Life and Death Episode 3 - The Shift that Kept on Giving

Hello and Welcome to Episode 3 of Life and Death. I wasn't intending to write about this, but given the weekend it just had to be done.  This week's episode features one of the more bizarre shifts I have ever done since qualifying.  It had everything from entertainment, to gossip and even included an emergency.  Grab a coffee, sit back and enjoy.

The Entertainment

Mid way through my shift, I received a patient with a foreign body stuck up their rectum.  Obviously, how do you keep a straight face with that?  You just can't can you?  Especially when taking observations and the patient moves, you occasionally hear a buzzing and vibrating sound from where the on switch of the bullet has been.  If only I could have had a remote control to the toy and the shenanigans that could have taken place.

So, how did it get there?  Well you see it all the time on these TV shows where someone has "fallen" on to whatever is stuck up their arse - whether it's a sex toy, toilet brush, garden gnome etc.  You only have to Google some pictures of X-Rays where weird and wonderful objects have been captured in places they shouldn't be.

Well I take my hat off to this patient for telling an honest story. It takes a great deal of courage to admit how something as embarrassing as that happened.  But this is where the gossip begins...

The Gossip

On handover and from the triage notes, the patient had been having sexual intercourse 10 hours prior to the incident.  Fair enough - each to their own I suppose.  However, when the patient's partner contacted the ward to try and get an update off the patient.  I thought I had better speak to the patient first because I did not know how much the partner knew about what happened.

So when the patient told me that their partner had been away from home when it happened, I realised that this patient had been cheating... Oh shit...  The patient requested that I inform the partner that the patient will ring the partner back on their mobile.  How I'd love to have been a fly on the wall when that happened...

*Top Tip* I don't ever condone cheating but if you ever go there, Karma can bite back - especially if you play with the arsehole...

I'd love to have gotten more involved, but at the same time that was happening, I had another patient who was rapidly deteriorating.

The Emergency

Next to the cheating patient, I had an absolute legend who you could tell lived the rockstar lifestyle.  I only ever saw this patient and looked after them once, but to me he was legendary.  This patient looked a bit rough when I first started shift, so I did a set of observations - as I like to do with every patient when going round my morning drug round.  I also performed an A - E assessment.  Something we all do subconsciously without ever realising it.  For educational purposes, I'll detail it below.

*Important! Learn the A - E assessment and get used to performing one.  It's one of the first things that will show an unwell patient.*

A - Airway.  Is it patent? Are patients able to communicate verbally or are they showing signs of a blocked airway (such as choking or anaphylaxis).

B - Breathing.  Is the patient breathing?  Is it regular in rate and rhythm?  Is it slow and deep or rapid and shallow?

C - Circulation.  Is there any bleeding or blood loss? Does the patient look well perfused or are they pale, grey and clammy? Is the capillary refill test 2 seconds or less?

D - Disability.  Is the patient alert?  Is the patient only responding to voice or pain?  Or is the patient unresponsive?

E - Exposure.  Exposing the patient to find any signs of trauma or issues that could be causing the patient to become unwell.

For the sake of my patient, the A - E read as follows:

Airway Patient.  Patient able to communicate in full sentences.

Breathing was increased in rate, but regular

Circulation wise, the patient looked awful.  Grey, clammy, tachycardic and hypotensive.

Patient was alert

No evidence of trauma, rashes or anything significant visibly causing the patient to become unwell.

Due to the patient's presenting condition, observations and complaints of indigestion type burning sensations not alleviated by IV Omeprazole or Gaviscon, I performed and ECG.

*Important! If the patient has a high heart rate (Typically 120bpm or above) or looks unwell.  Perform an ECG anyway regardless of whether the patient has any other symptoms.*

The ECG Showed significant changes and due to the ECG and NEWS Score, this was escalated to the medical doctor and Critical Care teams.

Whilst the normal treatment for any acute coronary syndrome is 300mg of Aspirin and GTN Spray, the GTN was contra-indicated as the patient had low blood pressure and GTN would drop it further.  Aspirin was the only option but with the patient being admitted for malena and an OGD showed an Ulcer, that wasn't a great option either.

What do I do?

If I don't give the Aspirin, the patient's heart would have killed them, if I do give it, it ran the risk of aggravating the ulcer and causing further bleeding.  I decided the heart would have killed the patient quicker so I requested the doctors prescribe Aspirin and I administered it.  Following on from that, regular observations showed the patient was still unwell. Cardiology advised to give IV Metropolol to reduce the heart rate as that may have increased the Blood pressure.  Cardiac monitoring was desperately required, but there were no beds available to provide that.

Doctors were still convinced it was septic related, but I was convinced it was cardiac. But who am I to question a doctor? I questioned about a DNAR, but the doctor was reluctant as the patient had a good quality of life.  Soon after, bedlam broke loose...

What Happened?

Following an episode of malena, the patient stopped breathing.  The emergency buzzer was pulled by me and CPR efforts started ( A more in depth analysis of what happens during a cardiac arrest will be created at a later date).  Whilst the heart was restarted, the patient was still critically unwell.  Fluid were being pushed through as much as possible and I was providing ventilation.  The decision was made to Cardiovert the patient.

Cardioverting is where doctors sedate the patient and deliver a shock while the patient is alive in a bid to reset the heart's electrical rhythm to a more normal state. However despite best efforts, the patient did not respond to treatment and the decision was made after over an hour to withdraw treatment.  The patient was kept comfortable surrounded by family and passed away peacefully.  It was only after this incident had occurred, that a bed was made available on Cardiology, but by that time, it was too late.

How did I feel?

Guilty as fuck to start with.  I was convinced it was cardiac related and I did not know if I had contributed to this event by talking the doctor into giving aspirin due to the nature of the ECG.  But what if I was in the wrong?  The patient definitely looked more cardiac the septic.  Either way it played on my mind for the next few days.

The patient lost their partner a few months ago, it must be a horrible time for the family - especially coming up to Christmas.  But it shows life can be so cruel sometimes.  It wasn't expected at all as the patient was apparently picking up on the previous day before I took over care.

It was only afterwards when the cause of death was identified as not being septic related that I felt better about the incident, but it was still a horrible thing for the ward staff and family to experience.  I just did what I could to get through the rest of my shift and went home with an air of sadness surrounding me.  Boy, what an eventful shift...

Things to Take Away:

1. If you ever cheat, be careful not to get anything stuck up anyone's arsehole.

2. Drill in the A - E Assessment

3. If in doubt, do an ECG and talk to someone.

4. Cardiac Arrest situations are chaotic and distressing.

5. Shifts can contain a rollercoaster of emotions. Talk to someone if you need to.

Until next week, bye everyone.