Medical Miracles

By and large, I don't believe in miracles. I am a vaguely religious man, so I'm sure they're possible. I just think the phrase is rather over-used, and had come to mean an unexpected, improbable outcome, not a true miracle.

Still, on Christmas morning, I found myself waiting in Resus, checking the kit. The call didn't offer much hope. An elderly patient, visiting family for the holiday, had fallen down the stairs. No output with the Paramedics. This sort of call tends to be an 'in-and-out' job. If they haven't got an output back by the time they get to us, they probably aren't going to. And while the NHS isn't ageist, God is, I'm afriad. Your chances of surviving cardiac arrest are not improved by being over 80...

Despite my fears, six minutes later, we were greeted with a bounding pulse. A moment of light relief passed us by, when the charge nurse briefly attempted one handed CPR while cannulating with the other hand. We waited, checking the scene, quiet bar for the slow rhythmic hiss of the ventilatotor; once the adrenaline wears off...

Half an hour later, the patient was warm, well oxygenated and ventilated, and still going. The intensivists duly attended and spirited our patient away.

Will they recover? I honestly doubt it, but maybe hope is all you get at Christmas.

Point and Counter Point

Anji left an interesting comment following my last post. For clarity, I'm reproducing it here, so as to offer my take.

I guess... as a patient and having experienced something say, a yeast infection or a urinary tract infection or a sore throat needing to be looked at, and getting the ol' "you're-wasting-my-time" look from the doc, I'd rather go to a PA while my doc goes and tackles something else much more challenging.

Or, at the very least... make my doc stop rolling his eyes when I haven't been able to swallow for two weeks and my glands are huge and I just want some antibiotics or some relief! :D

My husband is a medic with the canadian army and I'm encouraging him to go for his PA as soon as he is able to. He's too old (36) to start fresh and become a doctor but he's not too old to do the PA and still earn a living in his second career. We're so short of doctors here, anyone who can alleviate the pressure or at least, free up enough time so doctors can provide more care for serious things, would be nice. Something like, 10 million Canadians (out of 30 million in total) do not have a family physician. PAs would
really make an impact, in an area like ours with such shortages!

Personally, I think that, as Doctors, we should be happy looking at yeast infections/sore throats/UTIs. Generally, they don't need to be seen in the ED, that's true, and patients pitching up to the ED may occasion the rolling of eyes... BUT: if the system doesn'tprovide another opportunity for patients to see a Physician, then it's not their fault, and we should keep our eye-rolling to ourselves. That should be part of the deal: you can come to us with anything and not feel ridiculed. We should be allowed to roll our eyes BEHIND CLOSED DOORS. And I'm more than happy for PAs to see this stuff; but if their breadth of experience extends only to simple sore throats are they more likely to miss early meningitis? to mistake glandular fever for tonsillitis?

The point I'm trying to make, and labouring rather, is that Doctors have, or shoukd have, a breadth of experience, born of experience. And what at first glance appears simple and straight-forward may not be. I would argue that that is when we earn our pay - not in the vast bulk of practice, which is routine (and often gets better no matter what we do... sore throats are an excellent example of this, despite the public love of, and faith in, antibiotics), but in the recognition of, and prompt treatment of the more serious cases.

I reckon I could take one of my more dextrous, non-medical friends and teach him how to take an appendix out; but not what to do when things went wrong, or when the diagnosis doesn't match the operative findings. Being an expert in a very small area will mostly be fine. Mostly.

Do we need more practitioners? Yes.

But I'm not convinced that telling ourselves that, as doctors, we don't need to be dealing with certain conditions is the answer. Maybe, economically, it makes more sense to employ PAs, and if practitioners want to perform this sort of extended role - brilliant. But, like most solutions for thorny problems, I'm not convinced it's perfect.

Carry On, Doctor

Right.
It's early, it's dark, and it's cold. For the UK, anyway. My dear colonial readers can feel free to refrain from reminding me what real cold is like.

I've followed, with some interest a debate on the usefulness (or not) of the PA, or Physician's Assistant, over on some of my more erudite colleagues blogs. Check here, here or here.

As ever, it makes for interesting reading; and has fired up my little grey cells. Much has already been said on many UK blogs about extended role nursing practice, often not especially complementary...

I'm old nough to have seen the transition, and it does make me a little uncomfortable. Not because I'm not convinced that 'non-doctors' cannot do the job; they can, although I do occasionally have my concerns about the risks of such narrow fields of practice. But mostly because I increasingly see the 'extended role practitioner' doing the stuff on which I cut my teeth.

In 'farming' some of this work out, because wwe think it frees doctors up to do other (?more important) jobs, are we not mortgaging some of what makes us doctors?

I worry that we are.

Admitting Defeat

I had hoped to post one a day in December; it ain't gonna happen, I'm thinking now.

Ah, well...

A Nod To History?

A cellist rants:

Guilty Pleasures...3

And last: Neil Diamond

Guilty Pleasures...2

Also on my iPod: Natasha Bedingfield

Guilty Pleasures...1

On my iPod: James Blunt.

Separated By Common Experience

Chatting with one of the Paramedics the other night, shooting the shit, and all.

He'd had a bad run the night before, attending to a young patient, in cardiac arrest. Nothing to be done, but run the numbers, mark time and call it.

I could see it hurt him, hit him hard; the knowledge that it were all for naught.

I know just how he feels; I've been there, run the same code, counted the same numbers, marked the same time.

Somehow, this makes it harder to talk about. We share a look, and go our separate ways into the dark....

Ghosts

Do we believe?

I don't know; hospitals are surely the site of more strong emotions than most, so should be primed for supernatural activity. I worked in a hospital years ago that was reputed to be haunted; talk was of strange occurrances, and odd sitings on the first floor. This was the da case floor, and usually occupied at night only by the Resident Medical Officer.

Which, for a year, was me.

I never quite saw anything, though on one night a few lights and a t.v. may have switched themselves on in a room a few doors down. Or, the other staff may have been yanking my ding-a-ling.

Who knows?

Shroom's jury is still out, but the other night, while decamping from my car in anticipation of another happy night shift, I was sure I saw someone lurking in the car park, just out of the corner of my eye. On glancing round, there was, of course, no-one there. I'm sure it was but a trick of the light, reflecting on my glasses.

But, try as I might, I could not repeat the feat.

Until I stopped trying.

Twice more I 'saw' him, and each time, he seemed a little closer to me.

A trick of the light, I'm sure.

Nonetheless, I walked in a little quicker than usual that night.

Ask Me No Questions

One to think about, or not.

La Belle Fille asked me this one. She uses it t see inside the minds of children, or something.

"If someone asks you if you have a pen they can use, and you say 'no' without looking, is it lying?"

Anyone? Anyone? Anyone? Beuller?

Bare Below the Elbow

Another great 'evidence based' piece of guidance, condemning wristwatches and rings to the same bin as ties and white coats.

Personally, I like a white coat, and when I started out was able to get a fresh, clean one from the sewing room daily. Seems like a good idea, no? But cheaper not to, and just fuck 'em, instead.

The idea that disease is caused by organisms, and organisms that can be transmitted by hand seems commonplace now, but is, in fact, relatively new. This doesn't stop the idea that making me roll up my sleeves will prevent nosocomial infection being, simultaneously, clutched at by infection control nurses as the next big thing, and utter cock.

Where does it all begin?

Who is the daddy of cleanliness?

May I propose Ignaz Semmelweis. (1818 - 1865)

In my experience, very few infection control specialists have heard of him; and fewer DoH inspectors. History? Why should we care about the past...?

Alexander Gordon, and Oliver Wendell Holmes both had an idea that sepsis after childbirth (puerperal fever) might be caused by the introduction of 'putrid matter' by the delivering doctor or midwife. Influential practitioners such as Charles Meigs were quick to deny this idea.

Semmelweis however, working at the world's biggest maternity clinic in Vienna, found it hard to deny the evidence before his eyes. Those mothers attended to by medical students had a far higher rate of puerperal sepsis than those attended by midwives.

His suspicions increased when a colleague died after cutting his finger during an autopsy.

By introducing something as simple as routine hand washing, he was able to slash mortality rates. His work was published, but largely unrecognised by his contemporaries, and it is sad to report he died in a mental institute.

Hand washing, yes. Rolling my sleeves up...? Still waitin' for the evidence.

Belle Of the Ball

Now that I'm posting again, La Belle Fille has not been slow to remind me she is disappointed with the level of her air time. 

Damned if I do, damned if I don't, it seems...

Work commitments, and the impending Noel have limited the time we've been able to spend together, so I don't really have any great tales of 'The adventures of Shroom and Snaily' to report. She is spending much of the weeknights backstage, in make up this week, which I find endlessly entertaining.

Anyway, out of script does NOT equal out of mind.

So there.

Autologous Autosplenectomy

**Rant follows**

Hospital, and thus department, busy as f...eather boas.

Spent more hours than is seemly trying to organise admission of one consultant's patient under the care of another; consultant 2 didn't wanna do it, and consultant 1 thought this was very unfair, but, curiously, neither would talk to the other, preferring to use me as a go-between.

Ultimately, grown men should be above saying "I won't be calling him, but if he wants to call me, I'd be happy to talk to him"...

I left a patient behind today, handed them over, after failing to get anyone to take them seriously; well, it wasn't so much that they wouldn't take him seriously, it was more that the general opinion was "Sure, he's sick, but it's because of (body system looked after by rival speciality)"

Details to follow, but I'm convinced intra-abdominal mischief was to blame, and failed to convince either the KnifeMen, or the Moths. If I'm right, I'm sure they'll try to lay it at my door; for what it's worth, I still think he'd perfed a diverticulum, but God forbid anyone should take my opinion seriously.

Le Shroom: c'est grumpy.

Paranoia Strikes Deep...

Yesterday morning was spent trying to talk down a spectacularly paranoid fella, who, when he wasn't freaking out because he thought he was blue, was challenging my status.

His exact words?

"I'm not being funny, yeah, but I don't even think any of you are real doctors. I mean, you're all wearing trainers, for fuck's sake!"

And The Band Played On...

I have somehow acquired another follower; which serves to remind me how remiss I have been of late. Well, if you'll keep the faith, I have no excuse.

I undertake to get of my arse, and keep my end of the bargain again.

Starting tonight; promise...

(And, yes, I've back-dated it; I'm cheating, for reasons I will explain. It's sort of my version of the Kobyashi Maru)