Innocence revisited – 32

I underwent initiation – I mean did my internship – on the Central Coast. Somewhere between learning to take blood and understanding ECGs, I was shown an x-ray of a 70-year-old woman with numerous rib fractures. We were on our ward round and had just seen the frail patient who had been admitted primarily for analgesia and supportive care.

‘Well, that’s what happens when you get trampled by an elephant’, said my boss, a consultant physician. 

‘Geez’, I answered in a surprised squeal. ‘Wow, she’s lucky to be alive’, I said (I was quite the prognostician back then). The other intern on the team, Phil, and the consultant seemed to share a moment: ‘She obviously doesn’t have older brothers’, said Phil. 

I had never thought of myself as naive before then and have not thought of myself as anything else since. Somewhere between school and university and as a result of having no teasing older brothers, my education was lacking.

Baby? What baby? 

Later that year, during a term as night RMO, I was called to a disturbance ton the geriatric ward. Three elderly women were clambering around in the dark rather desperately looking for a baby under a fourth woman’s bed. Feeling the gravity of the situation, the first thing I did was to join the search – did I mention my hypnogogic and sleep-deprived state? 

Suffice to say there was no baby, just three highly impressionable women, partly deprived of their senses in the wee hours of the morning, and one woman who talked in her sleep, a lot...about babies. So I did as anyone would and pretended to find the baby and handed it over to an understanding nurse – I was gullible, but not unresourceful. Everyone was satisfied with that and headed back to bed – including me.

My first episode of backache 

In the emergency department, the number of patients presenting with back pain that you see is directly proportional to how junior you are.

My first case was a 45-year-old man with an acute exacerbation of chronic back pain, lying on a trolley unable to get up because of his pain. Examination showed no evidence of neurological involvement and his standard observations were fine. The patient told me that when this happens 100 mg of pethidine intramuscularly usually ‘does the trick’. 

A patient who presents complete with instructions appeared to be the answer to this new intern’s prayers. Moreover, a quick  scan of his two folders’ worth of notes confirmed that he’d indeed been given pethidine before, on numerous occasions, in fact for the same complaint. So I gave him the pethidine, he fell asleep comfortably and I documented my success in his notes.

A few hours later the man awoke demanding more pethidine and admission. When I mentioned his name to the registrar, I was asked why I gave the patient the pethidine. It was difficult to explain that it was something do with not having any older brothers. 

A fine line to walk

Nowadays, I know that a patient whose urine is positive for blood may be seeking narcotics, that every woman with abdominal pain is pregnant until proven otherwise and that the bigger the footballer the more likely he is to pass out when he sees the 25 gauge local anaesthetic needle. I know that warning signals for problem patients include more folders of notes than decades of age and that multiple previous surgery does not necessarily indicate past physical illness.

I find there is a fine line between being gullible and being cynical. As I lose my naivety, I edge my way nearer to becoming cynical. Sometimes it’s tough not to cross the line. But then I remember that although back pain is not an uncommon presentation among those seeking drugs, not all or even most back pain is associated with narcotic abuse. And that sometimes what you see is what you get...a mother’s concern about her child means look closer, there is something wrong with this child, and little old women who don’t move during your third attempt at a difficult cannulation deserve a bravery medal. MT