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.

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....

Voila Le Morse!

So, I'm lagging again. About a week behind. Good intentions trailing in my wake.



The problem is, the longer you leave it, the blurrier the edges get.



Last weekend (10 days ago now) wasn't so bad; along with the pressure of the trial period comes extra staff - which, shock/horror, moves things along a bit quicker - so a bit less for me... Saturday was tough; One of my favourite sisters was on... but she is a wee bit 'black smoke'. Her first words to me were: "It's not looking too bad..."



10 minutes later, and resus is humming. Contestant number one has complete heart block, and is not at home to external pacing. Actually, we did get capture very briefly, but then our new all singing, all dancing defibs gave it up.

I'm not sure I trust them. They talk to you, in a kind of mid-Atlantic accent, beloved of 80s DJs, or airline pilots. What they say wouldn't be amiss as porn dialogue (e.g "Harder! Faster! No, that's too fast... go slower, and deeper" They are of course referring to one's compression speed and dept, but...)

My other concern is that they'll turn out like HAL, from 2001. So:

Me: "Charge to 150!"
Defib: "I can't do that, Dave..."
Me: "What? Why not? And why are you calling me Dave?"
Defib: "I'm sorry, Dave, I can't tell you that"
Me: "Right! Where's the manual button..."
Defib: "Dave. What are you doing, Dave? Don't do tha..."

Anyway, his potassium is stratospheric, which clearly ain't helping, and made us look like hicks, when it took CardioReg to point it out... He won a trip to the lab for pacing wiring, and a brief, unfulfilling discussion between medicine and cardiology about who should look after him.

Contestant number two has fallen too high and broken most of her vertebrae; she's a hand-over, but ortho and neuro are arguing over who gets to do less work; neuro invariably win, and the Ortho Reg, a buddy o mine is grumbling about still clerking patients at his time of life. I feel the same, and wonder briefly where all the house officers went.

Contestant number three has tried hanging himself, and is GCS 3: flat and hurting. He arrives as I'm trying to stabilise Contestant number one. Just as I think I might be able to manage them both - if I run back and forth quick enough - number one's hear pauses long enough for Sister to demonstrate the art of percussion pacing. She ascends to the pantheon as my new hero. Patient isn't quite so thankful, but then all he knows is being forced awake, from the ultimate sleep, by a punch on the chest.



Squeaky bum time, so to speak.



We somehow find a way through; we always do. All my patients leave the department alive; sometimes that's the best I can say. I'm embarrassed to say, I don't know how they are now. Another girl falls from a window; suicide attempt? I'm not sure... she surely wasn't keen on the pain when she got to us. I find these cases the hardest. The physical hurt can be treated, can be rationalised... the mental pain? I don't know. But we seem to see an awful lot of people who thought they wanted to die, and only ended up adding physical pain to their already overloaded psyche.



The winner of the night is a psychotic fella. It is debatable as to whether his mental state was drug induced; indeed, I have debated it for more hours than I care to remember. What I do know is that he had dedicated the previous three days to smoking cannabis, and then something deep inside went 'boing'.



He was unmanageable; sometimes a body can reason with the truly raving. Not this guy.

He was just shouting, incessant, illogical demands. Sometimes for cannabis, sometimes for incongruous luxuries - a massive tv, a PS3. Sometimes he shouted his fears at us - that everything was black, that he was a Government experiment, a freak. Where were all the other freaks?, he wanted to know, why could he not meet them.

And yet, every now and then, for a few seconds, sanity appeared to return. 'Help me', he would implore, 'please..'

I sedated him.

Rapid tranq. A sledgehammer approach, perhaps but safe, and allowing me to assess him. In the end, we had to have him removed by the Police, for formal forensic assessment. His Grandmother and Father, so relieved that he was finally in hospital, struggled to understand why it had to come to this. My words seemed woefully inadequate, even to me, trying to explain that a police cell was safest for all, until the psychs could see him.

Actually, it became a moot point hen he biffed a copper in the face, but the principle was there.

I don't know what happened to him, either.

Sometimes, I lie awake at night, and worry that theses are the ghosts that will haunt me for ever.

Skimming The Knee

We were talking yesterday about Doctors we knew with... interesting personalities. A surgeon I worked for cropped up. He was a brilliant man. A plastic surgeon, with an amazing eye for scars. His speciality was burns and reconstructive surgery. He could look at a scar and, in a flash, tell you how he could release it and give the patient extra degrees of movement. I suppose some of it was learned, but can't help but feel that it was mostly God-given. (or innate, if you're that way inclined)

However, he was the rudest man I have ever come across; and yet I would crawl over hot coals to work for him again. Some people couldn't hack it. And, I believe, he could be mean spirited, but at least he was consistent. I've worked for various bosses who had short fuses, and found that difficult. But this fella... always, always rude.

Our conversations would go like this:

Me: "Good morning, sir. How are you this morning?"
Him: "Why don't you fuck off, you brown nosing little shite?"
Me: "Thanks you, sir. I'll see you on rounds, shall I?"
Him:"Why haven't you taken up something you're more suited to, like occupational homeopathy?"

I cut my teeth operating with him behind me shouting in my ear: "Jesus Christ, boy! What are you doing? The patient's bleeding to death, and you're just buggering about! Sort it out!"

On occasion, he would approach me, and, inevitably, shout: "Shroom! I'm feeling very uncomfortable!.
Me (trying not to screw up another shave and graft) "I'm sorry, sir. Why is that?"
Him: "My fucking trousers are falling down!"
Me: "I'm not sure how I can help, sir..."
Him: "You fucking can't! I just wanted to tell someone..."

Happy Days...

Simple Things...

Things that keep me happy; best to remember I am a simple man...

When we all tell the same gag. Yesterday, we had a patient who shared a name with someone famous. When I heard, I said: "Oh, not the ---? Famous for ---? Surely not? " (Cue deathly silence from staff... ever seen laughter actually curl up and die ?) Then BBP enters, clocks the name, and makes the same gag. Brilliant. Then, I come to refer the fella, tell the Magician his name, and: same gag. Awesome.

See also the miming of horse attacks; funny, unless you are a radiologist. (Laughter, death, etc.)

Love In Vain

Unhappy post.

Somedays, it's all just shit. Sometimes, you do everything right, and its still shit; sometimes you make things a bit worse; somedays it's all your fault.

I'll have one from the top, and one from the middle, Matthew.

We have new SHOs starting today. They're all called something new know. FY2 or ST1 or something. SHOs of varying experience. I worked with a couple of them today, and they seem competent enough. A few of them rubbed one of my colleagues up the wrong way; I find this basically amusing. I will enjoy the soap opera that is the bedding in time.

Anyway: number one. A woman found by her son, slumped in her chair, not moving her left side. Several fits later she is at our door. Her blood pressure is high and climbing. She offers us no response, not even with determined teasing. Her ECG shows ST elevation, laterally. To my mind it all points to rising intracranial pressure. A bleed, I am sure of it. Blood coursing about her brain, irritating, inflaming. I call the intensivists. They are reluctant to intubate her; they shre my concern that whatever the injury, it will prove unsurvivable. But they will take her to the scanner for me.

The scan is unexpectedly unremarkable, but th radiation hasn't enlivened her at all. Her pulse and breathing become erratic; the duty Magician comes to visit. We are all very earnest; but it doesn't help our patient. She must be leftt to fight this fight alone. Her card is marked (the trial was a pig-circus), but we can't help her.

Next: a fella just old enough to be considered old. Difficult to gain a history from, as his shhort term memory does not reach much further back than 10 minutes ago. But he is in pain, his belly swollen, distended, taught. His pulse is weak, rapid, fluttering in and out beneath my fingers. I talk to the Surgeon; he does not want to see the patient; he wants to see the scan. We pump him with fluid, drive his pulse down, and his pressue up. His colour improves, and his edges warm, just a little.

I watch him for a while. He holds the line, he is stable. I know he is sick, I know the intensivists need to know, but I think I can wait until the scan is done. I don't think his airway is threatened. I tell myself the scan obviates the need for plain radiographs. I tell myself I can manage the transfer.

We don't normally transfer patients. Department workload is too great. I take my break, and one of the supernumary SHOs, and we take the transfer. It's a good learning opportunity; I've done plenty of transfers in the past. We'll be fine.

We are not fine. All the medics reading will be familiar with the adage that whatever ca go wrong, will go wrong; and if possible it'll happen on the CT table.

As soon as we put him on the table, he starts vomiting. It rapidly becomes effortless, and the patient agitated; he resists being on his side. While I am belatedly calling the intensivists, he loses his airway, and rapidly his pulse. We try to run a resus, but it's chaos in the scanner. Help is not slow in coming, and we get him back. I think clearing his airway was all he needed.

Well, that and a smidge of adrenaline.

The surgeon bows to pressure and comes down. We eventually get our scan; it shows all the wrong things. Bowel obstruction, probably from a tumour. Closer inspection shows gas in the wall of the bowel; dead gut; gas gangrene; the writing is on the wall.

I am at a loss to explain why I did not X ray this fella in the Department. I might have had my answer then, might have convinced the surgeon to see him upstairs, might have avoided the indignity, and squalor of a disorganised arrest in a basement CT suite.

Sometimes we just make bad choices.

The fact that they changed nothing, that this man's family would have been surprised, horrified, destroyed by the news of his impending death, does not excuse them. If nothing else we owe our patients the right decisions on their behalf.

And for all my wailing and gnashing of teeth, I'm trying to remember that it's not about me...

Si Tu Dois Partir

The nights roll on...



I am failing in my duty to one of my SHOs. They are not working fast enough for the ED, and I am not showing them how. It is mkaing very unpopular with the Nursing staff. I will have to try harder.



Last night seemed to bring an unwelcome reminder of our limitations as doctors. Perhaps as people, too. Two patients, both ED 'bread and butter'; the first a 'blue bloater'; long term COPD, unwilling or unable to give up the cigarettes that have done this to him. Reluctant attender, as so many of them are, knowing all too well the poking and prodding that awaits. But tomight he was tired, too tired. His CO2 levels, always high, are creeping higher, slowly anaesthetising him, in front of our eyes. He has been here before, been judged in the eyes of the Intensivists, and found wanting. He is not for ITU, not for invasive ventilatory support. We all know that once attached to the vent, he will likely not get off it.



I offer him what we can, nebulisers hissing softly in the quiet of resus, steroids, i.v. because he cannot swallow, theophylline coursing through his veins, salvation in a plastic bag?



Not this time. His chest remains tight, each breath an effort, hardly lifting his chest. Non-invasive ventilation is next, an uncomfortable mask, held awkwardly on the face with a Heath Robinson-esque collection of straps, designed by the lowest bidder.



None of it does any good. His numbers stay the same, low, low oxygen, and high carbon dioxide, creeping slowly, slowly higher. He himself slips away as I watch him. The light has gone from his eyes, his defiant humour, that he held onto at the beginning is gone. All of his being is breathing now, and even that is an effort. He is exhausted.



The next, an elderly lady. Suddenly ill, suddenly very ill. Almost no warning. A little breathless, then she slipped away. By the time the Ambos get there, she is gone. But not so gone, as to be beyond us. Slickly, professional, she is resuscitated, her angry, irritated myocardium teasing them with hints of life. She is still slipping back and forth when she is delivered to us. A few more rounds, and she comes back, and sticks. Something we have done keeps her heart in synch this time. We wait a minute. Have all seen this before; false hope. A sort of 'dead-cat bounce'. But she stays with us.

How long? Long enough to call the intensivists. Long enough for us to gather and decide that although we have restarted the clockwork, the soul is long gone. We will keep watch, standing guard against the unlikliest of returns, but we all know it is futile.

Have we achieved anything?

Takin' Stock

As the New Year looms ever larger, I'm more prone to melancholia than usual. The usual - you've been there constant reader, don't pretend you haven't...

Missed opportunity, absent friends, previous New Years - good, and especially bad.

Without wishing to sound arrogant, which I'm afraid I surely shall, as I surely am, I have been dwelling on the only thing that keeps me going sometimes - treating patients. Sad to say I haven't got a lot else.

Anyway - success stories of the past. I hope I'm not repeating myself.

The first sticks in my mind, because it harks back to 'old school' medicine. That is to say with fuck all help from labs etc. I had just finished my pre-registration year, the first year out of med school, wherein you had to prove that yes, you'd passed exams, but would you kill patients when left alone. as long as the answer was 'no', or at least 'not many', you got fully registered.

Anyway; I had secured a 3 year surgical rotation, about which I was pretty smug, but deferred 6 months. So I was earning my keep doing a few locum jobs here and there. There was quite a ramp up in responsibility for some of these, as they were all short term, so no-one had time to hold your hand, or teach you. On this occasion I was providing cover at a rehab hospital. Small scale, elderly patients, none of whom was judged to need acute care, but none of whom could quite go home. Two rounds a day, a few jobs, and pretty much no calls at night.

Usually

So, I was roused from my sleep at ungodly o'clock in the a.m, as an ambulance had arrived. This was highly irregular. We weren't an acute facility, but the ambos decided some help better than none, and didn't think the patient would make it to big hospital, with it's bright shiny A&E dept. So, dropped into our laps was a fella, of, I think, late middle age, but he could have been older. His problem was extreme difficulty in breathing.

I remember looking at him, sat bolt upright, drenched in sweat, his skin a pale, waxy colour, tinged blue at the edges.

If you've been paying attention, you'll know what I think about these colours.

His face was vacant, lights on, nobody home, every ounce of his being dedicated to breathing. Arms locked to the sides of the trolley. Resps almost too high to count. JVP sky high, chest sounds drowned in wheezes and crackles.

Heart failure.

Now, the fun stuff. There was, I soon discovered, no working sphygmomanometer in the hospital. So, no blood pressure. Similarly, the pulse-ox readers were kaput. No labs or x-ray on site, and sending an arterial sample to big hospital wasn't an option because of the distance.

Great.

If truth be told, I can't remember what I gave him. Bronchodilators, diuretics and nitrates probably. A catheter to measure urine output, and so to judge renal function. My only measures of success were those I could see with my own eyes. The patients colour, his resps, his mental state, his jvp.

I sat with him all night, teasing him with a little of this, tickling him with a little of that. Slowly watching as he pinked up.

Should I have transferred him? Maybe, probably, I don't know. I didn't know any better. I thought I had to make him better. Out of my league, my depth? Maybe, probably.

But I managed. He managed.

Next...

I remember this, cos it's all a bit ER. Again, regular readers won't be surprised...

I was workin' in a DGH in the South East. I think as an A&E Reg, before my number. I was carrying the crash bleep, so I might have been in Anaesthetics, but anyway. The bleep squawked into life, the tinny voice of switch declaring adult cardiac arrest, in the car park.

In the car park?

Fair enough. Never one to shy away from attempted heroics, I up and ran. I remember it as pissing with rain, but it might just have been wet on the ground. It was dark, anyway.

The car park was just round the corner from the Ambo entrance, and the patient wasn't hard to find. She'd been visiting a relative on the ITU, and had just up and collapsed. I was first on scene, weak pulse, agonal resps.

For about 10 seconds, anyway.

Someone must have called the ambos, cos they pulled up. Which was nice, cos I had fuck all kit, and the car parks are not well stocked. Their AED clearly showed VF, but refused to shock the patient. There followed a brief argument between me and the ambos, first about how wrong their machine was (I was right), then about how best to scoop the patient and get her back to resus (they were right)

Back to shiny resus. A blur, resolving into shocking the patient...

And getting her back.

And sending her to the unit, to reside next to her relative.

And seeing her 5 days later, when she dropped by to say thank you...

Get in!

Well, folks, I'm working a special kindof graveyard tonight, and will be unstinting in my attempts to bore you with how shit it was. When midnight comes and goes, raise a glass and think of me and all the other poor bastards picking up the pieces.

Joy of the season to y'all.

A Day In The Life

**Warning - Medical Content May Go Down As Well As Up; Past Performance Is No Guarantee Of Future Return**

I'm up early again. All too often I seem to see the wrong side of 4 a.m. I slept well enough, for a few hours; then, my all too traditional waking in a cold sweat. A bad dream? Not one I remember anyway. I vainly try to go back to sleep. Most days I'll know whether it's going to work within a few minutes.

Half an hour later, I'm up.

Pad round the house, aimlessly tidying a few things away. I spend a few moments gazing out the window. Funnily enough, no other bugger is up yet. All is quiet. I rather enjoy the peace, my horizons limited by the pool of light cast out by my lamp. Except I know it means I'm not sleeping.

I'm able to divert myself surfing for a while. I try to catch up on a bit of reading, but I'm never sure how much I take in in the wee small hours. 0430 and it's time for coffee. I dearly love all things caffeine; a taste for coffee has grown on me, over the years, ad I'm not sure it'll ever leave me. Which is good. I really love the coffee.

I'm just about ready. The cold, dark morning awaits me...

Cold showers are over-rated, but they sure as hell wake you up. It's still proper dark as I leave; full night, with only a few foolhardy souls for company. I allow myself a brief slice of boy racer as I power down the road, tipping the scales at 7,000 rpm, and glorying in the throaty roar of my Sports Penis Extension's engine, before dullShroom regains control. The realisation that there really are very few other bastards on the road slowly dawns as I encounter next to no traffic and arrive at work embarrassingly early. Even more so when I figure out I read the rota wrong, and have come in for 8, but don't start til 9.

Arse.

The morning board round is preceded by the usual rounds of shooting the shit, most notably divulging that one of my SHOs is scheming to get a date with one of the radiographers. I think she's already dating someone, so this promises to be interesting; perhaps I can live vicariously through his exploits.

Proving once and for all that I am a sad old fart, with no life, I figure i might as well work, since I'm here. Number one punter is Polish, and we rapidly discover we have no language in common. Although interpreters are available, commercially, the trust seems reluctant to use them, preferring instead to rely on bilingual staff. Who are never around when you need 'em, and have their own jobs to do, anyway. Still, at least they're cheap. The patient smells of a three day bender, and is restless. He's 'MEWSing' at 5, which means his vitals are deranged. MEWS has replaced a sound knowledge of normal physiology, as far as I can tell. It is no longer necessary for one to look at a patient's obs, and decide if they are unwell or not. No, instead, someone distills the info into a handy MEWS score. Bah Humbug. Whatever his score, I think he looks pancreatitic; the bloods go off, and drugs and fluids go in. We wait.

Next a little old lady, with no real idea of why she is here. Dementia intercedes, making meaningful history taking defunct for the second patient in a row... My first, end of the bed guess is digitoxicity. A vain atempt to show off. I don't think it was right. Eventually we decide on a pleural effusion; the patient helps us along by having a small collection of fluid outwith her lung, and I ask the magicians for their assistance...

A young man offers us his racing heart with no good explanation. I take the easy route and blame his 10 day old son for upping his stress levels. Meanwhile, I'm trying to squeeze in a manipulation of a young girl's wrist, with one of my redoubtable SHOs. We have to do it in our MUA (manipulation under anaesthesia) room. It has recently been occupied by a patient with explosive diarrhoea. Despite a nuclear steam clean, the smell lingers. I'm amazed the patient can't smell it; this nasal insufficiency plays out in my favour a second time, as she briefly ends up with her face in my armpit; never the best of places to be, and not improved by a bout of strenuous tugging on a broken radius. Despite a good old fashioned Bier's block, she still finds uncomfortable, but backs down from her original offer to slap me afterward.

All the while an asthmatic COPD-er flirts with true respiratory embarrassment in resus. She is ably handled by another of our SHOs, but not before spectacularly vomiting. Excellent coverage; professional standard.

Polish guys's bloods lean towards the pancreas. I lean toward the surgeons, and they accept. I am briefly stunned.

We get something of a rush next. The specialist Cardiac nurse, or 'ThromboMan' as I like to call him, tries to monopolise Resus, smuggling in a fella with cardiac amyloid, among other things, and an elderly chap trying to see just how slow you can go. I deny him the chance to own resus by bringing in a young guy in status epilepticus. A tragic case, this young man's life ceased to be his own a few years ago when his blood sugar dropped low enough to provoke seizures, seizures that couldn't be stopped, and robbed his brain of oxygen long enough to leach most of its meaningful function. The patient is accompanied by a carer who assures us he does not have epilepsy, or seize 'normally'. Our efforts to stop these seizures depress his respirations long enough to force 24cm of semi-rigid plastic on him.

His trip to the Doughnut of Doom is uneventful - barely a hint of doomliness. The scan offers no new info, either. This passes to embarrassment when we look at his drug chart, and finally see the raft of anti-epileptic meds, and the letters from Neurologists in his casenotes, documenting his propensity to seizures.

At least we know why he fitted. He wakes, rejecting the tube, and another one is welcomed into the warm embrace of the magicians.

Lunch beckons, ad I leave Resus echoing to the cries of a lady who fell, catching the wheels of her zimmer on an escalator. Now, I know I'm a simple fungus, but I don't think those two particular advances in mobility technology were designed to go together. She has only slightly scalped herself, but sees everything we do as an outrage, loudly objecting to our attempts to examine her. She was still complaining 4 hours later, mostly about the fact that other patients were in the Department, using the toilet, and that she needed diazepam.

My post prandial slump encompassed writing a few sets of notes I had let slide. Resurgent after more coffee, I encountered another very young chest pain, again no evidence of cardiac pathology. My reassurances fall on partially deaf ears, but I know he's feeling better when I encounter him and his partner scarfing Burger King.

Another little old lady, another broken wrist. The redoubtable SHO and I spring into action. Our efforts are less successful this time, despite truly game counter traction from the patient herself; a second attempt is better, but produces the most shameful cast. I resolve to turn to Charnley more closely. My redoubtable colleague and I labour on, past our allotted hour.

And so, my shift that started an hour early draws to a close, 90 minutes late. It's dark again, and it's started raining. But I'm happy.

How fucked up is that?

Music Nazi recommends Wish You Were Here, by Pink Floyd. Do it; you kow you should.

River Of Dreams

In the middle of the night...

Doing an extra night tonight for a colleague. Normally this would provoke a great deal of grumblage, but as it's because he's a new daddy, we don't mind. I sure as hell am getting old tho'. I used to be able to do a week of these and not feel it, but here I am after three, tired as a wet kitten, and irritable with it. Like a bulldog with a mouthful of wasp.

Anyway...

Further evidence, as if it were needed, that people throw off all sense of personal responsibility when they step through our door. Twice tonight I have had people gesticulating wildly at me, alerting me to the fact that they are bleeding.

Not unreasonable, I hear you think. Well, no, not usually; but in these cases, the bleeding was from cannulation or venepuncture sites. Not from horrendous trauma, or awful limb-falling-off type accidents.

But because the cotton dental roll we place over these pin point hole wasn't taped on hard enough.

And they are always stunned when I stroll over and press on the wound with my thumb. Shroom's Blunt Haemostat. Amazing. Quite why these otherwise healthy(ish) and intelligent people can't summon either the nous, or strength, to think of, and then do, this themselves is beyond me. Instead they stand there, or sometimes move around a bit, to ensure even coverage. Oftimes they wave the offending limb, but always held downward, never upward. And they never, ever press on it. Ever.

Folks, I'll let you into a secret. If you can see a bleeder, and you can press on it, it will stop. I don't care how big. If your finger fits over the hole, that's the treatment, right there. But keep it to yourselves...

My favourite patient of the night (so far) was a young girl, visiting family. (i.e. not local... been to several other hospitals before...) Presenting complaint? Total body pain. Another personal favourite. Atraumatic, mind you. Total body pain is quite reasonable if you've, for example, been sat on by an elephant, or fallen out of a plane. But sudden onset, atraumatic total body pain? Well, we do see this, but it tends to be in a certain demographic of patient. For fear of generalising, or being accused of bigotry, I'll leave you to guess.

Needless to say, her first words to the triage nurse were to inform us that only morphine works for the pain, and that's what she always has. Her triage obs were all remarkably stable and normal. Despite several publicly agonising trips to and from the bathroom, pointedly in front of the doctor's bear pit, I explained that without a diagnosis, or any clues as to a possible diagnosis, I wanted to try other analgaesics first. Simply telling me that your previous treatment plan is i.v. morphine and home does not encourage me to give you some. Cruel, cruel Shroom.

Either way, when confronted with the harsh realities of the analgaesic ladder, and need for assessment and diagnosis, she decided to go home instead. Her gait on the way out was markedly free of the tortured limping and groaning that had characterised it a few minutes previously...

Lastly an SVT. This particular dysrhythmia is one of my favourites (sad, sad bastard) because, in my experience, it rarely compromises people, and responds well to a quick blast of adenosine. My SHO, running the case in his inimitable style, opined loudly to us all that he didn't see the point in 6mg as a starting dose as it "never works"; this minor rant against the system, and specifically the part that was compelling him to give this homeopathic dose of adenosine, continued until about 0.8 seconds after he injected the adenosine, when the patient flipped right back into sinus.

I guess protocols sometimes do make sense. Who'd have thunk it?

Oh, and the CherryPicker has started his own blog. Check it out; his tale is well worth hearing, although I can't vouch for his writing style... he did want me to offer more biog details about him here, but I'm thinking he can tell his own tale now. One doctor's battle with booze, and a reminder perhaps, of how close we all sail. Anyway, enough plugging.

Who By Fire

I seem to have caught up to myself, and my intention to manage a post a day (on average). Sadly my mo' hasn't managed a similar spurt.

I'm pleased to see I've retained a few of the extra readers generated by mt free press from Scalpel (see the side bar: "Fix Bayonets"; this incidentally is because his blog is called 'Scalpel or Sword' and the British 95th Regiment of Foot ('The Rifles') called their bayonets swords. In case you were wondering.)

I've also been added to the blogroll of another fave of mine, M.D.O.D. Anyone stumbling here from there, or anywhere is more than welcome. Pull up a chair, help yourselves to the scotch. You might need it, if my especial brand of jaundiced rambling ain't to your taste.

Here's an example of what you can expect....

I'm feeling extra proud of meself, as it seems I've successfully cemented my rep as the ED eccentric. (This is only marginally less important to me than the nurses thinking I'm an acceptable doc. It's almost pathetic how much their approval means to me. Well, the senior ones, anyway...) I confirmed this on Friday last, when, having unfortunately split the crotch of my scrubs was forced to undertake emergent repairs, using a 2/0 Silk on a curved; with scrubs still in situ, as I was in resus at the time waiting for a gasper. While my assembled team clearly thought this was funny, none of them were surprised...

Smug Mode

Inspired by the brag-file post I referred to in the previous post, a tale from Shroom's days on the Expensive Scare Unit:

As a 'non-specialist' specialist I always enjoy the opportunity to demonstrate that I actually know stuff. On this particular night, I was asked to review a young-ish man in respiratory distress. He was a local drug user admitted with a progressive neuro-muscular weakness. A brief history, but with features highly suggestive of Guillain-Barre syndrome.

This fella actually has a few atypical features, particularly in his cranial nerve exam, and his Donald-Duck - esque speech. Very eminent men and women had consulted on his case, and pronounced: the diagnosis was Miller-Fisher variant GBS. He had been deteriorating on the ward, and now his respiratory muscles were dysfunctional. His blood gases had gone off enough to qualify him for an entry to the free ventilator prize draw. A chance for healing through the medium of 24cm of semi-rigid plastic.

However...

When I got the phone call, something just didn't seem right. I freely admit that this was mostly because I knew little about GBS, and foxtrot alpha about the Miller-Fisher variant. Nonetheless...

Has this fellow got a fever?, I wondered...

Why, yes he has.
And he's a drug user... Does he have an abscess?

Um... yes he does. On his bicep.

AHA! Cries the Shroom.

This is not GBS; this is botulism. Wound botulism, say I.

I like to think that the whole hospital fell silent with amazement. It didn't, and in fact we admitted the fella and treated for both diagnoses until the mouse lethality bioassay confirmed botulism.

(Yes, they inject mice with the patient's serum, and wait to see if they die. Their fur stands on end first, and they develop narrow, waspish waists. Go figure; if you think that's weird, the botulinum anti-toxin comes from a special horse, living it large in Wales, somewhere. Ah, medical science...)

Smug mode activated...

(I didn't tell anyone I'd seen an identical case a few months before. I still dine out on this story...)

Sweet Nostalgia, or, It Seems I've Spent Some 20 Years Just A-Gazin' At Her Face

I continue to watch, intermittently, old episodes of ER. I enjoy it for its own, simple joys, but also for the memories inspires of who I was and what I was doing when I watched it the first time around.

I know, incidentally, that I need to get out more.

I particularly enjoy the episode depicting Carter's first day on the job. The sheer terror, and hopelessness of it all, countered by his eventually overcoming of the challenges set him. How realistic? I can't speak for my American cousins, but it was never that bad for the young Shroom, but we did pull long hours, and I did feel like going under sometimes, times that I now recall fondly, viewing the past thru rose tinted fertiliser, if you will. In fact, I think I was just approaching qualification myself the first time this was out...

All old farts eventually have 'war stories' about how hard things were "in their day". I'm disappointed to say I was too young to hear, or maybe too young to remember, GrandPa Shroom's stories, tho I'm sure there were plenty. He was good friends with the first Medic into Belsen at the end of WW2. Those were tales... I think my point was going to be that the common thread tends to be success in the face of adversity.

It makes it much easier to recount a tale of horrendous times if it ends well; sometimes well means getting to the end of the night. Sometimes that's all you can do. I encountered a 'brag-file' story of a different kind, over at M.D.O.D. Hugely satisfying, especially the exhortation to 'go fondle the guy's nuts'. My kinda medical jargon.

Tuesday's Gone

A little light relief?

I thought this was funny, but realise it's non-PC, and I'm kinda the wrong gender to comment. Make of it what you will.

First case of the day, an elderly fella, collapsed at the swimming pool. Arrest twice, RoSC twice. Arrived flat, with a suspicious ECG. Great flurries of activity. In the midst of this, one of the Cardiology magicians came down to echo the fella for us, and pronounce on whether a trip to the cath lab would be good for him.

My boss was directing affairs, and didn't know this (female) doctor. To remedy this situation he asked her:
"Sorry, what's your name, sweetie?"

Time froze, and the temperature dropped to absolute zero. Just for a second.
Then:
"It's Susan, NOT 'sweetie'"

'Wang': Normal activity resumed. My boss, for what it's worth calls us all 'sweetie'. I've got a lot of time for him.

The echo shows a poor LV function, but, probably, nothing new. No cath lab.

Before he leaves, my boss does a final, verbal, recap; to make sure all the jobs are being covered:
"So, Shroom, you'll do the NG; Bob's doing the foley; and Susan, formerly known as 'sweetie'..."

Exit, stage left, very pleased with himself.

Yes, I know it could be dreadfully patronising, and I've never had to put up with it, etc... so maybe from the other side of the fence it ain't so funny. Brightened up my day though...

I Wish That For Just One Time, You Could Stand Inside My Shoes, The You'd Know What A Drag It Is To See You...

Again, long time no jib...

Sorry. If any of my dwindling readership are still trying, I'm sorry.

I've been a little distracted of late. Shroom's fallow period has ended.

I have a new object of my affection. And it is mutual! I'm not a stalker. My current squeeze, my babyluv may feature here more later, but not for now. I don't want to jinx it, and I'm not sure I have the right to publish her the way I do myself; yet...

Anyway; I have a few local interest 'pieces' to blog about, but they will follow. They're mostly me grumping about what's happening at work. What follows, since we were talking of stalkers (sort of) is the tale of Shroom's only stalker - to date.

I know I've alluded to this recently, but don't think I've covered the details.

The whole sordid affair took place years ago, when I was a Plastics junior in a London hospital. At the time, I had rotated on to the Burns Unit, which meant I spent my days there, but shared the on call rota with the other SHOs covering Plastics and Burns. One Wednesday night, I took handover, and did my rounds, as usual. On the ward was a patient who had been waiting for surgery for a few days. I'm not sure why he'd been waiting but it was a bone of some contention to him, and he already had a reputation as a 'troublemaker' among the nursing staff.

The duty Reg and I stopped by to examine him, and see if we could get the op done overnight.

As I recall, the history was that this chap had been in a house that had been firebombed, and in trying to escape the inferno, he had gone out of a window, sustaining glass laceration to the dorsum (back) of one hand. On exam, it was obvious that his injury was substantial. There was significant skin loss, tendon and nerve damage. The op would require complex reconstruction and full thickness grafting - well beyond the capabilities of the Duty Reg and I, and as no consultant had expressed an interest in staying on to do it, we had no choice but to tell him he would have to wait another day.

He was not pleased; as we continued on our rounds, I was summoned urgently back to the ward. The fella was screaming and shouting at the nurses. When I went to find out why, he turned his attention to me. His primary complaint was that too much time had elapsed before the replacement of his dressing. He claimed that his hand had been left undressed for half an hour, and he was furious at the thought of it becoming infected.

When I pointed out that we had only left him five minutes before, he changed tack; the most vitriolic stream of abuse followed, the gist of which was that nurse were "bitches in skirts" who should be at his beck and call. He expected them to fetch and carry for him, and, I kid you not, "peel me grapes".

As this, almost laughable, rant continued, Sister attempted to re4place his dressing - made more difficult by the fact that he was gesticulating wildly. It must have been uncomfortable, because he flinched, mid-diatribe, and i saw his (good) fist curl up, and he went to swing at Sister. I did the only thing I could think of, which was to step in the way, and place my hand over his fist.

I suspect, in my mind, I was Clint Eastwood - as the Man with No Name.

This is part the first... I'm mid edit - apologies

Thomas Muir of Huntershill

Google it.

Maudlin again. Too many late nights and whiskey, I guess.

A couple of the blogs I like to read have gone invite only. I'm sorry if my side bar links lead you to a dead end. I'm slightly disappointed. I liked reading them - but folks have to do what they have to do, I guess.

I'm increasingly anxious about blogging my day to day work life here. Mostly because I'm less and less anonymous, and confidentiality is a huge part of what we do. Still, I'll try, for what it's worth.

Recently I've struggled with patients who have different ideas about what their best interests are than I do. Here's an example:

Let's suppose you elect to spend the afternoon drinking heavily. A few litres of your chosen spirit should do it, but feel free to wash it down with some beer chasers. I'm ok with that.

Next injure yourself; ideally, you should make the mechanism, the way in which you hurt yourself high risk - crash your car, fall off a bridge, you get the idea. BUT, and this is crucial, have little objective evidence of injury. A few grazes, here and there. Nothing spectacular, like being in more pieces than the good Lord intended.

On arrival at hospital, you should then slur your words, most of which should be Anglo-Saxon epithets anyway, and try to attack all hospital staff. This will involve removal of all the carefully applied devices protecting your cervical spine.

I am now left with the choice of allowing you to leave my department, with the knowledge that you might have significant occult injury, or restraining you, possibly at risk to my own health. I can guess that the way you are behaving is most likely an amplification of your own personality by your booze of choice... but it might just as well be your nascent extra-dural haematoma.

If the former, you'll wake up with a hangover, assuming you don't walk into traffic; if the latter, you won't wake up at all.

But, if I hold you down, and inject magic drugs into you, I have to be certain you don't have capacity, or I'm assaulting you.

I once treated a patient who was threatening to kill me; he has been my only stalker to date. I don't think I've blogged this before; I'll check - it might make good press. Anyway, I was reluctant to deal with a fella who was actively trying to stab me. My defence organisation informed me I had a duty of care unto him, right up until he actually did stab me.

I have to confess, I took my career into my own hands, and went against their advice, refusing to treat him. (It was neither a life, or limb threatening injury, for the record)

This country does not seem to have grasped the nettle of treating the (potentially) deranged, violent patient, who may simply be an arse, or may be acting like an arse because of their injury...

As for the example above... it might end like this:

You escape serious head injury, but turn out to have a broken neck. Despite assaulting every member of staff who comes near you, you avoid permanent paralysis. You wake up the next day with a hangover, and immediately discharge yourself from hospital, presumably reasoning that if the neck didn't give out during the fighting, it's good to go.

Sometimes, I wonder where my spirit went.

Secret Pleasures, Number 2

The grudging respect I earned on Saturday morning for my transformation from 'walking corpse' at woken up +1, to 'functional human being' at woken up +5.

Seems like all those nights on call taught me something, after all

She Comes In Colours Ev'rywhere

Or... "Flail of The Century"

No medical gib follows. Be warned and stop now if you have no interest in what I got up to in a field this weekend.

Pictures to follow - as usual I took a very expensive camera, and no pics. But plenty of others did, and with luck, thru the magic of digital media...

So, it was the wedding of one of greatest friends this weekend. In fairness, of two of my friends, but the Groom I have known for 20 years, and we've been through a lot of 'formative' shit together (I certainly wouldn't have been a doctor without him), and his fiance - now wife! - I have only known a few years, so although I consider her a dear friend, it is perhaps not the same thing. Whatever.

Thursday saw me at a dance / drama performance, a first for me. A slightly alien media to me. It was interesting, and a good evening, for a variety of reasons. Maybe it could have, or should have gone better. Only time will tell. Anyway, Friday found me pretty pleased with myself. Festivities were due to kick off on Saturday, but as the whole thing was essentially being held in a field (a place called ColdBlow Farm, which I can highly recommend), quite a lot of organisational flail was required. As Best Man, I was in the frame... so after a late night of modern dance / drama, I roused myself from my pit and packed up to deploy to a field in Kent.

My friend has never been even remotely conventional, so this was a fancy dress affair. As I may have mentioned, I was to be Puck. Puck is an interesting character, but not easy to define in terms of costume. I had found a production where Puck was dressed in red furry trousers and blue body paint. This was I had intended to go with, but singularly failed to find any red furry material, and lack the required Adonis like figure to make my torso my costume. Instead I cobbled some black furry trousers together, and paired it with a ruffled shirt, gold cravat and coloured waistcoat. Topped off with pointy ears, horns and some greenery, I just about passed muster. Still, at least I wasn't Bottom.

Lunchtime on Friday found me and the Groom alone on the Farm, drinking beer and shooting the shit. We were supposed to be erecting a marquee, but there was, inevitably, a delay. At some stage, about three beers in, I acquired my first injury of the event. Clinically this appears to be a mild ankle sprain - the bruising and swelling are minimal, but it gave me something to moan about. Eventually the Marquee and PA arrived, and we set everything up. A few pioneers were arriving by this stage, and it was agreed that we'd all have a quiet one, in honour of the big day on the morrow. The best laid plans...

The next morning saw a few die hards drinking on through, and Bottom (the other best man, resplendent in full ears, and a magnificent tail) pinning a nervous groom into his costume of Oberon. We left good and early, since there is always great flail potential in anything involving these guys. Lemons may get the job done, but sometimes it's hard work getting there.

We arrived at the Registry Office in good time, which was handy, as on our arrival, Oberon announced that he'd left the music behind. Despite being accompanied by Wonder Woman, and Zorro, it was left to me to make a madcap dash back to the farm. CD in hand, if you were in Maidstone this weekend, you might have seen a hairy legged hobgoblin scampering breathlessly through the churchyard adjacent to the Archbishop's Palace. 'Twas indeed I. When I got there, with literally minutes to spare, all I could see were regular getting married folks. There followed about a minute of panic while I wondered whether I'd taken a wrong turning, and weighed up the pros and cons of gate crashing a straight laced wedding dressed as Puck, when fortunately I saw our crowd of freaks, flying the flag... and the freak flag flew proper high over Maidstone - I don't think the Registrar had seen the like before, as Oberon and Tatania, Prospero and Queen Mab, Wonder Woman and Zorro, and even the Jolly Green Giant (ho! ho! ho!) all crammed in to celebrate . Fucking brilliant. The Bride and Groom exited to the sounds of Steppenwolf, and were driven away in a Black Pontiac Trans Am. (If this means nothing to you, you're too young)

The Reception was a blast. Fancy dress is indeed hilarious. The weather wasn't brilliant, but wasn't dreadful either. Speeches went off with only a little flail, and much fun was had engaging in jousting and Maypole based antics. Some of our friends had come as the Three Musketeers (which, incidentally, always seems a misnomer to me, as they were renowned for their swordplay, not their musketry) which gave me some concern as they were all wielding proper swords. Sure enough, one of them stabbed me in the foot (injury number 2) and then sat on me(black eye, injury number 3).

Suffice to say plenty of fun was had by all, especially me, in a most unexpected way. Funny how things seem to come in patches, complicating stuff unnecessarily. Or maybe it's me that complicates things. Anyway; it was good.

The next morning was a bit like a scene from Morning of the Living Dead, and the obligatory prank was played on Spuds, by hiding his car in the field. And now, we've all gone our separate ways, and I just about feel human again. My fourth injury appears to be classic tenosynivitis, of my left great toe extensors. Part of me is in thrall of the classic signs, most of me wishes it wasn't so fucking painful.

Anyway - Tatania, Oberon, Bottom, Jolly Green Giant, Michael Knight (and Kitt) and all the others, Lemon and non-citric alike. I salute you all. We may get older, but damn, we still know how to burn one down. (although we haven't worked out how to recover afterwards)

You Can't Always Get What You Want

Thus spake the philosopher Jagger.

Musing over my previous post, I am reminded of something that occurred when I was a HouseSurgeon at another DGH. The details are less well known to me, as I was just ScutBoy, but it illustrates the same principles well. I'm beginning to think that foremost among them should be "don't believe what you're told", no matter who tells you.

In this case, a patient was brought to the A&E (as was) having been 'found down' on a railway track. There was no suggestion that he'd been hit by a train - i.e. he was in one piece - but he was under a bridge. My understanding is that he was first assessed by a rapid response team. Two basic options present themselves:

One - he has jumped / fallen from the bridge above. Classification: trauma. Plan: rapid transfer, eager doctors waiting.

Two - he was walking along the railway track, and passed out here. Classification: Not Trauma. Plan: call some other guys to ship him to hospital; tell no-one he's coming.

The on-scene assessment was the latter.

He duly arrived in hospital labelled "collapse ?cause". No bother he can wait his turn. This was, of course, back in the 'good old days', when waiting really meant waiting.

He duly waited. After some time, the duty Senior HouseSurgeon was passing through the Department, and spotted said patient. She was of the opinion that he was entirely too white a shade of pale, and stopped to give him the once over.

One quick primary survey later, an open book pelvic fracture was discovered.

Much later an history of attempted suicide by leaping was discerned.
My memory does not extend to exactly what assessment this fella received on arrival, but it evidently didn't extend to routine re-assessment. Or did it? I genuinely don't know, bu somehow he slipped through the net, mostly because his initial label was along the lines of "he's o.k.", and it stuck.

On a lighter note, it was while working at this hospital that I had the pleasure of working on call over Christmas, and the A&E staff all dressed up for Christmas Eve / Day. Nothing beats the look on a patient's face when he opens his eyes post resuscitation, and the first thing he sees is a blond nurse dressed as an angel.

The Rag Man Draws Circles...

Another tough day.


I feel shit today. But that's my problem. More of that later.


Yesterday...

I had a tough day, but it was bookended by two people having it far worse...

It began:
A young fella, fallen from a window. I'm not sure how. In the final analysis, does it really matter? We always ask 'how?' People rarely remeber. Why should they? It's the last thing on their minds. How he landed was more important, but we don't know that either. He was admitted overnight, so one of the other middle-grades worked him up. The unalterable truth, the only detail that mattered was the sensory level at T8. Below that, he could not feel a thing. Not a flicker of movement, no reflexes.


Nothing.


By the time I came on, at eight, he was still waiting for a CT scan. All the important folks had been contacted, and all offered the same grave opinion. I was to go down with him. Hold his hand. Sympathise. Console? Give him morphine, really, and try and keep him calm.


The Department was empty at eight. By nine, we were drowning, flooded by a tsunami of octogenarians. (This phrase was coined by one of the SHOs. Thanks, Baron)


We stayed in the Department, he went down without me.




The scans didn't bring better news.

Peg Fracture

Burst Fracture T6

Significant intrusion into the Spinal Canal

The MRI wasn't any more encouraging.

So the most significant part of my day was telling a family their son would never walk again.

-------------------------------------

The day ended with my relief not showing up. I was already tired, but someone needs to stay on. As one last offering, the Ambulance service spewed forth another wretched supplicant. A young man. Found collapsed. How? We always ask... no-one knows, but we always ask. How long? We always ask...

I had hoped to get the SHOs to run this case, but it was too complex. He was too unwell. My brain chose this moment to slip into neutral. Running on autopilot. Back up arrived promptly from the ITU. Every question we ask gets a worse reply.

---How long was he down for? We don't know

---How's he been since you found him? He arrested just after we got there; came back after four minutes, but he hasn't woken up

His blood pressure wouldn't hold up, his ABGs were rotten. At least his sugars and his temperature were normal. He rides down to the scanner, accompanied, but unaware. The scan comes back normal. This is as close to a good thing as you can get in a situation like this.

The second significant thing I did was tell another family their father was in a deep coma, and I didn't know why, or for how long.

We did manage to relocate someone's ankle in the meantime. I'll post the films after the weekend, as it's an excellent job, and the guys that did it deserve credit.

Why do I feel shit? I don't know, but I slept badly, and woke up with swollen eyes and a sore throat. Coming down with something? Probably. Would help me explain why I slipped into neutral last night. I hope the patients didn't notice.