Late presentations “Hard Bastard”

Working in an isolated area with a reputation for hard “bastards” you see things presenting even later than you might imagine. Had this “Bloke” present to ED. (Not barry crump for clarification)

<—–Kiwi literature

 78 male. life long bachelor.

Presented with anorexia, lethargy and feeling “as weak as an Auckland accountant” Some clarification for those outside New Zealand, Auckland is our largest city almost half our population and residents are known less than affectionately as JAFAs  (Just another f#$%ing Aucklander)

So the had been off his food for a while and not eating any solids as was “difficult”. His main complaint was that he got tired when pushing his lawnmower.

 The patient last saw a doctor 25 years ago following a “small” accident with a chainsaw when working in the Forest.

He had stitched himself with twine as was 2 days walk from the bush-end. “It was only about 20 stitches”

He came to get the stitches looked at. Not a bad job according to the ED doc. Was going to be revised to some formal sutures but self discharged after theatre list was bumped to following day. Explained to me that the boys were going hunting and didn’t want to wait another day and miss out.

So this time he had a Biochem panel done which showed this.

 

ECG was as below.

 The following day with some potassium replacement ECG developed to this.

Pt left hospital a week later unfortunately with diagnosis of oesophegeal Ca with mets. Declined any further intervention, but accepted some fortisip for dietary supplementation and review in clinic in a months time as he didn’t have any trips into the bush planned then.

His plan “Ill hunt until I can’t walk, and then the boys can strap me to the back of the Ute(Pick-up truck) and ill shoot from there”

A Flying Kiwi!

I recently had my first helicopter transfer of a patient. Young pt in 20′s.

Presented at 2330 with hemetemesis and PR malena, initial Hb 105. Ur 9.3 Bp 105/80 PMHx of previous bleeds and duodenumitis on scope 3-4 months ago. admitted to the ward with IVF, omeprazole.

At 0300 the patient was up to commode and passed <1L of malena and “Flaked out”

BP 80/50 P 135. pale Hb 85

Transfused 2 units and Fluid resus with target BP 100 sys.

Taken to theatre in morning 0800, Scope found large clot in 2nd part of duodenum but no fresh bleeding.

Discussed with referral centre who felt was reasonable to transfer as unable to perform emoblisation if “rescue” required after clipping.

Pt holding BP 102/60 HR 100ish.

Pt was for Helicopter Transfer (fixed wing busy) and had blood running but was felt likely to require further en route.

In NZ paramedics cannot initiate further bags of blood if required (stupid system) so they required a doctor to take patient.

So it fell to me to go. I have done ATLS but no prehospital medicine courses but do like the PHARM podcasts and felt more or less comfortable with doing it.

So was happy with few things, A,B wise was stable at that time, had backup options but god would not have wanted to use them. C had good access as had two large bore cannulae placed. Collected 2 more units of blood as a good boy scout felt be prepared is a good way to be. Lots of fluids.

Its load into ambulance and then to the helicopter and loading up. Its a small place and doing anything is a bit fiddly. Safety brief from the pilot “dont walk into any rapidly spinning blades, it makes a big mess and I hate paperwork”

After the shuffle we were off!

Weather was pretty bad but the pilots here are guns and know all the passes ect, still felt nervous flying at 200ft over the ridges/saddles.

The Pilot put it well, “helicopter, mountains, beautiful. but I like them separately not together”

<—-Nasty weather shot

Patient had a good going fluid requirement and I was convinced he was still bleeding throughout the transfer. I was playing with pressure bags a bit as we dont use them much in hospital with rapid transfusers and pumps.

Over the course of the transfer, 80 minutes patient received 2 units of blood and 3 litres of saline. but was more tachy on arrival P 120 and BP 95/55 and taken straight to theatre where bleeding ulcer was clipped. Patient did not require embolisation but had further 2 units as arrival Hb was 78.

On review, I felt it went pretty well. I have a massive amount of respect for people who do this regularly. The pilots are really amazing, flying over mountain passes with low visibility was frankly scary. From a more medical point of view little stuff makes a big difference. Its an old rule of PHARM stuff but know your kit, playing with pressure bags ect was frustrating when it should have been simple. Helicopters are a very small you forget how often you move around to do procedures ect.

So to ask anyone whos reading, have you done transfers, lots? a few? do you remember your first?

 

And finally some scenery shots for you all:

 

Master of no trades, Jack of some.

Sometimes I feel very lucky to work somewhere you get to do a bit of everything.  So here was my day today, working the surgical side of the hospital ATM.

Arrived via bike at 0745, shower and into scrubs for work.

0800 the O+G consultant arrives for his round, 3 day 1 post op, 2 vag-hysts one open. all doing not too bad.

0815 the Urologist comes to review his radical prostatectomy from the day before. and a new pt with hx of stones and classic symptoms, USS no obstruction. cons management try avoid CTU.

0830 the General surgical round starts, 12 patients, 7 elective 5 acute. only 3 new today, appendix that went to theatre last night. a resolving SBO. diverticulitis. Epistaxis. Hartmann’s.

So few jobs to do after the rounds ect and a Coffee arrives from an angelic nurse. Remove the Rapid Rhino from the epistaxis, recharting ect.

0915 Acute Admission for Gen Surg, Haemetemsis/Coffee Ground vomiting, 85 y/o man. Pop to ED to be helpful as I will need to see them sooner or later. Pt to theatre me to blood bank to get couple units and get them to pt (happens faster if you do it yourself)

0930 General Surgeon lets me perform supervised gastroscopy, after brief bronchoscopy (happens to the best of us, mostly to the worst tho) gastroscopy shows diffuse gastritis. Review Pt post and get full admission done.

1100 Orthopaedic surgeon arrives for his round but keen to get on with his cases as he has couple to do. As I have been with him before he’s happy for me to do some cannulated screws supervised. As he needs his second coffee of the day he does not scrub just yells from afar. “Remember 3 dimensions, Dont make them convergent!” then argues with anaesthetic staff about regional nerve blocks. good retort from gas man as he raises a bottle of propofol “I prefer a generalised regional block..”

My Handiwork

1215 Lunchtime, Fish and chips (That is very important)

1230 Orthopod comes from theatre to review his pts on the ward. Argue about use of benzos in back pain (blaming some of you for this)

1315, Discharge 3-4 patients who are doing well and keen to get on their ways.

1400 Call from radiologist as hes got a case he thinks I would like to do. Pop down to perform a USS guided liver Biopsy.

1500. Then up to Maternity ward to do 3 baby checks. Aww they are so cute! One for paeds review at 3 months with undecended testis.

1530 on way back from maternity see the ED MOSS walking back to ED. asks if im keen to reduce a shoulder he’s just been called about. wander down for a very lightly sedated scapula rotation.

1600, Change back into my bike gears and get off home. Feel pretty lucky that I get to do a bit of everything. Can be hectic but worth the busy days for ones like today.

Hope you had a good day too!