Sunday, 8 March 2009

Made his own bed to lie in

I was just browsing some of the things I've written when I found this post from last year...


I answer my pager and listen to what Tal, the orthopaedic surgeon, says to me down the phone. I sit on the intensive care unit (ICU) and my heart sinks a little as he explains the story. It’s 3 a.m. on my third night on the trot and, to be honest, I’d been semi-expecting a call like this at some point. I sigh and tell the surgeon that I’ll be down to A&E soon. As I leave ICU, I scoop up some drugs and let the ward sister know where I’m heading. She rolls her eyes as I tell her what’s going on. “I know.” I respond, “I just don’t understand what some people do for kicks.”

I take a stroll down to A&E through the empty corridors of the hospital. My clogs create a faint echo with every step I take. I have a few moments to think about what I’m about to see and have to deal with and I surprise myself a little. You see, the main emotion I’m experiencing is not fear or excitement and it’s not sympathy or concern. It’s irritation. I’m annoyed by the situation that I’m being called to help sort out. I know that I took an oath to “make my patients my first concern,” but, despite myself, already I’m thinking that the man I’m about to meet in A&E is a bit of a dick.

A&E is busy, which is not surprising seeing as it’s Friday night, and as I wander through the department looking for Tal, I spy my punter. To be honest, I hear him before I see him. He’s shouting, he’s obviously in an awful lot of pain and he’s obviously very, very drunk.

Tal is in the doctors’ office scribbling some notes and he looks up at me as a walk in.
“The guy round the corner?” I ask, somewhat rhetorically.
“Yeah, sorry about this,” Tal replies. “He’s had 10mg of morphine from the paramedics, I gave him another 10 before I called you, he’s got some Entonox, but as you can hear, he’s still in agony.”
“Hmmm,” I grunt. “And his injuries are where, exactly?”
“Well, he’s lost two fingers and has a deep laceration going across his whole palm.”
“So, all three nerves then?” I enquire, referring to the three nerves that supply the hand: the median, the radial and the ulnar.
“Yeah, we haven’t dressed the wound yet, so you can look for yourself.”
“Cheers,” I say and smile at Tal. I can tell that he’s just as unimpressed with the situation as I am. I think there’s a bond that develops between hospital workers when you have to deal with situations like this in the middle of the night. “Tell me again, what happened to this guy.”
“Well, he says he got into an argument and thought it would be a good idea to light a firework and throw it at the other guy.”
“As you do…”
Tal laughs dryly, “As you do. Anyway, the firework goes off, the flames scorch his hand and then it explodes and blows his fingers off.”
I picture the scene in my head, it’s like something from a cartoon. It would be pretty comical if it hadn’t ended up with the guy in hospital “Why on earth did he think that throwing fireworks would be a good idea?”
Tal shakes his head. “I don’t know, I didn’t go into it. To be honest, he’s so pissed that it’s hard to get any sense out of him at all.”
“What’s his name again?”
“OK, I’ll go see what I can do.”

Simon is sitting on a trolley with his girlfriend and his Dad next to him. The two of them are sober and obviously really worried. Simon, on the other hand, is not. He’s totally off his face and is singing a Girls Aloud song between cries of pain. I introduce myself, but Simon’s not really paying any attention to me.
“It hurts! It hurts!” he yelps
“Of course it hurts,” I say. “I’m going to give you a couple of injections to help with the pain. They sting a bit when they go in, but it won’t be anywhere near as band as your injury.”
“It’s killing me!”
“Keep using your Entonox, I’ll be back in a minute.” I go off and find a syringe, some chlorhexidine and a small needle. I return to Simon’s trolley and tell him, “Right, I need to take a look at this.”
“I don’t want to see it!” he yelps.
“I need to see what I’m doing.” I respond, firmly. “If you don’t want to see it, close your eyes.” Simon keeps his eyes open and stares intently at what I’m doing. I shrug.

I remove the Incopad that Tal had put over Simon’s had and had a look at his injuries. Simon has lost all the skin and flesh from his middle and ring fingers leaving just the bones sticking out like something from a grotesque film. His little finger was missing altogether and a wide, deep gash ran from where his little finger should have been to the base of his thumb revealing the tendons underneath. It looked horrific. It was horrific.

“Aaargh!” yelps Simon as he catches sight of his mangled hand again. I ignore him and set about cleaning his wrist the best I can.
Simon starts to laugh. “Look at that!” he says as he lifts up his hand. He starts moving his fingers and the visible bones start to flex and bend. It’s a really surreal effect, it looks like something from a horror film. “Ha ha ha ha ha!” comes Simon’s laugh. “I bet you’ve not seen anything like this before, have you doctor?” He’s right, I haven’t. He jabs the skinless bones of his middle finger in my direction. “I bet you’ll always remember me now! Ha ha ha ha ha!”
“Simon! Pack it in! Behave yourself!” comes the sharp, reprimanding voice of his girlfriend. I look up at her and she looks really green.
“Are you OK?” I ask.
She nods. “Do you want to have a seat or maybe get a cup of coffee while I do this?”
“No, I’ll be OK, I want to stay with him.”
I turn back to Simon. He’s not really behaving like someone who, in all probability is about to lose is hand. I shrug. It’s most likely the effects of the morphine, the Entonox (a.k.a. “laughing gas”) and, most of all, the vast amounts of alcohol he’d consumed earlier in the evening.
“Put your hand down and keep still.” I tell him.
By now, Tal had come in as well because he wants to see how I do the nerve block. I talk Tal through what I’m doing, the landmarks I’m using to try and identify each of the three nerves and tell him what dose of Bupivicaine I’m using in each place.
“Right, that’s done now.” I tell Simon. “It’ll take about 20 minutes to start to work, so it the meantime, keep using the gas.”
“Will what you’ve done take the pain away?” asks Simon’s Dad.
I shake my head. “No, it’ll make the pain much less severe, but it won’t take it away completely.”
“What’s going to happen now?”
I look at Tal and he starts to explain the next steps to Simon’s Dad.

I leave them to it and go and jot down what I’ve done in Simon’s notes. My attitude towards Simon has changed since I first took the call from Tal. I still feel annoyed by him and what he’s done to himself, but now I see that how I feel about it is really not relevant to anything at all. This guy’s just lost most of his hand. When he sobers up in the morning, this realisation will hit home. There’s no point in me thinking about what a dick he’s been because every day for the rest of his life, Simon will have to live with his injuries. He’ll have to learn to write all over again, to dress himself to open jars, to do all the simple little things that we all take for granted. Every day, he’ll look down at his hand and he’ll think to himself “Why the hell did I pick up that firework that night? Why was I such a twat?”

Simon’s made his own bed to lie in and he’ll have to face up to that soon enough, my personal feelings towards him is neither here nor there. You see, I can walk away from the situation and not have to deal with it anymore, Simon doesn’t have that option.

I sincerely wish him all the best.


Exdoc said...

Great post. Any follow up? Were they able to save any of his hand? How was he when he sobered up?

Hospital Lab Tech said...

I think it can be very difficult sometimes to maintain professionalism when dealing with pillocks or the scum of society.

I remember years and years ago (before everybody had mobile phones, it was THAT long ago!) I was dealing with a massive 'traffic collision' (as I believe I'm supposed to call them now).

There was a drunk driver, a motorcyclist and a child pedestrian involved. The child had come off best (with just broken bones) but he needed to go for urgent orthopaedic surgery and blood was required. The motorcyclist was pretty bad with the handlebars going straight through his brachial artery - so he was bleeding profusely. But worst of the bunch was the drunk driver who had massive internal injuries (if my memory serves me right he had ruptured his liver because he wasn't wearing his seatbelt and he got half thrown through the windscreen when the airbag opened straight into his abdomen) and his blood loss was huge.

As I said, this was pre mobile phone days and it was a sunny bank holiday Monday afternoon. Switchboard kindly rang all my colleagues at home to try to get someone to come in and help me, but they were all out (as is their right of course!!).

I can only logistically deal with 1 bleed at a time. Two together is really difficult and there is a huge risk of error. As for three, I didn't have a hope.

Your heart tells you to deal with the innocent child first, but clinically, the one who needed the most urgent attention was the drunk driver.

I found it sickening enough to delay the child and motorcyclist in favour of some arsehole who's too arrogant to get a cab or drink coke - but quite how the staff on the frontline managed it, I'll never know.

Thankfully, all made a good recovery and I lost about half a stone from the stress! (Another example when nobody said thanks though...)

Dr Michael Anderson said...

I occasionally think about how Simon is getting on these days. He had a couple of operations by both the orthopaedic team and by the plastic surgeons and he lost most of his hand.

I didn't see him after he'd sobered up but by now he should have finished rehab etc and be leading as normal a life as he can.

I wonder what else he lost. His job? His girlfriend? Who knows?

rosiero said...

I can imagine your irritation, but ultimately he is a case like any other. You just have to detach yourself from the reasons that lead them to be there. I am sure it can't be easy though.

Susanne said...

Reading this sent a shiver down my spine - it's like a blast from the past, exactly what happened to my Dad. Only that he was 14 at the time and not drunk. I can imagine how difficult it must be to remain professional when dealing with somebody who stupidly caused so much injury and massive future implications to himself. I really hope he's doing ok.

Anonymous said...

I cannot believe that an unsupervised ST2-level trainee would attempt peripheral nerve blocks, on an acutely-injured patient, who is intoxicated.

As a experienced consultant anaesthetist and intensivist, with a major interest in trauma, I am appauled at your management of this patient.

Did you even consider discussing this with your supervising consultant? How many of these procedures have you performed in the past?

Have you any idea how ill-considered your actions were?

Anonymous said...

I’ve just heard about this thread. Are you for real?

Please tell me that you’re a fantasist making this up?

Are you seriously telling us that an orthopaedic SpR covered an open wound with an Incopad? Incopads are unsterile by the way. Simon needed urgent debridement. Why did you delay taking him to theatre, compromising his hand, just to show off, attempting nerve blocks?

Lets just make it clear that regional anaesthesia is completed contraindicated in the scenario that you describe. Analgesia for surgery involving the hand would best be achieved using a brachial plexus block. Most of the anaesthetists in my unit would use ultrasound, and/or peripheral nerve stimulation, to improve the accuracy of regional blocks. You used anatomical landmarks. How interesting. Obviously the consultants at my trust aren’t up to your standard.

The correct management of this case would involve a proper ATLS assessment for (the inevitable) associated injuries, followed by emergency surgery. Delaying surgery will jeopardise tissue viability. I’ve never seen an anaesthetist perform regional blocks for acute upper limb injuries. I would not allow any anaesthetist to perform blocks on one of my patients at risk of compartment syndrome (as this man was). If this patient sued you for nerve injury, associated with your block, how could you defend performing a block on a patient who was intoxicated?

Either you’re a complete fantasist, wrapped up with your sense of self importance, or you are seriously dangerous.

I’ve just checked your name on the GMC search engine. Most of the people matching the name you use (on this blog) qualified in the seventies and are unlikely to be working as junior anaesthetists. The two that qualified more recently are either on the specialist register or GP registers.

What hospital do you work in?

Anonymous said...

Take a chill pill, Anonymous 2 Michael doesn't use his real name, presumably to stop outraged people like you from hunting him down.

Looks like Anonymous 1 put Anonymous 2 onto the blog. Will there be another outraged doctor here soon?

Dr Michael Anderson said...

Good grief, Anon 1 and anon 2 - you need to calm down.

I think you've both got the wrong end of the stick. I wasn't "delaying surgery" or "showing off," just trying to help the patient in front of me. I didn't write all the facts around this because they weren't relevant to the point of my post but for your information, I'll include a bit more detail.

I take it that you both work in big hospitals, well I work in a small DGH and this patient was awaiting a transfer to TheBigTeachingHospitalDownTheRoad where he could receive definitive care (joint plastics/ortho). Transport was already booked by the time I arrived.

This block was for analgaesia, not anaesthesia (for the non-medics I mean I was attempting to relieve his pain, not give him a nerve block so he can have surgery). My aim was to give the orthopod a fighting change of cleaning and dressing the wound while we waited for the transfer ambulance to arrive, NOT analgaesia for surgery.

Obviously, he already had significant "nerve damage" because he'd blown most of his hand off, so I doubt my wrist block would have made it any worse.

He was screaming in pain and wouldn't let anyone touch his hand despite all the alcohol and 20mg morphine. He awaiting an ambulance transfer (with a paramedic crew) and was unlikely to get to theatres at the other hospital for another 2 hours minimum (most likely 5 or 6), so I attempted a nerve block so he can have his wounds dressed properly and to make him more comfortable. The block would have probably worn off by the time he realistically hit theatres anyway.

As for you assertation that "Lets just make it clear that regional anaesthesia is completed (sic)contraindicated in the scenario that you describe." Could I point you towards Pinnock's Fundamentals of regional anaesthesia.

Look, maybe you're right, maybe I made a bad decision (I'm going to post about decision-making soon), maybe I should have done nothing, leaving him in great pain for several more hours with an undressed open wound or I should have told the orthopod to give more morphine, risking respiratory depression on his (paramedic only) transfer. I did what I thought was best for the patient in front of me at the time. What would you have done?

You can believe I'm a "fantasist" if you like (bloggers quickly learn not to take anonymous abuse over the internet seriously), but a wise man once told me to forstall making judgements until you are in posession of all the facts.

Dr Michael Anderson is my pseudonym, any resemblance to real people is purely co-incidental.