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.

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.

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.

Timing

**WARNING: NAVEL GAZING**


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.

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.

eclipseArts Circus: Welcome to the first eclipseArts blog entry.

eclipseArts Circus: Welcome to the first eclipseArts blog entry.: Although eclipseArts have been in the biz for fifteen years, it’s never occurred to us to write a blog before. I mean, computers, what...

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...

30 Day Song Challenge 30

30: Your Favourite Song This Time Last Year.

Damned if I can remember.

It might have been this.

Seriously. Who remembers stuff like this?

Really Bored

But this was just too much fun to ignore; I've got a lot of time for this guy - Mighty Mike. Check his site, it's (now) in my blogroll...

Yes, I'm Bored

But is that Marc Bolan, Ronnie Wood and Elton all in the same video? Plus, I reallly love Bowie. And his son's films aren't too shabby, either...

Random Finds

I might have posted this before; I dunno.

I can't believe they didn't win...

30 DSC Day 29

29: A Song From Your Childhood

Define childhood. As a wee nipper, it might have been more Neil Diamond. So; two selections, one inherited from Ma and Pa, and one from my tween years.

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 28

28: A Song That Makes You Feel Guilty.

Nope.

Nothing springs to mind.

I'll think on it. (I'm scribing this two weeks in advance)

30 DSC Day 27

27: A Song You Wish You Could Play

Applies to almost all the songs thusfar listed. In fact, I like to be able to play any song.

As the old gag goes, I'd give my right arm to be able to play guitar like this.

30 DSC Day 26

26: A Song That You Can Play On An Instrument.

Cupboard is bare again, I'm afraid. Can't play, for toffee.

30 DSC Day 25

25: A Song That Makes You Laugh.

Scant pickings. I'll offer two; one a 'proper' song, the other intentionally comedic.

The Big Chill

In case you were wondering...

30 DSC Day 24

24: A Song You Want Played At Your Funeral

Another one that gave me cause to think. Quite fancied the organ version of Can't Always Get What You Want from The Big Chill.

If you're confused, go find the film, and watch it; you won't be disappointed, and you can play 'Spot Kevin Costner' while you're at it.

Anyway. I chose this.

(There is another live version on YouTube, but I wasn't keen on the sound quality, and this one coincides with the intro to one of my favourite films...)