Beware Of Liars

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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.

lethal_weapon_playfield

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 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”!

Benylin And Lemonade

cocktail

Some drugs leave you unshaken yet stirred.

Benylin, in two of its current formulations is an over-the-counter cough syrup containing the active drug dextromethorphan. I think it is a pink viscous syrup, flavoured with cherry-I have never taken it myself.

It is supposed to quell an overactive cough reflex by action upon the cough centre in the medulla oblongata in the brainstem, though some trials show it is no better than a placebo. Here’s the Wikipedia article about it.

Now I would be a strange kind of anaesthetist if I had any problem at all with drugs being used to relieve unpleasant symptoms and conditions. If I did, I would be arguing myself out of my job. Heck, I even approve of recreational drug use where it is legal, socially acceptable, and non-injurious to the good of the imbibers and those around them. Thus social drinking and moderate use of tobacco are fine by me, and I must confess to having both those minor vices, neither of which make me suffer personally, though my wallet is always starving.

I have no desire to truck with drink-driving, overdosers, or alcohol fuelled violence. Believe me, many healthcare professionals and I have lost an awesome amount of sleep trying to patch up patients who have fallen foul of that unholy trinity.

Anyway, dextromethorphan when taken at 3-5 times the normal dose can produce dissociation, euphoria, mania, hallucinations and even temporary psychotic states. It should thus be no surprise to the reader to discover that dextromethorphan is a common drug of abuse. It is particularly popular with “snowflake” abusers who want no hassle with the Fuzz, such as teenagers. It is just so readily available at any pharmacy, look you.

By all means, if a respiratory infection is preventing you from sleeping or otherwise functioning, by nasty symptoms like a dry cough, then freely medicate yourself while sticking to the proper dose. Cease use when you are better. Don’t become a “Benylinite”.

When I am feeling lousy with the dreaded lurgi, I dose myself up with a swig (20 mls) of “Night Nurse” which contains paracetamol, the dirty old antihistamine promethazine, and, errrh, a small dose of dextromethorphan, though not so much as you would notice.

“Night Nurse” looks and tastes like a cheap knock-off of crème de menthe. The product name is a piece of marketing and advertising genius:

Ash Wedneday 2018

Philippines Ash Wednesday

As a Catholic, I try my best to live my life according to Catholic teachings. One of these is to devoutly observe the Grace-filling penitential season of Lent, which this year commenced on 14th February, Ash Wednesday.

Following a night-shift and after a pretty dissolute Shrove Tuesday, which also included a rake of delicious pancakes with various toppings, I awoke the next morning like a teetotaller knowing that this was as good as it ever was going to get for the next forty days and nights. I had to fast and abstain for the next 24 hours at the very least. Fasting means getting by on one and a half meals per day, and abstaining means no meat. I had two huge mugs of sugarless tea to wash down my diabetes tablets. Fortunately I had a day off from work, so I did not have to worry about mental fitness to practise. The weather was cold and wet so I stayed indoors. My wife was at work at her school. I gave my son a lift to college. He is currently suffering from an ingrown toenail on his spastic foot, and I felt he deserved some help from my otherwise unemployed capacity that day. I returned home and did some housework. By now it was only 10am and I had six hours home alone before I had any company again…. (Our household has no pets).

The purpose of ascetic practises in the spiritual life is to prove to oneself that God will never let us be led away from Him, though our Faith will become seriously tempted in the process.

In this proper, Lenten, spirit and season, fasting and abstinence are simple ways for us to give our spiritual enemies, our weaknesses and our temptors, a beckoning finger or two. And thus we start to beat their dirty kung-fu with our more honest and humane, Divinely-gifted martial art: self-sacrifice.

This video provides a loose simile. Watch the neophyte in white being shown how to fight for his life by his master, playing his devil’s advocate, in black:

What that clip portrays to me is what Lent is all about: The more you think Salvation is all about your own efforts, the further it recedes from you. Salvation like all the best things in life is a free gift, from A Better Other.

Ash Wednesday’s summit for me was having the Christian symbol anointed with palm ash on my forehead by the priests fingers.

Who knows except God if I will ever receive the Holy ashes on my living forehead again, with these words being spoken over them.

Remember man that thou art dust, and unto dust thou shalt return

The Eskimo Joke

I have worked with a lot of eye surgeons over the years, and they are splendid chaps who do an awesome lot of good. The eye is the window of the soul, it is said, and these fellows are surely the window-cleaners, as it were. [OK, let’s get the silly video out of the way then-Ed:]

For the anaesthetist, eye surgery can be a bit of a bore. All the surgeon wants is a patient who isn’t running around the theatre during the minimally stressful procedure, and providing just that is child’s play, to be honest. Also, operative blood loss is less than I suffer when shaving my own chin of a morning.

To add insult to injury, they often require the theatre lights turned off so that they can better see what they’re working on under the operating microscope. If I get bored in a darkened room, I quickly start snoring. I’m a bit of a narcoleptic like that. Fortunately, my snores are so loud that I immediately wake myself up in a panic. I am sure I am very amusing to observe when I do this, like a dog is when awoken by its own farts.

Anyway, one afternoon during an eye surgery list, I decided to lighten the tedium by telling a silly little joke I had recently read or heard somewhere:

Q. Did you hear about the Eskimo who took his girlfriend to bed one night?

A. When they woke up, she was six months pregnant!

Now I know that this joke will never win the Nobel Prize for humour, but the surgeon and his assistant that afternoon were both so amused by it that they couldn’t continue to operate on the patient’s eye because they were convulsing with laughter. Their laughter infected everybody else in the room in a feedback kind of way (except the patient of course). It took a full ten minutes before order was painfully restored by the forced stifling of mirth. Ophthalmologists require the tremor-less dexterity of a master watchmaker to earn their crust, you see. I can’t explain why they found it so funny. Perhaps they didn’t get out much.

That operating list overran by ten minutes, but we never recorded exactly why. The incident, thankfully, became submerged in the sands of time. Nowadays, the overrun would be picked up by surveillance software and a bean counter might authorise an investigation perhaps, with formal interviews under caution…..

I exaggerate perhaps, but one thing is certain: NHS workplace morale is at an all time low right now because we the workers are more tasked with measuring mere process than in improving outcomes. The eventual collapse of the NHS will be perfectly recorded upon all available auditing media. Meanwhile the sick will just have to wait, or die.

Now Don’t You Laugh!

hand-with-iv

Only witch-doctors, quacks, and GPs can do without intravenous access

It was panic stations. The screaming mother in labour was wheeled rapidly into theatre and transferred tout suite onto the operating table. There was no time for the parenting friendly awake spinal anaesthetic. Only a rapid-sequence-induction general anaesthetic would save the life of her baby and herself.

I had all the necessary drugs drawn up already. The obstetricians scrubbed up at speed and approached the supine near-naked woman in their gowns, gloves, hats and masks. They waited on my say-so, for the lady was still conscious, and conscious most likely of her possibly impending doom.

My assistant was holding the oxygen mask to the lady’s face and also gently feeling for the cricoid cartilage on the front of her neck. Pressure applied there would prevent highly acidic gastric juices from flowing up into her throat and down into her lungs, which would kill her.

That poor woman was scared almost to death. Her adrenal glands were pumping adrenaline into her bloodstream in huge amounts. Her pulse rate and blood pressure were massively elevated, she was panicking and thrashing about, and her skin was deathly pale and clammy. There was not one second to to be lost.

I pushed the syringe of thiopentone into the cannula on the back of her hand and delivered the standard 375mg (15 ml). As I tried with one hand to disengage the syringe from its push-fit, the cannula itself came out from the patient’s vein. The adhesive dressing which had been holding it fast had failed because of her intensely sweaty skin.

At this moment, I had a severely compromised patient whom I had just rendered even more compromised by my injection of pentothal, and I now lacked a route via which to deliver any further life-saving drugs. The most important thing to achieve in the next few seconds was to deliver a muscle relaxant (suxamethonium) which would allow me to intubate her windpipe. I had never ever faced this scenario before. In the few moments I took to realise my near check-mate, the Angel of Despair gave me a knowing wink and a wicked chortle.

Brigid the obstetrician, a delightful Fraulein in other circumstances, chose this moment to giggle nervously at my clear and present discomfiture. I shouted

“Don’t you effing laugh!!!”

in my confusion and worry. This only made Brigid giggle all the more. The patient was beginning to turn blue, and it started to look like it would be “Game Over” very soon.

Then it was that the miracle occurred. I suddenly remembered accompanying a Consultant anaesthetist for an operating list over ten years before at some major teaching hospital. His surname was Harris, and thus he was awarded the nickname of “Bomber” by we unruly juniors. He was a solitary and eccentric young bean whom nobody ever really got to know.

He had asked me: ” How do you deliver suxamethonium (the fast-acting muscle relaxant) if you don’t have an intravenous cannula?”

After a pause I shook my head to clearly signal my witless ignorance of the answer.

“You inject the suxamethonium into the tongue!”

This made perfect sense to me. In mammals the tongue has a huge blood supply. Any overheated panting Alsatian will demonstrate this to you: They hang out their tongues to cool themselves off as they pant their breath over and around it.

Furnished with this recollection, I injected the 100mg of suxamethonium into the patient’s tongue and within a few seconds, her muscles began to twitch and relax. I successfully intubated her trachea and the caesarean section commenced and proceeded swimmingly.

In the time window provided, I inserted a new intravenous cannula, and all the other drugs were delivered via this route.

Mother and child did well, all thanks to good old “Bomber”. I discussed this scenario with all my colleagues, and none of them had heard of the intralingual injection technique before.

Professor Sir Keith Sykes

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This man first introduced me to the idea of pursuing a career as an anaesthetist!

Sorry, I can only provide a link to a (lengthy and detailed) video interview with him from after his retirement, because of copyright.

https://doi.org/10.24384/000432

I am delighted and amazed to discover that this dear fellow is still alive, at the age of 92 this day. Ad multos annos!

More stories later.

Absolutely Gutted

maindrainuncovered

Scene of the crime

His mother thought the best possible treat and distraction for her toddler son was a visit to the local paddling pool. She couldn’t know how ill-fated a choice that was to be.

***WARNING! SOME READERS MAY FIND THE FOLLOWING NARRATIVE VERY DISTURBING!***

Little Billy’s eyes lit up at the prospect of splashing around in the wading pool. His mother sighed with relief at the possibility of perhaps half an hour’s peace from his incessant neediness. Billy splashed and cavorted around in the shallow water while Mum rested her eyes. Then Billy noticed something that interested him: in the floor of the little pool was a large round hole. It was the pool’s drain. He approached and his toes told him that water was flowing swiftly just by it. What fun!

All swimming pools have some means by which the water is continuously siphoned off, filtered, sterilised, and then returned. This is to prevent them becoming venues for algal blooms. Little Billy was wearing no swimming trunks, and he thought it would be exciting to sit on that strange and fascinating opening.

As his buttocks became entrapped by the suction, the clock started ticking. He suffered immediate discomfort and started to scream. His mother awoke and ran across to him. There he was in the middle of the pool and she tried to lift and cradle him in her arms, except she couldn’t. He was stuck fast to the pool’s floor. She started screaming and some staff came over to help. The brightest of the lifeguards immediately saw the problem and ran to switch off the pump. Alas, the damage was already done.

Several feet of Billy’s intestines had become extruded through his anus by the suction. Billy was unconscious, having fainted from pain and by vasovagal reflex. An ambulance arrived almost immediately as it was already parked up nearby waiting for a shout. Fortunately, they scooped and ran with Billy, rather than staying and playing.

Little Billy was swiftly transferred to my hospital’s emergency room. I had never seen such an injury before, and neither had any of my colleagues there present. I did the necessary needful to restore oxygenation, and cardiac output whilst the on-call Consultant surgeon was urgently dug out of his outpatient clinic to provide some surgical eyes-on.

Mr E was a urologist by trade, or in other words he was an expert in kidneys, ureters, bladders and urethrae. However, he was sufficiently old-school enough to remember his general training in abdominal surgery. Within minutes Billy was anaesthetised and his abdomen was being incised. Mr E did what he could to retrieve the prolapsed bowels back into the abdominal cavity, but some of it was already dead or damaged beyond repair. There was also significant bleeding as several mesenteric vessels had been torn. Billy weighed about 15 kg and so his total blood volume was about 1200 mls. A lot of that blood was sloshing free inside his abdomen, and I remember vividly syringing transfused blood back into him. Mr E tied off the bleeders, excised the dead loops and then shrugged his shoulders: He was out of his depth. With Billy in a more stable situation, there was time to seek higher advice. Mr E spoke to his opposite number at the specialist children’s hospital. They wanted Billy to be there right away. The open abdomen was covered with an adhesive sterile dressing and I packaged him up for transfer. A helicopter would have been nice, but there was none available.

And so I took the still unconscious Billy on an extremely rapid transit from the suburbs right into the city’s very heart, all the while maintaining his blissfully unconscious state, and also all his other physiological parameters within acceptable ranges. The ambulance was given a police escort to help it along the way. This comprised one pursuit car and two motorcyclists. These vehicles raced ahead of the ambulance to clear any road junctions and facilitate our rapid progress. Without this, the journey through rush hour traffic would have been dangerously prolonged. The last two miles or so were through the shopping district and the ambulance slalomed violently left and right through gaps between buses and taxis, with lights flashing and siren blaring continuously.

I left Billy in the more capable hands of the children’s surgical specialists after handing over to them in the operating theatre itself, and my technician and I got a taxi ride home with all our kit. Billy survived but with a considerably shortened bowel, a condition he would suffer for the rest of his life.

The reason for this accident was negligence on the part of the pool staff. They had failed to replace the grating covering the drain after routine maintenance. I thought this kind of incident would be a one-off, but if you Google “pool drain disembowelment” you will find such things still happening around the world.

 

 

Customs Exercise

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[Is this the right image? -Ed]

For eighteen months of my career’s fallow period I worked at registrar level at a little hospital just outside the perimeter of a major international airport. We were the natural destination for medical emergencies arising at the terminal itself, or incoming from the arriving jets. There was even a view of the runways from one of the theatre suite’s windows. One of the male nursing staff possessed an air-band radio receiver on which he listened to the pilots and control tower doing their thang while watching the associated action through some binoculars. Yes, he was a rather sad and lonely individual.

My wife, daughter and I lived nearby the airport too. One night before Christmas, we were returning home en famille from visiting friends and as we drove on the main road parallel to the runway, an enormous jet visible only by flashing all its lights, roared into the sky just by us. My daughter who was two asked what that was, in an awed voice. I told her it was “Sannycaws” out delivering presents. Yes, I lied to my nearest and dearest, but then don’t we all, sometimes. Her belief in Santa outlasted many other children’s.

The hospital itself was a bit of an architectural dogpile. A lot of its buildings were survivals from a WW2  military predecessor. Single storey wards were organised Nightingale fashion alternately branching off a central  unheated vine corridor. I walked many freezing nighttime miles around that place during my time there. There was an all night call-order snacking restaurant though, which was very consoling on occasions.

Some parts were ultra-nouveau like the A&E/Theatres and Maternity blocks. While I was there, redevelopment of the older parts of the hospital was commenced. For some reason the builders erected some huge metal fence around the maternity building and its car-park. For me this meant a longer foot-journey from my on-call room to service the labouring mothers’ anaesthetic needs. A major movie about dinosaurs running rampant on an island had recently been released, and I nicknamed the new hospital arrangement “Obstetric Park”. It caught on.

Anyway, one night a blue-light ambulance delivered a young middle-aged patient to our resus’ bay from the airport. The story was that this guy was a “mule” transporting cocaine into this country within his gastrointestinal tract. He had wrapped a whole bunch of drug boluses in cling film and had swallowed them all just before boarding his plane home. He might have got away with it but one of the packets had started to leak during the flight, and he started to feel very unwell as a result. He ‘lost his bottle’ and ‘fessed up his misdemeanour to the cabin crew, in order to save his life. They radioed ahead to arrange an ambulance and police reception for him.

Cocaine is an interesting drug. It is a naturally occurring substance found in coca leaves, and is a local anaesthetic, but also raises monoamine levels (adrenaline, noradrenaline, dopamine, and serotonin) in the brain. It readily crosses mucous membranes which is why it is often snorted or smoked. ENT surgeons use it during nose surgery as it both numbs the nasal lining and also causes the nasal blood vessels to constrict, thus lessening bleeding. It crosses the blood-brain barrier readily and produces both disinhibition and stimulation of the brain simultaneously. Coke/crack-heads become manic as a result. Their brains spend all their excitatory neurotransmitters in one go, but then are left in a state of famine. Ginormous highs followed by humongous lows are the cocaine addicts’ mental weather. Permanent psychotic disease states can result from this monkeying with the mind.

What threatened this patient’s life most acutely though was the effects of the rising blood levels of cocaine on his heart. Local anaesthetics weaken the heart’s ability to beat at all, while overstimulation of the heart causes it to become jumpy and more likely to fibrillate.

This mule was pale and sweaty, and was writhing and vocalising with paranoiac terror. His pupils were dilated and his eyelids retracted. His pulse raced dangerously high and his blood pressure was likewise. To stabilise him I gave labetalol, a mixed alpha- and beta- adrenergic blocker, to protect his heart and circulation from overstimulation. To protect his brain, I gave diazepam and haloperidol. Within a minute or two he stopped thrashing and screaming, and his monitor readings became more normal. However, he was not free of the woods yet. The poison was still leeching out into his innards. He could only be healed by steel.

The resident registrar surgeon was coaxed out of bed by the prospect of some hot operating. Arne was a quick witted and humorous Icelander who was also an excellent surgeon. We had worked together a lot. He swiftly palpated a hard mass in the patient’s epigastrium, and with a wink said to me “Hey Burrito, I think it is time to gas-and-go!*”. Arne, like me, disliked wasting time.

In less than ten minutes the patient was upstairs on the operating table, anaesthetised and having his belly opened. Upon incising the stomach, the problem was plain to see. A huge wad of plastic-wrapped pellets had log-jammed at the pylorus. They were covered in slimy gastric juices. Arne scooped them out by the handful into the waiting kidney dish. There was almost a kilo. Then he examined the rest of the bowels to check none had progressed further along the gut. They were all clear, so he started to close all his incisions up.

It was at that moment that the theatre doors opened inwards and two uniformed men stood framed within the opening. They did not look like police officers. I wandered over to ask them their business. The shorter one explained that they were from Her Majesty’s Customs and Excise, and they were there to impound the illicit substances removed from the alleged miscreant. I looked them up and down: they were both identically dressed in black shoes and trousers, white shirts with epaulettes and dark ties. I didn’t think to ask them for ID. We handed over the evidence after rinsing it a bit cleaner. They bagged it up and then swiftly scarpered. The surgery finished and the patient was taken around to ITU for further stabilisation

To this day, I can’t be sure that those two guys really were genuine officials. Part of me still thinks they might have been the mule’s UK conspirators wearing disguise. The poor mule himself eventually left hospital only to be tried in court and then housed at Her Majesty’s pleasure for several years.

 

*There was a heavily promoted shampoo being advertised at the time with the slogan “Wash and go!”