Exploratory Laparotomy of Doom
FS is sick. The sort of sick that makes me want to rush for the tea pot and pour a sympathy brew for him for lack of any other real ideas; but when I do manage to get a syringe into his hardly pumping right radial artery (Allen's test only just acceptable as I later document) he comes back with the result I don't want to smell; Lactate 7.7.
"Yep, 7.7" I say to the ITU outreach person, who gets down panting about three and a half minutes later with not one, but two anaesthetists in tow. Mr FS is looking a tired, mottled lump in the corner and hyperventilating harshly while the HCA fusses over his bead linen, completely oblivious to the gravity of his condition.
I learn a lesson about belief in my own clinical acumen today. It's an isolated result, this rising lactate, with no obvious septic focus. Something acute has clealy occurred to drive it up from a normal value 48 hours earlier. But what? It's not clear looking at his abdomen that this is it; diffusely tender, but not, I convince myself, peritonitic.
For whatever reason, the registrar differs over this point, which alters the management utterly. Rather than being a candidate for a scan, he's prepped for an emergency laparotomy. The anaethetists float upstairs with that languid pre-theatre expression that they have mastered over time, and I float off to do more on call jobs.
The laparotomy is negative. Dilated small bowel loops, certainly, and I think mottled but not seriously so. A little bloodstained ascites. The anaesthetist looks brightly over the drapes about a half hour in, omentum and guts pouring out of a midline incision, and declares nonchalently that the lactate has returned to a normal value. The registrar looks like he has swallowed a jellyfish.
An unecessary procedure for a critically ill man? We'll never know. But I suspect that he might have done with some judicious resuscitation and observation rather than diving in, especially when the clinical signs were so contrivertible.
Do you catch these patients early? Do you act on your - no pun intended - gut instinct and catch them before things go down hill? Or run the gauntlet and risk a normal laparotomy? I suppose I'll have to wait until I'm a reg to know with any semi-certainty. But today I have a little more faith in my own ability to assess an abdomen.
Some small consolation, if not for poor FS, in that, perhaps.
"Yep, 7.7" I say to the ITU outreach person, who gets down panting about three and a half minutes later with not one, but two anaesthetists in tow. Mr FS is looking a tired, mottled lump in the corner and hyperventilating harshly while the HCA fusses over his bead linen, completely oblivious to the gravity of his condition.
I learn a lesson about belief in my own clinical acumen today. It's an isolated result, this rising lactate, with no obvious septic focus. Something acute has clealy occurred to drive it up from a normal value 48 hours earlier. But what? It's not clear looking at his abdomen that this is it; diffusely tender, but not, I convince myself, peritonitic.
For whatever reason, the registrar differs over this point, which alters the management utterly. Rather than being a candidate for a scan, he's prepped for an emergency laparotomy. The anaethetists float upstairs with that languid pre-theatre expression that they have mastered over time, and I float off to do more on call jobs.
The laparotomy is negative. Dilated small bowel loops, certainly, and I think mottled but not seriously so. A little bloodstained ascites. The anaesthetist looks brightly over the drapes about a half hour in, omentum and guts pouring out of a midline incision, and declares nonchalently that the lactate has returned to a normal value. The registrar looks like he has swallowed a jellyfish.
An unecessary procedure for a critically ill man? We'll never know. But I suspect that he might have done with some judicious resuscitation and observation rather than diving in, especially when the clinical signs were so contrivertible.
Do you catch these patients early? Do you act on your - no pun intended - gut instinct and catch them before things go down hill? Or run the gauntlet and risk a normal laparotomy? I suppose I'll have to wait until I'm a reg to know with any semi-certainty. But today I have a little more faith in my own ability to assess an abdomen.
Some small consolation, if not for poor FS, in that, perhaps.
posted by Bas at 10:07 AM
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