05 September 2008

The GCS Chronicals

I don't know what it is about the Glasgow Coma Scale that some doctors find it so difficult to master! Wow, why did I use the word master. Makes it sound like one needs to put buckets of blood, sweat & tears into studying the art of GCS application.

Could it be that the total 15 exceeds the number of digits on a pair of human hands? I know the theatre staff can't count beyond 5 when checking there are no missing swabs. (Theory : 5 fingers on left hand, right hand occupied as index finger outstretched from clenched fist, taps the count out on the fingers of the left hand).

Or marginally more likely, the assessor desirably needs to be GCS 15/15 himself in order to successfully evaluate the assessee.

Perhaps, it is all part of a master plan providing comic relief in dire and sad situations. I must say, I thoroughly enjoy the multifaceted, oftentimes creative interpretation of the GCS! So much so, I have decided to devote space here to relate, from my ever growing repertoire, stories regarding the enigmatic Glasgow Coma Scale...

Ignorance (including face-saving strategies)
Referrals from outside often elicit amusing responses to the question - "so what is the patient's Glasgow Coma Scale?"

"We are a very small, rural hospital. We don't have that scale here."

"We had one, but it is broken."

"Very, very severe."
And my personal favourite, came from an old GP doing sessions in a plattelandse dorpie :
"Hoor hier, Boetie. Toe ek geswot het, het ons nie sulke fancy goed gehad nie. 'n Pasient was óf in 'n koma, óf nie. Nou hierdie ou is in 'n KOMA!"*
Five stars, old man, plus 10/10!

Manipulation of Score
This commonly occurs to avoid having to intubate a patient. Always entertaining when the score is around that watershed 8/15...

"His GCS is 11 at the moment, but it is steadily declining. I anticipate you may have to intubate him by the time he arrives - you know how slow the ambulance service is."

"It is currently 9, but I suspect the patient will need to be tubed soon as her hepatorenal syndrome is likely to get worse before it gets better. Would you like to come do it down here, or would you prefer it when she arrives in the unit?"
I was mightily peeved when a patient for an emergency c-spine fusion arrived in theatre sans tube & GCS 7. Paging through the file, I noticed the patient had been in the ward for 2 days already (just don't ask) and the GCS was dutifully charted as 7/15 by the Interns & MO on multiple occasions. When I started bogging on the MO for leaving a patient so long without a secure airway, the Consultant protectively stepped in.
"I saw the patient myself and the GCS was more like an 8 than a 7."
I couldn't think of a diplomatic way to enlighten him, so I just left it at that. I think, in this instance, it is true what they say about orthopods! So I diffused the situation by making my stale old joke :
"What's the orthopaedic definition of the heart? The organ which circulates Cefazolin through the body."
And we all laughed & (they thought) all was forgiven.
Interestingly, this was the same MO who had written "PEARL"** in the notes of a patient who had had an enucleation decades prior.

Plain Stupidity
I overheard a doctor explaining to a patient's family, that she was brain dead and they should consider switching off the ventilator. I suppose he had been watching too much Bold and Beautiful because the patient was GCS 7/15 and improved to 9/15 a few days later. We managed to pick up the pieces before a case of culpable homicide ensued.
"His Glasgow is 15/15, but he's a bit confused."

"It's about...*heavy, pseudointellectual pause*... 5 to 10."

When explained to above doctor that it can't possibly be zero, he retorted :
"How do you know, you haven't seen the patient!"
Who am I to argue when he did, in a way, have a point.

I often wonder if these doctors ever think back, blushing, about the silly things they have said or done? I know I often do. I am the first to admit that nobody's perfect. However, I doubt many of the above quacks even realised their faus pax.
Oh well, comatose is bliss.

* Roughly translated from Afrikaans "Listen here, kid. When I studied, we didn't have such fancy things. A patient was either in a coma or not. Now this guy is in a COMA".
** Pupils Equal And Reactive to Light.


Karen Little said...

I love it especially when people get bonus points for being drunk - 'It's a seven... But we'll make it a nine because he's hammered...'

I mean, wasn't the GCS developed in Glascow, on a whole bunch of drunk people?

I have to say though, that Afrikaans dude is tight - a coma's a coma...

Bongi said...

one of my interns once admitted a patient with a gcs of 18. i immediately went looking for him (the patient). i concluded he must be enlightened and i could ask him the meaning of this life. i found no one who had a gcs of 18. maybe the intern lied?

Dr Gatvoltoo said...

Haha, you forgot about these two from our O&G genius doctors:

"Uhmm, the patient is not responding, so it must be a 14!"

"The GCS is 5/10"

Great post! Keep them coming please.

Dr Skakhi said...

Karen : I know of many politicians, judges & health ministers who score extra GCS points in this way.

Bongi : might have been on tik (patient that is... or intern too mind you).

GV2 : Ha, had the pleasure of working with Osama Bin Laden's daughter-in-law on September 11th (the irony)! Nothing's changed, her GCS is still 5/10. I really had to hold back as it occurred to me, she could climb into her boeing & bombdive my house. But then again, she is constantly feeling feint at the moment (fasting). Had a convenient and dramatic hypo spell at 10am (that's about 4 hours post-prandial?). So I guess we're safe this month.

Dragonfly said...

I remember a post MVA patient who the staff were worried about due to his persistent GCS of 13. When his family arrived they advised us that that was normal for him.