It All Sounds The Same...

Courtesy of Scalpel

Travelling Riverside Blues

Weekend japes.

Glad to get away from the Department for a few days; the potboiler atmosphere of work, commute, revision is getting me down. The looming exam has had to be deferred; I'm disappointed by myself, I wanted to take the bloody thing, and get it out of the way, but for various reasons I can't, I won't be. Maybe more of that later, maybe not. It's fairly tedious, and I'm not convinced it makes for good reading.

So, anyway, the weekend saw me and LBF away to Wales. The Alfa Shroom-mobile was back in the shop, with a holed radiator. I do love driving Alfas, but they are about as reliable as a chocolate teapot, once the warranty expires. I also had my suspicions that it wouldn't cope with the backroads I was sure we'd be taking.

So; I broke the bank and hired an Audi Q7 (I think). A big bastard of an SUV, and, for all that, it handled very well. I also discovered that giving a lift to folks has to be its own reward...

And so to Wales. Another Lemon Wedding; in Wales; in Winter.

It was brilliant. A nicer bunch of hedonists than the lemons does not exist. I shan't bore you with the full details, but the jaunt involved beautiful scenery, wool, steam trains, wool, expansive outfits, wool, brilliant hats, a wedding and wool.

The reception was held in a splendid barn, adjoining a Tipi village, and the Wedding feast deployed more meat than I think I've ever seen assembled in one place; at least without being on the hoof.

Music, dancing, hard liquor and nudity. Brilliant, happy, warm people, all gathered in a grand old celebration. The Tipis we overnighted in were a wee bit damp, but who's counting. I'm fairly certain I made a royal spectacle of myself, and happy about it.

I think, I hope LBF enjoyed herself. It was hard not to, really...

Wild Night

Morning everyone; I am, once again, at the mercy of insomnia in my post nights hangover.

So, here's what's occupying my thoughts:

1. I think I'm disappointed that the identity of 'The Stig' has been revealed. While I really wanted to know who he is/was, now that I know, I think I'd rather not. If you see what I mean.

2. I'm not sure Hillary Clinton has aged well.

Casa del Shroom - the place to come for insightful commentary

Two Sides Of The Same Coin..?

Part of my job involves being 'behind the scenes'. I get a secret thrill at being involved in everything (more or less) that goes on in the Department. I like being able to sneak under the tapes, push past the velvet ropes and nose about.

Sometimes, I don't like what I find.

It might have gone like this...

Romeo and Juliet loved each other. They loved each other very much, and had agreed to spend their lives together; and this is just what they did, happily, for many years. Nothing lasts forever, though, and life presented them with their toughest challenge. Juliet became unwell and required increasingly invasive treatment, necessitating more and more time apart from Romeo. This was not how they had planned it. It all seemed so very unfair. There seemed to be just one chance for them to go on being together; one last choice that they could make, together, one denied them by conventional society. They steeled themselves to do it, but in the end, only he was strong enough, and, as it turned out not strong enough for them both. Their last gambit had failed, and togetherness had become bitter separation.


Romeo and Juliet loved each other. They loved each other very much, and had agreed to spend their lives together, and this is just what they did, happily, for many years. Nothing lasts forever though, and life presented them with their toughest challenge. Juliet became unwell, and required increasingly invasive treatment, and the treatment, or the disease, changed her. She wasn't the same person she had been. Romeo tried to stay with her, but he felt her drifting apart from him, and from herself. He couldn't cope anymore; it was just too hard, and there wasn't the support. He had to do something, anything to stop the pressure... It wasn't really her, anyway; she wouldn't have wanted to go on like this.

There's a third story, but it doesn't bear telling. How many sides can a coin have?

Sometimes, maybe always, tragedy is just tragedy. Some of us just feel it more than others.

Crazy Man Michael

Another night passes. The promised 'thundersnow' has not materialised, at least not this far South. The weather was pretty shite, tho. I approached the shift with significant trepidation; my nerves clawing at the inside of my belly all the way down, leading me to wonder, at one stage, if I really had cooked my pork chops properly...

I can't stop revisiting the cases from the night before, and head straight for the information superhighway that passes as the hospital intranet as soon as I arrive. The fitter has had all the investigations and treatment I didn't instigate. All to no avail, which is some consolation. Maybe I was right.

I mull this over, and chew the fat with the SHO I ran the case with. He is more robust in the defence of our management, and I wonder if that's because I know more, or just that age has made me more defensive, more afraid of error...

A punter is brought in from the rain, cold and shivering, his right arm swathed in what looks like acres of swaddling; held aloft, like a blood stained Statue of Liberty. He has, for reason known only to himself punched holes through some armoured glass windows. I am, briefly, impressed by the strength that must have taken. Then my inner cynic comes back from his coffee break.

We gingerly take the dressing down, and everyone gathers round, craning their necks, as if we are unveiling a lost Leonardo. His arm gapes wide, split skin grinning with glistening fat. His muscles are clearly visible, for an instant, then the wound wells up with dark blood, a rich burgundy, hot under the lights.

We pronounce it venous, and are pleased with ourselves. Shroom's blunt haemostat is applied, and the arm hoisted once more aloft, a mocking victory salute. While the search is on for more gauze, he shifts in his seat, uneasy suddenly, and I feel a warmth run over my hand. The dressing is soaked through, and a gush of bright red claret, almost impudent, announces an arterial bleed; I assume he's cut his brachial, and the spasm had held the floodgates closed until we started poking and prodding.

All attempts at subtlety go by the by, and we double the pressure on his arm. This is less than comfortable, but needs must. He is crying when he leaves for theatre, and I want to feel sympathy, but he has done this to himself, and I can't.

I wonder if this makes me less than I was, but the Department is heaving, and I have no more time for navel gazing...

Double Or Quits

Some days it feels like you can't do anything right.

Last night started benignly enough, but midway through the night came to a unpleasant crossroads. Resus had been the stopping off point for a couple of teens who couldn't handle their beer. They both came round fair enough, with one taking a little longer than t'other... I still think he was on drugs, but I guess that's his business.

The Ambos broke the reverie of the ethanolic miasma by bringing in a young diabetic, unwell and sinking fast. His diet, eschewing food for vodka and coke, not helping. He was pallid, restless and crispy dry, reminding me all too well of the last diabetic I had in resus. Ketoacidotics are unwell, for sure, but there's degrees of unwell.

This fella was first class unwell; sick, with honours, if you will. He started vomiting shortly after arrival, great heaving spasms, spewing forth small volumes of coffee coloured fluid. Now this might be the result of gastric stasis, a feature of DKA; but it might be him trying to bleed to death.

Getting ready to focus all my attention on him, contestant number two arrived. A young woman, known to suffer non-epileptiform seizures, brought in, perhaps unsurprisingly, fitting. A complex case, for all sorts of reasons, and one that I'm still not convinced I manged well, or in the right way.

I tried, tho'. Tried to do right by them both.

And failed.

I'm furious with myself.

Sometimes, you will tell yourself, sometimes, I just need a break. I need for these patients not to be going off at the same time, I need for the department not to be heaving at the same time, I need for the fact that waiting times are skyrocketing to be on my mind.

However, that is not the way life works. I get paid to cope under pressure, to manage a busy department, to multi-task. To make everything work, to make everyone better.

In the cold light of day, it's all too easy to review the cases, to see what should have been done.

Last night I was fired in the crucible, weighed in the balance, and found wanting.

It is a sobering experience, and one it will be a while before I can forget.

I only hope that's a good thing...

What Next...

22 year old male, previously fit and well, presents at 4 in the morning. The previous evening he had had a curry, but nothing unusual. A few hours later he had begun to feel unwell.
He described epigastric pain, associated with nausea and vomiting. He had had no change in bowel habit, and there was no blood or bile in the vomitus.

He had had no recent foreign travel, denied drug ingestion, and none of his friends were unwell.

He was afebrile, warm at the edges and cardiovascularly normal, and stable.

Abdominal exam was untirely normal, routine blood tests and radiographs were normal.

As his pain had required opiate analgaesia, he was boarded on our obs ward for several hours.

Repeat exam some four or five hours later remained normal. His observations had been stable, and his pain had settled. He felt better.

Can I send him home?

What He Said...

I had intended to follow up with a rant on a particular fave topic of mine - the idea that "natural" equates to "safe".

However, the always thought provoking Dr Crippen has beaten me to it. And, inevitably, said it better than me.

So, read his piece here.

You Say 'Homeopathy', I Say 'Placebo'...

Or sugar pill...

Alternative medicine fascinates me; I hold some (reasonably) strong opinions about alternative therapies. As ,it seems, do lots of people.

I freely admit that I am not the most open-minded of individuals. My training is all in Western Orthodox medicine; so I am biased.

However, I am prepared to recognise that just because I don't believe in something, does not make it untrue.

But I do place a lot of faith in scientific method, and the assessment of therapies through randomised controlled trials. If something works, it should be demonstrable under controlled conditions.

Shouldn't it?

Whatever works for you is fine by me, even if I don't agree with it, or believe in it...

But it does seem to me that some of these therapies exploit people, or, in the worst cases, prevent them from accessing treatment strategies that are proven.

Can't we all work together?

Room For A Small One?

The Crisis continues...

The Hospital is full; yesterday an 'internal' Major Incident was declared. This sparked brief panic, as word spread around the Hospital. For those not in the know, a 'Major Incident' is usually declared in response to a sizable disaster - plane crash, train wreck, etc. The implication is that incoming workload will swamp the Hospital's ability to cope. An internal incident simply means we can't cope with the routine workload of the day...

While the difference between the two was sinking in, a variety of anaesthetists and intensivists pitched up, looking for work, causing more confusion, as most of us hadn't been told about the move to Defcon 2, or whatever it's being called these days.

As far as i can tell, a lot of Very Important People were summoned to the Department, and milled around. Normal services were extended, completely ignoring the root of the problem, which is that the hospital is full! It maters not one jot how many bodies we have in ED moving meat, if there's nowhere to move the meat.

So, only 'life and limb' threatening problems got admitted yesterday. This will backfire in about 48 hours when all the punters we sent home come back in extremis.

Brilliant.

In other news, La Belle Fille was a little bit disappointed with her billing in the previous post. So, for today, I'd just like to remind everyone how brilliant, beautiful and funny she is.

Evil Has Many Roots

Money troubles.

La Belle Fille is cross with me; for a variety of reasons - because I'm working all the time, because I can't help but act like an infant around her friends, and now, because of money.

I am convinced that money causes more trouble than it's worth; perhaps I can afford t have such an opinion because I've never been short of cash; Ma and Pa Shroom are well enough off, and Doctoring pays the bills... so maybe this invalidates my opinion.

Money still causes grief tho'. LBF is owed some cash by an ex-housemate of hers, and he hasn't paid her for several months. I don't consider it a large sum, but that is all relative, of course. Ex-housemate now appears to be throwing a strop over the debt.

I suspect there are valid points on both sides, but what seems a simple enough matter t me had now become acrimonious; what price stress and heartache?

I know there are both moral principles and material realities at stake, but I hate seeing her upset by it.

Sadly, my attempt to express this opinion wasn't well received.

Money brings its own trouble and spreads it far and wide.

Doctor, My Eyes

Never let it be said I am prone to hero worship, or hyperbole.

But, I witnessed the most remarkable act of resuscitation recently. It has to be said that I should probably have been less impressed, because, really, it should be bread and butter, but...

The calls on the BatPhone always bring a frisson of excitement to a resus junkie like myself. We got two in short order, both elderly, both low GCS. One carried a warning of low pulse, the other of high BM. Daytime brings high staffing levels, relatively speaking, so the first contestant went to one of the bosses and an SHO; patient didn't look too bad when she rolled in, so I left them to it and tried to prep for number two.

High sugars and low conscious level smells like diabetic ketoacidosis and cerebral oedema to me, and it ain't a nice smell.

When he rolled in it smelled worse. A veritable husk, wrapped in his own duvet. When the paramedics bring a punter in wrapped in their own duvet, it is never a good sign. This patient's duvet and feet were caked in blood and excreta. You would be correct in surmising that this is not a good sign, either.

What control had neglected to mention was that the patient had been found in a pool of his own melaena; semi digested blood, born at the top end, voided at the bottom end. He had also not had a blood pressure.

I've seen some dry folks before, some real crispy critters; but this guy - his eyes were shrivelled. Concave, flaccid, like party balloons two days after the last guest clocked out. I have never, in all my born days, seen anything like it.

Needless to say, access was an issue. I am increasingly in love with the Easy-IO, and drill that fires an i.o. needle into the bone of your choice, sweet as pie. Two of those bad boys gave us a start; medical students, eager for teaching, found themselves press-ganged into pushing fluids.

Two litres later and his eyeballs were back to normal. A few veins appeared, and more access; more fluids, more drugs. He came as close to arresting as it's possible to do an not. If you see what I mean.

He made it out of the resus room, but I don't hold out great hope for the final outcome. It's a mark of just how sick he was that, despite three hours of aggressive resuscitation, he left with a pH still below 7.

Sometimes hard work does go unrewarded.

Overheard In The Back Of A Police Van

"This is the problem! I need cream! Cream!! I am not on drugs, I just have FACE LICE!"

The Root of All Evil

On the contemplation of Billing.

I confess to not really understanding the complexities of Hospital Finance, either here or, specifically, in the US. (Or anywhere abroad, for that matter).

Scalpel, who is always worth readin', in case you're new here, has offered a couple of posts. Find them here and here.

By way of comparison, as I understand it in the UK, Emergency Departments here are paid flat fees for patients. 'Minors' (sprained ankle, cut finger) net us £35; 'Majors' (MI, bowel obstruction) £70 and stuff like major trauma £105.

Please note that I'm writing this from memory, so my figures may not be accurate, but I'm pretty sure there at least close. I am, as ever more than happy to be corected.

I'm also not sure where the funding for Radiology and Pathology comes into it, so that presumably ups the total tab to the state, but even so...

While I like the idea of going over to, e.g a 'means tested insurance' form of Healthcare provison in this country, the idea that we could fund it on the cash we pay in tax now may fall short if these figures were replicated.

You may well argue that £35 pounds for a cut finger isn't good value, but I'd say you'd be hard pushed to get much treatment in the US for $200 down.

Or maybe not.

As a last thought, we recently admitted a fella who had flown back from the US, with a diagnosis of acute appendicitis, because he couldn't afford the down payment on his treatment.

Allegedly.

This seems crazy to me, and any of my bleoved colonial readers who can elaborate on the likely veracity of such a tale... comments welcome.

Tears Of A Clown

The year rolls on, with barely a backward glance.

Big teaching hospital is creaking at the seams righ now; and not even under the weight of Le Morse and his visitors trooping up to glare at the ENT wizards. He's gone home, hurrah, and speedy may his recovery be.

No, it is the winter, and the cold spell it brings. This year has been especially rife with 'viral infections' and the elderly, or infirm - mostly with chronic lung conditions - have fallen from their perches in droves.

Result: Full hospital.

Consequence: My ED now regularly resembles a battleground. It doesn't take a genius to foresee it, really. If we see between 200 and 300 a day, and even half of them are majors patients, that equals about 5 ambulances arriving every hour. We have 16 cubicles (count 'em) and 16 obs beds, give or take. If there's nowhere for throughput to go, we saturate by about midday. Before, sometimes, if the night's been busy.

We've been boarding 14 or 15 patients for admission regularly when I come on shift recently. Some needing level 2, or 3(!) care.

The scene is set for a disaster; sure we laugh, and joke, and get on. What else can we do?

It is, frankly, a bit embarrassing.

(The Shroom would like to remind his readers, for legal reasons, that his views are his own, and do not reflect those of any official NHS organisation. Also, the above description is not intended to imply that sub-standard care is being delivered in the corridors of any hospitals, anywhere. I probably made all this up anyway...)

Even The Mighty...

Le Morse is in hospital!

He has been laid low, cruelly, and the Department is poorer without him. Like all of us, he does not enjoy the sick role, and all at Shroom Towers wish him speedy return to fighting fitness.

Slainte, Morse! and Good Health.

Dulce et Decorum Est...

Whatever we may think, however we may feel, being a Doctor represents considerable priveledge. We are party to the best and worst of other people's lives. We are granted power tha other people are not, and charged with exercising it responsibly.

Perhaps greatest among these are the rights granted us under Common Law, by the Doctrine of Necessity. It enables me, however briefly, to supercede your wishes, to act on your behalf, sometimes in direct contravention of your stated desire.

In practice this is usually when someone is incapacitated, and unable to express their wishes, but, on occasion, it is despite your active rejection of my proposed plan of action.

In overdose, for example.

It should, and does, weigh heavily, on my mind to do this.

If ever I needed reminding of why this is not entered into lightly, yesterday's shift provided it. I may sometimes think o myself as noble, or heroic, but there is no glory to be had in pinning a teenage girl down in order to administer treatment.

Did I do the right thing? I doubt she will ever see it so, but I have to believe I did, and that at least I've given her the chance to be around to resent me.

Come Join Our Insect Nation

Another New Year, another failure to cover myself in glory. Spent it with La Belle Fille and her friends, but failed to convince anyone that I'm funny, or interesting...

Her friends don't like me very much, probably with good reason. Wallowed in self pity for a while, then realised work was back to cheer me up.

Sometimes it's fun being me.

Medical Miracles

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

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

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

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

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

Point and Counter Point

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

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

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

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

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

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

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

Do we need more practitioners? Yes.

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