Birds and ships

The birds are singing in your eyes today,

Sweet flowers blossom in your smile,

The wind and sun are in the words you say,

Where might your lonesome lover be? 

Birds may be singing in my eyes this day,

Sweet flowers blossom when I smile,

But my soul is stormy and my heart blows wild,

My sweetheart rides a ship on the sea. 

- Woody Guthrie

Work it

As a parent, it's important to me that you understand that my daughter, the Hatchling, is the cutest, most adorable person in the world. Fact.

Yesterday evening she spent about an hour walking around the house "photographing" us and her toys. Her camera was in fact a large rectangular piece of Lego. She would come up to us and say, "pictures?", in her best air-hostess voice. She would then hold the Lego up in front of her eyes for several seconds and say, "smile!", before turning the Lego around and offering us a view of the beautiful picture she had just taken.

She took quite a few shots of us before moving on to her toys. They were photographed in situ, individually, before she realised the exciting artistic possibilities open to her, and she began arranging the toys in little tableaux, usually with the toys having their arms thrown casually over one another's shoulders as if they were just coming home from a night at the pub.

She was halfway through one particularly detailed shoot when she stopped, peered closely at the piece of Lego, and must have decided that it made a better airplane than camera, because she started saying, "zoom zoom zoom!", and flew it around the room several times.

That didn't last long though because it then became apparent that Baby (her doll, who has no hair) needed her hair brushed, and the airplane/camera was the perfect tool for the job. She was quite vigorous in her brushing and because I'd missed the plane-brush transition I thought that she was brutally beating Baby with an airplane. As a result she got a little lecture from me about how its very important to be kind and gentle to babies and thus beating them with vehicles of any kind was really not on.

She looked pretty baffled, but had the patience to explain to me that the plane was in fact a brush. So it was all okay. But I think my intervention kind of ruined it for her because the camera/plane/brush went back to being a camera shortly thereafter and remained so for the rest of the evening.

Smile!

True love

You are the cheese to my sky
You are the horizon to my eggs
You are the bacon to my sneakers
You are the laces to my peanut butter
You are the jelly to my face
You are the smile to my mashed potatoes
You are the gravy to my bath
You are the bubbles to my cookie
You are the milk to my pen
You are the ink to my french fries
You are the ketchup to my ocean
You are the water to my cupcake
You are the icing on my macaroni

Bip the clown

PTR

Have you had any vomiting?

Mr Nesby

No, no, what is this? I no understand this.

PTR

Oh. Um. Throw up?  Bleurgh!  Bleurgh!

[Mimes vomiting]

Mr Nesby

Oh! No, no, none of this.

PTR

Have you had any diarrhoea?

Mr Nesby

I no understand.

PTR

Never mind.

Witzelsucht

Nurse

What's the plan for bed 2?

Doctor

I'm just looking at her x-ray.

...

There's no fracture, she can go home.

Nurse

She can't go home.  The pain means she can't mobilize.

PTR

Does she live in a mobile home?

Ba-doom-TISH!

Best foot forward

I went to see a patient recently - while I was trying to examine him he started to peel off the sticky dots with metal buttons that serve as ECG leads.  I thought I'd give him a hand, just to try to build up some patient rapport, that kind of thing.  But as I reached down to the V3 lead he drooled on me, on my bare skin on the hairy part of my wrist.  Ew!

But wait, there's more.

Later on I was walked around and I noticed that my right shoe was going click, click, click.  Must be a drawing pin in the bottom of my shoe, I thought.  On inspection though I found that I had a big sticky ECG dot on the sole of my shoe.

So there I am, adopting the "I've just stepped in dog poo" posture while I'm trying to peel this thing off my shoe in the nurses station, when around the corner comes a nurse, who stops and raises an inquisitive eyebrow.

I paused dramatically and said, "I think I've been going too hard with my chest compressions".

Boom-TISH!

See no evil

I'm encouraged by the recently released stat that more than 100 people every year mistake superglue for eyedrops and glue their eyes shut.  Most obviously, I will clearly never be out of work as a doctor while humans are capable of such blunders.  Also, the more people walking around with their eyes glued shut, the less frequently I will have to iron my shirts or shave or brush my hair or blow my nose.  Perhaps if more people put superglue into their nostrils I could save a bunch of money on deodorant as well.  And if they put it into their ears I could buy more Bieber albums.

But the tragic corollary of this story is that there are probably at least 100 people per year whose model airplanes are falling apart because they were assembled using eyedrops instead of superglue.  It's a hidden epidemic.  Nobody turns up at the Emergency Department complaining that the wings fell off their Lancaster.  Nobody over twelve anyway.

But I'm sure that the long term health effects will be felt for decades.  I remember when I was five I had a yellow model Pontiac Firebird.  I was foolishly playing with it in the yard, thinking that it would be as robust as an actual toy car, when the front left wheel broke off.  My blood pressure shot through the roof and I could feel the seeds of atherosclerosis growing within me.

"I'll give you atherosclerosis in your head if you don't stop crying by the time I count to three!", said my Aged Mother.  But the damage was already done.

There must be many other disastrous incidents where people accidentally use their medications improperly.  People in the midst of renovating their bathrooms filling their mouths with polyfilla thinking that it is mouthwash.  In fact the Hatchling was onto something the other day when she was watching me shave - "Dada put toothpaste on face!", she said in astonishment, being unfamiliar with the concept of me shaving since it usually happens when she's asleep.

Have any of you ever made this type of mistake?  Glued your eyelids shut?  Swallowed Julia Gillard's contact lenses?  Given a patient a transfusion of passata arrabiata?  Accidentally transplanted the heart of baboon into a human?  It must be more common than we admit.

Crazy mixup #6

Finally (no! I hear you cry out in anguish), one last poor unfortunate came to my hospital with a tummy like a bowling ball. Once more unto the breach, my registrar found me and patient engaged in a stimulating discussion of the mystical philosophy of Martin Buber.

"What are you doing?" shrieked my registrar, "I asked you do do an ascitic tap!"

"Oh!" said I, "I thought you said a Hasidic tap."

I think we're done here now.

Crazy mixup #5

Just like before, only this my registrar came into the cubicle to find me blissing out to the Grateful Dead on my iPod.

"What are you doing?" shrieked my registrar, "I asked you do do an ascitic tap!"

"Oh!" said I, "I thought you said an acidic tap."

Crazy mixup #4

Blah blah blah an unnecessarily complex setup story involving somebody with free fluid in the peritoneal space, which ends with my registrar finding me lying in the patient's cubicle, my only visible movement being the feeble drumming of one of my fingers upon the floor.

"What are you doing?" shrieked my registrar, "I asked you do do an ascitic tap!"

"Oh!" said I, "I thought you said an asthenic tap."

Crazy mixup #3

So this elderly man came into the Emergency Department with a bloated abdomen.  To cut a long story short, vis-a-vis the diagnostic process involving the necessity of analysing a sample of the fluid within his abdomen, my registrar walked into the cubicle a bit later on to find me in the process of cracking open a big barrel of wine, only to find it had gone sour.

"What are you doing?" shrieked my registrar, "I asked you do do an ascitic tap!"

"Oh!" said I, "I thought you said an acetic tap."

Crazy mixup #2

A little old lady turned up at the Emergency Department not long ago with a grossly distended and tense abdomen.  We were pretty sure that her underlying problem was severe right heart failure but the fly in the ointment was that she did have hereditary angioedema.  I was halfway through working her up when my registrar walked into the cubicle to find me doing a beautiful soft-shoe shuffle in front of a bemused patient.

"What are you doing?" shrieked my registrar, "I asked you do do an ascitic tap!"

"Oh!" said I, "I thought you said an asthetic tap."

Crazy mixup

I admitted a guy to hospital a little while back.  He had liver failure and severe abdominal distension, probably due to his alcoholism but possibility of an intrabdominal malignancy couldn't yet be excluded.  A little while later my registrar walked into the cubicle to find me whipping the patient's stomach with a leather thong and making him wear a hair shirt.

"What are you doing?" shrieked my registrar, "I asked you do do an ascitic tap!"

"Oh!" said I, "I thought you said an ascetic tap."

Hooray for rationalisation

Day off - yay!

Compulsory grand round and tutorial - booo!

Decide to skip them - yaay!

Realise that I've also missed a scheduled meeting with my supervisor - booo!

Rationalise it by pretending that the meeting was just to tell me that I had to attend these things and not skip them - yaay!

The frogurt is also cursed - booo!

I did it for you

youTube.com is an amazing site.  Not only does it contain hilarious videos of cats, it also enables you to see children falling off bicycles.  Before youTube I used to have to fling cats at children on bicycles, but no longer.  It's win/Win/WIN!  Part of its genius is the name - it starts with "you" so it makes everyone feels like it's relevant.  The principle could be used to start up a bunch of other websites which I think could end up being just as big.  Here's a partial list - feel free to register and develop them yourself - I just don't have the time to give them all that they deserve.

youThyroid.com - This site would be handy for people to upload pictures of their goitres or of their Mel Brooks googly eyes.  They could trade stories about their pretibial mixoedema, and swap tips on how to use the internet effectively despite a severe tremor and a heart rate of 160.

youVolaemia.com - This site would be dedicated to enabling people to share hints, tips and tricks to do with their fluid balance.  How to best assess your jugular venous pressure.  The controversy over mucus membranes.  Skin turgor and the elderly.  The osmolality conspiracy.

youRopeanUnion.com - A fan site for European communalists of all stripes!

youClideanGeometry.com - Do your external angles sum to 360 degrees?  This could be the site for you!  Or perhaps that's just hyperbole.

youKaryote.com - Too long have plants and fungi been excluded from the internet.  This site would serve as a portal for all organisms with nuclei.

youPhemism.com - This site would have a lot of the you-know-what, eh!  Eh!  Especially for you-know-who!

youLersNameIsPronouncedOilerNotYoulerSoThisJokeDoesntWork.com - A site for looking up the names of dead mathematicians and the mispronunciations thereof.

Just give three

Nurse

You've charted 450 mg of clindamycin for this patient.

PTR

Yes.

Nurse

Well we only have 150 mg tablets.  How are we supposed to do that?

PTR

...

Got bicycle clips?

Fat in food is like salt. It's yummy and healthy and generally great. But its also something that you tend to become accustomed to having present at a certain level and major deviations from this can cause distress.

We had some friends in a previous life, when I was a woodsman in Depression-era Illinois, who would invite us round for dinner every now and then. We would secretly dread it because their fat barometer was set way below ours.

We generally like fatty foods. This is because my Smaller Half is Chinese and as for me, I am a greedy bastard. So we tend to load up on butter and oil when we cook. Perhaps the bed sheets do accumulate a yellowish tinge over time but we aren't too out of control.

Anyway, these friends were on a mission to cut down on fat. They would buy the leanest piece of pork they could then roast it at 4000 degrees on a rack so every molecule of fat was drained or destroyed. Then just before serving it on a delicious bed of shredded sandpaper they'd give it a light dusting with, well, dust, to really dry it up.

Not really our style.

Tonight we were eating out with friends and I ordered some roasted pork belly, an extremely fatty cut at the best of times. When it came it was quivering on the plate. There were pieces of meat the size of my hand which seemed to be nothing but fat.

Even I quailed somewhat. But not wanting to waste good food, I found that if you had equal parts fat and rice that it was great. Fatty and smooth and flavoursome and packed full of vitamin F. I really enjoyed it, somewhat to the horror of my friend opposite who is a cardiologist and knew that I should know better.

But nature has a way of interfering with mankind's fun. Just like drinking gallons of water is fun until you get cerebral oedema and die, just like bungee jumping is fun until your retinas detach and you get atlanto-axial dislocation and your skull falls off - there's only so much belly pork you can eat before your liver and pancreas stop playing along and you develop anal leakage. Not so fun now eh?

So the next time you try to show off by eating your own body weight in lard, remember my tragic tale and think to yourself, what do I value more: the smooth moist fatty feeling in my mouth or the smooth moist fatty feeling in my pants? Because you may end up with both.

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.

Outrageous

How can I be expected to plan out my leave for a full year ahead when I struggle to have a shirt ironed each day for work?

Floater

A nurse remarked to me recently, "Mr Surname has been particularly appreciate of his floater over the last few days."  Eh?

For those of you not in the know, a floater is a hot meat pie floundering in a mire of mushy peas, strongly associated with winter and football.  Mr Surname must have been ringing in the festive season in style.

But no - not that type of floater.  Surely he wasn't referring to a leftover bit of poop that resolutely refuses to flush?  Why would you be appreciative of that?

Or perhaps the floater he meant was the body of a drowned person, bobbing gently under the buoyancy of its internal gases.  Something to appreciate, surely, if only because of a schadenfreudesque relief - "There but for the grace of God go I..."

Aaaah - I have it!  He was referring to the perception of irregularities in the vitreous humor of his own eyeball.  He spends his days staring at the sky marvelling at the drifting, dancing angels always just beyond his reach.

Again - no.  The floater in question was a dose of oxazepam, an anxiolytic, available to be taken at any time as Mr Surname saw fit.  That would certainly make a trip to the football much more bearable.

Plot summary for generic espionage/action flick

Man is surprised to find that people keep trying to kill him.
Man executes a series of astonishing manoeuvres on a motorcycle.
Other man comes crashing through a large window with a big gun and tries to kill the first man without success and is himself killed right back.
Man speaks to other man wearing a suit over a telephone.
Man wearing suit says "Goddammit!" and slams the phone down.
First man sails away on a boat.

Movies is hell

As a recent commenter to my post Reading Is Hell pointed out, movie watching also suffers from the travails of internship, from the slings and arrows of outrageous offspring. We have been to the cinema twice in the last two months, which is remarkable because before that it had been more than two years since we'd been to the movies.

Apart from our non-existent cinematequing, we've been subsisting on offsite backup copies of movies provided by my Smaller Half's brother who obtains them in a manner unknown to us but which almost certainly involves the paying of royalties to any and all copyright holders in accordance with international treaties, arrrrr.

This has been quite good, except my poor old computer struggles a bit with the concept so every 15 minutes I have to pause the movie and persuade my computer not to reboot itself. Also, some films have such a low sound level that the dialogue is frequently interrupted by one or the other of us saying, "What? What did he say? He's going to buy a duck?" Fortunately these two disruptions are complementary so whilst I am fixing the computer we attempt to mutually reconstruct the dialogue.

Also fortunately, in our impoverished mental state, our viewing tastes veer more towards The Avengers and less towards Gosford Park. It's much easier to figure out that the Hulk probably screamed out, "RAAAAH! HULK SMASH!" than it is to decipher the intricate household intrigues of the Edwardian aristocracy, so the audio issues aren't as much of, well, an issue.

We finally did make it to the cinema. The first time, we ruthlessly bunged the Hatchling into the care of the brutal misanthropes at her childcare centre (note: this is obviously a lie. Her childcare centre is fantastic.) and took off into town. We saw an incredible film. The people in it had faces as large as a house. Their voices boomed out like thunder. Not once did the screen try to reboot itself. I think it might have had Richard Gere in it as well but I'm unsure of that.

The second time, we ruthlessly bunged the Hatchling into the care of the brutal misanthropes who are my Smaller Half's brother and mother (note: The childcare centre really is fantastic.) and took off into town. This worked a lot better than when my own brutal, misanthropic mother visited and said, "I really should offer to babysit so you can go to the movies but I'm not going to." Sad trombone.

We went to see the new Bond flick, Skyfall. As mentioned previously on this blob, I was unreasonably gobsmacked by the opening credits, largely because they were colourful and moved around a lot, as movies have tended to in general since the 1950s. Still, regardless of the objective merit of the film, it was a relatively novel experience for me, if I may be permitted to use such a bookish adjective in relation to a movie. So I think in 2014 I might go to the movies again, if they still exist.

I didn't have any instant coffee though. The choc-top is eternal.

Mental state examination

Appearance: Caucasian male, medium height and build, looks of stated age, short brown hair unbrushed, unshaven. Dressed in semi formal office clothes, clothes clean though rumpled.

Behaviour: calm demeanour, good eye contact though prone to reverie, no abnormal movements, gait symmetrical. Cooperative with interview.

Conversation: normal rate, tone, volume, rhythm of speech. Brief answers verbally, more expansive in writing. Some tangentiality and loosening of associations. Occasional inappropriate humour. Themes of anger, being misunderstood, narcissism.

Affect: reactive, engaged. Claims subjective inner turmoil.

Perception: apparently normal. No attendance to internal stimuli.

Cognition: not formally assessed. Grossly intact.

Intelligence: above average though possibly not as high as he asserts.

Insight: good though limited in the context of accepting and integrating criticism.

Judgment: impaired by innate laziness.

Rapport: superficially established.

Impression: ?tormented artist
?selfish prick
?dysthymia
?intern burnout.

Plan: 1. Ship him off to another hospital and let them sort him out.
2. Put him in the scuppers with a hosepipe on him.
3. Encourage writing: entertaining at times.

Nostalgia

I remember seeing the film se7en in the cinema when it came out. Apart from the pretentious alphanumeric title and the repulsive tortureporn vibe, the thing that struck me most were the credits. They were like a rock video. Jittery, buzzing, energetic, packed with attitude. And the best part of the film as it turns out.

When the first Daniel Craig 007 film came out, those credits were the best I'd ever seen. They were hypnotic. A shifting maze of colour and movement and danger. Which was no small feat given they came after arguably the best Bond prologue ever.

I thought they couldn't be beaten. But the most recent Bond film's opening titles left me gaping. The blood in the water. The skeletal teeth turning into tombstones. The underground/drowning/death/shadow thing was some heavy shit, man. I wanted to go and see the film again just so I could see the title sequence. So I looked it up on YouTube and you know what? They were clever but not all that, sister. Too clever. Too many references to the film itself. Too cerebral. Disappointing.

But you know the best opening credits OF ALL TIME??? A children's program called In The Night Garden. The visuals and the music fuse to form a perfect image so beautiful that every time I see the show I nearly cry. The boat recedes over the waves, the stars burn bright in the sky, and as the string melody swells, the stars burst into flower and we are pushing our way through the blossoms and into the Night Garden.

It captures for me perfectly that feeling when I was a child of being lost in a dream and half knowing it, half not. Of feeling the bed roll and sway as you float up towards the ceiling. It's the music of a lost age.

I can't remember if I've mentioned before that the word "nostalgia" derives from concept of a painful memory, but now has come to mean a longing for a thing long gone. These credits trigger memories I never had. They are the best ever. And it's on TV every night at 6.30 pm.

Tune in, turn back, drop off.

The stone

So here I am - stuck at the hospital on a lovely day with not much to do.  I'm on cover.  "Cover" means you're stuck here all day on a weekend dealing with whatever random stuff the regular doctors forgot to do or didn't foresee or simply couldn't be bothered doing.  Today is bizarrely un-busy for me.  Hence the flurry of blobbing activity, which I've cunningly scheduled to be published daily over the next week or so.

All that is by way of getting to what I want to talk about which is superstition.  When I'm on cover I get hugely superstitious.  All of my superstitions are aimed at avoiding having my pager go off.  Over the last year I've developed a decent set of tips for avoiding being paged.

1. Do not go onto the ward, through the ward, or near the ward unless you absolutely have to.  If they see you there or smell you out, they will page you.
2. Do not read a book.  Opening a book is a sign that you're getting comfortable, and they will notice and page you.
3. Do not watch TV.  Watching TV is practically begging someone to page you.
4. Do not sit down into a comfortable soft chair and wriggle back and forth a bit then curl your feet up underneath yourself.  They will page you.
5. Do not attempt to eat any food which gets substantially grosser if you try to re-heat it later on, such as cheese on toast.  As soon as you've got it ready to eat, you'll be paged.
6. Do not ever send anyone a text message saying, "Today is AWESOME!  There's NOTHING to do!" - you know how this ends.
7. Do not attempt to do any of your own work, such as chewing through your backlog of discharge summaries or doing MMSEs on your own patients.  This will generate a singularity in the pager continuum that will suck you in for the rest of your shift.
8. Don't arrange to catch up with someone you know and love for lunch or coffee.  Your pager will go off so often that you may not even see them except as a rapidly receding silhouette in the sunset.

"But PTR", I hear you ask, "What can I do when I'm on cover and want to avoid making the pager gods angry?"  A good question, mosquito.  The answer is to be found in nature.  You must be like the stone, which weathers all that the world can throw against it.  The stone does not read books, or sit in comfy chairs, or meet up with friends for coffee.  The stone does not try to catch up on discharge summaries or eat a delicious lunch. 

No.  You must be like the stone.  You must lie low, very still, in the dirt.  Let the ants crawl over your face.  Let the rain run into your shoes.  Let the frost rime your beard.

Do this and you will be like the stone, whose pager never, ever goes off.  Be like the stone.

Reading is hell

In between lurching from day to day as a hospital intern, raising a small child, and smothering my rage so as not to commit chargeable offences on this blog, I've not had time for much reading.  I used to get through a book every fortnight or so on average, even during med school when I probably should have been reading rather more about sick people than I actually did.

As a result I haven't updated the Bookshelf page of this blog for quite some time.  I'm sure that the more literary minded of you have been salivating at the thought of an update, and I'm equally sure that only one or two of you have ever actually noticed the Bookshelf page of this blog. 

Regardless of your level of interest, I'm going to bang on about reading for a bit, for a couple of reasons.  First, I'm sitting here in front of a computer on a cover shift with not much happening so far, so I've got the itchy fingers, and second, I've noticed some interesting trends in my reading.

Normally my reading tastes run to:

• literary fiction
• vintage sci-fi
• historical non-fiction
• scientific non-fiction

Now what I've noticed is that when my stress levels ramp up, the literary fiction is the first thing to go.  All that cortisol must shut down my frontal lobes.  After a while the scientific non-fiction goes too, followed soon after by the historical non-fiction as my brain withers and dies under the relentless assault of my unhinged amygdala.  All that's left is vintage sci-fi, and even that warps and mutates into a desire to read really awful genre fantasy.  Ugh.

But given long enough, even the bad genre fantasy goes away, and historical fiction rears its head again - but in a very specific way.  I get magnetically drawn to personal memoirs of people who've had really really traumatic experiences, mostly to do with getting shot at.

I think the protective mechanism at work here is an underlying desire to put my life in perspective.  Sure, I may have to attend multiple Code Blues in the middle of the night but at least I don't have to see the tortured corpse of my best friend as in Flags Of Our Fathers.  I may feel burdened by being called to assess yet another asymptomatic hypotension, but that's preferable to having to pretend to be dead while my pockets are looted by the enemy and bullets are fired into the heads of my injured comrades around me, as in We Were Soldiers Once, And Young.  And sometimes I rile at the selfishness and insensitivity of my seniors at work - but at least I'm not being systematically hunted down and exterminated by the State, as in The Pianist.

The good news is that phase of my life seems to be over.  I've recently been able to start reading scientific non-fiction again, with Oliver Sacks' Seeing Voices - a book about Deafness, Sign and language.  Prior to that I read Naval Warfare In The Age Of Sail and learned to distinguish a sloop from a brig.  Soon I might be able to crack open that Anna Funder book I've been sitting on since April.

Here's hoping!

Funny blog content

The other day during the nursing handover we were astonished to discover that one of our patients has been doing his own FBC - full blood count.

He gets all the blood taking equipment ready, puts on the tourniquet, finds a good vein, draws the blood, makes a slide and examines it under a microscope, counting the different numbers of cells in a random selection of high-power field views, and then analyses the rest of the sample to get a haemoglobin level and all the other palaver.  Pretty amazing.  But then I guess he has a fair bit of time of his hands, being a patient with nothing else to do.

Sadly, it was all in my mind.  He does indeed do his own FBC - but it's the fluid balance chart.  He merely keeps track of his fluid input and urine output volumes.  I preferred my version.

Call me nick

The Hatchling is going through what must be a developmental milestone of sorts: she finds it highly amusing to call me by my first name.  I remember when I was a kid I had one or two friends who would call their parents by their first names and to be honest, I found it creepy and a little bit frightening.  Somehow it breaks the child out of the "child" role and they become instead some kind of mutant evil genius in a child's body. 

So I always make a point of correcting the Hatchling - "No, Dada" - which of course is a trigger for her to turn it into a game.  Even stranger is when she copies my Smaller Half and calls me "Honey".  That's just wrong.

I realized the other day when the three of us were sitting in the cafeteria at work that I could turn the tables on her and see if she identifies with any of the nicknames I tend to give her.

So I asked her: "Where's sweetie-pie?" - she pointed to herself, pleased.

"Where's gorgeous?" - she pointed to herself.

"Where's beautiful?" - herself again.

Hmm, let's see what happens if I use something she hasn't heard before, I thought.
"Where's boombalada?" - being a generic nickname for a fat person that I remember from my childhood - and she turned around and pointed at the unfortunate person at the next table, causing me to almost bust an internal sphincter trying to not laugh.

Cheese blues

Gorgonzola is an unfortunately named cheese - the Gorgons being the snake-haired monstrous sisters of Greek mythology.  The idea of getting milk out of them just puts me right off.

Modern genius

Despite the Hatchling's shortcomings in classical mechanics and abstract algebra, she is doing well in fields.  Botany, for example.  She has been hampered somewhat by being unable to pronounce the word "flower" - producing something more akin to "fla-fa", but nevertheless her theoretical knowledge is excellent.

Just the other day when I was eating a plate of nasi lemak, she pointed at the red-skinned roasted peanuts on my plate and said, "Bean! Bean!".  Now it would easy to patronisingly assume that she had mistaken the red peanuts for kidney beans, which she had in fact eaten just several days earlier.  I, however, knew that she knew that peanuts are not true nuts but are actually a variety of legume, or bean.

Well played, little Hatchling, well played.

Modern primitive strikes back

The Hatchling doesn't really understand equivalence relations in set theory. She's so cute that way. Still, I hope it's something that she overcomes soon or she's really going to struggle when I start reviewing topology with her next year.

This all came to light during bath-time. I asked her what colour her little turtle was, and she quite rightly responded, "Green!". I then held up a green cup and asked her what colour it was, and she said, very confidently, "Purple!"

I had to explain to her that since the turtle was green, and since the cup was clearly the same colour as the turtle, that the cup must also be green. She was gracious enough to admit her mistake in this instance but didn't seem to be convinced by the more general principle.

Note to self: Hothouse not hot enough. Make more flashcards.

Modern primitive

The Hatchling doesn't really understand Newton's third law of motion - the one about "for every action there's an equal and opposite reaction". It hadn't occurred to me that kids actually have to learn this kind of thing, but I guess they do.


I'd been pushing her up and down the driveway on her little toy tractor. She can scoot herself along pretty well, Flintstone style, using her feet. But clearly it's much faster, less effort, and more fun to get me to push her. She would lean back as I pushed her in the small of the back, putting her feet up beside her hands on her steering wheel, and saying, "a-whee!"

It's all good fun, but I'm not as fit as I used to be when I was young, so after half a dozen times I got a bit puffed out and bent over so I told her that I need a rest and she can do it by herself. She pushed herself along for a metre or two, but then had a brainwave! She put her feet up on the steering wheel again, put one hand behind her back where my my hand had been, and gave herself a good push. All to no avail. She was most perplexed. And the upshot of it all was that I had to do another half a dozen runs up and down the driveway.

I downloaded a copy of Newton's Principia Mathematica and read it to her that night at bedtime. She fell asleep pretty quickly but I think she got the general gist of it.

My dog has no nose

Boss

Come in to my office.  Does it smell funny?

PTR

Why?

Boss

My last patient had urinary incontinence and I'm wondering if I've aired the room enough.

PTR

I've got a cold so I can't really tell.

Boss

How convenient.  You should cultivate that cold.

PTR

I have a 2 year old at home so there's no need. We have colds on tap.

Boss

How lucky you are.

Pain or something like it

Medical bloggers love to bang on about the 1-10 pain scale, usually to comic effect.  Here's my contribution, but with cynical intern burn-out substituted for comic effect:

So, the 1-10 pain scale, eh?  In my experience, there's no need for anything so elaborate.  There are only 4 actual subcategories of pain.

1-4. Bearable pain.  Take paracetamol (known in the USA as epinephrine.  No wait, that's something else. Forget it.).
5. Unable to articulate character, site, severity, onset etc etc etc.  Refer to a general medical team.  They love these guys.
6-10. Severe pain. Give opioids and request a general surgical review.  They'll need a baseline before the patient re-presents with constipation from all the opioids you gave them.
11. Drug seeker. Or renal colic.  Either way, some indomethacin up the butt will give someone some relief.

Ha.

Goose/gander

Went to an orientation session for my new position this morning and had this strange conversation concerning an Esteemed Colleague, Binky*:

Administrator

I don't think Binky is coming this morning.

PTR

He told me that he would.

Administrator

Well he doesn't need to. He won't have slept because he worked all night last night.

PTR

So did I.

Administrator

But he doesn't really need to come because he worked in this area earlier in the year.

PTR

Me too.

Administrator

It's really hard, you know, to send someone an email saying, "This session is on but you don't really have to come to it", because then people wouldn't bother to come.

 

Isn't it heartwarming to know that in these troubled times we still have people looking out for our best interests?

*Obviously his name is not Binky.  Names have been changed to protect the innocent.

PTR's guide to five weeks of night shifts

Week 1: you hate the nurses.  All nurses are blundering dolts who exist purely to waste your time and mislead you.

Week 2: you hate the home medical teams.  All doctors are inscrutable scribbling fence-sitters, refusing to actively manage their patients until forced to by multiple emergency calls to intensive care overnight.

Week 3: you hate the patients.  All patients are demented, stinking, crumbly bags of blood and faeces just waiting to crash out of bed the moment you settle down for a rest.

Week 4: you hate your family, innocent passers-by, Mother Theresa.  Humanity is doomed, and deaf to your plaintive cries to save itself.

Week 5: you hate yourself and yourself only.  Just do what it takes to get through the next hour, day, week.  The end is in sight, or it would be if it wasn't for this darkness.

Handle with care

Meanwhile, I'm still waiting for a job.  Which sucks.

Have had far too many awkward conversations with people who assume that I've got something sorted by now and are then left feeling embarrassed and unsure of what to say when I reveal that I'm languishing at the bottom of the heap.  Sigh.

I try to be philosophical about it.  The reality is that there are X jobs out there for which Y people are competing.  And Y is bigger than X.  So someone is going to miss out.  Hopefully it won't still be me standing when the music stops in November, which is when the last round of offers come out.  After that, it's a free for all, and I don't know what will happen.

Funny thing is, it hadn't occurred to me that I wouldn't be in top X/Yths of the cohort.  As far as I know I interviewed fine, and as far as I know my referee reports were fine, and my resume was fine too.  After dwelling on it for too long at night you start to develop conspiracy theories.

Such as: my referees hated me so much that they gave me good term assessments in order to lure me into asking them for references, in order to write me bad ones and destroy my career.  Actually I kind of admire those evil bastards for being so Machiavellian.

And this one: the admin officer at the hospital deliberately shuffled my name to the bottom of the list because I've been such a pain to deal with during the year due to my incessant demands for special treatment.  Because I'm heaps demanding, right?

Or this: I smell.  And the interview was in such a small room that I nearly killed the panel.  Could be.  Nobody ever tells you when you smell.

Every day I check my emails.  Nothing.  Well, nothing but ads for cheese festivals.  Maybe I can get a job as a cheese-guy.  It might mask the smell...

Anyway, if you run into me in the next little while and I look grumpy (grumpier than usual), you'll know why.

Infographic

Anecdotes

A couple more brain-numbing requests from my adventures on the dark wards...

The first one speaks for itself: "Patient's blood pressure 105/45 @ 2030 hrs.  Now 100/50 @ 1130 hrs.  Please review for falling BP."

The second one was to review a patient because his blood glucose was 12.6.  Now half the people walking around the Colonades on a Thursday afternoon would have a higher BGL than this, but sure, I'll take a look.  The first thing I notice when I walk in the room is that the guy is on a dextrose drip.  That'd explain it.  The nurse wonders if we should stop the dextrose because he's "hyperglycaemic".  Well, he's been admitted for an insulin overdose, so probably not. 

Next!

Avoidant

 
Something bizarre happened to me recently which I'm still trying to wrap my head around.  Here's the gist of it:

I got a call about a patient that sounded a bit dodgy, so I went and checked him out and came to the conclusion that he might have condition X, but the decision about this and any subsequent management was in any case above my pay grade, so I called the X-ology registrar.

There was a fair bit of back and forth involved with this registrar, but here are the lessons that he imparted to me, along with some sarcastic interpretive remarks by yours truly:

• If you suspect that a patient has a serious medical condition, don't document this in the notes, because if you do, the relevant expert will have to review the patient rather than simply dismiss your concerns out of hand over the phone.
• If you do get the relevant expert to review the patient, don't document this in the notes.  Instead, you should document their findings and recommendations as your own, because clearly an intern is the guy whose opinion you should trust about this stuff.
• Similarly, do not mention to anybody else on your team that you are getting the relevant expert to review the patient, or the long-suffering expert will be forced to write his own documentation and actually sign it, and ink is expensive these days.
• When you are documenting things, write as little as you can, or even less, or else people will think you are incompetent or retarded or trying to hide something. It will also ensure that subsequent clinicians will be able to start afresh in their own assessments, free from bias or preconception.

So yeah, the guy basically was happy to go out of his way to try to get me to stick my neck on the chopping block and assume a totally inappropriate level of responsibility.  Unfortunately I had already broken all his recommendations so he was forced to actually do his job.  So I'd say that I did mine too.

Medical magic

If medicine was a role-playing game, it would need some sweet magic items for us players to hunt.  Here are some suggestions:

• Gloves Of Probing - these mighty gauntlets, when donned, will magically extend from the finger-tips to the shoulders of any basically human-sized doctor.  They automatically exude a slippery lubricant which allow the user to probe into any orifice to palpate within, up to a depth of twice the user's height.  The lubricant makes it impossible for the wearer to manipulate hand-held items.
• Pager Of Silence - this small black box from the dawn of time bears a powerful enchantment which enables it to be perpetually silent and never emit the slightest noise, no many how desperately someone is trying to contact the user.  Legend has it that only registrars can use the Pager Of Silence without suffering the effects of a deadly curse.
• PTR's Everfull Cracker Box - no matter how many times crackers are taken from this box, somehow it is always full the next time someone looks within.  This item only works when you are not rostered on to take advantage of it.  More specifically, it will never work between 2 a.m. and 7 a.m.
• Stethoscope +5 - this mystical stethoscope imbues the wearer with the ability to distinguish between crackles (fine and coarse), crepitations, rhonchi, rales, wheeze, sneeze, cough, choke, stridor, and blitzen.  This item is totally ineffective if the patient is armoured with Blubber Of Concealment.
• Roster of Homecoming - this patient roster with attached list of your jobs is enchanted to fly back to its home in your pocket when a magic word is spoken.  The enchantment is effective against being left beside the ward computer, on the patient's bed, in the doctors' common room, in the cafeteria, in your car, in the operating theatre, or any other location where rosters may be mislaid.  If the magic word is spoken whilst the roster is already in the user's pocket, the roster will attempt to move to the other pocket, causing the user's pants to twist around back to front, causing a -4 penalty to hit in combat and automatic failure of any seduction attempts.

Any other suggestions?

Blogging vs internship

Blogging - sheesh!  Who knew it would be such hard work?

Actually it's not hard work, I just never seem to get around to it.  Which is annoying because working nights is fertile ground for a blog such as mine.  There is no end of bizarre stuff that happens in hospitals after hours, and as the cover intern it falls to you to deal with it.  At least two or three times per day I think to myself, "Now this is prime stuff, PTR, don't forget it!"

But of course, by 4 in the morning when it starts to quieten down a bit, the last thing on my mind is to jump on a computer and do some blogging.  I just want to curl up on the couch with my seven vegemite sandwiches and read mindless pulp sci-fi whilst crooning softly to myself.

The weeks off are no easier.  The Hatchling is at a great age where she's learning new stuff minute by minute, she's heaps of fun to do stuff with, she careens around like a pinball bouncing off everything, and by the end of the day I just want to curl up on the couch with my sixty-three cheese sandwiches and read back issues of wargaming magazines whilst breathing through alternate nostrils.

Blogging just never seems to get a look in.  Which is a shame, because I keep having ideas.  Just yesterday, I thought, "Hey - what if you were to rewrite the plots of famours adventure movies but set them in hospitals instead???"  And sure, that's a stupid idea, but in the past I would have actually done it.  But now I just dwell on it briefly and then fall asleep on my toothbrush.

Internship - sheesh!  Who knew it would be such hard work?

Once upon a midnight dreary

Lest you think that this blog has turned into a monologue on the idiocy of people other than myself, I have a story for you about my own idiocy.  Read on, gentle reader, and remember me in your prayers...

In the middle of the night I trundled off to a distant ward to review the person in bed 3 who was, according to the taskboard, mildly hypotensive and thus warranting a breeze-by from myself.  I got there and took a quick look at her observation chart, and was surprised to see that if anything she had been mildly hypertensive.

I grabbed a nearby nurse and asked if perhaps the most recent obs hadn't been charted, but they had.  That nurse was also surprised that I was there to review the patient in bed 3 and suggested that perhaps a mistake had been made and that someone had meant me to review the patient in bed 4.

"Choh! Typical!", I said, "Choh!  Lucky it wasn't an emergency! Choh!  Can't believe anything on the task board these days!  Not like the good old days when I first started, last Monday!  Choh!", and so on and so on.  (This may surprise you if you're under the impression that I'm basically a nice guy - I'd like to think I am but at 3 a.m. I get pretty damn self-righteous.)

But then when I got the chart for bed 4, he was pretty much the same.  No hypotension there.  So I grabbed the nurse again and pointed this out to her and started out again on my "Choh!" routine whilst unfolding my taskboard printout to show her the errant job that had all these errors in it.  Wrong patient, wrong vitals...

... and I got that awful sinking feeling that you get when you realize that you're the dickhead.  I was on the wrong ward.

A brief post illustrating in a few pithy sentences many of the issues which I feel permeate modern medical institutions with their excessive attention to hierarchy and acceptance of imbalanced power relationships between people who should see themselves as colleagues rather than master and servant

Today's oxymoronic utterance from a senior doctor:

"Don't do anything unless I tell you to!  And I need you to anticipate what I want."

Alfalfanumeric

 
You may or may not be familiar with warfarin, a drug that patients sometimes refer to as "rat poison" because it is used to poison rats.  Like most drugs, it was discovered when someone's cows died after eating mouldy clover, using a scientific process that is opaque to me, but undoubtedly involved much glassware.  The dose is often tweaked up or down each day depending on the results of that day's blood tests because otherwise the after hours cover intern would have nothing to do on the weekend.  Getting it wrong might mean that your patient bleeds to death internally or perhaps has a massive stroke.  No pressure.

So when I was called to the ward one day to clarify the daily dose of warfarin, I thought, yeah - fair enough - nobody wants to stuff this up, and doctors' handwriting is actually even worse than it is reputed to be.  But when I get there, the nurse points at the drug chart and asks, and I am not making this up, "Is that a '6' or a 'b'?"

I mean - like, totally, huh?  How could you prescribe someone 'b' milligrams of warfarin?

Not even I am nerdy enough to prescribe in hexadecimal.  Although if I was, I'd make sure that I did paediatric prescriptions in octal and neonates in binary...

Broken Arrow

 
When you're on night duty, you carry at least one pager.  If the nurses need to contact you they can page you and you respond as fast as you can.  Or they could use the online message board which you check at your leisure and prioritise yourself.  In theory, the message board is for non urgent tasks, while the pager is for urgent things.  In practise, this does not occur.  I got a page the other day, to which I duly responded urgently, and the subsequent phone call went like this:

Nurse

Hello?

PTR

Hello - you just paged me, what's happening?

Nurse

The man in bed 4 is having a hypo.

PTR

What's his blood glucose level?

Nurse

We haven't done that yet.  He just said he feels funny.

PTR

I see.  Why don't you measure his blood glucose and call me back?

They did not call back.  So I went round to the ward, wondering if perhaps they were too busy resuscitating the guy to call me.  They were sitting casually at the desk,  I picked up the patient's chart and saw that his blood glucose five minutes prior to me being paged was 7.9.  I said nothing but waved the chart at the nurse with what I imagine was a look of gentle inquiry on my face.

PTR

So?

Nurse

Oh, it turns out we'd done it but I didn't know about it yet.

This is an exciting development in medicine.  I look forward to being paged urgently to manage hypotension for which no blood pressure has been taken, catastrophic haemorrhage with no bleeding, and syncope with no altered consciousness.

Father's Day

Yesterday was Father's Day here in Owstralia.  I began Father's Day by calling someone in the early morning, waking them from sleep, and telling them that their father is dead.  I hope that your Father's Day was better.