Candle In The Dark

Someone died.

This should come as no surprise, I guess. It happens every day. I see more than my fair share of it, I would cautiously suggest.

I got a phone call on Saturday, bearing the unwelcome news. I had an idea something wasn't right, social networking sites being what they are, but the call filled in the blanks.

I've made these calls, and received them, and I still don't know which is worse.

To say this was someone I know, is stretching the point. We were aware of each other, but the most interaction I think we had was a disagreement about the NHS, and some slightly unkind things were said about my bedside manner.

But he was very dear to people who are dear to me.

Can I say that I feel their pain?

Not as deeply, surely; it cannot cut as deep, cannot burn with such cruel heat.

But I know that the sun seems to shine a little less brightly today, that the curtain seems to have been pulled a bit further across the light.

Farewell, Farewell (Reprise)

Farewell, farewell to you who would hear
You lonely travellers all
The cold north wind will blow again
The winding road does call


And will you never return to see
Your bruised and beaten sons?
"Oh, I would, I would, if welcome I were
For they love me, every one"


And will you never cut the cloth
Or drink the light to be?
And can you never swear a year
To anyone of we?


"No, I will never cut the cloth
Or drink the light to be
But I'll swear a year to one who lies
Asleep along side of me"


Farewell, farewell to you who would hear
You lonely travellers all
The cold north wind will blow again
The winding road does call
(C) Warlock Music; reproduced without permission. Lyrics: Richard Thompson

Superstition

Unsettled.

This was my overwhelming feeling heading into work.

This evening saw my first on call as a Consultant, as the man with the whom the buck really does stop. While I've done plenty of shifts as the senior doc on the floor, there's always been someone else to call; and now that someone would be me.

This in itself might have unsettled me, but I was unfortunate enough to see a cat get hit by a car on the way to work. I've seen tings die before, even hit and killed a deer myself, but this was as distressing a thing as I've seen. The poor beast had clearly not been killed outright, and performed the most awful convulsive dance on the road, leaping about, in an effort perhaps to get away from the terrible pain it must have been in.

It lasted just a minute, but felt longer, and left a pall over me that I just couldn't shake off; it's funny, I guess, what strikes deep, pierces defences we spend so much time erecting.

Sticking With You

Continuing the theme of the weekend...

Saturday was perhaps most notable for our avoidance of a cheese and wine party, a location where LBF would normally be found waxing lyrical about the virtue of cheese and its superiority over all other foodstuffs.

This casual truanting did afford us the opportunity to meet GermanyJones in the pub. Germany is another of LBF's amigos, and is a lively lassie, with more artistic drive and imagination in her little finger than I possess in my entire flabby frame.

Our conversation ranged from comparing Ross Kemp to PacMan (a dead ringer, apparently) to the grand plan to track down and interview 12 men from around the world who think they are the risen Jesus.

I can't reveal more details, as it's still a work in progress, but you heard it here first. A GermanyJones production

Prohibition Jazz

An unusual weekend.

The ongoing soap opera that is my own, and other people's lives continued. Spent the bulk of the weekend with LBF, work ahving intervened in our efforts to atend the weekend Lemon Wedding

First we went to see The Original Rabbit's Foot Spasm Band, who play prohibition jazz. This is the haunt of JazzMan, who seems unable to do right by Schlingo. Of course, that's my definition of right, and trying to throw two people together because YOU think it'll work is potentially fraught.

It is a shame tho', because Schlingo is aces, and JazzMan seems like a nice fella, barring this one thing.

Anyway, that's their business, not ours.

As for the jazz, they're excellent, and much grooving was done, wheels greased with joyous lager, and the stench of gin and sympathy.

I was somewhat surprised by the youth of the crowd, but I suppose the hepcats that shook their bad things to jazz in the 20s and 30s were young 'uns, so there's no reason why they shouldn't be this time around.

Anyway, I commend them to you.

Another Brick In the Wall (Pt 3)

I can't help but feel, again, that this is the death rattle of this blog. I just can't seem to find time to write it.

It's not that I don't have the time. I patently do, but just can't seem to make myself write it. I'm not sure why. Maybe it has just had it's time. Outgrown me.

I shall make one more, perhaps foolhardy effort to resurrect my blogging mojo, but can't quite shake the feeling I've said all I can usefully say.

Watch this space.

The Trolley Graveyard

Another One Bites the Dust..?

Show Me The Money!

As you know, I'm not one to grumble...

I have just found myself in the delightfully uncomfortable position of being underpaid by my current trust, while having been overpaid by my previous trust.

Brilliant

Black Ops

Mystery wrapped in enigma.

One of my esteemed colleagues was working when a blue call came in. Young male, cardiac arrest, immersion. Failed resuscitation.

The exact mechanism was... well, unclear. He's been in the water, but not for long, and there were no details about the patient.

He was accompanied by some heavyset, serious looking gentlemen, who were evasive about who they were and whether they knew the deceased.

They wanted to claim the body though, but something didn't quite ring true.

A young man, in the service of his country, perhaps? Lost his life, somehow. On a foreign field?

We never did find out, and can't imagine we ever shall.

Space Oddity

Another cluster of odd presentations; I can't quite figure these guys out either.

Invariably young males, usually adolescent, all complaining of lower abdominal pain, and an inability to urinate. All claim not to have pee'd for at least 24 hours. None have a distended bl;adder, nor any obvious cause for retention, nor any renal impairment, as measured biochemically.

Few, if any, have signs of infection, although I suppose an STI must be high on the list.

What I can't quite figure is that tey MUST have been urinating, and yet swear blind that they haven't.

One of us must be wrong...

It can't be me, can it?

No Help Required

While out and about on the Streets of LBFville, we were hailed by a couple of teens, supporting a third, semi-conscious, mate. They wanted help getting him up, so they could get him home. This is, in itself, admirable.

The mood was spoiled somewhat when they stopped worrying about him, and started begging for ciggies when we went over.

Info was fairly sparse, but it was apparent he had drunk ' a lot', and was sparko. Try as I might, I couldn't raise a peep out of him. Getting him home seemed increasingly ambitious.

As always in situations like this, a crowd gathered.They were all drunk too, and not really a great help.

By this time, I was making some progress at the head end, and he was beginning to respond to my less than gentle ministrations.

Suddenly home didn't seem such a far off dream after all.

I tried to engage his friends in this idea, but, the crowd told me, an ambulance had been called.

"Don't worry", they said, pointing to one of their number, "he's a first year medical student, at Oxford"

I opened my mouth, then closed it again. The 'casualty' was breathing well, and beginning to stir; an ambulance was en-route, and I had been trumped.

I left them to it.

Valentino

Another Valentine's passed.

The cynic in me says this is really just a great money spinner for jewellers / gift manufacturers / card makers etc, but it is undenisably nice to remind someone how much they mean to you.

I had planned a little break for LBF and I, but things don't always break the way you want to. Firstly I couldn't get the time off work, or at least not without really making some enemies, which is never a good idea. Then I contrived not to see the folks for a while, and Pa Shroom's birthday falls right after Hallmark card day, so I kindof had to hook up with them...

Anyway, I managed to spend some time with LBF and not fuck up the presents I bought for her. We also saw the film Valentine's Day which was... interesting.

It may not have been the most romantic of weekends, but I think it was a good one.

...Just A'Feelin' 'Bout Half Past Ten

Listening to the radio a while back, I was impressed by the blase attitude of some Australian OAPs I heard on the radio.

They were describing their experiences of recent bushfires. and were embarrassingly matter-of-fact about it, and how they coped.

I wonder if this is a product of the knowledge of a life well lived?

I'm not sure, but I can only dream of such aplomb and self possession.

Rode Into Nazereth...

I have had to admit, or at least refer for admission, a number of patients recently in a genuine display of Cover Your Ass medicine. I hate practicing CYA medicine, and yet it seems to form an increasing part of my practice. Evidence Based Ass Covering.

Increasing seniority brings with it a diminishing ability to be wrong. Mistakes are allowed, almost expected of junior staff, and as long as they aren't disastrous... well, you know what I mean.

However, the ever increasing pressure of the 4 Hour target (All Hail) gives me less and less time to think about what's wrong with, and what's best for my patients.

And so, I end up referring those folks who just aren't right. I am losing faith in my clinical acumen, because I know I can't always be right, and I can't afford to be wrong.

Of late I have seen a number of folks who present with odd neurology - non-anatomical numbness, or transient, fleeting symptoms, or symptoms that just don't match the signs.

And they are almost invariably drunk. And will deny this.

I am sure they have no pathology, but I can't send someone home who is telling me the whole right side of their body is numb. Can I?

It's Not The Falling That Hurts...

It's the landing.

Obviously.

Apologies, dear readers, all 40 or so of you. I have fallen off the wagon of late, slipped the traices. Got lazy. Been betrayed by technology.

Got behind.

My continued mission to moan about feeling unwell culminated in me failing at all my tasks this month. I have run very little, if at all; I have succumbed to the evil tobacco weed, and I have gotten behind with this monstrosity.

In my defence, I have been feeling increasingly unwell, a fact I am blaming on my anti-retroviral meds, which seem to produce a constant background of feeling shit; a sort of physiological equivalent of drizzle; I had lined some posts up for delayed publication, but that seems to have failed.

But it's time to get back up again.

Back up, stub out the butt, jog on and then write about it.

Good luck everyone.

Choice

I support choice. It is a good thing.

Mostly.

Sometimes, I think people abuse it.

Tonight, I saw 2 people whose choices upset me.

Which is a shame; the thing about choice, individual choice, is that it should be just that. Individual, not affecting anyone else.

But, of course, that is pretty much an abstract concept. Every choice we make is bound to have knock on consequences for others.

Maybe it's the reasons behind the choices that needle me? Maybe I have no right to be bothered by them.

The first choice I didn't really understand, nor the motivation behind it. Maybe that's the point. A young man, seeing his Cardiologist privately, has a dysrhythmia. His heart, intermittently, short circuits, surrendering the regular, ordered beat that thrums out our lives, for a cacophonous, disordered, irregular beat.

A number of treatment options are unfolded for him, and many rejected, some because they are unpalatable, or do not work. One is agreed upon; it seems simple enough, and yet he chooses not to bother.

And so to the ED. Why bother asking for, and taking, an opinion if you won't follow up on it?

Too busy? Forgot? Didn't seem important enough?

Maybe I just don't like this choice because the end result has been another patient in the ED, and maybe I'm workshy. But maybe I know choosing not to treat conditions sometimes has consequences.

The second patient was visiting their alternative health provider when they collapsed. Deep coma followed, and CT showed the deadly tendrils of sub-arachnoid blood, snaking around, and over the brain. The patient, it turns out knew they had high blood pressure, but elected to take herbal remedies rather than prescription meds. Because they didn't want to end up taking a pill for life. Was this choice made in the knowledge that there is little difference in taking a herbal remedy for life, versus taking a prescribed drug for life, purely in terms of the taking?

Is it any comfort that life had turned out to be much shorter this way? Did they make the choice knowing what the consequences would be, or at least could be?

I doubt it, and am ashamed to say I had to bite my tongue to stop from telling her family what a ridiculous choice this seemed to be to me. Not my choice to make, not my place to offer an opinion after the fact.

As if they needed any more evidence.

And Death Followed After

More evidence, if any such was required, that I attract trouble, that I am a 'Black Smoke' Registrar.

'Twas darkest night, tho the moon shone bright (which may be oxymoronic), when the clock struck shit.

That's right. I said the clock struck 'shit'. I would like to propose the term 'shit o'clock' to represent the time in the Department when the shit hits the fan. I suppose 'arse o'clock' would be acceptable, or indeed 'trouble o'clock', if you are less foul mouthed.

Anyway, all had gone just fine, until shit o'clock.

The BatPhone rang trilling of the impending arrival of a young sailor who had fallen 20 feet from a gate, part of which had detached itself and landed on his leg. He had, somewhat amazingly, avoided other injury, but as we peeled back the splinting on his lower leg, it became apparent that that was more than enough.

It was shattered, ivory white splinters of bone prodding obscenely through what was, under the circumstances, a relatively neat wound. It really was smashed.

It was then that the BatPhone belched into life again, this time announcing the arrival of a woman stabbed in the neck, and shocked.

While still digesting this, the Phone sounded again, this time forewarning of a patient in drink, having sustained a head injury, and with a GCS of 3. The paramedic calling chose an unfortunate turn of phrase to indicate that the patient was in Police custody.

"In drink, head injury with GCS 3; oh, and he's arrested."

So I was significantly relieved to see him full of pulse and breathing when he rolled in, seconds after the stabbing.

I barely noticed the arrival of the second stabbing victim

Pay Attention

I have seen a few tricks deployed to 'jump the queue' in the ED. Last night's took the biscotti. A patient old enough to know better presented heavily inebriated, having turned their ankle. Quick exam off the Ambulance trolley suggested a bad sprain, but probably a fracture. There was swelling, for sure, but no neurovascular embarrassment, and he beer jacket was providing adequate analgesia.

The Department was kicking, heaving, alive with criticals, and sicker people needing trolleys. She would have to wait, and we apologised for this, and left her in a chair.

She muled this over for a while, and took maters into her own hand. She levered herself out of the chair, took a step, tottered for a second, and before we could reach her, turned her ankle again.

Through 90 degrees.

What had seemed a simple injury suddenly became very complex, and her foot turned white. Our efforts to restore anatomy and circulation were hampered by the patient's state of mind.

I'm not sure where she thought she was, but was incapable of grasping the (relatively) simple concept that she was in hospital, and had a (now) badly dislocated ankle.

She fought us every step of the way, and we had to settle for a half baked job, afraid as we were of over sedating her and adding aspiration to her growing list of injuries. We managed to go from dislocated to subluxed, from white and cold to purple and warm, pulses restored if anatomy stubbornly remaining abnormal.

She at leas got seen quickly, even if she never walks quite the same way again.

Dumbing Down In Medicine