They come in threes...

To finish out my last week in Whoop Whoop I've been put on night shift. Just me and around 200 patients who all want to exsanguinate on me overnight.

The first few nights were great, very few sick people and enough time to sleep for 3 hours per night. However such times are rarely sustained. Tonight things took a nose dive.

Started the shift with the evening intern coming to handover late as she had been caught up in a MET call resulting in a patient dying. She hadn't had a chance to clear the wards of jobs before handover so left me with a hospital full of 'stuff' to be done.

I trudged up the stairs and began sifting through boards of tasks for me to do. IV fluids needing prescribing, medication chart rewrites, cannulaes to be inserted. It wasn't long before I got my first call.

"We need you to come and look at this patient. He's not for resuscitation or ICU but for full medical intervention. He's unresponsive and has sats of 88% on 2L NP oxygen"

I arrived to find Mr A unconscious and unresponsive even to pain (not a good sign). His notes indicated that he had been rathe runwell and as the medical team could do nothing more for him, they were going to transfer him to 'rehab' to die. I examined him, detrmined he was probably sedated form benzodiazepines and in fluid overload with APO secondary to CCF. Gave him a whack of frusemide, upped his oxygen and called his wife to come in as his prognosis wasn't great.

Over the next 3 hours we battled to get fluid out of him, his IV access failing and his oedematous hands not willing to give me a vein to stab. I paged the medical registrar 3 times for advice with no response. Battling on my own with a patient who I knew had little chance of recovery. Thinking through every possiblity for any slim chance to help this guy make it through the night.

3 hours later, after fighting as much as we could, I found msyelf trying again to get venous access and as I stabbed his arm in futility, the nurse next to me said "Um doctor, I think he's gone"

Sometimes you fight and it's just not good enough. Sometimes modern medicine just cannot stave off death any longer. Sometimes people just die.

As I sat back (partially in relief and partially in shock) I watched as his frail wife broke down in tears and began beating him on the chest. "How could you do this to me? How could you leave me alone?" She began yelling at his corpse, pouring out her grief and anger at his death. I couldn't do any more, so I did the necessary examination to certify him, then left to fill in the paperwork and death certificate.

Then just before sunrise I got another phone call. "Hi just wndering if you can come and certify a death on our ward? A guy who had his fingers amputated this week"

"Not Mr R? I've been seeing him for the past few weeks? Wans't he ok?"

"He's not okay anymore... we found him dead on our morning rounds"

This guy had been operated on by our team earlier in the week and had been on the improve. His obs were stable all night long and he didn't complain of any symptoms other than a bit of finger pain from the operation. As I walked into his room, his familar face looked different. Pale and cold. Devoid of life.

After filling in his paperwork I went to the roof of the hospital to watch the sun rise over the valley. The fresh dawn air assaulted my face and I watched the slow crawl of cars making their way and starting their days. Despite the darkness of night, despite the death and futility, the sun still rises. The dawn still comes. Its funny how on night shift I wont see any deaths until one night, when they all come in a bunch. And always in 'threes'.

After I called the bosses to inform them in the morning of their patients demises, I walked out of hospital and crawled into bed. Feeling like I'd lost the battle, but knowing I'd win the war. At times like these, you can succumb to fatalism... the patients are all gonna die one day.. why bother fighting so hard? Or you can fight to improve the life of each person you meet. You may not be successful, but you've tried. And once in a while, very occassionally, you might make a difference. To not be content with the brokeness of this world and to fight for something better.

Scrubs Finale

All good things must come to an end. Including surgical terms.

As a student I never liked surgery. Having failed anatomy 3 times as a student (I really should have spent more time studying instead of working in a pizza shop) it was a re-enactment of the embaressment I felt at not being able to describe the course of the brachial artery or the relationships of the hypothenar muscles of the hand. In clinical years surgery did not offer much to the lazy med student (ie me) Relegated to stand in the corner, we were occassionally lifted from obscurity to hold a retractor in some yoga like position for hours on end with no view of the actual operation being undertaken. My surgical mentors as a student were larger than life characters with ego's that had their own reputations.

Prof was one of them. A man whose stature was fitting for his ego. An old school surgeon from the mother country who despaired of the declining quality of medical education being offered up in the colonies. He would carry around a giant blow-up hammer and a water pistol with which he would punish his students for the most minor transgressions. We all feared going to his tutorials. We would be grilled about bizarre Xrays only to find out later they were not of humans but of sheep! He would berate us for being 'space cadets' and threaten to send us out to Wagga Wagga to work. One of my friends refused to go to Prof's tutorials for fear of embaressment or dismemberment. A surgeon to be feared, a man larger than life.

However despite his abrasive manner, he was a brilliant surgeon. A man dedicated to his craft and to excellence in everything he (and his junior doctors and students) he would take on the cases no one else would. Those patients relegated to the 'inoperable' category would be given a chance (however slim) on his list. He would operate for 24 hours straight and then come to teach us despite his lack of sleep.

I will always remember him telling us about his experiences as a student. When he was in our position he was asked by his mentor to look outside the window.
"What do you see on the lawn son?"
"Sparrows sir"
"That's right my boy, sparrows.... not bloody albatrosses!"

Point of the story: common things occur commonly in medicine... don't go looking for rare/obscure diagnoses all the time (life is not like House)

Many years later I find myself donning a pair of scrubs for the last time. Finding a nice pair of green tie scrubs, making sure the knot is firm (so my pants don't fall down mid-operation) grabbing a hair cover bandana and tying the ninja-like face mask loosely. Washing my hands 3 times ever so carefully, first with the scrubbing/nail brush and then twice working from the hands down in a meticuluous manner, making sure to not touch anything and to let the water run proximally down the arms. Backing into the door with arms raised like holy objects and gloving and gowning in a familiar theatre.

The pinging of the anaesthetic machines, the smell of the antiseptic prep, the sound and smell of diathermy burning through vessels. The bizzare names of retractors and forceps. The psychic nature of the scrub nurses who hand the surgeon his tools. The banter between the surgeon and anesthetist about their shares/kids/cattle*

It's a welcome haven from the incessant paging of the ward, an opportunity to 'do' something practical and see immediate results. A chance to 'fix' something with your hands and use your muscles.

During the past few weeks I've moved my way up so that in my last few weeks I was allowed by the bosses to apply the skin grafts to the wounds and staple them on. Then I was allowed to close the wound after a fem-pop bypass and stitch everything in place.

Then to put the icing on the cake, it finally came... the King of all vascular operations... a leaking abdominal aortic aneurysm. Statistically 50% of people with a leaking AAA don't come out of hospital alive. AAAs are ticking time bombs... and when they start leaking you know that the final countdown has begun. The boss let me scrub in and 30 minutes later we were covered in blood and securing the aorta and distal arteries. A simple graft was placed in the lumen and 1 hour later the patient was alive and in recovery. Someone who could have been dead that night would now live to fight another day.

It's humbling and amazing stuff! In the past few years surgery has let me pull babies out of abdomens, transplant kidneys, reimplant infant ureters, remove multiple appendices/gall bladders and do emergency bowel resections at 3am (just to name a few). There's an adrenaline high that comes from cutting people open, fixing up their insides and putting them back together again.

But now, I have gone to theatre for the last time. I've finished all my surgical terms and it's time to move on...

Good bye surgery... and thanks for the memories!

* we had a very interesting discussion about the prices of stud bulls whilst repairing a hernia the other day... very intriguing

Freak of Nature

In the last month at Whoop Whoop, there has been a fair amount of meterological happenings.

One day as we were chewing our undigestable free lunch from the hospital cafeteria, we heard the sound of banging on the roof. The banging turned into pounding and the sky turned a dark grey before we suddenly saw a storm of hail come raining down past the window.

Small at first... gathering in momentum, frequency and size. There was no time to react, no time to move our cars. All we could do was watch. And watch we did. For 30 minutes the hail pounded out of the sky and savaged the ground. Man made and natural were destroyed alike, the hail showing no discrimination between tress and cars.

Once the storm cleared we ventured outside, the ground full of golf ball sized ice covering the ground like a layer of popcorn. We walked to our cars to see the roof of every single car in town puckered like the dimples on a golf ball. No car was spared unless it was garaged. No window facing south was left intact.

The next day the government declared it a natural disaster zone.

However yesterday the sky turned an ominous dark shade and those clouds began to reform for round two. I dashed to the shopping centre for refuge and watched as the rain and hail returned to town, beating down against the city in fury and mocking its inhabitants.

Apparently the storm produced a freak tornado that lashed a nearby village with winds up to 150kmph. Vortices of destruction and chaos.

It's humbling that even in the 21st century we can land people on the moon, communicate in real time with people in other countries, yet are subject to the forces of nature. We are still human and frail and at the mercy of forces greater than ourselves.

Forces that seem to be writhing in pain like a woman in labour.

The Adventures of Batman and Robin

We have had a patient on our ward with a nice slowly healing leg ulcer which has required lots of VAC pumping meaning he's been on our ward a long long time now.

My registrar and I walked in at 7:05am on our daily ward round and were greeted by him:

"Well if it isn't Batman and Robin!"

The title's kinda stuck now... so Dr M and I have become the dynamic duo of the surgical ward. The first team to round (cos we usually have more patients and sicker ones too) and often the last to leave, we rid the city of surgical pathology.

I must say though that I've been very blessed to have a good registrar this term. He doesn't order many medical consults (which really saves me from getting grilled by the overworked med reg's) and is often willing to help me out if needed with my menial jobs. After our rounds we call a "Crisis Meeting" and have coffee/hot chocolate accompanied by scones/chocolate dotty cookies and read the daily newspaper whilst basking in the sun and discussing the latest goss.

We've gone to the gym together after work, played indoor soccer after work and had multiple meals together. We're a team in the true sense of the word.

So now he's taken it upon himself to try to set me up with a) a med student, b) a physiotherapist and c) a pharmacist. And apprently it's a competition between Team Surgery (Batman and Robin) vs team Medicine ("Ian-Thorpe's-slightly-less-metro-twin-brother") to see who can impress the barbie doll pharm chick. (I'm bowing out before the race even begins... but my reg won't listen)

Every morning I have a freshly printed patient list ready for him from the printers downstairs (which for some reason print the list in a different way to the printers upstairs??) I anticipate his thinking now so that on the ward I'll pre-empt his management plans and even have arranged management before he gets out of theatre.

If we finish theatre early we'll drive in his Audi downtwon to grab coffee or do some chores and if we're stuck in theatre I'll go buy sushi for him and the senior surgeon. Like battle hardened comrades on the frontline of the war against disease, we forge good strong mateship that grow over 'doing stuff' together. This is how guys relate... by doing stuff... like playing sport or amputating limbs.

I've only got 3 more days left on the team before I start my nights... so it's with much sadness that Robin will have to leave Batman on his own adventures and fight crime by night whilst the caped crusader cuts people open by day.

Grandad

I finally managed to organise my 2 days off up in Whoop Whoop. Only problem was 3 other doctors also decided on taking those days off. So instead of taking the whole day off, I had to come in at 6:30am and work till 11am to sort out my patients and make them stable so Dr Dolittle could take over their care.

I raced home, packed my bags into my hail-punctated car* and drove off into the windy hill roads towards the north. Just over an hour later I reached my Grandfather's home. Nestled in a former volcanic crater and along a meandering river, it was set in an idyllic village that time forgot.

We had a quiet lunch and retired to his living room to sip tea and discuss all of life's problems. Over the next 4 days we talked about anything and everything. The looming election, the soccer, love, family, my dad's impending death, my mother, my sisters, my job, my future, our faith, the price of bananas, the fuel effiency of hybrid cars. Nothing was vetoed and everything seemed so much simpler after being processed in his wisdom. His age supplied a calming effect to all my worries. His knowing smile assured me that my troubles were not unique.

He told me his own stories of his former youth in the London Metro police force. Breaking down doors, arresting inebriates and protecting women from violence. Political correctness and practical jokes. Wooing women and riding motorbikes.

He did not look his age. His youthful humour and energy for life hid his decaying body and concurrent illnesses from me. I saw a man before me worth imitating. A man who had fought many battles in his life and persevered. A man who stood up for what was right and was preparred to count the cost. And at the end of it could dispense advice to his green grandson.

I don't know how much longer he'll have on earth. With my father's failing cognition, I value Grandad's input as a male role model all the more. I drove back down the hillside today refreshed. Thankful to God for such great men in my family who have been such a blessing to me.

Thankyou Grandad!

* Whoop Whoop was subjected to a freakish hail storm which inflicted over 10 million dollars worth of damage and resulted in 643 repairs to various homes/businesses. Alas my beloved car was ravaged by golf ball sized icecubes and every single panal bears the marks of the storm. The insurance people tell me it'll be at least 3 weeks before they can get to look at her damage. My poor baby... =(

Loneliness

Just landed back in Whoop Whoop after a weekend back in Sydney (sort of).

It was refeshing to eat some decent Asian food and drink some much-missed bubble tea. To see buildings taller than 2 storeys and to catch up with people I hadn't seen for a while.

I spent the weekend with hundreds of other people. I spoke to so many different people about so many different things.

And yet as I left my home to go to the airport, a profound loneliness set in.

Perhaps I was emotionally drained from the weekend, perhaps I was scared about the big changes I'm about to embark on in my life... or perhaps I just feel like a lone soldier being sent back behind enemy lines to bear another 5 weeks of fighting.

Guess it's time to fight the good fight...