Patient: Abdominal Wound

Bob, normally healthy 23 year old male presenting with abdominal stab wound. Unconscious, Pulse 150, BP 60/30, Resps 27. Appears diaphoretic and ashen.

This is a patient we saw(minus a few identifying facts) in A&E. I thought I would outline how we treated him.

He was clearly in hypovolemic shock. His blood pressure was incredibly low so his heart couldnt pump the oxygenated blood to his cells. To attempt to compensate for this his pulse increased. We start getting concerned when a patients pulse exceeds their systolic blood pressure, its a sign of acute shock. In order to keep pace with the heart and oxygenate the increasing blood flow(increasing at first) his breathing became shallow and rapid. However long before this he would have passed out, Its not clear weather this is another one of the bodies failsafes or just coinsidence but an important step in immediate treatment of shock is to lay the patient down, preferably with their feet up so as much blood as possible is flowing to the brain. His blood vessels would contract in order to attempt to compensate for the plumetting blood pressure this would have caused the ashen appearance.

Going back to basics.

Airway/Breathing - the patient had a patent airway but his oxygen intake from the shallow breaths was insufficient so we placed him on highflow oxygen(15litres via non-rebreathe mask).
Circulation - We applied a heavy dressing and applied as much pressure as we could in order to slow down the blood loss. We obtained venus access. This was particularly difficult as he was peripherally shut down. We then pumped as much saline and gelofusin into his veins as possible increasing his circulating blood volume and taking blood for typing. Short term its important to increase the circulating volume with anything we have at our disposal, it will increase the blood pressure and hopefully decrease resp and pulse rates. Long term however the lack of red blood cells will cause hypoxia(among other things) despite the high flow oxygen. At this point several units of blood for transfusion appeared and he was deemed stable enough to risk surgery to repair the damage caused by the knife.

All this happened in a very short period of time, the patient survived(surprisingly).

Downtime

Its been an insane week. Many stressful situations which are thankfully now resolved. So I am now sat in my living room, alone(my fiance is on nights). Drinking a blended whiskey(I am normally a single malt man but this isnt a bad one). With my entire music collection on random(thats a lot of music). So I thought in the interests of pure laziness and at the risk of a massive blow to my standing amongst my loyal readers I would post bellow ever song that comes on. In bold you'll see any excuse I wish to make. May the comments begin!

Iron Maiden - Face in the Sand
Deep Purple - Black Night
Dreamevil - Book of Heavy Metal
Queen - Mad the Swine
Nirvana - Opinion (I have no idea how this got on here)
Luke Kelly - The Town I loved So Well
Corrib Folk - Wish it was Sunday
Anastacia - Secrets(I have no idea how this got here either)
Johnny Cash - The Wall
Hammerfall - Take the Black(Nothing like hammerfall for destressing)
Iron Maiden - Seventh Son of a Seventh Son(Parts of this song sound very Greek)
Van Halen - Running with the Devil
Toad the Wet Sprocket - Somethings Always Wrong(I love this song)
Savatage - Handful of Rain(My usual drinking song with a good video)
Ludovico Einaudi - I due Fiumi
Thin Lizzy - Jailbreak
Bad Company - Bad Company
Iron Maiden - Intro:Churchills Speech(One of histories greatest speeches)
Sonny Rhodes - Firefly Theme
Skyclad - Spinning Jenny(A truely Filthy Song!)
Elexorian - Dryads and Trolls(Hillarious lego video available on youtube)
Plain White T's - Every Second Counts
Skyclad - Any Old Irony?
Tyr - Ormurin Langi
Bon Jovi - Wanted Dead or Alive ("Bon Jovi Rocks....On Occasion")
Amateur Transplants - Anaesthetists Hymn(Medical Spoof Band, Highly Recommended)
Thirteen Senses - Into the Fire
Bruce Dickinson - Inertia
Free - Wishing Well (One of my Favourites)
Lynard Skynard - Freebird(This was my fathers song)
Iron Maiden - The Trooper
Kansas - Fair Exchange
Led Zepplin - Immigrant Song
Kenny Rodgers - The Gambler

Ok I'm going to end it there, that wasnt nearly as bad as I was expecting.

Broken Squirrels

Shortly after returning from the lake district recently I was sat in my local with a friend and we were discussing the complexity of reintroducing red squirrels to the south. The concept is referred to in ecological circles as humpty dumpty communities. The intruder greys came in and won dominance over the red squirrel. It seems the solution is simple, remove the grey squirrel and reintroduce the red squirrel but it is far from that simple. A species often has different requirements to establish themselves in an environment. A certain insect or plant which has long since died out may be required in abundance to allow the red to reach the necessary numbers in the initial stages in order to survive in an environment long term. Many people say they prefer the red squirrel but ultimately evolution has led to the rise of the grey squirrel and as much as many would like to see a predominantly red england again, what right do we have to tamper with the progression of nature?

The grey squirrel is larger, more aggressive and more of their progeny are likely to survive infancy. This clearly placed them at an advantage over the more timid, less hardy red squirrels.

This concept is best explained by Olivia Judson(one of my heroes). Whilst I was in the lakes I asked my fiance(a northern lass) why the grey squirrels dont seem to have penetrated the lake district(loads of red squirrels and I've never seen a grey in the lake district). Her reply made me laugh "we're better shots than you".


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I am aware that some of my readers are avid gardeners and I would like to ask for any tips when it comes to battling white fly on my pepper plants. Every year about 75% of my plants are ruined by the little buggers.

My Return

I have returned. I decided to take a little bit of time away from blogging(and the computer) whilst I was on my A&E placement just so I could keep focused. That placement is now over and I am really going to miss it. When I qualify I fully intend to find a job either in that A&E department or to one in a local hospital.

Now down to the business of the day. As many of you will have heard President Obama is presenting the idea of a government funded healthcare system(a bit like our own) in the US. This has been met with fairly aggressive opposition and frankly more than a little sniping at our system in order to discredit it. The problem is, as I see it. most if not all hospitals, pharmaceutical companies, etc in the US are businesses, they have many investors who will suddenly lose a lot of money if free healthcare finds a place. The current system mean thats most americans only have access to healthcare if they can afford it, leaving those that cant in a pretty sorry state. There are of course a few very badly funded, understaffed, underequipped services trying to cater to the needs of those who cant afford the care they need but it is wholly insufficient.

The problem here is how do you introduce a state funded system that will rival big businesses in an entirely capitalist society?

Shorthand

Pt biba following RTC. 3xPCW around R 4-5 IC spaces. ?# R NOF as S+R of limb and dec ROM. GCS 12. MEWS of 5 due to rr 22, pr 114 and systolic bp 98. 15l o2 via non-rebreathe, maintaining sats 89%. ECG done and shown to dr. IV morphine administered as per prescription chart. CXR, Abdo XR and Hip XR ordered. Pt a/w tx ESAU.


This patient was an absolute wreck, I was helping work on him. Later that shift I found this nursing note written by a charge nurse also working on that patient. I can understand everything written there but I feel nursing notes should be a little clearer. The translation is as follows -

Patient brought in by ambulance. Three penetrating chest wounds around the right fourth and fifth intercoastal spaces. Query fractured right neck of femor as there is shortening and rotation of the limb and decreased range of motion. Glasgow coma scale of 12. Modified Early Warning System score of 5 due to resp rate of 22, pulse rate of 114 and systolic blood pressure of 98mmol. Patient on 15 litres of Oxygen via non-rebreathe mask and maintaining oxygen saturation of 89%. Electrocardiograph done and shown to doctor. Intravenous morphine administered as per prescription chart. Chest X-Ray, Abdominal X-Ray and Hip X-Ray requested. Patient awaiting transfer to emergency surgical assessment unit.

A&E: Day Four

My fourth shift started with my primary mentor in majors, we had a couple of chest pains(?MI) and a headache with left sided vision impairment and limb weakness. All very pleasant patients. And then I got asked to take a set of obs on a patient in resus because they were rammed in there and didnt have the time to juggle everything. Seven hours later I left resus.....

It was incredible, juggling obs, drawing meds and just generally identifying jobs that needed doing and doing them before the qualified staff realised they needed to be done. At the end of my shift I got a chance to chat with two of my patients in resus(they were on half hourly obs and nothing else in there needed doing). One lady in her late eighties came in with chest pain(i'm told she was a little bit in love with me). I find that a lot of elderly patients get spoken down to. as though they have no right to know exactly what is happening to them as long as their progeny have been filled in. I do not agree with this, as long as the patient is competant and willing to know, they have every right to know whats going on with them. This also seems to help me form nurse-patient bonds. This patient was very stable when I went off duty.

Another patient was a lady probably in her late fourties, overdose of paracetamol. her fifteenth suicide attempt in the last twelve months. This told me several things. The patient felt rewarded by the attention her suicide attempts acheieved, the patient shouldnt have been in a position to make a second suicide attempt, let alone a fifteenth. She should have been sectioned under the mental health act. As a result I felt obliged to give her my most professional behavior, I did everything by the textbook, with no more than the professionally required level of warmth. Its a shame, the patient was such an intelligent person and she was wasting her life by trying to end it.

On the other hand we all over our stories and people dont end up like that unless a series of events has guided her path there. To be honest I had no idea what to do non-medically that would be in her best interests. I am sure she will survive to discharge and in all probability make another attempt, who knows one day she may accidentally succeed.

There was another patient who died under circumstances that really effected me but it is probabilty disrespectful to recount the events of his failed resuscitation on a public blog. Needless to say there are some parts of the job I will never enjoy.

However I have had another great day, largely thanks to the staff I have been working with. I am more than ready for my two days off now and a bit of sleep.

A&E: Day Three

Today has been the best(and most exhausting) day in my two years of training. I was working on resus. I lost count of how many chest pain patients we saw. We also had a few stroke patients. Normally my hospital thrombolyses(injects an agent to break down clots) about eight people a month. Today we did this to six patients. They have to meet a very specific criteria to be eligable. It was all very exciting. While we didnt have any actual arrests in resus all of our patients were very ill. We also had two patients with very impressive breaks (one elbow, one wrist) who were sedated and had their breaks manipulated (pulled into a more stable position and cast) both of these patients were admitted as they would require surgery.

Something that strikes me as very different here is that the doctors actually get stuck in with general nursing duties, a doctor helped me transfer a patient to the ward. She also later on helped me roll a patient so I could get a bed pan under her. This would never happen on the wards. The nurses in A&E are all so laid back and relaxed, someone could walk through the doors in flames and they would probably yawn before putting the flames out. There is no such thing as a rush in A&E. I like this approach, calm and sure.