The Jesus Nut

This is quoted from a little thing I found on the internet just now:

One day, long ago and far away, I
engaged in shoptalk with a helicopter
pilot who told me a story that
fundamentally changed my perspective
on the world.
We were discussing the kinds of
things that can go wrong with a
helicopter, especially when flying over
terrain inhabited by angry people with
automatic weapons. This pilot had been
shot down twice, and each time he had
brought his damaged craft to the ground
with no significant injuries to the people
in it. He was, as are many young pilots,
confident: “No matter where you’re hit,”
he said, “there’s always something a
good pilot can do to adjust and get his
ship down and keep his people safe.” He
paused, “Except when the Jesus Nut
goes.”
The Jesus Nut, he explained, is the
nut that secures the main rotor to the
aircraft. If this nut comes off, the main
rotor detaches, the chopper drops like a
stone, and those in the helicopter “meet
Jesus.” And, the pilot added, the cause
of the Jesus Nut coming off is invariably
a human failure to check that it was
securely fastened.
I remember thinking that the pilot
was pulling my leg. “Come on,” I said,
“checking the Jesus Nut has to be the
first and last thing every crew chief and
pilot does before takeoff.”
He countered with, “What’s the first
rule in baseball? ‘Keep your eye on the
ball.’ Ever take your eye off the ball?” I
admitted I had taken my eye off the ball
more than I cared to remember.
“It’s not that people don’t realize that
something is important,” he said, “but
they get distracted, and people who are
distracted have a great capacity to forget
the stunningly obvious.” In my mind’s eye
I can still see and hear him make his
point, and I knew intuitively that he was
right. He added that, when he was in
flight training, the school commandant
made all the candidates listen to the
recording of the last transmission from a
helicopter whose pilot had not checked
the Jesus Nut before takeoff.

One of the helicopter pilots who used to ferry me around, was the first to tell me about the “Jesus nut”. His own flight instructor used to secretly carry not the nut itself, but its locking pin, an equally vital component, with him during the flying lessons. The pin prevents the nut from becoming undone due to vibration etc. At exactly the right point in the student’s training, when the student was absolutely certain that they were God’s gift to helicopter pilotry, the teacher would fish out his little treasure and show it to the young man or woman actually flying the craft.

“Hey, look what I found on the grass just before I climbed aboard” he would say with feigned smiling innocence. “Have you ever seen anything like it before?”

The pilot, still high as a kite on their mastery of the collective and cyclic controls and other complexities of controlling a rotorcraft, would glance over, recognise the offered gem, and then suddenly lose coordination of the craft as the blood drained from their head and despair filled their heart. The training ‘copter would inevitably pitch, yaw, roll and spin in consequence. The instructor calmly took over control of course: there were no crashes or headlines. It was really a very private humiliation all arranged purely for the eternal betterment of the young pilot. There’s nowt more groundbreakingly powerful than a young whippersnapper being shown for the first time their ever-present risk of mortality: their own and that of others under their care.

Safety is always first. Always. Always. Always. Before ever leaving the classroom to explore one’s future working environment, the basics of this principle are universally proclaimed. This is sadly also universally greeted with the bored youthful refrain of “Yeah yeah yeah whatevuhhh!”

I hope to return to this interesting topic in future posts.

Jesus_nut

“A nut in the hand is worth less than one on the bush!” (Apologies to any engineers and squirrels who may be reading)

 

 

 

 

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For The Sake Of The Fox

red-fox2

Let’s not all go chicken, eh?

I wrote this last year, 2016.

Some years ago, while preparing an asleep patient for major bowel surgery, I blurted out “Oh, for fox sake!!” This was triggered by some hassle with the equipment I was using.

(I have a whole arsenal of euphemistic exclamations with which I avoid blasphemous or profane speech: Oh sugar! Cheese and crackers! FFS! etc.)

My surgeon colleague, a big burly and jolly Muslim from Yemen took the time to ask me why I was imploring the blessing of a fox. He genuinely wanted to know.

Speaking straight off the top of my heart, this was my reply:

Once upon a time, when this part of the world was called Christendom it was common to upbraid a falling fellow with the words “For Christ’s sake!”.

Sadly, in this post-Christian society Christ’s name has become taboo, it makes people uneasy, and so people use a vulgarity like “f**k’s” instead when they emote. I cannot abide with vulgarity in everyday speech so I use the word “fox” in its place.

Does that answer your question?

Everyone in the operating room had listened to this unexpected exchange and were moved by it. There was a short silence and then my Muslim friend smiled and nodded with understanding. He clapped me on the shoulder and laughed. “I never expected such an elegant answer”, he said.

Even in my dwindling professional capacity, I have many letters after my name. I am thinking of adding “FFS” to them as I increasingly utter those words while I battle to maintain my sanity working in the UK’s Notional Health Service.

-Dr B. Burrito BA BM BCh FRCA FFS

Stone Soup

stone

This is a typical soup stone but I don’t know which variety: Unfortunately the label has come off!

This is a retelling of an old Wisdom story. I honestly can’t claim any of the credit 😉

Once upon a time, somewhere in post-war Eastern Europe, there was a great famine in which people jealously hoarded whatever food they could find, hiding it even from their friends and neighbours.

Three soldiers trudged down a road in a strange country. They were on their way home from the wars. Besides being tired, they were hungry. In fact, they had eaten nothing for two days.

“How I would like a good dinner tonight,” said the first. “And a bed to sleep in,” added the second. “But that is impossible,” said the third. On they marched, until suddenly, ahead of them, they saw the lights of a village. “Maybe we’ll find a bite to eat and a bed to sleep in,” they thought.

Now the peasants of the place feared strangers. When they heard that three soldiers were coming down the road, they talked among themselves. “Here come three soldiers,” they said. “Soldiers are always hungry. But we have so little for ourselves.” And they hurried to hide their food. They hid the barley in haylofts, carrots under quilts, and buckets of milk down the wells. They hid all they had to eat. Then they waited.

The soldiers stopped at the first house. “Good evening to you,” they said. “Could you spare a bit of food for three hungry soldiers?” “We have no food for ourselves,” the residents lied. “It has been a poor harvest.”

The soldiers went to the next house. “Could you spare a bit of food?” they asked. “And do you have a corner where we could sleep for the night?” “Oh, no,” the man said. “We gave all we could spare to the soldiers who came before you.” “And our beds are full,” lied the woman.

At each house, the response was the same — no one had food or a place for the soldiers to stay. The peasants had very good reasons, like feeding the sick and children. The villagers stood in the street and sighed. They looked as hungry as they could.

The soldiers talked together. The first soldier called out, “Good people! We are three hungry soldiers in a strange land. We have asked you for food and you have no food. Well, we will have to make stone soup.” The peasants stared.

The soldiers asked for a big iron pot, water to fill it, and a fire to heat it. “And now, if you please, three round smooth stones.” The soldiers dropped the stones into the pot.

“Any soup needs salt and pepper,” the first soldier said, so children ran to fetch salt and pepper.

“Stones make good soup, but carrots would make it so much better,” the second soldier added. One woman said, “Why, I think I have a carrot or two!” She ran to get the carrots.

“A good stone soup should have some cabbage, but no use asking for what we don’t have!” said the third soldier. Another woman said, “I think I can probably find some cabbage,” and off she scurried.

“If only we had a bit of beef and some potatoes, this soup would be fit for a rich man’s table.” The peasants thought it over, then ran to fetch what they had hidden in their cellars. A rich man’s soup, and all from a few stones! It seemed like magic!

The soldiers said, “If only we had a bit of barley and some milk, this soup would be fit for a king!” And so the peasants managed to retrieve some barley and milk.

“The soup is ready,” said the cooks, “and all will taste it, but first we need to set the tables.” Tables and torches were set up in the square, and all sat down to eat. Some of the peasants said, “Such a great soup would be better with bread and cider,” so they brought forth the last two items and the banquet was enjoyed by all.

Never had there been such a feast. Never had the peasants tasted such delicious soup, and all made from stones! They ate and drank and danced well into the night.

The soldiers asked again if there was a loft where they might sleep for the night. “Oh, no!” said the town folk. “You wise men must have the best beds in the village!” So one soldier spent the night in the priest’s house, one in the baker’s house, and one in the mayor’s house.

In the morning, the villagers gathered to say goodbye. “Many thanks to you,” the people said, “for we shall never go hungry now that you have taught us how to make soup from stones!”

Carrion Regardless

One hot sweaty summer many years ago, the grotty old operating theatre block where I worked suffered an infestation with houseflies and bluebottles. It was of Biblical proportions, and because of health/safety and infection control worries, all operations were postponed until the problem could be addressed.

It took a while before action was taken, however as the plague was of gradual onset. The insects didn’t all turn up at once blowing trumpets! Even modern hermetically sealed theatres get visited on occasion by a lone ninja blow-fly. The sly little blighters find their way through the maze of corridors and swing doors, by tailgating staff as they go about their duties. Presumably they follow the delicious scent of surgeons operating which gets carried downwind by the powerful air stream that is always flowing through an operating suite. Once they get into the OR itself, a mild panic usually ensues. Orthopaedic surgeons who are particularly obsessed with sterility react the worst. It must be very frustrating for them encased in their sterile space-suits to be driven berserk by a tiny tormentor which they cannot even raise a hand against to swat it, for fear of becoming contaminated.

The great unscrubbed are therefore relied upon for extermination. We can’t use insecticide sprays because they can interact with some of the anaesthetic drugs, and they are too messy anyway. One solution is to turn off all the lights and then open one door. Freddie the fly usually will head for the proffered brighter future and promptly leave the room with the door being slammed behind him. Various aerosols have been tried. Surgical spirit is useless: you literally have to drown the fly before it stops kicking. If you try to spray them on the wing, they just lick their lips and soar on. Maybe they get an alcoholic kick out of it.

Plastic spray, normally used for wound dressing, has been tried. It certainly gums up their works, but the fallout and collateral damage are unacceptable: The solvent can destroy precious surfaces and you don’t want sticky residues left everywhere. I have had some success with ethyl chloride which is a very volatile liquid used to rapidly cool skin. It boils away instantly thus freezing whatever it touches. When you depress the nozzle a fine stream of clear liquid emerges with considerable force. This allows for sniping the enemy from a significant stand-off. Heat-death is instant, but this can’t be used against a moving target.

The most impressive take-down was demonstrated to me by a colleague. A particularly large and hairy specimen had survived multiple attempts on its life and was currently strolling around upside down and far above us on the theatre ceiling. From time to time it would pause and look down on us with a smug and superior expression on its face, rubbing its hands gleefully, or so I imagined. If I had ears to hear, I wouldn’t be surprised if it was blowing raspberries or yelling “Yah boo sucks” at us. The operation was on hold during all of this. My colleague nipped out to the office and returned with a big chunky rubber band. “Watch this!” he said, before stretching his weapon over his thumbnail and taking aim. 3…2…1…BANG and the bug was gone! One shot, one kill!

Gaping with amazement, I asked him where he had picked up that skill. Smiling sheepishly, he explained that while growing up in a rural tropical paradise, he had gotten plenty of practice in!

[Let’s get back to the headline topic please -Ed]

So back in the summer of Beelzebub, at first we just seemed to be experiencing a larger number of unwelcome pests than normal. The penny dropped when someone switched on the X-ray viewing screen one morning. The fluorescent tubes behind the large rectangular frosted glass panel flickered on. There then appeared the shadows of about thirty large insects running around on the inside of the screen. For all the world, they looked like they were kicking an invisible football about!

Clearly there was something seriously wrong with those theatres. Management were shown this incontrovertible evidence and credit to them, immediately suspended all operations. Engineers were sent into the plant rooms upstairs, and eventually discovered the rotting corpse of a large gull. It must have found its way in and become trapped. It then died of thirst or hunger, or perhaps loneliness-it left no note. To give it a good send-off, all the local insects of putrefaction threw a feast in its honour, and many maggots got to see the light of day. These eventually grew wings and set off in search of food. Some found their way into the wall cavity and then into the X-ray screen. Others found their way into the operating theatres below.

The dead bird was bagged up and sent to the incinerator. Every clinical area was kitted out with those electric bug zappers mounted high on the walls. The theatres began to resemble a high street butcher’s shop. From then on, the beeps, alarms, hisses and buzzes of a normal theatre were added to by an occasional fizz-bang-flash, as another one bit the dust. We were able to assure patients that their operation would be performed in a “No Fly Zone”.

Plans for a new theatre block were also set in motion, but I left that hospital long before they were realized.

 

Modified by CombineZP

“Take me to your bleeder”

(Picture: By Arjan Kop – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=61440544 )

A Nasty Injury

As a medical student I was dawdling and lolling about one day in the Casualty department when the screech of ambulance tyres awoke me from my daydreams.

A young woman was rushed through on an ambulance trolley to the resus’ room. She had been involved in a high-speed road traffic collision and was in a very bad way. She was very pale and shocked, and was thrashing around unhelpfully. Clearly, her brain was being starved of blood. There was hardly a mark on her, but her abdomen was very distended. The anaesthetist put her off to sleep and took over her breathing. Her blood pressure was awfully low. In those days, getting a CT scan of her abdomen was a tediously long-winded process and to be frank, she would be dead before the results were viewable. There was only one investigation possible: ‘Naked Eye Imaging”. In other words, take her straight to theatre and open her belly.

In such situations, the first and most important step to take is to take the brakes off and wheel the patient straight over to the nearest vacant operating venue. Indecision and faffing around can be rapidly fatal. The crew that day were all on the ball and in the groove. In no time at all, the patient was in theatre and a gaggle of surgeons was gowned up, and leapt to work.

Her abdomen was opened swiftly and a tsunami of blood came out spilling freely onto the floor. The surgical suction devices were simply overwhelmed by its quantity. Meanwhile, at the top end, the anaesthetists were pumping O negative blood into the patient as fast as the blood bank could provide it. This wasn’t just a massive haemorrhage, it was a SUPER massive one.

Because the blood was welling up so fast, the surgeons couldn’t see where exactly it was coming from. As the patient became completely exsanguinated, the flow stopped long enough for them to see that there was a tear in the vena cava (VC) just behind the liver. This explained the massive blood loss: the inferior VC carries all the blood from the lower half of the body back to the heart. They clamped the VC in the abdomen but the rapidly thinning blood continued to pour out from above the tear. Because the injury was hidden behind the liver, there was no way to clamp the VC above it.

It looked like a surgical check-mate. It was at this moment that Alf’, the single handed* veteran cardiothoracic surgeon wandered into the theatre, alerted perhaps by the pandemonium coming from therein. In seconds, he apprised the situation, scrubbed, gowned and gloved up, and squeezed in near enough to access the patient’s groin area. He sliced the skin and with his fingers exposed the femoral artery and vein. He inserted the largest available Fogarty catheter into the vein and advanced it up into the VC and past the tear. The VC was briefly unclamped to allow the catheter through. Then he inflated the balloon in the bit of the VC just above the tear.

The bleeding stopped completely. There was a very audible sigh of relief from everyone there. Granted this breathing space, the patient received plenty more blood and plasma. Her blood pressure began to approach normal levels. The frantic theatre burbling became less shrill and more chilled. Good old Alf’ had done it again!

Meanwhile, Alf’, the most humble and unassuming of people, checked that everyone understood what he had done, stripped off his surgical garb and left the theatre with a cheery wave and a chuckle. Perhaps he went to have a cup of tea and read the paper. He really was the most ordinary of workmen!

With the bleeding controlled, it was relatively easy to mobilise the liver and repair the big badly torn fragile vein. The clamps and catheter were removed. The repair proved to be blood-tight, and so the patient was closed up and taken to ITU for some R&R (Resuscitation and Restitution). A few stormy days later, she left ITU and went to the ward, and from there she went home with no lasting deficits.

So why did this patient survive her nearly fatal injury? With the benefit of 30+ years hindsight, let me offer some suggestions:

  1. Her trauma happened just a short distance from a big hospital
  2. Her ambulance crew got her to the hospital with no delay
  3. She was young
  4. The whole shebang of medics/nurses/etc. were top notch and wide awake
  5. No time was wasted with useless investigations
  6. The Blood Bank staff didn’t act like mean-spirited jobsworths
  7. The genius surgeon Alf’ was on the premises.

The young lady was clinically dead (ie pulseless) on several occasions during this episode. Her body temperature was very low due to exposure at the scene and all the cold fluids and blood she received. This protected her brain, I’m sure. Her blood ran as thin as dishwater for a lot of the time and had no ability to form clots either. Her injury happened because of the rapid deceleration during the crash. Her seatbelt probably caused intense shearing stresses upon her liver, thus tearing her VC.

All in all, I learned a lot that day in medical school. Alf’ got added to my list of heroes. I will give him a proper tribute anon.

*Alf’ actually possessed two well-functioning hands but he lacked any peers of equal rank. He was thus sentenced to be omnipresent at the hospital, ever ready to fix serious probs. I imagine his poor wife only knew if he had been home when she discovered the toilet seat was up 😉

ivc-geeky-medics-right1

This image might help the reader to understand, but then again it might not. The tear was at about T10. Alf’s balloon catheter was positioned around T8-9

 

 

My Heroes, Part 2: The Nutty Professor

Jerry Lewis

I shall die one day remembering many things from life, no doubt. Among them will be the short year I spent under the tutelage of the Professor of Nutcracking Anaesthesia.

It was the first and last time I ever met a person of such utter genius who was also laced with at least a triple measure of mania. That latter serious affective mental disorder, out of all those listed in DSM-5, is the only one  I’d go for if I had to make a choice. [Can someone call the CPN, I think BB is having a breakdown-Ed]

He was legendary for his lectures, every one of which was unique: His knights move thinking made it impossible for his listeners to know what he was going to say next. His knowledge of all areas of anaesthesia was greater than encyclopaedic. He knew and thought about stuff that the rest of the world was not even aware could yet exist.

One afternoon on a whim, he decided to hold mock viva voce examinations to prepare his registrars for their forthcoming RCoA exams. He assembled some Consultants and senior registrars to help him.  We all went forward to be tested. I ended up in front of the Prof. and his lieutenant.

“Tell me, young man, about the physiological changes that occur during pregnancy”, he said.

Partly star-struck by the Professor, and partly overwhelmed by the huge breadth of the question, I started to nervously stammer very badly: “Well, errh, errh, the woman’s breasts can become greatly enlarged during pregnancy…..” I blushed severely as I realised what a hole I had just dug for myself.

I tried to explain how excessively enlarged mammary glands can become problematic during anaesthesia due to how they might impinge upon the front of the neck thus endangering the safe management of the patient’s airway or how their weight on the supine ribcage might impede respiration.  I burbled on for a minute longer. Honestly, guv, like any good anaesthetist, I was just trying to answer systematically, starting with ‘A’ for Airway and B for Breathing.

To a casual observer, however, I must have sounded like a dirty little tabloid-reader.

I then sincerely suspected that my examiners shared some characteristics with those children who enjoy pulling the wings off of bluebottles and drowning them in bleach. My two interrogators’ eyes appeared to light up at my answer and they moved in for the kill, or so I thought at first. My words trickled to a full stop.

“Is there anything ELSE you would like to tell us about anaesthesia in pregnancy?” the Professor asked, smiling, to my surprise, quite unmaliciously. His colleague at the table was desperately trying to stifle his giggles. I clammed up as I claimed my right to silence and shook my head.

I then realised what exactly had happened: They had deliberately un-footed me, I had been sent flailing and thrashing under true exam conditions. This was exactly what I had been sent there to learn. It wasn’t a test of knowledge at all, it was a test of performance under intellectual combat.

I was dismissed briefly to allow the next victims to be tested.

At the feedback session a short while later, I was commended for inadvertently entertaining my examiners by my unexpected opening answer. It transpired that none of us had covered ourselves in glory that day.

Then the Prof invited us all down to the hospital bar for a few consolation beers, with the first round on him. All but the girliest swots of either sex joined him. The funny thing was that as the wee swallies began to sink in, the often hard to follow Professor started to make much more sense. I suppose in the early stages of inebriation and disinhibition, we were ascending up to his normal level of consciousness, or less likely he was descending to ours.

[More stories about the Prof. coming soon]

 

Take Five Pigeons, and One Dove – Part 1

Before I summoned the courage and the cash to purchase my own dwelling I lived in a successive variety of hospital accommodation which was of very variable quality. It reached its nadir at the teaching hospital in 1990. It was a long narrow room with the bed behind the door and a window at its far end offering views of endless brickwork, the nurse’s home and, with a severely cricked neck, even the sky. There was a sink for shaving at and a few cupboards in which to hang one’s clothes. All in all, it was a cell barely fit for a Trappist.

There was a big chunky radiator just under the window which was on 24/7/365 rendering the room intolerably warm. I thusly opened the window a few inches to let some cool fresh air in. And so my adventures began.

There was a phone on the bedside table, all the better for summoning me to my duties. One morning as dawn was cracking, it rang brilliantly. Summoned from my light coma, I reached out for the handset and my fingers closed upon something solid but which was not a phone.

It was a bloody pigeon! And I had it by its neck!

Imagine the scene: We were both of us in a state of undress and scared shitless. To ram the point home, Mr (or Miss) Pigeon began to besmirch the furnishings  with its indeliberate droppings. With the phone still urgently ringing, I raced over to the window and thrust the poor wee beastie outside to let it regain its freedom.

I then answered the phone only to discover that it was a wrong number!

This was the first of my encounters with the city’s pigeons. That poor critter had obviously entered my room through the open window in the night, seeking only warmth and shelter. It must have spent its time all night observing my prostrate snoring form before I awoke and nearly throttled it.

Here is the silly video link you are all expecting:

To be honest, it is a very catchy and memorable song.

My Heroes – Part One

{There is no image with this post as the subject was too modest to leave any]

During my career I have met many inspiring people. This is my tribute to them.

My first was a radiologist called Basil Shepstone. I first encountered him during my first year at medical school, while we were dissecting cadavers as part of our learning human anatomy. He came to teach us about X-rays and their use in diagnosis. He was very drily droll with his clipped South African delivery and hang-dog demeanour. All I can remember of the content of that lecture was that “radiograph” was a misnomer. Strictly speaking a radiographic image should be called a “radiogram”. We all hooted with laughter as we remembered en masse that a “radiogram” was the popular name in the 50s, 60s and 70s for an ubiquitous household item on which one played vinyl records and listened to the radio.

I ran into Basil on many further occasions during my training and was always left in awe of him. He was a cheeky blighter who for instance would introduce his beloved spouse at social gatherings with the words “This is my first wife”.;)

He was a rich source of witty remarks and insights and I loved him dearly for this, but I have sadly forgotten most of them. I remember mainly his rich persona, great warmth and humour. So inspired was I by him I even considered pursuing a career in radiology.

One of his sayings lives on with me even today: “I hate semantics, in fact let it be put on the record that I am fiercely ANTI-SEMANTIC!”

Of course, he was parodying the always horrible concept of “anti-semitism”.

May Basil Shepstone requiescat in pace. Amen.

PS: Here is a link to an obituary that Basil wrote about one of his colleagues who pre-deceased him. I think it perfectly demonstrates what a kind and wise soul dear Basil possessed:

https://www.rcr.ac.uk/college/obituaries/dr-colin-henry-woodham

The Nokandu Training Room

I just rediscovered this old jokey blog I created 7 years ago with the help of “Yoda” 😉

“Nokandu” is my favourite martial art as it involves no physical contact, just a firm desire not to get involved with anything dodgy, such as a cold caller from abroad trying to get your trade. In English, it translates as “No can do”.

Ye Little Green Ale'y Inn

Here, yoda will answer any queries on his spiritual art and practices, called Nokandu.

All practitioners, of any experience level, are invited to contribute to the stream of yoda’s wisdom.

A. May the Force be with us!  R. And also with them.

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