Sunday, January 27, 2008
I am failing in my duty to one of my SHOs. They are not working fast enough for the ED, and I am not showing them how. It is mkaing very unpopular with the Nursing staff. I will have to try harder.
Last night seemed to bring an unwelcome reminder of our limitations as doctors. Perhaps as people, too. Two patients, both ED 'bread and butter'; the first a 'blue bloater'; long term COPD, unwilling or unable to give up the cigarettes that have done this to him. Reluctant attender, as so many of them are, knowing all too well the poking and prodding that awaits. But tomight he was tired, too tired. His CO2 levels, always high, are creeping higher, slowly anaesthetising him, in front of our eyes. He has been here before, been judged in the eyes of the Intensivists, and found wanting. He is not for ITU, not for invasive ventilatory support. We all know that once attached to the vent, he will likely not get off it.
I offer him what we can, nebulisers hissing softly in the quiet of resus, steroids, i.v. because he cannot swallow, theophylline coursing through his veins, salvation in a plastic bag?
Not this time. His chest remains tight, each breath an effort, hardly lifting his chest. Non-invasive ventilation is next, an uncomfortable mask, held awkwardly on the face with a Heath Robinson-esque collection of straps, designed by the lowest bidder.
None of it does any good. His numbers stay the same, low, low oxygen, and high carbon dioxide, creeping slowly, slowly higher. He himself slips away as I watch him. The light has gone from his eyes, his defiant humour, that he held onto at the beginning is gone. All of his being is breathing now, and even that is an effort. He is exhausted.
The next, an elderly lady. Suddenly ill, suddenly very ill. Almost no warning. A little breathless, then she slipped away. By the time the Ambos get there, she is gone. But not so gone, as to be beyond us. Slickly, professional, she is resuscitated, her angry, irritated myocardium teasing them with hints of life. She is still slipping back and forth when she is delivered to us. A few more rounds, and she comes back, and sticks. Something we have done keeps her heart in synch this time. We wait a minute. Have all seen this before; false hope. A sort of 'dead-cat bounce'. But she stays with us.
How long? Long enough to call the intensivists. Long enough for us to gather and decide that although we have restarted the clockwork, the soul is long gone. We will keep watch, standing guard against the unlikliest of returns, but we all know it is futile.
Have we achieved anything?
Saturday, January 26, 2008
Anyway, since my Night Shift was relatively uneventful, aside from planning to elope with one of the Nurses to Cambodia, I was struggling to think of something to post. Kal's post struck a cord.
Now, I may have posted about this before... my memory bites, and I do have a habit of repeating myself, as any of Shroom's friends will tell you. But I just can't be arsed to plow thru' my own archives. So, if you've heard it before, I'm sorry. Perhaps someone could discretely let me know I've begun to tell the same tales over and over, before I turn into the old man in the corner, endlessly recycling war stories...
A little while ago, I was at home, visiting Ma and Pa Shroom. An old school friend and I were off out for a few drinks, passing through the collection of shops, restaurants and estate agents that goes to make up the senior Shrooms environs. As we approach one such restaurant (which, trivia fans, used to be a grocers), I see both Police and Ambulance outside. I am almost pathologically nosey, and sidle up to the window.
My gut tightens, then loosens, just a little. On the floor, surrounded by the attendant detritus that goes with it, is a young man being resuscitated. Full CPR. I approach the Copper on the door.
'Any need for a doctor on scene?' I enquire. In my experience, the Police are happy to let yo get involved. I remember him being young, and he looks pale, anxious, unsure.
'In there'; he opens the door, points unnecessarily. I can hear the sound cloud, the aural miasma that goes with an out of hospital resus. The Paramedic's voices, calm, ordered. Other voices, close to hysteria; these will be the patient's friends; we ask people if they want to watch the resus in Hospital, assign them someone to be with them, hold them, answer their questions.
These people have no choice - it's right here, live, interactive. No red button required.
The restaurant is divided into halves, by a low arch in the wall. Where I've entered is in the first half; the action is next door. The restaurant is full, and the patrons don't know what to do. Something dreadful is clearly happening next door; they can't see it, mostly, but they can hear it; they all know what's going on.
They don't know what to do. Most of them are eating, making small talk, desperately telling themselves that 10 feet away a small terrible drama is being played out. It's incredibly bizarre.
I pitch through next door, introduce myself, hoping that I will know this crew. I worked at the local hospital for 18 months, maybe they'll know me, remember me.
Now, while the Police are usually happy to let any Tom, Dick or Harry through, the Paramedics and Techs are not. Why should they be? They know what they're doing; they don't need help, especially not from someone who might be a nutter. If I offer to tube the patient, and stick it in his belly, they carry the can.
Somehow, I do enough to convince them I'm on the level. 3 people on the resus makes life easier. They let me do compressions, the AED tells us when to shock the patient. He is young, maybe younger than me, and something terrible has happened to frighten his heart into the violent, spikey rhythm we see on the monitor.
When the drugs are gone, the time has come. Time to run, get him to hospital now; a wider selection of drugs awaits, and maybe, maybe salvation. I see it in their eyes - do they see it in mine? He's been down 20, 30 minutes in total, and while his rhythm is still in turmoil, and he's still having electricity passed through his failing body, his chances are bleak.
Now, and this was the point of this whole thing really, outside the restaurant, the road is narrow, two lanes only, narrow lanes, one already blocked by the DayGlo rig, that we jokingly used to call The London Big White Taxi Service. To get everyone out safely, the Police block the second lane.
Now it seems obvious to me, that when someone is wheeled out of a restaurant, Paramedics clearly engaged in CPR (and surely everyone knows what that looks like? Don't they watch Casualty?), escorted by Police, a crowd of tearful, sometimes screaming people in tow, that this person is not well.
That his situation might be more serious than your dinner / the pint with your mate / whatever else you will know be 10 minutes late for.
While the cars further back quietly waited, used to jams around here, those at the front, those with the clearest view of the end of this man's life, begin to hurl a torrent of abuse. I see no point in reprinting it here, but suffice to say some of the invective was strong enough to result in an extra delay to discuss their choice of language with the Police.
5 minutes later and the road is clear. The diners are still eating.
I catch my mate, and we go for a pint, both just a little bit happier to be alive
Thursday, January 24, 2008
But, I'm trying (again) to get off the fags. Patches and gum have proved ineffective in the past, tho I suspect that has more to do with my lack of willpower. I'm currently on Zyban (buproprion) and am hoping this will compensate for my lack of will power, while not turning me yellow or making me commit suicide.
So, for the first few weeks, I have to keep smoking to give the drugs a chance to kick in. This has coincided with me having time off, so I've had no excuse not to smoke. Can I smoke? Like a fiend I can. (Apologies to Bill Hicks' estate)
What I have started doing again, is going to the gym. Frustratingly, I do feel better after a run. Maybe there is something in endorphins, after all. I find my gym vaguely amusing. Or rather, the people there, mostly because I find it difficult to take them seriously. I imagine they think the same of me, especially since I'm so vain I'm always checking myself out in the full length mirrors (well I haven't got one at home), and have discovered the fun I can have blow drying my hair. (Can you say bouffant?)
My other new trick is forgetting bits of my kit. In the last week, I have left 2 pairs of trainers behind. The club's lost property policy is to sweep it up and throw it away. The first pair of trainers wasn't too much of a loss - they were old, smelled funny, and probably had body fluids deep in their fundament. The second pair, bought to replace the first, natch, lasted two visits before I forgot 'em. Actually I'm not too upset. I was beginning to dislike the look of them. They cost me £20, which is a pain, but I actually consider it small beans in trainer terms.
I have recently started reading Mousie's blog. I commend it. She thinks the same way I do, and expresses things I wish I'd thought of far more eloquently. I think I'd like working with Mousie.
I recommend, especially :
Steep Learning Curve I and II
This is My Life
Things I Hate
The first two are serious, the last light hearted. I really loved the things I hate post. I get good vibes from Mousie.
I'm concerned I'm coming across a bit like a Mouse Stalker... sorry, but it's good to find kindred spirits out here.
Anyway, I'm on a 5 night stretch from tomorrow, so hope to have some tales to tell.
In my previous post but one, I may have suggested that medical students in general were maligning us whinging docs. That is not the case. What I meant was that much of the 'debate' was originating with e.g medical students rather than qualified docs. I did not mean to suggest that most medical students were engaging in the 'debate'.
The Shroom is happy to clarify this, and hopes he had not caused any offence. (This means you, TLM...)
On the matter of the huge piles of cash we're all rolling in: my salary is a matter of public record. You can go to a variety of websites and see the NHS payscale. This is in stark contrast to several of my friends whose salary is so secret that they are contractually forbidden to disclose it. I notice that when we worked for hourly rates, people were only too happy to share their details.
Now, it's vulgar, apparently - although only the people I suspect earn multiples of my salary think so.
Anyway, depending on how much you think I actually earn, and how many patients I see, the cost per patient works out to be about £20. This is excellent value if you're in a diabetic coma, and I spend six hours of my life resuscitating you. Not such good value if you have a sore throat, and I spend 30 seconds telling you it's viral, drink plenty of fluids, gargle aspirin and munch paracetamol. Granted, but this is averages we're talking about...
Anyway, think on it. £20, all in.
I don't think that's too bad. But then, I wouldn't, would I?
I've been tagged by Chrysalis Angel—my Angel of The North.
Here are the rules: Link to the person (i.e. Angel) who tagged you.
Post the rules on your blog:
Share 7 random and/or weird facts about yourself on your blog.
Tag 7 random people at the end of your post and include links to their blogs.
Let each person know that they have been tagged by leaving a comment on their blog.
Well, I'll try...
1. I firmly believe that God (or the Devil) is in the details. Especially in music, and often have a favourite bass line / drum fill etc in a song. (For example, Billy Preston's keyboards in Get Back, the little bass run toward the end of Son of a Preacher Man, the horns in Hazey Jane II...)
2. I am more sentimental than I would like to let on, and can usually be found carrying mementos of absent friends in my pocket.
3. My 3 favourite American Football players are Lary Csonka, Fran Tarkenton and Dan Marino.
4. I am becoming increasingly obsessed with the Napoleonic Wars.
5. I weigh exactly the same today as I did when I was 18; I'm not sure if this is a good thing, or not.
6. I cannot help but develop unusual favourites -for example: hernias (spighelion), bacterium (bacillus cereus, tho cytocapnophagia canemoris runs it a close second). I genuinely can't understand the looks I get when I tell other people this. You've gotta have favourites, haven't you? It's not like their my kids or anything?
7. I've been half a Best Man 3 times.
All in all, a bit lame... sorry. And because I'm such a curmudgeon, I'm not taggin' anyone else just yet. Maybe later.
Tuesday, January 22, 2008
Forgive me if I oversimplify. I am a simple man.
There appears to be a backlash, directed against 'whinging doctors'. Mostly, as far as I can tell, from medical students, and other non-doctors.
So; currently doctors feel over-worked, and under-valued. There appears to be a campaign in the media to portray us as overpaid, and underworked.
When we complain, the response appears to be that we don't know how good we have it, and should put up, shut up or fuck off.
As far as I can see.
So... I do feel undervalued, and increasingly asked to work to conform to targets rather than what is necessarily best practice.
Do I feel underpaid? Well, I get good money, make no bones about it. Although, I earn less now than I did three years ago. So in real terms I have taken a pay cut in the region of 6 - 8 % over 3 years.
But; if I complain, I'm told I shouldn't because I have it better than many others, or am seen as ungrateful. This is after all a vocation, so I must be altruistic and compassionate, working only for the love of it.
I feel undervalued because I see other professions earning shitloads. My cousin earns as much, if not slightly more than I do, working for a mobile phone company. I'm not sure anyone tells him he is overpaid, or not working hard enough.
GPs and Hospital Consultants have done very well of late, but it is no more than they deserve, as far as I can tell. Their rise has come from the Govt deciding to pay them for work rendered. It's hardly their fault if it turns out they actually work quite hard...
Comparisons to other professions, are, in my opinion lacking in validity. Are we special? Maybe. I consider it an honour, and a provelage to be a Doctor. There is nothing better than treating patients. Nothing. But nothing else offers the highs and lows. We know things you don't, but then loads of people know stuff I don't. However, I think the responsibility we take on is greater. Which is why we get so very roasted when we get it wrong.
And they think it's fine.
We're never really off duty. Have you ever heard the Captain of an aircraft ask if there's a lawyer on board? When the call goes out "is there a doctor in the house?", they sure as hell don't mean someone with a PhD...
Am I worth more, or less, than someone who sells mobile phones?
And will your answer be different when I'm thrombolysing your coronary thrombus, or treating your child's meningitis?
I don't want to be treated differently, but I sure as hell don't appreciate people telling me I can't vent.
Monday, January 21, 2008
This weekend allowed me a bit more Lemon exposure. It's hard to define the Lemons, as they are an eclectic bunch. The common denominator, I guess, is that they are all good people, and, almost unfailingly, supremely dedicated hedonists. I arrived on the citric fringe what seems like only yesterday, but was in fact four or more years ago. I hate the way that increasingly happens, but there you go.
My association is through my best friend, an old partner in crime from my school days, who has since quit this sceptred isle for sunnier climes. On Sunday, I finally located the Boat Lemons, not a million miles away from my house. In grand tradition, the bulk of them had extended their Saturday night through until Sunday. Usually, when I have begun the race with them, my bolt is long shot by now. Their endurance, and capacity for booze, is impressive.
Sadly, they were less well equipped for coffee. Undeterred, we set about constructing a percolator / filter. By MacGyvering a bit of sling (triangular bandage), some wool gauze, part of an egg carton, and the end of a Coke bottle, we were actually able to make coffee.
Our first batch did resemble brown water, it has to be said. But, we made coffee. Only took a few hours, but as my partner in coffee reminded me - 'It's the journey, not the destination'.
Sadly, this soiree marked the departure of another pair of Lemons, again for sunnier climes. Now, I know I've only known this pair for a few years, and that it gives us an excuse to go visit, and that they'll be back, etc, etc... However, this pair are among the friendliest, most generous people it has ever been my pleasure to know. I've probably met them less than a dozen times all told, by my life was a little bit better for it, and I'm worried it'll be a little bit poorer now they ain't around.
Thursday, January 17, 2008
Off work at the moment, which should enable me to fill this with exciting tales of my glamourous life.
No such luck. I've spent the time so far revising for a (mock) exam, which I had yesterday; it passed off without incident, which was nice.
So... no news. With ref to my previous post, and regarding the 'Name That Disease' puff piece, I was initially put out not to score full marks. I only got one wrong, and that was an ambiguous q about male STDs (humph...); however, full marks accords you 'Doogie Howser' status. (feel free to deploy Google at this point...)
Whilst I can't really be arsed to enter a long discussion about how wrong I think it is to pop Doogie at the head of the table, it plainly is. So, I'm happy being HawkEye.
In defiance of my friend and colleague, The CherryPicker, I continue to promote musical "flannel". I have recently encountered The Rolling River Band. Can't hardly recommend them enough. Elements of Dylan, Young, Springsteen, Cohen and Waits. Maybe. Anyway, they sound grand. If your feeling a bit folky, also seek out King Creosote. I dare you...
Get involved, get amongst it, it's all happening....
Monday, January 14, 2008
Saturday, January 12, 2008
There is almost nothing left of my essence, my being. I have left it all in Luton. This is what you get for partying with Lemons. A generally good night, with all too much beer drunk; the usual suspects were there, falling away at regular intervals, until the hard core remained at nine a.m. this morning. This was my time to bow out, but (?worryingly) many Lemons were just getting their second wind.
I am too old for this sort of thing; mostly.
My ex-beloved was there; and it was good to see her. Too good really; another reason to hate my job.
On a lighter note, ER is back on the TV. I can, once again, get my fix. My quest to watch them all again goes on; Santa brought me seasons 8 and 9... but they're all too soon gone.
A good friend of mine has been having a hard time of it of late. As usual, I don't feel at liberty to divulge why. Pregnancy related complications. I hate being on the outside. As I understand it, she and bubs are doing better now, but nothing is written in stone...
More burnout. One of the tricks I use to insulate myself from the psych-trauma of seeing how shit life can be is to try to disconnect; to de-empathise where possible. I think it makes me a little deader inside, but I discovered, when working on ITU, that I'm not strong enough to do it any other way.
I was confronted with a patient going South, whose background was very similar to my friend's. It suddenly became very difficult to be objective, to do my job. Let my feelings get in the way. The patient got the right treatment; in actual fact, the correct diagnosis was achieved by one of my SHOs.
But it wouldn't normally get to me.
Friday, January 11, 2008
Five Leaves Left. The first, minimal arrangement. Beautiful.
Bryter Layter. Contains Hazey Jane II, my own personal favourite. Possibly over arranged, but outstanding production values.
Pink Moon. Bleak, understated, tragic. Own it.
Thursday, January 10, 2008
This is not unusual these days, with the hospital running at 98% occupancy most days. But I did not comport myself well. Over excited, showing off?
i don't know. In the final analysis, it doesn't matter much, but I was in a stroppy mood. Thankfully, no-one takes me very seriously, and they were more understanding of my temper than I deserve.
My last patient on nights was a three week old baby. One so very, very new to the world, but already too much medical history. Today's problem: vomiting. The little fella wasn't clearing his own airway, and for a few minutes I thought he was going to plug off completely. Actually for about 5 seconds, I thought he had. But a little soft suction, and I have never been so pleased to hear a baby scream. In fact, I've never been so glad to hear any sound.
Last shift. Busy, busy, busy. But I told you that already.
Mostly in resus. Strokes, trauma, stabbings. Fractures, dislocations, head injuries.
The first was the hardest. A young woman, who had a 'minor' TIA middle of last year. All the right things were done. The proper work up.
None of which prevented a large, disabling stroke in November. Worse today. What little function she had had... gone. She came to us fitting. Easily treated.
The old routine, tourniquet on, hunt the vein. If you can't see it, feel it. A zen thing. It doesn't matter. I never miss these days. (Arrogant, moi?) The cannula slides in, almost a reflex after all these years, and a lorazepam chaser.
The fits stop; I told you that part was easy.
But she doesn't get better, she can't get better, she won't get better.
She gets worse.
I have to preside over it; the MC of this horror show. Her husband knows; he can't bring himself to say it; he tells me over and over how she was, how alive, how vital.
He's trying to do the terminal illness split. To distance himself from what his beloved has become, while staying true to her. When he looks at her, he still sees the love of his life, but he knows it's not her.
He can't do it, and we both have to take a few minutes out.
If all I have is being good at my job, and I'm not doing that well anymore, what's left?
I hope the break will do me good.
Wednesday, January 09, 2008
Back on days today, then off for a while. Feels like I need it. Weekend nights passed in a blur. A few oddments. A young guy pitched up with a 12 hour history of right sided weakness. 12 hours.
I mean come on... I can understand waiting a few hours to see if your cough gets better - but when half your body stops working... I would generally advocate seeking urgent medical attention.
This weekends theme seemed to be waiting for shift change to present in extremis. So several hours of inertia would be punctured at half seven by the arrival of one, or more, sickies.
Of these, the most hair raising was a three week old baby. More later, I guess...
Tuesday, January 01, 2008
'Remedial' duty for me and another Reg. Something to do with NYE being busy... Whouldathunkit?
Felt off my game all shift; probably because I was so very tired. It happens. The Department had a fairly steady stream of trauma. I suspect BBP will have a better write up than I.
This sums up NYE in an ED for me:
Quiet, ish. Not too many waitin', minors or majors. All is calm.
Jolly nurses and doctors patrol the Department, wishing all and sundry a Happy New Year.
Midnight plus one minute:
An hysterical woman is suddenly there, out of nowhere, as if by **whammo** special BeerMonkey magic, wailing and gnashing teeth, having consumed slightly more than her bodyweight in alcohol, hence her presentation.
Midnight plus two minutes:
The Department is now full of people whose only reason for being there appears to be that they can't handle their beer. And most (all) of the local Police.
So: to sum up...
All quiet; Shroom looks left. He looks back, and there is a screaming crying woman in an ethanolic miasma. He rubs his eyes. He opens them and suddenly cannot move for Police. And drunk shouty men.
Instant transformation. Amazing.
I don't wish to generalise, but I am never surprised by how the drunk ladies are mostly tearful, and the fellas punchy.
I think the most satisfying thing I did was help an old geezer, steaming drunk, hold himself up to take a pee. Sometimes, I guess, it's the little things.
Well, I hope you all had a good one, free from blunt head trauma.
For those of you who strayed to BBP, I did indeed give myself a papercut; then another identical one, just to prove the first wasn't a fluke. I thought about booking in... But my manners aren't as good as he seems to be implying...