ED haiku #5

There's nothing worse than
A vending machine dinner
Except no dinner.

Win at emergency

It's taken me a few weeks but I've figured out the secret of success in the Emergency Department.  First, some necessary background.  There are two halves to the ED: A side and D side.  On arrival, all patients are triaged into either A or D.  You go to A if you are likely to require admission to hospital.  You go to D if you are likely to be discharged after being seen.

My secret is this: always discharge everyone on the A side and admit everyone on the D side.  It doesn't matter how flimsy your justification is, or how ludicrously risky it is for the patient - the important thing is that you are creating a vibe, a persona, an imago, that will live forever and guarantee you'll pass.

Of course, you won't always be successful in executing this plan, since you need consultant approval.  But again, the key point is that you go into that conversation with the consultant with this firm recommendation and really shake things up.

Scenario #1, A side: Little old lady who lives alone with chronic renal failure comes in having been nauseous and ill for the past week.  Her potassium is up the wazoo, ECG changes, uraemic flap, confused and disoriented.
Your position: Discharge.  She'll be less confused at home, she has a renal clinic appointment next week anyway, all she needs is a litre of fluid over half an hour before we send her on.
Impression: You're a strong minded independent thinker who isn't afraid to voice their own plan.  Possibly somewhat confused and disoriented when it comes to clinical work, but at least you have the courage of your convictions.

Scenario #2, D side: Man comes in with bruise on toe that he dropped a block of wood on last week.  No disability but he had the day off so he thought he'd come in and get it x-rayed because he's never had an x-ray before.
Your position: Admit under orthopedics.  No wait, under plastics.  Get a CT foot done, then a follow-up MRI to assess for soft-tissue injury.  Run a panel of thrombophilia screens to alert the surgeons to your awareness of how serious DVT is.  Get three or four large bore cannulas in and a flatus tube for good measure.
Impression: You're a strong-minded independent thinker who demands the absolute best for your patients and won't take no for an answer. 

If you're not in ED at the moment, the general principle is the same.  Do the unexpected.  Nobody remembers the guy who was always boring and playing it by the book.  Step out there and make your mark!

ED haiku #4

Always check lipase.
You know you'll add it later,
Even for fractures.

ED haiku #3

To fit in don't shave
And wear a long-sleeved tee shirt
Underneath your scrubs.

ED haiku #2

The sick ones need it,
And it scares the well ones off,
So check the rectum.

ED haiku #1

Yellow eyes I wrote.
But the surgeon who came wrote
Scleral icterus.

Overheard in the emergency department

One doctor's plan for his sick patient:

"We're going to give him some stuff, do some things, and make sure he's safe."

Addendum

I've been thinking more about my previous words regarding virtual days versus real days.  I think the real nub of my gist is that any given day has only one paltry actual identity whereas it can have a multitude of virtual identities. 

For example, let's say I go in to work on an actual Wednesday.  Yawn.  How dull.

But what if that Wednesday was just a single day after a break, with a four day break afterwards?  Then that Wednesday is a virtual Monday, because it's the first day back.  But it's also virtual Friday, because it's the last day before a break.  And in fact it's virtual Maundy Thursday because it's the day before virtual Good Friday which will fall on actual Thursday.  That's three virtual days in one.

3 > 1, ergo virtual days are very physiological.

You're only a day away

The days of the week are, of course, illusions.  We usually aren't aware of this though because they are so ubiquitously subscribed to.  Somehow, somewhen, someone bullied everyone else into agreeing that this day, so indistinguishable from every other day, was in fact special and different, and should have a name.  And, weirdly enough, it would come back again in another seven days, just the same.  Think about it, it's a freak show.

No, I am not stoned.

It's just that working shifts for the first time in my life has torn the veil from my eyes, swept back the hoary eyebrows of familiarity, and shown me the truth.  It's made of people!!!!  Or something like that.

In my last position I was working a lot of Saturdays.  And on the Saturdays I wasn't working, I was working Sunday.  So Sunday kind of ceased to exist for me.  My week would start conventionally enough on a Monday, then go Tuesday, Wednesday, Thursday, Friday, then one extra day of work.  The Day That Dares Not Speak Its Name.

Being a programmer in the past, I was tempted to call it Friday++.  But that doesn't convey the full blackness of having to work that sixth day.  So instead I call it Double Scorpion.  Then the day after, that everyone else is calling Sunday, is my virtual Saturday.  If I had to work then too it would be Triple Scorpion.  This is when things get crazy, because the Monday after would be actually be Quadruple Scorpion for me, escalating all the way to Octuple Scorpion by your Friday and then Nonuple Scorpion when it should simply be my Double Scorpion on your Saturday.  That's only happened to me once, and it wasn't really that bad because the first Double Scorpion was only two hours work in the morning.  But that's the situation when you work a lot of overtime.

Shift work is different.  I'm now on my fifth consecutive day of work today, so it's virtual Friday.  (Not actually at work right now because my day starts at 11pm, but it's rostered for today.)  And this is my longest stretch of consecutive days for the next 2 months.  So this will be my only virtual Friday, and there will be not a single Double Scorpion for me.  Whoo!

Because my working week is broken up into little 3 or 4 day chunks, it means I'm frequently resetting the clock back to virtual Saturday, totally out of sync with the rest of the world.  When I started this placement it was (actual) Wednesday, but I had two days off, so for me it was virtual Saturday/Sunday.  Then I had three days of work, so it was virtual Monday/Tuesday/Wednesday.

Then I had four days off.  The first two days were virtual Saturday/Sunday.  But then the next two - what were they?  What happened is that at 11:59pm on virtual Sunday, the previous day was retconned to virtual Good Friday, and things proceeded from there to virtual Holy Saturday, virtual Easter, and virtual Easter Monday.  It was incredible! 

The practical effect of this is that for the next little while almost all my days are virtual Saturday/Sunday/Monday/Tuesday, with a few virtual Good Fridays and virtual Wednesdays thrown in.  A couple of virtual Thursdays, no more virtual Fridays.  It's amazing!  The only disadvantage is that my Smaller Half is also doing shift work but on a totally different schedule to me.  So right now I'm virtual Friday, she's virtual Tuesday, which coincidentally is also actual Tuesday.  But on Wednsday we're both on virtual Saturday which will be nice, although I'll be asleep for most of it, having worked all night, so it'll be more like virtual Friday night for me.

Still, it was worse beforehand.  The one time I had a Triple Scorpion, she was on her 5th day off because she was only working 2.5 days per week.  I don't even know what the 5th day off is.  It's unprecedented in my experience.  I guess if you went to a Twelve Days Of Christmas naming scheme you could call it Gold Rings.  I like the sound of that. 

Of course, this all goes out the window in August when I start a 7-on, 7-off roster.  So it'll be virtual Monday on Wednesday through to Triple Scorpion on Tuesday, then virtual Good Friday right through to Swans-a-swimming, then back to virtual Monday again.

I think it could catch on and be the next big thing.

Seine, Paris, France

Adding value

PTR

Hello, what's happening?

Man with moustache

Hi, this woman is having plasmapheresis and she's reported some peri-oral tingling.  Her ionised calcium before we started was 1.3 so I started with the standard citrate flow, but since she's gotten these symptoms I've turned it down 40% because I'm worried that she might be getting a citrate induced hypocalcaemia.

PTR

Mmmmmmmm.

[to patient]

How are you feeling now?

Patient

A bit better I suppose.

PTR

[to man with moustache]

So what do you think?

Man with moustache

Well we're nearly finished and her symptoms have resolved somewhat.  I think we might as well continue on as we are.  She's due for another run tomorrow, so what I might do is leave a note for the home team asking them to give some calcium prior and start off the citrate at a lower flow rate as well.

PTR

Ok then, that sounds good.  Anything else I can help you with?

Man with moustache

No, that's all thanks.

PTR

It was nothing.

 

A culinary proposal

Do any of you own a cafe or restaurant? Here's a tip: instead of having a cheese platter on the menu, have a “cheese splatter". It sounds much more hedonistic and indulgent.

First night last night

Last night I did my first night shift down in the Emergency Department.  It was also my first shift of any kind in the ED.  So I was a bit tense beforehand about a new environment as well as a bit tense about the whole "stay up all night and deal with stuff when there's only a skeleton crew on in the hospital" thing.

But you know what?  It was actually fine.

It's still a bit intimidating knowing that not only could literally anything walk (or be pushed) through your door, but also that the triage screen details sometimes bear only a tangential relationship to what's actually going on.  Like the guy last night who was noted to have haematemesis and malaena (ie: bleeding from both ends) who actually had neither.  Thankfully.  But the saving grace is that the staff who work there are all incredibly supportive and helpful.

Astonishingly, you are expected to function in accordance with your experience and training.  So if you're an intern like me, they keep an eye on you and give you lots of help.  And if you're new to the ED like me, they also are happy to explain the processes that you're unfamiliar with, without all the harrumphing and sighing and implied dissatisfaction that I have become accustomed to in some of my other rotations.

As you have probably guessed by now, this was a great revelation to me.  If only other parts of the hospital were as good, I would probably have been good deal less stressed for the past couple of years, and I would probably be a better doctor as well since people would actually have bothered to give me a headstart on what I needed to know and do, rather than lay guilt trips on me and stomp off into the distance.

On the other hand, the staying up all night thing is a bit pants.  I had a master plan to get myself into sync.  I stayed up late the night before, intending to sleep in and get as much rest as I could.  Instead, my Smaller Half got sick and had to sleep in instead, I had to get up early with the Hatchling, so I went into my stretch of night shifts even more tired than if I'd done nothing at all.

I got home at about 0900 today, was in bed by 10, crashed out and slept until 3.30pm.  So five and a half hours sleep.  I'm feeling a bit ragged but I've already got that seedy "too much coffee" feeling in my eyes so I guess I'll just be staggering through the night and hoping to catch up on sleep tomorrow.

By the way, the phrase "I'll sleep when I'm dead" really annoys me. No you won't, you'll be dead.  And you will have been really tired and shitty when you were alive because you weren't sleeping.  Just get some sleep while you can, moron.

Out.

Coffee tips

In a comment to my previous post, the boldly titled "Anonymous" questioned why I was calling a babycino a bubbacino.  Fair call.  To clarify, here are some similarly named coffee styles with explanatory notes.

Babycino: an espresso cup filled with frothed milk.

Bubbacino: an espresso cup filled with frothed milk served in a jail cell with a large, lonely, tattooed man.

Bobacino: an espresso cup filled with frothed milk served by a Mandalorian bounty hunter.

Babarcino: an espresso cup filled with frothed elephant milk.

Babayagacino: an espresso cup filled with frothed milk from a cannibalistic Russian witch.

Barbarinocino: an espresso cup filled with frothed milk served by a young John Travolta.

Bulbarcino: an espresso cup filled with frothed milk by a barista with a cranial nerve palsy.

Baabaacino: an espresso cup filled with frothed milk from a black sheep.

Not all of these are commonly available, at least not in Adelaide, but keep an eye out.  They're worth trying if you get the chance.

My bubba's too beveragalicious

PTR
Could I please have a cafe latte, a chai latte, a weak latte, and two bubbacinos?

Numbnut waiter
What's a bubbacino?

PTR
It's a little cup filled with milk froth.

Numbnut waiter
Oh, like a babycino?

And to save you the time making snide comments, I concede the following points:

1. Yes, bubbacinos are an absurdly yuppyish thing to order.  But at this place they were free, and I'd rather order a free bubbacino than have my $3.50 coffee sabotaged by a lunging Hatchling.
2. Yes, a weak latte is a girly thing to order.  Fortunately my Smaller Half is quite girly.
3. Yes, a chai latte is also an absurdly yuppyish thing to order.  But it was for a friend we were meeting hence I take no responsibility for her choice of beverages.

Now those issues are cleared up, let's focus on what a numbnut the waiter is.

Gargan Death Carrot

Yesterday I was alerted to the existence of the Gargan Death Carrot.

I know you think I made that up but I didn't.  Admittedly, even Google only seems to be aware of it tangentially, and Wikipedia not at all, but I can assure you it is real.

If you want to verify the truth of what I am saying, travel to the misty shores of far off Adelaide.  Go to the Botanic Gardens, just to the east of the Royal Adelaide Hospital, where the bamboo sways to unfelt breezes.  And find therein the eternal Museum of Economic Botany.  Enter by the door on the south side, amidst the deepest shadows.  Turn away from the temporary exhibit of Banks' Florilegium and the grim posturings of Robert Hughes displayeth on video beside.  Turn ye to your left and inspect the display of the members of the carrot family in the glass cabinet before you.

And quake as you behold the Gargan Death Carrot.  Marvel at the shrivelled pieces of unrecognisable vegetable matter in front of you.  Wonder at the simple description that from it can be extracted a resin that is mixed into plaster.  And leave, because that's it.  Yes, having included an exhibit called the Gargan Death Carrot, the curators then failed to provide any information on it beyond some simple home decorators tips.

What is the Gargan Death Carrot?

Is the carrot deadly?  Is it poisonous?  Is it very sharp and pointy and can be hurled like a spear?  Is it hard and useful as a bludgeon?  Or perhaps it incites in its devourers a murderous rage?  Perhaps, like the mandrake, it shrieks as it is uprooted, slaying all those in earshot.

Or is it a symbol of death?  Did the Society Of Assassins in distant Garg have as its symbol the native carrot, for reasons unknown?  Or were condemned criminals permitted one final meal of Gargan carrot, which is so delicious that consumption is otherwise only permitted to the Prince Regent in his Black Tower?  Or were slices of carrot used to weight down the eyelids of the dead, granting them eternal rest?  Are the shades of the dead welcomed to the gardens of paradise by the carrot?  Or perhaps the dead are terrified of the carrot, so bunches hang in every peasant hovel to guard against witches and hobgoblins.

I looked long and hard through the rest of the exhibits, searching for similar items of eldritch lore.  I sought out, but did not find, the Guinean Haemorrhagic Yam.  I heard rumours of the Batavian Agony Pea, but could not confirm its whereabouts.  And the Apoplectic Prussian Leek was conspicuous only by its absence.

The wheels of knowledge turn slowly.

What we do in between patients

PTR

What does this abbreviation FFMN stand for?

Registrar

"Fasting from midnight".

PTR

I wouldn't abbreviate midnight as MN.  I'd just write FFM.

Consultant

But that would be "Fat free mass".

PTR

What's that?

Consultant

It's the old-fashioned way of saying "Lean body mass", your weight if you weren't obese.

Registrar

Oh, by "mass" I thought you meant a church service, one just for skinny people.

Consultant

So a fat free mass would be where you give the anorexic the wafer and she just vomits it back up again.

Bored on a wire

Internship is all about balance.  People will give you all sorts of garbage advice about work/life balance.  It's garbage because it's impossible.  Work wins.  Life loses.  The end.

No, the balance I am talking about is the balance of how you spend your time at work.  At various times you are working for the patients, and at other times you are working for the consultant (the big boss).  Very occasionally you are working for yourself, such as when you go and get a cup of coffee or sneak off to open your bowels.  Refer to my previous comments about work vs life.  Pooping is life and is to be savoured as it arises.

So anyway, I was talking about patients vs consultants.  This is something I struggle with.  I tend to get caught up in spending lots of time talking to patients and their families.  Nobody else but the intern bothers to take the time to explain what the test results are, what they mean, what the prognosis is, what else might happen, whether or not this is all someone's fault or not, and in as much plain English as can be mustered.

I tend to spend a fair bit of time on this because:

1. Ostensibly it's what the hospital is there for.
2. I feel sorry for these people that Life has dealt a bad hand too and I want to help them out.
3. When I do it, they always say really nice things to me later on when they leave hospital about what a great doctor I am.

So it's a mix of idealism and rampaging ego that motivates me.

Unfortunately, spending my time working for patients means that every now and then my consultant misses out.  Such as the other day when I was busy explaining to my patient's family what was going to happen now that we'd discovered that a lot of bad shit was going down with him.  It meant that I was 5 minutes late to a drug rep talk about some new drug that does the same thing as some existing drug except it costs more.  It had been arranged by my consultant and clearly his dignity was bruised that I hadn't prioritised it above all else.  I could tell this because he said to me, "If you can't be bothered turning up to education sessions you can get the fuck off my ward."

You know, the more I think about it, the more I think I've got the balance just about right.

Awaken the giant within

Every now and then someone remarks to me that they wonder how I can cope with doing my internship at the same time as my Smaller Half whilst also trying to look after the Hatchling. The answer is of course that I don't. Cope, that is. I spend most of my waking hours desperately trying to catch up to where I'm supposed to be and never quite making it. And my sleeping hours I spend having bizarre dreams about imaginary medical conditions suffered by fictional patients that I have to try actively to forget upon waking lest I blurt out something insane sounding on the ward round the next morning.

"Mr Upendis hasn't had his brain biopsy yet so we still don't know where the chocolate is coming from!"

Be that as it may, it is made easier than it might be one you realise that caring for patients is almost exactly like looking after a one year old.

Patients: did they sleep well?
Hatchling: did she sleep well?

Patients: do they have a temperature?
Hatchling: does she have a temperature?

Patients: have they had their bowels open?
Hatchling: has she just made a special delivery?

Patients: how's their fluid balance?
Hatchling: has she had enough to eat and drink?

Patients: have you checked the gentamicin levels?
Hatchling: would you like me to read you Hairy Maclairy From Donaldson's Dairy?

Patients: can you get the neurosurgery registrar to review them ASAP?
Hatchling: you look so cute in those little purple trakkie-daks!

The similarities go on and on and it makes everything so much easier. So for those of you embarking on medical careers, my advice is to have children right now. Especially if you might be competing with me for jobs in the future. Yeah, that's it.

And if you already have small children, why then, enrolling in a medical degree and working 7 day weeks for some sociopathic overseer will be just the ticket to sharpen up your parenting and really bring you closer to your family.

And while you're at it, write some damn blog posts on your phone using the stupid touchscreen. Ow! My arm!

Watershed

This is a milestone. History in the making! One small step and all that. This is the first (and at this rate possibly the last) post I have written and posted using my mobile phone. So much technology! I am also typing it using my bionic arm. And it is packed full of subtle military nanomemes that will compell you to melt down your jewellery and send it to me. Electrickery!