The Christian Anarchist

Even at the age of 27, I remained much the same simple naive ingenue I had been as a child. This state persists even now. Here follows an example true story to make the point.

I had established a solid spinal block on a man in his sixties who required surgery on his hypertrophied prostate gland which was giving him continuous difficulty in passing urine and really needed to be fixed. The operation is quite simple to understand. A normal prostate is about the size of a plump apricot and it surrounds the urethra, the tube leading urine out from the bladder to errrh the outside world. It suffers a design flaw because it frequently enlarges with age, growing both outwards but also inwards, thus narrowing the urethra and making it hard to pee.

A urologist can access the urethra and prostate with a narrow telescope containing ingenious optics and a manoeuvrable loop of wire…. If a picture is worth a thousand words, then a movie must be worth a million:

The surgeon simply cores out the prostate from within, taking slivers of tissue away with an electric current which both cuts the tissue, and seals off the bleeding blood vessels at the same time. The pieces of dead prostate, which resemble shrimps, float away from the field of view because there is a continuous flow of non-conductive clear fluid emerging from the business end of the telescope. An isotonic insulating solution of the amino acid glycine is used during the procedure to both sufflate the prostate and bladder, but also to concentrate the electrosurgical current to the point of contact between the wire loop and the offending tissues. Often bubbles of steam are seen, but occasionally sparks too!

Urologists perform about 25% of all surgery in the UK, and are thus very busy people. A trans-urethral resection of the prostate (TURP) is one of the commonest procedures, but the same tech is used to resect bladder tumours (TURBT).

Because the irrigation fluid contains no sodium, and is readily absorbed into the circulation, there is a serious risk of causing an electrolyte imbalance, hyponatremia, if the procedure is prolonged much beyond an hour or so. Low sodium levels in the blood present with confusion, agitation and distress, symptoms totally more easily spotted if the patient is awake rather than rendered comatose by a general anaesthetic: Duh! This is the reason why spinal anaesthetics are preferred for urological procedures.

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My patient was a retired Professor of politics, philosophy, and economics. He was the most excellent and interesting of company, as he adjusted his conversation down to my level of understanding. Our conversation ranged over a wide area, but he eventually asked me to define where exactly my political, philosophical, and economic sympathies lay.

I had never quite been put on the spot like this before, but I polled my few functioning neurons to provide an answer worthy of his hearing.

“I suppose I am a Christian anarchist“, spake thus I, after several seconds of dreamy vacancy behind my eyes.

My private audience of one looked hard at me, puzzled by my response. “What kind of beastie is that?”, he queried, while looking like he was captive in the presence of a madman.

As I mentioned above, I remain a simpleton to the present day. I examined my two word answer carefully: I was certainly a Christian, because I had earlier received an unmistakable inner locution confirming to me in my alone-ness that all the words of the Old and New Testaments ring true, and that there really is a God-with-us, Emmanuel.

My understanding of “anarchist” was much less understood by me. To me it meant a person who was willing to destroy anything that stood in the way of some higher purpose. Bearded hell’s angels chucking dynamite at anything that offended them, was one mental image. A better one was any ordinary person who dedicated their life towards destroying everything that is contrary to the flourishing of the Divinely Created Human Being, Body and Soul, and this was the answer I gave.

Alas, my answer was not received kindly by my patient, for he could not understand my reasoning nor reasons; he was just too ideologically constrained, I suppose.

We had got on just fine while he benefited from my kindness and competence, directed towards his bodily and other flourishing. We only fell out when our encounter entered the world of sterile concepts and ideas, which is the dead sea occupied by too many clever folk.

Humans do best when they meet “cor ad cor loquitur”: Heart speaking to heart. Amen.

 

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Firth Of Filth 3

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“Àrd-na-Said” or is it “Àrd-thir Suidhe”?

Edinburgh has to rank amongst the most beautiful cities on Earth, what with its Georgian architecture and unique geological underpinnings. It is built upon the much glaciated remains of an extinct volcano, some of which comprise ‘Arthur’s Seat’ and also the hill upon which the city’s castle sits.

Despite all the imposed handicaps, I managed to provide safe anaesthesia care to all the patients I met that week. I learned to communicate and josh with the Big Birds, after a fashion, and the work flowed merrily enough. Eventually Friday lunchtime came around, and my thoughts turned to the journey home. My last case that morning was multiple dental extractions, which can be quite bloody. I had placed a pack of saline soaked gauze into the patient’s throat to soak up all the spilt ‘gravy’. Then I forgot it was there. That is a common enough error, well recognised, and can be fatal. The unconscious patient was safely breathing through an endotracheal tube, but his throat was full of a wad of densely packed pack.

The tooth pulling took only seconds to perform with the purpose made dentist’s pliers  and then the patient was swiftly manhandled from the dental chair across to the repurposed ambulance trolley and wheeled out to the recovery area, still intubated.

The recovery room was the adjacent conservatory of this suburban house, with a door opening out onto the winter garden. I went out there and lit up my first cigarette in the cool midday. As I paced around upon the spot, I remained aware of my patient waking up only a few feet away from me through the glass.

I witnessed him regaining consciousness and reaching for the uncomfortable tube in his throat, and pulling it forth, with the assistance of the recovery nurse.

And then I saw him start to choke on the throat pack I had forgotten to remove!

I dropped my fag and raced in. The patient was thrashing about as he gasped to death. I managed to push a Magill forceps through his gaping mouth and grabbed the throat pack. Several feet of gauze later, his airway was cleared, and he breathed much easier, and made a full recovery. Phew!

Mea maxima culpa. Every time in my career before, when I inserted a throat pack I would leave the tail-end of the green gauze ribbon trailing out of the patient’s mouth as I had been taught to. It acts as a permanent reminder of the pack’s presence, and also as an easy means to remove it at speed. Why had I forgotten or neglected this simple precaution on this occasion? Was I tired, distracted, or otherwise preoccupied? I certainly lacked the presence of a trained anaesthetic technician such as would accompany me in my regular NHS workplace. Such a person would never let me do such a stupid thing. I still wonder to this day why I did it. One thing is for certain, I have never ever forgotten a throat-pack again!

During the week I had worked with this cowboy outfit I had managed to completely compromise my hard earned professional standards and practices. I did all this for the princely sum of £17 per case. I must have been insane, or at least very very foolish.

I never worked for the P**** group again. The ‘filth’ of the title refers to the lucre upon which this business was modelled: maximum profit from minimum safety.

I got away lightly. Let’s just say that there were several deaths under anaesthesia at their dental clinics

PS: A few years later I received a menacing phone call from Her Majesty’s tax inspectors alleging that I had earned a lot of untaxed income from P**** et al. Fortunately, my immaculate record keeping was able to put that accusation to rest. I can only think that my details came up during an audit of the company as it eventually fell foul of the authorities

An old saying comes to mind: if you sleep with dogs, you’ll catch fleas

 

Firth Of Filth 2

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That would be big bird 1, or is it 2?

If I knew then what I know now, I would have fled that clinic, got in my car and driven home for dear life, but I didn’t so I didn’t. I was still naive enough to assume that if other anaesthetists regularly used this setup, then I surely should, without becoming a precious prima-donna about it all. Alas I still possessed the mindset of a pampered NHS junior doctor for whom everything was spoon-fed, and taken for granted…..

In brief, the problems that were a very real and present danger to the unsuspecting patients at that clinic were:

  1. The anaesthesia venue was in a remote site. It was a suburban house in a city district far from the nearest hospital.
  2. I was single handed, in a strange environment, with no skilled colleague(s) immediately able to help.
  3. My equipment was antiquated, of low quality. heavily over-used and unmaintained.
  4. My assistants were clearly not experienced or qualified, being only 16 year-olds.
  5. Patient monitoring was exceedingly poor: I forget the details, but I remember thinking that I was anaesthetising patients whilst amidst a vacuum of vital information, like trying to ride a bicycle with one’s eyes closed.
  6. I could go on, but shall pause here….

The airway equipment provided was sub-par even for a primitive jungle hospital: the laryngoscope batteries were flat, the endotracheal tubes were way past their use-by date, and the laryngeal masks were both(!) worn out and punctured with teeth marks, and thus unable to achieve a seal against the patient’s larynx.

So why, in spite of all the evidence before me was I still happy to work at this shit-whole of a clinical area? Naivete is my only excuse.

More to follow in part 3!

 

Poppers

800px-hopoppersI wrote this a few years ago. It is a true story:

I was urgently summoned to the “resus” room in A&E at about 6 am. (I refer to ITU doctors as “resus monkeys”…). There, a number of junior medics, nurses and I found a puzzling sight. On the ambulance trolley lay an extremely sick two year old boy. His skin was a peculiar chocolatey-purple colour. He was comatose, gasping for breath, and his heart rate was 200 beats per minute-the maximum. His blood pressure was unrecordable. None of us knew what the hell was going on.

His two Caucasian parents stood in the corner of the room looking terrified, but also a bit sheepish.

Then the smell hit me. It was the unmistakable sickly sweet odour of amyl nitrite. This is a medical drug originally used to treat angina and more recently to treat cyanide poisoning. It also is used as a legal high, known as “Poppers” popular with those of kinkier sexual practices. The child’s clothing reeked of it and also his breath. I ordered his clothes to be removed and double bagged for our own safety, and for his body to be washed clean. Amyl nitrite can be absorbed through the skin as well as by inhalation.

I took a sample of blood from the artery in his groin and sent it off for urgent blood gas analysis. I then gave a paralysing drug and passed a tube into his windpipe and ventilated his lungs with 100% oxygen. He remained comatose and critically ill. We might have been too late.

The blood gas result came back: Over 95% of his red blood cell haemoglobin was poisoned by the amyl nitrite and therefore unable to carry oxygen. His blood was racing around his body but failing to deliver life-giving O2.

This child was about to die. There was no time to phone a poisons helpline. What could I do?

Suddenly I remembered an obscure nugget of truth. The boy’s haemoglobin had been oxidised by the amyl nitrite to become met-haemoglobin. The iron ion at the heart of the haemoglobin molecule had been changed from Fe2+ to Fe3+ rendering it unable to carry oxygen. This also changed the colour of the blood from bright red to dun mauve.

The treatment for methaemoglobin is the opposite of the oxidising agent that caused it: a reducing agent. Quickly, quickly, I racked my brain. What medical drug is a reducing agent? I was stumped.

And then again I remembered: Methylene blue. This is a dyestuff with many medical uses but is also a powerful reducing agent able to turn Fe3+ back to Fe2+. I had to get some into this child.

This was the next problem. Where in the hospital could I get hold of this unusual compound at this unearthly hour?

Yet again, my memory saved me, and the kid. As a medical student I had witnessed a remarkable operation on a patient with osteomyelitis-infected bone. The operation was to excise all the dead infected bone. Methylene blue was given during the operation and stained all the tissue with a blood supply a vivid green colour. The surgeon simply had to excise all that was not green!

If there was any methylene blue to be had, it would be in the orthopaedics theatres. I raced up there and ransacked the cupboards. Eureka! I found a small stock of it.

Drug in hand, I now had to work out the dose. This was a two year old patient weighing maybe 12kg. The drug book I had to hand did not specify the dose per kilogram. Time was now very pressing indeed so I was going to have to guess, hopefully with intelligence.

I slowly injected the dye-diluted in saline- and waited. During this time I had a chance to grill the parents to find out the story. Their little fellow had wandered into their bedroom in the early morn. He opened a bedside table and found in there a little bottle of golden yellow fluid with a bright label. With his two year old’s logic he interpreted the label as “Drink Me”, and so he did. It was Poppers. He promptly collapsed and his parents called the ambulance, thankfully in time before he died on the spot. I didn’t ask them about their sexual practices. That wasn’t my job.

We moved the boy up to the intensive care unit and I sited all the monitoring lines necessary. The end of the shift was approaching. I went into the handover office to tell my fresh colleagues all about the developments of the previous 24 hours. The Consultant was not my favourite. He was a bit of an arrogant perfectionist who had never regarded me highly, and was not shy about telling me this. We had religious differences too: he was an uber-devout Hindu, and I was a very confused Catholic. We all left the office to tour the bedsides. The last to be visited was the newly arrived child. We went into his side room. The boy was now clearly awake and trying to pull out his breathing tube. All the clinical measurements were now acceptable. We extubated him and he immediately wanted his parents to hold.

Before I went home, I popped back in to see the little man. He was at play, and even running around the cubicle. I was very pleased for him and his mum and dad.

I bumped into my least favourite Consultant on the way out.  Uncustomarily shaking my hand, he beamingly said “That was a superbly good save. Well done!” I was totally gobsmacked and went home, to my young family and bed, as if walking on air.

PS: I checked up on methaemoglobinemia. Levels greater than 70% are usually fatal. I contributed to the resolution of this little guy’s misadventure, for sure. His young age was definitely on his side. I wonder where he is now.

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So what saved this patient? My memory.

I learned the smell of amyl nitrite as a bored casualty officer over ten years before while perusing the cupboards  at the back of the shop. There I found a box labelled “Cyanide Kit”. In it were several ampoules of amyl nitrite. Driven by the curiosity that kills cats, some nurses and I cracked one open and had a sniff of the amber liquid inside. Suddenly we felt the blood run to our face and came over all faint. We staggered as our blood pressure plummeted, as our blood vessels dilated. Fortunately, this was short lived. Chastised, we survived and recovered to finish our shift, never to take that risk again.

Smell memory is very persistent. We can all perhaps remember the smell of our childhood comfort blanket, our mother’s perfume on the saliva moistened hankie that dabbed our chops, the incense at church, the smell of a rain-soaked May Day morning at dawn in Oxford. We also remember the smell of our own guilt, fear and despair and our own debauchment. I guess that at the hour of our death we will all each have condensed and matured our own unique eternal fragrance, like a barrel of some single malt whiskey, long aged.

Memory is one of the Soul’s powers, along with understanding and will. My memories will be the evidence at my Final Judgement. Things sacramentally forgiven will be inadmissible then, for God will have forgotten them too. Good deeds might mitigate my fate for the better. God is a good and merciful judge, but he may still have to wrinkle His nostrils at my malodorous pong when I am presented before Him. My hope is in His infinite Mercy, attested to by Revelation, Scripture and Magisterium.

As is all of our Hope. Amen

The Firth Of Filth

In the late nineties when the family was still young and incomplete, cash was short and so I was tempted to seek income outside my NHS job. There was a company called the P**** Group which specialised in providing anaesthetists to to both high and low street dental clinics across the country. I got in touch and awaited my first assignment.

The destination was Edinburgh, and I was needed there for a full working week. I took the necessary annual leave, kissed my family good-bye and drove off one Sunday afternoon for a six hour journey ‘oop north’. In the days before GPS, finding one’s way anywhere was by means of a paper road atlas, common sense, asking directions from not-always helpful pedestrians, and a lot of luck. I eventually parked up outside the pub/guesthouse on Joppa Road in Portobello that was to be my home for the next five nights. I enjoyed an average pub supper accompanied by a pint of heavy and retired to bed early in my fatigue.

My attic room looked right out onto the riverfront, the famous Firth of Forth. Due to the northerly latitude, Scottish nights are longer in the winter and shorter in the summer. The various twinkling city lights provided a view at least as pretty as Monaco seen from the sea, or so my feeble imagination imagined. I lay myself down to sleep. Perhaps I noisily snored the night through: my wife was not there to wearily witness aye or nay.

I awoke early, did my SSS and broke fast at the bar with a full Scottish. Then I took a cab to the dental clinic some way off. I was swiftly welcomed in and shown my workplace. My heart began to sink as I surveyed the pokey ground floor room and its medical and dental accoutrements. I was introduced to the team: The dentist was also a locum and was assisted by two enormously tall strapping Scots lassies who were neither of them past their 17th birthday. My working space was perhaps a whole square foot in the corner of the room. My gas machine was of an ancient wall-mounted Boyle’s variety with only one vaporiser (Halothane). The airway equipment was similarly simplistic. A worry worm started burrowing deep in my guts. If I knew then what I know now, I would have fled that place without being seen for dust, but I didn’t so I didn’t.

The dentist was a very competent operator and uber witty with it. I enjoyed his company. He nicknamed his two dental nurses as Big Bird 1 and Big Bird 2. They were neither of them dim-witted, but they both possessed such strong local accents that I could hardly understand a word they spoke, and I doubt they could understand a word I spoke either.

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This episode in my life is so rich in fruit that it deserves more than one brief post. I shall resume the story after a brief rest. I shall explain the title then too. Here is a musical interlude to help you while you wait:

 

 

 

Bougie Wonderland

A bougie is a slender curved wand that is used to gain access to to any larynx that is playing hard to get. Once its tip is within the windpipe, a breathing tube can be railroaded over it to reach the same location, and thus a definitive airway can get formed. Such an achievement often saves a patient’s life. Bougies used to be made of ‘gum-elastic’. I once asked why it was called that, and my tutor, worn out by my incessant toddler-like querying despairingly growled: “Errh, perhaps because it is made from a length of elastic, coated in gum”.

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My teacher in joyful mode

Every throat is different, and until the moment of destiny, nobody knows how easy or difficult it will be to pass the essential breathing tube through the voice-box into the windpipe. We have many ways to assess a patient’s airway  as regards difficulty of intubation, but none are perfect. They all yield false positives, where the airway is predicted to be difficult, but isn’t, but also false negatives….

When prediction fails us, we are left with reality, and for that we must always be ready.

There is a simple precaution that is all plus and zero minus: Pre-oxygenation. If before we render somebody incapable of breathing at all we fill every space in their lungs with pure oxygen instead of 20% oxygen (air), we automatically prolong their ability to live without breathing from 60 seconds to 600 seconds+. Some patients dislike having a mask over their face for the minute or two before going off to sleep, but I do my best to sell this safety thing to them. Alas I do not always win. Their loss, I suppose.

gum-elastic-bougie

A gum-elastic bougie and endotracheal tube

It also helps to have all the best equipment available to cope with a difficult intubation situation, and of course the best trained technical help. We possess all that at St Nowhere’s, all thanks to charitable funds, and no thanks to the “regime”.

I am all for living and working in a ‘collective’, as long as it is a collective that resembles the naturally and organically derived and grown family that I grew up in, rather than some laboratory-assembled simulacrum designed by Marx or his demented sub-apostles, or worse the right-wing eejits who violently subscribe to government from the centre….

Ooops, I began to go off on one there! Sorry++++++. Normal service will resume. Please wait….

With the patient pre-oxygenated and then rendered unconscious, one first uses an everyday laryngoscope to address the airway.

  1. If it is easy, then pass the endotracheal tube under direct vision.
  2. If that fails, ask for ‘BURP’: backwards upwards rightwards pressure to the larynx to make the view better.
  3. If it is still difficult, then try to pass a curved bougie around the corner, blindly if necessary, and then slide the tube over it.
  4. If all the preceding maneuvers fail, then rapidly summon your local ‘Yoda of Anaesthesia’ for help….

Once upon a time I used to do all the summoning, but nowadays I have become one of the local Yodas.

Failure to intubate a patient doesn’t kill the patient; failure to oxygenate does. One has to make a firm decision early in the proceedings about what to do next. Here are the options, though in all cases, the help of another anaesthetist is always great help:

  1. Retreat: wake the patient up. This may require rapid reversal of the muscle relaxant so that the patient can breathe for themselves again. The amazing drug Sugammadex, which is also amazingly expensive, completely reverses rocuronium and vecuronium paralysis in seconds. Retreat is an option when intubation is not a life saving manoeuver to start with.
  2. Accept compromise: although an endotracheal tube provides the securest of airways, and protects the lungs from nasty stuff like highly acidic vomit etc, there are other ways to deliver oxygen and anaesthetic gases. Mask ventilation to the face may suffice, or a laryngeal mask, or one of several other supra-glottic devices. A well stocked emergency airway trolley will have a whole panoply of such MacGuffins in it.
  3. Clever kit: At St Nowhere’s, we have a whole battery of gadgets dedicated to helping single handed, ageing anaesthetists combat difficult airway situations. They all rely on clever optics +/- video to provide a view of the larynx hidden behind the tongue and epiglottis, and usually some means for guiding the ET tube through the vocal cords to home base. None are perfect, and all are costly. They all require training and experience, but are used often enough to justify their expense. Examples are the Glidescope, Ambuscope or Airtraq. They deserve a post all of their own, so I’ll pass on here.
  4. Front of neck: The windpipe is central to the front of the neck, and not far below the skin. It can be reached with a stout needle, and oxygen can be pumped through that if all else fails. Better still is to perform an emergency cricothyrotomy, though it takes some guts to do it, and can be a bit bloody: Push a big scalpel through the skin just below the adam’s apple and into the windpipe, dilate the hole with some forceps, push a bougie into the hole, and railroad a 6mm cuffed endotracheal tube over it into the trachea. Inflate the cuff and voila! It ain’t pretty, but you’ve probably saved a life. You can always apologise to the patient/survivor or explain your actions in court later. The alternative is a Coroner’s inquest and a funeral.

Up until the other week, that was the distilled wisdom for managing a difficult airway. Then a nubile young lady sales rep’ attended our weekly meeting to ply her wares. First out of the box was a new kind of bougie, designed by an Australian surgeon, no less. It possessed a unique superpower: it could be STEERED!

All my life, I had dreamed of such a simple solution to the problem of getting a bougie to negotiate the sharp turn deep in the throat which can be so problematic.

At the end of her presentation, she asked if there were any questions. Salivating heavily, the only thing I could think of was if there were any share options in her company…..

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Here is a video portraying the upbeat mood of everyone in theatres when an airway crisis has been averted:

 

Gas Boy

When I was a five year old, the family home was a three storey semi’ on Warwick Road, Redhill. When Mum, Dad, and the six kids were all inside, it was a pretty crowded house. As a result, my baby bro’ and I would find the quietest part of the house to play with our Lego, or Corgi and Dinky cars.

On the first floor at the back was a small bedsit apartment which was hired out from time to time to travelling workers and businessmen. At the far end was a kitchenette with a small gas cooker, and we boys liked playing in there the best because it had a bright window looking out over the garden, and caught the westering sun.

There is something about buttons and control knobs which strongly attract the interest and curiosity of all young boys. I vividly remember the apoplectic fit my toddler son had when he first got his hands on the TV remote.

Well, guess what, when we got tired of our toys that Saturday late afternoon, we turned our attention to the gas cooker. We discovered that if you pushed and turned any of the knobs, the machine would start hissing, and emitted a funny pong. How spiffing! So we turned them all on.

At the very next moment we heard Mum calling us down to the living room as Thunderbirds was about to start on the telly. That programme was like crack cocaine to us. Cool machines, lots of explosions, and none of that lovey-dovey stuff our sisters liked. In our excitement we forgot all about the cooker.

Actually, in those mid-60s days, the whole family used to watch TV together often. I would sit on the floor or an arm of the settee, and be completely entranced and absorbed by the moving pictures on our ancient black and white set. The episode was titled “The Mighty Atom”. Here is the plot summary from imdb.com :

The Hood takes a special interest in the technology being used to run atomic irrigation plants around the world. His first attempt at stealing the technology leads to an atomic explosion. His second attempt using newly acquired spy equipment proves more successful but he decides to take everything a further step and try to steal the secret technology used by International Rescue.

Early in the story, the baddie is in the Australian atomic plant, stealing secrets.

The critical moment is when the bald geezer with the eyebrows of Breshnev shoots the white globes marked GAS @ 0:37 ff. BOOM!!!

I couldn’t read back then, but I knew my alphabet. What does G-A-S spell, I asked my older brother, the fountain of all truth. Oh it spells gas, he explained tirelessly as ever. It is invisible stuff like air, but it burns easily, and can explode too. The following footage demonstrated this vividly enough to me that I suddenly remembered the gas-cooker upstairs. I became suddenly very uncomfortable, and probably quite pale too.

I rushed out of the room and up the stairs and into the bedsit. Mum asked me what was the matter, but I didn’t heed her. The pong was so strong by then, it was almost visible. I raced to the kitchen area, and turned off all the valves from where it was issuing. The hissing stopped, but I began to feel faint and sick. I staggered out of the flatlet and went back downstairs again to see the end of the show. Apparently I had a rosy red cheeks for the rest of the evening. Mum was always ever so proud of her little soldier.

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The above events took place in a time when cooking gas was derived from coal, and it contained a high concentration of carbon monoxide, a potent poison of the haemoglobin in our red blood cells. CO causes many deaths by preventing the blood from carrying oxygen to the tissues. It actually makes the blood redder than oxygen does, hence my high colour. Modern natural gas is almost pure methane, and can only kill by asphyxiation. Phew!

Of course, domestic gas leaks are a leading cause of deadly high detonation force explosions. Gas and air mixtures in the perfect ratio, are the most powerful non-nuclear explosives known: so called fuel-air bombs.They are particularly effective because their blast is of such a long duration, and is followed by a profound vacuum phase. This violent push-pull, and the removal of all oxygen from the air make such explosives lethal to all humans nearby, but also pulverise most built structures. Apparently they are particularly good against people hiding in caves, like at Tora Bora. Watch this:

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Over fifty years later, I am still twiddling gas knobs, though only oxygen, medical air, and rarely nitrous oxide these days, and I actually make a living out of it. I also recently bought the complete Thunderbirds series for a mere £9.99

This is the first time in my life I have ever related how I almost wiped out my family and part of the neighbourhood, and myself through what a Coroner might term juvenile misadventure.

Oh yes and my first priority on moving home and discovering we had an upstairs second kitchen, that we didn’t use, was to pull off all the gas knobs and hide them securely.

Geoff The Technician

I first met Geoff over 20 years ago when we were both locums at the Battle Hospital in Reading. We were tasked with anaesthetizing a patient for his cardioversion. Such a procedure is where a brief electrical shock is delivered to the heart to reset its electrical state so that it can beat with a normal rhythm again. It is a minor planned procedure, unlike defibrillation which is used to treat malignant dysrhythmias during a cardiac arrest scenario. Everyone has seen the defib’ being wielded in a panic on the telly or big screen, usually to no avail.

Anyway, the patient, some physicians, Geoff, and I assembled in a treatment area off the main cardiology ward. There was an intravenous cannula already in place, so I asked Geoff to pre-oxygenate the victim with 100% oxygen using a Mapleson C breathing circuit. This was to fully saturate his lungs with oxygen which would allow him to safely do without breathing for ten minutes or so, if anything went wrong, which was most unlikely.

I then administered some propofol, a common intravenous anaesthetic, in the smallest amount possible: I asked the patient to keep their free arm up in the air for as long as possible (-and not to muck us about neither!). As I trickled the drug in, eventually his arm sunk down by his side. I then signalled to the physician to do his bit. He placed the paddles from the machine across the patient’s chest, with some soggy gelatinous conducting pads to help reduce electrical resistance. The machine got charged up, and started to whine its warning. “Stand clear!” he shouted, and that we all did, to avoid getting inadvertently electrocuted. The buttons got pressed, the patient jumped off the bed a bit, and then we all stared at the monitor to see if it had all worked.

I had attended hundreds of cardioversions before. They are used to treat atrial fibrillation and other supraventricular tachycardias. Normally, after the shock is delivered, there is a brief period of flatline asystole – absent electrical activity – before normal sinus rhythm recommences all by itself. We waited five ten and thirty seconds but no trace appeared. Cripes, the patient was in permanent asystole!

I was the first to snap out of the group hypnotic daze, and did the correct thing according to the guidelines at the time: I rhythmically beat the patient’s breastbone with my clenched fist, as hard as I could, all the while looking at the monitor to see if my ‘pacing’ was getting captured by the dormant heart tissue underneath. After fifteen seconds or so, I gave up and looked at the physicians. They were all standing around like lemons, trying to decide whether to call their medical defence solicitors, or book a ticket to South America, perhaps.

This is a CARDIAC ARREST, I told them as gently as I could. Somebody start external cardiac compressions, somebody else call the ARREST team, somebody else fetch the CRASH trolley. Geoff and I attended to the airway and breathing at the top end, as was our role.

This was a witnessed cardiac arrest being promptly treated in a hospital setting. If we all did our jobs right, the patient stood a good chance of surviving.

After three minutes or so of ‘jumpy-pumpy’, as I call it, the patient’s heart began to beat again in normal sinus rhythm. The restored circulation washed the propofol out of his brain, and he woke up as if nothing had happened. In his grogginess, he failed to notice the highly stressed and dishevelled young medics all around him, welcoming him back to life.

**********************************************

And so that was the high octane occasion when Geoff and I first met one another. It wasn’t for another four years until we met again.

To be continued!

denym0txgaa7xay

To the left, normal sinus rhythm, to the right, ventricular standstill: There are still p waves visible. Asystole doesn’t even have p waves. They are both equally deadly. The V1 trace looks a bit dodgy too. Refer to a cardiologist…..

Thumper 2

It can be expensive for a client to use a security guy to guard their premises. Although I earned £1.20 per hour (day or night), the company would have charged many times that for infrastructure, supervision, admin, etc, plus a slice for the shareholders. In this case, the Greater London Council were footing the bill as the school belonged to them. Spending the public’s money seemed to be no problem for them, as I remember, ahem.

The clients do deserve some proof that the guard isn’t just sleeping on the job. The watchman’s clock was invented for this purpose. This hefty squat cylinder with a heavy leather case and strap contained a clock movement with a 96 hour reserve. This would accompany the guard on his patrol of the factory or office block, about which were stationed numerous keys firmly affixed to the walls with a chain. The brass keys had printing-type numbers at the business end, and were inserted into the clock and turned once. Inside, those numbers were impressed through an inked ribbon onto a paper tape,

clock_large_guardsman

This lump of mass on a strap could also be used as a weapon.

along with the time. Thus a record of patrols was easily gathered, and scrutinised. These linear records were particularly useful if some incident occurred, as they provided proof or not that the guard had not been negligent. Supervisors would visit the site regularly to rewind the clock and retrieve the tapes.

My inner little crook thought up several ways by which this system might be spoofed: gathering all the keys up and performing the patrol ‘virtually’ in one’s kip-space; getting hold of a complete private set of duplicate keys and doing the same; or even tampering with the clock. The latter was a bad idea, as opening the clock immediately perforated the tape. Gathering all the keys up

bank-security-guard-sleeping-cropped

Regular patrols prevent this.

was a non-starter as well because supervisors would often perform spot-checks on random key-points looking for evidence of just such a misdemeanour. As for keeping a private stock of keys, well don’t make me laugh. There were a thousand possible combinations of digits for them. All in all, it just was easier to perform the patrols as ordered. Any funny business meant instant dismissal anyway, and there were plenty of willing replacements……

 

 

This school had no key-points either. I was being trusted by my employers to carry out my duties of care to the pupils and staff on the strength of my personal ‘integrity’. I had a record of good service for three years with the company, and also to be honest in those days I still possessed the simplicity of mien, personality, and behaviour of any harmless eejit who wouldn’t con a fly.

This was probably the first time in my life when I was actually TRUSTED by strangers with matters concerning life and death!

******************************************

Let’s get back to the main story. My first patrol occurred while the Summer afterglow was still in the sky, about 9 pm. It was a warm evening and the glorious polychromatic clouds were away off on the western horizon. The brightest stars were just appearing above me. I familiarised myself with the ground floor layout of the school, before wandering outside, locking the doors carefully behind me. The scattered flats and apartments where the teaching staff lived all had lights shining from their windows. I could hear the sounds of Hifis and TVs coming from some of them too. At least I was not totally alone. Because of the sportsfield, the perimeter of the site was actually quite long. It took a full half hour to walk it and examine it thoroughly. There were lots of shady spots where a person of ill-will might hide in wait.

After returning to base, I munched a sandwich and drank some coffee from my flask. I then became a bit bored, and got up to peruse the classrooms for some book or interesting thing to play with. As I got up to go, I suddenly remembered that I hadn’t reported in to base!

I was equipped with a military grade walkie-talkie, about the size of a ciabatta. I composed my message carefully, as I had been trained to do, but still probably fluffed it a bit:

Romeo Sierra, receiving, over? [I nervously asked after pressing the transmit button]

Romeo Sierra, roger, receiving, over, [came the distant but authoritative reply.]

Romeo Sierra, this is the 149 check call, over.

Romeo Sierra, 149 check call received loud and clear, over and out.

I recognised the voice of the radio operator at the other end. It was Chris, an ex-Marine, and one of the supervisors. He was a huge great bear of a man, but kindly and humorous. It was hard not to like and trust him.

And that was it for the next hour. I went out to look for some reading materials or toys to help keep me awake.

Thumper 3 coming soon! (if anyone is interested).

Only Fools And Donkeys

In the last 24 hours I was given a demonstration, under fire, of the latest EU funded high technology to reach the NHS: the robotic drug cupboard.

On a typical shift at the UK intensive care coal-face, business varies from slack to frantic in a highly unpredictable manner. Last night was no exception. Near midnight, Bed 1 started to upset her nurses and I got summoned to help out. She was a youngster suffering complex acute medical and social problems longer term, but unexpectedly she had started shivering and behaving extremely agitated. I attended half awake/asleep as per usual. I’m no spring chicken look-you.

The girl was shaking and shivering like a dervish, but she had only had a mildly raised temperature. Her pulse and blood pressure were greatly elevated, and her mental state and behaviour seemed bizarre. There was a history of drug abuse, and it was floated that this filly was simply withdrawing from her usual comforters. That seemed like a reasonable theory to me, so I asked to urgently administer my favourite drug for such situations, clonidine, to provide for her relief.

The obliging nurse then led me over to the new robo-pharmacist. First, he entered his ID, erroneously. After several attempts he got it right. Then he had to carefully apply his fingerprint to the sensor. Eventually the machine accepted this. Then he had to select the patient from among several on the screen, and finally he had to select the drug from among thousands. After several more counter-intuitive screen-taps, the machine grudgingly opened a drawer within which the clonidine was finally discovered.

At least 10 minutes had passed from my request to the delivery of the right ampoule of a single drug. It took a further minute to snap that thing open and draw it hurriedly up into a sterile syringe, and finally deliver it intravenously to where it might help. Previously, using a simple drug cupboard, I could have chosen a dozen various remedies to be used in rapid-fire in seconds-flat. Technology had triumphed over simplicity, once again.

Despite the delay, this patient did OK. Most others would not have.

The next morning I vividly confronted the manager in charge of this ‘innovation’ with my most very vivid ire.

With the ultimately facile of chuckles, she told me to address my concerns to some committee or other within the all-new burgeoning hierarchy of chuckling committees.

With all the Christian charity and forbearance available to me, I stopped myself from throttling all of the life from out of her, and let her live to appreciate all the qualities of mercy.

I let her live another day, but I then vowed to fight forever against this shitty bureaucratic, centrally programmed crapola that seems to be endemic in the governance of the dear old UK.

Where I live nowadays is no longer the country I grew up in. That must be a serious occasion for tears+++

This clip from Robocop (1988) sums it all up: