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Somewhere in between..



October 18th, 2010

(no subject)


"What doesn't kill you makes you stronger." Really? I'm not sure about that one. It could also just cripple you badly.

Feel like I'm one-foot-in-front-of-the-othering it at the moment. Missing a bigger picture, missing a bigger point. It's no longer magic. I'm starting to see the cracks and flaws. And I'm tired of it.

It's one thing to enjoy challenges, it's another to have to face a constant gauntlet of them, to be followed by..yet more. The wins feel fewer and further between. What's great about being pushed up the tree? Can't see much yet.. The weight of more responsibility. What's great about that?

Perhaps it's sleep-deprivation talking. Fatigue. But I'm sure I used to be able to take more. 16-hour days used to be par for the course. 13-day runs. You just kept going. Now..less so. Less sure. Less driven.

I must be getting old.


"We can't all be Mary Poppins."
-Burn Notice

September 7th, 2010

(no subject)

Sans an image, or the usual layout (not that it's obvious, with the scrambled new design forced upon this by LiveJournal..) due to being on a computer other than my habitual..

Lately, I've been rediscovering voices I've been missing. Old stories, expressions darker and brighter.. Old characters, like old friends. The people who shaped me weren't all physically here. In fact, I'd venture as far as to say they mostly weren't physically here. But by example, and in some cases discourse, they played a large part in forming my approach to the world.

Much of everyday life is mundane. Hence the appeal of the larger-than-life. Perhaps that's at least partly why I find myself in Emergency Med as opposed to other fields.

I still believe in doing the right thing. I believe there is a "right thing". Most of the time, anyway. Lying, cheating, or stealing, I abhor, along with a raft of other vices. I think it would be great to have superpowers. Even if they come with great responsibility. I keep waiting for mine to appear. I think there's a greater point to our existence than just existing, even if I don't believe in there being a higher being.

Once upon a time, I wanted more. Perhaps I'll remember how to again.


"I believe nothing. I consider it wise. I believed nothing when I was mortal. I believe nothing now." -Marius, Blood and Gold

August 18th, 2010

(no subject)


An actual conversation that transpired:

Cardiology reg (over the phone): This woman failed her exercise stress test. She developed T-wave inversion, and the test had to be stopped because she became dizzy. She needs to be admitted under Cardiology, and has to go to a monitored bed. Tell the med reg to admit her. We're sending her back to you now.
Me: Hold on, you can't send her back here. This ward doesn't have monitoring. Do you have a number I can call you back on? I'll talk to the bosses on the other side of the department to sort out a place and ring you back.
Cardiology reg: I'm not giving you a number. We're not keeping this woman here. I am sending her back down.
Me: This ward has no cardiac monitoring capacity. I need to let the guys on the other side know. Acute and resus are both backed up and we need to make arrangements. (meaning, patients were backed up into the corridor still stuck on ambulance trolleys, and all available beds were already occupied in the rest of the department.)
Cardiology reg: Well, she's not on monitoring now, so it's no different.
Me: You've just told me she has ischaemic changes. Maybe she should be on monitoring. (note, at exercise stress test, they're put on treadmills with an ECG trace running. The logic of finding that someone develops ischaemic changes and then taking them *off* monitoring...)
Cardiology reg: She's not staying here. I'm sending her back to you. Talk to the med reg-
Me: Listen. She cannot come to this ward. I need to make arrangements for somewhere she can go. I'll let the med reg know. (at which point I handed the phone to the nurse who was also trying to co-ordinate this and was gesturing that she had an update for him..and got told off by him as she too tried to explain why the patient couldn't come to the ward..)

Sometimes, I really do wish you could just reach down the phone and slap people.


Amy: Go look at the manual.
Doctor: I can't. I threw it in a supernova.
Amy: You threw the manual in a supernova? Why?
Doctor: Because I disagreed with it. Stop talking to me when I'm cross.
-Doctor Who

July 27th, 2010

(no subject)


I stop, as the feelings of defeat and futility swirl, and realise..it's not fun any more. Yes, I realise, looking at that last post, that things seemed fine not so long ago. But it's so fleeting, that feeling of certainty. Brought down so easily by the next crap days that come along. And hard to recover.

I've been doing this for months, and it feels like for all the work, I've made no gains now from before. I'm still in the same role, still in the same rut. At the end of the day, I feel frustrated. The notional wins seem hollow. I'm tired of being superfluous, of being underestimated constantly.

A long time ago, I believed in the pursuit of dreams, I thought I would be someone who would dare to reach for happy. It's astonishing, and terrible, what we let ourselves get used to. We learn to accept mediocre. We learn to get used to being worn down. Why is that?

I need change. Maybe it's time to get out and be something else. People do. There are other paths. Maybe I should get out there, work for myself, be a gun for hire. Just roam. It works for some. It could work for me. Or I should find something entirely different to do...


Riversong: There's a plan?
Doctor: I don't know yet. I haven't finished talking.
-Doctor Who

June 25th, 2010

I am.


Some days, some days I get it. These brief instants of clarity. I see that somehow I've become just who I wanted to be. Or needed to be. I forget, often, when I'm surrounded by other peoples' dreams, and the societal notions of what's "normal". But I never was one of those who dreamed of white picket fences, some perfect wedding, a gaggle of children.. So instead I've become the maverick solo journeyer. As the line goes, I can stand on my own two feet. I am financially independant. I sprint. I sing. I sketch. I dare climb rock faces. I can make things out of metal, or threads. I can sew people up. I have an imagination. I kick ass. Literally, and figuratively.

Not all of us need to be coupled up. Unless someone can add something to my life, I can't see the point of being fettered. Other people mean uncertainty, demands. If we can't be happy in ourselves, imagining that we're going to be able to find happiness in someone else is a disasterous mistake.

Life's an adventure. I think I was always meant to go out there and hunt it down, rather than just mark some sort of calm existence.


"You get what you settle for." - Thelma and Louise

June 21st, 2010

(no subject)


Self-immolation is a nasty way to try to end it all. He had extensive burns to his thorax when the ambulance crew got there, and had airway involvement. The consultant who runs with them intubated him. He then went into cardiac arrest. CPR and adrenaline brought him back. Because of the full-thickness circumferential burns to his chest, escharotomies had to be done to be able to ventilate him. He arrived with a blood pressure in his boots despite over 2 litres of IV fluids, with uncertain oxygenation because the burns to his hands meant the finger sats probe didn't have much purchase..but with a pulse, at least. Had to keep hand-ventilating, because a background of obstructive airways disease plus airway edema from the burn meant high resistance to oxygen being driven in, but then a very prolonged expiration time and gas trapping. The adrenaline infusion kept being cranked up, but that didn't keep his heart from trying to give out again and needing another round of CPR. Monitoring wouldn't stay on because of all the blood. And there was a lot of blood. Burns and escharotomies and warfarin are a bad combination. Add in acidosis and you have a coagulopathy that even platelets and attempts at anticoagulant reversal can't catch up with. The units of blood he was given probably couldn't do much to prop up what he continued to lose. His blood pressure never made it above 60-odd systolic. After hours, with the numbers somehow managing to keep getting worse, it was decided that this was an unsurviveable injury. Almost 50% total body surface area burns, with his other co-morbidities, with no response to all we had tried.. The focus changed from resuscitation to palliation. The chaos petered out. He was allowed to fade away, his blood pressure falling, pulse slowing. Eventually, it was done.

Perhaps it was written all over this, from the minute they came through the doors, that it was bound to be a futile effort. 50% surface area full-thickness burns, with airway involvement, are hard to come back from. Cardiac arrest, and adrenaline-dependant to maintain cardiac output bodes badly. His medical co-morbidities (heart, lungs) were a superfluous last straw. And yet he received what really were heroic measures in an attempt to change the dire outcome he was headed for. Do we do it for the people they leave behind, so they can know that as much as possible was done? Do we do it to avoid being the ones who just "give up"? When it comes to picking the battles to fight, how do we decide? Sometimes, a win isn't a win. Like the person who is brought back after a prolonged period of hypoxia, and gets to live with the brain injury that means they will need 24hour nursing care for the rest of their lives and can't communicate with the people who love them..

And, after this, we do "normal" things, go back to the mundane parts of our lives. Until it's time to start over..


Woman: I just want to die with a little dignity.
House: There's no such thing! Our bodies break down, sometimes when we're 90, sometimes before we're even born, but it always happens and there's never any dignity in it. I don't care if you can walk, see, wipe your own ass. It's always ugly, always! We can live with dignity. We can't die with it.

June 14th, 2010

(no subject)


There's a sense of relief about finishing a run of nights. You know you won't have to do it again for..at least a little while. The nights..remind me how green I still am, really. I should be able to make decisions better, and faster. And yet..there comes a point when the decision-making wears you out. And managing people? That's a whole other issue.. I do have a long way to go. And not much time..

Ultimately, I don't know that I would pick another job over this one though. We have such opportunities to do positive things for people.. Granted, it's not always clear that our interventions make things better..but sometimes we get to win. And it's simple things, like digging something out of someone's eye, or reducing and casting a fracture, or stitching someone up.. They're the little satisfying things.

And this past week, I put in my first chest drain in an awake patient. It's different when they're sedated and ventilated. Awake procedures, particularly invasive ones, are more confrontational.. I had the good fortune of having a trauma surgeon there to guide me. An inordinately patient one at that, whose refusal to do things was actually the most helpful thing. When I was being stymied by my lack of progress blunt dissecting through the intercostal muscle layers, instead of just taking over, he checked the path, injected more local anaesthetic, and handed back the forceps.. Because I had to, I did get through to the pleural cavity. This in contrast to the past, where asking someone else for help meant that they took over and did the rest of the procedure.. This time, I actually learned how to do it. There's something to be said for being pushed..

I'm still learning, and will be for a long time...


Sam: I feel like I should do something more than sit in a cubicle.
Dean: Most people who work in a cubicle feel that way.

May 10th, 2010

(no subject)


I know now, first hand, how difficult it is to stand up to bosses who you think might not be making the right decisions.. There are the hurdles of seniority, if not because of rank, then because notionally they are more experienced and more knowledgeable.. We've been through the simulated scenario before. You try the probing questions, where you, in a non-confrontational manner remind them about other factors that impinge on the decision and highlight how their decision might not be the best one. Ideally, they would at that stage, take a step back and reconsider. If that doesn't happen, you then escalate it with the "are you sure you want to do such and such". The next step from that is essentially direct confrontation, or mutiny. Where you state blatantly that you think that they are making an incorrect choice, and get others onside with you. In practice, that last step is a hard one. It was the one I couldn't do today. All I can say, is that I am glad for the nurses there, and though it may have been a passive-aggressive way to go about things instead, we managed to avoid almost certain disaster.

Yes, I need to learn a different way to go about things.

Man: You were actually telling the truth.
Jack Sparrow: I do that quite a lot. Yet people are always surprised.

April 25th, 2010

(no subject)


Somehow, going home always makes me feel more lost. It's not the change here, though that happens at a breakneck pace. It's that..it makes me question the choices I'm making. Why am I far away when..this is home, really. Where it matters if I'm here or not. The really safe space, where I'm watched over, and wanted. Compared to..no attachments, when it comes down to it. Because work is..work. Maybe I see it as more because..I need to, rather than because it actually is more.

One foot in front of the other-ing it is the cheat's way out. You avoid looking at the gaping emptiness ahead.

I don't know where I'm headed. I have no greater guiding plan. I can't see myself working..anywhere when I'm done. I can't see being done. Will I come to the end of this and still be unsure? What if I detour here? Change my mind? Choose to be somewhere else instead?

It's not even my dreams versus someone else's, because I have no dreams of my own.

To be able to figure out what makes you happy, that's a gift in itself.

March 19th, 2010

(no subject)


I still struggle with navigating the line between over-investigating everyone, because of all the worst-case scenarios that are always hovering, and under-intervening because I don't realise that people are as unwell as they actually are. As has been expressed elsewhere, we're working in an environment where mistakes aren't just an option, it's only by ongoing vigilance that we avoid the worst of them. It is an environment that is chaotic by nature (sometimes, you manage to get the semblance of control). You can't schedule when patients present, and they present with undifferentiated problems. They don't describe things the way textbooks somehow imagine they do, you have to draw information out of them (which is sometimes harder than pulling teeth), and sometimes they lie (or, if you believe House and some doctors, they always lie). They don't always want help. Sometimes you're obliged to override that decision based on duty of care. Which is hard when drunk people keep being brought in and keep abusing you for all your effort to protect them from themselves.

I still can't get away from the feeling that I don't know enough.

Maybe I can manage managing my own patients now. But having to supervise juniors too, that's a whole new ballpark. Because there are lots of them who rotate through, it's hard to get a handle on who can reasonably/reliably work people up, and whose shoulder you have to closely watch over.. Trying to do that, while trying not to impose on what they're trying to do as they develop their skills, remembering that you were there once...

The notion of being the It person on nights scares me. I'm still not sure enough.


Q: Am I likely to survive a career in Emergency Medicine without making a serious error?
A: No. When you work in the jungle, you get bitten by snakes.
- Emergency Medicine Secrets. Markovchick, Pons.

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