There follows naught but non-medical jib. Those not interested in the maudlin naval gazing of a small fungus, best look away now.
I am in particularly bleak mood. There are, I'm sure, a number of reasons for his. There always are.
Whenever I feel like this, I get the urge to bloggin'. It often doesn't last, and I let it slide. I do not know if that's for the best or not. We may go some way to finding out in the next few minutes. Anything can happen in the next half hour?
A busy-ish weekend, but still so much to do. I spend a lot of time griping about the passing of time, and how old I feel. If you're older than me, that'll seem ludicrous. Younger... just wait. I feel it in my nights more than anything. I used to do whole weekends on call, Friday Morning to Monday Evening, with whatever sleep we could snatch. Actually, with two of us on the house, we'd be guaranteed at least one decent night's sleep, so it wasn't bad at all. Even a few years ago, I could do four nights, or five, and g out at the end of them; lead a productive day, and fall blissfully asleep in synch.
Now...
Two, or three, and I'm finished. Worked Wednesday and Thursday; tried to stay up Friday, but fell asleep. Managed a few hours then dragged meself out to see The Girl's play. An ambitious reworking of Marat/Sade. Beautiful and talented. I continue intoxicated. Dinner afterwards with her folks who'd come to see the play too. A good sign? On balance, not, it would seem.
Anyway, I woke at 3. This often happens to me now after nights, but I could not get back to sleep. These days I interpret this as a symptom of low grade depression. I'm tired but my mind won't let me sleep, and I sit, or toss and turn, or pace. All miserably.
I eventually got back to sleep around 8, meaning to get up for 10, and go shopping. When I finally surfaced at 4, it was time to go see some old friends of mine. One bright moment in my fundament. More insomnia was to follow, but at least I managed shopping today.
I can only hope sleep will not evade me this evening. Work awaits, and that usually centres me.
Sunday, December 16, 2007
Friday, December 14, 2007
Getting Amongst It
PC - Sore Throat
HPC - Swallowed cheiwng gum 3/7 ago; thinks it got stuck. Can feel it rising and falling at the back of her throat. No difficulty eating, drinking, breathing. Nauseated, but no vomit
ODC - Has been stabbing herself in the oropharynx with various pointed objects in an attempt to remove the gum
Findings - Raw, injected, erythematous oropharynx; no bleeding. Awake nas-endoscopy revealed no trace of gum.
Disposition - wisdom of stabbing oneself in the throat with pointy things discussed. Advice given regarding the consequnces above and beyond 'sore throat' that such a plan might have. Reiterated age old wisdom that swallowing your gum is a bad idea.
HPC - Swallowed cheiwng gum 3/7 ago; thinks it got stuck. Can feel it rising and falling at the back of her throat. No difficulty eating, drinking, breathing. Nauseated, but no vomit
ODC - Has been stabbing herself in the oropharynx with various pointed objects in an attempt to remove the gum
Findings - Raw, injected, erythematous oropharynx; no bleeding. Awake nas-endoscopy revealed no trace of gum.
Disposition - wisdom of stabbing oneself in the throat with pointy things discussed. Advice given regarding the consequnces above and beyond 'sore throat' that such a plan might have. Reiterated age old wisdom that swallowing your gum is a bad idea.
Wednesday, December 12, 2007
Scandal
Fine; if you want to split hairs, in this acute setting, for 'heart failure', read 'acute cardiogenic pulmonary oedema'.
Scandal, and gossip. Endemic in hospital. I seem to have created a little without realising it.
I'm ALWAYS the last to know, even when I was there apparently.
Scandal, and gossip. Endemic in hospital. I seem to have created a little without realising it.
I'm ALWAYS the last to know, even when I was there apparently.
A Bigger Picture
I'm still feelin pretty good about myself. I'm sure it won't last, but you take what you can get, eh?
Last night was actually quietly busy. Did I already tell you that? I can't remember... the department was stuffed, but with few real sickies. Which is nice. These days it seems a real rarity if our Resus Bays aren't overflowing.
It doesn't take much, though. Another midnight call, another breathless punter. At the best of times, I'm a resus hog, an adrenaline junkie, an SHOs nightmare. Turn around, and there I am, champing at the bit. No matter how quick you think you are... I'm faster. The SHOs I like the best are there quickly, too. I see in them a kindred spirit; they want to see the difficult cases, the interesting cases. This is markedly unfair to the many excellent docs who come through EDs but aren't especially interested in the Acute end of the spectrum. Sorry, guys. No offence meant.
I digress; the elderly breathless is pretty much bread and butter. Since pretty much everyone smoked in the 30s and 40s, they now all have COPD. If they don't, they have heart failure. As with all of medicine, the devil is usually in the details; history is almost all of it. If they're on inhalers up the wazoo, it's COPD. If their drug cupboard rattles with diuretics and other 'heart' meds, its their heart.
Usually. And for all my esteemed physician colleagues, I know it's never that simple, but it's pretty close, eh?
So, last night's arrival had a long smoking history, several admissions with 'exacerbation COPD', and a cabinet full of inhalers and nothing else.
COPD, right?
So much for history...
As I'm sure my medical colleagues know, these patients also have a look about them. This guy was exhausted, sweaty, cold at the edges and had a sky high BP. JVP virtually punching through the roof.
Heart failure.
Chest... pretty quiet, a few wheezes, a few fine creps. The good old fashioned ED mixed bag.
In short, his history was good for COPD, but his exam spelled heart failure. The difference is rarely as clear cut as we would like. When I was on the house, we used to call the treatment 'nebulised frusicillinalol'. Some bronchodilator, some diuresis, some antibiosis.
I was pleased to see my SHO run it like a pro. Good history, rapid assessment, right diagnosis, prompt treatment. The joy of it is, of course, that COPD-ers need limited oxygen and nebs, whereas heart failure needs as much oxygen as you can cram in, and offloading. Get it wrong, and...
Sometimes, whatever you do, it's too late to stop them circling the drain.
We used nebulised frusicillinalol nitrate. X-ray and subsequent intubation confirmed the clinical suspicion of left ventricular failure.
I spent most of the time with the family; it's one of the good things about having competent SHOs. I hope it's because we taught them something. Because I taught them something? I guess it doesn't matter as long as they learned it.
Last night was actually quietly busy. Did I already tell you that? I can't remember... the department was stuffed, but with few real sickies. Which is nice. These days it seems a real rarity if our Resus Bays aren't overflowing.
It doesn't take much, though. Another midnight call, another breathless punter. At the best of times, I'm a resus hog, an adrenaline junkie, an SHOs nightmare. Turn around, and there I am, champing at the bit. No matter how quick you think you are... I'm faster. The SHOs I like the best are there quickly, too. I see in them a kindred spirit; they want to see the difficult cases, the interesting cases. This is markedly unfair to the many excellent docs who come through EDs but aren't especially interested in the Acute end of the spectrum. Sorry, guys. No offence meant.
I digress; the elderly breathless is pretty much bread and butter. Since pretty much everyone smoked in the 30s and 40s, they now all have COPD. If they don't, they have heart failure. As with all of medicine, the devil is usually in the details; history is almost all of it. If they're on inhalers up the wazoo, it's COPD. If their drug cupboard rattles with diuretics and other 'heart' meds, its their heart.
Usually. And for all my esteemed physician colleagues, I know it's never that simple, but it's pretty close, eh?
So, last night's arrival had a long smoking history, several admissions with 'exacerbation COPD', and a cabinet full of inhalers and nothing else.
COPD, right?
So much for history...
As I'm sure my medical colleagues know, these patients also have a look about them. This guy was exhausted, sweaty, cold at the edges and had a sky high BP. JVP virtually punching through the roof.
Heart failure.
Chest... pretty quiet, a few wheezes, a few fine creps. The good old fashioned ED mixed bag.
In short, his history was good for COPD, but his exam spelled heart failure. The difference is rarely as clear cut as we would like. When I was on the house, we used to call the treatment 'nebulised frusicillinalol'. Some bronchodilator, some diuresis, some antibiosis.
I was pleased to see my SHO run it like a pro. Good history, rapid assessment, right diagnosis, prompt treatment. The joy of it is, of course, that COPD-ers need limited oxygen and nebs, whereas heart failure needs as much oxygen as you can cram in, and offloading. Get it wrong, and...
Sometimes, whatever you do, it's too late to stop them circling the drain.
We used nebulised frusicillinalol nitrate. X-ray and subsequent intubation confirmed the clinical suspicion of left ventricular failure.
I spent most of the time with the family; it's one of the good things about having competent SHOs. I hope it's because we taught them something. Because I taught them something? I guess it doesn't matter as long as they learned it.
Pigs On The Wing
More of the multi.
Quietly busy tonight, but at least the aircon was fixed. One of my patients was a young chap with learning difficulties. Having resolved his problems, I was discharging him, when he gestured at another patient. "That man's sick", he whispered, actually drawing close to me, and hiding a little behind my arm. He seemed very frightened. His family told me he was afraid of hospitals, and doctors, although he seemed quite content with me. Maybe the idea of sickness upset him. I tried to reassure him that the other patients would be ok, with little success. Everything seemed to spook him as I walked him out.
Until...
I thought if we changed the subject... I commented on his earring, a snazzy, shiny gold number. The change was immediate. His face lit up, and he beamed with pride. And, then, he actually held his arms aloft, a silent cheer for himself, for his earring, maybe for all earrings and those who proudly wear them day in, day out. The forgotten heroes of ear jewelry.
I don't know, but I made someone happy, and that's gotta be worth some good Karma?
Quietly busy tonight, but at least the aircon was fixed. One of my patients was a young chap with learning difficulties. Having resolved his problems, I was discharging him, when he gestured at another patient. "That man's sick", he whispered, actually drawing close to me, and hiding a little behind my arm. He seemed very frightened. His family told me he was afraid of hospitals, and doctors, although he seemed quite content with me. Maybe the idea of sickness upset him. I tried to reassure him that the other patients would be ok, with little success. Everything seemed to spook him as I walked him out.
Until...
I thought if we changed the subject... I commented on his earring, a snazzy, shiny gold number. The change was immediate. His face lit up, and he beamed with pride. And, then, he actually held his arms aloft, a silent cheer for himself, for his earring, maybe for all earrings and those who proudly wear them day in, day out. The forgotten heroes of ear jewelry.
I don't know, but I made someone happy, and that's gotta be worth some good Karma?
Oddments
A multi-post. I had several good ideas on the way home, again; once again, I appear to have left them on the motorway.
Last night was an odd one. Most Docs and Nurses were living it up at the ED Xmas do. Not me, obviously. The gremlins seemed determined to make the most of our discomfort, and so, for reasons I still do not understand, the temperature in the Dept fell steadily to a nice round 16 degrees (Celsius); or maybe it was 14. The corridors were lovely, toasty warm. But the treatment areas? Cold enough to freeze the balls off a brass monkey.
(Bonus points for any of my dear readers who can suggest the origin of this expression...)
I also began to suspect someone was playing silly buggers with the nitrous, as everyone spent more time than usual giggling. Or maybe I just had something on my face...
The evening ended on a sour note. Another failure.
Young patient. Extensive forensic history, IVDU, epilepsy. Attended as he was having frequent, multiple fits.
But he didn't want treatment; and refused even basic blood tests. He said he had a needle "fixation". I guess he meant that to mean phobia? I'm not sure, but I was cynical enough to note the multiple tattoos, and history of iv drug use.
What he did want was us to "sort my meds out". Not without blood for levels, I countered. No blood he assured me; he was fairly certain I wouldn't find a vein anyway. "I don't even want to be here", he mumbled.
And so I failed him. If I was a better physician, we could, I'm sure, have discussed his fears and desires rationally. Maybe I could have helped. Instead, I got annoyed. Don't wanna be here? Fine. Thanks for stopping, and we'll see you later.
This made him very angry, and he described, among other things as a "no-mark, toffee-nosed prick, who thinks he knows it all just cos he's got a degree off the back of a Cornflakes box."
I'm afraid this made me a little more annoyed. I am well used to people judging me on the strength of my accent. It is particularly... plummy, shall we say. Posh, even. This is not my fault. It is the way I am. I am well spoken, and proud of it. But if you aren't, or your accent doesn't sound like mine? I don't care. It is not who you are. It is how you sound. But to have a go at me, because I am the very thing you have come to see - a well educated, well spoken medical professional? This seems pointless, and despite being used to being the posh boy, I increasingly resent it being used as an insult. After all, I choose not to describe my patient as a "no-mark guttersnipe junkie, who can barely read the back of a Cornflakes box".
So, despite my attempt to reason with him, which probably made things worse - he clearly didn't want to be reminded that to a certain extent, I do know it all, that's why I have my four degrees from Kellogg Uni - our therapeutic relationship was irrevocably soured. And he left.
He did not come back.
But I should have done better by him.
Last night was an odd one. Most Docs and Nurses were living it up at the ED Xmas do. Not me, obviously. The gremlins seemed determined to make the most of our discomfort, and so, for reasons I still do not understand, the temperature in the Dept fell steadily to a nice round 16 degrees (Celsius); or maybe it was 14. The corridors were lovely, toasty warm. But the treatment areas? Cold enough to freeze the balls off a brass monkey.
(Bonus points for any of my dear readers who can suggest the origin of this expression...)
I also began to suspect someone was playing silly buggers with the nitrous, as everyone spent more time than usual giggling. Or maybe I just had something on my face...
The evening ended on a sour note. Another failure.
Young patient. Extensive forensic history, IVDU, epilepsy. Attended as he was having frequent, multiple fits.
But he didn't want treatment; and refused even basic blood tests. He said he had a needle "fixation". I guess he meant that to mean phobia? I'm not sure, but I was cynical enough to note the multiple tattoos, and history of iv drug use.
What he did want was us to "sort my meds out". Not without blood for levels, I countered. No blood he assured me; he was fairly certain I wouldn't find a vein anyway. "I don't even want to be here", he mumbled.
And so I failed him. If I was a better physician, we could, I'm sure, have discussed his fears and desires rationally. Maybe I could have helped. Instead, I got annoyed. Don't wanna be here? Fine. Thanks for stopping, and we'll see you later.
This made him very angry, and he described, among other things as a "no-mark, toffee-nosed prick, who thinks he knows it all just cos he's got a degree off the back of a Cornflakes box."
I'm afraid this made me a little more annoyed. I am well used to people judging me on the strength of my accent. It is particularly... plummy, shall we say. Posh, even. This is not my fault. It is the way I am. I am well spoken, and proud of it. But if you aren't, or your accent doesn't sound like mine? I don't care. It is not who you are. It is how you sound. But to have a go at me, because I am the very thing you have come to see - a well educated, well spoken medical professional? This seems pointless, and despite being used to being the posh boy, I increasingly resent it being used as an insult. After all, I choose not to describe my patient as a "no-mark guttersnipe junkie, who can barely read the back of a Cornflakes box".
So, despite my attempt to reason with him, which probably made things worse - he clearly didn't want to be reminded that to a certain extent, I do know it all, that's why I have my four degrees from Kellogg Uni - our therapeutic relationship was irrevocably soured. And he left.
He did not come back.
But I should have done better by him.
Monday, December 10, 2007
We Interrupt This Broadcast...
Raising Sand, by Robert Plant and Alison Krauss.
Buy it. There's no reason why it should work; but it does.
You won't regret it. (If you do, our tastes are far enough removed that nothing I say makes sense. But you are missing out...)
Buy it. There's no reason why it should work; but it does.
You won't regret it. (If you do, our tastes are far enough removed that nothing I say makes sense. But you are missing out...)
Ball of Confusion
Frankly I'm a little confused.
Had a grand old weekend, although if I'm honest, was probably a bit too drunk and loud. And annoying. In fact I'm lucky my friends put up with me.
Regardless, we had gathered at a friend's house in the flat east of this grand country of ours. A pre Christmas Christmas party, if you will. I asked the girl if she wanted to come. I did this a while ago, while feeling pleased with myself, or optimistic, or high, or something. I didn't think she'd say yes.
But she did, and so I had contrived to spend 24 hours in her company. I'm not sure I distinguished myself, unless she really likes rude songs sung overly loudly. I was also reminded , if I needed reminding, that I am not a young man anymore. Mostly this reminder came in the form of trying too hard to compete in drinking games. Put in my place by a Mary's Man. The shame of it. Time to hang my drinking hat up next to my dancing shoes.
So I had had plans of an attempted wooing. These seem scuppered when I had remarked how we were an anti-cliche, in that we have dinner, she asks me in for coffee, and then... we drink coffee. Of course, says she. I'd be horrified if you tried to jump me.
Horrified.
Let that one roll around in your mouth for a while, if you will.
Horrified.
No, I can't put a positive spin on it either.
Fair enough, I guess that's cleared that up, anyway. Best behaviour, then.
It seemed to work well enough, although my friends were keen to establish us as a couple. I think it's the novelty factor for them. Drunkeness ensued, in case you hadn't gathered, and I sustained a small, but annoyingly painful head injury. Tried, and failed to stay up for the Hatton fight.
But the morning... the morning brought not only the mother of all hangovers, but an interesting sleeping arrangement. Not planned, I insist. Not since I heard the word horrified, anyway. And while all that went on was sleeping, it was, shall we say, very companionable. Was this my time; a test?
Horrified, you'll remember. Well, I didn't see evidence of horror, but I'm still as confused as a fella can be.
Can men and women be just friends? Even if they're very good friends?
I'm no clearer knowing, frankly.
Last business:
Historical note. I've just watched the Alamo. I'm sure the thing is riven with historical inaccuracies, but one in particular has got my goat. General Houston makes reference to Wellington choosing the battleground at Waterloo. He didn't. While he generally preferred to fight on his terms, on this occasion, Napoleon stole a march on him, humbugged him, if you will, and he had to fight there to stop Napoleon splitting the Allied armies. So there.
Music Nazi recommends What We Did On Our Holidays, by Fairport Convention. Do it. You know you need more folk in your life.
Had a grand old weekend, although if I'm honest, was probably a bit too drunk and loud. And annoying. In fact I'm lucky my friends put up with me.
Regardless, we had gathered at a friend's house in the flat east of this grand country of ours. A pre Christmas Christmas party, if you will. I asked the girl if she wanted to come. I did this a while ago, while feeling pleased with myself, or optimistic, or high, or something. I didn't think she'd say yes.
But she did, and so I had contrived to spend 24 hours in her company. I'm not sure I distinguished myself, unless she really likes rude songs sung overly loudly. I was also reminded , if I needed reminding, that I am not a young man anymore. Mostly this reminder came in the form of trying too hard to compete in drinking games. Put in my place by a Mary's Man. The shame of it. Time to hang my drinking hat up next to my dancing shoes.
So I had had plans of an attempted wooing. These seem scuppered when I had remarked how we were an anti-cliche, in that we have dinner, she asks me in for coffee, and then... we drink coffee. Of course, says she. I'd be horrified if you tried to jump me.
Horrified.
Let that one roll around in your mouth for a while, if you will.
Horrified.
No, I can't put a positive spin on it either.
Fair enough, I guess that's cleared that up, anyway. Best behaviour, then.
It seemed to work well enough, although my friends were keen to establish us as a couple. I think it's the novelty factor for them. Drunkeness ensued, in case you hadn't gathered, and I sustained a small, but annoyingly painful head injury. Tried, and failed to stay up for the Hatton fight.
But the morning... the morning brought not only the mother of all hangovers, but an interesting sleeping arrangement. Not planned, I insist. Not since I heard the word horrified, anyway. And while all that went on was sleeping, it was, shall we say, very companionable. Was this my time; a test?
Horrified, you'll remember. Well, I didn't see evidence of horror, but I'm still as confused as a fella can be.
Can men and women be just friends? Even if they're very good friends?
I'm no clearer knowing, frankly.
Last business:
Historical note. I've just watched the Alamo. I'm sure the thing is riven with historical inaccuracies, but one in particular has got my goat. General Houston makes reference to Wellington choosing the battleground at Waterloo. He didn't. While he generally preferred to fight on his terms, on this occasion, Napoleon stole a march on him, humbugged him, if you will, and he had to fight there to stop Napoleon splitting the Allied armies. So there.
Music Nazi recommends What We Did On Our Holidays, by Fairport Convention. Do it. You know you need more folk in your life.
Saturday, December 08, 2007
Car-Nage
Another hot one...
Some of our 4pm til midnight shifts have slipped two hours, to become 6pm til 2 am shifts. Today's was just such a shift. Joyfully, I had booked a patient to come back for review at 4. I duly set off to make the commute; today, of all days, the traffic was shite. This coincided with my reaffirming my theory about drinking plenty of water. 3 litres a day? Balls. I am not convinced this makes me any healthier. It does make me piss like a racehorse. So, en route today, I dutifully drank a litre of God's finest tapwater. My timing is usually such that I arrive just in time to void, copiously.
Not today.
Constant reader, if you are not desirous of learning more than you really need about my bladder, look away now.
I made one pitstop about halfway, to stretch the Shroom's stumpy little legs, and add my contribution to the groundwater. The traffic jam 20 minutes away from work subjected me to the trials of patience peculiar to the bladder. I almost made it; but at the last, had to pull over. On this occasion, I could not find an appropriate bush to water, so was able to recycle my water bottle. And I filled it to the brim. A whole litre! Which went some way to explain why my back teeth had been floating. And yet 10 minutes later, once I got to work, I was able to void further. I didn't have a urometer to hand on this occasion, but reckon I passed another 500. So, one litre in, probably 2 out. I am the king of diuresis.
'Rehydration' my stretchy bladder.
Uriniferous miasma passed.
The department was once again heaving. My favourite boss asked me to weigh in early. I have so little life. I gladly accepted. Another shift in resus. Maybe I can get a little cot in the corner, and move in. It'll sure as hell cut down on my commute costs.
So - COPD decompensating in Bay one; serious trauma in 2 (donorcycle versus car); haemoptysis in 3. He ended up there because of a history of gastric carcinoma and abdominal aneurysm. He was pretty well, all things considered, which gave me time to goggle at the fact that bay 2 guy had done almost the same thin a year ago. He is surely getting the most out of his NHS tax dollar, but using up his nine lives, eh? I didn't quite keep up with what his injuries were this time, but our resus was for a time home to all the intensivists our little hospital has to offer.
The stability of haemoptysis man was further useful as it enabled a quick switch for status epilepticus girl. This wee lassie's story is confused by her non-diagnosis. We are all agreed that she has fits, but no-one knows why. The Neuro guys are pretty sure it ain't epilepsy; the Head shrinkers are pretty sure it ain't psychological; and the cardiac guys are wondering what it has to do with them. So far as I can tell, all tests are normal... which more or less adds up to 'psychological' seizures. Or pseudo-fits. The problem with this diagnosis is the stigma attached. It tends to be equated with 'faking it'. This patient certainly felt she wasn't being taken seriously by medical personnel, once they found out her non-epileptic diagnosis. And as far as I can tell, her fits were not epileptic, although I can see how they would appear to be to a lay person.
Does that change how I treat her? No, except possibly in that I'm less likely to give her benzos, or other anti-convulsants. Fits are fits; they still fuck up your day. Personally, I think they are psychological, but what do I know. I suspect this diagnosis will not ever be accepted by the family, or the patient. And as such, I'm not sure if she'll get better. Speaking to the family, it seemed to me that they considered the very idea offensive. I'm not sure this is fair. Like I say, fitting is fitting. Why should there be less stigma to a fit that has an 'organic' cause, as opposed to one that is 'psychological'? I guess this small question holds the nub of the stigma associated with all mental health issues.
Fuck it, what do I know?
A few more fits later, and a brief argument with the Magicians, and our lassie won a bed for the night. I hope her test results eventually tell her what she wants, and some treatment can be started.
She made way for a fracture dislocation of an ankle. Normally my bread and butter, I just could not relocate this one. I sheepishly had to turf to ortho. Macho Shroom? Not this day...
And with her passage out of the House of Fun, my nightly MI arrived. The MI that never was, fortunately. Brief panic, then transfer to CCU. Joy, and medicine of the highest quality. A few Paeds cases brought on the double bunking that seems de rigeur these days; in fact I even had the pleasure of treating a few in the corridor. To their eternal credit, the parents were understanding, and probably just glad to see a doctor. First world care, you see...
My shift ended with a smattering of trauma. Another donorcyclist, this one who worked in a brewery, and smelled like it, but seemed to have got away with facial injuries. The usual survey was complicated by the patients spectacularly awful dentition. He barely had a single tooth in his mouth, and could not tell me if this was how God intended him to be, or if the offending ivories might be nestling in his pulmonary nooks and crannies. At the same time, there was a great stacking of motor vehicles somewhere far to the north, disgorging copious numbers of inebriated youths, in various stages of injury. A major incident beckoned, but we were fortunate enough to be able to share the wealth with several sister hospitals. But this still left my colleague snowed under as the witching hour drew nigh.
A man of no doubt the highest moral fibre completed my night by overdosing on cocaine and heroin; an interesting combo, and another repeat offender, I noted with, sadly, little surprise.
My journey home was illuminated by the particularly piercing incandescent blues unique to ambulances. Erie when they aren't blaring the two tones... Over for the night?
Not even started, my friends
Some of our 4pm til midnight shifts have slipped two hours, to become 6pm til 2 am shifts. Today's was just such a shift. Joyfully, I had booked a patient to come back for review at 4. I duly set off to make the commute; today, of all days, the traffic was shite. This coincided with my reaffirming my theory about drinking plenty of water. 3 litres a day? Balls. I am not convinced this makes me any healthier. It does make me piss like a racehorse. So, en route today, I dutifully drank a litre of God's finest tapwater. My timing is usually such that I arrive just in time to void, copiously.
Not today.
Constant reader, if you are not desirous of learning more than you really need about my bladder, look away now.
I made one pitstop about halfway, to stretch the Shroom's stumpy little legs, and add my contribution to the groundwater. The traffic jam 20 minutes away from work subjected me to the trials of patience peculiar to the bladder. I almost made it; but at the last, had to pull over. On this occasion, I could not find an appropriate bush to water, so was able to recycle my water bottle. And I filled it to the brim. A whole litre! Which went some way to explain why my back teeth had been floating. And yet 10 minutes later, once I got to work, I was able to void further. I didn't have a urometer to hand on this occasion, but reckon I passed another 500. So, one litre in, probably 2 out. I am the king of diuresis.
'Rehydration' my stretchy bladder.
Uriniferous miasma passed.
The department was once again heaving. My favourite boss asked me to weigh in early. I have so little life. I gladly accepted. Another shift in resus. Maybe I can get a little cot in the corner, and move in. It'll sure as hell cut down on my commute costs.
So - COPD decompensating in Bay one; serious trauma in 2 (donorcycle versus car); haemoptysis in 3. He ended up there because of a history of gastric carcinoma and abdominal aneurysm. He was pretty well, all things considered, which gave me time to goggle at the fact that bay 2 guy had done almost the same thin a year ago. He is surely getting the most out of his NHS tax dollar, but using up his nine lives, eh? I didn't quite keep up with what his injuries were this time, but our resus was for a time home to all the intensivists our little hospital has to offer.
The stability of haemoptysis man was further useful as it enabled a quick switch for status epilepticus girl. This wee lassie's story is confused by her non-diagnosis. We are all agreed that she has fits, but no-one knows why. The Neuro guys are pretty sure it ain't epilepsy; the Head shrinkers are pretty sure it ain't psychological; and the cardiac guys are wondering what it has to do with them. So far as I can tell, all tests are normal... which more or less adds up to 'psychological' seizures. Or pseudo-fits. The problem with this diagnosis is the stigma attached. It tends to be equated with 'faking it'. This patient certainly felt she wasn't being taken seriously by medical personnel, once they found out her non-epileptic diagnosis. And as far as I can tell, her fits were not epileptic, although I can see how they would appear to be to a lay person.
Does that change how I treat her? No, except possibly in that I'm less likely to give her benzos, or other anti-convulsants. Fits are fits; they still fuck up your day. Personally, I think they are psychological, but what do I know. I suspect this diagnosis will not ever be accepted by the family, or the patient. And as such, I'm not sure if she'll get better. Speaking to the family, it seemed to me that they considered the very idea offensive. I'm not sure this is fair. Like I say, fitting is fitting. Why should there be less stigma to a fit that has an 'organic' cause, as opposed to one that is 'psychological'? I guess this small question holds the nub of the stigma associated with all mental health issues.
Fuck it, what do I know?
A few more fits later, and a brief argument with the Magicians, and our lassie won a bed for the night. I hope her test results eventually tell her what she wants, and some treatment can be started.
She made way for a fracture dislocation of an ankle. Normally my bread and butter, I just could not relocate this one. I sheepishly had to turf to ortho. Macho Shroom? Not this day...
And with her passage out of the House of Fun, my nightly MI arrived. The MI that never was, fortunately. Brief panic, then transfer to CCU. Joy, and medicine of the highest quality. A few Paeds cases brought on the double bunking that seems de rigeur these days; in fact I even had the pleasure of treating a few in the corridor. To their eternal credit, the parents were understanding, and probably just glad to see a doctor. First world care, you see...
My shift ended with a smattering of trauma. Another donorcyclist, this one who worked in a brewery, and smelled like it, but seemed to have got away with facial injuries. The usual survey was complicated by the patients spectacularly awful dentition. He barely had a single tooth in his mouth, and could not tell me if this was how God intended him to be, or if the offending ivories might be nestling in his pulmonary nooks and crannies. At the same time, there was a great stacking of motor vehicles somewhere far to the north, disgorging copious numbers of inebriated youths, in various stages of injury. A major incident beckoned, but we were fortunate enough to be able to share the wealth with several sister hospitals. But this still left my colleague snowed under as the witching hour drew nigh.
A man of no doubt the highest moral fibre completed my night by overdosing on cocaine and heroin; an interesting combo, and another repeat offender, I noted with, sadly, little surprise.
My journey home was illuminated by the particularly piercing incandescent blues unique to ambulances. Erie when they aren't blaring the two tones... Over for the night?
Not even started, my friends
Thursday, December 06, 2007
Choice Selection
Another ferocious day in the Department. I barely got out of resus; from start to finish, a cavalcade of the truly unwell. I am again frustrated by my inability to remember things that I think of as I'm driving that I'm convinced will make insightful, witty blog material.
Two things have managed to take hold.
First was an interview I heard on Radio 4. It was with an elderly lady who was a land girl during the war. These girls worked the land, doing the jobs left undone by the men so far away in the mud, blood and shit on the front. This lady had been a specialist in pest control, which essentially involved various inhumane ways of slaughtering rats and rabbits. She rationalised her job by telling herself that each beast slain meant one less piece of food that the Merchant Navy would have to bring.
She recounted a tale whereby the girls were taken to a farm and shown various fascinomas, including a caravan full of monkeys no less, and the corpse of a lion. This lion had done for the ex-rector of somewhere or other. Claspknife or something. It transpired that this rector had been helping the local fallen women, but had occasionally been helping them to fall a little further. He was subsequently defrocked and had taken to standing in a barrel on Blackpool Pier, protesting his innocence. He then moved to near Skegness, where a local man was exhibiting a lion. The ex-rector took to entering the lion's cage offering his soul to the Lord, proclaiming that if he were guilty, the lion would do the Lord's work.
Obviously, it ate him.
Justice? I found it morbidly entertaining.
Second was my thoughts on how different patients look when they're flat. I often form opinions about the patients I see while they're unconscious, only to have my ideas roundly disabused when they wake. This was particularly illustrated to me with one chap, brought by the Police. The story is all too familiar. A young fella, they're usually male, mostly young, is intercepted in his mission to drink too much then make a general nuisance of himself about town. Shortly after their arrest, they become strangely unresponsive. A quick trip to the hospital ensues, whereupon they are de-arrested, which usually brings on a rapid recovery and exit.
Cynic, thy name is Shroom.
So... this guy fulfilled all the above criteria, but I could not get him to wake. He looked like a rough-housing kindof guy. I saw him as a brawler, the kind of fella I might well cross the street to avoid. Anyway, I was still convinced he was putting it on. All his obs were normal, blood work the same. Catheterising, so often my go to procedure had barely raised a flicker. One last trick up my sleeve, before the onerous 3 a.m wake the Radiologist phone call...
This is one of my favourite tricks, but requires a serious voice. Standing over the patient, one opines, loudly, that the situation looks grim, and that a brain biopsy may be required. It helps if your assistant will gasp convincingly at this stage.
Next, equally loudly, ask for "The Large brain-needle". You, can, if you so wish, at this point, gently prod the patient's head with a bluntish sharp object. I use the end of a tendon hammer. The response was amazing. Rapid recovery. But what surprised me the most was how his features softened. He turned out to be the campest man this side of Liberace. He had great fun discovering, and removing his catheter.
Well, he didn't have fun, but we smiled a little when we heard the noise he made pulling it out.
Two things have managed to take hold.
First was an interview I heard on Radio 4. It was with an elderly lady who was a land girl during the war. These girls worked the land, doing the jobs left undone by the men so far away in the mud, blood and shit on the front. This lady had been a specialist in pest control, which essentially involved various inhumane ways of slaughtering rats and rabbits. She rationalised her job by telling herself that each beast slain meant one less piece of food that the Merchant Navy would have to bring.
She recounted a tale whereby the girls were taken to a farm and shown various fascinomas, including a caravan full of monkeys no less, and the corpse of a lion. This lion had done for the ex-rector of somewhere or other. Claspknife or something. It transpired that this rector had been helping the local fallen women, but had occasionally been helping them to fall a little further. He was subsequently defrocked and had taken to standing in a barrel on Blackpool Pier, protesting his innocence. He then moved to near Skegness, where a local man was exhibiting a lion. The ex-rector took to entering the lion's cage offering his soul to the Lord, proclaiming that if he were guilty, the lion would do the Lord's work.
Obviously, it ate him.
Justice? I found it morbidly entertaining.
Second was my thoughts on how different patients look when they're flat. I often form opinions about the patients I see while they're unconscious, only to have my ideas roundly disabused when they wake. This was particularly illustrated to me with one chap, brought by the Police. The story is all too familiar. A young fella, they're usually male, mostly young, is intercepted in his mission to drink too much then make a general nuisance of himself about town. Shortly after their arrest, they become strangely unresponsive. A quick trip to the hospital ensues, whereupon they are de-arrested, which usually brings on a rapid recovery and exit.
Cynic, thy name is Shroom.
So... this guy fulfilled all the above criteria, but I could not get him to wake. He looked like a rough-housing kindof guy. I saw him as a brawler, the kind of fella I might well cross the street to avoid. Anyway, I was still convinced he was putting it on. All his obs were normal, blood work the same. Catheterising, so often my go to procedure had barely raised a flicker. One last trick up my sleeve, before the onerous 3 a.m wake the Radiologist phone call...
This is one of my favourite tricks, but requires a serious voice. Standing over the patient, one opines, loudly, that the situation looks grim, and that a brain biopsy may be required. It helps if your assistant will gasp convincingly at this stage.
Next, equally loudly, ask for "The Large brain-needle". You, can, if you so wish, at this point, gently prod the patient's head with a bluntish sharp object. I use the end of a tendon hammer. The response was amazing. Rapid recovery. But what surprised me the most was how his features softened. He turned out to be the campest man this side of Liberace. He had great fun discovering, and removing his catheter.
Well, he didn't have fun, but we smiled a little when we heard the noise he made pulling it out.
Wednesday, December 05, 2007
Maid Of The River
Now that Mo'vember has passed, I've slackened off a bit. Sorry. I continue to find it difficult to find stuff to blog about; some days I'm pretty much too lazy to sleep, if you can credit it.
Today has found me on just such a day. A day off, after a late; slept late, then mooched about. I did have good intentions to get some work done... I guess it'll have to keep.
So tonight finds me immersed in my favourite pastime - watching old episodes of ER. This one is one of my especial favourites. Its called Exodus, and features Carter stepping to the fore in the face of a major incident. A benzene spill, with contamination of the ER. High melodrama at its finest.
In real life, shit continues to flow downhill. I am forever fascinated by people's reactions to our enquiries about their pain. Most if not all, places use a 0 - 10 point scale. 0 is no pain, 10 the worst imaginable. Yet people insist on telling me their pain is '12', or '20'. Now I recognise that your pain may be bad, but when I offer you a scale that tops out at 'the worst imaginable', there is no point telling me it's worse than that. It's childish. It's like saying 'infinity plus one'. Particularly when you then flinch as I put a venflon in.
I'm thinking we should tell people the scale is "0 for no pain, 10 for worst imaginable, and more than 10 means you're making it up.". I was once confronted by an angry young woman, who had come back from the waiting room, to ask when she would seen for her headache. Her pain, she said, was '20 out of 10'. I was amazed that she was able to converse with pain twice as bad as, for example, being cut in half with a rusty lemon. Interestingly, it always seems to be these people who insist they have a very high pain threshold. Never the people with horrendous compound fractures sitting quietly. Why do they never feel the need to brag about their pain threshold?
Something else that seems to confuse people is the pointing out of inconsistencies in their stories. I recently saw a patient, whose final diagnosis appears to have been cholecystitis (inflammation of the gall bladder), who assured me she had a very high pain threshold. Despite this, she was unmanageable with pain, despite morphine and enough entonox to sedate an elephant. The pain, she insisted was markedly worse on movement. 'But you're moving all the time', I offered. 'Your breathing, in fact, is using all your abdominal muscles, and you're rolling all over the bed (I know what you're thinking, it's colic; and it was), so is it really worse on movement?'
Patient just looked blankly at me. I mean, I know we sometimes blind people with science, but...
Well, it could be worse. I could be mopping up benzene...
Today has found me on just such a day. A day off, after a late; slept late, then mooched about. I did have good intentions to get some work done... I guess it'll have to keep.
So tonight finds me immersed in my favourite pastime - watching old episodes of ER. This one is one of my especial favourites. Its called Exodus, and features Carter stepping to the fore in the face of a major incident. A benzene spill, with contamination of the ER. High melodrama at its finest.
In real life, shit continues to flow downhill. I am forever fascinated by people's reactions to our enquiries about their pain. Most if not all, places use a 0 - 10 point scale. 0 is no pain, 10 the worst imaginable. Yet people insist on telling me their pain is '12', or '20'. Now I recognise that your pain may be bad, but when I offer you a scale that tops out at 'the worst imaginable', there is no point telling me it's worse than that. It's childish. It's like saying 'infinity plus one'. Particularly when you then flinch as I put a venflon in.
I'm thinking we should tell people the scale is "0 for no pain, 10 for worst imaginable, and more than 10 means you're making it up.". I was once confronted by an angry young woman, who had come back from the waiting room, to ask when she would seen for her headache. Her pain, she said, was '20 out of 10'. I was amazed that she was able to converse with pain twice as bad as, for example, being cut in half with a rusty lemon. Interestingly, it always seems to be these people who insist they have a very high pain threshold. Never the people with horrendous compound fractures sitting quietly. Why do they never feel the need to brag about their pain threshold?
Something else that seems to confuse people is the pointing out of inconsistencies in their stories. I recently saw a patient, whose final diagnosis appears to have been cholecystitis (inflammation of the gall bladder), who assured me she had a very high pain threshold. Despite this, she was unmanageable with pain, despite morphine and enough entonox to sedate an elephant. The pain, she insisted was markedly worse on movement. 'But you're moving all the time', I offered. 'Your breathing, in fact, is using all your abdominal muscles, and you're rolling all over the bed (I know what you're thinking, it's colic; and it was), so is it really worse on movement?'
Patient just looked blankly at me. I mean, I know we sometimes blind people with science, but...
Well, it could be worse. I could be mopping up benzene...
Sunday, December 02, 2007
"Taxi For The Man In The Arseless Gown..."
On dignity and nappies.
A fellow blogger has had a few words to say about how our clients comport themselves. Manners are rarely a big priority. It's just like any job, obviously. With a few more drunks. And wankers.
I apologise if I've done this already. I have a habit of repeating myself...
One evening many moons ago, a young-ish man was rushed to us. His friends had brought him in, from the pub. He had spent his usual Saturday drinking and smoking. His friends figured he'd had at least 15 pints. Not so much, eh? Then, he'd come over 'a bit funny'. And been sick. Everywhere. Then passed out.
And wet himself.
And crapped himself.
His mates had piled him in the back of one of their vans, which was now truly soiled. They told us he'd had a heart attack and a stroke (or brain attack, if you prefer) in the past. This fella was little older than I, and had the co-morbidity of a septuagenarian. Despite all of this, he still lived the life of a teenager.
Anyway, he was presented to us; a blank canvas, albeit one soaked in fresh, warm effluent. We worked him in the usual way, en masse.
Open his airway, check his breathing. All clear. Check the pulses, blood pressure. All good. Get a line in, blood out - precious, precious, oh, yes, my precious... - fluid in.
Run the neuro. Quick GCS, check his pupils. Apart from being flat out, and stinking of... stuff, not much focal to find. Gut instinct? 15 pints, plus grey matter = coma.
But...
Could it be something else? For sure. He's had one stroke, could this be another? The booze coma waiting game ensues.
IF: it's just booze, you can wait without a CT
BUT: if it's NOT just booze, you can't.
SO: you have to wait long enough for doubt to enter the equation, so you can buy a trip to the scanner from the Radiologist.
Wait too long, and you're a doofus. Jump too early, and he wakes up in time to negate the need for the scan, just in time to piss the radiologist off when he realises he's out of bed at two a.m for a scan that's not needed any more.
I decided to jump early with this guy. He seemed too flat for just booze. My team had shrunk by now, just me and a nurse; much more intimate. Me, my partner in crime and our patient. Our own special club. I was just bouncing the idea of the scan of the nurse, and opining that we'd need a catheter, when sleeping beauty stirred.
"No catheter" he slurred, offering us a share in his ethanolic miasma.
"No fucking catheter. Leave me my dignity."
My delight that he was waking, with now sign of stroke, mixed with joy that I had not yet called the Radiologist and sheer incredulity.
Your dignity? You spent the evening drinking heavily, before passing out, vomiting all over yourself and your friends, and their van before soiling yourself. And you're worried that my placing a urinary catheter, in private, with only an highly qualified nurse to witness the event, will impede your dignity?
My apologies.
Re-examination revealed a very drunk, slightly soiled man, with no apparent injury.
Another life saved.
As the fella's clothes were beyond wearing, we furnished him with an hospital gown - the kind that don't quite do up at the back - and pointed him to the nearest taxi rank.
I can't think why his friends didn't want to take him home
A fellow blogger has had a few words to say about how our clients comport themselves. Manners are rarely a big priority. It's just like any job, obviously. With a few more drunks. And wankers.
I apologise if I've done this already. I have a habit of repeating myself...
One evening many moons ago, a young-ish man was rushed to us. His friends had brought him in, from the pub. He had spent his usual Saturday drinking and smoking. His friends figured he'd had at least 15 pints. Not so much, eh? Then, he'd come over 'a bit funny'. And been sick. Everywhere. Then passed out.
And wet himself.
And crapped himself.
His mates had piled him in the back of one of their vans, which was now truly soiled. They told us he'd had a heart attack and a stroke (or brain attack, if you prefer) in the past. This fella was little older than I, and had the co-morbidity of a septuagenarian. Despite all of this, he still lived the life of a teenager.
Anyway, he was presented to us; a blank canvas, albeit one soaked in fresh, warm effluent. We worked him in the usual way, en masse.
Open his airway, check his breathing. All clear. Check the pulses, blood pressure. All good. Get a line in, blood out - precious, precious, oh, yes, my precious... - fluid in.
Run the neuro. Quick GCS, check his pupils. Apart from being flat out, and stinking of... stuff, not much focal to find. Gut instinct? 15 pints, plus grey matter = coma.
But...
Could it be something else? For sure. He's had one stroke, could this be another? The booze coma waiting game ensues.
IF: it's just booze, you can wait without a CT
BUT: if it's NOT just booze, you can't.
SO: you have to wait long enough for doubt to enter the equation, so you can buy a trip to the scanner from the Radiologist.
Wait too long, and you're a doofus. Jump too early, and he wakes up in time to negate the need for the scan, just in time to piss the radiologist off when he realises he's out of bed at two a.m for a scan that's not needed any more.
I decided to jump early with this guy. He seemed too flat for just booze. My team had shrunk by now, just me and a nurse; much more intimate. Me, my partner in crime and our patient. Our own special club. I was just bouncing the idea of the scan of the nurse, and opining that we'd need a catheter, when sleeping beauty stirred.
"No catheter" he slurred, offering us a share in his ethanolic miasma.
"No fucking catheter. Leave me my dignity."
My delight that he was waking, with now sign of stroke, mixed with joy that I had not yet called the Radiologist and sheer incredulity.
Your dignity? You spent the evening drinking heavily, before passing out, vomiting all over yourself and your friends, and their van before soiling yourself. And you're worried that my placing a urinary catheter, in private, with only an highly qualified nurse to witness the event, will impede your dignity?
My apologies.
Re-examination revealed a very drunk, slightly soiled man, with no apparent injury.
Another life saved.
As the fella's clothes were beyond wearing, we furnished him with an hospital gown - the kind that don't quite do up at the back - and pointed him to the nearest taxi rank.
I can't think why his friends didn't want to take him home
Saturday, December 01, 2007
Untitled
Silly o'clock on a Saturday morning. I've been awake since two, staring at the clock. Bugger.
A fresh day awaits me, replete with all the detritus that Big Teaching Hospital can throw at me. Weekend days are a little like nights, inasmuch as you're pretty much on your own. And busy. My nights have thrown my body clock off, hence my nocturnal roamings.
Had dinner with her again last night. Am equally sure, in equal measures, that I love her, and that she doesn't love me. Still, her friendship enriches me. I feel better for it, even if my soul aches. I wonder if, deep down, I know this is for the best. I am around so little, and our paths so divergent, that I wonder if we could ever be anything more. Perhaps, on some level I prefer it this way. Unrequited love... All the ache, none of the mess? Maybe I'm not explaining it right; I'm hopeless.
I've basically spent the last two days asleep; hence nil to blog. I'm pleased to see my friend blogging; I think he'll find it helpful. Therapeutic. Some shit like that.
I almost saw an accident recently, which was odd. I was at a petrol station, buying petrol, as one does. As I was going to get back into my car, I heard a loud crack noise. Not quite a bang, or a crash, but you get the idea. By the time I turned around, it was all over. A car had wrapped itself around the signpost for the petrol station. I had real trouble getting my brain to accept that all was still. That it had all happened. Although I could rationalise that by the time I'd heard the noise, it was all over, so by the time I'd turned round all would be quiet, it didn't seem to make any sense.
Go figure.
They guys in the car were ok; I think even the car wasn't too beat up. But the physics of it confused me. Still does, I think.
Random? For sure, but what did you expect at 5 in the a.m?
Oh, and fucking Mo'vember is over, and the Mo is gone.
A fresh day awaits me, replete with all the detritus that Big Teaching Hospital can throw at me. Weekend days are a little like nights, inasmuch as you're pretty much on your own. And busy. My nights have thrown my body clock off, hence my nocturnal roamings.
Had dinner with her again last night. Am equally sure, in equal measures, that I love her, and that she doesn't love me. Still, her friendship enriches me. I feel better for it, even if my soul aches. I wonder if, deep down, I know this is for the best. I am around so little, and our paths so divergent, that I wonder if we could ever be anything more. Perhaps, on some level I prefer it this way. Unrequited love... All the ache, none of the mess? Maybe I'm not explaining it right; I'm hopeless.
I've basically spent the last two days asleep; hence nil to blog. I'm pleased to see my friend blogging; I think he'll find it helpful. Therapeutic. Some shit like that.
I almost saw an accident recently, which was odd. I was at a petrol station, buying petrol, as one does. As I was going to get back into my car, I heard a loud crack noise. Not quite a bang, or a crash, but you get the idea. By the time I turned around, it was all over. A car had wrapped itself around the signpost for the petrol station. I had real trouble getting my brain to accept that all was still. That it had all happened. Although I could rationalise that by the time I'd heard the noise, it was all over, so by the time I'd turned round all would be quiet, it didn't seem to make any sense.
Go figure.
They guys in the car were ok; I think even the car wasn't too beat up. But the physics of it confused me. Still does, I think.
Random? For sure, but what did you expect at 5 in the a.m?
Oh, and fucking Mo'vember is over, and the Mo is gone.
Wednesday, November 28, 2007
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.
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.
Tuesday, November 27, 2007
A Night of Two Halves
Busy Busy Busy.
Interesting. The department was, once again, heaving when I came on last night. Patients queuing to get off ambulances, and mustachioed doctors groaning under the workload. A full hospital. I note that when this happened to the Norfolk and Norwich, they declared a 'code black' and made the news...
Two incidents stand out for me. Firstly, there was the delightful lady who seemed to think that because she had taken an overdose, she could behave as she wished. She took the opportunity to subject everyone within reach to a torrent of the foulest, most bilious abuse imaginable. She topped off her performance with a fine array of spitting. A command performance.
Having determined that her overdose required little in the way of acute management, we disabused her of her ideas about entitlement by having her arrested.
Next I once again had the pleasure of double bunking in resus. In a sort of homage to Steve Martin in the 'Man with Two Brains' I simultaneously treated 3 teens from an RTC. Single vehicle vs tree; they were all in reasonable shape, which was more than could be said for the car.
After this, the night fairly flew by. By six, all was quiet... for about 3 seconds. It was then that the patient handed over to me, with the fateful words "He'll be fine, you won't need to do anything", started fitting.
The fit subsided fairly promptly, but the spreading petechial rash, and frank blood in his catheter bag did not ease our minds. To compound matters, just as the possibility of meningococcaemia was rearing its ugly head, a young woman 2 weeks post chemo was wheeled in.
Now, for those of you unsure, chemotherapy, for all its many benefits, rogers your immune system good and proper. So, once that's happened, one becomes subject to all sorts of previously harmless infections. The hospital often beckons. But next to a patient teaming with meningococcus is low on the list of places you wanna be.
A bit of juggling later, we had achieved isolation. Of sorts. But the department had backed up sufficiently to give the morning crew the impression that we'd done buggerall over night.
Ah well.
On a lighter note, I was able to review some CT scans. These were of the cervical spine of an elderly patient. It was this patient whose condition I was afraid I had misdiagnosed. Had missed.
The CT supported my original diagnosis.
This is good for a number of reasons.
1) The patient does not have a broken neck
2)The patient does not have a spinal injury
3)I didn't miss a spinal fracture.
The altruistic Shroom is clearly glad that this means the patient is well.
(But it's quite nice to know I didn't make a mistake, for the sake of not having made a mistake...)
Interesting. The department was, once again, heaving when I came on last night. Patients queuing to get off ambulances, and mustachioed doctors groaning under the workload. A full hospital. I note that when this happened to the Norfolk and Norwich, they declared a 'code black' and made the news...
Two incidents stand out for me. Firstly, there was the delightful lady who seemed to think that because she had taken an overdose, she could behave as she wished. She took the opportunity to subject everyone within reach to a torrent of the foulest, most bilious abuse imaginable. She topped off her performance with a fine array of spitting. A command performance.
Having determined that her overdose required little in the way of acute management, we disabused her of her ideas about entitlement by having her arrested.
Next I once again had the pleasure of double bunking in resus. In a sort of homage to Steve Martin in the 'Man with Two Brains' I simultaneously treated 3 teens from an RTC. Single vehicle vs tree; they were all in reasonable shape, which was more than could be said for the car.
After this, the night fairly flew by. By six, all was quiet... for about 3 seconds. It was then that the patient handed over to me, with the fateful words "He'll be fine, you won't need to do anything", started fitting.
The fit subsided fairly promptly, but the spreading petechial rash, and frank blood in his catheter bag did not ease our minds. To compound matters, just as the possibility of meningococcaemia was rearing its ugly head, a young woman 2 weeks post chemo was wheeled in.
Now, for those of you unsure, chemotherapy, for all its many benefits, rogers your immune system good and proper. So, once that's happened, one becomes subject to all sorts of previously harmless infections. The hospital often beckons. But next to a patient teaming with meningococcus is low on the list of places you wanna be.
A bit of juggling later, we had achieved isolation. Of sorts. But the department had backed up sufficiently to give the morning crew the impression that we'd done buggerall over night.
Ah well.
On a lighter note, I was able to review some CT scans. These were of the cervical spine of an elderly patient. It was this patient whose condition I was afraid I had misdiagnosed. Had missed.
The CT supported my original diagnosis.
This is good for a number of reasons.
1) The patient does not have a broken neck
2)The patient does not have a spinal injury
3)I didn't miss a spinal fracture.
The altruistic Shroom is clearly glad that this means the patient is well.
(But it's quite nice to know I didn't make a mistake, for the sake of not having made a mistake...)
Monday, November 26, 2007
9 Crimes
Another week, another set of nights. Yay!
I'll try to add to this s the night allows, but mostly I'm just tired now. Unable to sleep and probing my own emotional lability with re-runs of (what else) ER, and (surprisingly) Dr Who.
For now, I'm away to the gym to continue my 'fat bloke to 5K' challenge. Wish me luck. I'm upping my distance today, which may provoke an MI. Still, 18 days off the fags (again) and counting.
Yes I know this is a nothing post, but I'm still trying for one-a-day. I warned you drivel would feature....
I'll try to add to this s the night allows, but mostly I'm just tired now. Unable to sleep and probing my own emotional lability with re-runs of (what else) ER, and (surprisingly) Dr Who.
For now, I'm away to the gym to continue my 'fat bloke to 5K' challenge. Wish me luck. I'm upping my distance today, which may provoke an MI. Still, 18 days off the fags (again) and counting.
Yes I know this is a nothing post, but I'm still trying for one-a-day. I warned you drivel would feature....
Sunday, November 25, 2007
Dammit
Apparently, the post gets recorded as the time you start, not the time you finish.
What a jip. I promise I'll add to this later...
What a jip. I promise I'll add to this later...
Saturday, November 24, 2007
Ev'ry Tiger In The Zoo Loves Little Tiger Sue
I promised I'd do this.
And, if I wait 10 minutes, it'll be tomorrow, and that'll be my posting done.
So... It's still the weekend, which I'm pretty happy about. Having had a day off yesterday, today feels like Sunday, and there is quiet joy in knowing that tomorrow is Sunday...ahhhh.
I'm currently home from a quiet night out, a product of my increasing age, but now safe back inside my bunker in Shroom Manor, a nice glass of port beside me. Oh, for a cigarette. I met with a dear old friend of mine tonight, one of my oldest from MedSchool, with whom I've shared some truly good times, and some truly awful ones. For the purposes of my blog he will be known as the CherryPicker. We had a few stand-up fights I'd rather forget, but I think we've both mellowed a little, and are better for it.
Anyway, he lives more or less just 'round the corner from me, and I was his best man (or one of them), but we still don't manage to see each other enough. So tonight was nice; it's always good to catch up with him, and reminisce about the old days. I discovered another of our old friends had put him on to my blog (thanks Colossus), but he was still unable to find it... This is despite it being fairly well telegraphed to my friends, if they're interested. I mostly suspect they aren't, they find it too creepy, like reading my diary, or they find it too boring.
Anyway... I promised him I'd write him up. Done and done, my cherrypickin friend.
He tells me he's going to the best restaurant in the world next year. Some 5 star place near Barcelona, I think. They're only open 6 months, and only take reservations on one day, for a 24 course, 4 hour meal. I believe I have found a new definition of the word pretentious. Further details will surely follow.
Lastly, musings on the anonymous nature of this blog. Just because. This was only ever semi-anonymous; using a picture of me saw to that. But I never thought anyone I knew would actually read it. Since clinical stories are all amalgams, I figured that was the confidentiality side sewn up... but nonetheless, part of the point should be an honesty to it. Which is difficult if my friends are reading this. It encourages self censoring. Having made the decision to make this semi public to my friends, I guess I'll always hold some stuff back, especially where it concerns people I think might actually read it. It's only fair.
But where I'm concerned... I'll try to be as honest as I can be, however dull/uncomfortable/**insert other emotion** that might be.
I return you now to your regular programmes, while I return, lovelorn, to my port and late night horror film...
And, if I wait 10 minutes, it'll be tomorrow, and that'll be my posting done.
So... It's still the weekend, which I'm pretty happy about. Having had a day off yesterday, today feels like Sunday, and there is quiet joy in knowing that tomorrow is Sunday...ahhhh.
I'm currently home from a quiet night out, a product of my increasing age, but now safe back inside my bunker in Shroom Manor, a nice glass of port beside me. Oh, for a cigarette. I met with a dear old friend of mine tonight, one of my oldest from MedSchool, with whom I've shared some truly good times, and some truly awful ones. For the purposes of my blog he will be known as the CherryPicker. We had a few stand-up fights I'd rather forget, but I think we've both mellowed a little, and are better for it.
Anyway, he lives more or less just 'round the corner from me, and I was his best man (or one of them), but we still don't manage to see each other enough. So tonight was nice; it's always good to catch up with him, and reminisce about the old days. I discovered another of our old friends had put him on to my blog (thanks Colossus), but he was still unable to find it... This is despite it being fairly well telegraphed to my friends, if they're interested. I mostly suspect they aren't, they find it too creepy, like reading my diary, or they find it too boring.
Anyway... I promised him I'd write him up. Done and done, my cherrypickin friend.
He tells me he's going to the best restaurant in the world next year. Some 5 star place near Barcelona, I think. They're only open 6 months, and only take reservations on one day, for a 24 course, 4 hour meal. I believe I have found a new definition of the word pretentious. Further details will surely follow.
Lastly, musings on the anonymous nature of this blog. Just because. This was only ever semi-anonymous; using a picture of me saw to that. But I never thought anyone I knew would actually read it. Since clinical stories are all amalgams, I figured that was the confidentiality side sewn up... but nonetheless, part of the point should be an honesty to it. Which is difficult if my friends are reading this. It encourages self censoring. Having made the decision to make this semi public to my friends, I guess I'll always hold some stuff back, especially where it concerns people I think might actually read it. It's only fair.
But where I'm concerned... I'll try to be as honest as I can be, however dull/uncomfortable/**insert other emotion** that might be.
I return you now to your regular programmes, while I return, lovelorn, to my port and late night horror film...
Blah, Blah, Drugs, Drugs, Mouse
Now none of you need buy, or read, Russell Brand's autobiography.
The Gospel of Shroom: a public service broadcast.
The Gospel of Shroom: a public service broadcast.
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