Big

Have finally calmed down enough to write this. Things have gone badly today, they may yet go worse. We may have to revise that previous number of fuckups.

Okay.

A few days ago the ambos brought Mr Baruch to us from Ratbite River, one of the smaller local hospitals. We got this phone message and apparently it said "forty eight year old man, low-speed single vehicle MVA, mild lumbar pain, no injuries observed, HR 80, RR 12, BP ?, neuro intact, unsuitable for Ratbite." So someone who had had a very minor sounding accident and sounded completely well (except for the missing blood pressure) who was being transported in an ambulance to the local trauma hospital.

I sauntered out later on and I saw why he was unsuitable for Ratbite. He weighed, by his own estimate, at least one hundred and ninety kilos. That's around four hundred and twenty pounds.

Mr Baruch did not have a particularly good time of it. Ratbite couldn't handle him, apparently, because they had no beds strong enough, and both they and the ambos were unable to accurately measure his BP, because no cuff would fit around his vast arm. And they had intended to Xray him but he would not fit on their Xray machine. So they sent him to us.

Anyway, what was going wrong? Mr Baruch was unwell. He laboured when he breathed. He had great logistical difficulties when he needed to go to the toilet. His heart was staging a tactical retreat from the impossible task it had been set, pumping blood around a body that occupied a good few hundred litres. His legs had hardly any circulation, he had chronic ulcers. And he'd had a car crash which, although it was low speed (how fast can an old Astra go in reverse with a one hundred and ninety one kilogram man in it?) involved considerable forces - the seat had snapped in half when he reversed into the tree.

He hadn't done any harm in the actual car accident, and I tried to explain the situation to him. We can't send people home if they can't cope at home. His wife (sixty kilos max) and three slender daughters were not coping with him. I reccomended him for admission and went home.

But - and here's the turning point - I didn't do any blood tests or Xrays. We don't normally do them for every low-speed car crash, like we don't do chest Xrays and CT scans for every twisted ankle. And he'd been worked up by his cardiologist less than two weeks ago, blood tests and chest Xrays normal, and his shortness of breath was unchanged in the last few months, and his ulcers were pretty much the same as they had always been, and he hadn't even hurt his back to any great extent. One small abrasion on his shoulder and that's all.

Anyway, home again, home again. And I saw one of the nurses a few days later and she said that Mr Baluch had not been admitted, he had been sent home with home nursing. And I suitably chastened, because I hadn't really thought of that, and that was that.

And today I arrived at work and found out what had happened.

The nurse had gone to Mr Baluch's house to dress his bandages, toilet him, etc.

As part of her normal workup she had done a blood test. I don't know if he looked better or worse at this point, I pray he would have looked sick but I fear he may have looked like he did when I saw him.

She had found he was in acute kidney failure.

He was sent to Florey, and more blood tests and a chest Xray were done.

We found he had an overwhelming infection in his blood - a white cell count of thirty five point five, three times normal.

He was admitted upstairs. He deteriorated rapidly.

He was transferred to the Royal. The transfer team arrived.

He went to the Royal, where he was intubated, sedated and paralysed and a tube stuck down his throat. He is unconcious, fevered, comatose. A sinister rash has appeared on his chest, great swathes of his skin are scarlet and indurated with infection. The ulcers proceed unchecked, they pump drugs into his blood to make his heart beat faster. Adrenaline, the fight-or-flight hormone, to push his fat-choked heart into one final desperate sprint before the finish line.

The prognosis is "guarded", according to the Royal. That means in the most highly supported hospital in the state there may be nothing that can be done. And he doesn't only have to get well, he has to get well enough for the stomach stapling/liposuction that he is lined up for. And that's sizeable surgery.

Now, my part in this. I saw him, I didn't do blood tests. He was sent home. Two days later he was very sick, three days later he was intubated. Which ever way you look at it, this is very very bad.

There are escape routes (for me, of course. Not for him). I handed over to someone senior who saw nothing that I didn't see. I recommended that he be admitted, I didn't want him sent home. I followed, to a certain extent, the protocols. I documented that he felt no worse (except for a bit of back pain) than he had done in the last month.

But in the end, I looked at him and didn't see acute renal failure and sepsis, I saw what he told me was the problem. It may well be that he wasn't that sick when I saw him - the district nurse said he was angry at being discharged from the hospital, and that he seemed determined to prove that he could not cope at home and thus jump the queue for the surgery. I tell myself that I cannot have missed a white cell count of thirty five point five.

But I don't know. We shall see - and by we I mean you too, don't think I won't be ringing up the Royal every few days. And I've changed what I do as a doctor - I have added extremely overweight people to my list (the very old, the very young, the mentally ill, the immune dificient) of people who may well be much more sick than they appear. In a few weeks I will be doing my "interesting patient" presentation, and it's always an opportunity for ritual flagellation.

And lest anyone think I wanted this man admitted to the hospital because I am a soft touch for people who pull at my heartstrings, it should be pointed out that he was a difficult man to feel sympathy for, in that he was an irritable man: whining, entitled, condescending, blaming everyone in the room for his problem except in any way himself. It might well have been a protective mechanism to help him deal with what he had to deal with, but if the truth be told he was a miserable, unpleasant son of a bitch.

Anyway. We shall see. Thanks for listening. Off for red wine and Doctor Who DVDs.

John

The trouble with you Australian women...

Hail,

More on the title later.

Just finished a most depressing shift in the prisons and am desperate to think about anything else. The fat kid is getting fatter, the girl who had turned some kind of corner got busted byt the police for walking along the street (she was on home D) and is back in prison, and although the psychopath in unit C is feeling less violent (sample quote: "That stuff's working great - I only hit one guy with a chair in teh whole week... but I would have done that anyway"), I am feeling iffy about the whole thing.

And apparently some of the patients escaped last Thursday - I open the paper and there's some lurid tale involving stealing an ambulance or something and driving through a fence, and eventually being picked up hiding in a roof. Well, that's at least one fewer patient I will be seeing on Wednesdays: one of them was eighteen and will be going to the adult prisons.

And last Saturday in the ED we were all staying behind for a resus, a bearded and tattooed man who had been brought in unconscious after taking an unknown quantity of unknown drugs, but which looked to include a months worth of antidepressants. Unfortunately (presumably) these were the old school antidepressants, the tricyclics. They are frequently lethal in overdose. I don't know how he was going to go, but it wasn't looking good.

Anyway, halfway through, when I was running a blood test one of the nurses came up to me and said "Look, can you just pop your head in and see the coppers* in cub 17 before you go - they want a medical clearance on a prisoner and then they're out of here." This is common practice - I think most ED doctors and nurses tend to try to bump ambos and police up the queue, the idea being we'd rather have them out there doing something useful than sitting in our ED for hours. So about fifteen minutes later, as the overdosed man is being wheeled out to either live or die, I pop into cubicle 17 to clear the patient.

And it's not any patient, it's Abraham Coper.

Abraham Coper is about seventeen, and he'd been released a month ago from Mauro. He was memorable for being one of the biggest hypochondriacs I've ever met. My diagnostic skills imporved tenfold after only a few weeks of seeing him, I was able to tell if someone had a heart attack ("No, you didn't have a heart attack this morning. Now get back to the football - aren't you menat to be on the wing?"), a blood clot in the lung ("No, it's the same virus everyone else in here has"), a stroke ("Your two days of paralysis of the left side of your body seemed okay during the pool tournament") and bone cancer ("No, it's a bump on your elbow. Because you bumped something with your elbow.").

Anyway, things got worse for Abraham when it turned out that he did have a problem. His brother (fit, young, athletic, five to eight in the adult system for a crime involving a bulldozer) had had a collapse while playing football and had required CPR. He was rushed to hospital and discovered to have a rare genetic condition called long QT syndrome. All the familyt were called in for tests and Abraham had it too.

What long QT meant (and this was only at the initial stages of the workup, there are different subtypes) is that whenever the heart goes too fast, it can bump into a weird rhythm that is really fast but not really useful - basically, your heart goes too fast, you could collapse and possibly die.

So we'd had to sit down and tell Mauro's biggest hypochondraic that he mustn't worry, because he could die. Or get angry, or frightened, because he might die. Or do much of anything. He should never ever ever take amphetamines, because they would kill him. Sport, exertion, etc., that was right out. Maybe he should just lie around. Then again, there was that subtype of long QT that killed you in your sleep, wasn't there?

Anyway, a few days later he was released (and like everyone who gets out of Mauro, never ever went back to the doctors - so he hsn't had any tests to work out what type of long QT he has or what can be done about it).

And here he was in the ED, in the company of two police officers who had pursued him from the stolen car across a football oval and into a suburban carpark. And it was them who brought Abraham to the ED and insisted that he tell one of us about the two or three occasions when he lost consciousness in the back of the police car for a few seconds. He wasnt' going to mention it.
They didn't know about the long QT syndrome, of course.

Anyway, he didn't go back to the cells. I feel soon he will be back at Mauro, but first I have to check on the results of any tests, etc they ran and see exactly what is wrong with him.

Anyway, work to do. See you all soon. And thanks again.

John


*that's the police, by the way.

Fuck-ups I have made

Well, big night last night at Florey.

What is happening all over the nation at the moment is the changing of the guard. Like geriatric adulterers, or fornicating tortoises in a cold spell, doctors in hospitals can change positions only a few times a year.

Half way through the year is a big changeover. So and so from anaesthetics goes to paediatrics. That guy with the spiky hair goes from paediatrics to surgery (and loses the spiky hair). That cheerful Kenyan girl goes from surgery to psych (and loses the cheer).

And Florey ED is losing several of the doctors from the "People we can put in charge overnight" list, and those places have to be filled, so that means people like me, Dr Longstocking (a cheery, very smart and deeply decent human being who is fast becoming my favourite co-worker), Dr Iskandar Hassan (who was there when we saved the Snow Maiden back in April) , and Dr Maad (a recent arrival from Saudi Arabia who is having a few problems with the nursing staff).

And we (individually) are going to be in charge overnight. In charge. Of one of the three biggest emergency departments in the state. Overnight.

You know, I'm not as scared as I would have been a while back. I still can't say it to anyone face-to-face, but I can type it into the electronic ether: I am good at some things. I'm one of the best in the ED at dealing with psychiatric patients. I am getting better at dealing with my fellow staff members - at being able to say "excuse me, and you may think this is presumptuous, and I do apologise for speaking, but is it not remotely possible that that woman with the chest pain that I asked you to see to admit but that you are sending home will die in the carpark?"

I'm pretty good at being safe. In four years as far as I know I have completely stuffed up the management of only two patients: there have been two where I failed to do something or see something and they suffered. One was an elderly lady with a broken wrist that I completely missed spotting - at four AM in intern year I somehow looked at an Xray and said "no worries there" when there was an obvious fracture. She never got it fixed and now she's got arthritis. The thing that chills me about it is I don't remember it, and I don't understand how I could have made the original mistake. Both bones in the wrist, like a dinner fork.

The other one was the prototype of what I later started calling "SLOP" syndrome: "sweet little old person". These are elderly people, (a lot of them seem to be British, but that's how immigration went around here in the fifties) who come in at three AM and say "Don't worry about me doctor" and describe "a bit of a niggle" in the tummy. An hour (if they survive that long) later the pathology lab rings you to ask if it was blood or chicken soup that you sent up, and the Xray of their abdomen looks like an octopus having an orgasm. Usually you go off to see someone who is complaining of twelve out of ten pain (but turns out to chave something mild) and meantime the sweet little old person is dropping like a rock.

What the autopsy generally reveals is that the blood supply to their intestines has been cut off. If this happens in the hezart, it's a heart attack, in the brain it's a stroke, in the intestines it's called mesenteric ischaemia. Twelve feet of dead bowel inside you is not compatible with life, and I know now that even if I'd diagnosed him as he was wheeled in the door I would not have been able to save him. Moses couldn't have saved him at this stage.

But anyway. Two, while too large, is not a large number. I don't want to add to it in the next few weeks. And weirdly, I'm not that sure I'm going to miss two of the senior registrars who have left: one in particular made me feel less confident rather than more. I know I'm slow, and overcautious (which may sound like a virtue, but can actually be a danger, because an overcautious doctor means an overful ED which means mistakes happen), and there's a lot of the minutiae that I need to get up to speed on pretty damn quick, and I'm going to live in the resus room between now and Wednesday fortnight... but I'm not terrified.


We shall see.

The psychopath in unit C

I have got a problem with the psychopath in unit C.

I am not alone in this, of course. The other kids in unit C have a problem, too. Their problem is that he is beating the crap out of them. According to him, he knocks heads together, kidney punches, throttles and elbows them in the head. Their problem with him is significant. Of course, nobody ever ever ever mentions the violence to the guards, so this is all underneath the radar.

My problem is he wants me to stop him.

See, he's in here for armed somethingother, or possibly grevious bodily whatsitsname. He's almost eighteen, and he's got a fairly substantial sentence - five months in the juvenile system, then the remaining three years or so in either the adult system or home detention. I am not a lawyer, but my suspicion is that the possibility of home detention is very slight - but stranger things have happened.

For the first few months he was content to keep his head down, but now he's "arcing up". He's getting more and more violent, and he wants some kind of medication that can make him less angry, or make it so that if he is angry, he doesn't react in the same violent way. The nurse wants me to see him and see if there's anything he can do that can stop either his anger or his violence.

I did see him. It was a fairly odd meeting. He has no psychotic symptoms - no voices in his head, no thoughts that are not his. While depression can manifest as anger in young males, he does not have any of the other symptoms of depression. He sleeps like a lamb and wakes fully refreshed. His appetite is good and he has neither gained nor lost weight while he has been here. He has energy and motivation (as much as anyone here). He denies any inappropriate feelings of sadness, anxiety or fear. Particularly, he feels no guilt.

I don't like to diagnose paediatric psychiatric problems myself but I suspect he is well on the way to an anti-social personality disorder. *

ASPD includes what in the old days we used to call psychopaths: people who don't feel bad when they cause others pain, but instead get a "rush" (he describes this quite clearly). But he's worried that his increasing violence will reflect badly on the parole board who are meeting in the next few months, and that rather than getting home detention he will be sent to the adult prison. So he wants me to give him something that will stop him getting that angry.

This is actually a difficult problem. Anger isn't a disease, it may not even be the symptom of a disease, there are no anti-angrys like there are anti-psychotics or anti-virals. There is stuff that will completely bomb you out, but I don't know that that's helpful either. There's something called quetiapine (don't know what they market it as in the US, over here it's called Seroquel), it's an antipsychotic with "unique calmative properties". They use it a lot in the prisons, where it meets with the approval of both prisoners and staff. But I suspect that it meets with this approval because the staff would rather look after zombified prisoners, and the prisoners would rather zombie their days away than be fully aware of their situation.

Then again, what about the other kids? The nurse will have a word to the security staff, but other than two months of solitary, there is no feasible way this guy can be kept from assaulting the other kids. He's bigger and older and nastier than most. So do I give him what he wants for their sake? There is some evidence that the stuff really works.

And as well as the whole parole board thing - do I want this guy on home detention? Do I think going to the adult system will make him a better person? - which thank God is out of my hands, there is also the question of diagnosis. If I put someone on a free antipsychotic, that free anti-psychotic won't last forever. It almost diagnoses him as psychotic, which he most definitely is not. What about next time he holds up a Chicken Treat with a shotgun: can he say it was because he was psychotic? What am I saying to him about his behaviour by saying there is a medication that can "fix" it - am I saying he's sick or not, in control of his mind or not?

There's a doctor in the western suburbs here who is legendarily bad. Ex-patients, many of them in the prison system, say how he sees people in the waiting room: walks around with a script pad, writing out more valium, more dexamphetamines, more codeine. Each "patient consultation", of course, is charged to Medicare, which probably means at least thirty dollars for one minute's work. By any meaningful definition, that guy has left medicine behind. But he'd
know what to do in this circumstance, while I've been tossing up this "should I or shouldn't I" thing for a week now, and I don't know I'm a lot further forward.

John

*Link doens't work. I'm still learning all this.

Laughing at the pain of others

Just finished a row of afternoons in the ED (And thanks to several of you for your very welcome comments - should be able to post something more individual tonight). And to my lasting shame I must admit that I spent a fair amount of yesterday laughing at the pain of others.

When you book into our ED this is the process - the first person you see is the triage nurse. The triage nurse gets the story and allocates you a priority out of five (priority one is to be seen immediately, priority two is "within ten minutes", etc., all the way down to priority five. Theoretically priority fives should be seen within two hours. In reality priority fours can often wait eight hours and priority fives usually leave "against medical advice", i.e.: before seeing a doctor). The triage nurse also takes a few lines of the story explaining why you are here, so that we can get an idea of what the next patient is. The brief history and the priority rating goes onto our computer screens out the back, and also onto a piece of paper they bring around, and then as soon as we can we pick up the bit of paper and see the patient.

Well, here's a few of yesterday's brief histories, with their priority ratings:

Priority 4: 23 y/o male, ten pin bowling, bowling ball got stuck on finger, swung up and hit patient on head, patient fell to ground and bowling ball hit patient on head again. No loss of consciousness.

Priority 5: Attacked by pet goldfish while feeding. Small bite to finger, no tendon damage.

Priority 3: Changing television antenna on roof during thunderstorm, fell from house roof onto car roof, then into fishpond. Appears heavily intoxicated.

Priority 4: Hand stuck in cheesegrater.

And then there was the hand-written note which several of us read as "Caught finger in dick chain", which turned out to refer to an accident with a deck chair.

So, not exactly "previously on ER...".

I remember this recent meeting we had where someone brought up some of the recent events in triage. My opinion is that the triage nurse is the worst nursing job in the hospital - a lot of people focus on the nurse as the cause of their (understandable) frustration at ridiculously long waitng times. But then, some people just like to complain. One of the nurses told me the following from a few years back when she was on triage:

A teenage girl presented to the triage desk and siad "I get this funny feeling just before I'm going to have a seizure, and I've got that funny feeling now". The nurse opened her mouth to say something and the patient went into a full seizure. She hurled herself to the ground, stopped breathing and lashed about on the floor, smashing her face repeatedly on the skirting board. The triage nurse called a code blue, every man and his dog ran out from the ED, there was blood and various other fluids everywhere, some woman had hysterics in the waiting room, babies crying, doctors and nurses clustered around this seriously fitting girl, people waving big needles and someone trying to make sure she kept breathing, and after a few seconds we finally got lines into her and wrestled her still-jerking body around the back.

And this woman stalked up to the triage desk and actually said "I was here before her! How come she jumped the queue?"

Can't please all the people. it is from events like this that I have formed the belief (and it has served me well) that if you ever hear something, and you can't believe it, but the only reason you can't believe it is that you think "Nobody could be that stupid", or "Nobody could be that cruel"... then what you heard is probably true.

Things work out for Mr Fantastic

Well, went and let my brain down and saw the Fantastic Four movie the other day, and I loved it. I thought it was the best superhero film I'd ever seen.

This opinion may not make much sense to anyone else who sees the film, I don't think it made a lot of sense to my three fellow geeks who saw the film with me. They seemed underwhelmed, but then, they like different stuff - they speak highly of Batman Begins and so on, which I haven't got around to seeing. But I came out of the FF movie grinning from ear to ear, bounding along the pavement, feeling perfectly and absolutely happy.

Why is this so?

As absurd as it sounds, when I was growing up, the Fantastic Four were my best friends. I used to run home from school to be with them. I had posters on my wall that we got out of Weeties packects (I am probably protected from alcoholic brain damage for life - in two months in 1975 alone I ate enough Weeties to supply me with thiamine for the next two hundred years) of Spiderman battling the Human Torch, and the Silver Surfer destroying some castle in Eastern Europe, and I knew where the FF parked the Fantasticar and what their neighbours said about them.

The friendship (and I know how sad it sounds to be using that word for the relationship between a ten-year old boy and some lines on some yellowing paper), like all friendships, was due to a complex mix of similarities and differences.

The differences were easy to see: Reed Richards (Mr Fantastic) was powerful. I was acutely powerless. Mr Fantastic had one of the most beautiful women on the planet as his wife, I fantasised constantly, inaccurately and uselessly about sex, but only ever experienced a series of one-way crushes. Mr Fantastic lived in New York, the greatest city in the world, and made regular sojourns not only to distant planets but to distant realms of reality, to universes we didn't even know about yet.

But the similarities were there too. We were both bookish nerds. We found science extremely exciting - apparently I would stand up in show and tell, after everyone had talked about how they had started the harvesting, and say "Today I'm going to talk about the speed of light". Neither of us understood people. We were surrounded by people who had powers we couldn't ever match - beauty, popularity, strength. We were both horribly lonely.

Anyway, the crude mechanics as to why a story like that made such an impact on someone like me should be painfully clear.

Anyhow, why did the movie work so well for me?

First, it was a kid's movie, and the time when the FF meant the most to me was when I was a kid. Those ideas shaped the structure of my developing brain like a trellice shapes a vine or a vase shapes water. You watch the movie, you see the characters, and you can feel that unadulterated childish joy that you used to feel.

And then there was the wish fulfillment. There was Mr Fantastic getting the girl, there was him saving his friends and his friends saving him, him not being lonely. There was the four of them together.

I don't know, there's no way I can articulate this kind of stuff. I'll just pull on this tee-shirt that says "Desperate geek" - hmmm, fits perfectly - and shuffle off to work.

But I don't know. One last try: somehow I've come out of that film with a picture of my life, the progression from loneliness to having friends, lovelessness to having my wife. I felt the movie was about my life - in some way what happened to Mr Fantastic happened to me - as well as Reed's life.

That's the core of all good fiction, I suppose - you identify with the protagonists.

But there was also the joy at seeing something good finally happen to a deserving friend. Reed starts out lonely and powerless and loveless and ends up saved. I think I loved seeing that because I left with the eye-witness proof that not only can things work out for people like me, but that things can work out for Mr Fantastic as well.

Anyway, posts of actual substance and meaning will resume soon.

ED jeebies

Hail,
Another apology for another hiatus in this blog thing. We have had a cat-associated loss of computer function for close on a week. I kept trying to dial up and got this arcane little message about some remote computer. I eventually told my wife, mentioning that there was nothing we could do because it was the fault of whoever was meant to be looking after the remote computer, whereever that was, and we just had to wait for them to get their shit together.

She gazed at me with the look she normally reserves for her most hopeless patients, walked into the study and fixed the problem with a few keystrokes. Then she explained, or tried to explain, how the internet worked. She said that there is no "remote computer", no vast Deep Blue kind of thing in a warehouse somewhere, that somehow contains the internet, that it's all just connections between computers and so on. After a few minutes, though, she gave up trying.

Anyway, what's been going on? A fly has appeared in the ointment about next year's rotations. It appears that reports of Lazarus' resurrection may be premature, and it may not be able to teach me stuff I need, such as the all-important anaesthetics term. I am looking around for other options as we speak.

I have joined a writer's group. More on this later.

And I went over to this friend's house, a nurse, to clamber up on her roof and fix the air conditioner, and had a chat, and she seemed quite upset, and she cried for about half an hour, and she said she wasn't sleeping, and she wasn't eating, didn't even have an appetite, food tasted like crap, and how since the kids left she lay in bed all day or watched daytime tv, and she was drinking what for her was remarkable amounts of white wine, and she didn't want to go outside to do the shopping because she didn't want the neghbours to see because she was ashamed, and how she was letting the bills pile up and she kept forgetting to pay stuff or even if she had paid it or not and ....

and eventually I said "Do you think it's possible that you're depressed?"

She laughed bitterly and said something unprintable and anatomically inadvisable. ED nurses, possibly even more than ED doctors, are unshakeable in their belief that any form of mental illness is for losers. Most of them retain this belief right up to the time they suffer from depression. If pressed, they say that their distain for mental illness stems from their day-to-day dealing with people who are classed as "psych" on the casualty sheet.

As I have said before, the problem with this is this is not a representative sample - "psych" includes not only the mad, but also the bad and the the dangerous to know. So when ED nurses and doctors think psych, the mental picture is more likely to be of some tattooed goon just out of prison smashing up the ED and spitting blood at the triage sister, or a hundred and fifty kilogram man exposing his genitals in the corridor. Not that those people haven't got mental health problems, but there's more to mental illness than that.

Anyway, my friend the nurse didn't believe in depression, even though she had some pretty damn classic signs, plus a family tree with a fine crop of mixed nuts, and after a half-hour discussion, we got onto "what now?".

"Well, I reckon you should find a doctor you can trust" I said.

"You're a doctor" she said, showing that her clinical acumen remained undimmed.

"Can't be me" I said. "I'm your friend."

"Why does that matter?" she said.

Anyway, I was going to launch into a discussion of the medico-legal implications of all of this but instead I sortof came up with a list.

1. You should be able to tell a good doctor anything. You should be able to tell a good friend anything. But sometimes it's not the same anything. I would not want to tell my friend about any retrograde ejaculation I suffered as a result of a medication, for example, or the spectacular vomiting/diarrhoea/increased urinary frequency trifecta that some people on lithium get. And I can almost guarantee that my friends would not want to hear.

2. Doctors have to detain people. Friends don't lock other friends up under the mental health act. Nor do they scan each other's brains, or strap each other to the bed perform, detailed physical examinations on each other, and stab at each other with syringes full of psycho-active substances.

Well, maybe some friends do. Your Saturday nights may be more full than mine.

3. You may sometimes have to bitch to your doctor about your friends, and you can certainly bitch to your friends about your doctor. But problems arise when you are bitching to your friend about your doctor (the self-righteous prick) and your friend is bitching to you about his patient ( a self-indulgent histrionic egomaniac) and you realise you are both talking about the other.

4. It's almost impossible for the doctor to be objective about you. Objective doesn't mean unsympathetic, or disinterested. It means you have to be able to treat patients you like no better than patients who frankly give you the shits. I'd end up treating her a little better, and then maybe I'd end up getting her cheap medicaions, or bumping her up the queue for a hospital bed, which would be cheating the person who is sicker or who has ben waiting longer but doesn't have the advantage of having a personal friend who's the doctor.

5. Although it makes no sense, I could not stand the worry. Say I prescribe gigglopram to some perfect stranger, after a discussion of possible side effects, etc. That person develops one of the extremely rare side-effects the manufacturers mention . I could possibly live with the idea that I had been responsible for giving some anonymous patient glow-in-the-dark nipples, or lymph nodes in the groin that sing in a pleasing tenor voice. But I'd feel inexplicably really really bad if it were a friend.

Anyway, we came up with a compromise with which I am not entirely comfortable, but she's doing something about it. We shall see how it works. I shall keep you all in touch.

John

Bad Doctor

Unusual discussion a few days ago.

We were looking at the medical roster, with all of the spaces where it was meant to say "Dr so-and-so working this shift", and running through the usual strategies for making sure we weren't overwhelmed:

( - Standing out the front of the hospital with those glowing sticks like they use at airports, waving people on to the Royal.

- Walking through the waiting room in one of those biocontainment suits, especially if we can get one with pincers for hands, saying "There is no cause for alarm. Repeat, there is no cause for alarm."

- Having a quick chat with any doctors who want to leave and reminding them that we can always detain them under the mental health act

- Mass consultations, with one doctor simultaneously treating six or so patients who have the same pathology in the same room: "Right, on the count of three we're all going to take a tablet of anginine and let it dissolve under our tongue. One, two, three. Excellent. Now, I'll be back in five minutes to check who still has chest pain....")

when Dr Quinsy, one of the senior consultants, had an idea.

"Why don't we ring Kuki?" he said. "He works hard, he's easy to get on with. And he's free"

There was this stunned silence. Dr Kuki was, indeed, free. He was free because he had been sacked from the Royal, asked to leave by Shipton and had had his employment terminated by the only locum service in town. Last I heard he was applying to be one of those doctors who goes to the kickboxing tournaments. We all know about this because this has recently been printed in the Daily Sackbutt, the local newspaper, which has been following the progress of a coroners report into a patient Dr Kuki appears to have killed a few years ago at Lazarus.

He is one of the three truly bad doctors I have met.

I worked with him at Shipton, when I was more junior. And he wasn't stupid, and he wasn't ignorant, and there was some stuff he knew quite a lot about. And he could, on occasion, work quite hard, and he was pleasant to work with - you could share a joke with him, you could ask him stuff and he was helpful, he'd teach you stuff.

But he had two big problems. Looking back, they may have been different facets of essentially the same problem, but either way they were crippling.

First was - I don't know whether to call it an ethical problem or a "antenna" problem. On the first day I met him I was showing him around the ED (emergency department) and I said "Here's the trolleys for suturing, gynae, getting stuff out of a kids nose, that kind of stuff" and he said "Cool, I've always wanted one of them. Can you give us a hand to load it into the back of my car after the shift?".

And he was serious, and he was some guy I'd only known for half an hour asking me to steal from my employer.

And then stuff started to go missing, lots of different kinds of things, irritating little things like where you'd go to get some thing out of a kid's nose and someone's flogged that "bright light on a headband" thing you use, which would set the whole thing back half an hour.

And he swore, too. Now, I have sworn at work. Two or three times where patients could hear: I swore when I stabbed myself with the needle, and I swore when the resus bell went off when I was in the other resus, and in the fishbowl (that big room in the middle where the doctors and nurses sit and imagine that the patients can't hear them) many, many people swear. But people don't want to hear that.

Note: the following contains un-necessarily graphic and deeply disturbing mental images. If I could put it on one of those "click here to read on" things I would. And yes, I'm a prude.

But Dr Kuki swore all the time, to everyone, patients, staff, you name it. I remember one time when we were walking through the waiting room, surrounded by children and little old ladies, and he's complaining about some recent proposal from administration, and he's not saying "I feel they have treated us unfairly", or "They are clearly not in accord with subsection three paragraph q of the industrial relations commission ruling". He's waving his hands and raising his voice and howling "And if that's their fucking attitude, they can all suck my cock! They can suck my big purple veiny cock!!"

And so on.

But the main thing that got stolen, and this I think is what made him dangerously bad, was the drugs. The Daily Sackbut said that on the night when he inexplicably sent some poor old Italian woman home to die, he had accidentally stolen the wrong drug from the pharmacy cupboard (he had meant to steal citalopram, his anti-depressant, but instead had stolen diazepam, a sedative).

I doubt this to be the case. He had a serious drug problem. The Sackbut revealed that he smoked marijuana, but to the best of my knowledge he never came to work intoxicated. But he stole diazepam (valium) and alprazolam (marketed over in the US as xanax) and anything with codeine in it and pretty much anything that he could find. I almost never worked on the same shift as him, but the effects of these drugs, in moderate doses, can be difficult to pick - s someone sleepy because they're tired? Is someone relaxed because they're that kind of person? Is someone making decisions that seem dodgy to the nurses because -well, because he's senior to them and he's seen more cases like this than they have and anyway, he's the doctor?

Towards the end, by which time he was working supervised at Shipton, he would drift off to sleep at the slightest opportunity.

There are lots of questions here. How things got so bad. How they were allowed to stay so bad for so long. And how many undetected errors of judgment are waiting to be uncovered - this current story in the Sackbutt happened four years back, he was at Shipton only two.

Anyway. I told Dr Quinsy that I was not working in the same ED as Dr Kuki again. Dr Kuki, while hard-working and easy to get on with, had problems that made him unemployable. And no matter how bad things get, with us being short-staffed and so on, they can always get worse.

Fat II

Right,
Sorry it's been so long between posts. But news:

The guy I posted on a while back, the approximately 130 kg (that's almost 300 pounds) guy who wanted to lose weight?

Well, the weight's dropping off him. He's doing the high intensity exercise. He's cut back from eating eight slices of bread with his lunch to none, he doesn't eat when he wakes up at night. He's feeling a hell of a lot better than any time since he's been in here. He's stopped the antipsychotics and he's thinking clearly. I saw him the other day and he is grinning ear to ear.

At this stage, and it's early days yet, it's a success story, one of the relatively few in Mauro. In a few years he may be appearing on the telly waving his trousers around. You heard it here first.

And now I'm going to use the internet for the time-honoured purpose of bitching about my colleagues.

Winter is crunch time in the ED. More people get sick, (including doctors), including many from sitting in the waiting room with the other sick people. More people get jacked off with the long delays. There are more traffic accidents, more pneumonias (pneumoniae?) and many many more sick kids. And if a doctor or nurse is going to decide they've finally had it with this shit, and tell Admin exactly where they can stick their proctoscope or rectal thermometer, odds are it'll be winter.

So every year we are understaffed.

But this year we thought ahead. We advertised over East and got two new doctors, junior registrar level (my level). They arrived with glowing recommendations.

Suspiciously glowing, in retrospect, because they are both crap. I can't say that with certainty about one, the female, because I've never actually seen her work (I was on one shift with her but honestly did not realise she was a doctor, because she just stood around watching people - I thought she was a medical student), but I've worked with the other guy, and he's no bloody good at all.

He's not all bad. He seems a nice person. And in anther context, it may be relaxing to watch him, his slow, graceful, almost tai chi like movements as he takes five minutes to walk from one cubicle to the next, fifteen minutes examining an Xray of a (not actually broken) forearm (two bloody bones, for God's sake!), and three quarter of an hour to examine a child's twisted ankle. Ninety minutes - I am not making this up - elapsed from my telling him that Mrs Quibble in cubicle sixteen needed three medications (and I told him what they were, how much and how they should be given) and him even writing them down so the nurse could get them.

Anyway, I feel bad writing this. He's a good person, and ED is frightening. But how in God's name did that other hospital sell him to ours as a level four doctor with significant emergency experience when he can't read a chest Xray or an ECG? He actually contibutes negative working hours, because everyone he sees I have to see too, and they stay in hospital so long I expect someone to celebrate a birthday in here, or perhaps conceive and bring to term a child.

I tell you what. I am going to find out the names of the two other hospitals. And then, if we can't send them a crap doctor, I'm going to send them some patients. I know the some pretty difficult to handle people, and not only via the prisons and the psychiatric wards. Mrs Quillscribble, who wrote eight volumes (I am not making this up, I saw five of them) of complaint letters to the hospital. Joe Testudangli, who presents every second day demanding someone look at his (remarkably unremarkable) scrotum. Clive "Monkey-boy" Carter, a seventeen stone bikie with Tourettes, paranoia, a short temper and an unattractive skin complaint. Jamie Harradine, with his crippling phobia about sobriety and a belief that women in uniform (any women, any uniform - once a trumpeter in the Salvation Army) find him a sexual magnet, whose idea of a good Friday night is to get arrested by two policemen and then attended by some nurses.

And I'm going to send each and every copy of the patient notes to those hospitals with a little card saying "Compliments of Florey Emergency Department."