Darwin Nights

Right now its about 5 o'clock in the morning on night shift number 5 of 7. Things are disconcertingly quiet, and I am fighting the urge to take a nap (the minute I lie down I can almost guarantee some surgical disaster hitting the ED), so I thought I might write a bit about work here.

Night shifts here are crazy (not counting tonight - one of those nights were I am paging myself just to make sure the thing is working). The other nights this week have been like some weird, sadistic test of endurance where I am amazed to finally emerge into the daylight come morning. Maybe two thirds of my cases are minor surgical bits and pieces - mostly infected wounds/burns/ulcers that have been neglected and allowed to fester (or partially treated in hospital with the patient then absconding or being non-compliant with further treatment). The other one third are at the complete other end of the spectrum - major traumas (beatings, stabbings, MVAs) and very sick patients with surgical disasters (perforated bowel, nectrotising fasciitis, renal abscesses, advanced erosive cancer).

I did my first fasciotomy tonight (cutting open the skin and underlying fascia on someone's leg to relieve the pressure building from inflamed muscles trapped within a closed space); I debrided my first case of necrotising fasciitis two nights ago (very nasty infection of the subcutanous tissues/fascia/muscles that spreads and kills very quickly - treatment is by cutting away all the skin and underlying tissue that appears involved - usually a huge area and a very messy operation)(my shoes have since been soaking in a bucket at home...) and three nights ago I saw more faeces coming out from someone's abdomen than I have ever seen before (should be INSIDE the bowel, not pouring out of the incision we were making)(horrible).

You know its a busy shift when you have to keep triaging your list of jobs - I should see that patient first because free intra-abdominal air means he is going to need an operation ASAP; I could squeeze that one in so that I can call the radiologist about his CT before it gets past midnight; I've got ten minutes between theatre cases - I can review that patient who ICU are worried about; the infected hand can start on some antibiotics and wait; I need to see that guy because ED have now called me three times and the patient is threatening to abscond; that pancreatitis doesn't sound too sick...

I have to admit, though, that it is very satisfying to get to the end of each of these shifts knowing that I have managed things alright (and that all of the patients have survived to the morning along with me). I'm still living in fear of the first time I will land a patient that needs a burrhole (or even worse - a craniectomy)(the realm of neurosurgeons in the other hospitals I have worked). Here general surgery means everything - neurosurgery, plastic surgery, urology, cardiothoracics, paediatric surgery. At least by the end of six months I should be able to do a whole bunch of new operations that I wouldn't normally get exposure to.

If I can survive that long.