Monday, 19 March 2007

Take Away?!?

Had a 86 year old post arrest. Flat and not particularly healthy. Shocked a couple of times by the paramedics and once by myself. A rather pro-active medical registrar suggested thrombylisis which was duly given, however the proglonged event lead to a termination of actively treating her.

Then the problems arose. The first two members of the family refused to believe she was going to die, and would not allow extubation til their sister arrived. Fine we said expecting them to be local. But hey no, they were coming from Wales. Didn't they know about breaches. Needless to say I had to try and keep this lady alive til these family members arrived. Cue ventilator and a bit of luck.

The family eventually arrived, and were with Mum. I extubated and 5 minutes later she died, with her family present. It gave the family some comfort.

As I was leaving one of the daughters came up to me and said that they wanted to take mum 'home with them'. Small problem she was dead.

Unfortunately not I said, as she was now the property of the coroner and it would be theft, also unethical and unhygenic. The transportation issue would have been fun too. A longboard and roof rack were mentioned.

Relatives are bizarre.

Sunday, 4 March 2007

The wheat from the chaff

The Trust is desperately trying to reach the Government target of 98% of patients are dealt with within 4 hours. |For the most part we have been doing well; that was until Friday. Two breaches by lunch and more than twenty by the end of the day.

I came across a senior sister crying as she was doing her best. Is it a good working environment when people, granted even the least clinically credible sister (although a decent person) is reduced to tears by virtue of the atmosphere. Maybe they are trying to cull those who cannot control the department, but when there are no beds available breaches will occur. And when there are sick patients, which they have been and there are shortfalls in nursing staffing levels then this will become the norm for breaches to occur.

On top of that we have been awarded a 1.5% pay rise this year by Patricia (No clue) Hewitt, lee than the rate of inflation. What an insult to the hard work by nurses up and down the country! Get a grip, the Medical training is ballsed up, the waiting lists are manipulated with minimum waiting times, MRSA is rife and nurses are becoming scapegoats, the NHS needs to be revolutionised by those who understand it; the NHS staff, not idiots in the DofH.

Friday, 2 March 2007

Trauma Continued

This is from the respected website on the management of severe Head Injuries.
(Us ED folk DO know what we are talking about) (most of the time).

Assessment of brain injury hinges on evaluation of the Glasgow Coma Score (GCS) and examination of the pupils. Traditionally a GCS of below 9 is considered to reflect severe brain injury. However with improvements in prehospital care and greater knowledge of brain injury, patients are arriving in emergency departments earlier and their brain injury may still be evolving. Therefore the following measures should be considered and porbably instituted in all patients with coma scores of 12 or below.


The specific goals in the acute management of severe traumatic brain injury are:

1. Protect the airway & oxygenate
2. Ventilate to normocapnia
3. Correct hypovolaemia and hypotension
4. CT Scan when appropriate
5. Neurosurgery if indicated
6. Intensive Care for further monitoring and management

Hypoxia and hypotension are the greatest threat to functional outcome in brain injury. Early acute control of the above three parameters may have more impact than all other measures subsequently employed. Progressive neuronal loss occurs from the time of injury, not the time of arrival in hospital. Rapid sequence intubation should be used where available to secure the airway and maximally oxygenate the patient. Hypovolaemia and hypotension must be corrected early and take priority over other interventions for the brain injury. Other injuries causing haemorrhage must be addressed first (or simultaneously) so that an adequate cerebral perfusion pressure is maintained. Patients should be kept sedated to prevent coughing or valsalva maneuvers from fighting the ventilator, as these increase intracranial pressure.

Another Life Saved!!!!

Yet again our Trust, or more correctly ITU surpasses its self in its ability to F*%K up trauma care management. Well, rephrase that, certain itu members have the innate ability to bugger up the patients process.

Trauma shout, man verses bus. Exceptionally agitated with head, facial and chest injuries. Typical pre-alert, just agitated male. It took 7 people to hold down this ten stone man, who did not have english as his first language. I think he was saying 'I need a tube', but hey the gasman wasn't listening. The team leader; ED Physician states this man needs RSI and a tube, our Consultant stated this man needed a tube, even I stated that he needed a tube. (Incidently his shattered mandible was causing an interesting gurgling to emit from this patient). Seconds led to minutes, and after 15 minutes the ITU SHO said he needed to check with his consultant before tubing!!!!!! (who was not in resus). Hmmm thats a new ATLS guideline is it. He would have no hesitation tubing a 95 yr old purple plus, but baulked at this. Idiot.

Eventually he was tubed and ventilated.
Injuries as follows:

Mandibular # (in 3 places),
CT NAD (wait for the difuse axonal injury to develop....),
R Pneumothorax,
R Acetabular # (comminuted).

Significant traumatic injuries.

The Pneumothorax was going to be managed conservatively, but he is receiving IPPV therefore an indication for urgent chest drainage. This had to be pushed to be done, and then it was placed sub cutaneously.

The decision then was to extubate and place on a ward. I argued so stongly to get him on HDU, but our Trust has amalgamated ICU and HDU, and it is nigh on impossible to get onto the unit. Post extubation he gurgled for 10 minutes requiring suction, a joke.

This man went to a surgical ward (no monitor etc), and fortunately was still alive the next day. It is so frustrating that the people who manage trauma effectively, i.e. us the ED staff are run roughshod over by clinicians who have no comprehension of polytrauma and its effects. ATLS guidelines, textbooks, even Blue Peter give definitive guidance on Trauma Management. Can there be any clinical justification in these clinicians management and 'ownership' of the ET tubes. No there cannot, I trust to God that there won't be an incident when someone will die by virtue of this route. I and my more clued on colleagues cannot be available all the time, if only the book is followed!!!

Needless to say I suffered major trauma to my foot as I kicked the wall in frustration. Not a good shift.