Lower back pain explained

In the last five weeks I've seen a lot of patients with chronic lower back pain.  Depending on the cause, they can also present with other symptoms which can be quite mystifying unless you have a detailed knowledge of the lumbosacral plexus - the network of nerves which leave the spine in the lower back and control the motor and sensory function of the lower body.

The problem is, the lumbosacral plexus is rather complicated.  That is, it has always been considered complicated until just this week when I realized that it can be easily understood in terms of the battle of Waterloo.  A little bit of work and voila!  This aide memoire inventee a moi pour la purpose de la education medique, as they say in France.

To use it, simply note that the French commanders are in blue, the Allied commanders are in red (British), grey (Prussian), and black (Brunswick), and the local villages and farm buildings are in brown.  (The Dutch are not included in this diagram since they correspond better to the visceral innervation.)

For example, if a patient came in complaining of lower back pain and sudden onset ineffectual cavalry charges in the genital area, the diagram clearly shows that this is the fault of Marshal Ney, and that the underlying lesion lies somewhere in the vicinity of the sleepy hamlets of Rossomme and Papelotte.  Or if the patient instead complained of lower back pain and surprise arrival on their flanks of a brigade of horse artillery, the diagram indicates that this is related to the activity of General Bulow of Prussia.

Every patient is different, of course, so please use these suggestions with caution and don't leap to conclusions.  But it's definitely worth asking, when your next patient comes in with long-standing back pain unresponsive to conventional treatment, whether or not a whiff of black powder or a snifter of grape-shot might help!

Insidious mind-control

As you know, life is unfulfilling unless I have something to rail against.  At the moment, things are going fantastically because I am on a righteous crusade against non-canonical nursery rhymes.  It may seem harmless when people tweak these little rhymes and songs a bit but stop for a moment and think about what these shadowy powers-that-be hope to achieve with their historical revision?  I put it to you that the culture wars are being fought (and lost!) right under our noses.  Soon our children will be placing calls to the Stasi in the dead of night to report on our activities.  Think I'm exaggerating? Read on.

It all started when we were given some type of poster-thing by a community midwife to encourage us to sing and read to the Hatchling.  All well and good.  But these are the lyrics to Twinkle Twinkle Little Star that were printed on the poster: (the emphasis is mine)

Twinkle twinkle little star

How I wonder what you are

Up above the world so high

Like a diamond in the sky

Twinkle twinkle little star

I'm so glad that you came by

How about that last line eh?  Stupid or what?  Stars don't "come by" to visit like they are your friends.  And it completely stuffs up the rhyming scheme of the song.  I can't say for certain why some faceless bureaucrat in the Department of Nursery Rhymes saw fit to change it.  But I'm pretty sure it's part of some leftist conspiracy to indoctrinate our children into thinking that it's nice to have people just dropping in out of the blue, so as to weaken our resolve in the Great War On Immigrants and erode the sanctity of property ownership.

It's amazing how many leftist conspiracies you can find in children's literature once you become sufficiently deranged and paranoid.  For example, one of the Hatchling's favourite books is one called Where is the Green Sheep?  This simple book shows us all sorts of other sheep in our lengthy search for the Green Sheep.  Entertaining stuff, to be sure, but the author and illustrator don't miss a single opportunity to brainwash us into their pinko views.  Here's a short list of some of the sheep in the book and their barely subliminal messages:

• The red sheep and the blue sheep - clearly intended to make us think that it's okay to look funny or to be born ethnic.
• The train sheep and the car sheep - the train sheep reclines in unnatural comfort amidst a seething menagerie of unhygienic foreign animals while the car sheep struggles to repair his broken vehicle.  How much multiculturalism, environmentalism, communism and other isms can be crammed into just one page?
• The thin sheep and the wide sheep - because sheep can't be called fat anymore because it might hurt their feelings.  Still, they can't stop me from the enjoying the juicy strip of wide down the edge of my lamb chops!
• The wind sheep and the wave sheep - more environmentalism, more lazy layabouts.  I see there's no brown coal sheep, no uranium sheep, not even a natural gas sheep.  Sheep don't need real jobs, being happy to fly kites and go surfing.  Hence no need for a construction worker sheep or a chartered accountant sheep or a soldier sheep or any other form of gainful employment sheep.  I'm surprised the illustrator didn't just draw the surfing sheep with a disability support pension sticking out of his back pocket while it laughs all the way to the bank!

 I'll bet you're not laughing now.  The next time you are reading a book to your child or singing a song to your baby, give some thought to what they might really be hearing.  Remember, if you don't vote Right, don't vote at all.
 

In a nutshell

Doctor

So, what did you think of that patient?

PTR

Well his relationship with his wife seemed very strange.  She's very passive and seems to out-source her aggression to him.  And she's very dependent on him but he just shuts her down when she vocalises her guilt.  He seems like someone with a lot of frustration in his life but the only way he is able to express that frustration is through anger.

Doctor

There's a simpler way of putting it - he's an arsehole.

My five favourite soups

My five favourite soups are:

1. Pho
2. Potato and leek
3. Pea and ham
4. French onion
5. Minestrone

Thank you for your help

Before I start... bugger.  Now that I've started, I want to make it clear that I do not have a seething contempt for nurses.  Oh sure, some nurses.  Like the bizarre passive-aggressive nurse I currently work* with.  He somehow manages to undercut me at me every opportunity.  Like the time I called in sick and he answered the phone.  When I told him I wouldn't be in, he said "Oh.  Well, I don't suppose it really matters anyway."  He's either a comic genius or a brutal misanthrope.  Or both.  Or neither.  Yep, that about covers it.

Anyway, I was telling you that I don't hate nurses.  I have no stories to tell you about likeable nurses to prove this because stories in which everyone acts in a reasonable and pleasant way aren't very memorable or interesting.  But just keep in mind that most nurses are great because I'm about to unload on one chump who happens to be a nursing student.

The problem is this - he seems to be very competitive with me and is always trying to show me up.  For example, on his first day I had a syringe driver that I was about to hook up to a patient.  The guy stops me and points to a series of tiny bubbles in the tubing and insisted that I flush them out of the line.  When I said I hadn't noticed them, he said "That's what nurses are for!  Lucky I was here."  For the record, to give someone an air embolus you need to get about 200 mL into their veins,  The bubbles in the tube would have been a fraction of a drop.  Still, nice catch there, Inspector.  He spent the next 10 minutes flicking the syringe to try to remove some errant molecules of nitrogen clinging to the side of it.

This week he managed to creep up behind me while I was discussing a patient's medication with her, and chip in with unhelpful comments just at the worst moment:

PTR

So you've gotten good pain relief from fentanyl.  This means we'll be able to think about a range of medications to find one that's right for you.

Annoying Nursing Student

It's a class of drugs called opioids.  Things like morphine.

Worried Patient

Morphine?  I don't want to take morphine! Isn't that for people who are dying?

PTR

A lot of people are worried about that.  But there are lots of people who use morphine or similar medications for pain control.  The reason that these drugs have this reputation for being for dying people is that they are effective.  So they do get used in extreme situations.  But they are also useful for people like you who only need much smaller doses.

Annoying Nursing Student

Watch out though, because if you take too much you'll stop breathing and die.

PTR

Sigh...

*"work" being defined in this case as performing pointless tasks for no remuneration.

The truth shall set you free

Baffled Consultant

I've never known students to be placed in that unit before.  Did you choose it?

PTR

Well, it was my 5th preference so, in a sense, yes.

Monologue

A rabbit.

A rabbit.

A rabbit.

Trust and safety

Today I simply present a longish quote from the book "Evidence-Based Medicine: How to Practice and Teach EBM".  Those long-time readers familiar with my tribulations in 2010 will understand why it resonates with me.

First, an extract from a table:

"Table 7.3 The top 10 mistakes we've made or seen in in teaching EBM.
Teaching EBM fails when:
...
9. When it humiliates learners for not already knowing the "right" fact or answer.
10. When it bullies learners to decide or act based on fear of others' authority or power, rather than on authoritative evidence and rational argument."

Then, the discussion:

"The ninth and tenth entries are included here because they are still commonplace among medical education programs, and at some of these institutions they remain a source of twisted pride.  Such treatment of learners by their teachers is not simply wrong in human terms, it is demonstrably counterproductive.  First, the resulting shame and humiliation learners feel will strongly discourage the very learning that the teacher's ridicule was meant to stimulate.  Second, in adapting to the rapid loss of trust and safety in the learning climate, learners will start employing strategies to hide their true learning needs and protect themselves from their teachers, undermining future learning and teaching efforts.  Understandably, learners with prior experiences of these behaviours may be very reluctant to even start the practice of EBM by asking a question, since it exposes them to the potential threat of repeated abuse.*

"*Contrast this with the actions of colleague David Pencheon, who asks new medical students questions of increasing difficulty until they respond with "I don't know".  Upon hearing these words, he rewards them with a box of Smarties and tell them that these are the three most important words in medicine."

Confidence booster

PTR

Hello, is it okay if I put a drip in your arm?

Patient

Oh my god! Oh Jesus!

PTR

Do you have a needle phobia?

Patient

No, I just saw what you did to that other woman.

Welcome to Port Adelaide

WELCOME to historic Port Adelaide! 

THRILL to the wide open vistas of the deserted streets. MARVEL at the endless blocks of boarded up shopfronts!  RELAX in a neighborhood cafe where moustachioed women ignore your every whim!  PONDER the local economy which seems to be dominated by the police station and magistrates court!  FEAR for your life as belligerent bikies roar past!  TRUDGE down the waterfront and wonder if things will open some other day!

Port Adelaide is happening.  No really, it is!  It's happening to you, right now!  Can you feel it?

Crazy horse

Being a parent sometimes seems to be a kind of benign psychosis.  You get so caught up in it that you lose track of reality.

The Hatchling really laughs and smiles when I bounce her up and down on my knee.  While I do this I sing an amazingly tuneful song that I made up about riding horses.  It goes:

Doo da doo doo doo-da-doo,
Doo da doo,
Doo doo doo-da-da-doo!
Riding on a horsey,
Riding on a horsey,
Doo doo doo-da-da-doo!

I've been doing this several times per day for the last two weeks and it only just occurred to me tonight, for the first time, that she has no idea what a horse is.  She doesn't understand a word I'm saying.  She just likes being bounced around.

It isn't her pretending that she's riding a horse, it's me.

I can speak English

Elderly Man
We've just been admiring your beautiful baby.

PTR
Thank you!

Elderly Man
If you don't mind me asking, where is your partner from?

Smaller Half
Queensland.

Leopard hunting

It is a truth universally acknowledged that it is more embarrassing to be caught staring at someone peeing in the park than to be stared at while peeing in the park.  Okay, perhaps it's not universally acknowledged, but it's the core tenet of my moral philosophy - one which finally came in handy yesterday when I caught someone peeing in the park.

We were taking a stroll in the crisp afternoon air down by the parks near the racetrack, when I glanced to my side and noticed someone behaving furtively.  She was middle aged, well-dressed, and would not have looked out of place sharing a bruschetta in a trendy cafe with her friends.  Except she was standing beside a clump of trees, looking back and forth anxiously.

Curious, I stared.  Suddenly she whipped her daks down and squatted at the base of the tree.  It was apparent to me that she was peeing in the park.  Normally I would have laughed and looked away, but now she'd committed to the act she was carrying it off with great zeal and elan.  In fact I wasn't even sure that she was peeing at all.  She wasn't hunched awkwardly forward - she was restfully squatting with a split-stance and gazing calmly into the middle distance in the manner of someone who is hunting a leopard and has just finished contemplating its spoor.  Perhaps I had misjudged the situation.  Perhaps she was in fact hunting a leopard in the Adelaide parklands.  With her pants down.

At this point I realized that if she were to look around and see me staring in astonishment I would be mortified.  The tables would be turned and I would feel like a creepy pervert.  The thing is, if you need to pee in the park, so be it - you just have to.  Whereas I was a voluntary participant in this sordid drama and I felt it reflected very poorly on me indeed.  So I alerted my companions to the situation so that we would be in the majority.  Excellent!

The woman then stood up, whipped her daks up again, and briskly strode off casually adjusting her fly as she went, in that way that people do when they are trying to look as if they aren't really fiddling with their groin when they actually are.  About 40 yards away a family picnic continued in blissful ignorance, which she then rejoined.

I wonder what she told them she was doing?

Aristotle said

"All men who have attained excellence in philosophy, in poetry, in art and in politics, even Socrates and Plato, had a melancholic habitus; indeed some suffered even from melancholic disease."

Maybe we still are in Kansas, Toto!

As usual, we went out tonight to celebrate Willie Nelson's birthday.  We had a great time, going back to our favourite Japanese restaurant.  We ate extravagantly, and lapped up the admiration of our fellow diners for the Hatchling.

Afterwards, we headed south and checked out a new dessert-only cafe.  Its doors don't open until 8pm and we fortunately arrived on the dot and secured a table to beat the rush.  Sticky black coconut rice, rose panna cotta and a stein of teh tarik.  Mmmm.

We got up to pay at the counter and I overheard one of the girls behind me admiring the Hatchling:

Girl

(to friend)

Look, look, how gorgeous!

PTR

(turning to show off the Hatchling a bit more)

Thank you.

Girl

(to friend)

Look at the little half-caste baby!

Gotta love Adelaide...

Comrades, fill no glass for me

Oh! comrades, fill no glass for me

To drown my soul in liquid flame

For if I drank, the toast should be

To blighted fortune health and fame.

Yet, though I long to quell the strife

That passion holds against my life,

Still, boon companions may ye be,

But comrades, fill no glass for me.

I know a breath that once was light

Whose patient sufferings need my care

I know a hearth that once was bright,

But drooping hopes have nestled there.

Then while the tear drops nightly steal

From wounded hearts that I should heal

Though boon companions may ye be,

But comrades, fill no glass for me.

When I was young I felt the tide

Of aspirations undefiled,

But manhood's years have wronged the pride

My parents centered in their child.

Then, by a mother's sacred tear,

By all that memory should revere,

Though boon companions may ye be,

Oh! comrades, fill no glass for me.

- Stephen Foster

Turnaround

Aged Mother

You're a dreadful photographer!

PTR

Why?

Aged Mother

In those photos you sent me of the Hatchling she looked like a real fatface.  But she's gorgeous!

Going with the flow

Each night, as I lift the Hatchling from her bath and place her gently in her mother's arms where she is wrapped in a thick white fluffy towel to soak up the water and keep her from the cold, I am accustomed to shouting out, "No prisoners!  No prisoners!"  It's just the way I roll.

A few days ago I was surprised when my Smaller Half asked me why I did it.  Naturally enough I told her that I was channelling Peter O'Toole in Lawrence of Arabia.  I'd been assuming for several months now that she knew what I was referring to.  It turns out she had no idea and thought it was just best to go along with it unquestioningly in order to stop me from becoming even more deranged.

How to win at med school

Medical school.  You can work your little heart out if you wish.  You could graft your buttocks to a library chair.  You could shamelessly brown-nose a senior doctor and hope to "noticed" and taken on as a new protege.  You could get all military and launch "Operation: Study".

But frankly, why bother?  The sole determinant of your clinical confidence as a med student is your ability to place intravenous lines into people's veins.  You may have eaten your textbooks for breakfast but if you can't slam in that cannula your mojo will be shot, down in flames, MIA.  Conversely, you may have skipped your last few years of classes but as long the first cannula of the day slides in sweetly, you'll feel like you can cure cancer.  Or at least dehydration.

When I was doing my anaesthetics rotation recently I noticed that anaesthetists like to hover over you and give you gratuitous advice.  If this happens to you, do not listen.  They are trying to steal your mojo using this old anaesthetic voodoo curse.  Shrug off the advice and dwell instead on this advice, given to me last year by a nice GP-anaesthetist:

Find the vein.  Put the needle in it.

Seriously.  You need to approach this task with a Zen-like serenity.  The less you are thinking, the better.

The reason anaesthetists try to steal your mojo is that cannula mojo is a zero sum game.  The better you get, the worse someone else gets, and vice versa.  Thus, it is important to mentally destabilise other students if you see them trying to place cannulas (or cannulae, as we used to call them in the Vetus Hospitium Romae).  This is easily done by offering advice, or more subtly, implying that they are so good that they don't need advice and thus the pressure to perform is on.

Last week on the wards, an Esteemed Colleague had been asked to change the cannula in one of the patients, a lovely old lady.  I wandered past in the nick of time and was able to wage psychological warfare on him from the outset.  Sadly, he got me back immediately.

PTR

Oh, going for that vein there, eh?  Huh.

Esteemed Colleague

Well it seemed like the best one.

PTR

Oh sure, you've got to go take your best shot.  

Esteemed Colleague

Darn it, I've burst the vein.  Big haematoma there.  Sorry, I'll have to try your other arm.

PTR

Oh yeah, that looks like a great one.  A sure thing.

Esteemed Colleague

Darn it, not again.  Maybe that first arm was best.

Lovely Old Lady

Maybe PTR should have a try?

PTR

Sure, I'd be happy to.  Hmm, this vein here looks good.

Esteemed Colleague

PTR's just done six weeks of anaesthetics where he did this all day, he's great at this.

PTR

Darn it.

On frailty

As previously noted, I own many books.  Many books.  This has been made abundantly clear to me by removalists, friends, visitors, and even - in what must surely be an exemplar of the pot calling the kettle black - my own Aged Mother.  Nevertheless, when I hear about a discount book sale I go rushing headlong to buy more.

I do this even though it would actually be cheaper to buy books online from places like abebooks in the UK, especially with the Australian dollar as strong as it is.  But I don't buy books online because I am inept at the key step of figuring out what I want to actually acquire.  Hence bookshops.  It's great to walk in and be immersed in walls of books, a paperback prison that frees rather than constrains.  It's not until I look at ten shelves of books on ancient history that I suddenly realize that my life hitherto has been incomplete because I lack a comprehensive knowledge of the campaigns of Scipio Africanus.  That's the kind of insight that you just can't get online.

Little did I know that this is merely the tip of the iceberg.

Yesterday my Smaller Half, the Hatchling and I went to the big sale at Borders in the city, which is going into administration due to bogus management.  20-40% off everything in store.  We split up and agreed to meet back in half an hour.  I was super restrained and only got two books: some stories by Jorge Luis Borges (whose name I mention here primarily because I don't know how to pronounce it and hence will never be able to use verbally) and a book by Jon Krakauer called Into Thin Air, both of which I have been coveting for some time and merely needed a tiny knock such as a 20% discount to crystalize the purchasing impulse in my mind.

My Smaller Half failed to arrive at the designated rendezvous point so I went searching for her.  With a dark sense of foreboding I made my way to the only possible place she could be - the children's books section.  Forty five minutes later I was only able to crowbar her away from there by surreptitiously provoking the Hatchling into a tantrum and announcing that it really was time to leave.  We had to leave the store with me carrying the Hatchling and the pram piled high with new kids books.  In a stroke our book-buying tendencies have multiplied.

Mind you, we got some absolute crackers.  Several Richard Scarry books, an incredible pop-up book that I probably would have bought for myself anyway, a set of Beatrix Potter books, some cute little fairytale books, and more.  And more.  And more.

Buying kids books makes me feel simultaneously old and young.  I tend to buy the books that I remember from my own childhood.  Partly it's selfish nostalgia (literally "the pain of homecoming") but also partly the sincere belief that if I know I'll enjoy the books that I'll read to the Hatchling then I'm more likely to read to her.  Reading books such as "The Very Hungry Caterpillar" again takes me right back to my childhood, when I would flip the pages back and forth looking at how the holes in the fruit line up - amazing!  What makes me feel old is when I try to poke my fingers through those holes and they are now too large to fit.

Hopefully I don't have acromegaly.