Archive for October, 2006

The serum rhubarb

Medicine is not an exact science. People see TV and read stuff in books and think that all the science is directly applicable to these darn nuisances of sick people.

For example.

People widely believe oxygen is good for you. And, yes it is vital to human existence. At very high doses it is kind of (!) poisonous. (One of the other ICU docs is a Scottish guy, excellent doc, very funny stories. He describes oxygen as a toxic substance found only on planet earth without which its victims would not have to endure 70 years of pain, toil, misery and suffering. There’ll probably be a lot of his stories in here).

People think exercise is good for you. And again yes it has its upsides so to speak. But it gives young athletes massive hearts that stop mid-exercise and it gives you arthritis and puts you at risk of nasty accidents where you might end up in hospital and then the world of medicine will get at you and then you’re really stuffed.

Medicine is not an exact science. It’s not even technology and design or woodwork (except orthopaedics I suppose). It’s more like a jazz lesson. Improvisation. Make it up as you go.

Every statement has a qualification behind it. I can say, yes, this patient’s blood pressure is good. But just cause his heart can generate a pressure does not mean it can get the blood to move round the body. Every good number is dependant on another number being good.

Blood tests are another thing. People think we take blood and send it to the lab where a Quincy like gentleman sticks it in a fancy machine and it tells us what’s wrong with the patient. Alas no. We have to tell the machine what to look for first and it can tell us if it’s there are not. The list of things to tell the machine to look for is staggeringly long (even longer than the 39000 words I’ve written since starting writing a blog 13 months ago).

The basic principle of a hospital admission is this. You get admitted because of certain symptoms, for example, shortness of breath, (SOB as we call it in the trade). You’ll get a chest x-ray done. Which will usually not tell us the cause. If there’s something wrong with it you’ll simply get a fancier chest x-ray done. You’ll get some basic blood tests done – we check how much blood you have and if your kidneys and liver works ok. Usually they don’t tell us what’s wrong either. So we do more tests, and take more blood and do more scans.

The natural history of such an admission will be a) we continue to test you till we kill you or, b) you get better of your own accord and leave before we can kill you by investigation. Or much more rarely c) we find out what’s wrong with you.

Sensible docs know when to take an educated guess what’s wrong with you, and get you out of here before we do damage. Lots of these doctors have been sued for occasionally getting it wrong. There’s not many of them left now.

If you get admitted to hospital then that’s generally a bad start. If you get admitted to ICU then you’re generally in trouble big style. If you get admitted to ICU then you’ve missed the boat with b) and so you’ve only a) and c) left and the chances of c) are increasingly less likely.

By this stage you’re either unconscious or we’ve made you unconscious and put lots of tubes in funny places. So now we can’t ask you what’s wrong with you. And it’s amazing how elementary that is.

So we tell the machine to test for lots of things, to test for the serum (blood) level of this and that. And then there’s the code phrase – check the serum rhubarb. And no, ingestion of large quantities of rhubarb has not got you to this position (generally at 30 degrees head up tilt, with a tube in your throat and one between your legs and a few others for good measure). This is code for “we haven’t a notion what’s wrong with you but we’re gonna keep trying for c) and hope we don’t get a)…”

This isn’t what we tell the relatives cause that’s just not PC and I doubt they’d believe us any way. So we just tell them what they want to hear anyhow and what they’ll remember whether or not we tell it to them.

That’s when I use my term “medicine is not an exact science“. I find it works well. My Scottish mate has trumped me with his own personal favourite that he can rubber stamp and apply to all such discussions with relatives – “it’s complex, multi-factorial and it varies from patient to patient.” The usefulness of such a phrase cannot be overemphasised.
He says he once knew a doc whose favourite line in situations where he wasn’t winning was to say “we have to be aggressively conservative in what we do”. Which is non-sensical rubbish but he was a surgeon, so that explains a thing or two.

Funny cheese and salmon

Andy’s journal 29/10/06 21:18

The period of time between waking acnd actually getting up. It’s part dream world. I have no over-riding conscience in that state to lead me away from the childish, selfish pillow hugger. A dangerous place to be. And I seem to always end up making bad decisions. So I got up at 8.00 and was at church for 8.30. It was good day. Church is done differently in NZ and I suppose it’s right to be. Spent all afternoon doing a lot of very little. Fiddling with iTunes and emailing an reading the paper. Doing anything to avoid spending time with GOD. Why do I do that? I think I need a list of things in front of me, so long that I stand no chance of getting through. Even the sight of the end of the end of the list is enough to induce boredom. Not nice enough to take the kayak out. Fed myself with funny cheese and salmon. I have funny cooking habits here. Listening to lots of Duke Special. Fantasise about being a singer/songwriter. Strruggle to think of ideas for blog

Retrieval

The main advantage of my current job, well not the main advantage, there are many, is that I get to do inter-hospital transfers. And no this has nothing to do with the Bosman ruling.

In NI I did a few transfers, but they were all very well people and they were all by ambulance, and if something would go wrong you could simply tell the ambulance to drive faster. It only takes about 18 mins to get from craigavon to the royal in an ambulance at 95mph.

Here the big hospitals are a fair distance away. Wellington is about 6-7 hours by ambulance up and down over mountains. The equivalent of dungannon from craigavon is a place called Wairoa which is about 2 ½ hrs away by road. Wairoa is truly in the sticks. Patients come from Wairoa with a ticked check list of medical conditions. Diabetes/heart disease/lung disease/morbid obesity (frequently greater than 150kg) and a legion of country yokel relatives with them too.

And they’re not great at ever taking their medication, and they’re all double-hard and tend not to visit a doctor till their leg is ready to drop off or they can’t reach another pie to their mouth without getting angina. Frequently they’ll have a heart attack in the peace and quiet of their own home and then drive in the next day cause they had to get the sheep in first. Yesterday there was a guy who got bucked off a horse and gave himself a really nasty (and potentially life-threatening) pelvic fracture (a near 10 cm pubic symphysis separation on x-ray!) and didn’t make it to us till the next day cause he couldn’t get anyone to drive him!

So this is my target audience so to speak. On Friday Im sitting in the tea room after lunch and Ted (my boss, I love it that he’s called Ted and i get to call him Ted too) asks me if I’d mind taking a wee flight to wairoa to retrieve an 84 year old with a pulse of 30 a minute (generally not a good speed that) and has probably had a big stroke too.

So I get all excited cause I get to go in a helicopter and then all scared because a patient with a pulse of 30 and a helicopter don’t mix well. I get my jump suit, which is designed to fit the 150kg patient instead of me I think. And most important of all I grab my camera, not to miss the opportunities of nice aerial photos on a sunny day.

I tried not to giggle and smile as the helicopter took off, that I actually get paid to do this. We fly from hastings to napier and I can see Mt Ruapehu in the centre of the island. I can see the marina and the apartments where I live and get a lovely shot of Napier and the port and the hill.

Dean, the pilot wearing a shiny, well-fitting red jump suit and sunnies, tries to scare the willies out of me by veering suddenly and diving. I smile to cover the fact that I’ve had the willies scared out of me.

Wairoa hospital reminds of a hospital I was in in South Africa, though that may be stretching it. The patient is a maori lady with grey hair and pig tails. Only Maoris (and south American natives) have pig-tails at 84. She has right sided neglect. With strokes you sometimes lose the knowledge that you have one side of your body and consequently ignore it completely.

We put her in the helicopter, which is a feat in itself. She’s trussed up in a blanket and a seat belt in a stretcher. Even if I wanted to do anything medically dramatic I wouldn’t be able to get at her to do it. Apparently the done thing is to just set the helicopter down and do whatever you need to do and then take off again. I have a heart monitor and I can see her wee spiky complexes of her heart beat on the screen. We take off and her heart stops for 3 seconds and then starts again. She does this all the way home till the helicopter lands again and then she stops. I mean she stops having the pauses, as opposed to her heart stopping altogether, as that would be most inconvenient.

I get back to the unit and I tell Ted that all went well and thankfully I didn’t have to do anything. Ted gives his knowing smile. He’s 64 and has been doing this for a long time, he’s allowed to give knowing smiles. And I realise that that�s why he sent me, cause it would be an easy one, and he’s breaking me in gently. Well either that or he wouldn’t trust me with anything more complicated cause he’s a bit suspicious that I’m a bit of a medical muppet. Couldn’t blame him really�

Day dreams

communication, as I’ve waxed lyrical on before about, is great stuff. I can have video chats with my folks and mates back home with no bother, the picture’s good, though my mum’s perennially in her pyjamas for some reason. I can send photos home and get sent photos too. In many wasy I’m communicating better with people than I ever did before. I’m probably speaking to my parents more often, even though I lived in the same house as them!

It’s great that I now have an RSS feed from the CE website and the podcasts on iTunes are simply amazing. And I’ve been listening to these as I drive about the country, catching up on where CE has got to. Most recently it was Rico Tice. He talked at one point on day dreams and how if you catch yourself in a day dream it�ll give you a good indication of where your heart is that.

I’d read something similar in a book by Don Carson before on the sermon on the mount. He listed a set of questions to ask yourself from the beatitudes and one was what do you think of when your mind slips into idle based on “blessed are the pure in heart”

That struck a chord (probably a gmaj7) with me. I’m a continual day-dreamer, I can never say that my mind ever really goes blank as such. Except for maybe when I’m leaving work and I can’t remember where I parked the car.

There’s a near continual dialogue going on in there. Mostly rehearsal I would call it. Now that may be for the soon to be made movie of my life that I seem to have continually running in my head, like the Truman show, except I’m in on it and pretending I don’t know there’s a camera on me. It may also be for all the situations, be it in work or socially where I’ll excel and come across as mr fantastic and everyone will love me and think I’m the dude or in work that I’m a FIG JAM (a rather rude acronym for a medical qualification over here).

So this is what is going on when you see me staring into space or focused on something. I may be writing my most amazing person ever acceptance speech.
That’s where my heart’s pointing, that’s where my desires are leading me. Just under the surface, below all the rational decisions and promises made that I’ve compromised�, is the stinking, rotten heart of ego, pride and arrogance that I’d like to pretend isn’t there.

So there’s a CS Lewis quote, there always is isn’t there:

All this is flashy rhetoric about loving you
I never had a selfless thought since I was born
I am mercenary and self-seeking through and through
I want GOD, you, all friends to merely serve my turn
Peace, reassurance, pleasure are the good I seek
I cannot crawl one inch outside my proper skin
I talk of love, a scholar�s parrot may talk greek
But self-imprisoned, always end where I begin.

Squinting my way through life

Some may take this blog as another sly attempt to sneak in comments about how sunny it is here all the time and how it’s just a wonderful place to be, and how it’s getting cold, wet and miserable back home. But you know me better.

There is an awful lot of sunshine mind you. And that brings me to sunnies, or shades, or sun glasses or artificial retina protectors as you may more commonly call them.

If you were painting a sketch of a typical kiwi you would have to include the sunnies as essentials. Now, to be fair they have more use for them than most but wearing sunnies indoors on a grey day is just plain weird. Following is a list of reasons why they fall onto my ‘things that I dislike’ list.

When people are wearing them you can’t see their eyes. Of course this is kind of the point but it’s impossible to have a heartfelt conversation with someone when you can’t see the whites of their eyes. It also allows you to sit in bars by yourself and check out all the ladies without fear of detection. I tried this without the sunnies and had to walk home with a limp and a bleeding nose…

They provide a shield to hide behind, to keep people at arms length, to avoid intimacy, honesty and the fear of social contact. Though that sounds like something I would love, it’s like a crutch I refuse to accept. The path of least resistance was never one I was keen to travel. Somewhere a paragraph or so back I was talking about sunnies…

They cost obscene amounts of money and then you set them in the glove box with a pile of twenty pence pieces and all of a sudden you’ve got a scratch down the lens and you can’t see through them. I buy a pair a year roughly. Of the BP filling station class of sunnies. A fiver with a twenty quid fill up. I tend to sit on a pair a year by mistake so this works out well.

They make your nose itchy and your ears hurt. Though once I was told they weren’t actually for nasal or otological insertion that cleared up somewhat. I’m lucky enough to have the eyesight of a… well some animal of good eyesight, can’t think of any right now, so I’ve never had to wear glasses. I’m not a big fan of anything on my person if you know what I mean – watches, jewellery, clean clothing, that kind of thing.

There is the one exception to this rule. Snow. Snow on a sunny day is a killer and you’d be lucky to last half an hour without the sunnies. In fact extend that to two exceptions (maybe I should start putting some actual thought into my writing…), in driving when the sun is setting into your vision and you’ve already clipped two cyclists.

There are few joys like squinting into the sun. Today’s paper before me, sitting in an outdoor café, with my eyes screwed up (usually my left one screwed up) staring at the sun. You end up with white crow’s feet round your eyes, a headache and a low-grade skin cancer in later life. Couldn’t beat it.

I have every intention of squinting my way through life. To hell with the sunnies-wearing beautiful people of the world. They never really liked me anyway…

Cyberspace

Now have the internet in the flat. Which is kind of cool as it saves me going to thei internet café to use skype. Where I shout down a mic at folk back home in a harsh norn irish accent. The wee asian guy who runs the place has no idea what I’m saying anyhow so there’s no difference in that respect.

Getting it set up was interesting. I had to phone telecom lots, and they’re always busy and they’re always on hold. And in true loyal New Zealand style they played kiwi music while you’re on hold. This consisted of a three song loop (that I became intimately acquainted with) of don’t dream its over by crowded house (kiwis), followed by some lovely wee song by a guy whose name I can’t quite remember now (also a kiwi) and then weather with you by crowded house (still kiwis).

When I did get through I had the pleasure of some hyper young girl whose name I never quite caught. Over helpful. Over chatty. Between each step of the process she’d start some small talk for a while, asking me where I’m from (surprisingly by NI accent isn’t as subtle and inconspicuous as I thought) and what I do and where I work and all. She then proceeded to tell me how I was doing her dream job and how she always wanted to do medicine but never got the grades and dropped out and ended up in a call centre – or something like that, I wasn’t really listening, I was kind of scared of giving personal details to her, like my address and stuff. Intense. Thankfully got the net working and I was half-scared she was going ask me could we meet up or something (I have these paranoid delusions often) and hastened to end the call.

I can now relax (though she knows where I live!) in the comfort of my home and ignore the sunny days outside and disappear into cyberspace. Well not really.

The first thing I did, pretty much, was to go to the BBC website and turn on the radio player at radio 4 and the Today programme. It was 1830 here so that made it 0630 there. I’ve never heard the Today programme at that time before. Novel experience. Jon Humprys how I’ve missed you�

Bread and butter

Today was a funny day in work. Maria and Otto (my hungarian bosses) were both off. They actually had to be forced to take a day off cause they’re kind of workaholics. Maria even rang in at one thirty in the morning to make sure a patient got a certain drug.

I work in an AAU (acute admissions unit) where we see folks who usually need a few investigations and chucked out the next day. An attempt to cut prolonged admissions to hospital. It’s a decent place to work. Fewer old demented crocks than usual.

So today the AAU was me and Bob (the ED/A&E boss). Bob spent most of the time running the ED so I was kind of my on my own. And i’ve been kind of baby sat since I started. I think maria and otto have me sussed as a bit of a muppet doc and are trying to stop me killing people. They’re probably right.

Today there was no such baby sitting so I kind of had free reign with the patients. Which is more what i’m used to. First guy. Mr A. He’s fat, a smoker, a diabetic, knackered kidneys, dodgy ticker and low on blood. His lungs are knackered from smoking. This is your standard medical patient. This is my bread and butter.

Except Mr A has a 10p piece on his chest x-ray. And I don’t mean he choked on it. It’s what’s described as a ‘coin lesion’. Lesion is a word doctors use to disguise cancer when we’re talking about it. Everyone knows what tumor and malignancy means these days so we use ‘lesion’ or ‘neoplasm’ to hide it from people.

Mr A doesn’t know this yet. I know this. I know it’s not definite, few things are in medicine but i’ve seen enough to know i’m not wrong. He’s a dead man. So he gets a scan of his chest and it shows he’s got one lesion on the periphery of his lung that’s spread from another one near his wind pipes. I know this. He doesn’t yet. This means he’ll be a dead man in a few months and there’s little anyone can offer him.

Mr A is fed up with hospital. He’s had his blood transfusion and Hawke’s bay are playing rugby tonight and he has work to do in the garden. He has no intention of staying. Mr A can’t complete a sentence without stopping for breath. He’s going no where.

He has to know some time. And Bob (the boss) has gone to a funeral and there’s just me. If it were me i’d want to know. So I go in and I sit down and explain that we saw a ‘shadow’ on his lung and we did a scan to check it out and that we think he has cancer. And that last word sticks in my throat. Like my voice has never said it before. Like it’s not quite sure it should be forming the sounds. The atmosphere changes. We make eye contact. And it’s not like there wasn’t eye contact before but it’s clear now he’s really listening.

He rolls his eyes and sighs. Then mutters an angry comment about how long he’ll have to stay in hospital then he looks at me again and he’s petrified. Anger, denial, acceptance and fear in seconds.

He asks me to ring his daughter and tell her to come over. I ring her. I fear she’ll ask me why I rang her. But she spares me that.

I have this fear of unexpected phone calls form unknown numbers from people I don’t know at odd times. I’m convinced the worst has happened. My heart thumps till the person on the other end of the line explains why they’re ringing.

So his daughters turn up, and his wife. And I tell them and him the same thing as before. I use the word cancer again. And still it sticks in my throat. If I didn’t say it then they wouldn’t get it. Until you mention the word everything you say to them will be meaningless. His wife cries, he cries. He thanks me. He thanks me. He thanks me for telling him he has cancer. My eyes fill with tears and I make myself look in his eyes and I make myself hold his hand cause he deserves it and so much more.


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October 2006
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