This service is designed to deal with what is known as the acute abdomen - the general surgical emergencies. Broken bones, punctured lungs and central nervous system trauma are of course dealt with by their respective specialties: orthopaedics, thoracic and neurosurgical teams.
Interestingly, one could come to call it the Acute Stupidity Unit, not because the team is retarded or its members idiotic; but because the people that refer patients to us do not seem to understand our role and what we do. It is a well-known fact among the medical and nursing staff that ASU is a general surgical service; not a "call whenever you need something" service.
Albeit helping at anytime would be lovely - it is not practical in the surgical setting and there are patients who are critically ill, requiring intervention quickly at all hours of all days of the week.
So let me explain to you two scenarios I saw yesterday with the ASU Registrar (reg) that puzzled me.
Scenario 1 -- The painful Abdomen
We were in the middle of booking an emergency case in the operating theatre for urgent colonoscopy after the patient's systolic blood pressure dropped to 80 from 130 secondary to a significant PR bleed. We had to identify the source of the bleeding and unfortunately the CT Angiogram was unsuccessful in demonstrating anything useful.
While this was all getting sorted, the ASU reg got paged from the O/G reg.
ASU Reg: ASU Reg
O/G Reg: Yes, hi. This is Gynae reg. One of our consultants saw a patient in his rooms with left iliac fossa pain, which was suspected to be caused by a haemorrhagic ovarian cyst and asked the patient to present to the emergency department. He then contacted me to ask for your assistance.
ASU Reg: So you're saying your patient has known gynaecological pathology that could be causing the acute abdominal pain and you want me to do what exactly?
O/G Reg: We would like you to see the patient.
ASU Reg: What the fuck for? You're telling me that there is gynaecological pathology in the pelvis that could explain the non-specific peritonitis in the short-term and the localised peritonitis eventually. The pain is in the left iliac fossa, the other common differential for now is diverticulitis and you've told me that the patient has proven gynaecological pathology.
ASU Reg: I can go and see the patient, but there will be no recommendation unless there is a clear-cut cause for abdominal surgery. I really don't see the point of this phone call. I also won't be able to see them until our emergency list is complete. Until then, you are responsible for the patient's resuscitation. I am not accepting care.
Of course all the profanity poured out of his mouth after he slammed the phone down. The Consultant and I heard half of the conversation until he filled us in.
We just got back to organising the emergency procedure for the patient at hand.
Scenario 2 -- The Rib fractures
We just finished the emergency colonoscopy on the patient as described above. The pager screams again, it's 2000hrs and the ASU reg still hasn't had a chance to hand over to the night ASU reg.
ASU Reg: ASU Reg
Emergency Reg: Hi, yes thanks for calling back. We've just had a 77 year old female present after a fall with 2 minimally displaced rib fractures. However, she also has acute pulmonary oedema. We were hoping you could come and see her?
ASU Reg: I'm sorry I must have misunderstood. Are you saying the patient sustained rib fractures after the fall and also has acute pulmonary oedema?
Emergency Reg: Yes. That's right.
ASU Reg: What is causing the patient's acute pulmonary oedema?
Emergency Reg: The rib fractures.
*Silence*
ASU Reg: Okay. Rib fractures do not cause acute pulmonary oedema. The most appropriate option here is to medically correct her pulmonary oedema before reducing the rib fractures.
Emergency Reg: Yes, but she's in a lot of pain and requires analgesia and I think the best option would be to reduce the fractures first.
ASU Reg: First of all, the thoracic team would be involved in rib fracture reduction. Secondly, analgesia secondary to rib fractures on a background of acute pulmonary oedema makes absolutely no sense. The case is "acute pulmonary oedema on a background of rib fractures." You have no evidence to suggest that the oedema was the result of a fall because you don't have serial images disseminated in time.
Emergency Reg: What do you recommend then?
ASU Reg: Well, contact the Cardiology registrar for urgent management and make the patient known to the Thoracic registrar. In the meantime, you might want to check the patient's haematology to assess anaemia for acute bleeding, back that up with haematocrit and perhaps assess renal function so that if you decide give the patient diuretics - you don't destroy her kidneys while doing it. Other then that, you might want to use some common sense.
*SLAM*
The ASU reg and Consultant just exchanged looks, and the nurses were having a good laugh.
Acute Surgical Unit... hmmm.
If you are at Distant Clinical School, I've worked with their ASU and found it really interesting - and indeed, I am considering a career in general surgery based on that experience (obviously with the intention of gaining much more before I decide one way or another!). You hit the nail on the head in your comment on my blog post - I do love the ability to effect a cure in many acute scenarios (be it in the ED or in surgery). :) I have been a chronic pain patient myself, but I'm just not cut out to handle unmanageable chronic pain day-in and day-out as a doctor.
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