The Smiling Assassin

One of bosses at work is known as the Smiling Assassin. Not the most original nickname, I'll grant you. But it's very apt. He will stare you down, and take you apart piece by piece, while grinning affably from ear to ear, as if he's your best friend in the world. 

Contrast this with one of the other bosses, the Inquisitive Assassin. He just keeps asking you question after question. What do you mean by this? What did the patient say about that? What other things might you consider? What's the evidence for that management plan of yours? Where exactly did you get your degree from anyway?

Then there's the Frowning Assassin. She will also show no mercy, but instead has a big scowl on her face the whole time. She's either perpetually disgusted at what you have to say, or very hard of hearing. 

Still, she's easier to deal with than the Surprised Assassin. Every time I speak to him about a patient, he reacts by jumping up, mouth wide open, eyebrows lifted, hands waving in the air like a jack-in-the-box. It's very unnerving, especially when he maintains that expression and pose while telling you why every thing you have said and done for the last three years was wrong. 

Once you've faced him down, you then might have to deal with the Weeping Assassin. He just sits there sobbing, presumably reflecting with a broken heart on the dreadful fate of the poor patients that we are trying to manage as we struggle along in our ineptitude. 

The last of the bunch is the Thoughtful Assassin. He sits there, rubbing his chin in contemplation, giving nothing away, just taking it all in. Then, when you've said everything you have to say, he kills you. Actually kills you dead. His favourite method is to wait until you turn away, then he stabs you in the back of your calf muscle with a poisoned umbrella. For the more senior registrars, he will use a more complex plan, as they are naturally wary from seeing so many colleagues fall along the way. For example, recently he obtained advance information on an incoming patient transfer from a regional hospital, and planted an explosive device in the handset of the telephone in the doctors' office, keyed to go off when the pager number of the relevant surgical registrar on duty is dialled. Kaboom. Whereas with the interns, he usually doesn't even let them finish their first sentence. He just has an accomplice in a nearby building pick them off with a sniper rifle. 

The Thoughtful Assassin is on duty tomorrow. I think I might call in sick. 

The day that you realize you're married to a psychiatrist

[Scene: On the couch, watching an advertisement for the forthcoming movie, Dawn Of The Planet Of The Apes] 

Smaller Half
Why do they keep making the same kind of film over and over? 

PTR
Aheywha? 

Smaller Half
They keep making these films about Man versus the Other, and the Other must be destroyed, but of course in the end it's Man who is the Other. 

PTR
Well thanks for ruining it for me.

Commentary commentary

And that's kick-off!

If you've joined us late, welcome to the exciting commentary between David Basheer and Craig Foster, who are commentating the World Cup match between Australia and Spain. This is expected to be challenging for both commentators, but possibly more so for "Foz", who, despite his big-match experience has been known to lose his composure and forget the big-match plan.  The challenge for Basheer, of course, will be to rein in his co-commentator and exert some control over the pacing of the commentary itself.

And yes, Fozzie is already starting to let his emotions get the better of him.  It's an exciting match, to be sure, but he needs to remember what his producers told him before the match: he's not part of the crowd now, he's part of a professional team delivering commentary to an Australia-wide audience, and to do that he just needs to relax a little and sit back - talk us through the action, try to provide some inside knowledge and perspective rather than simply rushing headlong into the play.

Basheer is having a good match though.  Each time there's a turnover from Fozzie, Basheer slows it down, uses his brain, constructs some good sentences by linking up words together to form coherent concepts.  It's a pleasure to watch him commentate, regardless of the result.  Oh! And that's an aggressive challenge from Fozzie during a key play, and Basheer is down! No, he's okay, back up again quickly and trying to get back into the action.  Fozzie needs to watch himself, if he gets too excited he could find himself on the bench for the second half.  The last thing the commentating team needs is to be down a man.

And that was a key moment, almost a blunder - Fozzie briefly referred to a player as Xavi when he was in fact Xavi Alonso, but immediately recovered and continued play.  An easy enough mistake to make, but it will get pounced on at this level and exploited.  I must say, the improvement in the Australian commentary team in the technical skills of name identification and pronunciation is remarkable.  We're simply commentating so much more fluently than even four years ago.  Some of the really tricky foreign phonemes have been rolling off the tongues of the team all tournament long.  Xavi is a case in point - that X, that V, neither of which are handled in the same way as they would be in Australia.  It's clear that both commentators have really done their research.

Oh dear, that's a let down - both commentators momentarily lost control of the situation when Australia conceded a sloppy goal.  Fozzie simply lying groaning on the floor, and Basheer sitting mute at the microphone.  This will be added to stoppage time at the end of the match.  The crowd back home will be disappointed in that - nothing but dead air coming over the audio.  They'll have to lift their game for the second half.

How interesting it is to reflect on the difference between the Australian style of commentating and the English.  Martin Tyler, the English great, seemingly ageless, able to stay calm and offer clear, dry, abstract commentary at all times.  Perhaps too calm for some, especially in the Australian leagues where the audience seems to require more overt barracking from their commentators, perhaps reflecting an underlying lack of faith in the team or lack of enthusiasm for the game.

But the team, Fozzie in particular, seems to have steadied their nerves now. Listen as he describes a poor sequence of Spanish play in objective teams, and then adds that it's disappointing to see that, whereas in the first half it would have been framed as an Australian triumph. He's acting much more in concert now with Basheer and it's clear from the way they hand the commentary back and forth, smoothly switching directions, effortlessly weaving anecdotes and analysis in between play-by-play descriptions  Surely if they keep up this level of performance they'll break through soon!

And here, Australia on the attack again, listen to Foz, he's really flying now. Back to Basheer, who rapidly disposes back to Foz - Foz to Basheer again, watch them go.  Basheer with a little metaphor there, very tricky, no, he's mixed his metaphors, but Foz has scooped it up and recovers well with some alliteration, but that's an opportunity lost.

The underlying structure and organisation of the team is emerging now as the game develops late in the second half.  Foz is taking over more when the ball is in Australia's half, with Basheer doing duty in Spain's half.  It's a good system which give some balance to the listener, and I think the producer has allocated their roles well.  When the ball is near the Spanish goal, Foz does become hysterical and incoherent, so Basheer is better placed to take over here, notwithstanding the screams and grunts that can be heard over the top of him.  And when Spain gets a good attack rolling you can hear the strain and desperation in Foz's voice but he retains control with occasional backup from Basheer.  How much influence, I wonder, has Les Murray had on this system, with his vast experience of managing Foz's enthusiastic ramblings on television?

And here we are, only two minutes of stoppage time added.  Both commentators, I'm sure, will be relieved to reach the end of this game.  You can hear them tiring, the energy is simply not there.  I can't help wondering if perhaps they didn't push just too hard in that first half when they were so hopeful.  I think it left them lacking legs in the second half when they really needed to keep the listeners involved after Spain's second goal.  Their talk became just a little lacklustre, lacking imagination and not as crisp as it really had to be to perform for a full 90 minutes at this level.  Nevertheless they put in a spirited performance which is so much a part of the Australian way of commentating.  I do wonder, though, if this might be the last time we see them commentate at a World Cup.  Sad to think that this could be the end of an era.

There's the whistle!  That's full time!  They push back their chairs, turn off the microphone, and take a deep breath. Another splendid performance from SBS's commentating team.  They're swapping shirts now, another one for the pool room.  Thanks for joining me, I'll see you next time with more commentary commentary.  If you have any commentary commentary commentary, leave a comment below.

Placebo effect

The placebo effect is oft misunderstood.  Strictly speaking, the placebo effect is the subjective or objective improvement in a patient's health after being administered a deliberately inert treatment which they believed would genuinely benefit them.  The label tends to get stuck on any number of unrelated though equally baffling phenomena.  Here's a few examples of similar effect which are in fact not placebo effects:

The nocebo effect. This is the subjective or objective deterioration in a patient's health after being administered a deliberately inert treatment which they believed would genuinely harm them.

The albedo effect.  This is the subjective or objective improvement of a patient's surface reflectivity after being adminisered a deliberately inert treament which they believed would genuinely make them more shiny.

The gazebo effect. This is the subjective or objective transformation of the patient into an outdoor, open-walled roofed area, usually octagonal, after being administered a deliberately inert treatment which they believed was a psychedelic drug.

The Placido effect.  This is the subjective or objective improvement in a patient's singing voice, particularly in the tenor range, after being administered a deliberately inert treatment which they believed was a gift from the Aoedean muse.

The libido effect.  This is the subjective or objective improvement in a patient's sexual drive or endurance after being administered a deliberately inert treatment which they believed was an aphrodisiac.

The bushido effect.  This is the subjective or objective improvement in the patient's ability to temper his violent martial instincts with forebearance, serenity and insight, after being administered a deliberately inert treatment which they believed was prescribed by the long-dead Japanese author and diplomat Nitobe Inazo. To be honest, it doesn't really come up that often but I thought I'd include it for completeness.

So the next time you go to your doctor complaining of having changed into a pavilion, belvedere, rotunda or pergola while you were tripping, and he mistakenly suggests that perhaps it was due to the placebo effect, you'll know precisely what to say!

No Known Drug Allergies

One day, when I have a bit more spare time, I'm going invent a medication which could be plausibly abbreviated NKDA, such as norketodopamine. (Does that name even make sense? Don't ask me, I'm a idiot blogger not a biochemist. But if you can have owlbears, I can have this.)

Then I will discover that it is not only therapeutically vital for the treatment of depression, acne, obesity, ischaemic heart disease, or some other such common condition, but also lethal if treatment is abruptly ceased.

And all over the world, pharmacists will have conniptions because patients will be bringing in prescriptions for norketodopamine re-supply, but the script will also have written, in the little box for Allergies/Adverse Reactions:

(Wait for it)

(You can see it coming, can't you?)

NKDA

That will be briefly amusing for me as I lounge on my Throne Of Spleens, contemplating my empire and watching the dancing girls.

A modest proposal for the solution of my employment woes

[Editor's note: this was written more than a year ago, and was recently unearthed from the dusty archives of my "Drafts" folder.  History does not relate the ultimate destiny of the young poet who scribed it to his beloved, so many moons ago blah blah blah but I forgot to hit the "Publish" button. Enjoy.]

Man, the last hour of work is always a real struggle.  Yesterday I powered through the first 11 hours of my shift with (relative) ease.  I was an admitting machine.  Ask ask ask. Talk talk talk.  Examine examine examine. Write write write write write write write write write write WRIIIIITE!!!  It's a doctor's life.  But the last hour, from 11 to midnight, was a killer. 

In all honesty, it was not a killer.  Nobody died.  I've had many many worse hours of work.  But it just sapped my energy and enthusiasm.  Lately I've really been struggling with my response to people who've had lifelong illness or disability.  I think my parental paranoia gets hyperstimulated by it and I start to dwell on the difficulties that these people and their families must have faced.

Then I get all shirty about how objectively wonderful my life is and why I'm not subjectively more over the moon about it all. But that's not important right now. What I'm talking about is how if I'd had that same patient earlier in the day I'd probably not have been so bothered about him.  But by the time I was tired and looking forward to going home, I was all fragile, like a beautiful butterfly or a little crispy cookie.

I think to address this, all my shifts should be one hour shorter.  Of course, it's possible that the same situation would recur, and I would once again become all dysphoric and whiny in the 11th hour of work rather than the 12th.  In which case I submit to you that the best thing would be to shorten my shifts again by another hour.

Eventually I hope to be working 1 hour days.

Dice man

Necessity is the mother of invention.  And boredom is the father.

Having to do solo ward rounds on the weekend is pretty easy.  Most patients don't need radical changes of plan over the weekend, and in any case the services often just aren't there anyway.  So most of the time you can make sure that nothing disastrous has happened and write, "Continue current management" as the plan.  All well and good.

But last year I was having to lead lots of ward rounds with me, the intern, and a med student.  My registrar had been off sick a fair bit and two mornings a week she was in theatre so I was "in charge" those days too. There's only so many days in a row that you can stall and do nothing before even the med student starts to look at you funny and (presumably) wonder if they couldn't do a better job themselves.  (I know this because I was a med student two years ago and frankly, the residents then were two-bit dumbo nothings. Not like now.)

So I needed some means of coming up clinical management plans despite not actually knowing anything.  (Necessity).  And one afternoon I found myself with 10 spare minutes while waiting for a phone call.  (Boredom).  Invention!

Presenting PTR's Patented Platonic Prismatic Planning Pthing:

I took one of the blue rubber cubes that come with ABG syringes.  On each of the six sides I wrote a clinical plan.  When you find yourself needing a quick change of direction in management, simply roll the dice and do as it says.  Here's a quick guide and accompanying commentary:

1. ICU.  You should call ICU and ask them to review the patient.  All patients benefit from an ICU review.  Even if they are completely clinically stable, ICU loves to be called so they get the chance to review patients before they get really sick.  It gives them something to aim for.
2. Discharge.  Everyone hates to be in hospital.  Everyone has to go home sooner or later.  We need the bed for the people who will be sick tomorrow.  Are you getting the hint?
3. Psych.  "You don't have to be crazy to be a patient here, but it helps!"  People who are sick in hospital often feel sad or withdrawn.  It's a reasonable reaction to a significant stressor.  But who is to say where the dividing line is between hidden relief at missing a day of work and crippling depression with suicidal ideation? Who is to say where the line is between an intermittently irreverent blog and complete psychotic breakdown?  A psychiatry registrar would love to get involved.
4. Nursing home placement.  Everyone hates to be in hospital.  Everyone has to get old sooner or later.  We need the bed for the people who will be sick tomorrow.  Are you getting the hint?
5. CTPA.  A honking great CT scan of the chest with plenty of radiation and some intravenous contrast to boot.  All to rule out some speculative nonsense diagnosis which was never going to be true anyway.  CTPAs are a great way to buy yourself extra time.  The radiology registrars need the practise, and for added fun you can remove the patient's IV line before the test so the radiologists can keep up their clinical skills by reinserting it themselves.
6. Palliative care.  Everyone hates to be in hospital. Everyone has to die sooner or later.  We need the bed for the people who will be sick tomorrow.  Are you getting the hint? 

Try it out yourself and let me know how it works out.  I'm thinking of developing a similar one for use in the Emergency Department so I'd love to get your ideas.

PE self-test

A pulmonary embolism (PE) is a dangerous, potentially lethal medical condition that is notoriously variable in its clinical presentation, hence is difficult to diagnose without performing invasive medical imaging. PEs occur most commonly when a blood clot travels down the pulmonary artery to the lungs, blocking circulation and thus preventing the lung from being able to absorb oxygen from the air properly. Not the sort of stuff you expect to see in a late night TV advertisement.

Yet a few nights ago I found myself watching an ad wherein an attractive young couple switched off the light in their bedroom, only to turn it back on again a few (subjective) minutes later, evidently much to the young lady's disgust. She then proceeded to harangue the young gentleman about his PE, urging him to seek assistance, whereupon the contact details of a suitable company were placed upon the screen. This all made no sense to me at all until I later discovered that PE is also an abbreviation for premature ejaculation.

It occurred to me that this type of mix-up must happen all the time, with potentially dire consequences. A patient turns up to hospital suffering PE and somewhere along the way there is bound to be some confusion unless everyone is clear exactly what is going on. So I have compiled this short quiz to help you test your knowledge of PE. Simply read each statement and decide which type of PE the statement applies to. Good luck!

1. Pregnancy can cause PE. 

2. A brief period of mobility in bed can cause PE. 

3. Patients with PE can appear breathless, tachycardic, and sweaty. 

4. PE can manifest within seconds, with little warning. 

5. A prolonged period of immobility in bed can cause PE. 

6. In PE the primary problem is often venous.
7. PE can cause pregnancy.

8. In PE the primary problem is seldom Venus. 

9. PE can cause sudden collapse and unconciousness.
10. PE is often preceded by the appearance of a hot, red, swollen extremity.

I will post the answers in a comment below in a week.