Issue 34 / 9 September 2011

LONDON, October 1993: I took my first steps as an advanced trainee in gastroenterology at King’s College Hospital Institute of Liver Studies … and by the end of only my second day, I had become the “experienced” liver registrar and was deemed “ready” to take over the care of an eight-bed liver intensive care unit.

As 5 pm approached, a sense of anxiety settled on me. I had spent 6 months as a mostly overwhelmed ICU resident at a large London teaching hospital, but I was hardly an expert in intensive care, let alone liver intensive care.

With extreme ease, the liver ICU day-registrar conducted the handover and provided me with all I needed to know for my first night, scribbled onto a small piece of paper. I was then alone, albeit with six patients, the highly experienced nurses and a very capable gastroenterology senior registrar at home should I need her.

By 5:35 pm, I had received my first telephone referral. As the resident — from Cornwall, some 300 kilometres away — described the referral, the number of boxes ticked that fulfilled super-urgent listing for liver transplantation was ominous. Clearly, the patient needed to come and would be my first of many acute liver failure admissions that year.

Within the next 2 hours, two expected admissions arrived. The first patient, admitted for routine elective orthotopic liver transplantation for amyloidosis, seemed to have utterly resistant hypotension due to his autonomic neuropathy, despite copious amounts of noradrenaline.

The other patient, transferred from a private institution, had multiple organ failure secondary to end-stage liver disease, and highly resistant hyperkalaemia despite continuous dialysis and medical therapy.

The next little excitement was that the apparently “stable” patient with acute liver failure from paracetamol poisoning was now becoming much less stable. The liver transplant surgeon decided to take her to the operating theatre to render her anhepatic — a procedure, I was informed, that would ensure haemodynamic stability while waiting for her imminent liver transplant.

Reassured, I relaxed when I saw her being wheeled out of the liver ICU. The relief was short-lived, as the next event was an expected death.

Then, a frighteningly short time later, the anhepatic patient was wheeled back into the liver ICU. Despite the surgeon’s earlier reassurance, this patient was more haemodynamically unstable than when I had last seen her. At this point, she had a cardiac arrest, and as I turned to resuscitate her, a second patient arrested.

Thankful for the experienced nurses, but still wishing I had four hands, I had to manage both patients at the same time. After a bout of frenetic activity, I ceased active treatment on the patient who had a hopeless prognosis — a decision that, on reflection, was appropriate but probably a little beyond my years of experience.

I called the consultant surgeon to ask, with some trepidation, if he would consider bringing forward his patient’s planned liver transplant. When she was taken to the operating theatre less than an hour later, I felt hugely relieved.

As the night raced into the early hours of the morning, the patient from Cornwall arrived and, with the aid of my crumpled piece of paper and the superb handover from the poor resident who had struggled with her during the 5-hour road ambulance trip, her condition stabilised.

With the wintery, watery sun came the realisation that it had been an extraordinary night in an extraordinary place. The memory of it would never dull.

In spite of my feeling of terror during that night, I switched discipline allegiance and commenced training in intensive care — only this time, I had to move countries to allow me to do so …

Dr Imogen Mitchell is the director of intensive care at The Canberra Hospital, ACT.

This article is reproduced from the MJA with permission.

Posted 12 September 2011

One thought on “Imogen Mitchell: Reflections on firsts

  1. Anonymous says:

    Imogen, your article sent a shiver up my spine. I was the Consultant in charge of the ED where the patient from Cornwall was initially treated. She had taken a paracetamol overdose, aged 16. She was under the threshold on the existing nomogram, so did not receive N-acetylcysteine. As you doubtless are aware, she did not survive. I was required to give evidence at her inquest, and recommended a reduction in the threshold for treatment with N-acetylcysteine in cases of paracetamol poisoning. This was not adopted everywhere in the UK, although is has been adopted in Australia. At the initial meeting with her parents, when I was asked to explain what had gone wrong, I promised to spread the word about liberal N-acetylcysteine treatment for paracetamol poisoning.I’m still doing it now.

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