Monday, March 31, 2008
Maybe some good news in the personal life of Shroom....
However, what is really cranking my handle at the moment is the ongoing furore about MMR. For those of you disinterested, check here, or thereabouts. I am almost incandescent with rage; however, some of my anger makes me seem decidedly right wing. So what follows is mostly rant, based on some small professional knowledge, but mostly bile.
You have been warned.
Vaccines. Named after the humble cow (vacca) by Pasteur, in honour of Jenner and his work with cowpox. Jenner noticed that milkmaids, while oft afflicted with cowpox, rarely, if ever contracted the far more deadly smallpox. So he experimented, by inoculating healthy subjects with pus from cowpox pustules. The rest, as they say is history. Contemporary records show that people were against such odd behaviour, even then - cartoons depict subjects sprouting small cattle from the inoculations. Fortunately, science held sway.
Does it work? There hasn't been a recorded case of smallpox since the late 70s.
When I was a little Shroom, there weren't so many vaccines about. I had measles, mumps and rubella. It was encouraged, as was chickenpox. If any of you know anyone who has had chickenpox as an adult, you'll know why it's better to have it as a nipper.
Enter MMR. An all in one vaccine to prevent these diseases. Why bother? I had 'em, you probably had 'em... so what?
Because these diseases kill people. Not many, but that ain't much comfort if yours is one of 'em.
And then doubt was cast on the safety of the vaccine. The 'evidence' produced was seized upon by the ever rabid media - in this country at least- and hundreds and thousands of parents voted with their feet. And their children's health.
The problem here is that, as doctors, we have a duty to do what is right for our patients; and if that includes breaking the news that a widely used medication is unsafe, so be it. If I thought the man at the centre of this whole mess was acting in what he genuinely believed was the public good, I'd be less scathing. But I don't think he was.
His research was shonky, and his practices questionable to say the least. And yet the establishment failed in it's duty; the checks and balances, designed to prevent this failed. Medical research is under the cosh a little at the mo', cos it turns out people fudge their research. Well, colour me taken aback. This has always gone on - Mendel almost certainly faked his all too perfect results, and the Thalidomide team hedged theirs in an attempt to prove safety that was to have disastrous consequences.
But now the idea is out there, and there are a number of people who will never be convinced of the wrong-ness of this charlatan's research. Any other evidence will be dismissed as Government cover up; we're back to pictures of cows sprouting from forearms.
But how far can a Government go to enforce the health of a nation? If parents don't want to vaccinate their kids, however ill advised I may think it, can we force them?
Maybe not, but it makes it that much harder to sympathise with the mother who's child is critically ill with pertussis (something I've never seen before either), who explains they decided not to get the kids jabbed after reading the Daily Mail.
By all means make an informed choice, but for Christ's sake, make sure it really is informed.
Friday, March 28, 2008
Here's Forty Shillings On The Drum
For Those Who'll Volunteer To Come...
And so the Three Line Whip. It has become apparent to me that increasingly, bods at work read this; so I can't pretend to be an heroic world saving, plague-curing stud monkey. I also have to watch who I slag off and / or eulogise. (Or for the crude, makes it harder to pass comment on the finer attributes of my female colleagues)
Anyway - I took the shilling. Years ago, I took it, but not blindly... or so I thought. But the goalposts have regularly changed. Still, took the shilling, can't argue now. The current party line to be towed remains the 4 hour target. Regular readers know what I think of this. To have medical care dictated by time based targets is, in my opinion, at best foolish, and, at worst, dangerous.
All that stands in the way of our glorious hospital achieving the glory of the Third Reich (Foundation status) is the Emergency Department, and the pesky target. So, all must be done to meet the target. We must 'engage' with the target.
So Fall In Lads, Behind The Drum
With Colours Blazing Like The Sun
Our latest pep talk hammered this message home. The Nursing Staff are not finding the middle grade attitude helpful. By which they mean: 'when we tell Shroom about breach times, he tells us he couldn't give a fuck, and that ain't helpful'.
It's not helpful, but I want to know if patients are unwell, or deteriorating, not that I must abandon treatment of sick patients to attend to well (-ish) patients who have been in the Dept a long time.
I guess it ain't their fault, so being rude just antagonises people. And, politically, it won't do me any favours, as my attitude gets referred from Nurses to Bosses to Management. I imagine, I will soon be referred for attitude readjustment, in a gulag somewhere. Or have my eyes pinned open, and be subjected to videos of people managing the breaches appropriately. (Clockwork Orange, anyone?)
If I Should Fall To Rise No More
As Many Comrades Have Before...
Interestingly, I was expecting the whip; it came as no surprise, and I have accepted I must tow the Party Line. Passive-aggressive pseudo-rebellion only goes so far. But my colleagues were upset and put out by it. They seem to have taken it personally; as a slight to their work ethic. Am I too jaded, too cynical to be bothered.
I'm not sure.
We follow the road, to come what may, nonetheless.
Tuesday, March 25, 2008
I should have known better. Superstition dictates that the Shroom who is planning a quick getaway brings ruin on himself; and the poor bugger that ends up in the ED, of course.
Control is calm; matter of fact. They always are. Car smash, sounds high velocity. Three casualties - two kids.
Enter the squeakers.
They arrive piecemeal, not in the order we were told. A 10 year old first - she looks well, and I deploy SHO Kingsmen.
We wait. Not for long. He's right behind, made smaller by the board. He looks tiny surrounded by the Techs and Paramedics; dwarfed by the monitors.
He's very quiet.
This makes me nervous; the quiet ones make me nervous. This fact is generally lost on adults, who generally believe that by shouting good and loud, they'll get dealt with quicker. It just tells me they have a patent airway, and breath enough to shout, and energy enough to waste doing it.
But the quiet ones...
A quick eyeball reassures me. He's alert, engaging his surroundings. I remember his eyes as piercing blue, but maybe that's dramatic licence. His view is limited by the sandbags stabilising his neck. The traditional ED view - nothing but ceiling tiles - and now me. He locks on as my face hoves into view. I try to think of something to say that will make this all alright for a 4 year old.
He looks less than impressed, but doesn't struggle as I clamp my hands and forearms to his head. A soft tissue vice, if you will. We run the primary survey ruler over him, and he comes up clean.
By know his sister has spilled the beans. L'il fella speaks no English. They were in a car hit at speed from behind, and rolled. Big sis crawled in to pinch him from his car-seat. My respect for both of them grows, enormously. I keep talking to him, aware now that tone is more important than words. He fixes me with his steely gaze once more; all the acknowledgement he can manage, he goes back to studying the ceiling.
Finally in a well fitting collar, we roll him; still no sign of injury, but we have to have his sister translate the indignity visited upon him. When I ask him to clench his buttocks, he does so with vigour. I half expect him to yell "Ta-Daa!" to accompany the demo of neuro-muscular integrity. (Which is the purpose of said request, in case the non-medicos were just thinking I was warped...)
He doesn't flinch as we cannulate him, draw his blood into tiny vials, virulently red against his pallor. I try to cheer him by making one of our Masonic teddy bears put on a little song and dance. He treats the display with the contempt it deserves. Everyone a critic...
By now I'm ready to hand over; pass his care like a baton; he is stable, needing some X-rays, but I feel he'll be OK. By now, his Mum has arrived. We MacGyver the trolleys next to one another, so L'il Fella can hear and touch his sis and Ma, even if he can't see 'em yet.
When he hears Ma, he breaks his silence, and a stream of language pours forth; the words spill into the resus bay, silent with relief that no-one appears seriously hurt. We've all seen the pics of the car the Paramedics brought in on their phones. Whether we like it or not, these images bring a flash of what could have been - the tearing asunder of the fragile forms before us.
With Ma nearby, and his voice rediscovered, it is finally too much for him, and he breaks; just a little at first, then rapidly, as his face crumples under the weight of what has happened to him. Finally he gets a little colour in his cheeks as he struggles to stem the flow from his bright blue eyes.
As I turn to leave, I have to cuff at my own eyes, just a little. Must be dusty in here...
It's my own fault.
Back at work, which generally cheered me up. This is sad; but still. However, with work comes my bad posture backache. Resus was frantic.
To relieve my backache - 2 co-codamol (probably tylenol to my N American cousins)
The co-codamol gives me a headache - oh! the irony
To relieve my headache - 2 aspirin
The aspirin gives me dyspepsia and nausea. My headache ignores the aspirin, and joins forces with my backache, which is enjoying a renaissance as the co-codamol wears off.
I am special.
Easter weekend served to remind me how few of us singletons there are left. Me and an old friend hooked up for a few beers; we could not find anyone else. All coupled up, all doing couply things. Jimbo and I descended on the Barfly in Camden. He sold me on a band called Ruby (or Ruby's, or Rubies, or something) They sounded melodic, anyway.
Instead we were entertained by the shouty warblings of an Italian emo-punk outfit. The band weren't too bad, but the singer was just a wee bit much for me. They also went to the trouble of having a violinist alongside the Guitars, Bass and Drums. Unsurprisingly, couldn't hear him much.
The singer spat in his face, tho', which was nice. He also spent much time clawing theatrically at his chest. Not quite carving pain into your arm with a broken bottle, but they're still finding their way, I guess. Brought their own fans / groupies, too, which was very considerate.
Next were Proxy. Different, and yet still rubbish. Sorry lads.
Anyway, it was good to quaff Guinness and shoot the shit. Felt slightly old, mind...
Never saw any variety of precious stone
Monday, March 24, 2008
Friday, March 21, 2008
I tried to think of some previous stories; I admire Dr Schwab's memorable patient series, but I have neither stories as poignant, nor the craft to tell the tales. Maybe later.
My hypothetical colleague has seen no fallout for complaining about the accidental mistiming of notes; but the drive goes on, and I'm still convinced someday someone will be sent home inappropriately to meet targets. We already push patients to the wards ahead of time...
I'm sorry to bag on about it, but right now it's the thing that dominates my working life and causes me the most stress. I'm not convinced it's good for training, so I'm sure is setting us up for problems down the line. Well, que sera sera.
My nostalgia has me reaching for the past again; I suspect it ain't a good idea, but I'll let you know. Any of my constant readers from Cleveland, Ohio? Just curious...
Monday, March 17, 2008
The medicine first; you can switch off thereafter.
Back on nights. Lovin' it. New guys, and gals, means more questions, all at once. Slower times. I set a new record. The entire board was full, 20 patients, ALL waiting to be seen. Awesome. Funnily enough, no-one was proud of me.
One of, if not my biggest, flaw, is my propensity to arrogance. I think I'm good at my job, and when it goes well, when the world falls into synch with my version of things, I get easily carried away. Sorry.
Anyway, I like nights. BBP was back on, and I thoroughly enjoy working with him. Not only is he good at his job, he's fun to work with, and gets some of my humour that otherwise falls very flat in the Department. Not all of it, and he might just be humouring me, but...
One of many I have, that should not exist. Medics among you can probably guess.
A young man, stabbed in the chest. Single chest wound, left side, posterior, infrascapular. On scene, agitated, hypotensive, tachycardic, hypoxic. Scooped and run.
On arrival; distressed, pale - deathly white, you might say - waxy. Airway patent, spilling forth garbled words. Respirations ragged, fast, shallow. His left chest running a beat behind his right. Trachea midline, but the left chest quiet, oh so quiet. Normal percussion note.
But he's shocked...
Where else is he stabbed? X-Ray light the room up as I probe, urgently, hurriedly.
I can't find anything; X-Ray lights up the room again, telling me I can stop.
So: for the non-medics; this is a tension pneumothorax. The term pneumothorax literally means air in the chest. If there is air outwith the lung in the chest, the negative pressure in the lung will cause it to collapse. Simple pneumothorax. If air continues to leak into the chest cavity, with no route out, it becomes a tension. As the chest has a fixed volume, the air will eventually displace the other structures within the chest. This fella's heart is in the right side of his chest. (as opposed to left, e.g incorrect. In case you were wondering)
It's quite the opposite of where it should be; and it is this that is causing his blood pressure to be low, his pulse to be high, and my adrenals to be in overdrive.
It is a premorbid condition, and should be a clinical diagnosis - hence why the picture should not exist.. The path should be: diagnosis - treatment - life saved.
If it goes ?diagnosis - x ray - treatment, the next step is usually death.
As it was in this case:
(Not one of mine, and followed by successful resus, I hasten to add)
Treatment is simply letting the air find a way out. We put a tube into the chest, syphoning the air away, allowing the lung, literally, room to breathe. I want to teach an SHO to put the tube in; this will take time. So first, we decompress the chest. A large needle, mid chest, straight in. Compared to the tube we're going to put in, this needle is tiny.
In real terms, it's big enough. The patient, bugeyed, doomladen already, finds it hard to relax. Fentanyl to taste sorts this. In fact, he relaxes enough to 'fess up to having indulged in some stimulants.
The transformation post needle is remarkable. Pulse and blood pressure normalise. Always one for the melodrama, I clap SHO Spot on the back, and congratulate her on a life saved. The tube goes in next. Mostly smooth, but she has trouble getting her finger through the pleura. I don't have any tricks; my way needs a little more fent, but the track is made. I am briefly reminded of a Jean-Claude VanDamme film. (I think..? maybe Seagal?) The one in which protagonists harden their hands by plunging them into cauldrons of heated sand. I try to convince SHO Spot that this is why I can poke holes in chests with my little finger, and she cannot.
She almost believes it.
She wants to do Paeds, so I let her off.
As tube goes in, he springs his last surprise - a litre of claret runs down the tube. Hot, urgent, messy. I am struck by the contrast it makes to the claret we put in, which is cold, cautious and dark. The smell of the butcher's shop embraces us again.
Cardiothoracics breeze in, encouraged by the output from chest tube to take a peek. His very presence intimidates the bleeding, and the gush becomes a trickle. Nonetheless, he wins CT angiography. There is no ongoing loss, but I am slightly anxious to see my tube in intimate contact with the aorta...
He's doing well; a good day.
I go to tell his dad. His brother, also stabbed, wants to see him. I explain that the Police have asked, for forensic reasons, that the brothers be kept apart for now. I am amazed to see him actually square up to me. He toes the line, puts his face in mine and extends the view that he, the brother, cares for him, the patient, and what the Police say is of little consequence.
I offer a counterpoint that I, the doctor, have just saved his brother's life, so it is me that has done most of the caring, and the idea that he appears to be gearing up to fight me is slightly shameful. He is undeterred by this tour de force of logic, and I am (probably) only saved from a beating by his dad.
My favourite joke? (Totally unrelated, I assure you)
Q: What do you do on cocaine?
A: More cocaine.
The rest of the weekend was less exciting, but saw me win the 'Guess the sodium in befuddled old ladies' competition, and be called a hero by another patient. (For crawling under a table to get some sponge forceps)
We also mourned the passing of BBP's trauma shears. He was very upset, and despite us pretending to be shears, we couldn't find them. Mine disappeared the next night, in sympathy, but he was not an happy bunny.
My mouth has run dry. The non-medical jib will wait.
Happy St Patrick's Day tae ye all.
Tuesday, March 11, 2008
For starters, Mousie, over at Mouse Thinks has some things worth reading about the current obsession with time that dominates Emergency Medicine in the UK. History would seem to have taught us that when you set a man an unrealistic target, he usually learns how to appear to meet the target, rather than actually meet it. (c.f Communist China, or USSR)Clearly, none of this occurs at Big Teaching Hospital, which is above reproach. I also have a few things to say regarding evidence based practice; none of these apply to my workplace either.
What I most wanted to commit to print, while the mood has me is this:
Purely hypothetically, you understand.
Consider the following:
When a service is judged as much, if not more, by a temporal rating as much as a clinical care rating, might time become pre-eminent? Might time come to dominate the clinical picture? Might this become more so when pressure is applied from above? When this temporal rating comes to have repercussions beyond care? When it might affect the hospital as a whole, and managerial jobs, specifically, might we lose perspective, and come to see time as the pre-eminent factor in patient care?
So, if this temporal rating is measured by timing patients in, and out of the Department, might there be a temptation to 'amend' the reading? If one loses points when patients tarry in your Department beyond a certain time (for example, four hours), might you consider changing figures so that more patients meet that target? Where's the harm? If my patient is in the Dept for 4 hrs and 10 ins, who gets hurt if I back-time him, just a little. Just enough that he appears to have been our guest for 3 hrs 59?
What if this is extrapolated, so you find a patient, still waiting to see a doctor, but ALREADY booked out of the Department? Half an hour ago. Officially, he's not here anymore.
Well... if it's a simple case, done and dusted in a few minutes... where's the harm? Right?
But what if it's not simple? What if you have to see a patient, already documented as having left the ED, with a diagnosis of "nothing wrong", legally recorded by one of your colleagues? What if they subsequently need treatment, need admission? What happens then, when the times don't match? When you have to explain why your entry in the notes begins almost an hour after that patient was discharged? When your entry is not of "nothing wrong"?
How far can you bend the rules? And if you don't, what of your colleague, who already 'saw' this patient...
This is, of course, hypothetical, and over the next few days, I will explore the hypothetical fallout from such an incident. Hypothetically, you understand.
Coherent edit to follow...
And on a lighter note, I've developed a crush on the Surgical SHO in Holby City...
Thursday, March 06, 2008
So, here it is; the Shroom's politics unveiled:
Your Vote Score: 16% Republican, 84% Democrat
You fit well with the Democrat party, and you should almost definitely vote Democrat this election.
In fact, you're so strongly Democrat, a political career (or at least some activism )may be in your future.
I'm not sure I'm any clearer for knowing this, but it beats navel gazing about how depressing work is while I wait to hear about my twin...
Monday, March 03, 2008
Now: I'm throwing stuff; kicking a chair. It's childish. I want to shout, to scream... but I won't. Not done, y'know? Fair doesn't come into it. I know this. The violence don't help; not really
5 minutes ago: We stand outside; shell shocked. Some of us are crying, maybe just a little. We've seen it before, knew it was coming. I want to hug him, tell him it ain't his fault...
5 minutes ago: It's all gone very quiet. I'm walking around in a circle; I can feel people looking at me. I can't hear the noise of the department for the blood pounding in my ears. I need some air...
5 minutes ago: We tell them; they knew. She told them what was coming, but now they've seen it, and the grief is real. Hot, angry, real.
5 minutes ago: I can't think of anything else to do. I've used all the drugs, my finger is in her chest, the act repeated opposite me; her lungs feel warm, but it's not helping.
5 minutes ago: They've all stayed. Usually the Paramedics and Techs get on; they've got other things to do; not tonight; not for her. They're all still here, pitching in, wanting to help. If desire was all it took... one last trick, maybe? I ask for the knife...
5 minutes ago: It's in; tube in, but I can't quite tie it. I'm coming apart a little, my voice cracking. We're not winning. I look up and se it mirrored in their faces.
5 minutes ago: I'm fighting; there's vomit everywhere, and we're slipping off the chest. I can't see the monitor properly, the lines aren't going. I'm trying to pass the tube, but the angle keeps eluding me. They know what I need, and we press on...
5 minutes ago: They're here. Already I know; she's been down too long, she's the wrong colour; too cold. Not coming back. But we always run the gauntlet. It would be an insult to her, to her family, to the Paramedics who've worked so fucking hard, just to get here. To be fair, like us, they already know, but none of us can accept it yet. We need hard proof, we doubting Toms, and so we go on my count...
5 minutes ago: I'm almost in. I hate putting lines in kids, but my SHO doesn't know how, or doesn't want to know. He doesn't want to learn as I learned, hard and cruel in the night. I guess, he doesn't have to, because I did. Then the call comes. Young, much younger than me, asthma, full arrest. Already our faces are ashen, prepared. I tape the cannula down. Mum has overheard them telling me, and suddenly her night doesn't seem so bad.
5 minutes ago: I'm at work. I actually feel pretty good about it. The department feels to be in a good mood. Let's see what the night has to offer...
Saturday, March 01, 2008
Misery comes in small packages.
They spin around each other, in small sad orbits. Sometimes they pass within easy reach of each other, close enough to touch; when this happens they accrete somehow, globbing together like oil; or mercury, if you're a hatter.
Sooner or later, we reach out to them, and embrace them. We spread the misery around, sharing it. The key is to blot it, but so few of us know this.
There seems to have been a trend recently in out patients writing on themselves, a semi-permanent record of their misery. Captured in time, to bring us in when we stand distanced from it. It is cruel, because it emphasises the final indignity, our wilful disobedience. One fellow scrawled "D.N.R", in blunt, bold ugly capitals on his chest; then overdosed. We saw it as we rent his shirt asunder. Too late, too late... did he really think we could be complicit in his request to not resuscitate him? Should we have been?
The next, another suicide attempt. This wee lass ran out of space on her paper, spilled her misery onto her belly and thighs. No request here, just an apology. All for naught. We found her too soon, or just in the nick of time, depending on who's side you choose to take.
The last, somehow the worst. Another wee lass, whose attempt at a teenage party somehow ended with a plummet from a balcony, the word "TWAT" scrawled in thick, black magic marker on her forehead. I'm sure it was meant to be funny; the laughter somehow caught in my throat, choked back, as we desperately tried to scrub her clean so her mother wouldn't have to see what cruelty had plucked her little girl from the second floor.
All of this misery spun narrow through our orbit; it's reach abortive.
Tonight's embraced too many. Another young 'un. Minding his own, his orbit destined to cross the paths of some urban street racers. The backyard F1 drivers, lap caught short by the rag doll flinging itself up onto the bonnet, and into the windscreen. Help was soon at hand; an old colleague of mine; not quite a friend, tho' I'd be honoured to call him one. A face I'd be glad to see looming over mine, if ever I stacked the car. But tho' he looks cherubic, he cannot wring miracles from the night.
We do our best, but the patient's injuries are many; are legion and severe. The Police bring misery to his mother. I make it worse. We spin on. Next time around we draw more people into the dance. His girlfriend, her mother. They sit, ashen faced as I draw them inexorably into the morass.
Round and round we go. I come back, and the numbers have increased again. Misery loves company, and still I have no good news for them. I want to tell them something, if not good, then at least not awful. But they would know me for a liar. The Police, and Sister, compliment me on the way I break the news. A backhanded compliment? I have become good at drawing people in, and shattering their dreams.
Then I break free. The sun is shining as I walk out, but, somehow, I can't quite feel it's warmth this morning