Wednesday, October 31, 2007

Crime and Punishment

Morning here. I’m doing Sarah’s shift at Central. We have a neurosurge appointment this afternoon, Sarah is at home in bed or sorting through MRIs and CTs. I don't know what the neurosurge will say - the pathology is definitely there, the symptoms are there, it's a question of whether he operates or not. From what we can work out the nerve root is being crushed, the one that runs down to her hand, but as well as that there is narrowing of the spinal canal itself, the bone tunnel through which the spinal cord runs. If he does advise surgery this will be a bigger operation than last time.

On the good side things seem to have stabilized in the last few days, but before that they had ben rather hair-raising: last Friday she lost sensation over most of the back of her hand, and it has not returned.

Since I would rather do almost anything than talk about this, I will write about something utterly unconnected.

Mr Grote is one of the patients about whom I worry pretty much constantly. I see him regularly, I discuss him with his care-worker whenever the occasion permits. I am in constant communication with his parole officer, his GP, his pharmacist. Unknown to Mr Grote, and on days carefully scheduled to ensure the two do not meet, I also see his ex-partner, a pale, thin woman with dirty blonde hair. Mr Grote is legally required to remain at all times five hundred metres or more from this woman, and faces considerable forensic penalties if he does so. He is also barred for life from three pharmacies and we are required to have a security guard present whenever he sees us.

Not that any of that was necessary Tuesday. I leant out into the waiting room and called his name, and Mr Grote looked up at me and smiled. Jamie, the soon-to-be second Mrs Grote, smiled too, one of those smiles like a flash of light, and offered to hold the baby. With evident regret, Mr Grote handed over a tiny someone swaddled in a clean white blanket, and followed me into the office.

He looked good. Put on a bit of weight – some of that was the methadone, but it often means the patient is taking less speed, maybe taking his prescribed dose of antipsychotics – and looking the better for it. His face had cleared up, he was notably calmer, he spoke mostly of his new child, his son. Half way through the interview he found the separation too much, excused himself to the waiting room and returned with his child in his arms.

"It happens, after a while" he said.

"What does?" I said, staring at one of the twenty or so new baby photos on his phone.

"You get over it. The smack. You sortof change. Different things become important. Since I had Blayde* everything's sortof come into place."

"You reckon? That's brilliant." I said, writing down what he had told me - no opiates, no benzos, no amphetamines for five weeks and three days.

"Sure of it" he said, his voice soft. "You know - I wouldn't recognize myself from when I was eighteen."

"Most of us wouldn't" I said. For a moment I remembered that line from "The Go-Between" - The Ram, the Bull and the Lion epitomized imperious manhood; they were what we all thought we had it in us to be; careless, noble, self-sufficient, they ruled their months with sovereign sway.

"No, but - " he stared down at the little bundle. "They change you."

"They do" I said. "You're doing bloody well. Congrats. And that's a beautiful kid."

The appointment stayed with me for most of the day, and it pleased and cheered me, and I told one of the nurses about it, and she seemed pleased and cheered too. And so we were all pleased and cheered, and it was in a pleased and cheered manner two days later I went through the pathology reports.

"Good Lord" I said. "Look at this."

It was Mr Grote's two-monthly urine drug screen, taken just before he saw me. Heroin. Amphetamines. Sleeping tablets. Buprenorphine (occasionally used as an adulterant in heroin, otherwise bought on the street). Six out of the nine illicit drugs we screen for, and two of
the remaining three we pretty much never see.

See, this is something I have to watch as a doctor. I believe anything people tell me. Always have done. That's why I ask for the urine drug screens, and I do the blood tests, and I measure all that stuff. Because I know if we ever have to rely on my keen clinical eye, or my innate sense of distrust, we're all doomed.

Anyway, as a result of this, Mr Grote goes from getting six doses a week unsupervised to having to go to the pharmacist every single day of the month and swallow his dose there. It's the loss of a recently hard-won privilege, and it will cost him time and money. He will, I imagine, be bitterly
disappointed. I feel bad about it.

See, the reason I am thinking about this is two articles I read recently. One was a letter by Tamara Speed**, the Treatments and Policy Manager of the Australian Injecting and Illicit Drug User's League to "Of Substance", the national magazine of alcohol, tobacco and other drugs. In her letter, she touches on a number of crucial issues which we as doctors rarely discuss. She talks about the unequal power dynamic, the frequently punitive response of doctors to client honesty, the range of issues that keep sick people away from their doctors.

Reading her letter was like listening to someone speak in a language in which I had once been fluent. She is sayingthings now that I said ten years ago, things I have not openly disavowed but things I suspect I don't take into account as much as I did.

Another, brief example of what I am talking about. Mr Hartley came to see us the other day. He is on a sizeable dose of methadone, no take-aways. His last urine test showed he was taking benzos, which are sleeping tablets. He frequently misses doses - two, three, four in a row - and when he does, he uses heroin, one hundred dollars at a time injected. When he turned up at the counter to see us he had a breath alcohol of 0.06 several hours after his last drink, and did not feel in any way intoxicated.

Later that day, I reviewed his notes.

Hepatitis C - not interested in treatment at the moment.

Several overdoses in the last few years.

Living from house to house.

I wrote him a letter, told him that I wasn't going to prescribe methadone for him any more, that his last dose would be on such and such a date, and that I had made an appointment for him to come in and discuss starting on buprenorphine treatment - a much safer, but less stonifying drug.

Unequal power dynamics. Punishment for telling the truth. Patriarchal, proscriptive, punitive. All of the above.

And the reason I did this is because of the second article I read that day. It's an overview of the characteristics of people who overdose. Basically, it points out that people who are on methadone are at much higher risk of overdosing and either dying or getting permanent brain damage than people on buprenorphine. People who drink a lot and are on methadone - they are at a huge risk. The homeless, people who attract a lot of police attention, people who inject publicly because they don't have a lounge-room crash out in, who buy large amounts because they don't know when they'll next be able to buy again, people who use large amounts because the don't want to be caught with it - each of tehse increases your odds of your methadone killing you.
People who take pills.
People with other illnesses.
People who are socially isolated, don't have friends, don't have a lot of fellow users.

People like Mr Hartley. I think he is one of the five or six highest risk people I have. They've done studies on this and those studies suggest that if I change him over to buprenorphine his life will be prolonged and his brain preserved.

But studies also show that people who die really fast are people who jump off the programme and then keep using. There are obviously a lot of factors that make people jump off the programme, but I can guess a few of them.

People who don't get treated with respect.

People who get their medications changed on them, without consultation by a doctor, who just get told about it.

People who get punished for being honest, people who get watched all the time, people who have their dose of medications cut if they don't obey.

I don't know. O don't know what would make Mr Hartley happy - to be honest I haven't asked, because his choices are fairly limited. I'm fairly sure what it takes to make the Drugs of Dependence Unit (who give me permission to prescribe opiates) happy, and I know I have to keep doing it, because if I deviate from what makes them happy they tell me pretty damn quick. I don't know what would make the Australian Injecting and Illicit Drug User's League happy, but from reading their fora I tell myself I can see the outline - respect, integrity, freedom.

So what's stopping me? The problem I have is balancing this with death, and overdose, and disease. There are less compassionate doctors than me - although I don't know that Mr Hartley would agree, and Mr Grote might be having his doubts around about now, when he gets his letter - but I don't know that they are any better at what they do. There are more compassionate doctors than me, but I know at least one of them has patients like zombies, has contributed to the vast benzo and opiate problems we have around here, has been called up before the medical board on many many occasions, has people who have died early, people addctied for years when they could have been clear-headed, had a normal life, people who can't get out of bed unless there's a pharmacist at the end of the trip.

I don't know. It's a balancing thing. Two years ago I was a lot softer, now I'm considerably more protocol-driven. The more I find out about this are the more I realise how dangerously ignorant I was and still remian. So I ring up for advice, and I read stuff, and I listen to someone tell me how much he's changed and then I send a letter telling him he's losing the very very few priveledges we've grudgingly given him.

And trying to manage all of that while knowing I am still as easy to fool as Mr Grote found me the other day.

Thanks for listening,
John Bronze

* Half-brother of Exavier and Jett. I am not making this up.

** Replaced the previous Treatments and Policy Manager, Elizabeth Smack, in a bloodless coup earlier this year. Her assistant is Gerald Cone and other members of the Treatment and Policy Team include Joanne Bong, Anh Whizz and David LickACaneToad. Okay, I made those names up. But not Tamara.
John Tablet.

Wednesday, October 24, 2007

Plan B


I had this blogging thing all worked out - the subject of the next few blog entries - the overall structures, the imagery: the "next in series" about the three other terrible deaths that happened in that last horrifying weekend in ICU, then a lighter entry about the truly remarkable happiness of Mr Stonemason and where it came from, and lastly something responding to something I read in the NYT - a career-ending entry on doctors and nakedness, the whole nude/naked/stripped continuum.

And I was going to reply to comments, and go to the pub with my friend, and do some study, and maybe later write a brief entry on the drunken man one of our nurses found in her back yard last New Year's Eve. He had fallen asleep on their child's swing, with his black tee-shirt pulled up over his head. When she woke him, calling cautiously from a distance, there was a moment's horrified stillness, and then he convulsed and jerked about, shrieking that he'd been struck blind. It took her several moments of careful explanation to assure him that this was not so.

And then my manager spoke about when her cleaning lady quit. Said elderly Irish cleaning lady had come over to the house one time and found my manager's cat apparently dead. Horrified, she had picked up the cat and ran the few hundred metres down the road to the veterinary surgeon. She burst in with the stricken animal and the vet performed CPR, including that modified mouth-to-mouth they do in these circumstances, and the cat coughed and came back to life, promptly being sick everywhere.

It was all very dramatic. Everyone was very grateful, and my manager lauded the woman to the skies, but three days later she rang in to quit.

"I just can't go back," she said.

"But why? You can't quit, we need you... anyway, why?"

"It's.... the cat," she said.

"Bobbles? The one you saved? But why? You brought him back from the dead!"

"I know," hissed the woman, in tones of the utmost horror. "I shouldn't have. That cat.... is evil!"

And she wouldn't be convinced, and that was that. Apparently five years later evil Bobbles is still continuing on his undead way, lying satanically out on the patio and chomping on his cat biscuits in what I assume is a decidedly demonic manner.

But these are not the main issues. The main issue, the reason no study and little work has been done and why we have been driving and phoning all around the countryside this last week or so, is Sarah is sick. Here is how it happened.

(I should point out that Sarah has told no-one any of this. She is like one of those feline predators, some desert cat or something, that never shows weakness. Not out of any machismo*, just because she's not someone who expresses her emotions like that. Me, as I've said, if I get a paper cut I call my scattered family around my bedside. Sarah's probably had three out of the top seven causes of pain, and she continues on at half my size under weights that would crush me).

Anyhow, ten years ago Sarah and I were in a car rollover. We were driving off to visit the horses and slowed down to turn right and there was a squeal of brakes (even now I remember thinking "Hmm, that's close") and some guy in a big old Statesman hit us driver's side rear. The minivan rolled two and a half times. I remember looking up and seeing Sarah still strapped into her seat, shaken from side to side as the van jolted, her head shaking back and forth. I was lucky - my seat snapped in half so I was able to lie down through the whole thing, curled up like an apostrophe.

Anyway, the van stopped and I clambered out and extricated Sarah and suddenly the road was full of people trying to help, and they took her inside and let her lay down on the bed and then the ambulance came and took us off to Fremantle Hospital.

She was a bit sore for a while but came good and for a while it like she had got away with just some whiplashy kind of stuff, and several years of exaggerated caution about turning right in a car. All seemed good.

Then a few years later, when she was in final year medical school, she noticed some clumsiness. Just a little at first, dropping things she would normally be able to handle, intermittent at first, but subsequently all day every day. She also noticed a deadening feeling, a loss of sensation over the thumb and forefinger of her right (dominant) hand. After a few weeks she could feel or do nothing.

This was all in the final year of medical school. It's part of the reason she's not a surgeon.

Shortly after that the weakness set in, and then the neuropathic pain. Neuro pain is a whole different kettle of worms to visceral or somatic pain, a deep, aching, drilling pain that doesn't respond to opiates, that nothing will shift and nothing will fix. She kept up with it as long as she could - I was driving, having to do everything for her - and when we finally got in to see the neurologist she was on a hundred milligrams of morphine a day, nauseous all the time, sick and sleepy and feeling as close to stupid as she ever got.

The neurosurge reg got her in to see his boss and he spread the CTs and the MRIs across the desk and we talked about what was going on. The nerve root, the thick, soft branch of nervestuff that comes straight off the spinal cord, threads through the foramina of the vertebrae, becomes the muscles that allow you to feel textures and write and pick things up, was being compressed. One of the disks between the neck-bones had swollen out and was crushing it, stopping sensation, stopping fine and gross movement, causing that horrible constant pain. Additionally, it was bulging inward, pressing on the spinal cord itself.

Mr Brophy suggested a minor response and a fairly major response. The minor response was something called a posterior discectomy - they cut a zipper-shaped scar in the back of your neck and carefully slice off the bit of disk that's bulging inwards, pressing on the cord. The major response was called "anterior fusion". In an anterior fusion they cut your throat open from the front. They slice back and cut out the entire disc between the vertebrae and replace it with a bit of bone they took out of your hip. No disk, no problem. You can't turn your neck at that joint any more because there is no joint - it sortof grows around the bit of hip bone - and that's that.

Sarah opted for the minor operation, about three hours. She woke up groggy and upset and for a few days felt not much better, a change in the nature if not the intensity of the pain, but over the next few days it began to recede and she did well. She never got full sensation back in her right hand, but she didn't have the pain any more and she wasn't crippled and I was deliriously grateful to her expensive-suited and gigantic headed neurosurgeon**.

Anyway. All that was ancient history, until last week when the numbness came back - but on the other side, the left hand. And then, in hindsight, she put things together - the difficulty taking blood the other day, the coffee cup that slipped from her fingers, the clumsiness feeding the kittens.

What we suspect has happened obviously is same disc, different side, and that means relatively emergent surgery. We drove in in the small hours of the morning to the Allnite Pharmacist - the 24 hour pharmacist in the city where we send many of our most violent patients, I got out the car looking around like an amphetamine paranoiac, planning to hospitalise anyone I didn't recognise who got within six feet of us - and we got some prednisolone. I got her into CT at Florey the same day, with maybe an MRI if they reckon she needs it later, neurosurge appointment the following week.

This is not good, for a number of reasons. For a start, our income protection insurance does not come into play for another few months. Second, prior to this we had been arranging an orthopaedic surgeon - Sarah has what Dr White calls a polyarthropathy and needs at least one hip, maybe two resurfaced - and Dr White pointed out that any anaesthetist is going to want to have a very good look at Sarah's rather-the-worse-for-wear spinal cord. When they put you under a general anaesthetic they sortof bend your neck back to fit the breathing tube in and in anything other than the most careful hands things can actually go very very wrong. You need your neck.

Anyway. Back to talking about me now - I have been rather concerned about this. I think it is possible that the more you know the more you can imagine going wrong. I oscillate between trying to reassure Sarah and imagining all manner of increasingly unlikely scenarios. I woke up early this morning, lay there in the pearl halflight, with the magpies outside the windows and the cats padding silently around in the lounge room and watched her breathe, slowly, in and out, dependable.

When I found out about all of this I was enraged, a kind of intransitive anger, an anger without object, all the more frustrating because of that. I wanted to fight, to smash, to hit something so it broke like bone breaks, kill whatever was threatening her and somehow make it all okay. But instead I lay there and listened and watched until it was light and then got up and made us both cups of tea.

Anyway. Speak soon, reply to comments soon too.

Thanks for listening,

*Still less out of any marianismo, which is a bloody depressing word.

** He was a remarkable looking man. A truly giant head, almost the same proportions as Charlie Brown, and long, slim, tapering fingers. I don't know if that's what he actually looked like or if that's how everyone to whom I have spoken remembers him, like some fifties pulp alien, here to bring peace and universal enlightenment to all mankind. Either way, it's reassuring, and he's very very good.

Wednesday, October 17, 2007


Evening here in the ICU, and I am deep bone tired. I’m too tired to go home right now – that time when you know your reflexes are just that tiny bit off, your decision making that teensy bit impaired, that yearning for warm soft bed and warm soft Sarah just a little bit too urgent – so I am sitting in the registrar’s room on the last day of my ICU rotation, drinking a weapons-grade slurry of coffee and writing about today.

Before I do, by the way, have a look at this. It's a documentary called "Guys and Dolls", about some truly unusual people. I haven't seen all of it, but it's startling, distressing, heartrending and frightening all in the same ten minutes. You might need broadband - I don't know how broad, the documentary's pretty long so you might need pretty broad.

It’s hard to put the last few days into words. I sit here and write and ten metres from me there are four people – four of my patients - between life and death, three people who are in the twilight in one way or another. In each case I have been involved in their care from early on, and in each case I feel, or know, things will end, or have ended, badly. In each case I will try and explain what happened. I don’t know if there is a less bad, a least terrible, but I suspect I will end up leaving the worst ‘til last. And tonight I am almost incoherently tired, and when I get that tired my glucostat goes awry, I can't detect overabundance of sugar, so this will probably dissolve into something cloying towards the end.

And I'll do comments tomorrow. I've jsut read them and I feel rather grateful.

Anyhow. I started at eight and got the handover from Dr Fang. He was walking with considerable difficulty – he’s come down with something contagious and as such is unlikely to be returning to work. I took over the patient, waved him on when he tried to finish off “ a few last things” and the CNC rang the consultant to get him to ring around for night-shifters. At eight thirty the pager went off – code blue in resus.

Code blue means someone in cardiopulmonary arrest, and ICU are required to attend. I walked down the stairs – code blues in resus are not the same as code blues at other places in the hospital. At resus code blues you walk in and the patient is surrounded by extremely competent doctors, they have high flow oxygen on, there are lines going in and fluid being squeezed in, you look up to the monitor and see heart rate, blood pressure and oxygenation. In non-resus code blues you run in and there’s one terrified looking agency nurse, no-one knows where anything is and a patient in the early stages of rigor mortis.

On the resus Mr Fell was a large man, well over six foot, easy two hundred pounds, with blue eyes and gingery-blonde hair and pale, soft skin. He had been attending a garage sale, started coughing, complained to his wife that he “didn’t feel too good”, was driven to the hospital, clutched his chest and stopped breathing en route. His frantic wife – and I can’t imagine what this must have been like – drove at un-natural speeds to get him to the hospital, and leant on the horn in the carpark. Ambulance men and a group of medical students dragged him from the car and ran him into resus.

By the time I got there Dr Hu was clearly exhausted, thin arms flexing, tiny hands placed precisely over Mr Fell's large and silent heart. I took over and started shoving. This is one area where physical mass, basic substance, is important. I looked up at the monitor. Blood pressure unrecordable. Heart rate unreadable – the line jittered each time I lurched forward, leant all my weight on that massive sternum. Oxygenation – none.

“Adrenaline,” said Dr Kaspar, a woman who gave up neurosurgery to be an emergency doctor, and one of the two or three most respected doctors in the ED. She spoke in that calm, enunciated way that cut through the alarms and the murmur of instructions and the jostling of the resus table, and she always said the right thing. Someone gave adrenaline.

“Pause,” said Kaspar. I stopped, breathed deep. We all looked up at the monitor, which functions something like an oracle and something like a judge.

Heart-rate thirty.

Twenty one. Five.

“Commencing,” I said and he started lurching again. I looked down and slightly to my left you could see Mr Fell’s eyes, ever-so-slightly open, like some people when they are asleep, watching me as I fought to batter some life into the unyielding, inert mass of him. We shocked him - Dr Kaspar calling "everyone clear", everyone standing back - in real life there is a pause between being able to shock and shocking, everyone looks around to check that no-one is standing close enough, the people closest to the patient edge back - and her pressing the paddles onto his chest and jolting. For that few tenths of a second life - movement, response, energy - enters into him, arms swing, maybe a grimace - and you can see why when electricity was discovered it was called "galvanizing". But as soon as the current stops, he falls back. I climb on top of him again and begin lurching.

After a while Dr Sanjeev takes over and I stand back. Every few minutes we stopped to check, every few minutes, nothing. Underneath the seeming chaos, the insistent ringing of the alarms, the calls back and forth of drug doses and blood pressures and milliamperes there is order, and underneath that a growing quiet, a sense of rising despair. People not directly involved turn to each other and murmur. At least ten minutes down-time in the car. Forty five minutes in resus without oxygen. Asystolic almost all that time. Survival after this is at best a matter of increments - we may save a bit of mobility, he may be able to open his eyes. The undamaged man is long gone.

The door bleeped behind me and Dr Kaspar emerged. She had been talking to the family.

"Pause" she says. Dr Sanjeev steps down, I step up, put my hands on Mr Fell's chest, right hand gripping left, elbows locked. Dr Kaspar gazes at the monitor. Nothing. Everyone gazes at Dr Kaspar.

"How long?" she says.

"Forty eight minutes."

"That's it" she says. "I'm calling it." She peels her gloves off. "Time of death, nine thirteen."

And like that, he is dead. It is as if she speaks death, as if her words slay. There will be no feeding tube for Mr Fell, no blank stare, no aphasia, no nurses turning him every few hours, tubes in and out of orifices.

Dr Kaspar turns and goes out to speak to the widow. I know she hates this bit. But I also know the last time Mrs Fell saw her husband alive he was walking and talking and laughing, the man she married. I hesitate to draw a moral from this kind of event, as if it were something performed with us in mind, played out for some didactic purpose, but if I did it would be that I believe, almost as much as I believe anything, that Dr Kaspar has said the right thing.

Tuesday, October 09, 2007

Chain of command


A brief insight into how it works our ICU. Sarah drove me in early in the morning. Most days I try to get there by seven o'clock, but today I particularly want to get in early - I have been told DrSanjeev is off sick. Dr Sanjeev, tall, cultured, incandescently bright - he whose name means, impressively, "the one who brings the dead back to life", is my intern. He is an essential part of the whole chain of command thing we've got going in the ICU, from the top (the consultant, Dr Black) down through the registrar (me) to said Dr Sanjeev.

The usual procedure in the ICU is Dr Black decides something needs to be done and tells me and I tell Dr Sanjeev. Dr Sanjeev goes off and does it. Occasionally Dr Sanjeev has a problem or discovers something of note about a patient and he tells me. I tell Dr Black and Dr Black goes off and solves it.

I worked out this morning that without Dr Black we don't know what to do. Without Dr Sanjeev, on the other hand, we don't get anything done.

Without me, I suspect, things go that little bit faster.

Anyway. A post of more substance tomorrow, or later today if Mr Grote doesn't turn up.

Thanks for listening, John

Saturday, October 06, 2007

Heart failure

Late morning here, the chickens are restless and the goats are at play outside. And today we are not getting family and friends over, as previously planned, to organise an Amish style chook-yard-building, because my car is having emergency surgery, and this will take care of that troublesome cash excess we've been having. The car died a few metres out from work, and was taken away by a towtruck, and will apparently require the services of the transport team.

Most vexing.

Anyway. Before I get carried away, here is a link to this year's Ig Nobel Prizes. The Ig Nobel prizes reward published scientific papers that... well, follow the link. My favourites this year have been those in Lingusitics (awarded to Juant Manuel Toro, Josep Trobalon and Núria Sebastián-Gallés, of Barcelona University, for showing that rats cannot tell the difference between a person speaking Japanese backwards and a person speaking Dutch backwards), and Biology (Johanna van Bronswijk of Eindhoven University of Technology, Netherlands, for a census of the mites, insects, spiders, pseudoscorpions, crustaceans, bacteria, algae, ferns (!) and fungi with whom we share our beds).

Ask me why I never finished in science.

However. I am back from the coast, which was brilliant. The city I sortof grew up in* has a different smell, all wattles and melaleucas, and you drive over the coastal plain and see the sunset over the sea... it works on you, something in it calls to you. Along the side of the highway there were paperbarks and I wanted to stop the car and step out on the soil and feel the bark between my fingertips.

Anyway. Paperbark pollen is flat and triangle shaped, something like this, pine pollen is hollow and ovoid and ridged like the Hindenberg, chenopod pollen (pollen from those little shrub things that grow on drylands) is shaped like a woven basket. Here you can see some eucalyptus pollen mixed in with some sunflower pollen.

You know, I always had the same trouble with science, and I've got it a bit with medicine too. They show me images and I look at the image, I don't look at what it represents. When I was doing my honours year, looking down a microscope for ten hours a day, fifty days in a row, I would put the droplet of oil, mixed with the fossil pollen, on the slide and stare at it under the microscope. And I wouldn't see pine pollen and eucalypt pollen and poacea pollen, I'd see these pink-stained bulbs and structures, the flamingo-coloured light coming through them, and marvel a how they drifted slowly across the field of view. Same thing when I saw electron micrographs of renal cells in medical school. Never really clicked.

And I'm not trying to show how much more fey and ethereal I was than the common clods with whom I sat, because I envied them their ability to look at, say, an ECG or a chest Xray and seize upon the salient points. But that kind of stuff always came hard to me.

Anyway. Tomorrow is one of my last shifts at the ICU, and the day after back to work. We have four patients in hospital at the moment. Three of them have infections of the heart valve - you have bacteria on your skin that look something like this, when you inject they can get pushed in with the needle into the blood stream. They whirl around, trying to settle wherever they can, often ending up on the heart valve. They grow, and as they do, they damage the valve. Two of my guys are okay, but the other one has bacteria running rampant in his blood and is swollen and weak from heart failure.

And the other one - and I have just heard this today - appears to be an overdose, of a medication I gave her. In another sense, another case of heart failure. She has suffered no ill effects, the medical intern tells me, and was dischraged soon after the event, but this is something that will occupy my thoughts from now until Wednesday, when I see her - and long afterwards.

Thanks for listening, will reply to comments tonight.

*Sadly, still a work in progress