Dr Wennberg’s Casebook: Guided by my Guardian Angel

ONE day, 1987, when I, as a very unexperienced doctor, was on duty at the emergency department of  the little hospital in Lycksele in Northern Sweden I got a telephone call from an even more unexperienced doctor. He worked in a small place nearer to the Norwegian border, some 300 km away. He told me he wanted to discuss a couple of  patients. The first was a man who had acquired an inguinal hernia, with pain but without alarming symptoms and signs. He was very detailed describing this man. Later, more or less by the way he mentioned: “And then I have a Norwegian tourist here who got  abdominal pain in intervals with radiation to his back, while driving his car…”

I could have said something else but said: “The first man you can send an ordinary referral on by mail, but the Norwegian guy you have to send here to Lycksele at once.” (Remember the distance.) The other doctor said: “Shall I let his wife drive him to you?” I could have said something else but said: “No, send him by ambulance, as his condition could become worse.”  (This was before helicopters came in more frequent use for transports over distances.)

The hours flew away and was busy with other patients. Just before it was time for me to leave the hospital for the day I heard someone say: “The Norwegian tourist has arrived!”  I went into the small examination room and found a man 60+ ash-grey in his face and sweating. Obviously he had abdominal pain. I put my hand on his abdomen and felt a huge resistance bulging and pulsating. I immediately called in the surgical team and the patient was informed about the seriousness of his condition. He took a possible last farewell of his wife before he was rolled into the operation theater. The operation took many hours, and I was assisting the surgeon. Of course the patient had an abdominal aortic aneurysm but it had also ruptured! The hole, thick as a finger, was lucky for him, directed backwards into the retroperitoneal spatium which was filled with a liter or two of blood. (If it had ruptured at the ventral aspect he would have been dead within a minute.) Luckily it was possible to cut the aorta safely under the renal arteries and he got a teflone-graft in the shape as a pair of trousers. The man’s life was saved and he could some days later return to Norway.

I was lucky too, making a series of correct decisions. It wasn’t by experience obviously. Was it good intuition? Was it gut-feeling? Or was I advised by my Guardian Angel…

Dr Wennberg’s Casebook: Just Another Day at the Office…

This is a recent case, and this is written with the informed consent of the patient in question:

One of the first weeks this year, 2011, while I was routinely auscultating the lungs of a middle-aged woman I discovered a strange pigmented mark on her back. It looked like a black comet with a body and a tail. She herself wasn’t aware of its presence or appearance, and no one in her family had noticed it either.

The possibility of a malignant melanoma had to be ruled out so I sent a referral to the hospital. Five (5) days later she was operated and the diagnostical procedures showed that it, in fact, was a radically removed malignant melanoma in situ.

Lucky circumstances and a well working organization made her cured, and potentially her life was saved, on just another day at the office…

Dr Wennberg’s Casebook: Att sjunka genom marken

 

This time I’ll write in Swedish as for some reason I don’t think I can make the story justice in English. It’s about an occasion when I wanted to “sink through the ground”, a Swedish idiom.

Sommaren 1982 arbetade jag som underskötare natt på Huddinge Sjukhus. Under nattpassen och på dagarna försökte jag plugga till en resttenta i anatomi. Denna sanna berättelse utspelade sig på en njurmedicinsk avdelning på Huddinge Sjukhus.

När ett nattpass börjar får man alltid rapport på de patienterna som är inlagda på avdelningen. Vi fick utförlig rapport på alla, utom på en tjej i 20-års åldern som endast skulle sova över för att dagen efter genomgå dialys.

På morgonen, när väcknings- och morgonprocedurerna börjar blir man som nattpersonal lite uppspelt och hurtig. Man skall ju då bara jobba någon timme till och sedan får man gå hem. När jag och en kollega kom in till salen där den unga tjejen låg hajade vi till. På stolen bredvid hennes säng “satt” hennes byxor med skorna placerade under byxbenen.

Oj, det där ser ju riktigt ut! utbrast jag.

Men hur har du gjort för att få det att se ut så där? frågade min arbetskamrat

Tjejen svarade: Det där är mina proteser…

  

Nu förstår Ni titeln på detta avsnitt i min Casebook…

  

 

Dr Wennberg’s Casebook: A Moment of Horror

In every doctor’s life there are moments that you most of all would like that they never had happened, or at least you would like to forget them. This was, for me, such a moment:

Almost twenty years ago when I worked at the University Hospital in Huddinge, there was a women, just a few years older than me, in a single room. She had some kind of cancer in the abdomen and was terminally ill. What can you offer a person in that situation?

I knew that many terminally ill persons last wish is to be at home with family and friends around. Today you can get advanced palliative care in your own home setting, at least in the Southern Stockholm area. I thought that I should mention that there was a possibility to arrange this for her.

She was hiding her face in the pillow. I went quietly into her room and presented myself to her. She immediately replied:

I don’t want to talk with you. It was you who told me that I was allright…

In a split of a second I felt panic-struck, total horror, pain and sadness. My blood felt cold as ice, with shivers of fear running down my spine.

Who was this woman? Had I met her? I went out of the room and made a quick research. Yes, I had met her before. She saw me at another clinic because of abdominal pain. I made an investigation with negative result. The second time I saw her she said she felt better, and I told her that she could return if the pain came back. That happened and she saw another doctor, and when a second investigation with ultrasonography of the liver, was made it was full of metastases. Of course I had never told her that she was allright. I said that I couldn’t find any signs of any disease, and that is quite a difference. Her cancer was of a kind that it didn’t matter if you had detected it earlier.

I’ve come to peace with this case. But I remember my moments of total horror being accused by a dying woman for, beween the lines, causing her death…

Dr Wennberg’s Casebook: Four Lives Wasted

Just a reminder: All cases in this series are real and are described as it was, or at least as I can recall them. The stories are not fake or fiction.

If you are sensitive to explicit descriptions, be warned!

February 1987 was a really cold month in Northern Sweden, with temperatures down to -32 degrees C. I worked as a young resident at the small hospital in Lycksele. One late Friday afternoon when I prepared to leave the Emergency Dept. for the day the telephone rang:

A car accident with many injured! was the message.

I stayed in case my help was needed, but the telephone rang once again…

All are dead…

OK, I prepared to return home when the telephone rang a third time:

Perhaps we should have a doctor at the scene! said the policeman.

As a young doctor willing to answer a call beyond duty I decided to offer my help…

What had happened?

This was when it was mandatory for all Swedish men to serve in the Swedish army for about one year. The weekend travel possibilities for the servicemen were generous. Three young men that had landed at Skellefteå airport could use a rental car for the weekend to get to their homes. The car was a new Saab. One of the three young men didn’t like that the driver drove too fast and careless, so he asked to get off the car in order to visit an aunt or something like that. This saved his life…

 It was perfect winter driving conditions. A lot of snow increasing the effects of the headlights. The road surface was ice perforated by the studs on the winter tyres. Typically good winter driving conditions, if you drive with care and good judgement. But the boys drove way to fast, and couldn’t keep the inner curve, and in a long bend to the right they collided front to front in high speed with an elderly couple driving in ordinary speed. When I arrived at the scene the couple’s car was removed. The boy’s car had flown through the air and landed wheels down on a field. I don’t remember the distance but there were no tracks in the snow from the road. The two young men’s car had caught fire and they sat, due to the impact, where the backseat would have been. They looked like mummies. Steam and smoke still evaporated from the bodies. If you touched them pieces of them fell off. At least one of the skulls was cracked and a coagulated brain’s surface was visible. On the wrists, where the hands were burnt off, their watches showed the time at the impact. If I remember correct it was 17:05. In their shirt pockets you could see the metal parts of their Ballograf Epoca ballpoint pens. Button, clip, cartridge, and spring in a neat line on the chest. All plastic parts were burnt off. I tried to walk around the car in the thick snow, trying to identify what was burnt body parts and what was not.

The situation was surreal. It was cold. It was silent. The sky was clear and huge green curtains of the most spectacular Northern Lightning I’ve ever seen moved slowly…

Four lives wasted…

Dr Wennberg’s Casebook: Writing With Blood

I took my Medical Degree at Karolinska Intitute in Stockholm, Sweden, January 1987. Under this heading I will tell some true stories from my career. I’m very proud of two things in my career so far. One is that during my eight years as responsible for the medical care of the inmates at a high-security detention centre in Stockholm we had not a single death within the compound. After I quit 2004 there have been at least four deaths as far as I know. Once though it was a close call, and this is the story:

One afternoon, when I was in the procedure of passing all the security gates and doors on my way home after work, I heard a call for me from the loudspeakers. It was nothing else to do than start the procedure to enter inside the security-shell once again. During a routine opening of a cell one inmate from one of the Baltic states was found in a very bad condition. He had cut himself and was bathing in his own blood. He was pale and very weak. The pools of blood on the floor had separated in its components so he must have been laying there for some hours. He could not speak Swedish nor could he speak English. He was not laying flat on the floor but he was stuck in some way in the door-opening to his toilet. When we entered the cell he was trying to say something, but it was impossible to understand. He then took his finger, dipped it in his own blood and wrote on the wall: “HIV

He made an effort to warn us!

The ambulance arrived to the scene and he was transported to Huddinge University Hospital and later returned in good condition after some transfusions. What happened with him later I don’t know. When you work at a detention centre you do not now who are still there tomorrow, who are released and who are transported elsewhere…

Me outside the detention centre, Häktet Huddinge, 2003.

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