Just another Saturday at the A&E

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*I secretly took this picture. If the HOD finds out, I might be decapitated*

‘Twas just like any other weekend in the Resus(citation) Zone. It felt like a quiet morning, everybody was just getting ready to start the day… and then there it was. The three bell rings. It was almost as if they signalled the clock turning eight.

Patient with SOB (Shortness Of Breath). Not long after that, patient with malaena, then another with seizure, followed by a few more also with seizures, and the list continues.

The interesting bit about working in the A&E of HKL is that you get the information of riots or disasters early, like the landslide in Bukit Antarabangsa. This time my specialist received a phone call from the police. There was a riot in Brickfields and they needed us to be on medical standby, in case the injured needed urgent treatment. It was only later on did we find out that it was one of the Hindraf protests. Thankfully none of them were serious enough to come to my zone, although one of them eventually did. He had to because he had a serious reaction to the meds he took for his injury.

It was pretty much non-stop for the whole shift – with referrals also coming in from Malacca, Seremban and even Ipoh.

Almost towards the end of the shift, this really interesting case came in. (I apologize for the jargon. I’ll try to keep it as simple as possible)

A 41 year old Bangladesh man, with diabetes and defaulted his medications for 4 days, came in with acute and severe SOB. He had right sided pleuritic chest pain. OK. That’s pretty much the history you can get before you start intervening and treating his acute state. Examination: Thin man. Sweating. Respiratory rate about 30. Chest examination: Reduced breath sounds on the right side. Coarse creps on the left. Hyper-resonance on the right.

Once we gave him the high flow mask. Proceeded with further history when he was a little more comfortable. He’s been coughing for 2 months. He has lost a considerable amount of weight. He isn’t sure whether he has contact with TB patients.

Take an X-Ray. What do you see? This.

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Now we have a dilemma. It’s TB complicated by pneumothorax. Not just that, notice the streak in his upper right lung. That could be some loculations right there.

Now how do we solve this? A pneumothorax naturally calls for a chest tube drainage, but given this special case, inserting the tube will not help. Why? Notice the positions of the loculations. That’s pretty much where we’d puncture the tube it and if the loculations has cause some compartmentalization in his pleura, you’re pretty much only draining the air from the upper zones. Further more, the tube may facilitate spreading the infections to other areas which we do not want.

So, to tube him or not? He definitely needs the air drained. Look at the deviated trachea. The pneumothorax has pushed the trachea and heart towards the left side. But how? The tube won’t help.

The story ends with my specialist planning to use a needle to aspirate the air from the 5th or the 6th intercostal space. I wasn’t there to witness it – I needed to get home to rest before starting the night shift. I was already staying back an hour to see the updates of this case. Don’t quite know what they did exactly then. I should’ve asked. 🙂

Yeah, working in A&E may be quite exciting in that sense – fresh cases, treating them in their most acute and where time matters most. Today, A&E posting didn’t feel so nice like it did. Some people in the department are such a pain. There isn’t that nicey feeling of working well when you’ve got ‘colleagues’ like that around who manipulates and be painful. I wish there was some meds to make them go away.

Ugh.

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