Saturday, 19 March 2011

Another hug

Thinking about the last hug made me think about a hug from long ago.

Some years ago, I was a surgical house officer working at a moderately-sized district general hospital. I was working the weekend. On Friday lunchtimes, the surgical teams all came together and had a big handover, where they'd discuss the patients they were concerned about and handover any weekend jobs. E, my colleague from another team, told me about Mrs V. Yep, I used to see adults as well. This one was quite small though, so I'm letting this post through on a technicality.

Mrs V had come in the prior weekend with large bowel obstruction. She had a distal stenosis in her colon, and the general opinion was that this was a cancer. She'd been for an endoscopy on the Monday and the consultant had managed to manoeuvre a stent past the blockage from underneath. This is a sprung tube, which can open up blocked passages. In surgical patients, these are a short-term measure; they release the pressure on the near side of the blockage temporarily, allowing the bowel to be more settled and thus easier to permanently repair.

However, the consultant was so delighted with this stent that he decided to sit on it all week, and ignore the warnings from the radiologists who kept doing follow-through tests to check its function that it was slipping and the opening was becoming narrower. E's handover wanted an early review for Mrs V, because if she was showing signs of re-obstructing, she would need to go to theatre sooner rather than later.

I saw her that night, and she was having diarrhoea - an early sign of obstruction (as the bowel is faced with a partial blockage, it works harder to push everything through it, meaning liquid stool moves through and reaches the outside faster - a concept known as overflow). I wrote quite clearly in the notes that this diarrhoea was not infective, and the patient should not be moved as they required an early review the next day.

I was called away from the ward round the next morning to attend an unwell patient elsewhere, and therefore did not realise the patient had not been seen, having been moved overnight to a side room elsewhere given the possibly infectious nature of her diarrhoea. The first I heard of this was at 12:30pm, when I strolled onto the orthopaedic ward to review a patient they were concerned about.

It was Mrs V. She looked dreadful. Tender abdomen, sweaty, pale. A quick blood gas revealed a lactate of 3.4 - not good. I thought she'd at least reobstructed, if not perforated. I order x-rays, bleeped my registrar and started some fluids.

The x-rays showed she had free air in her abdomen - she had perforated. The registrar wandered off to find a theatre. I repeated her blood gas - the lactate was now 6. Lactate, or lactic acid, is the stuff that builds up in your muscles and causes cramp when they're under anaerobic strain during exercise - it is a by-product of anaerobic respiration. Apart from a few rare metabolic disorders, a high lactate is usually a sign of poor perfusion; if insufficient oxygen is delivered to the tissues, more anaerobic respiration occurs, and the lactate rises. A rough rule of thumb; in severe sepsis, the lactate multiplied by 10 is your approximate mortality percentage. Not good.

I went back into the room, and Mrs V was weakly calling me over. She appeared to want to tell me something, so I moved closer, and she almost leapt off the bed and wrapped her arms around me, whispering in my ear, "thank you". She got progressively sicker whilst we waited for the orthopaedic team to finish - a 3 hour operation took them 5 hours 30 minutes, apparently for little other than the consultant's vanity - and by the time we got her into theatre, her entire gut was dead. She never woke from her anaesthetic.

When I'm dealing with very sick patients, I tend to make it fairly impersonal. It lets me think better and it stops me getting too attached. In this case, the hug ruined that for me. Mrs V stood out in my mind, because of that brief moment of human interaction. She still does.

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