30 DSC Day 19

19: A Song From Your Favourite Album

I have had to fudge a bit here. Van Morrison's Astral Weeks is probably my favourite, or Let It Bleed, or Get Yer Ya-Ya's Out by The Stones.

They've both featured, so I'll default to my next favourite album: Let It Be

There are innumerable videos for this song out there, including a demo where Paul swears at the beginning that I found once, but never again, and one where some dude has overdubbed the two different guitar solos; but I like this version; under-produced, nice backing "ooo-ooo"s.... though if I'm honest I prefer the original (album) solo. It's... dirtier.

Go, seek, find

Edit: Persistance does pay, it would seem, although my memory isn't what it was apparently. A demo with heavy vocals, bass and swearing, at about 1:54.

So not the beginning; and not Paul either, I think. I'm pretty certain this is the 'rude' version I remember, since that's what I remember him saying.

Anyway. One for the geeks.

30 DSC Day 18

A Song You Wish You Heard On The Radio

Another topic for which I could provide a dozen or so songs...

I'm trying not to duplicate artists, or songs, as there are a number of tunes that would answer any number of these 'subjects'.

Anyway, anything by this man would be welcome.

Interlude: Referral Politics 2

So: the last of the epic tales of my on call.

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.

30 DSC Day 17

A Song You Hear Often On The Radio

Problematic, as I mostly listen to Radio 4 and Radio 7, which are all about the talking. When I do listen to music radio, it's usually Chris Moyles on Radio One, which isn't so much about the music...

So it's another blank, I'm afriad

30 DSC Day 16

A song you Used to Love, But Now Hate
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.

Interlude: Referral Politics

Ah, the joy of the referral.

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.

30 DSC Day 15

15: A Song That Describes You.

Another one I'm prepared to edit.

Describes vs. sums up.

Comments please.

It's a funky song, anyway....

I've added a live version. The live vid has several details in it that I just love. You'll know when you see 'em; the Devil is in the detail.

Interlude: Politics

The first of a few posts about my last on call; in case, and I can't imagine why this might be so, you're becoming bored of my relentless music Nazi-ism.

Anyway; the following events take place over about 15 hours; I thought about jamming them all into one post, but figured that'd be massive, and might cause forced quit in some readers.

But, the muse is upon m, so I'll write it, and chop it, and preload it.

Part the First. On Hospital Politics.

I am terrible at politics. Terrible. If I was a good politician, I'd be a politician. But I quite want to help my fellow man; so I'm a doctor.

Anyway: for those of you not in the business, there's a lot of politics within even small hospital, an mine's a biggie. I'll be honest with you, I don't really give a shit about it; cheesy as it sounds, all I really care about is doing my job, and making sick people feel better.

I suppose the counterpoint to this is that by being a politician, I can do my job better; but I don't really see it that way. The profession needs politicians, for sure, although those we have appointed have sen us reamed by successive Governments, to the extent that I'm not sure we even count as a profession anymore, so emasculated are we.

So a fat of of good that did. I continue to stand on a single issue platform: what's right for my patient is what I'll do, and you can shove everything else right up your arse.

Vocalising this loudly, sees you marginalised, and less able to influence policy, so it's something of a double edged sword, but there you are.

The point of this rant is this: in the ED, our on-call shifts are rostered from 1pm until 10pm, with additional coverage as needed. We disagree with management on the meaning of that last phrase, but suffice to say, I am almost never off the floor at 10.

My last on call was no different; worse, in fact as we were short handed, and when everyone else goes home at 6, things can go runny very quickly. Rapidly, I had 7 patients needing my 4 bedded resus, and long waits throughout the department.

As I was contemplating taking a break, at about 9, one of our managers (whom I strongly suspect accused me of sloping off on a previous on call: another story) approached me, to tell me that the Duty Exec. was trying to call in the On Call Physician.

As far as I know, this never happens. We all work later these days, in the name of the targets, but I don't think physicians expect to be called in. I'm not sure surgeons do, at least not as much as in Pa Shroom's day, but this is opinion only.

Anyway, he was, so I'm told, declining the offer, unless I wanted him in.

I hate being put in this position. My department was busy, sure. But patients were having to wait longer; all the sick patients were being attended to. So I didn't need him, per se. Of course, extra hands are useful, but a Physician, even an acute one, is NOT an ED Doc, whatever you think.

So, I said I didn't NEED him, but if the Hospital 'escalation' plan called for him to be summoned, that was between him and management.

I'm given to believe he came and was grumpy about it. I never saw him: too busy in resus, but I expect there to be fallout. Questions will have to be answered about why I couldn't cope.

Well, shit happens.

No-one died who shouldn't have done.

Part the next: in which I discuss Bayesian probability with the Medical Registrar

30 DSC Day 14

14: A Song No-One Would Expect...

Another toughie, as it requires me to try and see myself through the eyes of others. I figure I could go either way here, and am prepared to edit if the public tells me so.

This piece is heart stopping, and I think at odds with how my musical taste is generally perceived. I think.

You tell me?

How about this one then ?

30 DSC Day 13

13: Guilty Pleasure

Hmmm... there are a few of these.

Try this on for size.

(There's a bit of banter to get through, but he's talking to Johnny Cash FFS)

(Cut to 2:15, if you have to...)

30 DSC Day 12

12: Song From A Band You Hate.

I'm not linking to anything; pick something by Britney Spears or any boy/girlband of the last 20 years.

30 DSC Day 11

11: Song From Your Fave Band.

Another toughie. Right now, that's probably the Stones, and I'm choosing this song, not only because it's brilliant, but this version shows Mick Taylor at his finest. This slide solo may be my favourite solo of all time, and the video, if you can be bothered shows Mick, beautiful, beautiful Mick, going all Najinsky.

I think I need to stop using the word 'Beautiful'.

30 DSC Day 10

10: A Song That Makes You Fall Asleep.

Don't really have any of those.

I could fall asleep to this one though. Achingly beautiful.

30 DSC Day 9

9: A Song You Can Dance To.

Well... I can't dance, not even for toffee, but I would HAVE to dance to this. Some of you will know why.

30 DSC Day 8

8: A Song You Know All The Words To.

A few of these.

This is probably my favourite.

A slightly 'odd' version, mayhaps?

30 DSC Day 7

7: Song That Reminds You Of A Certain Event

Not an happy event, but there you go. Tried hard to find a video that wasn't Harry Potter orientated; altho' the film introduced me to this song, it is not the event it commemorates.

Honest.

30 DSC Day 6

6: Song That Reminds You Of Somewhere.

Another relatively easy one. I love this song, and will never forget where I was when I first heard it. FWIW, it also reminds me of a person and an event...still

I might add, I was listening to it, so the big man's entrance took me completely by surprise...

30 DSC Day 5

5: Song That Reminds You Of Someone.

This was easy, sort of.

30 DSC Day 4

4: Song That Makes You Sad.

Too many of these to mention.

I choose...

Interlude, Part The Second

Another bad day. Bad for me, worse for others.

I had an unusual case yesterday, wherein a 21 year old lad presented with severe lower limb muscle spasm, and turned out to have bilateral fractured femoral necks; without significant trauma.

Yes, I'm stumped, too.

Today...

the first was a young man, in his 60s, previously well, in cardiac arrest. He had had a colonoscopy the previous day, and returned home without complication; after a few hours at home, he developed severe lower abdominal pain, cramping and colicky, although the notes document that this passed when he opened his bowels and passed flatus.

The notes document that he was symptom free when seen in the ED. He examined normally, and was discharged. Then she couldn't wake him this morning.

By the time he got to us, the Ambos had been working hard for an hour. They couldn't intubate, and I could see why. His jaw was clamped shut, clamped so hard, he'd bitten through his tongue. I couldn't get it to budge a millimetre. Looking down from the head end, I could see my colleagues struggling to straighten his legs out.

No dice.

There's usually only one reason why someone in cardiac arrest has muscle rigidity: rigor mortis. The poor soul had been down for several hours before even the Ambos were on scene, I'd say. We tried, and we tried, but he remained stubbornly in asystole, and his blood gases were those of a dead man.

His wife was utterly unprepared; she pleaded with me to do something, oblivious to my gentle suggestion that he had, in fact, died in the night, and that at best, with a downtime of 90 minutes, even if I could convince his heart to beat, his brain would never recover.

But I couldn't convince his heart to beat.

I knew the accusation would come; she couldn't help it: "He was here last night! Why didn't you see it?"

I had no answer, could barely look her in the eye.

...the second, another young man, found in a collapsed state. Known to be a fitter, prone to slow recovery, he looked post-ictal, but was too slow to come round. He gradually developed some focal signs, his right side becoming tense, spastic and useless, his conscious level ebbing away.

The diagnosis of a prolonged post-ictal phase began to ebb away. CT confirmed what we had all thought: a sizeable intra-cranial haemorrhage. Neurosurgery wasted no time in pronouncing no hope for meaningful recovery. They did offer to take him, to try a ventricular drain, but stressed this would be to prolong duration of life, not improve the quality of that life.

As we pulled the tube, and placed him on his side, I'm left to reflect: two sets of lives ruined, and not even lunchtime. Difficult to put a spring in my step today.

30 DSC Day 3

3: Song That Makes You Happy

Marvin and Tammi: Ain't No Mountain...

30 DSC Day 2

Day 2: Least favourite song.

Odd phrasing. The song I like the least, or a song I dislike..?

I choose the former.

I'm still not sure.

Of the songs on my 25 most played list, I think I like this one the least.

Which is not to say that I don't like it. Maybe that's not the point.

Van Morrison: Wild Night

Interlude

Been pre-stacking the blog with songs, so listening to a lot of music; not necessarily a smashing idea in my current mind set, but there it is.

Found this again. Stunning version. Would kill to be able to sing like this.

(Vid not so hot, but bear with it...)

30 Day Song Challenge 1

This is going to be problematic, looking at the list; there's considerable overlap in my choices / options, and i"m not sure I can answer them all.

Anyway.

Day 1: Fave song.

Currently... Joplin's Little Girl Blue.

So beautiful it unmans me every time I hear it.

This Might Be Interesting...

A meme I've only just come across...

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

Best vs Worst

No further rigors, no idea what the source was. Slightly worried I'm harbouring something nasty... but declined investigation so I guess I have to lie in my own bed.

Increasingly find myself gripped by malaise, and dark feelings of hopelessness, which is somewhat self-indulgant considering my situation versus how it could be.

Anyway, blame that for this post.

In general, I have a low opinion of humanity. Essentially, I don't think we're as far removed from the beasts as we like to think we are. Left to our own devices, I think most people will happily crap on their fellow man, if it's to their own advantage.

Altruism, generosity seem to me to be the exception.

La Belle Fille firmly believed quite the opposite; she does have a bright shining soul though. She may be right.

I suspect my job biases me.

Certainly LBF rarely encounters stuff like this: I was wary of telling this story, because it's sensitive, but I've seen it reported in the Daily Mail, which I think makes it common domain.

A young man died recently, and he probably didn't have to. Maybe it was his time, but he was awful young. He fell into a pond. The Mail reports he had an history of blackouts; I heard seizures. Semantics, really. If you were very uncharitable, you could argue someone with that history should probably stay away from unfenced bodies of water unsupervised. I assume he was alone.

I could be wrong.

Anyway, he fell in the pond, and was unable to get himself out, likely because he was unconscious. It took 25 minutes to get him out. No-one would go in after him.

The Mail is quick to chastise the EMS, whose bosses won't let them go in, in situations like this.

But someone called the ambulance. People stood about and watched. No-one, no-one even tried to get him out.

Stood and watched him die.

Music Nazi recommends Eccentric Soul: The Prix Label.

Chills

Today, I had a full blown rigor. One minute, I was fine: the next felt freezing, was shivering uncontrollably, and, I'm told exhibited pallor. My pulse was up a little, and my BP. My BM was normal, urine dip blameless. I had, and have no other symptoms.

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.