Traumatic start to the week!

Where better to start one’s week off with a bang than at the emergency theatres (Phase V). There are three actual theatres there – one for orthopaedics (bones), one for general surgery and other stuff and one ‘dirty theatre’ where they do the abscesses not laundering money! However a shift there can literally feel like you've had your entire being sucked from within at times (a bit like the Dementors from Harry Potter) and you often have to practice a bit of the dark arts there too!

Dementor sucking the life out of Harry!

To get to theatre (as a girl) you have to walk out of the hospital and in the A+E entrance. The boys can get changed in the changing room the hospital side of the (yes, you guessed it) red line! So I walked along remembering where I was going and then came to a sudden stop. My intended route was now blocked by what seemed to be a new ward: “female surgical ward”. So I meandered around amongst bodies strewn on trolleys, rows of people sitting on chairs in various states of disrepair and consciousness for quite some time, trying to work out where the ‘new’ entrance was to no avail. Eventually I found a nurse amongst the throngs of humanity all crammed into the one area – actually she was easy to spot with her starched white on her head. I get directed back to the ‘female surgical ward’. Apparently the entrance into the theatre was through this ward! A bit like platform 9 and 3/4 in Harry Potter! But fear not, the magic stopped there!

Male staff and patient entrance

Mystery platform or theatre entrance for girls!

 So I walked in and there were loads of women doubled up on beds, some on floor mattresses. Some with drips up, some with none. Some eating, some sleeping (well I hope they were sleeping) and some moaning in pain.  In the far corner was the large sign with Phase V entrance. It then dawns on me – the ‘new ward’ was actually the old corridor. They have turned a bit of the corridor into a walled off area which is now a ward. I didn’t see any signs of a sink or a bathroom, only beds and mattresses crammed in like at a brick-a-brack shop. Not especially enticing.

 Anyway I enter phase V leaving the mayhem behind (clearly change before crossing the red line) and then see nothing booked on the board. Now, having been here before I realize that this doesn’t mean that they have finished everything, oh no! It means that they are currently on a ward round and soon there will be a large influx of names on the board and it will continue to get longer and longer and longer until it gets really busy overnight. The morning is usually slow….

I start looking for the anaesthetic trainees and can see movement in theatre 2 (the general surgical one). I look in and see a guy who is conscious lying on the bed with bits of his head shaven and sewn up and multiple grazes/burns on his shoulders. He was alone apart from the theatre porter. My enquiries found out that this was a case being done under local anaesthetic – a suprapubic cather. (tube into the bladder but is put in via the abdomen). Interesting – not a particularly usual occurrence. I was told the surgeon had gone to look for a urologist to help him. And as they didn’t seem to need my services  I head down to find one of the Mmed trainees chatting to one of the surgeons at the other end of the corridor.

Smashed up minibus - the source of many an accident

It turns out that this gentleman really was going to be my concern. It seemed he was goig to be a few people’s concern over the course of the morning! So the story goes: a young man in his early twenties is brought to hospital by the police who found him in the road after he’d been hit by a car last night (this is highly usual – in fact we have two similar cases in ICU currently).  It is not uncommon to see smashed up cars all over the place especially as people drive at night with no light or intoxicated or pedestrians are intoxicated and veer into the unlit roads. 

Even the lorries acknowledge the states of the roads!

 Anyway on arrival in hospital his conscious state was low (GCS7) but they assessed all his other systems and decided that his lungs and heart were clear.  They decided he wasn’t bleeding internally as they stuck a large needle into his abdomen and didn’t get any blood back. After a few hours (to be fair he had been given a litre of fluid, some antibiotics over this time as well as having some bloods taken) he became lucid. So they stitched his head up in A+E after a skull x-ray. They also x-rayed his pelvis and right leg. This is where they noticed his fractured pelvis and then realized that he was likely to need a catheter and putting one in conventionally wasn’t advisable as he might have injured his urethra. So hence he was whisked round to phase V to have this done under local anaesthetic (no anaesthetist required).  However when they started on the procedure and made a small cut into the abdomen – that’s when they got a large gushing geeyzer of blood coming at them. Woops.

 That’s when we got called. So we went into theatre and chatted to the guy who indeed was lucid and recalls seeing the oncoming headlights and not too much after that until hospital. He was clear in that he had pain in his right chest, abdomen and hip. 

How he could be so clear when I put the oxygen monitor on his finger and found it to be running at  

 75%, I’m not so sure. 

How he was so clear with a respiratory rate of 43bpm (normal 10-14bpm), I’m not so sure. 

How he was doing so well considering his heart rate was 135bpm (normal under 90bpm) and pale conjunctiva, I’m not sure. How he was doing so well with less air entering his lower right lung and he was tender over the liver…. 

When I asked to see his chest x-ray (to see what was causing the low oxygen levels suspecting a lung injury)… Oh he hadn’t had one, oh and he hadn’t had a cervical spine (neck) x-ray done either, despite complaining of pain. And his pelvis was definitely broken but nobody had attended to putting a splint on that to prevent further movement/damage. It seems likely there was damage and bleeding to some internal vessels in the pelvis or the liver… neither of which are treated by the placement of a catheter. Both need a laparotomy (an operation and look round in the tummy to see where the mischief stems from). Both of which are likely to cause the patient to become shocked.. .well, more shocked than he already was. Both of which can be readily worked out by actually feeling the abdomen of the patient (which was something the surgeon had failed to do!) Anyway we needed to stop the bleeding but also needed something to fill him back up with again.

The surgeon was dispatched to get blood from the blood bank. The porter dispatched to get his blood results, the sister in charge went to see about us getting him an x-ray whilst we waited for the surgeon to return. It then became a bit like a cartoon character hurtling down a cliff face hitting every branch and boulder in sight…

Sister came back first:

No, there is no facility to get a portable xray into the theatre.

Ok, well can we bring the patient round then straight away and go straight in as we have him on portable oxygen and the cylinder is half empty…. No.

Why not? The machine that develops the radiographs is broken.

What? For the whole hospital? We cant do a single x-ray this morning… Yes!

Ok, well I guess we’ll have to do without!

Porter returns next:

The blood laboratories report that they haven’t got the sample.

Where is it then? I don’t know…. Shrugs shoulders and leaves.

Ok, luckily, a fortnight ago there was a promise that if cases were urgent then the high cost ( which costs more money and does the test quicker than low cost) laboratory will do the test for free.

Great – lets send the blood. And this time I’ll send the anaesthetic trainee so she can go there and impress the urgency.

Anaesthesia trainee returns (looking flustered):

Bit of a problem. The high cost laboratory have run out of reagents for the full blood count (was keen to see what the Hb or blood level was). So she had to go to the low cost one, which did have it and beg them to do it. They promised the results in an hour or so…. (this is Zambia – that equates to afternoon at best)! Not that the result was critical but whilst waiting for the surgeon its good to know what your starting point is in these cases of bleeding.

Hmmm… now less impressed. I dredge up a past memory from 18 months ago, we have a Haemoccue (special machine that measures Hb like the glucose testers on fingers). Great. Now, where is it usually kept I asked.

Obstetric theatres. Great. I ring there… nope, not there.

I ring Dave – he thinks its on ICU.

Now… (still waiting on the surgeon to return but at least giving the patient fluid and oxygen and morphine in the meantime) I decide I’ll go to ICU, as I want to discuss this guy’s probable admission there later. That is usually the difficult bit back home – here it was easy. Finding the Haemaccue – less so…. Not in ICU! Dave now arrives, also can’t find it on ICU. He goes to search in main theatres!

Return to Phase V .

Right, we’ll have to do without it then!

Now where is the surgeon? Eventually arrives with two O+ blood units. It’s the best we can get. The schools are still shut and the blood donation relies heavily on going to schools and getting blood from kids.  At the same time another theatre porter calls for Dr Rowly… it seems that R and L’s are interchangeable for L’s and R’s here (or at least I hope so and its not a comment on my weight!) And Lo and Behold he has got the Haemaccue. Dave found it! Great! Take the blood, put cuvette in the machine… and E02 flashes up….  Error! Yes, the machine was on the blink!

 Right, that’s it! Enough’s enough it is now 10am and we have been doing this since 8am!

Bleeding!

 The surgeon washed his hands. We put the guy to sleep with ketamine and then gave him the 2 units of (fresh whole) blood. Fair play to the surgeons, they were incredibly quick and soon they were looking for the cause of the 1.5 litre blood loss and large retroperitoneal haematoma  (large clot in the back of the abdomen). The good news was the spleen and liver were intact as were the kidneys. The bad news was the only thing they could find was a bruised bladder and likely oozing from the veins in the pelvis. That’s bad news as there isn’t much you can do except stop the pelvis jiggling about, pack some gauze there and hope that they clot and stop bleeding. At least you can remove a bleeding spleen! They did a good job and then put in the suprapubic catheter anyway which basically drained frank blood immediately. Mind you the surgeons were probably quick as they were the team on from the night on call (they have to stay until all their cases are cleared).

 

  Anyway he behaved (mostly) apart from some dips in the blood pressure and oxygen levels. SO, we were feeling relieved that somehow we’d got out of jail despite the ridiculous start to the morning. Or so I thought….

Going to intensive care from phase V usually involves a 100m push of the trolley, then the lift and then another 100m push to the unit. Of course, today wasn’t going to be simple, oh no, it went from ridiculous to sublime! We called the oxygen guys (who brought down a little cylinder of oxygen) so that we could hand ventilate him through the corridor.

 We start off and head for the lift – broken. 

         Ok, carry on up the corridor (500m) to the next lift – dismantled.

                                           

Ok, up the perpendicular corridor and then left for 500m in opposite direction to ICU and then another 200m right until we get to a ramp. Push/pull rapidly up the ramp (with the additional hurdle of a hairpin bend). I say rapidly as the oxygen guy is now phoning his mate as the supply of oxygen is perilously low…. The monitoring device – the Lifebox. Usually so dependable has just stopped working. However its not the battery. It’s not the probe falling off the finger, but the corridor is so bumpy that it jiggles the man in the bed around as if he’s shivering and it confuses the LED beams. So essentially we travel blind!

 …. Thankfully the oxygen storeroom is just up the corridor and he meets up there with a new one (something at last going our way!!!) By now, we are almost running the remainder of the 1000m corridor to ICU. Its like the krypton factor. Especially as we have to lift the trolley over the joins in the concrete which are now gutters and wade through some stagnant rainwater.

  We briefly get held up by the guys moving bits of the redundant lift to the side of the corridor before throwing open the doors of the ICU like some bedraggled contenders running the gauntlet with the Gladiators.

  It is now 12.30am. All the while alongside us in phase V, the orthopaedic team (with the aid of another anaesthetic Mmed) have been fixing broken arms and legs and the other surgeons have been doing biopsises and incising abscesses under local anaesthetic. The board is now full. It seems that despite our business we managed to achieve not that much.

 It’s amazing, considering the numbers of trauma cases we see here they aren’t processed smoothly. Its amazing that a University teaching Hospital can't even supply even the most basic tests or blood products. But it’s amazing what you can achieve if you believe in your clinical skills and work together as a team. And yes the board is full, but the board will always be full.

 As for the guy: I checked on him later on at 14.30 – his bloods were not back and he still hadn’t had a chest x-ray.  He had his chest xray last night after 9pm. This morning when my colleague Helen looked at it - she discovered the really rather obvious haemopneumothorax (air and blood in the lung) sitting there. He now has a chest drain in and will go back to theatre to remove the pelvic packs tomorrow. He at least should do ok!