfort food. then i feel bad for eating junk. it never ends. o my empty, meaningless existence.

there is only work. how sad.

bethlehem

its more aged care than palliative care, and its not ballarat. the cafeteria is horrible and the ward smells. but hey what does it matter - im back doing what i love.

cute frail oldies with their squeaky voices and grumpy ways. fixated family members and div two nursing staff (soooo different from icu). trying to cut through the crap and find practical solutions, always frustrating yet somehow so satisfying when it works (like nothing else ive done). continuity of care! working in a multi-disciplinary team! reasonable working hours! what a blast!

and it's a lot easier now - i have an intern! other doctors don't try to bullshit me because im a "registrar"! what a laugh. im still the same. yet everything is different somehow.

at least my coffee consumption has decreased. thats got to be a good thing.

i see you

these are scary times.

it's like being a brand new intern again. i print the patient lists in the morning, write in their notes during ward rounds, buy coffee for the team afterwards; i try to laugh at my boss's jokes (it's a bit difficult with the irish accent), try to guess the correct answer to their questions and inevitably get it wrong; and try not to kill anybody. the nurses know far more than i will ever know about everything that scare me: ventilators, haemofilters, and all the other machines that beep incessantly. and when they do (beep), i sneak out of the cubicle quickly, making sure that no one notices, and pray the patient doesn't die before someone else hears the beeping comes to their rescue.

it's great working in a team, partly because i get free coffee, but mostly because it means i don't have to make any decisions. i write what they tell me to write. the registrars are patient and explain everything to me. everyday i go home with a learning list as long as my arm and yet i continue to feel incredibly stupid at the beginning of the next day. in trauma icu everyone has about twenty acute problems. it's so hard to remember who has what injuries: (hang on, didn't we stop vanc on the guy with pseudomonas sepsis? - oh, but there are three guys with pseudomonas sepsis and they're all on different antibiotics regimens).

as well as regressing to my medical student befuddlement, working in trauma has had another effect on my mental state. my daily walks to and from work now fill me with anxiety. i had no idea that so many road accidents take place on melbourne roads. truck versus car. car versus tree, tree versus bike. bike versus pedestrian. so many non-survivable brain injuries. so many organ donations...

i guess it could be worse. at least i am still dreaming...