©2019 KIDS Dr Ken Hay MB BS D(Obst)RCOG
Kids test my emotions as well as their own and their parent’s. Treating them puts me through all sorts of emotions. Immense satisfaction after fixing a pulled elbow; profound sadness and disgust with the realization that a child’s injuries are the result of abuse – sexual or otherwise; anxiety when it is obvious the child will need an injection; remorse when the treatment inevitably causes the child pain or discomfort; humour with children using laughing gas for temporary pain relief; worry when a parent refuses permission to immunize the child against tetanus; happiness when children thank me for “fixing” them and I offer a brightly coloured T-shirt sticker pronouncing “I was brave today” or “Perfect Patient” . I am glad I am not a paediatrician because I don’t think I could properly manage seriously ill or dying children. That all began when a six year old boy died in my arms, from cerebral malaria, on Manus Island in 1965. (See HMAS Tarangau). I also worried every minute of every day about my own children and grandchildren – and still do.
We do see many children of all age groups in ED. Probably, the majority are brought in with relatively minor illnesses by worried parents who cannot get an appointment with their GP. They are usually a pleasure and relatively easy to manage - except when accompanied by an aggressive or particularly demanding parent. Some parents, for example, will demand x-rays when x-rays are not appropriate. On the other hand, some will strenuously object to x-rays when they really are necessary. Others refuse tetanus vaccination following tetanus prone wounds. Over the years it has become less common for parents to inappropriately demand antibiotics but many still do and, of course, there are those who refuse to let us use them. These are challenges we must deal with as best we can. Most times the problem is obvious and routinely sorted out and the patients cause no angst and parent are grateful for our efforts.
“Pulled elbows” are fairly common and usually easy to diagnose and treat. Managing them is immensely satisfying. The condition occurs most commonly in children aged 1 – 4 years. In 50% there is no known trauma – the child suddenly refuses to use the affected arm and lets it hang, limply by the side of the body. Many have a history of the affected arm being pulled or jerked – often by a parent swinging the child by either or both arms sometimes maliciously but usually in fun.
Characteristically the child stands with the arm hanging limply with the hand facing backwards. There is no distress unless the arm is moved. There is no obvious deformity, swelling or significant tenderness as would be present with a broken bone. Characteristically, the parents are very anxious, distressed and guilt-ridden - especially if they have pulled the elbow.
These children are best examined sitting on the parent’s lap. The arm can be very gently felt and examined. If there is no indication of fracture or dislocation it is easy to gently flex the elbow and hold it with one hand while gently twisting the forearm so that the palm faces upward. Usually a click will be felt by patient, doctor and - often - parent. The child will experience a brief pain and cry for a few minutes then relax. After about a half hour of trepidation it will then start to use the arm. The problem is fixed. The mother usually cries with relief, dad is abashed and both are embarrassingly grateful. It remains only to warn the parents that it can happen again and pulling the elbow must be avoided. Rarely, a child will have repeated episodes and require surgery to correct the torn annular ligament that is the root cause of the problem.
The Toddler’s fracture occurs in the same age group as the pulled elbow but is a real fracture in the lower leg. That is, it really is a broken leg. It can be caused by physical abuse but most commonly is a result of the child falling forward with the foot turning outward causing a twisting action to be transmitted through the lower leg. If the fall is witnessed then the description can help with diagnosis. Often, the fall is not witnessed but the child suddenly will not stand on the affected leg.
Examining these children often reveals only that it will not use the leg. There is no swelling and no obvious deformity. No matter how much effort is put into trying to establish a rapport with the child and gain its confidence they will be apprehensive of any contact with the leg. This is a good sign something really is amiss. They may indicate that the pain is coming from the knee or hip. Repeated examinations may give conflicting responses. The trap young players fall into is to conclude that there is really nothing wrong with the child and send it home. The leg must be x-rayed from hip to foot.
Even then, the x-rays may appear normal or, as in one such recent case, show a fracture in only one of several views. Usually, however, a spiral fracture of the far end of the tibia, (shin bone), will be easily seen. The problem is then solved. The treatment is simply to apply a plaster of paris back slab or a full cast for six weeks. (This is simple to do but the consequences are difficult for the parents to manage for six weeks.)
Sometimes the x-rays do not reveal the fracture. The experienced doctor will then treat the child as if there is a fracture, apply the cast and repeat the x-rays in two weeks. The healing process will become visible and the fracture revealed. If it doesn’t and the child still has symptoms then it may be time to involve a specialist.
The child who has been the subject of physical abuse is pitiful but it is critical that the doctor maintains an objective view. Western Australian law mandates the reporting to authorities of such cases or even if abuse is suspected. That removes a significant issue for the doctor who may be in conflict with his or her patient confidentiality ethics. Once reported the doctor can manage the treatment or arrange transfer to a children’s hospital and the responsible authorities handle the unsavoury business of the abuse.
Suspected abuse can be a more difficult issue. For instance, I recently saw a two-year-old who had a fractured collar bone and she screamed when I picked her up to place on the examination couch. (It subsequently transpired she also had fracture ribs.) The mother explained that the child had complained of a sore shoulder for two days but denied witnessing trauma of any type. Examination revealed the fractured collar bone.
There were clear warning signs of abuse here. Delayed presentation is a common feature of abuse. Fractured clavicle is very uncommon in toddlers given the flexibility of the bones at this age and very significant force must be applied to break this bone. I discussed the case with the senior people on the shift and handed the case over to them. The notification of suspected abuse was initiated but I do not know the outcome.
A sleepless night followed. Had the child, indeed been abused? Were the mother and her partner guilty of such repugnant behavior? Had I unnecessarily initiated a process that would cause them a great deal of stress even if they were innocent? Would it result in the child being taken from its mother? In the end one can only hoped the child’s best interests would be looked after.
Genital injuries in children, of course, also raise the same issues. One only feels confident that sexual abuse has not occurred when there is an independent witness to the incident. And that is uncommon. Girls falling astride monkey bars or the edge of a bath or bicycle frame are relatively common events. Delayed presentation of those injuries starts the alarm bells ringing. I have, thankfully, been spared having to deal with a child sexual abuse case in the acute phase and, with the grace of God, that will not change in the few years left to me in medical practice.
Most children are terrified of needles. I know I always was but, as one matures, one develops enough courage to overcome the fear and permits the cold steel to be thrust into the skin. (There can be no courage without fear!) Enlisting in the navy, as a sick berth attendant, erased my irrational fears given I was first subject to the usual battery of vaccinations and immunizations then, subsequently, found myself on the other end of the needles vaccinating sailors. Even so, I remain softhearted about injecting children but, of necessity, perform the task. Having done that it behooves me to attempt to erase the memory with a couple of bright stickers and a whole lot of sympathy laced with humour.
There are times when it is not possible to avoid causing some children pain during the process of assessment, investigation and treatment. Broken bones are a god example. The child arrives with the limb bandaged or ensconced in bandages or a splint – often makeshift. Usually, this must be removed in order to make a clinical diagnosis and the removal and examination can sometimes be painful. Similarly with burns and lacerations– the bandage must be removed to examine the wound. We often give the child oral medication to relieve pain before we do this but sometimes, if the available information suggests a general anaesthetic will be required, we must forgo it to ensure the child has an empty stomach for the anaesthetic. In such cases one does what must be done as gently and quickly as possible.
Entonox – a mixture of oxygen and laughing gas remains a handy tool. It is great when suturing lacerations in children aged about four and upwards as an adjunct to local anaesthetic. It is difficult not to laugh along with the kids – they really do laugh and giggle – as we get about the procedure. In younger children we tend to use Ketamine or Midazolam (which are required to be injected). These drugs put the child into a trance-like state under which sutures can be inserted, foreign bodies removed, minor fractures put back into place and plaster of paris splints applied painlessly.
If a toddler finds an interesting small object such as a piece of bean bag stuffing or a bead or such like it is London to a brick the toddler will want to insert it into a bodily orifice. The nose and ear are most common and frequently present us with the challenge of removing them. Often as not the child must be anaesthetized with Ketamine or Midazolam. Sometimes we can get away without that especially with foreign bodies in the nose. One very old fashioned method of removing a foreign body from the nose of toddlers is to get Mother or Father to hold the opposite nostril closed, place their mouth over the child’s and give one forceful puff into the child’s mouth. Sometimes this results in the foreign body being ejected from the nostril. I have seen it work – and I have seen it fail. With very cooperative toddlers we can sometimes convince them to let us insert the tip of a sucker into the nostril. This will pull out things like lumps of sponge rubber or bean bag packing but not peanuts, glass beads or similar solid objects.
Parents who refuse to have their children vaccinated are a real worry. There is no point in arguing with them – their beliefs are usually set in concrete – and, of course, we have no authority to act against their wishes. For whatever reason, they have decided that vaccination is not necessary and/or is dangerous to their children. It cannot be denied that there is a risk, albeit very low, of severe reactions to vaccination. It would be a dreadful situation to persuade a reluctant parent to allow us to vaccinate a child then have it suffer a serious reaction. It would be worse to deal with a child with tetanus as a consequence of parental refusal to allow vaccination following a tetanus prone wound.
Adolescents are an interesting group. They most commonly present to ED with injuries sustained in sport or play but occasionally with appendicitis or torsion of the testis or serious infections. With increasing frequency we are seeing them with conditions such as tonsillitis, glandular fever, gastroenteritis and other such common ailments. They present to us because they cannot get in to see their GP. Most of these kids are very pleasant and I enjoy chatting with them about their sports or school or what ambitions they may have. Now and then there will be one, quite young, who already has a realistic, set goal, in life and knows what must be done to reach the goal. I envy them – I didn’t seriously decide on medicine until I was about 21 and locked into nine years service in the navy. Most, though, don’t have or don’t want to divulge an ambition. Yet it is still interesting to listen to their impressions of school, society and life in general. Some even ask about being a doctor. If they express interest I encourage them but don’t pull my punches about what is involved in reaching the goal. I certainly do not glorify the profession for it certainly not glorious.
Occasionally an obnoxious child presents with bad manners or arrogance or demanding. They test one’s patience. Often they are accompanied by parents with similar personalities or with obviously inadequate personalities and the child treats them with as much contempt as they treat us.
However, it is one of the great pleasures of the game to receive a hug, a high five, a shake from a tiny hand or even just a shy smile from a happy child I have had the honour of helping.
©2019 Marines Stings and Things Dr Ken Hay MB BS D(Obst)RCOG
Fishing is reputedly the most popular sport in Australia - indulged in an enjoyed by thousands country wide. It is not without its hazards. People get washed off rocks when fishing, some are even taken by crocodiles or sharks. Few escape some sort of injury as a direct consequence of their participation in their piscatorial adventures.
Last summer I saw two shark attack victims in a week - a couple of weeks after a man was killed by a shark only a few kilometers from us. The first was a teenage lad who was bitten on the thigh while surfing. By the grace of God the wounds were not life threatening. He attended us for management of the wounds after initial treatment by a surgeon. They healed nicely. The other was was also a teenage lad. He was working on his father’s professional fishing boat. He walked out of the boat’s cabin in bare feet and tripped over a small, freshly caught shark lying on the deck. The shark took exception and promptly bit the poor boy’s foot inflicting nasty wounds. He was well treated elsewhere initially and we only maintained the pristine state of the wounds.
Fishermen often become the victims of involuntary body piercing. In the holiday season we see one or two just about every day. Fish hooks embedded into fingers, hands, feet or sometimes even the face, eyes or ears. There are several different methods we can use to remove them. I prefer the “Advance and Withdraw” method - infiltrate the area with local anaesthetic, grasp the shaft of the hook firmly with artery forceps and push the barb through until it is clear of the skin. Then, cut off the barb with side cutters and pull the shaft back through the skin. A good clean up, a tetanus vaccination and a script for antibiotics and the job is done.
During recent school holidays a young man presented with a large tailor hook embedded in a finger. Attached to it were two other hooks of the same size – a typical gang of tailor hooks. I asked how he had managed to achieve this calamity. Abashed, he replied, “I was teaching my teenage son how to safely gang tailor hooks.” I asked where the son was. “Last time I saw him he was rolling on the ground laughing!” he replied in a matter-of-fact manner. I had to cut off the two free hooks before infiltrating the local anaesthetic and removing the embedded hook. The very next patient also had a fish hook embedded in a finger. However, it was a small herring hook and not ganged. It was much easier to deal with.
Hooks embedded in eyes are a very serious matter and require treatment by an ophthalmologist – (eye specialist). We don’t muck around with those injuries – eyesight is too precious. And it is not only the hooks from fishermen’s rigs that can cause damage. Sinkers can and do smash eyes - often causing permanent visual loss. This happens when an angler casts vigorously but the line is not free to run through the ferrules of the rod. The loose end will flick around causing the sinker to strike the eye with tremendous force. Similarly, when a line gets snagged on some underwater obstruction and the angler stretches the line attempting to free it. The line parts from the hook but the sinker stays with the line and hurtles out of the water to strike the hapless angler.
The tackle box always contains a knife. I had a salty old codger, literally, come in late one afternoon with a knife wound in his left bicep region. He smelled of Dettol and had a blood-stained, wet and rather dirty crepe bandage wound around his arm. His story was that he had been about twenty miles, (as he said), out to sea, with a mate in his boat, when he landed a small shark at about eight o’clock that morning. In attempting to sever the shark’s spinal cord it had lashed around and “somehow” the knife finished up sticking out of his arm. He pulled it out and continued in his endeavours to dispatch the shark, eventually succeeding before losing too much blood. He then poured some neat Dettol over the wound, bandaged it up and got on with his fishing. He didn’t consider it serious enough to abandon the fishing trip.
We took down the crude dressing to reveal a classic stab wound that had gone through the skin and into the biceps muscle. I said I felt we should get a surgeon to have a look at it with a view to taking him to the operating theatre and explore the wound properly. He refused point blank and asked me to do only what was necessary. He could not be persuaded otherwise.
Reluctantly, I perfused the wound with local anaesthetic, ( containing adrenaline to help prevent bleeding), and had as thorough a look around as possible. There was no foreign material in the wound but the muscle sheath had been incised. I could find no evidence of blood vessel, nerve or tendon damage. After thoroughly cleaning the wound I sutured the muscle sheath and then the skin. We gave a large dose of an antibiotic cocktail intravenously, a tetanus injection and dressed the wound. I wrote a prescription for follow up oral antibiotics and sent him on his way with strict instructions to get back to us if he had any trouble with it. He expressed his sincere appreciation for our efforts and left. He was rather anxious to get home to let his wife know he was OK before she called out the sea search and rescue people. He had not let her know what had happened or where he was. His boat was on its trailer in the hospital parking area.
Fish bones stuck in the throat are not an uncommon problem. Some are easy to treat while others are extremely difficult. The easy ones are those where a relatively large bone becomes embedded in the relatively large tonsils of a patient with a weak gag reflex. Often the bone can be readily seen with a light and a tongue depressor. It is then a simple matter to arrange the light to shine over the right shoulder, depress the tongue with a depressor in the left hand, reach down to and grasp the protruding bone with long forceps and gently withdraw it from the tonsil.
Small, fine bones such as those from garfish or whiting can be very difficult especially in someone with a strong gag reflex. These bones are difficult to see at the best of times. They are fine and they are short and can penetrate most of their length into the tonsil or other tissue in the throat. One such patient was here on holidays from Melbourne and got a garfish bone stuck in his throat. Trying to see down his throat was absolutely hopeless – he would gag violently as soon as I touched his tongue with the depressor. I suggested we arrange for him to see an ENT specialist in Fremantle but he declined stating he was returning to Melbourne next day and would sort it out over there. That was a shame but we cannot force patients to take our advice. The ENT people, nowadays, have fibre-optic endoscopes they can pass through the nose into the back of the throat and clearly see all of the tissues and any foreign bodies.
It is not uncommon for patients to present with the history of fish bone in the throat but nothing is found – even by the ENT people. We assume that a bone has scratched the throat and passed on or that it was only partly embedded and dislodged later. The sensation of a bone can last for even a couple of days after it has gone.
The flip side of this is the bone that is not removed from the throat. This may well cause infection with subsequent abscess which may be life threatening due to septicaemia (blood poisoning) or by causing enough swelling in the throat to block off the airway.
We often see people presenting with marine stings. Cobbler, flat head, cat fish and sting rays can inflict extremely painful wounds that are very difficult to treat. They cause excruciating pain which does not respond to injections of morphine and similar drugs. The commonly used method of relief is to immerse the wound into very hot water and keep it there and keep the water hot. It usually takes many hours before the pain eases. Theory has it that the heat slowly denaturizes the protein–based toxins that cause the pain.
I recently treated a sting ray wound to the ankle of a young adult male. The triage nurses had initiated the hot water treatment as soon as he presented. It was about two hours before I got to see him and the pain still returned with a vengeance as soon as he took it out of the water or the water cooled. He wanted to go home but he also wanted the pain to stop. The former was impractical until the latter was achieved.
I recalled a marine captain telling me that instant relief can be obtained from any marine sting by spraying the wound with CRC, WD40 or RP7. He had worked his way up in the industry by beginning as a deck hand on prawn trawlers. When the deckies got stung there was no stopping work – all they did was grab a can of strategically placed CRC or one of the others, spray the affected part, and get on with the job. I told my poor, suffering patient this and he promptly sent his wife off to get some. She returned with a can of CRC, we sprayed it on the wound and the relief was immediate and lasting. Don’t ask me how it works – I do not know. I do know it has worked a treat on wasp stings I have personally suffered when trimming the creeper on the back fence.
That same skipper told me that, on the prawn boats, they got stung by every marine creature capable of causing a sting and that the treatment worked with anything. I had occasion, recently, to use it on a woman in a bikini who swam into a swarm of common blue-bottle jelly fish. I warned her it would make her smell like a mechanic until she showered. It afforded immediate pain relief. I do not know how it would go on box jellyfish stings and certainly would not recommend it as the first line of treatment in preference to pouring vinegar over the stings. However, it is something that might well be worthy of academic investigation. It gets an occasional mention, in a Google search, as being useful in this context. During that search I came across the following pearl of wisdom.
A person needs only two tools: WD-40 and duct tape.
If it doesn't move and it should, use WD-40.
If it moves and it shouldn't, use the tape.
By the way; sting-rays inflict nasty wounds that require special attention. It is important to determine that the barb has not broken off under the skin and that there is no foreign matter in the wound such as beach sand. Stingrays do not have a venom sack. The toxin that causes the pain comes from the layer of slime covering its sting. Some of this enters the wound when the barb penetrates under the skin.
An old school acquaintance turned up in ED one day. He thought he had been stung by a cobbler while wading for crabs. He was in severe pain and there was a small laceration on top of his foot at the site of the pain. He told me he was wearing old, leather shoes at the time. I explained that a cobbler was unlikely to penetrate leather especially on the top of the foot. The wound and history were consistent with him having stood on a sting ray causing the tail to whip over into the top of his foot through the shoe. Anyway, I immediately tried the WD 40 - it did help some but not a lot. The hot water treatment did. He was keen to return home, about 150 ks away, but couldn’t keep his foot in a bucket of hot water all that way especially as he was driving. He left, still in pain, clutching a request form for an ultrasound of the foot to exclude embedded barb. A few days later he rang me to report he had purchased a can of WD40 and sprayed his foot frequently during the drive with some relief. He also reported the ultrasound showed no evidence of embedded barb.
The other day a middle aged chap presented with a dislocated toe. I put that back into place with the help of a few deep breaths of Entonox – a mixture of laughing gas (nitrous oxide) and oxygen and then had his foot x-rayed. That showed the toe in normal position and no fracture present. It also showed a large calcified foreign body between the long bones of the foot. He was at a loss to explain it for a while then remembered the sting ray attack he suffered quite a few years ago. He became a little indignant because a doctor had operated on his foot and told him he had removed the embedded barb. Obviously it had broken into two in the foot, the doctor found and removed what he thought was the complete object but didn’t x-ray the foot on completion of the job. Why it didn’t get infected I do not know.
The local estuary has some of the best crabs you are likely to find in Australia. They are easy to catch using drop nets from jetties or by scooping with a net while wading in the water. Youthful enthusiasm often leads to the crabs really coming to grips with children or teenagers. The crab’s nippers can exert a grip like the Boston strangler on the skin but rarely do any serious damage. The pointed ends of the nippers will puncture the skin and the shaft can cause considerable bruising to the skin – not to mention to the ego. It is uncommon for people to attend ED for crab bites but, now and then, a protective mother will bring in a child or reluctant teenager. All we do, as a rule, is clean the wound and give a tetanus injection and they rarely need anything else.
Marine species can effect a nasty revenge upon us even post-mortem (of the marine species). The angler cleaning his catch can finish up with a fish scale stuck on the cornea – much like a contact lens. The dorsal spines of fish often inflict puncture wounds into fingers and hands. People have been known to slip on fish bits and fall causing various injuries up to and including broken bones. I have witnessed the friendly banter of anglers, around fish cleaning bays, turn to violence.
Even after cooking and consumption the fish can be troublesome. Shell fish allergy is common and deadly serious. Even traces of , for example, prawn meat in a dish can trigger a life threatening reaction (anaphylaxis). Survivors of this insult will carry an Epipen injection with them at all times. At the first sign of a reaction they use it to inject themselves into the thigh with a life-saving dose of adrenaline.
And, of course, there is always the odd, crook prawn, in the kilo, that causes a nasty gastro-enteritis. The vomiting and diarrhea can be severe enough to dehydrate the victim necessitating intravenous fluid replacement. The same can occur as a consequence of eating fish contaminated from poor cleaning, preparation or storage.
Bee sting allergy is another common, serious problem that necessitates the victims carry Epipen around with them. Immediate self-injection prevents anaphylaxis. Sensitivity is often treated with a course of desensitizing injections which is usually very effective. It seems, too, that bee sting sensitive people get stung much more frequently than those who are not sensitive. However, that may simple mean that the sensitive patients present to doctor or hospital while the others just get the sting out and get on with it.
Removing a bee sting is simple but often done incorrectly. The sting protrudes from the skin – it is torn from the bee’s head immediately it punctures the skin – and has a venom sac on the end. (The poor old bee flutters away and promptly dies.) Common, reflex, practice, is to grasp the sting between thumb and forefinger and pull it out. This effectively squeezes all the venom from the sac into the victim under the skin. The safe way to do it is to scrape it out with a finger nail or a blunt knife edge or such like.
Strangely enough, the wives and children of bee keepers are often highly sensitive to bee stings. The mechanism behind this is frequent exposure to small amounts of bee proteins conveyed into the household on the clothing of the bee keeper. The family inhale and/or ingest tiny amounts repeatedly and this sets up an allergic response and sensitivity that can be catastrophic and fatal if they get stung by a bee.
One basic principle of allergy, little understood by the general population, is that allergic reactions rarely occur with the first exposure to an allergen such as bee sting, eggs, peanuts, prawns, penicillin or grevillia bush etc. It is only after the initial exposure that the human body begins to manufacture antibodies that precipitate the allergic reaction when the patient next comes into contact with the allergen. Any one suffering an allergic reaction to, for instance, penicillin must have previously had contact with penicillin in some form or other.
At the risk of wandering too far off my path, here, I might make mention of a strange phenomenon I regularly experience in the ED – people present to triage and state that they have been bitten by a spider. That is all very well and good – so to speak – but, after getting them into the department and settled on a couch, the first question I ask is, “What did this spider look like?” In the vast majority of cases the response is, “Oh, I didn’t actually see a spider but a bloke I know had the same sort of thing last year and he had been bitten by a spider.” – or words to that effect.
It is pointless to enquire if “the bloke” saw a spider. London to a brick he didn’t. So then I start from scratch the process of making a diagnosis. Rarely, there is sufficient evidence to support the self-diagnosis. Most times the diagnosis is something like a pimple, a scratch, an innocent insect bite or an allergic reaction.
It might be worthy of mention here that, in the words of a medical philosopher, the best that any doctor can achieve is to optimize conditions for nature to effect a cure. The doctor can achieve nothing more – and should achieve nothing less!
©2019 MICK Dr Ken Hay MB BS D(Obst)RCOG
Mick came to us about seven o’clock one evening complaining of a lump in his throat. He was probably in his late fifties, scrawny, unshaven and unkempt. Nicotine stains were abundantly evident on his fingers and he displayed a degree of agitation. But he was pleasant and cooperative. The lump, he said, had been present for about a week, was getting a bit bigger every day and was uncomfortable but not painful and did not get bigger or more painful when he ate.
He did not have a fever and denied felling unwell. The lump was quite solid, could be moved about under the skin and was only mildly tender. It was located under the jaw rather than in the throat. I suspected it may be a blocked sub-mandibular salivary duct. The main glands that produce saliva are situated in the face just in front of the ears but there are other, smaller such glands under the jaw.
Apart from being underweight there was precious little else to find when I examined him. His liver was not enlarged – which surprised me.
I went around to the staff room where I knew a few nurses were having their evening meal break. I had seen some lemons in a bowl on the table earlier and, fortunately, a couple remained. I took one, cut it into four and took a quarter back to Mick. He didn’t question me when I asked him to suck on the quarter of lemon. The sour, acidic juice caused a grimace and his lump became a little more painful and a little more pronounced. I felt that was sufficient to diagnose a sub-mandibular salivary calculus or stone blocking the duct leading from the gland to the floor of the mouth.
I explained it all to Mick and gave him a request form for an ultrasound of the lump to be done in our x-ray department next morning. I asked him to get it done and return to ED and I would see him again with the report. He was most emphatic that he would do as I asked and be back next morning, “…without fail.” Next day, the morning came and went but Mick did not.
I was disappointed, got his notes out and called his phone number. No answer. No message machine. Damn! Nothing more I could do.
Late one morning, about a week later, Mick’s name appeared on the screen. I immediately put my name against his and got him into the department as soon as I could. I was about to berate him for failing to attend as arranged but the huge swelling under his jaw precluded beration. There was a huge, rock solid, very tender mass under Mick’s jaw and tender glands in the front of his throat below it. I arranged an urgent ultrasound and they managed to squeeze him in about an hour later. The report was disconcerting to say the least. It was most likely an abscess and urgent CT scan was advised. This was done and confirmed the presence of an abscess. There was no evidence of a stone anywhere in the region.
This, suddenly, had become a life threatening situation. Sub-mandibular abscesses are notorious for causing sudden death by obstructing the breathing passages or rupturing to pour pus into the throat. (This condition was once described as Ludwig’s angina but it has nothing to do with heart pain also known as angina.)
I explained my concerns to Mick and advised him that he required urgent surgery. His concept of urgency did not coincide with mine. He explained he could not have surgery for four or five days because he had some marital legal affairs to attend to including a meeting with his lawyer next day. That, in Mick’s opinion, could not be avoided. Try as I might I could not get him to accept the seriousness of his situation.
By this time it was late afternoon and we were very busy. I rang a teaching hospital and explained the situation to the facio-maxillary surgery registrar. He agreed we had an emergency situation and advised we send the patient in immediately and by taxi, not ambulance, because the ambulances were ramped at his hospital. Nothing unusual about that! He would await Mick’s arrival with a theatre on standby. And when I enquired I was informed the ambulances were refusing to take our patients “up the road” anyway because they would become immobilised with a patient on the ramp! Back to Mick; back to square one; but eventually, somehow, he began to grasp the seriousness of his condition. The best compromise arrangement I could get to was that Mick would drive himself home, pick up his tooth brush and toiletries then drive to the teaching hospital.
Mick left and I slept little that night worrying if he had followed the plan, had he survived the trip without harm to himself or to others and was he, I fact, still alive. I had no way of knowing. Next day I rang the teaching hospital but the registrar I had spoken to was not available. Then, other patients, other issues, other priorities pushed thoughts of Mick into deep recesses of my mind to emerge from time to time but to no avail – I could not devote the time to pursuing Mick’s fate.
A week passed then, one morning, there was a hand-written enveloped addressed to me in my pigeon hole mail box. It contained a note from Mick, written in block capitals on blank paper, and reads (verbatim):
“Ken, I allways thought I was bullet proof. I am not! If not for your tenacity of making me do what you told me to do I could be dead. They were waiting for me when I got to xxxxxxx. I did not realize how serious it was! And I can not thank you enough for your care and concern. Mick
I reproduce it here not seeking kudos but as a sort of gesture of appreciation. This sort of thing always brings a lump into my throat and sometimes even a tear to my eyes. Mick is a rough diamond but took the trouble to put his thoughts into writing and express his appreciation for my puny efforts. That letter will always occupy its own small space in a file in my desk at home. I hope that when the time comes my family, especially grandchildren, will read it and understand it meant a great deal to me.
But Mick was not finished with me. He re- appeared in the waiting room about a fortnight later. He proudly displayed the healed surgical scar under his jaw and explained he just had to shake my hand and thank me in person. Then he left and I have not seen him since.
©2019 Old Lady Dr Ken Hay MB BS D(Obst)RCOG
It’s never much fun accepting hand-over patients from other doctors going off shift – especially at eight o’clock in the morning. The doctors are usually tired and anxious to get home. The patients are usually exhausted - awake most, if not all, of the night with pain and or vomiting plus or minus diarrhea and bleeding. Some have had hallucinations or delirium. Not only that, but, because some ancillary staff such as x-ray , laboratory, psychiatry and social work people don’t work in dark hours, the patients often still have a long wait ahead of them.
Such was the case when I received an elderly gentleman who had collapsed in the lounge room at home late the previous night. His wife called the ambulance and he was conveyed, unconscious, to our hospital. The night shift doctor had done an excellent job of assessing the patient and documenting his findings. It was apparent, simply on the clinical findings, that he had suffered a catastrophic stroke. All that was needed now was confirmation by way of a CT scan of the brain. The patient’s wife and son were told during the night that things looked pretty grim. They had gone home in the early hours to try to get some sleep.
I did my own assessment of the patient concluding that the night doctor was entirely correct. The orderlies came to take him for the CT scan. Within the hour he was back in ED. The CT scan showed a massive bleed inside the skull. The brain was displaced and the pressure was squeezing the lower parts of the brain downwards into the space occupied by the spinal cord. His condition had deteriorated significantly. There was absolutely nothing that could be done for him. Surgery was out of the question given his age, the large blood loss and the damage done to the brain. All we could do was make him as comfortable as possible and await the inevitable.
I called the home phone number shown on the patient’s chart. His daughter-in-law answered saying her husband was in the shower and the patient’s wife asleep on the lounge. I told her then that I felt it would be wise for the family to come to the hospital as soon as possible because of the rapidly deteriorating condition of the patient. She seemed a little put out by this news and enquired why they could not come in later. I started to explained the situation again but was interrupted by the son. He was more receptive and said he would come in immediately. He asked if he should bring his mother given that she had been up most of the night and was aged and frail. I gently told him that I felt she should come because it was most likely the last opportunity she would have to say a goodbye.
The son and his mother arrived shortly thereafter. We stood around the bed, the patient comatose but breathing slowly and shallowly. The monitors above the bed flashed the ECG and respiratory traces, beeping as they do, the blood pressure cuff automatically inflated and deflated with the result showing on the monitor screen below the oxygen saturation level. I explained the situation again. The son nodded appropriately and asked a question or two. His mother, gaunt and haggard, stood alongside him staring at her husband, saying nothing. There was no physical contact between mother and son.
Then I came to the most difficult part of the process – raising the issue of resuscitation. As gently as I could I asked, “Have you given any thought to what we should do when his heart stops?” The lady looked up at me suddenly with a look of horror. “What do you mean?” she asked.
I did not have to explain as the son immediately said, “Yes! We discussed this situation quite often and Dad always said he would rather die than become a vegetable. If his heart stops and you get it going again he would be a vegetable – wouldn’t he?”
I thought the lady was about to faint and put my arm around her shoulders. Instead, she sagged, deflated and leaned against me before regaining her composure. We, all three, stood silently for a few minutes, the only sounds in our awareness those of the beeping monitor - the background noise of the ward not perceived by any of us. The poor, dear old lady stood bewildered, lost and lonely still with no physical contact from her son. Some people are like that while others are very “touchy- feely”. I think she may have been contemplating her future without the soul-mate of many years and wondering how she would cope.
“May I ask you both to sign a standard form that permits us to not resuscitate patients who have no chance of survival?” They both agreed; the son saying “Yes” and the mother nodding. I produced the form and we completed it on the bedside table. She signed last, hesitantly and with a shaky hand.
“We will move him to a private room in the hospital now. They will make him as comfortable as possible and you may stay with him as long as you like. I have spoken to your family GP and he will take over the medical care now.”
The son thanked me and his mother looked at me, distantly, then extending her frail hand, took mine gently shaking it and saying, “Thank you, doctor.”
The orderlies came and wheeled the bed away to the ward. Mother and son followed. He finally put his arm around her shoulders and drew her close to him as they walked slowly beside the bed.
©2019 Only The Lonely Dr Ken Hay MB BS D(Obst)RCOG
Let’s call her Joan. Joan was a lady of some sixty years who was brought to hospital by her daughter because she was always crying, sleeping poorly and not eating well or looking after herself as good as she once did. I asked the daughter to go to the coffee shop and give me some time with her Mum.
Joan sat in the dilapidated arm chair in a cubicle. She had obviously made an attempt at making herself presentable but the distinctive feature of her presentation was she looked sad. Very sad. I introduced myself with a smile and outstretched right hand as I sat on the bed alongside the chair – just a little bit of role reversal intended to make it all a little easier for her. She took my hand but avoided eye contact so I held on, gently. That caused her to look up. I smiled again, still holding her hand, and she managed a wan smile so I let go. The ice was broken.
“Your daughter seems very worried about you.”
“Yes, she is, but there is nothing wrong, really.”
“Hmmm. You are wearing engagement and wedding rings but your daughter brought you here. Can I ask where your husband is?”
“He died.” She replied, flatly, then burst into tears.
I brought down the box of tissues from the shelf above the bed and offered them to her. She took a couple and tried to dry her eyes but without success.
“Crying is OK. You can cry as much as you like. I don’t mind and we’ve got heaps of tissues. Would you like a cup of tea?” She nodded. “Milk and sugar?”
“Can I have milk please but no sugar?”
“Absolutely. You just sit there for a few minutes and I’ll be back with a brew.”
The Patient Care Assistant was busy so I made it myself and took it back to Joan along with a small plate of sandwiches from the stock kept in the tea room fridge. She thanked me and sipped at the tea trying to ignore the sandwiches but I persuaded her to nibble a quarter at a time. Eventually, only the crusts were left.
Joan’s husband had died six months previously – suddenly; unexpectedly – from a heart attack, early one morning when making tea for Joan who was still in bed. She heard the crash as he collapsed. She rushed out and he died in her arms with the sound of the ambulance in the distance. And her symptoms dated from that event.
I worked through the questions of a medical history looking for symptoms of illness and especially of severe depression. I had no doubt she was depressed but I was sure it was a secondary depression consequent upon the death of her husband. Then I changed tack.
“Who is in charge of your life?” I asked.
She looked up with a quizzical expression. “No one.” She replied with just a hint of indignation.
“OK. And who used to be in charge of your life?’
This time there was a suggestion of a frown as she replied, “My husband..... I suppose. But he was never bossy or aggressive or anything like that.”
“I was not suggesting anything of the sort. But I think it may have been him who made the significant decisions like how money was spent and that sort of thing. Did you do everything together?”
“Yes. We both played bowls twice a week and liked going to the pictures every now and then and gardening too.”
“And now you are lost without him. There is a huge space in your life that your husband once filled. And you don’t have his support or encouragement to do anything about it. Have you played bowls since he died?”
“No. I just can’t bear the thought of going there without him.”
“But you must have friends there?”
“Yes. They used to come around for a cup of tea and invite me to the club but they don’t seem to come any more.”
So it went on. Fortunately it was a very quiet day and I was able to spend a lot of time with her.
Eventually, with the help of the hospital social worker, the daughter and a friend who had turned up after learning that Joan was at the hospital we worked out a plan that Joan accepted. It revolved around her deciding she had to take charge of her life now and, with the support of others, gradually get back into a normal, but different, lifestyle.
She thanked me for my time and shook my hand as she left. The sadness had gone but she still had a long way to go.
On another day a man in his mid-thirties presented and as soon as I walked into the cubicle I was reminded of Joan. He, too, was profoundly sad, dishevelled, unkempt and unshaven. Again, I could find no clear evidence of physical illness but he was certainly depressed. It also turned out to be a reactive depression. His wife had been imprisoned for repeatedly driving while drunk and told him she wanted nothing more to do with him. She refused to allow him to visit her.
Again, I arranged coffee and sandwiches and spent a lot of time with him. I managed to upset the nurse supervisor when I asked that he be allowed to shower and shave. There are pretty strict rules around what we can let patients with mental illness do in the department. Giving them razors – even disposable safety razors – was a definite no-no. But I stood my ground and insisted he did not have a mental illness. She eventually capitulated, the patient showered and shaved and presented again feeling and looking much better.
After further discussion with him it became apparent that his marriage had begun to fail some years previously. There were no children – he wanted them; she didn’t. She drifted into alcohol and drug abuse and he just did not know what to do about it. And so, in the long run, he finished up telling me all about it.
He knew the marriage was finished and had decided he would not have her back even if she wanted that. He realized his best course of action was to initiate divorce proceedings and them get on with a new life. Coming to those conclusions had been very traumatic for him and he felt guilty about it. Further, he had not shared his problem with anyone else and had rejected approaches by his own family who could see he was struggling. Spontaneously, he shook my hand and said, “Thank you very much for your time. I going to see my Dad and talk to him about all this stuff. I didn’t want to worry him but he was always someone I could talk to.” With that he left.
There are many lonely people in our society. This man and Joan are but two examples.
©2019 P2G9 Dr Ken Hay MB BS D(Obst)RCOG
Pregnancy is a wonderful condition that ensures the continuation of the human race. Most pregnancies are planned and the conception takes place is a controlled environment with the willing consent of both parties. The outcome is, most often, a healthy child or two that makes the parents proud and happy. But that is not always the case.
It is a rare day in the emergency department that we do not have to deal with a complication of at least one pregnancy. Sometimes the complications are social – the pregnancy is not wanted for whatever reason; or it is in a single, young teenager who is bewildered and afraid; or the mother has been brutally bashed and often kicked in the abdomen by a drug or alcohol crazed partner; or the mother has been involved in a motor vehicle smash; or a miscarriage threatens.
Sorting out these problems often requires the services of a social worker rather than a doctor and we try to analyze the problem and make the appropriate arrangements. Sometimes the police become involved and sort out the violence issues one way or another. Sometimes we have to decide if the foetus is at risk and take appropriate action. One of the most common problems of pregnancy we are faced with is the threatened miscarriage in the first trimester - the first three months of the pregnancy.
The young woman usually knows she is pregnant and presents to us with vaginal bleeding with or without pain. We take a medical and obstetric history and do a very gentle external examination. We do not do an internal examination for fear of exacerbating an already precarious situation. If we find heavy bleeding, blood clots, solid tissue or a foetal sac then all is lost and admission to hospital is usually mandatory.
If these sinister signs are not present then there are two simple laboratory investigations that determine the course of action. The first is a blood test called a quantitative beta-HCG. This measures the level, in the circulating blood, of a hormone called human chorionic gonadotrophin. It is produced by the developing placenta and can usually be detected in the blood stream at about ten days after conception. It is this hormone that is tested for in the common pregnancy test. A pregnancy test simply determines if the hormone is present or not. The quantitative test measures the level of hormone present in the bloodstream and this can be correlated to the duration of the pregnancy although interpretation does require caution. If the levels do correlate with the date of the last period then it is a fairly good indicator that the pregnancy is viable. Serial tests over a week or more give a clearer picture.
The other investigation is ultrasound. A probe placed on the abdomen bounces sound waves off the uterus and contents projecting a picture onto a screen. (Sometimes, especially in very early pregnancy, the probe may be placed into the vagina to give a clearer picture.) This can detect a pregnancy as early as 40 days after conception but is more reliable after six weeks when the baby’s heart beat can be detected. If this is found then the pregnancy is definitely still viable. Again, serial tests over a week or two give a clearer picture.
On a good day during working hours we can usually have all of this done within 4 to 6 hours and then discuss where to from there with the parents. Most often, with a simple bleed, she can go home, rest completely and the bleeding settles down. Occasionally we advise admission to hospital for close observation in the hope it will settle down. If the history, examination and tests indicate the foetus has died then the patient will usually be admitted.
This is all straight forward stuff. Where the pregnancy has failed we offer follow up by an obstetrician and counseling. It becomes difficult when the pregnancy is the patient’s first and very difficult when the patient is the victim of recurrent miscarriages. In these cases we need to be extra specially gentle and caring taking the time to explain things and listening to the patients express their feelings and fears and answering their questions. Single miscarriages are extremely common and, with first pregnancies and in the absence of any known pathology, we can confidently predict a normal later pregnancy. Some women have multiple miscarriages and no normal pregnancies. Others have both.
One such patient who presented with vaginal bleeding in early pregnancy previously had two normal pregnancies and seven miscarriages. In the medical notes this is recorded in shorthand as P2G9. I had to inform her, later, that the blood tests and ultrasound indicated that the pregnancy was not viable. She was philosophical about it all. Grateful she had two healthy children, wanting more, but resigned to the fact it was probably not going to happen given the recurrent miscarriages. I arranged for her obstetrician to see her that day.
Ultrasound examinations are now routine in pregnancy. They are extremely helpful in accurately determining the age of the foetus and its growth rate, detecting twins, conjoined twins (called Siamese twins in days gone by), developmental abnormalities and placenta praevia. This latter condition occurs when the placenta completely or partially lies across the cervical outlet – the only way the baby can get out of the uterus naturally. When this condition is detected the baby will most often be delivered by Caesarian section. If it is not detected then both mother and baby are at extreme risk from haemorrhage if the placenta tears in labour – or earlier.
These days it is rarely that haemorrhage from placenta praevia will present in ED but it is always a possibility. Vaginal bleeding in pregnancy from six months onward is considered due to placenta praevia until proven otherwise. Unfortunately, it is most likely to present in circumstances least likely to have a favourable outcome. That is in patients who have not had proper ante-natal care and therefore no ultrasounds. That is most likely in remote, isolated places where sophisticated emergency services do not exist.
Pregnant women present to us with conditions that may or may not be a consequence of the pregnancy. I saw a young lady, twenty eight weeks into her second pregnancy, who had a dreadful, extremely itchy rash all over her body and limbs. She was on holidays from a distant, country town. She emphatically informed me she had the same condition at the same time in her first pregnancy. The poor girl scratched incessantly as I examined her. The skin was red, inflamed and there were scratch marks everywhere. It resembled no rash I had ever seen previously. It did not resemble scabies either and she was not jaundiced (yellow). She did not feel ill with it and, on careful questioning, I could identify no allergen of any type.
The uterus was the right size for her dates and the foetal heart was beating away exactly as it should. The babe even moved a few times during the examination which was an entirely normal thing for it to do. I was perplexed and she was agitated and for that I could not blame her. She repeatedly stated it had gone on for months last time and driven her almost mad and she did not want to go through that again. Then I recalled a colleague who was in the same year as me in medical school. He had gone on to specialize in the medical illnesses related to pregnancy. I rang him and described my patient’s condition. After careful questioning he advised me the condition was most likely one known as the polymorphic eruption of pregnancy and would respond to certain treatment which he described for me.
I wrote the prescription, explained the condition as well as I could and told her about my colleague and his qualifications. I gave her a letter for her country GP which included reference to my colleague. I advised her to start treatment immediately and to return if it did not have an effect within 24 hours. I never saw her again and hope it was because the treatment was effective.
©2019 PSYCHOSIS Dr Ken Hay MB BS D(Obst)RCOG
He was brought in, from a nursing home, by ambulance. We heard him being wheeled through the automatic doors, shouting abuse at the ambulance officers and anyone else in sight. I drew the short straw and put my name alongside his on the computer screen. A quick chat with the ambulance officers revealed they had been called to the nursing home because this patient had undergone a rapid change in his mental state. He had only been there a week and had suddenly changed from being a quiet, cooperative old chap into what we saw now – an aggressive, abusive, loud and disruptive person.
I was able to calm him briefly and ask him a few questions but his answers were always shouted and his behavior was quite inappropriate to his circumstances. Our attempts to examine him were frustrated by his aggression and the ECG was quite useless as he kept pulling off the leads and would not lie still for any length of time. Trying to take blood proved too dangerous for him and the medical staff. Eventually I decided to sedate him to facilitate a proper and full examination and an interpretable ECG to be taken.
Rather than inject him with a sedative I elected to use an oral sedative in wafer form. Simply placed on the tongue it rapidly dissolves and is absorbed. We had no trouble convincing him to open his mouth and allow the nurse to place the wafer on his tongue. In a very short time he was under control and we were able to achieve all our objectives.
The physical examination proved unrewarding. We took blood for a battery of tests and when he was taken away for a chest x-ray I called his son. He was not able to add anything to the history but did confirm his Dad had been quiet, cooperative and inoffensive up until a few days previously. He was somewhat distressed at his father’s condition.
Some hours later the patient had again become aggressive and difficult and we were forced to use injected sedation before transferring him to a ward in the hospital under the care of his GP. Then a phone call from the laboratory threw a whole new light onto the scene. Our patient’s serum troponin level was very high indicating severe damage to his heart. We concluded that at sometime in the previous week he had suffered a major myocardial infarction – a heart attack. This probably resulted in inability of his heart to maintain an adequate blood supply to his brain with the consequence being brain damage due to lack of oxygen and the demented behavior we had observed.
I rang the GP to let him know of this development then rang the patient’s son. I explained the situation and had to inform him that it was highly unlikely that any improvement could be expected. Both GP and patient’s son decided to come to the hospital and I arranged they should meet. I do not know the outcome.
So, we had a patient present as a psychiatric problem but the process of diagnosis revealed the cause to be medical.
That is rarely the case with psychotic patients presenting to ED. Many are “Frequent Flyers” and well know to the staff. They are brought in by the police, friends, relatives or of their own volition. And most become a major problem to us because, all too often, we have nowhere to send them. Rarely can we let them go home because they are out of touch with reality and at very significant risk of harming themselves or others. Trying to get them into a psychiatric treatment facility becomes a frustrating process of ringing around and being fobbed off by one facility after another. Unfortunately, the basic issue is political – there are nowhere near enough facilities available to manage such patients and those that do function are usually full. So we are stuck with them.
It is not uncommon to have such patients in the main ED area all day or even for days on end. Often two police officers will remain in attendance or one of the hospital security personnel will have to sit with the patient. Unattended psychotic patients will do irrational things. Some become violent and throw chairs and furniture about or assault staff or others. It can be terrifying for all including other patients and children not to mention the staff who have to deal with it. Sedation is often necessary; I have never used or seen used physical restraint such as tying people to beds.
Psychotic patients are a minority of those patients requiring psychiatric diagnosis and treatment. Psychotic patients are, basically and simplistically, out of touch with reality. They are human beings suffering a terrible, life destroying affliction that can be humanely and professionally managed. But that humanity and professionalism is hamstrung by the blissful ignorance of senior health bureaucrats, politicians and do-gooders. A few years ago it became politically trendy to treat psychiatric patients in the community. Major psychiatric facilities were closed with the loss of many psychiatric beds to the point where there are not enough to manage even the acutely ill. The whole concept became a disaster with poorly managed psychotic patients often left to their own devices in the community.
One major problem with these patients is that, left to their own devices and on medication, they will often decide that there is nothing wrong with themselves and cease taking the medication. They then inevitably drift back into ever deepening psychosis and loose touch with reality. I was once asked to see one such patient, brought in by his work foreman because he was behaving very strangely. Going through the normal assessment process I asked the patient if he had ever had any serious illnesses. He replied that he had been a schizophrenic once but a course of tablets had cured him and he had stopped taking them. The condition masked his insight and he was incapable of realizing his behaviour was bizarre and he was drifting back into psychosis.
Then there was another young man who was on the screen as wanting a repeat prescription. Unfortunately, due to higher priority patients, he had to wait a long while. When I got to him I was taken aback when he asked for a particular antipsychotic, he was visiting from another state and had run out of medication for schizophrenia. He even presented a letter from his GP confirming his diagnosis and treatment. I rang the GP who confirmed the patient’s story adding that he was one of his easier-to-deal-with schizophrenic patients. I happily wrote the prescription.
But not all ED patients with psychiatric conditions are psychotic. We see severely depressed patients, severely anxious patients, obsessive-compulsive patients, patients attempting suicide, ( unfortunately many others succeed), and so on. Many we can manage in the short term and with the help of their GPs or psychologists. Many we can’t manage and go through the agonising process of trying to get them professional help. Rarely, we can get them an urgent appointment at a mental health clinic.
©2019 STITCHES Dr Ken Hay MB BS D(Obst)RCOG
I never cease to be amazed at the mechanisms people use to inflict lacerations upon themselves – most often not intentionally. Sharp instruments such as knives of every description, exposed sharp edges, chisels, screw drivers, power tools, broken glass and ceramics and so on. I have seen deep, neat lacerations on legs caused by the sharp edges of house bricks; nasty full-thickness tears caused by angle grinders and circular saws; rough lacerations caused by falling onto or against rough surfaces - to name but a few. One of the most severe I had to deal with was caused by a man falling, upright, through the top of an old tree stump and tearing open both legs exposing bone and muscle. I have seen severe facial lacerations on the faces of kids who have fallen off their bikes into bushes or onto broken glass or piles of broken bricks. Crush injuries often split the skin necessitating sutures.
A deep laceration, down to bone, on the shin of a young bricky. Caused when the sharp
edge of a brick he had dropped sliced his leg on the way to the ground. It required deep
stitches as well as skin stitches. >>>>>>>>>>>>>>>
A laceration is defined as, “A torn, ragged wound.” In practice we tend to describe
any traumatic opening through the skin as a laceration. Lacerations most often need
to be closed with stitches but, these days, we sometimes use glue, staples or adhesive
strips to hold the skin edges together while healing takes place.
Steri-strips and glue are great for closing minor lacerations especially on kids. The use of needles to inject local anaesthetic, (which stings something cruel), can be avoided and the whole process becomes far less traumatic than it would be otherwise. (The glue stings too although it doesn’t worry most kids very much.) Most kids are up to date with their immunisations so a tetanus needle is not required. The parents of those who are not immunised will usually refuse permission to give it anyway.
It is difficult to predict how kids will react to injections of local anaesthetic if it must be used. It is wise to anticipate fear and do one’s best to allay that fear but without creating false expectations. The triage nurses will usually have filled the wound with local anaesthetic cream on arrival and this helps a lot. With toddlers, these days, we tend to use an intramuscular injection of a drug that renders them essentially unconscious but not deeply anaesthetised. This avoids the need to wrap the child in sheets and restrain it while an injection is given – a most undesirable situation. Most older kids will respond to the advice that we must give an injection into the wound, that it will sting for a short while but then it will all go numb. They will grit their teeth and grip Mum or Dad’s hand tightly while it is done. Some cry, some scream and some remain silent. Sometimes, this is a consequence of Mum or Dad fainting – happens often enough to be a nuisance and it is smart to keep an eye them.
Parents can be a bit of a nuisance in other ways too. A girl of about twelve was brought in by Mum late one afternoon. She had been riding a trail bike, without a crash hat, fallen off into bushes and a stick had penetrated and torn the skin along one eyebrow. She was remarkably composed and resigned to having a needle or two. Not so Mum who was in a state of hand-wringing remorse at letting the girl ride without the stack-hat. We were just about to start the local anaesthetic when Dad rocked up from work, took one look at the now-exposed wound and wanted to know if it might be better treated by a plastic surgeon. A fair enough question he was quite entitled to ask, and he was quite polite about it, but I had to stop what I was doing and discuss it with him, Mum and the daughter – who was quite happy to let me get on with it. In the end the parents accepted my assurance that I felt I could get a very satisfactory result and there would inevitable be some scarring but not ugly and would be masked by the eyebrow. I never did get to see the end result but had no follow-up complaint.
In the ED metal staples are rarely, if ever, used and then usually, only on the scalp. Surgeons sometimes use them to close wounds but they have not and are unlikely to ever replace the old fashioned stitches which, by the way, we describe as sutures just to maintain our superior position - of course.
And stitches ain’t just stitches! There are dozens of different stitches for different jobs and most come in different sizes. There are various sizes and shapes of needles – the business end of the stitch. Nowadays the stitches themselves are swaged onto the end of the needle. I can remember having to thread stitches through the eye of the needle. The stitch material may be absorbable or non-absorbable, monofilament or multifilament, dyed or not and coated or not.
For the skin there are a few to choose from. In days gone by BBS – Braided Black Silk was probably the most commonly used skin suture material. Haven’t seen it for donkey’s years now. Nowadays it is synthetics such as Vycril and Ethilon. My own preference is for Ethilon because I found its knots hold better than Vycril which tends to let them slip.
For repairing tissues under the skin the old fashioned cat gut is still used. (It is made from sheep intestine not cat’s.) It dissolves in the tissues and comes in plain and chromic types the latter taking longer to dissolve. The point is, “dissolving” stitches don’t just dissolve – they are foreign matter and trigger a reaction from the immune system that causes local inflammation, swelling and some pain. This can go on for 50 to 70 days before the stitch is completely broken down.
We use non-dissolving sutures in the skin. And most often we insert individual stitches rather than one continuous stitch. The reason being that, especially in traumatic wounds, infection of a stitch is not uncommon. If it occurs then the stitch must be removed otherwise the infection may extend into deeper tissues and into adjacent stitches. Removal of an infected continuous stitch usually compromises the integrity of the entire wound and it is likely to fall apart – dehisce is the techo term. However, we can often get away with the removal of one out of a series of stitches and retain the integrity of the repair. Infection of a stitch must not be confused with the normal inflammatory reaction on the skin against the foreign matter of the stitches. It results in the wound becoming red and itchy but without pus being present. It settles down rapidly after the stitches are removed at the proper time and the wound heals nicely.
Removing stitches is not painful - but little billy lids aren’t keen on having strangers approach them wearing rubber gloves and bearing stainless steel scissors and forceps and smelly antiseptics. This can present a challenge to the parents and nurses who usually perform the task. With the right approach it can usually be achieved without traumatising the child too much.
The skin will heal extremely well in most cases, provided the right conditions are established for nature to do its job of healing. Paramount among the right conditions is cleanliness. A dirty wound will inevitably become infected and not heal well if at all. Also, any foreign body or material must be removed. This can be difficult and sometimes require the use of scrubbing brushes and/or time consuming removal of small particles of dirt and debris, bit by bit, with forceps and swabs. And cleanliness must be maintained until the wound has healed.
Old habits die hard and one of mine is to shave the edges of skin wounds on hairy areas. The idea is to prevent hairs getting caught up in the wound and acting as a foreign body or a conduit for bacteria to enter the wound. Nurses frequently advise me this is not necessary but I thank them politely for their advice, grin and proceed to shave the area anyway. One exception is the eyebrow. Eyebrows are prominent features giving form to the face. Remove one or part of one and it stands out like a warehouse in the desert. With care, the coarse hairs of the eyebrow can be excluded from the wound during suturing. They also mask the presence of the wound and sutures. Teenage girls, and young ladies, in particular are always grateful for this little courtesy.
Every wound must be assessed properly before any attempt is made to repair it. It is critical to exclude or define any damage to blood vessels, nerves, muscles, tendons and bones. The simplest, neatest cut to a finger with a very sharp knife can conceal a severed nerve or tendon requiring micro-surgery under general anaesthetic. Crush injuries very often require x-rays to determine if bones have been damaged. Careful assessment of sensation by testing both light touch and pin prick, (and sometimes other methods), is mandatory with every laceration especially of hands and fingers. Modern surgical techniques now enable the repair of even the extremely fine nerves supplying the fingertips with sensation. Similarly, there is no excuse for failing to diagnose a severed tendon in any part of the body and the fingers in particular. They can be repaired with restoration of normal appearance and function.
There is quite a knack to inserting sutures that will not only make the wound look neat, tidy and professionally repaired but will heal with minimal scarring. Its important that the needle enters the skin at right angles to the surface before being rotated out through the wound then reinserted into the wound and emerging through the skin, at right angles, on the other side. Tying the knot is usually done using the needle holder and just enough tension applied to draw the wound edges together with a little eversion. Sutures should be placed as far apart as the exposed length of stitch after tying and cutting – that is they form a square. It is always tempting to young players to put the first stitch across the middle of the wound and draw the edges together. This results in too much tension on the stitch and compromises the blood supply to that area of skin. I usually start at one end and work my way down to the other or alternate the stitches end to end with the last one in the middle of the wound. Each stitch then has equal, minimal tension.
When I have finished stitching a wound I like to clean the wound and adjacent skin of any blood or dirt then paint the wound and stitches with old fashioned, but still readily available, Friars Balsam aka as Tincture of Benzoin Compound. It seals the wound edges and the stitch entry and exit points keeping out bacteria and dirt. Then a dressing is applied with the advice to leave it in place for a day or so.
Once the skin sutures are in they must be removed – after the wound is sufficiently healed and before they cause cross-hatching, inflammation or infection becomes established. The skin of the face, especially in children, heals rapidly and we like to get these sutures out after three to five days. The back of an elderly person is a different kettle of fish and we would be unlikely to remove them within ten days. Given that most wounds have very little tensile strength within five days it is necessary to leave sutures over joints, especially the knee, in place for ten days or even more. This because flexion of the joins stretches the wound and may cause it to fall apart and require re-suturing.
A dirty laceration on the hairy leg of an adult male. Caused by the sharp edge
of a sheet of roofing iron.
The same wound after cleaning, shaving and inserting six stitches then
applying Friars Balsam.
Potato peelers are nasty little instruments that can inflict very nasty wounds when used carelessly. The simplest wounds they inflict are simply the peeling off of a small piece of skin, usually partial thickness, without damaging underlying tissues. These we just clean and dress, offer tetanus booster and allow the skin to repair itself. However, I have seen potato peeler wounds, over knuckles, that have extended into the joint space and even severed a tendon over a knuckle. Severed tendons require surgery to repair and months of immobilization to heal. Seemingly innocuous wounds can have serious, unforseen consequences. A surgeon acquaintance once presented with a wound over a knuckled inflicted when he was kindly assisting his wife to prepared dinner and the potato peeler attacked him. It took out a full-thickness, sizable piece of skin but, fortunately did not cause other damage. However, it was not suitable for stitching and had to be covered with a dressing while it healed itself and that would take at least two weeks. And he needed to take a course of antibiotics. That’s all very well and good but – he had operating sessions booked over the next few weeks and surgeons cannot operate with bandaids or wounds on their fingers.
The appalling act of smashing drinking glasses or bottles into the faces of others has become so commonplace that it has attracted its own, disgusting, euphemism – “glassing”. It is not an entirely knew phenomenon – I spent most of one Saturday night in about 1977 in the then local hospital stitching up the face of a teenage boy victim. Fortunately all the lacerations were superficial and all missed his eyes. Not so for the all-too-common victims these days. And many were, previously, pretty young women and many are the victims of attacks by another woman. “Go figure” as the Americans would say. But these poor people require the services of plastic surgeons and often eye surgeons and/or fascio-maxillary surgeons and, even so, are never the same again.
At the other end of the spectrum, in the context of glassing, are the “tissue paper” lacerations of the elderly. The “tissue paper” description is my own but that is exactly what they resemble. They occur when an elderly person traumatises a limb by falling or by catching it on an object. Because their skin is so fragile the trauma causes the epidermis, or outer layer, to peel off. We usually see a triangular area of raw skin with what looks like a roll of wet tissue paper at one end. Stitching these wounds is an unnecessary waste of time. After carefully cleaning the wound the epidermis can be gently stretched back over the raw area and held in place with a dressing. They usually heal up nicely within ten days.
©2019 Things We Do On The Side Dr Ken Hay MB BS D(Obst)RCOG
Working Fast Track in ED is not all just sorting out real or perceived urgent medical problems – we do get our fair share of issues that do not fit that description. Writing prescriptions, for example.
It is amazing how many people will fly across the country for a holiday and forget to bring their prescription medications and/or the repeat prescriptions. Others, just on day trips from the city, do the same. There are those patients who just forget to visit their GP for repeat scripts; or can’t get an appointment for a fortnight; or run out of tablets on a weekend. To them, their situation is an emergency and, according to their logic, the ED owns the problem. Unfortunately, a lack of planning and foresight on their part DOES constitute an emergency on our part.
If they time their ED visit right and come in during a quiet period and know the name, strength and dosage of their medication, ( a set of circumstances that will occur once in a blue moon), then there is no drama. We can write the script and have them happily on their way in a short time.
Usually, however, we are busy when they arrive. Most are embarrassed, contrite and accept they will have to wait their turn. Others are aggressive, demanding and want to be attended to immediately because, “.. it only takes a minute to write a prescription....” and “... we have to be at the airport in two hours.” , and so on. And these might be the people who know only that the tablets are for their blood pressure. “The little white tablets!” How many times have I heard that? At least it narrows down the possibilities to several hundred.
We cannot dismiss these people. They do have a problem and while missing medication for a few days might be of little consequence in some cases, such as cholesterol lowering drugs, it may have catastrophic consequences in others. Epileptics, schizophrenics, insulin dependent diabetics and others must have their medication as prescribed. And if they do not know the name, strength and dosage then it is up to us to find out.
If the patient is a male the first step is to talk to the wife. Wives usually know these things. Often they will have a list of their own and/or their husband’s medication on a piece of paper in their handbags. If that fails, sometimes we, or they, can ring someone who might be house sitting for them or one of their adult children who can find the medication at home and read out the critical details from the containers.
Failing that we can ring the surgery of their doctor. That often requires a bit of detective work because the surgery number is attached to the fridge door at home. If we succeed then there is the wait while the receptionist gets the notes out, speaks to the doctor or practice nurse and they tells us what we need to know. Sometimes, when they are busy, it may take several hours for them to call us back.
Alternatively, especially out of hours, the patient’s chemist is a better proposition. They all seem to have easily accessible computer based records of patients and their medications. The only potential problem is the patient goes to any old chemist or can’t remember from which chemist they got the particular medication.
A further complication arises if the medication requires an authority prescription. The doctor must ring the health department in Canberra and provide the patient’s details, including Medicare card number, the diagnosis and confirmation that the condition being treated meets the criteria set by the department. They then give the doctor an authority number which must be written on the special authority prescription form before giving it to the patient. Ho hum! Meanwhile, the waiting room becomes much more cosy. So, we work through all that and usually the patient leaves, satisfied and sometimes even thanks us. Rarely, we get hit with the final test, “... but I haven’t got any money to pay the chemist...” And the waiting room becomes even more cosy.
It is a regular occurrence for patients with no or trivial injuries to turn up only because they have been advised to do so by the police – or their mother-in-law, spouse or a casual by-stander. People involved in road smashes and who have a sore neck or a few bruises get that advice. So do those involved in altercations with drunks, neighbours, friends, lovers and spouses. We have to examine them and carefully document our findings of, in most cases, precious little. Sometimes, usually months later, a letter will arrive from the police requesting a formal report on the matter. The existence of good notes then becomes very handy indeed. Very rarely do we get called to court for the minor stuff – especially if we can give a good description of our findings. Without good notes that is difficult - especially if one cannot remember anything at all about the patient. The coroner deeply appreciates good medical notes – almost as much as the doctor standing before him.
Teachers seem to project a strong sense of caring for their pupils by sending them down to us after trivial sporting injuries or schoolyard fights. I suppose, like us, they have to protect their own backs but it does become rather tedious. Having said that I once had a child of about 12 years, with a very nasty laceration, brought in by the teacher. It required suturing which required an injection of local anaesthetic and we never inject minors with anything without parental consent. This child’s parents both worked in the city and were very difficult to contact. This caused considerable delay and the teacher rang the headmaster to let him know what was happening. He got on the phone to me to inform me he was the child’s legal guardian, in such circumstances, and therefore would give me his permission to give the injection. “Yair, Barker – pull the other leg, it plays Jingle Bells.” I politely declined his kind offer saying I would wait until a parent could be contacted. The headmaster took this as a personal affront and became fairly pushy. I ignored his protestations and hung up. Fortunately the child’s mother turned up and the situation was defused.
One thing we do not do is prescribe drugs of addiction for people who come in asking specifically for prescriptions for those medications. It is a very awkward situation because most of them are addicted consequent upon long term dependence for relief of chronic pain. Some are simply addicts. But the law is perfectly clear – only one particular doctor is authorized to prescribe the drugs for that patient and that particular patient is required to attend that doctor for all such prescriptions. We are prohibited from doing so. Most of them know this and are just trying us out in the hope they will get a young, inexperienced doctor who will fall for their con. Others have genuinely become victims of circumstances that prevent them obtaining their scripts from the authorised doctor. The best we can offer them is a prescription for a small amount of a non-restricted analgesic. Some accept this with equanimity – others refuse and leave to try their luck elsewhere. Rarely, one will become hostile and aggressive. All in a day’s work.
Another thing we do not do, because we aren’t allowed to, is provide medication for people to take away. We can give a dose on the spot and sometimes a single dose to take home to tide them over until the chemists open next day but that is it. All too often there will be a patient who needs a course of antibiotics, for instance, who will ask us to provide it because they won’t have any money until “Thursday” – for whatever reason. Many see it as our problem; not theirs. Sorry, we can’t help. Some get abusive and angry others make noises like, “I’ll see if my mate can lend me some money.” or “I’ll ask the chemist for credit.” Or “ Centrelink should give me the money.” We can only wish them well. These circumstances will not apply to someone who is seriously ill – we will admit them to hospital – if they are willing, and their medication will be provided.
Back to the things we do and one of them is certify life extinct in the occasional patient who dies on a ward in the hospital and their treating GP or specialist is not available. It doesn’t happen often but does interrupt us occasionally. It is a serious business and must be done properly although it doesn’t take long. It is smart to read the patients notes to determine the diagnosis and to discuss the patient with the nursing staff. If the death was sudden or unexpected the police will be called but we still need to certify life extinct. (That is something your average policeman cannot, legally, do.) Usually, first glance is enough but I always test for pupil reflex by shining a light into the pupils - which should be dilated and not react to the light. Then a careful listen to the chest, with stethoscope, for heart sounds or breath sounds. In some circumstances a more detailed and extensive examination may be necessary. Then a written statement in the patients notes that, in my opinion, life is extinct with my signature, time and date. This is not a death certificate - that must be provided by the treating doctor. If he/she cannot provide one then it becomes a coroner’s case. A death certificate states the cause of death; certifying life extinct merely states that the examining doctor believes the patient is dead.
Death is not uncommon in the ED – a fact that should surprise no one given that many people arrive at our doors “in extremis” – a Latin term meaning “at the point of death” – or even past it. Modern emergency medicine practices and technology see the majority successfully resuscitated but for some our best efforts are not enough. Sadly, many could have been prevented by good management of underlying conditions such as asthma, diabetes, hypertension (high blood pressure) and chest pain. Far too many others could have been prevented by abstinence from alcohol and other drugs and not necessarily by the victims. Never-the-less, death is something with which the ED staff must deal.
Staff often seek medical advice about themselves or family members. This can be a bit troublesome at times. If the personal stuff is anything more than a general enquiry then we insist they go through the triage nurse and make everything formal. There are good medico-legal reasons for this. One needs to tread carefully when the enquiry concerns another person’s behaviour or symptoms or problems. It is wise to be non-committal and to more than once advise that the patient should really see their own doctor. Doctors and nurses, too, make the worst patients. They know too much and tend to see their own symptoms as the worst case scenario for a real or imagined illness. They diagnose and treat themselves and often incorrectly – any doctor who treats him/herself has an idiot for a patient! Having said that I am, myself, guilty.
The swine flu epidemic of 2009 turned out to be a bit of a non-event for ED although it did require some routine-disrupting changes. Patient numbers had only nuisance value. People presenting to the triage nurses complaining of flu-like symptoms were given a surgical mask to wear and put into a dedicated room. This was a bit of a nuisance because that room happened to be the one used by the psychiatry nurse to assess her patients. The flu patients took precedence.
Many patients presented without any flu symptoms at all but wanted to be tested because they had been somewhere where confirmed cases had been reported e.g. when the first cases were reported from Melbourne. Others had simply flown in aircraft. Some were sent by employers because they or someone else at work had symptoms of common colds. Some did have flu symptoms but without high temperatures. We had to assess each one according to the criteria set by the health department. They were all deemed to be Fast Track patients. We took nose and throat swabs from a few who did meet the clinical criteria but none was serious enough to require admission or anti-viral treatment. Follow up on the swab reports was handled by the hospital and I don’t know if any were positive for swine flu.
I think the way the epidemic was handled by the authorities was generally pretty good but I always had my personal doubts that there was anything really special about the disease itself and that the hullaballoo was a bit over the top. Certainly, there were a number of apparently fit, healthy, young people who died from it but that does happen with each major flu epidemic.
My doubts have been reinforced by subsequent events including reports that the global death rate, (about 12,000) is about one third of the average annual death rate for the flu. Also, there are some pretty serious allegations that it was all deliberately over-rated by experts in bed with the companies that make the vaccination. Something like 70 million doses of swine flu vaccine produced in the Unites States were not used, because the epidemic petered out, and were destroyed. Apparently, the World Health Organisation is investigating the role of some of its own experts. Perhaps all will be revealed with the passage of time – and perhaps it won’t.
Managing the Swine Flu Epidemic became one of the things we do on the side in ED.
©2019 What Diagnosis? Dr Ken Hay MB BS D(Obst)RCOG
It’s always nice to make a diagnosis, and have it confirmed, but that does not always happen. All too often we are left wondering what the diagnosis really is.
Fifteen year old Mellisa came in at about eight o’clock one night accompanied by her parents and complaining of abdominal pain. I was not working that night but was day shift next day. The doctor who saw her considered there was something going on in her abdomen but not life threatening or urgent. He gave them a request form to have an ultrasound done next day and told them to return to ED after it was done. The trio returned late in the morning after Mellisa had the ultrasound examination and it was my lot to see her.
Before looking at the ultrasound report I revised the history with Mellisa and her parents, finding nothing that differed from the previous doctor’s notes. I then examined her and the crucial finding was rebound tenderness. This is elicited by gently placing the flat of one’s hand on the exposed abdomen and tapping the middle finger gently with the same finger of the other hand. When I did this over the right lower abdomen she winced and reflexly pushed my hand away. It obviously hurt and this, for all intents and purposes, told me that the peritoneum – the lining of the abdomen - was inflamed. The most likely cause in a fifteen year old girl was appendicitis but ectopic pregnancy, ruptured ovarian cyst and pelvic inflammatory disease were among the alternative diagnoses.
Hoping that the answer would be in the ultrasound report I got it up on the computer and read it. It was entirely normal apart from the presence of a small amount of fluid in the pelvis. All that did was confirm my clinical diagnosis of an inflamed peritoneum but did not narrow it down at all.
I had a frank discussion with Mellisa and her parents. Mellisa was remarkably mature in her response giving frank, direct answers to my questions around the possibility of pregnancy. She denied any such possibility stating she had never had sexual intercourse. The parents, too, were mature about it all and understood that I had to explore the possibility. It is not always so.
Anyway, I advised we now needed to do some blood tests to see if the white cell count was elevated, which it usually is with appendicitis and pelvic inflammatory disease, and a pregnancy test on blood. I told them I would have a chat with the radiologist, (x-ray specialist), about the ultrasound. I did this and he recommended an CT scan of the abdomen sharing my view that the clinical findings were strongly suggestive of an inflamed peritoneum. So I started the ball rolling on a CAT scan as well. That will give me a definitive answer – I thought.
Several hours later I had all the new information. The blood tests were entirely normal and pregnancy test negative. The CT scan merely showed the presence of a small amount of fluid in the pelvis and nothing else abnormal. We were, as they say, up a gum tree – all four of us – Mellisa, her parents and me. In days gone by the options would be to wait and see or to look and see. That is, a senior and experienced surgeon would decide to wait and see if the pain resolved without interference or further developed into a state where a reliable diagnsosis could be made. A brash, enthusiastic young surgeon would decide to take the patient to theatre and do a laparoscopy – that is, operate and try to find the cause of the problem. If the appendix was normal it would be removed while they were there anyway.
If any studies were done on such situations I doubt there would have been much difference in the outcomes. Most of the wait and see patients settled down over the next few days. Most of the operative patients settled down over the few days following surgery. Rarely would a definitive diagnosis be arrived at in either case.
Mellisa still had her abdominal pain, but it had got no worse and had probably improved somewhat in 24 hours. The best, modern technology could not help with a definitive diagnosis. I suggested the parents take her home and wait and see. I advised them to return with Mellisa if they thought she was not improving in 24 hours, or if she was in any way worse. We waited but I did not see the outcome due to the vagaries of shift work.
People often speak ill of doctors in such circumstances but even more so if the patient returns to hospital and sees another doctor. “That brilliant doctor Watsisname just took one look at her and sent her for an MRI scan straight away. The other clown reckoned there was nothing wrong with her.”
Dr Whatsisname has several factors in his favour. Firstly, the condition may well have developed to the point where the clinical signs become distinct. Secondly, he has the advantage that the routine tests have been done and proven unrewarding thus leaving only the MRI scan as the investigation of last resort. Thirdly, the previous investigations may have ruled out all of the likely diagnoses leaving only one to be confirmed and at a later stage in the illness. And the retrospectoscope is generally acknowledged to be the most accurate instrument any doctor can possess.
It is not uncommon for a gall stone to cause severe colicky abdominal pain radiating into the chest and between the shoulder blades with vomiting thrown in just for good measure. But, sometime between being examined by the doctor and before the CAT scan is done the pain and vomiting suddenly stop. Patients with little faith will naturally consider the doctor’s clinical diagnosis of biliary colic to be hogwash and that consideration will be compounded by the CAT scan finding no abnormality.
The fact of the matter is that the gall stone has tracked through its course from gall bladder to intestine, stretching and dilating the bile ducts along the way and causing them to go into the most painful spasm then popped into the intestine which is too wide for the stone to dilate. When the next attack occurs, perhaps even years down the track, the patient may have cause to revise their opinion of the doctor.
©2019 Who Is The Patient Dr Ken Hay MB BS D(Obst)RCOG
We rarely have much difficulty identifying our patients – they are the people who are bleeding or screaming or look ill or are stretched out on the trolley or vomiting and so on. Sometimes, however, confusion does arise and it can cause problems - as it did the other day.
On the computer screen I put my name against that of the next patient to be seen then collected the medical documents. I noted the patient to be a young, adult female whose triage diagnosis was depression. I decided to take her to one of the very basic consultation rooms where we would not be overheard by others in the main treatment area with its simple curtains separating the treatment bays. The room contained one chair and one bed plus a sink and small work bench.
Opening the waiting room door I called out the patient’s name and watched as two young adult females, together, got up and walked into the room. Looking at them I started to ask which person was the patient but the first woman interrupted me emphatically stating that we needed two more chairs. “We must sit in a circle and hold each other’s hands as we work through this problem.” She continued. “I know what she is going through because I have been there myself and we have to communicate properly to help her get through it.” She paused momentarily and I thought I saw an opportunity to ask, “Excuse me but ….”, but that was as far as I got before she started again.
She rambled on and on and on while the other young woman stood silently, eyes downcast and shoulders slumped. I decided a bit of assertion was called for and, raising my voice just a little and talking over here tirade, asked, “Are you the patient or is this lady the patient?” indicating her companion. “Don’t you interrupt me! No I am not the patient. I have been a patient before …..”
“Then please leave the room and let me speak with the patient.”, firmly and emphatically but it was no use. My antagonist then accused me of arrogance and, “… the most unprofessional, disgraceful behavior she had ever come across ….. etc, etc, etc ………..” and “Come on Jenny, we are out of here. We will go and find someone who cares.” And the poor hapless patient turned to follow her “mentor” through the door.
I realized that the woman doing the talking was probably a manic depressive and currently in a manic phase, or getting close to it. She had mentioned in her opening statement that she had, “been there myself”. The patient had not uttered a word and was obviously dominated by her friend. I felt that if I could not persuade them to stay then either or both might come to serious harm. In a flash of inspiration I said, “Wait. Would you like to speak with a woman doctor?” They stopped. “All right, she can’t be any worse than you.”, replied the talker and they came back into the room.
By chance the shift supervisor was a young woman, a qualified emergency medicine physician and an extremely pleasant person to work with. I outlined my problem to her and she agreed to take over the case. Quite some time later the patient was admitted to the main area of the emergency room, where could be kept under continuous observation. The other woman came with her and sat beside the bed strangely quiet. I looked at the supervisor with raised eyebrows and a questioning look. She just smiled, “I’ll speak to you later.”, she said.
We got about our business and, apart from dutiful glances as the patient from time to time, which is a habit we all have when such a case is in the room, I thought little more of it. Then, a couple of hours later, the talkative one suddenly approached me saying, “Look, that ambulance is taking too long and I am going to have to take her to the other hospital myself.”
“I’m sorry, but you will need to speak with the lady doctor as I am not involved with your friend. But, as you will have noticed, the ambulance people are very busy. I’m sure they will take your friend as soon as possible.” She turned and walked back to her friend without speaking again.
It wasn’t long after that that I noticed an ambulance crew moving the patient onto their stretcher and take her out to their vehicle. The talkative one followed. And that was that.
Over a cup of coffee, in a rare quiet hiatus, my colleague told me the patient was indeed extremely depressed and required admission to a psychiatric facility. “And what about the other one?” I asked.
“Oh, she told me she used to be manic depressive but is cured now and doesn’t need the tablets any more. I did my best to persuade her to get back to her doctor for follow up. I hope she does.”
“I couldn’t agree more.”
That concludes Fast Track - for now anyway. There is much, much more I could write about
but that will have to do - for now.