Napoleon In Rags

I'm tired.

The melancholy lies especially heavy upon my shoulder tonight.

I wanted to call this 'Snippets', but was worried about copyright infringement.

It may be a bit disjointed; I'm not sure what proportion of the jib / chat will be medical. You've been warned.

I have a rare dayshift tomorrow, and we're being visited by Healthcare Nazis. I believe I'll be expected to spout Party doctrine. I may lose my job tomorrow. Perhaps I'll be able to bite my tongue, but it won't help me spew the party slogans they have pasted all about me.

Fuck you, I won't do what you tell me...

I'm beginning to find myself in two minds about this blog. I still think it has the potential to allow me to vent my spleen, which is good for my psyche. But it seems to become less and less (semi) anonymous, and some of my more maudlin rants... Well I'm not sure people who know me should read them. I'm not sure people who don't WANT to...

Much was debated over at Dr Schwab's regarding what one should and should not post. I like Dr S. Granted, I don't actually know him, but he writes well, and his Internet persona reminds me of Pa Shroom. I suspect their professional experiences are as similar as they can be in two so very different Healthcare systems. They seem like similar surgeons, anyway. So I enjoy reading what he has to say, whatever the subject matter. Some readers feel he should restrict himself to medical matters. This seems blinkered to me. A person's opinion is worth hearing, whether you agree, whether they are an 'expert'; people's opinions are the lifeblood of a populus surely?

I don't know.

My professional life is still dominated by my disaster in the CT scanner. I need to get over it. It's hard. Seems to get harder.

She who was my beloved is going away. A grand shebang celebrates this fact tomorrow. I can't go. Work looms large again. I'm jealous of people who can go out on school nights.

Several of my colleagues, including one who I think of as a good friend, have fallen off the top of our training ladder. These are the first of the trainees who I worked with when I started. They were all ahead of me, but I enjoyed working with them, learned a lot from them, will miss them when they're gone.

I hate change.

I'm conscious of the lack of pictures of late. I will try to resolve this for what it is worth...

More reason for me to hate the arbitrary time based target under which I must labour: the two most satisfactory patient interactions I have had of late (desperate to do some good, to purge the CT scanner from my mind), have been simple cases that frightened the patient. Simple for me; life-changing for them. I could have left them in their uncertainty, in their moment of darkness. Someone else could have tidied up the edges.

But they didn't.

I did. Sat and talked to the patient. Held their hand. Explained what was going on. Did it again, and again for their partners; again in simple terms, with pictures, with actions. It doesn't matter how. My gift to them - my time, encased by, framed by the displeasure of my boss, and the management (fuck you, won't do what you tell me), because of how I was spending my time.

No-one else thinks so, but it was worth it.

Oh, and we had the drunkest girl in the WORLD in the Dept recently.

Funny old world, eh?

Whiter Shade Of Pale

First:

STOP whatever you are doing. (Actually, since that'll be reading this, wait till you've finished the paragraph). Immediately find yourself a copy of King Curtis Live at Fillmore West. Press play. Your life is now immeasurably better. Trust me. Go on. Do it. Now. Then come back. I'll be waiting.

See: Told you so...

Not much to report. What follows is mostly non-medical jib, so feel free to sign out and tune in for my next installment of medical derring-do.

Nights were unbusy, which is unusual. Managers are prowling around, trying to avoid any breach, at any cost, in the final push for Foundation status (ein, zwei, ein, zwei, build an empire...). We are becoming even more unpopular throughout the hospital. It's just as well that we don't care.

Well, to be honest, I do care. The ED has ever been the sick man of the Hospital. Fine. But now our reputation for slipshod work, hasty workups and premature referrals is becoming deserved. Which, frankly, sucks balls.

In other news, I'm back to being insomniac again. A long series of lates and then nights has left my brain refusing to fall asleep until six a.m. I wouldn't mind s much if I could do something productive with the time. But I feel exhausted, so end up spending hours trying to sleep. I'm on a random day shift today and tomorrow, before re-embarking my mission to work only late shifts this month. Something's gotta give.

Lastly, in case you were wondering, I have discovered the worst cup of coffee, in the Universe. My standards are pretty low anyway. My North American cousins sneer laconically at me when it comes to my appraisal of coffee. What seems like perfectly reasonable java to me, barely classes as dishwater to them.

So for me to dislike coffee is rare. While a student, I drank revision specials that sent me into SVT, but kept me awake for two weeks prior to my second year exams. When I was on the House, I'd cane cold coffee to perk up at night. Hell, I'd even mainline freeze-dried granules. Discerning, I am not. I jive on caffeine.

However, Burger King supplied me with the worst cup of coffee I have ever come across. Yes, Burger King. Now I say it out loud, I'm not sure why I was surprised by this. But seriously; it was shit.

This Is Brilliant

Hat Tip to Kal, over at Trauma Queen for this post.

Watch it to the end. If you aren't laughing, you're dead inside...

You Need A Licence To Own A Dog, Right?

There may be ranting following. It may well paint me in an unfavourable light. I apologise.

Some housekeeping first. I have been following my track-backs. So welcome to the fella that found me by searching for "Small Breasts" on Google. And it was on page 6 - so a dedicated pervert?

Also to any of my new occasional readers - those who funk, and those who do not. All are welcome. And to my dedicated core, all 10 of you, I love you too.

For today's random thought: I cannot understand why some drivers, when stopped at traffic lights, make as if to pull away quickly. They creep over the stop line; they edge forward a little at a time. Then the lights change, and they pootle forward at geriatric pace. WHY? If you wanna be Charlie Big-Bollocks (Carlos Grandes-Cojones for the Spanish out there), fair enough. But why show blitz, and then weiner out? I don't get it. Obviously, because I am mature and drive a car that should in no way be construed as a Penis extension, simply pull up at the lights, wait calmly and then burn away as soon as there's a hint of lights changing.

And to tonight. I was called to see a patient, a young girl, who had been discharged, and was unhappy about it. This is often the way. No-one likes being discharged at one in the morning, and indeed we often keep people overnight for that very reason; but they are the elderly, the infirm, those who live alone. In fact the definition of 'too late to send home' gets looser daily. Today we admitted a medically fit 80-something at 6 pm, because it was "too late" to send her home.

But this patient was in her late teens. It transpired that she was mostly unhappy because of her blood results. She had come to us complaining of vague, non-specific abdominal pain. Of most significance in her history was her suspicion that she was 8 weeks pregnant. Urine testing corroborated her theory. A thorough work up by one of our new juniors did not appreciate anything sinister in her pain, or other symptoms. Follow up at an early pregnancy clinic was aranged for 48 hours. Personally, I think this is too late to wait for an ultrasound to confir viability, but there you go. If Mum is stable, she gets to wait.

This, however was not the problem. She wanted a copy of her blood results, specifically the one that showed that the baby was 'ok'. No such test exists, I explained gently. She protested that she had been told that that was what we were testing for. I'm fairly certain that no-one told her any such thing, but sometimes our communication ain't what it should be; sometimes patiets just hear what they want to...

I apologised, but re-iterated that, although her bloods were essentially normal, none of them guaranteed that the baby would be 'ok'. Then she demande pfoof that she was pregnant. This struck me as odd. I've never had this request before. I double checked the notes, and hand wrote a letter, on hospital stationary (no expense spared) explaining that, as far as we could tell, the patient was indeed pregnant, but that ultrasound evaluation would follow to confirm gestation and viability.

She regarded the letter with some contempt. The written word evidently does not carry much wieght in her world. I explained what I had written. At the mention of the ultrasound, she looked blankly at me. 'What's that?', she enquired. More communication breakdown; I guess no-one had explained follow up to her. Explaining what an ultrasound was proved beyond me. I'm embarrassed to say I resorted to saying: 'Y'know, the scans you see pregnant ladies having, on the telly.'

'Yeah, well my boyfriend's just gonna say this is my handwritin'.' I did not know where to go with this. It seems highly unlikely that our handwriting is all that similar, but maybe... It also seemed to me, unlikely that someone who was 2 months pregnant and did not know what an ultrasound was would be unlikely to use words like 'gestation', 'foetus' or 'viability', or for that matter hit upon the right combination of letters I string after my name - to show off, you understand.

But, who knows. Next she asked for the print out of her urine sample. I explained that there was no print out, that it was a dipstick test. She assured me that someone had promised her the printout. I'm fairly certain she could not have misunderstood this. There is no 'print out' to have. Bad communicators we may be, but we tend not to offer non-existant documentation to our patients.

I confess to being a bit frustrated by now. I gave her a pregnancy test to take home, including instructions, in case 'pee on the stick, if it turns blue, you're pregnant' was beyond her. I showed her my name at the bottom of the letter, and the direct ED line. If trusting boyf still thinks it's all a scam, he can call me. Somehow this still isn't enough. I am by now, thoroughly hacked off with this woman, who, it appears has come to the ED solely to obtain proof of her pregnancy. I am beginning to feel my Right wing side emerging, and can hear my inner Fascist grinding his teeth. Malthus, eat your heart out.

As she finally leaves, still unhappy with my attempts at providing her with copper-bottomed proof of pregnancy, I re-visit her notes. It seems that her boyf doesn't believe that she is pregnant, and has left her.

Suddenly I see why it was so important for her.

But I cant help but feel proof of insemination will bring boyf back. If he wanted her to be pregnant, why wasn't he here, now, waiting for the tests, pushing for a scan?

I don't think I've helped her at all tonight.

Love In Vain

Unhappy post.

Somedays, it's all just shit. Sometimes, you do everything right, and its still shit; sometimes you make things a bit worse; somedays it's all your fault.

I'll have one from the top, and one from the middle, Matthew.

We have new SHOs starting today. They're all called something new know. FY2 or ST1 or something. SHOs of varying experience. I worked with a couple of them today, and they seem competent enough. A few of them rubbed one of my colleagues up the wrong way; I find this basically amusing. I will enjoy the soap opera that is the bedding in time.

Anyway: number one. A woman found by her son, slumped in her chair, not moving her left side. Several fits later she is at our door. Her blood pressure is high and climbing. She offers us no response, not even with determined teasing. Her ECG shows ST elevation, laterally. To my mind it all points to rising intracranial pressure. A bleed, I am sure of it. Blood coursing about her brain, irritating, inflaming. I call the intensivists. They are reluctant to intubate her; they shre my concern that whatever the injury, it will prove unsurvivable. But they will take her to the scanner for me.

The scan is unexpectedly unremarkable, but th radiation hasn't enlivened her at all. Her pulse and breathing become erratic; the duty Magician comes to visit. We are all very earnest; but it doesn't help our patient. She must be leftt to fight this fight alone. Her card is marked (the trial was a pig-circus), but we can't help her.

Next: a fella just old enough to be considered old. Difficult to gain a history from, as his shhort term memory does not reach much further back than 10 minutes ago. But he is in pain, his belly swollen, distended, taught. His pulse is weak, rapid, fluttering in and out beneath my fingers. I talk to the Surgeon; he does not want to see the patient; he wants to see the scan. We pump him with fluid, drive his pulse down, and his pressue up. His colour improves, and his edges warm, just a little.

I watch him for a while. He holds the line, he is stable. I know he is sick, I know the intensivists need to know, but I think I can wait until the scan is done. I don't think his airway is threatened. I tell myself the scan obviates the need for plain radiographs. I tell myself I can manage the transfer.

We don't normally transfer patients. Department workload is too great. I take my break, and one of the supernumary SHOs, and we take the transfer. It's a good learning opportunity; I've done plenty of transfers in the past. We'll be fine.

We are not fine. All the medics reading will be familiar with the adage that whatever ca go wrong, will go wrong; and if possible it'll happen on the CT table.

As soon as we put him on the table, he starts vomiting. It rapidly becomes effortless, and the patient agitated; he resists being on his side. While I am belatedly calling the intensivists, he loses his airway, and rapidly his pulse. We try to run a resus, but it's chaos in the scanner. Help is not slow in coming, and we get him back. I think clearing his airway was all he needed.

Well, that and a smidge of adrenaline.

The surgeon bows to pressure and comes down. We eventually get our scan; it shows all the wrong things. Bowel obstruction, probably from a tumour. Closer inspection shows gas in the wall of the bowel; dead gut; gas gangrene; the writing is on the wall.

I am at a loss to explain why I did not X ray this fella in the Department. I might have had my answer then, might have convinced the surgeon to see him upstairs, might have avoided the indignity, and squalor of a disorganised arrest in a basement CT suite.

Sometimes we just make bad choices.

The fact that they changed nothing, that this man's family would have been surprised, horrified, destroyed by the news of his impending death, does not excuse them. If nothing else we owe our patients the right decisions on their behalf.

And for all my wailing and gnashing of teeth, I'm trying to remember that it's not about me...

The Wonder Of...

Happy post to start.

I firmly believe life is more enjoyable (or bearable) if one can take pleasure in the small things. Simple things, for simple minds, maybe, but I get excited by the simplest things. Some people take great joy from the first blossom of Spring, or puppies, or whatever. For me it's not usually quite so 'traditional', but the principle is the same. Little things make me smile and brighten my day.

Medicine is replete with opportunites for this. There are many things we, as health professionals, can do that have an instant effect. (ideally making the patient feel better.) Treating patients is great. What I mean is perhaps typified by the treatment of SVT. Supraventricular tachycardia. The patient's heart beats fast, caught in a feedback loop in its electrical 'circuitry'. A number of tricks will restore normal rhythm - squatting, blowing out a syringe, ice cold water on the face. Mostly we use drugs.

The first time I saw one treated was as a medical student. I was doing a surgical attachment in North Devon, and one of our patients had flipped into SVT on the ward. My Houseman and I moved the patient to a telemetry bed; she filled a syringe, and then turned to me - 'Watch this', she says. One quick flush, and the too rapid trace on the monitor was replaced by a nice normal one. 'Isn't that amazing?', she said. I know it sounds twee, but it was. It is. The drug in question was adenosine. There's others we can use, and I know most of you will be thinking what a sap I am; I don't care. This is what I mean about the small things. Nice, simple and instant. Hugely pleasing.

(As an aside, looking back it now also seems amazing that we, as junior surgeons, treated this all by ourselves...)

Now, when it comes to being amazed by things medical, much of what a person will be amazed by depends on your frame of reference; the more you see something, the less amazing it becomes, and the more commonplace. Unless you're a simpleton like me, continually surprised by the rising of the sun. For example, several years ago, I was treating a fella with a bad nosebleed. I tried cautery, but the bleed was too posterior, so I packed the nose and waited.

Evidently the packing didn't work, and he began bleeding from the corners of his eyes. It's basically the same trick as people blowing bubbles out their eyes, or laughing milk out their noses (well, sort of...). The blood, denied the usual route of egress found a way out through the naso-lacrimal duct. The blood leaked out of his eyes. I thought this was amazing, and I bresathlessly phoined the ENT doc.

'You gotta take this guy', I yammered down the phone, 'his nosebleed is coming out of his eyes!'.

'Yeah, whatever', he drawled, barely stifling a yawn. 'Send him up, I'll see him on the ward'.

I couldn't believe he could be so blase. It later dawned on me that, as a guy who spends the bulk of his life fiddling with noses (or whatever the ENT wizards do) he must have seen loads of eye-bleeders. So, it was old hat for him.

This might explain my reaction during the following tale. I was almost literally awestruck by the events I am about to recount. The other protagonist in this vignette was decidedly non-plussed, as may you be. But it made my day, and is easily the best thing I've sen this year.

The story begins with a chap sent up by his GP with transient bradycardia. His heart keeps slowing down, slow enough to make him ill. The ambos reported rates as slow as 20. If any non-medics are wondering, unless you are Miguel Indurain, a heart rate of 20 just isn't going to cut it. In fact it's even a bit slow for our Miguel. Anyway, his heart as ticking over at a happy and healthy 80-odd when he got to us.

For a bit.

He quite promptly dropped to the low 40s, and turned a whiter shade of pale. He was hustled into Resus, and hooked up to the machine that goes 'beep', and the machines that go 'buzz'. All the machines, in fact.

By then of course, his rate was back to normal. We called the Cardiologist down, and he came with a minimal of fuss. No choir of angels, no cherabim or seraphim. In fact, he was a bit grumpy, because we had failed to catch the slow heart rate on paper. No print out, no proof. It drives this particular cardiologist mad that we have such a low strike rate.

I can see his point.

Little did we know the moment of triumph was nearly upon us.

While writing up the notes, the patient began to drop his rate. He revisited Procul Harem as we gathered around the monitor, breathless, atropine in hand watchin the sacred print out. His rate dropped to 40, 30, 20... it reminded me of excitable Gridiron commentators, when someone breaks into the open: 'He's at the 40 yard line! Still going! 35, 30, 25, 20, 10 and touchdown!'

Except this ended with asystole. Just a pause? No. When three seconds elapsed with no sign of electrical activity, and the patient fading, as I was just about to fill him with atropine, my new hero thumped him square on the chest. The monitor registwered a beat. Another thump, another beat, and another, and another... at that point his heart fired up again. But I had witnessed percussion pacing. A technique I have never seen work. That I thought was pure bunkum; a tale to tell of the old days. Like ether as an anaesthetic.

I was completely goggle eyed. So simple. Percussion pacing, wherein the operator uses his fist to impart a low energy 'shock' to the patient's heart, causing it to contract. The most primitive form of defibrillation.

Cardiology, however, was very matter of fact about it. This is of, course, because he is cardiology, and his field is electrophysiology. Percussion pacing is his bread ad butter.

But I don't care. I think it was awesome, and my day was brighter because of it.

Burn One Down

Well, after five nights on the trot, you'd think I'd have something clever to write; or something intelligent; or thought provoking. Not really. My last few shifts have passed more or less without incident.

Instead, departmental politics are once again at the fore. I have yet to hear what the Management Consultants who were prowling about have had to say. The breach targets are once again getting maximum billing. The next few months requires an extra big push. One more push, lads, and it'll all be over by Christmas!

(Foundation! Foundation! Foundation! Arbeit Macht Frei!)

The upshot of this appears to be that we are asked to organise referrals for our patients increasingly early. Not, and this must be emphasised, in a way as to compromise patient care however. I am becoming increasingly disillusioned with this. I like treaing patients. It's what I signed up for. But there seems to be an increasing drive to postpone any but the most essential treatment until 'they get to the ward'... aside from the fact that I think we could and should be instigating treatment as soon as it is feasible, the increasing admissions rate is putting yet more stress on inpatient teams who hardly had it easy to start with. So it leaves me with little confidence that the treatment will be started 'when they get to the ward'.

I suspect that actual incidents of patient harm are few and far between, but it feels in general as if we're offering a slightly worse service. But how many times is too many?

My patient with a leaking aneurysm who nearly ended up on a medical ward because somone decided to book them a bed, so they wouldn't breach..?

My patient with low potassium, and attendent ECG changes, referred for admission as not safe to stay on the obs ward, then placed on the obs ward while waiting for an inpatient bed, so they wouldn't breach..?

Maybe I'm just too cynical.

One of my patients over the weekend was a young girl who had taken her second overdose of the past few days. Mostly fairly benign drugs, but enough to make her pathologically sleepy. She deteriorated suddenly, requiring a brief dash to Resus. Her father and sister were in constant attendence, calm and collected. I wondered how many times they'd been through this before. I offer the usual explanation - first we treat the physical, then the psychological. In her case we need to watch her while she wakes up, make sure she doesn't vomit and choke on it, stop her following Jimi Hendrix's example...

As if on cue, she begins to heave; she has enough presenceleft to slide sideways. At first I think she's trying to brain herself on the side rail, but it turns out she's just aiming over the side. She scattergun splatters the floor; her dad has reacted fastest, and has a bowl under her mouth. I'm impressed - he and I started from the same point; standing start and he beat me to it. Maybe he has done this before.

We clean her up as best we can, wiping her mouth, blowing her nose. Then she heaves again; this time her sister lunges forward. For a second, I don't see what she's reaching for. We've got it covered, haven't we? Almost; she brushes a lock of her sister's hair back; it was dangling right in harms way.

The devil, it seems, is in the details.

London Needs More People Like This...