Archive for the 'the rules' Category

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…”

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I let you down

I’m one of the slightly grumpy bitter ones who never enjoys new year – perhaps because I tend to have a difficult time actually enjoying myself at the inevitable social occasions that go with it, or maybe it’s the compulsive happiness that i object to. Or the reinforcement of the social ideal that is implied – get trolleyed and pull a random bird to go home with – do anything but don’t be alone…

Anyhow.

Since starting work I’ve now got a wonderful excuse to avoid such revelry. I’ve managed to work 3 out of the past 4.

3 years ago – with dying nursing home patient in resus in A&E in craigavon, wondering where all the nurses had buggered off to and not looking at my watch

2 years ago – sticking tubes and lines in the lady in NZ who was too pissed to walk home and drove – into a tree

1 year ago – outside a cottage in Donegal with cigars and Bushmills, trying our best to ignore countdowns and the fact that the rest of the guys in the cottage had locked us out…

Last night – examining some woman’s manky infected toe. Poor dear.

I was not looking forward to last night’s shift – these days I’ve progressed to on-call from home overnight instead of being in on shifts but New Years Eve is normally chaos so we put extra staff on on purpose. Though i the end it was lovely and we were twiddling out thumbs at 3am wondering if maybe the credit crunch meant that people couldn’t afford to go out, get hammered and punch a window through.

I spent most of the night thinking through my latest medical mistake.

We all make mistakes, most of you reading this will know this. And mostly that’s not killing people, it’s more missing things that you could treat, and usually only missing them for a few hours till someone else notices them.

Medicine is not exactly an exact science and the luxury of time and observation usually gives you the diagnosis. unfortunately thanks to the wisdom of our government we don’t always have that in the emergency department.

None of this is excuse, none of this gets me off the fact that I missed something, but all of it put together makes all of us medics go “yeah, I’ve done that, I feel your pain…”

Yes it was busy, yes I looked at the x-rays for where i presumed the pathology would be and not looking at it as if it was a fresh slate – one of those situations where seeing the x-rays only and not the patient is actually a benefit cause it forces you to be thorough and not just look at the part of the x-ray where the swelling and bruising is… And yes it was a difficult patient who had absolutely no regard or responsibility for his own health. Yes he was hammered and that always makes everything more difficult. And yes alarm bells in my own head did go – that cautionary panic in your gut about a patient (which I have found bizarrely to be almost never wrong – i wonder how we could evidence base and audit that one…) – but still I did not listen. Still I got it wrong.

I’ll not mention what I got wrong -if you’re keen to know I can send you some interesting scans that even the non-medics could spot from across the room. The problem is not the scans, the problem was the decision to order them.

Now let it be clear that it made absolutely no difference to the patient. My gaff was picked up on the x-ray review within 2 hours of him leaving the department. We brought him back the next day and got him sorted having come to no harm whatsoever.

But still. You can’t help but take a little bit of a look at yourself. You can’t help but beat yourself up about it.

Mistakes are an inevitability of the job – this is probably my biggest in 5 years –  thankfully of no consequence, though that’s hardly the point. The point is that it happened, and it happened due to a mixture of busyness, pressure, timing, a difficult patient and most of all breaking almost all of my own rules.

Lesson learned? I hope so. Though I got away with it – and maybe one day I won’t and some poor patient will face the consequences.  Anyone have a better idea of how we do all this?

I’ve been working

I’m back. I suppose. Whatever that means. I’m back in work. I’m back in my own house. I’m back, for the first time for two years, to what counts for stability and doing the same thing for perhaps slightly longer than a few months at a time. Not exactly the circumstances i would have wished for but it is what it is.

I’m now a fully paid up full-time, permanent contract member of staff in the chaos of the emergency department (as the kids are calling it these days…). It is chaos. It is horrible, it is wonderful. It is what i do.

I’ve made a list of about 20 or 30 things to change in the department, from knocking down walls to bits of equipment i’d like on order. The sisters told me to write a letter to Medical executive Satan Santa and see how i got on.

I’ve come up with a list of new rules i need to follow. I’m one of those people who likes rules. I like these little self-imposed commands that seem to represent some ethic or moral that goes with the conduct of each shift. I’m better at obeying some more than others.

– Be thorough in all aspects of history, examination, notation, treatment and disposal [though this would be supposed to be elementary, the temptation to be slack is constant…]

– Work slower [I work manically and far too quickly, i see a lot of patients. I’m not convinced this is a good thing]

– Fight for the patient [in the sense of annoying and if necessary pissing off other doctors if it’s in the patients interest – how not to make friends or influence them…]

– Always go and see the patient you’re asked about [when you’ve been woken at 4am for advice over the phone, you will almost inevitably say something stupid]

– Pee [15 hour shifts no problem…]

– Eat [easy to forget]

– Do not be afraid to follow up patients on the phone

– Keep a list of all the interesting patients

– Copy x-rays/CTs/ECGs [useful for teaching and remembering the interesting ones]

– Remember dual pathology on X-rays [just cause you’ve seen the broken clavicle on the x-ray doesn’t mean that’s the only break]

– Think laterally, always reconsider the differential despite what may seem obvious [just because the patient, GP and nursing staff are telling you they have appendicitis, does not always mean they have appendicitis]

– Ignore any pressure that is not in the patient’s best interests [4 hour target nonsense etc…]

All very noble and honourable ideals. We’ll see how long it lasts.

There are a lot of rules

Rules. We all follow them. Even those who say they don’t. The sub-groups and the trends and the stylish rebellious people of the world are the most conformist I know. (not that I know many of them, I never seem to get invited to the right parties…) Even if non-confomity is what they conform too.

There is possibly nothing less rebellious than being a goth or a 14 year old smoking. They only do it cause their friends do it. No one really wants to be different, they just need to have a group of a certain size where there’s others the same.

I’ve heard it said that everyone does what makes them happy. Even the man who comits suicide. The most altruistic, philanthropic act you can do is still motivated by a desire to be happy. Whether it’s the simple joy of doing the right thing or the joy of having someone see you doing the right thing. Morally there’s a difference in the two joys but that’s a whole nother story.

But in the same respect we all have rules that we follow. It’s part of our personality. Some will be dependable by one set of rules, others will be easy going. Some will be annoying to be with because of them and others will be a pleasure. We all have rules and we all conform to them because that is the only way we have peace and contentment and joy.

I have lots of rules. Many are basic moral codes, pretty much anyone will follow, many are moral things that I do only because of Christianity. And there are many I only do because I believe them to be important.

There’s lots of reasons I choose which rules to follow and which rules not to. I think about those reasons and analyse them and feel bad about them, then good about them, then bad about feeling good about feeling bad about them. This is the essence of my life.

Occasionaly this is therapeutic and beneficial and GOD honouring and occasionally it’s just neurotic and damaging and outright sinful.

And so in the beneficial/therapeutic sense here’s a taster. (and when I say therpeutic/beneficial I mean solely for myself, I am under no illusions).

1) thou shalt not be late.
Where I got this from i’m not sure. Perhaps from being in church twenty minutes before it started for most of my life. This gets to the point that I get nervous and anxious when i’m waiting to go somwhere or do something, or worse when i’m waiting for soemone to pick me up. Cause then it’s out of my control, and i’m never good with that. This flows partly from rule number 2.

2) if you say you’re gonna do something then you do it.
Strong believer in this one. I marvel at people who can talk about going somewhere or doing something and then change their minds shortly before if something else comes up. (i mean this in no critical way, the situations are mostly benign, frivolous things and no one, bar me gets excited if someone pulls out or doesn’t show. And the thing itself in most cases will be in no way affected by their absence. Yet I worry all the same.) I can’t mamage to do this. I view all plans and requests as concrete and set in stone once the initial agreement is made. Naturally there are good sides to this but there are many downsides. If someone, say, organises a kick about for a certain time and I agree, and then someone asks me to do something more useful, beneficial and simply more fun (yes it’s hard to imagine what could be more useful, beneficial and fun than footy but work with me here), then I will be simply unable to miss the footy for the other opportunity. I will simply fret and agonise over the silly rules that I follow.

3) that I will only be weak and wrong in the past tense. And I must insert that there is a world of moral difference between being weak and being wrong. As a freudian slip I put the two beside each other in the first sentence of this paragraph and perhaps that says more about me than anything else. Anyhow. When I talk about weaknesses and struggles I will never talk about them when i’m on the midst of them. When I talk about them it is always in the past, as some defect in me that I have wonderfully overcome and put behind me in no ones strength but my own. Which is all nonsense of course but this is what I would have you believe. And if i’m in the wrong, expect not an apology at the time, or an admission that someone else was right, but simply a long brood and a belated apology so full of justification and self-righteousness that you would probably have forgotten it began as an apology by the time I had finished.

4) that I must be all things to all people. Not so that by all means I may save some but that all will like me. I get on with nearly everyone. It takes an awful lot for me to say ‘i don’t like so and so’. But I depend on getting on with everyone and fear confrontation and creating a negative image of myself before anyone.

5) happiness is to be feared. The golden rule, that all men do what pleases them, even the man who comits suicide, was something I wanted to pretend did not exist. That happiness and joy in anything I did was obviously because it was wrong and ‘selfish’ in the old childhood sense of the word. Like in vanilla sky, where david screws up the lucid dream on purpose cause it’s like the sweet without the sour and he knows it’s all too good to be true. (i probably got much more out of vanilla sky than was actually there!) I suppose that’s like me. My whole life just seems a bit too good to be true and instead of thanks and praise I question its whole essence.

With luck most of you have either drifted off or have no idea what i’m talking about. This is just a taster of what I could go on for hours about, I haven’t even got to the rules about women yet. But i’m not quite ready for that one yet.


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