Sunday, December 31, 2006
A funny thing happened to me the other day. I actually saved a life. Right then and there. (Well, actually, there was a bunch of us, but I was there.)
Working in the ED we cover crash calls (cardiac arrests) for the odd areas of the hospital which no-one else covers - the main entrance, the toilets, that bit over there - you know behind the bins and stuff. So when the call came out for a cardiac arrest in the atrium, off we chuntered.
Usually these calls are NOT arrests. They are people fainting, or falling, or feeling a bit funny, and no-one knows how else to get help. So a sweaty mass of eager docs arrives to surround an old biddy, adding immeasurably to her confusion.
In this case, I arrived first, to find an obese woman prostrate on the floor, her airway being held open by someone (I still don't know who) while she made agonal breathing efforts. While feeling for a pulse, I gather she's waiting for a lift home, having just been discharged from coronary care, following her recent MI.
So myself and the next doc on the scene start CPR. We have no masks. I'm afraid to admit, I balked at mouth to mouth. A mask eventually arrives. No oxygen, mind. We crack on. It's an age since I did mouth to mask.
A monitor arrives. Asystole.
The team, by now, is massive. One of them cuts my tourniquet in half in all the excitement. She is coming to work with us in February. I think I shall call her Death-of-Tourniquets.
A better monitor arrives. VF. I silently curse the first, shitty, monitor. Sadly, many people hear my silent cursing.
Signs of life. This is a result. Proper 'ER' style arrest. CPR, one zap and there is life. We feel like Victor Frankenstein. (Well, I do, but I feel powerfully enough for us all).
Clever cardiology docs arrive and spirit the patient away to gleaming cath labs.
This does not happen very often. I have a self satisfied glow for days. Which id fortunate, because nights in the lead up to New Year, with slow SHOs and wankers on tap might have forced me to self harm otherwise.
Without wishing to sound overly saccharine, despite all the best efforts of the wretched bitch Hewitt, once in a while we do triumph in adversity, often in chaotic surrounds, such as the carpet of the main atrium. And I guess that's a large part of why we keep at it.
Merry New Year, one and all
Tuesday, December 26, 2006
This Christmas really was a rush. I only had four days off, which to be fair is more than some, and there are always loads of people to see. I guess I managed to see about half my friends, and most of the family. There was frankly no way I was going to be able to see everyone. It's a bit frustrating really. I find increasingly Christmas is a celebration for those not gainfully employed - kids and the retired - who have time to see everyone. I guess there are a lot of people who end up alone, so I shouldn't grumble, really.
Still, one of my old friends and I had an epiphany, brought on by excessive booze, about how many types of women there are, and how many there should be.
We're both still single.
(FYI, we think there should only be two, but actually there are three. Not that we were generalising or anything...)
Christmas Day was with the family, which was nice, because, other than my folks, I see them less than I see my friends. They all seem to be hale and hearty, and much cheer was shared among us. Along with healthy doses of egg nog.
And so back to work. Another day, another night shift. It really is q***t as the grave. I guess it may yet hot up. We'll see.
I hope to have more to report in time, but for now I'll close. Hoping you all had a grand Christmas, and the New Year brings much joy
Friday, December 22, 2006
Wednesday, December 20, 2006
I'm still feeling shit because:
1) I'm still hacked off about my aneurysm patient.
2) I've still got manflu
3) So has every other bastard in the hospital, and so now I'm covering a night shift, which will delay my holiday break for 12 hours. Bah.
I'm on an education day today, which all too often translates into time sat in font of a monitor not achieving much. This should not surprise many of you reading this... At least I'm resisting the temptation to continue on my quest to re-watch every episode of ER (Series 4, since you were wondering)
To complete the tale of how much Monday sucked balls:
after the trauma that was our unsuccessful resuscitation of the man with the leaking aneurysm, I was all set to resuscitate myself with a cup of tea. (Do any other nationals place so much import in a simple drink? I'm not sure, but, at least in patients over about 50, a cup of tea acts as a mighty panacea...)
That plan went out of the window when, within a very short space of time we received a young epileptic with a worryingly depressed GCS; an unusually heavy man in anaphylactic shock; and a young woman with a severe head injury.
My boss took care of the kiddie (he's fine), my good friend took the anaphylactic (he was actually septic; I haven't had a chance to check up on him), leaving me with the head injury.
Young women with head injuries fill me a little with dread. When I was just a young Turk in the Emergency Department (A&E as was), I treated a young girl with really severe head injuries. It all seemed so senseless then, and this was no different.
Here was this girl, unknown to me, found by her mother and brother, unconscious in her own flat, her face a mis-shapen lumpen mass of bruises. Breathing shallowly and noisily, she lay on our trolley, unprotesting at the cruel invasions of modern medicine - a drip here, a blood sample there, the C-collar, a urinary catheter. I can't even imagine what it must be like to find someone you know in that kind of state. To me, it takes on a degree of unreality. I can only empathise so far, otherwise I'd spend more time weeping than I do already. And that would really put a crimp on my tough-guy image.
Anyway, we got her tubed and ventilated and whipped her down to the CT scanner. A healthy does of ionising radiation failed to show any significant intra-cranial injury, and the ITU beckoned. It's hard to deal with relatives in this sort of situation - when all they want to know is 'what happened?', and 'will she be all right?' and all you can offer is: "We'll have to wait and see".
I don't possess the qualifications to take this opinion into a court of Law, but someone beat the shit out of her.
All so needless.
She went home today.
Monday, December 18, 2006
But I've had a really rough day.
It started out well enough. Quiet department. Easy does it. The first case I saw was a young chap, attempted hanging. Not too bad really. No obvious neck injury, lungs seemed ok. Slowly, slowly crept his hypoxia. I've seen this before - negative pressure pulmonary oedema. Can develop very rapidly, and produce profound hypoxia. CPAP should see him right, but I hope they're as watchful on the ward... details to follow.
Next a collapsed adult. 68 years old, driving his car, fainted. Developed severe abdominal and back pain. Hypotensive and tachycardic on scene, his blood pressure had picked up a bit when he got to us, but his pulse was still batting along.
I know what you're all thinking.
Me too. We have no vascular surgeons here. We're supposed to assess them 'on the trolley' and transfer them out. I almost sent him on his way. But there was a history of trauma, and no history of aneurysm. He'd fallen, injured his ribs, on the left side. I could see the bruising. What if it's his spleen?
Split second decision.
I kept him.
He faded away right in front of me. Tried almost everything. Not that there's much to try. Too late to reverse his warfarin. Ultrasound confirmed his 7.5 cm aneurysm. He lasted about 45 minutes. I have been reminded that even though this fella's fate was inevitable, the wrong decision is still the wrong decision.
Some days, I really love my job
Sunday, December 17, 2006
In which I complain about Christmas shopping.
If you're looking for ranting of a more medical nature, scroll down a post or two.
I really, really hate shopping. I especially hate shopping when every other bastard and their dog is shopping. Christmas is just such a time.
Do not get me wrong, I really like Christmas - although I am slightly disgruntled about how commercial it has become. In fact, I deeply enjoy Winter in general. Once the nights begin to draw in, and there's a frost in the morning, I'm generally a happy Shroom. I suspect this is because Winter houses both my birthday, and Christmas... but that may simply be coincidence. Also, I find it easier to warm up than cool down - but I digress...
For me, shopping is essentially a surgical procedure, to be carried out with an economy of movement, and as little interaction as possible. In, pay for goods, out. Job done.
Browsing is bad for me - firstly because I buy stuff I don't need, and secondly because I end up agoraphobic, with homicidal urges toward my fellow shoppers. So generally, I try to avoid it.
But there's no getting away from it at Christmas. I am, of course, aware of internet shopping, which would allow me to maintain my hermitic lifestyle. However, much though I hate browsing for goods, it's the only way I can find gifts for other people. Because I basically have no fucking idea what to buy...
So today was my annual pilgrimage / penance served in a shopping centre. Interestingly enough, the centre in question does not open until midday. I mis-timed the traffic, so got there early... as did every other bastard in Christendom.
An hour before any shop opened, the place was crawling with punters, wandering around, looking at closed shops! Anathema to Shroom.
I'm not sure if it's significant, but the first shop to open was one of the upmarket lingerie boutiques... go figure
I did eventually conquer my manflu, and get the bulk of The Shopping done. Now I just need to write The Cards... but of course I forgot stamps.
(Although I did buy a pair of trousers I don't need, and a copy of The Breakfast Club)
Right, I've got a fair amount to get off my chest, so this may be in several parts. First off, I'm come over all viral - hot, cold, shivery, cough, sore throat, stiff neck... that's right. I've got man flu. So I'm a bit grumpier than usual.
Next - the allegedly drunken bishop. Last week, it was reported that the Bishop of Southwark had been mugged while coming home from a party at the Irish Embassy. Shortly afterwards, a man came forward claiming that, in fact, the Bish had been stone drunk. This fella alleged that he had found the Bishop rooting around in his van. Being unaware who it was that was rooting, he extracted the chap from the van, during which the bishop bumped his head. An Ambulance was subsequently called, but the Bish, allegedly, ran off.
Over the next few days, when our witness discovered who the interloper had been (from news reports, and personal effects left in the van), the first ting he did was to call The Sun newspaper.
Initially, I thought this whole thing was pretty funny. I'm not so convinced now. This is a tawdry tale to be flashed over the front pages of the popular press; granted, we should probably expect more from our clergy, but binge drinking seems almost de rigeur these days... so should we really be surprised that it permeates all levels of society.
But I think what has really left me with a sour taste in my mouth, is that the alleged witness to the affair thought first of calling the press to make a quick buck from someone else's misfortune. I'm sure he could just as easily have quietly returned the stuff. What price dignity..?
Next - a recurrent rant, reverberating around many medical fora, and heard throughout the British blogosphere... how fucked up is the Health Service? I share the feelings of far more eloquent colleagues, Drs Crippen and Rant (among others).
The Health Service is being run into the ground. There isn't enough money - free health care is bloody expensive. What money there is is being spent on managers and chasing targets.
Once again, the Government insist on fucking around with training. The opportunity to spend time trying the feel of various specialities, before committing yourself, would appear to be long gone. So, too, the idea that medicine would be a job for life. I remember talking this over with Pa Shroom when I was 17 or so. He was keen to dissuade me from doing medicine for the sake of it. Hard work, he said, but rewarding. Pa Shroom thinks there's nothing better than treating patients. A job for life, he said. (Unless of course, you're shit)
A job for life.
Now there are people finishing medical school with no house jobs to go to.
Now there are basic trainees who can't find a higher training job to complete their education.
Now there are higher trainees who face the prospect of no job waiting when they finish. (Shroom counts himself among this number)
As far as I can see, ever since Nye Bevan agreed to choke the throats of doctors with gold, there has been a steady attempt to reduce their power and influence. Technically, we are no longer professionals, as we no longer exclusively govern ourselves. (Although this may not be such a bad thing...)
Although, generally speaking, the public still hold Doctors trustworthy, the Government seems to be in competition with their predecessors in showing us as little respect as possible.
What few perks there were to this job, are fading fast. Even now, my training budget, which is not a perk, but, I thought, a contractual obligation on the part of the Deanery, has been pulled from under me.
So; I am now expected to fund my own training, in the hope of being qualified for a non-existent job. It is surely no wonder that the medical profession does so well in the depression / substance abuse league tables.
And what are we doing about it? As far as I can see, fuck all. I will freely admit that I am a simple man; so maybe it just seems like we're doing fuck all. But the body politic of the junior doctor, should be among the most powerful in the country.
If we stopped signing death certificates, the country would grind to a halt inside three days. Then that bitch Patsy Fuckwit would have to listen to our concerns...
I am worried that we idle our time away, while all around us, Rome burns.
Friday, December 15, 2006
Meanwhile, back in the trenches. Tonight has been fairly slow. There have been a couple of high maintenance patients, making life difficult. The first was a nice fella, in his 70s, who lost control of his Mercedes (for legal reasons, you should know other cars are available), and stacked it into a field. Apparently he rolled it several times, and there was significant intrusion into all compartments. (it's fucked, basically) He had been in the department a while when I arrived. He had obvious external head and facial injuries, a compound (open) fracture of his left humerus, closed fracture of his right wrist, closed fracture of his right ankle and his bladder wasn't emptying. Oh, and he was on warfarin. (A rat poison, used by primates like us to thin the blood)
I caught up with him in the CT scanner.
1800 - take handover. Read through notes. Guddle about with various forms of contrast. Ponder the reasons why his catheter is not draining. Twiddle thumbs, while ionising radiation envelops patients whole body.
1830 - shudder with embarrassment when it becomes apparent that he still has his trousers on, with lots of metal rivets and coins therein, buggering up the CT scan.
1845 - breath sigh of relief as CT scan shows no serious injury to neck, chest or abdomen.
1847 - shudder yet more with embarrassment when CT reveals that the catheter is not in the bladder, but has been blown up in his urethra, causing some, not insignificant, trauma.
1900 - return to ED.
1915 - explain findings to patient, patient's son, orthopod, and general surgeon.
1930 - discuss catheter problem with urologist, who is in another hospital, 30 minutes away. And not leaving. We agree on a suprapubic catheter. I have never done one of these, but it seems easy enough.
1940 - orthopods want to take him to theatre, so agree to wait on SPC, on the grounds that it can be done while he's under.
1940 till about 2100 - attempt secondary survey, and clean up the fella's face, suturing as we go. Grumble about what passes for a fine suture set in the NHS these days.
So, for the first three hours of my shift, I was tied up with one patient. I did manage to fit in a quick hip reduction, while the orthopod was talking to him, but you get my drift. Now, the NHS, and indeed that bitch Hewitt, allow us 2 per cent breaches - i.e 2 percent of our patients can be in the department longer than four hours - and this guy would clearly be one. But this makes no allowance for the fact that while I am ensconced with this one guy, I am not out on the floor, seeing other patients. There is a domino like effect, and the breaches begin to mount up. I despise the four hour target, and the fact that it is trying to make time the most important factor in patient care, and especially the fact that it is trying to turn me into a triage monkey.
As I write this, the English cricket team is falling apart down under. Currently, nothing but a massive partnership between Freddie and KP will save us. I suggest you chase the blues away with your own print out, cut out and keep cricketer mask. Hilarious. No, honestly.
Lastly, I'm pleased to report an continued improvement in my mental state. When I began this, I felt depressed, although having read some of SHP's eloquent post's was forced to reconsider, and label myself miserable. However, I'm very nearly cheerful now. I'm sleeping better, and generally a lot less pathetic than two months ago. Hurrah. I think I started this purely to vent, in the expectation that it would fester in a little corner of the ether, and was genuinely surprised to discover other like-minded folks out there. Right now, I've got a lot of love for the community of blogonauts I've stumbled into. So it's probably time to cut back on my meds.
Which reminds me - drunken bishop. Great story, not such a great advert for the clergy. More later
Tuesday, December 12, 2006
Actually it was pretty quiet. My bosses were appraising another of the registrars, so I had to cover clinic; I'm not a big fan, but it was a small clinic, so not too bad. Interestingly, one of the cases was a patient I had apparently consulted on (according to the notes), with a locked knee. This is not the sort of thing I would usually send home... but there it was in black and white. (well, black and green actually. Our Paeds paper is a funny colour, but you get the gist.) I bounced her to ortho... but it goes to show how your brain stops functioning when you're tired. I was asked about this case late on Thursday night when I'd been up all day. I had to find the SHO who saw the patient, and apologise for handing out bad advice. Need to concentrate a bit harder, I guess.
The day began with one of the Nurses telling us all about her problem trousers. Apparently, since she returned from a year travelling her scrub trousers don't fit her. Much tears, and gnashing of teeth. She has one pair of baggy ones that do fit, but she split those. So now she has the denial trousers... and we were all on split watch. I quite enjoy the sense of family in an ED that allows her to feel comfortable sharing that with the whole team.
Then, a couple of kiddies. One with Brugada syndrome, another hypo from gastroenteritis, and a little one who kept turning blue... go figure. They're all doing fine; and that was more or less it. The big plus was finishing early. A real rarity these days, so always worth taking advantage.
Lastly, I phoned my buddy, who had his assessment today. Rather grimly, it didn't go well. He didn't go into much detail, but it sounds like the bosses had the knives out for him - although not regarding his clinical abilities. I don't think he was expecting it, so he's a bit pissed off. I'm not sure my phoning will have helped. I hope he doesn't think I was phoning to 'gloat'. (We had something of a childish bust up a while back, and aren't quite such good friends anymore...)
Personally, I find this quite odd. I've always thought of this fella as a really personable guy; he's very hard NOT to like.
Or so I thought. I guess we all have two sides to us, eh?
Monday, December 11, 2006
Those of you with even a passing interest is MMC, should look here. Very amusing, and my thanks to Dr Rant for shedding light upon it. I continue to be generally dismayed with what I think the future holds for medicine, medical training and Emergency Medicine in this country. I'm not sure where it went wrong, but I can't shake the feeling that a disaster of epic proportions is looming.
Sunday, December 10, 2006
Doctor -- "I can't figure out if this guy's chest pain is cardiac, or not.."
Nurse -- "Well, it doesn't really matter; he's breached anyway" (i.e, he's been in the department longer than 4 hours, so counts against us as a statistic)
Now call me old fashioned, but it seems to me that the nature of his chest pain is important, regardless of how long he's been in my ED. (High horse positive)
I know what was meant - which was that making a rapid decision is no longer important - for the Department - as he has already moved into the breach column on the great government ledger... so beloved by that bitch Hewitt... but it still distresses me that we are beginning to think like that. People's care should come first - and I accept that trying to minimise time in the ED is one way of trying to improve that care, but it shouldn't be the first thing we think of. Dammit!
As for vanity... I have discovered a link to my blog on another blogonaut's blogroll. Makes me feel loved. Perhaps I need to get out more?
Saturday, December 09, 2006
Today, a patient fell through the cracks in the system. She presented short of breath and was seen promptly by one of the SHOs (junior docs). When he went home, some of her investigations were still outstanding, so he handed her care over to one of his day shift colleagues. Sadly, he did not document to whom he handed over; it appears that his colleague promptly forgot about the patient.
She sat in the ED obs ward for 8 hours, with little or no intervention. Both shifts of doctors and nurses failed to notice this patient... she was then admitted to the main hospital, to the medical service; but sadly without any prior discussion with the medics. This provoked much wailing and gnashing of teeth.
When I came on shift, everyone knew about this problem, but no-one had done anything. I realise it had been busy, but it isn't going to get any quieter. So, 12 hours after we began to neglect this patient, I had to try and clear up the mess. I hasten to add that she has come to no harm; but this certainly appears to be more luck than judgement. Some days, I'm really proud of my profession.
I hate working weekend nights. Although I actually quite enjoy nights, weekends suck balls - they're busier, and you work in the knowledge that all your friends are out having more fun than you are. Anyway, rather ironically, last night was relatively trauma heavy. Assault with major head injury, and some bloke who fell 20 feet off a balcony. Rather bizarrely, he had his valuables stuffed in his socks (pack of smokes, and a door key). I wasn't really in the mood last night. This seems like a terrible thing to say, and I think it looks worse written down; but every now and again, I have an off day... last night was one, but I feel recharged tonight, so hope to acquit myself a bit better.
Had several beers with one of my bosses while on this course, which led to some very interesting topics of conversation. It's amazing what can be happening right in front of you, but in the background. Or maybe it's just me being dense. Anyway, my lips are sealed... for now.
Lastly, having only recently obtained the Stones' masterpiece that is 'Let it Bleed', I was surprised to hear 'Country Honk' - isn't this exactly the same song as Honky Tonk Woman? Is this the point? Have I missed something? Or did they really release the same song twice?
Enquiring minds want to know
Also while away in sunny Brighton, I had the opportunity to indulge my love of Thai food. The restaurant I ate in was very nice, but completely empty. This wasn't all that surprising, given it was on the seafront, and blowing a gale. However, the staff seemed particularly amused to have a solitary customer; or maybe something was stuck to my face... whatever the reason, they seemed unable to come near me without giggling furiously. I found the whole thing vaguely surreal, and offputting.
So, I have returned. I've spent the last few days on a fairly intensive ATLS course. This is the Advanced Trauma Life Support course, care of the American College of Surgeons. It teaches one safe way of caring for the trauma victim. The courses are pretty good fun, but fairly hard work. Since part of my job involves looking after trauma victims (or at least the British definition - we don't have much "proper" trauma per se) I expected, and was expected to do well. Which generally increases the potential to fuck up. In front of the boss.
Well, you'll all be pleased to hear I managed to avoid all / most banana skins. I am now all shiny in the ATLS fashion. It is interesting to see that not much has changed since I first did the course six years ago. I tend to find these courses are arbitrary, as they are trying to teach a UNIVERSAL method, which is 'proven' to be safe. Trauma care is especially difficult to get evidence for - it's very hard to ethically justify depriving multiply injured patients of care to see how it affects outcome. Getting consent can be a real bitch, too! A good case in point is the use of steroids in head injuries. This was considered a gospel treatment, in the UK at least, for years. Only relatively recently has it become apparent that not only did this not improve outcome, it actually does harm. Primum non nocere? Ooops.
Consequently, as far as I can see, most of the developments in trauma care originate with the military - WWI, WWII, Vietnam, Falklands, Afghanistan and now Iraq. Wherever there's a war, there are large numbers of traumatised patients... of course, they're mostly young, fit men and women. Or pigs. It always seems to be pigs that the military surgeons practice on...
So extrapolating data to the real world, which is slowly filling with fat, older people, may not work. Even so, I was disappointed not to see any comment on issues such as permissive hypotension / hypothermia. I seem to remember these being contentious issues six years ago, and I guess the picture's no clearer.
Thanks again B.R.N
Monday, December 04, 2006
It seems a few people out there are actually reading this. With minimal false modesty, that's nice to know, but also a little surprising, as I assumed this would get lost in the static... anyway, thanks for those who read and take time to add commentary. It makes this a little more interactive for me.
I also feel I should apologise. I started out intent on passing razor sharp commentary on the state of the Health Service today, backed with witty, and fascinating anecdotes, based on my clinical experience. Instead, I seem to end up mostly ranting, in a barely articulate form. This seems like false advertising, so sorry... but thanks for tuning in anyway.
I'm heading off for a few days on a course - as a student this time, not an instructor. I've spent the last God knows how long banging on about how easy these courses are, so expect tales of me falling flat on my arse.
'Till the next time
Saturday, December 02, 2006
Normally we do single weeknights, and three at the weekend. Last night I was covering for one of the other Middle Grades. Friday night always holds the promise of being a bit more exciting than a regular night. Especially when it falls just after payday. Last night, however, the weather was truly dreadful - at least by English standards. Clearly it wouldn't have raised much on a tropical storm scale, but I still thought I saw a man with a long beard working on a huge boat. (What about the evil fish, tho'. Still unexplained...) Bad weather sometimes works in our favour.
Things were actually pretty good when I came on. A couple of patients in Resus, but both stable. Only a few in the racks, waiting. Then - something went wrong. I'm sure my halving of my nicotine dose didn't help, but even so...
Suddenly, I found myself with no doctors; they were all on a break, or with someone, or something. Then all the doctors came back, but I think they'd been out collecting patients. I wouldn't put it past them.
It actually started well. We had to improvise some kit, to get a difficult NG tube down, and then visible on CXR. Very Heath Robinson; reminded me of when I first started out. But, then the onslaught began...
So - I had to move 'small bowel obstruction' out, and off to theatre, hope that 'stridor' would hold her own for a bit. That gave me the chance to see 'dislocated ankle' (with bonus 'altered conscious level') and pull the offending limb; once that was done, we whipped in 'dislocated hip' - lots of pain, very anxious - albeit with no real success.
This calm procession was interrupted by 'acute lower GI bleed (?perf)' man, and his party trick, "the vaso-vagal". Once MY pulse normalised, I was able to attend to 'young fractured wrist' , 'large scalp lac kid' and the re-do ankle manip. In the background was a poor unfortunate lady with a broken hip. To add insult to her, already substantial, injury, her heart kept trying to give out on her.
Time for a deep breath:
Then: 'suicidal overdose', and 'accidental (booze) overdose'. I punctuated this with a young lad who'd dislocated his elbow. To add insult to his injury, I had reassured him, prior to x-ray, that it wasn't dislocated. That's me taught, then.
(It went back, no trouble)
At some point, 3 giggling buffoons pitched up having stabbed themselves with a Stanley knife. Not having sustained life, or limb, threatening injuries, they were advised of our substantial waiting time. They promptly discharged themselves. Still, at least they got a nice ride in the 'Dorset Big White Taxi Service'.
I have an idea that there was more, but I can't remember.
No-one died, and almost everyone got treated in reasonable time. But I can't remember a night so consistently busy at this hospital.
The fallout to this happy clinical ballet was that I was still at work at half six this morning; this blew plans for a quick jaunt up to London right out of the water. Ah well.
I'm still not married, in case you were wondering.
I also didn't smoke any cigarettes. My final weaning programme is under way, and I've a feeling it's going to take a while for me to get used to the reduced dose...
Thursday, November 30, 2006
Next: my assessment with the bosses. This went pleasingly well, and has left me with written evidence that I "ooze confidence". This will undoubtedly make me even more big headed than I already am; fortunately the nursing staff were on hand to remind me that that's not all I ooze.
Lastly, and perhaps most randomly, a girl I barely know has agreed, on principle to marry me. Matron is worried that the lady in question will end up on the shelf; as for me, I think she's just worried. Anyway, just as I was on my way out the door, Matron pipes up - "she'll marry you if you ask her". Nice. Acceptance of a proposal I didn't make, by a girl who doesn't really know me... I've decided to take it as a compliment.
The department was fairly quiet today, in case you were wondering.
Wednesday, November 29, 2006
Whatever your personal views are about Doctors with God complexes, surely it has to work both ways? If I can play God by not treating someone, what am I doing by treating someone. Didn't God create meningitis? Is a ruptured aorta too not God given? As far as I can see, you can't have it both ways; playing God as meaning making life-or-death decisions..?
So why do the papers never scream 'Doctors played God by saving my critically ill baby'? Not good news? Or do I just need to up my lithium dose?
Answers on a postcard, please
Friday, November 24, 2006
Ranting to follow...
Previously on 'The Knifeman'... I contemplated giving up the drink, and smoked a cigarette.
This weekend, I got royally plastered, and smoked a cigarette. This might be a worrying trend. My dismay was tempered, however, by a very dear friend of mine who gave me a t-shirt for my birthday; it celebrates a triple birthday - mine, hers and another friend of ours, all within a few days of one and other - with a collage of amusing pictures. Only after a while did I realise that one of these photos was of my genitals... still it's not every fella who can boast he owns a t shirt like that.
Today, I find myself marvelling at how quickly someone gets sick in front of you. I know that sounds obvious... ill people will go off if you just look at them - that's what they do. But sometimes people become more ill in retrospect as you begin to realise the enormity of how unwell they truly are.
The only analogy that makes sense was one I heard used by soldiers in Vietnam. They talked about VC snipers getting older after they had died. They would convince themselves that the 12 year old gunman couldn't be that young. Small for his age, sure. And youthful, 'cos of his race, sure. So that by the time they got back to camp, the 12 year old kid was 18, maybe even 20.
Anyway- I know what I mean.
Here's how it happened today...
---The young man is brought to us, welcomed into our warm embrace. The call came ahead of him. 'Known alcoholic, post EP fit'. Right now, he's not too unwell. We've all seen this before.
---He's post ictal now, sluggishly unco-operative as we slide needles into his veins, push and prod and probe him. 'Mother says he's done this a lot... always fits when he comes off the booze'... he's still not too bad. Obs are stable (-ish)... another withdrawal fitter...
---Then: actually, maybe he hit his head, as he went down... maybe. Mum says she thinks he's normally come round by now... obs still ok, sugar fine... but maybe his pupils don't look quite right... shit. Maybe he's bled. (Bleeding inside your skull is bad. It should be right up there on your list of places not to bleed from)
---Next: he wakes up, rambling, all over the place, hallucinating, gibbering. Struggling. Shit. Delirium tremens?
Lots of people pick up the habit of casually describing withdrawing, tremulous alcoholics as having the 'DTs'. They're usually wrong. I've seen a lot of alcoholics in withdrawal. I've seen a lot of tremens... but the DTs is a different kettle of fish altogether.
---Shit. He really is sick, isn't he. And his temperature's what? Shit... 39? Shit.
---Finally: as if adding insult to injury, his blood results come back. The final hurrah underlining quite how fully I had underestimated this guy's condition. Sodium 102; Potassium 2.2. Balls. Time to admit defeat, and call the fellas from Expensive Care. My 'routine' withdrawal fit evolved in front of me, into an unstable, head injured, encephalopathic metabolic nightmare. With the DTs. He won 24 cm of rigid plastic, and at least one night on a ventilator.
Sunday, November 19, 2006
The statistics tell us that binge drinking in young people is up - see Panorama on BBC1 this evening - and that bastion of liberal, rational thought, the Daily Mail was screaming about the number of people hospitalised by booze on a daily basis. The more I think about it, the more I'm forced to admit, they've got a point. Somewhere, deep in our culture, is the idea that a good night out ends up with us paralytic. I'm as, if not more, guilty than most. Medical school is, or certainly was in Shroom's day, almost a training ground for hard drinking. It is no surprise the medical profession fosters more drunks than most; we get our training in early.
For myself I consider this a great shame, because I like a nice drink with friends, but I now have serious doubts about my ability to drink responsibly, or whatever the current PC phrase is. So I am faced with the unappealing prospect of giving it up altogether... of course this could be yet more melodramatic over-reaction on my part; that would not be out of character, but if I find myself unable to know when enough is enough, what are my options? I nearly lost a very good friend to drink, have seen colleagues go to the wall with it and I've soured more than one relationship through it. Maybe enough really is enough. Time, Shroom, please? I'll let you know.
Since I'm feeling confessional, you may as well know I smoked a cigarette today. Just the one, mind, but I'm quite pissed off about it. I'd managed seven weeks. Ah, well; gotta keep on keeping on I guess. One in seven weeks, isn't too bad. Not that I'm counting...
To keep up the cheery mood, I continue to be distressed about the Government's ideas about how Medics should be trained. Several of my more eloquent colleagues have also held forth on this matter. I recommend this and this for a neat summation of the frustration suppurating within the profession.
Actually, since we no longer govern ourselves, we're, strictly speaking, not professionals anymore. Which is nice. My father, Pa Shroom, is an old school, retired, surgeon, and I regularly see him shake his head in amazement at plans put forth by the bunch of chimps currently governing this country. I am especially concerned for the future of surgery in this country. As training is shortened, and 'simple' jobs farmed out to Nurse Practitioners, there seems that surgery will go backwards. Pa Shroom fervently believed that Surgeons should be Physicians who "knew how to cut". This idea is still clung to by a few, and mostly laughed at by the real Magicians. Which is probably fair enough. But it bloody should be true. However, increasing knowledge base, and sub-specialisation has meant the end to generalists of all kinds. My big fear, though, is that if surgeons keep allowing themselves to be thought of as technicians, rather than well rounded medics, that is what they will become. And it's no great leap from there to abandoning medical training for them, because if they only cut, why would they need all that extra knowledge rattling around. I realise this is very far fetched, and I'm sure all surgeons out there are interested in the pre- and post op management of their patients medical problems, but I increasingly see an attitude amongst my knife wielding brethren of disinterest in anything that can't be cured with cold, hard steel. I even hear talk of surgical requests for medical consults on febrile post-op patients because "fever is a medical problem".
Friday, November 17, 2006
It was four a.m when the phone rang, summoning me from the pit, urgent, breathless. Then the waiting. Hurry up and wait. Finally he arrived.
Young, much younger than me. Whiter than the sheet he lay upon, face a mess of blood, one eye ruined and his nose smeared across his face. Car wreck; high speed; no output; downtime 90 minutes. All around me, the staff are working, anticipating what needs to be done, almost eager, as if by sheer force of will we can play God.
But I know it's hopeless. We can try all we want; nothing will work. There's no simple solution here. It's done. No-one disagrees, but I feel their disappointment. They wanted to win one. But we're not God. And God don't play dice; at least not to lose.
What a fucking waste.
Anyway; the night has been interestingly busy, until now. I have had some spectacularly slow Juniors on with me, and been more than a bit lazy myself. But the way seems clear now, which is why I'm on here.
I'm slightly grumpy and agitated because a case report I'm trying to write appears to have spiralled out of control, and developed a life of its own. I've lost track of the number of papers I've read in preparation, and appear to have found all sorts of facts and figures one furious, delirious night... which of course, I now can't find. Somewhere out there is the evidence I need. The Shroom will get published.
Having perused some of my medical colleagues efforts, I'm slightly disappointed I don't have anything more profound, or serious to add; makes me feel a bit of a fraud really. Especially as I feel like I have plenty to contribute. But actually I'm just like a backbench M.P. making plenty of noise, but all of it actually bollocks.
I'm still frustrated about what the government is doing to health care. They insist more money is being plumbed into it, but I don't see where it's all going. Emergency Medicine seems like a speciality under threat to me; if time is your most important marker (all hail the 4 hour target), then clinical care is at risk of being sidelined. Some days I don't feel like I do any medicine at all. I'm just a well qualified triage monkey. Cutting back junior docs hours and their responsibility delivers ill trained, under prepared junior doctors to a system that doesn't have time to teach them. Or worse, doesn't have room for them. It makes me sick. The body politic of the junior doctor should be amongst the most powerful in the land. And yet all we seem to do is get reamed by the Govt.
Thursday, November 16, 2006
Good things this week - picked up a fella with recurrent PEs who was in danger of drifting through the system with other diagnoses.
Meningococcaemic boy is improving
Bad things this week - sent a woman home a bit precipitously post treatment for ?anaphylaxis. However I know now that there can be significant withdrawal PV bleeding with adrenaline; who knows, I might even have exposed another pathology early. That might be a good thing, but for now - a bad thing.
There's more to come; have faith, hold the line etc
Sunday, November 12, 2006
The first thing I did on my shift today was to hold the hand of a dying man, so he wasn't alone when he breathed his last.
The last was to consign a two year old child to the ITU with meningococcal sepsis.
So I'm too tired. I'm going for a beer. I suggest you do the same.
A people who sacrifice liberty to gain security will likely lose both, and deserve neither.
I'm paraphrasing, but you get the idea.
Whilst I generally rail against the Left wing liberal hippy side of the Shroom, today seems like a good day to hug a loved one a remind them how you feel.
More ranting later, I promise.
Saturday, November 11, 2006
However, I did later have the honour to meet (and treat) a veteran of The Great War; at least, that's what she told me, but as she wasn't 106 years old, I'm thinking she meant WW2. Either way, it's sobering to meet people like that. For all the talk of a war on terror, and the occasional fear of some nutter blowing up a tube, I don't think my generation has any concept of what it must have been like in either world war.
To have a real fear that regime change might be forced upon you, rather than something your government implements on your behalf on some other poor bastards, hundreds of miles away. Part of me thinks this is responsible for general apathy / anti-war feeling. I myself struggle to come to terms with how I feel about the various armed incursions we are prosecuting right now. It seems to me that where we are interfering, the incumbents (e.g Saddam, The Taliban) were bad. At least according to our value system. And I guess that's always going to be true for a certain value of "bad" anyway.
But I'm not sure what we're doing is making anything better. I just don't think you can take one culture and completely subsume it with another... not without wiping out entire races / tribes / peoples. Which is called genocide. And that's bad. Isn't it? And because most people can't see what the Armed Forces are fighting for either, the deaths all start to seem meaningless. Which I don't think can be right. Fuck it, I don't know... the whole thing confuses me. But I'm worried that people will forget the significance of today. Whether war is right or wrong is not the soldier's fault, but the government that commands them. Either way, we should never forget those who went before us.
On a lighter note, we all scanned our bladders at work today. I lost.
Friday, November 10, 2006
I finally do have a day off tomorrow, in anticipation of my working the weekend. This will be a real day off, as opposed to my pseudo day off I grumbled so much about recently. Today I saw my first dislocated knee, which was less than pleasant for the owner of the knee, but I'm pleased to report we relocated it with no difficulty. On the bad day side of things, I had a disagreement with my boss about the management of a patient. This is never good, especially when you think you're right. Fortunately the resident magician took the case, and saved me from having to flat out disagree with the boss. I now have to find the evidence to back up my belligerence, or apologise. The Shroom is not quite as good as he should be at saying sorry; and Lord knows I've had enough opportunity.
Maybe you can't teach an old fungus new tricks?
The patient is doing well, by the way, all politics notwithstanding
Wednesday, November 08, 2006
Enough griping; I have work to do... it's my day off, y'know
This is my favourite time to be in hospital; it's quiet, and the semi darkness gives the dreary grubby hallways an almost magical feel to them. It's somehow satisfying to be going about my business while the rest of the world sleeps. You see odd things - strange little vignettes of life. Odd machines, that look as tho' they date from the War are wheeled around, emitting little flashes of green light, and beeping mournfully. There's never quite enough coffee.
Enough. I must rage against the croup with a 3 year old. Time to look God in the eye, and see who blinks first. While I'm gone, try the following to keep you amused:
Lastly, without wishing to sound like a corporate whore:
Those of you with a desire to experience the thrills of an African safari in glorious Tanzania, could do worse than to look up a good friend of mine. He's a redhead, but don't hold that against him.
Good night, and may your God go with you.
Tuesday, November 07, 2006
Well, for now, I AM the man in the white coat. I'll let you know what the source of the smell is, but I'm terrified it might be code brown...
Till next time
I stand on the verge of another night shift, filled with the trepidation that comes with knowing there's a good chance someone will try to vomit on you in the next 14 hours. Still, my mood continues to improve, and for no apparent reason. This is both pleasing (because I no longer feel depressed) and frustrating ( because I have no idea why I no longer feel depressed). Maybe my brief wrestle with the concept of my own mortality has done the trick; or not. Recently I have become worried about what to do when my parents die. This is wretchedly morbid, but I know the day will come, because it comes to us all sooner or later - unless, of course, one or both of Ma and Pa Shroom are bionic, and haven't told me. But I'm also concerned because I'm a grown adult, so apart from the emotional trauma, I should be able to get on with the actual living of my life. And yet somehow, I fear I won't be able to. As if somehow there absence will expose me as a fraudulent adult, blagging his way through being a grown up.
Bollocks to it. Too much of that sort of thinking is what started me off in the first place.
More from the night shift to come...
Wednesday, November 01, 2006
Today has found me at work on All Hallow's Eve, which has least spared me the mind numbingly tedious rites of passage that is delinquent trick or treating... not that I'm a killjoy, or anything, but I fully expect to return and find Shroom Manor defaced with eggs/faeces/sacrificed goats, etc. One of my colleagues has made the effort of dressing up, with a fake knife through his head, and dark green lipstick. I'm slightly worried that many of the patients won't realise the significance, and will just end up 'tut-tuting' about how dress code standards have fallen.
The night has, so far, passed relatively without incident. Things have picked up a bit just now with the arrival of a few lads who have decided to celebrate Tuesday with a lager fuelled punch up. What I always enjoy about these occasions is that they invariably think the ED is a suitable place to continue their pugilistic endeavours. Security for us is usually provided by men and women more suited to less physical pastimes, so it's agreat chance to practice diplomacy... if your that way inclined. At least no-one seems to have been badly hurt.
Our one serious case today was a youngish man having a heart attack. Despite having been rapidly and appropriately thrombolised in the field by the Paramedics, his symptoms were not improving in the ED. I could almost hear my sphincter tightening as ECG after ECG demonstrated persistant, extensive ST elevation. And he was slowly turning grey (regular listeners know how I feel about grey...) To spice things up yet further, his ailing heart began throwing increasingly frequent ectopics into the mix, and he developed haemoptysis. Fortunately, with a great moan of relief, his pain settled, and his ST segments began to normalise. Another case of masterful inactivity getting results
Lastly, for those of you still with me, my mental state seems to be on the up. I'm not sure if this is just because I'm at work... sad, but true, but being at work almost cheers me up. I guess this is because it represents a (relatively) controlled environment for me, with managable problems. Regardless of cause, I'll take it.
Ah well... back to the floor.
Sunday, October 29, 2006
In GP land?
God love us all...
--- Many years ago, when Shroom was just a little fungus, he was asked to come review a patient. He had learned that when some nurses asked you to come, you came a'running; so he came apace. "I'm worried about this guy. He's blue"
Blue should also be on the list of colours you're not.
"Are you sleeping under this?" Nod, shiver...
Gently, I rubbed his skin; the towel came away blue, the skin beneath gloriously pink. 'Cured, Sister' winks the Shroom; 'needs a new blanket...'
Guilty Pleasures, no. 1
--- I'm secretly delighted every time a Paramedic or Policeman calls me "Doc"
I seem to have a little hope in my heart this morning; I hope this doesn't signal the onset of mania
Saturday, October 28, 2006
I'm on my way out; it's half past cold and dark, so I'm going to try and find some human companionship; people with whom I can spit at the advance of winter. But a couple of things occurred to me:
- At home I drink coffee in a mug purloined from my place of work. It has this fact emblazoned upon it, ostensiblt to prevent theft. But it actually egged me on. Where's the sense in that?
- A pox on medical technology. One of the things that keeps me going, especially through long dark nights of the soul, like this one, is the fact that we occasionally do some good. My most recent 'save' was a tiny baby. The call came through: "Seven day old child, unresponsive". This sort of thing is inherently sphincter tightening. Paeds really tests my comfort zone. Dammit! Who else is on..? Just me... Then they're here - mum in tears, dad confused tearing his air out, baby, quiet, not moving... grey.
I'm never quite sure what goes through the mind at times like this. Grey is not a good colour. It should be on your list of colours you're glad you aren't...
OK; airway's clear, and he's still breathing. God he's awful cool. Little heart is racing... I wonder if - and then the nurse pipes up "BM is off the scale low"! God love nurses, and little babies. His BM! This means his sugar is low. I don't know why, of course, but right now, I don't care. What do I do? I'm a professional, don't you know... I smear my finger with glucose, and I pop it in the little fella's mouth. He suckles himself right back to life. I think we both share a smile. Maybe a tear.
Now I know, he needs labs doing to determine the cause of his low blood sugar, and I know treating him without the labs makes subsequent workup a little bit more difficult, but today, I don't care. He came in grey, and went out pink.
And so it begins...
Good evening, good morning... whatever. If you've come this far, come a little further; you might just save my life. Or I might just be another drama queen. I'm not sure yet.
That's me on the left. I'm trying to look cool, and I thought I'd done a good enough job. I'm not so sure anymore. This blog will serve as my anxiety dustbin. It might even be a cathartic experience, but mostly I just want to sound off; vent my spleen as it were. Listen if you will; I guess this way, I don't have to know if you aren't.
The Shroom is a 32 year old Brit working in Emergency Medicine - Accident and Emergency as was ( or Casualty,
if you're old enough...)
I studied at a London Medical School, where I had more fun than was seemly.
I'm beginning to think I had more than my due
I've been qualified 8 years now, and find my self adrift in the Emergency Department. I feel like I've been left behind, but I'm not sure how, or by whom... more of that later, I guess
I'm currently trying to give up smoking
I think I'm clinically deperessed
I'm far too fond of three full stops...
Aims and Objectives
In an ideal world, we'd be having this conversation over a beer... but life doesn't always work out like that. I need to vent my feelings here I think, until I can find somewhere else.
This will include details of my life - patients and all. Of course,
confidentiality is important, and I believe the details will be obscured sufficiently to protect the innocent. It's all make believe anyway...
Once upon a time, I thought it would be easy. To be honest, it was pretty easy. I'm a lucky shroom. Ma and Pa Shroom are well off, and ourstanding parents. Having seen the raw deal the world deals to some people, I have nothing to complain about. But, as I'm sure you all know, nothing is quite what it seems
That's my grandfather; the Shroom is a thrid generation kniefman, and quite proud of it. But I think it has skewed my ideas. I'm forever stuck with a foot in the past, bemoaning what was; you'll get quite usd to this idea, if you stick with me for a while.
Anyway, here we are. Here I am. It's quite frustrating. The bulk of the hard work should be behind me, but most of the time I'm feeling lousy. I think this is the beginning of an existential crisis. I feel older than I am, and the fact of getting older is upsetting me. Good old traditional mid life crises. Many of my friends and family are moving on, getting married, having kids, settling down. Ma and Pa Shrom are getting older! Clearly this is the way of things, but it suddenly seems to have caught me unawares. I feel very unsettled - which is not unusual for the Shroom. I've been here before, when I went off to Fungal MedSchool. But this just feels like I'm only going to get worse... feel like i'm only going to get more disconnected. Churchill's Black Dog is my constant companion.
I've never wanted a cigarette more than I do now. Strong coffee, tobacco and self pity. Yum!
It is, ultimately, rediculous. But I want to feel better. I think the Shroom needs to put roots down again. Or whatever the hell mushrooms do.
Nuts to it. Thats a beginning. I'll be back, gentle reader, and I'll try to be less self absorbed, and share some tales from the floor; try to pique your interest. Tonight, I must make a dash to Luton, on a mercy mission for a beloved Lemon, and tomorrow lunch with Rage, and tea with Ma and Pa Shroom. Make of it what you will.
Let me know...