Que Sera Sera

We all waited, out front. When I worked in London, we used to wait for the Ambos most of the time, but we don't seem to do it so much here. Maybe just when we think it really maters.

The weather struck an odd balance; it was glorious, warm air, cool, crisp skies. Quiet, while we waited. Everyone's faces around me very serious, very drawn; I wondered if I looked like that. Too much thinking in the quiet time might drive you mad; fortunately, we don't have long.

We hear them first, and that's never a good sign; usually the sirens go off as they roll up the ramp; if it's proper bad, they stay on blues and twos until the last minute...

The door opens, more or less on the fly, and they're asking for help in back; this is also bad - the Ambos never ask for help - they don't need to.

I jumped in, and did what I could, which wasn't much really, just be another pair of hands, share in the anxiety; a problem shared, if you will.

We whipped into resus, only briefly held up by me having my foot trapped under the hydraulic 'lift' the Ambos use to offload trolleys - that's what happens when you get in the way.

Resus is a blur; bodies everywhere, and we try to focus. Lots of punters 'helping' is nice enough, as long as you don't get in the way. There's a bit of flail, but we find our way, find our rhythm, and soon the situation is being run smoothly. Or as smoothly as it can be. We're all on edge...

He's a big, and that makes life difficult - we're told he's asthmatic, so he gets his chest needled, and followed with tubes. We do everything we can, as if our sense of urgency will be felt by the patient, or maybe by God, and translated into tangible results.

But he's been down a long time. A long time, and we know what that means; we all glance at each other, but no-one wants to say it. My boss doesn't want to, but she knows someone has to, she has the courage, and is steeling herself, when the patient makes it moot; his heart coughs and splutters back to life.

I think we're all a bit taken aback, maybe too tired to be pleased, yet.

The drill continues, and he gets packaged up for the Unit.

I turn away, leave the room, have no more to offer.

I need space; sometimes it's best to do your grieving alone.

He was, he is, for now, four years old.

Benign Tremor

I recently discovered someone lit upon this blog while searching for advice on how to treat a torn frenulum (or "penis banjo string" as he - and I assume it was a he - put it.)

Dude.

Try pressure and hope it stops, cos you really don't want a stitch in the old fella....

Regarding comments made to this blog - it was never my intent to embarrass; just to let you know really. anyway, there it is.

I'm seconded to Paeds at the mo, altho' I still owe the ED my nights and weekends, so am trying to spend all of my time among the little people. It has reinforced in me the desire NOT to be a Paediatrician. Don't get me wrong - I love kids, but lack the mental strength to deal with them suffering on a regular basis. When kids go off, they do it properly - fast. Kal, over at Trauma Queen, writes about this, and the effects it has. He's also lucky enough to have seen that they come back up quick, too; but sometimes they don't, and I find that very hard to deal with.

So far, its mostly been wheezers, but I have got to go on a couple of transfers, which is always grand... provided nothing goes wrong.

Occasionally, I find myself wondering at how my entire speciality is basically dependent on the fact that shit WILL go wrong... someone's gotta do it, I guess.

Mind how ye go, now.

On Censorship

BBP hints at some skullduggery in the ED.
I like him, I enjoy his blog, I enjoy working with him; he is good at his job.

I am curious to know what has been afoot. I have been off the floor working with small people again, so can't speculate.

Freedom of speech. I'm a big fan; censorship is a bad thing. It's next to book burning. And yet... there must also be limits. Right? Does freedom of expression extend to someone who wants to come to work andshout obscenities at me? In general, no. I'll have him removed.

If something goes wrong at work, should it be public knowledge. There must be transparancy, but do people need to know everything? If you hide something, no matter how small, is it the first step down a slippery slope?

I think maintaining the moral high-ground is difficult. If I make a mistake, I'll own up to it. That's the way it should be, but I'll bet I could find an exception, one situation in which I could justify, if only to myself, bending the rules.

Ethics. Not just a county somewhere in England...

Burnout

I'm due a few weeks off; I'm beginning to think it couldn't come too soon. Off the back of a few nights, I worked a single day. It was not a good shift. Busy busy busy.

This is not unusual these days, with the hospital running at 98% occupancy most days. But I did not comport myself well. Over excited, showing off?

i don't know. In the final analysis, it doesn't matter much, but I was in a stroppy mood. Thankfully, no-one takes me very seriously, and they were more understanding of my temper than I deserve.

My last patient on nights was a three week old baby. One so very, very new to the world, but already too much medical history. Today's problem: vomiting. The little fella wasn't clearing his own airway, and for a few minutes I thought he was going to plug off completely. Actually for about 5 seconds, I thought he had. But a little soft suction, and I have never been so pleased to hear a baby scream. In fact, I've never been so glad to hear any sound.

Ever.

Last shift. Busy, busy, busy. But I told you that already.

Mostly in resus. Strokes, trauma, stabbings. Fractures, dislocations, head injuries.

The first was the hardest. A young woman, who had a 'minor' TIA middle of last year. All the right things were done. The proper work up.

None of which prevented a large, disabling stroke in November. Worse today. What little function she had had... gone. She came to us fitting. Easily treated.

The old routine, tourniquet on, hunt the vein. If you can't see it, feel it. A zen thing. It doesn't matter. I never miss these days. (Arrogant, moi?) The cannula slides in, almost a reflex after all these years, and a lorazepam chaser.

The fits stop; I told you that part was easy.

But she doesn't get better, she can't get better, she won't get better.

She gets worse.

I have to preside over it; the MC of this horror show. Her husband knows; he can't bring himself to say it; he tells me over and over how she was, how alive, how vital.

He's trying to do the terminal illness split. To distance himself from what his beloved has become, while staying true to her. When he looks at her, he still sees the love of his life, but he knows it's not her.

He can't do it, and we both have to take a few minutes out.

Burnout.

If all I have is being good at my job, and I'm not doing that well anymore, what's left?

I hope the break will do me good.

Let There Be Drums

So, actually, the last post had little to do with wishes, one way or t'other. This one does. Sort of.

Although, in unrelated news, I have decided the fictional doc I would most like to be is 'HawkEye' Pierce, as seem in M*A*S*H. But I'd most like to resemble the young Luca Kovac, from ER.

So... yesterday, I was workin a few extra hours, as penance for my record breaking oversleep. I owed 3, but asked to pay back 4, as a kind of debt of honour. It is always, always the little things that bite you.

As one a.m. rolled 'round (I should have finished at midnight), I was chatting shit with the SHOs, as is my wont. I heard the happy sound of a baby laughing; looking across the floor, I saw one of the sisters tickling a baby on a trolley in Bay Two.

In a split second everything changed. Almost in slow motion. In a film, or TV tie in, you'd see the smile fall off my face. The baby isn't laughing, he's choking, she's not tickling him, he's fitting.

As one, we're off, running across the floor, even as the call goes out - 'I need a doc here, NOW!'

He's a little one, 10 months, but chubby. A real cutey under different circumstances. He's hot, hot and clammy, and his whole body shakes, held in the grip of St Vitus' Dance. His parents, pushed to one side, are gibbering.

We have nothing paediatric out here... Sister and I support his tiny jaw, saturate him with oxygen as best we can; the adult mask looks ridiculous over his tiny face.

Soon, the carts arrive, someone hands me diazepam, in a little yellow dispenser. This stuff goes where the sun don't shine. No dignity now for the little fella; tho' in fairness it's difficult to maintain dignity when your 10 months old. Anyway, diazepam is in, and we switch to a better fitting mask. I can faintly hear his ma in the background: 'He's not breathing, oh, god, he's not breathing...'

The team is slick; I'm only vaguely aware of of them behind me, moving quickly, efficiently, handing me this venflon, that 'T-piece'. Now, blood bottles, now a saline flush.

Someone's with mum, explaining, reassuring; he is breathing, we are helping him, we're giving him drugs...

But, he's still fitting. iv access, a nightmare in chubby little ones... not this time; straight in, defying my shaking hands. Lorazepam, please. I revert to overly formal language, one of my foible.

'I'd be grateful if someone would do me the honour of passing me a miligram of lorazepam, at your convenience, please...'

Either way, it's there, as I ask for it.

In it goes, and now the monitoring is up and running. Other docs come and go, offering help, rubber-necking. The day has been quiet, now they all want a piece of the Shroom's circus. I'm not really aware of them. My mind is racing, trying to remember the algorhythm.

More lorazepam.

What's next? Paraldehyde? Paraldehyde. What's the dose? Do we even have it? Where do we keep it?

He'sbeen fitting for 20 minutes now. We're just about together enough to make the resus dash now; that's where the paraldehyde lives, after all.

Paeds have been called, but there's always something goin on, so it's us. It's always us.

We love it.

Paraldehyde is in, but he's still seizing, he's still hot. His airway is difficult to manage, but he takes an oral airway. This makes my life a bit easier, but doesn't say good things about his conscious level. Mum and Dad have finally had enough, and have stepped out, alone with their grief. I deploy a colleague to get the back story. I know nothing about this kid. Our entire relationship has been a fight between me, between us, and his febrile brain.

Next is phenytoin; my team have anticipated this, and 180 mg is drawn up, waiting. After that, we all know, is thiopentone; we aren't cut out for that, and the call goes out to PICU. As it's becoming apparent the paraldehyde ain't workin, Paeds enters stage left. God love him, he doesn't have any better ideas, and we start the phenytoin

Another line goes in, rectal paracetamol, and antibiotics, even before he can ask for it. Frankly, I'm still shitting myself, but my team are awesome.

Next onstage is PICU. The back story doesn't help, but the kid is sounding stridulous. This is high on the list of noises you don't want of hear when people are breathing.

The croup? Maybe.

I can still see thiopentone in all our futures.

But then...

As I'm holding his airway open, he reaches up, to push me away. He interrupts his tortured breathing to cry. I have rarely been so happy to see a grumpy frowning Winston Churchill look-a-like.

God love Phenytoin. He is coming around.

We sit him up, leave him to breath on his own. His airway no longer needs my sweaty grip. My focus begins to expand, and for the first time in an hour, I can see more than his little chubby face. My team swims into focus, and they're grinning. Like fools. I guess I am too. We're all pretty pleased with ourselves.

PICU is just as pleased. They always think we call them too early; we probably do. But I still see thiopentone in our future, and I like the company. Anyway, they fade to black, and leave Paeds centre stage.

As we all slip away, the chubby fella is sitting up, grizzling at us all. He's going to be ok.

He's going to be ok.

It ill becomes a man to brag, but we handled ourselves pretty well, considering we were caught with our shorts down to start with.

We can all feel good tonight.