Archive for the 'bitching' Category

Don’t worry about a thing

I got this through the post this morning:

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A flyer on screening for cardiovascular disease, where you can turn up and have scans done for “peace of mind” and all that bollocks.

I’ve no idea where they got my name from or why they think a 28 year old is at significant risk of stroke (must be all that cocaine use…)

It got me in a bit of a rage. These things do.

They use unproven, emotional driven language to make money out of people’s anxiety. Surely the fact that they “can see inside your arteries” impresses you?

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Yes it is true that being over 55 increases you risk of stroke – as does obesity, smoking and lack of exercise. But wait they’re all entirely modifiable risk factors, something you don’t have to pay 140 pound for the privilege of.

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My favourite bit of that photo is the fact that i don’t have to remove my clothes. Phew…

These tests are not accurate. Let me emphasise that. All tests have limitations. Some more significant than others. Lots of these tests find false positives. In other words they tell you have the disease when you don’t. When you screen a population with no symptoms (which is what screening does) then by nature you screen a population with a very low prevalence of the disease you are looking for. If you screen the whole population for pneumonia with a chest x-ray only a very small number will have the disease. If you only take a chest x-ray on people with symptoms of pneumonia then you will pick up far more.

When you screen asymptomatic patients then often the number of false positives outweighs the people actually found to have disease.

Which is why screening in the NHS is so controversial.

Some are now well-established – like breast screening for ladies of a certain age and cervical cancer screening for presumed sexually active women (incidentally they presume everyone is sexually active and therefore screen all women over 18, they just don’t phrase it that way).

Screening for prostate cancer has been less successful – all the men complained that just because they don’t have cervices and boobs that they shouldn’t be left out…

The problem with the PSA test for prostate cancer is that it leads to far too many false positives – it leads people to have prostate biopsies that confirm either no cancer or such low-grade cancer that it’s not actually going to be significant (ie you often die with prostate cancer, not because of prostate cancer).

Ask all the people who get false positive PSA tests if it gave them peace of mind.

Tests are not benign things – one trial (and i can’t find the damn reference) looked at the use of x-rays to assess low back pain. People were randomised (ie both groups were the same) to receive either x-ray or nothing. Those who received the x-ray had worse symptoms at 6 weeks. And of course the x-ray revealed nothing useful to help them. Simply by doing the x-ray these patients were worse.

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That is a plain old fib. Most tests are only worth ordering if you have symptoms but there are other tests that are often ordered in populations at risk – for example the screening programmes already mentioned or simple blood pressure measurement.

The goal to identify patients with significant disease before a problem occurs is very noble (even though their real goal is of course to make money) but unfortunately not possible with what they offer. Every now and again a patient or two will benefit – but over all people will not benefit and some even come to harm.

This one was my favourite – it’s not entirely clear if the Will had carotid dopplers done or not but at least they’re happy together…

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And just to finish: Read this if you’re interested and see what you think about peace of mind for the people found to have aneurysms in their brain.

Vernooij, M.W., et al, N Engl J Med 357(18):1821, November 1, 2007

BACKGROUND: Increasing use of MRI of the brain in clinical practice may be associated with increased detection of incidental cerebral findings of uncertain clinical significance.

METHODS: This Dutch study reports on incidental findings on high-resolution noncontrast- enhanced MRI studies of the brain performed in 2000 asymptomatic subjects aged 45-97 (mean, 63.3 years) (52.4% female) participating in a population-based cohort study.

RESULTS: Incidental findings were common, and most often included asymptomatic cerebral infarcts (7.2%), aneurysms (1.8%), and benign primary tumors (1.6%). The most urgent finding was a large chronic but asymptomatic subdural hematoma in a patient with a history of minor head trauma one month prior to participation. A possibly malignant primary tumor was identified in one subject and cerebral metastases in another. Of the 35 aneurysms, 33 were located in the anterior circulation and 32 were smaller than 7mm in diameter (believed to have a low likelihood of rupture). Operative intervention was considered to be indicated in two patients (the patient with the subdural hematoma and a patient with a 12mm aneurysm). Increasing age was associated with an increasing incidence of asymptomatic cerebral infarcts and meningiomas, and a greater median volume of white matter lesions, but not an increasing prevalence of cerebral aneurysms.

Wrapped around your finger

OK so i bought a new condenser mic for recording. At the same time I figured i would but a wee drum key for the church drum kit so that I wouldn’t have to keep using wee Philly’s socket set to tune the toms.

So in the huge box shown below arrived the small (indestructible) metal key. And a lot of styrofoam.

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The (delicate, expensive) mic arrived in a bag with some bubble wrap the next day.

The cost

Blogging while sleep deprived and a bit pissed off makes for good reading I expect but perhaps you say more than you meant to. I imagine this is the type of thing I’ll re tell on a comfy leather couch in about 20 years (or months depending on how it goes…)

The problem with medicine (says he, with finger pointed and all eyes watching the figure with the air of authority as he gets ready to put the world to rights…) is not neccessairily the medico-legal responsibilty.

Say that I cock up and kill someone, or miss something big or whatever – then there is a certain medico-legal responsibility that I have been negligent or incompetent and should (though not always and occasionally too often) face some kind of disciplinary action.

I figure I get paid for that kind of responsibility. That seems to be the way things work in the world, the more responsibility and education and learning you have the more you get paid. Like a top class economy crippling banker – you bring the world as we know it to an end and you still get your golden handshake…

[Although that is probably a tad unfair on the old bankers – no doubt they were unscrupulous and greedy but they were merely in the position to be so. Yes they’re bastards but I’m pretty sure we all are. Anyhow the dodgy millions they made are what paid the taxes that fund the whole NHS and now that their incomes (and tax revenues) are falling then the NHS will suffer. Anyhow it’s all a tad more complicated than a quick “bastards are bankers” “bankers are bastards” joke allows…]

Legal responsibility is one thing. Moral responsibility is a whole other kettle of fish.

You see that’s were the problem lies. I don’t give too much of a stuff about whether I’m legally responsible for a patient – fine sue me, see if i care. What I do care about is my moral responsibilty to the patient in front of me. Yes I am that self-righteously pious. It has taken years of practice believe me…

They turn up with their woes and sicknesses and it is to me they come. And me with my mythical diagnostic and healing powers, foisted upon me by a legacy of TV shows, movies and dishonest doctors, is the one that that has to give them some kind of answer and dare i say it – final solution to the whole mess. (No nazi killing reference intended…)

Do not get me wrong. I am not grumpy and moaning. I am not saying “why can’t you blood sucking parasites leave me alone and sort your own lives out and crawl into a corner and die as you best see fit”.

I enjoy the job. I enjoy that position. It is one of the highest honour and priviledges to face and speak to these people who are part scared, part hopeful, part accepting of what may lie before them.

It is the moral responsibility that I carry around with me. The simple notion that these people need sorted and that in essence is my job.

It is also what keeps me up till 3am worrying about all these little broken, sickly creatures wandering around out there in the community. It is what makes me come home and be grumpy with my house mates and my family. When you see me staring into space and grumpy and  uncommunicative I’ll either be thinking about Da or about all the patients I carry around with me in my head.

Without a doubt this is part of what makes me (i think) good at my job. It is also a large part of what makes me walk across the car park each day swearing inwardly at myself, the patients and the way we serve them.

While trying not to be too melodramatic – oh why the hell not… –  they come to me like ghosts, or apparitions, their faces, their names, their x-rays their CT scans, their veins and arteries and wounds all their weeping, worried relatives.

I have this uncanny knack of remembering every patient I’ve ever seen. Well not everyone but a scarily high proportion. I go in the cubicle and ask have i met them before then i’ll remember – you were in cubicle 4 two and a half years ago and you’d hurt your wrist and there was no fracture on the x-ray. Which is all very impressive till the patient says “oh yes but i came back a week later and the consultant said it was broken…” Which always takes me down a peg or two but I could do with that.

But i remember them all, the things we got right, the things we got wrong. Each one tells me a story.

I’m not entirely sure if all this psychotic craziness is since Da died or not. Certainly watching one of your own go through it makes you painfully aware of how important all this is. But I think I was like this to start with. Only now more so.

I sometimes I think I have a shelf-life, a period of time that I can pull this off for before it all comes crashing down around me and I end up pulling an into the wild and doing private practice as a dermatologist (awww that’s unfair on dermatologists, sorry…). I hope not.

“a man who has no memory has nothing left to hide… nothing and i like it…”

Be good or be gone

I never thought I would be one to get particularly excited about medical politics. But you get older and more frustrated with the system and dare I say it actually more idealistic.

Medical training is one of  many personal bug bears.

I got into medical school on the basis of grades and a UCAS form alone. No one spoke to me and asked me questions as to whether my personality and character and all the rest was in any way amenable to it.

I have said this before about medicine. You do not need to be smart to do this job. You need to be smart enough (echoes of outliers there…), but overall it’s not quantum physics or maths or anything truly requiring smarts.

The vast majority of what i do is talking to people and good old fashioned hard work. Grades are no reflection of this. As grades for entry to medical school continue to rise – in order to find some way of differentiating the thousands of candidates – then more and more we are producing legions of bookish docs with smarts coming out their arse but who couldn’t talk their way out of a paper bag. I’m not suggesting a better system. Just saying the one we have sucks…

I worked out in the first term of medical school that i could pass exams with little work and proceeded to spend five years getting solid below average marks. And no one pulled me up and said you should have done better.

I came out of medical school with just enough knowledge not to kill someone. And no idea how to make them better.

I have spent the past 5 years studying and learning all the things i think i should have learnt in medical school. Medical School was largely a waste of time in my case.

Hopefully that concerns you some what.

Over the past 5 years there have been significant changes in both under graduate and post graduate medical education. Not that they were perfect before but I’m pretty sure they’re a bit shit now.

Most will have heard the MTAS fiasco that made headlines a few years ago. That and the lost tribe of junior docs with few options for further training.

There as been a bit of an obsession in medical education on competencies and juniors being signed off as fit to manage and perform certain skills, procedures and conditions. No mention of them being good at it. Just as long as they’re competent.

Which brings me to this month’s EMJ editorial (yes i read a journal called the emergecny medicine journal. I’m comfortable with that. There’s a journal simply called “gut” for gasrtoenterologists…)  where someone sensible has piped up and said that maybe competencies aren’t all they’re cracked up to be and perhaps someone with all the competencies in the book mightn’t be quite what they’re cracked up to be.

Maybe i just like the cynicsm cause i’m one of the lost tribe in effectively a dead end job who in the grand scheme of things hasn’t so much as a single competency signed off.

I’m going to stop pretending that I didn’t break your heart

this story gets headline in the BBC Northern Ireland section as if it’s something new when we’ve been on divert as we call it maybe twice a week for the past month and have done it lots and lots of times in the past.

we’re not allowed to put up a “hospital closed” sign or anything but it means that any patients referred by GPs will get sent to other hospitals.

would be interesting to see what would happen if we did just stick up a closed sign. Very little I imagine. Pulling a randon unsubstantiated figure out of the air, I’d say that 90% of those who come through A&E in a day would be still fine (when I say fine I mean not dead – us emergency medicine doctors have a funny definition of “sick”…) the next day if they didn’t come anywhere near us.

That said, we should still be providing a decent servive for that 90% and we’re not. Believe nothing of what hospitals and politicians say about delivering normal high quality service under extreme pressure – we don’t. Let’s stop pretending we do.

Pizza and wine

Just a quick one.

1) my landlord just bought me a bottle of wine when he called for the rent. And he’s not even a patient. I’m so impressed.

2) I’m down with the old man-flu. Finally. The immune system of chmpions finally takes a hit… So i’m eating frozen pizza and watching a DVD, how low i have fallen.

[NB: Does anyone apart from my brother even remember Juiet Turner…]

Thank you for saving me

I got my first bottle of wine off a patient today. Not that I think patient’s should encourage their doctor’s to alcohol or anything, though there could be worse things.

Some people’s office’s and pigeon holes are coming down with thank you cards and pressies from patients – there is a certain speciality bias to that.

People who deliver babies get lots of gifts cause it’s generally a happy event and there’s lots of pressies being bought anyhow.

Surgeon’s get lots cause what they do to the patients is fairly dramatic and occasionally it even works (sorry, no surgeon bashing, sorry…) and you generally see lots of them over a month or two so there’s a certain relationship that develops there.

Anywhere, where you get to develop a relationship with a patient (not in any dodgy “let’s meet for dinner and a movie” type way) then there’ll be opportunities for free stuff.

Unfortunately given the nature of A&E we generally don’t develop too much of a relationship – the majority of what we do is basic management and diagnosis and then referral on for appropriate definitve care. The bit of the job that is truly ours and ours alone is the critically ill and resuscitation. Unfortunately most of our target demographic is nearly dead or technically dead and therefore not big into relationship building.

[Anaesthetists suffer a simiar problem in that they put all their patient’s to sleep and do the cross word till the butcher surgeon is all done.]

So we suffer a somewhat unfortunate lack of biccies and pressies relative the 70000 or so we see a year.

There are exceptions to this. Almost every patient of Gilly’s I review will have “a little something” for Dr Carson. But then he is truly exception as medic, Christian and human being. And he doesn’t even drink the whisky…

5 years I’ve been working now and not one pressie have I got (I once got given 20 quid which I put into the ward fund) – now I’ve got boxes of celebrations dedicated to the ward staff but nothing to me personally. Yes I’m that self-absorbed.

Till today. A young fella who I had blind luck to pick up sarcoid on got me a bottle of vino – even though it was the respiratory team who did all the real work of scopes and scans and biopsies. Seems unfair. But hey I’ll take what I can get –  deserved or not.

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.

Your vandal

Some wee ^%&$£@£ let the tyres down on my bike yesterday during work. Came out of the hospital at 10pm to find both tyres completely flat. I initially wondered what type of person would do that sort of thing and then realised that half the guys I work with may have done it just for a laugh, and to be honest it would have really been quite funny.

So much for saving the planet. Back to the volvo beast today.

More excitingly – the new Iain Archer album is out and kicks ass.

Most likely you go your way and I’ll go mine

Getting older (yes this may be one of those type of blogs…) brings with it mainly downsides. Heaven will be me and Simy at the age 7 and 9 respectively ctcling round Castlewellan lakes and feeding the ducks before a fried brekkie in the caravan. It has been mostly downhill since then.

Now I’m not at the fat, balding, mid life crisis stage, being mercifully none of the above. But I am finding myself increasingly set in my ways. There was time when enjoying your own company was pleasanty novelty but I find as I get older it becomes something of a neccessity. As I (we?) get older I seem to get less tolerant of other people, other people’s ideas, other people’s personalities, other people’s routines. Used to be you’d stick a stack of us together and we’d just get on with the bant and not think any more about it. Now we’ve all grown up (and thankfully differentiated into actual people as opposed to the homogenous mass of opinion, fashion and personality of being teenagers) and we all (to some degree) need “our own space”, be that physically on our own, or “our own space” in a social setting.

Bottom line, as I get older it seems that I don’t “suffer fools lightly” and perhaps am no where near as (naturally) tolerant as I used to be before I ruined my life by thinking about everything.Far too much I am used to “getting things my own way”. I suspect this is why old people in churches give themselves a bad name (with notable exceptions) and indeed is what scares me about growing up in the church myself.

There are of course plus points, which would inculde (normally) being able to grow a beard. Though perhaps I’m a bit fixated on that one. You’d think by 27 and being neither fat nor balding I’d at least be grateful, and not harping on for some decent facial hair…

But I figure the best thing about getting older (and grumpier and less tolerant) is that you finally get away from that nauseating tendency to care about what other people think. There comes a point where you’re contented to not have the approval of the people around you. And all of a sudden you find yourself free to enjoy things because… well… you actually enjoy them, as opposed to doing them because it is the “done thing.”

Every cloud and all that…

The natural history of the rhinovirus

images1.jpg It begins with the throat. Though I accept there’s probably a lot of variability from person to person. It’s usually wakening at 6am with that dry catch in the back of your throat, not quite a lump when you swallow, but more like there’s a bit of glass there. Then you know it’s coming. You know you’re in for the dreaded man-flu.

Then the head begins to ache, when you can feel your heart pumping with each throb, the rush of blood in your ear when you lie on one side. Your skin and muscles begin to ache, a symptom that rejoices in the name of hyperaesthesiae. You’re hot then you’re cold then all of a surprise you’re hot again. Though that may just be the menopause…

And last of all the nose kicks in. Feeling like you’ve been hit full smack with a football in the face, your eyes water. Like you’ve just watched Watership Down three times in a row. With that comes the sneezing, sneezes that rush up on you all of a sudden, that leave you no time to get a tissue to your face and you end up covering friends and colleagues with microscopic droplets of what may well be bubonic plague, cause by this stage this is what you feel like you have.

You become physically attached to a box of Kleenex, knowing that standing up quickly will provoke a change in the mucous distribution in your sinuses, leading to a whole new barrage of nose trumpeting.

You down paracetamol like smarties, thinking you’ll die of liver failure if the man-flu doesn’t get you. You hoak about, right at the back of the cupboard looking for the Ribena and drink gallons in the hope that the Vitamin C just might do something.

You lie in bed but can’t sleep cause no matter which side you lie on one of your nostrils will always be blocked, you try rolling over to let gravity shift the mucous but it doesn’t help. The only way it stays clear is lying on your back but then you can’t sleep at all like that.

But then one day you wake up and your nose has stopped running. Like it’s hit the wall or just finished the 10km fun run. Instead, when you blow you’re greeted by a whole new consistency. A kind of green sludge, like the type of stuff they used to pour over minor celebrities heads on Saturday morning TV shows back in the good old days. Now you know you’re on the road to recovery.

48 hours from the first symptom you’re running about like a mad thing in complete health. This is man-flu, the very definition of making a mountain of a molehill. Goodness knows how I’ll cope if I ever get proper sick.

Musack

I have a fear of boredom. Some people are scared of spiders or rats. I once knew a girl who had an irrational fear of bananas, but then she had a lot of issues… come to think of it, I’m not a big fan of rats either, or avocados, but that’s just a taste thing…

But boredom, really scares me. That I mightn’t be occupied with some task, with some activity, with some mental process. I fear the empty space of inactivity. There are lots of reasons for this which I’ll not go into now, cause I started this to talk about something else.

In the same way, I fear silence. I think it’s part of the boredom thing. That if there’s silence then maybe I’m not doing something and then I must be bored. Noise, music, recorded speech – occupies all my waking moments. I love to multi-task (I knew I should have been born a woman – oops, did I just say that… darn backspace key is broke… araghhh…). I cannot just read, or write, or study, I must do all at the same time, preferably with some ryan adams in the background.

Part of this is from society. We have ‘musack’ everywhere. Everything must be accompanied by some form of melody, however terrible it might be. There is an entire industry producing CDs for stores and supermarkets. In NZ they all seem to have to contain at least 2 Crowded House songs (usually ‘don’t dream it’s over’ and ‘fall at your feet’) and a selection of terrible 80s twaddle that I hate but end up singing along to as I wander round Woolworths buying my cheap noodles. Today I was singing bloomin well Eurythmics. My parents told me coming here would all end in tears…

And there’s of course elevator music. Which is kind of good in a way, cause I’ve never been more awkward places than elevators. There’s just you and the random punter, and you’re in the elevator, and it’s got mirrored walls and you don’t know where to look. And it opens at a floor where no one gets on and no one gets off, and there’s just the painful silence, like a scene from ‘the office’, and I feel I have to say something but I just can’t seem to put a rational sentence together. You then realise you have one of those pseudo-sneezes going on, and you do a few rapid inhales like you’re going to sneeze but you don’t – I know you’re all with me here, we’ve all been there. At that moment ‘Weather with you’ (flippin Kiwis and their crowded house everywhere…) comes on in the elevator, and we all breathe a silent sigh of relief and the guy beside you relaxes and feels able to clear his throat in confidence.

So, after that disproportionately long paragraph, then maybe I’m not completely against ‘musack’.

I do wish I could content myself with silence a bit more often. When I go for a cycle, or a walk, I make sure I have music with me. If only for the reason that young men walking by themselves look less pyschopathical (?) than young men walking by themselves with headphones. I’d probably be better with a dog though not sure if the dog would. Funny, that when I’m cycling (with music or a John Piper sermon or two) I’m actually less distracted than usual and can use the cycling to focus on what I’m listening to. If I just listen to something without actually doing something else, then I tend to drift and go ‘oh look a fluffy cloud’ and then I’m gone…

The flat where I’m living, while not especially small, is easily big enough for sound to travel throughout the whole place. And I have the computer wired to some cheap (but flippin lovely) speakers and i always have iTunes on or Radio 4, or as I have most recently found, video clips from Newsline 6.30 from the BBC website (how cool is that!). All I need is Angie…

So wherever I go, and whatever I do in the flat, then I can always multi-task. I find it hard to eat a meal in the flat in silence. I always have the music on, or I’m reading the paper at the same time as eating. When I go to the loo or have a shower then there’s always background noise, there’s always something to occupy my mind. Though you probably didn’t need to know the loo bit. Though while I’m here (wherever that is, there is a strong family –well me and Simon – tradition of prolonged, well occupied toilet breaks. Be it a newspaper a book, or as I used to do, take in a whole box of lego and play pirates with them. Beginnning to wonder if this needs censorship. Or at least editorial review…

The fear of silence is roughly speaking the fear of boredom. The fear of the cold harsh reality of who I am, that there’s all types of appalling stuff still going on in my head and my heart. And the fear that if I stop, then I might need to face up to some of it. That GOD might be speaking to me about some of it.

In the silence right now, all I can hear is the hum of the speakers (I told you they were cheap) and the noise of my fingers on the keyboard. And there’s fifty people living beside and above me and I can’t hear anything from them. And I’m not scared. And I’m not lonely. And I’m not bored.

It takes time, but the ‘tinnitus’ of the ‘musack’ and the ‘80s twaddle’ of my life slowly begins to die down. And I can hear my internal carotid pulsing as it angles past my middle ear. And slowly, following that, there rises the cacophony of my own soul. With the thousand images of who I think I am, and who I want to be, the movie-script ending. And the faces of all the people I love, like headshots in black and white. And all my fantasies and dreams. And all the patients I’ve ever treated and all the people I’ve watched die. And the history of GOD’s word and his people and his overpowering grace to me, a sinner.

And I’m not bored. I’m not scared. I’m alive.

There was a Paul Simon song, I believe there still is a Paul Simon song, if we’re talking tenses. Unlike ‘there was an old woman who lived in a shoe’, I presume she doesn’t live there any more, I presume she got benefits or DLA and moved out.

Anyhow, the song goes:

‘I’m heading for a time of quiet, of peace without illusion
When I can lie down on my blanket
And release my fists at last’

Playground politics

I have only vague memories of my first day at school. I remember being scared and not wanting to leave mum and I remember Anna Wilson’s bubble gum shoes – I have no idea why I must say. It wasn’t what I would call a significant event in the scheme of things.

I had my first day at work today. And I make the comparison to first day at school cause all the fears and insecurities I have about things like this (and many others) are garbled, grown-up versions of playground ‘politics’.

And no, I didn’t have my lunch money stolen, in school or today. Nor my head flushed down the toilet or even ‘wedgeed’ (tricky spelling, sorry).

But it’s the fear when you don’t know anyone, that no body will eat their lunch with you or share their toys. Which is why teachers make you share your toys with new kids. And yes, Jonny Lockhart I still remember (and harbour much bitterness) that mrs wallace made me share my lego with you in P2 simply because you were new.

And so I lay awake last night worrying about such things. Actually I didn’t lie awake all night at all, that such sounds dramatic but I did wake quite early and think that I should have worried about it.

The unknown can be daunting when you have to face up to it. Whereas the unknown from the far side of the world isn’t nearly as daunting cause you don’t have to practically deal with it.

I’ve only ever worked in one hospital, and that for 6 years in a row. So I knew everyone, I knew the way everything worked, I knew where to find the forms and how to work the phones – which is 90% of the work of a junior doc. As your man in Shawshank says, I was a man who knew how to get things. Some people may want to add a ‘wrong’ at the end of the previous sentence.

Like going from P7 to 1st year in junior high, I am no longer a big fish in a small pool. Or at least a pool where I knew where all the best algae was, and all the cool bridges to swim under were. Or something like that. Not good with those metaphor/similie thingys.

But sorry, this doesn’t really tell you anything of what happened. I turned up at 8am as requested and met Craig, the guy who organised the job and who i’ve been emailing for the past 4 months or something. Good lad. There was me and an english fella called Tafique starting on the same day, so we spent the first hour filling in various forms and signing various statements that will no doubt all come back to haunt me.

And then occupational health. Now they’re the folk who ensure you’ve not got some terrible contagious disease when you start work, and that you don’t give it to the patients. They’re also the same folk who advise you how not to catch some terrible contagious disease from the patients you’re supposed to treat.

This was more than the usual box-ticking session it usually is, I was swabbed, jabbed and prodded and probed to ensure I wasn’t smuggling so much as the common cold into the country.

MRSA, which I suspect you are all aware of, is much less of an issue here than it is back home. To the point that there was the ludicrous question on the occ. health questionnaire – have you ever come into contact with MRSA positve patients in your job. Those who work in the health service will realise that this is a ridiculous question as working with hospital patients is working with MRSA. Sorry that’s enough MRSA talk.

Had to listen to a crazy women telling me how not to poke needles into myself for 15mins. Though I thought this was all rather elementary and that if I stuck to the simple principle of not sticking needles in myself then I would probably be fine.

From there we had a wondeful computer training session. Which in most places is a 2 min chat on your password and not looking up porn on the net. But this was something else entirely.

In hawke’s bay (where I work, cool name eh?) they have tried to do what seems incredibly obvious to most people and computerise lots of the stuff. You would think this might simplify matters but the software itself is a mystery. Saving lives and raising the dead will be easy in comparison.

Got a brief tour of the hosptial from Craig. Confirming the fact that hospitals are the same the world over. That each ward needs a room to place the drugs, rooms for the patients, a room for paper work, a room for the linen and a room for all the poo-related issues. These rooms must be placed in no particular order and decorated in classic 19-whatever tat.

And it was then that I got scared. Not by the wards, but by all the people working there. Busy, focused-looking people who seemed to know where the forms where and how the phones worked. For all I knew they could have been doing the job for years. All I could see was them not understanding that I didn’t know how to page someone or get a CT done. I’m sure they’re all lovely folk really, folk generally are, but in my head I was going to be shown up as a big useless doc who couldn’t find a blood result.

And this is a fraction, a glimpse of the neurotic, self-consciousness that fills my waking hours every day. If it wasn’t for reason, common sense and a sense of humour i’d be a gonner.

And all of it was needless anyhow. The medical council of new zealand have decided they need to see me face to face to make sure i’m not the next Shipman (note to self – lose the beard) before they let me practice (got to love the truthful accuracy of the term) in NZ. Unfortunately they want to see me in Wellington (the city not the boots) which is a 7hr round trip from here. Not so good. I start work on wednesday instead now, if I can get rid of the beard and the criminal record that is.

But it’ll not be too bad. I like driving and NZ is a cool place to drive in. I bought a tool kit today (enough to build the next A-bomb, and all for 3quid), all men need tool kits. I took apart the CD player in the car, broke a few bits at the back, taped them back together with some medical tape stuck to my stethscope and managed to wire in a jack socket so I can plug in my MP3 player. There have been few things that have brought such a self-satisfied grin to my face since I arrived.


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July 2020
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