She was born at term, after a normal pregnancy and an uncomplicated delivery. All was well, until her mother developed a fever 3 days later. Her GP prescribed some antibiotics. Baby A wasn’t feeding that well, but her parents didn’t get too worried until a day later, when she started crying and simply wouldn’t stop. At that point, they brought her to A&E.
Unfortunately it turns out that they were already too late. Baby had a fever, so the A&E doctor did a full septic screen (this includes blood tests, a chest x-ray, urine sample and lumbar puncture). We do loads of these screens on miserable, febrile babies (I used to do about one every every week of nights when I was working in Children’s A&E), and they usually come back negative. However in this case, the spinal fluid – usually clear and with a consistency barely thicker than water – was like pus – Baby A had meningitis.
I first met her 2 nights later, when she had been transferred to the neonatal intensive care unit. She had had a brain CT scan earlier in the day, showing multiple infarcts (i.e. strokes). In the context of meningitis, this would be due to inflammation in the blood vessels of the brain leading to reduced blood flow and the brain tissue lacking oxygen in the territories supplied by the vessels in question. I noticed that she had an erratic breathing pattern – she would pause for up to 10 seconds, then suddenly gasp and breathe rapidly for another 10 seconds. I wondered if she was having a seizure. Then she started to jerk her head and one arm rhythmically. She had already been given phenobarbitone (an anti-seizure medication) a few times over the last 48 hours, so I loaded her with phenytoin (another anticonvulsant). I also wanted to intubate her and put her on a ventilator to support her breathing (there was a risk she wouldn’t start up again after a long pause, even though a blood gas test showed she was eliminating carbon dioxide and oxygenating sufficiently), but the nurses were resistant, saying she had been breathing in this way for the past 48 hours! So I ended up ringing the consultant again (the first time was prior to the phenytoin) just so I could tell them it was on her orders.
Baby A remained on the ventilator for about a day, then her breathing seemed to become more regular, and they took the tube out. The following night brought a new problem: her blood pressure, which had always been on the high side, rose until it was higher than that of an adult. An increased blood pressure, decreased heart rate and erratic breathing together form Cushing’s Triad, a late sign of raised intracranial pressure. It is not often seen in babies because they have an open fontanelle (soft spot), so they have a bit of ‘give’ when the brain swells up. Still, we treated her for cerebral oedema (by giving 3% saline), and it seemed to hold things for a while. Towards the morning I did a cranial ultrasound scan, which showed that the ventricles (the chambers in the brain which make the cerebrospinal fluid) were massively dilated – hydrocephalus. This is another common complication of meningitis in a baby. Assuming she survives, she would need neurosurgery to place a shunt to drain the fluid.
So all in all, a disastrous situation. I don’t mention the parents here, because as I was on night shifts, I never had the chance to meet them. I hoped that by presenting my cranial ultrasound scan findings and the events of the weekend at the Monday morning grand round, a sensible decision would be made regarding the direction of this baby’s care (i.e. intensive or palliative).
I was therefore disappointed to learn on Wednesday that things were still uncertain, and that she was back on the ventilator. Apparently they had agreed with the parents that if baby stopped breathing, they would put her on the ventilator until they could come in and hold her while she was taken off and allowed to die. So that all happened, but they then changed their minds about taking her off. I think it is quite unfair to leave the decision to withdraw care up to the parents. It is also unfair not to perform tests which will help to predict the neurological outcome, even if they will not currently alter the treatment. It is hard enough as someone who has been through medical school to understand the implications of each problem with each body system the patient has, never mind put it all together and try to guess how the person will function as a whole at the end of the current episode of illness (making the rather big assumption here that it will not kill them). I think part of our responsibility as doctors is to gather all the information we can – in this case, the brain MRI, full EEG and paediatric neurology consult that were not available to us over the weekend – and draw it into a recommended course of action, presenting the information in such a way as to guide the parents to the correct decision, and make them feel they have been empowered to make it. Some people might argue that this is a rather paternalistic view, but I think that the alternative is just irresponsible.
Suffering for one’s art appears to be a fairly well recognised phenomenon in ‘creative’ circles. But I would argue that suffering for one’s art is a fairly prominant feature of medical practice. I have just spent the best part of my evening crying as I feel really guilty about a young girl whose family are at present receiving her diagnosis of leukaemia. I sent her home from A&E last week, after she had presented with large lymph nodes in her neck and a possible but unclear history of fevers at home. I asked about weight loss, energy levels, foreign travel, immunisations…everything to cover the wide differential diagnosis. I examined her thoroughly, checking for nodes elsewhere and feeling her tummy for an enlarged spleen or liver. We sent blood tests, including a blood film, which showed a borderline platelet count of 128 and reactive lymphocytes. These findings would be compatible with a viral infection, so I sent her home with instructions to the parents to return immediately should she become more unwell. I also wanted her to be seen at the rapid review clinic in a week’s time, and the blood tests repeated. That is where things fell apart. The clinic was cancelled for the next two weeks so I couldn’t offer them an appointment. It didn’t seem urgent enough that I should phone the consultant at home, so I asked them to return to a&e for the blood test and requested an urgent outpatient appointment. I then forgot to alter the plan I had written in the notes. Fortunately, they actually turned up this afternoon, and the blood tests were done. They also got seen by the consultant, who happened to be on hand, but who then told me off for not ringing a consultant at the time. Today’s blood film showed blast cells.
Have just been printing out my feedback from various on-the-job assessments. The consensus seems to be that I am performing significantly below average compared to others with the same experience.
I think I have got past the stage of responding to this with tears, but it does make me wonder if I am inherently unsuited to the medical profession, or, at least, acute hospital medicine.
I particularly loathe the A&E setting, and night shifts are just an agonising countdown to their end. Every time the crash page goes off, I just want to run in the opposite direction and hide.
But there is more to medicine than emergencies. I perform best at journal club and clinics (and have been told so). I like to explain things to people, be they patients or junior colleagues. The most enjoyable part of this training year has been putting together a research proposal, even though it was unsuccessful. Unfortunately, the only route into academic medicine (and thus a life without having cover the ‘acute take’) seems to involve having to first prove yourself in the emergency setting. I know I only need to be signed off as ‘competent’, but it’s hurtful being rated below average, when I’ve been working so hard and being really keen (read: Professional) even when doing the things I find extremely unpleasant.
That phrase took me back about half a year, to a PICU evening handover. “He’s weaning ventilation, PTV 14/5; fluid balance is negative 100ml, urine output 5ml/kg/h”, said the day shift Fellow. “Ahh,” said Pete*, in his heavy Dutch accent, “he is Peeing For Scotland!” I looked up at Pete (he’s about 7 feet tall) and he was beaming, pleased that he had applied this new-found phrase in the prescribed situation.
The answer to this, ostensibly, would be straightforward – depends on how complex the case is. But in real life, this does boil down to a number. In GP-land the magic number is 7 – yes, that’s 7 minutes per patient. This morning I saw 10 patients in the space of 3 1/2 hours. That’s more than 20 minutes per patient. The clinic overran by half an hour, and the department was deserted (for lunch hour) by the time I finished. On paper, it was supposed to be 2 doctors seeing 24 patients in 3 hours. So that’s 15 minutes per patient. (Also means the quicker doc sees more patients, so makes me unpopular with colleagues) I guess that’s generous compared to the primary care consultation. It’s a balance between being thorough and being focused. And giving the patient the illusion that you aren’t rushed. I’ve never been the most efficient at seeing outpatients (because I’m too worried that I’ll miss something), but I’m also a bit out of practice at the moment, having been on intensive care for 6 months. To be fair, 3 out of the 10 had various psychological issues and a couple needed ‘expert’ reassurance (which is difficult when you look young, I reckon – and I mean being mistaken for 18 when you’re 30; NOT good if you are a doctor because patients assume you know nothing, and therefore refuse to be reassured). So it was a complete heartsink to discover at the end of it all that I had missed something (minor) on one patient. That made me miserable for the rest of the day. (Oh, and I missed lunch too) So it was a pretty rubbish day, which ended in having to learn yet more car anatomy – this time it’s ‘oil sump’. At least my car gets to be indoors while it’s snowing. Oh, I don’t know. I just wish I was better. Or perfect – efficient, never missing anything.
..can hardly breathe, shivery hot/cold, feel wiped out every time I bend over, nose running over the computer…
But enough about my physical condition. Which I partly blame on having volunteered to cover Sunday’s night shift. But my car works again! It’s got a brand new clutch. Which the money from working the extra shift should cover. Which is why I struggled with calling in sick today, but really, I’m not physically up to running the admissions unit for 12 hours, and I don’t imagine the parents will appreciate me sneezing all over their children.
So what am I up to today (glad this blog has hardly any readers, or I’d actually have to write properly!)? Finally had time to look up sclerema. It’s one of those things that people comment about on intensive/neonatal intensive care and then do nothing about, so I wanted to know a bit more about its natural history. The sentence about neonatal fat having a higher melting point is particularly disturbing. Sometimes you just don’t really want to know. Not sure how to translate the information in the article to a parent-friendly explanation the next time the mother of a really sick baby asks why the baby’s fingers are fixed in a flexed position.
Also catching up on my reading for the research proposal. More technical EEG stuff, and sleep electrophysiology. And if there’s time in the evening, maybe I’ll get started on my latest charity bookshop acquisition. Seeing as I’m too washed out to do any packing/cleaning up.