“The Regiment”

Like most blokes of my age I grew up with a daunting respect for the Special Air Services (SAS), a previously little known branch of the British Armed Forces.

As a teenager I had witnessed them on live TV storming the besieged Iranian embassy in London in 1980 wherein they killed all the baddies and liberated all the goodies (+/- one or two).

Their precious secrecy added to their cachet. They were apparently based somewhere near Hereford and could deploy to anywhere in the world with only seconds’ notice, for immediate lethal action, as required.

Their sudden publicity led to an awful lot of young men fantasising that they themselves belonged to “the regiment”, and so they boasted their ways onward through life, impressing the less discerning girls they encountered, and so on and so on.

During my much later brief professional encounter with the Royal Army Medical Corps as a locum, I got to meet a lot of military people both patients and staff. I quizzed them out of pure casual curiosity about the SAS. Most knew nothing, and most of the rest knew about as much as I had gleaned already. The remaining few were very cagey and hinted that if they told me, they would have to kill me! The only indication I ever got was that an SAS soldier was about as identifiable in public as a bird-shit on a pillar-box.

I eventually realised that my intellectual pursuit for some truth about the SAS was a vanity project, and I gave it up as such. It was just none of my business, at the very least.

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A year or two later, I was working in some operating theatre in Oxford one evening. My technician was a remarkable man with perfect manners and English diction. He was of inscrutable age, and obviously from the far east, possibly Hong Kong, Singapore or Nepal. He spoke little but was perfectly competent in every word and deed. I returned his reserve respectfully. We thenceforth danced together through our work like a married couple that has transcended mere chatter and polite conversation. The operating list just breezed by.

In a period of leisure, I asked him if he was ex-military. He nodded affirmatively. In one of my silly moments I then asked him if he was SAS. At this, his face darkened. “That is not a question that should be asked” he replied. I backed off rapidly and I apologised for my intrusive gaucheness. We carried on working together for a few hours more.

A good technician is essential to my professional accomplishment. I thanked him heartily for his help. As we parted company that night, he remarked to me with kindly cheekiness “I thought you were from the Regiment too! I returned home very flattered and very embarrassed and very confused.

 

 

 

 

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Arguing The Toss

This is a continuation from an earlier article.

The young boy had clambered out of the car like everyone else had. Sadly, as the door slammed to, his fingers got caught in it and he suffered an excruciatingly agonising crush injury to his fingerpads and nail beds. He fainted in response to the intense pain.

A faint is nothing much really: a brief interruption of the blood supply to the head is easily fixed by lying the patient down, preferably on their left side so that their airway remains patent, and waiting  a minute or so for the blood to start coursing through the brain again. Unfortunately, as he fell, he hit the side of his head on a pointy stone protruding from the grass. He didn’t wake up after a minute or two like he would if he had simply fainted. The family were on a driving tour of the rural area when this took place, and being sensible, mum and dad wasted no time trying to summon an ambulance to the middle of nowhere. They bundled their son into the back seat and drove like fury to my hospital.

He arrived thus unannounced and the trauma team assembled around his trolley. Blunt trauma to the head plus deep coma means urgent CT scan: It’s a no-brainer really, if you will forgive the expression. I intubated him and took him off to the scanner fully monitored and tout suite. It took only a few seconds for that marvellous machine to produce a wondrously detailed picture of the problem: a large extradural haematoma, which was expanding and squashing the brain dangerously. By now, it was an hour since the injury. If this kid was to have any hope of a normal life, he needed to have his skull opened by the fourth hour. The neurosurgeons were an hour and a half away at least.

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The large off-white thing is a blood-blister forming inside the skull. The pure white stuff is the skull. The disordered stuff on the left is the swollen misshapen scalp. The dark sliver is all that remains of the brain’s inner ventricles, its wriggle room. This brain is very tight, and needs urgent decompression!

While I brought him back to the resus’ room and got him onto the ambulance trolley, rigged for transfer, the images were beamed across to the neuro-guys and the phone call got made by our surgeon. The minutes were ticking by and I asked what the delay was.

The neurosurgical registrar at the other end was being obstructive. He wanted this test and that to be done, and for us to cross-match some blood for transfusion. I couldn’t believe my ears. Time really was of the essence, and this buffoon wanted us to waste some more. The red mist obscured my vision and I grabbed the handset off my colleague.

“Listen buster, we will finish this ‘fascinating’* conversation when we meet face to face in just a little while”, I yelled at him, rather sarcastically and rudely, before slamming the phone down and telling my team to “GO, GO, GO!!!!”

“How quick do want to get there, doc?” asked the paramedic behind the wheel. We were all aboard and ready for a 90 minute dash across winding roads to the nearest city.

“Pedal to the metal, please”, was my only reply, delivered stolidly. As I braced for a very uncomfortable journey, late into my shift, my eyes watered up. I blinked them clear and then closed them again to make a brief prayer: my own son was the same age as this kid. I had briefly met his parents and siblings to explain what was going to happen. They stood there, pale and distraught, in the corner of the resus’ room like some white marble sculpture, perfectly portraying tragic, grieving, powerlessness. I was already and inevitably involved emotionally with them, having lost a child. “Drive safely please”, I advised the family, as we were going out the doors. I didn’t want any more innocent blood shed.

Being strapped into a seat, sideways on to the direction of travel, inside a tin can with no view of the outside, hurtling, pitching, and yawing violently, is a perfect recipe for inducing motion sickness. Fortunately my technician and I were sea-legged veterans at this, and we both held it down for the duration. The second paramedic, who was out back with us, stood for most of the journey, holding onto the handrails and swaying with the dancing vehicle. He reminded me of a London bus-conductor, only this bus was on the Paris-Dakar rally route.

My main clinical concern was the amount of pressure inside the boy’s cranium (brain-box). Because it is a rigid container, too much pressure inside, can stop fresh arterial blood from entering the skull cavity to nourish the ever-metabolising grey and white matter that does our thinking and dreaming for us. Because the brain is hollow, the cerebrospinal fluid can get squeezed out and thus accommodate  quite a bit of swelling from elsewhere. When that reserve is used up though, the intracranial pressure ramps up rapidly and the incoming blood flow gets pinched off rapidly too. Once brain perfusion ceases, there are only minutes before the brain cells start to die off permanently, leaving only serious widespread brain damage as the best possible result.

There are a few therapeutic options which can buy time:

  1. Hyperventilation: By significantly lowering the CO2 levels in the blood, the blood vessels throughout the body, but especially within the skull will constrict, and thus provide a bit more space. Blood vessels contribute a large part of any tissue’s volume.
  2. Head-up positioning: Raising the head drains the veins within the skull, also creating space.
  3. Osmotic agents: These act by sucking the water out of cells thus reducing their volume. It is a benign sort of pickling. All tissues shrink as a result.
  4. Raising the blood pressure: There are many drugs which can do this; the blood supply to the brain is artificially brute-forced against the opposing raised intracranial pressure, and thus perfusion is maintained.

The problem with an extradural haematoma, which is usually from a bleeding middle-meningeal artery running through the bit of skull that gets fractured, is that all these worthy interventions only serve to promote further bleeding into the haematoma! The only real solution is rapid opening of the skull to relieve the pressure.

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We crashed the ambulance  trolley through the theatre doors at our destination. The full home-team were there waiting for us, including the head-honcho in charge of heads. We all worked together like the innards of a Rolex to quickly get the boy onto the table and prepared for an urgent burr-hole decompression of his skull. My tech-guy and I were rapidly rendered redundant as our hosts took over all care. As we were both already in scrubs, though shop-soiled, we were allowed to stay to witness their Kung-Fu.

The head was shaved, the scalp was painted with antiseptic, and the drapes were applied in a minute or two. The scalp was incised and retracted at exactly the right place and the white bone of the skull was exposed. A normal drill cuts a cylindrical hole, but a burr cuts a bowl shaped hole because the burr-drill has a spherical tip, about the size of a large marble. The bottom of the bowl eventually breaches the inside of the skull while the shallowly sloping walls of the burr-hole prevent the whole drill plunging through and liquidising the brain underneath.

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Top right is a traditional burr-drill. It can be driven by a powered source or even by a brace-and-bit, as beloved by carpenters.

It was like striking oil: The blood and clots gushed out under pressure, and the pressure within the head was relieved instantly. Though there was much more to be accomplished, the patient was now out of immediate danger. Barry-the-tech’ and I decided to withdraw then to our awaiting taxi. As we carried our voluminous transfer kit back out to the hospital entrance, waving to our distant healthcare cousins along the way, Barry remarked that the two of us must have resembled the “Ghostbusters”.

I had to laugh because this was exactly true: We were both bestrewn with backpacks, ventilator tubing, cables, hoses, assorted kit, etc, and we had both played our part in preventing a ghost from being created. Such is the “paranormal” world all healthcare workers inhabit when they “make a difference”.

[BETTER STOP THERE PLEASE: READERSHIP FATIGUE. – ED]

To be continued…..

  • For “fascinating” substitute some other word beginning with “f”.

 

The Second Pigeon Story

This is a continuation from an earlier post

During my incarceration in the worst hospital accommodation in all of creation, if I ever wanted a bath or shower or needed to use the loo, I had to walk to the distant far end of the corridor through three fire doors, each of which was half glazed with wire-reinforced glass. These allowed a partial view right down to the far end, but blocked vision of the intervening floor.

Shortly after moving in, I discovered I had a neighbour. He was about my age but tall and slim and better groomed. [Who isn’t? – Ed]. Unfortunately for him he had zero communication skills, steel rimmed glasses, and narrow set eyes. Our introduction to each other did not get much further than hello. “It’s good to talk” was an advertisement catchphrase at the time. I love irony like that. I was reminded of him in later years by the penguin in Wallace and Gromit:

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Yes this is a penguin disguised as a chicken, but read on…..

One morning early I emerged sleepily from my room draped in a towel robe plus slippers and carrying my wash things and thus began the long staggering walk to the distant grimy purgatory of ablution, provided by the state. The Spring morning sunshine brightly lit my way.

Suddenly, in the distance I glimpsed my very odd neighbour racing towards me from the far bathrooms. He was wearing only a towel, but his face was full of fury and murderous intent, and he was violently wielding a broom this way and that at some invisible opponent as if he was a practitioner of Kendo on an assassination mission.

My sleepy brain woke up with amazing alacrity and began to do risk-analysis: Strange people do behave strangely, I reasoned. Should I confront him or run for my life? Option two coolly won the vote as I am a bit averse to fighting even at my bravest, and so I looked around for the stairwell of hope and escape, as I was on the second floor. Alas, the maniac and I were now equidistant from my source of retreat.

Crunch-time: I had to face my crazed aggressor and possibly be brained in the process. I steely adopted the best faux martial arts stance that I had ever learned from Bruce Lee et al at the movies, and stood my ground to face imminent death….

It was then that my opponent pulled open the final door between us and I at last understood my fate:

There, on the floor between us, gripped by the crazy stick-wielding nutter’s intense stare, was a supremely terrified pigeon, as equally intent as me on finding its way back to normal life and safety.

The stairwell window to my left was half open. Walter, as I named it, seized the day and made a perfect powered-gliding exit through the proffered space, and was never seen again, by me at least.

My co-combatant and I panted with relief as we faced one another across that morn. He’d had his shower, and I needed my bath. We bowed and nodded to one another like ninjas at ease and then continued with our days without another word.

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I know it’s called chicken-wire but it keeps all avian critters from entering open bathroom windows. In my root-cause-analysis of this event, I suggest it’s use be mandatory in city hospitals, if only to prevent internecine bloodshed between its essential workers.

Casualty

Everybody should work in the casualty department of their local hospital, if only for one night. All of life is there, red in tooth and craw.

I was a casualty officer for just six months away back in the day. It was my first job as an SHO after my year as a house-officer/intern. Like an infant I learnt more during this period than at any other time subsequently. Firstly, I gained the superpower of being able to send  patients home whose treatment episode was concluded.  Picture someone with a gashed hand whose gash was now stitched up. Only the most paranoid of doctors would admit such a patient for observation.

On the night of 15th October 1987, when the great gale struck the UK, I was fielding the night duty. There were remarkably few customers that night. As a result, conversation flourished amongst the imprisoned crew. The charge-nurse told me a an awful joke, which has stayed with me ever since:

Q. What is the difference between an oral thermometer and  a rectal one?

I had to confess, I didn’t know the answer. With relish he delivered the punchline:

A. It’s the taste!

An interesting case was when I attended to a man of late middle-age who had been beaten up and robbed upon his own doorstep, as he returned from work one evening. He was thankfully only badly bruised and shaken up. He told me that one of his attackers had lobbed a punch at him, had missed, and his punch had broken the glass panel on his front door. The assailant’s hand had been injured  by this. I wrote all this down, and prescribed a treatment plan for him, and then proceeded to the next patient.

This young fellow, who was accompanied by a bevy of his mates in leather jackets, had a nasty injury to his right fist. Like all such patients, he claimed to have punched a wall, in a state of frustration. His story did not ring true however as his hand was clearly lacerated by some razor sharp mechanism, rather than contused by blunt injury. I sent him off for an x-ray and went to the office to write stuff up.

While there, I noticed a couple of policemen loitering near reception. They were attending to interview the attack victim when he was fit to go. I motioned them over and whispered my suspicions about the possible identity of the perp’ to them. They nodded sagely.

The young man was back from the radiology department and waiting in his cubicle with his chums. The film showed no glass fragments in his mit, so I was all clear to stitch up his wounds. Messrs Plod assembled just outside the cubicle’s curtain, careful not to betray their presence. Given the number of accomplices, backup had been summoned.

As I tied and cut the last suture, I informed him that there were some people who needed to see him, urgently.

The curtains opened and all in all. it was a very ‘fair cop’, as they say in old British gangster movies.

Wordplay: A Fair Cop.

 

 

 

Welcome Aboard “Emergency Airways”

This young guy had just been visiting the USA for the sheer fun of it, and had picked up a cold along the way. Travel exposes any of us to new viruses and we all succumb to them no matter how healthy we like to think we are. He shook off the cold, but it left his throat rather raw, and so an abscess formed in one of his tonsils or other pharyngeal lymph glands. The throat is the front door of the body, and is equipped with a lot of immune system tissues which act like bouncers to see off any incoming threats. Sometimes these worthy defenders become massively inflamed under fire and directly threaten the airway. I give you “the quinsy”:

tonsillitis

Nasty tonsillitis, impinging the airway.

On this occasion the abscess pointed both outwards and inwards. It bridged the outer airway and also the inner fascial planes of the neck, a place it had no business being in. With every cough and sneeze, pus was driven deep into the tissues of his neck and beyond.

Within a few hours the whole of his neck and central chest were suffused with very nasty bacteria producing gas which only insufflated his tissues more than his coughs and sneezes were already doing. This handsome young fellow began to resemble this personage:

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I was summoned in to the hospital by my colleague who was clearly out of her depth. I felt no more certain than her of solving the problem. The patient was rapidly choking to death. I asked the attending surgeon if he could perform an emergency tracheostomy under local anaesthesia, but he blanched at the suggestion as the front-of-neck anatomy was so distorted. This left only one option: an awake fibre-optic intubation; this was a procedure I had only read about but never performed.

An intubating bronchoscope was rapidly fetched from theatres and a narrow-bore endotracheal tube was slid over it. I inserted the ‘scope into the patient’s nostril injecting and spraying local anaesthetic all the way. The anatomy was all grossly distorted by the swelling. I found my way to his larynx and trachea by just following the bubbles of exhaled air. Once the tip of my endoscope was in the windpipe I ordered the general anaesthetic drugs be given, and I was then able to railroad the breathing tube over the ‘scope and secure his airway definitively.

At this point the crisis was over. We shipped the patient off to the care of ENT and chest surgeons who were at some distance from our simple district hospital. The patient did well and resumed his studies after a couple of weeks. This is a true story, and I earned a fair few grey hairs during the living out of it.

 

Taking The Micks

Michael is an ancient name.

From the Hebrew name מִיכָאֵל (Mikha’el) meaning “who is like God?”. This is a rhetorical question, implying no person is like God. Michael is one of the seven archangels in Hebrew tradition and the only one identified as an archangel in the Bible.

It is a very popular name the world over, but for some reason it has become associated with Eire, to the extent that Micks are synonymous with Paddys in the slang universe.

There were two significant Micks in my professional life, and this article is my way of mentioning them in despatches, for they are both excellent geezers.

The first Mick was my senior registrar at the major city teaching hospital. He bore a remarkable physical resemblance to Rodney Trotter, though he was very far from gormless. In fact he was very laconic and acerbic.

One time, a pale-skinned, copper-haired lady junior doctor of lesser rank spat venom in his direction over some minor clinical misunderstanding. He silently repelled the attack, but after she had left, he, speaking to himself mainly, remarked that only a few centuries ago, a woman like that would have been burned at the stake. I liked his sense of humour.

I bumped into this Mick a good few years later. I was still a junior anaesthetist, but he had become a Consultant at a large district general hospital. In the meantime he had married and had several young children. He hadn’t yet managed to break into the plentiful private practice available in that locale, so was only scraping by on the standard NHS salary. His everyday commuting vehicle was a lowly “Montego”of venerable vintage, and his snottier, more superficial, elder colleagues nastily nicknamed him “Montego Mike”. I think that says more about them than about Mick.

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The second Mick was also my senior registrar at the same hospital, but he was a very different character. Possessed of a Blackpool accent and upbringing, he had a low tolerance for any southerner’s nonsense. I learned a tremendous amount at his kneeside. He had long curly hair, like some rock artiste, and was mega-computer-literate at a time before “Windows” had even been written. He was also wise beyond anyone I could compare him with.

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This looks a little like Mick 2 as I remember him.

At the satellite hospital in the suburbs was an ITU sister who was pulchritudinous enough to launch a thousand ships. Unfortunately, she also knew this. As a result, she felt and acted like someone possessed of infinite power over men, and often she succeeded.

Mick was uncompromised by her looks and charms, though not because he was gay or such-like. Mick was just too “eggs, chips and beans”, and happily married, to fall for it. Whenever he encountered her, all he could see was a spoilt princess requiring some needful upbraiding. This he delivered with his workaday northern patter. She melted before his mastery every time. It was like the taming of the shrew, perhaps.

This second Mick taught me a lot of wisdom, though he was/is a professed atheist. Whenever I see an image of the “Angel of the North”, I think of him.

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By David Wilson Clarke – Transferred from the English Wikipedia. Original file is/was here. (Original upload log available below.), CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=38249358

 

The Impossible Question

Although I was automagically enrolled into the college’s student union, I chose to remain a non-combatant. The lies and fisticuffs of politics were just not my thing. What amazed me then, and still does, was the political sophistication on view from many of my peers. They like me were barely out of nappies but yet were full of the buzz-words and right-on opinions and attitudes du jour. Clearly, my prior education had been deficient in preparing me for this strange new world.

The most precocious of students were those studying Politics, Philosophy, and Economics (PPE). This is unashamedly a course designed to nurture future shapers of society. Several of these classmates of mine are nowadays political leaders in real life.

Anyway, in my second year I attended a full meeting of the college’s undergraduates to witness the election of the new president of the student body. There were six or seven candidates. Each gave their brief spiel, and then the floor was opened for questions. Several nasally voiced attendees asked about the finer points of policy or made issue with the political process itself. It was all terribly tedious to me, but while necessity may be the mother of invention, restlessness is a strong contender for its father.

And so, on a whim, I flung my arm up in the air and waved it around like an epileptic dervish might. My attention-seeking behaviour worked and I was asked to pose my question to the assembled. The college fool and dunce spake forth:

“If each of the candidates was NOT standing for office, then which of the other candidates would they vote for?”

As the last of my verbalised syllables reverberated off into the present quiet, an awkward silence fell upon the assembly, and lasted for some thirty seconds. You could  even hear a pin drop upon the threadbare carpet of that junior common room just then. Eventually the first candidate admitted that they were unprepared for this question, before dwindling away in a burbling fashion. None of the others did any better.

Eventually the Chair of the meeting asked for any other questions. Dissatisfied with the outcome, I headed out for the college bar, its incumbents, and its pinball machine which all provided far more solaceful company.

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I still think there has to be more to life than politics.

Mondegreens And Mumpsimi

A mondegreen is a misheard word, phrase, or song lyric that forever after is remembered and used as if it was the genuine article. This is an international and multicultural phenomenon with alternative synonyms for it including Hobson-Jobsons, soramimi, malapropisms and eggcorns.

Examples abound: “Old-timers disease”, “spectaclear”, “chimleys”, “immunogoblins”, “nucular”, etcetera.

A Mumpsimus has been defined as a “traditional custom obstinately adhered to however unreasonable it may be”, as well as “someone who obstinately clings to an error, bad habit or prejudice, even after the foible has been exposed and the person humiliated; also, any error, bad habit, or prejudice clung to in this fashion”.

I confess to being a bit of a mumpsimus myself. I thank my reverend mother for this gift. She was most definitely talented at liquidising ideas and words into some entirely new parrot-dimes.

One Sunday lunch, the whole family of eight of us was eating her wonderful roast lamb dinner and several glasses of wine had been sunk by all. At a pause in the banter, Mater asked if any of us had seen the new film starring Daniel Day-Lewis, about the severely disabled Irish author and artist Christy Brown, called:

“Mind My Foot”

We all of us scratched our heads mentally for a few moments before realising she had meant “My Left Foot”!

For ten minutes and more we all rolled around on the floor laughing at this mondegreen, though never at our mother. With such inspired but un-self-willed genius she had actually invented a better title for the movie and book. I still laugh to this day when I remember that meal.

Anyway, her gift passed onto me, and I commonly mishear and misunderstand a lot of what floods my ears ever since. For instance, this trashy pop-rock song was playing on the radio in 2003, while I was busy in theatre dealing with a leaking aortic aneurysm. Such a case is the most labour intensive of all for the anaesthetist: Blood loss is galore, haemodynamic instability is epic, and mortality is pacing up and down impatiently outside the door like an expectant father. I was squeezing bags of blood into this patient faster than I could complete the paperwork while I formulated my explanation for the coroner….

Then this rocky little ditty came over the airwaves:

Honestly, I thought the lyrics were “I believe in a thing called BLOOD”!