Oddments

A multi-post. I had several good ideas on the way home, again; once again, I appear to have left them on the motorway.

Last night was an odd one. Most Docs and Nurses were living it up at the ED Xmas do. Not me, obviously. The gremlins seemed determined to make the most of our discomfort, and so, for reasons I still do not understand, the temperature in the Dept fell steadily to a nice round 16 degrees (Celsius); or maybe it was 14. The corridors were lovely, toasty warm. But the treatment areas? Cold enough to freeze the balls off a brass monkey.

(Bonus points for any of my dear readers who can suggest the origin of this expression...)

I also began to suspect someone was playing silly buggers with the nitrous, as everyone spent more time than usual giggling. Or maybe I just had something on my face...

The evening ended on a sour note. Another failure.

Young patient. Extensive forensic history, IVDU, epilepsy. Attended as he was having frequent, multiple fits.

But he didn't want treatment; and refused even basic blood tests. He said he had a needle "fixation". I guess he meant that to mean phobia? I'm not sure, but I was cynical enough to note the multiple tattoos, and history of iv drug use.

What he did want was us to "sort my meds out". Not without blood for levels, I countered. No blood he assured me; he was fairly certain I wouldn't find a vein anyway. "I don't even want to be here", he mumbled.

And so I failed him. If I was a better physician, we could, I'm sure, have discussed his fears and desires rationally. Maybe I could have helped. Instead, I got annoyed. Don't wanna be here? Fine. Thanks for stopping, and we'll see you later.

This made him very angry, and he described, among other things as a "no-mark, toffee-nosed prick, who thinks he knows it all just cos he's got a degree off the back of a Cornflakes box."

I'm afraid this made me a little more annoyed. I am well used to people judging me on the strength of my accent. It is particularly... plummy, shall we say. Posh, even. This is not my fault. It is the way I am. I am well spoken, and proud of it. But if you aren't, or your accent doesn't sound like mine? I don't care. It is not who you are. It is how you sound. But to have a go at me, because I am the very thing you have come to see - a well educated, well spoken medical professional? This seems pointless, and despite being used to being the posh boy, I increasingly resent it being used as an insult. After all, I choose not to describe my patient as a "no-mark guttersnipe junkie, who can barely read the back of a Cornflakes box".

So, despite my attempt to reason with him, which probably made things worse - he clearly didn't want to be reminded that to a certain extent, I do know it all, that's why I have my four degrees from Kellogg Uni - our therapeutic relationship was irrevocably soured. And he left.

He did not come back.

But I should have done better by him.

Errare Humanum Est

On top of a fairly tough week, I was confronted with one of my mistakes today.

Clearly, no-one likes to find they've made a mistake; I guess it's worse in this business. The magnitude of my error will become apparent with time, but no-one died, thank God, and no-one should. The sum total is probably an extra week of discomfort for someone, but... it could have been worse.

It probably does us good to realise once in awhile that we can never be too careful. I can add complacency to my list of failures of late.

I can only hope to reconstruct myself: better, stronger, faster...

We have the technology

(Although not to grow a 'tache...)

Insight

GodDammit, I'm tired.

On nights again. Out shifts always seem to be unpredictable; predictably unpredictable? I don't know. Either way, I'm all over the shop, and it makes it difficult to keep up. I begin to see why shift workers kill themselves so often. Our staff numbers seem to be forever shrinking. I'm not sure it's any easier for the bosses, but...

Tonight I'm doubling up with another middle grade. I don't like it. I prefer working alone, or with a regular 'team'. This is a kind of babysitting, allowing my colleague to ease int nights. I guess it's a test of my higher management skills. I think I'm failing.

We never eased into nights. Maybe we should?

Working with another is fine, but in case of banditry... I dunno.

This, of course, is compounded by my growing concern that I am not doing my job very well any more. I have always struggled with the extra-clinical work. I really don't care about research, and struggle to keep up. I enjoy teaching, but find it hard to find, or make time, to do the students justice.

But know, I'm wondering whether I'm cutting it clinically. I've always had faith in my own ability, bordering on the arrogant. I'm not so sure any more. It's all very well bemoaning bandits, and the poor quality of medical training these days, but it needs to be backed up by actually being good at one's job. I think I was...

Time to try harder?

F.E.A.R

Dropping the Ball

When something doesn't go according to plan, it's usually a system failure. There are rare occasions when someone pulls off an act of sheer banditry that couldn't be anticipated or mitigated by anyone else. But mostly, everyone fucks up a bit. I'm guessing most people feel the same way I do about this - everyone makes mistakes, but we rarely like to admit / talk about it. Mistakes in medicine are always a little bit higher stakes than in other jobs.

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Personally, I've made my share of errors; I've learned from all of them, but the rude fact of life is that shit still goes wrong. Generally, I've got tickets on myself. I reckon I'm good at what I do, so when it turns out I haven't done it to my best ability, I feel shit about myself for days.

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I guess it's the same for us all.

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It's easy to write about times when you did something that worked, or that paints you in a good light. The reverse is harder.

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I could imagine it might happen something like this:

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Picture a man who is involved in a car accident. He is rescued by the Paramedics after some 30 minutes. They assess him as having sustained no serious injuries, and he is shipped to the local ED. He is boarded and collared, and assessed promptly on arrival. His spine is cleared, and no serious injury noted. He is left for formal assessment.

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Several other patients arrive in the Department around the same time. One is apparently critically ill, and goes straight to resus, prolonging the wait of our fictitious patient.

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He is eventually seen by a doctor about an hour after he arrives. He has no complaints, except of some pain in his knees, which he has grazed in the accident. Physical exam is unremarkable at this stage, barring the fact that he is cool and clammy. His pulse feels rapid, but of good volume. He is known to be in AF. The attending physician notes that he was given 20 mg iv morphine on scene, and attribute the beads of sweat on his forehead to this.

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The patient is moved to another clinical area for monitoring. His first set of obs are done, after some 90 minutes. His blood pressure is borderline low, and his pulse still fast. An ECG confirms AF with a rapid VR, and slightly ischaemic picture. He complains of no pain, and his doctor wonders if the appearance might be the effect of the digitalis he is taking. Repeat exam is still unremarkable, barring ongoing clamminess. His doctor is slightly concerned by this. It can't still be morphine after all..? A period of observation is proposed; the patient declines, stating that he feels fine.

Anxiety growing, his doctor asks him to wait a little longer, and asks for routine blood tests and a fluid bolus to be given.

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Something like an hour later, the patient looks worse. His BP is lower and his pulse faster. He now has abdominal pain - although his belly is still soft.

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Now: 3 hours after arrival, he is moved to resus. Repeat assessment reveals some firmness of the rectus muscles. This will rapidly develop into a peritonitic picture.

Finally he gets a CT scan, and surgical consult. CT shows intraperitoneal bleeding, and he goes straight to theatre. Operative course is uncomplicated, and he recovers on ITU.

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My guess is things like this happen all the time. In retrospect, the hypothetical patient was unwell for a while, but an unclear history and paucity of physical signs allowed false reassurance. That he waited 90 minutes before first formal nursing assessment didn't help. As I said, this was a fictitious example. The Shroom might learn from such a train of events however. If mechanism sounds high risk, it is, even if the patient looks and fells well. Never trust the abdomen - trauma is a frighteningly dynamic process. And, especially, even if you think you know you're shit, you probably don't know it as well as you think you do.

Like I said, this was just hypothetical, and I'm certainly not trying to teach anyone to suck eggs