Ephemera

Hail,
ANd the following contains stuff that is, according to Sarah, "really awful". You have been warned.

Firstly, I have recently found two of the best websites in the world. One of them led me to the work of these artists who made these:



What do you say after you've made something that beautiful?

Anyhow. Vaguely philosophical mood tonight, too tired to study the kidneys. I vaguely recall - and I may have said this before - that in old versions of the Old Testament the kidneys were supposed to be the site of the moral sense, the sense that differentiates wrong from right. Hence Psalms 16:7, which I learnt in Old Testament studies was originally "the LORD instructs my kidneys during the night".

Nowadays we are much more advanced than those foolish people - current versions say "the LORD instructs my heart". Still, it's an interesting idea, someone elderly and intellectually atherosclerotic slowly drifting into subclinical renal failure and becoming increasingly amoral.

Explains so much.

I suppose I am in a slightly ambiguous mood today because the last few weeks have been crowded with extremes. ICU and drugs and alcohol, and also Emerge, seem to almost be bipolarogenic. And I'm not complaining - indeed, it can hardly be co-incidence that I've chosen to work in fields where every few days there is a death, every few days a miraculous survival - but I have to be careful that not too much of this rubs off on me. I can't say that death and sickness and grief are to any real extent contagious, I can't claim I share in the suffering of my patients, but these things affect you, get under your radar, under your skin. I'd be a stupid person and a crap doctor if I thought otherwise.

And ICU has been particularly frantic lately. It is winter here, and winter is the dying season, all the wards overcrowded, pneumonia and influenza and infectious exacerbations, this hospital visit a little longer than the last, comiong on more frequently, saying longer, until in the end you come in and you never get out.

The names of bacteria are like the old names of demons, where before we had Shemyaza and Naberius now we have Pneumocystis and Haemophilus and Influenza. The names still have the poetry and the powers are still as strong - Shemyaza is "Infamous Rebellion", Naberius restores lost honours...

- and isn't that something, isn't that a power worthy of a real demon, a true Marquis of Hell, a power something that could tempt even the best of us on days that those sheet-wearing grape-dangling nymphs wouldn't get a look in? -

...Haemophilus is "Lover of Blood", in bed nineteen Mrs Damson breathes shallowly and rapid.

Anyway. I am at a bit of a loose end because of the man in bed eleven - seriously, it's that bed again, almost Lovecraftian, one day I'll look in the pillowslip and find Brown Jenkin or somebody - and his ongoing determination not to die.

The story of Mr Mason is relatively, almost horribly simple. He went out with his wife to visit their daughter, she served him tomato soup. He had had this many times before, always with considerable enjoyment, and he sat down to devour it with relish. Within a few minutes he noted an unpleasant itching sentation "in his throat", and a mild, almost comical swelling of his lips. He pushed the plate away, went into the bathroom, washed his mouth out and took some antihistamines. The problem did not go away, but neither did it seem to get worse, so Mr Mason finished playing with his grandchildren and went home. He felt unwell, a little nausea, and did not eat anything that night.

The next day there was still a mild swelling and a barely perceptible tingling of his throat. "Well, if you don't eat, you'll starve" said his wife, and she made him poached eggs - no tomatoes. He thanked her and said he was certainly hungry. He took a few mouthfuls, lurched back in the chair and fell to the ground.

What happened next is difficult to determine. Mrs Mason - fifty five, a short, strong woman - tried what she remembered of mouth to mouth, but it didn't seem to work. She remembered that his face was all swollen up, lips like balloons, face distorted. Someone called an ambulance, they came priority one, got him inside. They closed the door and he arrested, they were crunching on his chest as they pulled into Florey ED.

The ED got a tube down into his throat and started him breathing. He got the unholy triad of muscle relaxants to paralyse him, sedatives to make him unconscious, analgesics to kill the pain he was feeling. They put a line into his artery, took some blood out, ran it through a machine, got a stream of numbers on a sheet of curling, freshly smelling paper, filed it with the other notes, the amounts and concentrations of adrenaline, the minutes of cardiac compression, the voltages and electrocardiograms.

When he got up to us, intubated and unresponding, Dr Kala showed me the blood gas. "There is a set law governing how quickly the carbon dioxide rises in the arterial blood in the complete absence of ventilation" he said (he really talks like that). "Three to four millimetres per minute. What is the normal partial pressure of arterial carbon dioxide? How long has this man been without oxygen?"

"Twenty four minutes" I said.

"Twenty four minutes" he agreed. "What are the clinical signs that distinguish hypoxic from other forms of encephalopathy?"

I didn't know. He pulled the curtain aside, gestured with one long-fingered hand towards Mr Mason. Mr Mason's hands twitched, his eyebrow raised, the muscles in his cheek convulsed, making it seem like he was about to speak.

"Myoclonic jerks" he said "are a very poor prognostic indicator."

"Is this... permanent?"

"Possibly" said Dr Kala.

"Can we do anything?" I said.

"We must try" he said. "This is very distressing for the family. Clonazepam, valproate..." I began writing in the medication chart.

But nothing has worked. Mr Mason's family - small, internally riven - drift in and out at various times, studiously avoiding each other. Mr Mason's widow - because that is what she is - sits by his bed, holding his hand. He is in constant motion, almost seeming too alive, a man full of vitality, possessed by animal spirits. The corners of his mouth twitch as if at a joke. He smacks his lips as if tasting fine food. His hands clutch at his wife, his eyes open and he looks around the room.

But when you shine a light in his eyes, his pupils do not constrict. If you squeeze the sharp metal handle of a tendon hammer between his fingers, he neither cries out or draws away. The touch of cotton wool on his cornea - the white of his opened eye - does not cause him to blink.

There are requirements that have to be met here. After four days the neurologist will review him - sit down with the CT and the MRI, poke and tap him with his tendon hammer and his pin. While there is hope, even very little hope, thin as those lines of light on the horizon of planets when the day is just ending, while there is hope there we keep his heart going and his blood pressure up and his lungs filling and sighing.

But I don't know. By Sunday, when I work next, things will have moved on. The mathematics say that the most sensible thing to do is to turn off the respirator - almost no-one who survives this wakes without horrible disability. But I don't know how his relatives will go doing that if they have to decide when he is in the bed smiling at them and looking around and grabbing at their hand.

Anyhow. Thanks for listening,
John