Medical Miracles

By and large, I don't believe in miracles. I am a vaguely religious man, so I'm sure they're possible. I just think the phrase is rather over-used, and had come to mean an unexpected, improbable outcome, not a true miracle.

Still, on Christmas morning, I found myself waiting in Resus, checking the kit. The call didn't offer much hope. An elderly patient, visiting family for the holiday, had fallen down the stairs. No output with the Paramedics. This sort of call tends to be an 'in-and-out' job. If they haven't got an output back by the time they get to us, they probably aren't going to. And while the NHS isn't ageist, God is, I'm afriad. Your chances of surviving cardiac arrest are not improved by being over 80...

Despite my fears, six minutes later, we were greeted with a bounding pulse. A moment of light relief passed us by, when the charge nurse briefly attempted one handed CPR while cannulating with the other hand. We waited, checking the scene, quiet bar for the slow rhythmic hiss of the ventilatotor; once the adrenaline wears off...

Half an hour later, the patient was warm, well oxygenated and ventilated, and still going. The intensivists duly attended and spirited our patient away.

Will they recover? I honestly doubt it, but maybe hope is all you get at Christmas.

Point and Counter Point

Anji left an interesting comment following my last post. For clarity, I'm reproducing it here, so as to offer my take.

I guess... as a patient and having experienced something say, a yeast infection or a urinary tract infection or a sore throat needing to be looked at, and getting the ol' "you're-wasting-my-time" look from the doc, I'd rather go to a PA while my doc goes and tackles something else much more challenging.

Or, at the very least... make my doc stop rolling his eyes when I haven't been able to swallow for two weeks and my glands are huge and I just want some antibiotics or some relief! :D

My husband is a medic with the canadian army and I'm encouraging him to go for his PA as soon as he is able to. He's too old (36) to start fresh and become a doctor but he's not too old to do the PA and still earn a living in his second career. We're so short of doctors here, anyone who can alleviate the pressure or at least, free up enough time so doctors can provide more care for serious things, would be nice. Something like, 10 million Canadians (out of 30 million in total) do not have a family physician. PAs would
really make an impact, in an area like ours with such shortages!

Personally, I think that, as Doctors, we should be happy looking at yeast infections/sore throats/UTIs. Generally, they don't need to be seen in the ED, that's true, and patients pitching up to the ED may occasion the rolling of eyes... BUT: if the system doesn'tprovide another opportunity for patients to see a Physician, then it's not their fault, and we should keep our eye-rolling to ourselves. That should be part of the deal: you can come to us with anything and not feel ridiculed. We should be allowed to roll our eyes BEHIND CLOSED DOORS. And I'm more than happy for PAs to see this stuff; but if their breadth of experience extends only to simple sore throats are they more likely to miss early meningitis? to mistake glandular fever for tonsillitis?

The point I'm trying to make, and labouring rather, is that Doctors have, or shoukd have, a breadth of experience, born of experience. And what at first glance appears simple and straight-forward may not be. I would argue that that is when we earn our pay - not in the vast bulk of practice, which is routine (and often gets better no matter what we do... sore throats are an excellent example of this, despite the public love of, and faith in, antibiotics), but in the recognition of, and prompt treatment of the more serious cases.

I reckon I could take one of my more dextrous, non-medical friends and teach him how to take an appendix out; but not what to do when things went wrong, or when the diagnosis doesn't match the operative findings. Being an expert in a very small area will mostly be fine. Mostly.

Do we need more practitioners? Yes.

But I'm not convinced that telling ourselves that, as doctors, we don't need to be dealing with certain conditions is the answer. Maybe, economically, it makes more sense to employ PAs, and if practitioners want to perform this sort of extended role - brilliant. But, like most solutions for thorny problems, I'm not convinced it's perfect.

Carry On, Doctor

Right.
It's early, it's dark, and it's cold. For the UK, anyway. My dear colonial readers can feel free to refrain from reminding me what real cold is like.

I've followed, with some interest a debate on the usefulness (or not) of the PA, or Physician's Assistant, over on some of my more erudite colleagues blogs. Check here, here or here.

As ever, it makes for interesting reading; and has fired up my little grey cells. Much has already been said on many UK blogs about extended role nursing practice, often not especially complementary...

I'm old nough to have seen the transition, and it does make me a little uncomfortable. Not because I'm not convinced that 'non-doctors' cannot do the job; they can, although I do occasionally have my concerns about the risks of such narrow fields of practice. But mostly because I increasingly see the 'extended role practitioner' doing the stuff on which I cut my teeth.

In 'farming' some of this work out, because wwe think it frees doctors up to do other (?more important) jobs, are we not mortgaging some of what makes us doctors?

I worry that we are.

Admitting Defeat

I had hoped to post one a day in December; it ain't gonna happen, I'm thinking now.

Ah, well...

A Nod To History?

A cellist rants:

Guilty Pleasures...3

And last: Neil Diamond

Guilty Pleasures...2

Also on my iPod: Natasha Bedingfield

Guilty Pleasures...1

On my iPod: James Blunt.

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....

Ghosts

Do we believe?

I don't know; hospitals are surely the site of more strong emotions than most, so should be primed for supernatural activity. I worked in a hospital years ago that was reputed to be haunted; talk was of strange occurrances, and odd sitings on the first floor. This was the da case floor, and usually occupied at night only by the Resident Medical Officer.

Which, for a year, was me.

I never quite saw anything, though on one night a few lights and a t.v. may have switched themselves on in a room a few doors down. Or, the other staff may have been yanking my ding-a-ling.

Who knows?

Shroom's jury is still out, but the other night, while decamping from my car in anticipation of another happy night shift, I was sure I saw someone lurking in the car park, just out of the corner of my eye. On glancing round, there was, of course, no-one there. I'm sure it was but a trick of the light, reflecting on my glasses.

But, try as I might, I could not repeat the feat.

Until I stopped trying.

Twice more I 'saw' him, and each time, he seemed a little closer to me.

A trick of the light, I'm sure.

Nonetheless, I walked in a little quicker than usual that night.

Ask Me No Questions

One to think about, or not.

La Belle Fille asked me this one. She uses it t see inside the minds of children, or something.

"If someone asks you if you have a pen they can use, and you say 'no' without looking, is it lying?"

Anyone? Anyone? Anyone? Beuller?

Bare Below the Elbow

Another great 'evidence based' piece of guidance, condemning wristwatches and rings to the same bin as ties and white coats.

Personally, I like a white coat, and when I started out was able to get a fresh, clean one from the sewing room daily. Seems like a good idea, no? But cheaper not to, and just fuck 'em, instead.

The idea that disease is caused by organisms, and organisms that can be transmitted by hand seems commonplace now, but is, in fact, relatively new. This doesn't stop the idea that making me roll up my sleeves will prevent nosocomial infection being, simultaneously, clutched at by infection control nurses as the next big thing, and utter cock.

Where does it all begin?

Who is the daddy of cleanliness?

May I propose Ignaz Semmelweis. (1818 - 1865)

In my experience, very few infection control specialists have heard of him; and fewer DoH inspectors. History? Why should we care about the past...?

Alexander Gordon, and Oliver Wendell Holmes both had an idea that sepsis after childbirth (puerperal fever) might be caused by the introduction of 'putrid matter' by the delivering doctor or midwife. Influential practitioners such as Charles Meigs were quick to deny this idea.

Semmelweis however, working at the world's biggest maternity clinic in Vienna, found it hard to deny the evidence before his eyes. Those mothers attended to by medical students had a far higher rate of puerperal sepsis than those attended by midwives.

His suspicions increased when a colleague died after cutting his finger during an autopsy.

By introducing something as simple as routine hand washing, he was able to slash mortality rates. His work was published, but largely unrecognised by his contemporaries, and it is sad to report he died in a mental institute.

Hand washing, yes. Rolling my sleeves up...? Still waitin' for the evidence.

Belle Of the Ball

Now that I'm posting again, La Belle Fille has not been slow to remind me she is disappointed with the level of her air time. 

Damned if I do, damned if I don't, it seems...

Work commitments, and the impending Noel have limited the time we've been able to spend together, so I don't really have any great tales of 'The adventures of Shroom and Snaily' to report. She is spending much of the weeknights backstage, in make up this week, which I find endlessly entertaining.

Anyway, out of script does NOT equal out of mind.

So there.

Autologous Autosplenectomy

**Rant follows**

Hospital, and thus department, busy as f...eather boas.

Spent more hours than is seemly trying to organise admission of one consultant's patient under the care of another; consultant 2 didn't wanna do it, and consultant 1 thought this was very unfair, but, curiously, neither would talk to the other, preferring to use me as a go-between.

Ultimately, grown men should be above saying "I won't be calling him, but if he wants to call me, I'd be happy to talk to him"...

I left a patient behind today, handed them over, after failing to get anyone to take them seriously; well, it wasn't so much that they wouldn't take him seriously, it was more that the general opinion was "Sure, he's sick, but it's because of (body system looked after by rival speciality)"

Details to follow, but I'm convinced intra-abdominal mischief was to blame, and failed to convince either the KnifeMen, or the Moths. If I'm right, I'm sure they'll try to lay it at my door; for what it's worth, I still think he'd perfed a diverticulum, but God forbid anyone should take my opinion seriously.

Le Shroom: c'est grumpy.

Paranoia Strikes Deep...

Yesterday morning was spent trying to talk down a spectacularly paranoid fella, who, when he wasn't freaking out because he thought he was blue, was challenging my status.

His exact words?

"I'm not being funny, yeah, but I don't even think any of you are real doctors. I mean, you're all wearing trainers, for fuck's sake!"

And The Band Played On...

I have somehow acquired another follower; which serves to remind me how remiss I have been of late. Well, if you'll keep the faith, I have no excuse.

I undertake to get of my arse, and keep my end of the bargain again.

Starting tonight; promise...

(And, yes, I've back-dated it; I'm cheating, for reasons I will explain. It's sort of my version of the Kobyashi Maru)

"I Dressed The Wound, And God Healed Him"

First in an occasional series of my personal medical heroes.

Ambroise Pare practised in the 16th century; he came from a family with strong surgical connections: his brother was a Master Barber-Surgeon and his sister married one. He served on the House at the Hotel Dieu for a few years, but appears to have been too poor to pay the barber-surgeons union dues, and joined the Army.

Gunpowder had been deployed on the battlefields of Europe since the 14th Century, and had completely changed the pathology of wounds received there. The military surgeon, was, at that time, of a mind to treat gunpowder wounds in a way designed to destroy the 'poison' such wounds were thought to contain. The 'obvious' way to do this was through extensive cautery, or by pouring boiling oil into the wound.

Pare, however found himself forced to improvise; having run out of "oil of elders, mixed with a little theriac" (which was applied boiling t the wound), he was forced to use an alternative - "a digestive made of egg yolk, rose oil and turpentine"

On reviewing his patients early the next morning, he found those on whom the digestive had been used in an altogether better state, and resolved "never again to so cruelly burn the poor wounded by gunshot"

He also went on to describe the technique of ligating blood vessels in the context of amputation.

Highs And Lows

Back, at least for a while. I had intended to wait a day or two, to refit my life all at once; but this idea came to me, and I felt i ought to write it before I lost my mojo again.

I am become a creature of the twilight; lates and nights stalk my rota, and I've forgotten what a normal day looks like. I'm sitting among the detritus of my life that late shifts bring, drinking rum, if that helps.

Sometimes, I feel like we make a difference; sometimes I'm sure we don't. But I guess we try anyway.

The first comes early; or late, depending on which end you're starting from. The shift is a swap, and horror often seeks you out on a swap. Whatever Gods look down ensure that no good deed shall go unpunished. Actually, the shift had been fine. I'd been cloistered in Paeds and Minors all night, my most challenging case a complex nail bed injury; some poor fella's thumb transformed into an horror of pulp. I spend an indecent amount of time trying to put it back together before admitting defeat and sending him to see Plastics.

I look up, and it's seven in the morning. The department is pretty quiet, and I allow myself the thought that I might get away on time.

The phone rings, and the shrill tones gently nudge my adrenals. The sound of that ring is embedded in my cortex, somewhere, along with crash bleeps I have known, all of which still exert a Pavlovian pull on me.

Enough. The story is bad, telling a tale of a young patient hit by a van, not breathing. I have to push selfish thoughts, the knowledge that I'll be late away out of my mind.

We wait. The department seems to take a breath, and hold.... on.....

Then the Ambos arrive, and it's let out in a gasp. Our patient isn't breathing either, and not tubed - the crew are double tech, and no doc able to attend. We lift him over, and I see his colour for the first time, pale and waxy. It is the absence of colour, that in my experience means all his blood has left the building, so to speak. It is always a bad colour, and in trauma, and in the young, spells disaster.

He is not breathing, and we call for the Intensivist.

10 seconds later, it is worse; his heart is not beating. The ECG monitor glares at us, the flat line telling me what I already know. He's bled out, his heart empty.

Blunt trauma, cardiac arrest. Only his youth stands on his side; but I know it won't be enough.

I struggle, briefly, with the tube. Not long enough to make a difference to him, but enough to unsettle me; when the Intensivist arrives, i stumble over my words; this has gone runny really quickly, and I am, as ever lucky to work with a cool, efficient team.

I decompress both chests, to prove the lungs are up, hunting for blood, not finding any. We drill into his shins, cut into his groins, filling him full of blood cold from the fridge. His pelvis and thighs feel stable, and I still can't find his blood. We slide a needle into the thin sac around his heart, and tap 10 mls or so out. SonoSite tells me there's no more there, and that his belly is full of fluid, in this context, the blood I've been searching for.

I look around; an hour has passed, and we've replaced his volume, pumped his chest, pumped his lungs.

It has done no good.

We all know it. I ask for dissenting opinions, and there are none. We make eye contact, one last time, a gentle shake of the head. My day is done now, and I won't be able to see his family, to tell them how hard we worked, how hard we tried. I leave the department unable to meet anyone's gaze.


The next day; the same phone. An elderly patient, bellyache and low blood pressure. The ?aneurysm. During the day, the Department is that much busier, the waiting isn't the same. At night, you may become the focus for h whole department, everyone coming to help, or at least rubberneck. On a day like today, everyone has enough to be going on with, and the only breath holding is done by me.

He arrives, awake and groaning. We lift him gently over, and I see his colour for the first time, pale and waxy. At least he's still talking to me. The Ambos belt out the history, of an hypertensive, elderly patient, 2 day history of worsening abdominal pain, now going to his back and groin. They couldn't feel an aneurysm, but the history and the pale, sweaty patient in front of them meant they didn't need to.

I feel it right away. It's big; too big, I suspect for the Paramedic to have found it; but, to be fair, the Surgeon, who arrives within seconds, is also skeptical. The SonoSite, showing a seven cm mass convinces him. Big lines, a trickle of fluid and some morphine kit our fella up, and we run to theatre. I love theatres out of hours; long corridors, deserted, with odd trolleys stacked neatly, promising work to come. We deliver our patient, and I'm pleased to see how quickly everyone else gets going. Surgeons, Gasmen, Intensivists. I miss this life.

As we leave, I look at the clock. 30 minutes have passed since he hit the trolley downstairs. I don't know whether I should feel proud of this fact, but I do. My good mood is improved immeasurably when one of the nurses skids on a wet floor while trying to open the door to resus. I should add, she didn't fall, or hurt herself, but the effect was hilarious. After she's skated past me, I look at the floor of resus; I'm struck by how similar success and failure are in what they leave behind.

Before I leave, word comes down that he made it out the other side, and there's a little spring in my step as I leave.

Lest We Forget

In Flanders fields the poppies blow
Between the crosses, row on row,
That mark our place; and in the sky
The larks, still bravely singing, fly
Scarce heard amid the guns below.

We are the Dead.
Short days ago
We lived, felt dawn, saw sunset glow,
Loved and were loved, and now we lie
In Flanders fields.

Take up our quarrel with the foe:
To you from failing hands we throw
The torch; be yours to hold it high.
If ye break faith with us who die
We shall not sleep,though poppies grow
In Flanders fields.

It's Back...

Farewell, Farewell

Continue in low mood; work has presented me with considerable flail, more than I ever banked on; more than I need right now... so, I'm not sure I'll be much of an author for a little while. Not long, I hope, but for now, a little hiatus.

Be Well, one and all... until the next time our paths should cross.

Farewell, farewell to you who would hear

You lonely travellers all

The cold north wind will blow again

The winding road does call

And will you never return to see

Your bruised and beaten sons?

"Oh, I would, I would, if welcome I were

For they love me, every one"

And will you never cut the cloth

Or drink the light to be?

And can you never swear a year

To anyone of we?

"No, I will never cut the cloth

Or drink the light to be

But I'll swear a year to one who lies

Asleep along side of me"

Farewell, farewell to you who would hear

You lonely travellers all

The cold north wind will blow again

The winding road does call

(C) Warlock Music; reproduced without permission. Lyrics: Richard Thompson

Thought For The Day

You can't make war in the Middle East without Egypt and you can't make peace without Syria.

HENRY KISSINGER (1923-)

My New Favourite Quote

There are, in fact, two things, science and opinion;
the former begets knowledge, the latter ignorance

Hippocrates

Borrowed from Trick or Treatment, by Simon Singh and Edzard Ernst. I commend it to you.

Why I Love Tech...

A pox on iTunes, which took it upon itself to delete several of my Floyd and Stones albums; and no they weren't backed up....

A Sort Of Open Reply

If only because some good points were made, and, if I have mis-represented myself, then explanation should be public.

I want to apologise for over-egging the pudding, suggesting that No-One, from the aforementioned NotDrRant laid all the blame at the foot of the docs. And I concur, there are indeed some truly awful docs in the system, and rooting them out has been, and remains, difficult.

I don't object, by and large, to swearing. I swear vigorously myself at any given opportunity, and the example I gave may have given the impression that it was an indirect dig, or slight, aimed at No-One. Not so. My complaint was more in general, and I freely admit that No-One has indeed not named any specifics. But sites do exist where people can, and do; and the lack of a right-of-reply remains. My own experience of this is acute. Where patients want something from the health service, often for a relative, that it cannot provide, their anger often vents at the nearest professional, rather than the system. Sometimes this is justified, sometimes not. Some of my patients seem to think it acceptable to call me a "cunt" to my face, to suggest that I obtained my degree "from the back of a cornflakes box", and then complain about how poorly they were treated....

Anyway, if you wanna swear, swear on. I meant no criticism.

On a more general note... will giving all the power to the patient solve the problem? I doubt it. Just as Doctors weren't meant to be administrators, neither were the bulk of patients. Yes, they can vote with their feet; but turning it truly 'private' might have a few unexpected side effects. Are we, the medics, afraid of having our snouts displaced from the NHS trough? Maybe. Bevan, after all, only swung the agreement of the Consultants in 1948 with a promise to choke their throats with gold.

For me? Makes no odds. I work in Emergency. Voting with your feet is rarely an option, and I expect I'd make more money if you paid for service. I'm all for patient power, but it has to be tempered with the knowledge that, just occasionally, I might know what I'm doing, might know better than you what the best treatment is. Currently, I have no financial stake in how you're treated.

Will I give you better care if I do?

(The answer's "no", by the way...)

Folk Music Re-'Imagined'

Buy the album, see them live... do it. You know you wanna...

Odds And Sods

Ruminations...

Struggle on, trying to finish some work related research, revise, generally live my life. It goes slowly; I think I'd be good as a sloth. Although not sure I'd pass the entrance exam.

La Belle Fille continues to understand, which is good of her; spent the weekend hanging out, which is good for the soul; I also had the pleasure of seeing possibly the world's biggest round of cheese at the local French market. God love the French.

A brief flag for NotDrRant. This blog has a very different spin on the NHS; a patient's view, and not a complimentary one. I'm in favour of free speech, so you should feel free to check them out, tho' I don't hold with their take on the causes of the faults ( to whit, it's all the doctor's fault. ) That having sad, the author doesn't seem to have been served very well by the NHS.

It raises at least one interesting point. (For a certain value of the word 'interesting') While patients can, almost without fear of censure or repercussion, write what they want about the medical profession, or indeed specific members therof, the medical profession has little, or no, right of reply. So, there is little to stop Mr Smith naming me as, for example, "a cunt", for all the world to read. But if I name Mr Smith as, for example, a wife-beating kiddie-fiddler... the Law has me by the balls.

On balance, I'm in favour of confidentiality. Publishing lists of naughty people all too often results in hysteria, and Paediatricians having their houses shit-bombed; but shouldn't there be some sort of quid pro quo? As a medical professional, I must be completely transparent; I accept this. I must also be inscrutable; I accept this, too.

But should there be some sort of checks and balances to stop my being compared to reproductive anatomy?

Surely Shome Mishtake...

You are a Social Liberal (75% permissive) and an... Economic Liberal (21% permissive) You are best described as a: Socialist Link: The Politics Test on OkCupid.com: Free Online Dating Also : The OkCupid Dating Persona Test

Bloke In A Dress

Casually, and swiftly, photoshopped by a good friend of mine.

I should add that the Shroom does not consider kilts to be dresses, skirts, or, indeed, anything other than manly clothing, especially whn worn 'Highlander', as both I and the Groom were.

I also have nothing against blokes wearing dresses. All power to all people, that's what I say. In fact, it's quite liberating, as long as yo remember to keep your knees together, and avoid scaring children / being placed on the sex-offenders register...

Gratuitous 'Skirt' Shot

God's Dandruff

Continue in low mood; it is what comes of spending long days alone, at home, ruminating on my own inadequacies.

My impending exam - the Fellowship, the exit exam, the big one... what it takes to be board certified, I think, if you're one of my Colonial brothers or sisters... dwells heavily on my mind. I've spent the last year pretending it was an age away; and know it isn't. I'm not sure where the last year has gone; it seems to have slipped away from me.

There must have been something on my mind (at least for the last 6 months).

Caught a programme on the Beeb a few days ago, about the birth of the NHS. 'Twas interesting, if only to hear the concerns of the (largely) middle class docs regarding the State control of medicine. That the doctor would no longer work for the patient, but for the state. That there would be no autonomy.That we would be told what sort of medicine to practice. Told what we could do and not do, say and not say.

While the GPs were against it, Bevan swung opinion through the influence of Lord Moran, President of the Royal College of Physicians; not by much mind - he only won re-election that year by 5 votes.It wasn't clear what role Surgeons had in all this, but I'm guessing that they too were amenable to having their throats stuffed with gold...

The objections seem to mirror those I see expressed by my Colonial brethren today, when threatened with Socialised medicine, and indeed they would seem to be (at least partly) valid... what was prophesied has indeed come to pass.

Is the NHS a good thing?

Fundamentally, yes it is.

I can't not believe that. People don't die because they can't afford to see their doctor anymore, childhood disease is a shadow of it's former self, and is only really coming back because of the gullibility, stupidity, superstition of certain sections of the populus, encouraged by the media.

Is the Continental system better? The American system? I suspect the practitioners thereof would tell you "yes", but, and I think there's some evidence out there to support this idea of mine, I'm not sure they offer better results per unit spent.

But maybe all that proves is that spending more equals better care... up to a point - see the way China works. But maybe I just don't know any better.

And a man can become little more than the sum of his ideas, his obsessions.

Get it right, and you're a genius. Wrong, a crackpot. We need to be careful about being defined by our own horizons, our own experience.

Consider the American tourist visiting the Bodleian Library in Oxford. Much impressed, she enquired of one of the Security Guards: "This place looks so old. Is it pre-war?"
With a haughty sniff, the Guard drew himself up, puffing out his chest."Madam", he replied, "it is pre-America..."

Does that fit a pre-conception? Should it? Is there any mileage listening to the ramblings of a man who thinks the height of comedy is a Gorilla drumming?

Thank you for bearing with, constant reader. Sometimes I just need to let the mind wander.

More sense soon.

(Or possibly just a picture of me in a kilt...)

Friday Random

If there's a better way to advertise chocolate, I don't know what it is...

Nights Drawing In

I continue in low mood; the 'Black Dog' and I always seem to end up struggling about this time; I suppose if I wanted to, I could call this Seasonal Affect Disorder. It always seems to coincide with the shortening of the days... but, not only do I dislike what I consider pointless labelling (see: IBS; CFS; Fibromyalgia...), but I actually enjoy this time of year; I enjoy the cold, crisp nights and mornings; I'm not quite so keen on getting up, and going home in the dark, but...

I think it is just overpowering nostalgia. Some of my happiest memories are rooted in these months; and I think it just serves to remind me how far I've travelled from them. I miss my friends and my family increasingly these days, and all the more so at this time of year. This year, my mind is troubled with impending exams, and the amount of work I haven't done - some things never change, I guess.

I think this is especially hard on La Belle Fille, who works as hard as I do, for less money and with considerably more organisation; so she finds it hard to see why I should be so stressed, and hard to find ways to help me. And she finds it hard to put up with my bleak moods; the stress isn't good for our relationship, which already labours under the constraints of both our jobs. I know she reads from time to time, so hope she'll manage to put up with my increasingly monk-ish behaviour over the next few months.

Name in lights...

Ever Wondered Why They Called Him "God"?

The sax solo ain't too shabby, either, but nothing beats Eric's guitar face....

Things That Make You Go 'Why?'

Hat-tip to Kal at TQ.
Further details to follow, especially involving La Belle Fille, who was heard to complain that her 'character' appeared to have been written out...

I could survive for 1 minute, 22 seconds chained to a bunk bed with a velociraptor

My Promises Are Nearly Kept

Saturday was unbearably busy; Sunday just unbearable. It was busy, I was irritable. The SHOs are hard working, God love 'em, but have a deal to learn about the appropriate time to strap on in Emergency Medicine. I'm not sure I helped much.

The tone was set, not so much by Drs Greene or Carter, but by two patients. The first, a young man with his own version of a biological clock; his aorta distended, over-ripe lay swollen and pregnant within him. He knew it was there and had had the 'full and frank' discussion with his surgeon. Weighed the odds of success against the chance of failure and the consequences inherent therein. He had, he thought faced his demons, made his choice, and defended it. The ultimate act of self determination.

Funny how circumstances can change a body's perspective. Each man faces death alone, and sometimes it hurts. He faced death in the company of us all, and asked for one more roll of the dice. We gave it gladly, some less calm than others, but we stood by him.

Snake eyes is still snake eyes, no matter how many hands help roll it.

Number two had other gifts, unknown, only now bearing fruit; spoiled and rotten; foul and terrible. Still I bore them, my words harsh even under the bright lights of the ED. My words, short, to the point, still have the power to bring tears.

Still, the next will be better, eh?

Knifeman's Blues

Shall I whisper to thee of the nights I have seen...

My nights are full of coffee and hope; hope for a quiet life, and yet hope for a chance to show off and do my job. It is an interesting dichotomy - I enjoy seeing the big cases, treating the really sick guys and gals... but it means someone has to be sick...

Quiet? Or busy? I know which I prefer, but it's for selfish reasons.

Shall I tell thee of the ways the nights begin?

Heading to my car, I realise it's dark, and with a slight chill in the air; I have blinked and missed summer. Actually, the last year has been something of a blur, but I was counting on summer. Driving to work, I feel cocooned in my car; isolated. I try to use the time to prepare for the joy that is too come. Sometimes it works.

Shall I tell of the tells we see?

The first is the ambulance bays. If they're full, and especially if there are plenty of Police jostling for position, it bodes for an... interesting night. Resus is next; I see it as I come in the ambulance bay doors. Last night it was humming, full of eager doctors, jumpsuited road warriors and coppers. A stabbee and the stabber all in a messy package. The first 3 people I see advise me to turn about and run, before it's too late. The next is the Charge Nurse - he asks m to start early - 'becaue we're a bit fucked'.

It's going to be a fun night.

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.

Honesty In Advertising?

The Love Of Money...

So, today, I both read, and heard on the radio of the hardship QCs are being forced to endure. The new minimum rate of legal aid work is a paltry £91/hr, rising to a max of £145. The say this is risible, especially as they reckon half of the cash goes on overheads and taxes.

By my reckoning, if I earned £91 an hour, and took home half, I'd clear almost 9 grand a month, and more like 14 grand at the higher rate.

Poor bastards; how do they manage?

(Incidentally, they say that the lack of paid holidays and pensions makes the rates reasonable; to be on my take home, which, let's be honest is not to be sniffed at, I suspect they'd have to be paying 90% of their gross in taxes and pensions and unpaid hols... on balance, I think I'd take their pay and terms over mine... if I could find a lawyer who'd trade...)

In Case You Were Wondering...

Comments get e-mailed to me.

Tales of derring-do from Paeds to follow...

Musings Of A Medical Dinosaur

A work in progress.
Worth reading, to start with.

The wind is changing; has changed. Jane Doe, writing the jib I've tagged above, typifies what I have come to think of as the 'modern' attitude. Respectable papers in such august journals as the Annals of Emergency Medicine are chronicling the decline of the once mighty General Surgery. In part, this is because specialisation makes being a generalist difficult, but, and perhaps this is the greater part, also because no-one wants to work the hours.

Long hours, once seen as the domain of the macho surgeon, are no, it seems to me, increasingly seen as both unnecessary and unfair. Many young Docs, confronted with the sort of punishing shifts once common in the NHS were taken aback. It was not what they were expecting. I must confess I find this hard to credit; it was hardly a well kept secret, and many medical dramas made it a key feature - see The Houseman's Tale, Cardiac Arrest or even ER for reference. Perhaps I write from a privileged position; Pa Shroom was in the business, so I saw the routine 12 hour days, and 1 in 3 (1 in 2 when someone was on leave) he worked - and this as a consultant.

I knew exactly what sort of hours I would be expected to put in.

But if you weren't sure... surely it wasn't that hard to find out..?

The way I see it, the way I saw it... you worked all the hours God sent when you were young, and I will never be that young again, and it got easier as you got older. I was always at work earlier, and later than either my SHO and Reg; I'm sure they worked harder, were cleverer... but I worked as long, if not longer.

Was I tired? Yes, all the time. Did I make mistakes? I'm sure I did. My shroomy pride has blotted the copy-book of my memory clean, but I know I didn't kill anyone. Did I learn anything?

Almost everything I learned, I did on call; often in the darkest hours of the night, often in desperation. Was this the best way to learn...?

I can't say that it was, that it is. I'm sure it's not, but it worked for me; doing my time pulling scut duty taught me the basics. Some might say that putting iv lines in, mixing and starting iv drugs isn't real doctoring. It certainly ain't glamorous, but it's as much the duty of a doctor as anything else. And what happens when the iv techs aren't there, or can't get it?

They call me, or other grumpy bastards similarly full of themselves.

Continuity? Sure, you can never have absolute continuity, but it seemed to work better. It was the exception, rather than the rule that someone on the firm was away, and we all knew all of our patients.

Is the way I learned better? I don't know, but it did work for me, and I know I'm not alone. Is that reason enough? No. To say 'I did it this way, so you have to too', is blinkered.

But it shouldn't be dismissed out of hand either.

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...

Son Of A Sunweasel

I know, its basically bragging. But it's nice to feel appreciated once in a while...

Jiggling Like Hopeful Ducks

See this. And this, the original.

A veritable foaming sea of bilious ranting. Nurse K has much to say on this, as ever. It's worth reading her blog, even if you don't agree, though it might push your blood pressure up.

The truth, I suspect, as ever lies somewhere between the two extremes. Migraines are ever a hot topic. I'm faintly curious that we seem to suffer the problem of the migraineur who may or may not be drug seeking less in the UK than in the US. Or do I just see less of it. Or maybe it's because we don't give dilaudid for migraine. I think, but feel free to offercorrections, dilaudid is pethidine. I used to dole that out like sweeties to old ladies with broken hips when I was but a young fungus. Now, I'm given to believe it doesn't work so well as a painkiller, but does get you off your tits.

I don't see much comment on this matter in the US blogs. Specially not for the patients who say it's all that will treat their pain. Put yourself in my shoes. When someone asks for a drug which, as I understand it, has no more analgaesic potentcy than, say, morphine, but does get you high, what should I think?

I'm sure it relieves your symptoms, and makes you feel better... but booze does that for an alcoholic. I haven't seen many posts advocating my prescription for Tennants Extra on demand.

I should declare a conflict of interest:
--- I don't believe in certain medical conditions, fybromyalgia, among them
---By which I mean I believe in your pain, I just think it represents a failure of coping mechanisms
---I don't believe narcotics prescribed in the ED are apt ways of dealing with these conditions

However, I recognise that this doesn't give me the right to dismiss your complaint. Just cos I don't believe in a medical label, don't make me right - plenty of folks didn't believe bacteria might cause ulcers. Plenty of folks don't buy into the theory of evolution through natural selection.... vive la difference.

I also recognise the need to spend more, not less time making sure we don't miss anything on the 'frequent flyer'. One of our regular attenders, a fella who for years laboured under the effects of his excess alcohol consumption, who for years was managed more on the basis of his past than his present was recently diagnosed with a malignant tumour. Did we miss it by dismissing his claims - "drug-seeking"; "pisshead"; "always doing this"?

I don't think so; I hope not, but a timely reminder that the boy who cries wolf daily is sometimes being chased by a big fucking dog.

Do we lack compassion? Sometimes, despite our best efforts, of course we do. It was said of Napoleon's Surgeon that he was the 'least among men'. Good practitioners sometimes lack people skills. Or does this automatically disqualify them...

Lest We Forget

tug-o-war.

tug-o-war.

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Hard Done By

Self deprecating... maybe; it's almost a requirement of the Citizenship exam these days. "Hard-done-by"..? Not really, and we all know it... but it does make for better copy.

For most of you, this will make precious little sense... but you know who you are.

Sometimes you see people get sicker before your eyes. I know that sounds somewhere between common sense and bollocks, but it fits, if you think about it. I've blogged about it before, but can't quite remember when; no bother. What I bring to the table tonight is the opposite. Which is always better. Almost by default, we of God's Children in the ED tend to assume the worst, and work backwards. You miss less that way. And when BatPhone goes, you prepare for the worst.

For example: the call comes in, warning of an adult male, stabed in the leg, in the thigh. Pale sweaty, tachycardic. The thought that flickers in to view, that crawls out of the back of the subconscious is the Butcher's Cut. Well, that's what Pa Shroom called it. KnifeMan slang for the wound that cuts BigRed, BigBlue and BigRed again. One cut, in the groin; the unkindest cut, the Butcher's knife slipping past the apron...

Plenty of claret, difficult to stem.

So you prepare for it, steel yourself and in rolls a very healthy looking fella with a wee knife in the front of his thigh, minimal bleeding. And he's waving. A jaunty smile, God love 'im. He has the decency to look slightly embarrassed, but by now, you don't care, because the patient just got better in front of your very eyes.

Last night: the call is worse. A young 'un, a tweenager, found down, unresponsive, no blood pressure... no more details, but what you have is bad enough. Late at night, it's just you; you hurry to guess-timate their weight, prepare the drugs you hope you won't need, gather your wits.

The Ambos roll up, and already its better. They're older, more responsive and obs sit on the normal. You take a breath, but still have a vomiting comatose teenager to deal with; this is still not an happy combo. They have definitely NOT been drinking you hear as you offload onto the trolley. They heave, determinedly, and you do the gallant thing, and roll them onto their side, but ensuring it's the side that faces Sister.

In the vomitus? Vodka. Sister has a nose for it. I can't smell it, but she assures me it's there. I learned early not to doubt Sister.

So, in about 30 seconds, my patient has transformed, from one with no blood pressure, and no neurological function, to one who just had a bit too much fun.

Now, granted, people still die from drinking too much, but rarely, and here is something we can deal with, something significantly more benign. Drunk teenagers? It's virtually our speciality...

The same patient provides us with the best quote of the year a little later. Sister, while assessing our patient's response to pain, employs a technique not unlike Mr Spock's Vulcan nerve grip. As well as confirming our ability to wake this patient from the alcohol induced slumber she presented with, it elicits a response that draws heavily on an epithet that might derive from instructions to procreate issued by a monarch.*

Sister is not keen on bad language. "Don't say that!", she implores. "Couldn't you say something else? Something like: 'Oh, Fairies!'"

*Fornication Under Command of the King since you were wondering....

It is three in the morning, and all is not well; I have had to recuse myself from the floor, after suffering a compassion breakdown. (I hope I’ve used the word recuse in vaguely the right way, as I’m only doing so to try and impress my legal readers; well, one in particular… ;)) Today is changeover day, so all the characters in our ED drama have changed; I wonder if the punters of our catchment area know this, but suspect coincidence.

On the good news front, La Belle File is back; in fact when I was finally able to re-establish voice comms, her first words were: ‘I’m back!’ delivered with some conviction. I’ve been on nights, so joyous re-union has been slightly muted. Work, however continues to provide cortisol raising frustration;

The complaint
Complaints piss me off. I should say that I am in favour of them – people must be able to challenge our decisions and our authority if they feel we have wronged them; and we must be transparent in our practice, and robust in our defence, even of controversial or unpopular decisions. But people who complain when they are ill informed, or who will not let something drop… it is these guys that hack me off. I am currently answering for my actions of a few months ago, largely because someone not connected to the case is trying to dodge the real issue. Clearly I cannot go into detail, but a situation arose in which we had to deal with a particularly difficult patient, and were required to make several decisions for this patient, and implement them against the patients wishes. Further assessment required specialist practitioners, who were duly called and advised the patient be removed to a place of safety; some force was required to do this, and the patients relatives were unable to see the patient for some time thereafter. They clearly felt excessive force had been used, and that the law surrounding management of this kind of patient is archaic.

They have a point.

They wrote to their local representative asking what might be done to bring about reform of the laws governing this sort of situation. Their letter barely mentions the hospital, and is not critical of our treatment. Yet this representative, who I suspect spends more time polishing green leather sofas with her ass than knowing her job, has written to enquire why the patient were not more closely supervised, and why transfer to another facility not enacted earlier. The patient in question was given one-one care at all times; they could not have been more closely supervised; and the transfer did not take place because the other facility did not want the patient, not in the state in which they ran amok in my department. And yet a casual question implies poor practice on our part; and does nothing to address the original question, of what could be done to make the law more palatable.

In truth, part of the problem lies in that there is no gentle way of subduing large, violent aggressive patients, and their restraint will invariably leave them shaken; laws will not change this. Some people cannot be talked down, but relatives will always feel for their own; there is, of course no mention in any complaint of the physical violence visited on us by the patient…

The poor wee fella found at the bottom of the stairs by BBP has had insult heaped onto injury. Any death with 24 hours of admission must be referred to the coroner, and the circumstances of this case mandate an inquiry. Because the patient still lived when I went off shift, I could not contact the coroner, and neither the doc who certified, nor the admitting physician, nor the neurosurgeon who would offer no hope nor the intensivist who passed and pulled the tube would spend 10 minutes on the phone to the coroner to tell him this. An huge round of shoulder shrugging, not my problem, don’t wanna get involved. All that was required was to phone the coroner’s office, and tell them the sad circumstances. I did it; it can’t be that hard, but their indifference has left a family in limbo for a further six days, until I came back on shift.

As for tonight, and my recusal…

I generally try to be empathic, and compassionate to everyone; but as I started this piece, the only patients inn the department were as follows:
Hypoglycaemia – known diabetic, brought on by not eating, and drinking 12 cans lager
Drunk, slightly hysterical following argument with friends (not present in dept)
Drunk, decided to go swimming. Got cold, may have fainted
Drunk, mixed (non-lethal) OD
Not one among ‘em with a proper problem not self inflicted. One ended up punching a staff member, and left with HM constabulary. The rest enjoyed a restful, warm night at the taxpayer’s expense.

The last two nights have been a bit psych, in that we’ve mostly ended up chasing semi naked girls about the dept as they scream at us. One, declared fit for d/c, escaped and was found in a bush, shivering against the thin covering afforded by arseless hospital gowns, with her thong tied around her neck.
Our psych cover seems woefully inadequate. The liason service soldier on, but their primary mission was never intended to be the MH assessment of all and sundry in the ED; and yet we have nowhere else to turn. Why the psych SHO cannot do an on call like every other bugger is beyond me. And woe betide you if you’re over 65. They do have an on call doc, but they don’t get out of bed; at least not to come to the ED

If you have severe aortic valve disease, and undergo surgery to have it replaced, basal atelectesis post op is not unusual; nor is it unheard of for LRTI to develop; but when you return, 12 days later, with that LRTI inadequately treated, and worsening chest pain, breathlessness etc, it seems that your problems no longer concern your surgeon. Post op complications would appear to be either a thing of the past, or something the surgeons are only to keen to farm out to others. If our knifemen are only going to be just that - knifemen, technicians, hernia specialists - then why the fuck should we pay to send them through medical school..?

**Rant ends

On Politics

It's mostly bollocks, let's be honest.



La Belle Fille has been away, I have been moping. Drank far too much yesterday, celebrating a friend's impending wedding; have to work today, which obviously I am very pleased about...



Was paid a sort of backhanded compliment by a neurosurgeon the other day, when they opined that I broke bad news well. I suppose if you're going to ruin a family's day, you should do it well, but I can't help but feel it's a sad thing to be good at.

On Responsibility

Talking to the mother of one of our patients today was hard work. She was on the end of the phone, in a tropical hideaway. Her relative was with us for the second time in three days, brought by family friends.

The first visit followed a fit, but we knew they had epilepsy, and there was nothing unusual in this. Even if it was, as she put it, 'a big fit'.

Today was for an overdose. We ran the medical ruler over the patient. All clear, no ill effects, the recommended observation period passing with incident. The headshrinkers came down and opined. No need for sectioning, no need for admission. Community support in place.

The phone call was hard work because, after all this, I proposed to discharge the patient. It was half five in the after noon. 'So you're just going to put them out in the street?' she spluttered; I allowed that, while that's not exactly how I would phrase it, we were going to discharge the patient.

'But getting home means taking buses, and trains...'

The patient was well over the age of 21, living independently, and had been taking public transport, unaccompanied, for some years.

I just know there'll be trouble from this, but I'm not sure where they think their parental responsibility ends, and mine, as Emergency Physician, ends. I think what they wanted was the patient detained, possibly encased in cotton wool. The outrage, that we would not admit them for either their chronic, stable medical condition, or for the psychological flair up, or indeed because the patient's keys were at a friend's house, was palpable.

On Pathology

Students in the department today. This usually means it's very quiet, but not today. Chief among the citizens who walked right out of a textbook was a fella who had been rather too friendly with the booze; years of one too many had rotted his liver, shrivelling it and firming it up, making it almost impassible for its rich blood supply. So now blood finds another way round, and one of those ways is through large dilated veins at the base of his oesophagus.

When these varices leak, they do so like a hose. He's been through this once before, but been lost to follow up. So he sat before us, shivering, an odd lemon yellow tint to his gaunt skin. Even as we called the Magicians and the endoscopist, telling them that he was stable, we knew it would turn out to be a lie.

But he didn't look too bad.

'Fooled you'

Innocently mumbling something about feeling a bit rough, he sat up and disgorged a river of claret. Bowl after bowl he filled, till his pressure dropped low enough that he couldn't hold his head up no more.

And still it came.

Then we moved in a blur. Organised flail - central lines, arterial lines, blood, platelets, the works. Curiously, he was most worried about having to have a catheter, and fretted about the speck of vomitus that streaked his chest, daubing him like some sort of Biblical door-frame. Odd, what seems important when one's life is literally draining away.

As all this raged, a young fella stabbed to the chest occupied my colleague on nights, and as I left, I saw the Sister of the Night pass him a CodeBlue sheet. I didn't catch the full story, but distinctly heard the words septic and unwell.

When it rains, it rains...

On Flail...

Grand old weekend with La Belle Fille... mild deployment of crossface. I think the honeymoon period is over, and we grump at each other a little more. This is probably a good thing; stops the evil humours building up.

And then... after driving to Kent for a toddler's birthday party, with balloons an' all, then back to La Belle Fille's place, my concentration wavered for a mo'... and wang!
Clipped the curb at 60, and shredded the offside near tyre. Didn't roll it, flip it or get rear-ended which is to be thankful for, I guess.

Swore a lot, the called the AA. Their rep took an hour and a half to find me, and when he did arrive, gave me an earful for not knowing where I was.

Charming.

He recovered me to the nearest services, before gleefully telling me I'd fucked the wheels good and proper, and would not be going anywhere that evening. He then told me the AA wouldn't recover me, as my 'breakdown' was an RTC.

Balls.

Reaching into my oversized wallet, I found my insurance details... missing. A panicked phone call to the Belle Fille, and she was able to surf the Web to the number I needed. My affection for her knows no bounds.

Insurance company eventually arranged for me and the car to be recovered. The following morning, the fattest Oriental man I have ever seen handed over a courtesy car, but kindly refrained from sucking his teeth at the state of the Shroom-mobile. I still wait to hear, and the Insurance will cover it, unless I've secretly written it off.

Details to follow as news warrants...

If I Should Fall To Rise No More...

Another one of us runs aground; a fellow blogger, whose work I try to follow closely has been rumbled. It's always a risk, if one tries to keep this sort of thing secret. For those of us who blog about events that might have involved other people have to worry about libel, and, for the medical blogger, issues of confidentiality.

There have been a few relatively high profile cases, and I think it's why most, if not all of us write hypothetical, or composite cases. I occasionally mention real people, and talk about patients, but I remind you all once again that the details of the cases are representative only.

Except of course when I saw that Patricia Hewitt is a bitch. That's true.

Fact.

Anyway, I'm not sure what fate awaits our fellow blogger. People I work with know I blog, but have chosen not to take me to task over it; I'm fairly sure my writing is cast iron enough. I guess it's probably good advice not to describe colleagues in a derogatory way unless you don't care if they read it.

Which brings me nicely onto another rant about my surgical colleagues. I apologise for the overly whiny nature of my recent posts. But I need to vent. Colossus, God love him, had to endure my initial autologous autosplenectomy on my way out this eve. Now I choose to share it with y'all. I'm trying to vent enough that I won't chew La Belle Fille's ear off.

In defence of my colleagues, I'm sure they are all excellent surgeons; and, I have no doubt, that if you quizzed them about me, there would be plenty with which they could find fault. It is easy to paint a picture that seems to make your point of view the reasonable one. What follows is thus not an objective telling.

It's my blog, however.

Again, this morning, the facial surgeon was confronted with a patient with diabetes. The mere presence of this rare and exotic condition seems to have struck fear into their hearts, and they duly requested a medical review. When they were directed in the direction of the phone, and provided with the bleep number, the better to discuss the case themselves, it was decided that, perhaps, discussion with the duty magicians was not necessary, but would the nurses ask me to look over the results.

When I was a wee fungus, we always directed our questions up the chain before going sideways. I'm not sure when that stopped.

The patient managed to give their own insulin, as they do every day, without sustaining horrific mishap, and got to outpatients in one piece.

This afternoon, I spent a joyous time talking on the phone to several of my colleagues; my conundrum concerned a young woman, obviously shocked, with obviously intra-abdominal mischief. The cause was not immediate apparent, but we were leaning toward an abdominal aneurysm. The General Surgeon was sure it was an aneurysm, and wanted a scan. He was reluctant to see, or touch the patient. The Vascular Surgeon was equally sure it was not an aneurysm, and wanted a scan. He was equally reluctant to see, or touch the patient. I eventually managed to get them together, but this did nothing to disabuse me of the idea I have that we are increasingly substituting 'a scan' for examination of the patient.

Interestingly, despite all the assurances to the contrary I received from the Vascular boys that an aneurysm was not the problem, the scan suggested otherwise. I saw the vascular boys after the scan; no comment passed between us about how interesting the results of the scan were; I suppose they were rushing too quickly to theatre to talk.

Lastly, and what eventually kept me at work two hours after I should have left, I spent some considerable time with a young patient. They have a complex psychological disorder, which results in frequent visits to the ED. Much time has been devoted to the investigation of their symptoms, and they frequently take their own discharge. Tonight was no exception, but what nearly pushed me over the edge was when the patient was returned, against their will, by two well meaning non-clinical staff. Despite my best efforts, I surely felt that they considered me derelict in my duty, as our patient did not look well. The idea of capacity, and right to refuse treatment did not seem to compute. We eventually parted company, agreeing to differ, as my well meaning colleagues were not willing to wrestle to patient into the Department, not willing to section someone they know nothing about. Which is just as well, since merely behaving in a way you don't approve of is not grounds for declaring someone mentally incompetent.

I suspect I may hear more about this one.

I'll try to be less sanctimonious tomorrow; I'm sure it doesn't become me...

Singing The Body Electric

Hacked off.

Lethargic, a bit febrile, and with, as ever too much to do, and too little motivation.

Spent the weekend with La Belle Fille, but was so intent on trying to make her proud of me in front of her friends, rather became a show off, and then something of a penis. Just once, it would be nice if I could cut loose without being an arse; mea culpa, mea culpa, mea maxima culpa.

Have found sleep hard to come by the last few days, so increasingly ratty at work. I always resent being tired ad grumpy at work; it makes me short with people who don't deserve it, or at times when more could be achieved with less acid on the tongue. Particularly frustrating to me today were the efforts of some of my surgical colleagues to avoid admitting an old boy with a dental abscess.

I fully recognise that I am, at times, less than the most conscientious doc, but I always try to do my job. I do not turn away from what is difficult, because it is so.

So, when confronted with a patient labouring under the ravages of a dental abscess, it would be nice if this was greeted with pleasure; not at the illness, but at the opportunity to make someone better.

Not with excuses, and lame promises to treat the patient "as an outpatient", while at the same time suggesting admission under an alternative team. To say that, as a doctor, you do not know how to treat someone who is confused, should really be too embarrassing to contemplate. Instead it seems to be a valid reason for not treating the patient.

I find this increasingly among the surgical specialities, who seem set on returning to the days when they were not Doctors, but tradesmen. One of my orthopaedic colleagues, when referred a patient who had, with a sharp knife, opened her wrist into the joint itself, declined to take on the patient because she had also taken an overdose, That the OD was non-lethal, and over 12 hours old meant nothing to him. He was genuinely afraid that the patient might become unwell in a way that was beyond his ability; and was quite prepared to neglect treatment of her semi-severed wrist to avoid such a possibility.

I sometimes wonder if we all really did go to medical school...

Finale

Wimbledon is going to the wire as I write...



So - yes, a fractured clavicle, which was spotted; but as the second recall X-Ray shows, a few busted ribs too. Try as I might, I cannot see them on the original, even with the advantage of digital viewing, denied you guys...




It's still not a brilliant image, but I think you can see the healing right sided rib injuries. Thankfully, no underlying lung damage.

Nights pass, as they do; Friday was busy for TooTall Student, so I think she got a good flavour of the ED. My main flail was trying not to call her by La Belle Fille's name... We ended on a Shroom 8 a.m. special. Just as we wound down for handover, the call came in, courtesy of BatPhone. The real deal - 40s, cardiac arrest 15 minutes away. !5 anxious minutes to try and gear up, try and get your mind running again. The nurses change at half seven, so they're fresh, but we medics all smell a little fusty. It's an odd scenario, as the bustle in resus goes on with the night guys drifting out, saying their goodbyes, making breakfast plans...


As our patient arrives, so do the day staff; we're short handed at weekends, so I stay and DayReg takes handover; he floats on the periphery, filling in the little details that my morning brain can't quite fix on.


The damage - a young fella, we think he has Wolff-Parkinson-White, an electrical short-circuiting of the heart, predisposing him to arrhythmia; we think he may have taken some drugs... we know he was found down at 7, we know he had no output at quarter past. He is unceremoniously dumped on our trolley, the Ambos herding round, bright-eyed, a sheen of sweat on a few brows; they've done their bit, and done it well. They know this, and don't need me to tell 'em, but want to know if we can finish what they started.


Chaos ensues, for a minute or two, checking the tube, forcing air into unwilling lungs, hands slipping on his greying chest. Then, we pause, come up for air, re-assess.


Got him.


Weak, yes; thready, yes. Hardly a thing to be proud of, but he's got a pulse. His rhythm is crazy on the monitor, never staying in one place long enough to get a fix. More drugs, more air. ITU and Cardio arrive.


Lost him. Four more frantic minutes until we find him again, pull him back over the edge. ECG shows a large MI, and we know why; the CathLab is being warmed up - we have indeed moved into the 20th Century - but I'm not sure we'll get him there.


Thankfully ITUMan is. He doesn't strike the epitome of cool across the room, but he is. Collected, organised, he casually takes over... and I am glad. Slowly, the patient heaves to, listing a little, for sure, but slowly doing what we want him too. ITUMan disabuses me of some ideas about the properties of fentanyl, and I feel generally clumsy next to him. I blame my 8 a.m. brain.


No matter; just under an hour later, he rolls out, with our patient, stable for now, onward to the CathLab. From what is undoubtedly at least two people's public tragedy, we are all smiling. We've done well, here today. Done what we were paid to do. We don't know if it will make any difference in the long run, but that's not our job. A little messy, disorganised? Probably; I expect I shouted a bit too much, too, but he came in dead, and went out alive... cliched?


Sure, but right now, I don't really care.


They're still on at Wimbledon...

The White Hare

Another long week... nights to follow; I swapped a while back, without realisation that this would lead to a 14 day stretch... I suppose our sins always find us out, and it could be worse...

Too-Tall medical student is on with me tonight, and has promised not wear heels, so maybe I can play some part in furthering the education of the next generation. Or not...

Many brave small folks this week. I think I've offered before on how the self-possession of some children just takes my breath away. I don't know whether his is because they've been brought up that way, or if they just are.

This li'l fella let us straighten this with just nitrous; he barely blinked...

Go figure...

Well, time to see what joy the night will bring. UK readers should take the time to go see Kung Fu Panda. You know it makes sense.

Dance Like Nobody Is Watching

ImpactED nurse is always worth reading; but occasionally unearths a real gem. There's hope for us all...

Mea Maxima Culpa

Continuing the missed X-Ray series.

I thought the second radiograph was o.k; so I fell back on the age old staple of serial observation. The patient settled, so no CT. 3 weeks later she called to say the pain had not settled, and returned for a review...

I apologise for the limited quality of the images thusfar; but I think the abnormalities are visible on this one; sadly my colleague, who reviewed the patient, didn't...

The Gathering Dark

Some shifts you just want to go home and stand under a hot shower...



La Belle Fille has been away this weekend, living it up in the country. I have missed her, perhaps more than I expected. Which I actually think is a good sign, at least for our future. We seem well suited, despite the fact that what I intend as gentle teasing oft emerges as slightly insensitive / poor humour. My boss thinks she's to good fro me, and she might be right. Still, I am assured that she acquitted herself admirably both on guitar and vocals (in Rock Band.)



I am proud.



The Department was generally quiet today; but the BatPhone trilled its urgent call to shatter all that. Normally the figures Control relay to us are all business - pulse rate, blood pressure, Glasgow Coma Score... tonight, they added another - the patient's weight. 30 stone. (420 pounds, or 190 kilos) The raw details - respiratory arrest, found by his ex-wife; she'd been worried about him as he sounded off on the phone. His medical rap sheet made for grim reading. COPD, startlingly poor mobility; his house a veritable shrine to the machinery we gather to force the breath of life into us; deus ex machina if you will.

Too late, too late. Somehow the paramedics had managed to get a tube down, and his heart still struggled on. But he'd had no drugs, and showed no sign of wakening. As we tried to gently ease the news into his family's consciousness, he showed his hand. Harder and harder to bag him, higher and higher airway pressures. Pneumothorax - a collapsed lung - is always a possibility in these cases, and worse, because we were ventilating, the collapse progresses, air displacing heart and lung, literally squeezing his life out.

Needle decompression not feasible through such a massive chest wall, we set to thoracostomies. An elegant word for a bloody, violent procedure. They push the knife into my hand. It's a 15 blade, a tiny knife, a child's blade, but proves adequate to my task. Skin and fat offer no resistance, and my finger worms down to his ribs. I thought they'd be bigger, somehow, but they seem tiny inside his bear-like chest. The last push is blunt, brutal, with forceps. A gush of air greets my penetration of his pleura, the thin, greasy membrane that lines his chest cavity; the diagnosis is confirmed. Sweeping my finger between his ribs, his lung feels stiff, and is stuck to the chest. I feel a rent in the tissue of the lung, and a wave of nausea nearly overcomes me.

Have I slipped in too far? It shouldn't be possible, if the lung was fully collapsed, but maybe it has remained stuck to the chest wall in a few critical places? Maybe it is the lung itself that has yielded under my finger? My act is repeated across the chest from me, a distance that seems absurdly far. We place drains with shaking hands, and the water sealed drains bubble vigourously, angrily. Too much air, there must be an ongoing leak, and I know I've done something, something to add to his misery. If he could feel it.

He ventilates better for a while, then slackens off again. On my side, his chest is inflating, the soft tissues distending; under my fingers it feels like bubble wrap, and I know air is forcing its way into the fat under his skin, despite the angry bubbling of my drain. I check the holes - they're all inside the chest cavity, but still air leaks out elsewhere. Did I make two holes?

I've lost focus now. Fortunately, my colleagues have not, for our patient is circling the drain. I'm fixated by the drain. My mind is running overtime, replaying the act, searching, searching for the thing, the one thing that I might do, that I kid myself will make any difference; but I can't find it, and I know I've failed him.

My boss taps me on the shoulder, urging me to go and clean up. I look dumbly at my hands and arms. Somehow they're stained with blood; I don't remember it getting there; I clean up, scrub up, quickly. Things are moving apace now, and a crossroads rapidly approaching - one road leads to ITU... and one dose not. Wiser men and women than I will help him now. Another boss sees I'm running on empty, and ushers me out, to check the rest of the Department.

I turn, and walk slowly out of resus, my failure complete.

It is no surprise to learn later that he exceeded to limits of support we could offer him, and was finally allowed to complete his short journey. I hope someone was there to hold his hand, at the end.

La belle fille didn't ask about my day that evening, and I think I'm probably glad of that.