Intervene before your patient is moribund

If I could sum up the general theme of how I run my on call it would be this “I try to avoid death and major complications by prompt and proactive investigation and management of my patients”. Another way of saying this, which sprung more readily to my mouth on Saturday night was “I am not in the fucking business of letting Grannies bleed to death before I will get a CT angiogram” (yes, those radiologists again). And so, I found myself in the CT scanner with somebody’s Granny who had bled 1500ml of blood out of her bottom over the last 3 hours and a CT scan that revealed that the bleeding had now stopped.

The radiologist was angry! Angry that she was no longer bleeding to death and that her platelets and clotting cascade had finally mobilised themselves to form a clot and she was, for now, out of the woods.

These guys have a weird way of looking at things, I had a relieved family and a stable patient and felt that this was a good outcome. He felt he had done “an unnecessary CT” and I should have let her bleed much more before getting her scanned.

When I requested the CT (it took over an hour for them to get organised) she had bled from a starting haemoglobin of 81g/dl as she had bled at home and gone from her usual 11 to 81. I had given her 6 units of blood over 2 days and we now had an Hb of 76g/dl. An octogenarian cannot tolerate this sort of blood loss for very long, they fall off their perch and die.

He and I agreed to disagree, I’m not sure if he has a Granny, but if his Granny was on her way down a slippery slope he’d no doubt want her rescued.

I understand that many people become radiologists because they don’t want to be up all night (like me), don’t want direct patient contact, don’t want ownership of patients; they want a 9 to 5 controllable life. The deal with that life of radiology is that they are a service speciality, it’s my patient, not theirs, I am responsible for the proper care and ultimately for the life of this person.

In order to do that job properly, I will occasionally request a CT that is negative because that’s the nature of trying to do a good job and not miss anything.

Mrs Granny is stable and has not rebled, she is happy so are her family. I have emailed Dr Darkness a paper on managing bleeding in the elderly, which he won’t read, but it makes the point that modern management of bleeding involves avoiding near death inducing levels of hypovolaemia and anaemia.

If you’re going to become a radiologist there is an element of accepting that it is our patient, our call. We’ll take your advice and are happy to do so, we value your contribution hugely.

Not all of you are like this colleague of course, I have my favourites who are truly great and help me out immensely and I value their expertise and opinion. 

Nobody should ever say that a patient that stops bleeding and is no longer going to die (for now) was a waste of his time.

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11 thoughts on “Intervene before your patient is moribund

  1. Maybe you can convince Dr Darkness that his magic rays cauterized the bleeder? If he’s a good boy, you’ll even allow him to do ‘pew pew!’ sound effects the next time you scan a bleeder.

    • He is a patronising wee pest, very junior and spent ages advising me that we may cause a kidney injury with his contrast. I have probably been responsible for more AKI’s than he has had hot dinners.

  2. I guess it wouldn’t go down well if you tell him that unless he wants to specialize in general surgery, he should just shut up and be the geek who reports black and white photos in a dark room. Because that’s his JOB!

    • I know. I don’t understand why some of them are unaccepting of that fact. I don’t presume to tell them what buttons to press and how much contrast to give. They should leave me alone to do my job. Are they like this everywhere or just in the UK?

  3. Sterling example (5 minutes ago):

    LSS: It could be an intestinal atresia with midgut volvulus. Can I get an upper GI contrast study please?

    Dr Xray: But I’m at home already…

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