Essex boys

Revising for my exam and have just read about cystic fibrosis, which reminds me of a patient I saw the last time I was on nights.
I had a bleep at about 1 in the morning. "I'm sorry," began the nurse (always a bad sign when nurses are apologetic for no apparent reason), "*Damien's cannula has tissued. Can you come and put in a new one?" Damien is a 13 year old boy with cystic fibrosis (CF). He was in hospital for an infective exacerbation and was on intrvenous antobiotics. His Portacath had been removed after it had become infected, and he did not like to admit it, but he was needle-phobic. I arrived on the ward to be greeted with a loud, "Hi Doctor!" He grinned at me from behind the nurses' station, where he was in the middle of ordering a pizza using one of the ward's telephones. He looked about 9, and had a thick fake gold chain round his neck, more little ones around his wrist, and was wearing a basketball jersey over his hospital gown. As Inner City Hospital is in the middle of what seems like Little Bangladesh, the CF kids stand out for being white, and they all seem to come from Essex. "Hi Damien," I said. "Ready for your cannula?" I motioned toward his room, but he swaggered a few steps in the opposite direction, and stuck his head into someone else's. "Hey *Jen," he said, "come and see this." A skinny blonde girl (another CF patient) emerged. She was wearing a pink tracksuit and a similar gold chain around her neck. Damien wanted an audience for his ordeal.
Having finally coaxed him into his room (and banished Jen from it), he stuck his hand out. "You can have one try, there," he said, pointing to a vein in the back of his left hand. I was still trying to get over the surrealness of his manner. Fortunately the cannulation was an easy job (having done loads of thalassaemics with totally shot veins and very dark skin). "Thanks, doc." said Damien, running off to find Jen and his pizza.

It hurts

KT looked a little like a hamster with his swollen parotids. It had started on the left, behind his ear, several weeks after he had returned from Nigeria. His dental hygiene was good, he was fully immunised (DTPs, MMR, BCG, the lot), and he didn't have any sinister symptoms (i.e. of lymphoma). He'd had a couple of fevers, but was otherwise well. On examination there was a smooth parotid swelling on the left, and some cervical nodes on the right. The A&E doctor had sent mumps and EBV serology, but the results were not yet available. Should I order an ultrasound? Did I need to give him a follow-up appointment? I wasn't really sure. I have been plagued by uncertainty in the last 2 weeks. 12 months as a house officer (otherwise known as 'housedog' or 'houseplant'), and then 3 months in haematology in what is essentially the role of a house officer have left me incapable of making my own decisions. I am now paralysed by the fear of doing something wrong - having come close to killing a febrile neutropenic, and prescribing imipramine to some poor kid with enuresis who probably didn't need it. I know that anyone who is junior in their profession must learn by making mistakes, but mine are too painful to bear - children suffer and may even die when I get it wrong. The weight of this has become overwhelming and I am getting nightmares (literally) again, awakening in terror at 3 or 4 in the mornings.
Fortunately, Dr. P (my consultant) came to my rescue, and pronounced that it was a typical case of mumps (which can sometimes occur despite vaccination), which needed no follow-up apart from checking the serology. I felt stupid. I feel almost constantly stupid nowadays. Obviously I need to gain more experience, but it all just seems too painful.

photos

as promised earlier

Whitechapel Market

Am moving house today so will be offline for a while. So here's goodbye to Whitechapel (outside of working hours, that is!) Look out for my photographic study of Council Architecture in East London appearing on my photoblog as soon as I get reconnected...

Kidneys

*Saida is 18 months old and had been suffering from diarrhoea for 4 days. On the ward round she seemed a bit 'flat' - drowsy, pale, floppy, cold round the edges. She had not passed any urine in nearly 24 hours. Her tummy was tender to touch and I thought I could just feel a bladder. She had a smattering of little red spots - petechiae - on her arms, legs and back. She looked septic. Diarrhoea is exceedingly common, and most children recover quickly with rehydration. Sepsis secondary to gastroenteritis in small children is also not unusual. But a couple of things didn't fit, which in retrospect seem to be the most obvious clues. She was hypertensive - one would expect a low blood pressure in shock - and when we did get some urine (with the help of a very fine nasogastric tube as a urinary catheter), it was very frothy (3+protein). We took some blood, but as sod's law would have it, the specimens just sat in the lab and were not processed until I called to hassle them 3 hours later. Meanwhile we gave Saida a fluid bolus (appropriate management for shock but not appropriate for her in retropspect). They rang back to say the child was clearly in renal failure. She was also very anaemic. A blood film showed haemolysis. (for the medical reader: guess the diagnosis) We rang the consultant on his mobile phone, and he rang the Big Famous Hospital to get Saida transferred in case she needed dialysis.

*Shah is a 7 month-old boy who was found to have a dilated ureter (on ultrasound scan) before he was born. He has vesicoureteric reflux - meaning the urine in his bladder goes back up the ureters into his kidneys - and as a consequence has repeated urinary tract infections. His right kidney is scarred and hardly functioning. It will probably never recover. But his left kidney is working, and one can have full 'kidney function' even with only one physical kidney. The problem is he has a terrible urinary tract infection at the moment, and the last time he had one it grew horrid bacteria that were resistant to a large number of antibiotics. We have got him on two broad spectrum antibiotics - one of which is potentially toxic to kidneys - while waiting for the urine culture results.