Monday, June 25, 2007

Now I’ve always been puzzled by the yin and the yang

Sitting at home, listening to one of the best five albums ever made - Tom Waits, Orphans, buy it now, listen to "2.19" and cry - and thinking about yesterday.

I was called down to see Mrs Callahan yesterday, and she seemed a little bewildered, a little confused, bright blue eyes wide open as she asked us what was going on. I sat by the bed for as long as I was able and answered truthfully what I could, but what I told her was that I didn’t know, none of us knew, but in a few days we would be able to tell her everything.

Mrs Callahan was not someone I knew well. This was unsurprising, she was eighty one years old, and she hadn’t been to a doctor in seventeen years. Her hair was white and her nose was aquiline and she was one of those upright, erect women, the ones you see wearing gloves in autumn and who dress up to go down the shops. She was evidently well loved – the walls of her cubicle were plastered with crayon drawings by her grand-children saying “get well soon”, and her three daughters sat by the bed throughout.

From what I could trace out, the story went thusly. She had gone to the local butcher’s shop to buy something for her dog, had completed her purchase, and as she turned to leave, turned and collided with a large young man. She had fallen onto her outstretched hand, and the butcher had called an ambulance, despite her protestations, and taken her to Florey, where she was seen by Dr Ravneesh, one of our young, keen, but relatively inexperienced interns.

For those of you who do not work in hospitals, I should elucidate – doctors do not do as they wish, their behaviour is tightly controlled. There are standards, and protocols, and guidelines. The reason for this is economically driven - numbers of emergency trainees grow slowly, numbers of patients sky-rocket, it is an assumption that each year more will be done with less, and that this process will continue indefinitely. A few years back ED was a seasonal discipline, like saltwater fishing or fruit-picking - winter was busy but summer relatively calm. In terms of patient numbers it has been winter now for three years, and worsening.

Because of this, we are rigorously controlled with respect to what we can do. Don’t bother asking your ED doctor what your cholesterol is – we won’t be checking it, go back to your General Practitioner. Your thyroid – not our problem. Anything preventative – you’d be lucky. The American model of Emergency Medicine, the “greet them, treat them and street them”, is so much the dominant paradigm that its primacy, let alone its efficacy, is no longer even challenged.

(Obviously, I am talking rampant anti-Americanism here, and I hate their freedoms. But I feel I should re-iterate – America has the best music in the world. It invented superheroes. It gave us Philip K Dick and Serenity and E Annie Proulx and Scorsese and so much other stuff it beggars belief. Man on the Moon, for God’s sake. But slightly more than half the voting public can be brought to their knees in terror by uttering one of the following three words or phrases: “Socialism”, “Black men”, or “non-Christian”.

Weird, isn’t it, the way some people go on about these threats, almost as if their livelihoods depended on it. Is there such a thing as a phobocracy?)

Anyway. Somehow the intern who saw Mrs Callahan had slipped through the net. She asked her questions, and in fact took a complete history. She performed a detailed physical examination, including listening to her chest. Aware of what she had found, she ordered a set of bloods and, along with the X-ray of the wrist, a chest X-ray.

Which found Mrs Callahans lungs more than half full of fluid.

Now, there are two main possibilities here. Mrs Callahan has a massively enlarged heart, a murmur that can be heard almost without the stethoscope. She may be in severe, possibly end-stage heart failure. The other possibility relates to Mrs Callahan's breast cancer, treated fifteen years ago. She had had surgery, radiotherapy, was given the all clear. But this fluid in the lungs could be a malignant effusion. The cancer may have returned.

Either way, things are bad for Mrs Callahan. She is booked in for an urgent echocardiogram, an ultrasound of her heart, which is the first step in finding out what is wrong and what, if anything, can be done about it. Although she is fit and well, she well be in no shape for cardiac surgery. She is also booked for a bone scan and an MRI of her brain. It may be, says Dr White, that the cancer has spread to her brain. Our role may be to determine, once all is known, if she is suitable for resuscitation.

Anyhow. We don’t know yet, I may know when I return in a few days. Everyone to whom I have spoken seems shocked by the rapidity of it all – Mrs Callahan came to us a healthy and independent woman and now the same woman lies in bed, her heart maybe failing, her bones maybe riddled with cancer. It is hard to avoid thinking of the evil eye here, how looking causes illness, or if not that, then Schoedinger’s writing, things that become true because they are observed.

We shall see.

In other news, the man in bed eleven, Mr Steed, continues to defy medical prognostication and has so far not died. I feel this shows a disregard for common courtesy, a contempt for medical authority and a cavalier disregard for hospital finances. He has been in bed eleven for twenty eight days now, initially in acute hepatorenalcardiopulmonarybrainiosplenic failure, and is now off the ventilator, un-yellow, and sitting up talking (in whispers, and weakly).

This has cost us, Dr Fang assures me, two and a half thousand dollars a day, not as much as the penniless man in the Royal who was in ICU more than seven months at a total cost to the taxpayer of more than half a million dollars, but still, money that could have been spent elsewhere. For example, said Dr Fang, did I realize how much Dr Black must be on?

Anyhow - the problems is, Mr Steed is now in his twenty eighth day of kidney failure. There is less and less hope he will recover kidney function, and he will almost certainly have to go on dialysis. Long term dialysis requires an almost religious commitment, I am told, to three ten hour sessions a week, on a machine that cleans your blood. Mr Steed is a man with a long history of IV drug use, his family suggest he is not a man who faces problems straight on. He may not be able to cope with ten hours three times a week on a machine.

If this is true and he misses a session the levels of potassium in his blood will rise, toxins will begin to poison his system, and after several weeks he will have a heart attack and die, presumably wasting even more money.

We shall see.

Anyway. Thanks for listening, see you soon,



Anonymous ozma said...

Recent events require me to agree with everything you said about America and Americans. Very sad about Mrs. Callahan and it makes me think of my 93 year old grandfather and how he wants me to visit him twice this summer but I am afraid to because of work. I should, I know I should. He is in great health but he is also in his mid-nineties and somehow I imagine he will live forever while also knowing that is foolish. I don't care about age--do we ever want to let those we love go? Never, we never do.

6:15 PM  
Blogger Midwife with a Knife said...

a phobocracy.... That could be what we have here.

And you do hate us for our freedoms! (tongue securely in cheek, btw).

Also, I love the phrase acute cardiopulmonaryhepaticorenobraniosplenic failure. I'm going to try to work it into conversation somehow. :)

11:30 PM  

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