'Wash your mouth out'

To : Hon Plastic Surgeon on call

Thank you for accepting this patient.

As you will see he has an extensive infection to his right hand from what appears to be a human bite.He is pyrexial at T39,3*C with marked tracking extending up to his bicep and he feels unwell.There is no bony injury.This is his dominant hand.

The patient reports that he was out at a club 2 nights ago , and during the course of some vigorous dancing, apparently his hand may have inadvertently got in the way of someones mouth.

He denies any history of assault and appears to regard this as some sort of spontaneous event.

There are however 16 teeth-marks around his right thumb and thenar eminence-8 on the palmar surface and 8 on the dorsum,suggestive of his hand having been bitten.

He denies this but admits that possibly he has sustained a "hand vs. mouth" injury.

He reports that he has had a similar injury in Sydney in Australia last December which necessitated a 5 day admission to St Bondi-by-the-beach for IV antibiotics and EUA.

He further reports that he was told by the Australian plastic surgeon that if he ever again sustained a "hand vs. mouth" injury that he should seek immediate medical attention .

I have naturally asked him why he has delayed care today and he is under the impression that's its only Australians who have dirty mouths.

I have therefore advised him that the "dirty mouth" that the Australian surgeon was referring too was the bacteria in the mouth and not because they had called him a "stupid , whinging Pommie bast*rd" of which he is indeed a prime example.

Kind regards
Lucien de Beer

So I've had the flu and have been reading the FT to pass the time...

It has been pointed out to me by some Anonymous commenter that the quote below would appear to be fictitious .The following comment was posted:-

That supposed Marx quote is a hoax that has been repeatedly debunked. See:
The Atlantic http://meganmcardle.theatlantic.com/archives/2009/01/faux_marx.php
International Herald Tribune
http://www.iht.com/articles/2009/02/25/business/col26.1-437515.php

You will appreciate that this quote was published on the belief that it was true...furthermore...it was published to give me the platform to link the 3 photos...

Apologies!! I apparently got it wrong!!Lordy lordy...I'm fallible...I havn't read the collected works of every body who was ever alive!!

BTW...to the Anonymous commenter...please feel free to criticise my work but if I'm happy to apologise...then at least have the balls to say who you are


Owners of capital will stimulate the working class to buy more and more expensive goods, houses and technology, pushing them to take more and more expensive credits, until their debt becomes unbearable.
The unpaid debt will lead to bankruptcy of banks, which will have to be nationalised, and the State will have to take the road which will eventually lead to communism.

Karl Marx, Das Kapital, 1867

...its all coming back to me...

I don't think that I have PTSD.

But I wonder ...

Like tonight when I was watching an episode of the final series of ER...where Dr Benfield is resuscitating a child whilst Mark Green is simultaneously...in her memory...resuscitating Dr Benfield's own son...

...and I find that I am crying hot tears that turn cold on my face...that my chest feels tight....
...and I am transported back to somewhere else...
...somewhere usually hot...and its usually night and I am resuscitating a dying child...a shot child...a stabbed child...a drowned child...as part of a team or by myself...in the back of a wildly driven ambulance... or in 'Room 1' of Area 161,the Children's Emergency Unit at the Johannesburg Hospital...jumping from Echo One with the rotors still turning and running desparately into the ER of some distant cottage hospital...sometimes in some dusty Godforsaken township with desperate parents keening already in the background, knowing that the umlungu can't save their child

No one ever blamed me...indeed I often received letters of thanks...I was always the last person to stop cardiac compressions,or to switch the monitor off or to stop bagging...

And always ...always...there is the "Lost Boy"...a street child...a boy of about 7 , who in the winter of 1986 was standing next to an open fire when some bastard threw petrol on it and he was brought into 161 with over 90% burns...he was dead,he just didn't know it...

I say a prayer for him most nights,which is difficult since we never knew his name and I am -at best- a retired catholic...but what else am I going to do ?

And so I start to shake and need to stand up and stick my head out of the window...and... like tonight...I have to break into my emergency stash of mini-Bar-ones that my kids always seem to give me for Christmas.

So I don't think that I have PTSD...maybe I am just hypoglycaemic.

Thanks for the Bar One.

The South African Army knee stress test

In truth , there are few advantages to being a middle-class , middle-aged white South African male...except for the biological imperative to drive a huge 4x4...

...and of course , being able to support the Springbok rugby team...

And so...last Sunday , driving through '7 o'clock in the morning'-empty streets ,on un-gritted roads , with big fatty globules of snow falling from a beaten pewter-coloured sky...indeed...the snow falling like tears from an English rugby supporters eyes...I was able to get to work on time...

...to find a queue of 9 punters already waiting patiently at the door. In fairness the car park was empty with a pristine covering of snow , so at least some of them had walked to the Unit ....fair enough then...clearly these were all very ill people...

Sitting in my cubicle drinking directly from a 2-litre carton of OJ , and stuffing my face with pretzels covered in white fudge that I had bought in New York just 2 days earlier,I fired up the computer and prepared to do battle with the Great Unwashed.

"Mr Street ? Mr Carnaby Street?"

A young man dressed in the Contemporary Student style stood up ,switched off his iPod and walked briskly into the Unit.

He was wearing skin-tight yellow jeans and what the ever-trusty Julian described as 'a pistachio-green cardigan with a pale violet romantic -style shirt'.

Say what ?

He was also wearing shoes of the type that I remember from my distant past were called 'winkle-pickers'-long,thin,very tight shoes, that come to a sharp point

"Right...good morning...what can I do for you today then?"

Well...what it is...obviously...its my knee...its painful and gets in the way of my course...

"Okay...and how long has it been painful then ?"

Well ...it first got painful when I played a football game in November last year...

"That's over three months ago...jah?"

Yes...well...I didn't want to bother anyone...but I'm still getting some pain in the knee occassionally...ummh...I've played a few games of football and sometimes its got a little sore...

"Did you take anything for the pain ?"

No I don't like taking medicine...

*groan*

Its just that it gets in the way of my course...when its painful...

"Okay...and what course are you doing ? Are you in the Army ? Fire brigade ?"

(I can see Julian standing at the door , smirking)

Uhmm...no...I'm at University...I'm majoring in International Property Marketing...

"Really ? That's an actual University course then ? You really need to go to varsity to learn how to sell timeshare ?"

Well !! Its a very difficult course !!

"Uhh huh...and whats your minor subject then ? 'Latte etiquette' ? 'Nineteenth-century paisley patterns' ? The mandatory 'dole queue and my future life in it' course ? "

No!! I'm also doing 'media studies'...

"Of course you are...so...how does this 3 month old injury affect you then ?"

Well...its painful sometimes when I walk up the stairs to the lecture room...and I'm worried that there is something seriously wrong with my knee...

"Okay...but not actually worried enough to come in to get it seen too any time in the past 3 months though ?"

Well...first there were finals ...and then Halloween...and then Christmas... and then new year parties...and then I went skiing with some friends....and you know ...I try to go to a club most night...so I suppose ...really...that this is the first chance I've had to come in...

"Okay...well as long as that makes sense in your head then..."

He gets undressed , hops onto the bed and despite the worlds most thorough examination I can find absolutely nothing wrong with his pale pasty knobbly little knees.

(Did I mention that I hate young people !)

"Well Sir...I can assure you that there is nothing wrong with your knee...the muscles and ligaments and tendons and nerves and veins and arteries and cartilage that make up your knee-, that are around your knee-, and that generally support your knee... are all normal..."

So whats wrong with my knee then?

"Well...I think that you had a very mild sprain...that didn't completely resolve as you firstly didn't take any analgesia... and secondly...continued to go out dancing every night..."

Oh...are you sure...you couldn't be missing something could you ? Its just that you sound Australian ? Have you done all the tests an English nurse would do?

"AUSTRALIAN ??"

"Good grief...why don't you just accuse me of being a paedophile ?"

"That's a South African accent...still...all you Welsh people sound the same to me..."

I'm not Welsh!!

"Sure...anyway Sir...I can assure you that I have done all of the internationally recognised knee tests..."

"However...since you ask...there are some tests that I learnt when I was in the South African Army...and we had to test the paratroopers knees...I would be happy to do those tests if you want ? "

"They are ...vigorous...even a little painful...but if you don't mind...then I can assure you that I don't mind either..."

Okay....that's fine....what should I do then ?

"Well if you'd like to stand up...just over there by the door...if you don't mind I'm going to ask some of my colleagues to come and watch this as they haven't seen these tests before ?"

Okay

"Julian...please ask UglyJulie and The Curate to join me..."

(The Curate is a colleague who last year was going to become an Anglican priest until she discovered...much to her horror and amazement...that not only was she expected to live a moral and ethical life..but that she actually had to believe in God)

"Right...the first test is to check the flexibility of your knee joints...their ability to act as a shock absorber..."
"So...please stand on your tiptoes...now...do you see the floor tiles...some are white and some are black ?"

Yes

"Well...I want you to run down the passage way...on your tiptoes...only on the white squares..."

"And then...when you reach the end,turn around and run back-also on tiptoes...but this time on the black squares...okay?"

"And I want you to run to the end and back three times in 2 minutes...Okay ?"

And off he lurches...looking as if he has a carrot stuck up his rectum...bouncing on his tiptoes...arms held out to the side to try and stay balanced...bouncing... from square to square...bouncing off of the walls...the wheelchairs...the linen trolley...and a wastepaper basket Julian has kicked into the passage

Exhausted...he makes it safely back to the bed.

"Okay ? Feeling alright ? Do you see then how springy and absorbent your knees are then ?"

Yes

"Right...the second test...we're going to check that your joints are properly lubricated-as it were..."

"So...lie on your back on the bed and stick your legs up in the air as if you are about to ride a bicycle...okay ?"

He duly does that, supporting his hips with his hands.

"Now...I want you to 'peddle' really fast for 2 minutes...I really want you to work up a sweat...and...'GO'! "

He peddles furiously for the 2 minutes coughing and gasping , quickly turning purple...his violet shirt soon drenched in sweat.

"Okay...stop now...just catch your breath"

Exhausted he lies on the bed trying to catch his breath...

"Right...the final test then is to stress all the surrounding muscles...those in your thigh and in you calf...to make sure that they can support your long bones and your knees...Okay ?"

"So...have you seen a Cossack dance...you know how they squat right down on the floor and kick their legs out in front of them ?"
"Well...I need you to do that ten times...I'll clap my hands and when I do that you have to hop from leg to leg...Okay?"

He duly squats on the floor with his right leg extended in front of him...

Clap !...up he jumps...extends his left leg and squats down again
Clap !...up he jumps...extends his right leg and squats down again

Amazing...he manages to do it ten times in a row...
Even Julian is impressed

"Okay...so you see ...the muscles that support your knees are working superbly..."

"Now...now...do you think that I've missed out on any of the tests that an English nurse would have done ?"

No.....
Thank you...

Even The Curate believes in God now!

The House of God

I was talking to a colleague the other day about a patient who happened to be a 'GOMER' and not only did she not know the definition of a 'GOMER' but had not even heard of the "House of God" never mind actually read it.

*sigh*

Either I'm to old to be doing this job...or...no wait...I am too old...

Anyway...for the benefit of the Poms ,who do not believe that anything good ever came out of the USA;and for the benefit of readers under 40...who do not believe that anything funny was said before 1999... herewith...The Rules of the House of God

By the way , a "GOMER" is an acronym for Get Out Of My Emergency Room and is a slang term for a patient who, -according to the original book -, "has lost--often through age--what goes into being a human being" -typically an extremely ill, extremely old, Alzheimer's ridden/demented, mute and non-communicative patient.

When GOMERS come into the hospital they are unable to communicate so the admitting doctor will order many, many, lab tests hoping to discover why the patient was sent to the hospital. GOMERS never come to the hospital, they are only ever sent by someone else. This battery of tests is sometimes called a "Gomer-Gram."

I. Gomers don't die

II. Gomers go to ground (ie fall out of bed at the first possible opportunity)

III. At a cardiac arrest ,the first procedure is to take your own pulse

IV. The patient is the one with the disease

V. Placement comes first (ie, getting the patient accepted by another service)

VI. There is no body cavity that cannot be reached by a size 14 needle and a good strong arm

VII. Age + BUN = Lasix® dose (a bit dated but still a useful guide)

VIII. They can always hurt you more (by pulling out their only working IV line)

IX. The only good admission is a dead admission

X. If you don't take a temperature , you can't find a temperature

XI. Show me a BMS* who only triples my work and I will kiss his feet

* Medical Student from the "Best Medical School."

XII. If the radiology resident and the BMS* both see a lesion on the CXR , there can be no
lesion there

XIII. The delivery of medical care is to do as much 'nothing' as is possible


And the point of the rules is to "Buff and Turf" the patient...find the most 'saleable' diagnosis , massage the results and findings, and 'sell' the patient to another service...anywhere else but here !

from 'House of God' by Samuel Shem,1978 by Samuel Shem

He also wrote 'Mount Misery' , in which he takes on psychiatry. Dr. Roy Basch (protagonist of Shem's earlier novel) has decided to become a psychiatrist and is taken on at the prestigious Mount Misery, where, he quickly learns, "psychiatrists specialize in their defects" and "the worst psychiatrists charge the most, and world experts are the worst."

Not as funny as the House of God,-in fact often dark and depressing- , its still worth reading!

Watch my lips..

So there I was, sitting at home today and playing catch-up with yesterdays newspapers...and the very first story in the (London) Sunday Times was about the alleged link between the MMR triple-vaccine jab and autism.

THE doctor who sparked the scare over the safety of the MMR vaccine for children changed and misreported results in his research, creating the appearance of a possible link with autism, a Sunday Times investigation has found.

Confidential medical documents and interviews with witnesses have established that Andrew Wakefield manipulated patients’ data, which triggered fears that the MMR triple vaccine to protect against measles, mumps and rubella was linked to the condition.

The research was published in February 1998 in an article in The Lancet medical journal. It claimed that the families of eight out of 12 children attending a routine clinic at the hospital had blamed MMR for their autism, and said that problems came on within days of the jab.
The team also claimed to have discovered a new inflammatory bowel disease underlying the children’s conditions.

However, our investigation, confirmed by evidence presented to the General Medical Council (GMC), reveals that: In most of the 12 cases, the children’s ailments as described in The Lancet were different from their hospital and GP records. Although the research paper claimed that problems came on within days of the jab, in only one case did medical records suggest this was true, and in many of the cases medical concerns had been raised before the children were vaccinated.


By chance , I had a smug ,middle -class , eco-friendly, sandal-wearing, yogurt-eating, incense-burning, hair-in-her-armpits mother tell me just last Saturday , that her child had not received an MMR because of the "scientifically proven link" between the jab and autism.

Naturally ,I asked the "and what do you do for a living then Ma'am ?" question

And she -of course-replied that she 'had a job in IT'

(Jah...right...like Windows has never crashed then?)

I responded with the "I beg your pardon...are you really telling me that you believe that crap?" cough...actually...not so much a cough , as a statement.

She got offended...they always do...and then got even more offended when I laid the deaths of children in both the UK and the developing world due to measles, at the feet of stupid people who live in the First world/Northern hemisphere/Sod-all-scientific-training-shire...

*sigh*

So that's another complaint then...

Cos honestly...its really really time we all stood up against the craziness of this belief ...

Like everybody else in medicine and nursing and medical research , I take my job and my career very seriously...
I have a very expensive and very lengthy training...that continues to this day what with mandatory training and professional accreditation and just plain , old fashioned interest in my job...

And what ever other thoughts are in my mind at work in the morning,there is no a priori desire to deliberately cause death or disability

So tell me Mrs Righteous Indignation...do you really think that I just blithely and glibly dispense meds without considering the implications?

That as an Emergency Nurse Practitioner with 30 years of experience, some 10 years specifically in mother and children's health that I never read new journals or attempt to stay up to date...that I just vaccinate children without any due thought and consideration?

And the assumption by the smug chattering classes that those original test results were not immediately and rigorously scrutinised by all sorts of motivated and interested people all over the world...that somehow...despite no one else ever being able to replicate the original finding...that the infamous Dr Wakefield got it right...well please...pass the vomit bag Alice.

So I'm not sure why The Lancet screwed up so big-time...but they did

We all do...

But one of the joys of this profession is that there are so many people out there doing research...trying to find causative links...testing strange hypotheses..

I have worked in cutting edge medicine in South Africa...where everything you even say at an M&M meeting...never mind write down and publish...is vetted by all of your competitors and detractors and even your friends and allies...

And on the other hand of course,the smug parents also choose to overlook the changes with regard to the label of autism...that it is now considered to be a 'spectrum disorder'...and by changing the definition-widening it in fact-...that a whole load more children are now going to be "diagnosed" and labelled...and that more doctors and nurses have been trained and medicine has advanced generally...so of course the numbers have risen...although actually...they really haven't

So...to the weekend-denim-wearing,tofu-eating,soap-opera-watching,called-my-child-Apple-like-Gwyneth,4x4 driving,sunday-supplement-reading, parents...let me say four things to you...

(1) This year...this year...in my Unit,I have seen 2 children with measles-one of whom developed meningitis

(2) The next time your child gets sick,call Jim Carrey...don't call me

(3)Of the three of us in the room , only one of us needed to have gone to medical school/university...and today...God has chosen me to be that person

(4) Do you also believe that Prince Philip killed Diana and Dodi?



http://www.timesonline.co.uk/tol/life_and_style/health/article5683671.ece

Car seats can kill sleeping babies, coroner warns

For many parents, the baby's car seat has long been a magical spot where even the fussiest infant would finally drift off to a peaceful slumber.

But a Quebec coroner who examined the sudden death of a two-month-old boy has issued a stark warning: Parents who leave their newborns semi-reclined in car seats for hours on end are putting them at higher risk of sudden death by asphyxiation.

Coroner Jacques Robinson published the warning yesterday in his report on a baby's death in a car seat one year ago at a family home in the Montreal suburb of Pointe-Claire.

The colicky baby's mother found the car seat was an effective way to get the boy to drift off, so she left him in it overnight, with the seat and baby placed in his bassinette.

The mother rose at 3 a.m. to feed the baby and again at 6 a.m. when he started to cry.

When the boy did not wake at his usual 7 a.m. time, the mother discovered he wasn't breathing and had white, waxy skin. The boy's parents and emergency responders tried to resuscitate him without success.

"Car seats are named that for a reason. They're not for the house, they're not meant to replace a crib, and they're not meant to be left in a bassinette," Dr. Robinson said in an interview.

Properly installed infant car seats are set at a precise angle, usually 45 degrees, to balance head support against safety in a collision.

But more than a couple of hours sitting at any angle is too much for a newborn, Dr. Robinson said.
"A baby sitting, or semi-sitting, even at an angle of 30 degrees, does not have the strength to keep his head straight, and it's easy for his airway to be blocked."

Dr. Robinson emphasized that a car seat is still vital for transporting babies in vehicles but he said long trips should be broken up every couple of hours. Even babies need a break to stretch and change positions, he said.
"A couple hours is fine. Overnight is not fine," Dr. Robinson said.

Researchers at the coroner's office went back 15 years analyzing babies who died from sudden infant death syndrome and found 15 to 20 deaths might have been triggered by sleeping sitting or semi-reclined.

Separate studies by Quebec and New Zealand researchers in 2006 analyzed deaths among babies under 12 months and found an increased likelihood of death in car seats.

The warning about car seats adds to a growing list of warnings about potential causes of sudden infant death syndrome. Parents are now advised to avoid letting infants sleep on their stomachs, or in cribs crowded with soft objects. Sleeping in the same bed as adults or other children is another no-no.

Dr. Robinson offered more detailed instructions: "A baby sleeps on his back, on a firm mattress, in his own bed, with no objects in the bed with him, not even covers, if it's possible."

Read the complete article at http://www.theglobeandmail.com/servlet/story/LAC.20090205.CHILDSEAT05/TPStory/National

The famous "two-for-the-price-of-one"-deal

Busy , busy , busy and a very cold Saturday evening and the Unit is heaving with all the Local Yokels trying to get their illness sorted out before it snows on Monday.

In the midst of this we get a phone call from the 'duty doctor' at St de La Creme de la Crazy , the local psychiatric hospital.He needs a dressing done on a one of his crazies...who for a whole load of reasons needs to have a supra-pubic catheter dressed.And despite it being a hospital they have neither dressings,or any nurse capable of doing a dressing.

Whilst this is not what we are here for,we are nevertheless reasonable people...and anyway...Julian was in a particularly smug mood because his new puppy can 'roll over and play dead'...so why not rain on his parade...lets spread the misery around!

Some time later the patient arrives and is accompanied by a truly stunning young blond female student nurse.

Who keeps looking at me coyly...and smiling.

(Oh be still my beating heart!)

Excellent I think...she knows how to deal with crazies so will be able to deal with me!!

I finish examining the patient and leave the room so that Julian can do the dressing.

And as I sit updating the computer,she knocks on the door ...

"Hello again...what can I do for you ?"

Well...I was wondering if I could get the Morning After Pill from you?

(So...no sex for me tonight then!)

"I'm sorry...are you asking if we have it in stock and can prescribe it ? Or are you asking for an actual tablet ?"

Well...I had unprotected sex last night...and was wondering where I could get the MAP...and as I was sitting there with my patient I was reading the Unit brochure and saw that you can prescribe the MAP ?

*sigh*

"Okay...so...yes we can give you the MAP...but first of all...you're here in a professional capacity...at work...with a very troubled young man...whom you have now left unattended...and secondly...you think that I am just going to hand over the MAP without you either booking in as a patient or without me assessing your suitability to take it ?"

Well...she smiles coyly,batting her eyelashes...why not...we're both here...and it will save me having to get a taxi to come back later?

"Jah...well...as enticing an offer as that is for me...two things..."

"Firstly,this is not a supermarket..."

"Secondly...you probably need to save your money...to pay for the taxi to take you to your Disciplinary hearing".