An unfocussed ramble after a minor head injury

The Emergency Department can be a rough and tumble place to work.  I've been spat on, called a "greasy white maggot", had my underwear filled with jelly while I've been distracted.  And that was just the nursing staff. You should see how badly I'm treated by the other doctors.

But last Friday evening was a first for me: I was assaulted!

As you have probably guessed from the fact that I'm making smart-arsed blog posts about it, I wasn't hurt.  But I was briefly shaken.  I won't go into details, beyond making the following observations:

1. Old people may be puny but they can still be bloody fast.
2. If the nursing staff warn you about a patient, they probably know what they're talking about.
3. It's a myth that if you get hit by a patient, you are allowed to hit them back within 3 seconds and claim that it was self-defence.
4. Shouting at demented people does not make them any less demented.
5. Buy low, sell high.

All important lessons to learn, mark my words.

It's (a little bit) interesting to reflect on the general public's impression of emergency department mayhem and how it differs from reality.  Talking with non-medical people gives me the impression that they think the most dangerous patients are:

1. Patients with mental illness.
2. Patients high on the street drug du jour.
3. Drunks.

In my experience, the most dangerous patients by far are little old demented people.  They are really unpredictable and can be extremely aggressive, and it's very easy to underestimate them.  So my list of the most dangerous patients would go:

1. Patients with dementia.
2. Drunks.
3. Guard dogs with bees in their mouths.

Note that patients with mental illness do not feature on my list.  That is mostly because they are seldom dangerous (except to themselves, sadly enough).

Anyway, I came home at midnight on Friday with a jaw that clicked a bit when I chewed but by Saturday it was fine.  Which was a good thing because I spent the whole weekend eating non-stop.  What better way to celebrate your Smaller Half's birthday than by performing disgusting acts of gluttonous consumption? I should have known better than to butter and eat two more bread rolls shortly after saying, "Oh my God, I have eaten about four times too much already".

My position was that I ate the extra rolls to ensure I got value for money.  Her point of view was that the rolls were free.  My point of view was, "Aha! Exactly!" - a winning argument in my book.  At least until I had to be taken to hospital with a bowel obstruction.

So actually my top three list of most dangerous patients should be amended as follows:

1. Patients with dementia.
2. Drunks.
3. Gluttons.

Make of that what you will.  I'm tired and it's time to go to bed.

Non-renewable resource

"I'm so sorry for wasting your time."

It's surprising to me how often people say this to me at work in the Emergency Department.  Actually, it's not - it's surprising WHO says this to me at work in the Emergency Department, and WHEN, and WHY.

People never say this AFTER I have finished with them.  They always say it BEFORE-hand.  And the people who say it are usually the people who are absolutely not wasting my time.  These are the people that emergency departments exist to help.  They are most often elderly people who are quite frail and live alone, polite to a fault.  For example, they may have fallen down during a dizzy spell and been unable to get up again for some hours until they were discovered by chance.  You know - the people who could easily have turned up (or not) the next day - dead.

The other big pre-emptive apologisers are parents of very small babies, only a few months old, who have been dropped on their heads or have some kind of mysterious raging fever.  Again, people where things can go seriously wrong very rapidly, so coming to the hospital for a safety check is an entirely sensible thing to do.

Or the guy who broke a bone in his leg but didn't come to hospital for 9 days despite being unable to walk AT ALL because he thought it was just badly sprained and hadn't even taken any painkillers.  That guy apologised for wasting my time until I showed him his x-rays.

On the other hand, nobody has ever apologised for wasting my time when they have come to hospital on a busy Saturday night complaining of itchy arms.  And nobody has ever apologised for wasting my time for telling me that the pain in their ankle is so agonising that I can't even touch it, let alone expect them to bear weight on it, but who then, after being cleared of fractures with an x-ray, stand up from their wheelchair and walk unassisted out of the department.  And nobody has ever apologised for wasting my time when telling their child, who has bumped their arm and has a bruise, not to move it around like I am asking them to, just in case they hurt themselves.  These people do not apologise.

However, I can't complain too much.  Well, I can, and I just did.  What I really mean is that it is hypocritical for me to complain.  The person who wastes the most of my time is me.  And I don't even get paid for it.

Donate now.

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."

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."