Archive for December, 2008



When will i be famous

Almost makes the X-Factor worthwhile. Though i did say almost. I feel oddly privileged to call these guys friends…

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Put the book back on the shelf

David Copperfield  brief summary.

Life sucks, but it’s really quite intriguing all the same. Lots of people die, some move to Australia, the bad guys get their comeuppance in the end.

Best line [following his (unfortunately named) wife Dora’s death]:

I sit down by the fire thinking with a blind remorse of all those secret feelings I have nourished since my marriage, I think of every little trifle between me and Dora, and feel the truth, that trifles make the sum of life.

The same deep water as me

At least it keeps the pigeons off the square…

[Thanks as always to the Big Picture]

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London Calling [Part 6]

The course’s highlights today: Liver disease and intensive care stuff, from someone who really lived their liver patients – kind of inspiring but also slightly worrying – that maybe you should get out more. That and a great story about a guy successfully resuscitated after 4 and a half hours CPR and an initial temperature of 9 degrees centigrade. You’re not dead till you’re warm and dead. And then you’re dead and you get cold again… And it seems we under does all our status epilepticus patients – which is why they won’t stop fitting it seems.

I leave, inspired to do a better job than I do – inspired to study more and do better –  and audit anything that’s not tied down to see if we can do it better. Though I know when I go through the doors tomorrow it’ll be back to the conveyor belt of demands and waiting times and decisions and annoyed, angry, frightened patients.

Audit is something I hated for years – something I felt compelled to do my bosses who said that you’ll never get anywhere with your CV till you’ve got a few audits on board. This was perhaps the wrong way to explain it to me. I always say I am the least career minded person I know – if it’s not good old fashioned looking after people then I’m not interested. which is all very noble and all that but mostly bollocks. If I’m honest I’m sure I’m in it for the glory as much as the next person. And so if someone said audit was good for CVs and careers then I wanted no part of it.

Then I read some journals and in particular Atul Gawande, who in his simply articulate manner persuaded me that you cant get any better at what it is that you do unless you count the numbers I now love numbers. This was somewhat of a road to damascus experience for me.

What frustrates me in the current job is simply how bloody difficult it is to count the numbers and what an awkward specialty emergency medicine is for counting the numbers.

For example if you do bypass surgery for people with heart disease you almost invariably treat patients who have the same cause (burgers and ciggies and being from Norn Iron) for their disease and the patients themselves are a fairly homogenous group. You will have a fairly predictable number of these to do each year. The technique for doing them is largely standardized from operative technique to anesthesia to post-operative care to expected complications. Therefore it is relatively easy to measure your outcomes (who died, who lived, who had complications) and see how you’re doing.

In emergency medicine, anything (in terms of pathology) can walk through the door and frequently you have the wrong diagnosis when the patient is either admitted or discharged. The population you deal with is from as young as 2 days (the youngest one who i was involved with who i’d done the baby check on before they’d went home and came back dead within 36 hours – how good did i feel…) to 101 (who was fine and went straight home again). And even if you do know what’s wrong with them, you don’t tend to be involved in their ongoing care and therefore have no idea how they do in the longer run –  that’s a number for someone else to measure.

So you end up trying to find the stuff that is peculiar to us, stuff that belongs to emergency medicine as such. And the list is fairly small though significant. There are certain standards of care that are expected of someone with a certain diagnosis, for example early antibiotics in severe sepsis, nimodipine in sub-arachnoids, time to reperfusion in heart attacks(though that’s more down to the cardiologists these days…).

The problem is simply getting the data. In the twenty-first century we are still using DOS based systems for blood results, patient tracking and printing X-rays on film. We record all our notes on paper. Do you remember paper? And writing things with a pen and all that…? Welcome to early 70s… It seems the health service has the monopoly on dot-matrix printers – pleas just stop making them and we’ll be forced to change…

Without a decent digital record the whole thing is a complete nightmare to measure. How do you archive and database all this paper. How do you retrieve all the data. Well by simple hard work and lifting through reams of paper which is what people did in the old days but it galls me to even think about it.

It is important to note that computer systems and electronic care records and digital radiology are unlikely to save lives but they will keep your doctor sane and I figure that’s always a good thing.

Phew…

I skipped the last lecture, having to sneak out to get the train to Stansted, which seems to take so long that you might be better flying from Bristol instead.

I always used to say that I quite liked London to visit but I could never live there. And I suppose after a few days dandering around and being a bit older and a bit uglier i think i could probably live in London. I used to think it was only famous people and druggies and politicians who lived in London (often combining the two or even all three…) – in fact the only famous person i saw walking around was the chap Lizo who does the entertainment stuff for BBC news. And i suppose that doesn’t really count does it.

It turns out that London is in fact full of normal people, going about normal everyday lives. Just with worse commutes into work and better suits.

I’m not saying I want to live here, just that I’m no longer scared and intimidated by the place. Which has got to be some kind of step forward.

Incidentally – almost finished David Copperfield which I started back before Da died. It’s like all of the old proper books i read, initally a bit bewildering and dull, and nothing seems to happen, then a few folk die, people get older and the book ends. Though by the end you’ve been reading the book so long that you’ve grown rather attached to everyone in it.

London Calling [Part 5]

Back to work then. Well kind of.

The course for the next two days is much busier than the last one, we’re all kind of crammed into an old Victorian room, which fluctuates between too warm and too hot and there’s never enough coffee to go round.

But the course is good. We even had a repeat of the heart failure talk we’d had on thursday – and it was even more compelling the second time round. Though he was preaching to the converted. I’m a CPAP and morpine man with liberal use of GTN. In  youth i was a furosemide man, though i have perhaps seen the light and all that.

For the non-medics – you may not be aware that for lots of things we don’t know ctually how to treat you so we invoke the gods of anecdote and evidence based medicine and expert opinion to try to justify whichever options we choose. It’s great fun. Though not for the patient perhaps.

There was an interesting chat on thrombolysis for stroke which again reinforced what remarkable things we can treat that we didn’t used to, and also just because we can doesn’t mean we should be doing it where i work. People are always keen to throw money at wht’s fashionable – especially drugs, cause we think they’re like pixie dust or something. No one is willing to throw money at things like, nurses and beds and meticulous supportive care, which is what gets people through illnesses alive I suppose we’re just not willing to accept that we can’t “fix” things.

Anyhow, i must do a proper philosophy of medicine rant. Just not right now.

Back to London.

img_2749Tonight was proper culture – people in penguin suits playing violins and cellos and other instruments I can’t name. Schumann or Scubert or something like that. It was in the Royal Festival Hall which is all very nice, and to give it some credit is really quite egalitarian and evangelisic about the arts, running free concerts and that type of thing. I didn’t feel out of place in my combats at least.

Again we were front row – I don’t kowo how Carson does it – the man’s a genius.

Witihn seconds of the start I was in another world. I get bored listening to classical music on the radio or a CD – the whole thing seems so damned lifeless – I’m lost without my usual handles of rejection, unrequited love and misery that I find in all my “sad-bastard” music. But live it’s a different story – I’ve no idea what’s going on but it’s beautiful – and i suppose that’s all i need to know.

One of the great skills and knacks to life is to see beauty in everything. People write books, and paint paintings and sing songs – because they want to describe something of what it means to be alive. Now of course this isn’t always prettty – bad things happen remember – but it will almost always be something pretty heart felt and genuine. It will nearly always have a bit of “soul” to it.

A broad appreciation of how humans do all this is simply vital – it’ll vary, from footy, to songs, to books, to the things we say to each other. it’s just one persons way of looking at life – and yes we can have a long chat about whether it’s “true” or not – but no matter what way you look at it – it will not be unimportant.

Anyhow, vague, pooorly considered culture rant over.

More amusingly – the chief violin fellow broke a string half way through, and simply swapped the one with the broken string for his mates beside him and played that until his mate had fixed the one with the broken string.

Dandered back to Leiscter Square for a steak and were accosted by 7 or 8 ward sisters from Craigavon Hospital. We were naturally a little surprised. They were all on our list of people we didn’t expect to see that night. Good to see them all the same mind you.

It has started raining – after a good solid 5 days of icy cold. Almost enough to make me abandon the walking and get back on the tube. But then if i hear one more prat singing “let me take you by the hand and lead you through the streets of London” – then I’m going to cause someone grievous bodily harm. Could be worse – could be singing “Lady in Red”…

London Calling [Part 4]

Went and saw the mouse trap last night. It’s been running in London continually for something like 56 years or something silly. there’s a counter at te entrance saying this is now the 24000 performance or something. I can imagine the poor actors pleading “please kill me” during the performances.

Gilly was convinced that he’d seen it once before during his time in London, and was fairly sure that the butler did it. Which seemed understandable till we realised there wasn’t actually a butler in the cast at all. Anyhow good show. In a vertigo inducing theatre.

Breakfast in my hotel has so far been uneventful. Turn up in the dining room, sit down, man brings me eggs and bacon. Until today. The dining room is exceptionally small, not exactly big enough to hold all the guest at the same time, not even big enough to hold more than 8 of the guests at the same time. Which led to some entertainment. “would i wait outside?”, would I wait inside?”, “would I mind sharing a table with this lady?”, “would I mind sharing a sausage with this man?”, “would i mind waiting outside again?”

There were smashed plates, no glasses, an overflowing coffee machine, shouts from the kitchen, a foreign chap with no english waiter kept getting everything wrong and a rather frantic Englishwoman who followed him around apologising for all the mistakes. It appears that Fawlty Towers is alive and well. I loved it.

Met Gilly at All Souls, where inevitably he knew the first person at the door. All souls holds a bit of a special place, with all the previous visits with CE, and all the people who seem connected with the place. And they do a good job. Be it from music, to communion, to welcoming. Put a bit of hope in my soul which has been conspicuously absent over recent months.

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Spent the afternoon in the British Museum – which remains wonderfully free of charge – looking at mummies, and rocks and books. Fantastic stuff. I could get lost (physically and metaphorically) in there for weeks.

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Incidentally, the British Museum has the longest queue for coffee I’ve ever seen. I tell a lie, the longest queue i’ve ever stood in – normally i just see it and don’t bother.

By that stage it was time for the afternoon nap. Not that we sleep, we just go back to the Royal Society and i lie about on the sofa writing blogs and fiddling more with the drum samplers while Gilly either lies down or reads theology. All very pleasant.

This evening we met up with a couple of CE graduates, who’ve ended up working in London for the mean time. So good to see people you know in a totally different context. We went to All-Souls again to hear Rico Tice and have a pizza after. All very lovely indeed.

Tomorrow I suppose we’re back to work, looking at things as widely varying as status epilepticus to dermatological emergencies – normally that last one’s an oxymoron, but there are a few skin 999’s.

Maybe I should add this. I’ve found myself enjoying things. Enjoying this trip, enjoying musicals, and other people’s company and all that. I haven’t done much of that recently. There’s this odd guilt that by enjoying things you’re somehow being disloyal to the memory. That you’re somehow being disloyal to the grief process. I dunno. Maybe it’s just good days, bad days. The whole thing’s a bit mad really. I don’t pretend to be doing it particularly well. You just get though it somehow. You just keep going.

London Calling [Part 3]

I stayed up too late last night in the hotel fiddling with drum samplers (simultaneously an advantage and disadvantage of the laptop) and slept in this morning while Gilly did some Christmas shopping. I spent the morning looking for a razor (not being allowed any on the flight over) as the spidey fluff on the chin had started to get a bit embarrassed.

It is a world gone mad when it’s cheaper (2.80) to buy 10 razors compared to 3.80 fro 3 and a ridiculous 8.40 for one. Anybody need 9 razors.

It’s a glorious winter morning in London. the tourists are out in force in Russell Square, feeding the rather over tame squirrels and getting photos and videos of them.

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Spent the afternoon in the cabinet war museum under the ministry of defence. Given the office’s recent obsession with the warmongering, ginger, cigar smoking hero of the second world war i’ve been somewhat drawn toward his history of the second world war. The opportunity to see the no 10 annexe and the cabinet war museum was too good to miss.

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I love museums, i love the little audio guides yo get. the last one i get was on a tape deck in a museum in london in the mid-eighties on holiday with the family. this one was all wi-fi and technological and very impressive. it even had kate aidie doing the commentary on part of it.

the museum was simply fantastic. lots of nerdy factoids and quotes from the man himself. various items of clothing and even a half-smoked havanna.

walked back via reagent’s street in all it’ hellish christmas glory. get me out of here…

Gilly is staying in the royal society of medicine – which sounds all very erudite – and well maybe it is but it’s got good sofas and internet and a humongous library that gets me excited just looking at it. I love librarys. second only to cafes. though librarys where you can get coffee are the pinnacle of everything.

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