And a warning - the following post is rated R for contains Rather Distressing Concepts.
I am sitting in ICU, having just had a discussion with the Upper GI Registrar. For those confused by the terminology, registrar is a term that means anything from decider to dog's-body, depending on the team. The Upper GI Reg is a truly tiny woman, someone who seems too small to lift even a paediatric endoscope, and from the expression on her face she seems more of the dog's-body type. We had a brief and depressing discussion about the fate of Mr Wells - a seventy year old man who had suffered a catastrophic series of events (the surgery for his pancreatic cancer had caused a loss of blood supply to his small intestine which had required the insertion of a central catheter which had then become infected with a fungus which had spread to his blood which meant that his kidneys weren't getting enough blood...).
We had passed the point where medical interventions actually benefit the patient some days ago. Mr Wells was no longer able to speak, and the impetus behind these increasingly futile measures was his brother, a man who lived a thousand miles away and seemed unable to accept how bad things are.
I have seen this before - the enormity of some ideas means they require time to grow, time for the mind to make space for them. Ten feet from me a family is gathered around a twenty year old girl who may die before the weeks is out. They have brought a photograph of her and her husband and baby from a year ago, and the rapidity of the decline (methamphetamines, increasing psychosis and now some truly horrible viral encephalitis from which she will not recover) is something her parents are unable to accept. Three times in the last two days Dr White has met with them, and explained in his careful Cornish accent, how it is quite possible that their daughter will not wake up ever again. He uses unambiguous tierms, like "die" and "stop breathing" and "her heart will stop", and each time the parents nod and look grave and then ask when she will be waking up.
A truly ghastly tale of what we call fungaemia - fungus growing in the blood. I can't remember if I told this story before, but when I was working in the injecting drug field I heard of a couple, both HIV positive, one of whom was on buprenorphine (the tablet for heroin dependency that goes under the tongue). He was diverting the medication to his partner (spitting it out so his partner so his partner could inject it). Unfortunately he had oral thrush, and when his partner injected it, he got oral thrush in his blood.
This meant he got hideously sick, and died three months later in the ICU with multiple organ failure.
Anyway, this is all horribly depressing. I am trying to think of something cheery but staring out at the serried ICU patients does not really evoke thoughts of joy. Directly ahead of me is my 208 kilogramme man, the bed next to him is waiting for our 37 kilogramme man - eyes sunken into his head, a chest that is too bony to listen to, a perpetually confused expression on his face.
Weirdly, this means that on average, our patients are relatively normally proportioned.
Aside from this, I have been trying to load medical text books onto my new Palm Pilot. More on this later, but the geeky amongst you will have heard of Clarke's Third Law: "any sufficiently advanced society is indistinguishable from magic".
The problem with the usual application of Clarke's Law is most people imagine it relates to some time in the future, when we all wear lycra bodysuits and jetpack to work. This is untrue - for me it happened about nineteen forty three, the year that that big computer in Pennsylvania started up. Since then it's been increasingly baffling. Computers and stuff like that I just do not understand. For all I know, instead of logic gates and flip flops inside my Palm Pilot there could be tiny tiny little picosorcerers inside, rummaging through the innards of a nanogoat.
Anyway, off to resuscitate our skeletal man.
Thanks for listening, will reply to comments soonish.