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Archive for the ‘BMA News Articles’ Category

See One, Do One

BMA News, 31st January 2009.

Aidan M. O’Donnell

Julie was fit and well and having an elective Caesarean section. As a post-fellowship anaesthetic registrar, I went to see her beforehand. Her two boys had been born by Caesarean, and she was very comfortable and familiar with the procedure. I anticipated no difficulties.

The spinal anaesthetic took effect rapidly, and the surgery was started. After a short while, the baby was delivered. Normally the midwife will take the baby away briefly, dry it off, wrap it up snugly and bring it back to show to the proud parents. Some midwives take a couple of extra minutes to administer vitamin K and to do other tasks. This can sometimes seem a long time to expectant parents who are keen to hold their new baby, so some distracting chitchat can help to pass the time.

On this occasion, Julie interrupted me. “Why isn’t the baby crying?” she asked me. She was right. The baby was already a few minutes old, and there was no sound of crying. “There’s probably nothing wrong,” I told Julie, “but I’ll go and have a look”.

As I approached the Resuscitaire, it was clear there was a real problem. The baby was blue, mottled and limp. A trainee paediatrician was attempting ventilation by bag and mask. Two midwives were also in attendance, and the paediatrician was giving instructions to them in a low urgent voice. I came up close.

“I’m the anaesthetist. Is there anything I can do to help?” I asked. There was no response. I didn’t know if the paediatrician hadn’t heard, or had decided I had nothing to offer. From listening it was clear that help had already been called. I stood closer and repeated myself more loudly. Still no response.

I stood for a moment in indecision. It was clear that the bag and mask ventilation was ineffectual, and that the baby was dying. However, having little experience of neonates, I wasn’t sure I had the skills to improve the situation. If I elbowed the paediatrician out of the way, I might make the situation worse by being less skilled than she was.

After a few more seconds, I decided to intervene. It was clear that nothing was working, and I could certainly not make things any worse by trying. Just then, however, in rushed the sister from the neonatal unit. She grabbed the bag and mask and in a less than a minute the baby was pink and squealing.

I found the paediatrician in the corridor trembling and weeping. She told me this was her first week, and she had previously only practised bagging the mannequin. She was so absorbed she had not heard me offer to help. I tried to comfort her by pointing out that everything was now fine.

Julie took home her longed-for daughter, who seemed to have suffered no ill effects. I filled in a critical incident form. Later I sought out training in neonatal resuscitation, and next time will be much quicker to intervene.

Aidan O’Donnell is a consultant anaesthetist from Livingston, West Lothian. At the time of this article he was a trainee working in a different trust.

Copyright © Aidan O’Donnell 2009.
This article first appeared in BMA News on 31st January 2009.
Unauthorised reproduction prohibited.

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See One, Do One

BMA News, 9th August 2008.

Aidan M. O’Donnell. 

Late one afternoon, I took my last patient to the recovery room. In the corner I saw Nina, a recovery nurse, in tears, being comforted by a couple of her colleagues. She told me she was very worried about her friend who had been admitted that day. The story was that the patient, a fit and healthy 25 year old woman, had a sudden headache, and collapsed unconscious. When she came round she was drowsy and had difficulty talking. She was admitted to the hospital, under the care of acute medicine, where she had not had a CT scan of her brain. Instead they had waited many hours before performing an MRI scan. Nobody had revealed the results of the scan.

When Nina had gone to the ward to see her friend, she was still drowsy and couldn’t talk normally. The staff had refused to say anything to Nina on grounds of patient confidentiality. The patient’s parents lived far away but they were on their way to the hospital at that moment.

Nina asked me if there was anything I could do. It sounded as if the patient had suffered a subarachnoid haemorrhage, and had a significant cerebral insult. She should have had a CT scan as an emergency, not an MRI scan several hours later. She might even need neurosurgery. I wondered what was going on and whether she was being mismanaged. I tried to find her scan result in the computer but it wasn’t there.

I asked my consultant what he thought and his advice was “stay out of it”. I ignored his advice and went to the ward, and read the casenotes, even although she was not my patient.

What I read was a very different story. She wasn’t a healthy patient. In fact she had had several recent admissions with transient neurological symptoms, and the presumptive diagnosis was of demyelinating disease. She hadn’t collapsed suddenly that day but instead had deteriorated over the preceding few days in association with a febrile illness, presumed to be a UTI. Since admission she had been seen by two consultants, one of whom was a neurologist. I could find nothing in her notes to indicate anything other than that she was being managed extremely well as an acute exacerbation of multiple sclerosis.

I closed the notes very quietly and sneaked away. By the time I saw Nina again, she already knew.

I had, in all willingness to help, broken rules of patient confidentiality, only to discover that my conclusions were dead wrong. This was a stiff lesson in not going off half-cocked and poking my nose where it doesn’t belong, and trusting my colleagues to be doing the right thing for their patient.

Aidan O’Donnell is a consultant anaesthetist from Livingston. At the time of this case he was a trainee in another trust.

Copyright © Aidan O’Donnell 2008.
This article first appeared in BMA News on 9th August 2008.
Unauthorised reproduction prohibited.

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Vital Signs

BMA News, 2nd August 2008

Aidan M. O’Donnell. 

How would you feel if you lost a finger?

I still have all mine, but I am certain I would feel angry and bereft. Having burned a finger quite badly once, I was astonished at how many simple daily activities seemed to require that finger. From the way I did my buttons, to the way I put my front door key in, I became aware that my fingers get on with a multitude of jobs without fuss.

Jim was a 54 year old man who had degloved his finger in an accident at home. The plastic surgeons wanted to repair the finger, but this was going to take several hours. Jim was adamant that he just wanted to go home. He had a plane to catch.

It turned out that he had degloved the finger when attempting to take suitcases from the attic in preparation to go on holiday. This was a much needed holiday, he told me. He didn’t care about the finger. He would rather it were amputated than face a delay to his plans. He wasn’t particularly angry, or frightened. I believed that he meant it. On the consent form, he scored out what the surgeon had written and wrote “Amputation” on it in capital letters.

Rachel was only 32, and her finger was already gone. She had had a malignant tumour of her right index finger, which had previously been removed. The tumour had recurred in the stump of the finger, and she was listed for a mid-forearm amputation. I noticed that all her fingernails were professionally manicured and painted, and asked her about this.

She told me that she had had a farewell party for her hand. Her sister and friends had come round, and they had paid a professional nail artist to do all their nails. Rachel wanted to celebrate all the fun and good use she had had from her hand. Rachel was not angry or frightened either, but displayed fortitude and composure which astonished me. The nurses wanted to remove the nail polish but I insisted that they leave it.

Would I rather cancel my holiday than lose a finger? Without a doubt. But would I be able to bid a fond farewell to my hand, to thank it for all its hard work, and reassure it I would be OK without it? Not in a million years.

In theatre, the surgeon showed me that Jim’s finger could not have been saved anyway. His wife changed the tickets, and they went the next day.

Aidan O’Donnell is a consultant anaesthetist from Livingston, West Lothian.

Copyright © Aidan O’Donnell 2008.
This article first appeared in BMA News on 2nd August 2008.
Unauthorised reproduction prohibited.

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Vital Signs

BMA News, 1st December 2007

Aidan M. O’Donnell.

Agnes was 65. She was listed for a carpal tunnel decompression on a list of minor orthopaedic cases for which I was the anaesthetist. I was in early and went to see her first thing.

The ward nurse told me Agnes had suffered an asthma attack during the night.

I flicked through the notes. Agnes was from an impoverished part of town. She had lived at three different addresses in the previous five years. She had attended out-patients in a variety of specialties with minor complaints (including asthma), but otherwise there was little. At two o’clock that morning she had become very breathless and wheezy. The house doctor had sensibly started oxygen and nebulisers, and given antibiotics and steroids. An arterial blood gas had been taken and the results were normal.

Agnes was sitting up in bed, with the oxygen mask perched on her forehead. She was a little unkempt, but pink and undistressed. She could readily speak in sentences. I introduced myself, and asked her how her breathing was.

“A lot better now doctor, thanks,” she replied. “I don’t mind if you have to cancel the operation for a day or two.”

“Well, maybe we could do it under local,” I said. “Let’s go through the rest of the history.”

She was overweight, and a smoker, but her asthma seemed normally well controlled. She had never had a hospital admission for an asthma attack, although she told me it flared up in the winter.

I took out my stethoscope and listened to her chest. It sounded dreadful, with loud, rasping groans and shudders heard throughout both lung fields, on inspiration and expiration. On an impulse, I pulled one of the earpieces out of my ear as I listened. Agnes was deliberately closing her glottis, making her breath sounds very abnormal. I put my hand on her shoulder.

“Just breathe quietly through your mouth, Agnes,” I said. “No, just quietly, in and out, like this.”

The breath sounds were clear, without a hint of a wheeze, right down to the bases. Agnes looked disappointed when I said her breathing was normal and we could go ahead with the operation.

I told the orthopaedic registrar that there was no sign of asthma, and that I thought that Agnes was deliberately exaggerating her symptoms, perhaps to prolong her stay in the hospital. The registrar went to look at the wrist, and came back. “She doesn’t have carpal tunnel syndrome. I’ve cancelled her from the list. She can go home today.”

Agnes needed to feel safe and cared for, perhaps only for a couple of days, and feigning symptoms must have seemed like the best method. Sending her home when she needed help made me sad, but performing a needless operation was not the way to help her. What we did was right from our point of view, even if wrong from hers. I still don’t know if there was a way for us both to be right.

Aidan O’Donnell is a consultant anaesthetist from Livingston.

Copyright © Aidan O’Donnell 2007.
This article first appeared in BMA News on 1st December 2007.
Unauthorised reproduction prohibited.

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See One, Do One

BMA News, 10th November 2007

Aidan M. O’Donnell.

Eight years ago I was the anaesthetic SHO on call one sunny Saturday in a DGH near you. A stand-by call came from A+E. A 7-year old boy had fallen out of a tree. CPR was in progress.

Hurriedly I prepared everything I thought I might need: endotracheal tubes, laryngoscopes, a selection of emergency drugs in paediatric dilutions. Meanwhile the rest of the resus team made their preparations in silence.

We exchanged worried glances while we waited for the ambulance to arrive. It seemed to take an eternity. The child had had a lengthy down time at the scene, and a lengthy trip in the ambulance: both extremely poor prognostic factors.

This was my first paediatric resuscitation as the lead anaesthetist, and my greatest worry was that I wouldn’t be able to secure the airway. Although he arrived in a hard collar and strapped to a spinal injury board, I intubated him easily. He was in asystolic cardiac arrest. We continued with the CPR.

After a short interval, his parents arrived. The senior A+E doctor allowed them into the resuscitation room to observe. It was clear that the boy was dead, and it was also clear that the parents could recognise this for themselves. They were hysterical with grief and shock.

As we continued with the resuscitation, poignant fragments of the boy’s life emerged from the parents. His name was Christopher, but they called him “Crisps”. He was the boldest of his friends; indeed he had climbed higher in the tree than the other boys had dared to go. He was crazy for the football team whose strip he was wearing. He stopped being a casualty and became a brave and beautiful little boy.

At one point, the Dad suddenly fished in his pocket for a few coins: perhaps a pound’s worth, and stepping forward, pressed the money into the boy’s hand.

“Here’s that money, son,” he said, quietly. Then, to me, he said “Make sure he keeps his money, will you, doctor?”

I nodded mutely, unable to reply. I never learned the significance of this gesture. Was it pocket money? Money he owed the boy? Perhaps some sort of bribe to make him come back?

We stopped the resuscitation when the lateral cervical spine X-ray showed a clear inch of daylight between his foramen magnum and his atlas vertebra. He had died the moment he hit the ground.

Despite all our training and experience, we are sometimes forced to be helpless witnesses to tragedies which unfold before us.

Aidan O’Donnell is a consultant anaesthetist from Livingston.

Copyright © Aidan O’Donnell 2007.
This article first appeared in BMA News on 10th November 2007.
Unauthorised reproduction prohibited.

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Vital Signs

BMA News, 20th October 2007.

Aidan M. O’Donnell.

Nicki was 23 and required a minor gynaecological procedure as a day case. As the anaesthetic registrar, I went to assess her beforehand.

Her history and examination presented no concerns. As I described the anaesthetic, however, she blanched when I mentioned the cannula in her hand.

“I hate needles,” she told me. “Can’t I just get the gas?”

This was somewhat unexpected, as it had not escaped my attention that she had a lot of piercings. One eyebrow had two rings. Both ears had lobe, helix and tragus piercings. She had a tongue stud and a nostril stud. She also had tattoos on her arms.

I challenged her about the piercings. “Surely,” I said, “you managed to tolerate all those piercings?”

“Oh, no. I couldn’t do it. I had to get knocked out for it,” she replied, unguardedly.

I was bewildered. “Knocked out? As in, put to sleep?”

“That’s right. They gave me this stuff and I was knocked out.”

“Who gave you the stuff? The hospital?”

She became suddenly guarded. “Erm… yeah.”

“What sort of stuff?”

“It was, erm, tablets. It wasn’t the hospital, it was my own doctor.”

“And where did you get the piercings done?”

“It was, erm, Joe’s Skin Shop.” She named the town.

I left the room in a turmoil. At least one interpretation of these statements is that there was a tattoo parlour where you could go, and if you were a bit nervous, they could give you some stuff which made you go to sleep while they did it. This would be, not simply illegal on a variety of counts, but also potentially deadly to some unfortunate victim.

Unfortunately, my clumsy questioning had caused Nicki to clam up without revealing any of the vital details. Joe (or whoever) had probably cautioned her to keep very quiet about it.

To cover the bases, I telephoned her GP, who said that under no circumstances would he prescribe an anxiolytic for a piercing or tattoo, and Nicki’s file indicated no such prescription.

Next, I telephoned the police and reported my concerns to a very helpful officer. I stressed there was a potential risk to the public. They subsequently looked into it, but found no evidence of crime.

Finally, I gave Nicki an inhalational induction, and she had an uneventful anaesthetic.

Faced with this situation, I did everything I could to ensure safety of my patient and the public, but I still sometimes scan the news for reports of an unexpected death in a tattoo parlour. So far, there have been none.

Aidan O’Donnell is a consultant anaesthetist from Livingston, West Lothian.

Copyright © Aidan O’Donnell 2007.
This article first appeared in BMA News on 20th October 2007.
Unauthorised reproduction prohibited.

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See One, Do One

BMA News, 1st September 2007.

Aidan M. O’Donnell.

Leanne was 18. She was tall, blonde and extremely beautiful. She was also unconscious. She lay on the trolley in the resuscitation room of the A+E department at about 3am. I was the admitting medical SHO.

There was very little history. She had been drinking in a nightclub with two of her friends. She had apparently had a row with her boyfriend earlier that evening. The friends found her unconscious in the alley beside the nightclub, with some empty packets of tablets beside her. Predictably, neither the friends nor the ambulance crew had retrieved the packets.

On examination, she had the sinus tachycardia and divergent gaze of the tricyclic antidepressant overdose, but there was nothing else to find. There was no sign of injury. A vigorous sternal rub produced no response. I sent off her bloods for paracetamol and salicylate levels.

I paged the ICU registrar. He listened, then came round. Impatiently, he crammed an oropharyngeal airway into her mouth. She gagged. He removed it. “She’s protecting her airway,” he announced. “She doesn’t need to come to ICU.” Then he left.

I phoned my consultant. He decided we should admit her to our medical HDU for close observation.

As I was writing in the notes, without warning, Leanne sat bolt upright, eyes wide. “Burns!” she shouted. “Where’s Burns?”

“I don’t know,” I answered. “You’re in the hospital. You’re very ill.”

“I need to get to Burns’s house!” she protested. “Burns will kill me if I don’t!”

She resisted all my efforts to keep her in the hospital. I still did not have her blood results. I paged the psychiatry registrar and told him the details.

“Clearly a crisis response,” he told me on the phone. “No suicidal intent. She can go.”

“No she can’t,” I replied. “She might have taken something lethal.”

“Nothing I can do,” he said. “She is not sectionable. Goodbye.”

I phoned my consultant again. “Get it all down on paper,” he advised. “Then let her sign herself out. If the blood levels come back high, we can ask the police to bring her back in.”

I burned with frustration. It seemed as if no-one wanted to help me deal with a patient I was extremely worried about. In my opinion, Leanne was not safe to be allowed to discharge herself. I felt as if I was wasting my time trying to help her. However, I documented everything very carefully, and let her go. I hoped Burns was pleased to see her. Later, her levels came back normal.

There was, however, a follow up. One of the A+E nurses bleeped me to say that, about 10 o’clock that morning, Leanne had called the A+E department, very worried. She had woken up and discovered ECG electrodes sticking to her chest, and had no memory of how they had come to be there.

Leanne’s lucky escape demonstrates how frustrating it can be to deal with patients whom the law insists are competent, even when that competence can be objectively challenged.

Aidan O’Donnell is a consultant anaesthetist from Livingston.

Copyright © Aidan O’Donnell 2007.
This article first appeared in BMA News on 1st September 2007.
Unauthorised reproduction prohibited.

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Vital Signs

BMA News, 25th August 2007.

Aidan M. O’Donnell.

When one meets a celebrity, one is sometimes struck by the fact that the reality one sees bears little resemblance to the popular image.

So it was with Barry. I had heard tales of Barry’s legendary violent exploits for some years, although hitherto I had never met him. He is a little younger than I, but we grew up in the same district. I had taken a post as an SHO in A+E in that area’s local hospital. His career took a somewhat different turn. It was somehow inevitable that we would meet.

He was much smaller than I had imagined: a pint-sized scrapper with the close-cropped hair, multiple tattoos and scars of the dangerously unstable. His size was contrasted by the two enormous police officers to which he was handcuffed, one on either side. His eyes were sizzling with hostility and rage. And he also had a sore knee.

He gave almost no history, but permitted me to examine his knee. It was swollen and bruised with the convincing patellar tap of an acute haemarthrosis. The knee would not come out straight, and my diagnosis was of a locked knee secondary to a torn meniscus.

I asked one of the police officers if I could have a word. He handcuffed Barry to the trolley before leaving the cubicle. I asked if there was any more history he could provide. He told me Barry had injured his knee climbing a wall to evade capture. People in police custody are frequently brought to A+E, but I had never seen the police treat someone as being quite so dangerous before.

I mentioned this to the officer, who conceded that Barry had been apprehended leaving the scene of a murder for which he was the only suspect.

I arranged an X-ray of the knee, to buy myself some thinking time. It was normal.

I knew that the knee required arthroscopic evaluation and probably debridement of the torn meniscus. If Barry received this treatment, his knee would be fine after a week or two.

If I sent him away with a support bandage and some ibuprofen, within a few weeks his knee would be permanently ruined. This would not stop him from murdering anyone else, I reasoned, but it might stop him from running away afterwards.

It was the early hours of the morning, and I was the only doctor in the department. I considered at some length whether my duty to my patient was greater than my duty to society.

Ultimately, however, I filled in the referral form for the arthroscopy. I still wonder about Barry and his knee from time to time. And if we should happen to meet again, I hope that the outcome is equally satisfactory to both parties.

Aidan O’Donnell is a consultant anaesthetist from Livingston.

Copyright © Aidan O’Donnell 2007.
This article first appeared in BMA News on 25th August 2007.
Unauthorised reproduction prohibited.

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