Floater

A nurse remarked to me recently, "Mr Surname has been particularly appreciate of his floater over the last few days."  Eh?

For those of you not in the know, a floater is a hot meat pie floundering in a mire of mushy peas, strongly associated with winter and football.  Mr Surname must have been ringing in the festive season in style.

But no - not that type of floater.  Surely he wasn't referring to a leftover bit of poop that resolutely refuses to flush?  Why would you be appreciative of that?

Or perhaps the floater he meant was the body of a drowned person, bobbing gently under the buoyancy of its internal gases.  Something to appreciate, surely, if only because of a schadenfreudesque relief - "There but for the grace of God go I..."

Aaaah - I have it!  He was referring to the perception of irregularities in the vitreous humor of his own eyeball.  He spends his days staring at the sky marvelling at the drifting, dancing angels always just beyond his reach.

Again - no.  The floater in question was a dose of oxazepam, an anxiolytic, available to be taken at any time as Mr Surname saw fit.  That would certainly make a trip to the football much more bearable.

Plot summary for generic espionage/action flick

Man is surprised to find that people keep trying to kill him.
Man executes a series of astonishing manoeuvres on a motorcycle.
Other man comes crashing through a large window with a big gun and tries to kill the first man without success and is himself killed right back.
Man speaks to other man wearing a suit over a telephone.
Man wearing suit says "Goddammit!" and slams the phone down.
First man sails away on a boat.

Movies is hell

As a recent commenter to my post Reading Is Hell pointed out, movie watching also suffers from the travails of internship, from the slings and arrows of outrageous offspring. We have been to the cinema twice in the last two months, which is remarkable because before that it had been more than two years since we'd been to the movies.

Apart from our non-existent cinematequing, we've been subsisting on offsite backup copies of movies provided by my Smaller Half's brother who obtains them in a manner unknown to us but which almost certainly involves the paying of royalties to any and all copyright holders in accordance with international treaties, arrrrr.

This has been quite good, except my poor old computer struggles a bit with the concept so every 15 minutes I have to pause the movie and persuade my computer not to reboot itself. Also, some films have such a low sound level that the dialogue is frequently interrupted by one or the other of us saying, "What? What did he say? He's going to buy a duck?" Fortunately these two disruptions are complementary so whilst I am fixing the computer we attempt to mutually reconstruct the dialogue.

Also fortunately, in our impoverished mental state, our viewing tastes veer more towards The Avengers and less towards Gosford Park. It's much easier to figure out that the Hulk probably screamed out, "RAAAAH! HULK SMASH!" than it is to decipher the intricate household intrigues of the Edwardian aristocracy, so the audio issues aren't as much of, well, an issue.

We finally did make it to the cinema. The first time, we ruthlessly bunged the Hatchling into the care of the brutal misanthropes at her childcare centre (note: this is obviously a lie. Her childcare centre is fantastic.) and took off into town. We saw an incredible film. The people in it had faces as large as a house. Their voices boomed out like thunder. Not once did the screen try to reboot itself. I think it might have had Richard Gere in it as well but I'm unsure of that.

The second time, we ruthlessly bunged the Hatchling into the care of the brutal misanthropes who are my Smaller Half's brother and mother (note: The childcare centre really is fantastic.) and took off into town. This worked a lot better than when my own brutal, misanthropic mother visited and said, "I really should offer to babysit so you can go to the movies but I'm not going to." Sad trombone.

We went to see the new Bond flick, Skyfall. As mentioned previously on this blob, I was unreasonably gobsmacked by the opening credits, largely because they were colourful and moved around a lot, as movies have tended to in general since the 1950s. Still, regardless of the objective merit of the film, it was a relatively novel experience for me, if I may be permitted to use such a bookish adjective in relation to a movie. So I think in 2014 I might go to the movies again, if they still exist.

I didn't have any instant coffee though. The choc-top is eternal.

Mental state examination

Appearance: Caucasian male, medium height and build, looks of stated age, short brown hair unbrushed, unshaven. Dressed in semi formal office clothes, clothes clean though rumpled.

Behaviour: calm demeanour, good eye contact though prone to reverie, no abnormal movements, gait symmetrical. Cooperative with interview.

Conversation: normal rate, tone, volume, rhythm of speech. Brief answers verbally, more expansive in writing. Some tangentiality and loosening of associations. Occasional inappropriate humour. Themes of anger, being misunderstood, narcissism.

Affect: reactive, engaged. Claims subjective inner turmoil.

Perception: apparently normal. No attendance to internal stimuli.

Cognition: not formally assessed. Grossly intact.

Intelligence: above average though possibly not as high as he asserts.

Insight: good though limited in the context of accepting and integrating criticism.

Judgment: impaired by innate laziness.

Rapport: superficially established.

Impression: ?tormented artist
?selfish prick
?dysthymia
?intern burnout.

Plan: 1. Ship him off to another hospital and let them sort him out.
2. Put him in the scuppers with a hosepipe on him.
3. Encourage writing: entertaining at times.

Nostalgia

I remember seeing the film se7en in the cinema when it came out. Apart from the pretentious alphanumeric title and the repulsive tortureporn vibe, the thing that struck me most were the credits. They were like a rock video. Jittery, buzzing, energetic, packed with attitude. And the best part of the film as it turns out.

When the first Daniel Craig 007 film came out, those credits were the best I'd ever seen. They were hypnotic. A shifting maze of colour and movement and danger. Which was no small feat given they came after arguably the best Bond prologue ever.

I thought they couldn't be beaten. But the most recent Bond film's opening titles left me gaping. The blood in the water. The skeletal teeth turning into tombstones. The underground/drowning/death/shadow thing was some heavy shit, man. I wanted to go and see the film again just so I could see the title sequence. So I looked it up on YouTube and you know what? They were clever but not all that, sister. Too clever. Too many references to the film itself. Too cerebral. Disappointing.

But you know the best opening credits OF ALL TIME??? A children's program called In The Night Garden. The visuals and the music fuse to form a perfect image so beautiful that every time I see the show I nearly cry. The boat recedes over the waves, the stars burn bright in the sky, and as the string melody swells, the stars burst into flower and we are pushing our way through the blossoms and into the Night Garden.

It captures for me perfectly that feeling when I was a child of being lost in a dream and half knowing it, half not. Of feeling the bed roll and sway as you float up towards the ceiling. It's the music of a lost age.

I can't remember if I've mentioned before that the word "nostalgia" derives from concept of a painful memory, but now has come to mean a longing for a thing long gone. These credits trigger memories I never had. They are the best ever. And it's on TV every night at 6.30 pm.

Tune in, turn back, drop off.

The stone

So here I am - stuck at the hospital on a lovely day with not much to do.  I'm on cover.  "Cover" means you're stuck here all day on a weekend dealing with whatever random stuff the regular doctors forgot to do or didn't foresee or simply couldn't be bothered doing.  Today is bizarrely un-busy for me.  Hence the flurry of blobbing activity, which I've cunningly scheduled to be published daily over the next week or so.

All that is by way of getting to what I want to talk about which is superstition.  When I'm on cover I get hugely superstitious.  All of my superstitions are aimed at avoiding having my pager go off.  Over the last year I've developed a decent set of tips for avoiding being paged.

1. Do not go onto the ward, through the ward, or near the ward unless you absolutely have to.  If they see you there or smell you out, they will page you.
2. Do not read a book.  Opening a book is a sign that you're getting comfortable, and they will notice and page you.
3. Do not watch TV.  Watching TV is practically begging someone to page you.
4. Do not sit down into a comfortable soft chair and wriggle back and forth a bit then curl your feet up underneath yourself.  They will page you.
5. Do not attempt to eat any food which gets substantially grosser if you try to re-heat it later on, such as cheese on toast.  As soon as you've got it ready to eat, you'll be paged.
6. Do not ever send anyone a text message saying, "Today is AWESOME!  There's NOTHING to do!" - you know how this ends.
7. Do not attempt to do any of your own work, such as chewing through your backlog of discharge summaries or doing MMSEs on your own patients.  This will generate a singularity in the pager continuum that will suck you in for the rest of your shift.
8. Don't arrange to catch up with someone you know and love for lunch or coffee.  Your pager will go off so often that you may not even see them except as a rapidly receding silhouette in the sunset.

"But PTR", I hear you ask, "What can I do when I'm on cover and want to avoid making the pager gods angry?"  A good question, mosquito.  The answer is to be found in nature.  You must be like the stone, which weathers all that the world can throw against it.  The stone does not read books, or sit in comfy chairs, or meet up with friends for coffee.  The stone does not try to catch up on discharge summaries or eat a delicious lunch. 

No.  You must be like the stone.  You must lie low, very still, in the dirt.  Let the ants crawl over your face.  Let the rain run into your shoes.  Let the frost rime your beard.

Do this and you will be like the stone, whose pager never, ever goes off.  Be like the stone.

Reading is hell

In between lurching from day to day as a hospital intern, raising a small child, and smothering my rage so as not to commit chargeable offences on this blog, I've not had time for much reading.  I used to get through a book every fortnight or so on average, even during med school when I probably should have been reading rather more about sick people than I actually did.

As a result I haven't updated the Bookshelf page of this blog for quite some time.  I'm sure that the more literary minded of you have been salivating at the thought of an update, and I'm equally sure that only one or two of you have ever actually noticed the Bookshelf page of this blog. 

Regardless of your level of interest, I'm going to bang on about reading for a bit, for a couple of reasons.  First, I'm sitting here in front of a computer on a cover shift with not much happening so far, so I've got the itchy fingers, and second, I've noticed some interesting trends in my reading.

Normally my reading tastes run to:

• literary fiction
• vintage sci-fi
• historical non-fiction
• scientific non-fiction

Now what I've noticed is that when my stress levels ramp up, the literary fiction is the first thing to go.  All that cortisol must shut down my frontal lobes.  After a while the scientific non-fiction goes too, followed soon after by the historical non-fiction as my brain withers and dies under the relentless assault of my unhinged amygdala.  All that's left is vintage sci-fi, and even that warps and mutates into a desire to read really awful genre fantasy.  Ugh.

But given long enough, even the bad genre fantasy goes away, and historical fiction rears its head again - but in a very specific way.  I get magnetically drawn to personal memoirs of people who've had really really traumatic experiences, mostly to do with getting shot at.

I think the protective mechanism at work here is an underlying desire to put my life in perspective.  Sure, I may have to attend multiple Code Blues in the middle of the night but at least I don't have to see the tortured corpse of my best friend as in Flags Of Our Fathers.  I may feel burdened by being called to assess yet another asymptomatic hypotension, but that's preferable to having to pretend to be dead while my pockets are looted by the enemy and bullets are fired into the heads of my injured comrades around me, as in We Were Soldiers Once, And Young.  And sometimes I rile at the selfishness and insensitivity of my seniors at work - but at least I'm not being systematically hunted down and exterminated by the State, as in The Pianist.

The good news is that phase of my life seems to be over.  I've recently been able to start reading scientific non-fiction again, with Oliver Sacks' Seeing Voices - a book about Deafness, Sign and language.  Prior to that I read Naval Warfare In The Age Of Sail and learned to distinguish a sloop from a brig.  Soon I might be able to crack open that Anna Funder book I've been sitting on since April.

Here's hoping!

Funny blog content

The other day during the nursing handover we were astonished to discover that one of our patients has been doing his own FBC - full blood count.

He gets all the blood taking equipment ready, puts on the tourniquet, finds a good vein, draws the blood, makes a slide and examines it under a microscope, counting the different numbers of cells in a random selection of high-power field views, and then analyses the rest of the sample to get a haemoglobin level and all the other palaver.  Pretty amazing.  But then I guess he has a fair bit of time of his hands, being a patient with nothing else to do.

Sadly, it was all in my mind.  He does indeed do his own FBC - but it's the fluid balance chart.  He merely keeps track of his fluid input and urine output volumes.  I preferred my version.

Call me nick

The Hatchling is going through what must be a developmental milestone of sorts: she finds it highly amusing to call me by my first name.  I remember when I was a kid I had one or two friends who would call their parents by their first names and to be honest, I found it creepy and a little bit frightening.  Somehow it breaks the child out of the "child" role and they become instead some kind of mutant evil genius in a child's body. 

So I always make a point of correcting the Hatchling - "No, Dada" - which of course is a trigger for her to turn it into a game.  Even stranger is when she copies my Smaller Half and calls me "Honey".  That's just wrong.

I realized the other day when the three of us were sitting in the cafeteria at work that I could turn the tables on her and see if she identifies with any of the nicknames I tend to give her.

So I asked her: "Where's sweetie-pie?" - she pointed to herself, pleased.

"Where's gorgeous?" - she pointed to herself.

"Where's beautiful?" - herself again.

Hmm, let's see what happens if I use something she hasn't heard before, I thought.
"Where's boombalada?" - being a generic nickname for a fat person that I remember from my childhood - and she turned around and pointed at the unfortunate person at the next table, causing me to almost bust an internal sphincter trying to not laugh.

Cheese blues

Gorgonzola is an unfortunately named cheese - the Gorgons being the snake-haired monstrous sisters of Greek mythology.  The idea of getting milk out of them just puts me right off.

Modern genius

Despite the Hatchling's shortcomings in classical mechanics and abstract algebra, she is doing well in fields.  Botany, for example.  She has been hampered somewhat by being unable to pronounce the word "flower" - producing something more akin to "fla-fa", but nevertheless her theoretical knowledge is excellent.

Just the other day when I was eating a plate of nasi lemak, she pointed at the red-skinned roasted peanuts on my plate and said, "Bean! Bean!".  Now it would easy to patronisingly assume that she had mistaken the red peanuts for kidney beans, which she had in fact eaten just several days earlier.  I, however, knew that she knew that peanuts are not true nuts but are actually a variety of legume, or bean.

Well played, little Hatchling, well played.

Modern primitive strikes back

The Hatchling doesn't really understand equivalence relations in set theory. She's so cute that way. Still, I hope it's something that she overcomes soon or she's really going to struggle when I start reviewing topology with her next year.

This all came to light during bath-time. I asked her what colour her little turtle was, and she quite rightly responded, "Green!". I then held up a green cup and asked her what colour it was, and she said, very confidently, "Purple!"

I had to explain to her that since the turtle was green, and since the cup was clearly the same colour as the turtle, that the cup must also be green. She was gracious enough to admit her mistake in this instance but didn't seem to be convinced by the more general principle.

Note to self: Hothouse not hot enough. Make more flashcards.

Modern primitive

The Hatchling doesn't really understand Newton's third law of motion - the one about "for every action there's an equal and opposite reaction". It hadn't occurred to me that kids actually have to learn this kind of thing, but I guess they do.


I'd been pushing her up and down the driveway on her little toy tractor. She can scoot herself along pretty well, Flintstone style, using her feet. But clearly it's much faster, less effort, and more fun to get me to push her. She would lean back as I pushed her in the small of the back, putting her feet up beside her hands on her steering wheel, and saying, "a-whee!"

It's all good fun, but I'm not as fit as I used to be when I was young, so after half a dozen times I got a bit puffed out and bent over so I told her that I need a rest and she can do it by herself. She pushed herself along for a metre or two, but then had a brainwave! She put her feet up on the steering wheel again, put one hand behind her back where my my hand had been, and gave herself a good push. All to no avail. She was most perplexed. And the upshot of it all was that I had to do another half a dozen runs up and down the driveway.

I downloaded a copy of Newton's Principia Mathematica and read it to her that night at bedtime. She fell asleep pretty quickly but I think she got the general gist of it.

My dog has no nose

Boss

Come in to my office.  Does it smell funny?

PTR

Why?

Boss

My last patient had urinary incontinence and I'm wondering if I've aired the room enough.

PTR

I've got a cold so I can't really tell.

Boss

How convenient.  You should cultivate that cold.

PTR

I have a 2 year old at home so there's no need. We have colds on tap.

Boss

How lucky you are.

Pain or something like it

Medical bloggers love to bang on about the 1-10 pain scale, usually to comic effect.  Here's my contribution, but with cynical intern burn-out substituted for comic effect:

So, the 1-10 pain scale, eh?  In my experience, there's no need for anything so elaborate.  There are only 4 actual subcategories of pain.

1-4. Bearable pain.  Take paracetamol (known in the USA as epinephrine.  No wait, that's something else. Forget it.).
5. Unable to articulate character, site, severity, onset etc etc etc.  Refer to a general medical team.  They love these guys.
6-10. Severe pain. Give opioids and request a general surgical review.  They'll need a baseline before the patient re-presents with constipation from all the opioids you gave them.
11. Drug seeker. Or renal colic.  Either way, some indomethacin up the butt will give someone some relief.

Ha.

Goose/gander

Went to an orientation session for my new position this morning and had this strange conversation concerning an Esteemed Colleague, Binky*:

Administrator

I don't think Binky is coming this morning.

PTR

He told me that he would.

Administrator

Well he doesn't need to. He won't have slept because he worked all night last night.

PTR

So did I.

Administrator

But he doesn't really need to come because he worked in this area earlier in the year.

PTR

Me too.

Administrator

It's really hard, you know, to send someone an email saying, "This session is on but you don't really have to come to it", because then people wouldn't bother to come.

 

Isn't it heartwarming to know that in these troubled times we still have people looking out for our best interests?

*Obviously his name is not Binky.  Names have been changed to protect the innocent.

PTR's guide to five weeks of night shifts

Week 1: you hate the nurses.  All nurses are blundering dolts who exist purely to waste your time and mislead you.

Week 2: you hate the home medical teams.  All doctors are inscrutable scribbling fence-sitters, refusing to actively manage their patients until forced to by multiple emergency calls to intensive care overnight.

Week 3: you hate the patients.  All patients are demented, stinking, crumbly bags of blood and faeces just waiting to crash out of bed the moment you settle down for a rest.

Week 4: you hate your family, innocent passers-by, Mother Theresa.  Humanity is doomed, and deaf to your plaintive cries to save itself.

Week 5: you hate yourself and yourself only.  Just do what it takes to get through the next hour, day, week.  The end is in sight, or it would be if it wasn't for this darkness.

Handle with care

Meanwhile, I'm still waiting for a job.  Which sucks.

Have had far too many awkward conversations with people who assume that I've got something sorted by now and are then left feeling embarrassed and unsure of what to say when I reveal that I'm languishing at the bottom of the heap.  Sigh.

I try to be philosophical about it.  The reality is that there are X jobs out there for which Y people are competing.  And Y is bigger than X.  So someone is going to miss out.  Hopefully it won't still be me standing when the music stops in November, which is when the last round of offers come out.  After that, it's a free for all, and I don't know what will happen.

Funny thing is, it hadn't occurred to me that I wouldn't be in top X/Yths of the cohort.  As far as I know I interviewed fine, and as far as I know my referee reports were fine, and my resume was fine too.  After dwelling on it for too long at night you start to develop conspiracy theories.

Such as: my referees hated me so much that they gave me good term assessments in order to lure me into asking them for references, in order to write me bad ones and destroy my career.  Actually I kind of admire those evil bastards for being so Machiavellian.

And this one: the admin officer at the hospital deliberately shuffled my name to the bottom of the list because I've been such a pain to deal with during the year due to my incessant demands for special treatment.  Because I'm heaps demanding, right?

Or this: I smell.  And the interview was in such a small room that I nearly killed the panel.  Could be.  Nobody ever tells you when you smell.

Every day I check my emails.  Nothing.  Well, nothing but ads for cheese festivals.  Maybe I can get a job as a cheese-guy.  It might mask the smell...

Anyway, if you run into me in the next little while and I look grumpy (grumpier than usual), you'll know why.

Infographic

Anecdotes

A couple more brain-numbing requests from my adventures on the dark wards...

The first one speaks for itself: "Patient's blood pressure 105/45 @ 2030 hrs.  Now 100/50 @ 1130 hrs.  Please review for falling BP."

The second one was to review a patient because his blood glucose was 12.6.  Now half the people walking around the Colonades on a Thursday afternoon would have a higher BGL than this, but sure, I'll take a look.  The first thing I notice when I walk in the room is that the guy is on a dextrose drip.  That'd explain it.  The nurse wonders if we should stop the dextrose because he's "hyperglycaemic".  Well, he's been admitted for an insulin overdose, so probably not. 

Next!

Avoidant

 
Something bizarre happened to me recently which I'm still trying to wrap my head around.  Here's the gist of it:

I got a call about a patient that sounded a bit dodgy, so I went and checked him out and came to the conclusion that he might have condition X, but the decision about this and any subsequent management was in any case above my pay grade, so I called the X-ology registrar.

There was a fair bit of back and forth involved with this registrar, but here are the lessons that he imparted to me, along with some sarcastic interpretive remarks by yours truly:

• If you suspect that a patient has a serious medical condition, don't document this in the notes, because if you do, the relevant expert will have to review the patient rather than simply dismiss your concerns out of hand over the phone.
• If you do get the relevant expert to review the patient, don't document this in the notes.  Instead, you should document their findings and recommendations as your own, because clearly an intern is the guy whose opinion you should trust about this stuff.
• Similarly, do not mention to anybody else on your team that you are getting the relevant expert to review the patient, or the long-suffering expert will be forced to write his own documentation and actually sign it, and ink is expensive these days.
• When you are documenting things, write as little as you can, or even less, or else people will think you are incompetent or retarded or trying to hide something. It will also ensure that subsequent clinicians will be able to start afresh in their own assessments, free from bias or preconception.

So yeah, the guy basically was happy to go out of his way to try to get me to stick my neck on the chopping block and assume a totally inappropriate level of responsibility.  Unfortunately I had already broken all his recommendations so he was forced to actually do his job.  So I'd say that I did mine too.

Medical magic

If medicine was a role-playing game, it would need some sweet magic items for us players to hunt.  Here are some suggestions:

• Gloves Of Probing - these mighty gauntlets, when donned, will magically extend from the finger-tips to the shoulders of any basically human-sized doctor.  They automatically exude a slippery lubricant which allow the user to probe into any orifice to palpate within, up to a depth of twice the user's height.  The lubricant makes it impossible for the wearer to manipulate hand-held items.
• Pager Of Silence - this small black box from the dawn of time bears a powerful enchantment which enables it to be perpetually silent and never emit the slightest noise, no many how desperately someone is trying to contact the user.  Legend has it that only registrars can use the Pager Of Silence without suffering the effects of a deadly curse.
• PTR's Everfull Cracker Box - no matter how many times crackers are taken from this box, somehow it is always full the next time someone looks within.  This item only works when you are not rostered on to take advantage of it.  More specifically, it will never work between 2 a.m. and 7 a.m.
• Stethoscope +5 - this mystical stethoscope imbues the wearer with the ability to distinguish between crackles (fine and coarse), crepitations, rhonchi, rales, wheeze, sneeze, cough, choke, stridor, and blitzen.  This item is totally ineffective if the patient is armoured with Blubber Of Concealment.
• Roster of Homecoming - this patient roster with attached list of your jobs is enchanted to fly back to its home in your pocket when a magic word is spoken.  The enchantment is effective against being left beside the ward computer, on the patient's bed, in the doctors' common room, in the cafeteria, in your car, in the operating theatre, or any other location where rosters may be mislaid.  If the magic word is spoken whilst the roster is already in the user's pocket, the roster will attempt to move to the other pocket, causing the user's pants to twist around back to front, causing a -4 penalty to hit in combat and automatic failure of any seduction attempts.

Any other suggestions?

Blogging vs internship

Blogging - sheesh!  Who knew it would be such hard work?

Actually it's not hard work, I just never seem to get around to it.  Which is annoying because working nights is fertile ground for a blog such as mine.  There is no end of bizarre stuff that happens in hospitals after hours, and as the cover intern it falls to you to deal with it.  At least two or three times per day I think to myself, "Now this is prime stuff, PTR, don't forget it!"

But of course, by 4 in the morning when it starts to quieten down a bit, the last thing on my mind is to jump on a computer and do some blogging.  I just want to curl up on the couch with my seven vegemite sandwiches and read mindless pulp sci-fi whilst crooning softly to myself.

The weeks off are no easier.  The Hatchling is at a great age where she's learning new stuff minute by minute, she's heaps of fun to do stuff with, she careens around like a pinball bouncing off everything, and by the end of the day I just want to curl up on the couch with my sixty-three cheese sandwiches and read back issues of wargaming magazines whilst breathing through alternate nostrils.

Blogging just never seems to get a look in.  Which is a shame, because I keep having ideas.  Just yesterday, I thought, "Hey - what if you were to rewrite the plots of famours adventure movies but set them in hospitals instead???"  And sure, that's a stupid idea, but in the past I would have actually done it.  But now I just dwell on it briefly and then fall asleep on my toothbrush.

Internship - sheesh!  Who knew it would be such hard work?

Once upon a midnight dreary

Lest you think that this blog has turned into a monologue on the idiocy of people other than myself, I have a story for you about my own idiocy.  Read on, gentle reader, and remember me in your prayers...

In the middle of the night I trundled off to a distant ward to review the person in bed 3 who was, according to the taskboard, mildly hypotensive and thus warranting a breeze-by from myself.  I got there and took a quick look at her observation chart, and was surprised to see that if anything she had been mildly hypertensive.

I grabbed a nearby nurse and asked if perhaps the most recent obs hadn't been charted, but they had.  That nurse was also surprised that I was there to review the patient in bed 3 and suggested that perhaps a mistake had been made and that someone had meant me to review the patient in bed 4.

"Choh! Typical!", I said, "Choh!  Lucky it wasn't an emergency! Choh!  Can't believe anything on the task board these days!  Not like the good old days when I first started, last Monday!  Choh!", and so on and so on.  (This may surprise you if you're under the impression that I'm basically a nice guy - I'd like to think I am but at 3 a.m. I get pretty damn self-righteous.)

But then when I got the chart for bed 4, he was pretty much the same.  No hypotension there.  So I grabbed the nurse again and pointed this out to her and started out again on my "Choh!" routine whilst unfolding my taskboard printout to show her the errant job that had all these errors in it.  Wrong patient, wrong vitals...

... and I got that awful sinking feeling that you get when you realize that you're the dickhead.  I was on the wrong ward.

A brief post illustrating in a few pithy sentences many of the issues which I feel permeate modern medical institutions with their excessive attention to hierarchy and acceptance of imbalanced power relationships between people who should see themselves as colleagues rather than master and servant

Today's oxymoronic utterance from a senior doctor:

"Don't do anything unless I tell you to!  And I need you to anticipate what I want."

Alfalfanumeric

 
You may or may not be familiar with warfarin, a drug that patients sometimes refer to as "rat poison" because it is used to poison rats.  Like most drugs, it was discovered when someone's cows died after eating mouldy clover, using a scientific process that is opaque to me, but undoubtedly involved much glassware.  The dose is often tweaked up or down each day depending on the results of that day's blood tests because otherwise the after hours cover intern would have nothing to do on the weekend.  Getting it wrong might mean that your patient bleeds to death internally or perhaps has a massive stroke.  No pressure.

So when I was called to the ward one day to clarify the daily dose of warfarin, I thought, yeah - fair enough - nobody wants to stuff this up, and doctors' handwriting is actually even worse than it is reputed to be.  But when I get there, the nurse points at the drug chart and asks, and I am not making this up, "Is that a '6' or a 'b'?"

I mean - like, totally, huh?  How could you prescribe someone 'b' milligrams of warfarin?

Not even I am nerdy enough to prescribe in hexadecimal.  Although if I was, I'd make sure that I did paediatric prescriptions in octal and neonates in binary...

Broken Arrow

 
When you're on night duty, you carry at least one pager.  If the nurses need to contact you they can page you and you respond as fast as you can.  Or they could use the online message board which you check at your leisure and prioritise yourself.  In theory, the message board is for non urgent tasks, while the pager is for urgent things.  In practise, this does not occur.  I got a page the other day, to which I duly responded urgently, and the subsequent phone call went like this:

Nurse

Hello?

PTR

Hello - you just paged me, what's happening?

Nurse

The man in bed 4 is having a hypo.

PTR

What's his blood glucose level?

Nurse

We haven't done that yet.  He just said he feels funny.

PTR

I see.  Why don't you measure his blood glucose and call me back?

They did not call back.  So I went round to the ward, wondering if perhaps they were too busy resuscitating the guy to call me.  They were sitting casually at the desk,  I picked up the patient's chart and saw that his blood glucose five minutes prior to me being paged was 7.9.  I said nothing but waved the chart at the nurse with what I imagine was a look of gentle inquiry on my face.

PTR

So?

Nurse

Oh, it turns out we'd done it but I didn't know about it yet.

This is an exciting development in medicine.  I look forward to being paged urgently to manage hypotension for which no blood pressure has been taken, catastrophic haemorrhage with no bleeding, and syncope with no altered consciousness.

Father's Day

Yesterday was Father's Day here in Owstralia.  I began Father's Day by calling someone in the early morning, waking them from sleep, and telling them that their father is dead.  I hope that your Father's Day was better.

String or nothing

PTR

Guess what's in my hands?

Hatchling

Keys!

PTR

No, guess again.

Hatchling

Keys!

PTR

No, not keys.  What's in my hands?

Hatchling

Keys!

PTR

Nooooo.  Try again.

Hatchling

Duck!

PTR

Haha, not a duck.  I couldn't fit a duck in my hands.  What is it?

Hatchling

Poo!

PTR

That's a good guess, but no.

Hurrah for bilateral symmetry!

One of the Hatchling's favourite words right now is "two!".  Due to her limited vocabulary it's been difficult to elucidate the precise reason for this, but here are some speculations:

• It's the first number after 1.  If you went around pointing out all the things that were occurring once, you'd be overwhelmed with work.  But things occur in pairs infrequently enough to be worth pointing out.
• It's easy to say.  Probably the easiest number of all.  Far easier than seven, three point six, or negative pi, for example.
• It rhymes with "shoes", another of her favourite words.
• Nyup nyup nyup beebeebeebeeee! Dada!

Be that as it may, the great thing about her favourite number (indeed, her only number) being "two!" is that I can wind people up by asking her questions to which the answer is 2, and watch them gawp in amazement when she gets them right.

How many elbows do you have?  Two!

How many ears do you have?  Two!

What eleven minus nine?  Two!

How many terms did Grover Cleveland serve as President of the USA?  Two!

How many spleens do you have?  Two!

It's a great game that the whole family can play.  Try it yourself today.  (But not on the Hatchling.  That would just be creepy.  Bug off.)

Top doc

PTR

I've got this awful prickling paraesthesia on the side on my finger.  It feels like I've got a splinter in it.

Smaller Half

Maybe you've pinched a nerve in your shoulder.

PTR

Oh my god, I've actually got a splinter in my finger!

The Australian way

 
It's not that I was chucking a sickie, you understand.  It's just that I'd had two aspirin the night before so I obviously wasn't feeling top-notch.  Not capable of turning in the type of world-beating performance to which my supervisors in the emergency department have become accustomed.  So I called in sick.

I haven't called in sick since my first week of work this year, when I dropped my pen on the floor in the surgical ward then picked it up and stuck it in my mouth, and subsequently developed such a bad case of gastro that after I'd turned myself inside out with the bum-wees, it was easier to just keep going in order to get back to my normal self rather than try to work the process in reverse.  But that's not important right now. 

So I called the ED clerk and told them I was sick and wouldn't be in today.  End of story.  Except for some strange reason she then forwarded my call to the ED boss on duty via his emergency phone.  So I told him I was sick and wouldn't be in today.  And he asked me what was wrong.  It didn't used to work like this in the public service.  Back then you just had to sniff and you'd be frogmarched out the door pronto.

I was first of all tempted to try to be humorous and give him some exaggerated symptoms.  Chest pain, haematemesis, faecally loaded on PR, pus behind the eyeballs.  But he's a humorless type of man, dry as a old boot.  Whispering death.  So I blurt out something feeble like, sore throat, sinuses, feeling bad.  Boy, you certainly feel like an idiot saying that to the boss in emergency.  When patients turn up with stories like that they are pitied and quietly ridiculed behind closed doors.

Maybe I should have given him a plan, like we do in patients.  I'm going to take more aspirin, get plenty of fluids and rest, browse the local bookshop, watch some replays of the Olympics, and maybe turn up on Friday for my next shift if you're lucky.  I think that would have impressed him.

Anyway, he said okay, as he kind of had to.  It's not like was I staring him down face to face trying to walk out of work halfway through a shift, as I was sorely tempted to last night before I took those aspirin that rejuvenated me like the waters of Croatia, sunny Croatia.  So I'd scored the day off.  Hey, I'm technically supernumerary, which is a Latin word meaning "beyond coinage", meaning they don't have to pay me if they don't feel like it, but in return I don't have to actually be productive, so don't try to lay that guilt thing on me.

My Smaller Half was working the day shift so I caught up with her for lunch at a little Japanese place opposite the Fine Medical Centre.  Despite my illness I figured I could probably choke down some unagi-don.  Mmmmmm.  As I went up to the register to pay, someone tapped me on the arm as I passed the table.  Holy crap!  It's one of the other emergency consultants, the one I was on with last night until midnight.  Busted.  If I'd known I was going to run into him today I would have planted some seeds.  Asked him if it was really cold in here or was it just me.  Attended to absent stimuli.  That kind of thing.

We had a quick enigmatic chat, during which I tried to look under the way without actually pounding on my chest and rolling my eyes back in my head.  Mostly I do this by pursing my lips together as if something is moving about deep inside in an unpleasant way.  I also absently rub my neck, in a manner suggestive of scrofula.  Work it baby!

Once my Smaller Half and I are outside, she says, Holy crap!  And I say, I really hope he's not on duty this afternoon.  Fortunately I'd had the foresight to photograph the consultant roster pinned to the wall in the office, so I quickly grep it up, and his name's not on it.  Phew.  Off the hook.  By Friday this will all be a distant memory.

Being sick near a hospital is harder than I thought.

ED haiku #5

There's nothing worse than
A vending machine dinner
Except no dinner.

Win at emergency

It's taken me a few weeks but I've figured out the secret of success in the Emergency Department.  First, some necessary background.  There are two halves to the ED: A side and D side.  On arrival, all patients are triaged into either A or D.  You go to A if you are likely to require admission to hospital.  You go to D if you are likely to be discharged after being seen.

My secret is this: always discharge everyone on the A side and admit everyone on the D side.  It doesn't matter how flimsy your justification is, or how ludicrously risky it is for the patient - the important thing is that you are creating a vibe, a persona, an imago, that will live forever and guarantee you'll pass.

Of course, you won't always be successful in executing this plan, since you need consultant approval.  But again, the key point is that you go into that conversation with the consultant with this firm recommendation and really shake things up.

Scenario #1, A side: Little old lady who lives alone with chronic renal failure comes in having been nauseous and ill for the past week.  Her potassium is up the wazoo, ECG changes, uraemic flap, confused and disoriented.
Your position: Discharge.  She'll be less confused at home, she has a renal clinic appointment next week anyway, all she needs is a litre of fluid over half an hour before we send her on.
Impression: You're a strong minded independent thinker who isn't afraid to voice their own plan.  Possibly somewhat confused and disoriented when it comes to clinical work, but at least you have the courage of your convictions.

Scenario #2, D side: Man comes in with bruise on toe that he dropped a block of wood on last week.  No disability but he had the day off so he thought he'd come in and get it x-rayed because he's never had an x-ray before.
Your position: Admit under orthopedics.  No wait, under plastics.  Get a CT foot done, then a follow-up MRI to assess for soft-tissue injury.  Run a panel of thrombophilia screens to alert the surgeons to your awareness of how serious DVT is.  Get three or four large bore cannulas in and a flatus tube for good measure.
Impression: You're a strong-minded independent thinker who demands the absolute best for your patients and won't take no for an answer. 

If you're not in ED at the moment, the general principle is the same.  Do the unexpected.  Nobody remembers the guy who was always boring and playing it by the book.  Step out there and make your mark!

ED haiku #4

Always check lipase.
You know you'll add it later,
Even for fractures.

ED haiku #3

To fit in don't shave
And wear a long-sleeved tee shirt
Underneath your scrubs.

ED haiku #2

The sick ones need it,
And it scares the well ones off,
So check the rectum.

ED haiku #1

Yellow eyes I wrote.
But the surgeon who came wrote
Scleral icterus.

Overheard in the emergency department

One doctor's plan for his sick patient:

"We're going to give him some stuff, do some things, and make sure he's safe."

Addendum

I've been thinking more about my previous words regarding virtual days versus real days.  I think the real nub of my gist is that any given day has only one paltry actual identity whereas it can have a multitude of virtual identities. 

For example, let's say I go in to work on an actual Wednesday.  Yawn.  How dull.

But what if that Wednesday was just a single day after a break, with a four day break afterwards?  Then that Wednesday is a virtual Monday, because it's the first day back.  But it's also virtual Friday, because it's the last day before a break.  And in fact it's virtual Maundy Thursday because it's the day before virtual Good Friday which will fall on actual Thursday.  That's three virtual days in one.

3 > 1, ergo virtual days are very physiological.

You're only a day away

The days of the week are, of course, illusions.  We usually aren't aware of this though because they are so ubiquitously subscribed to.  Somehow, somewhen, someone bullied everyone else into agreeing that this day, so indistinguishable from every other day, was in fact special and different, and should have a name.  And, weirdly enough, it would come back again in another seven days, just the same.  Think about it, it's a freak show.

No, I am not stoned.

It's just that working shifts for the first time in my life has torn the veil from my eyes, swept back the hoary eyebrows of familiarity, and shown me the truth.  It's made of people!!!!  Or something like that.

In my last position I was working a lot of Saturdays.  And on the Saturdays I wasn't working, I was working Sunday.  So Sunday kind of ceased to exist for me.  My week would start conventionally enough on a Monday, then go Tuesday, Wednesday, Thursday, Friday, then one extra day of work.  The Day That Dares Not Speak Its Name.

Being a programmer in the past, I was tempted to call it Friday++.  But that doesn't convey the full blackness of having to work that sixth day.  So instead I call it Double Scorpion.  Then the day after, that everyone else is calling Sunday, is my virtual Saturday.  If I had to work then too it would be Triple Scorpion.  This is when things get crazy, because the Monday after would be actually be Quadruple Scorpion for me, escalating all the way to Octuple Scorpion by your Friday and then Nonuple Scorpion when it should simply be my Double Scorpion on your Saturday.  That's only happened to me once, and it wasn't really that bad because the first Double Scorpion was only two hours work in the morning.  But that's the situation when you work a lot of overtime.

Shift work is different.  I'm now on my fifth consecutive day of work today, so it's virtual Friday.  (Not actually at work right now because my day starts at 11pm, but it's rostered for today.)  And this is my longest stretch of consecutive days for the next 2 months.  So this will be my only virtual Friday, and there will be not a single Double Scorpion for me.  Whoo!

Because my working week is broken up into little 3 or 4 day chunks, it means I'm frequently resetting the clock back to virtual Saturday, totally out of sync with the rest of the world.  When I started this placement it was (actual) Wednesday, but I had two days off, so for me it was virtual Saturday/Sunday.  Then I had three days of work, so it was virtual Monday/Tuesday/Wednesday.

Then I had four days off.  The first two days were virtual Saturday/Sunday.  But then the next two - what were they?  What happened is that at 11:59pm on virtual Sunday, the previous day was retconned to virtual Good Friday, and things proceeded from there to virtual Holy Saturday, virtual Easter, and virtual Easter Monday.  It was incredible! 

The practical effect of this is that for the next little while almost all my days are virtual Saturday/Sunday/Monday/Tuesday, with a few virtual Good Fridays and virtual Wednesdays thrown in.  A couple of virtual Thursdays, no more virtual Fridays.  It's amazing!  The only disadvantage is that my Smaller Half is also doing shift work but on a totally different schedule to me.  So right now I'm virtual Friday, she's virtual Tuesday, which coincidentally is also actual Tuesday.  But on Wednsday we're both on virtual Saturday which will be nice, although I'll be asleep for most of it, having worked all night, so it'll be more like virtual Friday night for me.

Still, it was worse beforehand.  The one time I had a Triple Scorpion, she was on her 5th day off because she was only working 2.5 days per week.  I don't even know what the 5th day off is.  It's unprecedented in my experience.  I guess if you went to a Twelve Days Of Christmas naming scheme you could call it Gold Rings.  I like the sound of that. 

Of course, this all goes out the window in August when I start a 7-on, 7-off roster.  So it'll be virtual Monday on Wednesday through to Triple Scorpion on Tuesday, then virtual Good Friday right through to Swans-a-swimming, then back to virtual Monday again.

I think it could catch on and be the next big thing.

Seine, Paris, France

Adding value

PTR

Hello, what's happening?

Man with moustache

Hi, this woman is having plasmapheresis and she's reported some peri-oral tingling.  Her ionised calcium before we started was 1.3 so I started with the standard citrate flow, but since she's gotten these symptoms I've turned it down 40% because I'm worried that she might be getting a citrate induced hypocalcaemia.

PTR

Mmmmmmmm.

[to patient]

How are you feeling now?

Patient

A bit better I suppose.

PTR

[to man with moustache]

So what do you think?

Man with moustache

Well we're nearly finished and her symptoms have resolved somewhat.  I think we might as well continue on as we are.  She's due for another run tomorrow, so what I might do is leave a note for the home team asking them to give some calcium prior and start off the citrate at a lower flow rate as well.

PTR

Ok then, that sounds good.  Anything else I can help you with?

Man with moustache

No, that's all thanks.

PTR

It was nothing.

 

A culinary proposal

Do any of you own a cafe or restaurant? Here's a tip: instead of having a cheese platter on the menu, have a “cheese splatter". It sounds much more hedonistic and indulgent.

First night last night

Last night I did my first night shift down in the Emergency Department.  It was also my first shift of any kind in the ED.  So I was a bit tense beforehand about a new environment as well as a bit tense about the whole "stay up all night and deal with stuff when there's only a skeleton crew on in the hospital" thing.

But you know what?  It was actually fine.

It's still a bit intimidating knowing that not only could literally anything walk (or be pushed) through your door, but also that the triage screen details sometimes bear only a tangential relationship to what's actually going on.  Like the guy last night who was noted to have haematemesis and malaena (ie: bleeding from both ends) who actually had neither.  Thankfully.  But the saving grace is that the staff who work there are all incredibly supportive and helpful.

Astonishingly, you are expected to function in accordance with your experience and training.  So if you're an intern like me, they keep an eye on you and give you lots of help.  And if you're new to the ED like me, they also are happy to explain the processes that you're unfamiliar with, without all the harrumphing and sighing and implied dissatisfaction that I have become accustomed to in some of my other rotations.

As you have probably guessed by now, this was a great revelation to me.  If only other parts of the hospital were as good, I would probably have been good deal less stressed for the past couple of years, and I would probably be a better doctor as well since people would actually have bothered to give me a headstart on what I needed to know and do, rather than lay guilt trips on me and stomp off into the distance.

On the other hand, the staying up all night thing is a bit pants.  I had a master plan to get myself into sync.  I stayed up late the night before, intending to sleep in and get as much rest as I could.  Instead, my Smaller Half got sick and had to sleep in instead, I had to get up early with the Hatchling, so I went into my stretch of night shifts even more tired than if I'd done nothing at all.

I got home at about 0900 today, was in bed by 10, crashed out and slept until 3.30pm.  So five and a half hours sleep.  I'm feeling a bit ragged but I've already got that seedy "too much coffee" feeling in my eyes so I guess I'll just be staggering through the night and hoping to catch up on sleep tomorrow.

By the way, the phrase "I'll sleep when I'm dead" really annoys me. No you won't, you'll be dead.  And you will have been really tired and shitty when you were alive because you weren't sleeping.  Just get some sleep while you can, moron.

Out.

Coffee tips

In a comment to my previous post, the boldly titled "Anonymous" questioned why I was calling a babycino a bubbacino.  Fair call.  To clarify, here are some similarly named coffee styles with explanatory notes.

Babycino: an espresso cup filled with frothed milk.

Bubbacino: an espresso cup filled with frothed milk served in a jail cell with a large, lonely, tattooed man.

Bobacino: an espresso cup filled with frothed milk served by a Mandalorian bounty hunter.

Babarcino: an espresso cup filled with frothed elephant milk.

Babayagacino: an espresso cup filled with frothed milk from a cannibalistic Russian witch.

Barbarinocino: an espresso cup filled with frothed milk served by a young John Travolta.

Bulbarcino: an espresso cup filled with frothed milk by a barista with a cranial nerve palsy.

Baabaacino: an espresso cup filled with frothed milk from a black sheep.

Not all of these are commonly available, at least not in Adelaide, but keep an eye out.  They're worth trying if you get the chance.

My bubba's too beveragalicious

PTR
Could I please have a cafe latte, a chai latte, a weak latte, and two bubbacinos?

Numbnut waiter
What's a bubbacino?

PTR
It's a little cup filled with milk froth.

Numbnut waiter
Oh, like a babycino?

And to save you the time making snide comments, I concede the following points:

1. Yes, bubbacinos are an absurdly yuppyish thing to order.  But at this place they were free, and I'd rather order a free bubbacino than have my $3.50 coffee sabotaged by a lunging Hatchling.
2. Yes, a weak latte is a girly thing to order.  Fortunately my Smaller Half is quite girly.
3. Yes, a chai latte is also an absurdly yuppyish thing to order.  But it was for a friend we were meeting hence I take no responsibility for her choice of beverages.

Now those issues are cleared up, let's focus on what a numbnut the waiter is.

Gargan Death Carrot

Yesterday I was alerted to the existence of the Gargan Death Carrot.

I know you think I made that up but I didn't.  Admittedly, even Google only seems to be aware of it tangentially, and Wikipedia not at all, but I can assure you it is real.

If you want to verify the truth of what I am saying, travel to the misty shores of far off Adelaide.  Go to the Botanic Gardens, just to the east of the Royal Adelaide Hospital, where the bamboo sways to unfelt breezes.  And find therein the eternal Museum of Economic Botany.  Enter by the door on the south side, amidst the deepest shadows.  Turn away from the temporary exhibit of Banks' Florilegium and the grim posturings of Robert Hughes displayeth on video beside.  Turn ye to your left and inspect the display of the members of the carrot family in the glass cabinet before you.

And quake as you behold the Gargan Death Carrot.  Marvel at the shrivelled pieces of unrecognisable vegetable matter in front of you.  Wonder at the simple description that from it can be extracted a resin that is mixed into plaster.  And leave, because that's it.  Yes, having included an exhibit called the Gargan Death Carrot, the curators then failed to provide any information on it beyond some simple home decorators tips.

What is the Gargan Death Carrot?

Is the carrot deadly?  Is it poisonous?  Is it very sharp and pointy and can be hurled like a spear?  Is it hard and useful as a bludgeon?  Or perhaps it incites in its devourers a murderous rage?  Perhaps, like the mandrake, it shrieks as it is uprooted, slaying all those in earshot.

Or is it a symbol of death?  Did the Society Of Assassins in distant Garg have as its symbol the native carrot, for reasons unknown?  Or were condemned criminals permitted one final meal of Gargan carrot, which is so delicious that consumption is otherwise only permitted to the Prince Regent in his Black Tower?  Or were slices of carrot used to weight down the eyelids of the dead, granting them eternal rest?  Are the shades of the dead welcomed to the gardens of paradise by the carrot?  Or perhaps the dead are terrified of the carrot, so bunches hang in every peasant hovel to guard against witches and hobgoblins.

I looked long and hard through the rest of the exhibits, searching for similar items of eldritch lore.  I sought out, but did not find, the Guinean Haemorrhagic Yam.  I heard rumours of the Batavian Agony Pea, but could not confirm its whereabouts.  And the Apoplectic Prussian Leek was conspicuous only by its absence.

The wheels of knowledge turn slowly.

What we do in between patients

PTR

What does this abbreviation FFMN stand for?

Registrar

"Fasting from midnight".

PTR

I wouldn't abbreviate midnight as MN.  I'd just write FFM.

Consultant

But that would be "Fat free mass".

PTR

What's that?

Consultant

It's the old-fashioned way of saying "Lean body mass", your weight if you weren't obese.

Registrar

Oh, by "mass" I thought you meant a church service, one just for skinny people.

Consultant

So a fat free mass would be where you give the anorexic the wafer and she just vomits it back up again.

Bored on a wire

Internship is all about balance.  People will give you all sorts of garbage advice about work/life balance.  It's garbage because it's impossible.  Work wins.  Life loses.  The end.

No, the balance I am talking about is the balance of how you spend your time at work.  At various times you are working for the patients, and at other times you are working for the consultant (the big boss).  Very occasionally you are working for yourself, such as when you go and get a cup of coffee or sneak off to open your bowels.  Refer to my previous comments about work vs life.  Pooping is life and is to be savoured as it arises.

So anyway, I was talking about patients vs consultants.  This is something I struggle with.  I tend to get caught up in spending lots of time talking to patients and their families.  Nobody else but the intern bothers to take the time to explain what the test results are, what they mean, what the prognosis is, what else might happen, whether or not this is all someone's fault or not, and in as much plain English as can be mustered.

I tend to spend a fair bit of time on this because:

1. Ostensibly it's what the hospital is there for.
2. I feel sorry for these people that Life has dealt a bad hand too and I want to help them out.
3. When I do it, they always say really nice things to me later on when they leave hospital about what a great doctor I am.

So it's a mix of idealism and rampaging ego that motivates me.

Unfortunately, spending my time working for patients means that every now and then my consultant misses out.  Such as the other day when I was busy explaining to my patient's family what was going to happen now that we'd discovered that a lot of bad shit was going down with him.  It meant that I was 5 minutes late to a drug rep talk about some new drug that does the same thing as some existing drug except it costs more.  It had been arranged by my consultant and clearly his dignity was bruised that I hadn't prioritised it above all else.  I could tell this because he said to me, "If you can't be bothered turning up to education sessions you can get the fuck off my ward."

You know, the more I think about it, the more I think I've got the balance just about right.

Awaken the giant within

Every now and then someone remarks to me that they wonder how I can cope with doing my internship at the same time as my Smaller Half whilst also trying to look after the Hatchling. The answer is of course that I don't. Cope, that is. I spend most of my waking hours desperately trying to catch up to where I'm supposed to be and never quite making it. And my sleeping hours I spend having bizarre dreams about imaginary medical conditions suffered by fictional patients that I have to try actively to forget upon waking lest I blurt out something insane sounding on the ward round the next morning.

"Mr Upendis hasn't had his brain biopsy yet so we still don't know where the chocolate is coming from!"

Be that as it may, it is made easier than it might be one you realise that caring for patients is almost exactly like looking after a one year old.

Patients: did they sleep well?
Hatchling: did she sleep well?

Patients: do they have a temperature?
Hatchling: does she have a temperature?

Patients: have they had their bowels open?
Hatchling: has she just made a special delivery?

Patients: how's their fluid balance?
Hatchling: has she had enough to eat and drink?

Patients: have you checked the gentamicin levels?
Hatchling: would you like me to read you Hairy Maclairy From Donaldson's Dairy?

Patients: can you get the neurosurgery registrar to review them ASAP?
Hatchling: you look so cute in those little purple trakkie-daks!

The similarities go on and on and it makes everything so much easier. So for those of you embarking on medical careers, my advice is to have children right now. Especially if you might be competing with me for jobs in the future. Yeah, that's it.

And if you already have small children, why then, enrolling in a medical degree and working 7 day weeks for some sociopathic overseer will be just the ticket to sharpen up your parenting and really bring you closer to your family.

And while you're at it, write some damn blog posts on your phone using the stupid touchscreen. Ow! My arm!

Watershed

This is a milestone. History in the making! One small step and all that. This is the first (and at this rate possibly the last) post I have written and posted using my mobile phone. So much technology! I am also typing it using my bionic arm. And it is packed full of subtle military nanomemes that will compell you to melt down your jewellery and send it to me. Electrickery!

Breaking bad

Doctor 1

[Bursts into room, sweeps aside the curtain around patient's bed]

So mate, turns out you've got cancer.  Any questions?  No?  Sure you'll think of some later.  We'll see you tomorrow, okay?

[Sweeps out again] 

Doctor 2

And that's a really good example of how not to break bad news to someone.

Honestly

The truth is, it's been a dark time.  My last post before my prolonged exile from blogging was back in January.  On that day I got news that my cousin, just a few weeks younger than me, had died.  It was unthinkable to resume writing here as a professional smart-arse, so I thought I'd take a break before posting a moving tribute to her.

And the break grew.  Because I didn't know what to say.

How is it, I wondered, that I can write an eloquent and moving tribute to my crusty and decrepit old cat, and even write a eulogy for a pair of underpants, but can't come up with something for a person - a person who had had their whole life, and the lives of her family and friends, stolen away?

So I waited.

I kept waiting for inspiration to strike.  I'm a doctor, I thought.  I'm close to sickness and death every day.  I must have some keen insight to offer.  Some deep philosophy to soothe the pain for those still living.  I even tried writing something a few times and came up with nothing but cliches.

Eventually I realized that I had nothing new to say.  How could I possibly even begin to enlighten, let alone comprehend?  How could I be so vain?

My cousin's brother, who, in a coincidence worthy of the Celestine Prophecy, is also my cousin, sent me a message after she died saying that she had really enjoyed reading this blog and that it had made her happy to laugh at it.  I was thinking about that message when finally I decided that if all I could come up with to honour her life was cliches, then I'd do so with the worst cliche of all - "This is what she would have wanted".

So, K, the resumption of this blog is dedicated to you and to everyone who shed a tear for you, myself included.  I like to think you would smile to read it.

PTR

They seek him here, they seek him there

So it seems I have some explaining to do.  My legion of fan has been baying for blood due to my extended absence from the blobosphere.  Here's the deal:

When the Australian dollar nosedived against the peso after a hijacked bus exploded at a tin mine in downtown Brussels, my finances took a battering.  I was sold so short that the debt collectors came knocking on my door before the rear-vision mirrors flew past The Hague.

So I cooked up an elaborate scheme whereby I sold my organs on eBay one by one - always to the same buyer mind you - an elderly squillionaire in Bombay who was naively seeking immortality.  Eventually the total mass of transplanted organs from me passed a critical point and my Theory Of Cumulative Metabolic Consciousness was proved correct when I suddenly found myself an elderly squillionaire in Bombay.

Getting a visa back to Australia was no obstacle.  I simply transferred all assets back to my old self who was still sitting on ice back in Adelaide before re-selling my own organs back to myself, resulting in me waking up cold, scarred, but my old self once more, and filthy rich.

Naturally this kept me quite busy so I didn't have time for blobbing, especially not whilst trying to work as an lazy intern in a busy hospital and being a marginally effective parent to the child progeny Hatchling.  So I apologise to those of you whose lives have been made more bare and stark.  I can only promise that herein I will imitate the sun, who doth permit the base contagious clouds to cover up his blah blah blah etc so it's all like "Here comes the sun, doo doo doo doo" you know?

I'm back.

Get out while you can

 

Get out while you can,
It’s not too late to start again.
For you know what you have known,
Nothing here can ever grow.

Wedding rings are broken wings,

You won’t need these things you’ll find.
Sail on my love and leave this place behind.

Leave before the tide,
Let the moonlight be your guide.
I want for nothing more 

Than for you to find a better shore.
Wedding rings are broken wings,
You won’t need these things you’ll find.
Sail on my love and leave this place behind. 

- Scott Wilson

Hyper-tension

Aah.  Today I got home at 6pm.  There's a small pile of late discharge summaries on my desk (the things we send out to the GPs telling them all the terrible screw-ups we made in hospital) but I have a new registrar arriving tomorrow so I seized the opportunity to be slack and took off.  My old registrar called me at about 5.45 asking me where I was and I was delighted to tell him that I was gone, all the patients were stable, and there were no new issues, goodbye and good luck.


I realized today that the suckiest thing about my job right now is not my job.  I actually kind of enjoy my job.  It's satisfying in that way that looking at a big pile of blood clots that someone has just pooped out can be.

No, the suckiest thing about my job is that when I get home it takes me about 4 hours to unwind.  I can't stop replaying the day in my head, wondering if I did this or that right, wondering what I forgot to do, trying to remember the detail of some x-ray or sputum culture in case I get asked about it the next day, trying to make sense of what's happening to me via the medium of sick people.  It makes me so tense that I lose my appetite and can't eat dinner, and I find talking to my Smaller Half and the Hatchling really hard.

I can usually stop this just before I go to bed.  Then I sleep (or not) and wake up tense again because I know that I have to go in for the ward round, which always brings a new shovel full of surprises.  So I can't eat breakfast much because I'm freaking out again.  As for lunch - ha!  The El Dorado of meals.  Much discussed, never seen.

I'm pretty sure that I've already lost about 5kg, especially when you factor in the brutal gastro that I caught in the first week on the ward.

So basically what I'm saying is that I've developed some kind of panic disorder precipitated by work.  From what I can gather, everyone does in this business when they first start.  It's just that people don't admit it.

Bee

 Oh. So. Tired.

Did another 13 hour cover shift yesterday (Sunday) and was busy busy the whole time.  Nothing too scary or deadly but it was exhausting.  It's a bit horrifying to realize that it's Monday and I feel like it's Friday.

The highlight of the shift was getting paged to go to a distant ward.  I walked in and the faces of the nurses behind the desk lit up like it was Christmas.  "Here's the doctor", they said, "He can help!"

At that moment I felt so proud.  The doctor is here to save the day.  "What seems to be the problem?", I asked in my most nonchalant manner, as if I've been doing this for years rather than two weeks.

They looked at each other eagerly, then turned back to me and asked, "How do you spell abscess?"

Telemedicine

On Thursday I was sitting in the ICU playing phone tag with my registrar and the cardiology registrar regarding one of my patients when my mobile rang:

PTR
Hello?

Caller
Hi, this is Kathy, could you please re-send that order for the iron infusion?  It's gone missing in pharmacy.

PTR
What?

Caller
The iron infusion for Mr Gibson.

PTR
[Desperately flipping through my patient list looking for a Mr Gibson and freaking out because I know nothing about him...]
Mr Gibson?  Where is he?

Caller
He's gone back to Caloundra.

PTR
Caloundra? I'm in Adelaide.

Caller
Is that Dr Hamface?

PTR
No, sorry, you have the wrong number.

My week so far

On Monday I kept telling myself that I just have to get through this year.
On Tuesday I kept telling myself that I just have to get through this rotation.
On Wednesday I kept telling myself that I just have to get through this week.
On Thursday I accidentally went to a nude beach.
Yesterday I kept telling myself that I just have to get through the day.
This morning I am telling myself that I just want to go back to bed.

Status idioticus

Thanks for your supportive comments to my previous post.  Since then things have improved a billion percent plus or minus 999,999,999 or so.  I'd like to think that it's because I am a winner, but that's only partially so.  Sadly, I still haven't managed to have any Vitamin C(ricket) but life can't be perfect.

Monday was not good.  I was there for 12 hours straight, didn't get to eat anything, didn't get to drink anything, if I hadn't been running around like a madman you'd have thought I was fasting for surgery myself.  Perhaps I'd be more productive if I wheeled a drip-stand around with me, with cool refreshing sea-water flowing into my veins, and a nice fat urinary catheter to cut out those pesky bathroom stops.

Things got off to a poor start when the Hatchling woke umpteen times the previous night.  I then managed to somehow miss half of the plans during the round and never quite caught up.  It didn't help that my RMO (the person between me and the Registrar, who is the person between the RMO and the consultant, who is the Big Boss) is away this week and there's no reliever so I'm kind of flying blind.

I failed to arrange some urgent consultations from cardiology and anaesthetics to prep a patient for surgery on Wednesday (today) because I simply couldn't get anyone to return my pages.  Either that or I wasn't in one place long enough to actually take a phone call.

Then the consultant surgeon came and asked me some questions about my patients and it turned out I had no idea about them because again I sleep-walked (slept-walk?) through the round, so he deservedly rebuked me for that.

Then I had two code blues (dramatic emergency for crashing patients) in 4 hours plus another patient started having massive rectal bleeding so I had to quickly arrange a whole bunch of stuff that I previously had no idea about.  And because of that, I fell further behind and the consults never got done and as I was sitting at my desk at 8pm scribbling out blood forms for the following day my Registrar came in and revved me about needing to get my shit together.

So I went home and the Hatchling was screeching because she hadn't eaten and was sick and was driving my Smaller Half bonkers because she's been just as busy as me and by bedtime I was pretty much ready to run away and join the circus until I realized that I already lived there.

Tuesday was better though and today was better again.  Here's some tips for new interns on how to make it so:

1. Get a student to write the notes.  Concentrate on trying to figure out what the plan actually is.
2. Review your patients yourself.  For surgical patients you need to listen to breathing, check IVT/fluid balance, check calves for DVTs, check the surgical wound is clean and ensure that they have correct anticoagulation.  This will put a cap on how much of an idiot you look like when the consultant starts quizzing you.
3. When your registrar starts flinging around multiple, ambiguous or conflicting instructions, make him clarify himself (or indeed herself).  He may in fact get annoyed that you "waste his time" by doing this, but if you don't you'll regret.  This is no time to be meek.
4. Page people once.  Give them 5 minutes to answer, then go through Switchboard to call their mobile.  Why we have a paging system when I am the only person who seems to actually use it is beyond me.
5. DO NOT LOSE YOUR PATIENT LIST WITH YOUR JOBS WRITTEN ON IT.  Seriously.
6. Ask for help within a few seconds of getting baffled or confused or being unable to find something or not knowing how to do something.  Sure, you might look silly, but at least you'll be able to go home at a sensible hour.  This is no time to be proud.
7. Write down everything you do in the notes.  Writing it down often makes you remember what else you should be doing as well.  Which may well make you yoyo back and forth between the patient and the notes, but hey, what's the alternative.  This is no time to be super-organized and work hard through med school so you know what you're doing.  It's too late for that shit.
8. Drink lots of water.  Do not eat the junk food in the office.
9. Stand up straight.  Sniff the morning breeze.
10. Be strong.  Be energetic.  Be determined.  Know yourself.  Be the ball.  Keep left.  Buy low.  Sell high.  Take the All-Bran Challenge.  Squeal like a pig.  Something's gotta work!

I just wanted to say good luck, and we're all counting on you.