Emergency Dept Patients

Introduction

This section of my web page is a compilation of short stories, or essays, I jotted down over the years working in Fast Track in a hospital Emergency Department - and have since refined. Each essay deals with a particular, memorable case I dealt with. While it may capture the attention of any person remotely interested in the medical world it may stir the interest of medical students and nurses. I imagine the average Emergency Medicine Physician would find it passé and boring.

Fast Track is where I worked for three of the last five years of my career. Fast Track and its patients, (rendered anonymous), is what this book is about. A fair bit of me rubs off in the book too.

Prologue – Written 2012

Most hospital Emergency Departments in Australia are chaotic places run by over-worked and poorly supported orderlies, nurses, clerical staff and doctors.

The “Floor” of the Emergency Department is that area in which the hard stuff is looked after. The heart attacks, strokes, leaking aortic aneurisms, the severe trauma due to road smashes, violence, industrial injuries, fires, explosions and so on ad nauseum. And there is no shortage of it believe you me! The central area of The Floor, where the doctors and nurses work is coordinated, and all the computers lurk, is known as “The Flight Deck”.Conversely, the “Fast Track” is that area of the department dedicated to diagnosing and treating those conditions that can be sorted out without too much fuss and a minimum, if any, of x-rays and laboratory tests. I spent the first two years of my time in ED working The Floor mainly because the Fast Track concept had not been introduced.The efficiency and effectiveness of the Fast Track is dependent upon many factors not the least being the effectiveness of the Triage system. Triage is usually performed by nurses whose function is to assess each new patient as soon as possible after they present to the Emergency Department. The nurse decides if the patient can be properly treated in Fast Track or must go into the main department – The Floor.

Fast Track patients will spend much less time than Floor patients waiting and being treated. It seems a bit incongruous at first and can result in a patient with a minor laceration arriving after someone with a broken leg yet being treated and discharged before the broken leg is even seen by a doctor. However, the department is not clogged up with both minor stuff and serious stuff all waiting ages for attention. Hence, an efficient Fast Track has a high patient turnover and there are few “Did not wait” patients.

I loved working in Fast Track. My skills, knowledge and experience are better suited to Fast Track than to The Floor. I can communicate better with the patients and establish rapport; I can teach nurses and medical students to diagnose and treat the simple stuff – the stuff they will see every day in general practice. I knock off after each ten hour shift exhausted but feeling I have achieved something worthwhile.

And now the time has come for me to leave it behind – to retire. I consider these five years to have been among the best years of the fifty I have spent in the medical orientation. I am deeply indebted to the bright, young Emergency Medicine specialists who taught me so much. I am no less indebted to the support staff – the orderlies, clerks, nurses and non-specialist doctors with whom I worked. And to the staff of the radiology department and the pharmacy with whom I had daily contact and who guided me through much of the new, innovative stuff in their respective fields.

I have hung up my stethoscope and already - I miss it all.

It is not a smart doctor who leaps to conclusions. Even though a patient may present with “absolutely classical” signs and symptoms of a particular affliction the wise doctor will still go through the process of taking a medical history, performing a proper examination and requesting appropriate laboratory investigations before making the final diagnosis. It is the final diagnosis that dictates the treatment. Short cuts to diagnosis may well result in inappropriate treatment. Inappropriate treatment may at best be simply ineffectual and at worst may have distinctly adverse consequences for the patient – and doctor. And all is not always as it seems in medicine. Several such examples are described, from my own experience, in the next few pages.

He appeared on the screen as a low priority, back pain. I signed on for a higher priority patient but, in walking past the low priority patient’s bed, I was a little surprised to note that he was a teenage boy. It struck me as odd that a fifteen year old would present with back pain. More commonly it would be back injury. But that was just a passing thought.

A little later I walked past his bed again and observed him to be in very considerable pain and writhing about on the bed. I noted he had not been picked up by any other doctor and there were still higher priority patients waiting. Never-the-less I spoke to the triage nurse and asked her what she knew of him. She told me he had simply told her that he had a sore back and that his observations were normal. Because he appeared very uncomfortable she had allocated him to a bed but had not given him a high priority.

Boys rarely present with back pain and people with back pain lay still – they do not writhe about. I clicked on his name and allocated him to myself. His mother sat alongside the bed looking rather apprehensive and worried. The boy was pale and could not lay still. He had vomited earlier. His urine had been tested and was normal. It became immediately apparent what his problem was. I asked him where the pain was and he indicated his left loin. I then asked if his testicles were painful. He blushed, turned his head away from his mother and nodded. Examination of his testicles confirmed my diagnosis of torsion of the testicle – the left in his case.

I arranged for the surgeon to see him urgently. He did so and took him to theatre a short time later. Afterwards he told me the boy’s left testicle had twisted around on its blood vessels and nerves almost completely cutting off the blood supply. He felt another hour or so would have seen the testicle become gangrenous and necessitate removal. Its colour had returned to normal when it was untwisted indicating it would survive. The usual procedure, when the testicle is salvageable, is to suture it into place to prevent it twisting again. The other testicle is also sutured because the pre-disposing condition is always bilateral. The testicle is normally attached by a ligament to the back of the scrotum. This ligament is missing in those predisposed to torsion.

The boy had been too embarrassed to tell either his mother or the triage nurse about his predicament. He did have pain in the back – referred pain from the testicle – and that had to suffice in his explanation to the ladies. All was not as it seemed to the casual observer.
On another day a sixty one year old woman was on the screen as a low priority with vomiting and diarrhoea. It was one of those all-too-rare quiet days and there was no one else waiting to be seen. She did not look very well at all and told me she had started vomiting four days previously. The diarrhoea had consisted of just one, small, watery bowel motion that morning. She had pain constantly, with severe waves passing on top of that. She had not passed any wind.

She was moderately febrile and dehydrated having no saliva in her mouth and the skin on the back of her hand remaining in a drawn up peak when gently pinched. Her abdomen was protuberant and very tender. Gently laying my left middle finger on her abdomen and tapping on it with my right middle finger caused severe, stabbing pain. This very simple action told me she was in deep trouble with much, much more than just the presumed gastro-enteritis that was “going around” - as it always is.

We had great difficulty getting enough blood for even basic tests. The poor lady endured us poking needles into her arms and even a foot and never once complained. There was only one vein we could find that would take a cannulla without collapsing. Fortunately, we were able to get a couple of litres of fluid into her over the next couple of hours while she waited for a CT scan of her abdomen.

I stood alongside the radiologist while he talked me through the series of CT scans. It was obvious, even to me, that she had a small bowel obstruction. What was causing it was not obvious even to the radiologist. However, small bowel obstruction was diagnosis enough to demand immediate transfer to a major hospital which task I got about arranging. (The bureaucracy is taxing!). Just before the ambulance arrived to take her away the radiologist rang me to say that, in fact, she had appendicitis and not only that but the appendix had perforated. In a process that been in evolution over four days the appendix had become inflamed and walled off by inflammatory reactive tissues preventing her developing the classical severe peritonitis. Such things can be very difficult to diagnose even with the modern marvel of CT scans and similar technology.

Appendicitis is very rare in people of 61 years. When it does occur it is often caused by some other pathology such as bowel cancer. I received no feedback from the major hospital so I do not know the outcome with this lady. All was not as it seemed with neither her presentation nor her CT scan.

We all dread dealing with the drug addicts especially the violent ones. But we cannot afford to “cherry pick” our patients off the screen. And so I had to take on a man whose problem was listed as wanting detoxification. This is not uncommon and usually translates into the person wanting us to prescribe morphine or oxycodon or codeine for pain or withdrawal symptoms. We are prohibited by law from so doing.
There was nothing to suggest this chap was any different from any other drug addict. He lay on the bed fully clothed but disheveled, gaunt, haggard, and agitated. He told me he had been suffering with chronic back pain for years and had been prescribed increasing quantities and strengths of analgesics until he finished up addicted to morphine. “Here it comes,” I thought. “He is going to ask me for morphine to tide him over for a while.” I was wrong. He wanted to be referred to somewhere to help him get off the stuff.

He told me he had not had any opiates or other analgesics for three days. He said he had been through the hell of three days of withdrawal but had hung in there and refused to give in to his body’s murderous screams for relief from the agonies. He had been in touch with two places that helped people get off drugs. One had told him they would take him in but not for another two days as they were full up. The other said they could not fit him in in the foreseeable future.

We had a long discussion during which I concluded he was genuine and his story was entirely true. Not knowing a great deal about the services available to such people I decided to seek the assistance of the hospital social worker. Saints, those people are. We are tested in the ED, at times to the utmost, but those people are saint like in the way they tolerate daily abuse, even assault and seeing hours or days of effort thrown back into their faces by the ingrates who consider the world owes them a living and much more.

The staff social worker was on leave and her replacement willingly came along to ED. I outlined the problem and she spent two hours or more with this chap. She got his wife to come in and that poor lady had to bring a pre-school child with her because there was no one to look after him. The social worker contacted the organization that had promised to take him in two days later and confirmed that he had done as he said. The upshot of it all was that we gave him two Valium tablets - one to take that night, and the next, to help him in his attempts to get some sleep. I doubt they helped much but he didn’t want anything else and I didn’t want to prescribe more. He had seen the worst of his cold turkey. If he could just hang in there another 48 hours he would be in the safe hands of professional detoxifiers. His wife was fully supportive of his efforts.

I don’t know the outcome. I sincerely hope he made it and is starting out on a new life which will not be a bed of roses but far better than the painful, terminal illness of opiate addiction. All was not as it seemed with him. I wished him well as he left. He shook my hand and the social worker’s, looked us in the eyes and said, “Thank you both for listening.”

“Rash”, said the problem under the patient’s name on the computer screen. The triage notes told me he had a CT scan, with contrast, three days previously. I, like the patient and the triage nurse, immediately assumed he was suffering an allergic reaction to the contrast medium. That assumption was blown to smithereens with his response to the first question – onset of the rash preceded the CT scan by a week or more. “Yes, it is very itchy and yes, the itch is worse at night.”

I could see no rash on his face or arms and asked him to let me see it. He removed his trousers and shirt to reveal an extensive, bright red rash extending from his navel to his knees, front and back. It consisted of large patches of angry red skin with surrounding areas of small red spots – macules, and some small raised spots – papules. Scratch marks were evident on the skin and on the left thigh there was a patch of skin weeping yellowish, watery fluid. As is my habit, I got my binocular loupe – an instrument similar to binocculars but with a very short focal length usually used to examine the surface of the eyes. I find it invaluable to closely examining the skin especially that with odd rashes.
Scrutiny of the peripheral areas of the rash revealed numerous macules and papules. Most informative were the short, serpentine lines within the skin beneath the surface layer or epithelium. They set the diagnosis in concrete – scabies. He was quite surprised when I told him and so was his wife who accompanied him. Close questioning revealed that he had gone to the bush to do a job a few weeks previously and was accommodated in a less than salubrious boarding house. That was probably where he contracted the disease.

Scabies is a very common and highly infectious disease caused by a microscopic, parasitic mite. The female of the species burrows into the skin and lays eggs at the end of a small tunnel. The tunnels are the serpentine lines visible in the skin. The eggs trigger an allergic reaction which causes the extreme itch.

Treatment is relatively easy consisting of the application of a permethrin based lotion from chin to feet, leaving it on overnight and washing off in the morning. This kills the live mites on the skin but not the eggs within the skin which will hatch within 3 to 10 days. Therefore, a repeat application is necessary at ten days, I always recommend a third application after a further five to ten days to ensure all mites are killed. The lotion does not require a prescription and is quite cheap.

I suggested to this patient that he try it and also advised him and his wife to wash the bed clothes in hot water next day and leave them on the line in the sun all day. I also asked him to return if there was no improvement in a couple of days. He returned the very next day and proudly proclaimed that the itch and rash had almost completely resolved already. He displayed the rash and it certainly was vastly improved on the previous day.

A similar patient had presented a couple of months previously. He worked at a remote gold mine in the far north of Western Australia on a fly-in fly-out roster. This necessitated the use of shared accommodation. He presented with an horrendous, bright red, intensely itchy rash which was very obvious on his face and covered his entire skin. He told me he had it for months and had seen several different doctors when he was back from the mine. He had been prescribed various treatments including steroid drugs which relieved his symptoms but they recurred within days of stopping the steroids.

It was difficult to find a patch of skin that was not grossly inflamed but when I did and examined it with my binocular loupe I found the tell tale serpentine lines of scabies. He returned of his own volition two days later to show me how much the rash had improved and tell me the itch had stopped.

Only last month a young woman was sent to us by her GP with a letter stating she needed to be admitted and treated with intravenous antibiotics for severe, extensive cellulitis of her limbs. Her skin was certainly red, hot and swollen but she did not have swollen glands, she was not toxic and not febrile as would be expected with cellulitis as extensive as the rash was. I found the serpentine lines. We commenced her on steroids, to deal with the severity of the inflammation, plus the scabies treatment but also arranged an urgent appointment at the dermatology clinic of a teaching hospital.

Rashes can be very difficult to diagnose on occasions and certainly the rash caused by scabies can mimic many others and is often misdiagnosed. Rashes are not always what they seem.

Medical students use alliteration and a lot of mnemonics to help learn anatomical relationships, causes of various clinical signs and symptoms and the signs and symptoms of various diseases. They also string together letters, words and even sentences and use alliteration to better their cause. One example of alliteration, used to describe the classical person who presents with disease of the gall bladder and/or biliary tract, is Fair, Fat, Fertile, Female of Forty – the five Fs.

Enterprising medical students will make up their own mnemonics or supplement some that already exist. The Five Fs, for instance, can easily become the ten Fs in a fertile young mind – Fair, Fat, Fertile, Flatulent, Fecund, Fervent, Febrile, Female of Forty or Fifty.

At about nine am the nurses asked me to see a thirteen-year-old girl who had severe abdominal pain and vomiting. I took one look at the mother, sitting, worried, alongside the bed and the five Fs sprang immediately to mind. The girl, too, was very big for her age - both tall and very much overweight. I thought to myself that she would doubtless follow in mother’s footsteps and also become a Five F later in life.

Anyway, I was able to determine that the pain had started about four hours earlier in the wee small hours; that it was colicky in nature – that is, it was present continuously but also came in waves of much greater severity. It was present in the upper abdomen in the midline but also radiated into her chest and through to her back between the shoulder blades. She had a strongly positive Murphy’s sign when I examined her abdomen. That means that when I pressed as firmly, deeply and as gently as possible over the right upper abdomen and asked her to take a deep breath in, she felt a severe stabbing pain and stopped inhaling. I did that once only. I could find no other abnormality.

This threw me into a bit of a quandary. The history I had obtained from patient and mother and the findings on examination led me to a diagnosis of biliary colic. This means she had a stone in her gall bladder or in the duct leading from the gall bladder down through the pancreas into the intestines and, probably, an inflamed gall bladder. The quandary was that I had never heard of such a condition in a thirteen year old. I had to be wrong. There had to be an alternative diagnosis - but I could not think of one.

Anyway, the history and examination had taken less than five minutes and the poor girl desperately needed relief from her pain. We inserted a cannula into a vein in her arm and took blood for a battery of tests. We gave intravenous morphine to ease the pain and metoclopramide to stop the vomiting. We then put up a drip of saline solution to replace the fluids she had lost through vomiting. It was fortunate that she had good, accessible veins in her arms. Obesity usually causes the veins to disappear under a layer of fat and become very difficult to cannulate. While all this was going on I explained my diagnosis to Mum and patient and also confided that I had never seen anyone so young with that diagnosis. I wrote up my notes, filled in the laboratory request form and also wrote a form requesting an ultrasound examination of the gall bladder.

I discussed my patient with another doctor. She felt my diagnosis was highly unlikely but could not offer an alternative. She agreed I had to at least exclude biliary colic before proceeding to further investigations.

An hour later the blood reports arrived - all entirely normal. That was reassuring and excluded a heap of other diagnoses. Meanwhile the patient’s pain had resolved completely. The morphine had worked, of course, but now she had no pain at all. That fitted my diagnosis because the classic pain of biliary colic lasts about four to six hours – the time usually taken for a gall stone to pass from the gall bladder into the intestine. It causes pain by stretching the ducts and causing them to go into extremely painful spasm. The stones are too small to dilate the intestine therefore, when they reach there, the pain stops.

Then the orderly took her away for the ultrasound examination. She returned beaming and happy; as was her mother. The technician had shown them other gall stones in the gall bladder and had found nothing in the ducts. They both thought the sun shone out of me. I was amazed and a bit non-plussed. I decided to wander down to the x-ray department and have a chat with a radiologist about it all. He was laid back and not a bit surprised that a thirteen-year-old had gall stones. “Not common, mind you, at thirteen, but we see lots of them in women of eighteen or twenty.”

I gave Mum a copy of the ultrasound report and advised them to take it to their GP. The girl would need to see a surgeon and have her gall bladder removed. Until that is done she is at high risk of another attack of colic and also of infection in the gall bladder not to mention a stone causing obstruction to the ducts. These latter two conditions are life threatening.

Perhaps the mnemonic should now read – Fair, Fat, Fertile, Females of Firteen.

I suppose the good news part is that most gall bladder surgery these days is done by laparoscopic “keyhole” surgery. I had mine removed this way a few years ago. It wasn’t a lot of fun but far less painful than the old-fashioned slash across the belly with its associated high rate of complications. I only scored two of the Fs – Fat, (well, let’s just say a little overweight), and Fertile, (I’ve fathered two offspring). I’m by no means Fair, I’m not Female and I was sixty five when I had the surgery – not Forty, Fifty - or Firteen.

The afore-mentioned Murphy, by the way, is not the one whose Law dictates that if anything can possibly go wrong then it will. Ours is John Benjamin Murphy (1857-1916) – the “stormy petrel” of American surgery early in the twentieth century. He was an innovative and flamboyant surgical genius and tall poppy and challenged many surgical principles of the time. Some of his contemporaries tried, unsuccessfully, to cut him down. He was called to attend President Theodore Roosevelt after he was shot in the chest but elected to treat him conservatively and leave the bullet in place. Roosevelt survived. Murphy described several other different tests and observations used in medical examinations and diagnoses.

On the subject of mnemonics, medical students all over the world use them to memorise the names of the twelve pairs of cranial nerves. “On Old Olympus Towering Top A Finn And German Viewed Some Hops” was one I used. The first letter of each word is the first letter of the name of a cranial nerve. E.g. “O” = Olfactory; “V” equals Vagus and so on. I have never forgotten the mnemonic but now struggle to remember the names of the relevant nerves. Wikipedia lists no less than forty different mnemonics for the cranial nerves. Many attest less to the inventive minds of students than to their prurience.

Abbreviations save us a lot of writing. FOOSH means Fell Onto Out Stretched Hand. NOF means Neck Of Femur and usually that it is a fracture of that bone. AAA does not mean First Class or 1.5 volts but Abdominal Aortic Aneurism – usually leaking or ruptured. BIBA – Brought In By Ambulance. SOAP – Subjective, Objective, Appraisal, Plan – a logical method of writing up medical notes. Some doctors actually use the letter, or even the word, as headings for the sections. NAD – No Abnormality Detected. But it is a brave young doctor who will use this abbreviation if working for a pedantic boss. For instance, if the notes contain the words, “Cranial Nerves NAD’ and the boss finds an abnormality when examining that patients cranial nerves he/she might say, “By this I presume you means that examination of the cranial nerves was Not Actually Done?” Should this eventuate then the BYD (Brave Young Doctor) can expect it to be said in public, (on a ward round for instance), and in a tone of voice dripping sarcasm and scorn.

PU – pass/ed urine. IDUC – Indwelling Urinary Catheter. TURP – Trans Urethral Radical Prostatectomy. A note might say, “TURP 5/7, RO IDUC, PU.” A more succinct way of saying – “This patient had a Trans Urethral Radical Prostatectomy five days ago. The Indwelling Urinary Catheter was removed and he subsequently passed urine.”

There are, literally, hundreds of other abbreviations used in medicine. Taken out of the context of medical notes, journals or books most are meaningless. Very few ever become part of everyday language but one outstanding exception is CABAG – Coronary Artery Bypass Graft. This method of surgically treating blockages in the arteries supplying the heart muscle has become so common place that the mnemonic has become an English language neologism. When we are taking a medical history from a patient, and enquire about previous operations, patients will often volunteer, “Had me cabbages done a couple of years ago.”

All Is Not As It Seems

Alliteration

I suppose it is simply due to the fact that I belong to a much older generation that I am not able to come to grips with the modern methods of adornment of the human body. Men shave their heads and cultivate stubble on their faces – I often wonder how it is that they can keep it looking every day like they haven’t bothered to shave for five days. Young women seem to be fascinated with tattoos on their shoulders or buttocks or both. And both genders seem unable to get enough metallic devices shoved through their various body parts.

Blokes started wearing ear rings quite a while ago – much to my amazement. Now, men and women quite commonly have a row of rings piercing both ears. Looking into throats now-a-days frequently reveals a steel pin, with a small, coloured, ball attached, stuck through a tongue. Eyebrows, lips, nipples and navels of both genders commonly have rings dangling from them and not even the genitals are spared from attack.

A young, adult male recently presented to E.D. complaining of anal pain. I had a look and diagnosed a small, external haemorrhoid which required only simple analgesic cream. What caught most of my attention, however, was the cluster of steel pins through his penis. Twenty one in number, each had been thrust through a pinch of skin (certainly not through the body of the organ). On each end was a small plastic knob.

I volunteered that it was none of my business but I asked if he would mind explaining it to me. In fact he was quite proud of it and said it was the trendy thing to do. I asked what he did with the bolts during intercourse. He just left them there, he said, and his girl friend loved them. He didn’t consider himself at any risk of infection or trauma. And that was that. My comprehension was not improved.

On another occasion a very angry mother literally dragged her fifteen year old son into the department. She was angry at him, not at us, because he had pierced an ear lobe himself with a needle and inserted a cheap stud. It had become infected and he now had grossly swollen and inflamed ear lobe which dripped yellow pus. Mum wanted the ring removed immediately. The boy didn’t want me to touch it, which was not at all surprising, as it was very painful. Eventually we got him to consent to me having a close look.

My heart sank because I could not see any part of the stud - it had been engulfed by the swollen and inflamed skin. I began to think he would need a general anaesthetic to incise the tissues, drain out the pus and locate and remove the stud. Neither Mum nor the boy was keen on that suggestion. Mum explained that all I had to do was unclip the fastener on the back end of the stud somehow and the shaft would come free. All very well but I couldn’t see any part of the stud let alone the clip.

I explained I could possibly gently probe with a pair of fine artery forceps in the hope of feeling the clip then grasp it and free it. We decided to give it a go. The boy was quite stoic about the procedure until, much to my amazement, I felt the forceps contact metal. He began to shout at me to stop while Mum shouted louder at me to get on with it. I maneuvered the forceps into what I thought was the correct position to squeeze the clip and release it and - it did so. The boy let loose with a tirade of vituperation which brought other doctors, nurses and orderlies rushing into the room thinking I was being bashed or worse. Mum was shouting at him to shut up and he suddenly did so as I lifted out the forceps with the clip attached. The stud popped out the other side without assistance. Pus and blood ran freely from the wound. Sweat poured freely from my brow.

We cleaned him up, dressed the wound and gave an antibiotic by injection with a script for follow up oral antibiotics. I asked if they wanted to keep the stud. The boy said yes but Mum grabbed it and threw it into the bin. That was that. He was big enough to swallow his pride and thank me for my efforts with a hand shake. I didn’t think I deserved it as it was not one of my prouder surgical moments.

Another chap presented one Monday with a grossly swollen, obvious infection in his left eyebrow. The ball screwed onto the top end of a stud could be just seen. The other end was invisible. He told how he had a “few beers” on Saturday night and had tripped and fallen on his garden path. On waking on Sunday he realized he had hit his face on the path and he had the beginnings of a black eye. He did nothing about it until Monday when it was obvious to him his wound was infected. So he presented to us.

Gently palpating the swelling with gloved fingers I could feel the steel ball on the bottom of the stud deep beneath the skin. At least that confirmed it was still there, was still attached to the stud and had not been lost in the fall. But what to do, short of deeply incising the infected skin, to locate and remove the thing?

With fine artery forceps I was able to grasp the stud immediately beneath the protruding upper steel ball. Then I was able to manipulate the lower ball to pass back through the opening it had torn in the deeper tissues and pop it onto the surface. I could then grasp the stud with another fine forcep to immobilize and control it while I unscrewed the upper ball. That done the stud and lower ball easily slid out. I could only sigh when he thanked me but asked me to clean, reassemble and put the stud and balls into a clean container for him to take home for reinsertion later.

Then there was the guy who presented with what he called a “torn penis”. In fact his description of the injury was accurate but I still have my doubts about the veracity of how it came about. He told me he had a ring through the frenulum - the small fold of skin on the under-surface near the end - until about an hour previously. He said he decided to see how far he could stretch the skin by tying a piece of string through the ring and the other end to a table. (Please do not ask me why – I didn’t ask!). As he was stretching things out his mother-in-law, of all people, happened to walk into the room. He turned away in haste – a bit too much haste, as it turns out – because the ring tore through the skin. He did not elaborate on any discussion with his mother-in-law or her reaction.

He didn’t much enjoy the injection of local anaesthetic but was quite stoic about it and I assumed that the piercing had been done without it anyway. But I was as gentle as I could be and inserted two stitches to close the tear.

Later, while driving home, I wondered what would happen if the guy with the penile studs manages to get one or more of them infected. I fear we are in line for an epidemic of such afflictions. I suppose that, if I had a rush of blood to the brain, and decided to offer the insertion of objects into the human body, I would smartly be hauled before the medical board and severely admonished if not struck off! But society and health authorities turn a blind eye to the activities of shady characters who perform these acts of mutilation in dingy premises, and pharmacists, too, for that matter, and often on the bodies of minors. Oh well, I suppose they all take solace from the fact that we silly buggers in E.D.’s and the plastic surgeons will save them from the consequences of their own stupidity.

Body piercing is the trendy thing for the young people to do but it can cause major problems. My dentist tells me the tongue piercing wears away the enamel at the back of the front teeth. Rings, in particular, can catch on objects and tear through the skin - even without being tied to tables. They can cause severe infections and subsequent illness and scarring. Most, however, do not cause any complications – they just look unsightly to most people of my generation – and wonderful to the young people.

Body Piercing

Sport, person-on-person physical violence, motor and other vehicle smashes, “accidents” (I believe there is no such thing as an accident), anger and frustration often result in people attending the ED for management of bone and joint injuries.

I mention anger and frustration and will deal with it first because these emotions cause a lot of bone injuries. Believe it or not, a week rarely goes by when we don’t see at least one or two people with “boxer’s fractures”. This is a break through the far end of the fifth metacarpal which is the long bone in the hand right behind the little finger. Sure, many we see are inflicted by the victim punching another person on the hard bones of the face or skull. We just have to accept that as a fact of modern life. The hard-to-believe bit is that we frequently see this bone, and others in the hand, broken by the owner punching a wall or other solid, immobile object in anger or frustration. Most often seen in young males in their late teens but occasionally seen in young women as well.

According to a set of clearly defined criteria, some of these fractures we deal with by splinting the hand, others we send to plastic surgeons or orthopaedic specialists for treatment. These latter patients have bone that is significantly displaced and /or the broken bit is angulated more than fifteen degrees. They may require open surgery or internal splinting with wire or fine steel pins. Given the nature of the injury the skin is often broken which then makes the injury a compound fracture. That is, there is an open wound through which bacteria can gain access to the broken bones and cause bacterial osteo-myelitis. This is a very nasty situation with the potential for very serious complications. I don’t pursue the causes of the anger or frustration but I often wonder just what compels young people to punch a fist with full force into a brick or solid timber wall.

The flip side of the boxer’s fracture is the broken nose or jaw. Some patients have all three. We don’t get too excited about broken noses unless there is severe displacement of the bones. Even then the patient’s are usually booked into an outpatient clinic in a week or more for review after the swelling has gone down. Disfiguring fractures are put back into place. Minor fractures left alone.

Jaw fractures can be a worry. The jaw most commonly breaks in two places and it is a trap into which young players often fall. These fractures usually result in the jaws being wired together until the fractures heal. CT scans are much more reliable with face fractures and we rarely do plain x-rays looking for fractures of the face. This turned out to be a good thing for a little old lady I recently treated. She had tripped on the hose on the garden path and fell forward striking here face on the gravel. She had not lost consciousness and seemed only to have abrasions to her nose and the tip of her jaw. But she did complain of an earache. Examination of the ear revealed nothing abnormal. I was acutely aware that pain from the temporo-mandibular joint (the jaw joint) can often be felt in the ear but her joint was not tender and she had a full range of movements without pain. I requested a CT scan and, lo and behold, there was a severe fracture of the jaw. That part of the jaw that fits into the socket in the skull bones, just in front of the ear, had snapped off completely and was displaced out of the socket. The dear old soul had to be dispatched off to the facio-maxilliary surgeons.

Little Jason was a six year old boy brought in by his parents after falling over backwards and his left upper arm striking the edge of the gianormous back pack tiny kids appear compelled to wear to school every day. He was very distressed and obviously suffering a lot of pain which, he indicated, was in his left upper arm. There was no deformity and no bruising but he was very tender when I gently felt around the mid-shaft of his humerus, (the bone in the upper arm). I was sure he had a fracture even though the mechanism was not consistent with that.

We gave him a good dose of oral analgesic, (pain killer), then waited until it kicked in before sending him off for an x-ray. I got the images up on our computer screen as soon as they became available. Sure enough, there was a comminuted fracture through the mid-shaft of the humerus with considerable displacement of the fractured bone ends. This mean there was not just a simple break through the bone but that it was shattered. Not only that but the cortex of the bone appeared abnormally thin and there was the appearance of empty space within the bone.

I nipped around to x-ray and grabbed the radiologist just before he knocked off for the day. He confirmed my findings and announced that there was, indeed, a large bone cyst at the point of the fracture. In technical terms we were then dealing with a pathological fracture, that is, a fracture with an underlying disease involved. The good news was that the cyst was benign, not malignant.

I rang the orthopaedic registrar at a teaching hospital and he advised me to send the boy up immediately. We put a plaster-of-paris back slab splint on his arm to keep it immobile, and his parents elected to drive him up. I heard no more until, a few months later, his parents brought him in again after a fall. Parents and patient were convinced he had broken the same arm again. It had transpired that, the night of the original fracture, the orthopaedic consultant on call had advised they wait for a few months and let the fracture heal itself – which that type of fracture does – but to then let him perform a bone graft that would permit the arm to develop normally and prevent further fractures. He had sternly warned patient and parents to be careful to prevent another fracture in the interim. So, on the second occasion I saw him he had fallen onto the same arm, it hurt and all were convinced it had broken again. X-rays disproved that. We could easily see the original fracture but it had thick, healing callous around it and the broken ends were not displaced from their original positions.

We applied another plaster-of- paris splint and sent him home. I gave them a letter and the new x-rays and advised they get back to the orthopaedic specialist. In fact they already had an appointment within the next week. I haven’t seen him since.

At the other end of the age spectrum are those with osteoporosis and prone to falling. Just about every Monday morning two or three ambulances will roll in each with an elderly patient, usually from a nursing home, and a history of falling and a painful hip. The ambulance officers usually splint the affected led by tying it to the other. When we remove the ties the affected leg is obviously shorter than the other and the foot will be turned, usually, outwards. These are classical signs of a fractured neck of femur- the femur being the thigh bone - and it snaps at the hip joint. X-rays confirm the clinical diagnosis.

We often do a femoral nerve block by injecting local analgesic into the femoral nerve in the groin. This relieves the pain. It is necessary to insert a catheter into the bladder and leave it there to control the flow of urine into a bag. We immobilize the legs again and arrange transfer to a teaching hospital where surgery will be performed to repair the fracture. The patient will most often be up and about and back in the nursing home within a few days.

On occasions patients with fractured NOF – neck of femur – or other fractures, sustain the injury in their home. These people, all too often, live alone and it is obvious to one and all that they really should not live alone. They may be dirty, disheveled, underweight, dehydrated and often confused. When asked, the ambulance officers will report the house to be sadly untidy especially in the case of elderly men who live alone. When the next of kin arrive – usually an adult off-spring of the patient – they hasten to reassure us that they try their hardest to look after the parent and have repeatedly but unsuccessfully tried to persuade them to move to accommodation where care and support is provided. We have no cause to doubt them and need to reassure them that they have no reason to feel guilty.

With the presenting injury managed and under control I will often take it upon myself to have a quiet chat with the patient and suggest the time may have come to seriously consider alternative accommodation. The spectre of “a nursing home” and horror stories of many years since may be raised. Many, though, realize just how precarious their existence has become; with others the prime concern is inconvenience to their children. My next move will be to suggest to patient and next of kin that our hospital social worker can be very helpful at times like this and seek their permission to ask that good lady to attend. Expert at dealing with such crises at such times, the social workers invariably set the family on the right track to explore the options and help them make rational decisions.

Another fracture common in seniors is Colle’s fracture of the wrist. The patient usually trips and falls onto the outstretched hand breaking the radius just short of the wrist and displacing the broken fragment backwards. This almost invariably requires intervention to get the bone back into near-normal position and alignment. Once-upon-a-time this was always done under general anaesthetic in the operating theatre. Now it is usually done under local anaesthetic in the ED. A plaster of Paris splint is applied and the patient goes home with an appointment for orthopaedic follow up in due course.

In younger people the same mechanism of falling onto outstretched hand often results in a fracture of a small bone in the wrist joint – the scaphoid. Even though there is a classical injury history with classical symptoms and clinical signs it is often difficult to diagnose in the early stages because the fracture line will not clearly show on x-rays for ten to fourteen days. Most of us in ED, whenever we suspect such a fracture, will immobilize the wrist in plaster of Paris and arrange repeat x-rays and review in two weeks.

Even though this is a small bone it is an important bone. And this complicates matters because its blood supply comes from an artery than runs backwards onto the bone. That is, the artery branches off its parent at a point past the scaphoid and runs into the bone at its furthermost point. Fractures of the scaphoid most commonly run across the mid-point waist of the bone hence can disrupt the blood supply to the near half which may suffer ischaemic necrosis (death from lack of blood) and crumple up. The end result of this is severe arthritis and limitation of function of the wrist joint.

While we are discussing the upper limb – fractures of the clavicle (collar bone) are common especially in the young. (Young can mean not as old as me; but here let’s say in those under forty.) Falls from horses, motor bikes, push bikes, fences, monkey bars and swings often result in a fractured clavicle. And so do person to person collisions as occur in many contact sports such as Aussie Rules footy. This fracture , traditionally, was considered to be of no great significance and treated with a collar and cuff sling and analgesics. (The collar and cuff was preferred to the full arm sling because it allows the weight of the arm to pull the broken ends back into position.) The Generation Y orthopaedic specialists seem to be taking a different view of this fracture. They are doing “open reduction and fixation” – that is – operating to get the bone pieces back into place and holding them there with plates and screws. Some use a large, ugly screw that looks like an auger and is screwed in to the bone marrow.

There are advantages to the surgical approach. Normal function is returned quicker and, because the broken bones ends are immobilised sooner, there is less pain. The flip side is risk. Immediately behind the clavicle runs the brachial artery and vein and, a bit further away, the brachial plexus or bundle of nerves. These organs supply the arm. Without suggesting that any surgeon is careless, operating on the clavicle requires meticulous care to avoid damage to any of the afore-mentioned structures the consequences of which could be disastrous.

Just at the tip of the clavicle in the shoulder lies the shoulder joint and this is commonly dislocated. The ball shaped upper end of the humerus bone in the upper arm fits into a shallow socket called the glenoid cavity formed by three parts of the shoulder blade aka the scapulla. The humerus can be dislocated in front of the glenoid cavity, behind it or below it and it is very difficult to determine, on x-rays, which way it has gone or even if it has gone at all. That is, if you do not know of the Mercedes Sign. Picture the symbol of the Mercedes-Benz motor company – a circle with three equally spaced radii. OK? Well, if you take an x-ray of the shoulder from the side the three parts of the scapula forming the glenoid cavity resemble the mercedes Sign inverted. Overlying it is the humeral head. If the centre of the head overlies the centre of the cavity the shoulder is not dislocated. The location of the centre of the humeral head relative to the centre of the Mercedes symbol tells us if it is dislocated and if so if it is to the front, behind or below. This is important as it dictates what manoeuvres are necessary to get it back in place.

As a bit of an aside, we have all heard of Mercedes Benz and, perhaps Daimler-Benz. Karl Benz built and patented the first petrol-powered automobile in 1886. Gottlieb Daimler added a petrol engine to a stage coach later in 1886. In 1926 the Daimler-Benz Motor Company was formed and all of their product vehicles were to be called Mercedes-Benz. So, who was Mercedes? She was, in fact, the daughter of one Emil Jellinek who was a member of the board and who had some racing cars built to his specifications. He insisted that the engine be named the Mercedes… and the rest is history.

All of that has precious little to do with the Emergency Department other than that motor vehicles provide us with a great deal of work although not a lot from Mercedes per se – probably because, in Australia, their smash numbers are statistically insignificant. And now, let’s move on to another bone.

Calcaneus is the name given to the heel bone. It is commonly broken in falls from heights with the victim landing upright. A favourite of roof carpenters who fall and people who slip off the rungs of ladders landing on their feet, as well as drunks, or the adventurous, jumping onto solid ground from heights. In fact, in the literature, they are sometimes referred to as “Lover’s Fractures” because they could, presumably, result from a lover leaping from a bedroom window to escape an enraged spouse – honestly! The bone is usually impacted into itself but the fracture can be difficult to see on x-rays. CT scans give better results. The clinical clues to diagnosis are severe pain, with the patient being unable to bear any weight on the affected foot, swelling, bruising and severe tenderness. Often (7%) both heels are smashed.

These fractures present challenges to the orthopaedic surgeons – into whose care most of these patients are referred. Surgery is usually required to attempt to dis-impact the crushed bones and get them back into as normal position as possible. 70% of these fractures run into the adjacent ankle joint and even good repair may still results in severe arthritis in the ankle. Not at all a nice fracture to have and we do see our fair share of them presenting to ED.

Sport – a variety of physical activities, undertaken by many and passively but passionately followed by many more Australians, provides us with much of our bone and joint emergencies. I have never seen any statistical research results of studies into what sport costs the nation but I would venture to suggest it would be astronomical. Joint injuries are most common especially ankles and knees. Football of any type and netball/basketball are the prime contenders for ignominy.

Inversion injuries, commonly known a rolled ankles, roll into ED with monotonous regularity on Saturdays and Sundays. The ankle is usually very painful, tender and swollen around the lateral malleolus - the bony protuberance on outer side of the ankle. Careful examination will usually differentiate between a sprain, in which the ligaments holding the lower leg onto the foot are torn, and a fracture in which bones are broken. These ankles are usually x-rayed because it is difficult to exclude an avulsion fracture – where ligaments are torn out of the bone or a fragment of bone is ripped away.

Ankle fractures demand a plaster of Paris back slab and orthopaedic specialist consultation in due course. Sprains are occasionally also treated with a plaster of Paris back slab but usually just supported with an elastic tube or bandage. We advise ICE – Ice packs, Compression and Elevation for the first day or two. Non-steriodal anti-inflammatory medications are often prescribed along with analgesics and we advise the use of crutches until the victim can bear weight without pain.

Aussie Rules footy and netball cause more than their fair share of knee injuries. In netball, the rule that requires the player to catch a ball and immediately turn through 180 degrees before throwing it to another player is an abomination. It is difficult to imagine a mechanism more effective at screwing up knees. And the Aussie Rules player who takes a spectacularly high mark is just as likely to inflict a spectacular injury on a knee when he touches down.

A very common knee injury is a torn meniscus – the meniscus being the rim of cartilage that forms a rather inefficient shock absorber between femur and tibia (thigh bone and shin bone.) There is one on each side of each knee. The classic mechanism of tearing it is twisting the knee when it is under pressure just as the netball player does and so does the Aussie Rules player twisting and turning on the run. In days that have fortunately long gone the treatment of a torn meniscus was to operate and remove it. The end result of that, all too often, was serious osteo-arthritis on the knee with bone scraping on bone and necessitating knee replacement surgery. The modern treatment is still surgery but a far more sophisticated operation done via an arthroscope to nibble away only the damaged edges of the meniscus.

The rite of passage for the modern footballer now seems to be torn cruciate ligaments demanding knee reconstruction. It is not uncommon for us to see patients with new knee injuries and proudly proclaiming that they have had one or more previous knee reconstructions. They seem to think the operation can be done over and over with each one giving them another season – or part thereof –on the field. Their ultimate fate might best be demonstrated by the chap I met in a caravan park recently. Ten years or more younger than me he hobbled about the place with great difficulty and in considerable pain. “Aussie Rules!” he explained. “Both knees reconstructed twice and both replaced last year.” I gave him a chair, which he accepted very gratefully, and a can and we had an interesting chat about footy.

Mind you, not all knee injuries are due to sport. Just recently a Good Samaritan brought in a chap who had fallen off his bike and injured a knee. He could not put any weight on the knee at all and was in severe pain. We gave him something for the pain and he explained that his bike wheel got caught in a groove between road and kerb, at low speed, but he fell side ways. As he fell he put his leg out to break his fall but it all went pear-shaped and he finished up on the ground with agonizing knee pain. The Samaritan had him with us within fifteen minutes of the fall.

His knee was grossly swollen and impossible to examine formally but I did determine he was extremely tender around the outer side of the knee. Because the knee had swollen so quickly it was reasonable to assume it was bleeding inside. Testing the cruciates and collateral ligaments was impossible but the knee cap and patella tendon appeared intact.

At first scrutiny the x-rays appeared unremarkable. Very close examination using the eye of faith suggested there was a fracture through the boney protuberance on the tibial plateau to which the anterior cruciate ligament attaches. (The tibial plateau is the wide surface at the top of the tibia through which the thigh bone transfers the body weight to the lower leg, ankle and foot.) This situation demanded a CT scan even though they are not as reliable as PET scans at revealing knee damage especially to the ligaments. But we don’t have a PET scanner so off he went to the CT machine.

The pictures confirmed a fracture through the anterior cruciate insertion. However, I was surprised to find a crush fracture of the tibial plateau on the inner side. Serious stuff! The causative mechanism was the knee trying to bend sideways when his foot was in contact with the ground as he fell. Of course the knee will not bend sideways but the forces produced were enough for the thigh bone to crush the tibia. The unfortunate patient had to be admitted to hospital for management by an orthopaedic surgeon.

Broken ribs are a common consequence to fighting but there are other causes of course. They are not considered to be terribly important, (other than to the suffering patient), and are most commonly treated with rest and analgesia. In the olden days we strapped the chest with elastoplast but too many patients developed pneumonia so that fell out of favour. (The strapping stopped the fracture end from moving but also stopped the lung from inflating which leads to pneumonia.)

Rib fractures are difficult to see on x-rays unless the fractured ends overlap or are otherwise displaced. However, most doctors do ask for x-rays any way. It helps to diagnose a pneumothorax, haemothorax or flail chest. A pneumothorax is free air in the chest outside the lung. A displaced rib fracture can tear the lung allowing air to escape. A haemothorax is free blood in the chest caused by the same mechanism. They can co-exist. A flail chest is caused by one or more ribs fracturing in two places which is not uncommon. This upsets the respiratory process and when the patient inhales the affected part of the chest wall moves inward when it would normally move outward. If several adjacent ribs have flail segments the paradoxical movement can seriously compromise the patient’s breathing.

Spinal fractures vary from life threatening fractures of the neck to relatively minor fractures of those bits of vertebrae that stick out to offer attachment for muscles. The serious stuff is always sent off to the specialist management hospitals. The not-so-serious may be treated in the local hospital or even in the home. Any suspicion of spinal fracture is always regarded and assessed very carefully. And so it is with skull fractures also. They are all treated very seriously and often require surgery to correct bleeding inside the skull or even heroic surgery to remove bone to allow the brain to swell – and then putting the bone back when the swelling goes down.

Pelvic fractures are usually a consequence of severe trauma and are often associated with injury to intra-abdominal organs. The pelvis – like the jaw – will usually fracture in two places rather than one. Uncomplicated pelvic fractures are most often treated with rest in bed with appropriate analgesia. Others require surgical intervention toreduce and immobilize the fractures. (Reduce means to get displaced bones back into normal or near normal position.)

And now that we’ve broken just about every bone in the body that part of the journey ends.

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Bones

No one enjoys diagnosing cancer. Everyone particularly hates making the diagnosis in young people. Little kids are the worst even though they do not understand what is happening – it is Mum and Dad, Nanna and Granddad and the sibling and other relatives who bear the brunt of the shock and heartache. But these poor littlies still suffer the agonies and tortures of treatment that adults suffer – the only difference is they do not understand why. Teenagers usually know enough about cancer to realize what an appalling situation it is to be in.

In the ED, strangely enough, we diagnose a lot of cancer. People come to us with bleeding from the bowel or intractable headaches or chest pains or broken bones from pathological fractures or coughing blood and so on. These problems are all emergencies – in the eyes of the patients at least. After taking a history and doing an examination we have rapid access to laboratory tests, x-rays and CT scans. A diagnostic process that may require several visits to the GP over a week or two, after a week or three wait for an appointment, can be fast tracked into a few hours. And immediate consultation with appropriate specialists or transfer to a tertiary hospital can be arranged the same day.

Troy was seventeen and enrolled at TAFE doing a personal trainer course. He had been doing a lot of cricket training of late, especially bowling, and he was left hand dominant. He attended with his Mum. Both were intelligent, pleasant, likable people. Troy complained of left chest pain, constant, radiating around the chest and worse when he bowled a cricket ball or took a deep breath. He said it had started after the intensive cricket but his mother disputed that and said he had complained of it frequently for the better part of a year.

He looked quite fit, had a mild scoliosis in the chest (curvature of the spine). He had no neurological signs and no abnormal sounds in the chest but it hurt him when I applied rapid compression to his chest side-to-side. His ECG (electrocardiogram) was strangely abnormal to the degree I asked nurse to do it again – with the same result. I requested a chest x-ray and was dismayed to find it grossly abnormal. The radiologist suggested an immediate CT scan of the chest and there was the diagnosis.

Troy had a tumour the size of a mango sitting in his chest behind and to the left of his heart. It was encroaching into two inter-vertebral nerve outlets thus causing the pain radiating around his chest. The radiologist was of the opinion it was an advanced non-Hodgkin’s lymphoma - a form of cancer. It was my duty to inform Troy and his mother.

Such tasks are painful to all involved. I take the view that there is no point in beating about the bush – the patient must be informed of exactly what we have found and of the most likely diagnosis. But this must be done clearly, gently, with compassion and empathy, and without delay. This I did.

Two worlds fell apart before my eyes. Troy was obviously shocked. His mother broke down crying with her face in her hands. Troy rapidly regained his composure, hugged his mother and told her, “Mum, don’t cry, I am going to beat it!” Then followed the questions and answers. I informed them of what good news there was – the tumour appeared to be above the diaphragm only and that rapidly advancing treatment modes have dramatically improved the survival rates of this disease.

Then followed the arrangements for Troy’s transfer to a teaching hospital. His Mum left and a bewildered and confused Dad arrived. I walked him through it all. It was another hour or so before the transfer arrangements were completed. Dad volunteered to drive him rather than use the ambulance. I was busy with another case when the time came for them to leave but they waited until I was free, both shook my hand and thanked me most sincerely for my efforts. It is those moments that distress me immensely yet deliver the greatest intrinsic rewards in medicine – patients expressing sincere gratitude even though I had delivered them the most frightful news.

There is an interesting sequel to that day’s events. Six months later Troy, his mother and younger brother arrived back in the ED. Troy had broken a bone in his foot in a minor event on his bike. It was easily sorted out. His mother carried a folder containing, as it transpired, all the medical notes and laboratory reports about Troy’s lymphoma. She wanted me to see it and I duly perused the contents. Then the mother got my complete and undivided attention as she described how she felt when I first told them Troy’s tentative diagnosis. “I wanted to get up and slap you across the face as hard as I could. I suddenly hated you for what you were doing to us. But a few days later, when the specialists told us the full extent of Troy’s illness, I realized you had actually saved his life. You didn’t send us away like some other doctors had. Troy would have died if you had.” That caused me a certain amount of introspection. I am satisfied her reaction was a consequence of the message, not the messenger.

We had been wrong in our initial assessment of the extent of the disease. In fact it had been a Grade Four, (very widespread), Hodgkin’s lymphoma with a poor prognosis. Troy had undergone six months of chemotherapy and a recent PET scan had found no evidence of tumour. He is not out of the woods yet but he is as optimistic as ever. I feel he will beat it.

Only a week before Troy another young man of about twenty years presented with a small, tender lump in his thigh just below the groin. He appeared athletic, fit and well. Examination confirmed the small, tender lump under the skin of the thigh but also a mass of tender lymph nodes in his groin and there were others in one armpit. There were a couple of minor abrasions on his lower leg but nothing that could be considered a focus of infection severe enough to cause such a reaction in the lymph glands. There was nothing else to find in a thorough examination. Taking a more detailed history added only the fact that he had lost four kilos in weight in recent weeks for no apparent reason.

His chest x-ray was normal but his white cell count was grossly elevated. I went to the laboratory and had a chat with the scientists and asked them to examine a blood smear. This revealed some abnormal white cells of a non-specific nature – that is to say they were not normal cells but not the cells seen in leukaemia or other sinister diseases. I then rang a haematologist – a specialist in disorders of the blood and lymphatic systems. He agreed there was cause for concern and agreed to see my patient at his clinic a few days later.

Sitting on the side of the emergency ward trolley I explained the situation to the patient as best I could. It was awkward, (the telling, not the sitting), because I could only tell him I suspected he might have something serious going on but I did not have enough information to make a firm diagnosis. He asked what was the worst case scenario. I had to tell him it would be a form of cancer such as leukaemia or a lymphoma. He appeared philosophical about it saying, “Oh well, I’ll just have to wait and see what the specialist has to say.”

I heard no more for a couple of weeks then ran into the specialist in the hospital and asked about this patient. He informed me that when he saw the patient the glands were barely palpable, the lump in the thigh had gone and the white cells had returned to normal. We don’t know what had caused all of this but I was delighted the worst case scenario had not eventuated.

The hospital rang me the other day and asked if I could come in to help out in a very busy period with two doctors short. On arrival I took over the care of an elderly gentleman – among several other patients. He had presented with pain in the right hip, present for several months with increasing severity but had reached a stage where he could no longer ignore it. He could not put foot to floor now because of severe pain but was pain free at rest. He did not look at all well and told me he was being treated for aggressive cancer of the prostate as well as lymphoma and both were “in remission”.

His wife was with him and asked if I thought the pain could be due to cancer. It would be a pointless lie to say no, so I told her it was possible but there were other possibilities also including a fractured bone. And that was what the x-ray revealed – he did have a fractured neck of femur. It was not of the type that occurs with a fall but more of a gradual giving way of very osteoporotic bone.

I took the x-rays around to the operating theatres where I knew an orthopaedic surgeon was working. My timing was impeccable as he had just finished one case and was waiting for the next to arrive. He looked at the films while I told him about the patient. His considered opinion was that the patient needed surgery to insert a “pin and plate” to stabilize the fracture. Failure to do so would inevitably result in the bone shearing through into a complete fracture that would be very difficult to deal with and leave the patient with a very poor quality of life in the time left to him. The concurrent prostate cancer and lymphoma reinforced the need for surgery rather than being contraindications.

Patient and wife accepted, with equanimity, what I had to say. However, he was very surprised when I said I would arrange transfer to another hospital, where the surgeon performed such surgery, by ambulance. He wanted to drive himself. “How on earth can you drive a car.” I asked.

“Well, it is a bit awkward, but I use my left foot on the accelerator and brakes. It takes me a while to get in and out too.”

It took the best of my powers of persuasion to convince him that an ambulance would be much more satisfactory. Then I had to work through how we could get his car home. He had driven it to the hospital and his wife did not drive. We eventually arrived at a mutually acceptable solution, the ambos turned up and away he went. His wife thanked me and apologised for his intransigence. I smiled, thanked her and told her apologies were not necessary.

From time to time I have a medical student tagging along behind me. I enjoy having students with me and making whatever contribution I can, not only their knowledge base, but also to their “life experience”. By that I mean I deliberately expose them to such situations as informing patients, such as young Troy and his mother, of dreadful diagnoses. I had a student with me that day – a mature age Emergency Department nursing sister who had decided to do medicine and was at the end of her third year. Despite her work experience she had never participated in such discussions previously. With permission of patient and mother she observed what took place. Afterwards we sat down and discussed how I went about it and the respective reactions of patient and mother. (The mother had given no indication of her anger with me.)

A few days later she had the opportunity to participate in a similar discussion with another doctor. This time the patient was a man in his fifties who had come in blue in the face and very short of breath which he said had come on while mowing the lawn. In fact it had been building up for some time. His body’s compensatory mechanisms had become exhausted when mowing the lawn. I was not looking after him but, as he was an unusual but classic case, we doctors had a discussion about it and reviewed the x-rays together. These showed a large tumour in the apex of his right lung. It was undoubtedly lung cancer – he was a heavy smoker – and the tumour was compressing the veins that bring blood back from his head and right arm. His doctor invited the student to participate in the process of informing him and his wife of the dreadful diagnosis. After that he was sent off to a teaching hospital for urgent surgery to decompress the veins.

I occasionally allow myself a wry smile when I feel I should show a student something mundane but which, to me, is interesting. But, when I look for them, I find they are engrossed in trying to interpret a CT scan of the brain or are observing treatment of a convulsing drug addict in one of the resuscitation rooms. Diseases such as scarlet fever, (I saw a case just recently), quinsy, scabies, embedded corneal foreign bodies, foreign bodies in the ears or noses of children, a basal cell carcinoma on the face of woman, hand-foot-and-mouth disease in a child –these are some of the afflictions that first present to the GP – or the ED. Most of these young doctors are going to finish up as metropolitan GPs and these are the conditions they will have to diagnose and treat. They will have a better chance of success if they have seen at least one case previously. In general practice the will not do much CT brain scan interpretation – it will be done for them by radiologists - and, unless they move into the country to practice, they will do precious little resuscitating.

Shingles is another case in point as it does not always present in its classical form but it does often present in cancer patients – a most undesirable complication to their disease. It is caused by the chicken pox virus which, after a child has that disease, may settle and reside for many years, in the dorsal nerve roots in the spinal column. At a time of its own choosing, usually when the patient is severely stressed emotionally, physically - or both – as in the case of cancer victims, the virus decides to multiply and migrate down the sensory nerves to the skin where it forms vesicles (blisters) and causes severe pain. It can be treated with anti-viral medication provided such treatment is commenced within 72 hours of the onset of symptoms. So, if the doctor does not recognise the affliction at first presentation the boat will be missed and the cancer patient will have yet another burden to carry.

A diagnosis of cancer does strike fear and dread into most patients. It is, indeed, a dreadful diagnosis. Roll on the day when the scientists will have found better cures than those we already have for most cancers – and cures for those we cannot cure now.

Cancer

The community, in general, perceives nurses to be a chosen few engendered with more than the average degree of compassion. The media, too, take a similar view - and rightly so. Doctors aren’t far behind the nurses in the compassion stakes although one doesn’t see the media often portrait them in that light. Compassion is certainly desirable in all those who attempt to tend to the ill and injured but it is not the sole preserve of nurses and doctors.

We received the call from the ambulance people near dusk. A five year old girl had been hit by a car on the highway not far from the hospital. She was unconscious, had suffered a seizure and they would arrive in a few minutes. Her father and ten year old brother had witnessed the event, were both distraught and were coming in another ambulance.

The emergency medicine physician, the bright young emergency medicine trainee and several senior nurses immediately dropped whatever it was they were doing and moved into the resuscitation area. Quickly and efficiently they all got into plastic aprons and gloves and started preparing the area. We could hear the distant ambulance siren. The ECG machine was switched on, drip stands and giving sets prepared, syringes and needles laid out, endo-tracheal tubes prepared, laryngoscopes checked to ensure they worked and so on. They were still at it when the ambulance entrance doors swung open and the ambos wheeled the trolley briskly into the resuscitation area at the nurse supervisor’s direction.

There was no real place for me in the resusc team and it was better I kept out of the way. There was plenty to do because the two doctors now working on the little girl had been attending to other patients and no other doctors were rostered on. Also, there were several patients in the waiting room. My job, along with the few remaining nurses, was to keep things running as best we could. I went to the waiting room, apologized to those waiting and explained they would probably have to wait an hour or so because we had an emergency to deal with. No one complained. One young bloke in work clothes said, “She’ll be right doc. We’ll just wait our turns.”

I then went around speaking to each of the patients in the ward cubicles explaining that their doctor had to attend to an emergency. I reviewed their notes to determine the stage of assessment and treatment each patient was at and told them I would attempt to keep the processes moving.

By this time the ambulance officers had finished transferring their patient and were collecting fresh linen for their stretcher. The senior officer seemed a bit stressed and I started a conversation with him. It turned out he was very upset that, while he was treating the girl in the middle of the two southbound lanes of the dual carriageway, only a couple of vehicles stopped. He had to get a needle into a tiny vein in the little girl’s arm, while she was having a seizure, start a drip running then give intravenous medication to stop the seizures. This would be difficult enough in the emergency ward with the child on a bed let alone on the roadway. Traffic poured around him, his assistant, the child and the driver of the vehicle that had hit her. It was more than ten minutes before the police arrived and took charge of the very dangerous situation. We talked about it for five minutes or so and he seemed much better. I suggested he might want to avail himself of the ambulance service counselors. He said he thought he would be OK.

A commotion at the ward entrance led me to the child’s mother, confused and distraught and demanding to see her daughter. She worked at the hospital and the orderly and nursing assistants knew her. We decided to take her into a small consulting room while we explained the situation as we knew it. Within a few minutes the father and brother arrived and the scene became one of tumultuous emotional chaos. We let it run until the initial outpourings of shock and grief had run out. While that was happening I quickly went to the resusc area and asked for a condition report to give to the parents.

Returning to the family I found Jimmy, the orderly, preparing tea for the parents and he had obtained a soft drink for the brother. I suspect he had bought it from the dispensing machine with his own money. Claire, another orderly, was on her knees in front of the seated father holding both hands in hers and quietly speaking words of guarded reassurance. He sobbed and cried wretchedly. Helen, the Patient Care Assistant stood alongside the mother holding her head against her waist while she, too, sobbed and cried with her arms around Helen’s body. The boy sat quietly with tears streaming down his face and the soft drink can clutched in both hands. They stared at me without comprehension as I explained their daughter had serious head injuries and once stabilized would be flown by helicopter to the children’s hospital in the city.

I did another round of the ward then checked with the triage nurse to ensure there was no new patient requiring urgent attention. The resusc team had the situation well and truly under control. Their patient had a tube in her trachea and was breathing with the help of a machine. She was unconscious and paralysed in order to control the fits and her breathing. The ECG monitor clicked away rapidly but steadily and the oxygen saturation indicated showed an acceptable level of oxygenation. They were now preparing to take her to x-ray to have an urgent CT scan of the brain. The younger doctor was on the phone to RFDS organizing the helicopter.

The family were rational now. The initial shock and disbelief waning - being replaced by stark reality as the situation became clearer. Helen, Claire and Jimmy were still with them; still speaking to them, listening to them and reassuring them. They had their situation wonderfully controlled. Jimmy’s pager buzzed and he excused himself – it was his job to wheel the patient to x-ray.

In due course, after Jimmy brought the patient back from x-ray, she was taken off to the helicopter landing pad and whisked away to the city. Everyone returned to their previous tasks and got about their business, including Helen, Claire and Jimmy. I thanked them for a job extremely well done. They were the unsung heroes of that little drama – doing what is not expected of them and not in their position descriptions but doing it extremely well and much, much better than I could have done. Compassion is not the sole preserve of nurses and doctors.

Compassion

Each of us, from time-to-time, experiences sudden and unexpected encounters with our past. Working in a hospital emergency department, in a small city, provides more than the average number of such encounters. It is usually in the form of a patient or a member of the family. Sometimes it can be very distressing.

In my youth I spent nine years in the Royal Australian Navy. I enrolled in medical school after I paid off. At work in the E.D. on the day before Easter last year, I recognized a name on the computer screen which lists the patients yet to be seen and their triage precedence. We usually select the highest priority patient, put our name alongside that of the nurse and get about solving the presenting problems. It is my habit to not select patients known to me and I did not select this patient. However, I determined that it was, indeed, the person I thought it was and introduced myself.

He recognized me immediately, although the last time we saw each other was in 1969 and I was wearing a Petty Officer’s uniform. He was a long-retired naval officer now very, very ill and a shadow of his former self - as I remembered him. We chatted for a short while. He complimented me on my achievements. I thanked him and told him he was one of the few naval officers I admired and respected. He thanked me for that. We shook hands, wished each other well and I got on with what I had to do. A colleague looked after him and told me later that he had arranged for him to go to a teaching hospital.

Exactly one year later, on the day before Easter, that name was there again. And it was the same retired naval officer. This time he looked much better than previously and his presenting complaint was not serious. He told me he was cured of his previous problem. Again we chatted for a while and he expressed the sentiment that it was a pity we had to meet in this place. I smiled, shook his hand and said, “See you next Easter.” But I didn’t. I worked the day before Good Friday yet again but that patient did not present. I had recently learned that he had died while I was interstate. I would have liked to have attended his funeral and paid my last respects to a real officer and gentleman.

On another occasion a lady of about my own age was brought in by ambulance and allocated a bed alongside the access way between the various areas of the department. I was working the late afternoon shift and had to walk past the bed frequently. I did not recognize her but that is not uncommon because even very familiar faces are not familiar when seen out of the context of their usual environment, lying horizontal in a hospital bed and, often as not, ill or in pain or both.

I was tidying up in preparation to knocking off when, as I walked past her bed, she called my name. I stopped. “You have the advantage over me.” I said with a smile. Even close up I did not recognize her.

“I thought it was you.” she said, “Then, when one of nurses used your name just now, I was certain.” She asked me if I remembered a certain man.

“Yes, indeed I do. But I haven’t seen or heard of him for donkey’s years.”

“I was his first wife.” she said.

“Ah! Now, as I recall, I was at your wedding.”

“Not only that but you were our best man.”

So that, I thought, was that. We chatted for quite a while until a colleague came along and informed her that the investigations were OK and she could go home. She told me she still kept in touch with her first husband and I asked that she remember me to him. She agreed and we went our separate ways.

When I arrived home my wife told me of a distressing episode at bridge that day. A lady, whom she did not know personally, had collapsed and was taken to hospital by ambulance. Of course it turned out to be the lady who had spoken to me at work. Subsequently, via the bridge club, I was delivered of a set of photographs of the wedding including myself as best man. I cut a dashing figure, in those days, even if I do say so myself. It is amazing, not to mention distressing, the physical changes inflicted upon one by forty odd years. Age certainly does weary us, and the years do condemn!

Then there was the shop steward. He was with a boy who had fallen from a bike and broken his arm. The nurses had moved him directly into the treatment room and made him as comfortable as possible. I saw him within minutes of his arrival. I walked into the room and was taken aback to see the shop steward standing alongside the boy. He recognized me immediately and greeted me by name. “Arrh…. G’day, Chris,” I said. “Have I got the right patient? I’m looking for a patient named Thomas.”

“Yair, you’ve got him, Ken. I’m his uncle. Long time no see. How are you keeping?”

“Oh. I see. Yair, I’m all right. But what’s the trouble with Thomas? I believe he fell off his bike and broke his arm.”

The accident was explained to me, I examined the boy’s arm and arranged analgesia and x-rays. The shop steward chatted away quite affably all this time while I was, frankly, rather stand-offish. I had never liked this bloke and we had had some torrid arguments when I was an occupational physician with a large mining company and he was a senior shop steward.

“You still working at the refinery?” I asked, as the boy was being wheeled off for the x-ray.

“Yair. Still there and still giving management curry.”

“I know what you mean. You were pretty good at that. You and I had our moments, too, as I recall.”

“We did, Ken, we did. But I was simply doing my job of looking after the interests of the union members and you were doing your job. I think, a lot of the time, we were singing from the same song book but neither of us was prepared to agree with the other. Anyway, that’s all water under the bridge now. I’m not bearing any grudges. How about you?”

I had to think for a short while but then smiled and extended my hand. “No. As you say, it’s all water under the bridge now.”

He shook my hand firmly and asked if he could go to x-ray with his nephew. I agreed and explained how to get to the x-ray department. He thanked me quite politely and left.

On the way home I reflected on that encounter and had cause to wonder at who was the better person. Then there was Gabby – he had also been in the navy but we first met through a mutual friend long after we had both returned to civilian life. He was sitting alongside his ill wife in one of the E.D. cubicles, one day, and called out to me as I passed. We chatted as old friends do after the passage of some years without contact. His wife, although ill, contributed to the conversation. She was to be admitted and subsequently went home, cured. Gabby was. “… fighting fit, Ken, fighting fit!”

The better part of a year passed before their roles were reversed. Gabby was on the bed and his wife sat alongside him. She called out to me. Gabby weakly took my hand whispering a fond greeting. I had difficulty concealing my distress at his obviously terminal illness but held his hand for what seemed like a long time while we chatted. Then the ambos turned up to take him to another hospital in the city. We said our farewells. I read his death notice in the morning newspaper only a week later.

I was suturing a lacerated leg on a busy day. The patient was a reticent type and seemed to have something on his mind. On completion, as I was applying a dressing, he said, “You did a better job this time.”

“Excuse me?” I asked.

“Don’t remember me do you?” he said.

“No, I’m afraid not. You have the advantage over me.”

“Well, I was a fifteen year old Junior Recruit at Leeuwin in 1968 and you were a Petty Officer Sick Bay tiffy. You stitched up my foot and it hurt like hell. I always reckoned you didn’t use any local anaesthetic. Today you didn’t hurt a bit.” (The Navy, in those days at Leeuwin, would not let us inject local anaesthetic unless there was a doctor present.)

We had an affable chat, shook hands and away he went, as happy as Larry.

De Ja Vu

A chap in his mid-fifties, accompanied by his wife, wanted a swollen ankle sorted out before flying home to England next day. They had arrived in Australia three weeks previously for a holiday with relatives. He mentioned, too, that one week previously he had experienced some severe chest pain and shortness of breath. A doctor had done an ECG and told him everything was fine. Alarm bells were already ringing in my mind but the only physical abnormalities I could find were mild swelling of his left ankle and the circumference of his left calf exceeded that of the right calf by four centimeters.

I explained that it was possible he had a deep vein thrombosis in his left leg - given the swelling and the fact he had flown out from England three weeks previously. He thought the flight was now far too distant to be associated with DVT but I assured him it was not. I did not mention that I was also worried the chest pain may have been due to a pulmonary embolism – clots coming from the leg and lodging in the lungs. He agreed to wait two hours for the earliest possible Dopler ultrasound – the definitive test for deep vein thrombosis.

The ultrasound technologist came to see me, immediately after completing the procedure, to inform me that there was extensive clotting in the patient’s left leg extending well above the knee. We both went off to see the radiologist for his specialist opinion. He confirmed the presence of clots and suggested we should immediately do a Computerised Tomography Pulmonary Angiogram (CTPA). This we did and within the hour had confirmed the presence of, not one, but numerous small blood clots in both lungs.

This devastating news had to be conveyed to the patient and his wife who, dutifully, remained at his side. They were alarmed initially at the impact of the diagnosis on his ability to fly home next day. I told them there was no possibility of that happening and they would have to cancel. I explained that we would happily give them a letter to confirm he had developed a medical condition that prevented him from flying. It was necessary for me to explain that, quite apart from the impact on their travels, his condition was life-threatening. Understandably, when the reality of that set in, they were both distressed.

The distress was tempered with the information that the condition can be treated with high success rates. We arranged admission to hospital and for a battery of blood tests including a detailed assessment of his blood clotting mechanisms and a baseline INR level. Then he was given an injection of Clexane – a derivative of heparin which is a quick acting anticoagulant. The aim was to prevent any further development of the clots. This was followed by a first oral dose of warfarin which takes about five days of a daily dose to work by inhibiting the effects of vitamin K on the clotting mechanisms. Ongoing dosage is monitored with a regular blood test known as an INR which measures the time taken for a blood sample to clot. When that reaches a therapeutic level the Clexane is ceased.

This unfortunate chap and his wife had their holiday ruined by the sudden onset of an unexpected illness.

Of all the millions of people who fly long distances relatively few suffer this problem but it is a common occurrence. Sitting for long hours in, usually, cramped seats causes blood flow in the legs to decrease and/or become turbulent. Both mechanisms cause blood to clot and once a clot forms it gets bigger. He was very lucky that one large clot did not break free and obstruct the blood flow through the heart and lungs – a common cause of death in such circumstances.

There are numerous high risk factors, other than flying, for deep vein thrombosis. Pregnancy, oral contraceptive pills, cancer, limb immobilization with splints and plaster casts etc, surgery, prolonged immobilization in bed, and some congenital clotting disorders, are all well recognised as associated with DVT. Pulmonary embolism still causes a significant number of deaths despite its causes, prevention and treatment being well known. What greater tragedy can there be than a young mother, delivered by Caesarian section and refusing prophylactic anticoagulants, developing DVT and fatal pulmonary embolism two weeks after the arrival of her first baby?

We do a lot of investigations to rule out DVT and PE. For example, an elderly person presenting with a swollen leg, perhaps with varicose ulcers or an infected scratch must have DVT excluded or diagnosed as the case may be. The only definitive practical investigative tool is the Dopler ultrasound. There is a blood test, D-Dimer estimation, but the incidence of false positives and false negatives is far too great to rely upon it in isolation. We must also consider the problem occurring in the arms or pelvis in some people – it is not solely a problem occurring in the veins of the legs. An acquaintance of mine had an hereditary blood clotting disorder and also had the habit of sitting on upright chairs with one arm dangling over the back of the chair. He inevitably developed a blood clot in one arm and required anticoagulation while it cleared up. Even so, despite this life threatening condition, he still needed to be chastised for dangling one or other arm over the back of chairs.

The management of DVT has changed over the years and continues to change. Not long ago the discovery of even a small clot in a deep leg vein demanded immediate admission to hospital for anticoagulation etc. Nowadays, things are different. Blood is taken for the baseline tests, an injection of Clexane is given and a Warfarin tablet given. The patient is most often sent home with a prescription for both and a request form for a blood test to be done in five days and advised to see the GP at first available appointment after that blood test. The patient is required to self administer the Clexane injection or have spouse or other inject it – it is quite simple - and to take a Warfarin tablet daily.

Complicated patients such as pregnant women, those with ultrasound-proven massive blood clots and those with symptoms of serious pulmonary embolism – among others - will be admitted under specialist care.

Deep Vein Thrombosis

Our eyes are especially important organs. They enable us to see and hence to live independently of others. In the vast majority of people the eyes function so perfectly, up to middle age at least, that they are taken for granted. This is especially so in young people in the workplace who neglect to wear eye protection appropriate to their work places or particular tasks. There is still an attitude among workers that it is not macho to wear safety glasses or goggles and another among management at all levels that it is too much trouble to ensure proper eye protection is worn. Consequently, there is rarely a day goes by that we don’t have at least one patient with a work caused eye injury.

The most common injury is the embedded corneal foreign body. These are usually metallic and caused by grinding metal without wearing goggles. Sometimes they are wooden and caused by cutting wood with power saws again without wearing goggles. Many workers will wear safety glasses when performing these tasks unaware that safety glasses do not adequately protect the eyes from the showers of red hot metal particles thrown into the air from grinders or saw dust from power saws. It is not uncommon for some individuals to state they have had numerous such incidents but they continue to ignore the lessons and not protect their eyes. Little do they realize that every such incidence contributes a little more damage to their corneas.

So, at 8 am daily, there is usually at least one person sitting in the waiting room with one hand over one painful red eye that has kept them awake all night. If they have their hands over both eyes it is usually because of welding flash. After asking what has happened the first thing we do is to check the visual acuity. That is, we get them to read the eye chart on the wall first with the affected eye covered, then with the good eye covered and finally with neither eye covered. This tells us if the injury may have affected the patient’s vision and/or if the uninjured eye has a visual deficit. This information has monumental implications for the patient and serious medico-legal implications for the doctor.

It is my personal practice to then examine the eye through an old-fashioned instrument – a binocular loupe. This acts like a large magnifying glass strapped to my face to leave my hands free. In the case of a worker who had used a grinder or power saw, it will usually reveal a foreign body stuck on the cornea over the iris – the coloured part of the eye. It also enables me to determine if there is any blood behind the cornea or perforating injury to the cornea. It is also imperative to evert, (turn inside-out), the upper eyelid and ensure there is no additional foreign body stuck under there by careful examination with the loupe. Only last week a young lady presented complaining of getting “something in her eye” while gardening that day . I found a piece of grit stuck under her upper eyelid and a very large corneal ulcer. If no foreign body can be found then we are into a whole new ball game- the unilateral red eye which I will discuss later.

If a foreign body is found then it must be removed. To do so requires the use of local anaesthetic drops to make the procedure painless. Then, a gentle wipe with a cotton bud- while using the loupe or slit lamp – will sometimes suffice to remove the object. Most, however, are quite adherent to the cornea and must be removed with a needle. Obviously, this requires extreme care in optimum conditions to avoid further damage to the eye. I prefer the patient lying down on an examination couch with the height adjusted to suit me. I then work from the head end of the couch with the loupe securely in place, my left thumb and index finger holding the lids open and the patient keeping the eye still by staring at a spot on the ceiling. The needle must be held at a tangent to the cornea and the tip used to dislodge the object which usually comes away in bits especially if it is metallic and has rusted. (Ferrous metals will begin to rust within hours of contacting the eye.)

Sometimes that is all that is required. However, if ferrous metal has been in the eye overnight then a rust ring will have formed and this must be removed. It can be done with a needle but a better result is obtained by using a fine dental drill burr in a small, battery operated tool - and extreme care. Some doctors are unwilling to use this instrument for fear of perforating the cornea – a catastrophe if it does occur. But, with careful technique and bearing in mind the cornea is of about the same hardness as the thumbnail, success can be readily achieved.

At this stage it is smart to instill some fluorescene into the eye and examine through a slit lamp using a blue light. Fluorescene is yellow in colour and gets taken up by damaged cornea and fluoresces bright green under a blue light. This will reveal the size of the area damaged by the foreign body, and its removal, and any other areas of cornea that may have been damaged by foreign body or its removal. Penultimately, the visual acuity must be again assessed to ensure the procedure has not resulted in any further damage to the eye. This has major medico-legal implications.

The ultimate and, arguably, the most important part of the process is to correctly apply a double pad to the affected eye. This is because the cornea is a bit like Perspex covered with a very thin layer of cells about six cells thick and these cover the nerve endings. The removal of the foreign body inevitably results in the removal of the entire layer of these cells and exposes the nerve endings. If the eye is not padded then, every time the patient blinks, the eyelids wipe away the new cells trying to grow across the wound – which we call an ulcer. A gauze eye pad is folded in half and placed into the eye socket with the folded edge parallel with the eyebrow. Then a second pad is placed over the first and secured into place with several narrow strips of light adhesive tape. This must hold the eyelids closed without the patient making a conscious effort. I advise this is left in place until the patient switches off the light to sleep that night. The ulcer will heal within twelve to eighteen hours.

It is also important to advise the patient that, with the eye pad in place the visual field is reduced by about half and, if driving, hazards may not be seen on the affected side – this included kids on bikes or foot or vehicles at intersections etc. Further, with only one functional eye, depth of field cannot be judged with the same resultant hazards when driving and even when reaching for a cup of hot coffee, (or cold beer), it is likely to be knocked over because the patient cannot accurately judge how far away it is.

That entire process only takes about ten minutes to run through. Patients so treated rarely need follow up but those who do not have the pads applied, or who remove them, will almost always return next day with a painful, red eye due to an unhealed ulcer. It seems this is not taught to medical students or young doctors these days. I am for ever seeing these patients, treated by other doctors, returning next day with unhealed ulcers.

While we are on the industrial scene I should mention welding flash. This is an extremely painful result of exposure to the intense ultra-violet radiation emitted from the welding arc. The UV destroys most or all of that thin layer of cells covering the cornea thus exposing the nerve endings. The dead cells must be replaced by new cells growing from the edge of the cornea. This is relatively easily achieved by padding the eyes, after using local anaesthetic, for twelve to eighteen hours. The condition is less common among welders than among people passing by in the workshop or idly watching welding in progress.

Penetrating eye injuries are not common, fortunately, but are a real emergency situation. Kids run into plants like grass trees, Bougainvillea or roses and the thorns can penetrate the eye. Tradesmen hammering cold chisels or drifts with burred heads can have steel splinters penetrate the eye. Thrown objects like darts, sticks, nails and glass may do the same. We tend not to muck about with them but send them for eye specialist treatment immediately. The old saying we chanted as kids, “Sticks and stones may break my bones but names will never hurt me.” Could well be modified to, “Sticks and stones may break my bones … and make a hell of a mess of my eyes, too.”

Chemical burns to eyes are always serious. Common causes are oven cleaner, battery acid and detergents accidentally splashed into one or both eyes. Oven cleaner is very serious as it consists mainly of caustic soda, (sodium hydroxide), an extremely alkaline chemical which tends to soak into human tissues then destroy them. Oven cleaner in the eyes is a real emergency and the key to successful management is the immediate first aid – getting the eye, or any other part of the body contacted – under running water. The shower is best but any tap will do. The eyelids will go into spasm with first contact of the caustic and must be forced open to allow the water to run over the eyeball. This must be maintained for, at very least, twenty minutes or more if possible. Then medical attention is mandatory and transport is best by ambulance.

Caustic in contact with the eye will often turn the cornea opaque. This is irreversible and the patient will require a corneal transplant. It can also penetrate into the iris, sclera and other parts of the eye often causing total blindness in the eye. Anyone using oven cleaner, or any other chemical, should protect their eyes by wearing goggles. Glasses, even safety glasses, are not adequate.

The same principles apply for the use of and treatment of any chemical contact including the eyes. Battery acid is sulphuric acid and extremely damaging to human tissue. Spirits of salts is hydrochloric acid and almost as strong as sulphuric. Fluoric acid is the strongest possible and contact with even small amounts can be fatal as a consequence of burns and of the effects upon the chemical balance within the body.

Wet cement is very alkaline. It contains lime which, when dissolved in water, forms calcium oxide which is extremely alkaline. It is very difficult to remove cement from the eyes and, as long as it is there, it continues to burn the eye. Urgent treatment by an ophthalmologist – eye specialist - is mandatory. We had such a patient recently. He worked on a building site and hearing someone shout some levels above him he looked up just in time for a large blob of wet cement render to fall into his right eye. He was not wearing any eye protection. The force of the cement striking his eye was probably enough to do considerable damage but the alkaline burns were worse.

His eye was flushed with water on site then he was taken to a doctor’s surgery where a morphine injection was given and local anaesthetic drops were instilled onto the eye. He was immediately sent on to us. On arrival half of his right cornea was opaque and there was a large lump of hard cement stuck to the eyeball adjacent to the cornea and extending under both eyelids. We placed a pad over the eye after instilling more anaesthetic and I arranged for his immediate transfer to a teaching hospital and spoke to their duty ophthalmologist. As usual, we received no feedback but I cannot help but conclude that the unfortunate chap would lose much, if not all, of the sight in is right eye. An injury entirely preventable by wearing at least safety glasses.

Occasionally someone, usually a woman, turns up after splashing detergent into the eyes. Provided it is simple kitchen or Washing detergent it isn’t too much of a problem. (After all, shampoo is simply a detergent, with the odd miracle substance added, and we often get it into our eyes.) It can irritate a bit and cause temporary dryness of the eyes because it disrupts the tear film – which is not just a film of water but a complex triple layered film of precisely arranged fats, water and mucin. Treatment consists simply of irrigating the eye with water then using artificial tears for a day or so.

But detergents ain’t just detergents. There are some that contain other chemicals added for specific purposes. An example is some of those made for use in dish washers. Some of these have strong alkaline substances added and this will cause severe eye damage as discussed above. A simple rule of thumb is that anything that gets into the eye and causes pain required immediate medical attention.

Like thousands of other Australian, many of whom seek relief in the ED, I suffer dreadfully with allergic conjunctivitis in early winter and spring. It is simply irritation of the eyes caused by allergenic substances in the air. The winter attacks are caused by spores from mushrooms and other fungi that flourish with the first rains. The spring, or vernal, conjunctivitis is caused by pollens from flowers and crops. These allergens are picked up by prevailing winds and deposited on the eye of the poor, suffering thousands of sensitive victims. These allergens trigger a reaction by the human immune system. The conjunctiva becomes red, intensely itchy and may even become swollen and look like a lump of jelly on the eye. This alarming condition is known to us as chemosis.

My own eye doctor, (ophthalmologist), advises me to not use antihistamine eye drops. He prefers that I flood the itchy eyes with simple, lubricating eye drops. This, he says, will wash the pollens and spores away. Yair, well, sometimes it does and sometimes it doesn’t. When it doesn’t I am compelled to use the antihistamine drops. I offer my ED patients the same advice but, if they come in with chemosis I use the antihistamine drops up front.

The most common eye infection is conjunctivitis caused by bacteria although some viruses also cause it. It is usually bilateral – in both eyes – and produces pus which causes the lids to be stuck together on waking in the morning. It is very distressing and interferes greatly with vision. When I was a kid it was much more common than today and we called it sandy blight – probably because it felt like sand in the eyes.

Treatment is simply antibiotic ointment applied at least half hourly during the first day and hourly on the second day. (Viral conjunctivitis requires special antiviral ointments.) This is easily achieved by pulling down the lower eye lid and squirting about half a centimeter of ointment in behind it. It makes vision more blurred and things a bit mucky for a while but it works. In my most humble opinion antibiotic eye drops are useless – they stay in the eye for less than three minutes before being flushed down the tear duct into the nose. They aren’t much use there. The ointment will hang around on the conjunctiva – where the germs are – for about twenty minutes. And I always advise the victim that personal hygiene is critical to prevent others catching it. Strict use of only their own towel and face washer is imperative.

There are other, far more serious, eye infections. We tend not to intervene with these but send them off to an ophthalmologist. Shingles, by the way, can infect the eye. Shingles is caused by the chicken pox virus that lays dormant in the spinal cord after causing the disease in childhood. Then, usually when the victim is stressed physically or emotionally it flares up and tacks down the nerve to the skin where it causes a very painful rash. It can track into an eye – it almost invariably attacks only one side of the head or body – and it can cause blindness but, these days, treatment is available and is very effective if commenced within 72 hours of onset of symptoms.

Glaucoma is a condition caused by abnormally high pressure within the yes. It is usually due to an imbalance between the production and the drainage of the fluid that fills the eyes. Too much accumulates in the eye and the pressure increases. There are two types the most severe being of sudden onset and usually quite painful. It can threaten blindness in a short period of time. The other is of gradual onset and less threatening if properly treated and monitored. The definitive diagnosis is made using an instrument called a tonometer – it measures the pressure inside the eyes. We don’t see a lot of glaucoma in ED but it is a condition we must always bear in mind when diagnosing eye problems.

I did mention earlier the unilateral red eye. That is one eye being red and, usually painful with or without visual disturbance. There are several serious, sight threatening conditions that can cause a unilateral red eye and there are several less serious conditions causing the same symptoms. It is our responsibility to make an accurate diagnosis. Failure to do so can cost the patient their vision in at least one eye. We also need to be on our guard for detachment of the retina and of eye symptoms presenting as indicators of other afflictions such as strokes, brain tumours etc. Diabetes and high blood pressure can cause changes in the retina that we can see with proper use of the ophthalmoscope. The eye is a window through which we can look into the body.

And, finally, there is the contact lens. The invention and introduction of contact lenses was a giant leap forward in ophthalmology as measured by the popularity of the devices. Yet they are not without their problems and the emergency department is often used to solve the common problem of missing lenses – usually late at night.

Most people, rightly, remove their contact lenses before going to bed. They run into trouble when they can’t remove one, or both, lenses. Often, but certainly not always, befuddled by the effects of alcohol or other drugs the poor patient might get one lens out without difficulty but then spend hours trying to remove the other without success. At some stage they give up and get themselves to the ED. In the vast majority of such cases we do not find the lens. This is because it was, either, not inserted in the first place or was removed and forgotten. Some people present frantically concerned that the lens has slipped around behind the eye. Contact lenses cannot do that.

After a thorough examination most such patients accept that the lens is not in the eye. Occasionally considerable persuasion is required - especially with the inebriated. All are advised to return in the morning if their eye remains red or painful or there is visual disturbance.

Eyes

Infections

Infection is defined as a pathological state resulting from the invasion of the body by pathogenic micro-organisms. These pathogenic micro-organisms may be bacteria, viruses, mites or other less well known germs such as prions. “Germs” is the non-technical collective name for these organisms.

That’s all very well but doesn’t mean much to those people suffering from such afflictions as sinusitis, bronchitis, tonsillitis, pneumonia, meningitis, gingivitis, abscesses, boils, cellulitis, food poisoning or even honeymoon cystitis. Each of these is an example of infection which is or may be caused by invading micro-organisms. And the poor, unfortunate victims beat a well worn path to the doors of ED. The infections discussed here are representative of a much larger spectrum but this is not the right venue to try to describe them all – only a few.

I never cease to be amazed at the number of patients who present to us with cellulitis. Two or three in a shift is not uncommon. Cellulitis is a diffuse inflammation of the skin and the tissues immediately below the skin. It is an infection caused by common bacteria, such as staphylococci or streptococci, which gain entry through skin damaged by cuts, scratches, burns or other trauma. Sometimes it is an extension of a common boil and at other times there is no evidence of skin damage.

Diagnosis is usually easy. The patient presents with a painful, hot, red, swollen and very tender patch of skin. It can occur anywhere on the body but is most common on the legs. The glands in the lymphatic drainage area, e.g. groin or armpit, of the affected limb, are usually swollen and tender. It may be circumferential , that is, extending right around the affected limb. Often the patient has a fever and feels sick. There is a strong association with diabetes – especially insulin dependent diabetes and a stronger association with poorly controlled diabetes.

The management is straightforward. We ask about diabetes in the patient and family. If possible we take a finger prick blood sample and determine the blood sugar level. The infection requires aggressive treatment with antibiotics. Sometimes, especially when there are signs that the infection has spread beyond the skin, we take blood to culture for bacterial growth and other tests such as white cell count. Most often we give intravenous flucloxacillin, a modern and potent form of penicillin, because we know this is effective against the most likely causative bacteria. For an adult two grams is appropriate and this is followed up with oral capsules in a dose of one gram six hourly for at least five days. We usually mark out the limits of the inflamed skin with black felt tipped pen and ask the patient to not wash it off. If the inflammation extends beyond the marking then the treatment is not working and they must return to us. Rarely are these patients admitted to hospital but they are if surgery is indicated or they are particularly ill.

There are a few traps for young players in this. One mistake is to assume there is free pus under the inflamed skin and try to drain it by making an incision in the skin. This will only work if there IS free pus and it is pointing and fluctuant. That means the pus has formed a “head” or patch of white skin surrounded by red inflamed skin. This is usually extremely painful to touch. It will also feel like there is fluid under the white skin. If these signs are present then incision is mandatory and the pus is drained away. If these signs are absent then no pus will be evident and all that is achieved is a hole in the skin to add to the patient’s woes. Hippocrates had this one worked out. An immortal aphorism attributed to him is, “Ubi pus evactuo.” This translates, loosely, into English as, “Where ever there is pus I drain it.” Smart fellow! The flip side to that is, “if there is no free pus then don’t muck about with it”.

Another trap is to completely muck up the diagnosis. It is very dangerous to assume simple cellulitis and to not diagnose a compartment syndrome. They can both have much the same symptoms and signs but require careful differentiation. The compartment syndrome is one in which tissues, usually muscle, located in a confined space become inflamed and swell. But, because it is located in a confined space, the swelling is limited to that space and compresses blood vessels and nerves within the space. It is a surgical emergency requiring immediate decompression of the tissues by surgical incision of the confining tissues.

The forearm and the lower leg are commonly affected areas. The disease process may be initiated by surgery, trauma or even simply the repetitive overuse of muscles in athletics such as long distance running, cycling etc. Going back a couple of years I saw a middle aged woman with compartment syndrome in her forearm. She was an intravenous drug user. At the time she came into the ward the diagnosis was evident – rapidly increasing pain, swelling and tenderness in the forearm and severe pain with finger movements. The surgeon saw her within the hour and immediately took her to theatre by which time she could not move any fingers or the hand and morphine provided scant pain relief. A long, deep incision down the arm, through the skin and into deeper tissues, relieved the pressure and saved the limb.

Another, rare, condition that must be considered is necrotizing fasciitis. This condition took the fancy of the media a few years ago and was rather flamboyantly dubbed the flesh-eating disease. Untreated it can be devastating and result in the loss of limb and/or life. It is most often caused by a Type A Streptococcus but is sometimes caused by other bacteria or more than one organism. The bacteria gain entry beneath the skin via surgical or traumatic openings and then spread - not only beneath the skin but also down into deeper tissues. Severe pain, out of proportion to any wound or even cellulitis, (which may co-exist), is a hallmark and may be accompanied by fulminating, generalised illness and fever. Treatment is surgical excision of as much infected tissue as possible and high doses of antibiotics. However, the disease process causes blockage of small blood vessels which obstructs delivery of antibiotics to the infection and also causes the blood starved tissues to die with resultant gangrene.

Contrary to popular belief, there is nothing new about necrotizing fasciitis – it has been around for donkey’s years. A French venereologist, Jean-Alfred Founier who practiced in Paris from 1869 to 1902, described a particularly vicious form of it that occurs in the genital area of men. It may involve all or any of the penis, the scrotum and the perineum. (The perineum is the area of skin between the scrotum and anus.) Untreated it results in gangrene of the affected parts and severe, generalised illness and often a very ugly death. Curative surgery can be somewhat mutilating.

Much more common than compartment syndrome and necrotizing fasciitis are common boils and carbuncles. Again, there is a strong association not only with diabetes but also with obesity. When I was a kid – in the early 1940’s, most of us had boils from time to time. It was probably secondary to the poor diet we endured during World War Two when food was strictly rationed. In 1943 families were issued with books of ration tickets for butter, meat, sugar, tea, chocolate, petrol and clothing. Food was sent to the UK in large quantities and, of course, to Australia’s armed services in the various war theatres. I have digressed, but there is no doubt that poor nutrition jeopardises the immune system and hence resistance to infection.

Some obese young women seem prone to staphylococcal infections especially in the arm pits. They develop large boils that coalesce to form what are known as carbuncles. These very painful, large swellings are incapacitating and debilitating. Often, fluctuant pus can be felt under the skin without pointing. These girls are usually ill and require incision and drainage under general anaesthetic. This usually releases copious amounts of pus and relieves their symptoms. However, the incision must be kept open with a drain to prevent more pus building up under the skin. Regrettably, it is not uncommon to see the same girls present again with recurrences at the same site or elsewhere on the body.

Another, dangerous, form of infection is quinsy. It is a complication of tonsillitis in which the infection extends into the tissues around the tonsils and forms an abscess behind either or both tonsils. (An abscess is simply a collection or pool of pus within the body. The common boil is a form of abscess.) Untreated the abscesses can enlarge to the extent they push the tonsils together and block off the airway. They can extend into the deeper tissues of the neck. The infection can get into the blood stream causing septicaemia (blood poisoning). Quinsy, therefore, is a diagnosis that must not be missed. When it is diagnosed it becomes an emergency situation requiring urgent surgery and extremely careful monitoring of the patient’s airway and general condition in the interim. Treatment of quinsy is with surgery to open the abscesses and drain away the pus. Antibiotics are also given in large doses.

Wikipedia tells us that the first president of the United States of America, George Washington, died from complications of quinsy as did Pope Adrian IV. Not only that but the composers Georges Bizet (of Carmen fame) and Hector Berlioz both suffered it at least once.

Emergency Departments are plagued with dental problems including dental abscesses. It is not uncommon for dentists to direct patient to us for management of severe pain and/or obvious dental abscesses. And, of course, most tooth aches start after dental surgeries are closed or, at least, when they are fully booked for the next two weeks or so. Even patients who have had teeth extracted by dentists often present to us for pain management. But people in pain are patients regardless of the cause and require our best efforts.

The simplest solution to the pain of a dental abscess is to open the abscess and drain the pus. For reasons unknown to me dentists seem very reluctant to do this. We do it occasionally in ED if the abscess is pointing through the gums but often-times the abscess is not pointing and therefore cannot be drained by incision. It can, however, be drained by extraction of the tooth. A dental abscess can form inside the tooth pulp compressing the nerves that run through the pulp causing extreme pain and a sensation that the tooth is going to explode. Another form of dental abscess forms under the roots of a tooth. The pressure generated can actually force the tooth partially out of its socket with pain proportional to the pressure generated. In either case, the tooth must be removed because the abscesses will not heal with the tooth in place. And while the pain of toothache is well known to most of us the pain of a dental abscess can be excruciating. Occasionally it can be so severe we send the patient to a teaching hospital to be looked after by a facio-maxillary surgeon.

The use of antibiotics is mandatory in the treatment of dental abscesses for several reasons. One is that bacteria can escape from the abscess into the blood stream to cause septicaemia and/or bacterial endocarditis – an infection on the inner lining of the heart chambers and valves. A second is that the abscess can infect and destroy bone and cause sinuses (channels) to form in the bone and sometimes to even burst through the face. Even more serious is the propensity for dental abscesses, especially in the upper front teeth, to cause “cavernous sinus thrombosis”. This is a blood clot in a large vein that drains blood away from the brain and is usually fatal. Another serious complication of dental abscess is “Ludwig’s angina”. This is nothing to do with heart pain but is the spreading of infection from lower teeth into the glands under the jaw causing swelling and abscess formation there. This is a life threatening situation requiring urgent surgical treatment. (See the character sketch “Mick”.) In the days before antibiotics dental abscesses were a common cause of death through one or more of the complications described here.

Other forms of infection cause illness or death indirectly. For example, scarlet fever is caused by infection, often of the throat or tonsils, by bacteria known as streptococci. These bacteria produce a toxin that moves into the blood stream, circulated around the body and causes a rash, fever, illness and sometimes death. Tetanus is an infection caused by a bacterium – Clostridium tetani. It releases into the bloodstream toxins that cause paralysis of breathing muscles and violent spasms of other muscles. (Just the other night I sutured a wound on the foot of a young girl. Her mother refused permission for us to give her a tetanus immunisation because she had immunised her with homeopathic substances.)

The “Golden staph” germ that causes boils can also cause a particularly nasty form of food poisoning. The germ gets into food from an infection on a food handler and proliferates if the food is kept at room temperature for any length of time. It produces a virulent toxin, that is not destroyed by reheating the infected food. It causes vomiting, diarrhoea, cramping abdominal pains and malaise. These symptoms begin soon after the infected food is eaten – often as early as thirty minutes later. Fortunately the illness is rarely life threatening and is treated symptomatically – that is with fluid replacement, rest and medication to reduce cramping in the intestinal tract. Antibiotics are useless because they have no effect on the toxin. Strangely enough few people present to ED with food poisoning probably because the victims know what it is and treat it appropriately themselves.

The ambos wheeled him in, sitting upright on a stretcher, with his right hand bandaged and held up at face level. Even then, he was nattering away to anyone whose attention he could capture. At that point in time I was fully occupied and wasn’t much interested. About an hour later, I became free and he was the next patient to be seen - I had to become interested.

“What have you done, mate?” I asked, as I approached the trolley.

“Well, it’s like this,” he said, and I was reminded of those crusty old codgers one will occasionally find propped in the corner of the bar in a country pub. World wise and weary of it all they usually have a jaundiced view of the world which they express in a colourful idiom. “I went to the dunny and the lock on the door broke so I couldn’t get out. I shouted out to Mum but she was out the back, with her music playing loud, and she couldn’t hear me.”

“Strewth,” I said. “That must have been a worry. Couldn’t you fix the lock or at least get it to work somehow.”

“Come off it! The thing’s been buggered for ages and today it just fell apart. It’s completely knackered.”

“Couldn’t your Dad fix it?”

“Haven’t got a Dad! He bolted years ago. There’s just me and Mum and me little bother Jason and me little sister Kylie. Yair, he’s gone and it was me birthday on Saturday and me with no Dad.”

“What did you get for your birthday?”

“A cricket set. Me and Jason have been playing with it but he’s too small. I always beat him.”

“Yair. OK. Now tell me how you managed to injure your hand.”

“Well, like I said, I was locked in the dunny and couldn’t get out so I climbed up on the seat and then onto the flushing thing and punched out the glass in the little window. As soon as I did it I knew I should have wrapped me T-shirt around me hand first but I didn’t and blood started spurting everywhere.”

“Yair? By the look of your shorts and shirt you could have done a couple of rounds with Casseus Clay.”

“Casseus Clay? Who’s he?”

“Ahhh - he’s a kind of old fashioned Danny Green. Champion American Negro boxer from the last century.”

“Danny Green! I reckon he will beat that tall skinny bloke on Sunday night, don’t you?”

“Hope so. But I don’t seem to be getting any closer to the problem with your hand.”

“I told you. I cut it on the window glass.”

“And so you did. Which part of your hand?”

“Me thumb was what was bleeding the most.”

“Was the blood squirting out like from a hose?”

“Nuh. It was just pouring out all over the place.”

“OK. Now, how did you get out of the toilet?”

“I kept punching all the bits of glass out of the window then climbed through and jumped down onto the ground.”

“Let’s have a look at your feet.” I asked as I pulled the sheet up.

“Why? I only cut me thumb.”

“Well, I reckon that if you punched the glass out of the window then jumped out of it you may well have landed on broken glass and cut your feet.”

“Nuh. I thought of that and made sure I jumped as far out as I could.”

He was right, of course, and I could find no evidence of laceration on his feet which, obviously, had rarely, if ever, been enclosed in shoes.

I then took down the dressing from his hand. The bleeding had stopped but there was a nasty gash across the crease on the palmar surface. Testing his perception to light touch revealed a numb area on the thumb distal to the laceration indicating he had severed at least one branch of the three nerves that supply that surface of the thumb.

By chance there was an orthopaedic surgeon operating in the hospital that day. I asked him to have a look. While examining the wound he asked me if I had tested sensation to pin prick. I said no and he informed me light touch was not sensitive enough. (He was not at all condescending and I appreciated the learning.) He proceeded to test with the tip of an hypodermic needle. Jack said “Ouch!” quite a few times and, “I can’t feel that.” When the numb area was pricked.

“I agree. He appears to have severed a small branch of the nerve and I think it warrants exploration and possibly an attempt at a repair.” The surgeon said to me.

Jack had to have his ten cents worth and said, “Yair? Ken worked it out without having to stick needles into me!” He had obviously read the name badge I wore and decided it was OK to refer to me as Ken rather than Doctor Hay.

The surgeon asked me to arrange for written permission to operate, plus complete the other paperwork without which no one can be admitted to hospital, and returned to the theatre. He would add Jack to the end of his operating list for the day.

“OK Jack. Do you understand what is happening?”

“Yep. He’s gunna operate on me thumb to fix the nerve so I can feel it again.”

“That’s right. An anaesthetist will put you to sleep first, of course. Now, where is your Mum? I need to get her to sign some papers before the surgeon can operate.”

“Well, the ambulance blokes said they couldn’t bring us all to hospital so Mum said she would ask the lady next door to drive them here. I reckon she should be here any time now. I’ve been here for ages.”

With that, Jack’s mother and siblings came into the cubicle. A little boy of about seven and a little girl of about five. Mum was about five feet tall and walked with the gait of someone who had, probably, spina bifida. I explained the situation to her and the poor lady immediately started crying. So did Jason and Kylie. Jack started protesting that he would be all right.

“Jack, I reckon you should give Mum a big hug.” This he did and he also hugged Kylie and Jason although Jason wasn’t too keen on the idea.

When they had all settled down Mum signed the forms and Jack was wheeled off to the ward with Mum, Kylie and Jason tagging along behind the trolley. He called out, “Thank’s, Ken.” as the trolley passed through the doors. I never saw them again.

That boy – for that is what he was and only ten years of age – was just brim full of personality. It seemed to me he was the man of the house and they were all lost without him. He is going to face an uphill battle as he gets older. If his social circumstances permit him to make it into adulthood without falling foul of the law then I reckon he will grasp life firmly by the scruff of the neck and shake the bejesus out of it. I hope he does. And one day he may well finish up as one of those crusty old blokes propped in the corner of a country pub - or better ….

Jack

WRIMAGING

By Ken Hay