Saturday, September 09, 2006


Sorry about the extended delay, the remote computer has not been responding. One day I'm going to go over there with a pickaxe handle and give the bugger something to respond to. In cyberspace, no-one can hear you thump something.

So, what's been happening in the interim?

Firstly, it's been so long since I posted that planets have been delisted. I suppose this means that there are pople know who could remember when there were eight planets, then nine, and now eight again, like those people who were born in Petrograd and grew up in Leningrad and died in St Petersburg, all without moving from their home.

This means next time I get nostalgic and maudlin I can whine on about how "in my day we had a real solar system." I can go on about how there was none of this eight planet crap", and I can stare into my winebottle and mutter about how our generation fought for our nine planets, we did the research, we put our bodies and our brains on the line and did the hard yards, and now those goddam milksop liberal appeasement-junkies are eroding our solar system one goddam plutino at a time.

My niece, by the by, has told my fellow drug and alcohol workers that I drink a bottle of wine a night, straight from the bottle, while staring at the computer. You won't be hearing from her again.

What else from the world of science? A researcher has published something suggesting that beautiful people really are smarter than the rest of us - with special exceptions for blonde women and large-breasted women.

Yes, truth is stranger than fiction, and scientific truth is stranger than science fiction.

Currently, this is an opinion held by some Japanaese guys, and does not have the status of a scientific law, and anyway, Hilton's Law already exists. Although there is room for Jordan's Law, I think.

Hmmm. Maybe the beauty/smart thing only works for women who remain bipedal.

What else? I have been working in the ED (yesterday) and Drug and Alcohol centre otherwise. The ED was yesterday, and it was damn fine, although the things I loved most about it (the cameraderie, the growing clinical confidence, the knowledge) are less dependeable now that I am only there fortnightly. I haven't forgotten as much as I thought, but everything takes me longer.
And I am definitely more state of the Ark than state of the art now, more trailing than cutting edge. I am surrounded by bright young things who have yet to forget what I probably never knew. They are clean-featured, and dynamic, and often beautiful, and must therefore be smart, and they are always confident people - and to be honest, I've always mistrusted supremely confident people - and they are almost always right.

But yesterday, and I have to tell someone this because I've told my niece and I've told my wife and one of my better friends, and they're all sick of hearing about it, yesterday, fear and temerity and hubris-phobia won over youth and brains and beauty.

And I am pleased, and terrified, and enraged, in about equal parts, and will tell you about it. A terror shared is a terror halved, or whatever.

When I got there at seven thirty (after a most enjoyable evening watching Futurama with Algernon, who has yet to send me his blog address) I was put in charge of the "low stress" end of the ED, the one with more patients who are less sick. This is the minor trauma end, the end away from the heart attacks, the exploding aortic aneurysms, the burns and so on, and is considered a bit of a doddle by some of the more interventionist ED doctors.

No worries, I said, and took handover of the hallucinating drunk, the vomiting child with the extremely angry parents, the woman with the bowel obstruction and so on.

The big worry ended up being the two alcohol dependent patients. Alcohol dependence is a diagnosis that requires a careful history taking, such and such a period of demonstrated withdrawal phenomena, exclusion of certain other medical conditions and so on. Or you can just look at the fact that the woman walked in with a blood alcohol of nine times the legal limit and the man had a liver that was, God strike me dead, palpable just above his hip, and you can go straight for alcohol dependence.

Anyway, the alcohol dependent man was being treated for alcohol withdrawal, with benzos and thiamine and the usual treatment. The thing is, he wasn't gettting any better.

I went in and stood next to the security guard, who was trying to read a book on Helen of Troy.

"How's he going?" I said.

"Just like that" said the guard. Äll day".

"Do the medical team know?"

The nurse nodded.

I looked into the cubicle. Inside the darkened room the lanky man with the carbuncle on his face was moving about, carefully stepping over imaginary objects, opening doors that were not there, squeezing around and under bulky and inconveniently placed objects must have struck him as most inconveniently placed.

I gazed at him and for a moment felt that weird, cold feeling you get when you realise things are worse than you've thought.

"That's not withdrawal" I said. "How much has he had?"

"One hundred of diazepam."

"Any better?"

"Not really. We don't want to give him any more because his BP's only ninety over seventy, and he's going to fall over."

"The medical team know that?"

"I rang them, they say they know. They don't want him shackled."

I wondered for a moment about a man with alcoholic liver disease, with about one clotting protein per litre of blood, falling over and smacking his head.

"That's not withdrawal" I said. "If it was withdrawal he'd be getting better. And he's not. It's something else."

I went over to the notes, and had a look, and paged the registrar. This had been done multiple times without success. After three pages I got the intern.

"Hi, I'm Dr Bronze, I'm one of the ED registrars. Sorry to bother you - "

"What do you want?" said the intern.

I paused for a moment, and continued a little more carefully.

"I'm a bit concerned about your patient, Mr Binj in cubicle thriteen. He's acting unusually -"

"He's got alcohol withdrawal. Haven't you read the notes?"

Ï have them open in front of me, and very fine notes they are"I said.

I am one of those people who speaks more slowly, gently and politely as I get angry, and I was already addressing this sprat in tones I usually only resort to for the congenitally retarded.

"So what's your problem?"

Ï was just wondering if it was not possible that something else was going on. You know how unwell these patients can get. He's got an unmedicated INR of 1.4 and platelets of 47 and I was wondering if it's possible he might have given himself a bleed?"

Translation - maybe your patient is bleeding into the brain, and I am trying to save his brain and your arse.

"I tried looking in his ears. He won't co-operate"

That's right, blame the brain-damaged guy.

Änd people like this are at a pretty big risk for pneumonia, and he might benefit from a chest Xray..."

"I told you, he won't be still for the Xray!"

"Mmm. I know it's difficult. We might even have to increase the sedation a bit so that we can fully examine him - that'd stop the risk of him falling over and smacking his head, too."

He dismissed what I said. "Too much risk of respiratory depression".

And how much respiratory depression is he going to have when he bleeds into his brainstem? If you don't do your job, this guy will die, we will end up in front of the coroner, and I am writing down that you are to blame.

"It could be helpful, though, if we could examine him. Also, I was wondering if he maybe had a touch of encephalopathy? That would explain - "

"We've given him thiamine!"

And he's still not better, is he? Perhaps this thirty four year old man is getting brain damage as we speak.

"Mmm. I suppose I was thinking that it's possible that, since he may have missed the odd meal lately, that he might be pretty magnesium deficient. That can affect absorbtion, so I was wondering if you'd mind if I sent off a blood and then maybe gave him a bit more thiamine if he needed it - "

I am asking you permission to do your job for you.

He carefully considered this. "That'd be okay, I suppose."

Änd of course, there's the other forms of encephalopathy, and this guy's liver - hello? hello? Jesus Christ, the little bastard's hung up on me.!"

I ordered the medications, but before we actually got them into him he deteriorated, and the nurses called a code on him, and in the end the high dependency unit team took over, and he was shackled, sedated, and wheeled off to CT.

And the med intern had to explain the situation, and write in the notes just after the three pages of notes about how he had not answered his pages and had refused to see the patient when asked, and managed get through all of this with an attitude of one who had been unfairly victimised, rather than one who had ballsed up his job despite repeated offers of help.

Anyway, there is no epilogue here. God knows what he had, but I'll be looking it up Monday and finding it out. But it's amazing how blase some people can be in the face of oncoming disaster.

Anyway, much to write about next time, weddings and teenage brains and so forth.

Thanks for listening, and for letting me vent my spleen. I feel better already.


Blogger Benedict 16th said...

I remember a certain Intern a couple of years ago....

Actually your story has happened to me, except I was the Surgical night intern, the patient had a BMI of agout 16, alcohol withdrawal... and low Potassium, so the RMO (acting registrar who was also sunlighting* in the emergency dept during the day, so did not like being interrupted) kept trying to order KCl over the phone for this patient - his last order was 10 mmol x 3 over 1 hour. I tried to explain about Magnesium and stuff... in the end I convinced the HDU nurses to talk to the surgical ward nurses (who were going to refuse to administer 2.25 g of KCl anyway), to perhaps give her some MgCl2.

* Well this was his night job, y'know

6:07 PM  
Blogger Foilwoman said...

Again, for any and all emergency medical work, I'm flying to Adelaide. Oh, and do spleens vent? How? How did that become a figure of speech?

12:29 AM  
Blogger Benedict 16th said...

Foilest - re Spleens a venting
10 seconds on google and wikipedia but my favourite is from usenet alt.spleen faq- you are slipping (yay for once I beat the clever clogs)

9:04 PM  

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