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

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(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.