Thursday, November 26, 2009


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...

Tuesday, November 24, 2009


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.


I fucking passed.

Take that world.

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

Thank Christ.

Thursday, November 19, 2009

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.


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.


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?


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?

Wednesday, November 18, 2009

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?

Tuesday, November 17, 2009


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

Monday, November 16, 2009

Supergroup - Bass

John Paul Jones?

Or John Entwistle?

Bass break at 2:50...

Saturday, November 14, 2009

Friday, November 13, 2009

Supergroup - Brass

The Miami Horns

Esp. from 3:16

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

Thursday, November 12, 2009

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...

Wednesday, November 11, 2009

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...

Tuesday, November 10, 2009

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?

Monday, November 09, 2009

Supergroup - Sax

One, or both, from two.

King Curtis

David Sanborn

Sunday, November 08, 2009

Supergroup - Piano

Again, no contest.

Billy Preston.

Quick view at 1m 20s.

Saturday, November 07, 2009

Supergroup - Organ

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

Steve Winwood. No contest.

Friday, November 06, 2009

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.


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.


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.

Thursday, November 05, 2009

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.

Wednesday, November 04, 2009

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

Tuesday, November 03, 2009

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....

Monday, November 02, 2009

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

Sunday, November 01, 2009

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.