Thursday, November 03, 2011
Friday, April 15, 2011
Whether I can climb back up again...
Time will tell.
For now, I have been fired in the crucible, and found wanting.
I hope it doesn't end this way...
Monday, April 11, 2011
Sunday, April 10, 2011
Saturday, April 09, 2011
I appear to have successfully blotted them out of my mind.
I feel guilty about a variety of things; it comes with the territory of a Catholic upbringing, and I suspect this is not the forum for me to go over them. It would make terribly dull reading.
I might as well tell you how much my back hurts today.
(More than usual)
I am struggling to shake the memory of the epistaxis patient who arrested on my watch. Could I have done more? Could anyone?
We'll never know. There's no reset button, no save point to return to. I've looked.
You just have to plough on, apparently.
I really need a break.
Or some therapy.
Friday, April 08, 2011
Thursday, April 07, 2011
Wednesday, April 06, 2011
Tuesday, April 05, 2011
Monday, April 04, 2011
Sunday, April 03, 2011
Saturday, April 02, 2011
On how things go wrong, and on not knowing.
The patient, hypothetical as always, might have been middle aged and in renal failure requiring regular dialysis. Imagine they present with a nosebleed. These are the patients who carry a burden of hindsight with them. It is neatly packaged, and in my experience you won't see it unless you're careful.
Patients with open fractures, overdoses, an overcrowded Paeds Department: all of these things might get in your way, might cloud your vision.
Suppose the bleeding starts again. It's obviously vigourous; despite packing, blood continues to flow freely, from the other nostril and from the mouth, obviously coursing down the back of the nasopharynx. Threatening to choke her, but not quite making good on this threat.
Imagine you can't see anything to cauterise; more packs? A foley to tamponade posterior bleeding? Something I've not done much of. Will it make it worse?
Patient is stable; call ENT. You will tell yourself it makes the most sense; you have other patients, this one is ok (now) and needs an expert.
Half an hour later, you're bagging the patient; the airway resembles an abattoir. The tube goes in ok, and maybe 10 minutes of CPR will get him back.
But your patient came with a nosebleed, and arrested while you watched.
Could I have done more? Should I have?
I feel like I'm burning out
These patients, hypothetical as they are, are the ones that will challenge your very soul.
If you still have one.
Friday, April 01, 2011
Thursday, March 31, 2011
Wednesday, March 30, 2011
Tuesday, March 29, 2011
I knew I'd be late on the floor; 2 down and busy, no way was I getting off on time. Half two in the morning is close to my limit. If there are sick patients, well, strap on when it seems apt, but if its just busy...
As I was preparing to escape, I was introduced o one of my absolute favourite ED dilemmas. The 'problem' patient that no-one will admit, or discharge. Typically, this will be someone well known to one service, or more than one, with a chronic problem. They inevitably attend out of hours, with a flare of their problem, usually requiring strong painkillers.
In this case, the problem was abdominal pain. Surgical review diagnosed "not a surgical problem' with a plan of "refer medics'. But of course, the surgeon couldn't possible make that referral. Since the problem is "not surgical", the patient reverts to us.
Medical review resulted in a diagnosis of "not a medical problem", with a proposed plan of "have the surgeons admit, and we'll review"
This backing and forthing can go on for days.
It is a waste of everyone's time, especially my registrar's.
Usually, a polite call is enough. It makes sense for the two specialities to talk to each other, and agree a mutually acceptable plan, or discharge the patient.
Being a consultant, it has the added advantage that I can always suggest if they don't want to talk, I'll call their bosses in, and we three consultants can review the patient at the bedside, and agree a plan. After all, I'm still here at 3 a.m., I'm sure their bosses wouldn't mind coming in to join me?
Well, I left them talking, which doesn't guarantee resolution, of course.
But I'm hopeful.
There may be some follow up here.
Don't touch that dial.
Monday, March 28, 2011
Not sure I really hate this on. Not sure there are any songs that I once loved but now hate... But this has been overplayed, so I can't listen to it right now, and that may have to do.
Times have changed. The all powerful target means less time for us, in the ED to reach a diagnosis; often the decision to refer for admission is based on a lack of a diagnosis, coupled with the fact that the hospital says I can't stop and think.
And so, the soft referral. I like to think that most of my referrals are kosher, and if I'm not sure, I'm honest about it. But sometimes, I just don't know what's wrong with a patient, but I'm pretty certain they need longer obs than I can offer in the ED, and maybe more tests. (More tests! The answer to everything!)
I had just a conundrum recently, and was given a hard time by the MedReg. Not necessarily inappropriately; I really couldn't figure out what was afoot, but I tried to be honest about that, and why I though the patient ought to come in.
Her SHO, one of our old trainees, told me a few days later, that she hadn't realised to whom she was speaking, and had been apologetic thereafter. (Apologetic, or worried that I might complain?)
This, of course, if bullshit. If she was rude, and I didn't think she was, especially, then who i am is irrelevant. No mater what some practitioners seem to think, there isn't a sliding scale of how rude you can be to someone, based on their job title.
If, on the other hand, she thought the referral was shit, who I am is equally irrelevant. Shit referrals transcend all boundaries.
Anyway. Last week, I'd seen a young girl, complaining of pleuritic, left sided chest pain, shortness of breath and cough. No temp, pulse 120 bpm, resps 30. Normal bloods, normal chest XR, normal gases. Despite her normal gas, I was still concerned about PE.
(The arterial blood gas measures oxygenation of the blood, and, in pulmonary embolus, should be abnormal.)
The MedReg was distinctly unimpressed, and wanted to know why I hadn't asked for a d-dimer.This is a blood test that, if positive, may indicate the presence of clot. It's more often used to rule the condition out, as it is more commonly negative when there is NO clot, than it is positive when there IS clot.
However, in certain circumstances, where risk is perceived to be high enough, even a negative d-dimer isn't really enough to rule out PE. This is, broadly, Bayesian probability, which deals with pre test probability, and how the result of a given test influences that figure to generate post test probability.
So for example if you have a 15% chance of having a PE, and negative d-dimer would allow me to reduce that below 1%, and I might say that's enough to rule it out. But if the pre test is higher, maybe 50%, then with a negative d-dimer, your post test is only maybe 5 or 6%. Enough to rule out?
I think not.
We backed and forthed on this for a while. Ultimately, it came down to, if she doesn't have a PE, why is she in pain, tachycardic and tachypnoeic. I CAN"T send her home. If she settles in 12 hours - brilliant. If she goes home and dies...
Not so good.
Now, I'm pretty boring, so I'm happy to talk Bayesian probability theory, and the evidence behind d-dimer all night. But it occurs to me that my juniors probably notsomuch, and this was all a bit hard work, for what may have been a soft referral, but was, at the end of it all, a patient with ongoing symptoms, and abnormal vitals.
I've seen cases like this before; not many. One or two, maybe, but that's all you need to know that sometimes what seems unlikely turns out to be real.
And I'm happy for a few uppity fellows to think me a por diagnostician, in exchange for avoiding the coroner's court.
Sunday, March 27, 2011
Saturday, March 26, 2011
How about this one then ?
Friday, March 25, 2011
Thursday, March 24, 2011
Wednesday, March 23, 2011
Tuesday, March 22, 2011
Monday, March 21, 2011
Sunday, March 20, 2011
Saturday, March 19, 2011
Friday, March 18, 2011
Thursday, March 17, 2011
Wednesday, March 16, 2011
Tuesday, March 15, 2011
Monday, March 14, 2011
Sunday, March 13, 2011
Saturday, March 12, 2011
day 01 - your favorite song
day 02 - your least favorite song
day 03 - a song that makes you happy
day 04 - a song that makes you sad
day 05 - a song that reminds you of someone
day 06 - a song that reminds you of somewhere
day 07 - a song that reminds you of a certain event
day 08 - a song that you know all the words to
day 09 - a song that you can dance to
day 10 - a song that makes you fall asleep
day 11 - a song from your favorite band
day 12 - a song from a band you hate
day 13 - a song that is a guilty pleasure
day 14 - a song that no one would expect you to love
day 15 - a song that describes you
day 16 - a song that you used to love but now hate
day 17 - a song that you hear often on the radio
day 18 - a song that you wish you heard on the radio
day 19 - a song from your favorite album
day 20 - a song that you listen to when you’re angry
day 21 - a song that you listen to when you’re happy
day 22 - a song that you listen to when you’re sad
day 23 - a song that you want to play at your wedding
day 24 - a song that you want to play at your funeral
day 25 - a song that makes you laugh
day 26 - a song that you can play on an instrument
day 27 - a song that you wish you could play
day 28 - a song that makes you feel guilty
day 29 - a song from your childhood
day 30 - your favorite song at this time last year
Wednesday, March 02, 2011
A day spent sweating under a duvet seems to have restored me.
I don't engage in high risk practices.
I didn't enjoy it.
But I don't like not knowing why?
I hate being unwell. This makes only my second sick day in 12 years, but my temp was 39C, so I figured I was due.
I let you know if I die.
Saturday, February 26, 2011
Friday, February 18, 2011
Saturday, February 12, 2011
Thursday, February 10, 2011
For those of you with an interest in movies, games, comics or TV series, let me advert you to an up and coming podcast. The cast of 3 fellas and one girl provide pleasantly informal reviews and attendant banter. While their tech occasionally betrays them, it's early days, and the general vibe - of listening to some good friends chat about stuff - is just what this Doctor ordered. You can find them HERE, or search MGCTv on iTunes.
Get involved; you won't regret it.
Sunday, January 23, 2011
Saturday, January 15, 2011
I know this to be true, and mostly use it as a defence, to protect my fragile mind, but sometimes, sometimes, things leak through. No man is an island, and this man certainly isn't a rock.
The Christmas period was as horrendously busy as I've ever seen it, and I've worked a few Christmases. The rest of the hospital seems to operate a fingers-in-ears policy; interestingly, a few weeks after Christmas, when all the patients we'd seen had been admitted, and the burden of care was shifted up a level, 'they' sat up and took notice.
Suddenly we were flooded with extra staff, and, as is so often the way, they came on a day when we had precious little to do, having admitted all the sick patients in the area.
Until, of course, after 6 p.m., when everyone goes home.
We've seen a lot of very sick folks in their 20s and 30s, with awful, awful pneumonias. At first I though it was all 'flu related; the histories seemed to fit, and indeed some of them tested positive, but more of them are testing positive for strep. pneumoniae, which I haven't seen before.
Tuesday, January 11, 2011
Do you ever regret choosing Emergency Medicine? Does the quiet life of a GP ever seem more appealing?
Never; I wanted to be a General Surgeon (or a trauma surgeon) but since the K doesn't really have dedicated trauma surgeons, and general surgery is effectively an historical speciality, EM was the obvious next choice for me.
I'm not clever enough to be a GP
Toxic epidermal necrolysis, probably. Though I have, of course, seen the usual complement of objects lodged in body cavities
Tuesday, January 04, 2011
Of course, this, at least in part, depends on your definition of unusual.
Sounds pretty unusual, but in the UK, that might be as many as 60 times a day...
So maybe it just seems unusual; or maybe, as a great philosopher once wrote, "It's not unusual"
Nonetheless, it is a truth universally acknowledged that patients collapsing in Radiology have,usually, just fainted, sometimes as badly as Gillian McKeith. (Or, "Gillian McKeith" to give her her full medical title.)
So, today, when the Resus doors banged open and he was wheeled in I was not unduly concerned.
Shows what I know.
To be fair, he did look worse than the usual fainter, and his thready pulse and agonal respiration pattern did little to reassure us. Even that meagre effort didn't last long, and his light went out. There was surprisingly little fanfare.
His history, gleaned in shouted snatches between the requests for adrenaline and flushes, demands for pads and tubes, added little. But we did get him back, and after a prodigious bout of vomiting, he declared himself better.
Well, he didn't know he just survived a VF cardiac arrest brought in by a substantial STEMI.
In fact, one almost wonders how he'd have fared if he HADN'T gone to the pub and fallen over.
But he came back. I still don't know how long he'll stay this time, but he came.