Monday, December 31, 2007
Missed opportunity, absent friends, previous New Years - good, and especially bad.
Without wishing to sound arrogant, which I'm afraid I surely shall, as I surely am, I have been dwelling on the only thing that keeps me going sometimes - treating patients. Sad to say I haven't got a lot else.
Anyway - success stories of the past. I hope I'm not repeating myself.
The first sticks in my mind, because it harks back to 'old school' medicine. That is to say with fuck all help from labs etc. I had just finished my pre-registration year, the first year out of med school, wherein you had to prove that yes, you'd passed exams, but would you kill patients when left alone. as long as the answer was 'no', or at least 'not many', you got fully registered.
Anyway; I had secured a 3 year surgical rotation, about which I was pretty smug, but deferred 6 months. So I was earning my keep doing a few locum jobs here and there. There was quite a ramp up in responsibility for some of these, as they were all short term, so no-one had time to hold your hand, or teach you. On this occasion I was providing cover at a rehab hospital. Small scale, elderly patients, none of whom was judged to need acute care, but none of whom could quite go home. Two rounds a day, a few jobs, and pretty much no calls at night.
So, I was roused from my sleep at ungodly o'clock in the a.m, as an ambulance had arrived. This was highly irregular. We weren't an acute facility, but the ambos decided some help better than none, and didn't think the patient would make it to big hospital, with it's bright shiny A&E dept. So, dropped into our laps was a fella, of, I think, late middle age, but he could have been older. His problem was extreme difficulty in breathing.
I remember looking at him, sat bolt upright, drenched in sweat, his skin a pale, waxy colour, tinged blue at the edges.
If you've been paying attention, you'll know what I think about these colours.
His face was vacant, lights on, nobody home, every ounce of his being dedicated to breathing. Arms locked to the sides of the trolley. Resps almost too high to count. JVP sky high, chest sounds drowned in wheezes and crackles.
Now, the fun stuff. There was, I soon discovered, no working sphygmomanometer in the hospital. So, no blood pressure. Similarly, the pulse-ox readers were kaput. No labs or x-ray on site, and sending an arterial sample to big hospital wasn't an option because of the distance.
If truth be told, I can't remember what I gave him. Bronchodilators, diuretics and nitrates probably. A catheter to measure urine output, and so to judge renal function. My only measures of success were those I could see with my own eyes. The patients colour, his resps, his mental state, his jvp.
I sat with him all night, teasing him with a little of this, tickling him with a little of that. Slowly watching as he pinked up.
Should I have transferred him? Maybe, probably, I don't know. I didn't know any better. I thought I had to make him better. Out of my league, my depth? Maybe, probably.
But I managed. He managed.
I remember this, cos it's all a bit ER. Again, regular readers won't be surprised...
I was workin' in a DGH in the South East. I think as an A&E Reg, before my number. I was carrying the crash bleep, so I might have been in Anaesthetics, but anyway. The bleep squawked into life, the tinny voice of switch declaring adult cardiac arrest, in the car park.
In the car park?
Fair enough. Never one to shy away from attempted heroics, I up and ran. I remember it as pissing with rain, but it might just have been wet on the ground. It was dark, anyway.
The car park was just round the corner from the Ambo entrance, and the patient wasn't hard to find. She'd been visiting a relative on the ITU, and had just up and collapsed. I was first on scene, weak pulse, agonal resps.
For about 10 seconds, anyway.
Someone must have called the ambos, cos they pulled up. Which was nice, cos I had fuck all kit, and the car parks are not well stocked. Their AED clearly showed VF, but refused to shock the patient. There followed a brief argument between me and the ambos, first about how wrong their machine was (I was right), then about how best to scoop the patient and get her back to resus (they were right)
Back to shiny resus. A blur, resolving into shocking the patient...
And getting her back.
And sending her to the unit, to reside next to her relative.
And seeing her 5 days later, when she dropped by to say thank you...
Well, folks, I'm working a special kindof graveyard tonight, and will be unstinting in my attempts to bore you with how shit it was. When midnight comes and goes, raise a glass and think of me and all the other poor bastards picking up the pieces.
Joy of the season to y'all.
Sunday, December 30, 2007
Friday, December 28, 2007
I'm up early again. All too often I seem to see the wrong side of 4 a.m. I slept well enough, for a few hours; then, my all too traditional waking in a cold sweat. A bad dream? Not one I remember anyway. I vainly try to go back to sleep. Most days I'll know whether it's going to work within a few minutes.
Half an hour later, I'm up.
Pad round the house, aimlessly tidying a few things away. I spend a few moments gazing out the window. Funnily enough, no other bugger is up yet. All is quiet. I rather enjoy the peace, my horizons limited by the pool of light cast out by my lamp. Except I know it means I'm not sleeping.
I'm able to divert myself surfing for a while. I try to catch up on a bit of reading, but I'm never sure how much I take in in the wee small hours. 0430 and it's time for coffee. I dearly love all things caffeine; a taste for coffee has grown on me, over the years, ad I'm not sure it'll ever leave me. Which is good. I really love the coffee.
I'm just about ready. The cold, dark morning awaits me...
Cold showers are over-rated, but they sure as hell wake you up. It's still proper dark as I leave; full night, with only a few foolhardy souls for company. I allow myself a brief slice of boy racer as I power down the road, tipping the scales at 7,000 rpm, and glorying in the throaty roar of my Sports Penis Extension's engine, before dullShroom regains control. The realisation that there really are very few other bastards on the road slowly dawns as I encounter next to no traffic and arrive at work embarrassingly early. Even more so when I figure out I read the rota wrong, and have come in for 8, but don't start til 9.
The morning board round is preceded by the usual rounds of shooting the shit, most notably divulging that one of my SHOs is scheming to get a date with one of the radiographers. I think she's already dating someone, so this promises to be interesting; perhaps I can live vicariously through his exploits.
Proving once and for all that I am a sad old fart, with no life, I figure i might as well work, since I'm here. Number one punter is Polish, and we rapidly discover we have no language in common. Although interpreters are available, commercially, the trust seems reluctant to use them, preferring instead to rely on bilingual staff. Who are never around when you need 'em, and have their own jobs to do, anyway. Still, at least they're cheap. The patient smells of a three day bender, and is restless. He's 'MEWSing' at 5, which means his vitals are deranged. MEWS has replaced a sound knowledge of normal physiology, as far as I can tell. It is no longer necessary for one to look at a patient's obs, and decide if they are unwell or not. No, instead, someone distills the info into a handy MEWS score. Bah Humbug. Whatever his score, I think he looks pancreatitic; the bloods go off, and drugs and fluids go in. We wait.
Next a little old lady, with no real idea of why she is here. Dementia intercedes, making meaningful history taking defunct for the second patient in a row... My first, end of the bed guess is digitoxicity. A vain atempt to show off. I don't think it was right. Eventually we decide on a pleural effusion; the patient helps us along by having a small collection of fluid outwith her lung, and I ask the magicians for their assistance...
A young man offers us his racing heart with no good explanation. I take the easy route and blame his 10 day old son for upping his stress levels. Meanwhile, I'm trying to squeeze in a manipulation of a young girl's wrist, with one of my redoubtable SHOs. We have to do it in our MUA (manipulation under anaesthesia) room. It has recently been occupied by a patient with explosive diarrhoea. Despite a nuclear steam clean, the smell lingers. I'm amazed the patient can't smell it; this nasal insufficiency plays out in my favour a second time, as she briefly ends up with her face in my armpit; never the best of places to be, and not improved by a bout of strenuous tugging on a broken radius. Despite a good old fashioned Bier's block, she still finds uncomfortable, but backs down from her original offer to slap me afterward.
All the while an asthmatic COPD-er flirts with true respiratory embarrassment in resus. She is ably handled by another of our SHOs, but not before spectacularly vomiting. Excellent coverage; professional standard.
Polish guys's bloods lean towards the pancreas. I lean toward the surgeons, and they accept. I am briefly stunned.
We get something of a rush next. The specialist Cardiac nurse, or 'ThromboMan' as I like to call him, tries to monopolise Resus, smuggling in a fella with cardiac amyloid, among other things, and an elderly chap trying to see just how slow you can go. I deny him the chance to own resus by bringing in a young guy in status epilepticus. A tragic case, this young man's life ceased to be his own a few years ago when his blood sugar dropped low enough to provoke seizures, seizures that couldn't be stopped, and robbed his brain of oxygen long enough to leach most of its meaningful function. The patient is accompanied by a carer who assures us he does not have epilepsy, or seize 'normally'. Our efforts to stop these seizures depress his respirations long enough to force 24cm of semi-rigid plastic on him.
His trip to the Doughnut of Doom is uneventful - barely a hint of doomliness. The scan offers no new info, either. This passes to embarrassment when we look at his drug chart, and finally see the raft of anti-epileptic meds, and the letters from Neurologists in his casenotes, documenting his propensity to seizures.
At least we know why he fitted. He wakes, rejecting the tube, and another one is welcomed into the warm embrace of the magicians.
Lunch beckons, ad I leave Resus echoing to the cries of a lady who fell, catching the wheels of her zimmer on an escalator. Now, I know I'm a simple fungus, but I don't think those two particular advances in mobility technology were designed to go together. She has only slightly scalped herself, but sees everything we do as an outrage, loudly objecting to our attempts to examine her. She was still complaining 4 hours later, mostly about the fact that other patients were in the Department, using the toilet, and that she needed diazepam.
My post prandial slump encompassed writing a few sets of notes I had let slide. Resurgent after more coffee, I encountered another very young chest pain, again no evidence of cardiac pathology. My reassurances fall on partially deaf ears, but I know he's feeling better when I encounter him and his partner scarfing Burger King.
Another little old lady, another broken wrist. The redoubtable SHO and I spring into action. Our efforts are less successful this time, despite truly game counter traction from the patient herself; a second attempt is better, but produces the most shameful cast. I resolve to turn to Charnley more closely. My redoubtable colleague and I labour on, past our allotted hour.
And so, my shift that started an hour early draws to a close, 90 minutes late. It's dark again, and it's started raining. But I'm happy.
How fucked up is that?
Music Nazi recommends Wish You Were Here, by Pink Floyd. Do it; you kow you should.
Monday, December 24, 2007
Last two shifts have been hellish. Busy, busy, busy, punctuated by flail and trauma.
A patient bought beer for the ED staff, however, and I intend to finish my shift drinking one in the Ambulance Bay. Merry Shrooming Christmas.
Tonight, my last for a few days, was eerily quiet. Quite nice, actually; but a quiet department makes me nervous. It's superstition, I know, but I also know it means something shit is waiting.
Tonight was no exception.
Having begun to think that we might make it through, actually having an entire shift that was nice and quiet, the BatPhone trilled into life. While this usually means someone unwell, we do get a variety of stuff phoned through. If you're dying, you'll come through on the phone, but if you come through on the phone, you ain't necessarily dying.
First, a cardiac arrest. I'm embarrassed to say that I can't remember how old he was, even though he slipped away from us less than an hour ago. 70s, I think. The crew that brought him had been going an hour, with no encouraging signs. There's really no comeback once you've been dancing with the Angels that long, but we'll try. The team is ready, and eager; callous though it may sound, it's also a good opportunity for the juniors to try their hands at running an arrest.
Another 30 minutes with us and we were finally ready to accept what we all knew was true. So my SHO got to learn the art of breaking bad news; this time of year it seems especially cruel.
As we were getting our breath back, the unwelcome trilling rang out again. Another gent, 70s again; bellyache, low blood pressure, poorly responsive. Time only to wipe our brows and breath in.
When he arrives, I can see he's in trouble. A raven might as well have been perched on his shoulder. He had apparently gone off as soon as the Ambos arrived, slipping into unconsciousness, and abandoning all attempts at breathing. His pulse, fluttering, weak, thready; barely evidence of a tenuous hold on life.
It didn't last.
Within minutes, he was gone. We were still gathering obs, still trying to make sense of the puzzle before us when he lost his fight. CPR started immediately, and I tubed him; slick as you like - Grade 1 view, some airway soiling, but the semi rigid, impersonal endotracheal tube whipped between his cords as easy as you like. Forcing air into him desperately, I couldn't tear my eyes off his belly, which was blowing up in front of our eyes.
For a few frantic, soul searching moments my 'satisfaction' with the tube turned to self doubt.
'It's in his fucking oesophagus...'
Then the CO2 monitor lit up. CO2 only comes from the lungs, so the tube couldn't be anywhere else. I think that might be called 'cold comfort'.
Another undignified struggle. Nothing made any difference; every intervention a small victory, but in a losing campaign. As is so often the case, all the cajoling, all the pleading in the world, couldn't get his heart started.
My turn to talk to the family. The usual explanations; the apologetic, quietly spoken words. I don't know how they hear them, but they echo dully in my own head.
And finally, they take it in, for now anyway - tomorrow will be different, and the next day, until the realisation finally takes root - and they thank me.
'For all you did for him'
For ruining Christmas
Sunday, December 23, 2007
Regarding being careful what you wish for, I simply meant that before, I couldn't get a spare pair of hands for love nor money; but when the baby went off, so they tell me, every doc in the world drifted in to see if they could help.
Friday, December 21, 2007
Although, in unrelated news, I have decided the fictional doc I would most like to be is 'HawkEye' Pierce, as seem in M*A*S*H. But I'd most like to resemble the young Luca Kovac, from ER.
So... yesterday, I was workin a few extra hours, as penance for my record breaking oversleep. I owed 3, but asked to pay back 4, as a kind of debt of honour. It is always, always the little things that bite you.
As one a.m. rolled 'round (I should have finished at midnight), I was chatting shit with the SHOs, as is my wont. I heard the happy sound of a baby laughing; looking across the floor, I saw one of the sisters tickling a baby on a trolley in Bay Two.
In a split second everything changed. Almost in slow motion. In a film, or TV tie in, you'd see the smile fall off my face. The baby isn't laughing, he's choking, she's not tickling him, he's fitting.
As one, we're off, running across the floor, even as the call goes out - 'I need a doc here, NOW!'
He's a little one, 10 months, but chubby. A real cutey under different circumstances. He's hot, hot and clammy, and his whole body shakes, held in the grip of St Vitus' Dance. His parents, pushed to one side, are gibbering.
We have nothing paediatric out here... Sister and I support his tiny jaw, saturate him with oxygen as best we can; the adult mask looks ridiculous over his tiny face.
Soon, the carts arrive, someone hands me diazepam, in a little yellow dispenser. This stuff goes where the sun don't shine. No dignity now for the little fella; tho' in fairness it's difficult to maintain dignity when your 10 months old. Anyway, diazepam is in, and we switch to a better fitting mask. I can faintly hear his ma in the background: 'He's not breathing, oh, god, he's not breathing...'
The team is slick; I'm only vaguely aware of of them behind me, moving quickly, efficiently, handing me this venflon, that 'T-piece'. Now, blood bottles, now a saline flush.
Someone's with mum, explaining, reassuring; he is breathing, we are helping him, we're giving him drugs...
But, he's still fitting. iv access, a nightmare in chubby little ones... not this time; straight in, defying my shaking hands. Lorazepam, please. I revert to overly formal language, one of my foible.
'I'd be grateful if someone would do me the honour of passing me a miligram of lorazepam, at your convenience, please...'
Either way, it's there, as I ask for it.
In it goes, and now the monitoring is up and running. Other docs come and go, offering help, rubber-necking. The day has been quiet, now they all want a piece of the Shroom's circus. I'm not really aware of them. My mind is racing, trying to remember the algorhythm.
What's next? Paraldehyde? Paraldehyde. What's the dose? Do we even have it? Where do we keep it?
He'sbeen fitting for 20 minutes now. We're just about together enough to make the resus dash now; that's where the paraldehyde lives, after all.
Paeds have been called, but there's always something goin on, so it's us. It's always us.
We love it.
Paraldehyde is in, but he's still seizing, he's still hot. His airway is difficult to manage, but he takes an oral airway. This makes my life a bit easier, but doesn't say good things about his conscious level. Mum and Dad have finally had enough, and have stepped out, alone with their grief. I deploy a colleague to get the back story. I know nothing about this kid. Our entire relationship has been a fight between me, between us, and his febrile brain.
Next is phenytoin; my team have anticipated this, and 180 mg is drawn up, waiting. After that, we all know, is thiopentone; we aren't cut out for that, and the call goes out to PICU. As it's becoming apparent the paraldehyde ain't workin, Paeds enters stage left. God love him, he doesn't have any better ideas, and we start the phenytoin
Another line goes in, rectal paracetamol, and antibiotics, even before he can ask for it. Frankly, I'm still shitting myself, but my team are awesome.
Next onstage is PICU. The back story doesn't help, but the kid is sounding stridulous. This is high on the list of noises you don't want of hear when people are breathing.
The croup? Maybe.
I can still see thiopentone in all our futures.
As I'm holding his airway open, he reaches up, to push me away. He interrupts his tortured breathing to cry. I have rarely been so happy to see a grumpy frowning Winston Churchill look-a-like.
God love Phenytoin. He is coming around.
We sit him up, leave him to breath on his own. His airway no longer needs my sweaty grip. My focus begins to expand, and for the first time in an hour, I can see more than his little chubby face. My team swims into focus, and they're grinning. Like fools. I guess I am too. We're all pretty pleased with ourselves.
PICU is just as pleased. They always think we call them too early; we probably do. But I still see thiopentone in our future, and I like the company. Anyway, they fade to black, and leave Paeds centre stage.
As we all slip away, the chubby fella is sitting up, grizzling at us all. He's going to be ok.
He's going to be ok.
It ill becomes a man to brag, but we handled ourselves pretty well, considering we were caught with our shorts down to start with.
We can all feel good tonight.
First, the suddenness of disaster.
Patients who I see probably give me an unrealistic idea of how ill prepared we are for the end. Our patients are subject to an inherent selection bias. It isn't a true representation of the general populus. I guess. Or that could just be arse.
What I mean is that we often see people at the 'end of life' with diagnoses that seem terminal. It's often those who have a recent diagnosis. So, suddenly, you go from being healthy, to having lung cancer with brain mets. It must be hard enough breaking this news, without having to discuss the imminent prospect of death.
And so it falls to us.
A gradual deterioration - 'he's not been very well today', then, in a flash - 'he won't wake up'.
And so it falls to us.
It's in the eyes. I see it in your eyes: willing us on, willing us to fix it, to do something, anything to buy a little time. I see it in your eyes: they're blank, staring, unfocused. Windows of the soul? In your case, they let me into your skull, warn me of the pressure within. Straining to get away.
An escape we both know isn't possible.
A review of the notes tells me all I need to know; talking to the family, it seems obvious to me that this thought has not been allowed to take hold. They must know it's coming; but not now, surely.
The CT confirms what his eyes had told me. Bleeding everywhere, pools of angry white on the scanner. Tortured brain struggling to cope. It won't be long now.
And so, finally, it falls to them.
Thursday, December 20, 2007
As part of my ongoing quest to establish my rep as the Resus Hog, I spent my entire night therein. Yesterday was particularly Code Blue-full. And we seemed to have a special on Paeds, too. Buy one, get one free - that sort of thing.
Some days, one can't move for Docs milling around resus; somedays - no-one. At one stage yesterday, I had ownership of all tree resus bodies. Now, admittedly, they were patients who could tolerate being left alone for 5 minutes at a time. So I could attend to one, start treatment, go to the next, assess and treat, and so on. With good nurses, a body can just about manage. As I'm sure you can imagine, it doesn't take much to bring the pack of cards down.
So, of the 3, one was an exacerbation COPD. Blood gas, CXR, quick eyeball. Hypoxic, but not hypercapnic; chest mostly clear. Up on the Ox, bounce to magicians. Next, small(-ish) pneumothorax; little local, quick aspirate, repeat the CXR. Third was , sadly, the worst. Young fella, flat GCS. History of brain mets. Another quick lookover, open the airway, crank the Ox.
I am holding it together... until - Paediatric Code Blue, Now...
COPD is holding her own, better on the Ox, started on antibiotics. Good, she can escape resus, and onto the medics. Pneumo boy is a little better, but not all the way. He too, can leave, but not all the way... I need to see him in a bit. GCS 3 clearly isn't going anywhere, but I can't manage him and an emergent kid.
The call goes out for another Doc.
In comes the kiddie. Shortof breath, now hot, altered, foaming at the mouth.
Another pair of hands?
GCS 3 is stable - as he can be. Fine; to the kiddie then. Still hot, but not foaming now. Another doc, please?
Anyone? Anyone? Anyone?
Just as we're finding the right sized mask, and after a third call, help finally arrives.
I guess the down side to being the Resus Hog, is people jus leave you to it? I reap what I have sown...
In fact, I was only woken by the Boss phoning to find out why I was an hour late for my shift. I had, it seems managed to sleep for 18 hours straight, through two alarms.
Insomnia, it seems gets you both coming, and going.
Tuesday, December 18, 2007
Anyway; of scut, and scutmonkeys. Faith is having some difficulty with her nurse mentors. Now, I don't pretend to understand nursing training. Mostly, I don't understand nurses. I just do what they tell me.
All the student nurses we see are attached to a trained nurse (or maybe more than one? one per shift, one at a time? You See! I don't know!) and so I guess they do what the trained nurse does, and learn how to become the shining examples of patience and goodliness that are nurses. Or at least the ones that have to put up with me, anyway. How nurses decide what their trainees can do, or are allowed to do, I have no idea.
With medical students, I ask 'em what they wanna do, then make 'em do what I think they should be doing. Hopefully there is interaction between the two. Where possible, I like to try and stretch the students, get them out of their comfort zone, doing something they aren't quite comfortable with; but something they'll need to do sooner or later. A 'get it over with' strategy.
Faith, on the other hand, seems to spend most of her time being told what she can't do. It seems to me that there are really very few things that a person should be forbidden to do. If your entrance programme works ok, that is you aren't admitting muppets to your training programme, then why not let 'em at it?
Of course, this has to be a 'within reason' strategy. But if a third year student wants to cannulate someone, why not? Hell, if they're too afraid to do it on patients, I let 'em do it to me. I firmly believe in 'see one, do one, teach one'. And I don't see why it should be different for nurses. These are intelligent people we're dealing with, surely. Can't they be treated as such? Or am I just blowing gas about something I know very little about?
Lastly, for the sake of Devil's Advocacy, I think, in fairness, that being a student is mostly about being the scutmonkey, in all it's various guises - bedmonkey, admisions monkey, arsemonkey, etc. Sometimes, you just have to chimp up, and get what you can from the grooming.
(Yes, I know chimps aren't monkeys. It's dramatic licence. Don't make me fong your wanging eyes...)
Recently, for example, one of my SHOs used the expression 'wang-eyed'. This was as an alternative to 'cock-eyed'; I can't remember how it came about, or in fact who we were talking about; me? you? a patient?
Either way, I found the expression hilarious. It became the expression of the moment, and the oncoming tea were bemused to come on to find the night guys giggling, slightly hysterically about eyes being wanged.
It was funnier than it sounds.
Monday, December 17, 2007
And so to work; it's man flu season. Even some of the female nurses were admitting to it. I'm sure that's 'bird-flu', but anyway...
I guess I must have looked more pasty than usual; I sure as hell felt it. It was all I could do to not throw up when I got in. Sure, I can work on no sleep, but it ain't clever. Domperidone sorted that out. Resus was in full swing when I arrived. Baby blue pyjamas knows. He was there. I missed all the action, but did get a chance to relocate a posterior shoulder dislocation, something I haven't tried before. It seemed simple enough, and one of my SHOs and I produced a satisfying clunk. Smug mode all round.
Nope. Apparently, one clunk does not a relocation make. I'm sure it went back, but slipped out again, while we were assessing stability; or when the Radiographers were X-Raying it. Yes, that was definitely it...
So.... the Boss asked me to check out a fella who had had his legs unpleasantly squashed in an RTC. As he put it, when the car in front stopped, he stopped about six inches too late. One bust patella, and a mashed radius. As luck would have it, this was today's lucky combo for an Ortho admit.
Meanwhile... the Boss reattempted the shoulder. I was quite pleased to see he appeared to struggle with it too; until BBP stepped into the breach. Before you could say 'counter-traction' there was a distinctly lesser clunk, but a whole lot more reduced joint. Next time for Shroom, I guess. I just have to remember to take BBP wth me...
I have more wisdom to impart (well, true for a certain value of the word 'wisdom'), but I really am tired... So, until I edit, a reminder to myself - wang-eyed, end of the night shift and nursing scut vs doctor scut.
On Saturday, when visiting my friends in Kent, I spent the entire evening trying to get their 17 month old daughter to say 'botox'.
Almost got it, too; managed to get her to say 'bo' and 'tox', but couldn't quite get her to run the two together. Still, I was unreasonably pleased with meself.
Simple things, and all that....
Found this, which I'm lovin'.
Sunday, December 16, 2007
I am in particularly bleak mood. There are, I'm sure, a number of reasons for his. There always are.
Whenever I feel like this, I get the urge to bloggin'. It often doesn't last, and I let it slide. I do not know if that's for the best or not. We may go some way to finding out in the next few minutes. Anything can happen in the next half hour?
A busy-ish weekend, but still so much to do. I spend a lot of time griping about the passing of time, and how old I feel. If you're older than me, that'll seem ludicrous. Younger... just wait. I feel it in my nights more than anything. I used to do whole weekends on call, Friday Morning to Monday Evening, with whatever sleep we could snatch. Actually, with two of us on the house, we'd be guaranteed at least one decent night's sleep, so it wasn't bad at all. Even a few years ago, I could do four nights, or five, and g out at the end of them; lead a productive day, and fall blissfully asleep in synch.
Two, or three, and I'm finished. Worked Wednesday and Thursday; tried to stay up Friday, but fell asleep. Managed a few hours then dragged meself out to see The Girl's play. An ambitious reworking of Marat/Sade. Beautiful and talented. I continue intoxicated. Dinner afterwards with her folks who'd come to see the play too. A good sign? On balance, not, it would seem.
Anyway, I woke at 3. This often happens to me now after nights, but I could not get back to sleep. These days I interpret this as a symptom of low grade depression. I'm tired but my mind won't let me sleep, and I sit, or toss and turn, or pace. All miserably.
I eventually got back to sleep around 8, meaning to get up for 10, and go shopping. When I finally surfaced at 4, it was time to go see some old friends of mine. One bright moment in my fundament. More insomnia was to follow, but at least I managed shopping today.
I can only hope sleep will not evade me this evening. Work awaits, and that usually centres me.
Friday, December 14, 2007
HPC - Swallowed cheiwng gum 3/7 ago; thinks it got stuck. Can feel it rising and falling at the back of her throat. No difficulty eating, drinking, breathing. Nauseated, but no vomit
ODC - Has been stabbing herself in the oropharynx with various pointed objects in an attempt to remove the gum
Findings - Raw, injected, erythematous oropharynx; no bleeding. Awake nas-endoscopy revealed no trace of gum.
Disposition - wisdom of stabbing oneself in the throat with pointy things discussed. Advice given regarding the consequnces above and beyond 'sore throat' that such a plan might have. Reiterated age old wisdom that swallowing your gum is a bad idea.
Wednesday, December 12, 2007
Scandal, and gossip. Endemic in hospital. I seem to have created a little without realising it.
I'm ALWAYS the last to know, even when I was there apparently.
Last night was actually quietly busy. Did I already tell you that? I can't remember... the department was stuffed, but with few real sickies. Which is nice. These days it seems a real rarity if our Resus Bays aren't overflowing.
It doesn't take much, though. Another midnight call, another breathless punter. At the best of times, I'm a resus hog, an adrenaline junkie, an SHOs nightmare. Turn around, and there I am, champing at the bit. No matter how quick you think you are... I'm faster. The SHOs I like the best are there quickly, too. I see in them a kindred spirit; they want to see the difficult cases, the interesting cases. This is markedly unfair to the many excellent docs who come through EDs but aren't especially interested in the Acute end of the spectrum. Sorry, guys. No offence meant.
I digress; the elderly breathless is pretty much bread and butter. Since pretty much everyone smoked in the 30s and 40s, they now all have COPD. If they don't, they have heart failure. As with all of medicine, the devil is usually in the details; history is almost all of it. If they're on inhalers up the wazoo, it's COPD. If their drug cupboard rattles with diuretics and other 'heart' meds, its their heart.
Usually. And for all my esteemed physician colleagues, I know it's never that simple, but it's pretty close, eh?
So, last night's arrival had a long smoking history, several admissions with 'exacerbation COPD', and a cabinet full of inhalers and nothing else.
So much for history...
As I'm sure my medical colleagues know, these patients also have a look about them. This guy was exhausted, sweaty, cold at the edges and had a sky high BP. JVP virtually punching through the roof.
Chest... pretty quiet, a few wheezes, a few fine creps. The good old fashioned ED mixed bag.
In short, his history was good for COPD, but his exam spelled heart failure. The difference is rarely as clear cut as we would like. When I was on the house, we used to call the treatment 'nebulised frusicillinalol'. Some bronchodilator, some diuresis, some antibiosis.
I was pleased to see my SHO run it like a pro. Good history, rapid assessment, right diagnosis, prompt treatment. The joy of it is, of course, that COPD-ers need limited oxygen and nebs, whereas heart failure needs as much oxygen as you can cram in, and offloading. Get it wrong, and...
Sometimes, whatever you do, it's too late to stop them circling the drain.
We used nebulised frusicillinalol nitrate. X-ray and subsequent intubation confirmed the clinical suspicion of left ventricular failure.
I spent most of the time with the family; it's one of the good things about having competent SHOs. I hope it's because we taught them something. Because I taught them something? I guess it doesn't matter as long as they learned it.
Quietly busy tonight, but at least the aircon was fixed. One of my patients was a young chap with learning difficulties. Having resolved his problems, I was discharging him, when he gestured at another patient. "That man's sick", he whispered, actually drawing close to me, and hiding a little behind my arm. He seemed very frightened. His family told me he was afraid of hospitals, and doctors, although he seemed quite content with me. Maybe the idea of sickness upset him. I tried to reassure him that the other patients would be ok, with little success. Everything seemed to spook him as I walked him out.
I thought if we changed the subject... I commented on his earring, a snazzy, shiny gold number. The change was immediate. His face lit up, and he beamed with pride. And, then, he actually held his arms aloft, a silent cheer for himself, for his earring, maybe for all earrings and those who proudly wear them day in, day out. The forgotten heroes of ear jewelry.
I don't know, but I made someone happy, and that's gotta be worth some good Karma?
Last night was an odd one. Most Docs and Nurses were living it up at the ED Xmas do. Not me, obviously. The gremlins seemed determined to make the most of our discomfort, and so, for reasons I still do not understand, the temperature in the Dept fell steadily to a nice round 16 degrees (Celsius); or maybe it was 14. The corridors were lovely, toasty warm. But the treatment areas? Cold enough to freeze the balls off a brass monkey.
(Bonus points for any of my dear readers who can suggest the origin of this expression...)
I also began to suspect someone was playing silly buggers with the nitrous, as everyone spent more time than usual giggling. Or maybe I just had something on my face...
The evening ended on a sour note. Another failure.
Young patient. Extensive forensic history, IVDU, epilepsy. Attended as he was having frequent, multiple fits.
But he didn't want treatment; and refused even basic blood tests. He said he had a needle "fixation". I guess he meant that to mean phobia? I'm not sure, but I was cynical enough to note the multiple tattoos, and history of iv drug use.
What he did want was us to "sort my meds out". Not without blood for levels, I countered. No blood he assured me; he was fairly certain I wouldn't find a vein anyway. "I don't even want to be here", he mumbled.
And so I failed him. If I was a better physician, we could, I'm sure, have discussed his fears and desires rationally. Maybe I could have helped. Instead, I got annoyed. Don't wanna be here? Fine. Thanks for stopping, and we'll see you later.
This made him very angry, and he described, among other things as a "no-mark, toffee-nosed prick, who thinks he knows it all just cos he's got a degree off the back of a Cornflakes box."
I'm afraid this made me a little more annoyed. I am well used to people judging me on the strength of my accent. It is particularly... plummy, shall we say. Posh, even. This is not my fault. It is the way I am. I am well spoken, and proud of it. But if you aren't, or your accent doesn't sound like mine? I don't care. It is not who you are. It is how you sound. But to have a go at me, because I am the very thing you have come to see - a well educated, well spoken medical professional? This seems pointless, and despite being used to being the posh boy, I increasingly resent it being used as an insult. After all, I choose not to describe my patient as a "no-mark guttersnipe junkie, who can barely read the back of a Cornflakes box".
So, despite my attempt to reason with him, which probably made things worse - he clearly didn't want to be reminded that to a certain extent, I do know it all, that's why I have my four degrees from Kellogg Uni - our therapeutic relationship was irrevocably soured. And he left.
He did not come back.
But I should have done better by him.
Monday, December 10, 2007
Buy it. There's no reason why it should work; but it does.
You won't regret it. (If you do, our tastes are far enough removed that nothing I say makes sense. But you are missing out...)
Had a grand old weekend, although if I'm honest, was probably a bit too drunk and loud. And annoying. In fact I'm lucky my friends put up with me.
Regardless, we had gathered at a friend's house in the flat east of this grand country of ours. A pre Christmas Christmas party, if you will. I asked the girl if she wanted to come. I did this a while ago, while feeling pleased with myself, or optimistic, or high, or something. I didn't think she'd say yes.
But she did, and so I had contrived to spend 24 hours in her company. I'm not sure I distinguished myself, unless she really likes rude songs sung overly loudly. I was also reminded , if I needed reminding, that I am not a young man anymore. Mostly this reminder came in the form of trying too hard to compete in drinking games. Put in my place by a Mary's Man. The shame of it. Time to hang my drinking hat up next to my dancing shoes.
So I had had plans of an attempted wooing. These seem scuppered when I had remarked how we were an anti-cliche, in that we have dinner, she asks me in for coffee, and then... we drink coffee. Of course, says she. I'd be horrified if you tried to jump me.
Let that one roll around in your mouth for a while, if you will.
No, I can't put a positive spin on it either.
Fair enough, I guess that's cleared that up, anyway. Best behaviour, then.
It seemed to work well enough, although my friends were keen to establish us as a couple. I think it's the novelty factor for them. Drunkeness ensued, in case you hadn't gathered, and I sustained a small, but annoyingly painful head injury. Tried, and failed to stay up for the Hatton fight.
But the morning... the morning brought not only the mother of all hangovers, but an interesting sleeping arrangement. Not planned, I insist. Not since I heard the word horrified, anyway. And while all that went on was sleeping, it was, shall we say, very companionable. Was this my time; a test?
Horrified, you'll remember. Well, I didn't see evidence of horror, but I'm still as confused as a fella can be.
Can men and women be just friends? Even if they're very good friends?
I'm no clearer knowing, frankly.
Historical note. I've just watched the Alamo. I'm sure the thing is riven with historical inaccuracies, but one in particular has got my goat. General Houston makes reference to Wellington choosing the battleground at Waterloo. He didn't. While he generally preferred to fight on his terms, on this occasion, Napoleon stole a march on him, humbugged him, if you will, and he had to fight there to stop Napoleon splitting the Allied armies. So there.
Music Nazi recommends What We Did On Our Holidays, by Fairport Convention. Do it. You know you need more folk in your life.
Saturday, December 08, 2007
Some of our 4pm til midnight shifts have slipped two hours, to become 6pm til 2 am shifts. Today's was just such a shift. Joyfully, I had booked a patient to come back for review at 4. I duly set off to make the commute; today, of all days, the traffic was shite. This coincided with my reaffirming my theory about drinking plenty of water. 3 litres a day? Balls. I am not convinced this makes me any healthier. It does make me piss like a racehorse. So, en route today, I dutifully drank a litre of God's finest tapwater. My timing is usually such that I arrive just in time to void, copiously.
Constant reader, if you are not desirous of learning more than you really need about my bladder, look away now.
I made one pitstop about halfway, to stretch the Shroom's stumpy little legs, and add my contribution to the groundwater. The traffic jam 20 minutes away from work subjected me to the trials of patience peculiar to the bladder. I almost made it; but at the last, had to pull over. On this occasion, I could not find an appropriate bush to water, so was able to recycle my water bottle. And I filled it to the brim. A whole litre! Which went some way to explain why my back teeth had been floating. And yet 10 minutes later, once I got to work, I was able to void further. I didn't have a urometer to hand on this occasion, but reckon I passed another 500. So, one litre in, probably 2 out. I am the king of diuresis.
'Rehydration' my stretchy bladder.
Uriniferous miasma passed.
The department was once again heaving. My favourite boss asked me to weigh in early. I have so little life. I gladly accepted. Another shift in resus. Maybe I can get a little cot in the corner, and move in. It'll sure as hell cut down on my commute costs.
So - COPD decompensating in Bay one; serious trauma in 2 (donorcycle versus car); haemoptysis in 3. He ended up there because of a history of gastric carcinoma and abdominal aneurysm. He was pretty well, all things considered, which gave me time to goggle at the fact that bay 2 guy had done almost the same thin a year ago. He is surely getting the most out of his NHS tax dollar, but using up his nine lives, eh? I didn't quite keep up with what his injuries were this time, but our resus was for a time home to all the intensivists our little hospital has to offer.
The stability of haemoptysis man was further useful as it enabled a quick switch for status epilepticus girl. This wee lassie's story is confused by her non-diagnosis. We are all agreed that she has fits, but no-one knows why. The Neuro guys are pretty sure it ain't epilepsy; the Head shrinkers are pretty sure it ain't psychological; and the cardiac guys are wondering what it has to do with them. So far as I can tell, all tests are normal... which more or less adds up to 'psychological' seizures. Or pseudo-fits. The problem with this diagnosis is the stigma attached. It tends to be equated with 'faking it'. This patient certainly felt she wasn't being taken seriously by medical personnel, once they found out her non-epileptic diagnosis. And as far as I can tell, her fits were not epileptic, although I can see how they would appear to be to a lay person.
Does that change how I treat her? No, except possibly in that I'm less likely to give her benzos, or other anti-convulsants. Fits are fits; they still fuck up your day. Personally, I think they are psychological, but what do I know. I suspect this diagnosis will not ever be accepted by the family, or the patient. And as such, I'm not sure if she'll get better. Speaking to the family, it seemed to me that they considered the very idea offensive. I'm not sure this is fair. Like I say, fitting is fitting. Why should there be less stigma to a fit that has an 'organic' cause, as opposed to one that is 'psychological'? I guess this small question holds the nub of the stigma associated with all mental health issues.
Fuck it, what do I know?
A few more fits later, and a brief argument with the Magicians, and our lassie won a bed for the night. I hope her test results eventually tell her what she wants, and some treatment can be started.
She made way for a fracture dislocation of an ankle. Normally my bread and butter, I just could not relocate this one. I sheepishly had to turf to ortho. Macho Shroom? Not this day...
And with her passage out of the House of Fun, my nightly MI arrived. The MI that never was, fortunately. Brief panic, then transfer to CCU. Joy, and medicine of the highest quality. A few Paeds cases brought on the double bunking that seems de rigeur these days; in fact I even had the pleasure of treating a few in the corridor. To their eternal credit, the parents were understanding, and probably just glad to see a doctor. First world care, you see...
My shift ended with a smattering of trauma. Another donorcyclist, this one who worked in a brewery, and smelled like it, but seemed to have got away with facial injuries. The usual survey was complicated by the patients spectacularly awful dentition. He barely had a single tooth in his mouth, and could not tell me if this was how God intended him to be, or if the offending ivories might be nestling in his pulmonary nooks and crannies. At the same time, there was a great stacking of motor vehicles somewhere far to the north, disgorging copious numbers of inebriated youths, in various stages of injury. A major incident beckoned, but we were fortunate enough to be able to share the wealth with several sister hospitals. But this still left my colleague snowed under as the witching hour drew nigh.
A man of no doubt the highest moral fibre completed my night by overdosing on cocaine and heroin; an interesting combo, and another repeat offender, I noted with, sadly, little surprise.
My journey home was illuminated by the particularly piercing incandescent blues unique to ambulances. Erie when they aren't blaring the two tones... Over for the night?
Not even started, my friends
Thursday, December 06, 2007
Two things have managed to take hold.
First was an interview I heard on Radio 4. It was with an elderly lady who was a land girl during the war. These girls worked the land, doing the jobs left undone by the men so far away in the mud, blood and shit on the front. This lady had been a specialist in pest control, which essentially involved various inhumane ways of slaughtering rats and rabbits. She rationalised her job by telling herself that each beast slain meant one less piece of food that the Merchant Navy would have to bring.
She recounted a tale whereby the girls were taken to a farm and shown various fascinomas, including a caravan full of monkeys no less, and the corpse of a lion. This lion had done for the ex-rector of somewhere or other. Claspknife or something. It transpired that this rector had been helping the local fallen women, but had occasionally been helping them to fall a little further. He was subsequently defrocked and had taken to standing in a barrel on Blackpool Pier, protesting his innocence. He then moved to near Skegness, where a local man was exhibiting a lion. The ex-rector took to entering the lion's cage offering his soul to the Lord, proclaiming that if he were guilty, the lion would do the Lord's work.
Obviously, it ate him.
Justice? I found it morbidly entertaining.
Second was my thoughts on how different patients look when they're flat. I often form opinions about the patients I see while they're unconscious, only to have my ideas roundly disabused when they wake. This was particularly illustrated to me with one chap, brought by the Police. The story is all too familiar. A young fella, they're usually male, mostly young, is intercepted in his mission to drink too much then make a general nuisance of himself about town. Shortly after their arrest, they become strangely unresponsive. A quick trip to the hospital ensues, whereupon they are de-arrested, which usually brings on a rapid recovery and exit.
Cynic, thy name is Shroom.
So... this guy fulfilled all the above criteria, but I could not get him to wake. He looked like a rough-housing kindof guy. I saw him as a brawler, the kind of fella I might well cross the street to avoid. Anyway, I was still convinced he was putting it on. All his obs were normal, blood work the same. Catheterising, so often my go to procedure had barely raised a flicker. One last trick up my sleeve, before the onerous 3 a.m wake the Radiologist phone call...
This is one of my favourite tricks, but requires a serious voice. Standing over the patient, one opines, loudly, that the situation looks grim, and that a brain biopsy may be required. It helps if your assistant will gasp convincingly at this stage.
Next, equally loudly, ask for "The Large brain-needle". You, can, if you so wish, at this point, gently prod the patient's head with a bluntish sharp object. I use the end of a tendon hammer. The response was amazing. Rapid recovery. But what surprised me the most was how his features softened. He turned out to be the campest man this side of Liberace. He had great fun discovering, and removing his catheter.
Well, he didn't have fun, but we smiled a little when we heard the noise he made pulling it out.
Wednesday, December 05, 2007
Today has found me on just such a day. A day off, after a late; slept late, then mooched about. I did have good intentions to get some work done... I guess it'll have to keep.
So tonight finds me immersed in my favourite pastime - watching old episodes of ER. This one is one of my especial favourites. Its called Exodus, and features Carter stepping to the fore in the face of a major incident. A benzene spill, with contamination of the ER. High melodrama at its finest.
In real life, shit continues to flow downhill. I am forever fascinated by people's reactions to our enquiries about their pain. Most if not all, places use a 0 - 10 point scale. 0 is no pain, 10 the worst imaginable. Yet people insist on telling me their pain is '12', or '20'. Now I recognise that your pain may be bad, but when I offer you a scale that tops out at 'the worst imaginable', there is no point telling me it's worse than that. It's childish. It's like saying 'infinity plus one'. Particularly when you then flinch as I put a venflon in.
I'm thinking we should tell people the scale is "0 for no pain, 10 for worst imaginable, and more than 10 means you're making it up.". I was once confronted by an angry young woman, who had come back from the waiting room, to ask when she would seen for her headache. Her pain, she said, was '20 out of 10'. I was amazed that she was able to converse with pain twice as bad as, for example, being cut in half with a rusty lemon. Interestingly, it always seems to be these people who insist they have a very high pain threshold. Never the people with horrendous compound fractures sitting quietly. Why do they never feel the need to brag about their pain threshold?
Something else that seems to confuse people is the pointing out of inconsistencies in their stories. I recently saw a patient, whose final diagnosis appears to have been cholecystitis (inflammation of the gall bladder), who assured me she had a very high pain threshold. Despite this, she was unmanageable with pain, despite morphine and enough entonox to sedate an elephant. The pain, she insisted was markedly worse on movement. 'But you're moving all the time', I offered. 'Your breathing, in fact, is using all your abdominal muscles, and you're rolling all over the bed (I know what you're thinking, it's colic; and it was), so is it really worse on movement?'
Patient just looked blankly at me. I mean, I know we sometimes blind people with science, but...
Well, it could be worse. I could be mopping up benzene...
Sunday, December 02, 2007
A fellow blogger has had a few words to say about how our clients comport themselves. Manners are rarely a big priority. It's just like any job, obviously. With a few more drunks. And wankers.
I apologise if I've done this already. I have a habit of repeating myself...
One evening many moons ago, a young-ish man was rushed to us. His friends had brought him in, from the pub. He had spent his usual Saturday drinking and smoking. His friends figured he'd had at least 15 pints. Not so much, eh? Then, he'd come over 'a bit funny'. And been sick. Everywhere. Then passed out.
And wet himself.
And crapped himself.
His mates had piled him in the back of one of their vans, which was now truly soiled. They told us he'd had a heart attack and a stroke (or brain attack, if you prefer) in the past. This fella was little older than I, and had the co-morbidity of a septuagenarian. Despite all of this, he still lived the life of a teenager.
Anyway, he was presented to us; a blank canvas, albeit one soaked in fresh, warm effluent. We worked him in the usual way, en masse.
Open his airway, check his breathing. All clear. Check the pulses, blood pressure. All good. Get a line in, blood out - precious, precious, oh, yes, my precious... - fluid in.
Run the neuro. Quick GCS, check his pupils. Apart from being flat out, and stinking of... stuff, not much focal to find. Gut instinct? 15 pints, plus grey matter = coma.
Could it be something else? For sure. He's had one stroke, could this be another? The booze coma waiting game ensues.
IF: it's just booze, you can wait without a CT
BUT: if it's NOT just booze, you can't.
SO: you have to wait long enough for doubt to enter the equation, so you can buy a trip to the scanner from the Radiologist.
Wait too long, and you're a doofus. Jump too early, and he wakes up in time to negate the need for the scan, just in time to piss the radiologist off when he realises he's out of bed at two a.m for a scan that's not needed any more.
I decided to jump early with this guy. He seemed too flat for just booze. My team had shrunk by now, just me and a nurse; much more intimate. Me, my partner in crime and our patient. Our own special club. I was just bouncing the idea of the scan of the nurse, and opining that we'd need a catheter, when sleeping beauty stirred.
"No catheter" he slurred, offering us a share in his ethanolic miasma.
"No fucking catheter. Leave me my dignity."
My delight that he was waking, with now sign of stroke, mixed with joy that I had not yet called the Radiologist and sheer incredulity.
Your dignity? You spent the evening drinking heavily, before passing out, vomiting all over yourself and your friends, and their van before soiling yourself. And you're worried that my placing a urinary catheter, in private, with only an highly qualified nurse to witness the event, will impede your dignity?
Re-examination revealed a very drunk, slightly soiled man, with no apparent injury.
Another life saved.
As the fella's clothes were beyond wearing, we furnished him with an hospital gown - the kind that don't quite do up at the back - and pointed him to the nearest taxi rank.
I can't think why his friends didn't want to take him home
Saturday, December 01, 2007
A fresh day awaits me, replete with all the detritus that Big Teaching Hospital can throw at me. Weekend days are a little like nights, inasmuch as you're pretty much on your own. And busy. My nights have thrown my body clock off, hence my nocturnal roamings.
Had dinner with her again last night. Am equally sure, in equal measures, that I love her, and that she doesn't love me. Still, her friendship enriches me. I feel better for it, even if my soul aches. I wonder if, deep down, I know this is for the best. I am around so little, and our paths so divergent, that I wonder if we could ever be anything more. Perhaps, on some level I prefer it this way. Unrequited love... All the ache, none of the mess? Maybe I'm not explaining it right; I'm hopeless.
I've basically spent the last two days asleep; hence nil to blog. I'm pleased to see my friend blogging; I think he'll find it helpful. Therapeutic. Some shit like that.
I almost saw an accident recently, which was odd. I was at a petrol station, buying petrol, as one does. As I was going to get back into my car, I heard a loud crack noise. Not quite a bang, or a crash, but you get the idea. By the time I turned around, it was all over. A car had wrapped itself around the signpost for the petrol station. I had real trouble getting my brain to accept that all was still. That it had all happened. Although I could rationalise that by the time I'd heard the noise, it was all over, so by the time I'd turned round all would be quiet, it didn't seem to make any sense.
They guys in the car were ok; I think even the car wasn't too beat up. But the physics of it confused me. Still does, I think.
Random? For sure, but what did you expect at 5 in the a.m?
Oh, and fucking Mo'vember is over, and the Mo is gone.