Monday, June 29, 2009

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 But nowadays the concept of a 'scoop' news story is obsolete.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.

A Monkey's Wedding

La Belle Fille's birthday has come and gone again. Having a Summer birfday affords her the luxury of celebrating with a picnic in the park. This was, despite my sour mood brought on by the Rugby, was a grand day.

One of her friends, who shall remain nameless, provided the moment of the day, when opening a bottle of Cava; the cork erupted, unbidden, which is always a slightly worrying sign, but she then committed the ultimate schoolgirl error by glancing down, whence the cork had come, to be greeted, a split second later by the volcanic discharge of Cava.

It's hard to convey quite how funny this was, although the consensus was that she dealt with it pretty well, because it was, as LBF put it 'pretty embarrassing'.

Things That Made Me Smile

Recently discovered that Jose, one of my juniors studied very small ants as part of her journey into medicine. I'm not enormously bothered by ants per se, but there's just something about this that is immensely pleasing.

Take it or leave it.

On a more sour note, the British and Irish Lions lost their series against the SpringBoks this weekend. I've got a 101 reasons why they didn't deserve to, but that just makes me sound even whinier than usual, and as a Brit, I don't need a great deal of help doing this.

Couldn't Think Of A Clever Title

I ought to spend more time keeping up with literature than I do; at least if I was going to waste my time, I ought to do it reading around medical stuff. Or, I could just get a life, I suppose.

Anyway, the point of all this drivel is that among my MedBlogging colleagues there has been some warring of words. Point and Counterpoint. I sometimes wish my blogging would generate some outrage. However, I just don't think I'm literate enough, or, more importantly, have a big enough readership.

I'm not sure if these little spats have always been there, but they seem more prevalent to me; maybe it's the weather?

Controversy, per se, has always been rife in medicine, and you might say it brings progress, or at least holds hands with progress.

Anyway: here's a nice summary of the latest outbreak.

I would also commend you to both the blogs concerned. Nurse K is worth a read, as, I think, is Happy. Nurse K and Scalpel have been sparring a little, too. Do the decent thing. Read and think about it.

Strong opinions will always provoke strong reactions; that doesn't make them any less valid. For what it's worth, I'd be happy for any of these practitioners to look after me in my time of need. Tho given there all from America, I might not be able to afford it.


Sunday, June 21, 2009

Swine Fever

Contains Nudity. You've been warned...

'So, we've asked the Police to pop round and see you. O.K?'

There are few, if any, times a body will be pleased to hear that. I suppose if you're being forcibly pillaged, you'd be glad of the presence of Her Majesty's Constabulary. But I'd cautiously suggest they wouldn't be 'popping' round under those inauspicious circumstances.

Anyway, how did we end up here?

The BatPhone trilled away; the call slightly unusual. 'Young male, GCS 3, ?swine flu'

For those less in the know, 'swine flu' is the current strain, H1A1, of pandemic influenza. Complex protocols exist for it's management, and more importantly containment. These are hard to enforce when your patient is critically ill. The GCS, or Glasgow Coma Score, measures one's conscious level; 3 is the lowest. It is safe to say GCS 3 suggests critical illness.

The history we had been provided with offered few clues, but more details were forthcoming. It transpired our patient had collapsed in a shop. He had popped in the previous day to brighten the tedium of the checkout girls and boys by proclaiming to all and sundry that he had swine 'flu.

And then leaving.

Today, he had gone one better, striding manfully into the shop, stark, bollock naked.

Skyclad, if you will, possibly in honour of the Solstice.

Nudity is always funny; fact.

Sometimes, not for the reasons you think it is, but it's always funny.

Random nudity is usually enough to create a talking point. Or stop conversation. It gathers a crowd, anyway. Occasionally stops traffic. A well endowed female patient of mine once fled my care, for fear of the Military Police, clad only in a tiny thong. Several taxi drivers stooped at the ED, all asking 'guess what I just saw', all disappointed when I guessed...

In this case, onlookers assembled, and our our Nude Ranger coughed heartily on them all, then passed out in a small pile of his own vomit.

Matron and I met him in the Ambulance; the crew were masked up, and had little more to offer. The decision we had to make was how ill he really was, and might he really have flu. Of any sort.

Our initial assessment was promising: it's hard to explain, but there's GCS 3, and then there's GCS 3; one really is coma'd; the other... you get the feeling that they just don't want to respond. The rest of his obs were normal, and he looked well... just... sleepin', sorta.

A little 'gentle' pressure to the nail bed, to establish his response to painful stimulus, one of the components of the GCS, transformed him from 'flu-coma' man, to angry confused man. A startled naked man with a sore finger sprang, like a 21st Century Lazarus, straining against the restraints designed to stop him falling off the trolley en route.

He launched into what I have come toi think of as the waking coma victim's litany:


'Fuck off! Fuck. Fuck, FUCK!'

'FUUuuuuckK OFF!'

'FUUU... Hey, where are my fucking pants?!?'

This erudite conversation dealt with, and reassured that he was no longer in coma, we tried to find out what had brought him, in all his pink glory, to our humble establishment.

Unfortunately, he was trying to figure this out, too.

Waking up, to find a pasty man in green scrubs crushing your finger, and two Ambos in masks leaning over you is not well designed to reset your normality.

He wouldn't fess up to any illicit activity (they never do; I suspect they think we'll shop them), and was confused as to his whereabouts; and the whereabouts of his pants.

He eventually coughed to having smoked some weed that morning, but was sure this had had nothing to do with him proudly patrolling the high street, playing willy banjo and passing out.

In case he had ingested something else, we decided to call his girlfriend.

She was also in, shall we say, an advanced state of refreshment; highly relaxed. More to the point, unable to offer any coherent sentences that might aid in our quest to guess the drug. In fact, she was convinced he was still in the house with her. It was this, slightly frustrating, slightly circular conversation that prompted Matron to suggest we'd send Plod round to talk to her face to face.

Now, I respect the kind of fella who decides he's going to spend Sunday getting ripped to the tits on drink and drugs; indeed, it takes a real effort to get so banjaxed that you tear all your clothes off, and bestride the High Street with your balls swinging back and forth by ten in the morning. But I'd rather you didn't bring it to where I work.

I did feel slightly sorry for his lassy tho'. After being called because a loved one has died, I imagine she enjoyed the prospect of the Boys in Blue at her doorstep less than most.

Thursday, June 04, 2009

Que Sera Sera

We all waited, out front. When I worked in London, we used to wait for the Ambos most of the time, but we don't seem to do it so much here. Maybe just when we think it really maters.

The weather struck an odd balance; it was glorious, warm air, cool, crisp skies. Quiet, while we waited. Everyone's faces around me very serious, very drawn; I wondered if I looked like that. Too much thinking in the quiet time might drive you mad; fortunately, we don't have long.

We hear them first, and that's never a good sign; usually the sirens go off as they roll up the ramp; if it's proper bad, they stay on blues and twos until the last minute...

The door opens, more or less on the fly, and they're asking for help in back; this is also bad - the Ambos never ask for help - they don't need to.

I jumped in, and did what I could, which wasn't much really, just be another pair of hands, share in the anxiety; a problem shared, if you will.

We whipped into resus, only briefly held up by me having my foot trapped under the hydraulic 'lift' the Ambos use to offload trolleys - that's what happens when you get in the way.

Resus is a blur; bodies everywhere, and we try to focus. Lots of punters 'helping' is nice enough, as long as you don't get in the way. There's a bit of flail, but we find our way, find our rhythm, and soon the situation is being run smoothly. Or as smoothly as it can be. We're all on edge...

He's a big, and that makes life difficult - we're told he's asthmatic, so he gets his chest needled, and followed with tubes. We do everything we can, as if our sense of urgency will be felt by the patient, or maybe by God, and translated into tangible results.

But he's been down a long time. A long time, and we know what that means; we all glance at each other, but no-one wants to say it. My boss doesn't want to, but she knows someone has to, she has the courage, and is steeling herself, when the patient makes it moot; his heart coughs and splutters back to life.

I think we're all a bit taken aback, maybe too tired to be pleased, yet.

The drill continues, and he gets packaged up for the Unit.

I turn away, leave the room, have no more to offer.

I need space; sometimes it's best to do your grieving alone.

He was, he is, for now, four years old.

Wednesday, June 03, 2009

Tarred And Feathered

Every once and a while, I get sucked into debate about the pros and cons of the NHS; I shouldn't really, as I never quite acquit myself in the way I intend, and it upsets me.

I always seem to end up with an 'intent/perception mismatch'

What I find frustrating, tho I suspect we all do it, is the way in which people seem to generalise, and inevitably about their BAD experiences; maybe it's because they really are all bad.

Such debates seem to go along the lines of: ' I had a bad experience on the NHS, thus it is a bad system, and doctors in general are shit / wankers / a waste of time '

One would think that there would be a way to refute this without coming acxross like an arse.

I have not found it.

More than once, it has been suggested to me, directly or indirectly, that my bedside manner is lacking in those qualities desirable in a manner designed to be deployed at the bedside. Curiously, it is usually in a situation far removed from any part of beds, sides or otherwise. Once, it was over a game of pool.

Such complaints from my actual patients have been rare. I think they number four in the last eleven years / 30 - odd thousand patients. And no, I don't think that's because they're all dead.

Yes, the NHS is an imperfect system; but I happen to think it does some things very well - accident management being one of them, which I also think represents good value for money. (Controversially, I also think Drs wages represent good VFM, especially when compared to e.g Barristers who said they couldn't afford to take on legal aid cases for £91/hr)

There are many faults, there are bad doctors, but most of us work bloody hard, and try to do the best we can. (Small violins playing just for Shroom can be put away now)

For those who will always find fault ('...what about MRSA, then? Penicillin-monkeys, not part of the solution = part of the problem...'), I'm sure you're right. We could always do better; I think the same could be said about anybody, in any job.

That's not the same as always doing badly, I hope.

For everyone who's waited too long on a waiting list, there's someone who's life was saved with PCI - or some other shit.

Is it enough to balance one man's poor service with another's good?

I guess not, but ndon't assume it's cos we don't care or aren't trying.

//Autologous autosplenectomy ends

In The Presence Of Greatness

I have just met Superman.

Or at least someone claiming to be him; I was having an innocent conversation with Hozza outside Resus, and he appeared, a propos of nothing, in a cloud of ethanolic miasma.

Reflecting, his smell may have arrived before him. His opening gambit was to tell me about his X-ray levels, and how high they were; maybe this passes for a chat up line in Superland. He then asked for more. I'm not sure why you'd need, or want a top up, but maybe they keep him going.

When I suggested this might not be a good idea, he let slip his secret, introducing himself as Superman. I have to say, ol' Supe has let himself go a bit, and turned to the fucked side a little... he initially found my confusion hilarious, then, inevitably, offensive; he was on his way to explaining how he might have to kill me, when he was distracted by the good Dr Jackets, who placated him by offering him a chair.

I can't help but feel I should have asked for an autograph...