Thursday, 30 April 2009

It's that time of year again

We had one of our regular teaching sessions at TheBigTeachingHospitalDownTheRoad today. I actually quite like these afternoons, it gives us a break from the day-to-day clinical work and also allows us to meet up with junior anaesthetists from other hospitals in the region and it gives us a chance to swap stories and just have a good old-fashioned gossip.

 There was something different about it today, though. When I arrived at the Postgraduate Centre at TheBigTeachingHospitalDownTheRoad, I was surprised to see that the foyer was really packed. It was full of smartly dressed young men and women and lots of them had a glassy-eyed, haunted expression. There were several young women crying and being comforted by their friends and it took me a moment or two to figure out what on earth was going on.

 Then it hit me. Of course! It’s that time of year again.

 We don’t have medical students at my current hospital, so I’m a bit out of the loop, but I’d like to wish all the final year medical students sitting their medical finals the very best of luck. I’m thinking of you.

Wednesday, 29 April 2009

Global 'Flu Pandemic

As a doctor who spends a lot of time looking after patients on life-support in the Critical Care Unit, I have a vested interest in paying close attention to the reports of the spread of the “Swine ‘Flu” epidemic.

 From the moment the story broke on Saturday morning, we’ve had people from the Department of Health and the Health Protection Agency on the telly and radio telling us that “the UK is the best prepared country in the world to deal with a pandemic.”

 I really hope that this is true and our preparation is sound, but the thing that’s worrying me is that no one seems to be telling me or my colleagues what the plan is. There doesn’t seem to be any advice about how we actually treat someone who becomes critically ill with swine flu. We haven’t been told what type of protective measures we should take to prevent the in-hospital spread of this flu or how to protect ourselves from it. Should we use special masks? If so, where do we get them from? What should the isolation policy be? What do we do with the rest of the inpatients? Should we come in to work if we start to feel a bit rough? The hospital is pretty much constantly full anyway, so what happens when we get a big influx of admissions with ‘flu? What happens when we run out of beds? What happens when the staff start getting ill?

 These are all questions that we’ve been given no official guidance on. Obviously, we’ll do the best we can and try to deal with situations to the best of our ability, but it would be nice to know what sort of special measures or help is available to us.

 The thing that’s really worrying me is that nobody in the hospital seems to know the answers to these questions either. The consultants don’t know, the critical care sisters don’t know, and word is that the chief executive only has a sketchy idea about how manage an outbreak in this town.

 Reading between the lines, what I gather from the radio is that there seems to be some sort of secret masterplan and I really hope that this is the case. I really hope that a whole chain of events swing into action once we have a suspected case come through the hospital doors.

 I’m covering intensive care next week and I want to know if there’s anything different I should do from normal if the medical reg bleeps me and says, “I’d like to refer you a 31 year old man for consideration of ventilatory support. He presented with severe ‘flu-like symptoms after returning from a holiday in the USA on Tuesday…”

Monday, 27 April 2009

Blood on the dancefloor, part 2

This is a continuation of this post. 

A bougie is basically a bendy stick, and when using one to incubate a person, you’re aiming to feel the stick running across the rings of cartilage in the patient’s windpipe – a bit like a child running a stick along a wooden fence. As I pushed the bougie down into this man’s body, I didn’t feel that sensation at all.

 “Are you in?” asks Dawn, the ODP, who is standing next to my right shoulder, with the endotracheal tube (breathing tube) poised in her hand.

 I don’t know if I’m ‘in’ or not. The bougie could be in this man’s windpipe, but equally, it could be in his foodpipe and, if I put the endotracheal tube into his foodpipe, he’ll quickly run out of oxygen and die. As this thought flashes through my brain, a surge of panic rises through my body. It feels akin to being suddenly woken from a deep sleep. My heart hammers against my ribcage and I actually start to feel faint. I need to focus. I clench my jaw and swallow and concentrate on what I need to do. I decided to do this to this man, so it's up to me to see it through to completion. I claim victory in my personal battle with my own emotions, a battle that lasted only a split second, and I look again into this man's mouth.

When I was putting the bougie in, my hands must have shifted slightly. Either that or the swelling and bleeding has got worse, because as I try to look down the man’s throat, I can no longer see what I thought I could see initially. It just looks like a bloody mess and I wonder if I ever really saw anything in the first place or if it was just my brain playing tricks on me and making me see what I wanted to see. 

I figure that taking the bougie out and trying again is probably not be the best thing to do, but I did remember something that Dr Harrison told me when I was first learning how to use a bougie. ‘The trachea isn’t very long, even in the tallest of men. If you keep pushing the bougie down the trachea, you’ll get to a point when you can push it no further. If you push I down the oesophagus, you can pretty much push it all the way in.’

 I push the bougie in further, and further, and further and it stops. I can push it no more.

 “Oh, you’re definitely in!” says Dawn, who’s been intently watching what I’ve been doing. She puts the tip of the bougie through the endotracheal tube and I take hold of it and push into the man’s lungs. A few squeezes of the air bag and I confirm that I’ve put the tube into the right place.

 "Well done!” says the surgeon and I breathe a large sigh of relief as Dawn tied the tube in place and Ken and I set about putting the man’s hard collar back on. 

One of the things that I’ve noticed when dealing with acutely critically ill people like this is that as soon as the patient is intubated, everyone calms down a couple of notches. It’s almost as if the team breathes a collective sigh of relief. I think this mainly because when you induce anaesthesia and paralyse the patient, obviously they stop screaming and thrashing around which means that it suddenly becomes much easier for everyone else to do what the have to do. That could be that cutting off clothing, listening to the chest, feeling a pulse, palpating the abdomen, phoning radiology or simply taking in information and thinking about what the next steps should be. Whatever it is, it’s easier to do when you don’t have a screaming, thrashing patient in front of you.

 I certainly noticed it with this man. I set the mechanical ventilator and sorted out sedation while the A&E consultant (trauma team leader) reassessed and went through her A-B-Cs again. When I suction down the endotracheal tube I get moderate amounts of blood back, and this confirms that my decision to intubate him was the right thing to do.

 The patient (turns out that his name is Carl) was actually quite stable from the point of view of his vital organs.  From a doctor’s point of view, one of the things that I quite like about dealing with trauma is that the management is relatively straightforward. What makes it difficult tends to be more the organisational and people-management side of things. With Carl, we were doing well. We quickly organised chest and pelvic X-rays and, whilst he was having these taken, I turned back to the paramedics and ask her again what happened to him.

 “Basically, he was in a bar and from what we can gather was allegedly assaulted by two or three other men. Apparently they were kicking him and stamping on his head and it took security and the police a long time to get them off him. When we got there, he was pretty much as he was when we arrived here. GCS at the seen was 15, but he was combative and the only sats reading we got was in the 80s.”

 Ugh, I think to myself. The bar in question does have a certain reputation for being really rough, but I’d never heard of anything this bad happening there. “Well, he’s certainly had a good going over,” I comment.

 “It’s OK to come back in.” The voice is that of the radiographer, letting us know that she’d finished taking her X rays.

 The paramedic stops me as I start to walk back towards Carl’s trolley “Can I just ask you something?” He looks rather tense, like there’s something playing on his mind.


 “Well, when we tried to get a sats reading, it said they were 85%. I was thinking about putting in a NPA (naso-pharyngeal airway), but didn’t because of the state of his face…”

 I frown and scrunch up my face, “I wouldn’t have…”


 “No.” I gesture towards the motionless Carl, “He could have fractures to his face… to his skull… we don’t know. A nasal airway could have made things worse.” A slight smile starts to play on his lips, “You did the right thing,” I conclude.


Carl needs a CT scan of his head to see if he’s bleeding into his brain and thus needs urgent neurosurgery. Someone gets on the phone to the radiologist and the radiographers go off to warm up the CT scanner.

Major trauma really is time-critical. The sooner patient receives treatment, the better their outcome is. If you have an interest in trauma, phrases like “the golden hour” and “the platinum 10 minutes” will be familiar. In situations like this, the clock really is ticking and every minute unnecessarily wasted is potentially detrimental to the patient. The thing is, it’s so easy to waste time. It’s really tempting to “stay and play” in the resus room. You can put in arterial lines and central lines, set up infusers, warmers, splints etc… etc… All of these things take time, but these things may not be necessary or even helpful to the particular patient in front of you. You can spend lots of time trying to “do every thing by the book,” but lose sight of the fact that the whole point of “the book” is to identify the patient’s injuries and get them treated as quickly as is humanly possible.

 Anyway, I’m digressing a little. I’ve learned that one of the key things you can do to avoid time wasting is to think several steps ahead, and I’m getting better at this. Whilst waiting for the scanner to come online, I busy myself with setting up the pumps and refreshing the infusions and that are going to keep him asleep while we move him. I recheck Carl’s vital signs, give him some intravenous fluids and then go off and check I have all the equipment I’ll need on the transfer.

 I’m going to stop now and not say any more about Carl and what injuries he had. The events I’ve described actually happened quite a while ago, but this ended up being quite big news locally and I don’t really want to say much more for worry of compromising Carl’s real identity.

 All I will say is that Carl had surgery and survived to walk out of hospital several days later. Though Carl will never have any idea about what the paramedics and hospital staff did for him that evening, it does give me a real sense of satisfaction to know that as I sit here typing this, he’s out there somewhere living the life that I helped to save.

Monday, 13 April 2009

Blood on the dancefloor

The last patient on the emergency NCEPOD list is sitting in recovery after his operation. He’s drowsy, but comfortable and I’m chatting to Sara, one of the nurses when my pager goes off.

“Trauma call – A&E resus immediately please… Trauma call – A&E resus immediately please… Trauma call – A&E resus immediately please…”

I sigh and roll my eyes at Sara. “Just when you think all the work has been done, something else happens,” I say.

She smiles sympathetically as I turn and make my way out of Main Theatres towards A&E. To be honest, I’d been expecting this. I hadn’t had any trauma calls on my last couple of on-call shifts so, on the balance of averages, I was due one today.

Dealing with major trauma is one of the things that really worries me as a junior anaesthetist. Over the past few months, I’ve been making a big effort to improve my trauma management and get more experience of managing patients with major trauma. One of the things I wanted to achieve by the end of my ST2 year in anaesthetics was to be much more comfortable in situations just like this, and to some extent, I’ve succeeded. If I’d been in this situation a year ago, I’d be absolutely shitting it, but as I round the corner into the A&E resus room, I feel in control of my own emotions.

The first people I see are a couple of police officers looking intently at the scene that was unfolding in front of them. I give them a brief nod and headed into the resus bay.

The scene that greets me is bad. Very bad.

A young man lies on the casualty trolley screaming unintelligibly. He’s trying to trash around and two paramedics are trying their best to prevent him from hurling himself onto the ground. The bloody footprints of the hospital staff have created a perverse mosaic on the floor of the resus room as they desperately try and get control of the situation. A nurse has the man’s left arm locked in his vice-like grip in an attempt to keep it still as the surgeon is trying to shove a cannula into the man’s vein. I glance at the portable obs machine next to the trolley. It’s impassive display reads:

HR: -?-
BP: -?-
O2 Sats: 84%

Like I say, this is very bad.

Ken, the A&E charge nurse is trying to give this man some oxygen, but he screams again and thrashes his head from side to side.

“Are you the anaesthetist?” Ken, asks me.

“Yes, I am” I reply as I scan the bay for a pair of gloves to put on. The only box of gloves I can see contain small gloves, this has been a recurring annoyance throughout my medical career so far. I squeeze my goal-keeper hands into the gloves, quickly connect together an anaesthetic breathing circuit and turn on the oxygen. Ken stands aside as I plant my oxygen mask onto the patients face.

The patient looks horrific. His face is massively swollen to the extent that he cannot open his eyes and I cannot open them for him. The whole of his head is completely covered in blood, he is bleeding from his scalp, his cheek, his nose and appears to be bleeding from somewhere inside his mouth. My fingers keep slipping off his face as I try to hold the mask on to enable him to breath the vital oxygen.

Paradoxically, in the few moments that I’ve been there, I’ve been reassured by the situation. It’s probably not as bad as it looks. The mere fact that he is able to scream and fight means that he is not at the end of the road yet so, while things are undoubtedly very bad, they’re not yet critical. The surgeon has secured IV access and has moved on to examine the man’s torso.

“Can I have some suction?” I say and Ken passes me the Yankeur sucker which I put into this poor guys’ mouth. I suck blood, clots and saliva away from the back of his throat, which enables him to scream even louder.
"What's happened to this guy?" I ask. One of the paramedics starts to tell me the story, but to be honest I'm not taking it in at all. The patient is trying to sit up again and I lose my grip of my oxygen mask, which tumbles onto the floor.

“AAAAAAAARRRRRRGGGGGGGGGHHHHH!!!!!!!” he screams, but I notice that his scream gurgles towards the end as blood re-accumulates in his throat.

“This is fucked,” I state. “He’s got loads of blood in his mouth, he’s not spitting, he’s not swallowing, he’s probably going to aspirate if we leave him like this for much longer – I’m going to intubate this guy.” No one disagrees with me, and I quickly try to formulate a plan of how I’m going to intubate this man without killing him.

“Ken, are you OK to hold the oxygen mask while I draw up some drugs?” He nods to the affirmative and I hand him the mask, peel of my blood-soaked gloves and go to the drugs cupboard. It’s locked.

“Anyone got the drug keys?” I say, but I’m ignored as the patient continues to trash around. “WHO HAS GOT THE DRUG KEYS?” I shout. Sometimes, you have to make yourself heard.

“They’re over here,” comes the voice of Mary, one of the nurses.

“Thank-you” I say as she opens up the cupboard for me. I take out the thiopental and suxamethonium and start to draw the drugs into syringes. This takes a few moments and gives me time to pause for thought. I figure that this situation has the potential to go from serious to critical to fatal very quickly. Taking this into account, I conclude that it’s worth getting as much help as I can muster. I’m going to need to phone a friend.

“Mary, could you please call theatres and ask for one of the ODPs to come down to resus.”

“Certainly,” she says as she heads towards the phone.

“Oh, and Mary, could you also please bleep the ITU reg (my immediate senior) and ask him to come down too.”

I turn my attention back to the patient.

“Thanks Ken,” I say as I take the oxygen mask from him.

I put the Yankeur sucker back into the patients mouth and hoover out more blood. As I do so, he coughs and sends a spray of blood and saliva into my face. I feel the warm fluid trickle down the side of my face and my stomach turns. I make a face at Ken and he gives me a sympathetic look. “At least I had my mouth shut,” I say. Thank God for small mercies.

“Right, everyone; this man needs to go to sleep.” I say loudly. “Ken, can we take his hard collar off, now? And what I’d like is for you to do manual in-line stabilisation [of his neck], when the ODP arrives, she can do cricoid pressure and help me with the intubating equipment and we’ll get some one else to give the drugs.”

“Sure,” comes Ken’s response and he manoeuvres himself so he can comfortably keep the man’s neck as still as possible while Mary and I take off the hard collar.

I put the oxygen mask back on his face and right at that moment, like a cavalry unit, both the ODP and ITU reg arrive.

“I’m going to intubate him,” I tell them.

“What’s his GCS?” asks Ben, the ITU reg.

“Twelve” comes the voice of some bright spark in the bay. I’m pretty sure that his GCS is much less than twelve, but now is not the time to start a debate about it.

I shake my head, “He’s got a mouthful of blood and he’s not spitting or swallowing.”

“Can he maintain his own airway?” asks Ben

“No,” I reply
“OK then, I’ll draw some drugs up.”
“I’ve already got them,” I say. “They’re behind me.”
Ben picks up the drugs and goes round to where the surgeon had secured an intravenous cannula.
“Is everyone ready?” Ben asks. We all affirm we are. “OK, I’m giving the drugs now… Thio is in” the man on the trolley stops trying to fight us and becomes suddenly very limp. “Sux is in” The patient’s muscles ripple under his skin in an uncoordinated dance as the drug works its way round his body and paralyses every muscle as it goes.

I know it’s down to me now. Thanks to us, this man can no longer breathe and I have a small window of time to get a breathing tube into his lungs before he starts to die. The room has gone eerily quiet and I know that all eyes are on me as I pick up the laryngoscope and put it into his mouth. I’m hoping to see his vocal chords. What I’m aiming to do is push the tube between the chords into his lungs. They say that intubation should be a calm, smooth process, but I can immediately tell that this is going to be difficult.

All I can see is a lake of bright red blood. I pick up the Yankeur sucker and try to suck it away. The lake recedes annoyingly slowly, revealing the anatomical structures beneath it. But this doesn’t look like it does in the textbooks. It doesn’t look like any other intubation I’ve seen before. Everything is swollen, everything is red and everything looks sort of… twisted. I can’t see the vocal chords. I can’t see where I’m meant to put the tube. Worse, I can’t see any of the things around the vocal chords that are meant to give you a clue as to where to aim. I can’t see the epiglottis, I can’t see the arytenoids.

“Fucking hell,” I whisper to myself.

“Sats are 92%” comes Mary’s voice.

This man is starting to run out of oxygen and I’m going to have to do something. I pull harder on the laryngoscope handle, hoping to improve my view. The man’s throat is starting to fill with blood again, but I can’t see from where. Just at the limits of my view, I can see something pale and bumpy. I think it’s one of the arytenoids, but I’m not sure. I have a decision to make now. Do I step aside and let Ben see if he can intubate this man or do I try and do it myself, knowing that if I fail, it will be even harder for Ben to succeed? I trust my judgement and pick up the bougie [an intubating aid].
“What do you see?” says Ben
“Tricky,” I reply
“Sats are 88%” comes Mary’s voice again
Things are really serious now, I know that I only have a few seconds left to get the tube down before his body runs out of oxygen. There probably won’t be enough time for a second attempt before he is genuinely hypoxic. I hear the surgeon say something about a tracheostomy kit and have to act.

I push the bougie down where I think it should go and hope for the best.

To be continued…

Thursday, 2 April 2009

Let's get tattoos

“What do you think about it Michael?” I’ve just walked into the doctor’s mess at lunchtime and the person posing me this question is my friend Andy, a junior surgeon.

“What do I think about what?” I say as I pull up a chair and open up my lunchbox.
“I’m thinking of getting a tattoo – but I’m not sure if it’s a good idea. People might look down on me because of it and I’m not sure that people will like it.”
“What are you going to get?”
“I don’t know, some sort of pattern – here on my arm he says as he point to his forearm.
“Personally, I think tattoos there are pretty cool. If you want one, you should go for it.”
“Yeah – but what if the bosses don’t like it?”
“I wouldn’t worry too much about that – it’s your body after all and you can always cover it up.”
Bare below the elbows, Michael!”
“Oh yeah, I forgot about that, you’re quite right, though I think we should take the ‘bare below the elbows’ thing with a pinch of salt.”
“And people will see it when I’m scrubbing up and stuff.”
“You’ve also go to think about what the patients might think,” pipes up Jo, one of the medical house officers.
“To be honest, I really don’t think that patients care,” replies Andy. “It’s more what my colleagues think that worries me.”
“To be honest with you Andy,” I interject, “I know that personally, I’m far too fickle to have a tattoo, but if I wasn’t and I found one I really liked, I’d probably get it done. But it’s up to you. All I’d say is that you should decide if you want it and if you do, go for it and not worry too much about what other people think.”
Andy furrows his brow, “Hmmm… perhaps you’re right, perhaps not. Watch this space.”

I’ll be watching with interest.