stable and unstbale..

It was not a good day to start...I saw 2 ambluance parked at the ED entrance while I was walking into the hospital..Through the ED glass window, I saw our nephrologist performing physical examination on one of the trauma patient...well, not a good sign, that means some major trauma had occured.
I was informed earlier in the morning that one of my patient had noted with respiratory failure and he was intubated. The ICU was +2 beds at the time. I proceeded to the ICU and started my routine. The patient had had a noscomial pneumonia and septic shock. He was given Tienem and I think he would not make it throught the night. I informed the family and took a round in the ICU. The drowning child was stationary however not much improvement on his neurogical condition. No ARDS and pulmonary edema was noted though. The rest of the patient was unstable and most of them were hooked onto ventilator and no way I could sent them out.
Later, the ED informed us that 2 polytrauma patients were currrently in the OT and would be transferred to ICU later.
I look they imaging studies of both patient and knew that I would not have a good call that night. The female patient had a splenic rupture with left hemopneumothorax. The male patient had a blunt abdomen contusion and scheduled for a exploration laparotomy eventhough the CT was negative of ascites. I asked around and found out that it was a motor vehicle accident. The car with 3 passenger had lost control and rammed the hillside. The backseat passenger had suffered from lower limbs fracture and also being operated in the OT. L ( my classmate cum colleague) told me that the female was in severely shock state on arrival. Appearantly the EMT had mis-triage at the scene. The male patient(also driver) was stucked in the car and moaning in pain but the female who was in shock condition was too weak to moan. So the EMTs sent the one who moan louder first. The female was sent over 20 minutes later with BP of 60/30mmHg on arrival. She was given 16 u(1 unit ~ 250cc ) of pRBC in the ED[plus some plasma and hispander as well].
Later in the evening, the female patient was sent to the ICU and the surgeon had told us that splenectomy was done but tear over the omentum and splenic artery was noted. Retroperitoneum hematoma was noted. The surgeon said he had done his best - he expect oozing and he felt that the patient might still bleed to death.....The last platelet count noted was 68000 before she was sent to ICU. I ordered some platelet for transfusion. The Vital sign was stable when she was passed over. 1 hour later, the BP started to crushed again and heart rate risen to 140/min. The drain(peritoneum) had poured out some 200cc of fresh blood. I began to worried about DIC at the time. I ordered some more plasma and pRBCs....She was stable few hours later after the platelet was transfused.
The male was better, no internal bleeding and simple repair of tear over the small bowel was done. The patient was extubated and pending transferred to ward when the family arrive.
Only 1 family came. The 3 casualties were family. The younger child came and he told me that he was unable to look after 2 patients in 2 different room(the hospital was almost fully occupied and couldn't placed both of them in the same room). So the father was placed in the ICU.
I thought everything would be fine as I did my final round by midnight.
However there was this wife who was brought into the ED by her husband claiming that the wife had attempted suicide. The husband claimed that she had drunk some insecticide. The wife denied initially but later admitted that she just had a small sip and spitted it out as she was trying to frighten her husband after a quarrel. Well, I retained her and asked the husband to get me the bottle... Hours later, the husband showed up with a bottle - Organophospate ... The pupil was still ok but I believed absorption througth the oral mucosa could be fatal as well and insisted she stayed back and observed till morning. I was right, her symptom although mild appeared later. I managed accordingly and just while I was going to sleep. Another patient was sent in by the police. A male was found in a car parked at the roadside. He was confused and 2 bottle was found besides him - rice wine and a bottle label insecticide : pyrethroid. He was drowsy due to the alcohol and vomited like don't know what. The SpO2 was not stable wandering from 90-95%....No more bed in the ICU and I "persuaded" the family for a transferred. The family requested this KCXXHospital. I called them up and the ED physician replied me in a unpolite tone," no more bed and please don't sent them over...". It was the last month of this quarter, most the hospital had used up all their allocated budget - more case means more lost....I finally got another medical center which willing to take over the case.

pyethroid	Organophosphate

Just while I was laying down for a nap. The ICU informed me that the SpO2 of the father with blunt abdomen trauma was crushing and the ABG was compatible with the readings. I remembered the chest xray and CT was ok for the patient.....I rushed to the ICU and saw the patient - he was alert but sleepy. Coarse crakle was noted and I decided to intubate him; the SpO2 was 70% only~!!!!.. My heart sunk when I saw the suction substasnce after the ETT was placed - it was coffee ground as what came out from the NGT. He had an aspiration. The CXR after the intubation had confirmed my diagnosis. Now the stable patient become unstable....
I was comatose for the next 1+ hours disturbed by various call from the ward - some of them really drove me crazy : 
       " the XXX bed patient with gastric outlet obstruction had pulled his (left internal jugular) just now accidentally.."
       " well, anymore fluid to run in ?"
       "nope, we shall start his infusion tomorrow morning..."
       "ok, I would re-insert it in the morning..."
   it was 5:00am when this conversation occured. I was too tired to throw the 6 letter word start with KNN...

The ICU called me again by 6am. Another patient who was admitted for recurrent CVA had noted with crushed of BP and dropped of SpO2. I went up and saw a BP of 66/20mmHg and SpO2 of 70% on Nasal canula. I intubated him stat and inserted a CVP....another aspiration pneumonia....

By this time, 2 of the stable patient had become unstable ( recurrent CVA and BAT father), the most unstable one (mesentery tear and splenic rupture) had been stabilized...

Well, my eyes was almost shut during the Thursday morning meeting session....