How much medicine is too much?

So I posted a question about how much medical detail is too much over in the community forum, and they suggested I post some here to see if I'm pitching it at the right level.

Basically the story is about two doctors - one of whom is a victim in a train accident, the other is a first responder to the accident - and the relationship that develops from their shared trauma. Given my two main characters are both doctors, I want to make sure that what I write from their perspectives are understandable. I'm posting a few of the more medical-ish parts to see what you guys think.

Thanks!

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I leave our office and walk out towards the nurses’ station. There’s only a skeleton crew on at night – three nurses for the thirty patients on our ward. Two of them are sitting in the corner, playing cards, and the other one is reading a magazine. Hannah, one of the nurses playing cards, lifts her head and looks at me. Hannah’s a recent nursing graduate, and sometimes it shows. She’s probably my age, but still insists on wearing her straight platinum blonde hair in pigtails. She’s wearing blue mascara tonight and pale pink lipstick. I’m impressed. I can never be bothered putting on makeup for nightshift.

“Doctor Spencer.”

She stumbles as she stands from her chair and walks towards me.

“It’s Cadence,” I say, like I always do. I’m still not used to being addressed to as doctor, even though I’ve been one for three years now.

Hannah smiles.

“I was wondering if you minded going and checking on Mr Geddies. He’s still complaining of abdominal pain, even though we’ve given him the pain relief and aperients Doctor Francis prescribed.”

I rub the back of my neck.

“Yeah, sure.”

It wasn’t like I was doing much else. At least it was something to do to keep me awake. I walk down the ward to Mr Geddies’ room. Mr Geddies has been in hospital for nearly three weeks now. He had presented with an exacerbation of his heart failure, and had come in for medical management. However, whilst he had responded well to treatment, he had developed cellulitis of his leg, which we were now treating with IV antibiotics. If it wasn’t for that, he would have gone home weeks ago.

The lights are off in the four bay room, when I enter. I walk over to where the obs charts are hanging on the wall, pulling each of them out of their cradle in turn, until I find Mr Geddies’ chart. I squint at the number on the front, before walking over to the light switches and turning on the light for bay sixteen. I hear someone moan in response to this sudden entreaty of light. I walk through the curtain to find Mr Geddies lying in his bed, and I’m shocked when I see him. Normally when I saw him on rounds, he was a bright and cheery old man, but tonight he looks pale and sweaty. His chest heaves with every breath, and he’s holding a hand protectively against the left side of his abdomen.

“Mr Geddies?” I ask, as I walk towards his bed. “It’s Doctor Spencer. How are you feeling?”

Mr Geddies lifts his pale blue eyes to meet mine, and he tries to pull himself up in his bed. His face contorts and he groans, giving up.

“Doctor Spencer,” he gasps. “You are here late tonight, my dear.”

“Mr Geddies, what’s wrong?” I ask again, walking towards his bed.

I look down at his obs chart. I can see that throughout the evening that his heart rate has increased, but other than that, his observations are stable.

“Oh, it’s just this dratted pain, my dear.” He winces when he moves again. “Doctor Francis tells me it’s cause I’m all blocked up.”

Doctor Francis is an idiot, I think.

It’s obvious that something is very, very wrong. I grab the blood pressure cuff from the wall and wrap it around Mr Geddies’ arm and pull my stethoscope from around my neck and place it in my ears. I studiously inflate and deflate the cuff. His blood pressure is not elevated. In fact, for him it’s a little on the low side. I look into Mr Geddies’ eyes, as I listen to his heart. He looks far paler than I remember him, and there is a fine sheen of sweat on his face. When I do get to his abdomen, it’s dead silent. I gently press on it, and he moans loudly.

“I’m sorry, Mr Geddies,” I apologise. “But I have to touch to find out where it hurts.”

“It’s fine, my dear,” he insists, panting. “It’s just this silly old coot being a softie in his old age.”

Looking at him, I somehow doubt it. I try to get the rest of the abdominal exam out of the way, while inflicting the least pain I can. I don’t even attempt a rectal exam. If he’s this tender with light palpation, I hate to think what pain I could inflict by getting him to role onto his side. My eyes fall on the drip sited in his left arm, and I feel my mouth twist. Someone has felt the need to insert a 22G – so small we use them on kids – into his elbow. Surely they didn’t have to waste his biggest vein for something so small?

“Mr Geddies, I’ll be right back,” I promise. “I am going to get some stuff so I can put another drip in your other arm.”

“Another drip?” he asks. “Is that really necessary, my dear?”

“I’m sorry,” I apologise. “But I think you could really do with some fluids, and the drip you currently have is a little bit small for that. I also think we’re going to have to take a trip downstairs for a scan.”

“A scan?” he asks.

“I just want to see what is going on in your belly,” I reassure him.

“Oh, I’m sure it’s nothing,” he dismisses.

“I hope so, too, but I’d just like to make sure,” I say. “Can you humour me?”

He smiles.

“For you, my dear? Anything.”

I leave his room and walk back towards the nurses’ station. Hanna and Diane are still playing cards.

“Hannah, can you do me a favour?” I ask, distracting her from her game.

She lifts her eyes to meet mine.

“Yes, doctor.”

I sigh. I’m not going to correct her this time.

“Can you please go and get some equipment for a drip set up for Mr Geddies?” I ask. “I’ll put it in. I just have to make a phone call first.”

“Of course.”

Hannah stands and Diane follows her out, as they go and round up what I need. I sit down at the nurses’ station, pick up the phone and page the surgical registar. I can feel my scalp prickle. My heart is racing and my stomach feels like it’s floating. That’s never a good sign.

Finally, the phone rings.

“Rajesh.”

“Hi, it’s Cadence Spencer here. I’m the Cardiology night resident,” I introduce. “I’m calling for a consult.”

“Well, you’re hardly going to be calling for anything else at this time of night,” he quips.

“I have Mr Ian Geddings. He’s a sixty-seven year old man who was admitted with exacerbation of heart failure and medical management. His symptoms of failure have improved, but his continued admission is for treatment of cellulitis of his left lower leg. He has a past history of hypertension, type two diabetes, ischaemic heart disease, peripheral vascular disease, and diverticulitis…”

“…Get to the point, Doctor Spencer.”

“Anyway, he presents tonight with acute lower left abdominal pain. He’s tachycardic but normotensive and afebrile. He is extremely tender to abdominal palpation with guarding…”

“When was the last time he took a dump?” he interrupts again.

I quickly look at his obs chart.

“About two days ago.”

“Rectal exam?”

“I didn’t do one. He’s in too much pain.”

“Then give him some analgesia and do it,” he snaps. “Don’t call me unless you’ve done a proper assessment.”

I can feel myself seething.

“I did do a proper assessment. I am worried about this patient, and I think he needs immediate attention.”

“And what do you want me to do about it?”

“Come and assess him,” I snap.

“You’re a doctor, aren’t you?” he quips.

I run a hand over my hair, exasperated.

“Look, I think this guy needs a CT scan and an immediate surgical opinion. I’m worried that…”

“You’re worried about what? He’s probably just constipated or has had a flare up of his diverticulitis,” he insists.

“I’m worried that he has a bowel obstruction, an ischaemic gut or a ruptured triple A…”

I hear Rajest snort down the line.

“Does he have a history of an aortic aneurysm?”

“Well, no…”

“And what’s the likelihood of him having ruptured a previously unknown triple A?”

“You haven’t seen this guy,” I insist. “He looks like complete shit…”

“Is that a proper medical term?” he asks. “Look, Doctor Spencer. How many years out of medical school are you?”

I sigh, but answer him anyway.

“Three.”

“Well, I’m seven years out,” he says, like that means something. “You wanted my opinion, and I’ve given it. It’s unlikely to be anything serious. If you’re really worried, get and x-ray of his gut and we can CT him in the morning.”

“But…”

“Goodnight, Doctor Spencer.”

He hung up!

I hold the phone away from me and stare at it in disbelief. He really hung up on me. I slam the phone down on the receiver, and Greta spins to face me, eyes wide. I take a deep breath in and out. Calm, Cadence. I pick up the phone and page Ryan. He sounds sleepy when he replied.

“Ryan here.”

“Ryan, it’s Cadence,” I say, trying to sound as calm as I can.

“Cadence. What’s up?” He sounds surprised.

“I think there’s something wrong with Mr Geddies, and I can’t get a surgical consult.”

“Mr Geddies?” he asks. He still sounds a bit vague. “The guy with the cellulitis?”

“Tonight he’s got abdominal pain. He’s tachycardic and his abdomen is rigid. I think something very bad is going on,” I say.

“Did you call for a surgical consult?” he asks.

“I did. He said no,” I reply.

“Who was it?” he asks.

“Rajesh.”

I hear Ryan sigh down the line.

“Look, Cadence,” Ryan says. “Do what you have to do. Go get your patient a CT scan. Put my name on it. I’ll call Rajesh.”

“Thanks,” I reply.

I really hate involving my senior in this, but I am really worried. I grab a radiology request form and hurriedly scribble a note on it. I’ll go and make my arguments to the radiologists once I stick a large drip in his arm.

I’m sitting on the colorectal ward, writing in a patient’s notes. I had to admit, when I was initially called to a surgical ward for a consult, I felt vaguely bitter. It didn’t seem fair that they could reject my consult, but I couldn’t theirs. As it turns out, their consult was justified. This little old lady that was day one post bowel resection had, in fact, had a heart attack. As soon as I’ve completed the paperwork, she would be moved to the acute cardiac unit for management.

Just then I hear Greensleeves start to play again. Dammit. I thought I had changed that. I look down at my pager, and I don’t recognise the number. I pull the phone across to me and dial. I’m surprised when Thom, my best friend Anna’s fiancé and also the radiology registrar on tonight, answers.

“Cady, where are you?” he asks. He sounds vaguely panicked.

“I’m on colorectal,” I reply. “Why?”

“I’m just looking at your patient’s CT scan. Cady, his belly is full of blood. He’s ruptured a triple A.”

I feel my stomach twist.

“Are you serious?”

“I’d hardly joke about that, Cady,” Thom replied. “How’s he doing? Are the surgeons involved yet?”

“They weren’t interested.” You can hear the fury in my voice. “I bet they’ll be interested now. Look, I gotta go.”

I hang up and I run. I really run. I grab onto the handrail and spin myself into the stairwell, bolting up the stars two by two, towards my ward. I call Ryan on the way and tell him what’s going on. He says he’ll be right there, and he’ll call ICU and vascular. I’m panting by the time I’ve climbed the two storeys to my ward. Hannah, Diane and Greta are sitting there having coffee. Why isn’t anyone with Mr Geddies?

“What are you doing?” I demand, leaning forward on my knees as I catch my breath. “I told you guys that someone had to be with Mr Geddies at all times?”

Hannah just blinked at me.

“I thought that was only til he got the CT.”

I’m astounded. Seriously?

“Well, I’m sure the CT scan made his ruptures triple A all better,” I say sarcastically.

I watch as the colour drains from Hannah’s face.

“Greta – call transfusion. Get a massive transfusion pack up here ASAP. Hannah – go get me the largest drip you can find. We have to put another line in. Diane – Dr Hastings, the ICU reg and vascular surgery will be here soon. Tell them where we are. I’m going to go check on Mr Geddies.”

It’s amazing how fast things can happen, when everyone realises what’s going on. Within the hour, we have two more large bore drips in, we’ve transfused sixteen units of blood, eight units of fresh frozen plasma, and Mr Geddies is being wheeled off to theatre. Experiences like this are strangely dissociative. Your body knows what it’s meant to be doing, and does it. It’s like your mind, filled with all the terror and panic of the moment, has gone onto screensaver, to allow you to do what needs to get done. Your own personal feelings can wait until you have time to deal with them.

I’m sitting in the residents office, and my whole body is shaking. Adrenaline continues to rush through my veins, even though the stimulus is gone, and I’m finding it hard to focus. My mind just keeps running through the events of tonight, over and over, wondering how things could have gone so wrong?

Mr Geddies started complaining of abdominal pain two hours before my shift started. It was another eight before he made it to the operating table. That makes ten hours since his abdominal aortic aneurysm started leaking, and when they started to fix it. I’ve had a chance to look at his CT scan, and I can’t even estimate how much blood was in his abdominal cavity. Maybe Thom can help me.

But the thing was, he looked too well. I’ve never seen a patient with a ruptured aneurysm before, but shouldn’t he have looked sicker? His heart was just going a little bit fast. Don’t get me wrong – he looked sick – but he didn’t have the classical central abdominal pain radiating through to his back. I mean, I had thought of it, but did I really think that was what it was? There had been other things on my list of differential diagnoses above that. What would of happened if I didn’t know the radiology reg on tonight? Would my request have been rejected? Would Mr Geddies still be sitting on our ward, bleeding out into his stomach? Would he be dead by now?

“Cadence.”

I look up and I see Ryan standing by the door. His ash brown hair is skewwiff around his head, flattened on one side from where he had been sleeping. There’s a splash of blood on his shirt from when he had inserted Mr Geddies’ central line. I shouldn’t have been surprised that someone who did angiograms for a living knew how to put one in. He looks as drained as I feel.

“Dr Hastings,” I reply.

I watch as he crosses over to the lounge in the corner of the room, and collapses on it.

“Please, call me Ryan,” he says, and rubs his face. “I hate all that Dr Hastings bullshit.”

“How’s Mr Geddies?” I ask.

Last I had seen Ryan, he had been heading down to theatre. I didn’t know if it was a good or bad thing that he was back so soon.

“I’m guessing still on the table.” He rubs his hand across his face. “I didn’t actually go into theatre with him.”

My brow furrows.

“Then where were you?” I ask.

Ryan had been gone for at least forty-five minutes.

He grimaced.

“Tearing Rajesh a new one. That was just a complete fuck up on his behalf. Oh, no - ” Ryan leans forward onto his knees, when he sees my face twist in response. “Cadence, you did nothing wrong. That man would be dead by now, if you hadn’t done what you did.”

“He might still die,” I reply.

Even for in-hospital rupture of aortic aneurysms, the mortality rate was high.

“Well, at least now he has the chance to live,” Ryan insists. “Cadence, you did everything right. You should be proud of yourself.”

I just shake my head, unwilling to accept that right now. There must have been something I could have done to make all this happen earlier. Maybe I should have checked on him, when Rob said he was unwell when I arrived tonight. Ten hours is too long.

Just then, my pager buzzes.

Ryan holds out his hand.

“Here. Let me,” he says. “You deserve the rest.”

I shake my head again.

“Actually, I’d like to have something to do.”

I am wound up too tight, to just sit here and think about how I stuffed up. I stand and leave the room and head off to my next consult. Only three hours to go until this damned night is over.