press "1" now

Did I mention my job was repetitive? I think I should send in a robotic stand-in. It would have a smiley, baby-friendly face and a built-in weighing scale heated to 37 degrees, and a growth-chart reader.

"Good morning Mrs. Lopez. How are you? [pause] Have you had your own 6-week check with your GP?" [Mrs. Lopez mutters something about not being registered with a GP] "Not to worry. Many families move house around the time of having a new baby. Do register with a GP as soon as you can. Does your baby smile back when you smile at him? ["oh, yes," says Mrs Lopez] "Good. Does he follow your face with his eyes? [pause] Does he startle to a loud noise?" The standard 6-week review questions over, the Child Health Surveillance Bot would then play a recording explaining the benefits of the BCG vaccine and why we offer it to all babies in Hackney. "Do you consent to your baby having the BCG?" Mrs Lopez answers in the affirmative. "Please place your baby's left upper arm against the Injection Module" The robot's screen replaces its Smiling loop with a short video clip showing the correct position for the baby. A 26 gauge needle is inserted intradermally at precisely 0.1mm below the surface of the skin and exactly 0.05ml of BCG injected. As Mrs. Lopez comforts and dresses her baby, the Bot says: "have you any further questions for me?" "Yes," says Mrs. Lopez. The Bot cuts in: "you now have 5 options: if you wish to discuss your baby's growth and nutrition or any feeding problems, please press 1. If you wish to discuss nappy rash, thrush or any other skin problems or lesions, please press 2. If you are worried about your baby's breathing, please press 3. If you wish to discuss vaccinations, please press 4. If you intend to refuse a vaccination, please press 5." This last button would deliver a nasty electric shock. [I've had several encounters with parents refusing their childrens immunisations, but that is another story!]
Did I mention my job was repetitive?

professional MOM

We have a lot of acronyms in community paeds - there is CCC (complex communication clinic), CHC (child health clinic), PAC (physical assessment clinic), DAC (developmental assessment clinic) and LAC (looked-after children) clinic. This last one I attended today. Looked-after children are children who are under Care Orders, many of whom live with foster parents. They might have been abused, or their parents might be mentally ill or in prison. All of them need Medicals, theoretically within 28 days of the Order being issued. (not always possible in practice - I am told we have a backlog of about 70)

I saw a lovely little Vietnamese boy today. He was accompanied by 3 adults: mom, tall with dyed brown hair, silver high-heeled sandals and a couple of nasty keloid scars; mom's 'friend', a short middle-aged vietnamese woman with chipped red nail polish; and foster mom, an overweight white woman with straw-like hair scraped back into an Essex facelift and a chunky gold pendant - MOM in capital letters encrusted with fake diamonds. Just in case we didn't know who she was. But she had a kindly face, and seemed very sensible - she'd obviously done this all before.

Which got me thinking - why do people become foster parents? They are paid a small sum of money for their trouble, but I am told it is barely enough to feed the child in question. (on the other hand, they do get tax breaks) Is it pure altruism? Some fostering organisations would have you believe so:

"if you are able to guide and support and care for the children we place with you, you will not only have achieved something remarkable for yourself, you will have changed lives for the better - forever." -Community Foster Care

The truth is that fostered children have a dismal outlook (I suppose the quote above is qualified with an 'if'). I guess even biological parents are not completely free of selfish motivation for having a child, and adopters can sometimes be looking for something to fill a void in their own lives. But why would someone make a career of taking in a series of damaged children?

didn't I say that already?

After an art-filled weekend (I highly recommend both this and this)I returned to work on monday to find a large wooden model of an erect penis in the middle of my clinic room table. It took a minute for me to realise this must have been left by the Family Planning people, and was in fact not incongruous with its surroundings at all. I shoved it into one of the drawers and hastily set up my clinic stuff - opthalmoscope, measuring tape, toys, a baby book, and the BCG vaccination kit. Halfway through the clinic, I found myself saying to one of the moms "and so I've explained to you about the BCG injection..." and she stopped me and said "no, you haven't." And she was right. I'd repeated myself so many times in one morning that I believed I had. Child Health Clinic is incredibly boring. It is so repetitive I think I might die of repetition.
I think it was Tolstoy who said "all happy families resemble one another; but each unhappy family is unhappy in its own way." In the same way, well children are all the same (or, at least, require the same treatment) but ill children are each ill in their own way. Which (by a rather skewed inversion of this observation) makes well children rather boring to deal with. Which is why I've had no patients worth blogging about lately. I know the value of child health surveillance etc but it's becoming increasingly hard to get out of bed in the mornings - to go and see lots of well kids and repeat myself a hundred times. But I suppose it could be worse - I don't envy the person whose wooden penis model that was.

space pens!

One of the disadvantages of working in Paediatrics is that my supply of free pens has run dry. (There are, of course, some who disagree with accepting such bribes from the drug industry, but that is another story) As everyone in hospital seems to be 'borrowing' and then 'losing' each others pens all the time, it was handy to have an endless supply of cheap (free!) pens. Also, much of a junior doctor's time is spent writing - I would go so far as to say that it was possible to do my job without a stethoscope, but impossible without a black ballpoint pen. Every admission means at least 2 pages of writing (including diagrams if there are injuries or a rash), and a ward round means 2 paragraphs each in about 10 sets of notes. Each discharge requires a GP letter - this is handwritten onto a self-carbonating form. And then there are the prescriptions, procedures to document, consent forms etc etc. So my pens never last long.

Yesterday I unearthed two old pens that dad gave me when I was in my initial years at medical school. Though long used up, I had kept them because they had been excellent pens, and their casings felt particularly solid. Unscrewing one, I read the print on the spent cartridge: "#PR4 BLACK MEDIUM BK1 #3 400 For Refill Send $4.00 U.S. To FISHER SPACE PEN CO. Boulder City, NV 89005, U.S.A." Sending away by post for a refill - how quaint! I figured if they were real 'space pens' they must have a website by now. So I Googled it and ordered a couple. And they've arrived! Can't wait to try them out on some blood-spattered specimen bottles.

...take 50 nurses

Foulden Road from our window this morning

There is a new childhood immunisation programme rolling out across Britain , which on paper looks simple enough: the introduction of universal vaccination against pneumococcus, and a re-jigging of the meningitis schedule. The problem is this: 4500 babies are born annually in Hackney, and more arrive from overseas each year. A significant proportion of their parents do not speak or read English. Worst of all, the central computer system cannot automatically generate appointments for all the targetted infants, and not all the local GP practices have computerised records. Add to that 50 overworked nurses (gathered in a room on a hot afternoon to hear about the changes) and you have a potent brew. This is admittedly my first glimpse of public health at ground level, but I can begin to see that policy does not translate at all easily into practice. The presentation is (I feel) rather succinct, yet, 5 minutes after the speaker (one of my consultants) has explained something, a hand goes up somewhere and someone either asks a question that has already been answered, or brings up some (usually valid) practicality. The meeting drags on, the heat becoming oppressive. There are jibes at the Department of Health people - "obviously they haven't seen a real patient in ages". So these are our troops; a roomful of tired, sweaty ladies armed with boxes of leaflets, refridgerators full of small glass vials, and lots of needles.

my so-called weekend (or how to get back into daytime mode)

Monday 4/9/5 09:00 end of (extremely busy!!) 3rd consecutive night shift
4/9/5 11:00 to 13:30 nap
4/9/5 13:30 - 14:40 lunch with youee
4/9/5 afternoon: revision
4/9/5 20:00 dinner at restaurant for youee's birthday
bought some fruit from the Turkish corner shop on the way back
the guy says its called a 'babuska' (which as far as I know is a russian grandma) and it's like a fig, so I 've included a fig in the picture for comparison- note the near absense of similarity!

meanwhile M. acquires an instant record collection. titles include Frank Zappa's "Baby take your teeth out (leave them on the kitchen table)"
5/9/5 00:00 into bed exhausted
5/9/5 09:00 shower, breakfast, more revision
5/9/5 12:11 on the train to liverpool street for exam
5/9/5 16:30 end of exam. off to oxford street for some post-exam shopping

bought some vintage Gina shoes- shop assistant tells me he acquired them from an old lady who has recently gone into a nursing home. odd thought, that.
5/9/5 21:00 dictate clinic letters to give to secretary tomorrow
it feels like it should be monday tomorrow, but it's wednesday. My body clock is coming back to normal but my internal calendar is still completely messed up and i have a dearth of motivation. note the apalling flash photography.

Piss poor

You can tell you're approaching Bethnal Green because the station smells like a urinal. In fact, it IS a urinal. Rain or shine, the steps leading from street level to platform are damp and ammoniacal and suspiciously sticky to walk on. It is best to avoid the sheltered areas because every pillar has an offensive puddle at its foot.

What is it with poor areas and collective incontinence? I remember years ago stepping into a lift at Boon Lay shopping centre (aged about 7) and asking my mom "why does it say 'please do not urinate in the lift?' why would anyone wee in a lift?"

(at this point I was going to post a drawing I made of Bethnal Green, but my scanner is misbehaving) It shows the platform, littered with empty drink cans and crisp packets and cigarette butts and chewing gum. The sheter is made of corrugated metal and there is a brick wall topped with barbed wire. Beyond the barbed wire, the City of London is just visible, particularly the phallic Swiss Re building.

This reminds me again of Enuresis Clinic (see previous post). The widely accepted Paediatric wisdom is that '10% of 5 year-olds wet their beds, and 5% of 10-year olds'. In Hackney, there are 2 enuresis clnics every two weeks, and these see only new referrals. All the 'old' patients are seen by the Specialist Enuresis Nurse (what a grand job that must be, perhaps a little better than the nurse last night who got the job of hunting for a swallowed watch battery in a 3-year-old's poo). I couldn't help but think, 'how many bedwetters can there be in one borough?' While most children who wet the bed do not have any other problems, some (particularly those who were perfectly 'dry' before) start wetting following a family tragedy (e.g. a house fire or parental divorce) or physical or sexual abuse.

I wonder if this bears any relation to grown-ups weeing in inappropriate places. Or do they take the general dilapidation of the railway station as permission to make it smell as bad as it looks?