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Monday, July 25, 2016

Making of a Child Psychiatrist: (44) Work, if you want to call it that (2)

WARNING: If you are in any way 'squeamish', please do not read this part chapter of my story.

You become a Jack-of-all-trades working in a Casualty Department, and there is no part of the body that remains strange. During daylight hours there was always support from other departments and services, but after about 6pm you were expected to manage – even if your work is checked out in the cold light of the next morning. So we learned to take bloods and all sorts of other specimens for pathology. We were taught how to use the ECG machine, interpret the results sensibly and use that understanding to assist with accurate treatment. If a chest pain patient was in serious distress and their ECG looked like they had a disordered rhythm or signs of a coronary thrombosis, then it was reasonable to call in a medical registrar. But if you called as a matter of course just to pass on the responsibility, and ultimately the problem was adjudged to be minor, you gained a bit of a reputation. Conversely if you did not take things seriously enough, you could also land in hot water. And sometimes your registrar was busy elsewhere, or had only been asleep at night for the last 20 minutes, so you had to become more and more confident with your own decision–making. In so many ways it was a brilliant basis for my later brief career in general practice.
There were sad events. In the middle of an extremely busy evening a young woman came in complaining of abdominal pain and vaginal bleeding. She had been about 4 months pregnant, but it was clear from what we could see that she had lost her baby. There were difficulties staunching her bleeding, but initially there was not much concern, and she stayed with her husband in a curtained off cubicle, while the on-call gynaecology staff were called. Everyone was busy elsewhere. When the husband eventually raised the alarm because his wife seemed to be losing consciousness, and blood was seeping through her bedcovers, our patient was in extremis. The gynaecology registrar had still not arrived. There was controlled panic trying to get a saline drip into a vein, and suddenly everything was action as she was wheeled off to theatre for surgery under an anaesthetic. The casualty staff were subdued, but then had to get on with all the other problems of that night needing attention. We learned later that the young woman had died - an unnecessary and devastating loss of young life. There was discussion later of what might have saved her life; the general consensus was that a drip could have been placed in her arm earlier. But it was with hindsight in a rare situation; not many people who lose a baby in the early stages lose that much blood that quickly. But you never forget such events; they caution your future.
There were really odd events. One morning, a middle-aged somewhat obese man came in complaining of buttock pain, and a weeping spot that would not heal. He was triaged by a junior nurse, and then a sister asked for my help. She seemed amused, but I barely noticed as we went into the cubicle.
“So what is the story?” I asked.
“I don’t know, Doc. But I have always had a bit of an infection from time to time, ever since the war. I got some shrapnel in me, and I think there must be some bits left in me be’ind”.
The man had a large infected spot on his buttock that had begun to drain. We decided it warranted some help. “You will need a bucket,” suggested the sister. “Really?” I asked. Again she smiled, and added: “And we will need some masks”. I put on a plastic mac and gowned up with some rubber gloves, put on a mask and we incised the area of the spot. Pus oozed out in large quantity, and soon we needed to empty a kidney dish into our bucket. We went on, filling our kidney dish again. The sister suggested I might need to use my finger to break down loculi under the skin, and demonstrated. I did so and, to my surprise we found more pus, and then another loculus and more pus. Eventually we had a fair sized hole from which I needed to extricate most of my hand, and we also had a third of a bucket of extremely smelly stuff. “How did you know?” I asked, realising I had just passed some sort of initiation. “Experience”, she said as she bustled about cleaning trolleys and the cubicle, still smiling. I was glad to get rid of my gown and mac and gloves, and I seem to remember I spent rather a long time washing. We took some blood, specifically to test for Diabetes, and made a referral to General Surgical Clinic.
Another odd event was provided for me by a couple of ambulance officers one morning. If they brought a dead body to Casualty, they needed to get a certificate from one of the doctors to say the patient was DOA (dead on arrival), before they could take the body to the mortuary for further action. Apparently, I was the only doctor available, so with some trepidation, I climbed into the back of the ambulance in the courtyard. When I lifted the blanket, there was an obviously dead man laying face up on a stretcher. I estimated he was in his thirties, a strange age to die with no apparent cause. I asked the ambulance men how they had found him.
“We were called to the ground floor flat, and the front door was open. We found him in the lounge lying on his back.”
“Were there signs of a struggle, or anything?”
“Not that we could see. He was obviously dead. We just lifted him onto the stretcher, and brought him down here.”
I began to examine the fully clothed body for signs of injury, beginning with his head. As I got down to his chest, I noticed that there was blood on the stretcher, and some had dripped onto the floor of the ambulance.
“Where is the blood coming from?” I asked.
“Oh, didn’t notice that…”
“Can you help me turn him over?” I asked. We lifted our subject and I peered underneath. There for all to see was a flick knife, sticking out at an angle from the poor chap’s back.
“Oh, didn’t notice that…” my friends chorused.
“Well, he is clearly dead. And I think we may have found the cause…”
I signed my first DOA form, adding my newly minted letters MBBS underneath, and the ambulance men drove down to the mortuary. I phoned our local police to report on the incident. I didn’t hear any more, so I guess it was all dealt with.
And then there were the thirteen elderly ladies. As we got to the last months of time, the weather turned on a cold snap, with some sleet, and very icy pavements. Over two days Casualty collected thirteen cases of elderly ladies, each of whom had slipped on some ice just outside their homes, or at the local shops, and had put out their arms to stop themselves getting damaged. Xrays showed that each one of them had a classic Colles fracture to the radius bone at the wrist. The team organised the next day to have two anaesthetists, and using two surgical beds side by side, each of our dear ladies was put to sleep, and their fracture reduced by a combination of technique and brute force that left your thumbs aching. The registrar thought it an excellent opportunity for us to learn, and so two of us were shown Xrays, shown what needed to occur, had the demonstration on a couple of cases, and then were expected to reduce the fractures on our own. When the technique works, there is a satisfying click putting the end of the radius back where it should be. When it does not work first or second time, you are grateful there is an experienced registrar to take over. So I managed three successful manoeuvres, eventually, but failed on two. I never did really fancy doing Orthopaedics.
Finally there are cases that get you into trouble, sort of. Again, towards the end of my time in Casualty, I was allocated to see a young woman who claimed to have been raped within the last two hours. I took the history with a nurse as a chaperone taking her own notes, and assisting me. When it came to the physical examination, I noted all the signs of bruising pointed out by our patient, and we then (with permission) did a very gentle vulval examination, and took swabs in an attempt to gain samples of semen, but also to look for infection. I had no reason to do a vaginal examination, which in any case would have further traumatised our already distressed patient. This was in the days before much medical photography, and before the technology of iPhones so accepted by today’s society. So I drew detailed drawings of the bodily bruising, and also drew the abrasions to the vulva. I got the nurse to countersign my drawings in the notes. I was not sure what was likely to happen after that, but heard nothing for many months. Then I had a summons to appear on behalf of the prosecution in a rape case to be held at The Old Bailey in the centre of London. There was little preparation other than a short phone call from a lawyer for the prosecution who explained the process of examination and cross-examination. On the appointed day I turned up, looking as dapper as I could manage, and feeling truly overwhelmed to be ‘Appearing at the Old Bailey’. I sat outside the court until I was called. After the usual palaver with swearing in, the prosecution lawyer took me through my credentials and the history I had taken, what I had noted about the emotional state of my patient, and asked me to explain what I had drawn so well in the notes. Then I was handed over to a defence lawyer who went over the same ground, attempting to gain some change in my views perhaps. Finally he said: “In your testimony and in your notes, you used the term ‘excessive force’. Would you care to describe, in your experience, what you mean by ‘excessive force’? I remember saying something to the effect of: “Well, in my experience, consensual intercourse does not traumatise the vulva or vagina and leave the kind of marks that I saw. I believe considerable violence led to the damage I saw.” That seemed to be it. “Thank you Dr. Martin. You are excused and may stand down.” I never have enjoyed going to court, even if it is my expected duty to support patients.

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