brain drain

i haven't listened to music for ages. i used to, every day, on the way to and from work. my little ipod shuffle blasting at my half-deaf ears. these days i shuffle along (and sometimes, catch the tram, filled with guilt) still trying to wake up or slowly sinking back into a daze. i tell myself it's so i can pay more attention to my surroundings, see and hear what is going on in the world around me. but that's a lie - i am oblivious to it all. work. sleep. work sleep...

nor do i read or write any more. it's such a battle trying to describe a feeling, or recall a moment. its as if im banging my head repeatedly against a wall. my brain is lead; thoughts stifled just as they are born; instead of ideas and emotions bursting to express themselves, there is only emptiness behind my eyes. oh how far have i fallen since... i don't remember...

promise

she is going to die.

rapid af. hypertension. desaturation. increased work of breathing. rise in arterial carbon dioxide. drowsiness. raised white cell count. diaphoretic but unable to raise her body temperature. lack of improvement after antibiotics.

all i could do is give her digoxin. fluids. more antibiotics. a few smart-arse remarks to lighten to atmosphere in the windowless cubicle with her three anxious daughters. fill out a nfr form.

i promised her i'd see her later. will i get a chance to keep that promise on monday?

ward service

i love and hate being back on the wards again. i dig the sense of belonging and comraderie, continuity of care, responsibility and satisfaction; but loath the hours, frustration, emotions and most of all the dickheads that let the side down.

there is something wrong with me when it comes to authority. i dont think its about whos the top dog. rather, its about being able to trust my colleagues and for them to have faith in me. but getting in the way of this is my inability to share responsibilities and blame. and i need to figure it out or i will continue to be a difficult person to work with, either as a leader or follower.

last weekend was fantastic. caught a tram north to melbourne's fringe (it took bloody ages) to visit thommo and taisia. had a wonderful indian dinner. played a game of scrabble. the next morning allowed thommo to convince me to help him build a set of steps for their new foster dog. who knew those woodwork lessons in grade 8 would come in handy one day?


skooshie tries out the new steps

another life saved

it was the day after this particularly anxious personality was transferred from a private hospital. she had fallen over at home and spent two weeks in hospital with lower back pain radiating down the left leg. no fractures on plain films, but mri showed a smidgeon of narrowing of the left L5/S1 intervertebral foramen. she was put on tramadol and panadol osteo, and had the joint injected with local anaesthetics and steroids under ct guidance. so basically a typical story of lower back pain, not much to find on investigation, but having a drastic impact on her mobility. the private guys finally handball her to us for "slow stream rehab", ie out of their hair. whatever.

except, then she develps new right pelvic rim and hip pain. not much to find on examination except focal tenderness over the greater trochanter. full range of movement in the hip joint. nothing on the original x-rays. doesnt sound particularly radicular or neuropathic. hmm...

later in the evening, just as i was about to go home after three admissions, one of the nurses came up to me with a tinge of panic in her voice: "she's got a pale, pulseless right foot". uh-oh. turns out i could actually feel all the pulses: dorsalis pedis, posterior tibial, popliteal. the foot is pale and cool. tone is reduced, 3/5 strength, reflexes absent and absent plantars. what can it be? i was almost convinced it was neurological but the spectre of ischaemic limb loomed. i put the call through to the on-call consultant, who is also unconvinced but says "she sounds like she won't be happy until we get her back to the private hospital to see a vascular surgeon, but try and talk her out of it." i didn't try too hard - perhaps they could get a neurosurgeon to look at her this time? a letter and a call to the ambos, finally i leave work only three hours late.

the next morning, while getting handover in my day job back at the alfred icu, i get a phone call from my intern: emergency femoral embolectomy. phew! all i can say is, thank god she was a grumpy old fart...

half measures

the patient has been in hospital for three months, in and out of icu for most of that. a young bloke, he went for a drive on his birthday with his nephew and they smashed themselves up good: broken bits, burns, the works. he has been making slow slow gains, his grafts and regrafts are mostly not taking. he is on tpn and ng feeding but remains cachexic. he is withdrawn and rarely engages. he hasnt moved his right arm for weeks and his left fractured femur is held together by metalware but hasnt made any attempt to form a callus after all these weeks. looking at a double amputation, weeks more in icu, months of rehab and years of recovery, his family have decided to pull out.

my consultant told me he was a bit surprised because he felt the patient had been making gains. but he could understand where the family was coming from. so the plan is to withdraw treatment, and quickly. he told me he didnt like to do thing by half measures. the patient could die by a thousand cuts, slowly succumb to infections and malnutrition over days and weeks. or he could die with dignity. we would turn the sedation up to ten and ten of morph and midaz per hour initially, then titrate upwards freely. three days later, we'd turn the ventilator off, knowing he'd be comfortable and lapse into apnoea.

i don't know if i agree. this seems to go against everything i believe in about medicine, about palliative care, about my role as a doctor. and yet, there is something dangerously seductive in what he says. it feels both right and wrong...