Sorry

Sorry; been quiet too long. I think I'm running out of stuff to say. another brief hiatus follows. Next year, I intend to try and post one a day. If it fails, I think it will be time: I will have run my course. Thank you for your patience, constant reader. I'll see you in 2010

Meme

Alice has tagged me...

"Give me five great things that your Blog or Websites rank number one for in Google searches..."

I'm working on it...

D-Day

So, after the best part of 12 months sweating and a five year training programme, today was do-or-die day. Possibly literally.

The College kept us waiting, and their results webpage recorded something like 25000 hits during the day, which, considering there were less than 100 people waiting it out, is pretty good.

Anyway.

I fucking passed.

Take that world.

I can now add FCEM to my motley collection of qualifications.

Thank Christ.

Duty Of Care

If you're sick, I have to look after you.

Does this exist for dentists?

A friend of mine, a redoubtable Lemon, probably had the flu recently. It thus might have been H1N1. She managed this very sensibly, with self isolation and OTC remedies, and without the need to traipse down to the ED.

However, as she was on the mend, she began to develop worsening pain around an impacted wisdom tooth. Now, generally, this will settle, and can be treated symptomatically.

BUT...

Sometimes, there may be infection, and in the presence of some constitutional symptoms, it would seem reasonable to have a dentist take a look and opine as to the need for antibiotics. I'd have done it myself, but distance presents a problem.

HOWEVER...

Once she raised the possibility of infuenza, the local dentists shut up shop, and refused her appointments.

So... if she were to go on and develop sepsis from a dental abscess, or Vincent's angina, or worse, Ludwig's Angina (which another Lemon so developed after some dental work, and he ended up on ITU) who is responsible?

Anyone?

After all, dentists all wear fucking facemasks anyway, and if the patient isn't coughing on you, the risk is fairly small.

I can't refuse to see patiens on the basis of their illness, or even their behaviour, why should dentists be different?

Cometh The Hour

I have found this difficult to write about.

I suspect that we all, at one time or another have confronted our worst fears, either really, or in our minds. If you haven't you should.

It still might not be enough.

To me, an Emergency Physician is one who knowswhat needs doing, and how to get it done, in any given situation. Frankly, most of what we do, most of medicine, is not time critical... in as much as you can spend a few minutes mulling over your options.

The way I see it, my paycheck is the massive hoard it is because once in a while we don't have that luxury.

Imagine this.

Let us say a patient has been brought to you, having arrested out of hospital. They have survived, which is, in itself, a rareity. But they are now unmanageable, and need 'optimising'. In short they need their physiology dominated, by us, and controlled to maximise their eventual function. This will necessitate airway control; in this situation, there is a ittle time. The patient is maintaining an airway, and oxygenating and ventilating adequately, for now. It won't last. He will need intubation, and have to, effectively undergo a general anaesthetic.

You call for help from ITU, and go to talk to the family, update them and gain information. On hearing the phrase "general anaesthetic", the family immediately venture the fact that this patient has a difficult airway; you report this to your ITU colleague, and go back to the family. Having tidied things up at that end you return to your resus room, to find that the shit has hit the fan.

I had figured that we would wait until all the extra "difficult airway" kit was ready, and all hands were on deck, but somehow, matters had proceeded rapidly to a "can't intubate, can't ventilate" situation, in my absence.

For those of you not of a medical bent, this is my worst nightmare. Having paralysed a patient to pass a tube into their windpipe, you find you cannot pass the tube ("can't intubate") and moreover, you cannot force air into their lungs using a standard bag and mask combo ("can't ventilate".) In short, having stopped the patient breathing for themselves, you find you are unable to do it for them.

This is, I would argue, one of those time critical moments.

You should anticipate this sort of thing, prepare for it, be ready.

Walking in on it is not ideal.

Could you step up to the plate? Make the difference?

Controversial?

Polemic, but, from one perspective, at least, with some truths...

Supergroup - Bass

John Paul Jones?

Or John Entwistle?

Bass break at 2:50...

Supergroup - Drummer

Keith Moon. No contest

Supergroup - Brass

The Miami Horns

Esp. from 3:16

The USC Marching Band, as heard on Fleetwood Mac's 'Tusk'

Management Flail

I hate being stuck in the middle.

It happens a lot, mostly because many of my colleagues still regard the ED docs as non-specialist, and think we will be their scut-monkeys. Old habits die hard, an all that.

Recently, I was presented with a challenging patient. A young woman, with a non-specific history of headaches, who had suddenly gone bananas. I apologise for the use of technical jargon. She had rapidly become delirious, with a fluctuating conscious level, and was spouting mostly gibberish.

Part of the work up was to include a CT scan, and we doubted our ability both to transfer her safely, and to convince her to lie still. ITU helped out with both of these things, but then pretty much washed their hands.

Her scan was normal, but bloodwork suggested and infective process and acute renal failure. Obs showed her persistently hypotensive, with diminished urine output. Getting near her, necessitated recurrent chemical restraint, physical restraint not being an option.

My medical colleagues were reluctant to admit her to the floor, concerned as they were that she was a) pretty sick, and b) difficult to manage safely.

ITU flat out refused to take her.

A 3 way argument between my boss, the medical and the ITU consultant ensued, with the end result being she stayed in my Resus room for 7 hours and then went to the medical floor. I can't help but feel that this once again paints us as the bitches in this piece, especially as less than an hour after arriving on the medical ward, she was transferred to ITU and tubed...

Lest We Forget

They shall not grow old, as we who are left grow old.

Age shall not weary tem, nor the years condemn.

At the going down of the sun, and in the morning, we will remember them.

Taking Ones Eye Off The Ball

The targets we must labour under continue to insert themselves into out minds, insidiously, until we think they've always been there.

Where I currently work, there seems to be a strangely blase attitude to some of the stuff that comes in on the BatPhone, and I can't help but wonder if that's because we know they've got 'plenty of time'. Of course, they might die during that time, but, hey, at least they won't breach.

Maybe I'm wrong, and, of course, this is not the party line, but I keep finding patients in Resus, with no Doctor. Most recently was a fella found by his flat mate, unconscious. He was still unrousable on arrival at the ED, and went almost an hour before being formally assessed by a Doc. He ended up tubed and on ITU.

Now, maybe that's just me; no-one else seemed overly bothered, but I can't help but feel dudes in a coma ought to jump the queue...

On Pain Releif

Providing appropriate analgaesia seems to me to be one of the greatest challenges we face. We have a variety of analgaesics at our disposal, which work in different ways, and, often synergistically, complementing each other.

Part of the problem is that the stronger painkillers have side effects that some people enjoy, and are habituating, thus addicting. Using opiate painkillers appropriately should minimise the chances of this... but:

I have it in mind that the quicker one gets control of someone's pain, the longer the effect lasts, and the less analgaesia they need in the future.

So: should we be giving more opiates not less?

Or do we have to accept some pain in our lives?

Supergroup - Sax

One, or both, from two.

King Curtis

David Sanborn

Supergroup - Piano

Again, no contest.

Billy Preston.

Quick view at 1m 20s.

Supergroup - Organ

And on the organ, on the Hammond B3 Organ...

Steve Winwood. No contest.

The Needs Of The Few vs The Cost To The Many

One of the problems with trying to adopt an evidence based approach, to anything, but in particular, to medical testing and treatment, is that population studies do not tell individual stories.

The problem with using individual stories is that the plural of anecdote is not data, and association does not prove causation.

However....

A young middle-aged woman with chest pains present to the ED. They had woken her from sleep, but been transient, and she had gone back to sleep. In the morning she had something of a dull ache behind her breastbone, and felt a little short of breath. Simple remedies had not helped. Her pain had settled at time of exam, and she examined normally. An ECG was normal.

Past history, family history, all negative.

How to proceed?

She was admitted for observation and serial cardiac enzymes. Should she have had something else? A CT scan? CT coronary angiography? CT triple testing, looking at aortic root, pulmonary vessels and coronaries?

While waiting the result of her serial enzymes, she collapsed on the way to the toilet. Immediately after the collapse, she was alert, if slightly clammy, and her pain had returned. ECG now showed some T wave inversion, laterally, in keeping with an ischaemic picture.

Before she could be further assessed, her pain became excruciating, and she developed marked cyanosis, centrally. ECG continued to show ischaemic changes, but had not changed from the immediate post-collapse trace.

Within about 15 minutes, she became profoundly bradycardic, and then arrested. Prolonged resuscitation was, ultimately, unsuccessful.

I don't know what the PM showed.

PE?
Dissection?

If she had been investigated more invasively, might the outcome have been different? Maybe... maybe not. But most folks who present as she did, DON'T keel over. So if we scan everyone, won't most of them just have a normal scan, and increased radiation load?

So not scanning makes sense for the population in general... just not for her, I guess.

Sudden And Unexpected.

It's amazing how much better I feel having finished my exams. Conscious of the stress as I was, I'm still surprised to see how much better I feel, with them over. Of course, now I have to wait 3 weeks before learning of my fate,and possibly starting all over again.

Ah, well...

LBF has had to endure more than her fair share of deprivation, and I hope that now, we can spend more time making mischief. Although, of course, my rota may well continue to get in the way. She has been somewhat under the weather of late, but, having undergone emergent needling treatment, and something to do with balls in ears, is feeling more like her old self. Which, in case there was doubt, is witty and funny. (Almost always)

Anyway; the ED is often witness to the unexpected; as it should be, really. Almost by definition, emergencies ARE unexpected. Of courser, that's not always what brings folks to the ED, but there you go...

A young woman spent her evening getting drunk; I'm assuming that's what she did. To be fair, she might have been up to almost anything, but at the end of the day she was virtually insensible. An all too common problem reared its head - she ran out of, or could not find any, money. Her taxi driver called the Police, and they tried to intervene with her family, but they were unwelcoming. How many times must the have heard this call before? For they would not answer the call. Why?

We'll never know.

The Police had subsequently arranged for her to stop overnight in an Hostel, but by the time she reached it, she had grown cold and still. I suspect she choked on her own vomit, en route, but again, we'll never know.

Almost an hour of aggressive resuscitation did nothing to improve her countenance, nor restore her cardiac output.

To see the death of the young is always sad, and to see one that could so easily have been avoided, more so.

Maybe it's true, we pays our money, and we takes our choices, and the Devil take the hindmost.

Supergroup - Guitars

Currently, mulling over Hendrix, Clapton, Mick Taylor and Chuck Berry...

I think there are simply too many legendary guitar players out there.

Mick Taylor on show from about 2:50

Supergroup - Vocalist.

Exams all finished. Now just3 weeks of anxious waiting.

As for my supergroup, I think I want Freddie Mercury, and Janis Joplin. And maybe Elvis. Can't quite decide...

Then again, what about Tom Jones....

Night Shifts, Hard Work and Sickness

Another set of nights, another Doc off sick.

Trying to compare 'now' with 'then' is often fruitless... memory is, by its very nature, unreliable; we both forget things, and remember things falsely. Rose tinted spectacles.

That having said... I'm sure short notice sickness is more prevalent now than it was when I was younger. And I definitely wouldn't have remembered it wrong.

Maybe it's just me. When I was on the house, being off sick meant someone else having to cover your work, or, perhaps more to the point, you having to cover someone else's work when they were off sick. So, in general, we weren't enormously sympathetic to anything we perceived as someone pulling a sickie. There was a culture of 'working through it'. Is it a good thing that's gone?

I'm sure it is. No-one should have to feel obliged to come to work if they feel a bit peaky.

But I can't help but feel we've washed a little bit of the work ethic away, too. I should point out that I'm slightly biased, having had only one sick day, in eleven years.

Anyway, I have yet to work a set of nights with the allocated number of docs.

That's fine. I'll work a bit harder. I'm used to it. But maybe, just maybe the constant stress is what's causing this increase in sickies. Maybe.

What frustrates me the most about working short handed is that management always act surprised, and then lose the plot at about 2 a.m when our breach targets start to drift...

The latest, slightly sinister, attempt to combat this, was foisted on us from on high. Once a patient has breached (waited for more than 4 hours in the dept), perhaps we could see our way to ignoring them, in favour of those who haven't yet breached.

Let me make that clear; people in the ED get seen in order of clinical priority, and thereafter, time. But once you have waited 4 hours, the department is not penalised further until you wait 12 hours... So management appear to have decided that once you have waited 4 hours, you should be being punished by being made to wait another 4 hours so that we can meet our targets.

I'll let you think about that

Ultimate Supergroup..?

Clearly, as exam stress builds, my mind should turn to all things medical...

So, naturally, I have instead been contemplating who I'd like to see appear in a one off 'supergroup'. The supergroup seems to me to have been a short lived trend of the 70s. I imagine there were good resons for this, but still...

Expect uninteresting musing on who I'd choose to follow.

The Black Dog

Apologies for the silence; exams pending have had me all distracted. Game on tomorrow, and I'm decompensating a little bit. I'm sure my ability to deal wit this shit gets less with every passing year.

Anyway, I'm not sleeping, and generally of low mood, and this reflects in my work, which, I guess makes me a bad professional.

We'll see, I guess.

The patient so keen to declare her love for bum sex survived her 4 metre fall, and seems none the worse for her frontal contusions.

Must stop now before I become bogged doen with navel-gazing; the Black Dog looms large on my horizon.

More later; I'm on nights this weekend, which will surely be a fertile hunting ground.

What The Future Holds...

If only we knew. The cliche, the thing they always say is that you should always wear clean underwear, in case you get knocked down. Actually, if you do get knockeddown, no matter how clean your undercrackers were this morning, they're sure as hell soiled now.

I discovered a varient of this aphorism. When graffiti'ing your clothes, just cast a little eye to the future.

Because when, after 6 pints of snakebite, you faceplant into a concrete floor, and bruise your brain into a coma, it won't make it any easier for your parents to bear when they find your nice white shirt has "I love bum sex" scrawled in massive letters on it.

Learning On The Job

There are, it seems, some lessons you have to keep on learning. Unlike to aphorisms pertaining to those in possession of a blue rinse, or wearing sunglasses indoors, at night, some things keep cropping up.

Lesson One: History is important

We are taught this almost from day one at medical school. Diagnosis is mostly in the history, and the skill, the art, is in teasing out those details that give you the answer you seek, while ignoring the dross, the red herrings. Refining the art allows this to be done at speed. You might call it pattern recognition. I like to think I'm good at it.

And yet...

She fell at home, a simple fall. What we call a 'mechanical fall', much to the consternation of my Physician colleagues. She bumped her head, but did not black out. An Ambulance attended, the Paramedics found her uneasy, but otherwise well, and settled her into a chair, left her with her husband. A little later she had what is often described as a 'funny do'. She missed her mouth with a piece of cake, and just wasn't herself. By the time she arrived in the ED, this too seemed to have passed, and she was her old self again. No amount of prodding and poking, pushing and pulling, no light cast into the darkness could illuminate any abnormality.

The history, however spoke volumes. The textbook history is a head injury accompanied by LoC, then recovery, then further, and often final lapse into coma. Natasha Richardson walked this road. It is a history that whispers of bleeding within the skull, typically an extradural haemorrhage.

This history didn't quite fit, but the pattern was close enough, and set the voice in my head a-chunterin'.

I mulled this over; our Radiologists are often less free with their CT scans than my North American colleagues, and, even with a suspect history, I wondered whether the normal examination would preclude what would have been an out of hours scan... Perhaps I should have asked them? I didn't. I elected on a middle path, admission for observation.

I didn't have to wait long. Inside 10 minutes, she was unresponsive, and 10 minutes after that, her right pupil had dilated, mocking my decision. Her subsequent CT scan confirmed my fears, and showed in ugly monochrome an extensive bleed. It was subdural, not extradural, and the Neurosurgeons took but a few minutes to tell me there was nothing to be done.

Should I have held true to the history, and pushed for an earlier scan? Probably, yes, although it wouldn't have changed the outcome. Would it have been better for her to know what was brewing within her skull? I'm not sure, but maybe goodbyes could have been said, last words spoken, a few minutes spent settling accounts. Maybe that would have been worth it.

Maybe. Sometimes 'what if...' is the most painful phrase you can say to yourself.

Lesson 2 - People with pathology get sick too

She was young and a known fitter. Brought in because she had had a fit. People who fit, fit. Shroom's aphorisms. Sometimes there's another reason, usually benign, mostly there's not. Make 'em safe, watch 'em wake up, and send 'em home.

What if they don't wake up?

When nothing else seems out of kilter, should you scan 'em? Now, later, when?

I waited. Gave her an hour. The law of Sod, says if you call for intubation early, they'll be awake by the time ITU get there; if you don't, it'll turn out you should have called early.

I waited.

After a bit, the patient gave me a nudge. Her pressure stared to rise, and she started posturing. 'Posturing' means she stared making atypical, abnormal movements with her limbs. Not 'I'm waking up now' movements; more 'my brain is bleeding' movements.

A quick tube and CT later showed a head full of blood. A sub-arachnoid haemorrhage.

I waited because she was a fitter. Did it make any difference to outcome? I don't know. I hope not. Interestingly, my Radiology colleagues, whom I have upset with a variety of requests for out of hours CTs this week, were sceptical about scanning her, for precisely those reasons. She was a fitter.

A wise man once told me you have to try harder with certain patients: the frequent fliers, the rude and annoying, and those with pre-existing pathology that masks the assessment. Because they too get sick, and sometimes we don't look hard enough

Doctor Shroom's Guide to Medical Bullshit.

If I can work out a way to link to this permanently on the side bar, I will, so that I can add to it.

One of my dear readers has mailed to point out there are an awful lot of three letter acronyms in my writing. I hope this will provide clarity.

Hat tip to NV who has provided almost all of these, taken ad verbatim from my comments box. Thanks.

Here I will only offer the long version of the acronym; for further info, follow the link. Many of these links may go via Wikipedia, which would cause several of my SHOs socks to blow off, were they to read this drivel....

ABG: Arterial Blood Gas; sometime referred to as 'gas' or 'gasses'
BP: Blood Pressure
CT: Computed Tomogrophy
US or USS: Ultrasound
AAA: Abdominal aortic aneurysm
TAA: Thoracic aortic aneurysm
CPR: Cardio Pulmonary Resuscitation.
ECG: Electrocardiogram. EKG to my American colleagues, for some reason.
CXR: Chest X-Ray (Chest radiograph, for the pedants)
AXR: Abdominal X-Ray
DIB: Difficulty in Breathing
SOB: Short of Breath
KO'd: Knoecked Out
LOC: Loss of Consciousness
BM: Blood sugar. (no, I don't know why either)
GCS: Glasgow Coma Score
O/D: Over dose
OB/G: Obstetrics and Gynaecology (Obs and Gobs)
GYN: Gynae
ABx: Antibiotics
OD: Omni die - every day, daily. See also OM - omni mane, every morning and ON - omni nocte, every night
B(I)D: Bis (in) Die - twice daily
TDS: Ter Die Sumendus, or TID Ter in Die, Thrice daily
QDS: Quater Die Sumendus, or QID Quater In Die; 4 times a day
PRN: Pro Re Nate - As occasion requires. As needed
TTO: To Take Out, or TTA To Take Away. Prescription drugs for the patient to take home.
R/V: Review
ABR: Awaiting Blood Results (?)
PO: Per Oram - by mouth
PR: Per rectum - by rectum, rectally. Sometimes referring to exam thereof
PV: Per vaginum - vaginally. Sometimes referring to exam thereof
DRE: Digital Rectal Exam
DLE: Declared Life Extinct; dead
My American colleagues use terms such as "q6h" meaning "quaque 6 hora", or every 6 hours. Other numbers can be inserted as appropriate, obviously

There are clearly more; I'll edit as I think of them, or steal them from the comments box.

CVA: Cerebro-vascular accident
TIA: Transient Ischaemic Attack
MRI: Magnetic Resonance Imaging
NOF: Neck of Femur
MSU: Mid stream urine
CSU: Catheter sample urine
IV: Intravenous
FBC: Full blood count
U+E: Urea and electrolytes
G&S: Group and Save
HB: Haemoglobin
INR: international normalised ratio
MI: Myocardial infarction
PE: Pulmonary embolism
AF: Atrial fibrillation
COPD: Chronic obstructive pulmonary disease
UTI: Urinary tract infection
VD (or STD): Venereal disease/Sexually transmitted disease
(N)IDDM: (Non) Insulin Dependant Diabetic Mellitus
Ca: Cancer, or carcinoma
RTA/RTC/RTI: Road traffic accident/collision/incident
NKDA: No Known Drug Allergies
ENT: Ears, Nose and Throat (Otolaryngology)
MaxFax: Oral and Maxillofacial surgery
GUM: Genito-urinary medicine
Obs: Obstetrics OR Observations (vital signs) depending on context
SYS: Systolic
DIA: Diastolic
?: Query
#: Fracture

Not strictly medical terms but job titles (and a few wards) often get the works as well:

HO: House Officer (F1)
SHO: Senoir House Officer (F2 to about CT/ST 2 or 3?)
Reg: Registrar (?CT3+)
RN: Registered Nurse
(S)SN: (Senior) Staff Nurse
(S)SR: (Senior) Sister
(S)CN: (Senior) Charge Nurse
HCA/NA/Aux: Healthcare Assistant/Nursing Auxillary
OT: Occupational Therapy
CAU/MAU/AAU: Clinical/Medical/Acute Assessment unit
CCU: Coronary Care unit
ITU/ICU: Intensive Treatment/Care unit
HDU: High dependency unit
NICU/SCBU: Neonatal Intensive care unit/Special care baby unit

These probably are more regional since I'm a London lad:
LAS - London Ambulance Service (See also EMS - Emergency Medical Services)
G4S - Group 4 Security (Transport ambulances)

And my personal favourite that has appeared a lot recently:
FLU: Stupidity

Shameless Plug

For all your bespoke wood needs. Fallen Woods.

Go. Click. See for yourself.

(No it's not me. I am no carpenter...Wood-based goodness courtesy of Delwreck, a Lemon of high reknown.)

Memories

Memory is a curious thing. It is almost infinitely plastic, and malleable. We can play with our memories, and over time convince ourselves our version of the truth is more real than someone else's. Even with insight we spin and play events, trying them out for size.

History is written by the victor, and memory is constantly re-written by our subconscious, seeking the most palatable version.

Earlier this week, a patient was brought to us from a hostel; he had been staying there for some sort of reunion. He had collapsed, perhaps losing consciousness briefly. All he could say was that he felt unwell.

He looked bloody awful. Pale, clammy, breathing fast and shallow, pulse strong, but fast. The sternotomy scar announcing his membership of the cardiac club. His sats were low, but not catastrophically so, and his pressure good. His lungs sounded clear, and his ECG looked clean.

Interestingly, the 12 lead done by the Ambos showed a Right bundle, conspicuously absent now.

While rummaging around his radial artery, trying for an ABG, his pulse volume seemed to waver and fade. I glance up at him, trying to use my patented diagnostic eyes; he still looked pale and ill, but no more so. Maybe...

"Just check his pressure again for me, please..?"

A minute later, he declared himself. I just decided I wasn't going to get an ABG on this side, when he announced his intention to be sick. This always makes me anxious, because it's often a side effect of a piss poor BP. A quick glance at the monitor showed long pauses punctuated by ugly, broad ventricular escape complexes. Instead of vomiting, the patient slumped back on the trolley, his head lolling, his tongue protruding from his pallid lips.

A few quick shakes of the shoulder and calls to attention, produced no response. The monitor still showed a rate in the 20s.

I punched him in the chest.

The correct term is probably pre-cordial thump.

The effect, dramatic. It was accompanied by a beat on the monitor, and the patient opened his eyes, wide, surprised. I suspect his look was mirrored, not only on my face, but on those of the nurses working with me. The pause was long enough, and his heart beat no more, and I lost my nerve.

A minute of frantic CPR, and he was reaching up to pull out his OPA, the monitor bright and alive with joyful activity.

What had I hoped to,achieve? A precordial thump is intended for use in a witnessed, monitored, shockable cardiac arrest. I think it had been in my mind to percussion pace him. I'd been talking about that earlier in the day. If that was the case, I didn't do it right, I lost my nerve after the initial thump.

Maybe I just panicked?

My memory rejects that version; I'll let it, for now. The patient is alive, and, at the end of the day, that's what counts.

Parking Spaces

LBF is often enquiring after her character. I'm not sure she'll thank me for this...

Part of exciting lives dictates that we occasionally go to the Supermarket. On our last visit, we were confronted by a Pay-and-Display car park. Having no change, we elected to fight the power, defy the man and park without paying. Ever fearful of parking Nazis, I stayed with the car, while LBF shopped. (Yes, that might be the 1950s calling)

On returning, arms laden with produce, LBF pressed a 50p coin into my palm, not in an attempt to press gang me, but for the Pay-and-Display machine. She looked pleased with herself, I puzzled.

She later explained she thought we had to buy a ticket, in case someone came round to check...

(She doesn't drive a car)

Spare Chaynge

Our attitude to death, or Death, if you will, constantly fascinates me. I suspect it is, at least in part, related to the secularisation of society. I think people fear death considerably more now they aren't assured that it means going to paradise to meet one's maker. Coupled with the idea that we can do so much to stave off death, this seems to me to have resulted in a world where we no longer accept that death comes to us all, and devote much time and money to prolonging the inevitable.

Even when this has been accepted, people seek to transfer the responsibility to someone else, usually the medical profession, often me, because I stand by the front door.

Last week, among the throng that seems to be increasingly the norm at South Coast General, and this is only the beginning of Winter, were two elderly patients who spent their last minutes in an overcrowded, noisy ugly room surrounded by strangers.

The first, an elderly lady, from a Care home. Her quality of life sounded poor, heavily dependent, demented. This is an all too familiar story. We are not evolved to live so long. Her family had seen her deterioration, and seemed to have made the sensible choice, that if she should become ill, she should be kept comfortable at what had become her home, and allowed to die. So when she did become ill, and collapse, the Ambulance was called. Once they arrived the Staff told them of the families wish that she should not be actively resuscitated. No 'formal' documentation of this plan existed: the fabled DNR, or Do Not Resuscitate. This leaves the Ambos with little, or no, choice. If you don't want someone resuscitated, don't call an Ambulance. Why call someone, to tell them you don't need, or indeed want them?

I suspect they wanted validation of their decision. Or maybe they just panicked. I don't know, but the end result was a crumbly, frail woman intubated and ventilated in my Resus room. Yes, her heart was beating again, but she showed no sign of purposeful neurological activity.

Next door, an elderly man, not quite so dependent, but a cardiac cripple, a man so determined to be at home he had taken his own discharge from hospital that very morning. He was unwell, and had been told so; much time had been expended counselling him, warning him of the risks he was taking. He understood, he was clear about that. He didn't care, he wanted to be at home.

He lasted a few minutes.

Now, I respect people's rights to give the NHS the big "fuck you". Many members of the public avail themselves of this right in my face, on an almost daily basis. Adults have to have the right to choose; I must confess to being slightly frustrated when this happens. We spend time counselling someone of the risks, they give us the big "fuck you", we spend money (taxpayers money!) getting them home, then whist we said would happen, happens, and they call an ambulance to come back again. (MORE taxpayers money!)

He, too was dying, and I think he knew it. His resolve to do it at home had crumbled.

They died on trolleys next to one another, both with plans to do so with dignity, at home, in comfort, in tatters.

Is it possible to have a good death? I think it is, but not in an overcrowded ED. I wonder if my nerve will hold when my time comes?

Light Relief

LBF's in Wales, and I'm at work. The very definition of a modern relationship.

I have some grim tales to share, but the talk of the Department this week is definitely the discovery in bay 10, of a very drunk woman attempting to relieve the chest pain of her, equally drunk, husband in an unusual way...

More to follow but till then:




And to think, some say he was the 3rd best guitarist in the Yardbirds

Flag! Flag!

I am embarrassed to realise I haven't flagged this yet.

What is 'this'?

bunchacunce.org: an oversmug look at a pseudo-interesting
sub-intellectual collection of semi-randomness trawled from not only the peaks
but also the bowels of the internet. ...and why not?

Go, look see for yourself

The Nanny State

Some time has passed since the latest E. coli outbreak in the UK. So this should cement my reputation as contemporary.

For those not aware, or who can't be arsed to read the Wikipedia entry linked above, escherichia coli is a bacteria, commonly found in the alimentary tracts (guts) of mammals. It is generally an harmless commensal bacteria, that is to say one that lives within its 'host', cheek by jowl, without causing symptoms.

However, certain subtypes can cause symptoms, usually those of food poisoning - diarrhoea and vomiting, but occasionally progressing to more serious complications, such as renal failure.

This is an over-simplification, but if you really want to know the ins and outs, the info is out there.

The point is, if you get shit on your hands, or anything else you might put in your mouth, you may ingest someone / something else's e. coli, and poison yourself.

I generally reckon it should be self evident that putting shit in your mouth is a bad idea. So, in case you were unsure is rubbing it in your eyes; but that's another story.

Certain groups of people DON'T realise this. Among them are the pathologically stupid, and children, who don't know any better. Animals also have a less than scrupulous attitude to their own, and other people's faeces.

So, it would seem to me, it stands to reason that if you stroke an animal, that animal might have been rolling it, rubbing up against shit, in one form or another. So, really, you should wash your hands afterwards. Children may not be aware of this, and should be encouraged, or indeed, forced, to do so.

I have nothing but sympathy for the latest victims of the e.coli outbreak. I am unsure as to how the farms related might be culpable. Not enough warnings? No handwashing facilities?

I suspect people living in towns have become inured to the idea that animals, living as they do, might be less than sterile.

What I find most interesting is the roller coaster attitude that the British press takes to incidents like this. When something awful happens - children hospitalised - the press virtually froths at the mouth looking for someone to blame, denouncing the authorities for not providing enough protection.

And yet, when steps are taken to prevent accidents - before they happen - the frothing diatribe is against the Nanny State, or Health and Safety Gone Mad!

You can't have it both ways. We have to take some responsibility, don't we?

As I said, I don't know what factors at the farms involved might have made it more likely that infection be passed on, might have made conditions more unsanitary, but I do know it's just good common sense not to put shit in your mouth, and I can't help but feel we shouldn't need to be told to wash our hands after stroking animals...

Randoms...

Day off, so no on the floor navel gazing.

Instead: a blog that may be interesting reading. I'd like to pretend I'm getting in on the ground floor of my own accord, but it was flagged by the incomparable Lisa Lynch, she of Alright Tit fame.
It's, I guess, a dating diary of an expat Brit... I'm thinking it'll make for interesting reading; we'll see.

Also for your consideration - things that have made me smile today:

1. A man walking his dog. Not obviously smile worthy, but the man seemed a little too old for the dog, which was a sort of terrier puppy, and furiously energetic in the way only the children of all species can be. The dog was an extendable lead, and just belting around the man, aimlessly running at full tilt in ever-expanding circles. I realise it's wrong to try and anthropomorphasise animals, but the dog really did seem to have an expression of pure joy. It must be nice to derive such pleasure from something so simple.

2. Two people reversing toward each other in a supermarket car park. I've seen this several times, and I don't know why people find it so difficult, or why it please me so much, but it does. The sheer bloody mindedness of these folks delights me. Both drivers appear to be aware that, if they continue going backward, they will crash into each other, but both appear to think it the duty of the other driver to stop. A low speed crash inevitably results, and I can't help but think they deserve it. I'm not sure what this says about me.

Too Late

She came too late...

I don't know why, but I guess she was scared.

Afraid of what we'd tell her.

Afraid of what we'd find.

Maybe it didn't seem that bad?

Maybe she lacked the wherewithal to know better.

She fell at the exact opposite end of the spectrum to those folks who bump their heads on a car door while getting in, and pitch up complaining of a 10/10 headache. They end up with a CT scan that undoubtedly does more harm than good.

She got the full force of medicine and surgery, and it still wasn't enough.

She came too late.

Entry Redacted

With satisfying timing, LBF contacted me today to express some concerns about the details included in the episode in which Schlingo made her debut...

I should therefore make it perfectly clear that I know teachers, of all varieties are highly skilled, overworked, underpaid pillars of society. Their work is much more than colouring in shapes.


Sometimes they stick the shapes on bits of card afterward.

Suffer The Little Children

Considering I spend all day dealing with people, I occasionally find them surprisingly annoying. Sometimes, I might suggest, this is well deserved - the pisshead who thinks it's funny to take a crap on the floor, for example. Sometimes, I think it's probably futile. People are the way they are, and I'm not sure i can blame them for that, any more than I might scold a cat for eating a mouse.

Children, specifically teenagers, and their parents are among the leading perpetrators.

Consider:

If you think you are old enough, are mature enough to get drunk, go skateboarding au naturel, and then fall on your head, you should be mature enough to accept that your treatment will have to be in hospital, that a cervical collar is a bit uncomfortable (tho only for a bit, and much less uncomfortable than 60 years as a quadraplegic...) Instead, you will whine incessantly about wanting to go home, about how there can be no needles involved in your treatment. This last is despite your multiple piercings.

And this makes me cross, but perhaps it shouldn't, because my attempt at logically suggesting that your decision that you're mature enough to get drunk and arse about isn't made because you are mature, but precisely the opposite; and so when you act like a scared child, it is because that is what you are; and I can't blame you for that, can I?

Consider:

If you're child gets run over while in the charge of another child, and if she bears the insult of a fractured femur with quiet dignity while you fret about how you didn't see anything, and sway from side to side, smelling faintly of drink, I can't help but feel slightly aggrieved, if only on behalf of the child whose leg we will soon be pulling straight. But maybe it's too much to expect you not to drink, and to supervise your children crossing busy roads. The Green Cross Code Man has gone the way of C90 cassette tapes, so who does teach kids road safety? Maybe that degree of responsibility is just beyond you.


If you take your child to a party, and they get drunk, so drunk that when you bring them home they become belligerent, shouting abuse at you, breaking your lamps, it surely isn't really your fault that you can't cope. If that level of common sense, or emotional maturity is beyond you, I shouldn't be surprised it's beyond your growing offspring, and it really is unfair to be cross with you...

After all, shit does happen, eh?

One By One

South Coast General provides pathology, thick and fast. One by one, sometimes all at once.



Today's shift provided more good evidence that empiricism lets you down. A fella came to us, pinged ahead by the MobiMed, a computer link up with the Ambos, allowing them to flag patients and their ECGs. Telemedicine, I guess we should call it.



It offers real time comms with the Ambos, and sometimes, the opportunity to see the poor buggers go off, en route, in real time. The first message forewarned of a patient with a headache and left-sided weakness. Otherwise, stable, so far, nothing so unusual, unfortunately. Within minutes, they pinged back. His Glasgow Coma Score had dropped to 5. This is a score ranging from 3 (which even a corpse would score) to 15. 5, you can deduce, is bad.



Minutes later, he had dropped to 3, and was fitting.



He was still fitting when he arrived, and the thought going through all of our heads was one of a head full of blood. Haemorrhagic strokes, or intra-cerebral bleeds produce cerebral irritation, and, in my experience, often result in seizures. The outcome is always bad.



We stopped the fits, relatively straightforward, and prepped him for the CT scanner, anticipating the dread images that would allow us to decide his fate. The family were unprepared; they always are, to varying degrees. This family, especially unprepared, left devastated by my visit, sold an awful bill of rights by my 'pep-talk'. It's hard to offer hope when you don't believe here is any.



Whilst he went to the scanner, the Department coughed up its next surprise - a woman described as 'normally fit and well', looking as far from those words as I've ever seen. To start, she was the very definition of morbidly obese. Her BMI approached that of Tonga, and any skin that wasn't parchment white, was mottled purple. Apart from her eyes, bright, and frightened, she could have been one of our failures.



The only history, from her niece, was of abdominal pain. Her belly was ice cold to the touch, and firm. I was sure her abdominal wall was rigid, the hallmark of peritonitis, a diffuse inflammation of the lining of their abdominal cavity. This can be caused by many pathologies, all of hem highly undesirable. Intestinal perforation, for example.



I don't wish to blind any of you with science, but having a belly full of shit should be high on people's list of things to avoid happening to them. This woman looked as if she'd been harbouring a belly full of shit all week, and was just about ready to give up the ghost.



To be fair, there was some debate as to why she was so ill, but actually, when you're that sick, the exact cause is, probably, somewhat moot in the initial phase of resuscitation.



Either way, I had now managed to stack up two families, next door to one another, for whom I represented their worst day. Families united in grief, never further apart.

As it happened, the first chap's CT wasn't as bad as I feared, although I worry this will only prevent the inevitable final delivery, and the second showed a belly full of pus, not shit.

Worth trying to keep track of your tampon, it would seem...

Introducing....

Women are... interesting... make of this what you will.

When I first wrote about LBF here, she phoned me up to complain; not unreasonable, you might think, since I hadn't let her know she was going to feature, and some folks don't want their comings and goings splashed on the 'net. However, this is, after all, the ramblings of a grumpy old man, not The New York Times, and mostly anonymous(-ish), so one might argue few people would either see it or recognise her.

So, her entry was removed.

It seems that the only thing worse than being talked about is not being talked about, and LBF now regularly mentions, just in passing that her character has been disappointingly quiet recently.

Now it seems I have to expand her character and provide more back story.

LBF need more companions to keep her company when she's not having adventures with me.

And so I have the pleasure of introducing Schlingo, LBF's comrade in arms. She, too, is a teacher, and lives downstairs from LBF. She teaches younger kids than LBF, and I suspect they both think their job is a little bit harder than the other's.

I think its all basically colouring in shapes.

(This may not be the kind of storyline Schlingo was hoping for...)

Anyway, in case you were thinking Schlingo is a kind of two dimensional charactwer I've invented, to give her depth, it's worth noting she's dating JazzMan, who comes from the 1930s; or 1950s, depending on who you ask. She also once described yet another of LBF's friends as looking like 'an angry blue smartie', and suggested that Susan Boyle looked like a 'haunted tree', proving at a stroke that she has a far greater gift for language and imagery than I could ever hope to.

Anyway, she wanted in to this merry soap opera, so here she is.

Welcome aboard, Schlingo.

Giving It All You've Got

One of Shroom's tricks manifests itself as pessimism. I prefer to think of it as realism, but it's really pessimism.

My reasoning runs thus: many of my patients will be in extremis, and I may well know their fate before they do. Worse, it may be obvious that, no matter what I do, the outcome will be grim.

So I try not to get my hopes up. This is not to say I don't go Full Tilt Kozmic Boogie, where it's apt, but thatI steel myself to the idea that despite it all, they're going to meet their maker.

It just hurts more when you invest a bit of your soul in the belief that they might just be ok.

Maybe this makes me less of a human, but that's how I choose to cope.

For example: a few days ago, a fella arrived, clapped out, with a history that screamed 'ruptured aneurysm'. A man of middling years, with belly-ache suddenly worsening, crashing blood pressure and fluctuating conscious level.

When he arrived, he genuinely was pale as a sheet.

That should tell you, as it did me, that he was only ever going to leave Hospital by the back door.

And yet...

Full Tilt Kozmic Boogie.

And it seemed to be working. His pressure cam up, he woke up, and the surgeons clustered, waiting. A little voice piped up: "Maybe... just maybe..."

But then he got to theatre, and the surgeons volte face-d.

Now, I'm not a vascular knifeman. Never was, so I'm sure the decision was the right one. Of course it was. And I knew he was never going to do, but we'd worked so hard to buff him, and had seemed to be working, so I thought he'd at least get knife to skin.

Somehow, it just seemed harder to take than if he'd never perked up at all.

Still; we tried, and maybe this means I do still have a soul.

Coming Soon...

By popular demand, more on the adventures of LBF, and a new character to grace the soap opera that is Shroom's life.

Moving On...

The written part of my exams have been and gone, and I passed. It feels like an anti-climax, something that ha sbeen weighing heavily on every aspect of my life for almost a year; still, at least, as Colossus put it, I didn't "fuck it up at the first hurdle"

I now have parts 2 and 3 to come, and remian pessimistically sure that I'll fuck oneof them up. Even if I don't, my contract runs out in January, and i really haven't figured out where I want to work next / for the rest of my life yet.

I have also gone full circle, and back to South Coast General, where I started my Specialist Training. The all seem pleased to see me, which makes me wonder what I did right the first time around, and fills me with fear that I can only be a crushing disappointment this time around.

South Coast General is busy. I had forgotten quite how busy. South Coast Teaching was busy, and I had thought the two were comparable.

They aren't.

I'm not sure that it's just numbers; I'm sure that ED footprint size makes a difference. SCG is much smaller, and although they have a brand new Hospital bolted on, beds always seem in short supply. Staffing, although better than when I started, is, I suspect, still inadequate.

Whatever the causes, SCG is busy, and the pressure is, as ever, to meet the targets. It makes me uncomfortable; I really feel that all the patients I see are getting about three quarters the work up they should get, in order to feed to time target monster.

This can't be right; I don't believe it's how it should be, and I think it's only going to get worse.

Good From Afar...

I t has been suggested to me that I should be writing more, and indeed, more about certain subjects; I surely agree that to keep my part in our covenant, dear reader, I should be writing more. Writing under duress, however, worries me; I worry that my output will resemble drivel more than usual. Duress, is probably too strong a word, and I certainly need the prodding.

Well I'll try.

I had something I wanted to pitch about close ups. Real and figurative. La Belle Fille shouldtake particular note that this an example of me thinking out loud in general terms, and not talking about specifics.

I had ben struck by how many things in modern life look very shiny, or nice, or fun, until you see them close up, until you see their faults writ large. Everything, everybody has faults, but I fear modern life conditions us to expect the impossible, that everyting should be blemish-free.

Maybe I'm just disappointed in myself for buying into it.

Once again, this is just aimless generality. I think its important that we should all be aware of that.

Hope I Die Before I Get Old

Awesome bass playing, and stuff explodes. What more could ye want?

Still Revising....

If there's a better version of this song, I don't know of it... I can't find live footage, except of the Altamont version, which is slightly disquieting, as we all know some poor bastard is getting stabbed to death in the background...
Anyway, I commend you especially to the guitarwork from about 3 minutes in; let us glory in the fine work of Richards and Taylor.

Cheers.

P.S The second guitar solo, for those who care, is, I think the better , and Mick Taylor.

The Return of The Music Nazi

For your consideration:

Nina Simone The Essential Nina Simone
Fleetwood Mac Rumours (tho shame on you if you don't already own it...)
Richard & Linda Thompson Shoot Out The Lights
Janis Joplin Pearl - Legacy Edition and The Woodstock Experience
David Bowie The Rise and Fall of Ziggy Stardust...

So When We Meet Again, Introduced As Friends...

Work avoidance.

Or, dangerously close to stream of consciousness thinking.

Swine 'flu continues to rumble on in the background, although it seems this wave has broken. Now, we wait for the second wave in the Autumn.

BBC4 has run a few interesting 'docudramas' recently, one on the Penicillin story, and, more recently, one on the 1918 'Spanish 'flu' outbreak. Well timed to help keep hype levels cranked up to 11. Except that, being on BBC4, I expect most people missed it.

Dr Crippen offers his thoughts on swine 'flu here.

As far as I can see, pandemics are a lose-lose situation for any Government. Either you 'over-react' and close shit down, and nothing much happens (quite possibly because you closed shit down), and everyone gets cross; or, you 'under-react' and people die, and then people get cross.

It's an interesting time to be an health care professional. This 'flu doesn't seem any more virulent than regular 'flu, which makes over-reaction all the more likely. Unlike in 1918, young, fit healthy folks are not dying in their droves. There has been no cytokine storm.

Will there be?

Watch this space.

Is it possible that, in fact, in 1918, the virus was much as it is today, but that a world freshly riven by war presented potential carriers more susceptible to its onslaught? I can't help but fell that society today, for all its fat, wheezy kids, is healthier than 90 years ago.

I guess we'll see in the Autumn and Winter.

What the desire to keep people at arms length has provoked is a concern that we'll get it wrong. Dr C touches on this far better than I could, but let's be honest, you don't need to be a genius to figure out that telephone diagnosis is DANGEROUS. Especially when your criteria are so vague.

I can only assume that someone, somewhere has weighed up the options: the flooding of the health service by ?'flu patients, versus the occasional death by misdiagnosis, and decided that this is the lesser of two evils.

The needs of the many outweigh the needs of the few?

Housekeeping

Sorry, but I'm getting s boring amount of Oriental spam.

So, as far as I can see, it's either no more Anon comments, or Word Verfication. I'm trying the latter. Suggestions, comments (English language only) welcome.

Slainte dear reader, as ever.

Set Adrift

On leave, so not much medicine. La Bell Fille is away, living it up, demonstrating that, yes teachers get beater holidays than doctors, but that they are also better at managing their money than, at least, this doctor.

If I think I'm underpaid, don't get me started on teachers.

Seriously, how important do you think education is?

The amount people pay for 'private' education answers the question.

It's just a shame, as with pay per service health care, that we (the high earners) don't want to pay for everyone to have the good stuff.

Last shift before leave, a night shift I swapped with Giganticus. It was, with a certain degree of inevitability, awful. Had to call the Boss in - first time in years. Multi vehicle pile up. Nothing we couldn't deal with, but the waiting time was going to go to shit, and in the current climate this is, arguably, more important.

So, the unwelcome early morning call.

Only one really sick. The Surgeon, Snowball's husband, a fella I quite like. Even if he is very surgeon. I call him, give him the dope.

27, high velocity RTC, prolonged extrication, a whiter shade of pale, numbers shocky.

I think he should come down.

Can't you get a scan? The question is born partly of modern surgical practice, which seems to start with CT scan, before even history, and partly of his being asleep.

I'm cautious, at first. I suggest he won't get to the scanner, or if he does, he won't make it back. I suggest this is one he really ought to see before the scan.

God love him, he demurs, and appears in the room. He tasks one look at the poor bugger's colour, and his numbers, resolutely resistant to the fluid we're pouring in.

Straight to theatre for this one.

I thought so.

The rest of the night breaks me, and I can barely see straight at the end. I tell myself this must be age, finally catching up on me. I pass H on the way out, my last shiftchange with her, and I'm sorry for it, for she was good, is good at her job, and I enjoyed working with her. I struggle to find a way to express this that doesn't sound either cheesy, a come-on or both.

I mumbled something, undoubtedly inadequate.

Ships that pass, and all that.

Shock boy made it out of theatre, which, sometimes, is as much as you can ask.

Addendum

I'm a little concerned the previous post might not read as i intended. It is not meant as a criticism, but as an attempt to demonstrate that, no matter how hard you work, no matter how good you are, sometimes fate deals you a shit hand, and then takes half your cards away.

That sometimes shit happens, and then happens a bit more, just to rub your nose in it. That when you think it can't get any worse, sometimes, it does.

Anyway, I'm just saying

Be Careful What You Wish For

On minor irritations, and major catastrophe

I know I need a break when I become more irritable than usual; this doesn't take much, to be fair. One of my colleagues, through no fault of their own, has begun to irritate me hugely, and, more or less, whatever they do.

I need a break.

Then everyone started to irritate me.

I need a break.

Last night dragged, dragged on and on. I found myself wishing for something interesting, something... acute. Something to set the adrenaline on edge. Something to set against the seemingly never-ending tide of people who should know better.

People who think they can stroll into my place of work, roundly abuse me for 10 minutes straight, than apologise, and it will all be o.k.

People who really think drinking until they piss themselves and vomit on me doesn't need an apology.

People who don't know how to cope; or worse, don't want to know.

That's what I'm here for, eh?

Sometimes, we get what we wish for, and then you can't take it back.

The call came, almost inevitably, as swine 'flu. And then seizures.

Fitting isn't too bad. We can treat it. So much of what we see, we can't treat, or if we do, it's by accident, or in fact it's you, treating yourself, while we ease your symptoms. One of the things that appealed to me about surgery was that it, occasionally offers real cure. Not pill pushing. This is of course debatable; but I digress.

The point is, acutely, most seizures respond, quickly, to simple drugs. But in the context of an infection, even 'flu, a host of more worrisome prospects rear their heads.

Then it got worse; the call came through, updating us, informing us that the patient had gone into cardiac arrest. Which is awful at the best of times - of which, really there are none - but in a young patient, as this was, it fills me with all the adrenaline I could want.

It doesn't matter how much you prepare, you still have to confront the same thing. The one, unavoidable fact. Soon, a patient will be delivered to you; dumped, unceremoniously on whatever brand of trolley you have. Cold, or cooling; skin waxy and clammy; often there is a blue purple tinge. There is often a leakage of secretions, pumped forth from the mouth and nose, egged on by the chest compressions that strive to keep them alive.

What was once living, breathing, laughing, crying... now is so much mater. And resuscitation almost never works.

Well, we all have to go some time.

Not this young.

He had been fitting for over an hour, unresponsive to meds; a difficult airway, he couldn't be tubed in the field.

And worse, as the Ambos rushed him from the warmth of his home, knowing that his only chance lay at the Hospital, weighed down by the fact that they had done all they could, and it hadn't fucking worked, they slid and slipped into the rain. Chest compressions are hard to do in the dark, and in the rain.

The unthinkable happened. The stretcher, slick with the morning rain, shifted, wheeled, away. How much? I don't know. Not much, but enough. In among all of this, among all the fear, and fitting, the patient slipped off the trolley, and onto the ground.

And after that, he arrested.

We got him back.

Not often, but occasionally. It happens.

And for what? CT showed massive anoxic brain injury, a non-specific swelling of the brain, a blurring of the borders between grey and white matter. Another thing we can't treat

The Ambos were in bits. For a group of folks who have seen it all, and I mean all, this was there worst nightmare.

As it turns out, the bump on his head was the last of his worries.

I cannot conceive what went through these guys' and gals' minds when it happened. For all the jokes, all the frustrations we vent about the patients that annoy us, that tax our patience, they are our charges. We do what we think is right for them; it is not supposed to end like that.

Cold comfort to find out the injury was clinically insignificant. That it was a dreadful accident; that fate was to blame, nothing more or less.

That it was the seizures that did for him, starved him of oxygen, drove him down the dark path...

Be careful what you wish for.

Someone always suffers.

From The Mouths Of Nursing Sisters

One of our patients last night was a classical scholar.

I could tell this because, as he grinned at me in his ethanolic miasma, while my colleague tried to patch up the head injury he sustained falling down drunk, I observe, tatooed across his epigastrium, in a Gothic Calligraphy, the phrase "Homo Sum".

I remarked on this.

'Oh', said Sister, 'I thought it said Homo Simpson!'

Dude, Where Are All My Friends?

In celebration of the Friday Night Drunk...

You, who called an ambulance because you went out drinking and were sick...
You, who wanted an ambulance to take you home again, because you'd spent "all your money" on drink...
You, who'd "hardly had anything", but were slurring your words so badly I couldn't understand you...
Who banged your head on a door, and cried when I took the plaster off...
Who lasted an hour in the bar before shitting yourself...
Who showed no shame in waking up in netty-knickers and a massive nappy...

I salute you all. Your good sense, self awareness and sense of accountability is a credit to us all.

Roll on Saturday

Under Pressure

Shit, as you all know, rolls downhill.

Th more I see of what passes for management in the NHS, the less I like it; everyone seems to have an agenda, and increasingly, it doesn't seem to be about the patient.

The four hour target is a cracking example of this. There are many, or at least some, aspects of this target that are a good thing. Waiting for 16 hours on a trolley is a bad thing. But please don't pretend that a rapid transit through an Emergency Department speeds up your treatment. We're just pushing the wait back one level, so you at least wait on a bed; but you still wait.

Anyway, the pressure is on where Shroom works. The targets are not being met, and we must fix it. What frustrates me is that the management seem to see this as a problem that is just down to us, to the ED. The management seem reluctant to take shared ownership of the situation, although i am reasonably sure they are happy to accept praise when the targets are met.

And so the pressure is applied; I might normally claim to thrive under pressure, and maybe that's true... but right now, there's a bit much for me, and it's beginning to tell.

I had a bad week last week. It happens, but last week was particularly so, and several of my patients were sicker than they looked, sicker than I gave them credit for. And so, I have had to answer for this; once again, the responsibility comes solo, and no-one wants to hear that i felt under pressure to 'move the meat', as it were.

I'm struggling to find the way to deliver the same care in half the time.

Maybe I just need a break.

On Swine Flu

I'm sure most of you will follow the flaming, chaotic bandwagon that is Pandemic Influenza with at least some degree of interest. It seems unfortunate that we are incapable of delaing with such medical stories with any degree of perspective.

It's flu.

I think one of the problems is that most people have never seen, or indeed had, flu. Most people think the common cold id the flu, and so when they get flu, think they're dying.

Yes, there's more of it about, so there are more cases of the complications associated with flu.

It's still flu. A relatively mild, probably quite infectious, viral illness.

And now every bugger with a fever and a cough is being told they have the flu.

I share the slightly anxious feeling some of my medical colleagues have toward the shotgun prescription of tamiflu. And the shotgun diagnosis.

9 million hits per hour on a swine flu advice line. I don't realy understand this. The advice is simple, and well publicised. Go home, stay there, drink plenty of fluids and sweat it out.

Some people aren't happy with this advice apparently. I'm not quite sure what they want. An immediate cure perhaps?

Tough.

And why are we getting our knickers in a twist abou tamiflu, a drug that, at best, seems to reduce symptom duration by 24 hours, out of a 2 week run.

Why bother?

It's flu. Yes, some people die, but rarely healthy people, and there's not an enormous amount we can do.

A few thousand people die from flu, and everyone wants a mask; AIDS is rampant, but no-one wants to wear a condom.

Von Gogh: Genius Or Digitoxic?

There isn't a great deal of connection betwixt title and post.

Again.

I'm currently listening to more Janis Joplin. You should too.

I'm also bricking it at my impending exam; but more of that later.

A few snippets:

Crane Man

A peaceful dayshift was interrupted recently; there is a massive building site outside the ED at present, and it's main 'feature', if you will, is a mahusive crane. Of the sort that moves shit around, not a giant bird, wonder of the natural world, and envy of other flying dudes the world over. The site is well locked up, and it never occurred to us that someone would break in... I can't think why we were so naive.

Crane man took against the world, and decided to make his stand atop the mighty metal edifice; which made conversation difficult, as shouting a hundred feet up into a brisk breeze just isn't conducive for that sort of thing.

Or for spitting at concerned passers-by, but I guess if you have to make a point, you have to make it. For a while I thought it was going to get exciting, Saturday night TV style, but the hostage negotiator never materialised, and as the evening drew in, and the drizzle got steadily heavier, and he got colder, everything fizzled out, and down he came.

For which we were all eternally grateful, especially

Sprite Bottle Man

from whom attention was diverted. SBM had taken it upon himself to add a little fun to bathtime, but became, shall we say, entangled. Despite his best efforts at home with hacksaw, he remained phallus entraptus, and we had to deploy the ring cutter, and an hefty bag of ice thereafter.

Which left us all looking at the neck of a Sprite bottle in rather a different light afterward.

Lastly

Vodka Man

VM was bet by his friends that he couldn't down a bottle of vodka, presumably in one. He won the bet, and shortly afterward found himself a little tipsy; he stumbled and fell, without really sustaining any injury, but this was enough for his worried friends who called the Ambos. At least we think they were worried. The Ambos said the 'friends' were laughing so hard, it was difficult to get an accurate history. They certainly weren't worried enough to come to hospital and sit with, or translate for, VM, who spoke no English; to be fair, he spoke very little of anything once the vodka kicked in. He just sat on his trolley and wept; possibly at the thought of how lucky he was to have such good friends.

On Vaccines... Again

This article at Discover is worth a read.

Hat-tip to Becky.

On Nutrition

RIP MJ

Alternative Medicine

On Perspective

I do have a serious (ish) point to make; but the heat is making me sluggish. Everything seems a bit harder when it's this close and muggy. Even my coffee mocked me this morning - the milk looked good, smelled ok (ish) and, on adding to coffee, seemed good.

Sadly, it tasted like shit.

So, a few days ago, you will have noticed - unless you live in a cave, or are deaf dumb and blind, and spend all your days playing pinball - someone famous died.

Well, two, really. Farrah Fawcett, and Michael Jackson both shuffled off this mortal coil. On La Belle Fille's birthday, as it happens, but I'm sure that was a coincidence. Farrah's death slipped by me un-noticed. Not entirely surprising, as her people have no real reason to keep me in the loop.

Jacko, on the other hand, was a different matter altogether.

I was working lates. Unintentionally late, as it went. I thought I was on till two, so turned up at 6, only to discover I was on till midnight, and should have been on at 4. Still... I think if I hadn't been working, I'd have missed it. But nowadays the concept of a 'scoop' news story is obsolete. I still recall films where reporters at a Courtroom, for example, all rush to the bank of PayPhones (remember them?) to try and be the first to get the story back.

Now - the story, whatever it may be, is flashed across the globe at the speed of light. The internet has made us all neighbours.

But there's still an odd feeling when something is breaking. The news began as a sort of ripple, word of mouth. People whispering, asking 'Have you heard...?' (which sounded like it ought to be a joke, and soon was...)

I was in resus, with a patient who had collapsed at home. Fitted, stopped breathing, tubed without drugs, still not responding an hour later, BP steadily climbing...

I didn't need the CT to tell me what had happened, but we have to get it anyway; it showed, as I knew it would an huge, catastrophic mass of blood in his head. Unsalvageable, unsurviveable... there's no way to put it that doesn't sound awful.

What follows, what I hate doing, is the telling of the family. Then what's worse is pulling the tube. Until that moment, he looks as if the vestiges of life are still there. His chest is rising and falling, in time with the wheezing of the vent, and he's warm.

But I have to pull the tube, and I know he won't breath by himself. I only hope he won't choke as I do it, only hope that his reflexes have gone, to save him the final indignity.

His family gather around him as his heart beats his last.

Later, after the paperwork is done, and after I have seen confirmation that Michael Jackson has gone just as suddenly, the family seek me out to thank me; I look from them, who seem shocked and unsure of what they'll do next, as they walk slowly out into the night, to the pictures on the computer screen, of hundreds of folks outside UCLA (or wherever it was).

I'm sure there's a meaningful comparison here, if only I could find it.