It was my first day on the intensive care unit which made the lessons all the more memorable.
I had been asked to assess a patient who had recently been discharged back to the ward. I delegated the task to a senior house officer (SHO) explaining that he should assess the patient’s condition and need for intensive care.
Half an hour later he telephoned. After describing the patient’s condition he concluded that the patient would benefit from more care than the ward could provide. As our hospital has no high dependency unit for such patients an intensive care admission was required. I joined the SHO on the ward to assess the patient and to assess his clinical judgment.
From the end of the bed I saw a man who seemed to be in his late 60s although he was actually 58. He was propped up, with his head drooping, eyes closed, a rapid respiratory rate, and sweating profusely. Introducing myself he responded appropriately to my questions, unable to speak because of his tracheostomy—a legacy of his recent intensive care admission. Relieved he was still cerebrating I glanced at his chart and urinary catheter bag and made the assumption that his kidneys, as well as his brain, were being adequately perfused despite the presence of rapid atrial fibrillation. His temperature was 38.5oC. On examination I found bilateral basal bronchial breath sounds with crepitations in the right mid zone. His abdomen, scarred from recent surgery, was soft and there were bowel sounds present. Throughout my examination I was struck by his profuse sweating.
The SHO showed me a recent chest x ray, which confirmed bilateral basal atelectasis and consolidation in the right middle lobe. He had made a good assessment, correctly concluding that the patient would benefit from more care than the ward could provide. My working diagnosis was of another episode of sepsis, probably originating from the chest, in an already debilitated patient. I had a gnawing doubt, however; something didn’t quite fit with this picture. Yes he was in rapid atrial fibrillation, he was tachypnoeic, sweaty, pyrexial with signs of a chest infection, and a raised white count, but why was his blood pressure 210/95mm? This must be due to catecholamines I reasoned, but why? Pain? He denied any. Thoughts of hyperthyroidism and phaeochromocytoma entered my head but these had to be long shots. So I was left with that familiar nagging feeling of “I’m missing something.”
As always happens it was on the consultant ward round that the answer revealed itself and the penny, with a deafening thud, dropped. The nurse casually mentioned that the patient’s urine output had been poor in the first hour of admission but a bladder washout had produced a dramatic effect.
I’m not sure whether he realised quite how dramatic his intervention had been as I looked up to see a relaxed 58 year old man with a heart rate of 110/min, a blood pressure of 140/85mm Hg and a respiratory rate of 20 breaths a minute. He was no longer sweaty and more importantly did not look like a patient who required intensive care.
In that instant I heard numerous voices from the past: “Always thoroughly examine the patient” and “common things are common.”
The intensive care retrospectoscope is no more powerful or any less frustrating to use than its counterparts in the operating theatre or on the ward. I was just going to have to relearn those valuable lessons again and own up to my novel management of a blocked urinary catheter.
Footnotes
We welcome articles up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.