Sunday, July 26, 2009

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.

Saturday, July 25, 2009

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.

Friday, July 24, 2009

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?


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.

Wednesday, July 15, 2009

Von Gogh: Genius Or Digitoxic?

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


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.


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