Blood

*Jermaine was admitted again last night. His story reads like a fictitious case history for a Medical Ethics tutorial. He is *16, with sickle cell anaemia and recurrent priapism. Besides being an excrutiatingly painful condition, it carries the not insignificant long-term consequence (because of damage to the penile vasculature) of impotence. In patients with sickle cell disease, priapism is treated with an exchange blood transfusion. The logic is that by removing sickled cells and replacing them with normal (donor) ones, the vessels will unblock, and the symptoms resolve. However, Jermaine's parents are Jehovah's Witnesses and priapism is not life-threatening, so the usual caveats surrounding children of such parents and blood transfusion do not apply. On this occasion, the issue appears to have resolved itself.

If you are fluent in both Thai and English and live in East London, it seems you could make a small fortune. Our hospital switchboard lists on-call interpreters for Bengali, Hindi, Urdu, Cantonese, Vietnamese, Turkish and Sylheti (in reality, these are 4 women who speak 2-3 languages each), but none of them speaks Thai. A couple of weeks ago a 2-year old was admitted with extensive bruising and a rash over his arms and legs. His platelet count was about 20 (less than 1/6 normal) so the most likely diagnosis was idiopathic thrombocytopenic purpura (ITP), which in very young children usually resolves on its own with time. However the blood film showed a few abnormal white cells, so leukaemia could not be ruled out, and we needed to take a bone marrow aspirate. Now try explaining that to parents who speak about 10 words of English between them. We had no choice but to hire a professional Thai interpreter - at a cost of 200 pounds an hour!

East Enders

[for anyone who's wondering what's been happening to me since mid-july: I've moved to a new city, started a new job (in a new specialty and in a more senior position) and someone close to me has moved 500 miles away. Also, have lost my internet connection in the process and they are trying to charge me 70 pounds to reconnect! Am off sick today so have time to write at last.]
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I stepped out of the hospital yesterday to shouts of "Mang-GO!" "mango-mango-MANG-GO!!" My throat had been scratchy all day, and the thought of sweet, slippery mango going down it drew me toward the grocer's. The stall is manned by 3 Hajis, and among its wares are miniature aubergines, giant jackfruit, grapes, tumeric, and many fruit and vegetables that I don't even know the names of. The said mangoes look and smell tantalisingly ripe. The eldest Haji beams at me through his thick cataract glasses. "What you like?" he asks. "Can I have 2 mangoes please?" I say. "Oh no," he exclaims, sounding almost offended. "No 2 mangoes! We sell BOX! This box 2-pound, that box 3-pound." "Oh." I say, realising of course, that they cater for the (much) extended Bangladeshi family. Observing my dismay, he tries to console me: "nevermind, you buy, keep in fridge." He pauses and notices that I am not impressed by his suggestion and am on the verge of walking away. "Make juice!" he says, exasperated. I make do with a 1 pound bag of oranges instead. It must weigh about 3 kilograms.

Whitechapel market consists of a row of tarp-and-steel stalls that spring up each morning from out of the backs of white Transit vans. My walk to work between Stepney and Whitechapel is never dull, what with grocers and mobile-phone-unlockers setting up to the left of me, and Halal butchers and shops with all the latest Bangladeshi fashions to the right. City slickers in pinstripe suits scrurry in the direction of St. Mary's Axe (better known as The Gherkin) and the financial district, which looms to the west. To the east are Ilford and Essex. All this makes for an interesting collection of patients - but more about my patients another time...

How to take blood from a baby

First, send its parents out of the room.
Amir* is a 9-week old baby boy who has been losing weight since his mother stopped breast-feeding him at 6 weeks. He is now back to his birth weight. He lies in his cot sucking contentedly on a dummy. His baby-gro hangs off him, as does his very skin. He is missing patches of hair from where scalp veins have been cannulated before. Danny*, the senior SHO, knots a small piece of gauze around Amir's arm as a tourniquet. He is crying even before the needle has come out of its sterile packet. Danny bends the tiny wrist forward until the hand is almost doubled back on the arm. The needle pierces his skin and he bawls. He kicks with all his might, but Danny has got his arm pinned to the cot with two fingers.
We finally get into a vein on the third attempt. The veins are so delicate and collapsible that you have to just wait and let the blood drip out. Amir stops crying and takes the dummy in his mouth again. He seems to have forgotten the whole ordeal.