Another Pair Of Eyes

Abberration

I have seen a lot of medical interventions in my time in medicine. Today, for the first time, I saw an ECMO (extra-corporeal membranous oxygenation – basically a lung bypass machine) machine in full use, and for the first time ever I was struck by the thought that this intervention, this man-machine hybrid thing before me was a step too close to being an abomination. There was no logic to it, no rationale for such a sense of the unnatural; the machine was keeping him alive and all hopes were he would recover. There was just something about it, about this device with its thick, blood-filled tubing draining from the neck and re-entering the groin that made me distinctly uncomfortable.

After a minute or so I realised what that was. The patient wasn’t breathing. Their chest just kind of shook slightly, an uncoordinated fasciculation, while the patient stared upwards with sightless eyes – open, but totally unaware; consciousness-stealing propofol running through his veins. It’s strange because I’ve always kind of considered that heartbeat and pulse would be the cornerstone of my instincts regarding death but this is evidently not the case. Without breath, my subconscious was screaming death, but the ECMO machine was beyond that. Somehow the ventilator, the dialysis machine, all the organ support systems which maintain life in the presence of an absolute system failure have never evoked the feeling of abhorrence which this construct did.

Of course, I got used to it. Medicine requires it, and I’ve spoke to people who’ve had ECMO save their lives before. It is a powerful tool in the intensivist’s box of tricks, and there is occasionally simply no other choice. This patients lungs were filled with blood (swine flu is not always the mild disease of 99%of cases) and without the support of ECMO he would long ago have been dead, choked on the very fluid he was trying to oxygenate.* Thinking about it now, I visualise not this dark, bloody technology that my instinct would have me see but instead a powerful weapon to resort to when all else has failed. It has its issues – the ECMO machine has the capability to maintain life far beyond the point it should have ended, and it is a scarce resource (the last time I checked there were 8 ECMO beds in the UK). Ethics galore.

I’m glad I saw this. I’m sure one day I’ll be able to explain just why it was so potent an experience.

*they tried to bronchoscope him but they couldn’t suction fast enough to counteract the blood flooding his lungs. When they stopped trying it filled right up to the top of his endotrachel tube. Doctors looked at eachother, shrugged and just said “well, we’ll try again tomorrow” which was impressively blasé.

Imminent

I just sat in on a consultation with a lady in which she decided that it was her time to die. She has a metastatic tumour in her brain, and a decision regarding palliative radiotherapy turned into a decision that, actually, further treatment wasn’t what she wanted.

I listened silently as the doctor explained what the likely course of the disease would be. A steady increase in weakness. A progressive decline in mental agility and, eventually, consciousness. That it would not be painful, and that it was a matter of months.

Through it all, this woman sat serenely, facing her ‘imminent end’ as she put it with this incredible dignity. I can only hope that if I am in a similar situation one day that I will be able to manage half the grace that she showed in the face of death. The doctor offered to call her daughters to inform them of her decision. ‘That would be lovely, thank you,’ and there it is. I supposed after 80-odd years you can have lived the life, done what you wanted, and be ready for it to be over.

I looked out of the window and I saw a greying cloudy day, but I can ever-so-easily imagine that, if your days are numbered, it could be one of the most precious things you had. I don’t yet understand how I’d be able to face losing that.

Funny thing, this elective. On the weekends it’s a holiday and during the week it’s something quite separate.

Rotorua

Rotorua -a small town on the New Zealand tourist trail. It stinks of sulphur (I refuse to Americanise it to ‘sulfur’), is packed with adventurous activities, and in theory is an awesome place to be.*

And actually, it was amazing. Three hour drive, which was just stunning. Hostel with a geothermal swimming pool and a dorm, which while about 300 degrees** were a lot of fun. And then caving and luging and a massive swing thing and all sorts of stuff that broken arms probably aren’t supposed to be involved in. ‘t was awesome.

Luging: not actual, face-inches-from-the-floor luging, but some kind of strange mini go-kart things which you ride down a track which winds down a hill, then chairlift back up to the top. Sounds pretty tame but they are low to the ground, skid happily around corners, and the more advanced trails are damn quick and come complete with chicanes, banked corners, and steep straight sections.

Caving: the caves at Waitomo are filled with freezing water and freezing air in equal measure. We were (wet)suited and booted, and floated through the caves on inflatable tubes, pausing occasionally to jump off waterfalls or squeeze through rocky clefts. You can’t quite convey the atmosphere down there – the darkness is absolute, and the thunder of unseen water is constant and somehow both threatening and intriguing. Underground the caverns are timeless, grand and mysterious even in the well-travelled, guided sections we explored.
On top of all that were the glow-worms. At points we turned off our lamps and plunged into absolute nothingness, only to glance upwards at the constellations of them above. Stunning.

Geothermal park: pretty tame by comparison, and most definitely not worth the $30 entry fee. Go to Iceland, as it’s infinitely more awesome. A steaming coloured pool doesn’t do it for me anymore unless it regularly explodes or something.

Summary: this sort of weekend is why I came travelling. I’d write more but it’s time to hit the wards again…

*operative word: ‘theory’. Broken arm much.
**botha the room and the pool, actually.

Airborne

So. This week I am on PICU, or paediatric intensive care unit. It’s hard to write this because I’m currently sitting in a helicopter on route to an emergency transfer patient and the vibration makes it hard to type. Basically, in comparison to DCC (department of critical care, with the waiting and the staring and the hours of nothing happening), PICU is undeniably awesome. Yesterday: angiography (visualising blood vessels in the brain using a massive x-ray machine and radio-opaque contrast to map out the locations of abnormalities) and watching a baby’s chest being closed after a successful repair of tetralogy of Fallot. Today started with the usual dull-as-dishwater ward round but an hour later I’m wearing a flightsuit and en route to the airport. Originally we were going to be flying a planebulance (not a real word) but it got requisitioned by a priority one cardiac ICU transfer ECMO patient (Extra-Corporeal Membranous Oxygenation, which requires a plane to transport) so instead we got upgraded to a helicopter. And that is why I am typing this at 6000 feet, vibration, etc. We’re going to land on the hospital helipad. It is pretty damn exciting.

Right, we’re coming in to the town location now, so I’ll write more later.

Later: now flying back, with a child and father on board. The kid isn’t too ill at present – it’s more a worry about deterioration later today that prompted calling in the chopper. We’re landing directly on top of the hospital, with medical priority through Auckland airspace, as facilities aboard the helicopter are understandably limited and there isn’t a lot of free movement if anything should go wrong. Weather is rough as well; can’t see anything and there is significant turbulence so landing might be interesting. On the plus side, PICU is about 100m from the helipad so won’t be much delay between landing and being on the unit. ETA 15 minutes.

Later again: day done. Admitted the little boy to HDU (high dependency unit – a step down from true ICU in the quantity of nursing and intensity of treatment, but beds are inside the overall PICU so transfer is as easy as moving staff if necessary) for the night, having spent 6 hours completing the transfer door-to-door. It’s been a pretty awesome day, no less, and totally not what I expected to be doing! Learned a little along the way, but mainly it was just damn awesome.

And that’s that. Pictures to follow.

Heartbeat

Today, I watched a baby’s heart beating.

Literally. Directly. With my own eyes.

Holyshit.

Code

‘Code red, ward 54, room 15′ reads the pager, and we move, abandoning the chest drain we have spent 15 minutes meticulously preparing.
It’s the role of doctors on the ICU to respond to any code red* (something potentially life threatening requiring urgent review) or code blue (start CPR) in the hospital, as they have the most experience dealing with arrest situations. A code red callout covers a large range of issues from the worried nurse of a distressed patient to serious and deadly emergencies in which every minute counts. This was my first code, it was code red, and as we hurried down 4 sets of stairs I didn’t really know what to expect.

We were back in the ICU within ten minutes. The code red should have been a blue, and the blue shouldn’t have been issued. When we got there the patient was already dead, not for resuscitation, and so we turned around and walked back to the unit. His name was John. I never did find out why he died.

Sometimes we win, sometimes we lose, and sometimes we’re not sure.

*along with a host of other people.

Arrival

I arrived in New Zealand on tuesday after a very long time spent in very small (and not hugely comfortable) spaces and have had a few days to get an impression. New Zealand is like Britain Mk.II. The winter is milder, the bottles of coke are 600mls, steak is cheap, rugby is the national sport and scrubs have pockets on both sides. BOTH. SIDES. Have you any idea how much of an improvement that is?!*

Ahem.

Today is day 3 of one-armed ‘working’ in Auckland City Hospital intensive care unit. It’s a mixed bag – there are things going on here which are far and away beyond the average ward business and can be really quite amazing (closing up a chest on the unit, anyone?). Sadly the rest of the time nothing is happening, the patients are all unconscious and there is nothing to do.

Example: day one. Turn up, ward round, then see two tracheostomies and a cardioversion (like a planned defibrillation, with the electronic pads and people yelling ‘CLEAR!’). Never seen any of that and it was non-stop action. Then, in the afternoon, I sat in the office staring at walls and admiring the paintwork.

It’s difficult to do the things you’d normally do on wards when it’s quiet as well – as mentioned previously the patients are either unconscious (and can’t talk) or have a tracheostomy (and can’t talk) so you can’t chat to them. Bastard-bloody-broken arm means I can’t take blood or put in lines or even examine people, so all that’s left is to wander aimlessly around or sit and read. Even trying to find out about patients is hard because the intensivists speak medical jargon to a whole new level of speed and abbreviation, and do not seem to require patient notes, cues, or traditional English vocabulary to do so. It’s…frustrating. There is so much to learn/do here but it is just out of reach. I don’t want to come across negatively, it is good, but not ideal. Then again, what is?

Other stuff – we’re going to hire a car to get around as public transport is poor at best, but until that happens at the weekend it’s nothing going. The houses here are huge and spacious, the views are gorgeous, and frankly if it weren’t for the 24 hours flying I’d need to do to visit family, I’d probably emigrate here. I say probably – not everything about New Zealand is good. For example today there were only extra-large scrubs available, so I’m feeling disillusioned. Oh, and the Kiwis really suck at driving. Even so, I’m only half joking about emigrating in future.

I’d say more but other than be in the hospital (which is just amazing and spacious and new) we’ve not really had the chance to see or do anything so there isn’t a lot more to add at this juncture. Hope the British is treating you well, and watch this space.

*there are still, however, no medium tops. It’s not perfect.