one-way or return?

"from 19 November if you don’t touch in and touch out you will pay a maximum cash fare for your Tube/DLR journey"

...as you may have heard/read on the radio/paper in the last few weeks. the oyster card for those non-londoners reading is a credit card sized ticket onto which one can buy tube/bus tickets. the option also exists to load a preassigned amount of money onto the card so that each time it is touched on the yellow disks above at ticket barriers the travel fee is automatically deducted from the card.

anyway it was with the above warning in mind that Ms D&C and I descended into the depths of the underground on Saturday night.

a bit of background: she'd just finished a fourteen hour shift and i had of course been bumming around at home. a good friend of hers was having a house party in islington and given that poor Ms D&C was so tired by halfway through the shift our initial plan had been to stay in, put on the Shrek soundtrack, eat some cereal, dance in our pyjamas - you know the usual saturday night stuff that everyone does.

however on her way home she had a change of heart, decided that if all we did was go to work and sit at home that would make us very very boring indeed. so at about ten thirty we were all set to head off. the bus was going to take five million years and it was icy so we made the executive decision to head on the tube.

crate of beers in my arms and bottles of wine in hers we switched at oxford circus to get onto the victoria line to highbury and islington. i powered through the crowds to cross platforms. i saw an opening in the throng and nearly made it through when a hand pulled me back. i turned around to see Ms D&C gesturing with some import at the ground.

a man in his 70s lay there. let's say he wasn't looking too well. blue in the face, not breathing. this is generally a pretty bad thing. people were standing around but not doing a great deal. so we started CPR.

after three rounds we weren't getting anywhere. still no pulse, still not breathing. the staff were clearing the station and then one of the ticket people ran back with a defibrillator. first aiders will tell you that the whole point of CPR is a holding measure until the heart can be restarted with electricity. sure enough after the first shock, his pulse came back and he started breathing. we waited for the ambulance.

his pulse started to get more thready and weak and then it disappeared. he was shocked again and then did two more rounds of CPR and during the third he came back. by this point the paramedics had just come round the corner and we proceeded to load him onto the stretcher.

it was that night i realised that the only way out of underground stations is the escalator. there are no emergency lifts. this man was quite heavy what with the oxygen and everything so eight of us had to carry him on the stretcher up those huge escalators to the ambulance waiting opposite topshop. i kept glancing at the heart rhythm which before the second shock had looked like supraventricular tachycardia (a very fast heart beat) but was now sinus tachycardia (a more stable heart rhythm) so was slightly more relaxed.

as we rounded the ticket barriers with this man on the stretched neither myself nor Ms D&C validated our oyster cards.

he disappeared with his wife and the ambulance crew into the night and we decided to give up on the tube for the evening and a taxi whisked us across town for beers and mulled wine.

the next morning we decided to call transport for london to explain why we hadn't touched out at the ticket barrier in the hope of not being charged 30 quid or whatever. i went through where we had got on the tube in excruciating detail and then described exactly what had happened on the platform to the guy on the helpline. the last part of the conversation went something like this.

"so this man had fallen down?"

"well kind of. he fell down because his heart had stopped."

"so he had a heart attack?"

"he had a big bypass surgery scar on his chest so that's a possibility."

"and you helped him upstairs?"

"well kind of. it was more we were trying to get his heart started."

"and why were you unable to validate your oyster card?"

"there was eight of carrying him on stretcher. i had no hands free. i think we were all quite worried and concentrating on getting him safely out of the station into the ambulance. going back through the barriers to touch out wasn't really a priority"

"ok sir. i'll refund you this time but may i remind you that from 19 November if you don’t touch in and touch out you will pay a maximum cash fare for your Tube/DLR journey and i won't be so lenient."

__________________________________

[the brian jonestown massacre were superb. a really really tight band. anton newcombe remains as narcissistic, self absorbed, talented, and messed up as ten years ago. i never know what to make of him. i flit between thinking he's a total wanker and then filled with awe and admiration. he spent five minutes having a go at a heckler. hilarious. joel gion seemed oddly mute though.]

__________________________________

i found out today that the man from saturday night survived and is doing well in hospital. i'm relieved and pleased for him. i might look at work slightly differently today. maybe it's not all so bad.

fight on stage

*ssshwooop* there it goes

another friday night disappears. and guess what i was doing. not out. not with people i love (well not till the dying hours.) not relaxing. not even on call. but yes i was at the hospital.

we have a ninety year old. he's a bit fragile. he hasn't been able to eat anything for a month because a peculiarity in the anatomy of his oesophagus (food tube from mouth to stomach) means that food isn't going down.

as a result the protein levels in his blood are very very low. as a result of that any fluid that goes into him as drips doesn't stay in his blood vessels but pours out into his arms legs abdomen lungs etc. similarly not a lot of blood is going to his kidneys and they are failing.

i had to put a large drip into one of the big vessels going into his heart on tuesday night (after work) because he was too swollen to get a normal drip line in anywhere else. however despite this the only way to get him any better is to get the protein levels up in his body and the only way to do this is to feed him. however every effort to get a feeding tube of some kind into him is failing.

he has one last chance. one of the clever radiology doctors (a top bloke as it happens) reckons that he can get a feeding tube into this man. this is scheduled for monday morning. in the meantime my patient continues to deteriorate.

there are lots of ethical questions. "did you say 90 dr D&C? have you gone out of your handsome little head?" how much should you do for someone so elderly and so fragile? there have been many occasions (see lady in last post) where we've pulled out. my man, despite his body being so weak, is completely with it. i've had about four or five chats with him along the lines of "how much do you want us to do?" and each time he says he says he's "quite up for a go with the tube through the nose."

we don't think that he's confused or lacks "capacity" and so our options are to give any therapeutic options a go (provided they don't harm him any more) or... well... to let him starve. the team sat down and had a bit of a discussion about this. despite my harsh impenetrable exterior, i found myself advocating for the "we've got to give him a chance" approach.

the problem then arose (on friday at 3pm as always) that we have to keep him going through the weekend. it could be argued that if he hasn't fed for so long is another two days going to make a difference. i always feel that if you make a plan to pursue a certain management plan, you do it completely, without fudging, and properly. so in order to get some protein into him we organised intravenous nutrition for him.

to provide this, my man needed ANOTHER big drip going into his heart. i elected to stay back after work with one of the other doctors to put this in, partly because i have more experience.

it was bloody hard. i haven't failed getting one in for a long long time but for whatever reason, it didn't work. my colleague had a go but also couldn't get it. i tried again. no joy. at times like this the anaesthetists are the people to call on and sure enough we did. by this time it was 830pm. i sent the other doctor home because 1) it's courteous to wait around for your help to thank them and explain the situation and 2) there was no point two of us being there.

the anaesthetist failed three times. finally at about 930pm it went in. my man started his feed.

by the time i got home it was late, i was exhausted and not even a cheese and tomato toastie could save me. not even johnny depp's peculiar cockney accent in From Hell either.

i'm not sure what i'm moaning about really. i'm not too fussed about failing the procedure as it clearly was a tricky one. i don't know if it's about staying late either. i suppose it's more that some of the doctors in this system actually do give a shit. i just don't think that managers/royal colleges/the daily mail/the department of health really care. management would have had a go at us for staying so long after our end of shift. they would have said we should have handed this all over to the night team. you can't just dump complicated situations like this on other people. maybe i'm trying to convince myself that i'm still a "nice person" and have some humanity left in me.

the flip side of this i'm starting to wonder why i bother. if/when i fail this exam in a few weeks time i'll think what is the fucking point? there are hardly any jobs available for february. if i'm unemployed then i'll also think what is the fucking point? if the change in training screws me over i shall also wonder what is the fucking point?

i guess if it give this guy a chance to get better then there's my answer. but, in the scheme of all the other crap in the NHS, i don't know how long "finding happiness in helping people" will keep me going.

_____________________

on a lighter/darker note, i did laugh to myself when i checked the sitemeter the other day and realised that most visitors to MOADD arrive by a Google search for "i hate medicine."

[i am off to see the brian jonestown massacre on sunday night. here's hoping for a fight.]

this is what happens when you fuck a stranger in the ass

not pleased.

friday night. the registrar informs me and the house officers that a hand in clinic is required on monday morning as the boss is away on leave. no problem i say, i'll give you a hand. the house officers are both here on the ward. they can kick things off in the morning, see the patients themselves, make some management plans etc etc. then i'll pop back after clinic, get the lowdown, see a few choice cuts, go to lunch and then grab the registrar for the afternoon to go through any issues. i can then nip off to do the third year medical student teaching i've been roped into and pop back for four thirty to tie up any problems. "it'll be great for the house officers" i say. "good practice and character building for the future... especially given that we'll be nearby, only a pager away."

fine? the best laid plans?

like fuck no.

neither house officer showed up for work. convenient annual leave day and A&E shift respectively, conveniently NOT mentioned last friday.

result. just got home, patients not properly seen, hurried teaching session, shitty care, and apologies all round.

i am FUCKING LIVID.

[i am listening to sufjan stevens in an effort to calm me down]

dreaming of you

i heard on the news that captain nob cheese himself pete doherty, the talentless gomer of the libertines inexplicably fawned over by indie kids all over, is releasing a clothing label. i presume this is because he has realised that he is a waste of space whose time in music is near over and soon his name will be less than a whisper in the abyss of lost z-list celebrities.

it was also good timing that i caught Calexico at the Camden Roundhouse this weekend. here are a band that have stayed pretty much off the mainstream (not sure why) but still have a strong following. needless to say they were brilliant. they are also such a bunch of chilled out guys (or so they seem) on stage and bloody talented musicians, each playing a couple of instruments. one of the guys (in the back, second left in the picture) is a superb guitarist/slide guitarist. he wandered onto stage with his funny glasses and his exceptionally non trendy shirt, waved once or twice to the audience and then blew us away with his music. at the end he waved again and toddled offstage with the rest of the band.

what a great life. he doesn't feel the need to have to impress by getting himself into the tabloids wasted on coke. he wakes up in the morning, puts on his geeky shirt and then goes off and plays his guitar. straight down the line. and people love him for it. a simple existence.

(he may be a total cock who beats his wife but go with me on this)

oh for the simplicity of it all! it's so simple it's elegant.

oh for a simple life.

the lady mentioned before passed away on sunday.
[i am listening to nina simone]

burning bright

i have increasingly found myself adopting something of a clockwatcher attitude to work and also conveying my ethos to the new junior doctors. part of this is because our bosses badger us to make sure we leave on time for fear of reprimand by the government. more, it is because the NHS is such a miserable place to work these days.

to be honest, apart from staying to help the person that becomes acutely unwell at 4.50pm, why would anyone want to stay a minute longer than they have to in the dirty wards, in the company of disinterested staff, performing eight contrived tasks to attain one simple goal?

"thankless" is the wrong word to describe my job for it suggests that i want some kind of kudos, some kind of appreciation, above and beyond my paycheque, for what i do. wrong. i don't want hordes of patients throwing themselves at my feet in gratitude, pawing at my converse hightops, shedding tears of euphoria. "halleluia we have been SAVED."

all i want is not to feel that i am constantly fighting against the system in order to make it work. everyday involves pushing and pushing and pushing to get things done. i feel like a shaven Samson (after a bit of how's your father with Delilah) trying to topple the pillars in the temple. only there is no divine intervention from God. because God has been replaced in the NHS by a protocol driven 4 hour maximum entry pathway into the kingdom of heaven and because divine intervention is not a part of Hospital At Night as it is provided as cross cover by the ENT registrar on call from home. is it a massive demand to want everything to flow a bit more easily, so that we can sit in a coracle and paddle calmly down the hospital river and out into the sea of good patient care without hitting big fuck off rocks.

but back to clockwatching. despite all my efforts, tonight i find myself returning home five hours after i should have. "why Dr D&C?" you lament. "surely you must have been on the beers?" no. i shake my head.

there is a lady who is dying on one of the wards. she was brought to hospital on death's door, nay, looking through death's letterbox asking if anyone was home. she has had a big stroke and her body is also riddled with infection. the bacteria have formed colonies on the valves of her heart and with each contraction of the heart little pieces of these colonies fly off into the blood stream and seed her lungs, her skin and her brain. she has been treated aggressively, perhaps out of scale with her pre admission quality of life (largely chairbound, her family doing EVERYTHING for her) but over the past few days it's been clear that we aren't winning and she is slipping away.

it has fallen to me to speak to the family to tell them what's going on. i've called them several times each day but no response on their home phone. hardly surprising: the patient's daughter has four kids to school and work at the same time. anyway it gets to today - friday. again no response from the daughter's house but the nursing staff inform me that she did pop in at four and would be coming back later in the evening.

the daughter is an intelligent worldly woman and she doesn't need to be a doctor to know that her mother is dying. she knows this and i know that she knows this from talking to her before. i could have just left it, packed my bags at five and taken off. the nurses could tell her that things weren't looking good and that her mum might die this weekend. and when her mum does die the nurses could also tell her that it was to be expected and she would probably have known that too.

but i couldn't just leave it like that. nor could i do it all over a five minute phone call. i wanted to see her again in person and talk to her.

i waited till she came back from picking her daughter up at 8pm, made her a tea and sat down with her. as i expected, she already knew what was going on, that her mother had not responded to treatment and was deteriorating. i told her that she would probably die in the next few days. she cried and cried and i felt like a proper cunt. i spent another half an hour talking to her about her mother, her life and her kids. she is exhausted from rushing to the hospital daily to looking after her kids and trying to work at the same time. she is in the real sense of the word remarkable. we then went to her mother's room and made sure the pillows were in the right position and that the blankets were covering her properly and that she was comfortable. i stopped all the unnecesssary medications and made sure all the drugs that she might need for pain relief, sickness, etc over the weekend were written up. i went and told the nurses three times what was going just so they wouldn't forget or fuck things up even more. i went back to the daughter, said my goodbyes and took myself off home as she cuddled her mum.

so the clockwatching didn't go to plan. and five hours later i am finally home though drained and lacking a third of the weekend. but how could i leave work tonight with a situation like that? i couldn't leave that. you would surely have to have a heart of stone and acid for blood to leave her. and besides no-one else was going to do sit down and talk to her. i wonder whether the nurses would actually do it when faced with thirty other people to look after.

i wonder if someone will do it for me or for my kids when i'm leaving this life. and when this lady dies this weekend i hope her daughter in her utter shitty grief can take maybe an atom of comfort in the knowledge that someone had the decency to tell her what was going on during her last days.

and that's the final and probably most important thing i want. i can do without making the fancy diagnoses and performing the clever surgery. i can do without the stupid exams and the teaching hospital jobs. i just want this system to have a bit of fucking decency.