Science

Hatchling

Mama, do you know how to make science?

Smaller Half

How to make science? No, tell me.

Hatchling

You need, you need, vinegar! And bottle poda. And green colouring.

Smaller Half

Bottle poda?

Hatchling

Yes. And you put them all in, and it goes up, up, up and all over, like a volcano!

Smaller Half

Do you mean baking soda? 

Hatchling

Yes. Baking soda. To make science.

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.

Alternative pain scales

Fahrenheit Pain Scale:
If your pain was a number between 32 and 212, where 32 is no pain at all and 212 is the worst pain you've ever had, what would it be right now?

Complex Pain Scale:
If your pain was a number with a magnitude less than or equal to 1, where 1 is the worst pain you've ever had, and i is defined as the square root of an immense sense of well-being and fulfillment, what would its magnitude and phase be right now?

Vintner's Pain Scale:
If your pain was a volume of wine, such as a gallon, rundlet, barrel, tierce, hogshead, puncheon, tertian, pipe, butt, or a tun, where a tun would be the worst pain you've ever felt, how much wine would it be right now?

Sagan's Pain Scale:
If your pain was a number between 1 and billions and billions, where billions and billions was the worst pain you've ever had, what would it be right now?

Hertzsprung-Russell Pain Scale:
If your pain was a letter from the sequence M, K, G, F, A, B, O where O would be hot, luminous pain radiating in the ultraviolet, what would your pain be right now?

It's all Welsh to me

Had a med student trail me around for a few hours this evening.  He seemed like a decent guy, in that he was interested in discussing things other than medicine.  As a result, when he asked me to sign his "attendance book" (to prove that he bothered to turn up, a program probably instigated as a direct result of students like me who took the university's unofficial slogan of "Teach Yourself Medicine" rather too literally), I wrote some feedback in there to the effect that I thought his pronunciation was excellent and that I appreciated his willingness to contribute anecdotes from his extensive and esoteric background knowledge.

We had this strange conversation where somehow he ended up explaining the etymology of the word "dysdiadokinesia" to me.  Because it relates to Alexander the Great and his successors, I ended up talking to him about Ptolemy, and because that sounds vaguely like Potomac we ended up talking about the American civil war and Washington crossing the Delaware river.

Interestingly, when I got home I attempted to verify the etymology of dysdiadokinesia and found it less easy than I expected.  I ended up trying to use Google Translate to translate the word "diadochos" from Greek into English, but Google insisted that "diadochos" is actually Welsh.  Welsh for "diadochos" in fact.  However did we live before Google?

So then I tried translating "diadochos" from Welsh into Greek, and got "Διάδοχος", which I then translated back into English and got "successor".  The Diadochi were indeed the Macedonian successors of Alexander the Great, like Ptolemy (who ruled in Egypt).

But I'm still not so clear on what that has to do with dysdiadokinesia.  Oh well.

A word of advice

In a recent comment on my post regarding pain scores, the indefatigable Lumpage asked, "Uhoh, I set my pain scale between 0 and 10. Am I doing it wrong?"

No, Dr Lumpage, you're not doing it wrong.  You're just doing it different.  Which is my way of saying you're doing it wrong.  Stop - collaborate and listen.

You see, I don't offer the patient the option of a pain score of zero, for the following three reasons:

1. I have already asked them if they have any pain.  And I only ask them for a pain score if they actually have pain.  If they told me that they were in pain, and then told me that their pain score was zero, I think my brain would haemorrhage from sheer frustration. The medical history is a battle of wits.  Patients will delight in flummoxing you at every opportunity.  You must learn to close off every avenue of potential nonsense, building up your innate feel for these types of simple traps so you can conserve your energy for the real battle ahead: presenting the patient to your boss.
2. Having a pain score of 0 to 10 is actually an 11 point scale.  This sort of thing works well for humorous effect in rock 'n' roll mockumentaries, but isn't very practical when it comes to taking medical histories from patients at 4am when neither of you can think good.  Say the person's pain score improves from 10 to 5 after 4mg of IV morphine.  In my system that is a 50% reduction in pain.  In your system that is 5/11 or a 45.4% reduction in pain.  Which is frankly absurd. Especially since if the pain drops again by another 5 points to zero, that's another 45.4% drop, for a total of 90.8%, and they are now pain free.  What the fuck? Where did the other 9.2% of their pain go?
3. Is the patient alive? Then they are in pain.  Life is pain. Only the dead feel no pain. Or people that you've put a really good ring block in - you can just rip their nails out using haemostats and they don't feel a thing.  It's full on.  But aside from them, everyone else feels the exquisite pain of living, every waking moment, swimming in the agony of existence until they can swim no longer.

So, yeah, you're doing it wrong. 1 to 10, my friend. 1 to 10.

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.

There's a word for it in German

Zehennagelschnurrbartangst (n.) - The experience of, having hours earlier extracted an infected ingrown toenail from a patient, smelling the pus again, and worrying that perhaps some of it has squirted up onto your moustache without your knowledge.

Obligatory blog post about pain scores

PTR

So if you had to give your pain a score between 1 and 10, where 10 is the worst pain you've ever had, what would you pain score be right now?

Mrs Lumbago

10

PTR

So this is the worst pain you've ever felt?

Mrs Lumbago

No, it was worse this morning.

PTR

Ok, so if it was 10 out of 10 this morning, what score would you give it now?

Mrs Lumbago

10

PTR

So it's just as bad now as it was this morning?

Mrs Lumbago

No, this morning it was much worse.

PTR

Right. So the pain was at its worst this morning, 10 out of 10.  If 10 is the worst, what's it like now that it's a bit better?

Mrs Lumbago

10

PTR

Excellent. Excellent.

Dream envy

The Hatchling got up from an afternoon snooze the other day and I asked her if she'd had a dream.

"Yes, I had a lovely dream" - what about?

"Fairies." - what colour were they?

"Pink, like a pom-pom" - lovely - what were they doing?

"They were building a statue" - out of what?

"Out of pieces that one of the fairies brought along" - how did you stick the pieces together, with glue or with tape?

"They stuck'ded themselves together, like Lego" - and did you help them?

"Yes I helped because if you were the best friends of the fairies you could help, otherwise you could only watch, like the elves" - were there elves there?

"Yes, they were naughty elves who were slapping and punching each other, but some other elves were good and they help'ded us".

I felt kind of envious after hearing this.  It does sound like a lovely dream.  When I was a kid I mostly had dreams about giant yaks devouring the carpet from under my feet faster than I could run away. Still, it made me the man I am today so I mustn't complain.

Yaaaaaaaak.

Niche talent

All parents consider their own children to be geniuses, presumably as a way of gaining street cred for having the enabling genes to make it possible, despite so blatantly failing to achieve anything in particular themselves.  And I'm no different.

So I was naturally pretty impressed when the Hatchling, newly minted 4 years old, asked us the other day why people at the bottom of the earth don't fall off.

I explained to her, using my best Up-Goer Five talk, that things always fall down, but "down" is not an absolute frame of reference (and I'm clearly paraphrasing myself here) - rather it is relative to the nearest large mass, which in our case is the Earth, so things always fall towards the centre of the Earth, this direction thus being perceived locally as "down".  She took that in her stride and didn't ask any further questions - a clear indication of either:
(a) superior intelligence and innate grasp of Newtonian physics, or
(b) superior intelligence and innate tolerance of my babbling nonsense.
The common thread being superior intelligence, I hasten to remind you.

So I was somewhat put out later that same day when she was attempting to eat a bowl of ice-cream and was dropping the ice-cream all over the floor, the table and herself.  On closer inspection, I realized she was holding the spoon upside-down.

Derr.

When he nerved himself to return...

... the fire had done its work.

Corrosion

You laugh at me when I need help.

You act incredulous that I can't read your mind. 

You make me guess when you know I don't know. 

You answer my question with a question

You question my answer too.

You're too busy for me. 

You've heard more interesting stories far away, in another time. 

You won't meet my eye. 

You wander and hide and make me chase you. 

Your affectation of indolence tells me what I need to know. 

You dismiss me. 

You monitor me. 

You check up on me behind my back. 

You offered, I agreed, but then the offer changed. 

You made me feel like I could do this. 

You stare at me disbelieving. 

You mistrust me. 

You threaten me. 

You tried to take away my options. 

You talk and talk and talk. 

You don't listen. 

You won't listen. 

You don't trust me. 

You brag and strut and pout. 

You grin and smile and act like my friend.

You seize the opportunity to belittle me. 

You assert your dominance. 

Your perception of my admiration is all too wrong. 

You are lazy. 

You make me do your dirty work. 

You mock and boast and preen. 

You trust me. 

You thank me for what I have to give. 

You listen to my opinion. 

You sympathise. 

You make me feel like a human. 

You interrupt. 

You correct. 

You don't listen. 

You look so bored. 

You make your obligations seem like favours. 

Your contempt is showing. 

For the new doctors

A new crop of medical students have radiated, shining forth from the Fine University that I attended, and tomorrow they start work as doctors. This post is just to say to them: good luck. It's going to be an incredibly intense year. You'll learn more in the next year than you have in the last four, and you'll forget almost as much. Nobody who hasn't gone through it themselves will ever really understand how it will change you. 

Work hard. 

Take a break. 

Be interested in people's stories. 

Sleep. 

Read a good book. 

Ask questions. 

This too shall pass. 

The moment of revelation

Which reminds me, there was a period of a few months in the late eighties when I actually believed there were two bands, one called "In Excess" and another called "Inxes" (rhymes with "lynxes"). For some reason I never twigged to the fact that I only ever heard about In Excess and I only ever read about Inxes. Until one day I was on a plane listening to the pop music channel (8 separate channels!) through those old rubber-tube stethoscope-style earphones (aaah, no wonder I became a doctor) while perusing the playlist in the back of the in-flight magazine, and I realised that I was listening to INXS. 

Game over, man, game over!

PTR

What spell do you think I would cast on you if I was a fairy?

Hatchling

I don't know, what?

PTR

I would cast a spell to make you BEAUTIFUL.

And a spell to make you CLEVER.

And a spell to make you FUNNY.

And a spell to make you PLAY A MUSICAL INSTRUMENT.

And a spell to make you KIND.

And a spell to make you LEARN ANOTHER LANGUAGE.

And a spell to make you STRONG.

But if I could only cast one spell on you, I would cast a spell to make you HAPPY.

Hatchling

Thank you Dadda.

PTR

What spell would you cast on me if you were a fairy?

Hatchling

I would cast a spell - ALIEN!

PTR

What? Really?  Why would you do that?

Hatchling

Because all of the aliens are friendly.

PTR

Thank you sweetheart, that's very kind. 

The story about the happy Bony-Head

One day Bony-Head had a birthday.  Do you know how old he was?  He was one!  So invited all his Bony friends to the party.

He invited Bony-Fingers, and Bony-Elbows, and Bony-Chin, and Bony-Feet and Bony-Bottom.  They all came to his party and they brought Bony-presents for him, wrapped in pretty Bony-paper.  They played Bony-games, and sang Bony-songs, and ate Bony-cake.  They even got to take turns riding on the Bony-Pony.

It was the best birthday party ever.

Oh my god, it's full of wax

So the med student had been off to assess this 1 year old, who was fine, and I'd gone in afterwards to check him out.  All was ok, but the kid certainly did have waxy ears (the patient, not the student).  No biggie.  The main task is to dissuade the parents from trying to prise/scrape/plunge/burn the wax out in future.

And as usual, I got the med student to do the write-up which I then counter-signed.  But, as always, I like to read what I'm actually signing, and when I got to one particular sentence I did a double-take:
"Unable to visualize tympanic membrane due to excess ceruleum"

From the context, waxy ears, but what the hell is ceruleum?  I'm 99% certain he meant to write "cerumen".  So I show it to my colleague Dr Rmo, and we have a good old chuckle about it.  Then it occurs to us that ceruleum might be a real thing rather than a typo, so we google it.  And it turns out that:

"Ceruleum is an energy source in Final Fantasy XIV. Ceruleum is a refined form of Aether, obtained by draining elemental Crystals of their energy, usually in processing factories. It is a powerful yet highly unstable source of energy, mainly used by Garlean Empire to power Magitek engines."

At which point we basically pissed our pants laughing. 

But honestly, it's not the first time this kind of thing has happened.  I remember when I was an intern on nights, trying over and over to get a nasogastric tube down into an elderly lady with a bowel obstruction.  Eventually I sent her for a lateral neck x-ray and, sure enough, she had a retro-pharyngeal deposit of dilithium which was almost blocking her oesophagus.

Then there was the guy whose prostate was jam-packed full of unobtanium, preventing me from forcing a urinary catheter through.  I would tell you about the young woman and her vibranium but that might be sailing too close to the wind.  Suffice it to say that a day without an orifice filled with imaginary power sources is like a day without sunshine.

The story about the dinosaur, the Bony-Head, and the school-children

Once, the teacher at the school decided to take all the school-children out to dig up fossils.  They went out into the country and the teacher gave each of the school-children a little spade to dig with.  They started to dig, and soon they found a bone!  They kept on digging and they found another bone, and another bone, and lots more bones.

They took all of the bones, and they put them together into a Mr Bony-Head.  But the bones were actually dinosaur bones, not Bony-Head bones, so the Bony-Head they made was very very angry.  He stomped all around, stomp stomp STOMP, and was chasing the school-children, trying to eat them up.

So they took the Bony-Head apart again, and used the bones properly to make a dinosaur.  And the dinosaur was so happy that he had been put together properly that he was really really nice and friendly and made friends with all the school-children.  So they took him to the museum to live, and he really liked it there because of the other dinosaurs there.  And the school-children would come to visit him on weekends to play.

Guest post by The Hatchling

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Med students = softcocks

My latest shift in the ED was made more awesomer than usual by the presence of some med students.  Med students can be a mixed bunch.  I'm not very keen on the ones who are both diligent and knowledgeable, because they often ask me questions that I don't know the answers to, which requires me to respond by crushing them like helpless ants.  The ones who are neither diligent nor knowledgeable are also useless, because, well, they are useless.  You can't effectively delegate anything to them because they'll either stuff it up or wander off because they saw something shiny.

I suppose that in theory there could be med students who are not diligent, but are knowledgeable.  For a moment I was going to pretend that I was one, but that would be stretching the truth too far even for the interwebs.  Which leaves the diligent but not knowledgeable students.  Eeeeexcellent!

These are the guys you can send off to do stuff and they'll actually do a good job.  Usually better than I will do, actually, at least in the sense that it will be more thorough.  And as a special bonus, I often know how to answer their questions.  And if I don't, they can't detect my bullshit.  Or at least they aren't confident enough to call me on it, which is effectively the same as far as I'm concerned.

So it's great if you get the right students, because you get them to do all your work for you while you sit back on the couch eating bon-bons and sucking down all the Imperial Dust instant coffee you like.  It's prudent to go and actually check the facts for yourself at some stage, but you still save a bunch of time.  Presumably the students get something out of it as well.  I have vague memories of being a student and having nothing but respect and admiration for the junior doctors who exploited my labour so ruthlessly - yes, that's it, respect and admiration.  Made me the man I am today.  And I'm sure the respect and admiration flowed in both directions, as it most surely does still.

Having said that, a couple of the student were total softcocks.  One of them did a really good job of history taking and examination and writing up his notes, but I was shocked, SHOCKED, to discover later on that he had forgotten to list the patient's medications.  Instead there was a forlorn empty paragraph beginning (and ending) with "Meds:" - it took me at least a minute to enter the patient's four medications there.  Sheesh.  Next time I see him I'll crush him like an ant.  But not before I guilt trip him into buying me a coffee and giving me a footrub.

Another student was an even bigger softcock.  She found out from the nursing note that the patient has tested positive for parainfluenza by her GP, and then didn't want to see that patient in case she got sick because she had exams coming up.  In how long?  Six weeks.  Six.  Weeks.  If you don't recall, I actually gave birth to triplets DURING my med school exams while recovering from breaking the land speed record wearing sandpaper undies.  Honestly, if you're going to get frightened of parainfluenza, maybe you need to rethink being a doctor.  Or at least buy me a coffee and give me a footrub to make up for being such a softcock.

My day was lightened though, by the aforementioned patient. She said to me, "Parrot influenza? I don't have anything to do with birds!"

Gold.