Wednesday, September 26, 2012

On Dignity

Dignity seems to me to be an odd quality; I wonder if it means different things to different people. Most words do. I suspect we all ant to be accorded our dignity, while at the same time wanting the right to conduct ourselves in any manner we wish, dignified or otherwise. We can give it away as we choose, but no-one can take it. Or rather, no-one should take it.

I see many people conduct themselves with quiet dignity, often in conditions of extreme stress, and others behave abysmally, often under much less stress. Or, at least, what I perceive as less stress. We all react differently to different stressors. It seems to me, however, that my generation, and thise that have come after me, don't like stress, or rather, don't deal with it. At least, not well. I can't work out if I think this is part of a wider sense of entitlement, or just so. There's something to be said for being involved in whatever goes on around you, and, sadly it is usually the squeaky wheel that gets the grease. And everyone likes grease.

But there seems to be a pervading idea that you can behave however you want in an hospital, and that's just fine. That your illness excuses your behaviour. That you don't normally behave like that. It's the pain; or the drink. Or something. I'm sure there is a degree of truth in that, but not everyone behaves like an arse, so I'm afraid it is you.

Perhaps it is just to be expected, living at the sharp edge of life, where everything seems to be changing so very quickly, where everything seems of vital importance. We lose perspective. Should we care about our dignity? Is it important? Who really cares?

I once treated a man who became unwell after drinking too much. He was young, but had a significant cardiac, and neurological history - I think. Maybe just one of those. Either way, he self medicated with a lot of beer, on that particular evening at least, then passed out. He soiled himself, with every effluent available to him. When, as part of my resuscitation efforts, I went to catheterise him, he woke up long enough to demand I left him his dignity.

Different things to different people.

Thursday, August 09, 2012

Kind Of Blue


There was a pall over the Department today; not the usual end of nights lull that you see in weary faces across the country, as people realise the night is at an end, and they can step, blinking into the day. Not the almost palpable sense of loss when something has just gone bad, but somewhere in between. The feeling that something has been and gone, and we haven't quite decided how to feel about it yet. Except that we don't feel good about it.

Working as part of a team, in extremis, or close to it, is an interesting experience. It is bonding and team building in a way that corporate events will never understand, let alone capture; actually, I suspect there is always another level of jeopardy in which one can find oneself, which you just can't under stand if you weren't there, man. Shared experience binds us powerfully, especially if there is hazard, even if that hazard is at someone else's expense. You discover a lot about your own mettle when everything goes a bit runny. I have rarely felt closer to my colleagues than when we are trying to pull the fat from the fire. Maybe that says a lot about my ability to form relationships...

But it can be extraordinarily disheartening when all your efforts are for naught.

As Physicians, I suspect many of us adopt a moral compact whereby we take on the responsibility for identifying the truly sick, and trying to divert the course of their illness; if we are 'good' enough, or experienced enough, we may even expect to be able to do this. Or perhaps we tolerate failure to do so less. We become, willingly or otherwise, more sensitive, but less specific, But I wonder if we still harbour the belief that, when confronted with the really sick, we will recognise them. For if not, if we cannot make that difference, what does all the rest count for?

To be fair, I can't, obviously, speak for my colleagues. But I suspect most of us know that the obviously sick patient is just that: obvious. And so identifying them, treating them is not where we like to think our skill lies. Our grasp on the art of medicine depends on us being able to reliably identify the patient who looks well, but isn't.

Unfortunately, no matter how good one is, sometimes this just isn't possible. Sometimes, it's true, they slip through the net because mistakes were made. These are usually multi-factorial, systematic. But sometimes a disease follows a course so aggressive that it eludes us. It is a sobering reminder of our own frailties.

When this happens, especially if the result is a bad outcome, there is often an agony of soul searching. Do not weep for us, gentle reader, because it is usually worse for the patient, but we must subject ourselves to harsh criticism to see what, if anything, could have been done differently.

In this way we learn; but sometimes, there is nothing more we could have offered.

We might feel relief: I did everything 'right'. But we don't feel good about it.

Wednesday, August 08, 2012



Timing, it seems, rules all of our lives. Make of that what you will; be it in a Sliding Doors sort of way, or My Parents Failed At The Rhythm Method sort of way, it's hard to deny, and maybe even a bit twee to say so.

So it goes.

I've had a lot of time to think, the last few months, maybe, maybe too much time. Thinking is all very well, but unless you're Descartes, some sort of action is required. Too much contemplation of the existential, is, in my experience, bad for your health. It leads one to ponder one's place in it all. I'm left with the idea that it's hard to get beyond the Pale Blue Dot.

And yet... somehow, I feel that despite that, perhaps because of that, one can still make a difference. What I can't decide is if it's enough to make a difference just by smiling at someone you might otherwise have scowled at; should you risk striving to make a really big difference, running the risk of foundering on the rocks of your own self-regard? Or is that the point?

You can see why I'm wary of too much navel-gazing. And it doesn't get the tax return done.

Fate and free will? I find I have no choice but to believe in free will. And yet... My circumstances over the last year and a half or so have not been what I would have chosen, ever; but now I find myself confronted with whole new sets of possibilities. Am I a 'better' man for what has come to pass? I'm not sure I can, or should answer that. I'm probably a different man, but isn't that true for any given set of circumstances? Aren't we constantly re-inventing ourselves, with every decision we make? Perhaps e want to believe in some over-arching plan, but if it is there, it is of our own making. I have experienced things, done things, met people that I would not have done, but for what was, at the time, and in my memory, a painful experience. One that I would not have chosen, but that has resulted in some events I'm glad of. So, was this 'meant to be'?

No. Shit happens. Alan Moore is on record as saying:
"The truth of the world is that it is chaotic. The truth is, that it is not the Jewish banking conspiracy or the grey aliens or the 12 foot reptiloids from another dimension that are in control. The truth is more frightening, nobody is in control. The world is rudderless."
Sometimes, the timing is all wrong; but sometimes, maybe every time, did we but know it, it's just right.

Tuesday, July 03, 2012

Back Again

So, I've been away; there may be clarification as to why in the future; we'll see.

It seems to often be the way that the patients you really like end up with the shitty end of the stick. I saw just such a patient yesterday; we had seen them a few days before, and sent them on their way, reassured with a simple diagnosis of 'constipation'

I dislike 'constipation' as a diagnosis; to my mind it's a symptom, but I guess that's open to debate. We all have our own foibles, or pet hates, or what have you. This is one of mine. I think it's more important the more elderly the patient is, and that's built on a deal of experience, but I recognise that 'in my experience...' are dangerous words in medicine.

Anyway; the patient was at least of pensionable age. I subjected them to an 'end-of-the-bed-ogram', and concluded that they looked pretty good, actually. Sitting in a chair, chatting happily to the MedStudent. Not gowned and trolled by the nurses, which often says something in its own right.

The tale; ah, well, its all in the telling. I'm not sure how sensitive, or specific, my 'gut' is; clinical gestalt is supposed to be pretty good, but one only tends to remember the times when you get it right, or are proved wrong spectacularly. The patients about whom you really worry, but turn out fine, tend to fade from view.

Anyway: this tale, of gradually altered bowel habit, loss of weight, loss of appetite made me anxious. And lying the patient down, removing the bulky pullover gave the lie to the idea that they looked 'ok' when sitting in the chair. The drum-tight belly, empty rectum and slightly hollow, pale eyes tell a tale all of their own.

Throughout all of this, the long wait, the uncomfortable, undignified examination, the merciless poking of the blood tests, this apteitn remained cheerful and upbeat. Grateful. Chipper.

I really like them.

So, it came as no surprise when the belly film confirmed an obstruction, the gas pattern neatly nipped off around the mid descending colon.

Of course, I don't have a diagnosis yet, but the probabilities hang heavy around my neck.