"24 Hours in Rural A&E"

Recently I have been contacted by friends living in Australia saying that my mug shot was aired on a TV documentary over there: a show called “24 Hours in A&E.” This reminder brought back fond memories of working in the Kings College Hospital emergency department where it was filmed. Without a doubt, it is the most exciting and uplifting place I have ever practiced as a Doctor. The people who work/worked there really did affirm my bizarre affection for casualty. At the end of the day, it’s all about the people.

I was thinking about how different life is now, where I spend a fair amount of time at Holy Cross casualty.  At King’s I didn’t really need to think a lot of the time as all the blood tests and investigations would be done before I could say: “HELP!” And, if I did need help, it would be there in the form of porters, nurses, doctors, technicians, radiographers, specialists and Google. However, the lack of this luxury is part of the thrill and excitement of working at Holy Cross. One really has to think and keep returning to the start to make sure the point hasn’t been missed entirely.

Last weekend I had a rather obese girl in her twenties present fitting – she was in status epilepticus. She was brought in by her colleagues who were working with her at the time of her fit in KFC. Now, I do despise KFC, but it does appear to provide a lot of employment around here. However, I wonder if my patient’s obesity had anything to do with her job. Anyway, she had been fitting continuously on and off for about an hour. Her colleagues knew nothing about her as she had only just started the job. As it happened, they were all quite slender – they said that they would never eat KFC after working there. So, maybe there is some hope for the habitus of my patient. I digress. So, I went through the motions – secured her airway (she had quite marked stertor – snoring - and was dropping her oxygen saturation levels, which wasn’t fully relieved by simple airway manoeuvres, so I popped a guedel airway in), asked my nurses to slip in an intravenous line, another to fetch the diazepam and a third to check her blood sugar level (there is some help on demand here – especially if I ask in the correct tone and pitch of voice) whilst I performed a quick assessment.

There we were – myself, my nurses, some KFC employees and this fitting girl. It took two shots of diazepam and a phenytoin loading dose to terminate her seizures. There are one thousand and one different causes of fitting, or so I am led to believe, but a handful of common ones. Was she a known epileptic? No one knew. Was she diabetic? Her blood sugar was fine. What was her HIV status? Again, shrugs from her colleagues. She had no signs of meningitis or fevers. The examination was normal. Then I thought: “EUREKA! Maybe she isn’t fat, she’s just pregnant. Shit, is this eclampsia?” However, a quick ultrasound and a pocket pregnancy test later (I keep them in my pocket – quite useful when the lab is closed) revealed no evidence of pregnancy. So, I played the “watch and see” approach. The next morning she was awake and chatting. This was her first seizure, she was HIV positive. She was seen by another doctor and discharged with follow up after some investigations.

The point of this case is that here one has to really think what is going on so that any obvious reversible causes can be dealt with. Back home one can just order all the tests and think later when they come back abnormal. Even if I wanted to, I couldn’t just “buff” the patient up and “turf” them off to another speciality because unfortunately when on call I am the casualty doctor as well as the admitting physician, paediatrician and obstetrician – the ball always bounces back. Fortunately, I like playing ball.

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This week saw the launch of our new clinical teaching programme at Holy Cross. It sounds far grander than it actually is, but one needs to start somewhere. As it was my idea to get the programme started I thought it only fair that I volunteer to give the first presentation. In truth, the boss volunteered me, but if he hadn’t then I would’ve come forward anyway. I’d written a nice little presentation of the new WHO 2012 Tuberculosis guidelines (very topical as it was World TB day on March 24^th) and raised some discussion points pertinent to Holy Cross. Unfortunately, the first day of my programme and presentation was hijacked by one of the senior medical officers who decided to give a didactic presentation on a recent neonatal resuscitation course he had attended.

There were three main flaws to his presentation – the first was that I had already attended the course and debriefed my colleagues, including him, on the pertinent points. Secondly he spent an hour almost repeating the presentation he had been taught, starting out with how to wash ones hands (with a physical presentation for the full 2 minutes required) to the delivery of the child, but seemed to miss the most important notes on how to make sure the baby is breathing. Thirdly, he failed to engage any of his audience – if one was to walk into the office last Thursday morning they would have seen six bored looking doctors slumped in semi comatose states on their seats with eyes rolling back and forth alongside deep sighing.  So, I have rescheduled my presentation for next week and shall attempt to keep to a programme that gets everyone engaged.

Our local referral centre.

"Doctors rounds will resume after essential prayers." It was rather nice actually - some beautiful singing and dancing.

No caption required, except to say that the guy was absolutely fine, if you ignored the knife coming out of his head.

Quite difficult to see - but these two xrays taken a month apart show two very opaque artifacts (encircled in red). The man was shot in 1976 with a shotgun and two pellets remain.

The brand new 30 foot cross at Holy Cross that lights up at night, standing in the fog. I really hope hospital money wasn't used for this - we still have no soap or paper towels.

One of my favourite xrays of all time. It is a child balling his eyes out while having the image taken. Notice his mouth caught wide open as a result of crying on the table. In case you were wondering, the image is otherwise normal.