Bleak, Bleak, Bleak.... Happy

Another flying visit to La Belle Fille.

We went to see The Road, an unremittingly bleak piece, until the very end. I haven't read the book, but can't help but wonder if the (admittedly only slightly) upbeat ending was influenced by Hollywood.

Or am I just too cynical?

Trust Me...

Trust is a difficult concept. It should have to be earned, and yet I find myself in the position of having assumed trust.

Maybe you don't trust me; why should you, you don't know me? But when yo are ill, when you roll into my ED, you have to take my opinion and advice at face value, and accept that I believe what I am doing is the right thing, that I have weighed up the pros and cons, and made a rational decision on your behalf.

Most people do. Doctors are supposed to be trustworthy; and yet...

One bad apple, and suddenly we are all in the spotlight. Either because he or she was one of us, or because we are acting to silence the prophet, the truthspeaker, who would pull the wool from your eyes.

That's fine. I don't ask that you simply accept what I tell you at face value; I'll give you the options as I see them, and let you make the decision.

What do I know, anyway?

Shameful

Andrew Wakefield.

A disgrace, a charlatan, a mountebanc, a flim-flam artist of the worst kind.

Did he think he was doing the right thing? Does he believe so?

I hope so. History is littered with trail blazers who had to endure the taunts of the establishment, or worse. Maybe he groups himself with those folks.

He certainly has an army of followers who will never believe the worst of him, because they want to believe what he says is true.

But no further research supports his theory; to continue accepting it is a question of faith, faith on a massive scale, and it requires that you accept what he did to children under false pretences was worth it.

I don't, and shame on you if you do.

Maybe there is a massive, worldwide conspiracy that I am, unwittingly, or maybe willingly, part of.

Are you happy that this man had needles stuck into the spinal columns of children for interests' sake? That h paid for blood samples at a child's birthday party? That he never declared his conflict of interest?

Is this how you do business?

Shame on you.

"...Had The Pope And I Not Been Out On The Razz..."

I left the previous post in situ, tho I'm not sure it says very much, except that I am grumpy; and not firing on all cylinders, not at m best.

Off game enough to recuse myself from work? I don't think so. I hope not.

In the aftermath of the Wakefield trial, I want to write something about trust, but it will have to wait.

I'm too tired.

Instead, a teaser from today.

One increasingly finds that the junior staff to whom I refer fail to grasp the point when I'm referring someone I think is really unwell. Unless, of course I use the phrase 'really unwell'. Which I don't like too, unless I really have too.

So, tonight, a poor unfortunate arrived in he ED quite literally spitting blood. He had had his tonsils removed a few days previously, and in considerable pain since... until this evening when the pain suddenly ceased. Unfortunately, this relief coincided with torrential bleeding, presumably from the wound. For those not in the know, the tonsils are anatomically very close to the carotid artery. Bleeding from the tonsillar bed can be catastrophic, not only in its volume, but because its location compromises the airway, and makes it difficult to apply Shroom's Blunt Haemostat. (That is, press on it)

As he rolled in, I was on the phone, pre-warning the ENT SHO of his arrival. When he rolled through the doors, he had two vomit bowl on his lap, brimming with congealing blood, and a steady flow of clots was joining them. I relayed this information to my colleague on the phone, and explained that i thought she and her registrar might want to come see this guy.

She asked a few vital questions (what was his full name, date of birth, that sort of thing), and then casually told me that she and her Reg were reviewing a patient on the ward, and would make their way down when they could.

I told her that was fine, but made her promise to tell her Reg what I'd told her before they went on their ward round, and let him make the decision about which patient was more important.

He was out of breath when they hit the door, two minutes later.

Next stop, theatres.

Anger Management

I occasionally have issues with my temper; this mostly manifests itself in the form of sweary ranting. I returned to work on Monday after a week off, following my last exciting night wherein there was a catastrophic breakdown of the the therapeutic relationship.

This led to an assault on my person, and some inconvenience to my life in general, and has not pre-disposed me to feel good about my fellow humans. Which is unfair. I had a disagreement with one individual, not everyone; but I have found myself more grumpy than usual.

While I feel happy that I have dealt with how I feel about last week's incident, it seems that my subconscious may disagree. I capped my day off by performing a substandard manipulation on a distal radius fracture, requiring me to ask for assistance from the Orthopods; I was then fortunate to meet possibly the rudest Orthopod I have ever come across.

Which is saying something.

I realise it's not fun for them to have to remanipulate a fracture I should have done better with, but surely everyone has an off day?

Or maybe, just maybe I'm being a bit over-sensitive and grumpy.

High Days And Holidays

Spent the weekend feeling a bit sorry for myself, while trying to have fun with LBF. Sick role avoidance. She had schoolwork to do - for those of you that think teachers have it easy, don't forget the marking. Oh, the humanity.

Anyway, worksheets planned, books checked, we deployed to the supermarket where I fulfilled my stereotype by grumbling and generally acting like a 2 year old. LBF was very tolerant, as usual.

We then whiled away a few happy hours watching a programme called 'Watch Me Showing Off', or 'If I Bend Over You Can See What I Had For Breakfast', or something. There was dancing in it, anyway, but I lost the thread when one of the first dancers elected to wear a pair of hotpants so small they barely deserved the name.

Then Schlingo appeared, just in time for a new horror of a dating programme on ITV, unleashing a volley of commentary so sharply honest regarding the contestants, I was in danger of soiling myself laughing.

And then to pub. Beer was drunk, and I didn't vomit, which you'd normally think ought not to count as an achievement, but the Quad-Cocktail I'm on makes it a bit more challenging. I briefly tried my hand at limbo, but aren't as good at it as I remember. Go figure.

Sadly, at the end of the evening, there was no chicken. Although considering the relationship I have with my gut at the mo', this may have been for the best.

The next day was LBF's Poppa's birthday. A grand spread, much laughter. Good time had by all. LBF was moderately put out, when I suggested she likes the art of conversation. The spark for this perhaps unwise observation was her unleashing a comment, a propos of nothing, about her mum vomiting on her dad. She took slightly against me when I passed comment, remarking that we spent many comfortable silences together.

'Only', quipped I, 'when you're asleep'

While this was not massively popular on the LBF side of the car, my point was slightly proven when, on the return journey, she tried for comfortable silence, and fell asleep.

She may just be perfect.

Wounds and The Wounded

The first, on my upper arm, sort of looks like a love bite, doesn't it. Which is ironic.

The second, demonstrating how far between the seventh and eighth ribs a pair of scissors had been inserted. The patient wept when I told her I couldn't give her i.v morphine, which I found telling regarding her motivation for (repeatedly) sticking herself.

End Of Life Care

A few days ago, a British jury found 57 year old Frances Inglis guilty of murder.

Her case is at once both simple and complex. That she carried out a pre-meditated attempt to kill her son can be in no doubt. She used a fale name to gain access to him (having tried this once before), carried two syringes loaded with heroin which she is said to have injected him with, barricaded the door, and glued the lock shut.

So by the law of the land, this is murder. She killed her own son. She had tried and failed before, she knew exactly what she was doing, and that it was wrong.

Her son, Thomas, was resident in a long term care facility, I believe, having been in a persistant vegitative state since sustaining a head injury jumping out of an ambulance.

She felt keeping him alive was crueller than killing him, declining to believe there was any chance of meaningful recovery.

Should this be considered murder?

Well, that's how the law stands, and as medics, we don't take life. But we're also supposed to alleviate suffering.

In my experience, while a few, very few, patients like Thomas g on to make some degree of recovery, they're never the way they were.

Should we be keeping them alive? Would we have done if he were 90?

I'm not sure I'd want to go on like that, but we can never know what Thomas wanted. And allowing exceptions, however reasonable they seem to be, surely paves the way for 'less' scrupulous 'mercy killings'?

I don't know, but I do believe that taking the law into your own hands isn't the answer. If you feel that's what you have to do, have the full courage of your convictions, like Mrs Inglis, and be prepared for the jail time.

Not There Any More

I was saddened to hear of the death, late last year, of one of my first bosses. Read his obit here.

'Smoking' Joe Cahill was a good man to work with. He achieved a great deal, and mixed with many of the great and good. But, more than that, so much more than that, he was a good surgeon, good teacher, good boss.

He will be sadly missed.

(I don't know why we called him 'Smoking' Joe, as, as far as I know, he never smoked)

Sick Role

I'm not going to teach you very much about sickness behaviour here. There's plenty written by wiser and cleverer folks than I. Try Susan Sontag.

Anyway, as I understand it, and remember that it will actually be considerably more complex than this, the sick role is a sort of contract between individual and society. It identifies the unwell and allows us to treat them aptly, both in making allowances, and in preventing the spread of contagion.

Different people and different cultures have different ideas of what the sick role means. Some people delight in having the way they feel medicalised, so that they have both an explanation, and, if you're a bit cynical, an excuse to act in a certain way.

When I first qualified, the NHS in which I worked had very clear ideas as to what the sick role was. Either you're in hospital, or you're in hospital. This attitude has changed, not only because we're much more touchy-feely these days, but also with a realisation that we could be making others ill.

I don't like being ill, like most men.

In eleven years, I have taken one clinical day off sick. Mostly because I've been lucky enough not to be ill, but also because I resent having to cover for people who are ill, so don't wish to inflict the same inconvenience on others.

However, the last few days have seen me 'forcibly' signed off. And it appears, it doesn't take much for me to slide into the sick role, moping about and generally doing nothing. It's a bit too easy.

So, I'm on a mission to get my shit together. While it's true I don't feel 100%, I've got to stop wallowing.

Wish me luck

The Quiet Darkness

I find myself trapped, so to speak, at home. I am due to be working nights, but have been released from my burden. Surprisingly, I am not happy about this.

Imagine the following,if you will; a young man is brought to your ED, having been discovered unconscious, barely breathing. It is believed he has taken a drug overdose; he is suspected of having certain other medical problems.

On his arrival, he is awake, but raving. He seems incapable of conversation, sensible or otherwise. He is having to be restrained by security staff.

A decision has to be made. He clearly doesn't want to be here, and is making very clear efforts to resist assessment in the ED. Does one say 'fair enough', and let him go, free to wander where he pleases? What if hurts himself? Interferes with other patients? What if something else is wrong with him? If he is on drugs, are they wearing off?

What if his medical condition is one that might inflict itself on you?

So, if he continues to rage, but is only going to hurt himself, perhaps he should be left to get on with it, and the pieces picked up afterward?

Maybe; there will always be at least two ways to handle a situation. The way you did, and a better way, viewed from the future.

Another blogger wrote about the treatment of 'bad' people. 'Bad' is clearly objective, and I've always believed we are not paid to make moral judgements about people. And we shouldn't.

When do we put our own safety above that of our patients? What price the duty of care?

Clearly the above is all entirely hypothetical, and on an entirely unrelated note, I have to take some time off work, and, coincidentally, some fairly unpleasant drugs.

Is It, Like, Out Of It's Socket And Stuff?

Yes.

Hard At Work

It is my wont, being a sarcastic bastard, to mock my colleagues protestations of being busy. It's not that I don't believe them. I'm sure they are busy. It's just that they occasionally deploy the phrase with a subtle undercurrent, as if to imply that we aren't.

"It's not as if", I will frequently mutter, "we're sat around with our feet up, smoking cigars and drinking port..."

Well, it turns out, occasionally we are...

Lazy Sunday Afternoons

So, after agreeing to work Saturday, then quietly grumbling about it under my breath, like a passive aggressive chimp, I tripped up to La Maison Belle Fille. I wasn't much use Saturday evening, barely able to stay awake for dinner, and frankly I'm not sure I was much better Sunday, but at least it was more fun.

We schlepped down to a local pub for lunchtime, to sample their sandwiches, which LBF had described as 'amazing', a term she is fond of. They weren't bad after all, but I'm not sure they were amazing. Still, one man's meat, and all that...

We picked up Schlingo on the way. She is always good company, being as prone as I am to outbursts of rage, and not afraid to speak her mind, which I respect greatly. Which made it all the more amusing when a phone call from her boss spooked her into accidentally answering the phone, then hiding it in her bag.

Ensconced in the pub, we turned our attention to the serious matter of the day: a game of Scrabble. The girls are Scrabble geniuses (genii?) so I tried to put them off by flooding the pub with smoke from the wood burning stove; on reflection this was always doomed to failure, and didn't endear me to the rest of the pub's denizens.

We were also joined by JazzMan, whom I like very much, tho' his and Schlingo's relationship is more complex than it should be, which is a shame.

Predictably, Scrabble was won by Schlingo, with LBF in close second, and Jazz and I bringing up the rear. Schlingo was gracious in victory, a fact I forgot when getting a question right during a game of Trivial Pursuit. It turns out no-one else like my 'victory dance'

Smug dance notwithstanding, a good time seemed to be had by all, although I probably drank a bit too much Guinness.

Ah, well; here's to more Sundays by the fire, with me struggling to make the word 'Cat'.

Stressors

I'm about to start a series of nights; I once again hope for some interesting tales to fill these pages. They may just be my last set of nights, too, so I'd better make the most of them. I should, in the next few weeks, evolve from Registrar to Consultant. (Attending, I think, in the language of my North American cousins)

it is what I have trained and worked for, for all these sodding years. I have sat numerous exams, and slowly seen my mind rareify to the exclusion of all else.

This transition, especially the final passing of my Fellowship exams, should have brought my stress levels down. And those of La Belle Fille. But that hasn't quite happened yet. I guess the effects haven't quite kicked in yet. Or, in the grand way of yin and yang, as my job stress goes down, so La Belle Fille's goes up.

Teaching is a thankless enough task at the best of times, but it seems that at LBF's institution, the grand strategy is to wring as much from your teachers as you can. It isn't enough to have them become good at teaching. They must continue to be good at teaching and absorb any amount of extra-work, curricular and extra-curricular. The parallels between hers and my job are fairly plain. To me, anyway.

But it makes it hard. LBF knows what is expected of her, but has the temerity to want a life outside the school, whereas the school seems to want to syphon all the life out of her.

Is it just her? I think not. Many teachers seem to pull long hours, far in contrast to the stereotypical idea we have of the short hours, and long holidays. Confusing the pupil with te teacher, it would seem.

I'm sure there are plenty of polymaths out there capable of handling all of this, and plenty of folks prepared to dedicate their every waking hour to what they do. I suspect many professions depend on people like that.

But shouldn't there be room for people who just want t be good at what they do?

Snow Memories

Holding The Hot Potato

Being the right man, or woman, in the right place, at the right time... sometimes isn't a good thing.

When Shroom did a brief stint as a Plastic Surgeon, we rotated the days on call on a weekly basis, and the nights nightly. So this meant one week in 5 was pretty Hellish, but that the others allowed for concentrating on elective work, on learning.

But, if you'd just done the day on call and the night guy didn't show... well you were holding the bleep. Right person, right place, etc. No-one really tried very hard to find alternate cover, and damn the fact that it meant you pulling a day-night-day 36 hour shift.

I came in early today to cover a colleague's illness. Internal Cover. A stroke of genius by the NHS. The first thing Ol' Bosso said to me when he saw me concerned the fact that Ill Colleague was due on the weekend as well... he was quick to add that he wasn't telling me this to nudge me in the direction of covering... but: right man, right place.

I was supposed to see LBF this weekend, but not till Saturday arvo, so work can only rob us of a few hours this time.

And, at least this time I'm getting paid for carrying the potato.

(Actually, since I'm only doing Saturday, it's only half a potato really)

Harder Than It Looks

Blogging every day. I'm managing to keep up with running (almost) every day - I get a rest day per week, but struggling to find something to write here. So, while I'm thinking, here's another musical interlude. A version of Let It Be, with both album version and single version guitar solos overdubbed together.

See what you think.

Post Nights (2)

And... Now I'm bastard awake...

Post Nights

Been asleep, sorry.

Missed It (2)

A healthy dose of schadenfreude.

A patient with end stage COPD rolled in. She also had a pulmonary malignancy, for good measure. The usual story - gradual deterioration, struggle to manage at home, sudden failure and collapse.

The Ambos reported low sats, recovering with hi-flow oxygen, but a fall in GCS concomitantly.

We see this a lot. I raised my eyebrows, ran the ABG. Acidotic, pCO2 15, pO2 15; both too high, too much O2. Turning it down, we aim for sats in the raange 88-92. Air entry thru the chest is poor, tight. I put it down to COPD, rack up the nebs, quietly confident.

We'll have her up and running in no time.

10 minutes later, I'm wrong. She's gone downhill fast; cyanosed, moribund, circling the drain. Fortunately, the X-Ray fairies have just been, and I gaze at the film.

Pneumothorax.

We know it happens, know they're more common in these guys.

Still missed it.

Still: gives us something to aim at.

Chest tube slides in, a slightly hurried, messy affair, but I hear the air rush out, and five minutes later, the patient feels well enough to complain about the pain in her chest.

I have never been so glad to hear a complaint voiced.

Must try harder next time.

Missed It

A lot of what we do is pattern recognition. With experience, our diagnostic process moves from the 'scattergun' approach to the focussed, guided by the signs, subtle or obvious.

Often, we rely on bypassing a lot of 'routine' or standard investigation, if the pattern before us stands out strongly enough. Sometimes the pattern shouts at you. An 'end-of-the-bed' diagnosis.

Of course, not all disease choses to present that way. Sometimes the obvious is not what it appears, and sometimes, perhaps often, the presentation is atypical.

Sometimes it's not.

A young man with a few week history of general malaise. Tired, weak, off his food, weight loss. Even a dose of oral thrush. Three days before, he had taken to his bed, nauseated, vomiting, listless.

He lay on the bed, looking like nothing more than a survivor of Bergen-Belsen. Like cancer, like AIDS.

His eyes were sunken, his tongue dry and sticking to his mouth, his respirations deep, and sighing. Pulse weak, thready and racing.

he'd seen his GP at some stae in his illness. It must have been at the beginning, because no-one cpould pass this off as anything else.

I aked the only question that needed asking. His blood sugar was 52 mmol/dl. He has diabetes, until now undiagnosed, and had drifted slowly into keto-acidosis.

There is satisfaction in even this most simple of diagnoses.

Dedication

"I don't care what it's made of, I'm tagging it..."

Night Fever

Night shifts upon us again; so far, so unbusy. The bulk of our work has come from people slipping in the ice. I briefly debated with Pa Shroom the chances of people curtailing their usual Friday activities (getting drunk, starting fights) in view of the inclement weather.

He thought they might.

They didn't.

I admire that aspect of British resolve; the locals are in no way going to modify their behaviour based on environmenta concerns. Beer exists to be drunk, spouses punched; the big difference is that they then fall over and break something, or, occasionally, freeze to death.

Happy Days.

A Sense Of Humour

Zombie Apocalypse

More evidence, if any were needed, that Great Britain can't cope with snow. And, latterly, that every time I agree to swap shifts with someone, it goes tits up...

Tuesday, two days ago, I should have been on a day off, but had agreed to cover a shift for a colleague. It was the swing shift, 4pm until 1am.

By just after 6 it was snowing pretty heavily, but didn't seem to be settling. By about 8 it was lying thick on the ground, and the flail had begun. Cars were getting jammed on the roads, big and small, and even the Ambos were getting trapped. It rapidly became apparent that no-one who couldn't walk home was getting home.

This clearly included me.

The only upside being that if we couldn't get out, no-one could get in. Ambulances couldn't even back into the Bay, a distance of some 10 feet, up a risible slope, and for a while we either unloaded patients in the road, or relied on 4x4s pulling the Ambos into place.

Just when I thought it couldn't get worse, we ran out of food. Management did their bit and pitched in with a plate of sandwiches. Fortunately, saner minds prevailed and we ordered in pizza...

And then... the power went out. We were, I'm told, struck by lightening. Twice. All the lights went out on majors, and it was all very M*A*S*H - medicine by torchlight. It was at about this moment I was expecting the zombie apocalypse, but the only pallid figures wandering the corridors were the staff.

A few rooms were cleared, and we all bedded down. This was not the sexy night-time hospital orgy it might have been if my life were a film, or if I were not blessed with LBF.

The next day wasn't much better, although numbers were still down, and at least after a double shift the roads had been cleared enough to get me home.

It's still pretty icy out there, and we, as a country still don't really know what to do about it, so the upcoming weekend nights should be a giggle.

SnowDay

I have been snowed in at work... Preparing for double shift which will become triple, if folks can't make it in tomorrow... And the hospital has been struck by lightening; So no power. And, I wasn't even on today, but covering for a colleague...

Full details to follow

Short and Boring

About to deploy for work; it is brass monkey cold... not sure I'll have a chance again to update to day, so there's just this.

My NikePlus gear, at least on my iPhone is now working. Frustratingly, I don't know why this is, so can't figure out what was wrong before.

Sometimes I hate being part-Luddite.

Tales of derring-do to folow, I hope

The Flail

An unremarkable day at work; started quiet, busied up. The usual. A couple of ectopics being shown round the Dept by one of the Bosses; not sure who they were, or what they do, but I suspect some form of management involvement - another attempt to streamline the Dept, ignoring the bleeding obvious: that we need more space and staff.

At home, my NikePlus kit continues to frustrate me; since my first sensor went dead and I changed it for another, iTunes now seems incapable of linking with NikePlus, refusing me the ability to log my pathetic attempts at running.

I know it's petty, but I need the visual record of what I've managed to help motivate me.

Ah, it's a hard life.

Still no ciggies, btw.

Giving Up

I'm trying to give up smoking, again; I don't really want to, but know I should. So I'll probably fail... but we'll see.

It's strange what we will give up, and what we won't, and our reasons behind it. We all make sacrifices of one type or another, and sometimes, I suppose I can't be alone in this, look back and wonder if it was all worthwhile. Have other people made the same choices as I have? Have they had too? Or did they just make better ones?

I don't know. I know how I have justified the choices I have made to myself, and they always made sense at the time, but sometimes, in the dark, alone, 10 years down the line... I'm not so sure.

Morecheerfully, had a grand old dinne with LBF last night, and managed not to act like a twat. The next big choices to make will have to be made together, which represents a departure for me.

Wish me luck.

What Would You Liike Me To Do?

An interesting shift; not as busy as I thought it might have been...

There is,as many of you will know, an ongoing struggle for us in the ED to convince our Specialist brethren that once in a while, we know what we're about.

I saw a young woman yesterday, with a long, complex history; the sort of history that makes life difficult for you - a mixture of physical and psychological, God-given and self afflicted. She has had many admits with belly-ache, and mostly managed with difficulty.

Yesterday she presented a week after taking a substantial overdose of tramadol, complaining of abdominal pain and an inability to open her bowels. So far, so constipation; except that her pan was uncontrollable (which may represent real pain, or simply a desire to obtain more morphine...) her pulse racing, and her lactate sky-high.

Her belly was tight, exquisitely tender, and I called for a surgical consult. The first surgeon I spoke to me told me he thought it all sounded "very soft". You can interpret that any ay you want, but I'm a stickler for tradition, and like my patients examined before their complaints are dismissed as "soft"

The next surgeon's input was limited to asking me what I was doing about the tachycardia?

Well, I've tried agressive fluids, enough morphine to kill a horse, and antibiotics in case she's perfed... I'm kind of stuck; so what I did was... call you.

Morning!

It's a new day, a new year, a new life?

Who knows. I'll try and update daily, though have my concerns that this may result in short, boring updates.

Like this one.

We'll see.

Happy 2010!