Monday, 23 January 2012

...in which I apparently stumble across the cure for the common cold...


Quickly swallowing a mouthful of cold coffee, I glanced at the computer screen to see what ShufflingBob had decided was wrong with the next patient to be seen...his triage notes are often the highlight of an otherwise depressing day.

He had written :- Doing karate,Patient accidentally kicked a wall = swelling + bruising + deformity R great toe.

I opened the door and stuck my head into the waiting room...

"Mr Sulin ? Mr Ian Sulin?"

An expensively dressed, well scrubbed,pink cheeked and cheerful young man waved and stood up and slowly...limpimg...folllowed me into the Unit.

"Would you like a wheelchair Sir?"

No....I'm good thanks...

"You sure...its quite far to my room...about 500m...and there's a little bridge...a water feature...the gnomes can be quite vicious this time of year..."

No....I'm okay to limp if you don't mind waiting?

"Wellllllllll...they pay me by the patient, not by the hour..."

Finally he sat down breathing a sigh of relief.

"So...my name is Lucien....what can I do for you today?"

Well...its my toe...but can I just say how nice it is to see you again...

(Huh...? I'm sure Bob didn't think the patient was confused or mad)

"Jahhhhh....?"

Yes....you saw me about three years ago when I had the flu...

"Jahhhhh....?"

I was really sick and my sugars were all over the place...I'm diabetic remember...?

"Jahhhhh....?"

And when I told you that I was commuting to London every day, for about an hour on the train both ways,-to my job as a banker-,you suggested that I move to London to avoid having people cough and spit over me for two hours a day,five days a week...!

"Jahhhhh....?"

Well....I took your advice...I bought a flat...and I stay in London all week and just come home at the weekend...

"Jahhhhh....?"

Well...I haven't so much as had a cold in the last three years...never mind the flu...and even my sugars have settled down....

"Jahhhhh....?"

I'm so much better...thank you

(Good grief!)

"Well...I'm glad that all worked out for you...whilst we're on the subject of health, can I interest you in subscribing to my weekly TopHealthTips email?"

How much is it...?

"£50 a month..."

Sure...I'd be glad to subscribe...

Note to self...Immediately start a TopHealthTips email.

So there you are....the cure for the common cold..."move to London".

Or maybe its..."don't travel on trains with poor people."

Hummh...actually...maybe its ..."don't live in Crapton-on-Sea."

Maybe its simply..."avoid poor people."

Darn...back to the research lab then...pity as I could really have done with the $1 million Nobel Prize money.

His toe wasn't broken.

Sunday, 22 January 2012

A little weary and slightly sad



Some days just empty out my reserves of optimism and happiness and fortitude...
...the type of day that stretches my 'cope-ability' to its almost-breaking point...
...when I feel that my heart will finally break ,my mind will finally fracture,my soul will finally wither,pushed over the edge not by any big crisis of love and death that comes to us all,but by the thousand cuts of everyday anguish...

...and which leaves me wondering about the futility of what we do in emergency/primary medicine...and how we can ever really help our patients have a 'good' or (statistically) 'normal' quality of life in spite of themselves and the evil hand that fate or G-d or happenstance...or maybe just plain old unadulterated genetics...has dealt them.

YummyMummyNurse was working a shift today,back from maternity leave.
She is smart and clever and well educated in the strange English way that is based on lots and lots of book learning and tutorials and empowerment seminars and human-rights-driven protocols and "group problem solving dialogues" , but has little to do with ever actually seeing or working with any actual people with real and complex health issues.
Her office is unfortunately next to mine.

Can you help me with this child I'm seeing ? she asked.

"Sure...whats happening?"

Well...her dad says she has 'MF1' disease...and I haven't heard of it before...have you?
...she asked,in that tone of voice that suggests that she doesn't really expect me to know more than her...since I trained in the Jungle...

"Ummh...nope...can't say that I have..."

Well...her dad brought her in because her face is all swollen...and I think it is but I'm not sure...

"Okay....well...lets go and look at the child and talk to the dad "

Now there was a rule of thumb in paediatrics when I was training,(in the days before accessible DNA testing), that suggested the following:-
'Normal Looking Parents' will probably have 'Normal Looking Children'
'Funny Looking Parents' will probably have 'Funny Looking Children'
But that if you ever saw 'Normal Looking Parents' who have 'Funny Looking Children',then you should have a high index of suspicion for some sort of congenital health/medical problem that may hither too have been missed...or which the parents know about but might not tell you about during the course of a brief ER type consultation, due to embarrassment or disinterest.
Yes...disinterest.

We went into my colleagues room.

The father was sitting holding his four year old daughter on his lap...she was 'well presented' as were her 2 brothers...but she undoubtedly,unfortunately,looked a little odd and all sorts of alarm bells went off in my head.
My heart sank.

"Hello gorgeous..." I smiled at her..."So...my name is Lucien...whats going on then dad?"

Well...we're here on holiday...and I think her face is swollen...and she has this illness called MF1 and I'm just worried about her...

"Okay....lets have a look at you then Miss...."

She quite happily let me pick her up and examine her.

"Okay then...there we go..." I gave her back to her dad.

"Are you sure the illness she has is called 'MF1' and not 'NF1"...?"

I dont know mate....I think its "M"....but I might be wrong...

"Jah....I think she has a syndrome called 'NF1'...or neurofibromatosis type 1"

Okay then mate...you probably know better than me.

Its just so sad.
He clearly loves her...she clearly loves him...he was clearly worried enough about her to bring her in to see someone...but he doesn't even know what her illness is called.

Fortunately the on-call paediatrician knew all about it...and since we were unable to distinguish between her usual/disease mediated physiognomy and the swelling that was worrying her father...agreed to see her.

They had no car.
They were going to catch a bus to the hospital as he didn't have enough money to pay for a taxi and she didn't warrant an ambulance.
We paid for the taxi.

Fortunately I had some emergency chocolate in the boot of my car.
It didn't stop me worrying about the child...and of reminding me of all the children with rare illnesses I have seen...
...fortunately I have even more emergency chocolate in my bedside cabinet.


Monday, 16 January 2012

Take the first right,stop at the lights,swerve around the umbilicus..


“Good afternoon…what can I do for you today?”

Well…what it is…obviously….I had a Cesarean 11 days ago…and I think the operation (sic) is infected…

“Okay…how’s your baby doing?”

Fine I suppose…

“Okay…do you have any underlying medical or surgical problems of any sort?”

No…

“Do you have any health conditions or problems I need to know about?”

No…

“Okay…so do you take any medicines of any sort-, on a daily basis-,for any reason-,medical or otherwise?”

Well…just the fluoxetine for my depression

“Is this post natal depression…since the birth of your baby?”

No….I’ve been depressed for years…

“Okay…are you breast feeding?”

No…it hurt too much last time

“Okay…ummhh…right…do you smoke?”

Yes!

“Are you married or do you live with someone?”

No…

“Okay then…lets have a look at your C-section scar then…please just lie down on the couch there...”

She got up from the chair to lie down on the examination couch as I went to the sink to wash my hands.

“So…where did you have the surgery then?”

She look at me like I was stupid...

On my tummy…?!?!

"I meant....which hospital...?"

I looked at her like she was stupid.

Only one of us was correct.

Saturday, 14 January 2012

I didn't really mind that...

Dear Madam

I didn't really mind that you came to a busy Minor Injuries Unit on a Saturday afternoon with a condition you described as "passing fresh blood from my back passage"...

I didn't believe you when you said that you had never had hemorrhoids...(or piles)...before,but I didn't really mind that I had to examine you...

I didn't really mind that your husband-,who is 25 years older than you-, sat in the consulting room the whole time...

I didn't really mind that your husband seemed to enjoy watching me perform what is quite an embarrassing examination on you...

I didn't really mind that your husband is a Registered Sex Offender and that was why I had to examine you as the Designated Nurse for Perverts in this area...

I didn't really mind that you had clearly not cleaned your "back passage" after your last bowel movement,despite knowing that you were coming to hospital...

...that is after all why I was wearing a mask...

I didn't really mind that I had to prescribe some medicines for you and that you will not pay any prescription charges because neither you nor your husband work because you are both on 'benefits' due to "stress" ...

But honestly...
...when I suggested that you go home and have a shower and clean yourself up before using the ointment...
...was it really necessary to turn to your husband...
...and in a simpering "little girl lost voice" ask him to wash you 'down there'...

...and then for him to smile tenderly back at you and agree to do so...

This job...
...this town...
...sometimes its like a government experiment in scum propagation...
...and my Unit is the petri dish...

*Oy*


Friday, 13 January 2012

Not a 'New Years resolution' as such...

...more the result of a quiet time of reflection and introspection sparked by an impending birthday...



I had a scheduled 'day off' today.
I worked last weekend...'Long Day' shifts on Saturday and Sunday,from 0745 to 2200;had some planned intensive study days on Monday/Tuesday/Wednesday at the local University Library as I am writing the nurse-prescriber exam on 29 February and only opened the course-workbook last week...
....dear Lord....there is soooooooooooooooooooooo much I need to read;worked a Long day shift yesterday;and I am working again all weekend.

So today was a day of rest.
A day to relax a bit;do a deep food-shop and think about my life in view of the upcoming birthday.

I am not someone who believes that external dates or events accurately reflect our passage though life or in fact in any way really benefit us individually...if you know how to use a calender....if you understand the concepts of a monthly salary cheque...of a yearly tax bill...and of the four seasons...(no...not the hotel...no...not Vivaldi...pay attention!) then really that's all you need to know to mark external time-,business-time-,family-time-,society time if you will-, and allow you to timeously buy Easter eggs. or go to your granny for Yom Kippur or your cousin for Ramadan.

I believe that the life altering events...the dates we look back as being pivotal in our individual and collective lives...are almost exclusively external and beyond the control of most of us for most of the time.
This year for example will mark the anniversary of the sinking of the Titanic and there are already any number of events planned.
Why? Was it really because it marked the end of the Edwardian Age in England and presaged a more eligatarian time which was to follow the First World War?

People in my current part of the UK still go on and on and on about 'The Thatcher Years" and how she ruined their life.
South African politicians still talk about the 'Apartheid Era'.To be honest,it still defines so much of my life and my relationship with my surviving family and friends.

I think that the dates we should use-,the dates which in fact end up marking the high tide and low tide moments of our life fall into four broad categories.

Firstly,there are those (many , many) times which are basically beyond our control such as when we are born...when someone we love dies...when we fall in love or get divorced.
These can be "personal" such as the birth of a child;"physical/environmental" such as a drought or tsunami;"ideological" like the Arab Spring;or "structural",like a recession.

Secondly,there are the (several) times when things happen to us that fundamentally alter our life and over which we have appear to have had no control but which might have been possible to predict;events though which allow us to change our behaviours and use the sequelae of the event to our advantage in an altered future ...an extreme example is having a heart attack which has been brought about by poor lifestyle choices...and which results in the person choosing to stop smoking and start exercising , resulting in a better quantity and quality of life.

There is a corollary to this of course when the events were more difficult to predict and over which we possibly had little control-,(such as being knocked over by a bus when sober in daytime)-,and where the consequences are as life changing but not necessarily for the better.

Thirdly ,there are the (few) times in life when the irresistible force of cognitive dissonance hurtles juggernaut fashion towards the immovable object of physical/financial/emotional reality and finally you understand that life-altering,paradigm-shifting and potentially emotionally (occasionally even physically) painful change needs to happen...when you finally internalise the concept that 'if you always do what you always did,then you will always get what you always got' .
You will change your behaviour irrevocably...you seek a divorce,leave a well paid job to work for yourself, you emigrate.

Finally there are the days when seemingly out of the blue,you will have a flash of insight into your life and how you are living it, which forces you to unexpectedly reassess your life when you weren't particularly planning or wishing to do so.
As a Freudian,I don't really believe that these moments are ever really random....they just appear in our conscious mind when our unconscious mind knows that we are primped and ripe for change,such as just before our birthday.
Sometimes it dictates immediate and manifest change...sometimes you just open a KitKat.

I had a 'fourth type' moment today.

It was a beautiful day , weather wise, here where I live.
I should probably put that in context for foreign readers.
What that means in England is this...for some part of the day...some part of the sun was visible...for some time....in a sky which was blue,for some time.
And that this morning,due to a 'perfect' alignment of the space/time continuum,the temperature was moderate,there was no wind and I had money in my wallet.

And so I set out to do some shopping.
I am a food snob.
I like meat to taste vaguely like the animal whose picture is on the package.

I remember at the Johannesburg General Hospital residence that meat was served in one of three categories....'Friday-night-alleged-steak'...."mostly-minced",in spaghetti bolognese...or "flat"...thickish slices of grey or pink or brown meat whose only discernible feature was that it was 'flat'.

And I have found that the quality of food available in supermarkets here...outside of London...is quite poor...so I tend to shop at Marks and Sparks where the ready meals are fairly priced,calorie counted, and generally edible in the middle of a 14 hour shift.

Also....their fruit and veg is of a good standard.
Also...there are no poor people shopping there,hauling their 27 snot-nosed kids around behind them,pawing at cut price packs of camel hump in chilli sauce.
Although it does get more than its fair share of old people who also wander around in a daze...but at least they don't try and mug you in the car park.

Anyway...I had done my shopping and was walking past a display of various bits of lounge furniture on the way out of the shop when I had a sudden bizarre thought...
...a moment of clarity into my life and how I have been choosing to live it...

....I am 55...
...I have never owned a sofa that I have chosen...

...I have never owned a reading chair that I chose...
...I have never slept on a mattress of my choosing...

...in fact....I have never owned any furniture that was of my choice...
...there are many items of furniture I have paid for...but none I chose...
....(with the single glaring exception of the chair on which I now sit and which I bought only 2 weeks ago)...

...growing up, my parents bought all the furniture,as you would expect...
....then I stayed in the nurses residence for years, as both a student-nurse and registered nurse,and which was furnished by the government...
...then I moved into a flat with my (future) wife and 'we' furnished it...
...now men know that this means you buy exactly what she wants after putting up a token show of interest and enthusiasm...
...now I liked that first sofa...its was a two-seater,Laure Ashley-inspired floral print job,but not deep enough for my fat bum,or indeed even long enough to sleep on...
...and this pattern continued throughout the years of marriage.

When she left (and took most of the furniture) I stayed in the house with the (by now) decrepit furniture.

And since living in the UK,I have stayed in a variety of furnished bed-sits, furnished shared houses;and finally in my current furnished and serviced apartment...which doesn't have a sofa at all.

All those years without a sofa.
All those sofa sales every easter.

And that prompted a stream of depressing consciousness if I am honest.

It then occurred to me that my birthday will mark another year in which I have remained celibate and unattractive to apparently any sentient female of any age anywhere in Europe.

Its odd because as an adult I have been single for longer than I was married plus in various odd relationships...and I am the constant factor in the equation...which makes me think...

Its not through lack of trying...I've dated The Troglodyte;The Racist;TheMoleWithThe WomanAttached;The Stalker;The DesperateTeacher;The Nympho...okay....I dated her several times until my cardiologist told me to stop...The FranklyDisturbedWoman;The MBGITW;and several assorted woman....oh...lets not forget the OneWhoPulledTheKnife.

Another year bereft of any actual loving touch...
...indeed the only physical touch of any sort in the past 2 years has been that of my very-butch,very-lesbian,very gorgeous,very funny chiropractor.

Mind you,I stand very very straight.

Also...there was that hug from the chimpanzee I've sponsored at the London Zoo.
She may be a monkey but at least she's female...
...and another mammal.

So....my fourth-type day.
Today.
The day on which I have decided to seek a more abundant life.

I can either change my life...
...or just join the church as a monk so at least I'm earning credit in heaven...

I'll make a decision just as soon as I've finished the packet of pork scratchings...

....ummhh...maybe I should just sponsor another chimpanzee?


Friday, 6 January 2012

Romeo + Juliet


The first rule of emergency medicine is this...all patients fabricate (at least) and pointblank lie (at worst) about part-, or all-, of the reasons and events which have resulted in their needing medical help.
Period.
ALL patients lie.

And that's okay really...we know that...we factor it into the consultation...its why we ask the same questions in different form...and keep asking them...and frankly,we'll lie right back to you..."no of course this isn't going to hurt you!"

The difficulty with 'head injury' patients is this though...what is their "normal level of stupidity" and what may be caused by an actual brain injury?
And what percentage of their inability to name the Prime Minister is due to indifference and what part is due to alcohol and/or drugs?

The patient was a 24 year old fisherman who had allegedly been assaulted in some local hostelry by some complete strangers whilst waiting to start a Bible study class.
He was completely oriented to the "time/place/person/prime minister/monarch" questions;his cranial nerves were all grossly intact;his pupils were 'equal,reactive and accommodating'...but he couldn't tell me the name of the pub he had been in when he was allegedly assaulted...well...I knew then he was lying.
Result.
If you're smart enough not to want your girlfriend to know where you were when you were assaulted , then your excuse-for-a-brain is probably working just fine.

He was a lanky young man with a stack of gelled hair , sticky-out ears ,and a chipped front tooth...apparently from another bar fight.
He was dressed in the ubiquitous tracksuit...and smelt of dried sweat,working sweat,stale sweat,sleeping sweat,old sweat,sexual sweat,Christmas sweat,New Year sweat..even Halloween sweat.
(I had to put on a mask to examine him he smelt so bad...I told him it was because I had a cold...)
(You see...we do lie!)

He was accompanied by his girlfriend...a pretty if grubby young woman dressed in electric blue jeans,-about 2 sizes too small-,and a grey woollen top covered with what looked like glitter.
She was clearly worried about him and was sitting holding his hand (with her right hand) and texting with her left hand.

Apart from various bumps and bruises, (and with no real concern for a brain injury),his main injuries were 2 lacerations that needed to be sutured:-the first was a 1,5 cm long laceration to the top of his head...it was deep and bleeding profusely.
The second cut was 'T-shaped' with the top of the 'T' just below his hairline and the vertical arm,-about 2cm long-,extending down his forehead towards the middle of his left eyebrow.

"Right Sir...I'm going to stitch the top of your head first, to stop the bleeding and to get it out of the way..."
"I'll pop in about 3 deep sutures which should stop the bleeding...it'll take about 3 minutes..."

Okay mate...

His girlfriend looked anxious...Will it hurt?

"Well...the local anaesthetic can sting a little bit...but it could be worse..."

How could it be worse...?

"Well...it could be my head needing the stitches..."

He laughed.
She looked anxious.

"And then I'll have a look at your facial laceration...that's going to take about 10 minutes...I want to get a good cosmetic effect on your forehead..."

What do you mean...'cosmetic effect'...?

"Well...the laceration is deep and is going to be visible...and I don't want you to have a scar like Harry Potter...so its going to take some careful apposition of the wound edges..and some small fine sutures...."

Don't bother mate...just stitch me up...

His girlfriend winced....Please take your time...

"Of course I will..."

No really mate...just stitch me up...why do you have to worry about the cosmetic thingy...?

"Well....I only know one way to suture a face...'mate'...and that's the Johannesburg Hospital way...the correct way...so if it's all the same with you,that's what I'll do..."

Okay then...well if you fancy you're a plastic surgeon,what about doing something to my nose...?

OY!
"No time tonight..."

Well then...
and he pointed at his girlfriend...
...have you got time to do something about her tits?

He laughed.
I winced.
She cried.

True love.
Its a wonderful thing.

I gave her my phone number...listen...I may be older, but I'd be very grateful.