Tuesday, March 20, 2007

The gamma male thing


I have discovered something distressing about myself.

I am a gamma male.

You know that short, chubby, bookish gorilla who hangs about on the outskirts of the troop while the silverbacks bellow and crash? The one intently studying the undergrowth when other gorillas say "someone really needs to take charge here"? The gorilla who can see that everyone involved in the conflict, really, does have a point and that what they are saying probably sounds quite sensible to them, and really we all just get along?

That'd be me. Listen to this story.

A few nights ago Mr Addams turned up to the ED. He was a chirpy, courteous ninety year old man with acute kidney failure and blood that would not clot, and what with his pace-maker and his blood results*, someone who had gone from being a very healthy man to a ratehr unwell one in a few days.

And another person who hadn't called an ambulance because he didn't want to bother the doctors. As part of the history I asked him if he had any back pain and he said "occasionally, when I mow the lawn or make my bed".

Anyway - he was unwell, and ED thought ICU needed to see him, and called me. I went down there, the first time I'd been there as ICU rather than ED, and was greeted by several nurses and Dr Klaus.

"Thank God" said one of the nurses. "John, you'll help us out, won't you?"

Dr Klaus, I should point out, has never been anything but courteous and supportive to me, yet I am deeply terrified of her. She is an efficient Teuton with an almost supernatural intellect - she used to do neurology, and sticks needles into people's spinal cords like other people brush their teeth. I suspect if someone ever saws open her skull, her brains will explode out like an airbag. She is held in almost religious respect by the other registrars.

"You won't have any trouble admitting this guy, will you?" she said, and smiled.

I shook my head. "Doubt it." It did seem that he would have done better in ICU than the ED. And the ED was chaotically busy, whereas the ICU was like the Marie Celeste.

I wrote up my note and rang my boss - as policy dictates.

"No" he said. "He doesn't need ICU. Let the medics take him." He said - doubtless correctly - that Mr Addams didn't need dialysis, that everything that was needful to correct his problems could be done by other units, and that he didn't want to create a precedent, whereby today we accept soft referrals from the ED, next week we are overwhelmed. Overall, he gave a number of very good reasons why the old man didn't need to be in the ICU. I listened, nodding and saying "Right" and "Of course" and "Probably shouldn't have bothered you" throughout, and put down the phone.

(See, when someone presents to the hospital with a medical problem, a ferocious tussle immediately erupts between the various treating team as to who gets the patient. Emerge says psych should have them. Psych say they should be looked after by medicine. Medicine tries to handball them on to ICU, or if that fails, surgery. ICU look to bounce them back. It's almost the exact opposite of normal commercial competition - in this market, everyone seeks not to win the customer, to force someone else to take them. To win the patient/customer is to lose, to lose is to win).

"We're not taking him" I said to Dr Klaus. Dr Klaus was not pleased. Her eyes glinted gunmetal blue. "He's got ECG changes because of his potassium. He's got no kidneys. He's a very healthy ninety."

I nodded, my divided loyalties probably evident on my face. "He doesn't need invasive monitoring, or one-on-one nursing."

She rolled her eyes. I don't know if at this stage I was still pretending to agree with the my team's decision or if I'd given it up, but either way, I have never been particularly good at that kind of deceit.

Anyway, I went and told the medical registrar. She was very happy and receptive - because changeover was coming, and although she'd get the handover she was basically agreeing for someone else to do the work and look after the patient. From medicine's point of view it was a loss. From ICU's it was a win. But from ED's point of view it was also a loss, because everyone knew that medicine would delay and delay and keep poor old Mr Addams in the ED looked after by ED nurses rather than medical ward nurses.

And from Mr Addam's point of view it was also a loss because the Pterodactyl Man, a very vocal psychiatric patient I saw five years ago and still remember, was being wheeled in strapped to a barouche as we spoke, screaming in fluent triceratops.

Anyhow. Unfortunately, later that night there was another patient bounced by ICU (Dr Fang being the decider) and the next moring the head of the ED and the head of the ICU had a meeting and clarified things. Everything turned out okay, but still, it is a part of medicine I don't like.

The thing is, if this is internal politics, I am internally politically dyslexic. I have an almost vestigial sense of self-presrvation when it comes to this kind of stuff, and I can't align myself intellectually and emotionally with my team. I am not one of these my country right or wrong people. I reckon we should have taken Mr Addams, just because he would have done better and been more comfortable if we had, and we had space and ED didn't.

I remember when I worked at Shipton, one of the ED doctors there, an obese chain-smoker who drank every night when he was not actually working who , referred patients to the medical team from the ED with the skill of a professional athlete, particularly since he was senior and the medical registrars were often peripubescent. One day the medical reg called in sick in the middle of a shift and they asked Dr Marlboro to fill in for him - to go from ED senior to medical registrar. He was then faced with dealing with several of his own referrals and actually tried to refuse one.

Anyway. One thing I forgot to mention about the whole bird flu thing - the 'bird flu is coming' talk was given by a woman who for much of the time wore one of the protective masks. So I sat there listening to a woman talk about bird flu while wearing what appeared to be a large, bright orange false beak, which wiggled as she talked. Possibly a form of protective colouration.

Luckily, she couldn't see me grinning - as I was behind my own false beak**. I later found out that our immunisation nurse has bought herself a portable generator and has stockpiled masks and canned food, in the style of Survivors. Good to see this being taken seriously.

Anyway, thanks for listening. Back to chew some foliage and stay out of everyone's way.

*Potassium of six point nine with ECG changes, creatinine of 360, INR of nine point six. To be fair, the potassium and creatinine had been high for a while, not helped by the ACE inhibitor.

**Sarah was disappointed that she was not measured for a beak, however, I did remind her that lying around the house we have a large number of (unpaid) bills. Bills... like beaks, geddit?


Blogger Camilla said...

So what happened to poor Mr Addams? Did he get sorted out in the end?

5:02 AM  
Anonymous The Regional Support Clerk said...

We had the same discussion at work not so long ago. The theory behind it is that because we deal with the public we're going to be seeing a lot of infected people when this plague finally erupts. The lady sat there and rattled off a series of facts and figures and quoted various sources, all the time ignoring me when I asked how many people worldwide have died of bird flu and aren't we more likely to catch something as common as Cholera, Bubonic Plague or even Ebola.

Nope, we're the front line and now we're equipped to deal with it. We'll have to serve the public wearing dust masks, again I was ignored when I suggested that perhaps we should do that now due to the reek factor of some of the people who come in. More of us will be staying home. We won't be immunized though and if we get it then we have to make sure we're over it before our sick days run out. It's all good.

What really amazed me is that the Federal Government have spent over $30,000,000 already to combat a disease that isn't likely to ever reach our shores.

Wish we had your beaks though. All we got was a handout (and, in my case, glaring looks and an outright "Shut up and stop asking me questions I don't have the answers for!").

8:30 PM  
Anonymous foilwoman said...

Not to light a fire under you or anything, but BJ, old buddy, old pal, it may be March 26 here, but I believe it is March 27 there (in Oz). Please, it has been seven days since your last post. You have a loyal public. And me, of course. Move the cat off the keyboard and write something. Please.

1:37 AM  

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