It never rains - it pours.

The day did not start off very well....to say the least.
It was handed over to me that Mrs G had passed away in the early hours of the morning. We did not know why she had died, but we had known that she was very ill. Her story is for another day, but it cast a damper on the day - I had never seen my SHO this upset before.
Mr B was admitted to my ward from a smaller village hospital to monitor his seizures and to get an EEG done. While on the ward he had about 4 seizures a day - only they weren't epileptic seizures - they were pseudoseizures*. A week into his admission and he started to complain of abdominal pain. My SHO examined him and was not convinced that there was anything really wrong. The next day he complained to me of his stomach ache - I examined him, and all I found was a very vague tenderness all over, which was very non-specific, and like my SHO I wondered whether this abdo pain was a 'pseudo' pain. However, just to check, we did some simple blood tests - which came back with a high white cell count and a slightly elevated urea and creatinine, indicating dehydration/renal impairment. I encouraged him to drink and in the meantime called radiology to organise a out of hours erect chest x-ray**, as requested by my SHO, and also asked the nurse to dip*** his urine. And then I went home for the day.
In the morning, this fateful day, I came back to find that the urine dip was normal, but that he'd never had the chest x-ray done. I went back to examine him - the pain was still there and if anything worse, but he was haemodynamically stable and had normal bowel sounds. So I went to radiology and requested an erect chest x-ray and also asked for an abdominal x-ray.
The chest x-ray showed a small collection of fluid in his right lung - this was new: he had not had it on his admission; the abdominal film was also abnormal - it showed prominent loops of small bowel. Usually all that can be seen on a plain abdominal x-ray is some faeces, some gas (in the bowel, which is produced by bacteria breaking down indigestible material) and anything that is calcified (from 10% of gallstones, to 90% of renal stones, lymph nodes and calcified vessels, which go by the fancy term of 'phleboliths'). My SHO and registrar weren't happy with the films, and so I called the surgical team to come and review him. By the time they came, it was around 1300. The surgical reg, felt there was an obstruction somewhere, and most unusually, asked for a CT abdomen. Normally, they tend to take patients straight to theatre, which was why, when I was sent down to state the case for Mr B to have an urgent CT abdomen, I had a very hard time convincing the consultant radiologist. Finally, as he was unable to get hold of the surgical team - they were in the middle of an emergency operation, he agreed to do the CT. But it would only be in three hours time. In the meantime, I had taken a set of bloods off him and got a cannula in one of his arms and was giving him fluids through it, as he was now nil by mouth, in case he had to go into theatre urgently.
At about 1615, I was checking the blood results on the computer, talking myself through them (as one is wont to do), when my SHO looked over my shoulder and nearly exploded.
"Occyrhoe, you were going to tell me about those results were you??"
"Yes, I was, I was just briefly going over them"
He didn't bother replying but got on the phone to CT to tell them to hold the contrast if they were going to use it. And barked out orders for me to get a trolley ready for a catheter and for another cannula and disappeared in search of our registrar.
The reason for all this was that Mr B's renal function had gone off - really badly, and he was now in acute renal failure. If he had received contrast for the CT, that would have killed his kidneys (intravenous contrast is dangerous for kidneys that are not working well). We needed a catheter to monitor his renal function and another site of intravenous access, cos he would be needing a lot of fluid pumping through (one of the treatments for acute renal failure). And also, as if that was not enough, Mr B's potassium was 6.5 - the normal range is 3.5 to 5.5 - anything higher makes the heart more likely to develop an abnormal rhythm, which can cause it to stop working. In Mr B's case this was especially bad, as he was known to occaisionally flip into an abnormal heart rhythm spontanously, making him more likely to develop one if he was going to.
While my SHO was looking for the registrar, I quickly got everything ready for a catheter and a cannula. It looked like I would have to do both on my own as fast as possible, as none of the nurses were allowed to catheterise men (only women, for some reason) and they hadn't been signed off to do cannulas either and there were no other doctors on the ward. I called the surgical team to update them, and was told to start him on iv antibiotics and also called the outreach team****. And then I started pacing, trying not to panic, or worse, start crying. But Mr B was still at CT, so I called them up to find out whether they were done with him yet, to find that he was lying in the corridor and they refused to expidite his return to the ward. My pleas to the nursing staff on the ward for someone to come with me to get him back did not work, as the evening meals had arrived on the ward and their priority was to get the other patients fed. So in desperation I called the porters - and thankfully there was one free, who brought him down in five minutes.
I had everything prepped and ready. So after explaining what was happening and why I was going to do what I was going to do, I started catheterising him. Half way through, my SHO walked in - I told him where to find the tray which I had set up to get intravenous access, but he just told me to get on with it and left. There was no time to be annoyed. I got the catheter in and proceeded to look for a large enough vein to cannulate. Four goes later, I still had not got access. So I went in search of senior help. By this time it was 1730 and the evening SHO was on the ward, as well as my SHO and the surgical registrar. Both my SHO and the evening SHO had goes at trying to get a cannula. In the end my SHO managed to get a vein in the leg - but that barely worked. So instead blood had to be taken from a vein in the groin, and we ran in fluids as quickly as possible through the cannula I had placed earlier in the day.
I was then busy calling the labs, alerting them that I was sending up samples that needed processing urgently, while a consultant surgeon came to see Mr B. He wasn't happy about taking Mr B to theatre, but my SHO who had got the on call radiologist to 'read' the CT, insisted that he be taken to theatre, as he had a collection under the right hand side of the diaphragm, around the liver, which needed draining urgently, cos now he had no bowel sounds#.
When I could no longer think of anything else to do, I asked my SHO whether he wanted me to do anything else. He reminded me of Mr B's high potassium level - for which I suggested starting him on a nebuliser - a simple way to lower potassium. In return, I got a cutting reply that he was thinking of starting him on an infusion to protect the heart, and thus keep him alive. When I suggested prescribing it, he told me to leave it for now, and wait for the repeat bloods to come back. Then why the biting remark?
Before I left for the day, I went to speak to Mr B. He was lying in the semi-darkness, scared and in pain. With my glassy eyes and a lump in my throat, I told him that I was off and that a close eye would be kept on him and that I'd see him in the morning. It did not help when he told me I was a 'lovely lady' and that he appreciated all I did for him. I got out of the hospital in time and thankfully managed to avoid eye contact - I was struggling to maintain my composure.
I was so angry with myself - I've never hated myself this much before. This man trusted me, and this is what I did? Just because he had pseudo-seizures, doesn't mean he's making up everything. Somehow I felt all this was my fault.
The next morning, I found out that he had been operated and they found a ruptured gallbladder - spontaneous rupture in someone without gallstones, like Mr B is very rare. He was stable after his operation and was recuperating on a surgical ward. Later in the day, I went to see him, but when I got there, I found out he'd just been transferred to the ICU - he'd developed his abnormal rhythm and had just been 'shocked' back into a normal rhythm. I caught a glimpse of him lying on the ICU bed - and once again the feelings of self-loathing threatened to suffocate me. I left as quickly as I could, in search of the nearest bathroom - a breakdown seemed imminent.
But it did not come. I got through the day - urged on by the fact that the weekend is here and I do not have to go into work for two days in a row.
When people ask me how I'm finding work, my reply so far has been that I am really liking it. But these last two weeks, have been stressful and upsetting and there have been no highs, but when the lows came, they were really really low and I have struggled to hold back the tears.
People tell me not to take things personally. But it is personal. It will always be personal. Because that's the type of doctor I want to be. But whether it'll cost me my sanity scares me. I don't think I could afford that.



*pseudoseizures - where the person mimics a grand-mal epileptic seizure, moving all four limbs, but coming round the minute they stop jerking and not losing consciousness or control of their bladder/bowel or biting their tongue (generally), unlike in epileptic seizures. Also known as a functional problem - ie where there is no underlying organic cause, but rather a behavioural one.
**erect chest x-ray - ensures that the patient has been sitting up for sometime before the x-ray is taken. This means that if there is any air in the abdominal cavity (which is a sign of a ruptured organ), it will be seen as air under the diaphragm.
***dipping urine - using special sticks that are dipped in a sample of urine and which within minutes can tell you whether there are red blood cells, white blood cells, nitrites ( a sign of infection, as it is produced by bacteria in the bladder), ketones or protein in the urine.
****outreach team = critical care team = team of doctors and nurses who work on intensive care, who also see patients who are not doing so well, in order to optimise their care and consider them for transfer to the intensive care unit.
#absent bowel sounds - very baaaad sign - implies that there has either been or will soon be a perforation.