Thursday, October 31, 2013

Missed

The woman is young, from one of the lower social demographics, and comes in with painless PV bleeding. I think it seems fair to call it 'torrential' loss, seeing the towels she has soaked by the time that she comes into the department, but it is all without any discomfort at all, and abating even as I conduct my workup. I've met this one before and she has been impeccably polite, so I treat her as gently as I can.

Given that we can't for logistical reasons get a urine BHCG from her, I take blood and send it off for the serum values, quietly hoping that the number comes back zero, so that she, and I, can get on with our lives. I talk her through my deductive process, go and work up another patient, and keep a watchful eye on her from the desk.

The value returns as about 18000. I inform her quietly of her unexpected pregnancy, likely already dying, and call up the gynae RMO.

I am a little surprised by how things turn out after this, but even writing with the cold clarity of hindsight, I can rationalise nearly everything that happens subsequently.

Rather than admit the woman, the RMO organises an outpatient ultrasound for the next day. I suppose at this point, we are both looking at a haemodynamically intact individual with the question 'where is this going?' on our minds. The case looks like an inevitable abortion rather than an ectopic, although we have not conclusively ruled out the possibility, but the woman looks stable, her bleeding is settling and she has no pain. There is an exit plan; she doesn't need a bed overnight for a simple scan.

She goes home with her partner given careful advice about what to look out for. I inform my consultant of the slightly unusual outcome, and find myself shrivelling inside under his quizzical expression. You should have scanned this yourself, he points out. Under the tide of withering self doubt, I had not thought to do so, as ever obeisant to the opinion of our 'specialty' colleagues. Always the servile, still.

I sleep restlessly that night. It only occurs to me two days later why that should be, the scars from my personal life as ever bleeding into the professional domain. I go in anyway, with a dark pall settling quietly over the world.

The consultant from the night before finds me in resusc and shakes his head at me. My heart sinks just a little lower into my tightened chest. He turns away momentarily to find the ultrasound report from our lady and I have enough time to choke back the doubt with as neutral an expression as I can muster.

There is a live pregnancy in the uterus. It is embedded within the caesarean section scar she has  received from previous parturition. Which, to my horror, makes this an ectopic pregnancy, of sorts. It has to be removed. The consultant replaces his expression of concerned disapproval with one of concerned and sincere disappointment, and I feel something small inside me die as well.

"What are you thinking?" he asks.

"I need to mull." I reply, wondering how I ever managed to make it this far. I need to leave. There is not enough air in the room. Charlatan. Charlatan. Charlatan.

He wanders with me to the other side of the department, advising about the serum values and LMP dates where scanning this myself would become a useful exercise. I'm listening half heartedly as the vortex opens up. She's sitting watching me from an open curtain as I walk into the lower acuity side of the ED. The consultant leaves me to it.

"I've heard what happened. I'm sorry." I tell her.

To my intense dismay, she brushes off the comment. Not your fault, she says. You treated me really well. You're the best doctor I've ever met.

She points to a poster on the wall and suggests that I should be nominated for employee of the year, focussing on the few kind words and the time I spent, rather than the fact that in this instance, I got it glaringly, painfully wrong. Such kindness in the face of failure.

Thank you, she says, again. Thank you.

I walk back to to TC, with my head low, and the same word going through my head over and over and over, like mantra.

Charlatan.


Monday, August 14, 2006

This heart

This heart is heavy this morning.

I've been on my new rota on A&E for a week. It's night 5 of 7, and these are pretty relentless. That's not to say that I'm not entirely in love with the job; despite all the dross - and I suspect that this blog will become full of stories of the inane - I do like the hustle, the autonomy and the idea that I'm actually fixing something.

I'm looking at a new card in the incoming box. 29 year old asian with chest pain. I'm inclined to think this is going to be a pneumonia, but I look at the ECG anyway. I'm not sure why this is; but for a moment my eye is drawn lazily to the 'nil acute' scrawled across the top. Then to the floird ST elevation in one lead.

I walk over to the patient, who looks tired, but OK, and take a history. It's a pretty classical description of ACS, the central chest pain, the hand splayed over the neck and the shoulder, the nausea, shortness of breath, the dizziness. He's been woken from sleep.

I believe him and do a Troponin, mildly worried.

The trop comes back 12 minutes later, and I rub my eyes incredulously. >2.0 ng/ml. "Massive cardiac damage."

I'm not sure how to tell him he is having a heart attack.

A half hour later, he is already half way through his streptokinase, and I'm warmed that I have contributed to saving his life. But there's a cold shadow to the words scribbled hastily on his ECG in a moment of oversight a good two hours before I ever knew of his existence.

A little part of me feels like Segun; can we ever slip for a moment again? And like my patient, I'm shuddering.

Tuesday, May 02, 2006

Anti-natal

I'm not saying I am, per se. I'm just curious as to how different mothers can be when they walk into my consulting room this clinic.

The first looks stressed from the moment she scowls her way into the room, blanking my smile and invitation to use my first name (and suddenly I realise why Nikki hates giving patients that degree of famliarity.) She has a clinically impalpable inguinal hernia and wants to know what I am going to do about it. I'm relieved it's a surgical problem rather than a difficult obstetric one.

I explain the limited options as carefully as I can, and I have to admit I'm pleased by my own forthrightness and lucidity. Maybe this is the slow release of carbohydrates from my cheesy potato waffles this morning; but I'm not sure.

"So are you going to fob me off with paracetamol?"

"Primum Non Nocere" I tell her. Anything else would cause harm to her and her unborn child, so I accept it may not seem like much, but it's what's best. "It's a fantastic drug" I confide, just stopping short of telling her that I actually think it's one of the world's unsung miracles. I don't think she'd care anyway.

"It's not an anti-inflammatory" she scoffs.

"It's a COX-3 selective inhibitor" I tell her, and the rest of the spiel. I'm puzzled why she should want to out-opinion me, like it's some sort of silly competition. But wowed by this bit of science, she seems to deflate a little.

I try and explain exactly why there is no simple solution to this for the next five weeks. And as I reflect woefully that the whole service has become a demand-led service provision for the pushy, I hear her demand the registrar's opinion as well. A little sigh and trickle onto my next patient. (For the record, the registrar backs me up entirely. But there you go.)

I have been describing to N over the weekend how beautiful and otherworldly expectant mothers seem - that sort of purity of purpose missing from the rest of us mere mortals. The next patient walks in with a furrowed brow as well, but she looks absolutely radiant with it, and I feel a little more Quakerly again.

She wants to know about IOL; suffering with SPD. Suffering horribly with SPD, actually. This is one patient where a sympathetic ear does help slightly, and we chat through prostin, and ARM, and the one hour wait, before I work out with Miss Street's help that the risk of C-section is about 30%. I advise her against the IOL and actually, she's happy with that.

Pain seems that much more endurable with that inimitable purity of purpose. She smiles as she leaves, and I feel a whole lot better for it.

Sunday, April 30, 2006

Inflammation

I wonder if it's my quakerism that means I don't bite people's heads off, or the fact that I don't bite which makes me a quaker. Whatever the causality behind the issue, it isn't always a good thing, it seems.

I'm on the wards, moaning gently about the fact that someone has bleeped me and the phone is engaged when I ring back literally three seconds later. A few moments after that, my reg's bleep goes off too. Same number. She rolls her eyes good-naturedly and I go back to my slightly ill tempered whining. No big deal in that, I think, except one midwife makes a point of it and scowls. 'Pugnacious' I note to myself, and leave it at that, though I'm a little irritated by her reaction.

Maybe five minutes later, a gentleman at the front desk pipes up. I'm scrawling in some notes about axillary tails. An interesting story there which may have to wait for another time.

"I have to say, this is the most unfriendly hospital I've ever seen. It's ridiculous."

He looks tired and grumpy. I'm wondering whether I should lend him an ear; but pugilist gets there first.

I think it's she who makes the allegation that he's being rude and hostile first. Technically, of course, he is: but then so would any person who has travelled from London only to find his daughter has gone into SROM and he's not allowed to visit 'out of hours'. I'm watching the midwife carefully. She scowls at him like she had at me, then makes some defensive comment before he has got his vent out of his system. Then I watch him - as his he gets edgier and louder to make himself heard over her crossed-arm deafness.

Another midwife stands next to pugilist, and reinforces that they don't have to take this abuse, that he's being hostile and confrontational. I'm a little puzzled as to exactly how this is supposed to help, and as if on cue, he reports back "I AM NOT!"

I stand up and smile. "Hello sir. I'm the Dr on duty today. Can I help?"

I do what any quaker (or any midwife) should do, using the only organ that matters in these situations; the humble ear. It's obvious he's cranky. He sees it too, it's bloody obvious.

"You can understand we have to be constistent - we can't have different rules for different people." He agrees softly, given that I have just agreed with him that the hospital is impossible to find in the Reading one-way system. It is! Did I not get knocked off my bike on that same interminable system when I came here for interview so long ago?

We're chatting more softly when the report comes back that his daughter is not on the ward. He looks irritated again and I look at my work to see whether it can wait a moment; it can. So I offer to help, with that vague echo at the back of the mind that helping the pushy and the irate perhaps lends itself to outrageous abuse of the system. But I do feel for this chap, so I do the courteous minimum to help him and he goes on his way.

So worried am I about Pugilist by now that I speak to the nurse in charge: she needs to be softer. I leave it at that; the bureaucracy serves less than a kind word might, so I'll let him pass that on. A droplet of human kindness? I don't know.

Colleague comes up later to inform me I had undermined them both.

On thinking about it later, I did, yes. And in all honesty, given the poor outcome their particular method was leading to, I would do it again, too: when a grave error is being made, you step in. I just wonder - as I hear later, third hand, that she was 'quaking in her boots' - whether next time she will be a little softer, a little gentler, a little kinder. And a little less angry at me.

The quaker in me is a little subdued right now. Frankly, I doubt it.

Wednesday, April 26, 2006

Matching the Technology

I've just had a brilliant 'oncology for non-oncologists' lecture from Dr Alice Freebairn. Lots of juicy numbers to remember, some curious facts, a lot of insightful and touching anecdote. I liked it a lot.

For instance:

4 Gray would likely kill me. But she'd happily fire 66 at my oesophagus.
We have 30k new cases of Lung Ca a year now.
Br Ca is the commonest Ca in women, but they're more likely to die of lung Ca. (The old incindence/mortality chestnut answered at last!)

But she says one sentence that will stay with me for a long time:

"I like my job, because I get do do an awful lot. But with 6 patients and the same pathology, you'll have six different treatments. My job is to match the technology with the human being sitting in front of me."

One day, hopefully, I'll have the knowledge to say the same.

Like Putty

I've just realised I love pre-clerking. I know this is a confession of the magnitude that immediately ostracizes people from civilisation, but there you are.

Today's magical finding has Peutz-Jegher's syndrome, though it doesn't twig for a moment. I'm quietly fascinated by the freckling on her buccal mucosa, but shy just clear of documenting it mentally as telangectasia. My silly reservations; as soon as she has talked about GI polyps, I know exactly what her diagnosis is, and a little skip of the myocardium when she mutters its name a second later. Hurrah!

I didn't ask her explicitly about neurology, but there isn't time for that anyway: I get the rest. Christina assures me that the facial haemangiomas have a larger incidence of intracranial extension with neurology when I go and babble excitedly later to her later. But it's obvious that she's OK from this point of view.

The patient and I natter away happily for a while and I fit my pre-clerking around our conversation. She leaves grinning, smiles happily. And as she does, I look at her delicately marbled lips, her freckled hands and find myself curiously elated that everyone I meet is so touchingly, marvellously unique.

Tuesday, April 18, 2006

Poking stuff

I'm surprised how different theatre etiquette feels in gynae. Perhaps this is because, unfamiliar with the new environment, I find myself a little on edge. I'm not sure.

Thankfully, Roddy is one of those characters who seems to understand the paucity of training opportunities these days, and seems willing to let me try my hand: tentatively.

First up, the 'lap' steri in the woman so morbidly obese that the allowed insufflation pressures are not enough to move her anterior abdominal wall out of the way of her bowel. He struggles for a while before calling the shot and moving over to a mini laparotomy. I'm not sure why, but the gynae people use a transverse abdominal incision - and when I think about it, Mr R-S has advocated exactly the same thing to me, saying it led to full access of the abdomen. I wfeel the need to find out about the different access techniques.

I get to do my first cystoscopy; and shamefully for such a keen photographer, I'm baffled by the wide angle on the scope, never quite getting a full view. Sigh.

The hysteroscopy and mirena insertion throws up only an interesting point about the diagnosis of DUB; which I realise I'm going to have to find out about.

Final thing, get to see some vault repairs and a vag-hyst; amazing stuff, that validates the old joke about the car mechanic.

Not quite as fast as general surgery, I would say, but more than confirms my feeling that I need to prosect for a few months to get a handle on things.

And not to get fat, of course.

Tuesday, March 28, 2006

More cutting

I wonder why it has taken me so long to write again. Things haven't been particularly busy apart from my readmissions audit. Ah, no, I was on nights. Funny how you forget that.

Leave Tom partly in the lurch and come up to theatre and do three appendicectomies in a row. Two of the patients are anxious young women, which is perfect; unlikey to be appendicitis in all truth, perfectly preserved anatomy and the opportunity to learn in a situation where you can't really go without an operation but aren't surprised when there's nothing there. There isn't, of course.

The chap is a different matter, with anm awful matted appendix, friable, screaming to fall apart and a caecum which staunchly refuses to be delivered through the incision. Alex takes over, crimps the stump and ligates it, then worries about the mesoappendix. It makes life a lot easier, this odd twist.

I'm sitting here wondering if it right that I should practice my skills on people like this. But then I think if I don't, what hope in years to come?

Primum Non Nocere. I'll have to think hard about that.