Emergency Doc as Italian Patient

aka Postcards from the Edge 009

This ‘postcard from the edge’ is from the now somewhat infamous (!) Dr Sandy Inglis, a peripatetic FACEM based in France, but allegedly in Australia’s Top End at present.

After my Irish debacle (see Postcards from the Edge 005 — A Taste of Guinness and Irish A&E) where my commentary on tough working conditions in Ireland, earned that hospital a GMC inspection and me a mountain of embarrasment, I feel somewhat apprehensive about putting pen to paper again. But a recent visit to an ED in Italy was great value and a memorable experience, being there as a patient and not as a doctor.

I had hurt my wrist and was worried about my scaphoid. I had spent the last eight days taking part in the Trans Alps bike ride which at 600km long and with 20,000m of climbing was probably the most brutal excursion I have ever been on, but the pain was suitably compensated for by postcard scenery and a dramatic trans Alps route. Day six had been a punishing 106km with nearly 3500m of vertical altitude gain and as much descent which had left my left wrist raw with flexor tendonitis thanks to constant braking. A helpful Englishman at breakfast suggested I bring the break caliper in, which I duly did, with dramatic improvement and my flexors felt
magically better. This was, however, to be my undoing, for after about 4 hours of riding the following day, a fast descent and deep ditch, saw me hit my super sensitive brake too hard and catapult me over the bars. Dented helmet and pride, grazes and painful palms left me stunned but relieved and I climbed back onto my bike. I couldn’t grip though and so an hour later had to thumb a lift on to the overnight stop.

The next day I convinced myself that my scaphoid was probably ok, loaded up with codeine and gingerly set off again, riding essentially with one hand. It was indeed a pleasure and a relief to arrive at the finish in Riva del Garda without further ado. Then I went looking for an ED and the fun started.

The helpful German trauma surgeon (and race doctor) at the finish said that the hospital was a few kilometers away and easy to find. I set off alone in my car sparing my family the pain of a long ED visit and reassured them that I would be back soon in time for a famous Italian pizza dinner. Now, unlike the vigorous red on white signposting of Australasian ED’s, this is not the case in Italy. In fact just finding a sign saying “Ospedale” was a
challenge. After weaving around back roads for some time and some pidgin-Italian I found the hospital and wandered into a very familiar looking ED. There was only a German cyclist with a dislocated finger and one other in the small waiting room, so I felt instantly optimistic. The familiar triage codes (very similar to ours) were advertised on the wall and a digital screen told us that there were no triage ones or twos in the ED, three triage threes and a few fours. I felt a bit like Mr Bean and looked about the waiting room knowingly. The dislocated German and his family advised me to ring the bell on the wall and I would be attended to. This I did but was disappointed to wait a good twenty minutes before I was asked to enter the triage booth.

My Italian triage seemed to focus more on my ability to settle the bill than on my pathology and my comment that I was an ED doctor seemed not to have got through when the nurse then asked me where this doctor was that I had seen! Anyway, I was despatched back to the waiting room where I became very familiar with the drinks dispenser, hospital fire drill (in Italian!), immunization schedules and various other health advisories. Time dragged, few other patients appeared and yet I waited. I was determined to be a good ED waiter and was sure that there must be a chaos of activity behind the double doors, but the digital triage screen failed to confirm this. During this time my German friend had his finger pulled and my discussion with him about finger blocks was not heeded by the Italian ED doc who told him that the injection was more painful (maybe true?) and tugged away with accompanying howls from one distressed German cyclist.

Eventually, some 90minutes later (can’t remember if I was triage 3 or 4) after some incoherent announcement on the intercom, and slightly desperate, I lunged through the double doors and was asked to wait in a chair near one of the consulting rooms.

There certainly was a bit of activity and it was only now that it became apparent that the ED was being covered by only ONE ED doc who had his hands full with what looked like a collared road trauma whose A,B,C,D’s seemed ok, an hysterical lass wailing (in Italian!) and sundry others drifting around in wheel chairs. The ED was clean and seemed well laid out with all the usual stuff we would expect. This was a small regional ED and looked to have only 3 or 4 consulting rooms including the trauma/resusc. bay.

Eventually I was seen in an office/consulting room by an elderly and portly Italian doc and a 5 second exam and sign language had me despatched for an x-ray. This happened fairly promptly and about 20minutes later was called in by the nurse who exclaimed “No fracture” repeatedly and this was echoed by the ED doctor later. He then gave me a CD copy of my x-rays, my bill and sent me on my way. Immobilization of the wrist, analgesia, or any further advice didn’t seem to come into the equation and I was relieved to escape after nearly 3 hours.

I joined my family for fantastic pizza, which at 7euros a shot and delicious gelato (ice-cream), these became our staple in italy.

Back in France my wrist discomfort continued but repeat x-rays were again negative. I then developed impressive ulnar nerve distribution pain and parasthesiae and MRI and CT demonstrated a hook of hamate fracture. Apparently these fractures seldom unite and management frequently involves excision of the fragment. A splint for 8 weeks and then repeat CT will seal my fate.

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Transient Inferior Injury Seen Only by Comparison Between First and Second ECGs. Also an example of a Right Ventricular "Pseudoanteroseptal" MI

A middle-aged woman with a history of hypertension presented with typical chest pain.  Her BP was 160/80.  Here was her presenting ECG, with chest pain:

There is no definite evidence of ischemia here.  There is, however, a very suggestive finding: T-wave inversion, with some ST depression, in lead aVL and some ST depression in lead I.  This suggests inferior MI.  There was no old ECG in her records for comparison.

The pain improved with Nitroglycerine.  Creatinine was 4.3.  She underwent another ECG at 6 hours (when she was pain free):
The T-waves in leads II, III, and aVF are now significantly smaller, the reciprocal ST depression is less, and the T-wave in aVL is upright.  The T-wave in I has also changed.

The troponin peaked at 16 and there was a "probable" inferior wall motion abnormality.

Because the patient had advanced renal insufficiency and because there was "no evidence for a current of injury on her presenting EKG's", a non-invasive approach was undertaken.  While undergoing a stress test as a part of the non-invasive approach, she developed chest pain and hypotension and had this ECG:

There is sinus bradycardia with massive inferior ST elevation, as well as ST elevation in V1-V3, diagnostic of inferior and right ventricular (RV) STEMI.  When there is ST elevation due to RVMI in V1-V3 in a left sided ECG, it is also called a "Pseudoanteroseptal MI".
She went immediately to angiogram and had occlusion of the RCA at the ostium.

Looking back, one can see ST elevation in V1-V3 on the initial ECG that is nonspecific, but, in retrospect, is probably due to RV Injury.