Got the New Hospital Blues...

One of the things I like most about my job is the feeling of being part of a team, or a family. I really felt like we were all in it together, when I started on the wards. That feeling was gradually eroded as we started working shifts, and the Nurses started leaving, or rotating.

I found it again in the Emergency Department; the staff pool is relatively fixed - although we all still rotate frequently, so maybe it's me that breaks up the family.

Everytime I move, it takes me a while to settle in, learn how everything works, learn how the people work, And they have to get used to me. Then I can start feeling comfortable again, start feeling at home at work, which is probably a bit sad.

So far, all I seem to do in my new job is flail. I'm making elementary mistakes, and seem to have pissed off at least one member of staff, while convincing the others I'm some sort of bandit medic.

I hope it'll get better.

With Nothing To Give, How Can We Ask For More

Faith has entangled me in the current meme...
8 random facts about me.

1. Shroom got his name at Reading Festival 1992
2. He has at least one other nickname, the origins of which no-one can recall
3. I drink faster than I get drunk, always to my own detriment
4. I secretly quite like Dire Straits
5. My favourite cocktail is a whisky sour
6. I spend hours formulating grand plans, then procrastinate about doing them until it's too late
7. I once cried watching an episode of Magnum, P.I.
8. I quite fancy the idea of sporting a huge 'tache, but am utterly incapable of growing one...

Random enough? I'm not sure.
I know I'm supposed to tag another 8 people, but for the now, I'm going to be a killjoy.

Boo!

As Good As You've Been To This World

Feeling maudlin today

Midweek blues, and everything that promised so much at the end of last week, seems to be vanishing in a haze.

So: Old jib from Shroom's casebook.

I don't think I've talked about this case before; apologies if I have.

Sometimes, you start with what looks shitty, and it keeps getting worse. I think this is harder to deal with that something that looks bad, and is simply bad.
When you deal with someone who looks really bad, and keeps getting worse, all the little promises you make to yourself, to the patient, to their relatives - all those minute fragments of hope you leave out, to keep it flickering, alive - they're all exposed as lies, oh, so quickly.

The start of a shift is bad for this. Especially in a busy Dept. That's when, through no-one's fault stuff slips through the cracks.

I came on to a particularly hectic department. Understaffed, undernursed, just barely keeping their heads above water. First thing I saw was a patient in the 'high - dependency' bay. (It's monitored, and visible from the Nurses / Doctor's station. The trolley was in Trendelenburg. (Head down).
Never a good sign.

All about me staff are rushing urgently, all busy doing something... but not for this patient. This is briefly re-assuring; maybe a vaso-vagal? My eyes casually flicked up to the monitor, all at once taking in the profoundly low Blood Pressure and fast heart rate. I remember only then looking at the patient and thinking how young they were. Young and pale. Pale enough to be on one of Shroom's lists.

The history is typical for this sort of thing in Shroom's experience. A young 'un, brought in, walked in, with parent. Innocuous, non-specific history for a few days, finally developing a few sinister symptoms, provoking the visit. People who walk in can't be sick, right.

Bollocks.

Eyeballed by the nurses out front, the patient is rapidly propelled 'round the back', or wherever your major treatment area is. Then something else happens, and they get left... it happens. The one's that don't, don't fulfill this sort of category.

Anyway, we booted this one to resus, and fired up the usual. Large bore access, oxygen, bloods. Fluids, fluids, fluids. Hot as hell, we chuck in broad spectrum antibiotics, and go rash hunting. Meningococcal sepsis finds itself high on my list of 'Diagnoses Not To Miss'. (As well, coincidentally, as my list of 'Illnesses Not To Be Afflicted With'.)

Clinically the picture is of septic shock, in a young patient. But how bad? Try to explain what's going on, serious but not too bleak. Yet.

Slowly, then in a rush, every test I did came back, the patients indices all wildly out of kilter, the case getting more serious by the second, and the response to 'simple' treatment unimpressive.

The source was revealed as a multi-lobar pneumonia. ITU were swiftly involved, and the clever medicines deployed, through big, ugly lines. And every few minutes I had to go back and explain that the situation was a bit worse than before, to unmask my lying optimism, to shred a bit more of he fragmented hope I'd thrown out.

As the patient left, I really thought it was all up. We had done all we could, they would do all that they could; but it wouldn't be enough.

It was.

Sometimes they do get better.

A Few Wedding Snaps 2

A Slightly Camp Puck, with Robin Hood

Puck Being Supported By Musketeers

False Taches

Seems like these were after the speeches, when I'd transferred my horns to the outside of my hat...

A Few Wedding Snaps

Bottom and Puck

Happy Family

Happy Couple

Plus Faeries

Secret Pleasures, Number 2

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

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

She Comes In Colours Ev'rywhere

Or... "Flail of The Century"

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

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

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

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

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

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

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

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

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

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

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

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

In Praise of Pharmacists

I actually don't have a great deal more to say about the noble practitioners of pharma; I'm just not sure they're feeling the love enough. And, to be fair, I'm sure they've spent more time correcting my mistakes than vice versa.

So, that's done. My great friend's wedding is only days away, and I'm stressing about it; I know there's shit I need to do, but I'm too agitated to think straight. In case you're wondering why there are no insightful, or cutting, remarks regarding the world of medicine, and my tiny orbit within it, I'm on leave.
For those of you who just have to have something to mull over, I'm increasingly worried about what's going to happen in August, when the fucking train wreck that is MMC / MTAS will be unveiled in the halogen lights of patient care, and docs with no jobs.

(Yes, I know that's a shit analogy; I wanted to say 'comes home to roost', but that made even less sense)

On the positive side, while getting drunk, probably excessively, over the Bank Holiday weekend, and ranting at anyone who'd listen, I became re-acquainted with one of my favourite people. There seem to be people around whom I orbit in weird ways, only crossing paths very briefly.

Sometimes, that's fine - we can't all be bosom buddies. But there are one or two who I always wish I could see more of. This weekend's meeting is of the latter category, and I'm seeing them again tonight. This can only up the world's net happiness score - and that's gotta be good right? (Unless of course I piss them off enough to counteract it... shit, I hadn't thought of that)

Please be aware that Shroom does not condone heavy drinking. It's not actually anywhere near as big and clever as he thinks it is, but i think I've passed comment on this before. I'm guessing if you care enough you can find it in the archive.

Expect gory details of this evening's entertainment, and 'What Shroom Got Up To In A Field In Kent' next time out.

I know, I know, you can hardly wait. Just pray for sun on Saturday.

Unbending, Neverending Tablets of Time

The storm has passed; the bad news that has haunted me these past few days is getting better. If that makes sense.

I haven't told anyone else about it; they've all got their own problems, and I'm not sure I was strong enough to do it anywhere but here. I'm sure it's not emotionally healthy to bottle shit up, but it's sometimes I can keep from being overwhelmed.

Whatever; things could have gone really down the shitter, and they haven't. Sometimes you have to cling to the little details.

I think I might have some good news, too, but more of that later - probably.

In Praise of Nurses

This post could be almost anything; I might, at a later date muse about the Doctor-Nurse dynamic, specifically as applied to Shroom.
I could simply write how great nurses are... that would surely be too simple, and runs the risk of being condescending.

However, and this is in no way related to a realisation brought on by a comment made to me by a valued colleague while we studied an archaic looking piece of equipment at South Coast General, I would like to say how much I've enjoyed working in my last post, specifically because of the Nursing Staff there and my relationship with them. They have stood by me, even when I didn't have a clue, and when the toys were firmly ejected from the pram, and they drank beer with me, then picked me up afterwards.

Mind you they never let me forget it.

Anyway, thanks.

The Lonesome Death Of Hattie Carroll

Well, I've moved hospitals... this is in general a pain in the arse, for a whole host of reasons. This is what I wanted to blog about, for want of a better, more pertinent thing.

But today I had some bad news... The details should remain obscure. Although it's my bad news, as it were, it belongs to other people more than it does me; and they have no real desire to see it plastered over here. Suffice to say it has knocked me for six a little.

Pain sure brings out in the best in people, doesn't it? Thus spake the philosopher Zimmerman. I'm not sure he was right. I guess it focuses everyone. When something like this happens, you wonder. Is this my fault? Could I have done something different, something that would have made a difference? I think the answer is mostly "no"; but I wonder... it continues to show my selfish side to the max.

This is someone else's pain, and around it are circles of despair, each one a little further removed from the next. Where mine is depends on who's pain it was to start with. I know it's not about me, but somehow I still find a way to make it about me.

Time after time, I have put things off, signing up to the theory of 'there's always more time'
I'm sure you all know it, but usually there isn't. Right now, I have never felt more regret for the lazy way I have abandoned my life for my work. Somehow it feels like I have abandoned more than just my own...

You Can't Always Get What You Want

Thus spake the philosopher Jagger.

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

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

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

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

The on-scene assessment was the latter.

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

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

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

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

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

F.E.A.R

Dropping the Ball

When something doesn't go according to plan, it's usually a system failure. There are rare occasions when someone pulls off an act of sheer banditry that couldn't be anticipated or mitigated by anyone else. But mostly, everyone fucks up a bit. I'm guessing most people feel the same way I do about this - everyone makes mistakes, but we rarely like to admit / talk about it. Mistakes in medicine are always a little bit higher stakes than in other jobs.

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

Personally, I've made my share of errors; I've learned from all of them, but the rude fact of life is that shit still goes wrong. Generally, I've got tickets on myself. I reckon I'm good at what I do, so when it turns out I haven't done it to my best ability, I feel shit about myself for days.

---

I guess it's the same for us all.

---

It's easy to write about times when you did something that worked, or that paints you in a good light. The reverse is harder.

---

I could imagine it might happen something like this:

---

Picture a man who is involved in a car accident. He is rescued by the Paramedics after some 30 minutes. They assess him as having sustained no serious injuries, and he is shipped to the local ED. He is boarded and collared, and assessed promptly on arrival. His spine is cleared, and no serious injury noted. He is left for formal assessment.

---

Several other patients arrive in the Department around the same time. One is apparently critically ill, and goes straight to resus, prolonging the wait of our fictitious patient.

---

He is eventually seen by a doctor about an hour after he arrives. He has no complaints, except of some pain in his knees, which he has grazed in the accident. Physical exam is unremarkable at this stage, barring the fact that he is cool and clammy. His pulse feels rapid, but of good volume. He is known to be in AF. The attending physician notes that he was given 20 mg iv morphine on scene, and attribute the beads of sweat on his forehead to this.

---

The patient is moved to another clinical area for monitoring. His first set of obs are done, after some 90 minutes. His blood pressure is borderline low, and his pulse still fast. An ECG confirms AF with a rapid VR, and slightly ischaemic picture. He complains of no pain, and his doctor wonders if the appearance might be the effect of the digitalis he is taking. Repeat exam is still unremarkable, barring ongoing clamminess. His doctor is slightly concerned by this. It can't still be morphine after all..? A period of observation is proposed; the patient declines, stating that he feels fine.

Anxiety growing, his doctor asks him to wait a little longer, and asks for routine blood tests and a fluid bolus to be given.

---

Something like an hour later, the patient looks worse. His BP is lower and his pulse faster. He now has abdominal pain - although his belly is still soft.

---

Now: 3 hours after arrival, he is moved to resus. Repeat assessment reveals some firmness of the rectus muscles. This will rapidly develop into a peritonitic picture.

Finally he gets a CT scan, and surgical consult. CT shows intraperitoneal bleeding, and he goes straight to theatre. Operative course is uncomplicated, and he recovers on ITU.

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

My guess is things like this happen all the time. In retrospect, the hypothetical patient was unwell for a while, but an unclear history and paucity of physical signs allowed false reassurance. That he waited 90 minutes before first formal nursing assessment didn't help. As I said, this was a fictitious example. The Shroom might learn from such a train of events however. If mechanism sounds high risk, it is, even if the patient looks and fells well. Never trust the abdomen - trauma is a frighteningly dynamic process. And, especially, even if you think you know you're shit, you probably don't know it as well as you think you do.

Like I said, this was just hypothetical, and I'm certainly not trying to teach anyone to suck eggs

Room Full of Mirrors

Nights again.

I still quite like them... tiring as they can be, I can't help but romanticise them a little. No actual romance, mind. A lot of limb injuries for some reason.
Fractured arms, wrists, shoulders and ankles. Lots of sedation, manipulation and plaster. Almost a good night at a special interest club.
One poor old soul has been given a grim diagnosis; one that we all knew was coming. One of those. An horrendous looking mediastinal tumour, with invasion around his spinal cord. I'm not sure what the exact diagnosis is, but it's clearly not going to be champagne and strawberries. As I've posted before, this sort of thing really takes the wind out of everybody's sails. I always wonder if we could have done more for these guys. Intellectually, I know this is slightly ridiculous, as they have presented with a diagnosis that will belong to a long standing pathology, but I still find myself wondering if the odd 30 minutes wasted in the ED will somehow turn out to be critical...

I singularly failed as an educator tonight. I took one of the SHOs to show her how to reduce a shoulder. There are a legion of ways of doing this; I attempted to talk he through a few, and then had planned to get her to do it. But in demonstrating procedure, I found myself saying "put your hands here, and then externally rotate, and..." **clunk**

Job done...

Ooops... sorry

I guess as mistakes go, it's better than pulling the arm off, but I still feel bad. It reduced the educational benefit to nearly zero. I say nearly zero, because I was able to produce a spectacular demo of the effect of nitrous oxide ('laughing gas').

We generally use morphine and midazolam for our procedures done under conscious sedation. It can be supplemented with nitrous oxide; I had commented that many of my peers dislike it, because they find it increases disorientation. Our patient had a history of previous opiate and benzodiazepine use, so I had thought to supplement her with nitrous. Sure enough, after 2 minutes, she was smoking the pulse ox monitor, complaining that she couldn't empty the ashtray, and drinking from the hudson mask.

Ah, drugs....

My last patient was a painful one. he admirably demonstrated the 'all mouth no trousers' phenomenon, however. He was wheeled into the Department, covered in blood, laughing and shouting. Waving his blood stained hands about he was shouting, mostly at the female staff:

"Darlin'! Oi! Darlin'! Guess what I done! Go on! Guess!"

**Guffaw**

"Nah, I ain't tellin' ya! You don't even wanna know what I done, innit!"

**Ha-ha-ha-ha**

What had he done? Torn his frenulum. This, for those not in the know, is the piece of skin on the underside of the glans penis, attaching it to the foreskin. It is essentially identical to the frenulum in the mouth attaching upper lip to gum. Sometime referred to as the 'banjo string'

I'll leave it to your imagination how he said he did it.

Tearing it is quite painful, and bleeds. A lot.

I should know.

His brash, loud exterior changed when I explained what we needed to do. The sentence contained the words 'needle', 'injection', 'penis' and 'stitch' in various order. Also 'local anaesthetic' and 'sting quite a bit'. It wasn't a warm, fuzzy sentence. No champagne and strawbobs here, either.

The repair was a breeze, and his attitude changed again. He refused to stand up, claiming he felt weird - not unreasonable, all things considered - but did want first to be brought gas-and-air (more nitrous) and second to be wheeled out for a cigarette. Both activities guaranteed to make you feel less weird...

One quick Hb check and a set of postural BPs later, re-assured that he hadn't left too much of his blood behind in his bedroom, we sent him packing. On a no-sex embargo.

I half expect to see him back before the week is out....

Bryter Layter

And so it goes on...

I still can't seem to find anything to write. For various boring reasons, I haven't really been in the mood. At least partly I'm stuck between the desire to write intelligent relevant comment - not least because I want to impress my small readership - and what feels like my need to just witter inconsequentially...

So what follows is mostly the latter. Be warned.

I've been off a few weeks, sort of, but I don't feel any more relaxed. Work continues to bug me. Which is shit, frankly, because sometimes it feels like all I'm good at. I think it speaks of a deeper self loathing because I'm so disorganised. Laissez-faire, you might say, if you were as pretentious as I am.

My best friend has returned from Africa t get married. I was honoured to be asked to be one of his best men (3rd time as a double act for me... is this fashionable, or am I not quite good enough to pull it off alone?) Clearly I'm pleased about this, but so far haven't really contributed anything... I'm actually embarrassed at how little help I've been. This isn't helping my self esteem.

On a lighter note, I discovered another medical blog today, which has brightened my day a bit. Especially a post about the dreadful habits men have of observing their female colleagues a bit too closely during CPR. (However, I'm confident that scientists will discover a gene that codes for looking down tops, and then we can blame it all on that.)

I'm going to try and ease my aching brain with a visit to my God-Daughter. Lunch with her folks always helps ground me a little, which can't be a bad thing. Then, this evening, I think I'll get drunk somewhere and make a fool of myself. Another great leveller.

I'm moving jobs in a couple of weeks, so expect exciting drivel about my scramble to pass my end of year assessment, and then the crap inherent in moving hospitals.

Oh, and I've gotta dress as Puck for the wedding. Costume ideas, anyone? (I quite want to wear an 18th century frock coat, but can't quite seem to make it relevant...)

Your Life's Waiting Like A Goddamn Fool

I seem to have an increasingly hard time 'putting pen to paper' of late.

I still feel a bit pressured at work; I'm guessing that's not helping. Also it seems like an increasing number of people I know keep finding this blog. I know this is ridiculous, because I haven't really made any attempt to anonymise myself, so should have expected it really; but I didn't. I guess I thought too little traffic wandered over to my little corner. Ah well.

So where are we at?

MMC / MTAS continues to fall apart around our ears, taking with it the careers of so many doctors. Just thinking about it makes me alternately furious and depressed. And I've got a job.

My yearly assessment draws near. And my paperwork isn't up to date. Ask not for whom the Bell tolls; it tolls for Shroom

Emotionally, work has been fairly shit the past week or so. I've treated several patients whose diagnosis appeared deadly obvious to me, but who seemed oblivious to the possibility themselves. It's like being the worst kind of fortune teller in the universe. I'm sure all the medics out there know the world know the feeling...

Patients present with what seems, to them, to be an innocuous collection of symptoms. To me, coupled with the inevitable signs they haven't noticed, or are denying, it's anything but innocuous. The knowledge that around the corner awaits the instruction to "get your affairs in order" fills me with nausea. I realise I'm being selfish, because at least I don't have to hear that about myself. But for a few moments when I'm certain of my dreadful diagnosis, I feel shit because I have to bear it alone. No-one can share my burden.

Then you divest yourself of your dark suspicion, your foetid information all but stinks up the room; a miasma of misery. Now it's their burden, not mine, and I don't have to shoulder the weight anymore.

I don't feel any better. Just a little more selfish, for trying to ease my pain with theirs.

Some days it seems all you do is ruin people's days, and, by extension, their lives.

Under Pressure

Some days, I feel like buckling...

More on this in a bit; I'm not really in the mood for navel gazing. I'm in the mood to vent. I often get to work early. It gives me a chance to have a coffee, catch up on e-mails and generally ease myself into the day.
It also makes one a target for people who say things like "As you're here, would you just..."

Of course, the argument runs, if you don't want to be asked questions, hide. (Or don't go in early..?) Either way, I accept this is going to happen, especially in this business. But I reserve the right to say that I'm not on duty. If the fuckers are going to treat me like shit, they can't expect 110% from me. Which I know isn't very caring, but there you go. We're not talking about life and death shit here.

So, there seem to be two ways a person might approach the early Shroom at work, while he is quite clearly attending to personal business, and not at work.

--- Firstly, you might bid the Shroom good morning and ask if he wouldn't mind reviewing a patient, as the SHO is tied up, and it'll save delays, etc.

Unless I'm in a really bad mood, I'll do it.

--- Secondly, you might march up to the Shroom. Do not say hello, do not introduce yourself. Instead, start moaning about the grief management is handing out about The Situation. Demand to know what Shroom is going to do about it. Look aghast when he explains he's just walked in, and doesn't know anything about The Situation. For extra sympathy, walk off while he's talking to you.

Whatever mood I was in before you started, it's now bad.

Of course this sort of thing could never happen in the NHS. Managers there value their Doctors, and more importantly, their patients as humans, not numbers, or targets. And God forbid that such a situation arose because the Management couldn't get the Department staffed adequately overnight.

In case you were wondering, the situation here might have been, for example, that waiting times had reached three hours. They hadn't, of course, so I'm sure that wasn't it.

Handbags And Gladrags

A tough day, followed by a quiet - ish (so far) night.

I've been in absentia for a while; sorry. For my occasional reader - no, I have not thrown you over. How could you think such a thing?! I've just been lazy preoccupied. But I'm afraid I'm still not letting anonymous posts in.

I can't really explain why I've gone off the boil of late. I suspect mostly because I ran out of things to say. This will become increasingly apparent as you read on...

I've been a little busy, too. Two of my very good friends got married at the end of February. A grand time was had by all, and sometimes it seems the only time we can manage a get together these days is Weddings or funerals. Which is a shame, really.

Work is beginning to get me down, again. Ironically, I can consider myself lucky, because at least I don't have to contend with the MMC/MTAS shit. But, my sloth, as always, is catching up with me, as the amount of extra-curricular work I should have produced grows ever further from the actual amount. I fucking hate research. I'm not interested in it, and I'm no good at it. Why can't it be left to those who are? I do enjoy teaching, and seem to be passably good at that. Why can't I trade?

Whatever; a period of hard work beckons. I need to focus.

I am pleased to see the medical profession develop some backbone over MTAS. As readers of my previous posts will know, I am fed up to the back teeth of the disregard, the disrespect that successive Governments have shown the medical profession. I have to curb my enthusiasm most of the time, for fear of sounding like the arrogant fucker I so nearly am.

But enough is enough. Unfortunately, my fear is now that the profession will descend into chaos, as no-one gets a job, or knows what the fuck is happening. I predict an orgy of finger pointing, as people struggle to distance themselves from this god-awful disaster.

The Royal Colleges have started; this comes as no surprise, as they are supposed to be the guardians of post-grad training, and collect ample cash from trainees. It's too little too late, as far as I can see. It is risible and contemptuous of them to now try and blame the government. The Royal Colleges were not in the dark about the monumental shafting being planned; but they sat back doing nothing.

How have we become so impotent in controlling our own destiny?

And yet we soldier on.

At work, a very young child was brought to us in extremis. I wasn't present, but such a terrible event leaves a miasma of grief behind it. The whole department is tensed, looking for ways to void the grief. But it will not be drawn tonight. We have been to busy, rushing from crisis to crisis, and the day staff, who bore the brunt of the psychological onslaught are at home now. I hope none of them are alone.

At the same time, a patient with some non specific limb pain took it upon themselves to start throwing shit at the nursing staff. This patient was not demented, not delirious. She was in full possession of her faculties. It was a deliberate, spiteful act. And it goes unpunished. This sort of thing really brings my contempt for this whole system to the fore. I cannot think of another profession where this would be acceptable.

I might try going to my bank tomorrow, and if I have to queue for more than a minute, start throwing faeces at the teller.

Lastly, I was struck tonight by another vignette you only see in hospitals. Parents with sick children bring in their favourite toys, to try and smooth the experience. Fair enough, but it looks a little incongruous to meet a flustered parent, red faced and anxious, furiously gripping a massive plastic elephant in one hand, and some unidentifiable soft toy in the other.

Maybe it's just me.

Final Report

It seems unlikely that I will achieve much more work this weekend - I've gt a lot of beer drinking and socialising planned... so:

1. Dentist visited; my teeth hurt more now, and I've gotta go again next month. I believe I'm putting his kids through College

2. Optician visited; eyes are fine

3. Hair cut; ears drafty

4. Hot water repair arranged; next week, I hope

5. Fence repair arranged; 10 days

6. House semi-tidy; about as good as it gets...

7. House re-mortgaged

8. Suits drycleaned.

9. Thought about painting; fail...

10. Paperwork up to date

11. And filed!

12. Audits still unwritten; fail...

13. Presentations done and done

14. Case report still in the pipeline; fail...

So, I got most shit done, and what isn't done should be within the week... not bad by my standards. Photos of fence to follow...

Oh, and I had my car serviced....

I realise this is all in a day's work for most people, but it's quite an achievement for me....

Heartwarming

The news today is full of a story concerning an off licence use of Viagra (sildenafil) to further the recovery of a premie baby.

This use is not really news. I'm sure you all know what Viagra is used for now, but it was intended as a drug to lower blood pressure. And it has found use in treating pulmonary hypertension in newborns before.

This provoked much controversy.

I must confess to being unaware of this potential use for Viagra before today, but received the news with great joy. Not just because a baby is alive who might otherwise be dead. But also because it does a little to restore my faith in medicine. There is a grand tradition of using unorthodox treatment in medicine. I remember my first boss reacting angrily when told by a drug rep that he couldn't use a particular medication in the way he did, because it was off licence. He was quite confident in his medical knowledge, backed by many years of experience. He reminded me that Registered medical practitioners are entitled to prescribe as they see fit. I suspect the local formulary has more to say about it these days...

In the 'good old days', I'm sure many unorthodox / experimental treatment was carried out without full consent. While I don't condone this, I can't help bu feel that the pendulum has swung too far the other way. In the modern age of Evidence Based Medicine and protocol driven care, delivered by practitioners with limited knowledge base and experience , there seems to be little room for the use of a medication or treatment for any purpose than the manufacturers intend.

I'm not proposing that patients should be peppered with untested drugs, or at random. But I think we are loosing the part of medicine that was, and is, it's art. The science is stronger than ever, but there should be more to it than that.

Sometimes you have to think laterally.

A Professor of Surgery, under whom I worked when I was an Anatomy Demonstrator wrote this:

And how many of us, having carried out some new and untried treatment, have had this experience of being unable to sleep and of creeping to the ward before anyone else is around, with pulse racing, to see whether the treatment has been a brilliant success or a disastrous failure!*

That was published in 1996. I suspect the answer is 'none of us', now.

So give thanks today, not only for a life saved, but for a flicker of life in the Art of Medicine.

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Operations that Made History, Ellis H CBE; Greenwich Medical Media 1996