04 September 2008

Does Anybody Examine Their Patients?

OK, so here's a geyser moment some of you have been waiting for!

I have just had a guts full of this week. Is everybody's clinical skills up to shit these days or am I on drugs? Perhaps I'm the one who needs therapy. I am by no means a special doctor or exceptional at my job - but for crying in a bucket. What the hell is wrong with the surgeons at Mount Doom?!?!?!

First of all, the Spirochaetes want me to dope an ectopic from the night before. Apparently she is stable, that's why she's been left for the morning. Only problem, her potassium is 6.9mmol/l, otherwise she is "fine" & her blood workup is "fine". So I ask if that is before or after treatment. No, actually she doesn't even have a drip up. I almost shat myself! These blood results were 12 hours old. "Please do the patient a favour, put up a drip & give Insulin & Dextrose. Get back to me once the patient is properly resuscitated."

A few hours later, I get a message. She is ready for theatre, her potassium is now 5.9. Right, that's a start. I bet the regime was given only once? Correct. I'm wearing my patience hat : "Now do it again. This time, change your fluid from Ringers (check the recipe on the bag - it contains potassium). You said the U&E was otherwise normal. I see the urea is 20 & creatinine 180. That is not normal, it seems a night of dripless dessication didn't do her any good at all."
I get a message 15 minutes later. "Can we please hurry, her BP is now low."
"How low, is low" I ask, "and what is her Hb?" I feel a sudden twinge of regret for delaying - she has probably just ruptured.
"47/20 and Hb is 9g/dl".

Wait a minute. This sounds very fishy & so not like an ectopic. So I go off to visit the patient in the ward myself...

There she was lying. Acidotic breathing, looking more dehydrated than the Sahara. Pink jelco & green jelco each in a cubital fossa (how aggressive), but with an empty 50ml dextrose & empty 1l Ringers and a unit of blood unneccisarily trickling in. Coffee-ground vomitus, diarrhoea, massively distended and acute abdomen, tympanic on percussion & no bowel sounds.

I put in a CVP & A-line to start a proper resuscitation. Do a blood gas, severe metabolic acidosis. So I stick my neck out against two consultants, a positive B-hCG & sonar evidence of free fluid in Pouch of Douglas. She may be coincidentally pregnant, but this is not an ectopic. Insisted she gets transferred to the Surgeons of Mount Doom for a explorative laparotomy because I'm convinced that this is ischaemic bowel. Now 24 hours since admission - well, well, well. Guess who had a necrotic exploded colon?

First patient up today on emergency list. "We want to drain an abscess."
"Where?" - "The left knee."
"Is she systemically septic?" - "Hmmmm?"
"What is her pulse & BP?"..... no idea.
"Why does she have an abscess? Is she diabetic? HIV? Trauma? Is it not a septic arthritis?"..... no idea.
Pissed off with their inability to answer a few ELEMENTAL but ESSENTIAL questions, I go ahead and slap in a femoral block & like fool didn't examine her knee properly myself.
When checking if the block has taken effect, I realise that granted, the knee was swollen, but the area of greatest fluctuation is actually popliteal (where a different block is needed). So I ask the surgeon where he is going to cut? Fail, fail, fail! Better get a crossmatch, I can just see that popliteal artery getting in the way of the I&D. You see, one has to think ahead for these monkeys!
"You should examine your patient properly, especially since you are about to cut into her in the wrong place!" I spit at him.

Then a friend asks me to cover for him in his theatre. It's his last case, but has to leave urgently. The intern is about to put in a spinal & will look after the patient when all is settled. (Fine, because I've got a stable brachial plexus block on my table for ORIF etc.) The patient is apparently quite sick, renal failure, blah blah and needs a below-knee guillotine. Anaesthetic plan is unilateral spinal. So I direct the intern with the spinal, ask the surgeon (& his assistant) which side they're working. "Left", they ALL tell me, "LEFT". Somebody checks the consent - "Left". Having used heavy bupivacaine, I turn her onto the left side. The surgeons sit watching me & the patient for 5 minutes while the spinal settles. When I flip back the sheets, I see a normal left leg & rotten right foot! Can't be! I don't know who was more shocked - me or the surgeons when I called them bloody retards and stormed out of the theatre. Feeling sorry for the patient, I went back to finish the job a few minutes later. By the heavy atmosphere in the theatre, I discover that I AM THE BAD GUY! For crying in a bucket, I was going out of my way to help! This is not even my patient, but was willing to go the extra mile to help! I didn't get my sides wrong - but I'm the bad guy with the nasty temper.

Last case of the day. Another patient with a rotten limb - foot this time. They would just like to do a bit of debridement and redressing. First to piss me off is, this adult has a paediatric 22G jelco which isn't even patent. No good should any complications (happen often at Mount Doom) ensue. I struggle for a good 15 minutes to get a 18G into an arm with none of her spidery veins left unpunctured. (All the while, surgeon just standing watching me - no help whatsoever). So I make a snide remark, "I wish patients would come to theatre with proper IV access. That way there would be more time for surgery & less anaesthetic faff time." But I have been saying this for ever and a day, so why waste my breath? Pop in a popliteal block, and off we go. Off come the dressings on the lady's foot... Well, well, well. The patient said it herself - "Oh no, you're going to have to cut off my leg now, hey?"

How does this nonesense happen in theatre? If doctors would just examine their patients properly BEFORE theatre, the appropriate course could then be followed. I'm so sick and tired of surprises, but also refuse to do the entire workup, and especially surgical advisory, of the patient. Besides not going down well with the surgeons, it is not my domain, responsibility or area of expertise.

Reminds me of one evening, they brought a patient for left above knee amputation. With my two-minute interview & examination - I ascertain the patient has had surgery a few months ago on the left hip. I have a quick look & see it was probably an intramedullary nail. So I tell the surgeons what they missed on their history and examination, but they ignore me and go on. I just sat back and watched with pleasure when they reached the bone & finally discovered the steel rod in the way.

This shit can only happen in state practice. But it doesn't make it less criminal. I've had a guts full. :( Today just sucked! And sorry for the bitch & moan session, but I need the (free) therapy! I'll delete the post once I have cooled down. I miss my Alma Mater. Surgeons were cool there!
Lessons learned :

  • I MUST follow what a wise man once told me about anaesthetics :
  1. Don't believe anything anybody tells you (especially a surgeon)
  3. Give oxygen
  • Don't use blocks at Mount Doom. Rather do GA's - that way, when the surgical plan changes at the last minute, you are not caught with your pants down.
  • When you lose your temper, YOU become unpopular, whether you were right or not. Don't ever visibly lose your rag.
  • Snide remarks, hints & jibes don't work. People are too thick-skinned.


Bongi said...

there is a discussion in the medical blogosphere dealing with how rigorous surgical training should be. i maintain when responsibility is too diluted these things will happen.

where i studied things were pretty spartan, but at least on the whole, people from my alma mater won't do this sort of thing.

great post. don't delete it.

by the way, take a look at my blog. about three or so posts ago, you got an award.

Dr Skakhi said...

Well, the surgeons of Mount Doom quite literally get away with murder. Interestingly, the perpetrators in this blog are all makwerekwere's. It seems this gets you an immunity necklace.

Wow, and thanks for the award! I'm not worthy (obsequious bow & scrape). LOL! Now whom to pass it onto? My nominees have already won it...