Fixed up real soon

Hail,
And morbid humour and bad works herein. Particularly the last few lines. If you are at all unsettled by this, skip this entry.

First off, read FW's blog. Very fine lately. Follow the links therein. And don't forget all this stuff next time you in the US have an election. You gave us Motown, Philip K Dick and superheroes - how about some of that quality in the White House?

Anyway. Another couple of shifts in the ICU survived. Sarah is playing with her new laptop, the cats are fighting over the smoked salmon (a dollar a pack, expires tonight, from the discount bin) and I am desultorily cleaning up the carnage of last weekend's birthday party for Sarah, writing, and studying the anti-arrhythmics.

ICU continues to be enjoyable - I am gradually growing in confidence, and may even survive next weeks' departure of Dr Hu and his replacement by Florey's Best Intern. Dr Hu had hoped for radiology but is being rotated to psych, and may tomorrow have to come and see the patient that today he dumped on psych.

Part of my enjoyment of ICU derives from Dr White's method of teaching, which relies heavily on the recounting of hair-raising stories of hideous mistakes he has seen in his long medical career.

He told us today about a case he saw when he was in Sheffield. A man, early forties, a labourer, came into the hospital with pancreatitis - nausea, vomiting, very very severe pain in the left or central upper part of his belly, and a general feeling of life-is-crapness. The pancreas contains all the enzymes your body uses to digest food, in pancreatitis it basically starts to digest itself instead, the pain is apparently top five.

However, the cause was quickly found (a gallstone blocking a duct) and the surgeon (from the South of the USA) assured him he would be "fixed up real soon".

Truer words were never spoken, said Dr White. The patient was put on opiates for his pain, but the overnight doctor, concerned about developing addiction, cut back on the opiates and supplemented them with anti-inflammatories. Anti-inflammatories are damn fine medications, but if your kidneys are compromised (say, by all the vomiting and so forth that accompanies pancreatitis) they are dangerous. The overnight doctor gave him the equivalent of two ibuprofen, not a remarkable dose, and the patient went into acute kidney failure.

Needless to say, the patient was now in "a spot of bother". He lay there, horribly dry from all the vomiting, and was given medication to stop him getting an ulcer, developing a blood clot, etc. His pain from his pancreatitis continued, however, necessitating huge amounts of something like morphine, and two nights later the night doctor - same guy as a few days back, wracked with guilt - decided to give him an injection of local anaesthetic into the membrane around the spine to finally give him complete pain relief.

This he did. A few hours later the pain started to get worse, not better, and soon after that the patient complained that he couldn't move his legs. The injection into the spine had bled, recounted Dr White, due to all the anti-clotting medication he'd been put on - and his spinal cord had been crushed beneath a vast bruise.

Anyway. There are only so many ways that story can end. The labourer never got out of the wheelchair. Dr White, who was the other assistant anaesthetist in this case, emigrated. I don't know if the doctor is practicing, there really seems no reason to say no, except to point out that some people would find it impossible to go doing that kind of thing after something like that.

Another distressing tale is the man who had a bit of asthma and took one of his wife's anti-inflammatories - actually a period pain medication. He remembers feeling a little odd and then waking in the ICU three days later, having stopped breathing. Given what happened, he did wellish.

Not that non-steroidal anti-inflammatories are bad for you. They are bad for a smallish proportion of people under some circumstances and good for others.

Anyway. Enough grim tales. We also heard today about the new gee whiz ventilators we are getting - if you are ever unfortunate enough to be in the Florey ICU (unlikely), and am lying there looking up at the ventilator (even more unlikely), it is worth noting that the ventilaors (small boxes on stands with screens in the front, fifteen centimetres each way) cost more than thirty five thousand dollars each. They are smaller but slightly noisier than the big ventilators, which are thirty centimetres cubes but cost seventy thousand dollars each.

And apparently a night in the ICU costs $3 000. I marvelled at this when I heard, and suggested to Dr White that one could get a pretty good hotel room for three thousand a night. He said that in a hotel room you wouldn't expect a highly trained professional attending to your needs twenty four hours a day, and then we agreed that for three thousand dollars a night, perhaps you might.
Enough smut. Looking after the patients is getting better now. A lot of this is just practice - telling a story in a certain way - and noticing stuff about how the ward runs, and what is wrong with patients. We spent a lot of time talking about hepatitis today - the discussion of "exactly how much diarrhoea do you give your patients with hepatic encephalopathy" dominated a fair part of lunch. Much mention was made of the Child-Pugh score in assessing chronic hepatitis, wherein each patient gets a calculated score between five and fifteen. A score of less than
six means a one hundred percent chance of living out the year*, a score of over ten means don't put off that fishing trip. This is similar to the New York Heart Association score (where the calculated score ranges from I to V, in increasing degrees of fuckedness).

In my more callow**, intern years I remember hearing my then registrar refer to a patient with liver failure of having a "Cornflake score of four", meaning he was actually about the same colour as a cornflake. Being too tense to appreciate humour, I actually went and looked this up. The only prognostic grading score the intern or night doctor needs is the INC*** (Intern/Night Cover) rating:

INC score 0 - will live indefinitely, probably bury us all.

INC score I - will die sometime.

INC score II - will die this rotation, ie, in the next three months, while me and the other three interns are on duty.

INC score III - will die this week, while I am on.

INC score IV - will die this shift. Wake the registrar.

INC score V - will die this hour, while the reg is asleep and I am trying to untangle these paddle things.

INC scores VI to VIII are reserved for increasingly advanced stages of death that have occurred but have not been detected by the doctor, as in when you are trying to prop the dead guy up in front of the X-ray machine, or, chillingly, trying for over half an hour to get blood from someone who was actually in clinical rigor mortis.

Anyway, too tired to be interesting. Sorry for the gallows stuff. Thanks for listening,

John

* note, of course, that this does not mean you are invulnerable.

** an adjective literally meaning "without feathers". Over ninety percent of my fellow students fell into one or another of these categories.

*** soon to be published in a Journal one of my friends is thinking of editing to which we can submit some of our clinical findings. The working title is AJS, or the Australasian Journal of Shit-We-Made-Up.