A Ketamine of a Year

One of the first patients I ever gave ketamine to was a forty-year-old man with a nasty open dislocation of his ankle. After having the distorted joint snapped back into place, he burst into tears and told me Jesus had visited him and turned him Irish.  Another patient, an elderly lady with a displaced leg fracture, was entertained by a troupe of dancing cauliflowers while her displaced tibial fracture was being set.  Most patients however report later they recall nothing much after ketamine, and are surprised the unpleasantness is all over so quickly. Some though, have a profound but brief moment of clarity on the way out of the “k-hole” in which they get a glimpse of existential terror.

 

I’ve never had ketamine myself, but after 2020 so far, I feel like I have. A trip to New Zealand in March to see heart-achingly distant adult children morphed into a dissociated weirdness of only seeing them through the glass of an AirBnB isolation house, plus occasional dream-like episodes of jogging through sunny empty city streets.  

In April, folk clapping the NHS in the UK, and fire trucks sounding their bells outside Emergency Departments in New York induced a teary intoxicated pride in being a key NHS worker. It was hypnotic recruiting-band music for selfless public service and the ideals of universal health care. Back in work itself however, clinical care with multiple new PPE rituals to remember, and a nightmarish new disease felt like a flashback to the first anxious imposter shifts as a newly qualified house surgeon dealing with sick patients with the Oxford Handbook open.

 

The summer months carried on into a sort of timeless partially sedated unreality. FFP3 masks, sticky hand gel, and yellow & black chevron tape on the floor. Endless Zoom calls into colleagues’ front rooms with their ensemble cast of young children and pets. All formed the blurry backdrop to a drama increasingly devoid of ongoing serious action. Painful stimulation to a higher Glasgow Coma Score mostly only came from new intolerances of other people’s behaviour: a mask under the nose in the supermarket or anti-vaccine posts on social media the equivalent of a brisk sternal rub.

 

Now the 2020 emergence phenomena are starting to break through with flashes of panicky alarm. Second waves, economic collapse, mental health crises, racism, climate change and anarchy all smashing through the bathroom door with Jack Nicholson grins announcing a serious intent to mess you up. If this were happening to a patient, we would do two things. Reassure them they are safe and that this will quickly pass. Then reach for the Midazolam to smooth their passage back to sentience and rationality. 

 

As 2020 moves to the autumn of its unpleasant and bizarre k-hole, there is unfortunately no sign yet of the confident clinician with the calm voice and a big syringe of normal.  Perhaps eventually, after the cauliflowers stop dancing, and we no longer feel compelled to speak with a Dublin Brogue, it will all seem to have passed in an instant. We will wake up groggy, but with all our essential parts back where they should be.

Totally Inappropriate

There were ten mourners at James’ funeral; two paramedics, two staff from Gregg’s bakery, and six staff from the A&E department. 

The paramedics brought James to A&E every morning after a 999 call for “man with SOB”. The A&E staff gave James his morning COPD nebuliser with a cup of tea, and the Greggs staff across the road gave him a breakfast pie after he was discharged. He spent the rest of the day walking around with his tartan shopping trolley before returning to his bed in a hotel doorway.  He always refused admission or social work, and never saw a GP. James was an inappropriate A&E attender. He should not have been there contributing to overcrowding. 

Inappropriate attenders roll in across the shift.  An older woman with new abdominal pain and vomiting whose worried spouse very reluctantly called an ambulance for her. A middle-aged builder, who for the first time ever, self presents with the worst headache of his life.  A diabetic man books in with new chest discomfort after a heavy meal last night. Two CT scans, a couple of ECGs, a bunch of blood tests and all are discharged home. Total waste of resources - A&E over-investigate everyone.  Gastroenteritis, migraine and reflux are never investigated like that in primary care. If only they could be redirected we would save a fortune and A&E would have enough space for proper emergencies.

  

Across in minors other inappropriate attenders wait and wait. Swollen optic discs from the optician, blocked catheter from the district nurse, intractable back pain from the physio, suspected drug ingestion from the police cells, suicidal thoughts from the social worker, post –op wound infection from the private surgical clinic, off legs from the nursing home, needle stick injury from the medical ward.  If only all these patients realised just how busy the ED is tonight, they would have thought twice about following the instruction to book themselves in - especially as there are no cubicles because of properly sick patients waiting hours and hours for a bed in a very full hospital.

The minister at James’ short crematorium service said he was glad that James had people who looked out for him:  “It is such a comfort that the A&E department always keeps a light on for any and all of us whenever we are sick and have no-one else to turn to”.  

Bizarrely, the four-hour target didn’t improve after James died.

NHS Tattoo

I think I need to bite the bullet and just get the NHS logo tattoo on my arm I’ve been thinking about for the last 20 years. I’ve nearly had a tattoo only twice before. The first was on the Incirlik Air Base, Turkey in 1991 en route home after the Kurdish Refugee Crisis. The American Army tattooist was however decidedly opposed to adorning the arm of a tipsy British civilian medic with an enormous campaign eagle. The second was after completing the Rangitoto Swim in Auckland. I’d promised myself a volcano tattoo if I managed the 4.6k open water crossing in a wetsuit, but was put off after being overtaken by bunch of teenagers effortlessly completing the swim in just their shorts.

 

The reason why I want the NHS tattoo now more than ever, is that over the last four weeks, I’ve realised it is my existential axis. To me, it is simply the best idea in the world: the ultimate demonstration of a civilised country, a pinnacle of social evolution. I’ve worked in it since I graduated, with the exception of an eight-year stint in its New Zealand equivalent. I’ve belligerently defended its many failings and faults, citing the sheer universality and measureable efficiency of it as a system. It is the Sydney Harbour Bridge, the Hoover Dam, the International Space Station – a massive visible-from-space triumph of collaboration, equality, courage, vision and public expenditure. I have taken great pride over the years in delivering exactly the same health care to the homeless drug addicts and asylum seekers as to Members of Parliament and celebrity sportsmen. Even in the many interminable management meetings, in which any kind of binding decision comes as a pleasant surprise, the break point is always what provides best care for patients.

So after the last four weeks in New Zealand Covid-19 quarantine and then lockdown, having spectacularly mistimed a visit over to see my two adult sons, I find the gravitational pull back to my Glasgow NHS team overwhelming. Getting back to answer this visceral call is not easy. Multiple flights have been booked, then cancelled by the airline and not refunded. I’ve started to feel like a spawning salmon instinctively drawn to its home; leaving the calm, safe, sunny waters of Auckland, and the comfort of being within a 500 mile radius of all my children (even if I still can only Skype them), to leap upstream into the uncertainty of working in a Scottish Emergency Department during a novel pandemic.

Emergency Medicine doctors always have a sense of FOMO when big thing are happening and they are not on duty. They have an intense desire to be part of the action, do a great job and receive the dopamine squeeze, inner validation and external acclaim that follows. This time it is different as there is real uncertainty, and risk, both physical and mental – but the sense in the NHS of resolve, camaraderie and destiny is not only palpable, it is reflected in the reactions of the public as they applaud in the streets. This respect for the NHS as both an entity and an idea resonates within me like a harmonic frequency. Every pub argument with a private healthcare supporter, every tough A&E night shift wrestling with drunks, every email written to document gaps in care suddenly have context and purpose.

Perhaps my NHS tattoo won’t actually happen. I expect like the eagle and the volcano, there will be others who already deserve one much more by the time I’m back moaning about yet another backshift in Minors.