working at the pointy end

•December 13, 2007 • 4 Comments

Sorry about the delay in writing, I’ve been trying to get a job back in Ireland to go over and see Miss GreenEyes and have had to present a paper at a conference, which has taken the majority of my time recently…

————————— 

I haven’t been able to write about this for a while because it has been in the media here in recent times. Some things also take a bit of time to put into perspective as well.

Seeing horrible things now and then is part-and-parcel with working in the Emergency Dept. but in an adult ED it is often easier to put things into context, believe that the person somehow deserved what happened to them – you know, ‘sure they were speeding’ or ‘no doubt they were involved in drugs too’, that sort of thing. It’s a bit different when it’s a child; as I found out. I was sitting in the corridor chatting to a little patient who had hurt their finger when one of the nurses walked past quickly.

‘Ben we have a trauma coming in.’

‘Oh, ok’ (rare in itself in a Paediatric department) ‘What is it?’

She just gave a grim little smile and kept walking.

‘How long till they’re here?’ I asked to her retreating back.

’10 minutes.’

I wandered into resus after apologising to the sore finger kiddy that it may be a little while till I get back to them. The nurses and my boss were already in there priming intravenous fluids and writing details on the board about the child’s assumed weight, drug dosages, equipment sizes.etc This usually indicates something a little more serious than falling off one’s bicycle.

‘Er, what’s coming in?’

’2 year-old, multiple stab wounds’

My heart sank. This doesn’t happen often at all.

As per normal, we set the room up and waited until they arrived. The double doors into resus looked out along the corridor to the waiting room where the other patients could look in, only to see a bunch of people standing around all gloved and gowned. The last thing they saw before we slammed the doors shut, was a little bloody body being rushed from the ambulance into the resus room.

She was so very small and covered in blood - the metallic smell quickly filling the room. Her little head was bruised and bloody, there were stab wounds over her neck and chest, but she was conscious, breathing well and stable which was an ideal starting point. She had IV lines inserted, fluids started and the surgeons attended promptly. When we looked her over, she was not only stabbed but also beaten soundly. Four stab wounds in the head, three in the neck, one on the front of her chest and another five in her back. There was a big boot mark on her arm.

We found out that her estranged father had come to the family home and attacked her and her mother. She had obviously been shielded somewhat by her mother who was also horribly injured in the attack. We ended up ventilating her on life support and performed CAT scans looking for internal injuries.

Mercifully, her wounds were superficial and there were no severe injuries. Her mother also survived the attack relatively unscathed (physically anyway). For the next few weeks we had police and security camped in our emergency department and wanted posters of the father from his previous domestic violence arrests pinned in the doctor’s area. There was uniform fear that he would come to the hospital to try and finish the job.

He still remains at large to this day.

that final decision

•October 1, 2007 • 8 Comments

When I was in university I performed in the medical revue – sort of a skit based comedy show with a loose theme running through it. It was great to get out, ‘tread the boards’ and make a complete arse of yourself in front of classmates or future bosses. In between the skits, when the next scene was being set up they would usually do some form of ‘funny’ voice-over to keep the laughs running and ensure there wasn’t any ‘dead air’. One such voice-over occurred to me yesterday at work.

‘Cancer…Go on say it…cancer…after all, it’s just another word for growth!’

‘Brought to you by the Australian Cancer Council.’

That was it. Simple, got a few laughs, filled the short gap before I was back on for another scene. I didn’t really think too much about it from then on. In the intervening years, I’ve dealt with hundreds of patients with cancer, terminal or otherwise. It’s affected our family and still I never really thought about what it meant to have cancer; I have retained some measure of distance from the realities of the diagnosis. Until yesterday.

In St Elsewhere’s children’s A&E a large proportion of the state’s oncology patients come through our department before being admitted to the wards. We were sitting at the doctor’s desk writing notes from patients I had seen earlier, when movement caught my eye. Ambulance officers were wheeling a breathless, pale form through the department. The stereotypical bald head and pallor made me automatically think ‘ok, another Oncology patient, probably with a fever who’ll need to be started on broad-spectrum, strong antibiotics fairly quickly’. The nurses asked me to come straight in and see him. He was/is (not sure which at the time of writing to be honest) a 15 year old boy in severe respiratory distress. He had oxygen running through his mask at the highest possible rate, and his oxygen level was still dangerously low. Dad, a young, normal looking guy sat in the room. His red-rimmed eyes told me that there was probably more to the story than I anticipated.

Chatting to Dad, it seemed that he had been diagnosed with a brain tumour 10 years ago and had been treated with surgery, chemotherapy and radiotherapy since. The last few months had seen a dramatic deterioration leading to him being largely bed-bound. In the last 24 hours his breathing had become increasingly worse until he required assisted breathing from the ambulance crew that came to pick him up. I examined this 30 kilo fifteen year old. Barely a shell of a person. He could tell me that he had pain, but not much else. The tumour had paralysed the right side of his body and he was plainly exhausted with the effort of breathing. He was clearly dying. Dad asked me to step outside.

‘Ah doc, I thought I should let you know before you do anything that he’s asked me to let him die.’

I was stunned, but I suppose not surprised. His father was barely holding it together.

‘Ok, I understand. Let me chat to the Oncology team. I know they like to be informed whenever any of their patients come into hospital. Have you got anyone else coming in, is there anyone you’d like me to call?’

‘His mother’s on the way in with the other kids…Is this it?’ He looked at me searchingly

‘He’s very very sick. His breathing is laboured and his oxygen level is dangerously low. We’re giving him as much oxygen as we can at the moment and making sure that he isn’t in pain, but I’m not sure if he’ll survive. Have you and your wife discussed what you would like to do in the event that he does actually deteriorate?’

He just shook his head, looked around the room and apologised for being upset.

‘I should let you know that there are options in this situation, like placing him on life-support, on a breathing machine in the Intensive Care Unit…but I have to say, I don’t think that us putting him on the breathing machine is ultimately going to be the best for him, I don’t think it’s going to help him survive, and I don’t think it’s going to improve his quality of life.’

‘Well he hasn’t got much of that anyway…No, it’s not what he wants…’

‘Ok, I’ll make sure that we keep him as comfortable as possible.’ His dad turned and walked back into the cubicle to continue his vigil beside his panting son.

We moved him and the rest of his tearful family up to the Oncology ward. It sounds paradoxical, however the Oncology ward is a depressingly cheery place with some of the sickest children possible lying in rooms with garish murals on the walls and ‘clown doctors’ occasionally wandering around the ward doing magic tricks. I hate it. We formed some sort of sick, quasi procession led by a small broken teenager who should have been double the height and weight and anywhere but there, being followed slowly by three generations of his family.

When I last saw him, he was lying in a quiet back room of the ward barely discernable from the sheets surrounded by his family. I wonder whether they think Cancer is another word for growth?

almost home

•September 1, 2007 • 3 Comments

Apologies for the delay in sending another post. Miss GreenEyes doesn’t know that I write this blog and so it is a little unsubtle to skive off and write a brief entry whilst using her computer. At the moment, I am sitting in Singapore airport basking in the red glory that only a hot shower can bring after a 13 hour flight, so this will be brief, and probably unrewarding!

I realised that British Airways had at least one redeeming feature when we had just taken off wheels still whining up into the undercarriage, when the plummy cabin supervisor came over the intercom:

‘Ladies and gentlemen, now that we have escaped the surly bonds of Earth and completed the most dangerous part of the flight I invite you all to sit back, relax and enjoy the British Airways service…’

I have never heard of gravity referred to as a ‘surly bond’ but God-Damn I’m going to use it from now on – love the English.

Will write when I arrive home of my travels to the Emerald Isle, and the heart and hearth of Miss GreenEyes and her fellow countrymen.

brief intermission

•August 14, 2007 • 8 Comments

There’s a chance that I may not write another post for a fortnight or so. No, it’s not that my current run of night shifts is about to end, and therefore won’t have as much time to skive off at work as I do at the moment (thanks State Health and your liberal internet policy). Rather, as it turns out, the benificence of St Elsewhere’s Children’s has extended to giving me 2 weeks off! Apparently, I had kept some accrued time-in-lieu before I left for Ireland a year ago and they offered me the chance to take it. A bit of a pleasant surprise really. Consequently, I am skitting off to Ireland briefly to catch up with Miss GreenEyes and travel around the west coast. We have pretty much been in touch every day and chatting regularly and I miss her, so it seemed like an opportune time given that we have been apart for the sum total of only 6 weeks! I think I’m going soft.

Hopefully we’ll also decide on the tricky issue of what we are going to do with ourselves…Do we continue the long-distance thing, or do I drug her and drag her back to Australia?! She’s fairly set on staying in Ireland and wants me to move back there…

Advice…anyone?

names

•August 13, 2007 • Leave a Comment

I just saw a child with the name of: ‘Spentza’. I can only presume it is a loose derivation of ‘Spencer’…At least it makes a nice change from the various forms of ‘Shakira’, ‘Brittany’ (or Brittni, which seems to be becoming popular) or the ubiquitous ‘Justin’. He has a lot to answer for, no longer just his music it seems.

 But no child’s name has yet surpassed ‘Abcde’ – pronounced, you guessed it ‘ab-ke-de’. Oh the humanity.

influenza city & a change of heart

•August 10, 2007 • 5 Comments

It’s flu season again. It should be said in the manner of ‘It’s Groundhog Day’ from that great eponymous Bill Murray movie (it was great, there shall be no correspondence entered into thank-you very much). Usually that statement doesn’t mean much, maybe the potential for a bit of a runny nose, someone sneezing or coughing a little bit too much at the water-cooler, but that’s it. No big deal right? Last Thursday I was sitting at home watching the news, enjoying my last evening off before a long run of shifts in St Elsewhere’s Children’s A&E:

‘Next up on Ten news, a 4 year-old child dies of Influenza.’

My heart sank. Not only for the poor child and family, but also (and I’m ashamed to admit it) on a very selfish, base level because I knew, just knew, that my run of shifts would be hellish. The helpful health representative came on the news stating:

‘Any child who is lethargic, has a fever, cough, or maybe even diarrhoea and vomiting should go straight to the emergency department…’

Now, I’m not a parent, but as far as I am able to tell, that pretty much includes every child around. I realise they have a job to do and the symptoms of influenza are vague at best and there is no real way of predicting which child will have a horrible response to the virus, but honestly, have a heart. I got up off the couch to head out and meet some friends for dinner. Half an hour later, I received the call of dread.

‘Hi Ben, it’s so and so from the emergency dept. Ummm, we were wondering whether you might be able to come in and give us a hand?’

30 children had been brought in to the emergency department in the time between the news report finishing and the call. When there are only a few doctors on, that makes a huge difference. Since that news report we have been hammered. Every day we almost reach the all-time record for number of patients seen in the department and then we finally broke it. We are history makers now, and not in a good way. For six straight shifts I have seen children with various viral infections, all of which pretty much mimic influenza, all of which we can only treat symptomatically (don’t get me started on ‘Tamiflu’ people). It’s not to say that the parents are being silly or over cautious, they’re not. They’re acting on the information they have been given and, like any parent, are concerned. Nonetheless, it gets wearing after a while.

—————–

Anyway, during this time we almost had a death in the department, fortunately a relative rarity in the world of kids emergency medicine. Our medical emergency phone rang:

’13 month old child, status epilepticus. Fever of 40 degrees. Given 4mg of Midalzolam (a sedative drug) with no resolution.’

Hmmm, easy enough in an adult. Sadly, I am still a little bit rusty on Paediatric medicine. The last time I actually practised in a mixed adult and children’s A&E was 3 years ago. We set up the resuscitation room, preparing various medications, intravenous fluids and, if things weren’t going well, equipment to induce the child into a coma and place them on a life-support machine.

He came in with the ambulance. A little baby. I could hear his breathing before they even came through the doors. Rapid, too rapid, partially obstructed, a horrible, gut-wrenching, somewhat terrifying sound. This little mottled body was shutting down in front of us, arms pointed straight out wrists flexed towards the bed, legs stiff with toes pointing like some sick ballerina (extensor posturing to those in the know) and his back arched. He was still fitting. It’s scary enough in adults as it looks so out of control and dramatic, but in a small 13 month old baby it’s simply terrifying and a little eerie. His tearful, pale, distraught parents came into the resuscitation as well, both nurses at our hospital. They knew what was going on and how seriously their child was.

As in most emergency departments, resuscitations are a calm, controlled event. People (unless they are in over their depth) don’t yell. Things get done smoothly and quickly. This was the first paediatric resuscitation I had been involved in for a long time, so I stayed controlling the child’s airway and helping him breath. My absolute godsend of a consultant was there getting intravenous access, controlling medications and talking to the parents. There was little choice, we sedated, paralysed and then I intubated. I don’t think my hands have shaken so much in a long time.

We watched his little mottled body being wheeled off to ICU, parents in tow. The sound of the ventilator pushing air rapidy into his body faded down the corridor.

It was Influenza Type A – the same virus that had killed a 4 year old a few days before. I looked at the screen filled with patients waiting ‘Fever, Fever, Fever, Fever’ for the first time in days I didn’t begrudge the worried parents, I didn’t sigh and roll my eyes at every well child that had been brought in. I thanked my lucky stars that they had parents who cared enough to make sure.

lazarus

•July 26, 2007 • 3 Comments

I am alive, really, just esconced in the world of the little people. Hmmm, that all sounds mysterious, it’s not. I haven’t been beamed into the land of the oompa loompas or anything nearly as exciting. Why were they orange? Anyway, I digress. I’m actually heavily ensconced in St Elsewhere’s (Australia) Children’s emergency department.

 The move back to Australia was a little less traumatic than I thought, luggage vagaries aside. I’m now waiting for a home phone and importantly an internet connection, hence the delay in writing anything recently. Be assured, I will be back in the swing of things very soon with some new stories from the frontline in Paediatrics…

 
Follow

Get every new post delivered to your Inbox.