Shortbrain

Initialisations, abbreviations and acronyms.  Medicine, like any complex field, is full of 'em. Some of them are similar but mean very different things.  And some of them are doctor's own personal shorthand and don't mean much to anyone else.  So if you're ever unfortunate enough to work in, visit, or be a patient in a hospital, be very careful when you start flinging them around or you may end up with more than you bargained for.

Last year I was talking to the family of a person who had had a stroke.  They were filling me on the patient's medical conditions.  I went and told my registrar that the patient had a family history of IHD, PVD and EPOG.

EPOG? asked my registrar.

Yes, I said.  The family told me that the patient's son had EPOG.

My reg laughed and said, EPOG is Enduring Power of Guardianship.  Difficult to treat.

What kind of sick do you has?

At the moment my job is kind of strange.  I do nothing but admit people to hospital.  I make some decisions about the immediate treatment and investigations but after that they aren't my responsibility any more.

It's bad in that I have to make an effort to follow the patients after that to find out whether or not I got things completely wrong (more on that another time).  But it's good in that I get a nice look at a representative cross-section of all the people who are getting sick and coming in to hospital, so I learn a fair bit.

For example, yesterday I admitted:

• a little old lady who got a urinary tract infection (UTI) and fell down,
• a little old lady who got a UTI and fell down,
• a little old lady who got pneumonia and fell down,
• a little old man who got a UTI and fell down,
• a little old man who got both a UTI and pneumonia (but he didn't fall down), and
• a little old lady who fell down.

I'm not convinced that this is preparing me well for the physician's exam in 2 years time, but I suspect it is good background for my Plan B of being a GP.  Also, I've decided that when I get old (ie: in about 5 years time) I'm just going to munch down on trimethoprim and amoxicillin for breakfast every day, just in case.

A prescriber's guide to cephalosporins

Antibiotics - they're confusing.  Especially the cephalosporins (Greek for "mushroom-head", or maybe not) which all have very similar names but quite different properties.  I keep having to look them up to make sure I get it right, so I decided to put together this quick guide to the main cephalosporins in use today in Australia's public hospitals.

Cefazolin - a first generation cephalosporin.  Acts by disrupting synthesis of the cell-wall of Gram positive bacteria.  Limited efficacy against Gram negative bacteria.

Ceftriaxone - a third generation cephalosporin.  Like other 3rd gens, has narrowed efficacy against Gram positive species, broader spectrum activity against Gram negatives, and has hi-speed Wi-Fi, BlueTooth, and data network connectivity.

Cefameme - protoypical Gen Y cephalosporin.  Has little activity or efficacy against, like, anything.  Known to be useless but still frequently indulged due to its vocal complaints of unfairness.

Cefalopithecus - the original ancestral cephalosporin, known only by recovery of several fragmented tablets in the Rift Valley, Kenya.  Acts by carrying a pointed stick and a flat rock.  Known to be effective against nuts, grubs, and berries but with little action against cave bears and hence seldom used.

Cefapene - only prescribed by dickheads.

Cefexazaxxayaxx - a potent 9th generation cephalosporin, with both broad and narrow-spectrum activity against Gram positive, Gram negative, anaerobes, fungi, cave bears, and students, depending on which magic words you speak as you take it.  Versatile, powerful, safe, and packaged in an attractive tangerine box of 13, its only side effect is to cause the patient to excrete delicious creamy chocolate instead of stool.  Never yet successfully prescribed in Australia due to the overly fashionable and difficult-to-spell name chosen by the marketing department of Pharma-Jim, the company that discovered it.

Little less conversation

We've been hearing possums in our roof.  So we called the real estate gangsters and told them there were possums in our roof.  They told us to send an email to them telling them that there were possums in the roof, so we sent them an email telling them that there were possums in the roof.  They sent a Man, who knocked on our front door and told us that, having looked at our yard, he reckoned we probably had possums in our roof.  He climbed up into the roof-space and poked around for a while, then came down and told us that we have possums in our roof.  He then sat on our couch and wrote a report to the real estate gangsters telling them that we have possums in our roof.  Then he left.

Now I know how patients in hospital feel about doctors.  Except nobody ever died from having possums in their roof.

Autonomy

PTR

There's a small chance your collapse might have been because of your heart.  We'd like you to come into hospital so we can monitor your heart for 24 hours.  What do you think of that?

Little Old Lady

What choice do I have?

PTR

In the end the decision is always up to you.

Little Old Lady's Daughter

Oh no it's not.  You're staying here in hospital.

Little Old Lady

You see?

Music hath charms

About two years ago I ran a poll on the eve of the birth of the Hatchling, asking if we should have a girl or a boy.  Well, now the truth is dawned on me - we had a Yokel.

For about 18 months I thought we had a little girl.  Whenever we took her anywhere in the car she would shout out "Baa-baa song! Baa-baa song!" until we put her favourite nursery rhymes on to play.  If I ever tried to put on the radio or play something more, shall we say, sophisticated, she would say, "No Dada music.  Baa-baa song!" - all of which is consistent with my initial diagnosis of Little Girl Syndrome.

Then about 6 months ago I found that if I sang to her in my best Johnny Cash voice that she quite liked it - at least for a song or two.  Danny Boy was her favourite, but she also liked Folsom Prison Blues and Ring Of Fire.  At that stage I was thinking that perhaps she was actually a Redneck.  Not that there's anything wrong with that.

This morning, though, I was playing bluegrass by Bela Fleck and Earl Scruggs in the car while driving her off to child-care, and she was loving it.  She was slapping her knees with both hands, and laughing.  When I asked her if she liked the music she said it was "Funny!", which is her all-purpose term of approval.  She also pointed at the sky and said, "Yee-hah!", which is something she picked up from the song She'll Be Coming Round The Mountain.  It was a real hoedown in the back seat of my car.  And that was when I knew - she's a Yokel.

Just like Dada :)

Lincoln

My Smaller Half and I went to see Spielberg's new film "Lincoln" the other day. It was good. It was like a two and a half hour episode of The West Wing, but without Alison Janney, which was a shame. Still, I recommend it to you if you're interested in a film which is mostly dialogue about politics. It might be worthwhile reviewing your American civil war history before you go though. I made the mistake of reviewing my Spanish civil war history instead, which wasn't as useful as I'd hoped.  Being largely ignorant of US history and geography made the film more baffling than it would have been to my american doppelganger, but on the other hand perhaps that allowed me to concentrate on other aspects of the film such as the relationship between Lincoln and his wife, and their housekeeper.

 

However, there were two things about it that were difficult for me:

• Abraham Lincoln's voice was uncannily like Grandpa Simpson.
• The soundtrack was eerily similar to that of Forrest Gump.

 I kept expecting old Abe to burst into a rendition of "On the road again" before collapsing into a narcoleptic stupor. But it didn't happen.  And the film is not well set-up for a sequel in which this could happen because *SPOILER ALERT* Lincoln is assassinated at the end of it.  Who knew?

Code lupp

There are a bunch of emergency codes in the hospital that for some reason are named for colours. If you're ever around a hospital you may hear them being announced over the loudspeaker system. So here's a list of what those codes are which may help you know what's going on in the hospital.

Code blue - medical emergency. If you hear a code blue called for your own bed number, sit up very straight and open your eyes or somebody will stick a very large needle into you.

Code black - behavioural emergency. Somebody's gone off their rocker and is going to be wrestled to the ground by security and bombed out of their skull with drugs by the doctors. This can be done to patients, visitors, staff, basically anyone who flips out. If you get a code black called against you, rush to a phone and call a code black squared against the person who called it on you. Who says you can't tip the butcher back?

Code brown - if called by a doctor, it means it's time to go and have a coffee. If called by a nurse, it means that someone's pooed their pants. So make sure you know the situation before eagerly volunteering to be involved.

Code red - fire. Or smoke. Or a funny smell, like burnt cheese. Or the battery has gone flat in the smoke alarm. Or one of the surgeons got too enthusiastic with the cauteriser while reaming out somebody's prostate. Either way, someone's gonna get their door chopped down by a burly firefighter. Meow!

Code yellow - it's the middle of the night and you really really need to eat one of those small pieces of cheese that you get on airplanes, but the box in the RMO lounge has been pillaged and is empty even though it was refilled yesterday. Throw out a hospital wide code yellow and everyone will check the fridges in the nearby ward kitchens and respond if there is any cheese present.

Code purple - is used signify that:

• the Artist Formerly Known As The Artist Formerly Known As Prince has been admitted to hospital, and is putting on an impromptu performance in his isolation room. Be there now!
• a patient has severe testicular torsion requiring urgent manual intervention. Be there now!
• both of the above. Run for the hills!

Code white - useful for alerting one of your colleagues, who has worn a suit jacket to work today because they are meeting with their mentor/stalker/sugar daddy, that their shoulders are covered in dandruff and need a brisk brushing. Best not announced over the PA system, but rather whispered discretely into the ear of the victim. Or into someone else's ear if you'd rather the victim was oblivious for the time being but you want to share the joy.

Code orange - there's a Dutch man who insists on bliintzinge his floogeboorts for some individueel slaapcomfoort. At least that's what we hope is happening. If not this could get upgraded to a code black quite rapidly.

Code green - extreme nasal congestion. All hands on deck!

With this list we've covered the basic of emergency situations in hospitals. You should be prepared for anything. And I just wanted to say, "good luck, and we're all counting on you."

Some terminology explained

I've noticed that my family, my friends, and pretty much everyone who isn't actually a doctor themselves tend to become confused by the medical lexicon. Not the endless names of drugs, diseases, and anatomical bits n pieces, but the terminology used to refer to other doctors and their jobs or levels and what not. So I thought I'd publish this little list of explanations that may help people decipher what I'm banging on about.

Intern - you're an intern for a year after you finish medical school. This is reckoned to be the most stressful year of work, apart from the others. Your responsibilities are basically to do everything that is too boring, too dirty, too repetitive, too inconvenient or too "easy" for your superiors to do. You're also the first point of contact for nurses, which is even worse than it sounds, as they have to call you whether they want to or not.

RMO - Resident Medical Officer. You're an RMO for between zero and forever years depending on local circumstances and your progression through a training program, or not. An RMO occupies a pleasant mid-ground between the intern and the registrar. They know enough medicine to not be freaked out on a day to day basis, and they have both a subordinate to delegate to and a superior to be guided by.

Registrar - basically the most senior person in a training program who isn't yet fully qualified. In some training programs you become a registrar on day 1, so you leap from intern to reg in one step. In others you have to slog out years of work and study and pass some frightening exams before you can call yourself a reg. Either way, you are working directly to a consultant, and you are making the majority of day to day decisions about patient care yourself. Because they are training so intensely, the registrars are sometimes more knowledgable and up to date than the consultants, but propriety directs everyone to behave otherwise.

Consultant - fully qualified and a fellow of the relevant college of medicine, which are kind of like the houses in Harry Potter. For example, all cardiologists are evil schemers bent on world conquest. Consultants lob in from time to time and make seemingly ill informed changes in treatment plans which nevertheless produce miraculous results. At least that's what the registrar tells them afterwards.

Cover shift - an extra shift of work that you are assigned out of hours such as in the evening or on the weekend because there needs to be a doctor on duty. You'll usually be covering the whole hospital yourself which means that you're constantly fighting fires. Not literal fires. Unless you're covering a psych ward.

Surgeon - a surgeon does operations. Obvious.

Physician - a physician does not do operations. But they can do procedures. Which is an operation where you don't actually cut someone open. Or if you do it's only a small hole. Distinguishing physicians from surgeons is not always easy for the patient but here's the general rule: if your doctor has a personality disorder, they are a surgeon. If your doctor is completely neurotic, they are are a physician. Psychiatrists come in two flavours - completely normal pleasant people, and cannibalistic serial killers. The ratio is about 50/50.

Any other lingo that I need to spell out?

Man up or else

Valentines day. The day when mainstream men suddenly get uppity about being "told what to do". Despite the fact that compulsory presents on Christmas and birthdays didn't bother them. They resent being forced to visit a florist. Perhaps somebody will mistake them for a homosexual. Better buy sunflowers instead. They're much more hetero.

Still struggling? Consider this: what if Valentines day was also your Smaller Half's birthday? Wouldn't that up the ante a little?

Yeah? And what if Valentines day was also your wedding anniversary? Going to be so curmudgeonly now? Too much trouble to break out the plastic for some stem therapy?

Oh, and by the way, not only is it Valentines day, birthday, and wedding anniversary, it also happens to be the birthday of your only child. Pressure! Plus, it's Christmas. And Easter. And Anzac Day too. The moons, you see. A great conjunction.

But it's not that easy. You can't just give in and buy flowers. What if your Smaller Half is allergic to flowers? And not just sneezy allergic. I'm talking full on anaphylaxis within seconds of boarding a bus which days earlier was brushed up against by a passing bee. What now?

But you can't just NOT buy flowers. The flowers, although grown in practically slave conditions by helpless immigrants in Holland, provide their only means of economic support, without which they'll be expelled back to the Congo to an uncertain life, or death. The guilt, the guilt.

But wait, they aren't Dutch flower growers at all. They're Belgians. Ew. Put the blooms back on the shelf please. Sorry child slave flower growers, I'm not risking homosexual double birthday anniversary anaphylaxis just to line the pockets of some fat Belgian. Not while I've got this terrible diarrhoea.

You'll have to wait for Mothers Day.

Virtual images

I'm pretty much hooked on Instagram. Not in the sense that I'm sneaking off to surreptitiously Instagram or that I leave my baby in a hot car while I Instagram for hours. But if you take the CAGE questions for alcohol dependence I actually have a decent hit rate re Instagram.

Have you ever felt the need to Cut down on your Instagramming?
Have people Annoyed you by criticising your Instagramming?
Have you ever felt Guilty about Instagramming?
Have you ever need an Eye-opener Instagram first thing in the morning to steady your nerves?

While considering this I did feel briefly concerned. But denial is the spice of life, so I realised that it really wasn't a problem. After all, many of the finer things in life would also score quite highly on the CAGE questionnaire. Coffee, blobbing, cheese, sleep, Peppa Pig, geometry, reading, hot air ballooning and picking of the nose. How could we live life without them?

Instagram, for those you who don't use it, allows you to take or upload little photographs and gives you some basic colour filtering and highlighting tools to make them look a bit jazzier, and then you publish them to you account. It's like a blog for photos. Other users can see your photos or search for tags that you've labelled them with. You can follow other users and see their new pictures come up on your feed.

Everyone seems to use it for different things. Some people only seem to take selfies - pictures of themselves looking, allegedly, "hot". Other people seem to be obsessed with taking pictures of their food. Or their dog. Or boats. Or sunsets. Or coffee, cheese, sleep, Peppa Pig, geometry, nose picking and hot air ballooning. That's more my arena, that list.

When I first started playing with it I was mostly interested in colour and patterns, like my intermittently series of Pretty Textured Rectangles that I post here. After a while I got distracted by the small size of the photos (on my screen) and the fact that they were square, and I seem to have been conceptualising the photos as almost like tiny icons, of the computing variety. I was trying to capture the essence of the banana (for example) and nothing else.

But now, things have changed again. Now I think of the Instagram photo as like a visual haiku. For me, it's a way of capturing a tiny moment of beauty. Being mindful of the multitude of episodes in life where I catch my breath and stop for a second to dwell on something unexpected. I use Instagram to record that oasis of existence and show it to other people.

It's tempting to fall into the trap of trying to take the same type of photo over and over again. It's a visual social medium so other people can indicate that they like your pictures. And there's always part of you that wants to please other people so you'll be "liked" in some sense. So you're tempted (or at least I am) to give the crowd more of the same. Perhaps this is how the guy who takes pictures of nothing but sneakers got started.

But operating that way just makes me edgy. My fundamental principle now is that I'm taking the pictures for me. They are a visual journal of my life - not the entirety of it, but the parts of it that remind me that life goes on happening all around us and we need to notice it before it passes on, or we do.

So I'm not so different from the people who only publish selfies. Theirs of their bodies and clothes. Mine are of my thoughts and the cogs turning inside my mind to grind the grist of my perceptions into reality.

No more gaps

I kind-of promised a few posts back that I would explain how I came to have my RMO (or residency) job this year.  It's a long, fascinating story in a short and boring kind of way.  And it goes a little something like this:

I wanted to do a year of General Training this year.  General Training means you're in no specific training program.  This is because:

• I am indecisive, and can't commit to a future career,
• I am cowardly, and am too afraid to apply to a training program in case I am rejected,
• I wanted to do some more psychiatry,
• I wanted to do some anaesthetics, and
• I am lazy, and didn't want to have to do any study any time soon.

So I applied for a year of General Training at the hospital I did my internship at.  Naturally, as an outstanding and handsome young doctor I was hired and my every wish came true - not.

What happened was that four thousand other people also had the same plan and the hospital decided that they should hire a bunch of bozos so they could be closely supervised before someone got hurt - meanwhile the superior interns such as myself were thrown back on our resources since we could so obviously cope with it.  Or something like that.

So I was stuck without a job. The process in the arse end of Australia is that we get three preferences for different jobs throughout the state.  The advantage of this is that if you don't get your first preference, they know that you're a hopeless dud and they throw your application in the bin while laughing maniacally and sucking on a giant cigar.

Then after about a month of bitter self-recriminations, I got a phone call out of the blue from another hospital that I hadn't applied to.  They wanted to interview me for a job.  So I said yes, sedated all my patients, and drove to the other side of the city for the interview.

The interview went for half an hour and mostly consisted of the 3 members of the panel discussing between themselves what would be the best route for me to take in the mornings to bypass the rush-hour traffic. The other bits consisted of them hanging shit on each other, and in one case almost falling off his chair.  They asked me the expected questions, prefaced with "I'm sure you'll know the answer to this one but we have to ask", and then after I started to answer they would interrupt me and say, "Yeah yeah yeah, blah blah blah, that's great."  I was watching out of the corner of my eye as the departmental secretary filled out her evaluation form, just running down the page ticking all the boxes marked EXCEPTIONAL in a perfunctory way.  Seriously.

It was pretty clear to me that somebody had unexpectedly quit their job and they needed a replacement pronto.  Somehow they had got their hands on my resume and they liked it (I know this because we discussed some of the research I did in my prior life as Cleopatra, Queen of the Nile) and decided to offer me the job as soon as they saw I didn't have three heads and wasn't a serial killer.

Which is all great.  Except that halfway through the interview I realized (by peeking again at the evaluation form) that this wasn't an interview for General Training.  It was an interview for Physician Training.  (For Americans, this means Internal Medicine.  For non-medical people, a physician is a medical specialist like a cardiologist or a neurologist.)

Physician training is intense, scary, competitive and I had repeatedly told many people that there was no way I would do it.  So when they offered me the job, I accepted it.  I accepted it because:

• They pay me a salary.

So that's what's happened.  I got a job I didn't want by not applying for it at a hospital I didn't want to work at.  So far, all things considered, it's going pretty well!

Gamut

A sudden flashback to the recent Olympics - a FaceBook friend posts a comment there about the opening ceremony - that he had "experienced the full gamete of emotions".

And I laughed, thinking that if your gametes got involved, you obviously enjoyed it far more than I did.

Wish list

I don't enjoy birthdays much any more. I used to think it was because I was:

• getting old and forgetful,
• jealous of the kids getting all those toys when I used to just get a cessation of whippings for 24 hours,
• exhausted from all the wretched children crawling around underfoot,
• a real prick,
• all of the above.

But I had a eureka moment the other day. Not in the sense that I rebelled against the imposition of a gold miners license, but in the sense that I had a sudden moment of enlightenment.

I realized that I really miss my Aged Mother's sticky-tape dispenser.  It belonged to my Dear Old Dad too in theory, but I never saw him use sticky-tape once in my life. He was more of an Araldyte and wire kind of guy. But that's not important right now.

My Aged Mother's sticky-tape dispenser was heavy.  When you lugged it into another room to wrap up your presents, it would softly thump down onto the table, its velvety black base smothering the sound under its weight.  It was heavy enough to work with one hand while you restrained the paper with your other hand.  It's little row of serrated teeth could neatly rip the tape off, leaving the end all zigzaggy like it had been snipped with pinking shears.

But in our house, the tape roll is just flung into a drawer with all the pens and bulldog clips and rulers.  It takes you five minutes just to find the end of the roll.  Meanwhile the wrapping paper has curled up and unwrapped itself from around the present you're trying to deal with.  It's garbage. Wrapping presents is so deeply psychologically scarring now.  It's no wonder I never remember anyone's birthday anymore.

So when my Aged Mother rang me up and asked me what out of the house I would like when she dies (which is an exercise she undertakes every few months), I should have nominated the sticky-tape dispenser.

But instead, I'm just getting the llama.  Sigh.

May contain coarse language

If you're (un)lucky enough to spend much time hanging around with doctors you'll undoubtedly hear them identify themselves or one of their colleagues as a shit magnet. Shit magnet doctors are the ones whose patients suffer sudden, unpredictable, bizarre, and potentially lethal complications, while the shit magnet doctor is on duty and typically after hours when little help or advice is available from more senior colleagues.

I don't believe in shit magnets.

You see, I don't believe in luck.  It's practically the only way I'm NOT like Han Solo.  Scoundrel? Check.  Corellian? Check. Sitting next to giant Wookiee? Check.  Believes in luck? Sad trombone. 

Luck, in the sense of a person consistently attracting bad luck or good luck, makes no sense to me, and long-time readers know that I am Captain Sensible.

So what's really going on?

For a long time I believed that these "shit magnets" were actually just whingers.  People who couldn't take the heat and yet didn't want to put down the hair dryer. Got two pages at once?  "I'm such a shit magnet." Your warfarinized patient fell down? "Shit magnet".  I do not concur. It's just run of the mill medicine and everyone else is dealing with it, so why can't you? This was consistent with my observation that shit magnets were often aesthenic control freak types, not that I'm a fan of such sweeping generalizations.

But recently I started to wonder.  I've seen a few self-proclaimed shit magnets at work, and also some self-pro-claimed non-shit magnets (who, from a physics point of view, are actually also shit magnets but with the opposite shit polarity so as to repel instead of attract the shit). And what I see is this - the same bad stuff happens to both.  But the shit magnets make a big effort to do everything properly and try to get things under control.  Whereas the non-shit magnets just let things slide. Their attitude is that if the problem isn't going to kill the patient before the end of their shift, it's not really their problem. This also was consistent with my previously mentioned observation that shit magnets were aesthenic control freak types, not that I'm a fan of such sweeping generalizations, also as previously mentioned.

So what's really going on is that the non-shit magnets are simply handballing their problems on the shit magnets who then deal with them properly.  At least that's my current theory.

Anybody got any other observations or ideas?

And falling right off again

[…]

Getting back on that horse

Since my habit of writing here is so broken, I'm starting small, with just one sentence a day.