The Thing That Came From Somewhere

Last of the year.

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.

No pulse.

Shit.

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.

Shit

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.

**SHOCK**

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

Ghost of Christmas Past

I had the opportunity to read the Christmas BMJ over the holidays, which is always good value. This year, I particularly enjoyed this article. It really appeals to the nostalgic side of me. Have a read, and let me know, if the spirit moves you so.

GoKart Mozart and the Backyard Bombadier

I have returned, peering bleary eyed from my temporary hibernation. Once again, I had intended to have a stockpile of interesting, amusing stories with which to regale you. Due to a combination of my poor memory, and not that much happening, I have failed.

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

Joy of the Season

Bah Humbug

I'm at work; another night, another party I'm not at. Not that I'm counting.
Unless anything exciting comes to pass, this'll be my last post for a few days, so let me take the opportunity to wish you all a Happy Christmas.

One more friend, blown off the mountain with the wind

I'm beginning to think I write an awful lot of crap. But a few of you seem to come by daily, so I'm guessing not everybody minds.

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.

Trading snakeoil for wolftickets

I had had a mind to write about cutting corners today. About how, in medical school you learn the formal way of doing everything, and then gradually learn to shave bits off, and streamline yourself...


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.

Aneurysm

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

Not necessarily stoned, but beautiful nonetheless

Last of the day, I think
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)

I couldn't have said it better myself

Read this. Please.

"I came through time for you, Sarah..."

The Terminator, of course. But what a brilliant line, eh?

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.

Class.

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.

It's my party...

Actually, it's not. It's the ED annual Christmas party, and I'm not sodding there. Yes, indeedy, I'm at work. Bastards. In fact, it's a grand old tradition that Shroom will be working on the day of any large, fun event that his department throws. So I shouldn't really be surprised. And my friends did phone up, from the party, while steaming drunk, to tell me how much fun they were having. Which was nice.

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

Bad news travels quickly

Odd day today. My first day shift for a while, which is nice. You get to inherit a fresh department, full, of optimism and hope. For a few minutes anyway. Then the day comes a knocking... or whatever.

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?

The end is in sight

Or at least I hope it is... a few more hours, then I can snooze into my 'day off'.

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.

Being, as I am, something of a sceptic / cynic / old school practitioner, I have always been quick to get a bee in my bonnet about alternative therapies. In general these remedies or treatments have no real evidence to support their use and efficacy. However, I accept that some of them do work... but most of them are bollocks.

Anyway, the reason I mention this is that I have stumbled across Le Canard Noir, a feathery advocate for real science, intent on rooting out the charlatans among us. He's worth a look. (Although I was disgruntled to discover that the Shroom has a relatively high canard count himself. Well, no-one's perfect...)

Tonight has been on the grim side. It was busy again. The sort of soul destroying busy, that welcomes you into the department with 6 waiting and three booking in in majors, and a full waiting room in minors. One side effect of the four hour target (all Hail!) has been a change in people's expectations. Now that waiting times are down, almost any delay pisses them off. And it is hard for people to see beyond their own crisis - which is natural enough really. But when several 'sickies' are in the Department together, everyone else kinda has to fend for themselves for a bit. Which they don't like...

---So, my last patient this morning was a young girl with meningitis. In truth, it was more like meningococcaemia, but for non-Medics that's really semantics. Of course, it makes a difference to how you treat 'em, but Mum doesn't need to know that.

Anyway; as with so many of these cases, she got sick really fast. In a matter of hours. By the time I arrived she looked dreadful. Really flat, and listless. As if all her energy was occupied just being. She had proper bags under her eyes, which is always grim in a child, and was parchment white. This is not the same colour as sheet white. There's a slight tint to it, as if she was sheet white, then someone gave her a sepia wash. (This is also one for the list of colours you're glad you aren't)

Actually her numbers were never that bad - pulse, BP, sats, CRT, resps... they were all more or less normal - but she was off away somewhere else. Lights on, no-one home etc. As if in addition to just existing, she couldn't allow for the existence of anyone else. She seemed completely unaware of her surroundings. And of course, she had The Rash. I find the non blanching rash of meningococcaemia particularly sinister. Especially when you see it spread right in front of you.

Well we dosed her up with antibiotics, and I here she's doing better today. She's still not focusing properly, which makes me a little anxious, but time will tell...

---------------------------

Today, almost at the same time, I had my attention drawn to two patients. The first was in his 80s, and had had a 'collapse' at home. The presenting complaint "collapse ?cause" is generally a real heart-sinker for the British emergency physician. I'm not sure what the equivalent would be across the pond, but many of these patients are GOMERs, or aspire that way. Anyway, patient A (names have been changed, etc...) was not a GOMER. He had a history of blackouts, thought to be cardiac in origin, and had, it seemed, had another one. He had initially been quite chatty at scene, but slowly become less so. The crew who brought him in had left him on high flow oxygen, and so it was that he was found by my SHO in the grips of CO2 narcosis.

---ECG showed right bundle and chest radiograph confirmed significant pulmonary oedema, with bilateral pleural effusions. So, in essence, his body had turned his lungs into massive sponges; so much so, that water was collecting outwith his lungs as well. Some Lasix and GTN will dry him out, thinks Shroom, and BiPAP will rid us of that wicked carbon dioxide...

Meanwhile, on the other side of resus...

-------------------------------------------------

---Enter patient B, also in his 80s, who was minding his own business at home, when he began to fell light headed, dizzy, clammy and nauseated. When this feeling got worse, he called the Ambulance. They found his pulse to be 25. (This, as I'm sure you all know, is one of the many pulse rates you should be glad yours isn't)

On arrival, during his initial assessment we lost him... just for a moment, 15, maybe 30 seconds.

Then he came back. Good blood pressure, alert, comfortable. Pulse of 20.Sporting...

I gave him atropine; little by little, looking hopefully at the monitor. Watching. Waiting. It didn't work. 12 lead showed a junctional brady. I guess his atria, or more specifically, his SA node, just gave up the ghost. Anyway, but for the pulse of 20, I was happy with him. So I called the Magicians to admit and pace him. I hoped he wouldn't need transcutaneous pacing.

A bit later, when the clever docs came to see what fun we were having, it all went a bit wrong. First they said - see patient A; he has had a heart attack, and you have done nothing. This was very distressing, for patient A was perking up, and I had been feeling pleased with myself.

To cut to the chase, they were wrong. His ECG, which I had thought right bundle, and they a posterior infarct, was indeed right bundle. The Shroom, and indeed patient A, breathes again.

But patient B; poor patient B.

He had used the oldest trick in the book, and gotten unwell, while I wasn't looking. His pulse and BP were still the same, but his belly had blown up and he was getting all sorts of pain in his back.

---Many docs came to see him, including surgeons.

---Many hushed and whispered conversations.

---All ended with grim shaking of the head.

(Dammit, Jim, it doesn't look good.)

Mrs B took it hard. She was now seeing her husband of more than 50 years get sick right in front of her. I'm still not sure what the primary pathology is, or was. But it made a liar out of me. I told him, and Mrs B, that it was just his heart, and that the clever doctors could fix that, with wire and an box of electrical tricks. And I was wrong. Which sucks. Although not as much as it does for them, eh?

---Anyway, my point in this, before I got morbid, was that, while this was all ongoing, in minors was a lady who had been unfortunate enough to be bitten by her guinea pig. A small uncomplicated wound, with minimal bleeding. on her finger. Large trials suggest that these wounds do better if left alone (i.e no stitches) and our policy tends to be to leave animal bites alone. If it really needs closing, it also needs debridement etc. Anyway - it did not need stitching.

So while we were ministering to patients A and B, her waiting time increased.

I was asked several times about her, and advised that no suturing would be required; if bleeding was a problem, direct pressure with a finger should be tried first. (Shroom's blunt haemostat).

But this was not good enough for her partner / friend / whatever. He kicked up all sorts of stink, about the wait, and especially about the fact that we weren't going to stitch it. Pa Shroom, who was a proper knifeman, didn't believe in suturing any wound unless bleeding was an issue. (That is perhaps a slight exaggeration, but he certainly had a liberal policy of not suturing...)

In fact this fella insisted we suture her finger. He seemed to be labouring under the impression that in the same way as patients can refuse treatment, so they can compel me to treat them; he was most put out to discover that the decision about medical treatment is usually made by a person with a medical degree. In short, we wanted to bring the upstart round to resus, to try and get some perspective on life, and on the difference between waiting a bit longer for your tetanus shot, and getting the chance to be with your partner of 50 years at the very end.

But I'm not sure he would have understood.

Nobody loves you when you're down and out

Just about done for the day. Not much exciting has come to pass, which is generally good. I almost got on my high horse, however, when I overheard the following conversation:

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?

Autologous Autosplenectomy

I really hate it when there's a departmental fuck up waiting for you when you get to work.

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.

Off the record, on the QT and VERY hush-hush

The joy of nights...
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.

Going Nursical

Brilliant. The title bears no real relation to the post, but a fellow Blogonaut - the Bohemian Road Nurse - left it, and I thought it too good a phrase to lie hidden. I hope she won't mind.

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

An announcement

Just a quickie, so to speak
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

The Best Laid Plans...

Another weekend, another crappy night shift. I meant to write this as I went last night, but the Department went bananas, and I didn't get a chance.

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...