Monday, December 6, 2010

Apocalypse in the ED

Following on from my idea of a post-apocalyptic geriatric-zombie movie set in the Werribee Hospital: the apocalypse came to Melbourne!

On Saturday there was a flash flood which affected several parts of the hospital. We even had to go on bypass for a couple of hours while the PSAs were tried to stem the tide. You know, stop the life-support machines getting too water logged. Simultaneously, a code red (FIRE!) was called for another part of the hospital.

Usually if there's a code red it's only called once, then presumably someone takes the smoking piece of bread out of the toaster and it's all fixed. This time the code was called every three minutes or so, indicating an ACTUAL FIRE! So for about an hour there were announcements every few minutes, "Respond Yellow: Flood, level 1", then a couple of minutes later: "Respond Red: Fire." Hilariously, the location of the code red kept sounding like: "Respond Red, Evil Child Unit. Respond Red, Evil Child Unit." I'm still not sure what they were actually saying.*

*This is hilarious because the hospital where I work sort of has an 'evil child' unit: the child and adolescent mental health service. It provides inpatient support for kids with oppositional-defiant disorders etc.

Monday, November 29, 2010

Old person-a-rama!

One thing about my job is the old people. Here are some observations about old people. (Don't get me wrong, I defected FROM paediatrics to do Emergency Med. I like old people).

1. Some old people can talk a LOT. Especially if you ask them about what they've been eating, or who does their grocery shopping. When I listen to an old person talk I can't help but think of the Simpsons episode where Grampa Simpson tells a really long boring story as an old-person weapon:

We can't bust heads like we used to. But we have our ways. One trick is to tell stories that don't go anywhere. Like the time I caught the ferry to Shelbyville. I needed a new heel for m'shoe. So I decided to go to Morganville, which is what they called Shelbyville in those days. So I tied an onion to my belt. Which was the style at the time. Now, to take the ferry cost a nickel, and in those days, nickels had pictures of bumblebees on 'em. Gimme five bees for a quarter, you'd say. Now where was I... oh yeah. The important thing was that I had an onion tied to my belt, which was the style at the time. You couldn't get white onions, because of the war. The only thing you could get was those big yellow ones...


And then if I'm really tired I'm in danger of laughing really really loudly while the old person is telling me, "...oats aren't what they used to be. Oats these days, they come in a box. You see I'm used to storing my oats in a jar..."

2. Old people would be great in a zombie movie!!
On Black Saturday last year- the day of the Victorian bushfires- I was the general medical resident at the Werribee Hospital. (already a black Saturday, I know). I knew it was going to be hot, but the weather was actually apocalyptic. The skies were black and enormous tumbleweeds tore past the windows. At 3pm it reached 46 degrees and the airconditioning broke. By 4pm the old people ARRIVED! A stream of delirious, dehydrated old people. I was sweating like a runner putting in drip after drip. Meanwhile, the old people roamed the hallways, mumbling, calling out, "Vernon. Vernon?". Some of them just sat at the 'bus stop'- a row of chairs near the nurses' desk.

A solid start to an awesome zombie movie!

3. Old people can fall over
One of the my favourite medical school tutorials of all time- assessing an old person for falls:
-ask the person to stand up, and see if they fall over
-ask them to close their eyes and see if they fall over
-if, perchance, the old person is still standing, give them a little push and see if they fall over.

Oh dear. Next time: children and the middle-aged!

Tuesday, November 23, 2010

Pen V. Stethoscope

I have nearly finished reading ‘The Pen and the Stethoscope’, an anthology of writing by doctors, edited by Leah Kaminsky. The book is approximately half non-fiction and half fiction. I admit that I enjoyed the non-fiction more- there was a predominance of doctors writing about their early experiences as interns and residents. The stories were often familiar to me- a missed diagnosis of leaking AAA, the frustration of continuing intensive care on people who should be allowed to die in peace. But I was thoroughly impressed at how exciting the stories are- these doctors can really write!

I think that the early years of doctoring- internship and residency- provides the richest fodder for writing. In these early years you are most acutely aware of the chasm between your experiences as a doctor and your previous non-medical experiences. You are innocent enough to be properly awed or disgusted by things. The junior doctors are also the ones most often put in ridiculous situations trying to negotiate the ridiculous hospital bureaucracy and advocate for their patients in the under-funded public health care system. Identifying the treatment or test your patient needs is often the easiest part- then comes the frustration of speaking to six different administration staff, four registrars, a pharmacist and a chaplain in order to line it up for them.

For this reason that the only medical show I’ve ever been able to watch is (the early seasons of) Scrubs. It captures this aspect of medical work perfectly. In one episode a patient needs an operation that his health insurance does not cover, and the patient in the next room qualified for the operation but didn’t need it- so they swap the patients temporarily in order to get the first patient’s operation done. This is so close to the truth it’s not funny: for example trying to ‘trade’ with another inpatient team for a spot on the endoscopy list: if you let us take your patient’s spot on the gastroscopy list tomorrow, we’ll insert your patient’s port on the afterhours list tonight…

On my second day of internship, I had an unbelievably quiet afternoon. I was working on the renal team, and we shared a workspace with the neurosurgery team. James, the neurosurgery resident, came into the workroom looking stressed and demanding help from a female doctor. My (male) registrar quickly volunteered me for the task.

As we walked down to the operating theatres together, James explained his problem to me. He had been told- on pain of death- to book his patient for an aneurysm clipping that evening. But operating theatre bookings for the after hours list didn’t open until 4pm, and at exactly 4pm residents from all the surgical specialties- vascular, orthopaedics, plastics, hepatobiliary- would begin ringing the bookings nurse to secure their patient’s spot on the list.

James realized that the only way to ensure his patient got their aneurysm clipped was to be there at 3:58, to ask the nurse in person. “But she hides in the change rooms, Lucy!! You need to find her in there!” He laid out his plan: he would be out in the theatre recovery rooms, “sweeping the area” for the bookings nurse, whist also serially phoning her every 30 seconds. I would ‘stake out’ the female change rooms.

The funniest part about this procedure was that it worked, and James was considered one of the best surgical residents in the hospital. He subsequently got into one the most competitive specialty training programmes in the country.

Wednesday, October 20, 2010

online wino

Yesterday one of my colleagues had an alcoholic patient, who gets all her wine via online supermarket shopping. She need never leave the house again!!

Friday, October 15, 2010

Today my love for you...

I used to ask Jason, "Will you leave me this week?" And he would say, "Hmm....no, not this week." "Okay!"

Now I tell him,

"Today my love for you is as big as Uluru."

"Today my love for you is as big as Chadstone shopping centre, including the carpark!"

"Today my love for you is as big as the Pacific ocean"

"Today my love for you is as big as the Royal Exhibition Building." (Jason: "Hey, that's not very big!")

He told me,

"Today my love for you is as big as the shipping yards."

"Today my love for you is as big as the spaces between the stars."

Thursday, October 14, 2010

Kickboxing, dinge etc

Today a patient presented after participating in a 'no-rules' kickboxing match. Apparently the bouts go for 9 minutes- the winner taking home $15 000 and the loser a measly $5000. In this chap's case I don't think the $5000 will begin to cover his rehabilitation costs. But who even knew this type of match happened here in Melbourne?? It sounds like dog-fighting or cock-fighting.

Last weekend Jason and I went to see Sifter's Dinge, a Melbourne Festival show (Goebbels) with a fantastic mechanical set and no actors. I suppose it's an audio-visual installation, but presented as a discrete performance- unlike the looped installations more commonly found in galleries. It was enthralling. There were four pianos that played themselves with mechanised arms, a steam-engine type contraption and spooky constructed trees. At the start two 'stage hands' come on to shake some sand into enormous containers. Then they turn on taps of three large watertanks allowing the water to fill the containers. I found this part of the performance absorbing, quite calming. It reminded me of the TV channel at the Royal Children's Hospital that broadcasted a live feed of the hospital building site. Some of the patients' parents watched it *all the time*- spending hours watching a bulldozer dig a hole. Engaging with a mechanical process in an aesthetic way.

Tuesday, September 28, 2010

The TV and the couch

When did I start watching all this TV?? When I first moved out of home in 2002, we didn't have a TV. In 2004 we got a TV, but the only show I watched was Twin Peaks- which is *practically* film. In 2006 I started watching Six Feet Under, which singlehandedly converted me to TV. Now I watch:
-Mad Men
-Thirty Rock
-United states of Tara
-The Wire
-Freaks and Geeks
I can't even remember them all! I keep telling myself that it's because TV is smarter now, edgier. BUT WHAT IF I'VE JUST BECOME DUMB?? A DUMB AND LAZY COUCH-SITTER??

Excuse me I have some TV to watch.

Friday, September 10, 2010

Intensive Dream Unit

I have just started a week of night shifts. Seven long nights in a row, but in what other job do you get a full seven days off every 8 weeks?? And it's not all bad- nightshift can be freeing to the mind! As Daniel Kitson described in his awesome show 'It's the Fireworks Talking', staying up all night can make you feel INVINCIBLE!!! Or at least give you the type of meandering, loose-associations-type thought pattern that 9-5 never delivers.

Last night on my drive to work I was thinking about the amazing monitoring capability of the intensive care unit. When you first start working with intensive care patients- those in an 'induced coma'- it is completely bewildering trying to figure out if they're okay or not. The senior staff will suddenly become very concerned about one particular patient, who to the casual observer, looks identical to all the other apparently sleeping patients in the intensive care unit. Of course, the senior staff are responding to the monitors- heart rate, blood pressure, intracranial pressure, core temperature, oxygen levels, compartment pressures etc. Anaesthetists also use BIS to monitor how deeply asleep their patient is. It is used during surgery to prevent the patient unexpectedly waking up to see their gall bladder being wrenched from their body.

Last year I went to check on a patient who'd been in our Intensive Care unit for two weeks and was transferred to a general ward. She had worked in the unit herself, so everyone was very concerned for her and curious to hear of her experiences on the supine side of the bed. When asked how it was, she said, "Well, I flew to Paris." And she wasn't talking about taking a Qantas flight- she *flew through the sky* to Paris.

Apparently the 'induced comas' of ICU can cause a peculiar delirium, intense dreams that the person will often remember for life. Some patients have dreams so terrifying that they never enter a hospital again- they would literally rather die than risk repeating the experience. I imagine that given another 50 years, we will routinely monitor patients' dream sequences. Just another high-def, touch-screen monitor showing their propofol-induced adventures in technicolour.

Friday, August 27, 2010

Blow darts

Sometimes I get very anxious, this doesn't seem to correspond to particular events. Some days I'll just wake feeling diffusely anxious.

Today Jason suggested that he get some tranquilliser blow darts to shoot at me when I'm getting anxious. "See, I will support you with love. Love and blow darts."

Monday, August 16, 2010

Out of Oz

We returned to Melbourne 10 days ago, and I am haunted by the sense that i have returned *from* Australia, to *another place*. My idea of Australia has grown so much that Melbourne seems like an international city, part of an international community of cities, but certainly not integral to the Australian identity.

We spent a week travelling from Broome back to Alice Springs, through the Tanami desert. I had decided to read Australian books on my holiday- I read 'Cloudstreet' and 'Dirt Music' and a true crime book about Bradley Murdoch. I had attempted Cloudstreet before, and found it unbearably kitsch. A story from my parents' childhood. This time I loved it. I suppose things can seem kitsch just because they are unfamiliar.

Monday, July 26, 2010

Crocodile fever

Jason and I have made it north of the Berrimah line to Darwin. We may have caught a bit of croc fever on the way- it being clearly too early in the year for mango madness. We saw seven crocodiles on our wetlands cruise at Yellowwater, then set off intrepidly the next day to Koolpin. In order to get to this 'jewel of Kakadu', we had to cross a river containing an *actual saltwater crocodile*. I was so scared!! I told Miriam that if she was killed by a crocodile- and therefore definitely frontpage news for the croc-obssessed NT Times- I would be sure to tell them she was wearing her lovely Gorman bathers at the time of death.

Crocodiles are basically primordial monsters. They sit on the banks as still as rocks, then slip soundlessly into the water and *completely disappear*. Their teeth sit outside their mouths, giving them an evil grin.

On the way back we opted to scale a sheer rock face in order to avoid the river crossing.

Sunday, July 11, 2010

Leaving the desert

Ahh, gloomy old day in Alice Springs. I have no contingency plans for inclement weather here! The fact that our house is at least half packed up isn't helping.

Last night one of our friends reflected that it wouldn't be "so bad" moving back to Melbourne. After all, she said, "You can walk along Merri Creek and pretend that you're in nature!" Which, from a Central Australian point of view, is simply hilarious. In this town, you can ride a bike for fifteen minutes in any direction and end up in proper, unadultered BUSH.

I will definitely miss the sky- 360 degree horizons!! The feeling that the sky is so big and round above me that I am actually a tiny figure in a snow-dome.

It is going to take some getting used to the plush environs of a big city ED. In the department here I can sit at the main doctor's work desk, and, if I reach my hand behind me, tickle a patient's toes as they lie on their trolley.

I also suspect that the Melbourne patients will be not so easily placated with a bandage. Many of our patients are *fixated* on getting a bandage. It doesn't matter how severe the injury, the patient's top priority is getting a good bandage. I remember one night assessing a patient with a depressed skull fracture- ie organising their CT, making sure they weren't about to die, arranging an interstate transfer. The patient had a dressing over the wound, so that I could show the surgical registrar. Menawhile, the patient kept asking for a bandage. I imagined her watching all my apparent pfaffing around, thinking, "When will I get my BANDAGE??" I've only recently discovered a likely explanation for this phenomenon: the spilling of blood is considered very bad luck in local indigenous cultures.

I am thinking of setting up a Bandage Clinic down the road from the hospital.

Tuesday, July 6, 2010

Big Smoke

Today Jason and I officially became locals in Alice Springs- the Todd river has flowed three times whilst we've lived here!

I will tell a story, but not in a Crocodile Dundee, or Gods-Must-Be-Crazy way, I hope.

One of my patients was a middle aged Aboriginal lady, who came from a long way out bush. At least one day's drive. She had never been to Alice Springs before in her whole life. As luck would have it, she injured herself whilst here in the Big Smoke, and had to come to hospital.

She sat in the cubicle looking terrified, and told me quite frankly, "I'm very scared. I've never been to Alice Springs before." She asked if her husband could be called in from the waiting room- unlike the locals, she didn't realise that most people bring a family member through to the department with them. So he came through. When I told them both that she would need to stay in hospital, her husband said- so very softly that I had to literally put my ear up to his mouth-"We've never been here before. I should stay with my wife." He indicated that he would sleep on the floor by her bed.

So we organised for him to stay in the hospital too. A couple of hours later I ran into him upstairs on level 1, looking for an office that is actually on the ground floor. It was strange, because I realised that he was in exactly the right position, but one floor up. In hindsight, I think that they'd taken the elevator and he didn't realise he'd gone up a level.

So I showed him the way down to the office, via the stairwell. We entered the stairwell and he stopped completely, just looking at the stairs and at me very carefully. Then he grasped the handrail firmly and stepped down very slowly. When he reached the landing, he continued holding the handrail and walked the long way around to the stairs again. Then continued his slow descent.

I don't think he had used a staircase before- or at least not a big, two-storey-building staircase. Retelling this story, I feel terrible that I didn't show him the way back to his wife. I hope he found the way.

Saturday, June 26, 2010

Working too hard

By early last week, I had done so many ED shifts in a row that I felt constantly on the verge of a temper tantrum.

Nurse: "What time do you want the next troponin on Mr Smith?"
Lucy: "WHY DON'T YOU JUST LEAVE ME ALONE???"

I found myself seeking solace in the more boring ED activities- quietly suturing a large stab wound on a drunk man's chest, or moulding a plaster for the broken ankle. I felt completely incapable of making any clinical decisions.

On my precious days off we cycled to Simpson's gap. The bicycle track was stunningly beautiful: 20km of meandering paths through low lying, scrubby bushland interspersed with huge ghostgum trees. We scrambled up the gorge to reach the sunny rocks and ate an amazing picnic of roast beef sandwiches, apples and chocolate cake. Enid Blyton would be proud!




Sunday, June 6, 2010

Magic

Many of our indigenous patients also receive traditional healing from a Ngangkari. I would love to find out more about this. I understand the ceremony often involves removing an errant object that is causing illness in the body, for example a misplaced rock.

I often think that medicine as we practise it does not have enough magic. It is thoroughly transparent and mundane, and doesn't engage the beliefs of our patients well enough.

Early Western medicine had more magic! For example, the secretive use of obstetric forceps during a difficult delivery: the forceps hidden under the operator's gown, before bringing forth the (often dead) baby. Though this particular example is mired more in patent concerns than the powers of culturally-embedded healing.

The other day I sedated an Aboriginal boy with ketamine and when he awoke he spoke English for the first time. Perhaps I shall have to settle for this small wonder.

Monday, May 31, 2010

Rock vs Stick

I had a throughly awesome weekend with Deanne, who flew up from Melbourne for a holiday.

We started off at the pub on Friday night, discussing an important teaching of the Alice Springs ED: all assault weapons are either rocks or sticks. A stick is an object that the perpetrator holds onto whilst hitting their victim, whilst a rock is any projectile weapon. A tin of food and a TV are both rocks. A nulla-nulla is a stick, but so is a cooking pot. A children's tricycle could be either a rock or a stick. This expedites clinical handover; '28 year old man hit to the head with a stick;' and speaks volumes of the ridiculous amount of violence in this town.

Saturday morning we went to the Steiner School Fair. I admit to being fairly cynical about Steiner schools, particularly as there is apparently an outbreak of whooping cough at the Alice Springs Steiner school at the moment. (Insert disparaging comment about hippy parents and vaccine-preventable illnesses). But by the time I had eaten a delicious pancake for breakfast, bought some outdoor plants, a jar of homemade chutney and a gingerbread man, all in the idyllic school grounds at the foothills of the East MacDonnell ranges, they had nearly converted me to their Steiner ways!

Then we picked up our hire car- a RAV4 so that we could take the Mereenie Loop to King's Canyon, and do some 4WD side trips on the way. As it happened, our car was brand-spanking-new: 23km on the odometer. Oh, what fun we had flogging it around the Mereenie Loop in our shiny white car! On the way we saw a caravan of camels, a drove of donkeys and a mob of brumbies.

The King's Canyon rim walk is probably the best short bushwalk I've ever done. We also visited Rainbow Valley, where I ran around maniacally on the claypan in front of the spectacular colourful cliffs. We made it part of the way to Palm Valley, but nearly got bogged in sand (a RAV4 isn't a real 4WD, after all!) and had to turn back.

Happy days.

Tuesday, May 25, 2010

The Outback Wedding

This weekend was the festival of Miriam and Marcel's wedding. The Outback Wedding, and my first ever Jewish wedding.

We were super-excited about attending our first Jewish wedding. Jason carefully packed a bobby pin for attaching his yarmulke, and then was quite proud when it stayed on of its own accord. We practised our three Yiddish expressions; schvitzing, schlepping and alter kocker; and carefully read the 'Guide to a Jewish Wedding' enclosed in our invitation. I even befriended a teacher of Jewish studies who told me about klezmer music and the hora. So exciting!!

We gathered at the entrance to Alice Springs' botanic gardens, and were lead into the desert garden by two traditional owners and a klezmer band. Several people (including my Jason!!) carried colourful flags in the procession. It rained during the procession, but during the ceremony the sunlight snuck in right under the huppah. Miriam's little nieces sat around the huppah clutching their banksia bouquets, occasionally running back to their parents in the front row. The ceremony was performed by rabbi Gersh, with English translations of the sung Hebrew. His blessings were punctuated by bursts of Miriam's overjoyed laughter. Marcel stomped on the glass and we shouted 'Mazel tov!'

I was astounded by the overwhelming joy of the Zimmet family in particular. Seeing Marcel's father Paul on Friday night, I remember thinking ,'He looks like the proudest man in the world!'. Then Sunday saw Hendrik holding a post of the huppah, wearing an impossibly wide smile. And finally the groom Marcel, confirmed for me the extraordinary capacity of Zimmet men for unabashed happiness.

Other highlights were hearing Miriam's father, a high court judge, admit to making Ferris Bueller jokes in court (AWESOME!), the trays of mini-desserts (mini desserts mean you can eat seven, right?) and dancing under the outback stars.

Nice job, Miriam and Marcel. Mazel tov!!

Wednesday, May 19, 2010

tummy bugs

I was struck down by a tummy bug at approximately 5:30pm yesterday. I feel this is the best way to describe it- 'hit me like a ton of bricks', 'struck down' or 'knocked out'- a sudden outbreak of WAR IN MY TUMMY!!

I am now convalescing with Sarah Waters' 'The Little Stranger'. Things could definitely be worse.

Monday, May 17, 2010

Outback Doctors

I saw an ad for the ABC documentary series 'Outback Doctors' and immediately thought, "I should be on that show! I'm an outback doctor!"

And I am Outback Doctor now, of sorts. I've worked in Alice Springs for nearly 4 months. I know about nulla-nullas and redback bites. I'm no longer surprised by the pus or the maggots, or the patient who sprints off half way through the consultation to retrieve his swag from the Todd riverbed before someone nicks it. Actually, I understand this one now: a good swag costs about $300.

Of course, the real outback doctors consider Alice Springs to be the 'big smoke' so I guess I've got a way to go before I'm a documentary star.

My friend Marcel is a paeds registrar working in community paediatrics. He likes to make fun of the short-term mindset of the ED doctor: after all, he works in preventative medicine. When he visited the ED the other day I gleefully said, "Slow day for preventative medicine Marcel? You didn't prevent any of this!" - with a sweeping gesture around the busy ED.

I often think that I am too jolly, not serious enough, during my work in the ED.

Yesterday I picked up a patient and the nurse in charge asked me to pick up her sister- the next patient- at the same time. I got cross and refused: to my mind there is nothing worse than seeing two or three patients at once. This invariably happens when a whole family has gastro, and the history proceeds, "Well, Johnny started vomiting last Tuesday, after we had some fish fingers that I'd bought from Coles because I couldn't find a park in Woolies. Their parking is terrible, you know. And Kate had a spew that afternoon too, I think. Or was that me??" And it just becomes impossible to know, or even care, which of the three little patients might be getting dehydrated.

Anyway, these particular patients were adults, who could surely manage on their own. So I went out to the waiting room well pleased with my decision not to admit the patient's sister to the ED yet, only to discover that the sister is completely blind. I looked so mean and foolish that I laughed and laughed with the the nurse in charge.

I finished Coetzee's 'Summertime' today, a beautifully self-deprecating autobiography. "But what if we are all fictioneers, as you call Coetzee? What if we all continually make up the stories of our lives? Why should what I tell you about Coetzee be any worthier of credence than what he tells you himself?"