I’ve noticed an odd groundward trend, somewhere between the hospital car park and the emergency department. I’ll call it my daily Hansel and Gretel. Always a little different, sometimes it’s just a relic, or a clue, or an odd discarded piece of peculiarity, or, at its best, a good going trail. But there’s always something. Like a treasure map leading into the department, with a tale chasing behind it, these are the things I’ve seen walking into the hospital (and I apologise if you’ve seen these before on my twitter feed. In fact, I feel I ought to apologise to any of you poor things if you’ve read my twitter feed (aside again. Twitter feed. Bird feed. We’ve come full circle here. Back to Hansel and Gretel. Although in the Grimm story the trail led from, or to, a house of cake and confectionary. No amount of imagination will transform our ED such.). ):
- Dollops of blood. This was very CSI. Leading from an unassuming bay on the third floor of the car park and punctuated by a hand print and smear down one wall of the stairwell, this didn’t let up until it reached the triage area. Requires the least inventiveness of all to work this one out.
- Coffee stains. Much sadder, this one. Somebody spilling precious fluid in an obvious hurry to get into work.
- A polystyrene esky, its lid half off, with a peeling Biohazard label on the side. It was, presumably, full of discarded organs, trafficking gone wrong, a bad internet deal. I couldn’t bear to look inside.
- Those little cartridges of nitrous oxide, usurped from their respectable role inside canned cream dispensers, they’d been crushed by the hand of somebody seeking cheap oblivion. Laid out like shame.
- Decreasingly sized blobs that looked like basil pesto. No. I don’t know either.
- The most recent, a mass of bloody feathers, arranged with the suggestion of a sacrifice. I pondered on this one the entire day, and by the time I left a rather draining shift, my heart emptied out, I figured it was the remains of Icarus, the last of his singed feathers dropped on our doorstep, to remind us of man’s complacency and hubris.
But it does always make me smile, encountering these trails, the scent of what’s to come for the day. As I dodge the raucous man selling The Big Issue (I find I cannot buy more than two or three copies before I start averting my eyes), the splintering piano in the corridor (frequented at night by lonely patients playing with their gowns gaping open at the back), and the LOLs (the little old ladies – the purple haired volunteers – oh but they are another whole post), I am alway ludicrously cheered and steeled by the time I walk through the sliding doors of the department into the chaos, a place made not of candy and chocolate, but a Grimm tale, all of its own.
I watched a woman die today.
Twenty-seven years a doctor and I still haven’t become accustomed to it. I’m not even sure when the exact moment is, that instant of death. Is it the last beat of the heart, or the concluding gasp, or is it the terminal neuron sparking out – the final neurotransmitter molecule crossing the last closing synapse like a desperate man jumping Niagara Falls? What, officially, counts? She was a beautiful old thing – a palace of a woman – her body a castle of stories and history. You could tell by the family, the loving way they held each other round the bedside, that she was a good woman. Had led a worthy life, and her legacy had spread through her progeny with the steady stealth of a slow burning fire.
But still, I found it difficult. I, unlike her beautiful children, had only just met her, a few hours before. She had turned frail with the last season; her lungs had thought about giving up several times in the previous month, and this episode of pneumonia was determined to take her out. At 83, the decision by everybody who hovered over her, to cap care at an agreed upon ceiling, was entirely appropriate. So we all gathered around in a quiet little side room, with not much more than a gentle hiss of oxygen, and some moistening of her lips, to bear witness as she departed.
I watched intently. I don’t often get the chance to do this. Would there be some sign? Something to indicate that a solid, practical, blood circulating life of flesh was changing places with a world inert? Was her life flashing behind those papery thin eyelids with their spidery, barely pulsating veins – an old fashioned silent movie reel? The word spiritual came to mind, but I was no closer to understanding. Whatever time it was, I made note of it in her records. Rest In Peace. And it was peaceful in that room, only a quiet, juddering sob here and there.
The family, all four of the children, hugged me. We’d made all the decisions together; they’d been heard, their mother, and her life – that good one, full of friends and dinners and choir meet ups and laughter – had been respected. The rarity of being thanked, and for letting someone die, stopped my own breath. And then I had to go, because a rhinoceros of a meth-addict was screaming down the corridor just beyond, and something needed to be done.
What a job. What a phenomenal, amazing, heart-breaking, privilege of a thing.
Dustfall. I’m with you, it’s an odd word. It is, however, the title of my first novel, and somewhere within it is the semblance of sense.
Dustfall is a book 6 years in the making. Its release date is February 2018, and it’s being published by UWA Publishing, a cracker of an independent press who produce quality books of both non-fiction and literary fiction flavour.
When I was an intern (let us not lower the tone of this post by mentioning the year), I was flung out to Port Hedland Hospital for a term (my second only as doctor, the first being ten weeks in psychiatry), during which I was occasionally rostered on to staff the Emergency Department, alone, overnight. As you will easily imagine, this was a rather formative period for me. Frankly terrifying doesn’t begin to encapsulate it. Several times during this stint, searching for solace, I travelled round the surrounding countryside – that parched, red, horizonless outback of ours. On one of these occasions, I ended up in Wittenoom, a crumbling, soon to be ghost town. Amongst the shadows and the ruins, I came across the abandoned Wittenoom Hospital, and wandered through its shell, its broken corridors, its clanging, destroyed rooms. It was like the Mary Celeste – looking as though it had been abandoned in a hurry, with no one set to come back. Gauze rolled through the corridors, waterlogged piles of journals sat off to one side, and an old anaesthetic machine, a strangely shiny relic, gleamed in the corner. This image has stayed with me for decades, and I always knew there was a story to be had there.
Of course, Dustfall is a work of fiction, but it explores the crashing consequences of a doctor’s single mistake, as well as shining a light on a heinous chapter in Western Australia’s mining history.
More than this, I won’t say for the moment. Over the next six months, leading up to release date, there will be lots of news and numerous updates, most of which will find their way here.
It’s been a journey of wonder, writing the manuscript. A personal campaign of learning, of failure and rejection, and the rediscovery of the immense power and sublime beauty of the written word.
Let it never be said that we resist change. We, the consultants in my ED, have been reinvented. Previously our title was Duty Officer, which had a pleasantly communist, scratchy grey-overalled sound to it, but now we are the EPIC. An imperious title, in my opinion. This stands for Emergency Physician In Charge. Here’s where the duplicity begins.
I’m hardly in charge of my own brain, so feigning tight command of the beast of the Emergency Department is a bit of a stretch.
But still, I turn up for shifts. At least I dress appropriately. I wear scrubs which make me look like a scrawny Police Officer but without the fun stuff hanging from my belt.
I carry THE phone. Yes, the one that has the broken ice-cream truck ring tone that peals out horribly during the depths of sombre conversations; the phone that conveys endless information bytes about patients who may, or may not, pass through our doors, or otherwise random requests or facts upon which I am allegedly supposed to act. With this, though, I am firmly in charge. I don’t answer it. That’s the limit of my in-chargeness, I think.
The days vary, like all good days in the vortex of Mount Doom. Let’s take one.
I start it by thinking about coffee, which is then rudely interrupted by waves of patient chaos. Busloads of them and their relentless pathology. By nine I am wondering whether I am coming down with some rare form of illness, perhaps vasculitis, or takotsubo cardiomyopathy, but it turns out I just want coffee.
I am supposed to be at, or possibly in, a huddle. I don’t know what a huddle is. I find out it is a meeting with people who are pivotal in managing patient flow, who will tell me exactly the number of beds we don’t have. Some people will get told off. I don’t get told off, because I don’t know such meetings are being held. And I don’t answer my phone.
Next the bat phone goes off. This is good, because this is what we train for. The registrars go head to head, fighting to answer the phone, because whoever answers it gets to run the code. A registrar is injured in the elbowing melee. They need to go lie down in resus. As I am puerile I announce the incoming code over the tannoy like an airhostess. No one is amused.
The code is a patient with crashing sepsis. Because I am so epic, I am not allowed to touch the patient. I look longingly at the patient’s veins, and imagine slipping a central line into the subclavian to a round of applause, using only landmarks and the fairy dust of a clinician who has been around for so long that they have a sixth sense where these structures are, like a Baggins in the Shire. This does not happen. The registrar slides the CVC in with exquisite skill, brandishing the ultrasound probe like nun-chucks. He does not need applause.
By now my need for coffee has become sentient, and is talking loudly in my head and causing hallucinations. I decide I will have to drink the hospital brew. Sadly, our hospital cafeteria has insisted that the coffees need to be reproducible, so they have replaced the baristas with an automated grinder. I am not joking here. Something about benchmarks and KPIs. For coffee. At this point it doesn’t matter. I am prepared to drink anything, and don’t judge the drink for its dystopia.
I am ready, then, for the next patient (keeping in mind that I am so epic I know exactly what’s going on with every single one of the rest of the 45 patients in the Emergency Department – what their plans, vital signs, and backstories are, as well as the reasons for them breaching some weird militarily-enforced time-target. How do I know? Well that is the secret of being epic). The next patient is a trauma, a rather bloody and moderately deconstructed victim of speed and inattention. This time, I get to watch a registrar running the trauma, who is doing something called a work-place based assessment. This seems to be a mechanism designed purely so someone as garrulous as me is forced to shut their mouth and watch a trainee perform. In this way I can constructively educate and assess the registrar at the same time. My hands are so itchy to get in there and be involved in the intimacy of patient care they could be weeping in my pockets. The registrar does a fabulous job, and I have only interrupted her about eighteen times. The patient does fine.
I’ve had enough. I want to see a patient myself. I sneak into a cubicle and stealthily close the curtain, where I begin to take a history from a fabulous old man who has been waiting (patiently) for 3 hours to be seen, who is telling me where he fought in the war. But now I am hauled away to a meeting, because I wasn’t smart enough not to answer the phone. I am in trouble. They ask me why it’s taking so long to see the little man who fought in the war. I would like to make a witty joke about the irony of this, but the people with clipboards don’t look in the mood for a joke.
Basically the day continues like this. Sometime after lunch I feel I would very much like a nap. I look plaintively at the distressed relative’s room, and wonder if I could jigger the lock so I could have forty winks, but the phone rings again.
I am surprised by the variety of requests that come through on the EPIC phone. Mostly my job is to try and concoct an answer without getting too cross. Often the answer will end up being of little use to anyone, but I have learnt to phrase things just right so nobody knows that until well after they’ve rung off. A resident calls in sick. This is bad, because it now leaves the number of residents to staff the evening shift as a negative integer. We are suffering from junior staff cachexia at the moment. Everything has been downgraded. For political reasons our hospital has been repurposed and rebranded. Where we used to be the state’s top dog, we are now the punchy little sibling. Things may well change, and it is likely they will. Working here for decades has made it clear that the health ride consists of the dizzy peaks of the rollercoaster interspersed with the gut dropping lows, complete with arms flailing and eyes squeezed shut (or that could just be me). I am immensely proud to work amongst a team that has hung in there, undistracted for the most part by the flighty decisions made by health bureaucrats. The professionalism and commitment of my brethren to patient care has never wavered.
And then, just like that, the day ends. My shift trying to keep the lid on the bubbling pot of entropy is done. I hand over the phone. Someone else gets the chance to be epic. And I’m sure they will be.
This post originally appeared on Life in the Fast Lane.
There’s a torso at the front of the queue. Towards the back of the line, patiently waiting their turn, are several uniformed staff-members. Some of them are cracking their knuckles. They mean business. Well one doesn’t, but he’s a first year medical student with a sweat sheen on his upper lip and a hairy look in his eyes, clutching a wilting assessment form. The current contender bouncing on the sternum has forearms like roo tails and there’s a quiet admiration from the entire team. She’s managed to get the end tidal CO2 so high Al Gore would be outraged.
Me, I’m just perplexed. I’ve lost count of where we’re supposed to be in the sequence. We’re somewhere in the midst of an alternate cycle, so, I think, we are drugless and ready to charge. I don’t want to announce my heresy by questioning the algorithms out loud (writing this I have realised how close the name Al Gore is to algorithms, and I wonder if there’s an essay in here? A sort of linguistic marriage between fame and medical terminology? No, sorry, you’re right.) I’m lucky though. It doesn’t matter if I am struggling to follow the ACLS recipe, because everybody else knows exactly how to count in the actions, like being the next one to enter a kid’s skipping game.
The correct person at the precisely correct moment dumps an unwanted charge. I wonder for a moment where the rejected electrons have gone, but then another command hauls me back and everybody rotates, cranking up another round of the chant.
I’m sure I’m not alone experiencing an odd derealisation whilst running an out of hospital cardiac arrest. There’s the human underneath it all, of course. The bone white legs, a bloodless hand hanging unheld off the bed. A husk of a person gilded by the twilight sun streaming through the high windows. I don’t want to make light of it, for that patient, for these final violent moments. For a family gutted to see their loved one on this precipice of life and death. But the ritual of CPR? What a strange biological liturgy.
Imagine the body as a theatre. It’s the heart only under the spotlight. The audience is transfixed by its monologue, unaware of what’s going on in the wings. We applaudingly compress the myocardium like a metronome, and every so often bathe it in a drug that doesn’t work and then shower it in sparks. Left unnoticed the rest of the body goes all Lord of the Flies. We have a fair idea what anoxia does to tissue – can you picture the anarchic storm of molecules billowing up offstage? The rest of the body’s going to hell in a handbasket, and we only have the myocardium in our sights, hoping to stop it progressing from flab to stone. We have a few blunt tools, but our ACLS teaching lulls us into thinking of them as fine instruments, wielded at exacting moments in a protocol. Eyebrows are forcefully raised if deviations occur.
It’s not that conventional CPR doesn’t work – it’s the most effective technique we have to keep the heart sated and blood trickling to the other organs like a drink in the desert, until the defibrillator delivers the reboot (the best ‘have you tried turning everything off, then turning it on again,’ method), or a reversible cause can be identified (the new spar and parry spectacle between echo and compressor), or, in the fanciest of places, a diminutive machine attached via the way of hosepipes which can do the living for a bit. It just doesn’t happen that often. Great that we’re all speaking a common language, but having confidence in what we’re achieving? Ah, therein is another matter.
And, like a thousand Shakespearean ways to die, each arresting heart comes at this grand finale via a different route, along different time scales, and, ultimately, different needs at this rather pointy end.
There are things we do know for sure – pauses are bad, so if you’re going to have any hope, do it well and do not stop. Pre-hospital, bystander CPR makes a difference. Defibrillation works for VF. Adrenaline? That argument is best had down the bottom of a rabbit hole.
It reminds us though, that we, like Socrates, know almost nothing. So much is ahead of us to discover, in so many areas. How wonderful that in the first half of 2017 we have learnt so many extraordinary things about such varied areas; that the mesentry itself is a complex organ (after so long considering itself just a yolky bowelhanger prone to embarrassing plumpness in middle age), lungs make the majority of our platelets, and there are taste buds in our lungs as well as testicles. It feels like being in medical kindergarten. Are we on the cusp of unearthing a subatomic explanation for bodily functions? After discovering that there are quantum effects in the way plants photosynthesise, scientists have become very interested in qubits in consciousness, or entangled quantum bits of information, and that perhaps our wet, mushy biological systems can be better understood by nuclear physics. Exciting times, for sure.
Which brings us back to ACLS. Basic in principle. Simultaneously brilliant and terrible. CPR, same (no cats in boxes jokes). For hearts whose futures are irredeemable (if only we could convincingly know, besides the obvious, which ones these are), it is uniformly awful. So one mustn’t feel too guilty about questioning the rigidity of the guidelines. Although they are currently based on best evidence, and give us a useful common parlance, the truly effective interventions may be many moons away. The heroes in all of this are not the providers in the queue, or the chef calling out the menu, but the scientists and researchers, beavering away, coming at solutions creatively. Until we have better, however, we need to go back to queuing up, modestly and mostly obediently, with our sleeves rolled up.
This post originally appeared on Life in the Fast Lane.
I’m not sure how we ever used to manage multi-traumas. We must have been frightfully underprepared. Back in the days before mandatory training we relied, rather guilelessly, on experience, a suite of knowledge from texts and journals and M & M meetings, the good-will of a team, and the wisdom of our trauma specialists. A precarious position, you’ll agree. And an area where you were never entirely clear whether you, and what you did, were good enough.
Now, thankfully, we, as employees, are standardised – acceptably and holistically checked off. Benchmarked and compliant and up to date with our mandatory on-line modules. This is good. Most aspects of emergency medicine are chaotic and messy enough as it is, seriously in need of a good digital check-list groom, let alone considering trauma, that most unpredictable of diseases. Trauma is another grade of disarray altogether. Anarchy held together by skin.
The beauty of on-line modules is the certainty. And the reproducibility. It is beyond edifying to know that the person working next to me is signed off as competent in accountable decision making, and I know they can safely handle a patient over a certain weight-grade. I can be confident the web spaces of their fingers are flawlessly washed and germ-free, and that they have practiced a variety of safety stances in the case of impending violence. They are, in the eyes of our executive, trained.
Although this does bring us back to the consummate violence – the type manifest by our major trauma patients. These patients are so damned disordered. Internally dishevelled. Disobedient. Take your eye off them for a second and they’re setting off fireworks somewhere in their innards, right where you didn’t expect. So we don’t. Take our eye off them.
Trauma is the ultimate team sport, best played with the slickest and most integrated, respectful team, peopled by the most experienced team members possible, running the shebang from the moment of the traumatic event somewhere in the giddy light-filled outdoors, sliding through the corridors of ED, then off to their various destinations; the end string of the maze chosen efficiently by leaders with a beady eye on the patient’s belligerent biology. But these people, these team members, seriously worry me. I have a growing suspicion that not all of them are up to date with their mandatory training. They seem to embrace uncertainty. Are comfortable with it. Are able to work within it and make quick, dancing decisions based on all sorts of unmeasurable factors. This simply will not do.
No. The tremendous sequel to the staggering increase in administrative staff over the past decade has been the glorification of the black and white. Nowhere is this demonstrated better than in the increasing production of mandatory on-line modules, and the reliance on these as a tool for signing off hospital staff as being compliant and competent. Time well spent, I can hear you all cry. What better way to prove that you are proficient in managing complex patients than by spending precious hours taking quizzes on terabytes of information about the muster points for a fire in the café? I know I’m not alone when my heart leaps a little with joy if I make a single error on the quiz, thus allowing me to return the start of the information package. Who wouldn’t rather read how to operate the hover mattress than a discussion of the nuances of trauma induced coagulopathy? Let us all learn to play chopsticks, not Chopin. No gaming or glazing while doing these tests, that’s for sure.
But, you say (rightly calling out my unseemly sarcasm), you have trauma meetings, missed injury reviews, audits and registries, discussions with colleagues and debriefs, to ensure you’re at your most capable. Yes we do (and thank the deities for these). Mostly, however, these are voluntary, certainly for the individuals within this vast swirling system. No. The only thing the institution expects of us is printed off, signed off, grinning compliance with the mandatory on-line education. And these are not the only digital incursions we must fill out, sitting lachrymose over our congealed coffee. The Working With Children Check (otherwise known as a ‘tax’) (a biennial, utterly baffling piece of bureaucracy that requires an ACTUAL visit to a post office), on-line credentialling at hospitals we have worked in for years if we want to even sneeze inside, and just when one’s hair is ready to be torn from its roots at the internal agony, an online mandatory training module for resilience and mindfulness (not yet at my institution – the irony bar has not yet swung so low).
It sometimes feels like a war. Us versus them. Complexity versus simplicity. Unmeasurable versus yardsticks. Commonsense versus the absurd. It shouldn’t be. Our goals should be aligned, we clinicians and non-clinicians – to provide the best patient and community care, approached sensibly, with respect enough that neither party should waste time on activities which do not contribute to either. We should not both be drowning in madness, in either the thick, or the administering of it. We await the return journey of the pendulum. In the meantime, it’s back to the mostly, unquantifiable mayhem.
This post originally appeared on Life in the Fast Lane.