Stupider and stupider

I used to be fairly intelligent. I used to know things, to grasp concepts quickly, to 'accidentally' memorise people's telephone numbers etc. I used to be good at puzzles. Perhaps it has to do with working nights and not sleeping enough, or the mind-numbing nature of my job, but my mind feels increasingly dull, clouded over. I have an exam in January, but my brain now seems resistant to retaining new information. I used to absorb reams effortlessly at one sitting, but now it is all I can do to memorise the aetiology, presentation, treatment, prognosis of 3 or 4 diseases each time I sit down to read. I can't seem to think laterally anymore; feel stuck in a rut, slow, thick, old.

Early morning existential crisis

At 7 o'clock my bleep went off - unusually, it was the Neurorehabilitation ward. *Mohamed, a 12 year-old recovering from a head injury, was complaining of pain in his chest. "Is he short of breath?" I asked the nurse, immediately thinking of pulmonary embolism or a sneaking pneumonia (being confined to his bed he was a sitting duck for both). "No, his resp rate is 20, temperature 37 (both normal), bp 105/59. Heart rate is 90 and he's a bit anxious." If it was a PE it wasn't a massive one. I didn't have to run.
I'd actually been pleasantly surprised to hear of Mohamed 'complaining' of anything; he isn't one of my usual patients, so the last time I'd seen him was the last time I was on nights, about a month ago. He'd just arrived from India, having fallen 40 feet from some scaffolding while on holiday at his grandparents' house. He was admitted to hospital in India, where they'd pretty much given up on him. There had been no physiotherapy and he was 'not for resuscitation'. They'd made a half-hearted attempt at nutrition - he couldn't swallow, so a makeshift PEG tube (actually a urinary catheter) had been shoved through the skin of his abdomen into his stomach, and he was fed pureed vegetables through it. He was emaciated, unable to speak or move any of his limbs. But he didn't die, so his parents brought him back to London.
I examined Mohamed, and satisfied myself that his chest sounded entirely clear and the pain was most likely muscular in origin. I told him so. I asked him if there was anything in particular he had been worried the pain might be. No, he said, but he had a question for me. "You know, in my religion you have to read the Book, and then you can go to heaven. I am in here twenty-four seven, I don't know... is my God angry with me? I try to memorise the Book, it has 30 chapters, but I have only memorised one..." I paused. "You're asking a difficult question," I said, at last. "It doesn't have an answer I can give you in one sentence. From what I know about what happened to you, it was an accident. And bad things often happen to people who don't deserve them." I waited for him to speak again. "I want the hospital Imaan to come and teach me the Book." he said. He said this with an urgency that made me realise he feared he was dying, running out of time. "Do you remember the last time I saw you? You were in that little room over there, and you couldn't speak." "Yes," he said, "and soon I could point to alphabets on a board." "You're getting better," I said. "We don't know why this happened to you, but you're recovering from it well. I've had a good look at you and I don't think there's anything wrong with your heart or your lungs. I'll make sure someone gets the Imaan to come and see you today, ok?" He nodded.

an unfortunate sequence of events

JD lifted his leg off the bed yesterday (a Sunday - I hate working Sundays). Have been wanting to write about him for days, but have been too self-absorbed lately (multiple unresolved issues in personal life; the spectre of loneliness, the dilemma - limited self-induced heartbreak now or potential soul-destroying heartbreak in the future; a badly timed wedding invitation from an old school friend. Oh, and I hate London).
Anyhow, JD is a 13 year old with sickle cell anaemia, who a few months ago discovered a lump in his neck. A biopsy revealed it to be Hodgkin's Lymphoma. The sparkly New University Hospital was having a few problems with its operating theatres, so he came over to Inner City Hospital on Thursday to have a line inserted for chemotherapy. After the operation he seemed a little slow to get back on his feet, but by Friday morning had sat up and even managed to have a row with his dad. On Friday afternoon I thought he looked drowsy, and a closer examination revealed that he couldn't move his left side - at all. Uncharacteristically for a Friday afternoon (or I am just being cynical), we managed without too much wrangling to get an urgent head CT, which confirmed the worst - JD had had a massive stroke. He'd also had a carotid artery dissection. My job on Saturday was to carry out his second exchange transfusion (read first link for explanation) - this involved cannulating a vein so that JD's blood could be drawn out (manually with a 10ml syringe - gives you thumb cramp) while donor blood was infused into his newly inserted line. It took several hours. I also had to explain things to his mom, which was difficult, as I have only just (now) had the time to read up about stroke in these circumstances. I explained as best I could from my understanding of stroke in adults, stressing that the next 48 hours would be crucial and that JD's final ability/disability would not be evident until weeks or months later.
JD remained in a haze all weekend. His dad turned up on Monday, and having examined JD on the evening ward round and answered a few of dad's questions, was turning to leave when he said "doctor..." I stopped. "Can I have some Pringles?" he breathed, through the right side of his mouth.

an innate defense?

Woke up at 9:00 today with a pounding headache and nausea. Called in sick, but felt so guilty I still went in at 17:00 to do my on-call tonight. I was sure I had set my alarm clock, but while I had adjusted the alarm to 07:00, had accidently neglected to switch it on. I feel (physically) much better for sleeping in (slept until lunchtime today, then tidied up for the first time in weeks). Perhaps if I had set my alarm clock I would have been well on my way to killing myself from overwork. (Certainly came near to collapse on Saturday) I did long days (13 hours shifts) on monday, friday and saturday of last week, would have had one today, have got one on wednesday and one on sunday. With only coming saturday off in what would have been 21 consecutive working days. Perhaps my body is trying to tell me something. I can't win though. Every time I take days off, I have to swap all my on-calls, therefore doubling the on-calls before and after my holiday. So I spend my holiday being ill and then come back to...Hell. Yes, my life at the moment is a living hell - chronic sleep deprivation (by far the worst thing) and trudging up and down corridors with a bleep that goes off continually. Being so utterly worn out on your one day off that you are unable to enjoy the people and things you value in life. I have nothing interesting to say today. Work ceases to be interesting when it becomes all-consuming.

Indignation

..belatedly reading the BMJ from 24 Sept 05, which reminds me how angry I am about the BMA's "neutral" stance on euthanasia. Doctors have a responsibility to take a stand. It is all very well quoting people's experiences of their relatives' deaths, but each bereaved individual has only that to draw on - an intensely personal experience (or at most, a handful of experiences) at the deathbed of someone they love. No matter how strong a lay person's system of religious or ethical beliefs, they simply do not possess enough knowledge of the workings - physiology, pathology, pharmacology etc. of death, and have certainly not seen enough of it (in the setting of home or hospital). In my 6 months as a medical house officer, I saw at least 5 dead or dying people a week; often, I would have to explain things to their families, and help comfort them. I prescribed countless diamorphine infusions and other palliative measures, and have been present both at resuscitations and at discussions of do-not-resuscitate orders. And that's just me as a doctor freshly out of med school. How much richer and more complex must be the understanding of more experienced physicians. And how unspeakably irresponsible of them to abstain from making a public statement for or against euthanasia.

clinic again

Day 2 of Ramadan. *Ahmed, the other SHO on my firm, is feeling the effects of hypoglycaemia. "Aahh!" he groans, "you know, I have this bad headache. I think I need to leave early." I am just about to offer some paracetamol when I remember that he is, as they say, nil by mouth.

I saw three patients in clinic today - still frustrated by my own inefficiency. Everyone else saw between 6 and 10. Although I guess I have the added challenge of fobbing off the dumb bleeps from nurses on the ward (and taking any calls from A&E) so that the registrars can get on with actually running the clinic. I like clinic because it is a team effort. There is a long list of patients (usually 30 to 40) to be seen, in theory, by one consultant and one registrar between 09:00 and 13:00. These are all children with chronic haematological disease (mostly sickle cell anaemia - we have the largest clinic in London), and its attendant effects on growth, development, education, home etc. so there is a lot to discuss with each family. Some patients need vaccinations or blood tests, or letters to the Council regarding housing or Disability Living Allowance, and each patient's GP needs a letter detailing the encounter. In short, it is a lot of work, and we all pitch in. Apart from the new patients (mostly babies diagnosed on newborn screening or new arrivals from Africa or the Indian subcontinent), who Dr. *F sees and enters into his amazing database (more about this another time), it is a free-for-all. Between the 5 of us (supported by 2 specialist nurses, community nurse, educational psychologist, dietitian and a bevy of translators) we somehow give each patient the time required to unpack and address their concerns as well as assuaging ours.

I saw *Kevin, a 5 year-old with sickle cell anaemia who had been in hospital a month ago. He'd come in with pain in his chest, which spread to his abdomen. His urine turned dark red, while he went that ghastly shade that black children go when they are anaemic and jaundiced. We gave him several units of blood, but his blood counts dropped further- the cells were being broken up as soon as they went in. His spleen was enlarged and tender. Eventually he had to have it removed. He's recovered well. Today his mom seemed more worried about the school he'd missed.