Mudgee, Day 5 - Things happen at night in small towns too

Exhausted! Dr P and I were on cas-duty in the ED this evening after spending the day taking "walk-in" consultations at the medical centre. I just got home and I'm *so* exhausted! Let's recap what happened (again I'm conscious that it's a small town so in this instance while I am going to write about what happened, I'll change any obvious identifying features):

5.30pm: arrive at cas - Dr P asks me to interview and examine a patient who suffered a workplace injury to his right hand, then heads off to maternity ward to attend to a case that I'm not involved in. Middle-aged man, with an obviously deformity in his right hand just proximal to the 4th MCP joint (and causing the right knuckle to become inverted). Complaining of pain and weakness, but on examination his motor strength, range of mobility and sensation are normal. DDx: sprain, strain, soft tissue injury, fracture? Report back to Dr P who has returned from maternity. Orders an X-ray which reveals a spiral/oblique fracture to his 4th MC. Can't really do much in the way of "fixing" these kinds of fractures with a cast (I guess the intrinsic muscles, tendons and fascial sheaths of the hand have an inbuilt stabilising "cast" within them) so we bandage it up for him and ask him to return if the pain get significantly worse over the next few days.

6.00pm: attend to an elderly woman with colicky pain in her RUQ who is febrile and has been vomiting all day. Suspected cholecystitis - confirmed by an ultrasound (which shows multiple gallstones in the bile duct) and something in her blood-test (maybe a raised wbc count, GGT and alk phosphate levels?). Call Dubbo Base Hospital to get a surgical consult - surgeon advises to "wait it out" before considering a cholecystectomy. Inform patient and send her up to the wards.

6.30pm: Dr P attends to a patient with abdominal pain and sends me to see an elderly man with "flu-like" symptoms. Take a respiratory history and examination - patient is in obvious respiratory distress and his lungs sound pretty crappy (crackly, wheezy, gunky). Pneumonia, swine-flu (!), LRTI, bronchitis? Report back to Dr P who orders a CXR, which reveals diffuse interstitial lung opacities consistent with pulmonary fibrosis. Oh, and he had some LRTI.

7.00pm: Start talking about whether to send aforementioned man up to the ward where he could potentially infect other people but never finish discussion because a code is called to maternity. Dr P bolts, I bolt after him then realise it's probably for his special-case patient so I stop, turn around and walk back to the ED. As I walk in I look down and realise there are a couple of spots of blood on the floor. My eyes quickly follow a short trail around the corner to a man collapsed on the ground, drenched in blood. Lots of blood. Everywhere. Lots and lots of blood everywhere. On his pants, on his top, all down his back, all over his face and covering the entire back of his head. He's semi-conscious. All of a sudden, the nurses see him too and about five people simultaneously find the nearest pair of gloves and run up to him. We discover pretty quickly that he's bleeding from the back of his head (occipital region) - puncture wound that's severed a major artery completely. God Almighty - the head is such a bleeder! I stick my finger in the wound while the others find guaze/padding. We somehow manage to get him on a bed with my hand now applying pressure through thick padding directly onto the wound. It's futile - I can feel the bleeder throbbing and the pad saturated with blood. Warm, free-flowing blood is unnatural and creepy. One of the nurses tries to cannulate him and misses, once, twice, seven times!! He's lost so much blood his peripheral vessels are shutting down. His BP is ~ 85/40 and skin is icy cold. She eventually gets in and starts a free-flowing bag of saline. At some stage someone realises that because Dr P is attending a code in maternity, we don't actually have a doctor with us (!), so Dr J (a GP-anaesthetist) who is the second doctor on-call gets called in. He puts in another line (also misses a few times!), then orders an x-ray to clear his C-Spine because we find out that the mechanism of injury is a fall on the head. C-spine cleared, pupils equal and responsive to light, patient semi-alert (can squeeze hands and move toes) - patient positioned laterally and I can finally release my hand of its compressive role. Dr J inspects as best as he can with blood still gushing out of the wound then implants his pinky firmly into the bleeder while he sorts out what to do next. Many attempts are made to stop the bleeding - all in vain though :-S Finally tries to settle things down by stitching everything he can latch onto the needle together, both edges of the wound, and prays to whomever it is he believes in that the patient doesn't develop a massive epicranial haematoma. Does the trick (or so it appears)... bandage and clean him up (realise that he looks quite handsome without the veil of blood all over his face!). Keep him in overnight in the ED. Someone finally gets a chance to sit down and suss out what actually happened - find out, amongst other things, that he DROVE HIMSELF TO THE HOSPITAL!! Oh. Dear. Lord.

8.30pm: find Dr P and watch him attend two teenagers who had a head-on collision whilst playing foodball, leaving each with a pretty impressive cut - the first above his right eye, the second on his left cheek. The former gets stitches, the latter gets glue.

9.00pm: three patients in a row attend complaining of abdominal pain and episodes of vomiting. I'm told by Dr P that, being a Friday night, the key task is to rule out the worse case scenario (ie - need for surgery) because then arrangements can be made for transfers to Dubbo or Sydney ASAP.
- First patient: 10 year old girl complaining of pain over McBurney's point, has obvious guarding, but nil tenderness, rigidity, rebound tenderness or loss of appetite - appendicitis therefore unlikely. Is shit-scared of needles and thinks that I'm hiding one in my pocket that I'm going to pull out surreptitiously and jab her with - I assure her that I have no such intentions. Send her home and asked to return if worse.
- Second patient: 18 year old girl complaining of nausea and a generally-distributed cramping pain. "Any chance you might be pregnant?" - "Nope, I have an Implanon". Patient suspects it might be from a dodgy sausage roll. Good enough to leave it at that. I give her an IM gluteal shot of Maxalon and Buscopan and she's discharged. Asked to return if worse.
- Third patient: 3 year old girl - was febrile and vomiting earlier in the day but currently asymptomatic. Mum seems frustrated that her kid is now perfectly fine and happy when a few hours' ago she wasn't. Dr P tells her she did the right thing by acting on instinct and that kids have a tendency to oscillate symptom-wise when they're ill. Panadol, sent home, asked to return if worse.

10.00pm: Monitor Mr Head-Bleeder for an hour, taking his blood pressure manually on a regular basis because the damn machine isn't working properly. Dr P attends to his case in maternity. Chat to the nurses about working in a small rural town hospital - highs, lows, in-betweens? All are, for the most part, very happy and feel supported by the system. They tell me about the recently-released management guidelines that are designed to assist them in situations when a doctor is absent. Main complaints are about locum staff covering 24 or 48 hour weekend shifts - "they're rude, inconsiderate, unattentive, inefficient and clearly doing it for the money" (apparently they get over $5000 to cover a weekend - shit, no wonder NSWHealth is in debt!!). They give me pointers about how to get on the nurses' good side, which I note down very carefully.

11.00pm: since the ED is clear and there is no one waiting to be seen, Dr P and I decide to call it a night and retire to our respective abodes. Technically-speaking we're still on-call but we don't have to be at the hospital if we're not needed. I'm so totally exhausted even though the night is still young. I'm shaking from the thrill of having spent my first evening in an ED - I think I've found another favourite niche of medicine.

Above all, I'm rather impressed that things happen at night in small towns too...