Tuesday, July 31, 2007


The exam draws near, and I am still alternating between sitting it and using my handy-dandy get-out-of-jail-free card. In the last month before the exam you can only withdraw if you have documented medical grounds, which I most certainly have, but I don't particularly want to use that excuse. So, most days I can spare I spend reading and re-reading the textbooks and drinking kilolitres of coffee.

I read somewhere that the LD50 (the dose that will kill 50% of those who consume it) of coffee is about seventy cups in twenty four hours. I will probably be safe.

Anyhow. I will, objectively speaking, probably fail this exam. It's not certain but it's the most sensible extrapolation from how I'm going. Even if I do fail, I suspect I will pass next year. The brutal truth is I am not particularly good at exams, never have been. I don't have that kind of crystalline memory, that ability to make rapid, confident sounding judgements. Even when presented with a multiple choice question I spend most of my time trying to work out how every answer could be right. A lot of my day-to-day medical practice is spent looking stuff up. I've only done really well on one exam in my life, and that was the one that got me in to medical school. The rest of them have been barely survived bludgeonings.

Anyway, enough wallowing, it'll be here in six weeks whether I whine or not. What's been going on at work?

A few depressing things, actually, depressing to the extent that I was thinking about starting my study leave early. Mr Steed died. He was the man with the omni-organ failure - infections in his heart and blood and brain, another in his liver, a machine breathing for him through a tube in his throat while another machine cleaned his blood. He had spent close on three months in the ICU, attended each day by his sisters, his father and his mother. It was a death a long time coming, in fact a long time forestalled.

I had come in early that day and glanced at him - a slim, small form, surrounded by his family. I had only seen him dimly through the glass and curtains of the isolation room, in the last few weeks he had contracted MRSA, a very difficult to treat skin infection caused by farmers, doctors and politicians. Despite that he had seemed to be making a gradual recovery. The nurse told me that few days ago he had been showered and had spoken with his family. A few hours after I glanced at him - while I was on the phone, or getting a coffee - he had died.

All I can tell is it was - I don't know, dislocating. Knowing he had died ten steps away, silent and unmarked by us. And knowing he had died, and we, his doctors, had done nothing, despite knowing there was probably nothing that could have been done.

I went into the room - the family were outside, the nurses were already in there, cleaning the blood and shit from the body, it had not been a good death - and I certified the death. I do this in a kind of ritualised pattern - stethoscope on the chest, a minute's silence, listen to the lungs, another minute, the pen-light in their eyes. If the eyes are wide and dark and the pupils do not shrink away when you shine the light on them, you can under most circumstances declare the death.

And I knew I had a job to do, people to keep alive, but all day I couldn't stop thinking about it. And then I spoke with the man in bed eleven, who had just been de-intubated, and I looked down and saw that he had been born the same month and year as me. And something in the look of him reminded me of me six months back - the same round, slightly confused face, the same smiling and nodding as he agreed he'd do things we both knew he wouldn't do.

And so I spent the rest of the day thinking about that. First intubated patient who's got to me in that kind of way.

Anyway. Enough personal trauma. I am going half-time for a month to study, we will see how that goes. What I was going to try to do was give an idea of how things worked in the ICU by following a group of patients as they happened. Here is what has been happening.

Mr Ayre has already gone to the ward. We came around the next day and he was off the oxygen. He looked pretty bad - speaking in short phrases, a visible heave of the chest between each mouthful of words - but he assured us this was pretty good for him. And he was keen to leave. I wrote up the discharge medications and dutifully gave him my "perhaps smoking isn't for you" talk. I am not good at the scary talk, I tend to frame things in terms of "if there's anything we can do to help...", but the truth is in this case stopping smoking might double or quadruple his expected life span and he'd still be dead within a year.

Mrs Burns does not do well. As you will recall, she had had a colonoscopy which perforated her bowel. Every morning the surgeons come and cluster around the bed, and try to screw up the courage for another operation. Her gastroenterologist - the man who did the damage - has been on the phone every day, sometimes twice. She is in kidney failure, has lung disease - it's all bad.

Mr Mettle - the giant of a man - is, if anything, worse. He is the only person of the five with single organ failure - heart like an ox, fit, clean-living - and every day brings more visitors. There are photos of him and his family and friends almost covering the wall.

Still, he does very badly. His lungs are stiff - the ventilator has to work extra hard to inflate and deflate them, use pressures four or five times higher than normal. Those high pressures are almost certain to further damage his lung, but without them he won't be getting oxygen in. His white blood cell count - white blood cells are the ones your body uses to fight illness - is thirty six. Above eleven is considered abnormal.

Mr Wood remains about the same. He has not spoken or moved or indicated anything much at all, but that is how he often is. If anything he is slightly better, which is good news for his son, possibly less so for Mr Wood - although perhaps not, who can tell? Several of the staff - doctors, nurses - have expressed their disgust at this situation, a man with severe dementia and chronic pain being kept alive by a son he hasn't seen for eighteen years - and the senior doctors have rung him every day to explain the situation to him. I don't know what's going to happen here. We all wait on the son, who should be here "soon, the weekend at the latest".

Interestingly enough, by the way, doctors are empowered to make certain decisions and carry out certain procedures against the will of the patient (and the patient's relatives) - the frightened three year old who needs emergency surgery against the will of the parents, for example. Those patients can be forcibly made a ward of the state. But I don't know - and I could be just ignorant - if such a provision would ever exist in the case of an elderly man who no longer recognises his children. And there's a long way to travel from that case to this.

Erica Stone looks relatively good, and her numbers (blood pressure, heart-rate, oxygenation) look good, but that is because she herself is doing relatively little of the actual work of living. Still, tomorrow or the next day we will withdraw the sedation and see how she goes when she wakes up. Her drug doses - the morphine, the midazolam - are remarkable, and from what I have been able to find out the doses of stuff that would kill most of us are what she takes recreationally.

Anyhow. Two have been saved, three at least still to go. More on this later.

Thanks for listening,


Blogger Benedict 16th said...

The LD50 assumes you have no tolerence, like my patient who scarfs* 240mg Oxycontin and washed it down with about 8 standard drinks, 30mg diazepam, 20-40 mg temazepam, oh and did I mention chronic chest infections and severe heart failure (and under 40 yo)... hardly touches the sides....

* Patented BJ word

11:22 PM  
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11:32 PM  

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