Sunday, January 28, 2007

Faking it

Hail,
The following contains medical stuff.

Been randomly reading some other people's stuff - a blog called waiter rant, another about a bouncer in some kind of nightclub, and Sarah has suggested I read something called "Girl With A One Track Mind".

And what is the reason behind this sudden switch from physiology textbooks to a diet of customer service, beating folk up and hardcore sex?

Well, these are three blogs that have been made into books. And somewhere along the line that was one of my stated aims. Make Stranger's Fever into a book, or at least collect material, make rough notes that later I could hammer into something saleable.

I'm not one hundred percent sure about that anymore. Part of the reason some of these blogs have been made into books is just the sheer quality of the writing - have a look at this, for example. But part of it seems to be that these (especially the first two) are blogs written by people who have

a) insider knowledge to impart (how not to have your soup adulterated, how not to get beaten up, how to give someone orgasms like a string of firecrackers),

and

b) tales of human suffering (usually theirs).

Now, don't get me wrong, I am not saying that these blogs are whiney, because they are not. But the writers seem to encounter a fair number of stupid, arrogant, downright deceitful people who make the writer's job harder than it has to be, and upon whom the writer must exact whatever small revenge s/he can. If I had to put up with what the writers have to put up with, I'd be angry too.

But my blog, and my life isn't like that.

For a start, there are few "secrets" as to how to get better treatment in the ED or the ICU. But there are secrets which seem like secrets on how to get better treatment, but end up being secrets of how to get treated worse: here are some of the few I can remember:

In the old days you used to be able to get a bed in the ED for a few nights by beating yourself up (literally, not figuratively) and then turning up claiming chest pain. The doctor would do a blood test (called CK) which would show muscle damage (from where you'd beaten yourself up), and admit you for a cardiac workup. Nowadays no-one uses CK anymore, they do either serum troponin I or serum troponin T, which show up pretty much only when heart muscle damage has been caused.

And years ago it used to be simpler to get opiates, too. Diagnoses of choice were either migraine, back pain, sub-arachnoid haemorrhage (evocatively described as a "thunderclap" headache) or kidney stones. You turn up to the hospital displaying the symptoms (it is difficult to display all of them, most people can't vomit on request) and get the treatment.

The first problem is the quality of the opiates we supply, if any.

Migraine is not treated with opiates anymore, you get megadoses of aspirin and some IV fluids in a dark room. Note: when faking symptoms, do not bother "bringing your own vomit", and do not (this happened at the Royal a few years back) attempt to substitute canned chicken soup for vomit.

Non-traumatic back pain is a nightmare for all concerned, but the skilled patient can often get some IV morphine out of the unskilled doctor, for a short period of time, until the skilled doctor hears about what's going on, and kicks the patient out of the ED.

SAH gets opiates, no questions asked, as do kidney stones (again - few people can pee blood on demand, and if you turn up at the ED with a sample of your own blood-adulterated urine in a container that has blood on the outside too, don't expect miracles).

And if you do get some opiates, virtually no ED stocks the good stuff anymore. In the UK heroin is used as an analgesic - it's in my Handbook of Anaesthesia, along with a warning about its potential to cause addiction - although I doubt it is much used in the ED. Which is a pity, because it has some good effects, and if I was dying of cancer, that's what I'd want.

Over here we used to use IV pethidine (Demerol), which has a rapid onset of action (therefore more "rush") and for some people a weird speedlike effect; nowadays no ED in the state prescribes it. You still get old-school heroin users coming in to the ED asking for pethidine, but I think there is literally none in the ED.

So what you're left with is morphine, which, if you're used to heroin, is pretty piss-poor. Heroin crosses over into the brain quickly, and a big part of addiction is the short lag time between use and effect. That's why eating something, (i.e.: morphine tablets), is less rapidly addictive than injecting something (i.e.: those same morphine tablets ground up). So, you end up with morphine.

The second problem is the investigations. To get treated for SAH you have to have something called a lumbar puncture. The procedure is this - you curl up like a comma while someone washes your lower back with antiseptic. A junior doctor comes in, wearing full surgical scrubs and looking nervous. S/he appears to be prepubescent. S/he tells you to relax. A senior doctor, similarly garbed, accompanies him/her and talks him/her through the process.

The junior doctor shows you the equipment s/he will be using and explains what will be going on. The equipment consists of several long long LONG needles, and the explanation seems to require sticking a needle through several layers of protective membranes so that the needle is alongside but not quite into your spinal cord. As the doctor shows you the needles the end trembles.

The doctor also explains any risks associated with the procedure. These are not insignificant - they include paralysis, meningitis and death. S/he also explains the risks associated with not carrying out the procedure - these skip past paralysis and meningitis and go straight to death. S/he asks if s/he has your informed consent.

Assuming s/he does so (and I am saying s/he because behind the mask, protective eyewear, scrub hat and surgical gown your doctor could well be a hermaphrodite) the doctor then injects an inadequate amount of anaesthetic into your back. Then he or she inserts the needle, under the careful guidance of the senior doctor, into what will turn out to be the wrong place. You can actually feel the scrape of the needle against the vertebrae. This happens three or four times.

Eventually the senior doctor takes over and slides it in effortlessly. We get the fluid out, put the bandaid on and tell you to lie there for an hour or so or get up and get the headache from hell.

So, not something you want to have done if you don't have a sub-arachnoid haemorrhage.

Of course, you can always stay for the drugs and then bugger off fifteen minutes before the lumbar puncture. You can do that once. Which brings us to the third and most significant impediment to presenting to the ED seeking opiates.

Everything now is on computer. This causes me personally some small amount of concern - my recent ED and ICU admissions are fairly easily available for perusal by my peers, for example.

(Bear this in mind when planning suicide - most people don't succeed, and living with the consequences can be difficult. I got off incredibly lightly, but still it's cost me a fair amount. I am actually in a worse place now than before the overdose - but I feel considerably better, because I am less depressed. That's why depression is a mental illness)

Anyway: if a doctor or a nurse forms the impression that you are seeking opiates he or she types a warning on the notes (all on computer). The warnings come in several forms - violence, contagious illness, allergies... and drug seeking. And a warning typed in in, say, Sabin General or the Royal is accessible at Florey or Lazarus, and vice versa.

This means you've pretty much got one, maybe two presentations with SAH available to you, and only one renal colic. After that, especially if doctors or nurses note how you soak up thirty mg of morphine like it's buttermilk, or you attempt to leave the hospital with the iv line still in, that's it. The next doctor to see you will read "drug seeker" in your notes, and everything changes.

And it changes in a very bad way. People on opiates get treated like shit by the ED. Their pain gets undertreated. Their illnesses, which are often more severe, are overlooked. The DS warning on the patient notes spreads throught the ED like a poison in water, and everyone hardens against you. It's a bitch, and if it is changing, it's changing slowly or not at all.

Anyway. Not particularly useful secrets. The turkens are calling. More later.

Thanks for listening,
John

6 Comments:

Blogger Midwife with a Knife said...

John,

I'm fascinated that you use heroin for pain. In the USA, we wouldn't consider it. Actually, where I did my residency, we couldn't use demerol for anything but rigors, either. So it was either NSAIDs or morphine or dilaudid for pain, pretty much. People seemed to like the dilaudid a lot, though.

I've been wondering, what's a turken?

12:58 AM  
Blogger Camilla said...

Well, that was an eye-opener. Do people really do stuff like that just to get drugs? 0_0 The idea of BYO vomit just...urgh.

I think your blog provides excellent book material, in a similar vein to the traditional "day in the life of" books (like James Herriot's, for example). Your writing is compelling because it's interesting, often funny, informative and very personal. Some blogs I keep up with have the occasional entry that I skim-read. I've never had that with your blog.

Camilla
:)

(ps: psst - this entry appears to be double-posted)

1:02 AM  
Blogger Foilwoman said...

What's a turken? (I really don't have anything to add. I have a congenital condition that makes it impossible for me to read a post of yours without commenting.)

2:12 AM  
Blogger Camilla said...

Because I'm too lazy to go back and find the place where you were writing about...well, writing, here is a link you might find interesting: http://vanderworld.blogspot.com/2006/10/piratical-guidelines-spread-em-far-and.html

Beneath all the frothing and foaming, I do believe there's a Pirate Anthology looking for submissions.

Camillaaaarrrghhhh, me hearties
:D

3:02 AM  
Blogger Camilla said...

ps Turkens here: http://www.feathersite.com/Poultry/CGP/Turkens/BRKTurkens.html and http://www.cacklehatchery.com/turken.html

3:04 AM  
Blogger Juanita J. Sanchez said...

Camilla, you'd be amazed at what people BYO. The favorite of many labor & delivery patients was to Bring Your Own Mucous Plug.

1:42 PM  

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