In Stitches

by Nick Edwards

  We did the usual emergency medical treatment indicated in these sorts of cases: strong painkillers which had the added effect of calming him down, and cleaning the wound properly before getting him X-rayed. His X-ray showed a nasty fracture of the tibia bone. As it was an open fracture (a break which is exposed to the outside world via the cut), he would need it operated on quite quickly or risk losing the entire leg due to infection.

  He was quite nervous about the operation and a general anaesthetic. I told him it was much safer than riding a motorbike and he needed to try do everything that he could think of to relax. I left him pondering this and got on with the rest of the shift. I didn’t think about him till later in the night when the orthopaedic registrar came and spoke to me.

  ‘What did you tell that young lad?’ he enquired curiously. He went on to tell me that when he went to see him, and opened the curtains, that he interrupted his girlfriend providing fellatio to him. The young lad’s response was that the A&E doctor told him he needed to do anything to relax and this was the best he could think of. The orthopaedic registrar left and scrubbed out the pre-op sedation from the drug chart. It wasn’t really needed now.

  Broken leg

  The ambulance phoned ahead to say that they had a 12-month-old baby girl coming in with a broken femur (top bone of the leg.). This is a rather unusual fracture in a child, especially in a 12 month old. It takes rather a lot of force to break the thigh bone, and it would be very unusual for this to happen in a child by accident. The minute the call came in everyone was concerned that this was caused by a deliberate action from an adult – child abuse

  The mother came in – she looked like a child herself and didn’t seem to realise the enormity of what was happening to her child or that we would be looking closely at her story.

  In these sorts of cases, the parent’s history when compared to the physical injuries is paramount and both need to be carefully recorded. No one wants to unnecessarily accuse a parent/carer of abuse but then we also don’t want to miss anything and risk further harm occurring.

  Since cases like Baby P and Victoria Climbié, all health care professionals have regular teaching on how to spot ‘non-accidental injuries’ and it is often at the forefront of our minds in cases like this.

  I sat down with the mother and tried to go over how her daughter had become injured. According to her she had stood her up on the nappy changing table and the leg just snapped.

  The likelihood of this being true was quite low. Her story also seemed to have several inconsistencies especially about who was present when the accident happened. One minute one of her friends had been there, then just her boyfriend, then the next minute no one else was there.

  X-rays showed the baby had what is called a spiral fracture of the thigh. Instead of a clean snap across the bone, the fracture was twisted just as if the leg had been twisted. Careful examination of her body also revealed some bruises that were clearly made several days ago as well as some small scars that were possibly cigarette burns.

  Throughout this whole exam the baby just wanted her mummy. I don’t know what had actually happened to the baby. We still don’t exactly and maybe never will. Maybe the mum’s boyfriend had hurt the baby and lied to her and she had just retold the story. Maybe she had twisted the leg in a fit of anger as she couldn’t cope. I don’t know. What I did know is that I had grave concerns about the safety of this child and the family situation.

  We admitted the baby and she went up to the paediatric ward where again the paediatricians examined her and listened to the mum’s story. Duty social workers were contacted and they and the police needed to do the full investigations to find out what truly happened and if the child should be removed from its family or put on the ‘at risk register’ and carefully monitored.

  Throughout this whole case I felt sick to the depths of my stomach. She was about the same age as my daughter and looked quite similar. How could someone have done this to a poor defenceless baby? Who could hurt a child? Why should this child be treated so badly when my one is just spoilt rotten? And worst still, why is not just an isolated case, but rather an increasingly frequent occurrence in my line of work?

  Nice bum

  It was a busy Thursday night and walking into the waiting room was like being a gladiator, choosing which animal you would fight with next. All the usual A&E suspects were there – drink, drugs and plenty of fighting. I couldn’t cherry-pick whom I could see, and just picked up the next card.

  On this particular night there was one female patient waiting to be seen. Every time I went into the waiting room, she would try to catch my attention in order to jump the line. Usually her tactic would be to embarrass me by shouting, ‘Oi sexy. See me next, doc.’ What she didn’t know is that I am generally immune to embarrassment and I ignored this banter and got on with the job.

  However, each time I went into the waiting room she got a bit louder and feistier and the waiting room got a bit more information as to why she was there.

  ‘Mr. Smith please,’ I would say.

  ‘Oh darling, Yes, you sexy doc – my bum’s bleeding!’ she would tell everyone.

  Ten minutes later, ‘Mr Jones please,’ I would call.

  ‘Come on sweetheart. See me next. The dog bit it’

  This went on a bit longer till I called another patient. ‘Mr Andrews ple—‘’

  ‘For f**k’s sake… Just have a look at it and tell me if I need stitches.’

  In the middle of the waiting room, she proceeded to whip up her skirt, bend over and give everyone a good look at her ample derrière that had a small scratch on one cheek. Not really a good reason to be moved up the queue. I carried on seeing Mr Andrews who limped into minors on his twisted ankle with a slightly glazed, happy expression.

  ‘Do you know what, doc? I feel better already,’ he said.

  The power of the mind, or not

  Some people are not fans of western medicine and we must respect their wishes. A few months ago I had one. She was an odd lady, kept on insisting on telling me she was a feminist who had gone to prison for her beliefs. (She looked like a lady who definitely should have been put behind bras, but not necessarily in jail.)

  She had sustained quite a nasty fracture to her wrist and it needed pulling into a straight position. I told her I wished to put local anaesthetic into the fracture and give her some sedation and sort her out.

  She insisted that she only wanted natural treatment. She had never taken a tablet, immunisation, an injection or anything which can harm the body, which was odd considering she smelt of tobacco, but hey ho.

  I tried to explain the need for the repair of the injury. She said she understood and asked me to go ahead and proceed in 10 minutes when she was ‘prepared’. I was warned again that she must not be given any drugs.

  I continued to persuade her. I failed. She insisted that I manipulate the fracture when she had prepared the mind. After trying to convince her of just how painful this procedure would be with out appropriate painkillers, I reluctantly agreed. I had no option. She was well within her rights to refuse painkillers.

  She asked if she could play some music – I had no objections. Whale noises started coming from the iPod. She then started to close her eyes and rhythmically chant. This was going to be amazing. I had heard of the fire walkers and others who put mind above matter but never seen it before. A case report in a journal beckoned. I could retell her story. I started to get quite excited about what I was about to witness.

  She raised her left arm, the signal we had agreed when she had prepared her mind. I gripped her fracture, content in the knowledge of her mystical powers and that this was the first non-urgent fracture that I would manipulate without analgesia. And then as I went to move the break… She screamed like she had never screamed before and I had never heard before. The whole A&E department was silent except for the screams.

  ‘Give me the drugs now. I want the drugs. I need drugs. I couldn’t give a damn about polluting my bo
dy. Drugs, drugs, drugs.’

  Just then my boss walked in. ‘Give her what she wants, Nick’, and off he walked content that he could mock me to our colleagues.

  Why wanking turns you blind

  A 60-year-old man walked into A&E.

  He complained of sudden onset headache during the process of masturbation. It was like a sledge hammer to his head, he said. He had been sick once and was a bit confused.

  On examination he was generally well, but with some neck stiffness. There were no hairs on his palms.

  An urgent CT scan showed a bleed on the brain – a specific type of bleed called a subarachnoid haemorrhage with extension into an intracranial haemorrhage (a type of ‘stroke’).

  He developed left-sided weakness and a blindness on the left side. He was soon stabilised and referred to the neurosurgeons for them to try to stop any further bleeding.

  What had happened was that this man had a ticking time bomb, a small aneurysm (outpouching) of a blood vessel, which was liable to bleed by anything which put up his blood pressure. It just so happened that the thing which put up his blood pressure was self-gratification.

  So you can see for this case that a stroke lead to a stroke, and that wanking can really turn you blind. I doubt that is going to put many men off but it’s always good to have all the facts!

  Teaching at every opportunity

  One of the things I love to do is teach. This is probably, though, because I like the sound of my own voice and I can pretend I am on stage doing stand-up. I had agreed to give a talk to 20 medical students at the hospital as part of their preparation for their final exams. A very big deal to medical students who at that stage of their careers are in a mass panic and gladly grab any offer of teaching with two hands. I liked doing it and wanted to help them as much as I could. Even though my wife was pregnant with my son and was due around that time, I was confident I could make the time and help them out.

  Early that morning, however, my wife’s waters broke and mild contractions started. ‘This is it,’ we thought, all excited to meet our new son. I called grandma to come and babysit our daughter, got her an endless supply of ‘Peppa Pig’ DVDs (for my daughter, not my mother) and drove my wife to the hospital. While my wife was booking in, I called the medical school secretary to apologise. There was no one else able to give the talk and so they put up a note cancelling it.

  When we arrived she was only 3cm dilated and the contractions had all but stopped. So we were advised to go for a walk for several hours to get things moving again. Fun as this sounds it was actually quite dull and I was feeling peckish so I convinced my wife to go to the hospital canteen for a fry-up breakfast. Obviously my wife couldn’t eat much as she was in labour and didn’t fancy it, but I thought it important that I keep up my strength for possibly a long day. By the time I’d eaten and read the morning papers it was still only 9 a.m. and it was clear that not much was happening with the baby. Another circuit around the local park and we were both fed up.

  ‘Well, as not much is happening shall I see if any of those med students are around still and you could sit at the back and learn what to do for patients in respiratory emergencies?’ I asked brightly, thinking this was a great solution. Strangely my wife seemed a bit upset by this idea but I put it down to the hormones.

  Thirty minutes later the lecture was back on, with many of the students having hung around and more than happy teaching was back on. They did seem to think it was a bit odd that there was a heavily pregnant woman sat at the back, sweating and moaning repeatedly. But the lecture went well I thought. Back on the labour ward things had sped up again and only three hours later I was clutching a beautiful baby boy. It was then pointed out to me that this might have been a bit self-centred to take teaching in the middle of my wife’s labour but everyone was happy in the end. Weren’t they?

  Why being a doctor outside work isn’t always good

  Sometimes it is best off not mentioning you are a doctor. A National Childbirth Trust (NCT) meeting is one of them. So that we could meet other new parents in the area, we attended six two-hour antenatal sessions in the run up to our first child’s birth. These classes were designed to prepare us for the birth and answer any questions as well as introducing us to other parents-to-be in our local area. It was my wife’s idea. I went with it.

  The classes were torture. Each week I would come back with more and more bruises on my upper arm, from my wife’s elbowing me to be quiet, and with blood in the mouth from all my tongue biting. NCT classes are very good and informative but we both felt they had a slight anti-medicine slant; all about natural home births are best and no medical interventions and just what horrible things doctors would do to you if things started to go wrong. While well meaning and true in some aspects it was not good to hear when you are a doctor and have repeatedly seen what ‘hospital medicine’ does to save the lives of mums and babies during childbirth. At the penultimate meeting, I couldn’t control myself. They were talking about vitamin K after birth for the newborn baby. This is a vitamin that is given routinely to all babies in the first day or so after birth to prevent those who are deficient in vitamin K from suffering bleeding on their brains. It is a treatment which saves lives throughout the world, is cost effective and evidence based. However, our class leader was trying to inform us of the side effects but seemed to be using tactics that scared more of the class rather than reassure us all. We were told to think very carefully about having it as the dose given to babies was very high and was it more than they really needed. We were then asked why we thought that dose was given.

  I couldn’t help myself. ‘That’s the dose given because that’s the dose that all the evidence and safety data have shown is safe for babies and is effective enough to saves lives. Yes, it means giving an injection to a newborn baby but personally I would prefer to have an unnatural “medicalised” birth with mum and baby who are alive and well at the end of it rather than a natural birth and a dead baby and possibly mum at the end of it!’ There was silence throughout the class and the instructor hurriedly changed the topic. The bruise from my wife was enormous and was still there when my daughter was born a couple of weeks later. Despite a few differing attitudes to childbirth, we made some very good friends in that class whom we still see four years later. We all had healthy babies and no one (well, possibly my wife still) seemed to mind my outburst.

  Cheeky patient

  It was 10 a.m. in the morning and I called the cardiology on call doctor.

  We had quite a sick patient in A&E with an irregular and fast heart rate – atrial fibrillation. He was running at a rate of 200 and, at the age of 69, it was putting some dangerous pressure on his heart and he was suffering severe pain.

  He needed to be ‘shocked’ out of his abnormal rhythm. For that you need two doctors, one to put him to sleep – the job I was going to do – and a second doctor to time the defibrillator to deliver the electric current and shock his heart back into a normal rhythm.

  I was setting up my drugs while the cardiologist was chatting to the patient trying to find out more of a history. However, he wasn’t getting very far as he was being repeatedly called away by other wards paging him. At first he ignored it but then realised it might be important.

  The ward nurse apologised as they knew he was busy and they had already contacted him about the same thing twice but things were heating up. A 65-year-old inpatient who had had an angiogram (investigation of his heart blood vessels) in the morning wanted to go home asap. He had started kicking up a fuss about the waste of time he was having. The nurses had explained that the doctor needed to come and discuss the results with the patient but that he was busy. The patient had insisted that the nurse phone my cardiology colleague again.

  The conversation was short. Twenty seconds and a few muttered swear words later, he was back with our very sick patient.

  ‘I am ready to go, Nick’ he said. I slowly injected the anaesthetic, a white fluid called propofol – often referred as ‘m
ilk of amnesia’ – and off the patient floated into a world of sleepiness.

  We shocked his heart. No effect. Our heart rates went up. His, however, didn’t change. The cardiologist’s bleep went off. He ignored it.

  We shocked him again and his heart paused. Two anxious seconds left it went back into another rhythm – but not normal. His bleep went off. He ignored it.

  We shocked him for a third time. This time it worked. His heart rate went back to normal. The cardiologist’s bleep went off again. It was an outside line and he went to answer it.

  ‘Hello, there my name is Mr Smith. I am on the cardiac ward waiting to be discharged. Do you mind pootling down to see me. I am awfully busy tomorrow and want to get home in good time…’

  He went on, ‘I am calling from those new patient line phones – switchboard kindly put me through, I said you wouldn’t mind…’

  I only wish I could put a picture of my colleague’s face in the book. It would paint a thousand words.

  What patients have taught me

  As doctors, we often forget that encounters with patients often end up teaching us quite a lot of lessons. Here are a few of mine.

  Never using a euphemism for death

  A colleague went to tell the relatives of a 70-year-old man, who had died from a car accident, well… that he had died. Except he didn’t use the words dead or died. He said that he had gone to a better place. The family just nodded and so to give them some time to be alone and grieve, he quickly left the room. The family came out five minutes later asking for the directions for the local trauma centre, as that is what they thought of as a better place.

  We should change the way that we teach juniors

  I saw a patient who needed a chest drain for an accumulation of fluid in his lungs. I had performed this procedure many times before and wanted to teach a junior colleague what to do. I asked the patient, expecting a ‘yes of course doctor, three bags full doctor’ style of answer, but when I told him that it would be the junior doctor’s first drain he said: ‘Would you go on an aeroplane where the pilot had not practised on a flight simulator first?’