blue light, part deux

There I was sitting at the back of the ambulance - the only time I was actually chilled, after a really busy night drawing up drugs, chasing up blood results and doctor referrals. Then there’s the most challenging bit, I think. Reassuring family at bedside. You wouldn’t send a family home when there is a possibility of ‘movement forward’ to another facility, need for involvement in a significant decision making process and quite possibly termination of therapy if deemed futile.

I felt weird (I always do, anyway) that there I was running around pushing drugs and fluids to preserve or keep organ function stable and restoring a family member’s confidence every time the machine beeps, but at the same time painting a rather bleak picture as quite often, it is better to offer little or no hope to prepare them for any negative outcome. You would have to continuously assess the family's emotional stability and intellectual capacity to understand the situation obviously.

It is during these times (early morning) when Consultants are hard to come by and decisions become really slow. The family have also decided to go home at this point which I thought was fair enough since they were practically up the whole night. We haven’t heard from the London hospital and dispiritedly, I was looking after a patient with a very unstable blood pressure and not blowing off his carbon dioxide despite of all the tweaks done on the ventilator. A high CO2 concentration on a head injured patient is basically, a ticking time bomb.

So I was quite happy that by six in the morning, we were whizzing our way to London. I didn’t mind that I had to catch a syringe flying in my direction from an ever so sprightly young doctor who can’t be bothered with her seat belts. These things happen. Once not so long ago, it was a sickie bowl.

I phoned up the patient's wife explaining to her that they might place a bolt through her husband’s skull to monitor the pressures inside and they may or may not operate on his brain depending on the degree of the damage. And that he may or may not survive the operation. I really felt sorry for her and she was really grateful for all the care and the honesty. I have omitted that part where we ask if the patient is on the organ donor register.

I apologized extravagantly when I handed over to a colleague. I know, I passed the buck.

blue light

Still couldn’t sleep after one yet long graveyard as I clocked two hours more than my 12 hours shift last night. Good thing it’s my day off and it’s a lovely Saturday morning. Which doesn’t make any sense really as any random week day is fantastic as long as it’s my day off, to be quite honest. Well, aside from the fact that Subway’s £1.99 ‘Sub of the Day’ today is beef. I have to say it’s a greasefest already equivalent to my one week calorie requirement, but what the hey. It’s all about the jalapeños, baby. And I had zero calorie points last Saturday to make up for.

Grilled scallops with carrots and asparagus. Not so sure about the caviary pink fish roe mess though.

The reason for the two hour delay trip to the ever so lovely land of nod was the fact that by six o’ clock this early dawn, I was sitting at the back of the ambulance with all the liquids – what remained of the uninteresting shabby cuppa tea swirling in my gut space as it blue lighted (I would imagine more than 90 mph) it’s way off the motorway to London. I had admitted a patient from Accident and Emergency last night – a 60ish gent with subdural haematoma and cerebral contusions according to scans taken off his head.

A proper Level 3. Score we give to intensive care patients depending on how many organ failures they have equivalent to how often you have to run round the store cupboards like a headless chicken rummaging for wires and monitoring equipment to keep you interested.

Quite often the gizmos work, but other times they just become random number generators producing randomly generated algorithms i.e. the machine is telling you that patient is really dry and needing lots of fluids when obviously overloaded. Sorry Asimov, but sometimes Artificial Intelligence is just shite.

To be continued. I got a party to attend to this evening.

Who's Mad?

So I turned up at work feeling like a toilet roll. This is the continuation of a previous post that got sidetracked when I made it to the First Edition of the British Medical Blogs. Yey! I can not really provide an explanation why I’ve chosen to use these banal two words to describe my state of being but it was the one closest to feeling like crap that I can think of at the time. Seems like an appropriate metaphor for feeling really thin, featherbrained and can’t be bothered to do anything as challenging as a therapeutic transaction with patients who sometimes if not more often know more about their medical conditions than I do. I once looked after a patient who has Googled every ache and pains she ever had, every pills or tablets taken and every diagnoses accumulated as if it is some form of a “fascinating morbid collection”, literally and figuratively. Makes you wonder: What’s wrong with collecting stamps? Or stuffed dead animals? How could anyone obsessively collect an alphabetically arranged mental card index of a random number of pathologies or allergies that they could just pull out from the back of their heads each time they see a slight rash or a spot of discolouration on their skin? I remember having this kind of anxiety each time we had a trip to the hospital to see actual patients or diseases for our related learning experience as a student. This may sound like a fun outing or a field day, but more often than not you end up lying down on your stiff bed in the dormitory having cancer or tuberculosis. Imaginary ones at least. Thanks to the web for wider access to medical information, medical blogs like " this " and popular medical programs on TV, now this kind of phenomenon is not just unique to medical / nursing students.


Hypochondriasis is the new opium for the masses. So it’s quiet possible that anytime soon after you’ve extubated ( remove tube / artificial airway ) on an asthmatic patient who had a respiratory arrest ( ceased breathing ) you might find yourself unprepared to his / her witty sense of humour:

“Nah, TB’s my disease.” And wished you had equipped yourself with appropriate House MD’s unconventionally artsy verbal skill: “You own a disease? Well, I’m sorry I missed the IPO on dengue fever.”

It’s quite easy to get psyched about it, and on the other hand, quite hard to psyche yourself up about them especially now that more and more people are crazy about medicine or just plain crazy. Of course, verbal interactions in reality unfortunately deviate quite steeply from art. You can not look at a heavily bruised patient who jumped off a nearby bridge and say: “Oh, well that rules out the race thing, ‘cause you were just as black as last week.” May work hysterically on TV, but I doubt it if you can pull it off in reality without getting sacked for being un-pc ( politically incorrect ).

Although patient’s in ICU who are subjected to sensory overload, sleep deprivation, loss of control and lots of other various factors could be ( unable to find a pc word at this point ) just as mad: known as ICU psychosis. Most have grown dependent to their carers from prolonged helplessness that they reverse back to being a child:

Client: Can I go out please ?
Nurse 2: No I am afraid you can’t.
Client: Why ?
Nurse 2: Because you said this morning you were going to jump off a bridge.
Client: How do you know ?
Nurse 2: Because all nurses are psychic !

So unless you are like these witty, witty Mental Health Nurses that could read patient’s minds and could maintain a childish conversation to an adult with an otherwise child’s brain called reciprocal transaction in psychoanalytic theory - looking after a conscious, chatty and wardable ( should live in the ward if there is a bed there! ) patient can be really, really daunting indeed.

The Big Tasty

Oh, wow. I was about to publish the second instalment of my previous post this evening when I peeked at my stats-counter: blimey.

What’s this bloody traffic all about?

You fancy hunting down every arse or perve trawling the web for bits of smut or any kind of titillating information - you stick a tracker device on your web page. It shows statistics of every visitor that reads your blog including visitor paths, visit length, country, city, state, ISP, recent book bought, shopping habits, etc.

It gives you a mental picture of how sad this people are and it’s quite interesting to see the trend change: whoa, this miserable git who bought Vladimir Nabokov’s Lolita and likes Parliament of Whores at Amazon’s is trying his luck today, especially if you tag your post with words like: death, evil, melancholy, and even the silly word – sperm.

Well, since Monday evening my counter is reeling from hits by all sorts of really nice and decent medical people. Huh? So I traced back the paths and found out that the ever so respectable Dr. Crippen: yeah, the world famous GOD (just a bit) NHS BLOG DR JOHN CRIPPEN has included this blog alongside the august line up of other British bloggers in his First Edition of ‘The Britmeds 2006’.

It’s going to be a weekly round-up of medical blogs where every sentient puppet on God’s stage is given a wider audience.

Or something like that. You may call him a chauvinist he says, but this round-up will have a strictly toff accent. No more Mc Donald’s or French bloody fries… This is the Big Tasty. Although he admits this is not going to replace well-established colonial institutions such as Grand Rounds and Change of Shift. Well…

What are you waiting, lads! Let’s go blogging. As HE said so himself:

“Who could disagree with a sad Pinoy nurse…”

Bloody well done! Doc Crippen. And Happy Anniversary. Oh, he is such a lovely Doctor. Very socially aware and sensitive. “He watches and weeps as the Health Service, slowly, but inexorably, is destroyed.” His own words. I feel the same sadness, really. I wouldn’t mind sitting down with him for a Pint and fat chips in my garden one afternoon underneath a downcast grey English sky.

Amyotrophia

I cringed to the idea that I’m getting two patients at the beginning of the shift even though I was promised that if push comes to shove we would shift my other one to the ward. That means unless somebody pops in the Accident & Emergency after doing something silly like slashing his or her epiglottis in the middle of the night, I’m stuck looking after two babies weaned off from life support and milkshakes of various types of narcotic drugs. I’d rather have one proper ICU patient to be honest, especially at the end of my fourth night.

The unwritten definition of proper patient: attached to a breathing machine, a lot of wires and completely sedated or even paralyzed.

I don’t normally mind having a chatty whingeing patient, but after doing 34.5 of your 46 hours all night before the weekend, you’d wish for a really chilled, inanimate, unconscious patient to cap the end of your shift.

It doesn’t help that you only spent four hours on your bed Friday morning as you find your main electricity supply switch tripping off every time you turn the kettle on to boil water for your cup of tea. Thank heavens for yell.com! I felt all my muscles have wasted and found myself unable to lift our dog-eared cumbersome Yellow Pages book.

Certified electrician came after an hour and a half which I though was quite impressive considering that it takes an hour for the Pizza man to find our door on a clear day. That was 1.5 hours knocked off from my nine hours sleep day before I go back to work in the evening. Routine checks done by electrician in switch box took another 20 minutes plus 10 minutes to unplug all the various appliances stuck in all electrical sockets.

To tell you the truth, I have enough of them to suck out all the electric juices of an entire city and greenhouse gas emissions enough to eat away a big chunk of the ozone layer the size of an Alaskan village.

Electric power is revived after some tinkering but for some reason, every time kitchen power supply is switched on the whole thing trips off again. Fuses are checked and that sorted, the culprit was eventually found: hiding deep inside a socket box of the cooker was a loose wiring. Another 15 minutes spent fixing the problem and 15 minutes having that well deserved cup of tea until electrician left. Total time lost so far 3.5 hours.

Gave up another half an hour or so to watch day time television as brain still spinning around from all the adrenaline, never mind the biologic clock thrown completely off a maelstrom of bad work schedules and unpredictable eccentric English weather. Tired and sleep-deprived, I can’t help turning up at work feeling like a toilet roll.

To be continued...

Nurses Taking the (chokie) Bickey

From the other side of the planet where I schooled and trained, the doctor is god: an omnipotent, autocratically patriarchic kind of god. Nurses are relegated as angels or cherubs. Angels are people of exceptional holiness. Like nuns or sisters. When some nurses holiness become nonpareil, they become Sisters. Cherubs are also special. They are an angel of the second order. They are most loved by patients because they coo and smile. In fact they smile a lot they grow their wings by smiling.

It is not always a good thing to be god, so most angels are quite happy to stay as angels. In other words, doctors are doctors and nurses are nurses. If a nurse wants to become a doctor, he or she goes to medical school. Yeah, he or she carries them heavy books and burns the eyebrows. You don’t become a doctor by being struck by lightning from mount Olympus.

Oh, the good old days. Nurses nowadays apparently don't smile, and I didn't notice this until I stumbled upon this blog by The Angry Medic. No! They don't.

Good Nursie! Here, Have A Biscuit.

I was so busy writing about The Melancholy Death of Evil Sperm I forgot stuff that really matters. I know that this will not generate as much comment as the previous post, but what the hey.

NHS Trust Offering Nurses Chockie Biscuits – to encourage them to smile at patients. This is actually quite funny.

In this part of the planet there are no such things as gods and angels: you are made to feel part of the team. This is a good thing, really. Most nurses are happy to stick to their roles and doctors do their own bit to achieve the goals of the team. Some nurses are given roles that obscure the demarcation between each role, and as long as they work within a framework that protects them i.e. defends them from danger, injury, loss, lawsuits etc., and with a fair amount of compensation for this added role, he / she is happy to oblige. Whatever the reason is:

To save Trust money – as it pays peanuts to hire nurses to do the job or to recompense for the shortage of doctors, the latter being highly unlikely, added to a lot of confusion and mayhem that bedraggles the modern NHS.

“In recent years there have been growing concerns about nurses who are “too posh to wash” and prefer to spend their time on administrative and technical tasks rather than basic care. Two years ago a resolution at the annual congress of the Royal College of Nursing proposed that nurses were now “too clever to care” and suggested that the compassionate part of their job should be delegated to healthcare assistants. The provocative motion was a reference to nurses increasingly concentrating on technical duties.”

The way that language * in bold italics here* is used in a country where political correctness is the order of the day, along with the rest of the article, I find it really naughty. Absolutely demeans the value of nursing and I suspect the reason behind the culture of disdain to what is now being perceived as old-school or traditional nursing:

Washing or feeding a patient is not posh or clever.

I have to admit, I have met quite a few nurses with this kind of mentality and they are usually not the clever ones. They don’t see the theory behind the importance of hygienics – the science concerned with the prevention of illness and maintenance of health, or nutrition, but see it merely as hands on activity not worth wasting a few brain cells with. They are also the ones who always like to nip out for a ciggie all the time as if that doesn’t waste a few of their brain cells but that is just my stupid theory, and I don't mean to diss people who smoke. Everyone's got a right to have cancer. As long as you get your work done, it's a free country.

I also see really brainy nurses who don’t wash patients. They only assess and make diagnoses (and debate with doctors) like Nurse Ratchet. They are a pain in the ass.

Fortunately, there are still a lot of proper nurses, especially in ICU who are very, very skilled, technically savvy, they could set-up a Galileo Ventilator and a PICCO machine blindfolded, line a Haemofilter in under a minute and still back –up all the data files of the main computer server, yet would be happy to do mouth care, eye care every four hours, make everyone a cup of tea, wash a patient at the end of the shift, then recite Shakespeare’s Sonnets backwards from 154 down to 1. But that is in Critical Care where if possible, patient to staff ratio is kept at 1:1.





In the wards, you see an entirely different picture. A Picasso painting of an abattoir where more than 30 patients are lying in their own filth, relatives curbing a fantasy to kill and one single nurse running round like a headless chicken.

So yeah, no smiley face here.

Sink, Swim.

I met the student nurse again today. She was in the coffee room and looked really shattered. I sensed that she had been crying. When I asked her if she’s alright, she told me that the patient that we looked after the other day, passed away. I’m not surprised. He was already on a maximum dose of adrenaline yesterday, and required a lot of filling- you give them lots of IV fluids to maintain a decent circulating volume or at least a decent central venous pressure. I wasn’t sure what the diagnosis was but from what I can gather, he probably died from cardiogenic shock – basically what happens when the heart gets tired from pumping really hard to compensate for low blood supply as a result of acute ?MI, ?PE or pulmonary embolism that we talked about in great length yesterday. These are all purely conjecture, but this was the most probable cause of death that I can think of by just connecting all the dots and without actually looking at what the doctor wrote in the notes.

I felt sorry for the student, obviously her first time to witness a tragic scene in ICU. You do indeed feel a strong sense of empathy to the patient’s family when this happens. Not for us though, we have already developed tough emotional shields to deal with it. It is stressful, but at the end of the day, you got to do what you got to do. I wonder if this is a reason why ICU nurses are the most soulless and insensitive ‘unprintable’ colleagues that you could ever work with. I’m not gonna push for it, but it’s an interesting theory. She told me that she is going to finish her course after a year and will soon be a proper nurse but still feels ‘out of whack’ – her own words. She asked me how long I’ve been working in the unit blah-blah: Hinted interest to work here, so I felt obliged to give her some encouragement. You don’t really want to scare them, do you? So, I told her:

“Oh, it’s lovely to work here. People are really supportive.”

Basically, I didn't tell her what I've been through. If it isn't too over the top, I could have described a hippy commune where everyone group hugged after a task is done, and working here is like playing ball in a lovely white sandy beach where everything is warm and you work hand in hand as a team, when I thought: Yeah, right. They will throw you in the middle of the deepest ocean, and you either sink or swim, so I told her instead:

"People will help you and guide you every step of the way."

Chaos, Control.

The unit is like the double sided painting of Wassily Kandinsky called Chaos / Control in that John Guare play: Six Degrees of Separation, although it looked more like chaos all throughout and not a smidgen of control when I came this afternoon. They are about to tie the tube on patient’s mouth to keep the airway, whilst the doctor is bagging/hand ventilating him. Meanwhile, poor Galileo – our ever so reliable breathing machine is screaming low oxygen. I thought I could be useful by trouble shooting the bloody machine and hopefully shut him up. I’m not really sure if he [ the machine ] is a he as he sometimes get premenstrual and become so hysterical. You got to learn how to press the right buttons with him. I tried to check if any of the tubes are kinked, checked if the machine is plugged to the main oxygen supply, clicked menu screen, with that really annoying smug look, I thought I looked smart whilst I was doing it and I'm not really, so I clicked the buttons, hell - any button because I really didn’t have a clue what I was doing, but it worked. Man, I was good.

“Okay, Howler. You take charge of this one.”

“I’m not yet here, sister. Remember I’ve just arrived in the unit, [ thought I could have a cuppa tea but this bloody-ancient-heretic-piece-of-science-not-ashamed-to-be-called-Galileo is having a fit. ] I’m just trying to help.”

Sister gave me the Naomi Campbell look.

“Oh, okay. I don’t know this patient.”

“Neither do I. He came this morning, but he’s not in the system yet. The notes are with the doctors.”

I can see what seemed like notes scattered on the work station. “Yeah, right.”

“Honestly, we have been busy.”

Fair enough. It looked like they have done quite a lot indeed. The poor man appeared to have lots of invasive looking lines in various parts of his anatomy. Arterial line, CVP, Femoral cath, you name it, he’s got them.

“So what happened to him?”

“Oh, nightmare.” Sister hissed, then sashayed off and disappeared from the hallway like it was a catwalk. Lovely.

“They think he’s had PE’s whatever that means.”

“Blimey.” The curtain just spoke like that ‘voice’ that sometimes lent itself to cute farm animals or burning bushes in the middle of the desert. I opened it, and there she was. Student Nurse. Poor little bugger looked really terrified.

“You gave me a fright, dear.” C’mon in, and see what we have here."

Wished she hadn’t because she then asked me a barrage of questions.

“Hold your horses. I don’t really have a gift with translating gobbledygook either but let’s say PE is a plug, sometimes gunk, but mostly a blood clot that travels from your legs to your lungs then bugger off your heart, basically. I was told 10% of patients who develop PE die within the first hour and 30% die subsequently from recurrent embolism. They sometimes call it economy class syndrome. You know, you go to some beer festival in Germany, but you’re trying to save your booze money so you took the cheapest easyjet flight where it’s so cramped and you end up having a massive heart attack and a dead brain [ similar to what you get if you watch a lot of old american musicals, usually with Julie Andrews on it ] somewhere in the mountains in Salzburg where the Sound of Music was filmed in the 60’s.”

“Oh, DVT.” She said.

“You’re a rock star.”

I wanted to show her the PICCO machine as I was getting inspired, and I was explaining to her how you could inject cold saline to the patient’s heart and then the machine will pick up this cold saline at the end of the art line and be able to calculate cardiac output by analysing the thermodilution curve using this algorithm called the Stewart-Hamilton, when she looked at me terrified.

“What is it dear?”

“Is it like that Pulp Fiction thing? When they draw that circle on her chest with a lipstick and jammed a fat syringe of something into her left breast?”

“Naaah.”

“You inject the saline through the tube, of course. Then it will tell you the patient’s CI [ cardiac index ] which is basically cardiac output indexed to his weight. If it’s low, maybe patient is dry, so you give him lots of fluids. Or SVRI [ systemic vascular resistance index ] when peripheral blood vessels suddenly turn hip-hop and hang out loosely like a baggy trouser, so you loose that pressure. Then you need to give a drug called noradrenaline to act like a belt and squeeze that trouser up so you won’t have blood pressure down to the floor.

I was really enjoying it. It was like Beauty and the Geek. "My favourite is the GEDI…" And before I finished, I knew what she was going to say.

“Oh, I see. Obviously, you like Star Wars. I love them.”

Global End Diastolic Volume Index is the volume of blood contained in the four chambers of the heart.

“Bloody hell, you've seen way too many movies.”

Funky Neuroleptic Malignant Soup

I’m off today. Yippee!!! Last night I was made to look after a very interesting case. It is not often that we have psyche patients in the unit, unless of course you count those that OD’d [overdosed] on some bizarre mix of whatever tablets they found in their toilet cupboards and those that fiddled and got carried away with whatever vegetable they found in the kitchen fridge.

This one is really catatonic schizoid and was sectioned 5(2) which translates to being actually legally restrained and detained in hospital when deemed necessary by the medic as sanctioned by the UK Mental Health Act. I thought, this is going to be very exciting – although, after a rethink I wondered why do I always get a sick patient? I know, patients come to ICU when they are really, really sick but I was also thinking along figurative lines like: Yeah, let him deal with an antisocial mind and of course, violence. I can sense a bit of sexism in the allocation as I am the only male staff, but I can understand as this chap is really ‘huge’. Not a politically correct choice of word, but this one really tipped the scales and the bed.

I wasn’t really convinced that he was a proper ICU candidate looking at the working diagnosis from the wards. It’s quiet often that those patients go to ICU because they are physically rather than medically demanding. I don’t mean to slag off the colleagues from the wards because I know they are really hard working and understaffed, but it’s quiet funny to see patients that you have just attached to wires and monitors one minute and then offered tea and newspaper the next. They are not on an aeroplane, and definitely not in business class. It is ICU for crying out loud, and it’s an absolute waste of hospital resources.

Looking at his notes:

Query CVA [ Stroke ] – found in dumpster / skip , not responsive, GCS 12/15. I thought: Oh, okay. But also, he is catatonic and he is psychotic.

Query Septic, UTI smell. – I wasn’t sure if I’ve read this correctly, but this was in the medical notes. Honestly. And I thought, wow. If you happen to have this wonderful sense of diagnostic olfactory skill, think of the hospital money that can be saved.

Who needs that lonely git with the Petri dish and culture bottles in that sad cubbyhole called the lab when you can go round the park and sit beside a group of greasy ragbags that stank of horse piss then tell them:

“Oi! You mingin’ little bastards take a couple of tetracycline three times a day because you lot got a urinary tract infection.”

Query Neuroleptic Malignant Syndrome, on Quetiapine , Amesulpride – Very fancy and had no idea of it to be honest. Mental note: Will Google the damn thing as soon as all admission paperworks are out of the way.

Past Medical History- Stroke a few years back. Old CT Scan, showed Lacunar Infarct.

Outstanding problem:

Elimination – Not peed since morning. Massive bleed from urethra. I was told that they tried to insert catheter in the ward but failed miserably. Had a look and it appeared that meatus is very, very small. Managed to insert size 10 catheter and blood flowed instead of wee. Did bladder washouts but clots seemed to block passage. Wondered if they rammed this poor man's tackle with a 12 gauge shotgun instead of Foley's invention. In the end, Doctor inserted Suprapubic Catheter – And ouch! This procedure is not for the squeamish. Made sure relative is tucked away in a corner in case there are outbursts of ‘unprintable’ language. He did a portable bladder scan then stabbed the poor chap’s tummy with the tube. I would say, it worked really lovely. Urine flowed. Well done.

Overnight, respirations and gas exchange have been monitored. Kept an eye for hypoxemia and acidosis. Intubation set kept at bedside. Monitored temperature and ECG for arrhythmias. Full blood work including CPK, liver and thyroid function. Hourly neuro observations.

By morning, patient remained stable. There were discussions of lumbar puncture to rule out CNS infection, but I was already looking forward to ravage this nasty but highly nutritious miso.

Miso Soup Simple English Wikipedia

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graveyard. inertia of the body. runs. counter to. cerebral. paralysis. agression sublimated. brought deep. introspection. vagrant matter. exhumed. the abyss. where. time is just a concept. the spirits. meandering. gave the illusion. of coming back. on exactly the. same temporal length of event. i screamed to ascertain. its reality.