For a limited time only, here is a link to my new blog:
[link removed. If you know me and would like to read my new blog, please email me for the link.]
oh. oh. Forgot to say - I bought myself a yahama clavinova! Cost me nearly one and a half thousand pounds, but it feels and sounds very nearly like a real piano. It will be delivered in a week and a half - the first time I will have had my own piano in more than 10 years! Can't wait to put my finger muscles and certain underused portions of my brain back to work again. Finally won't have to feel a fraud for putting my piano performance diploma on my CV. And the only time I have been grateful for my technically illegal Band 2A rota which means I get paid so much for antisocial working hours that I can actually afford the piano.
Here's reporting from the European Paediatric Neurology Society conference in (rainy) Harrogate! Check out the professors in the front row, some in bright orange t-shirts, the colour of the EPNS logo! The conference bags are a fashionable 'not plastic' black jute, and the sandwiches full of squishy egg mayo.
London Fashion Week this is not, but I think the world of paediatric neurology (and I imagine any other branch of medicine) has its own insiders and outsiders, rising stars, institutions (sometimes literally!) and trends that come and go.
Being a bit of an outsider (for the moment!) I spent most of my tea breaks among the hundred or so posters. There seems to be a surfeit of case reports, but some posters were quite brlliant - Ng et al made centile charts for Gower's sign, and there were a couple of molecular/genetic ones that were pretty fascinating. The best science is simple but elegant. So it will be interesting to see which one wins the prize.
Right. Have to get to bed, 08:30 start tomorrow (a lie-in compared to the 07:15 starts on thursday and today).
Typing this from a cafe... (the mobile broadband reception in my flat is almost non-existent)
Went in just for teaching today and it was a transport team review. It's quite fascinating and a good insight into the decisions that need to be made when a request for retrieval is received. The statistics were followed by a simulated telephone referral.
They've been in some quite hairy situations, but then I suppose they're the ones who get called when everyone else is in a pickle. Am finding it quite hard to blog about individual patients, as there are only so many retrieval teams, paediatric ICUs and paediatric cardiac transplant centres across the country, so it's almost impossible to hide the patient's identity whilst describing the clinical situation. Well, too bad, readers! I think you have to actually work in a PICU to get any idea what goes on. Everything dramatised on television is dull by comparison. Ask me out for a coffee if you really want to know. Perhaps by the end of these 6 months I'll have first hand stories to tell too. Or maybe I'll just have to write a work of fiction...
Day off pre-nights today; typing this on my laptop in the public library as there's no 3G reception in my flat, and I'm trying to download ubuntu.
Had a slightly better day yeterday than the day before - by that I mean I did something slightly more than failing to put in a venous line and an arterial line. In fact, the main useful thing I did was muster all my confedence to sit tight on a very slightly hypotensive patient, whose blood pressure resolved itself. And I know what lusitropy is now, too.
Got a new book from Foyles - Handbook of Paediatric Intensive Care (by Gale Pearson) which I wish I'd found a few weeks ago. I like the way it's written - the author doesn't shy away from decriptive language, such as "rampant catabolism" or from stating simple facts that need emphasis, like "this is a human blood product" (in reference to albumin). All this in amongst the usual textbook language - "systolic dysfunction requires inotropes, with or without vasodilators, whereas diastolic dysfunction can deteriorate with inotropes and may respond better to volume replacement". So the aim is to eventually read it from cover to cover, starting with the chapter on post-operative cardiac surgery patients.
Lesson for today - if the patient gets worse, sometimes it isn't your fault. (In fact, it may even be someone else's.)
Zac* is a 4 month old baby with a "mildly" hypoplastic left heart and critical aortic stenosis. He'd presented to a small hospital with shortness of breath and poor feeding, and oxygen saturations of 73% in air. He was treated with a prostagladin infusion to keep the ductus arteriosus open, then underwent stenting of the ductus, and banding of both pulmonary arteries. He recovered well and thrived. But he would eventually have run into complications, so he needed another operation. But which one?
It's like those multiple choice questions where options A and B both seem plausible but in fact the wrong option will give the opposite effect. For instance, to turn left when reversing, should you turn the steering wheel a)clockwise or b)anticlockwise? I've got that one wrong before and reversed into a post. The problem is when it's real life, and it's someone's heart.
By the time we receive patients in intensive care, the decisions (good or bad) about their management have often already been made. In the case of surgical patients, their anatomy has already been altered. There is only so much you can do by tweaking the physiology, so it isn't your fault if it doesn't quite work. Also, if all the major arteries and veins have been b**gered beforehand, it isn't your fault if you can't get a line in. But it took me all of today, looking after Zac to realise this.
I'm liking PICU a bit more this week; it does seem to be a thinking specialty (unlike neonates, which is completely protocol-driven), and there is certainly variety - patients from all specialties and of all ages. Yesterday there was a 70kg teenager in the next bed to a 2 month old baby.
Thursday was Transport Training Day for the PICU (paediatric intensive care unit) seniors, and we joined in to learn the relevant bits for transferring critically ill children to other parts of the hospital (e.g. for CT scans). The last session was interrupted by one of the consultants rushing in and asking for a volunteer (meaning one of the seniors of course) to come along in the aircraft to retrieve a child for ECMO. Of all the tasks in the working life of a PICU doctor, that's probably as 'glamorous' as it gets - critical patient, going in the airplane, and arguably the last bastion of life support. That was the moment I realised that no matter how much I learn in this job, I don't think intensive care will ever enter my list of career options. I can just about cope with supporting a sick patient who's just come in the door until the intensive care team arrives. But actually being the ultimate port of call is a different thing altogether. While I admire people who can think on their feet and stick a line in any bodily vessel/compartment, I think the very acute specialties do attract a certain personality type - one that doesn't really get along with quiet, introspective types like me. In addition, after a certain point, the law of diminishing returns kicks in. I think a large part of the art of medicine is knowing when to stop.
********
[patient and staff details have been changed to protect their identities]
So there he was, on a specially raised bed, draped and having lines the size of garden hoses inserted in his neck. Dr. T had unwittingly attracted quite an audience - pharmacists, dietitians and half the new PICU juniors. I've never seen a child being put on ECMO before; in fact every day for the last 2 weeks I have been dismayed at the number of things I've never seen before. It's really frustrating being in a completely new environment and feeling ignorant and useless, having come from being the most senior paediatric doctor on site in the whole (district general) hospital overnight. I know it's about the patients, but that's where the frustration lies - I feel like I'm not doing an awful lot for them, being unfamiliar with the drugs and treatments they are on and taking ages to even untangle in my mind the various things that are wrong with them. I can no longer make any decisions without checking with someone in case something goes wrong, where before I could manage most patients on my own. And it's been 2 weeks of this now; I've been reading up on stuff every night, and trying my best to learn things, but it just feels too slow.
So that's me BSc(Hons) , MB ChB, MRCPCH
Passing the exam was a bit of an anticlimax. It was a relief rather than a triumph, a bit like "achieving" the medical career equivalent of a delayed puberty.
The good thing, I guess, is I can now talk about (and think about) all the other things I've always wanted to do, like research. (and collecting more Alphabets) Went to see the Training Adviser about this and he basically said what can only be summed up as "you're on your own, kid." So I've got to go on a hunt for a suitable supervisor and project and lab. (i.e. lots of emails, PubMed-ing people etc). While trying to transfer my clinical training down to London at the same time. (more emails to Deanery people and CV sprucing and 'workplace assessment' chasing). While also working completely crazy shifts. (was on from 16:00 to midnight yesterday, and there was still one patient waiting to be seen when I left at 00:30)
And what of family life? It's pretty non-existent as it is - and we are actually living at the same address at the moment (which will all change in August). The problem is that there isn't enough time for all that one wants to do in life. Came across this account of the life of Rita Levi-Montalcini in Nature News today - highly inspirational. But she never married or had children.
"I hate Mother's Day," said K, 13 years old, and 4 months in foster care. She'd taken an overdose of ibuprofen last night, triggered by thoughts of her own mother, who is currently in hospital having taken an overdose herself. TJ*, in the next room, is less than 2 weeks old and is already being taken into care; he is attached to a baby alarm (sounds like a car alarm); it has to be disabled by turning a key in the lock at the end of his cot before lifting him out of it. It's been going off every few hours, because the auxillary nurses (in these gentler parts - compared to Hackney anyway) aren't used to this kind of thing, and keep forgetting.
*Tom had arrived on Saturday evening by "rocket" (his name for the helicopter ambulance). An ex-premature baby, now nearly 5 years old, he looked tiny in the full sized hospital bed. He sat with a furrowed brow, misting his oxygen mask as he scribbled furiously a green crayon. "He's worried about the Mother's Day present he's hidden under his bed," said his mum. Tom looked up at Dr. M. "You'll just have to have Mothering Tuesday, then" he said. Tom smiled in agreement.
This is the bus journey from our front door to Central Station:
Boarding the double-decker with hastily folded-over sandwich in hand (made with homemade bread! but that's another story), I bounce into a seat with the glee of having caught the bus at the last second. Suddenly, the driver stomps up the stairs and yells at a scraggly, puffer-jacketed figure slumped at the back "You, get out here!" "Nah." she mumbles. "This bus isn't moving." He tramps down again and turns off the engine. It turns out she had only fare enough to get her here, the bus stop in front of our recently grafitti'd front door. After a 5 minute stand-off, she slopes off the bus and we get moving.
The bus pulls away, past the park with its ducks, swans and astroturf 5-a-side football pitches. Past the run-down pubs, the Natives smoking outside in their T-shirts despite it being 6 degrees with a northwesterly wind. Past the local concert hall, where Lily Allen (Lily Allen?!) is playing tonight (SOLD OUT it says, on the billboard), and the bingo hall next door. Past the underground station, its austere brick decorated with incongruous hanging flower baskets, and the Habib Islamic bank and Halal fried chicken joint. Under the rail bridge we go, beyond the Foam Car Wash, Used Car Sales and a yard containing brand new carved headstones, a few, disturbingly, teddy-bear shaped.
A sharp right takes the bus onto a bridge over the river Clyde, and then, quite abruptly into the centre of Glasgow.
Number 42
There's something depressing about the quality of the sunlight in Glasgow; I'll admit that I'm a little out of practice with the camera, but the pervasive greyness is difficult to get round (without some extreme post-processing).
So 4pm to midnight shifts are good for something - blogging!
I really feel like I need to take the camera out as haven't taken any photographs since...probably October 2008. (Mainly because a) Christmas 2008 was cancelled due to night shifts and b) it rains all the time in Glasgow) And it's sunny today! (It will probably start raining shortly now.)
Yesterday's patients were like a parade of Short Cases (patients in a Clinical Exam who have interesting or classic signs/ stories and that you have to see in 7 minutes).
Here's a selection:
- new diagnosis of Henoch Schonlein Purpura
- toddler with painless limp
- new diagnosis of diabetes mellitus (not in acidosis)
- teenager with headache and weakness in one limb
- teenager with headache and photophobia
- known asthmatic with moderate exacerbation of asthma
- known nephrotic syndrome with fever and heavy proteinuria
- known cerebral palsy with community acquired pneumonia
- infant with croup
- assorted snuffly and/or wheezy babies, including premature twins
Unfortunately, it takes a bit longer than 7 minutes to sort each one out in real life - things like examining the rest of the child (not just the body system in question), taking the full history, writing up drug charts, inserting lines and taking blood if needed, explaining things to anxious parents etc. means each patient takes about 30 to 60 minutes (divided between 2 to 3 doctors). They also have a knack of turning up 3 or 4 at a time, thus ensuring that anyone not critically ill has about an hour's wait during which to wind themselves up beforehand.
OK maybe that's just being cynical. It was a good shift.
There is a lot of acting involved in medicine. I saw for the first time, in outpatients, a girl with precocious puberty. It's something I'd read about in books, but had never before encountered in real life. But I had to pretend I knew all about it (well, I did afterall know all about the theoretical aspects) and not let on that this was the first case I'd ever seen. The "it might be a brain tumour or it might be nothing" bit (obviously said in other words!) was particularly tricky to convey.
Last night was a particularly horrendous shift, not because of any of the patients, but because I developed a terrible headache on the way to work - it's a truly bizarre experience feeling car sick from your own driving. But there I was at work, and the day shift person was waiting to go, so I took a couple of ibuprofen and got on with it. They didn't do much for the pain, and did even less for the nausea. And then a teenager staggered in with diabetic ketoacidosis (DKA). He was pale, drawn and sunken-eyed, and retched continually as I spoke to him. When I leaned over to examine his abdomen (taking care to give the right iliac fossa a good prod), I felt like I might be sick myself. Luckily my brain clicked into DKA autopilot, and (with help from my SHO) we did the required blood tests, got lines in, and I even managed all the fluid calculations in between seeing a sick toddler who had arrrived at the same time. The hard part was again the acting - I imagine a doctor who looks like they've done it before (true, in this case) inspires confidence, but the danger lies in the temptation to "process" the patient by algorithm, thus failing to convey the seriousness of the situation.
Being a perfectionist by nature, I find it highly unsatisfactory when I am forced to do a job more shabbily than I would have liked. Last Thursday was my first proper day in the new job, so I wasn't too bothered that things didn't run as smoothly as they could have (had I had a computer password and known where various items such as tongue depressors and growth charts were stored). However, I was surprised to find that it was just me and one junior covering both the inpatients and the acute admissions, on a weekday. The junior (a house officer) was being used by the consultants as a one-man phlebotomy service for outpatients at the same time, with me having to step in for the 'difficult' veins. This meant that many routine jobs for the stable inpatients didn't get done until late in the afternoon, and waiting times for the admissions were dreadful.
How naive of me then, to imagine that the weekend would be any better (I reasoned that without the outpatients, I would have the house officer to myself). Saturday arrived, and as I started the ward round, I wondered aloud how the house officer could be so late. "There isn't one on weekends," said the nurse. The consultant wandered in to join me for a few patients, but then got bored and went home, because none of the patients was critically ill. "Call me if you're worried about anyone," she said. So that left just me, to finish the ward round, do all the jobs, take all the referrals and see all the admissions. Naturally things were going to be less than optimal. So I did my level best, and I am confident none of the patients came to any harm. But I did lose my rag at one point and snap at a mum who demanded to know why I hadn't come back with her daughter's blood result yet. Then I felt really guilty for being rude. I'm fed up with being human.
I'm also fed up with working weekends, that was the third one in the space of one month! And then this weekend when I am finally off, Mark is working. I hate my life.
Spot of comedy on the Saturday morning ward round: nurse opens baby's nappy and lifts its legs up to change it, when the baby explodes! There is poo on 3 of the 4 walls of the incubator, while the (arguably rather cute for a 30-something weeker) baby lies in the only clean corner, looking brightly about her as if nothing has happened.
Well, I'm out to the shops (not that I need anything) just to be out in the sunshine (a rarity in these parts) as I go onto night shifts again tonight. Night shifts are RUBBISH - they ruin your physical and mental health and destroy any semblance of a social life you had before. I am sure they could also quite easily destroy a marriage or a family. In fact, I think perpetual night shifts would be a brilliant form of torture.