Wednesday, November 28, 2007
Doing an extra night tonight for a colleague. Normally this would provoke a great deal of grumblage, but as it's because he's a new daddy, we don't mind. I sure as hell am getting old tho'. I used to be able to do a week of these and not feel it, but here I am after three, tired as a wet kitten, and irritable with it. Like a bulldog with a mouthful of wasp.
Further evidence, as if it were needed, that people throw off all sense of personal responsibility when they step through our door. Twice tonight I have had people gesticulating wildly at me, alerting me to the fact that they are bleeding.
Not unreasonable, I hear you think. Well, no, not usually; but in these cases, the bleeding was from cannulation or venepuncture sites. Not from horrendous trauma, or awful limb-falling-off type accidents.
But because the cotton dental roll we place over these pin point hole wasn't taped on hard enough.
And they are always stunned when I stroll over and press on the wound with my thumb. Shroom's Blunt Haemostat. Amazing. Quite why these otherwise healthy(ish) and intelligent people can't summon either the nous, or strength, to think of, and then do, this themselves is beyond me. Instead they stand there, or sometimes move around a bit, to ensure even coverage. Oftimes they wave the offending limb, but always held downward, never upward. And they never, ever press on it. Ever.
Folks, I'll let you into a secret. If you can see a bleeder, and you can press on it, it will stop. I don't care how big. If your finger fits over the hole, that's the treatment, right there. But keep it to yourselves...
My favourite patient of the night (so far) was a young girl, visiting family. (i.e. not local... been to several other hospitals before...) Presenting complaint? Total body pain. Another personal favourite. Atraumatic, mind you. Total body pain is quite reasonable if you've, for example, been sat on by an elephant, or fallen out of a plane. But sudden onset, atraumatic total body pain? Well, we do see this, but it tends to be in a certain demographic of patient. For fear of generalising, or being accused of bigotry, I'll leave you to guess.
Needless to say, her first words to the triage nurse were to inform us that only morphine works for the pain, and that's what she always has. Her triage obs were all remarkably stable and normal. Despite several publicly agonising trips to and from the bathroom, pointedly in front of the doctor's bear pit, I explained that without a diagnosis, or any clues as to a possible diagnosis, I wanted to try other analgaesics first. Simply telling me that your previous treatment plan is i.v. morphine and home does not encourage me to give you some. Cruel, cruel Shroom.
Either way, when confronted with the harsh realities of the analgaesic ladder, and need for assessment and diagnosis, she decided to go home instead. Her gait on the way out was markedly free of the tortured limping and groaning that had characterised it a few minutes previously...
Lastly an SVT. This particular dysrhythmia is one of my favourites (sad, sad bastard) because, in my experience, it rarely compromises people, and responds well to a quick blast of adenosine. My SHO, running the case in his inimitable style, opined loudly to us all that he didn't see the point in 6mg as a starting dose as it "never works"; this minor rant against the system, and specifically the part that was compelling him to give this homeopathic dose of adenosine, continued until about 0.8 seconds after he injected the adenosine, when the patient flipped right back into sinus.
I guess protocols sometimes do make sense. Who'd have thunk it?
Oh, and the CherryPicker has started his own blog. Check it out; his tale is well worth hearing, although I can't vouch for his writing style... he did want me to offer more biog details about him here, but I'm thinking he can tell his own tale now. One doctor's battle with booze, and a reminder perhaps, of how close we all sail. Anyway, enough plugging.
Tuesday, November 27, 2007
Interesting. The department was, once again, heaving when I came on last night. Patients queuing to get off ambulances, and mustachioed doctors groaning under the workload. A full hospital. I note that when this happened to the Norfolk and Norwich, they declared a 'code black' and made the news...
Two incidents stand out for me. Firstly, there was the delightful lady who seemed to think that because she had taken an overdose, she could behave as she wished. She took the opportunity to subject everyone within reach to a torrent of the foulest, most bilious abuse imaginable. She topped off her performance with a fine array of spitting. A command performance.
Having determined that her overdose required little in the way of acute management, we disabused her of her ideas about entitlement by having her arrested.
Next I once again had the pleasure of double bunking in resus. In a sort of homage to Steve Martin in the 'Man with Two Brains' I simultaneously treated 3 teens from an RTC. Single vehicle vs tree; they were all in reasonable shape, which was more than could be said for the car.
After this, the night fairly flew by. By six, all was quiet... for about 3 seconds. It was then that the patient handed over to me, with the fateful words "He'll be fine, you won't need to do anything", started fitting.
The fit subsided fairly promptly, but the spreading petechial rash, and frank blood in his catheter bag did not ease our minds. To compound matters, just as the possibility of meningococcaemia was rearing its ugly head, a young woman 2 weeks post chemo was wheeled in.
Now, for those of you unsure, chemotherapy, for all its many benefits, rogers your immune system good and proper. So, once that's happened, one becomes subject to all sorts of previously harmless infections. The hospital often beckons. But next to a patient teaming with meningococcus is low on the list of places you wanna be.
A bit of juggling later, we had achieved isolation. Of sorts. But the department had backed up sufficiently to give the morning crew the impression that we'd done buggerall over night.
On a lighter note, I was able to review some CT scans. These were of the cervical spine of an elderly patient. It was this patient whose condition I was afraid I had misdiagnosed. Had missed.
The CT supported my original diagnosis.
This is good for a number of reasons.
1) The patient does not have a broken neck
2)The patient does not have a spinal injury
3)I didn't miss a spinal fracture.
The altruistic Shroom is clearly glad that this means the patient is well.
(But it's quite nice to know I didn't make a mistake, for the sake of not having made a mistake...)
Monday, November 26, 2007
I'll try to add to this s the night allows, but mostly I'm just tired now. Unable to sleep and probing my own emotional lability with re-runs of (what else) ER, and (surprisingly) Dr Who.
For now, I'm away to the gym to continue my 'fat bloke to 5K' challenge. Wish me luck. I'm upping my distance today, which may provoke an MI. Still, 18 days off the fags (again) and counting.
Yes I know this is a nothing post, but I'm still trying for one-a-day. I warned you drivel would feature....
Sunday, November 25, 2007
Saturday, November 24, 2007
And, if I wait 10 minutes, it'll be tomorrow, and that'll be my posting done.
So... It's still the weekend, which I'm pretty happy about. Having had a day off yesterday, today feels like Sunday, and there is quiet joy in knowing that tomorrow is Sunday...ahhhh.
I'm currently home from a quiet night out, a product of my increasing age, but now safe back inside my bunker in Shroom Manor, a nice glass of port beside me. Oh, for a cigarette. I met with a dear old friend of mine tonight, one of my oldest from MedSchool, with whom I've shared some truly good times, and some truly awful ones. For the purposes of my blog he will be known as the CherryPicker. We had a few stand-up fights I'd rather forget, but I think we've both mellowed a little, and are better for it.
Anyway, he lives more or less just 'round the corner from me, and I was his best man (or one of them), but we still don't manage to see each other enough. So tonight was nice; it's always good to catch up with him, and reminisce about the old days. I discovered another of our old friends had put him on to my blog (thanks Colossus), but he was still unable to find it... This is despite it being fairly well telegraphed to my friends, if they're interested. I mostly suspect they aren't, they find it too creepy, like reading my diary, or they find it too boring.
Anyway... I promised him I'd write him up. Done and done, my cherrypickin friend.
He tells me he's going to the best restaurant in the world next year. Some 5 star place near Barcelona, I think. They're only open 6 months, and only take reservations on one day, for a 24 course, 4 hour meal. I believe I have found a new definition of the word pretentious. Further details will surely follow.
Lastly, musings on the anonymous nature of this blog. Just because. This was only ever semi-anonymous; using a picture of me saw to that. But I never thought anyone I knew would actually read it. Since clinical stories are all amalgams, I figured that was the confidentiality side sewn up... but nonetheless, part of the point should be an honesty to it. Which is difficult if my friends are reading this. It encourages self censoring. Having made the decision to make this semi public to my friends, I guess I'll always hold some stuff back, especially where it concerns people I think might actually read it. It's only fair.
But where I'm concerned... I'll try to be as honest as I can be, however dull/uncomfortable/**insert other emotion** that might be.
I return you now to your regular programmes, while I return, lovelorn, to my port and late night horror film...
Friday, November 23, 2007
Which Action Hero Would You Be? v. 2.0
created with QuizFarm.com
|You scored as Batman, the Dark Knight |
As the Dark Knight of Gotham, Batman is a vigilante who deals out his own brand of justice to the criminals and corrupt of the city. He follows his own code and is often misunderstood. He has few friends or allies, but finds comfort in his cause.
I'm pleased to see I've retained a few of the extra readers generated by mt free press from Scalpel (see the side bar: "Fix Bayonets"; this incidentally is because his blog is called 'Scalpel or Sword' and the British 95th Regiment of Foot ('The Rifles') called their bayonets swords. In case you were wondering.)
I've also been added to the blogroll of another fave of mine, M.D.O.D. Anyone stumbling here from there, or anywhere is more than welcome. Pull up a chair, help yourselves to the scotch. You might need it, if my especial brand of jaundiced rambling ain't to your taste.
Here's an example of what you can expect....
I'm feeling extra proud of meself, as it seems I've successfully cemented my rep as the ED eccentric. (This is only marginally less important to me than the nurses thinking I'm an acceptable doc. It's almost pathetic how much their approval means to me. Well, the senior ones, anyway...) I confirmed this on Friday last, when, having unfortunately split the crotch of my scrubs was forced to undertake emergent repairs, using a 2/0 Silk on a curved; with scrubs still in situ, as I was in resus at the time waiting for a gasper. While my assembled team clearly thought this was funny, none of them were surprised...
As a 'non-specialist' specialist I always enjoy the opportunity to demonstrate that I actually know stuff. On this particular night, I was asked to review a young-ish man in respiratory distress. He was a local drug user admitted with a progressive neuro-muscular weakness. A brief history, but with features highly suggestive of Guillain-Barre syndrome.
This fella actually has a few atypical features, particularly in his cranial nerve exam, and his Donald-Duck - esque speech. Very eminent men and women had consulted on his case, and pronounced: the diagnosis was Miller-Fisher variant GBS. He had been deteriorating on the ward, and now his respiratory muscles were dysfunctional. His blood gases had gone off enough to qualify him for an entry to the free ventilator prize draw. A chance for healing through the medium of 24cm of semi-rigid plastic.
When I got the phone call, something just didn't seem right. I freely admit that this was mostly because I knew little about GBS, and foxtrot alpha about the Miller-Fisher variant. Nonetheless...
Has this fellow got a fever?, I wondered...
Why, yes he has.
And he's a drug user... Does he have an abscess?
Um... yes he does. On his bicep.
AHA! Cries the Shroom.
This is not GBS; this is botulism. Wound botulism, say I.
I like to think that the whole hospital fell silent with amazement. It didn't, and in fact we admitted the fella and treated for both diagnoses until the mouse lethality bioassay confirmed botulism.
(Yes, they inject mice with the patient's serum, and wait to see if they die. Their fur stands on end first, and they develop narrow, waspish waists. Go figure; if you think that's weird, the botulinum anti-toxin comes from a special horse, living it large in Wales, somewhere. Ah, medical science...)
Smug mode activated...
(I didn't tell anyone I'd seen an identical case a few months before. I still dine out on this story...)
I know, incidentally, that I need to get out more.
I particularly enjoy the episode depicting Carter's first day on the job. The sheer terror, and hopelessness of it all, countered by his eventually overcoming of the challenges set him. How realistic? I can't speak for my American cousins, but it was never that bad for the young Shroom, but we did pull long hours, and I did feel like going under sometimes, times that I now recall fondly, viewing the past thru rose tinted fertiliser, if you will. In fact, I think I was just approaching qualification myself the first time this was out...
All old farts eventually have 'war stories' about how hard things were "in their day". I'm disappointed to say I was too young to hear, or maybe too young to remember, GrandPa Shroom's stories, tho I'm sure there were plenty. He was good friends with the first Medic into Belsen at the end of WW2. Those were tales... I think my point was going to be that the common thread tends to be success in the face of adversity.
It makes it much easier to recount a tale of horrendous times if it ends well; sometimes well means getting to the end of the night. Sometimes that's all you can do. I encountered a 'brag-file' story of a different kind, over at M.D.O.D. Hugely satisfying, especially the exhortation to 'go fondle the guy's nuts'. My kinda medical jargon.
Thursday, November 22, 2007
Clearly, no-one likes to find they've made a mistake; I guess it's worse in this business. The magnitude of my error will become apparent with time, but no-one died, thank God, and no-one should. The sum total is probably an extra week of discomfort for someone, but... it could have been worse.
It probably does us good to realise once in awhile that we can never be too careful. I can add complacency to my list of failures of late.
I can only hope to reconstruct myself: better, stronger, faster...
We have the technology
(Although not to grow a 'tache...)
Wednesday, November 21, 2007
Last night was not so bad. Better than my last nights. My colleague with whom I was to share the duty swapped out of it. So, flying solo again. Good.
Not too busy, but enough to keep time ticking over. And I feel like I did a reasonable job.
Until this morning, when an elderly fella with a whopper of a scalp lac provoked a good deal of flail. Turned out ok in the end, but I guess I won't be winning any plaudits for how cool I am.
And I was slightly disappointed with one of my SHOs. You know who you are, if you've found me. There has been an air of disquiet of late, as the juniors feel demoralised. Not getting to do enough, not getting enough exposure; fair enough. This job is becoming service orientated; but when the opportunity presents itself, shouldn't you take it? Or have we broken your spirit so, that you really don't care anymore?
We're doin' something wrong.
I still can't bear it.
Once again, we allowed ourselves to dare to dream. The England football (soccer...) team flattered to deceive, and we thought: 'maybe, just maybe...'
As I write, I see mortar flaking down around my ears...
It has come out today, or maybe last night, that the British Government has lost data concerning millions of families claiming child support; or benefit; or whatever the term is. So somebody, somewhere could be in possession of names, addresses and bank details of these folks. Bank details... score.
While this is undoubtedly a disaster for all concerned, what made me laugh this morning was an interview with one such affected person. She said what she found most incredible was that the Government could have lost the info.
How could the high powered organisation that is the British Government ever misplace incredibly sensitive data, in an act of sheer, crass stupidity?
Say it ain't so, Joe!
The financial security of millions of people is jeopardised. Government response: "Sorry! We fucked up!"
Anyone lose their job? Watch this space...
I'm not sure whether I think that it is sweet, that someone still has faith in Government, or unbelievable that such naivete still exists.
I know, I know: cynic...
Tuesday, November 20, 2007
One of the choices?
Now I really do feel old.
When did this become an option? I can't think of a better way to learn anatomy, and I can't think of a more important cornerstone to medical practice. Granted, I have a surgical bias, but I don't claim it is the most important... just that I can't think of anything that should stand above it.
So, having read the blog, I know realise it's 'Selected' Study Module. I still can't understand the rationale of allowing people not to choose dissection.
And, I still can't grow a fucking Mo'.
Music Nazi recommends Most Likely You'll Go Your Way... by Bob Dylan - original or remix.
On nights again. Out shifts always seem to be unpredictable; predictably unpredictable? I don't know. Either way, I'm all over the shop, and it makes it difficult to keep up. I begin to see why shift workers kill themselves so often. Our staff numbers seem to be forever shrinking. I'm not sure it's any easier for the bosses, but...
Tonight I'm doubling up with another middle grade. I don't like it. I prefer working alone, or with a regular 'team'. This is a kind of babysitting, allowing my colleague to ease int nights. I guess it's a test of my higher management skills. I think I'm failing.
We never eased into nights. Maybe we should?
Working with another is fine, but in case of banditry... I dunno.
This, of course, is compounded by my growing concern that I am not doing my job very well any more. I have always struggled with the extra-clinical work. I really don't care about research, and struggle to keep up. I enjoy teaching, but find it hard to find, or make time, to do the students justice.
But know, I'm wondering whether I'm cutting it clinically. I've always had faith in my own ability, bordering on the arrogant. I'm not so sure any more. It's all very well bemoaning bandits, and the poor quality of medical training these days, but it needs to be backed up by actually being good at one's job. I think I was...
Time to try harder?
Monday, November 19, 2007
Doing a bit of extra curricular reading, I came across a few posts by MonkeyGirl. I apologise for the lack of link at the mo', but my server is flailing... I'll rectify as soon as. The gist runs around a story of a patient dying in an ED after being 'underdiagnosed'. The problems are bilateral - it seems the patient was known to the Department, and had a reputation for being non-compliant, and a drug seeker. (This is how I understand it, and I apologise if I have mis-represented anyone, specifically the Girl Simian). On t'other side, it seems that this ED did not offer a particularly high standard of care to anyone, and has subsequently been down-sized, or closed or something. MG's point centred on the family of the unfortunately dead patient suing for $45m. If I understood, she considers this... taking the piss?
It has provoked some polemic.
This is an old problem, and one unlikely to go away. While a system exists that can be abused - e.g free or subsidised healthcare, for e.g drugs - people will abuse it. People's sense of entitlement seems all too often to find ways to overpower their sense of responsibility, both personal and collective.
I think this is particularly true of the UK. People aren't keen to consider their own 'emergency' in the context of others'. And why should they?
Rationing. That's why.
And people have very different ideas as to what constitutes an emergency for them, as opposed to others.
Yes, I know this is sweeping generalisation. I think that's kindof the point.
As medical professionals, nursing professionals, paramedics, whatever, we seem to have our natural cynicism nurtured and enhanced by our exposure to certain types of people. But if we dare to openly suggest that some people allow themselves to be 'legitimately' classed as ill by the state, allow themselves to slide into a sick role because it might be an easy option, we are pilloried.
Of course there are many folks out there whose lives are ruined by chronic conditions, the effects of which are difficult to see, hard to comprehend, even to so-called experts; but there are equally people out there who make use of the system to live of the state, or feed a drug habit.
We, I mean I, am not suggesting that they are one and the same. But some people allow themselves to become medicalised
And if you have spent years feigning illness, or exaggerating your symptoms to get a quick fix, or a warm bed for the night, or time off work, it makes it a bit harder to take you seriously when you really are ill.
I note that critics of the medical profession have rarely had to deal with manipulative, 'professional' patients; have rarely tried to reason with people who feel that their own unhappiness must be the fault of some internal locus, that absolves them from blame - this ranges from the obese patient who blames all their troubles on some mysterious glandular / hormonal conspiracy, to the man who's bad back prevents him working, but not enjoying leisure time with his mates, to the patient with the unexplainable headaches who chooses your ED over the two nearer his home address, for equally inexplicable reasons.
I don't see the same criticism labelled at banks when they give you a poor credit rating for constantly being overdrawn and defaulting on all your loan payments.
But maybe I'm not looking hard enough.
For every genuine patient, with a seemingly 'dodgy' story and/or collection of symptoms, there's at least one who's motives are not pure. There seem to me to be few other professions that have to spend so much time trying to tell one from t'other.
Cynicism seems almost inevitable; we are human too, are we not. And if we vent from time to time, please don't tell us to get out of medicine, unless you've walked a few miles in our shoes.
I would be sincerely grateful if the press would fuck off, and stop writing ill informed pieces about doctor's pay, posing as factual articles.
The idea that medical salaries have gone up at the expense of patient care is ludicrous. The Government felt that doctors, and specifically Consultants and GPs were not doing enough work and should therefore pay them for the work they did. This, it seemed would equate to large savings. If it seemed fair to pay people for the work they do when you thought that meant a pay cut, how is it now unfair when you discover they actually do more work that you thought, and in fact this has meant a pay rise. This suggests that before now, these doctors were doing that work without due financial recompense. You cannot announce a deal to pay people for what they do, only to try and renege because it transpires these guys and gals work far harder than you realised.
And particularly not when it is MPs doing the carping; a bunch of useless bastards who vote on their own pay increase. (Which is never below inflation, as far as I can see. Oh, and they don't have restrictions on what other jobs they can have... but private medicine is to be discouraged?)
I am a simple Shroom; maybe I've missed the point. But I still remember the glee on one the face of one of my old Bosses, when he submitted his work pattern, as instructed by 'the management' and calculated that he was owed 9 months compensatory rest.
Why should medical professionals not be paid at a level commensurate with e.g lawyers, or dare I say it, bankers?
But mostly, I'd like the press to fuck off.
I've added a Reciprocity list to the blog. If you've linked me, and I haven't already, I'll link you. I hope this isn't bad blog etiquette; if so I apologise. If you don't wanna be associated with my rantings, let me know.
And, I have decided. You must all now go out and buy Astral Weeks, by Van Morrison.
You won't regret it. (Seriously)
I think we do our best to frighten people out of it. Or are people just afraid of being responsible for their own decisions?
I think a lot depends on the back up they expect to get from their colleagues, or professional body. Or how used they are to making independent decisions. Thus, I expect doctors to be able to make, and justify, their own decisions, even if these run contrary to "usual practice", or "protocol", or "guidelines".
Nurses and Ambos are reluctant to do so. Because they can't? I'm not sure; I'm certain their training is less about the synthesis of a plan based on the available info, than about responding in a set way to pre-defined parameters, but I'm also pretty sure they get bugger all support if they step out of line, even if it's to do the 'right thing'.
An example, which also goes to my post about dignity.
An elderly lady is discovered collapsed in bed at her nursing home. She appears to have had a stroke. She had been physically disabled by a previous stroke, but her mental faculties were in fine fettle. She had previously expressed a firm desire not to be resuscitated in the event of physical deterioration; in fact she had left written instructions expressing her desire not to go to hospital in such an event. These instructions had been communicated to her daughter, who was in complete agreement.
So, when she is found, what happens? An ambulance is called, obviously. Was this right? Was it wrong? Could the GP not have come out?
Either way, when the Ambulance arrives the situation is made clear to them. But, the written request for non-transport is not countersigned. The patient's daughter is present, and re-iterates her mother's wishes.
This is apparently not enough, so into hospital she comes
My assessment was of an intra-cranial catastrophe of such magnitude as to be unsurvivable; intervention might preserve life, but not in a way she would have wanted, as far as I can see. I discussed this with her daughter, and the home. We agreed she would want to be in familiar surroundings, and arranged for transfer back there, priming her GP as to what had happened.
Was I wrong? I can't be certain of my diagnosis, but I can be pretty sure. This was not a response to something easily correctable, the resolution of which would have returned her to her old self.
Should she have come to hospital? I don't think so. The primary reason she did was to cover the Ambos. Is this their fault then? Of course not. If their organisation does not support free thinking, they have no choice.
Is it anyone's fault? I'm not sure. The system failed, despite all this patient's best efforts, she almost did not get the end she wanted.
Now, I know that the whole area around resuscitation, and 'living wills' is hugely contentious, but surely there's still a bit of room for us to use our common sense? Or are we to become so afriad of criticism, of litigation, that medicine will become a series of giant algorithms, with no room for indepndent thought?
Medicine is an art, and art is sometimes ambiguous.
I recently had the unusual experience of attending the ED Talent Show. This is evidently a nascent tradition at my current place of work. I think this was year four, and it felt very much as if it was the brainchild of one particular consultant, but I maybe wrong.
It had been my intention to avoid entering at all, as I have precious little that could be described as talent; my plan almost worked, as most of the recruiting appeared to have been done in the week after my worst-weekend-ever experience, when I was off. (Track back a few posts if you really want all the gory details of that shebang...)
However, one of my colleagues had other ideas. Aware that moves were afoot to stage a production lampooning one consultant's appearance on a tv programme featuring a German anatomist, he had generously suggested me for the role of said anatomist.
I guess I do have a little of the Aryan about me (e.g pale and blonde, not necessarily intent on a European land war...)
So, Friday afternoon found me collared by one of the Nursing Sisters, urging me to step forward and 'do my bit'. For fear of being labelled a miserable bastard, I agreed.
Sunday night found me frantically downloading TV footage of the guy I'm supposed to be spoofing, desperate for any little character quirks he might have. Other than being German, and slightly odd, there weren't any...
Monday afternoon saw our company meet for the first and only time to thrash out a rough idea of where we wanted out sketch to go. And so to that evening, and the command performance...
The rest of the skits were a mix of the sublime, and ridiculous. There were musical turns, ballet dancers, and an inspired version of Queen's Bohemian Rhapsody. Our entry went last, ensuring that the audience were well lubricated.
Much to my surprise, it went down a storm. Apparently nudity, a cod-German accent, one Boss spoofing another and the throwing of offal into the crowd went down very well. (You remember, of course, that they were all one or two over the eight...)
We won. Well, joint first, with the Queen team. No' bad, eh?
An evening of surreal clubbing ensued, as many of us remained in the angel wings and tutus used for the mini Swan Lake production...
The next morning, I began to question the 'wisdom' of having won, as it dawned on me that I had done so by taking the piss out of one boss, and beaten another into second... (well, third, but I didn't labour that point)
So... maybe there is life after medicine?
Those patients who present with a seemingly hopeless condition often have only their dignity left. Whether we let them keep it or not, seems to be related to their age. I don't know if this is right or not;
Elderly patient, presenting flat, found GCS 3. Exam might reveal an huge aneurysm, slowly leaking the patient's life blood into their belly. Or the telltale signs of an intracranial bleed. Any sort of injury, of insult that is unsurvivable. They cannot be salvaged...
Here, we gather all their nearest and dearest. With solemn faces we pass the dread news on, share our unwelcome burden. Then we leave them be, let them make their own peace, neatly, quietly, calmly.
Young patient, presenting flat, but from trauma. Shot, stabbed, crushed. It doesn't matter, really. You still know. There is no comeback. We half admit it, but we run the case anyway. Full tilt kozmic boogie. It never works; and the patient leaves us in a blur of shouted requests, of bloody gloves and discarded sharps. There is no time to gather their kith and kin; we know they will come later, and maybe it is for them we form ranks for one futile charge; so that we can tell them of the thin red line that wavered and broke.
Is that better than dignity? Or are we afraid of being wrong?
Sunday, November 18, 2007
While I do have more meaty subjects in mind, time ain't on my side. (Thus paraphrasing the philosopher Jagger)
Curiously, I have noted a blip in my reading figures. Up until last week, I've held fairly steady, 20 - 30 punters a day, give or take.
Last week, I averaged 115.
I'm not sure why, either. Someone out there linking to me, or preaching the Gospel of Shroom?
I'll check, and let you know, cos I'm sure you're all dying to know. Welcome anyway, dear readers. Stay awhile if it suits.
Oh, and my upper lip continues to look ridiculous...
Thursday, November 15, 2007
I haven't had time to blog about my glorious march to triumph in the ED talent show yet, but, oh yes, my brothers and sisters, it is coming.
I read with interest that November is NatBloPoMo... National Blog Posting Month. A post a day. Well, I don't know if this applies internationally, and I'll never manage it anyway, bu in the spirit, I'll try for 30 posts this month. Be prepared for some truly inane shit.
Mo' importantly, it's Mo'vemebr. A tradition I'd never heard of, which seems to have originated with my crazy Antipodean cousins. November has become the month to 'grow the Mo''. So there's a lot of unshaven ED staff wandering around right now.
For the facially follicly challenged, this seems terribly unfair - especially as that's basically me. But I've been kinda shamed into it, so have resigned myself to not only getting older this month, but looking ridiculous doing so.
Reports to follow...
(Oh, and I'm back off the fags! One week and counting...)
Tuesday, November 13, 2007
Sunday was proper shit. I left the department in a state, and it never recovered. Playing catch up was impossible. So, it was an unhappy return for me on Sunday night.
Once again, my evening was dominated by Resus. This evening's specials were the very breathless. I find it odd how cases seem to come in a run. I guess it's because we only remember the runs. When 3 breathless punters come in one after t'other, it sticks. 3 different cases doesn't seem such a big deal.
I got some lessons in assertiveness from the duty Surgical Reg. (Who else...) Its all about language. Our patient is an elderly chap, brought in when his wife found him collapsed, and unresponsive in bed. He had been fine earlier in the evening, but complained of a bit of pain in his hip, and retired to bed. The ambos had just confirmed his flat GCS and scooped and run.
At first, I was at a bit of a loss, but his BP of 50 systolic shed some light on his incapacitation. As did the presence of a firm, pulsatile, expansile abdominal mass. ED USS showed an aneurysmal aorta, with fluid in Rutherford Morrison's pouch.
Says I to the surgeon: Think this fella has a ruptured AAA...
Says the surgeon to me: He's got a AAA
Says I to he: That's what I said!
He to I: No; you said you thought he had.
Me: Ah, sorry. I was trying to be polite...
I guess I always say 'I think' before offering a diagnosis. But for me, 'I think' often means 'I'm sure'. Guess I should just say what I mean.
Anyway, an aneurysm it was, but not one amenable to surgery. Another night, another family whose hopes I've dashed.
All that's left is an attempt to find quiet dignity. We just about managed. It's hard to do in the ED. More of this to follow. Right now, I just wanna finish exorcise this weekend.
Sunday, November 11, 2007
Bad news, bad news, come to me where I sleep.
Had a grand old day yesterday; pottered about at home, actually getting a few things done, which is unusual. Then in the eve, out with an old friend, for a slightly surreal evening. First, multi-national big band jazz, in an historic town. Then we slipped out to a local pub for beer, and encountered an energetic four piece rock covers band. Oh, and a late licence. The pub patrons were an interesting bunch, who really did dance like no-one was watching. Took a bit of getting used to. But a grand old time... except.
My heart is lost. I am infatuated by someone new. Since my beloved left me to the NHS, I have been solo Shroom. It's probably what I deserve. But I am head over heels, intoxicated, can't get enough of her. So, consequently, every time I'm anywhere near her, I fall apart.
I think she knows. And I think she doesn't feel the same way. But maybe...
I guess we're pretty good friends, and I am torn between preserving the status quo, and playing my hand, terrified I'll fall flat, and that'll be all she wrote. But maybe... she's waiting for me to make the first move..? Every time I even think about it, all marrow, all moral fibre deserts me...
I am pathetic. But she is fabulous...
Then today I heard more bad news. It really puts my 'bad news' into perspective. Two of my very good friends have run afoul of the occasional shitstorms that life throws at you. It seems unlikely that either of them read this, but maybe they know someone, who knows someone, etc, who might.
So, no details,
But it's put a real downer on me. I feel oddly disconnected from life. It seems more unfair than usual.
I can only wish them well, and try to be around a bit more for them, for what it's worth.
Lastly, today we remembered the dead. Whether they agreed, or understood fully what was asked of them, they offered a sacrifice beyond what most of us can comprehend. We should never forget.
While car crash fella was under the knife, our attention was diverted by car crash gal, and another trauma that BASICs seemed to have smuggled into Majors. I'm sure they didn't do it deliberately, but 'twas a while before I found them.
Car crash gal, was the passenger in the same wreck that gave us the fella on the operating theatre. One of my SHOs ran the rule over her. My eyeball of the patient had suggested she was a bit more stable that the guy, but still...
Sure enough, although her numbers were all in the right place, and stable, she had considerable bellyache, and was developing a bit of rigidity. There followed a slightly confusing conversation with my colleague on call for radiology. What I wanted was a CT head and abdo. It seems that we scan all or nothin' here, so was I sure that's what I wanted. My SHO had been a bit 'uncertain' about the physical findings on the phone. My big beef with radiology is this. They have fixed criteria for what they'll scan. Fair enough, they are the guardians of ionising radiation, which is not a toy. But, without seeing the patient, I don't see how you can say they aren't tender enough to warrant a scan. Or, because their numbers are normal, they don't need one...
So one has to be fairly definite about what the problem is; it's the least they deserve.
Reluctantly, she went through the scanner.
Which showed free air aplenty... (For those uncertain, this is not a good deal. It's not like free chocolate. You don't want anything free in your belly, really...)
Another for the surgical conveyor belt; it transpired she had a few holes in her small bowel, which is a not uncommon result of a deceleration injury. More evidence that people lie and cheat, even when they ain't trying. This wee lassie had significantly more serious injuries, but you'd never have known it to look at her...
That must be it, right?
The trauma smuggled in turned out to have an unstable lumbar spine fracture, but thankfully no cord injury, and our night was completed by a six a.m blue call to an unstable MI. Chest pain, with fat ST elevation, uncontrolled hypertension, and profound hypoxia...
I'd like to say I was cool under pressure and successfully treated all of his problems, systematically, and thoroughly.
It didn't quite work out that way.
God Bless Cardiologists.
Thursday, November 08, 2007
It can't be any worse, right. Not worse, maybe, but just as bad in a different way.
The Dept was as busy, if not more so. I think the second board was out on arrival. (This means there were so many patients in the department, that we'd run out of space on the regular board. It is not a good sign)
Again, the details are beginning to escape me. I'm not sure if my memory was always this shaky. I can't remember.
A heaving department, but resus call after resus call. Once again the department becomes crystallised into this small room. Outside I know we're up shit creek without a paddle, but I can't do anything about it. I can't get out of here, they won't stop coming.
Tonight's featured cases are trauma, again.
First up an RTC. High speed, head on collision. Two victims. The driver was the subject of a prolonged extrication; a BASICs doc was on scene and asked for a surgeon to be waiting. The BASICs guys, and gals, are pre-hospital docs, working in their own time. They embody the spirit of the orange jumpsuit.
Anyway - we had a fifteen minute heads up, but that didn't translate well to the duty surgeon, who was crash bleeped to resus, and slightly nonplussed on his arrival. Eventually the patient rolled in. His entrapped state had required ketamine on scene. This is a 'battlefield anaesthetic'. Can be given intramuscularly, and produces analgaesia and dissociative anasthaesia. There is an occasional view among the ED regs that the BASICs guys are a bit too liberal with it.
So, the guy is boarded and collared. His airway seems ok, but I'd better check.
--'Sir?, Sir? Can you tell me your name?'
He opened his eyes, very slowly, looked me dead in the eye, and said:
'Wow!' (I'd like you to imagine this being spread out over about five seconds. That gives you the idea)
I guess there's something in this drug being used illicitly.
Primary survey revealed a tender abdomen and pelvis, with hypotension, transiently responsive to fluids. Chest X Ray showed pulmonary contusion, with possible haemothorax, and FAST scan was negative.
As per usual, my knife wielding colleagues wanted a CT scan, but the patient's blood pressure intervened, and straight to theatre he went.
One ExLap later, and all that could be found was significant retro-peritoneal bleeding. He continued to behave in a labile fashion, and I can't help but wonder if there was some other injury, but haven't heard yet. More or less a tick in the positive box; ah, but the night was yet young...
While keeping an eye on some poor fella who'd been stabbed in the belly - We guessed he wasn't too bad when he began devoting his time to feeling up the nurses - I was chatting to one of the local Constabulary. I think they were all in the ED at some point that evening. Anyway, their little shoulder radios are always going off; they sound a little like the teacher from Charlie Brown to me. You can never quite hear what the jazz is.
Anyway... this time, the radio goes off, the copper listens intently for a while then looks over at me. I raise an eyebrow, quizzically. (In my mind...)
More squawking chatter; another glance.
Rueful smile. 'More business for you, Doc...'
Shake of the head. 'Doesn't sound good...'
'Another stabbing. In the neck. They're not sure if he'll do'
I look around the rest of the Dept. Minors and Majors are both heaving. I can't remember what the wait was by this stage, but I'm guessing it was over 6 hours to be seen. Ambos were already queueing...
Sure enough, a few minutes later the call came. Young man, multiple stab wounds, suspended. I remember the first time I took a call like that, I couldn't figure out why everyone was so excited, or why someone would be suspended.
From what? Eh? Oh.... that's what it means...
How times change.
The next few hours were very ER.
The details blur around me, faster and faster as the days go by. I remember his colour, a pale, waxy yellow. It's never good, but you don't need me to tell you that. His chest laid bare, the wounds on his chest so small, so innocuous looking. So little blood.
That didn't last.
Part of you knows there's no hope. But most of you doesn't want to believe it; and you want to try. He's so fucking young. The worst part of you feeds on the adrenaline, and wants to act because it's cool. It's exciting. It feeds the beast.
As ever, telling the family was the worst. They look you in the eye, and plead: 'Why can't you fix him. Do something, fix him, make him better...' The despair tailing off as the brutal reality slowly sinks home; oh, so slowly.
You could stick a fork in me after that. I was done.
Does it count for anything? Does it tally somewhere that we all tried as hard as we could, flying in the face of a lost cause.
I'm not sure. The only tangible results will be a blip in the waiting time for those hours when we tried. Will a time come when I see this case and call a halt straight away, when I admit the hopelessness, and devote myself to the big picture?
I don't know.
Wednesday, November 07, 2007
Actually, I like working nights. More autonomy, and it feels vaguely romantic to me. It's ok, I have insight. I know this is weird, but I can't help it. There's something about hospitals at night...
The Department is busy when I come on. Not the best sign, but it's do-able. The waiting room is bristling as usual. The world's most aggressive goldfish bowl.
I have resolved to try and let the SHOs run resus tonight. It doesn't quite work out that way.
Resus is packed when I come on. In bay one is a patient waiting to go to the ward. Some have been waiting 9 hours for this privilege. I think she's got a broken femur, and assorted other fractures. In two is wheezy, short of breath. Also waiting on the ward. I forget who was in three.
This strikes me as terrible. It was less than a week go, and already I have forgotten so much. I think maybe it was a kiddie.
A few simple resus cases flow in. Then it starts to clog. At one stage we have 5 acute cases in a 3 bedded resus.
Then the first of the big three:
Young-ish. Attempted hanging. Head injury on being cut down. Agitated.
When he arrives, my worst fears are not confirmed. His airway is patent. No laryngeal fracture that I can appreciate, and although he looks congested in the upper half, I can feel no sub-q emphysema.
(This is air within the skin. It feels a little like Rice Krispies, or bubble wrap. It is indicative of air leaking into the tissue, usually from the lungs. It is high on Shroom's list of Ways I do Not Want My Skin To Feel.)
He is agitated tho'. And de-cerebrating - an abnormal extensor posturing of the limbs. This is, of course, high on Shroom's list of Postures You'd Rather You Weren't Exhibiting.
He has an ugly wound on the back of his head; evidence of where he was dropped. The final indignity, if you will. Cruelty, heaped upon cruelty.
While trying to restrain him safely, we get to play the ED sedation roundabout / roller coaster game. Up and down, round and round she goes... where she stops, nobody knows. Fortunately, I'm a veteran of this game, and we stop just where we need to. Help arrives in the form of a friendly gas-passer, and we send our guy away to a better place. This, at least affords me the opportunity to come over all ER by straddling the trolley to provide manual in-line stabilisation from the bottom end.
The long, dark walk to the scanner, while I make a few unwelcome phone calls, and break a few hearts in the relatives room. I do not feel a better person.
The scans all come back negative, which is only slightly reassuring. Anoxic brain injury can be like the wife-beater's kidney punch, ruining lives without leaving a mark. That will come later.
There briefly follows a surreal period where I and my anaesthetic colleague try to arrange admission for our guy. Ortho and Neurosurg all agree he will need their input; just not right now, so they aren't admitting him. I am disappointed to discover this doesn't really surprise me.
After a brief hair tearing, my Maiden in Shining Armour (she of the Expensive Scares) convinces the Magicians that they should take the patient.
I can't pretend to understand it, but at least we found him a nice warm vent for the night.
I need a drink. I think I'm out of scotch...
I had a hellish weekend. I composed several posts in my head during the course of it, all of which have flown by-the-by. Maybe a Dictaphone..?
Of the people I work with...
They are, by and large, a sterling bunch. 3 of my peers I am particularly fond of, and will be sad to lose them at the great rotation in May. Or maybe it's August... I forget. One, however, is increasingly showing their true colours as a bandit practitioner. The shady instances just keep mounting, and mounting.
I suspect the bosses know. I'm just not sure what we / they can do about it. I guess we all just work a bit harder? I think this particular colleague is moving on; and their human rights being as they are, I'm not sure we can tell anyone what a bandit they are, without being accused of prejudice, or bias, or something.
I always figured if you were shit, you were shit, and the sooner someone told you, the better? Not any more... it's always someone else's fault you weren't quite good enough.
Thursday, November 01, 2007
I'm going to try and pen something sensible, instead of the usual drivel. I'm not sure it'll work.
Big Hospital is trying to achieve Foundation Status. I'm sure this is very important, but can't shake the image of committee rooms full of people stood, arms aloft, fists clenched, chanting 'Foundation! Foundation! Foundation!', in a vaguely 1930s Germany sort of way.
All that stands between them/us and it, is the ED. We need to achieve 98% in the four hour target. To the uninitiated, this means 98% of our patients need to be in and out within four hours. I think it's a facile target. It does not mater what happens to these patients, as long as it takes less than four hours. So, me, a triage room and a large syringe of potassium (or air, for that matter) would actually improve our performance ratings.
Anyway, we're falling short by 0.62%, overall. Most of the damage is done at nights and weekends, when staffing levels fall, and patient numbers do not.
So, the three line whip is out. See more people, faster. But don't let clinical care suffer. After a point, these two things become mutually exclusive. To avoid that, the solution will inevitably be to refer more people for admission. If you're not sure whether you can discharge someone, simply admit them. Why waste time trying to sort out (i.e treat) patients in the ED, when it's far quicker to refer the job to someone else. (Buck, anyone? Anyone? Anyone? Bueller?)
To aid this process, the Senior Docs are engaging in a Rapid Assessment process. (Rapid Assessment and Treatment? or Triage?... I'm not sure. I've missed it being up on PICU, but re-enter the ED today.) Patients are seen and rapidly assessed on arrival, before being palmed on to an SHO, with a provisional diagnosis and plan - i.e. do these bloods, this X-ray and refer them to these guys.
We are becoming triage monkeys.
This will undoubtedly speed flow through the ED. But is it right? I don't think so. We are being asked to work more anti-social hours to achieve this target. To agree to this is surely a mistake. Other specialities do not have two Registrars on overnight. Other speciality consultants do not routinely work on the floor until midnight. (ITU excepted)
By increasing numbers of referrals we will clog the hospital with patients awaiting a 'specialist' opinion. Why not make these bastards change their working practices? Ask the surgeons to have a team dedicated to operating, an another to seeing ED referrals. That would speed up decision making, and flow. Ask the other consultants to work until midnight, seeing patients and making decisions - and, incidentally, for less money.
I can't imagine they'd stand for it.
Why should we?