Chapter 21: Emergencies, home and roadside visits

Toward the end of the morning surgery, I was asked by the police to inspect and advise on a body ‘found in suspicious circumstances’. In due course, I was conveyed in a police car to where the television cameras and the police were waiting.

The background story was that a man had been arrested the day before for driving under the influence of alcohol and disqualified driving. He had been released from the watchhouse at 8.30 pm the previous evening to appear at court at 10.00 am. His parting remark had been, ‘I will not be appearing in court’. He did not appear, and on going to the house where he lived alone, the police had found him lying still. When I looked I saw him lying prone in a room at the top of the back stairs—four in number—with a pool of blood spreading from under the head. The light was still on from the night before.

After ascertaining that photography was finished and it was clear for me to proceed to examine the body, I proceeded to turn him over to determine the source of bleeding. I did not usually wear gloves to handle bodies, for as I have remarked to various onlookers, ‘The incubation period for HIV is such that I didn’t have to worry about it’. Next time I wore gloves.

He was a heavy man and a tentative pull at his clothes had little effect. A hand under the shoulder brought some movement and as he rolled over I felt a ‘kick’ and there were cracks and sparks, something like a Chinese New Year celebration. After the power was turned off at the meter box, I had a closer look. An electric power cord had been partly unravelled and the electric wires connected to each index finger. The cord had been unnoticed where it passed out from under the body––through a door to a high-power point in the next room. The blood came from where he had fallen on his nose.

One very cold wintry Sunday we experienced one of those dreaded emergencies when a bus load of tourists returning from a trip to the Mt Baw Baw snow resort plunged off the mountain road. Forty-two people from Italy and expatriates were affected and they were transported to our small bush nursing hospital to be managed by two doctors and two nurses. The scene was somewhat chaotic especially as many could not communicate in English. Most of the patients had relatively minor injuries but some stressed victims who claimed to be ‘shocked’ took a disproportionate amount of our time. While moving around the cubicles I noticed one woman lying quietly and looking pale. She then received priority attention and was found to have a ruptured spleen.

It was one of those Saturday mornings when every time you should have been locking the front door someone arrived. Important and urgent matters—a repeat prescription, a certificate for home help, the signing of a passport application!.

This call was to see a husband with dizzy turns. He lived beyond the usual confines of the practice. ‘No, he couldn’t come to the surgery … Well he’s been having them since yesterday afternoon and the doctor who usually sees him said he’d always come.’ It sounded like just one more case of that medical dustbin ‘inner ear trouble’ or what is occasionally, and quite inaccurately, ascribed to Ménière, and for whose existence Messrs May & Baker must be eternally grateful.

His records, meticulously documented, showed that his dominant trouble was backache, allegedly caused by heavy lifting as a sheet metalworker in the business owned by his wife, a condition for which he was (admittedly with some difficulty) claiming workers’ compensation. The patient and his family were so distracted by issues related to his back problem that the heading to their correspondence looked anything but professional and their bills resembled those that used to come from the grocer.

His most recent treatment, instituted by a teaching hospital surgeon of his own choosing, included the use of TENS—a discipline appearing to lie somewhere between acupuncture and hypnosis—from which the surgeon, as reported in his notes, claimed he was getting ‘substantial benefit’.

At the home (a large Italianate sub-mansion) the doorbell echoed through the halls for a considerable number of minutes before being answered by an obviously anxious wife, dimly visible in the entrance, which was shrouded completely by drawn blinds—a situation repeated in the patient’s bedroom upstairs.

His story was that his lower thoracic backache had been present for some two to three years. It was intermittent and several consultants were about to press his claim for justice in the workers compensation court. What, at first, appeared to be a new form of tape recorder turned out to be the TENS instrument, which was demonstrated and which on this occasion had failed to relieve his backache, his dizziness (that was worse when he was erect) or his mild diarrhoea that had started the previous afternoon.

On examination, central abdominal tenderness was the only significant finding—that is, until his blood pressure was found to be 90/70, falling to 80/50 standing. Pulling up the blinds revealed that his olive ethnic complexion was emphasised by pallor and his diarrhoea was black.

As hospital staff never regard admissions late on Saturday afternoons with much enthusiasm, the urgency for his admission was questioned. Wasn’t his pallor due to his southern European complexion and weren’t southern Europeans always pale, and was his blood pressure really as low as alleged when his admission was sought, because he was normotensive now? These criticisms were to some extent withdrawn in the face of a haemoglobin level of 7.6 and gastroscopy showing a large penetrating ulcer on the back wall of the stomach, not actively bleeding at the time of the examination. Blood and H₂ antagonists relieved his dizziness and his backache as never before—TENS included.

CASE 1

It was just before the evening surgery. One of those nights when the partner who usually shares it with you has the ‘flu’ and the previous message your wife had taken (before you arrived home for dinner) said that a child with abdominal pain was coming and would you see the child before the appointments. You hoped that something less dramatic and time consuming than the asthmatic in incipient respiratory failure, who arrived unannounced last week, would not turn up too.

The patient was a boy of 17, well until two days previously when he complained of mild sore throat. He had attended one of the partners and penicillin had been prescribed for tonsillitis. He had not been unduly sick until that morning when he had become restless and, during the afternoon, progressively more drowsy and somewhat disoriented. His father, a distinguished academic, wondered whether his recent failure in annual exams might have contributed to his general affect.

He was very drowsy, uncooperative and afebrile but with a dry tongue and no other abnormal findings apart from mild pharyngitis. There was no neck stiffness, no positive Kernig’s and no evidence of drug overdosage or adverse reaction. He had previously been an active, healthy young lad with no history of serious illness.

Standing at the foot of the bed with both of his parents, now joined by a sister or two anxiously quizzical, and the time being 20 minutes past an expected arrival at the surgery, it was obvious that a tentative diagnosis had to be made fairly smartly. Masked bacterial meningitis seemed a good bet, until it suddenly occurred to me that his breathing was a bit more stertorous than one should expect from his level of consciousness. But what really helped the diagnosis were three large, empty lemonade bottles on the bedside table—not the sort we used to get for fourpence with a penny back on the bottle when I was a boy, but these monstrous two litre disposable flasks. ‘Has he drunk those three bottles recently?’, I asked. ‘Doctor, he’s been drinking all the afternoon. I can’t satisfy him’, replied the mother. Rather unusual for somebody who is apyrexial. There was no family history of diabetes; he had no prior symptoms of thirst, loss of weight or polyuria; he was too uncooperative to get a specimen of urine and I have never been really confident of identifying the smell of new mown hay.

‘I’ve got a young man with diabetic acidosis.’

‘Oh yes’, answered the admitting officer, ‘a known diabetic I suppose, and I suppose you’ve tested his urine for ketones’. Under persuasion and somewhat reluctantly, he dispatched an intensive care ambulance with that air of resigned acceptance peculiar to all admitting officers and with ‘they’d have a look at him and see what they thought’.

An hour later he rang. ‘You were right; he’s got a blood sugar of 61.5 with a pH of 6.95 and a pCO₂ of 11. What made you think of it?’

‘Lemonade’, I replied, ‘bottles of it’.

CASE 2

And bottles also clinched the diagnosis in the second patient.

She was 52, recently returned home from a metropolitan hospital whose reputation for management of infectious disease is international and whose ability to make rapid and correct assessments had, more than once, led at least one local practitioner to wonder how his tentative diagnosis could have been so far from the truth.

During the last year the patient had been admitted several times with ‘recurrent’ infectious hepatitis. Fifty-two is an unusual age for hepatitis of the infective type and frequent relapses are excessively rare. She was deeply jaundiced and had all the features of liver failure, which included spider naevi, gross hepatomegaly and the first really convincing liver flap seen in a clinical lifetime.

Excessive alcohol intake was flatly denied and her husband supported her, both when we were together with the patient and even more strenuously when we withdrew to discuss the diagnosis. The evidence against their statements seemed so strong that I suggested we look for it. Rooms and cupboards were searched, plus under the house and, finally, a very long back garden. Almost on the rear boundary was a shed, literally stacked to the roof with gin bottles. I looked at the husband, he looked at me and, without a trace of hesitation and with what seemed complete conviction, the answer came to my silent inquiry: ‘Oh those—she collects them for the Red Cross’. My remark that I was unaware that august society had gone into the bottle-oh business was received as frostily as my look when we first discovered the obvious aetiology.

He, of course, won. His wife died many months later attended by one of the other partners of the practice, and none of the family has seemed to need my diagnostic skills since.

CASE 3

Time was when any visit to the home terminated with an invitation to ‘use the fresh towel’ and a ‘new cake of soap, Doctor’ while management and treatment—and occasionally diagnosis—were discussed.

The patient apologised—the bathroom was out of action and would I mind using the kitchen. She was 47, had had a cough and fever for two or three days preceded by headache, her temperature was 104.8 °F (40.4 °C, metrication and its machinations had not yet arrived) and she had moist sounds in the chest localised to the right mid-zone.

That winter had seen a small epidemic of what we used to call atypical pneumonia—now known, of course, to be due to mycoplasma which, we all know, is one of the few chest infections in which treatment can be initiated with a reasonable chance that the antibiotic chosen will be the right one. The picture seemed to fit; a prescription was written and arrangements made to visit her the following day. She was too sick to see me out but ‘the kitchen’s the first door on the right, Doctor’.

A half-dozen or so parrots in their cages—one or two looking somewhat dispirited—are hardly what one expects to find looking up from washing one’s hands in a kitchen. I shot back into her bedroom asking how long she had kept parrots and if any had been sick lately. She replied that she sold them at work—a variety store now apparently branching out from its original practice of selling nothing over two and sixpence (about twenty-five cents)—and that she usually brought home the sick ones, two of whom had recently died.

It was the first and only case, confirmed by rising serum titres, of psittacosis I have seen and, subsequently, the least contentious claim for workers compensation in which I have appeared.

Some of my most vivid memories of country practice are urgent calls to people who have collapsed in the toilet, some being in those small outhouses. Add the effects of a cold, windy, dark, wet night and the scene is macabre and unforgettable. In hospital, a call to someone who had collapsed on the bedpan often meant sudden death from a pulmonary embolus or myocardial infarction. In the real world, it usually added up to intraabdominal bleeding, a cerebrovascular accident (CVA) or myocardial infarction (in that order).

CASE 1

‘Would you come to see Alex. He’s had stomach pains since dinner and he’s just passed out in the toilet.’ I arrived to find Alex, a 68-year-old farmer, on the floor looking very pale and moaning with abdominal pain. The tender mass of an abdominal aortic aneurysm (AAA) could be palpated. Alex was fortunate to survive emergency surgery after the insertion of an IV line and a long trip to a major hospital.

CASE 2

‘Doctor, come quick. Diane has collapsed in the toilet; she hasn’t been well for the past hour.’ Diane was a 16-year-old shop assistant and as I drove to her home I wondered if she had been a victim of the pandemic of gastroenteritis that had struck the area. However, Diane had a life-threatening problem. Her severe abdominal pain was the result of a ruptured ectopic pregnancy.

CASE 3

I was called to see Hans F, aged 57, a new arrival from Germany who had collapsed in a small outside toilet. I arrived to find his wife and daughter unable to reach him as all 125 kg of him was jammed against the door. All this drama on one of those bleak, howling, wet winter nights. I expected to find yet another ruptured AAA, but after we managed to remove the door, I discovered that he had a CVA. He survived only 24 hours.

CASE 4

Eric G, a 62-year-old barman, had fainted or felt faint on a few occasions over two days when he sat on the toilet to defecate. He was complaining of mild abdominal pain. When I examined his abdomen there was tenderness and guarding in the epigastrium and centrally. His blood pressure was 100/60 and his pulse 102. I figured that he was bleeding from somewhere but where? Our visiting gastrointestinal surgeon arranged admission to hospital and concluded that he had peritonitis. At laparotomy, a ruptured hepatoma was found in a cirrhotic liver and this was bleeding slowly into the abdominal cavity.

It was during a hot afternoon’s busy surgery that I received a call from an ambulance officer. ‘We’ve been called out to this bloke who’s fallen down an old mine shaft: the rangers reckon he’s dead but we’re not sure’, he said. ‘He’s probably been down there for days and he really smells. His legs are broken and some snakes are down there with him. The hole’s about 12 m deep, so do you think we should attempt any heroics? Is it worth hauling him up carefully?’

I decided to visit the scene immediately and arrived to find the men hauling the ‘body’ up the mine shaft. Suddenly, two large battered serpents were flung from the hole: red bellied black snakes (very dead, fortunately). Eventually, a rather tragic sight emerged: the malodorous, distorted unconscious figure of a pale, young man. Incredibly, he was still alive despite having been down the shaft for almost three days. I recognised him as ‘David M’, a pleasant 20-year-old who suffered from epilepsy; he was an avid gold prospector.

A rapid examination revealed several large lacerations on his scalp and back with a fractured leg and posterior dislocation of his right hip. The foul odour was due to faeces; his pulse was rapid and thready, and his systolic blood pressure was 60 mm Hg. The question remained: Did he have envenomation from those black snakes? Red-bellied black snakes are not very venomous, but they still deserve respect. One significant finding really stretched the imagination. Peering into his wound I thought I could see a pulsating artery, but closer inspection revealed it to be large maggots.

I quickly inserted an intravenous line with Hartmann’s solution as the ambulance sped off to the bush nursing hospital. David responded to the resuscitation and started moaning with the pain. Cleaning the poor fellow was a task for strong stomachs.

Managing the problem

This difficult case included blood loss, dehydration, a dislocated hip, fractured tibia and fibula, multiple wounds full of maggots and the possibility of snake bite.

The patient’s haemoglobin was 60 g/L and so we began a transfusion following typing and cross matching. We decided not to give antivenom but to ‘play it by ear’. Removing the maggots proved impossible because of their countless number deep in the wounds (which appeared amazingly clean). I contacted an experienced surgeon who recommended bathing the wounds with chloroform. It worked like magic: the anaesthetised blowfly larvae were flushed out easily.

The patient improved dramatically with a blood transfusion and passed urine that was essentially normal. When he had recovered sufficiently we took him to theatre, reduced the hip and fractured leg, and finished cleaning and suturing the wounds. David made a remarkable recovery, highlighting yet again the amazing recuperative powers of the human body.

One Saturday morning while in metropolitan practice I received an urgent call to a nearby lady’s hairdressing salon because one of the clients had collapsed. Apparently some minutes beforehand she had been sitting in the chair having a perm when she seemed to fall asleep. She then quietly slid down under the drapes to the floor. I arrived to find an unknown (to our practice) woman of about 40 years lying unconscious but breathing. One of my first strategies is to perform a blood sugar test by a test strip but I looked in her handbag where a card indicated that she was an insulin-dependent diabetic. This was a hypoglycaemic attack demanding urgent attention. I then had to make a decision whether to give her intravenous 50% dextrose or glucagon since I always carried both in my emergency doctor’s bag. I administered 25 ml of the sticky solution into a good looking vein and she recovered as expected. This is one of the few times that we can impress onlookers!

This tale is a tribute to Dr Gordon Burles, my predecessor at Neerim South, who saved the life of George E, a 42-year-old farmer who was struck on the head by a falling timber beam as he was demolishing a shed.

George had sustained a large laceration to the left side of his head with considerable blood loss and Gordon responded to an urgent home call from George’s wife. George was initially unconscious, recovered to a lucid state and then lapsed into unconsciousness on his bed. When the doctor assessed the situation he realised that George had developed an extradural haematoma. He was a long way from expert help and both the local bush nursing and base hospital.

Gordon searched the toolkit in the workshop and found the brace and bit tool unit. He handed the bit and his scalpel plus forceps which he carried in his emergency kit to Joan and asked her to sterilise them in boiling water. He then extended the wound over the scalp haematoma, elevated the visible fractured skull bone and then drilled a hole about 3 cm above the zygomatic arch. The patient did recover and the story is folklore in the district.