Way To Blue

Yes, I'm back. Again.

Again.

A little housekeeping.

Those of you still here, and keeping up, will have noticed all pretence of anonymity has gone. Well, more or less. I cannot be bothered to go back through all of these posts and remove the fungal refs, but all of these posts now bear my actual name. Those of you who really want to can Google me. Or Bing me. Why not Bing that shit? Either way, I am there. For better or worse. The GMC, they who must be obeyed for the registered medical practitioner, have taken a decidedly dim view of the anonymous online physician. You can make of that what you will.  There's an interesting take on it on The Pod Delusion, if you feel it's worth more than a cursory shrug of the shoulders. Anyway; I'm out. It's probably not that important really; I'll take the opportunity to remind you all that any clinical situation I discuss herein is at least non-contemporaneous, and possibly fictitious. Names have been changed to protect the guilty, and me. If you think you recognise yourself, or someone close to you, you're wrong.

Some things, however, never change. I'm still, mostly, gazing at my own naval, overusing the word maudlin.

Debriefing. I don't know where debriefing first took hold. I want to think its the Military, but I couldn't swear to it. It sounds like it should be the Military, though. The After Action Report.

In any line of work, when things get runny, they usually do so somewhat chaotically, running with an energy all of their own. Even when it feels like you have a handle on things, that control is usually fleeting, or illusory. Without accounting for everyone else swept up in this particular tempest. As a contemporary of mine is fond of quoting,

"Good judgement comes from experience, but experience comes from bad judgement."

So we crave exposure to whatever it is we try to do on a daily basis, crave our own experience, and crave that of others. Hoover it up, in the hope that whatever was done well can be assimilated, copied and pasted into our own experience, ready for deployment next time out; and that whatever was done badly can be picked clean to try and remove it from the deck next time. More than that, it offers a chance to meet with your colleagues when everything hasn't just slipped agonisingly through your fingers. A chance just to sit down, and acknowledge what it was you just did. Sometimes, I think, its enough to look each other in the eye, and have a little cry. I don't think I did enough of this when I worked in ITU; I'm pretty sure we don't do enough of it now. Sometimes, we can't meet each others gaze. We (I) aren't so good at the more empathic sphere of what we do.

Recently, we had a tough shift. I can't go into the details, obviously. But most of us, if not all of us, have a 'worst-case' scenario. The patient we fear most; the one that we dread. Even the non Medics among you will have no trouble trying to imagine the clinical situation you would least like to be faced with. This was mine.

Actually, the case was run well; but the outcome was bad. Awful. I don't want to be any more melodramatic, but you get the idea. And debriefing something like this, talking it out, is hard when you're talking it out with people who weren't there, people not in the business. Not because we're special, but sometimes these cases are deeply upsetting, and there may be a reason why the person you're talking to didn't love ER. Or maybe it's a defect of my character, that I don't trust my friends to be able to process the chat in a way that I can; or have to; or think I can. I think there's a danger of casting oneself as the martyr, then. The only one capable of managing the psychic trauma.

Which is bullshit; I'm not that special.

Kind Of Blue

**MORE NAVEL GAZING**

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.

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.

19th Nervous Breakdown

I'm afraid it has all caught up with me. Maybe you do have to hit rock bottom. I think I may have done just that.

Whether I can climb back up again...

Time will tell.

For now, I have been fired in the crucible, and found wanting.

I'm sorry.

I hope it doesn't end this way...

Encore Une Fois

Best I can come up with, but a video that speaks redemption, and isn't Redemption Song. Listened to this far too much when revising for my membership (the third time, when I finally passed... so maybe no bad thing)

Further Interlude

Still can't think of a song that makes me feel guilty; I'm sure there must have been songs playing when I've been up to no good, doing things that I should be ashamed of, that should make me feel guilty.

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.

30 DSC Day 22

22: A Song You Listen To When You're Sad.

Too many to count, but this is an oldy, one I used to over-lsten to mourning the break-up of a relationship.

I can still smell her perfume when I hear this song. I think (hope) she's happy now. Most of my exes seem to be. Maybe I'm a pit stop on the road to happiness.

Yes, I know, I'm wallowing

Shaking What You've Got

Another interlude. Typing on my iPhone, so may be shorter than usual. It's awkward, and the events herein upset me.

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.

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.

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.

"You shall not pass!"

One of, if not the most difficult things I have to do is watch people die.

This, clearly, is never easy, unless you're a psychopath. (I am not)

Sometimes, it is expected; after all none of us live forever, and so sometimes it doesn't feel so bad. Especially if you can make that passing as easy for all concerned as possible, and sometimes you can.

But sometimes, you have to watch people die in the knowledge that they shouldn't be dying, and worse, that you don't know why they are, or that you can do nothing for them.

Because what we're supposed to do, is stand there, Gandulf like betwixt patient and death. Only sometimes, you're not a wizard, you're an impotent old man, with a wispy beard.

This happened once before when I was here before, in a different time, or a different life. We then, and still do, as far as I know, take dive casualties, as we have a decompression chamber on site. It might have gone.

The problem with decompression illness is that usually you are too sick to transfer, and will die without transfer. I don't know if there's a answer. I certainy didn't that day.

The patient was a young woman, with, probably, The Chokes. It's like The Bends, but involving your lungs, or the pulmonary vessels. It's having a massive PE with the only treatment a massive metal tube, too far away for me to reach.

She was blue, with crushing chest pain, hypoxic, hypotensive, dying.

I knew why, and I knew I could do nothing about it.

I've never felt so sick.

Then she got better. It was nothing to do with me. she just got better. I guess the gas emboli in her pulmonary vessels just... broke up.

Maybe God looked over my shoulder, and felt our pain.

Death passed us by that day, and I still don't know why; maybe that's best?

The Black Dog Returns

I once again find myself wrestling with the Black Dog; posting may be affected

I Believe I Have Transcended...

Irony:

The best thing about living alone, is living alone.

The worst thing about living alone, is living alone.

Funny, eh?

Hard Times...

Sometimes shit just happens.
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.

Except, me.

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.

Anyway, this shift, the BatPhone went off, twice in quick succession, forewarning of 2 such patients; one slightly older, one younger. The older of the two arrived first, and looked o.k-ish, just confused, in a lights-on-no-one-home sort of way.

The second, a young 'un, looked really sick. All numbers awful, half-dead in the bed already. I had to take no. one to CT, so left her in the more than capable hands of my Registrar and the ITU team.

No. one's CT checked out ok; I'm still not sure what was going on there, but when I came back, no. two had active CPR ongoing. The guys had been trying to site a central line, when her BP dropped from bugger all, to fuck all. A subtle, but important distinction.

Well, we worked as hard as we could, for as long as we could, but nothing worked, not even a flicker.

I hate losing the young ones, especially when I'm not sure why.

The conversation with her dad, was as hard a conversation as I've ever had.

Cases like this leave no-one untouched. They spread ripples of shit everywhere; they can destroy families, and ruin perfectly good clinical staff, like the Reg I left in charge of the case, who is more than capable, but will be asking himself what more, what else he could have done for weeks.

Maybe it's selfish to think of ourselves, but we can't help it.

We're not supposed to lose these ones, and it hurts.

It hurts, but I suppose it's not so much the falling down, as the getting up again afterwards.

Abandoned Luncheonette; Track 4

I believe I may begin again.

Reasons may, or may not be obvious.

More later

Candle In The Dark

Someone died.

This should come as no surprise, I guess. It happens every day. I see more than my fair share of it, I would cautiously suggest.

I got a phone call on Saturday, bearing the unwelcome news. I had an idea something wasn't right, social networking sites being what they are, but the call filled in the blanks.

I've made these calls, and received them, and I still don't know which is worse.

To say this was someone I know, is stretching the point. We were aware of each other, but the most interaction I think we had was a disagreement about the NHS, and some slightly unkind things were said about my bedside manner.

But he was very dear to people who are dear to me.

Can I say that I feel their pain?

Not as deeply, surely; it cannot cut as deep, cannot burn with such cruel heat.

But I know that the sun seems to shine a little less brightly today, that the curtain seems to have been pulled a bit further across the light.

Be Careful What You Wish For

On minor irritations, and major catastrophe

I know I need a break when I become more irritable than usual; this doesn't take much, to be fair. One of my colleagues, through no fault of their own, has begun to irritate me hugely, and, more or less, whatever they do.

I need a break.

Then everyone started to irritate me.

I need a break.

Last night dragged, dragged on and on. I found myself wishing for something interesting, something... acute. Something to set the adrenaline on edge. Something to set against the seemingly never-ending tide of people who should know better.

People who think they can stroll into my place of work, roundly abuse me for 10 minutes straight, than apologise, and it will all be o.k.

People who really think drinking until they piss themselves and vomit on me doesn't need an apology.

People who don't know how to cope; or worse, don't want to know.

That's what I'm here for, eh?

Sometimes, we get what we wish for, and then you can't take it back.

The call came, almost inevitably, as swine 'flu. And then seizures.

Fitting isn't too bad. We can treat it. So much of what we see, we can't treat, or if we do, it's by accident, or in fact it's you, treating yourself, while we ease your symptoms. One of the things that appealed to me about surgery was that it, occasionally offers real cure. Not pill pushing. This is of course debatable; but I digress.

The point is, acutely, most seizures respond, quickly, to simple drugs. But in the context of an infection, even 'flu, a host of more worrisome prospects rear their heads.

Then it got worse; the call came through, updating us, informing us that the patient had gone into cardiac arrest. Which is awful at the best of times - of which, really there are none - but in a young patient, as this was, it fills me with all the adrenaline I could want.

It doesn't matter how much you prepare, you still have to confront the same thing. The one, unavoidable fact. Soon, a patient will be delivered to you; dumped, unceremoniously on whatever brand of trolley you have. Cold, or cooling; skin waxy and clammy; often there is a blue purple tinge. There is often a leakage of secretions, pumped forth from the mouth and nose, egged on by the chest compressions that strive to keep them alive.

What was once living, breathing, laughing, crying... now is so much mater. And resuscitation almost never works.

Well, we all have to go some time.

Not this young.

He had been fitting for over an hour, unresponsive to meds; a difficult airway, he couldn't be tubed in the field.

And worse, as the Ambos rushed him from the warmth of his home, knowing that his only chance lay at the Hospital, weighed down by the fact that they had done all they could, and it hadn't fucking worked, they slid and slipped into the rain. Chest compressions are hard to do in the dark, and in the rain.

The unthinkable happened. The stretcher, slick with the morning rain, shifted, wheeled, away. How much? I don't know. Not much, but enough. In among all of this, among all the fear, and fitting, the patient slipped off the trolley, and onto the ground.

And after that, he arrested.

We got him back.

Not often, but occasionally. It happens.

And for what? CT showed massive anoxic brain injury, a non-specific swelling of the brain, a blurring of the borders between grey and white matter. Another thing we can't treat

The Ambos were in bits. For a group of folks who have seen it all, and I mean all, this was there worst nightmare.

As it turns out, the bump on his head was the last of his worries.

I cannot conceive what went through these guys' and gals' minds when it happened. For all the jokes, all the frustrations we vent about the patients that annoy us, that tax our patience, they are our charges. We do what we think is right for them; it is not supposed to end like that.

Cold comfort to find out the injury was clinically insignificant. That it was a dreadful accident; that fate was to blame, nothing more or less.

That it was the seizures that did for him, starved him of oxygen, drove him down the dark path...

Be careful what you wish for.

Someone always suffers.

Double Or Quits

Some days it feels like you can't do anything right.

Last night started benignly enough, but midway through the night came to a unpleasant crossroads. Resus had been the stopping off point for a couple of teens who couldn't handle their beer. They both came round fair enough, with one taking a little longer than t'other... I still think he was on drugs, but I guess that's his business.

The Ambos broke the reverie of the ethanolic miasma by bringing in a young diabetic, unwell and sinking fast. His diet, eschewing food for vodka and coke, not helping. He was pallid, restless and crispy dry, reminding me all too well of the last diabetic I had in resus. Ketoacidotics are unwell, for sure, but there's degrees of unwell.

This fella was first class unwell; sick, with honours, if you will. He started vomiting shortly after arrival, great heaving spasms, spewing forth small volumes of coffee coloured fluid. Now this might be the result of gastric stasis, a feature of DKA; but it might be him trying to bleed to death.

Getting ready to focus all my attention on him, contestant number two arrived. A young woman, known to suffer non-epileptiform seizures, brought in, perhaps unsurprisingly, fitting. A complex case, for all sorts of reasons, and one that I'm still not convinced I manged well, or in the right way.

I tried, tho'. Tried to do right by them both.

And failed.

I'm furious with myself.

Sometimes, you will tell yourself, sometimes, I just need a break. I need for these patients not to be going off at the same time, I need for the department not to be heaving at the same time, I need for the fact that waiting times are skyrocketing to be on my mind.

However, that is not the way life works. I get paid to cope under pressure, to manage a busy department, to multi-task. To make everything work, to make everyone better.

In the cold light of day, it's all too easy to review the cases, to see what should have been done.

Last night I was fired in the crucible, weighed in the balance, and found wanting.

It is a sobering experience, and one it will be a while before I can forget.

I only hope that's a good thing...

Separated By Common Experience

Chatting with one of the Paramedics the other night, shooting the shit, and all.

He'd had a bad run the night before, attending to a young patient, in cardiac arrest. Nothing to be done, but run the numbers, mark time and call it.

I could see it hurt him, hit him hard; the knowledge that it were all for naught.

I know just how he feels; I've been there, run the same code, counted the same numbers, marked the same time.

Somehow, this makes it harder to talk about. We share a look, and go our separate ways into the dark....

My Body's Aching And My Time Is At Hand

Now: I'm throwing stuff; kicking a chair. It's childish. I want to shout, to scream... but I won't. Not done, y'know? Fair doesn't come into it. I know this. The violence don't help; not really

5 minutes ago: We stand outside; shell shocked. Some of us are crying, maybe just a little. We've seen it before, knew it was coming. I want to hug him, tell him it ain't his fault...

5 minutes ago: It's all gone very quiet. I'm walking around in a circle; I can feel people looking at me. I can't hear the noise of the department for the blood pounding in my ears. I need some air...

5 minutes ago: We tell them; they knew. She told them what was coming, but now they've seen it, and the grief is real. Hot, angry, real.

5 minutes ago: I can't think of anything else to do. I've used all the drugs, my finger is in her chest, the act repeated opposite me; her lungs feel warm, but it's not helping.

5 minutes ago: They've all stayed. Usually the Paramedics and Techs get on; they've got other things to do; not tonight; not for her. They're all still here, pitching in, wanting to help. If desire was all it took... one last trick, maybe? I ask for the knife...

5 minutes ago: It's in; tube in, but I can't quite tie it. I'm coming apart a little, my voice cracking. We're not winning. I look up and se it mirrored in their faces.

5 minutes ago: I'm fighting; there's vomit everywhere, and we're slipping off the chest. I can't see the monitor properly, the lines aren't going. I'm trying to pass the tube, but the angle keeps eluding me. They know what I need, and we press on...

5 minutes ago: They're here. Already I know; she's been down too long, she's the wrong colour; too cold. Not coming back. But we always run the gauntlet. It would be an insult to her, to her family, to the Paramedics who've worked so fucking hard, just to get here. To be fair, like us, they already know, but none of us can accept it yet. We need hard proof, we doubting Toms, and so we go on my count...

5 minutes ago: I'm almost in. I hate putting lines in kids, but my SHO doesn't know how, or doesn't want to know. He doesn't want to learn as I learned, hard and cruel in the night. I guess, he doesn't have to, because I did. Then the call comes. Young, much younger than me, asthma, full arrest. Already our faces are ashen, prepared. I tape the cannula down. Mum has overheard them telling me, and suddenly her night doesn't seem so bad.

5 minutes ago: I'm at work. I actually feel pretty good about it. The department feels to be in a good mood. Let's see what the night has to offer...