brain rot!

...bit of an odd thought to push its way through at the height of my exam panic (36 hours to go), but I'm suddenly seized with the fear that large swathes of my brain are in danger of rotting away through disuse.
When I recall my teenager-hood, it is usually with much relief that I will never have to live through it all again. But despite the traumas - broken friendships, never being in the 'in' crowd, (perceived?) parental and teacher underappreciation - I have to admit that my mind was almost always sufficiently stimulated. Physics special paper tutorials used bits of my brain that have definitely fallen idle now; I was practising for my piano diploma, submitting poems to an online poetry guild, playing tennis with my dad at weekends, reading books. And I could actually speak chinese. At university (apart from Medicine) I edited a magazine, learned photography, and read the bible for the first time from cover to cover.
Why is it that when we grow up and start work, it all falls to pieces? (Or is it just me?) My work has taken over my whole life, and I flop, drained of energy (particularly if it's been an 08:30 to 21:30 day) into bed each night. It's almost like Charlie in Flowers for Algernon. And it's way scarier than, say, a former athlete losing muscle tone - at least they can keep tabs on it by looking in the mirror. I can't even begin to assess the damage to my neurons caused by more than a year of neglect. This exam with all its memorising has been more mind-numbing than stimulating. (I am conscious that you may have little sympathy for my situation - what? being a doctor not mentally stimulating? - I assure you, it isn't, not much. Emotionally taxing yes, every day. Intellectually stimulating, perhaps once a week.) Am I in the wrong job? Maybe. But I live in hope that the balance will shift...
AND I need to learn something completely new before it is too late!

...you talking to me?

I do a Prolonged Jaundice clinic on Thursdays (my very own list of patients!) and the jaundice bit is easy enough to deal with. The babies are usually referred by a midwife, and they have usually been jaundiced for about 2 weeks. With babies, the general rule is if they are feeding well and growing well, there is unlikely to be anything serious going on. (The rationale being that the most strenuous thing babies do is feed.) Add to that a good number of wet nappies, a few soft yellow poos a day, and you are almost sure to have a healthy baby. There are a few more complex issues of course, like hereditary blood or metabolic disorders. Among other questions, I ask if mom and dad are related (first cousin marriages are common in the Bangladeshi population) and usually just say we need a few drops of blood and we have a standard panel of tests to exclude some rare but treatable causes of jaundice. The questions out of the way, I examine the baby from head to toe. At this point, the mother will inevitably bring up something like "he always vomits after he feeds" or "he keeps pushing the nipple out of his mouth with his tongue". I always feel slightly awkward with these questions. I mean, I know what further questions to ask, and how to exclude anything serious, and I know most of the (textbook) answers, but here's this articulate, middle aged Kurdish woman who has 2 other healthy children asking me (single, childless, still gets asked for ID whenever I buy wine at the supermarket) what to do with her baby. And then I remember I'm a doctor, silly. I wonder how many years it will take until I become a doctor in my own mind's eye.

freak show

What a long 2 days. My mind wanders back to the Diane Arbus exhibition I saw with M at the V&A a few days after Christmas. Her pictures have a (perhaps not unintentional) freak show quality about them. Countless photographers have been fascinated with the idea of finding beauty in the unlovely, but this is the concept taken to an uncomfortable extreme. She went in search of freaks, and, predictably enough, got what she was looking for. Sideshows, nudist camps, and finally, a home containing (by her pictures) mostly middle-aged women with Down's syndrome. At one point, the exhibition blurb reads:

In her photographs, the self-conscious encounter between photographer and subject becomes a central drama of the picture.

That is her problem: self-consciousness. This stands out in particular contrast to the photographs I saw in Edinburgh not long ago at a brilliant exhibition of the works of Henri Cartier-Bresson (same exhibition is currently showing in Amsterdam). Cartier-Bresson's pictures convey a certain love for life. Indeed, he lived to be 95, while Arbus commited suicide aged 41. Now, it may seem I am being unkind to Arbus, but the truth is, her story and the vibes one gets from her pictures remind me alarmingly of myself. My fascination with medicine (and paediatrics in particular) is, at its core, a fascination with the myriad weird and wonderful (not so wonderful if you are the patient of course) things that can go wrong with the human body. Although I am a doctor, I still feel a bit of a voyeur on the wards, and I am sure my self-consciousness (that huge, floundering thing at my shoelaces) shows through my thin doctorly facade. And it is entirely inappropriate, a hundred times more so than it was for Arbus to be wandering around institutes for the mentally infirm with her Rolleiflex.

Pear juice

Bit of an odd day back at work. Having arrived back from Edinburgh at 11pm yesterday (all for the sake of a cheap train ticket!), ended up staying up til 2am (exciting things in the post, including a letter from my 'godfather', who says he hasn't been to central London in 20 years!), then got up at 06:50 to go to work. On arrival, the ward is full of patients but there is no sign of any other doctors. I have been left a sheet with 12 patients' names on that I have never met. *Ben is a 9 year old who has been suffering from diarrhoea for 3 months. He has lost about a stone in weight - his clothes hang off him, and his eyes look sunken. Somehow, his electrolytes are completely normal, and so is his renal function. Inflammatory markers are raised. There is no rash or joint pain and no mouth ulcers. He has no history of recent travel or past history of food intolerance and the rest of his family are well. He is fully immunised. His parents seem pretty cool about the whole thing (cf previous entry) considering he is still pending a diagnosis. The likely diagnoses are 1. infective diarrhoea (including various bacteria, amoebae, TB etc) 2. inflammtory bowel disease 3. coeliac disease (or some other kind of malabsorbtion syndrome). So he's had lots of tests, including a Mantoux, which I watched Dr. M administer. Ben was very brave about the whole thing, as he has been about his entire ordeal so far. He's one of those incredibly sensible kids where you catch yourself speaking to him as if he were 10 years older, when at best he might grasp the facts with no idea the implications.

Anyhow, it was one of those busy, interesting and exhausting days. I went home via Liverpool street, where there is a greengrocers that I have never seen closed (which is very odd considering that I work nights, weekends, and even the new year). I bought 4 chinese pears for a pound, and was very much looking forward to sharing them with my little brother (who is here to stay for a few days) after dinner. Unfortunately in my tiredness and distractedness I accidently left them on the train. Which annoyed me very much until a rather amusing scene popped up in my mind - watch out for it on the news some time tomorrow: someone discovers my "unattended package" and the transport police in their bullet-proof vests rush to detonate it, only to be spattered by pear juice!

A picture of my foe

External diameter: 0.6mm
Length: 19mm
Needle: Siliconised, bevelled, back cut ground stainless steel needle
Catheter: PTFE (Poly Tetra Fluoro Ethylene) / FEP catheter; dual tapered, bevelled tip & siliconized

Instructions: Lay baby on flat surface. Place absorbant towels under chosen limb. Give parent option of leaving the room. Get (preferbly experienced) nurse to hold limb in white knuckle grip (serves both to foil attempts at wriggling away and as a tourniquet) with one hand while fending off kicks/punches from other 3 limbs with the other. Ignore baby's cries. Visualise vein and pin down by stretching skin taut with non-dominant hand. Insert cannula at roughly 30 degree angle (adjust according to how deep/superficial vein appears. Ignore baby's cries. Watch for blood in flashback chamber. Insert a further 1mm, then withdraw needle and advance catheter. Ignore baby's cries. Tape cannula down. Instruct nurse to loosen grip (just enough to allow venous return, but not to let baby withdraw limb). Remove needle. Flush cannula with saline. Tape cannula down with the strongest tape available (check baby isn't allergic!). Ignore baby's cries. Splint and bandage the limb. Release grip and comfort baby. Be thankful that (most) babies have short memories.

Nights misery

The fireworks over Canary Wharf were just visible from the 4th floor of the hospital. The nurses were probably watching it on TV on the ward somewhere, but I prefer to see the real thing, even if through a dirty window in a dark room on my own. It's my second new year in a row where I've had to work overnight. It just turns the whole thing into a non-event, making it feel like I'm stuck in the old year and that yet again, life is passing me by. It wasn't even a busy night on call, so I was deprived even of a sense of purpose, of having to be there for a reason. Had been on nights since before Christmas, had the intervening week off (lonely Christmas 'celebration' with siblings, jet-lagged from being on nights, trying in vain to study for my exam) and then on nights again for new year. My entire cristmas/new year ruined yet again by constant sleepiness and having to miss out on all the best bits, yet feeling under pressure to be 'merry'. I would be, if I could just for once spend the turn of the year with people who care about me.

Spotted!

(: (: very excited! my photos have been spotted by an online gallery that wants to help me put them up for (proper) sale! Despite everything, deep down, I've always really wanted to be an artist. Last chance to buy my work on the cheap!

Punchbag

It will be one of those patients who has had an unusual presentation of a rare disease, with symptoms mimicking something more common and invariably more benign. And now they've developed diarrhoea, or bleeding from some orifice, and we need to take some blood for further tests. "No, you are NOT taking any more blood from my baby," the mother fairly shouts at me. She stands up - her arms planted on her hips, her face stony, eyes burning. It is Sunday, and she vents her frustration at the events of the past week. She feels the doctors are hiding something from her, and keep changing their minds. She demands that I somehow produce the results of all the tests done on Friday afternoon (most of them are microbiology specimens, which will take at least 5 days to return final results). Having seen her child for the first time 5 minutes ago, I am at a loss as to what to say. My task is to take the blood. I have 10 other patients to get through before lunchtime. I decide to do the 'see things from the other person's point of view' thing. I let her go on for a bit. "I can see why you're frustrated," I say, at last. "K* is clearly very ill, and we don't have a certain diagnosis." I am just about to artfully explain the delays and justify the need for further tests (clotting, electrolytes as she is on IV fluid, and stool culture), when she interrupts and lets forth another torrent. Why, if we think K* has an infection, is she not on antibiotics? Why do the doctors tell her one thing and then contradict it? I begin to explain that the commonest cause of infective diarrhoea in children is a viral infection, and that antibiotics do not help a viral infection. "Why didn't they grow the poo for viruses then?" At this point I am exasperated, and return, rather too bluntly, that we have treated her child to the best of our knowledge and that the results of today's tests will help take things forward. In order to escape from the room, I say I will give her some time to think over things and come back later. She shouts after me that no-one is going to take any samples from her child and that's final. In retrospect, I guess she wasn't really interested in the logic behind the decisions, she just wanted someone to shout at, and it happened to be me. I hate my job.

What I saw on call today

...busy but unusually interesting day at work. Too tired to write proper entry, so here's a list of things I saw:
-CSF leak in child with base of skull fracture
-cri-du-chat syndrome
-VACTERL
-paracetamol overdose
-pneumonia
-two PUOs (pyrexia of unknown origin)
-newly diagnosed diabetic - the 7th of 10 children - and her pregnant mom (large orthodox Jewish family)
-lots of babies with bronchiolitis, and
-Dr. X, self-titled 'architect' of the BREATHE trial

Weekend misery
Still not impressed by the fact that the first train into central London tomorrow is at 08:38 when I need to be at work by 08:30. So I have to get up extra early for an extra long commute by BUS just to get to work on a SUNDAY. I miss my bike...

Still on study leave

I miss work (though will probably regret saying this when I am on call at the weekend). The exam is on the 17th of January but I've had to take my study leave now as I will be working lots of nights just before. Am sitting in the flat without any curtains in the windows at the moment as the workmen came round to put the double glazing in today. It's noticeably warmer already. I've also done all my christmas shopping in the last 2 hours without leaving the house (or, indeed, my seat). So its been a productive yet incredibly boring day. Read the Economist over lunch too, as M has a subscription. I like how it's written. Perhaps it is my profound lack of knowledge of economics that makes the magazine so fascinating, but I just get the feeling the BMJ is a whole lot less intelligent.

Lullaby

...just recalling the last time I was taking blood from a 1 year-old. Her (young, very bling) mother was singing to her to try and calm her down. The song of choice? Don't cha by the Pussycat Dolls.

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.

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.

saturday night on whitechapel

"paediatric trauma team to resus, paediatric trauma team to resus" my bleep crackles to life at 2 in the morning. What are children doing up at this time of night is the inevitable thought as one runs down the corridor toward A&E. A 14 year-old has been stabbed - once in the leg and once in the pelvis. He is just conscious, smells strongly of alcohol. His heart rate is 37 a minute - in other words, he is stoned. The team move swiftly; he is examined, blood taken, xrays etc. Then a plaintive voice from behind the curtain: "I was stabbed too." Another boy, who had accompanied the first, and is equally inebriated, shows off his war wound. At this point, I am sent away to Majors as a child with sickle cell anaemia has arrived. It is *Jermaine again, who has come in with excrutiating pain in his abdomen and groin. Before I have finished examining him, another patient is sent over from Adult Majors. It is a 17 year-old with cerebral palsy. He is microcephalic, gastrostomy-fed and in nappies, and has been running an intermittent fever for the past 6 weeks. Lyn, th other SHO sees him. I fail to put an IV in Jermaine, so he gets some morphine orally and is sent upstairs to the ward.
My bleep has by now gone off about 5 times; would I come and see a child who has developed blisters on her arm? One of the teenagers with cystic fibrosis needs a new cannula and he is refusing to have it put in by anyone but me (just because I had been lucky and gotten it in first time the night before). The 5 month old on HDU is needing more oxygen, could I come and see her?

last night of the poms

...not that I am rooting for Australia in the Ashes. Just that I may not be as British as I thought I was. Went to Proms in the Park - that plebeian adjunct to the institution that is the Last Night of the Proms - with an old school friend. We stopped to pick up ice-cream cones and union jacks - the latter essential for audience participation when the old Elgar came on. Funny how one never notices the words of anthems until one comes to sing them. I know from my time in Edinburgh that the unoffical national anthem of Scotland (Flower of Scotland) is all about giving the English a good kicking; and I guess that is what national identities are about - Us against Them. The words to Rule Britannia I found quite disturbing; ironic that when it was written the British were busy enslaving other peoples halfway around the world. Harmless (and half-drunken) flag-waving fun? Or something akin to Japanese people gathering in a park to sing Kimigayo and wave the Hinomaru?

eponymous syndromes

*Billie died at 6 on Thursday evening. She'd been at it for weeks. Billie had Batten's disease, a tragic condition where the brain and nerves gradually stop working. She had uncontrollable seizures, fitting for hours on end despite a full complement of antiepileptic medication - carbamazepine, phenytoin, Keppra, and a midazolam infusion. I was called at least once a night during her last week by nurses who said "Billie's fitting again, can you come and see her." My heart would sink, because I knew there was nothing further I (or anyone) could do. She was on an amount of midazolam one might use for anaesthesia. Rectal diazepam and paraldehyde had been given, and paracetamol for her fever (presumably from a chest infection). She lay there, a pale, floppy 9-year old in nappies, already dead to the world, her gurgly breathing and the beeping of sats monitors her only communication with it. Her eyelids flickered and her right arm jerked continually. Her mother looked on - her eyes no longer imploring, only resigned to Billie's fate.
*****
There is a little boy named 'Jihad' on the ward at the moment. I shall not describe his condition, but suffice to say it is rare, inherited, complex and life-shortening. Perhaps his parents had in mind a personal struggle rather than a holy war on infidels.
*****

nightmare

quick post before i have to get dressed for work...
rather bizarre episode last night. having done our rounds for the night and sorted out all the new admissions, i lay down on the sofa in the doctors' mess for a snooze. And within the space of those 2 hours, I had a nightmare! i dreamt that i was there, lying on the couch, and ravens were flying in through the open windows, clawing at me, and glaring at me with iridescent eyes. i was trying to defend myself with a battered copy of the Guide to Children's Medicines and a few coffee mugs. then my bleep went off. it was 04:45 and i was indeed on the sofa in the doctors' mess, but there was no sign of any invading birds. i was also relieved that i hadn't actually thrown the coffee mugs at them.

Madhouse

"Do you know what HRT stands for?" asks *Ali, the rotund Egyptian Gynae staff grade. "emm. hormone replacement therapy?" I say, knowing that the answer is most likely going to be some coarse joke. "no, no it's HUSBAND replacement therapy. All the old woman, they take, then replace the husband. haha." Ali retrieves his customary mound of chips and 5 halal burgers from the oven and heads to his room. "See you later, Ali...you should eat some vegetables.." I can't help adding, half in jest and half out of real concern for his coronary arteries.

My flatmates are a motley crew (i was the last to move in, and am trying to move away ASAP); apart from Ali, there's the benign big-haired Portuguese guy, the girl who told me off on my first day here for inadvertently using one of her pans, the Vegetarian med student who sticks "keep off" post-it notes in the fridge, and the one in the room opposite mine who i haven't even met and rather inexplicably avoids looking at me and keeps slamming the door in my face. I discovered yesterday (on talking to The Vege) that she'd had a quarrel with the girl who used to live in my room, and that she hasn't realised that a different person's moved in!

Of course the sickest joke was when my pay came through yesterday - I am earning more than I did as a House Officer, but only just enough to cover the rent on my matchbox-sized room, right down to the last pound. Still waiting for Ching to give notice on her flat so I can move out!! Meanwhile, am attempting to create a friendlier atmosphere by 1) leaving my stereo in the kitchen with a "use as you please" post-it and 2) proposing a shared (vegetarian) meal next week. I don't have particularly high hopes for this (so far Ali and Vege are coming) but one has to try...

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.]
*******

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.

Bad news for Mrs. B

"You know what the problem is with Mrs. B?" says Dr. K, in a typical ward round aside "She just sits. Like a pudding." It's not a generous comment, but it is obvious what he means. Mrs., or rather, Dr. B (she is a retired physician) isn't looking too bright these days. We have been trying to explain the importance of her being on warfarin to prevent further strokes. She doesn't appear to understand. The next day, the Physio comments that she has difficulty following simple instructions. "See, a pudding," says Dr. K. I am given the task of performing a mini-mental state examination. She scores 23/30, which is way below normal for her age (late 60s)and level of education. We check the report on the MRI scan she had in May. There are multiple small cortical infarcts - tiny strokes affecting the bits of the brain important for language and calculation. Just in case, we check her thyroid function and folate too. These prove normal. The diagnosis is vascular dementia. How do you tell someone (who is still cognitively intact enough to care)that they have dementia? That they will become progressively less intelligent and eventually become dependent on others for all activities of daily living? How do you tell their family?
I asked her husband if he had had any concerns about her memory lately? Had she seemed 'not herself' at times? He appeared at first to be in denial of the obvious. She did not seem to comprehend - or perhaps did not want to. Until suddenly she said, "so it's not going to get better then? the writing, the counting..." her eyes searched me for some reassurance. "It's not to say that nothing can be done to help things, I said. "Like you can write things down to help you remember, and the Physio gave you a walking frame." We both knew nothing could be done to halt the loss of intelligence, the eventual loss of dignity and self. How awful to feel one's own mind failing, yet have enough of it left to worry about the consequences.

too hot to string a sentence

its 29 degrees and there is no ventilation in my room apart from a wide-open window but the air outside is muggy and still

London on Saturday  

Warning to all would-be medical students

We had 4 sixth-formers on work experience today. And a medical student as well. Unfortunately for them I was in an incredibly foul mood from having worked all weekend. I was particularly abused this weekend by some nurses who had the collective intelligence of a woodlouse. I managed to muster just barely enough niceness for the patients and their relatives, but had none spare for anyone else. It's one of those 'I wish I did Architecture' days. Or any job where you get all your weekends (or at least all your Sundays) off. The warning is this: a career in medicine means you will have to work at LEAST one weekend a month for the rest of your life. This month I have worked 2 out of 4 weekends. No amount of life-saving or gratitude from anyone, or intellectual satisfaction, or money is worth giving up 2 weekends a month for. And that is not to mention how ungrateful people can be. Too many bright, promising young people become doctors through parental/societal pressure, or simply lack of imagination, and lack of effort toward finding out about other career options. So if you are 18 and reading this, consider your options carefully. A career in medicine does NOT give you 1. Money (I get around on a borrowed bicycle and can't even afford a mortgage on a one-room flat) 2. Respect (see previous entries re: rude/racist patients) 3. Intellectual satisfaction (if you want that, become a proper scientist; Medicine is primarily an Art) 4. Emotional/spiritual gratification (on the contrary, most weekends on call leave you emotionally wrecked). What is left? I guess it is the same masochistic gratification that a marathon runner aspires to.

time to move on

last month as a house officer and I am getting thoroughly bored of my job now. Did my first sucessful lumbar puncture this afternoon. Nice clear cerebrospinal fluid dripping out of the hollow needle and into sterile pots ready to send to Oxford. Spilled a little on my trousers. (this is why i always use Bio detergent!) "Ok, it's all done. How are you doing?" The patient replies in the affirmative. "You might get a headache, so we usually say to lie down for the next 4 hours. We'll tell you as soon as we get any results." "Thank-you, doctor."
Saw a lady with haematemesis (vomiting large volumes of part-digested blood) and aspiration (having some of it go down her lung) yesterday when on call. Knew what to do and went through all the motions without really having to think. (Even the talking to the patient and empathising with distraught relatives is second nature. If only dinnertable conversation were this simple!) Organised tests for a patient to go onto the lung transplant waiting list. Wrote up some chlordiazepoxide for a patient withdrawing from alcohol, Piriton for a rash, blood gas then oxygen and salbutamol for a man in respiratory distress. Obtained permission from some grieving relatives for a post mortem on a man with cancer of unknown primary. We've had a load of moribund patients lately and as a result i've had to go to the mortuary a lot too. (it's right next to the canteen, so you drop by to see the corpses at lunchtime) It's all becoming routine. It's a drag to get out of bed in the mornings to do all this stuff all day. How can i be so bored with it all so soon? I'm looking forward to being a bit out of my depth again come August.

"Ah! Brrreathe the Scaaw-Ishh airr!"

My exact thought articulated by a skinhead in a Scotland rugby shirt, stepping off the train from King's Cross. A shower in soft Scottish water, a freshly made bed in a spare room in Marchmont. A sunny day at a cool 20 degrees. A lift to church; kids from creche all grown up. Old friends from university; someone who actually remembers it's my birthday this week. It's like coming home...

And now I'm back in Reading and it's back to work for another 12 days in a row. ):

homework

My first day off after working 12 days in a row (particularly demanding as we've had a run of patients presenting with hypercalcaemia due to cancer of unknown primary - but that's another story) and I've got homework! I've got to do a case presentation on Monday. This is how it goes: 23 year old lady from Zimbabwe presents with a 3-month history of weight loss (10kg), painful joints and muscle weakness. Her only past medical history is a miscarriage two years previously. She had a negative HIV test then. I went down to medical records to get the notes myself, and when looking through them, was amazed at the number of complex tests she had had in the space of about 3 days. My own contribution was arranging an urgent echocardiogram when a pericardial effusion was seen on high-resolution CT. She also had lung function tests, nerve conduction studies and a bronchoscopy. One ward round entry states "patient exhausted after today's investigations". The eventual diagnosis was of mixed connective tissue disease. In addition, an HIV test was positive. So the second bit of my presentation is on HIV and autoimmune disease. A quick look on pubmed reveals that this is in the 'case report'/ J Exp Med realm (i.e. vanishingly rare/ newly noticed). Unfortunate for the patient but pretty fascinating stuff re: T cell suppression etc. Takes me back to my BSc year - probably the last time I actually had to use my brain (day to day medicine is pretty brainless). I miss that.

minutiae

Whoever said 'the devil is in the detail' could have had my job in mind. Patient has INR (International Normalised Ratio-a measure of bleeding time) of 9.0 (9 times normal). Easy - give him intravenous vitamin K. But it falls to me to put in the intravenous cannula. He has tiny, delicate veins and paper-thin skin. Every time I put the needle in, it draws blood, and then, he squeals with pain, moves, and the needle goes right through the vein, leaving a haematoma the size of a golfball. Seven purple golfballs later, the cannula is finally in and I write up the prescription. "Thank you, doctor," he says. Not at all.

This had me in stitches so I had to record it for posterity: "If you fart at school, you have to shout "safety!" and then you have to run and touch the nearest door handle. Otherwise you could get beaten up." - My little brother, on the goings-on at a certain public school for boys

No offence but....

I was on a ward round with *Jo, my registrar, when one of our patients remarked carelessly to her: "your lady colleague there looks like she should still be in school." It's the sort of thing I've come to ignore (or my day would be filled with annoyances). But Jo snapped back immediately: "How rude! She's been through long, hard training to get to where she is today."

It reminded me of some other nasty/ignorant comments I've had:

"I'm really grateful to all you Filipinos - where would the NHS be without you?"
(several erroneous assumptions there...)

"Nurse! I need a bedpan! NUUURSSSSE!"
(usually a gaffe by the same patients who call white male nurses 'doctor')

"Which part of China do you come from?"
(Huddersfield!)

"You look far too young to be a doctor."
(Would you say this to your financial adviser? or your lawyer?)

and of course, anything that begins with
"No offence but...."
(most of these don't bear repeating!)

Day 3 on Rheumatology

Ward 2 appears to be staffed mostly by a bevy of camp male nurses of various nationalities. *Emilio swaggers up to the nurses' station. "Guess what?" he croons. "I'm off to New York and we're staying in a 4-star hotel!" "Who are you going with?" asks *Michaela, a female nurse who is about 6 feet tall and looks like a man. "Oh, Curtis, of course!" Eyelids flutter all round.

Battle Hospital is a strange place. The block across the carpark is literally a pile of rubble. Within Ward 2 there are a few disused bays where not only the paint, but the lights and other fittings are peeling off the walls. I arrived on the hospital shuttle bus, and almost missed the stop. More prominent than the sign with the name of the hospital on is a large placard: "For Sale". In an operation called "Consolidation", the remaining departments are to be moved across town to be become part of the Royal B. Meanwhile the small community of nurses, physios, security guards, doctors, cleaners etc. that remains struggles to offer modern medicine within what can only be described as little more than a ruin. This is not to say Battle is a nasty place to work - I rather enjoy the fact that it is a small hospital and that you are a person here rather than a bleep number.

Dr. K, my new consultant, is a bit of a character (I guess they all are). We're looking at a chest x-ray, and he goes: "hmm... the lungs look fairly clear.. well, there might be a bit of shadowing in the bases, but then, she's Big and Fat." He says this with complete nonchalance. Later, he muses "all these old, crumbly patients, they sit there going nhgh nhgrgh nhgrg (mimics demented old men chattering)..." then he interrupts himself - "mustn't say that, I'll be next (he looks in his 60s). My old man, he was like that when he died. You know, I used to be quite rude when I was younger..."

..so am back home. There's not a lot to do here, merely to melt in the 35-degree heat. The fact that I've only about 2 people to catch up with reminds me of how unpopular I was at school. The old house looks the same, and the volume of suicidal poetry I composed as a morose 14 year-old remains in the bottom of the drawer - right where I left it more than 10 years ago.
Am feeling very rested though, as mom and dad are spoiling me as usual. The Diesel bag I usually use for work looks pristine now that mom has finished with it (the stains from various patients' body fluids washed away). Clothes return washed and ironed and meals just materialise. I could get too comfortable...

the obligatory cheesy entry

It was a good weekend on call. 2 of my patients died and a

further 2 came close - but it's not about the mortality or the

sickness. I guess it was good because I learned loads, got to put

some knowledge (previously classed in my memory as 'obscure')

into practice, with the end result of several grateful relatives

for a change. The challenge, as they say, is to "heal the sick

and comfort the dying" - and not get the two mixed up! Also, some

things are best not mentioned to cheesed off relatives - such as

the real reason I took 2 hours to come and speak to them.

(Because I am the only doctor covering 6 medical wards!)
****
LJ is a 60 year-old lady with terminal lung cancer. I'd first met

her by chance about a week ago, because she had come in for a

neurolytic block (injection of phenol to destroy the nerve

supplying a painful area-normally an outpatient procedure), and

had been so short of breath afterward that she had to stay in

hospital overnight. As the on-call doctor, I was asked to see

her. The anaesthetist who had performed the block had thought of

the possible complications- pneumothorax (a punctured lung) and

paralysis, but a check x-ray showed no pneumothorax, and her

chest expansion was symmetrical. When I listened to her chest,

she was extremely wheezy, but denied having asthma or ever having

been a smoker. I prescribed some nebulisers. She stuck in my mind

because of something quite silly- the nurses hadn't removed her

red nail polish, so the pulse oximeter readings were completely

useless. I guess I would have taken an arterial blood sample

anyway, but I was frustrated that the ward didn't have any nail

polish remover. It took about 4 attempts to get an arterial

sample. She screamed every time the needle went into her wrist,

and kept moaning for "Eddy", the elderly man I assumed was her

husband. Anyhow, her saturations improved with the nebulisers and

oxygen.

I didn't see her again for more than a week, and presumed she had

gone home. Yesterday I was bleeped to say LJ was on a different

ward, and her heart rate was 170/min (nearly 3 times as fast as

normal) and she was drenched in sweat, with a temperature of 38.

I instructed the nurse to take blood for various tests, and to

give her some paracetamol. When I arrived on the ward, she looked

dreadful, slumped over and dribbling from nose, mouth, hair. The

front of her nightdress was covered in vomit and she had wet the

bed. She shook her head when asked if she had pain in her chest

or tummy. Her pulse was thready, even at the femorals. I went for

the biggest cannula I could find (still feeling trigger-happy

from inserting two greys into a lady who nearly bled to death

from a duodenal ulcer the day before - but that is another

story!) and got the nurse to push in a litre of saline as quickly

as it would run. For all that, her pulse dropped to - 120. Not

good. I was convinced at this point that she might die, so I had

the nurse contact her son. I had her cleaned up and sat up, the

oxygen turned up, another bag of saline run. I prescribed some

antibiotics to cover a possible aspiration pneumonia. She now

seemed a bit more stable, so i left the ward as my bleep had gone

off about 8 times, including a call about a man in renal failure

(as he hadn't passed any urine for 18 hours) on the other side of

the hospital.

Her son, *Joe, arrived about 2 hours later. I got him into the

ward's quiet room, and tried to impress upon him the seriousness

of the situation. Although he seemed to understand the terminal

nature of her underlying illness, he still had rather unrealistic

expectations of the outcome. Eventually, I said "if your mother

were to stop breathing and her heart were to stop, would you want

us to do everything to bring her back to life?" At this he became

tearful. He paused. Nodded. "yes, of course," he sobbed. I paused

for a bit, then left to let him gather his thoughts. It felt

cruel, but I'd rather paint a grim picture and have them be

pleased when the outcome is better than expected. (rather than

the converse!)

Called away again. I returned to see him standing by her side,

shaking her. "Mom!" She wasn't opening her eyes. She had

definitely been conscious in the morning, despite being in

extremis. I peeled her eyelids back and sure enough the pupils

were pinpoint. Her dehydration had probably caused a build-up of

oxycodone. I got the nurse to draw up some naloxone. "What's that

stuff?" Joe asked, suspiciously. I explained as best I could, and

started to inject it (see entry below - "a suicide, maybe"). She

came round with a jolt. Joe was visibly relieved, but his face

soon fell when she looked him in the eye and said, "I want them

to stop." "Stop what, mom?" "All this," she said, holding up her

arms, which were covered in lines and monitoring equipment.

Oops, have to go head to the airport soon! to cut a long story

short, she survived to see another day. Also, it turned out that

Eddy and Joe are not on speaking terms as Eddy is his step-dad.

And I am going on holiday so I will never know the outcome - will

Joe and Eddy come to accept that intensive care, CPR etc are not

in LJ's best interest? And so on. Every on-call is a bit like

starting a dozen books and never finishing them.

"Don't live to 101, I don't advise it..."

Edith* has silky white hair and bright, gray-green eyes. Her voice is low and raspy and posh, and larger than you would expect from such a tiny lady. She is very deaf, and on close questioning, is not entirely lucid. But she puts up an expert front - "..and are you one of the doctors? Did you have to train for many years?" "..I'm a hundred and 2 months. Don't live to 101...." she smiles wryly. She came into hospital as her GP thought she wasn't quite herself and looked pale. Her haemoglobin was 4.9 (normal >11) though there was no history of bleeding. We gave her a blood transfusion and some iron tablets. She looks a bit pinker now, but where do we go from here? How far do you go looking for a cause of anaemia in someone who is 101?

...but I don't feel rested

managed some proper sleep last night for the first time in about a week. I can't remember if I've mentioned this in a blog entry before, the Work Nightmare. It's not a proper nightmare in that it isn't particularly terrifying, and certainly does not make you wake up in a cold sweat. Rather (and cruelly), it doesn't wake you up at all - just lets you lie inert while a bland continuation of the day's events at work plays on. Ward rounds, discharge letters, cannulas, deaths... And you wake up exhausted, as if you havn't had any sleep at all, and then you have to get up and go to work again. I think I need a holiday.

presenting... my new picture blog!

in the interests of keeping work separate from real life, i suppose. a one-off link, add it to your bookmark list!

Liverpool v. Juventus

(alternatively titled 'doctors do have a life outside hospital').
quite surprisingly the first game I have ever watched at the pub. 0-0, by the way, just to emphasise the pointlessness of it all. I have no clue about the offside rule, and at the end of the game my only comments were "well, the last 10 minutes of that was actually quite good" - Ranj was unimpressed, and has taken it upon himself to educate me on the appreciation of the beautiful game. Still, I have to admit that its much better in the pub than in your own living room - nothing like 20 simultaneous commentaries from various corners of the room, and people jeering, shouting and clapping at the screen, jumping up in unison at almost-goals.

me-just testing

suicide concluded

phonecall to the coroner today. Mrs. K died on Friday night. So she got her way; but something tells me she didn't know she would be subject to an autopsy (for a graphic description, see my earlier entry ('nausea'). So much for RIP.

a suicide, maybe

...too lazy to try and make this entry reader-friendly, so here goes:
80 year-old woman took 75 GRAMS of tramadol - thats more than 100 tablets- she had obviously been hoarding them for ages. 'Doctor! she's having a fit!' by the time i got there she was lying still, looked pretty much dead, had a smile on her face. the sats monitor was bleeping - sats of 83 - possibly normal for her as she had advanced emphysema and usually had oxygen at home. airway was fine, nasopharyngeal in situ. got the nurse to turn it up all the same- then did a blood gas - first time i've seen a CO2 retainer- so had to turn it baack down again. They always go on about them in textbooks. left her to attend to other patients. bleeped by the nurse - "the patient's daughters have arrived, they want to speak to a doctor." oh no. her suicide note was signed "by the way, I am in my right mind. Love, M (member (lapsed) of the Euthanasia Society)" I wondered if perhaps her daughters were Euthanasia Society members too. or maybe firece opponents? afterall, they had called the police when she had refused to come to hospital. Her daughter was quite calm and collected. I think now that i didn't paint a bleak enough picture. i mean, being realistic, she will almost certainly be dead by monday. even if she lives she will be severely brain-damaged. Her breathing slowed to 8 resps a minute. tried to get a nurse to give some more naloxone. both nurses tied up with another dying patient. finally, exesperated, i said "julie, if you could just get me the naloxone, i'll draw it up and inject it myself" julie is one of the nicer nurses to she opened the cabinet and gave me an ampoule. the IV drugs book said to inject it slowly. good thing i followed that instruction. the stuff works fast. before i had injected the 2mls or so, her breathing had normalised. i left her. and now it is the weekend.

The giraffe and the relly and me

I am so fed up of patients dying on me (though Susie*, one of the

nurses, pointed out that they die on everyone, not just me). But

I'm the one who usually gets the job of examining the body after

death (before the nurses have cleaned up the vomit and closed the

eyes), and then I have to face the relatives. Paticularly at

weekends, when it's either the house officer (i.e. doctor less

than a year out of med school) or nobody at all.

I clipped *Tommy Peters' obituary out of the Reading Chronicle

yesterday, just to make him seem more human to me again. Mr.

Peters was an 87 year-old man with known heart failure, and he

had either acquired some kind of pneumonia, or his heart had

taken a turn for the worse, resulting in all the fluid in his

body being outside of his circulation, and pooling everywhere

else (legs, lungs etc.). We gave him some medicine to try and

offload the fluid, but it only made him better for a few hours.

Then whoever was on call at night gave him a whopping great dose

of the same stuff, causing him to collapse suddenly the next

morning when I came on duty. I mean, he was on his way out

anyway, but he didn't need the extra kick. Nathan*, our

registrar, happened to be on the ward at the time, and he (being

more experienced than me) had the presence of mind to phone the

relatives while Mr. Peters was still alive (but arguably on his

last legs) and get them to agree that CPR would be futile. By the

time his daughter arrived (about 20 minutes later) he was dead.

I think she knew, because she was already in tears when she

walked on to the ward. Nathan had been called away by then, so it

was just me, and it being a Sunday, I didn't even have the luxury

of a nurse to do the hand-holding and tissue-paper offering bits.

I got a nurse to sit her down in the relatives' room while I

gathered my thoughts and nicked the box of tissues I had spotted

at the dead man's bedside.

me: "hello, my name is Dr. Chan, i'm one of the doctors who was

looking after your father. Did you speak to Dr. Miller* on the

phone?"
her: "yes. he said my father was very sick....and that.... he

might not.... make it."
me: "yes, and in the time between you speaking to Dr. Miller and

arriving here, I'm afraid that he has died."

At the word 'died', she burst into tears. I offered her one of

the tissues, and held her hand. "I'm very sorry," I said, and

paused for her to sob, for what seemed like ages. "He just

slipped away," I continued, almost to fill the silence. "He

wouldn't have felt anything. His heart slowed gradually, and then

it stopped." I'm sure she didn't hear any of this. I could just

as well have muttered that he'd been run over by a giraffe in his

sleep. However, this only lasted about 5 minutes, and then she

became sensible again and said, "shall I go and see him?... oh...

I've never done this before, perhaps I should wait for the

others." "yes, sometimes it helps to have someone with you," I

said, knowing that i'd broken the news a bit too fast, and that

the nurses would still be removing the lines from the body, and

making it decent. "Do you want to just sit for a while?" She

nodded, and I left her.

I ended up examining a further 2 bodies that day. The next day, a

Monday, and so a 'normal' working day, we had a transfer from

A&E. An 80 year-old lady, she had just had a massive stroke. I

don't know how or why they get these patients into a CT scanner,

but they had done, and on CT she had had such a massive bleed

that it had shoved the right side of her brain over to the left

and out through the bottom of its vault - a situation definitely

not compatible with life. To make matters worse (and a whole lot

messier), she had aspirated some stomach contents into her lungs

and was pouring out horrid brown secretions from mouth and nose.

The relatives had been warned that it was a grave situation.

Our ward is 6 floors up from A&E, and before the nurses had even

properly received the patient, she had lost her pulse and become

completely unresponsive. I was called to see her. Unsurprisingly,

she was dead. I got the nurses to put the rellys in Sister's

office while I examined the body. I reflected on the events of

the day before. Maybe I should try and break the news a bit more

gently. Armed with a box of tissues, and accompanied by the burly

male nurse from A&E, I entered the little room and shut the door

behind us.

me: "Hello, my name is Dr. Chan. I'm one of the doctors working

on this ward. I heard that one of the doctors downstairs in A&E

has spoken to you?"
patient's sister:"Yes. Dr... oh, I've forgotten her name. Well,

she was a lovely doctor. She said my sister was very ill, she'd

had a stroke or something."
me (trying to look very serious):"yes, that's right. She had a

scan of her head and it showed a very big bleed into her brain."
pt.'s sis: "oh, Margaret* was always ever-so-healthy. she had a

few problems with her heart, but she would take it slowly and she

would be ok. she's had trouble with her breathing before, you

know..."
me: "Margaret had a big stroke. The blood put pressure on her

brain and that would have stopped her breathing. And then her

heart would have slowed and stopped..."
pt's sis (interrupting): "oh. you know, she would be wheezy

sometimes. they said it was her heart. what do you think would

have caused that?"
me (taking her hand): "Margaret's heart slowed and stopped today.

Margaret has died."

At this point, the old lady paused. She looked over at her son.

Then she started to cry.

I guess you can't win. Tell them directly, and they look shocked

(despite being forewarned). Tell them gently, and they just don't

get it. What is a doctor to do?

Dog

I went to the petrol station to get a pint of milk. And there,

tethered to the tire pump was an Afghan Hound. If I'd been in the

middle of Chelsea, this would hardly have been a surprise, but

here in central Reading, the word 'dog' conjures up the image of

an old lady's scruffy demi-poodle. It was the size of a small

pony, with a slender grey face and long, oat-coloured hair parted

neatly down its middle. It peered quizically at me - I felt a bit

stuck as I had only ever encountered pictures of them in

childrens' encyclopedias and it was quite overwhelming to meet

one in the flesh. Anyhow, I got my milk, and when I came out of

Costcutter, the hound was gone.

It (like everything else these days!) inevitably made me think of

work. I come across about 10 things (whether medical conditions,

bizarre family relationships etc.) every day that I've only ever

seen in a book, and my first reaction is inevitably 'oh look, it

really exists!' Then I struggle to conceal my amazement, as

patients don't like it when you haven't seen something before.

Even if you are only 25 and they are going on 90.

I see dead people

A most horrible thing happened today. (well, that along with about 50 most horrible things). My bleep goes off. "Can you come and certify a death please," says the nurse - her exact words. "I'll come as soon as I can," I say earnestly, which is my standard and unfeeling reply to all requests these days. My thoughts: signing a piece of paper saying someone is dead is last priority compared to the various things with live patients that I have to sort out. I've learned from previous mistakes on-call that you must Ignore The Voices - the most persistent nurse does not necessarily have the most urgent problem. So it is about 5 hours before I get round to 'certifying' the death. Unfortunately, it turns out that 'certify the death' in this hospital is slang for "can you examine this patient to confirm he is dead". So this poor dead guy lay behind the curtains in the middle of the ward waiting to be examined for 5 hours. Luckily for me there were no relatives.

The second body of the day was that of a woman on the Oncology ward. I was bleeped about this at 9:45, past the time that I am supposed to finish. But having learned my lesson, and knowing that the night person would be even busier than I had been, I decided to stop by the ward on my way out of the hospital to examine her. "She's behind that curtain there," said the nurse, trying to get me in as quickly as possible. The relatives were 10 minutes away by car, she said, and heading to the hospital now. But I would not be hurried, and insisted on reading the patient's notes first, as I had never met her before. When I did go to the bedside, I was very glad I had done that, because the patient had died of bleeding from a huge fungating tumour on her face. You could smell the tumour from the end of the bed, and apart from projecting for a good 2 inches from her face and being covered in fresh blood clot on its various projections, it had consumed most of her nose and right cheek. I could not prise open her right eye to examined for its inevitably fixed, dilated pupil. But of course, there was no doubt she was dead. Warm and smelly and dead. I was nearly sick all over the body.

Emerging from the curtains, I was immediately hassled to prescribe some painkillers and sedation for another patient. I wrote the requested drugs up and then bleeped the night person (a senior house officer) to hand over the leftover 'jobs' I hadn't managed to complete. There were a couple of sick patients I had dealt with earlier whom I hadn't had the time to review. The SHO rang back quite promptly. "Hi, its Sam, the on-call house officer. I need to go now, and have a lady on Ward 5 who needs review," I said, starting to relate the patient's history to her."That should have been done 3 hours ago!" she snapped. She went on to tell me off over the phone. She didn't seem to get that the whole point was, you treat the patient, then check back some hours later to see if they are any better, and if anything needs changing. In that particular patient I couldn't tell if it was heart failure or a worsening of pneumonia that was making her ill, so I had initiated treatment for both and taken some blood and ordered a chest x-ray. She was much better when I left her, but I needed someone to look at the xray and bloods to alter the treatment as needed. Maybe I was wrong, maybe I should have checked on her earlier. But that was no reason to shout at me. I hung up and left. If she didn't want to hear about sick patients from me, she could wait for the nurses to call her when the patients went off again. I'd had more than enough for one day. More than enough for a week even.

Despair

I will make no attempt to be coherent or grammatically or politically correct. This job has been pretty rubbish so far (I say 'so far' as I need to believe this in order to get up and go into work tomorrow). As the only house officer in the team, I get stuck with all the rubbish while I have 3 useless SHOs who know even less Medicine than my surgical SHOs did- in other words, I'm not learning anything from them and they are competing with me for what precious few learning opportunities there are. The nurses don't care about the patients - they actually grumble when you ask them to do more frequent blood pressure and pulse measurements on sick patients, the ward clerk doesn't file the notes properly and the whole attitude just pervades the ward. Which incidentally is a dump. And is located on the 6th floor, and 2 of the 3 lifts are broken. Patients are neglected - one man ate nothing for 10 days and the nurses didn't even bring it up on the ward rounds. It wasn't until I looked in the notes (he was admitted before I started work here) that we found out. More than half our patients are simply sitting on the ward waiting for a nursing home place - until they come down with a nasty hospital-acquired pneumonia. (But more about my gripes with nursing homes and granny-dumping another time.) Our ward is the only one without a doctors' office, which means that if you so much as sit down for 5 minutes to check blood or xray results or write a discharge letter, the nurses will come and hassle you for something that you've either already done or were going to do anyway. The doctors' mess is damp and dingy, its telephone resting on a chair with only three and a half legs. I've tried my best to be positive; I've smiled at and chatted with everyone, taken the time to go through the notes, sat and explained things to patients, explained things to nurses. Kept up with my log book of things I've learned (so far: how to manage hypercalcaemia, diabetic ketoacidosis, how to do a lumbar puncture). Its exhausting, and as I've said before, the emotional aspect of it is the most tiring. After a hard day of empathising with people you just get really irritable and its a struggle to even be reasonable. At least the recurring 'work' nightmares - when you go to sleep but your dream is just an extension of your work day and you wake up exhausted - have stopped now.

And at the end of the day, I come back to my room in the old block of the doctors' accommodation. All the other house officers are in the new block down the road - apparently my application was received late. But that was only because they sent it to the wrong address - twice. My room is heated by a bizarre system of pipes that runs all along the wall and that you can't adjust. With the result that the inside of the wardrobe is toasty but the rest of the room is usually freezing. There is no hot water in the basin or the shower, and the tap water is brown. There is not a single pot in the kitchen. But I could live with all that if it wasn't so lonely. Which is made worse by the fact that the phone line is dodgy - it just about works, but there is a loud ringing sound that drowns out all conversation, and slows my modem down to 40K. Have not felt like eating properly so have existed on instant noodles (cooked in my own non-stick frying pan) and breakfast cereal, and lots of fruit for vitamins. And bottled water of course. I had been too busy adjusting to my new job to realise how rubbish my living conditions were until yesterday. And yes, I did get on to the housing people and threatened to take it to the BMA, but they don't have a better room for me until Feb 28 so I have to put up with this for another two weeks. At least I have my mobile phone.

And so its back to work tomorrow. (and I am working this weekend too - I have three thirteen hour shifts to look forward to - not). What do patients know about the s**t doctors have to put up with just to be doctors.

oh whatever

cheered myself up a few days ago with the purchase of a bright pink electric toothbrush

Skiving the party

Just finished my second day on call in a row and all I want to do is go straight to bed. But there are pressures in this job that go beyond working hours. Everyone's at the pub as it is the last Thursday before we all change jobs. Friday is a bad day to be in hospital as half the house officers are hung over from the night before.

I really loathe nights out. Loitering in a smoke-filled room, insipid music blaring to fill the gaps in inane and meaningless conversation. The evening inevitably deteriorates as the more people drink, the better a time they think they are having. Can I be the only one with insight into the stupidity of the situation? These are people who are normally fairly intelligent and sensible - my colleagues, to be precise. Doctors by day, intoxicated cretins by night. I hate the pressure to fit in, to act like you're enjoying it, despite the fact that even a small amount of alcohol feels to me like a head-on collision with a large truck. I thought I'd stop caring about trying to be 'normal' when I was grown up. But I guess some things you don't grow out of.

2 out of 3

there's the old adage:
work, family and social life - you can quite easily maintain 2 of the 3, but it takes something superhuman to sustain them all.
and then there's this one:
the patient, the consultant (i.e. Boss/Reference) and yourself (i.e. sanity) - you can please 2 of the 3, but the third will suffer as a result

A Good Night

It started with an old lady in a faded yellow puffer jacket. Someone had parked her in her wheelchair and fluffy pink bedroom slippers right in front of the glass doors of the side entrance. "Do you want to go back inside?" I asked, seeing as I would have to push the wheelchair aside if I was going to get into the building. She stole a glance at the smoldering cigarette butt on the ground beside her. "Oh yes," she chirped, "I'm finished now." As I headed down the corridor towards A&E, she called out "Don't work too hard, doctor!"

How did she know. I bleeped Kay, the house officer who'd been on call in the daytime. "We're on Ward 1," she said, "doing a round with Mr. A." I knew something was up; registrars never do a round in the evening unless there's something interesting brewing - and I mean in the sense of tabloid newspaper rather than medical journal material. "You've got to see this." Behind the curtain lay a rather plump, middle-aged woman, her dark hair looking badly in need of a wash. Mr. A pulled up her nightdress to examine her belly. She had stuck a pair of nail scissors into her abdomen, right up to the hilt. Before he could lay a hand on her, and in front of a riveted 'audience', she pulled it right out. Due to the smallness of the scissors and the largeness of her abdominal wall, nothing happened. It was a bizarre moment."Theatre. Laparoscopy, maybe laparotomy and proceed. Psych review in the morning." Mr. A doesn't mince his words. He had 10 more patients to see and he wasn't going to be bogged down with "psychosocial issues".

[argh have to run! time for work... to be continued....]

Nightclub

Anna*, who is blonde and leggy, says he is "pervy". But I reckon Ben*, the A&E registrar, is rather like a bouncer - in both form and function. He is about six and a half feet tall, and as wide as a standard hospital trolley. He wears CK underpants (the band deliberately peeping from the top of his scrub bottoms), and a tight black T-shirt. His growl is part Carribean, part Essex. He is a lean, mean triaging machine, shunting patients to Orthopaedics or Medicine or ENT, or, best of all, Home - bouncing them back where they came from.


(*all names that appear on this blog have been changed!)

I am a panda

How can I still be alive? i've had about 3 hours' uninterrupted sleep in the last 48 hours. What part of "do not disturb" do the cleaners not understand?!
A sure sign that I am not feeling so good is an urge to write (and publish) bad poetry:

if you're tired and you know it
wear a smile
if you're grumpy and you know it
fake a smile
if you're unhappy and you know it
you would be a fool to show it
if you're exhausted and you know it
give a smile

argh 10minutes to another 11-hour night!! have to run

A guilt-free lunch

This is the dilemmma:
You are on call and have three patients waiting in A&E, all in considerable pain, one of them bleeding from the rectum, but none so sick as to be in danger of death. The A&E nurses are pressuring you to see the patients before they 'breach' the all-important 4 hour mark. However, you've just been on the ward sorting out a patient in heart failure, and that has taken the best part of an hour. Your bleep goes off - it is the ward nurses bleeping you about yet another patient - he has fallen over in the shower and hit his head on a hand rail, but seems fine apart from a large bruise. And here's the crunch - it's lunch time. If you've any medical experience you'll realise that the situation as described is perfect to take a break in - no lasting harm will be done if no action is taken within the next 10 minutes. What I have also learnt (from bitter experience), is that you have to grab these opportunities when they come, or you might not have the luxury of anything to eat (or drink) for the next 10 hours. (see 2 entries down)

So you take a break for lunch. But it is a furtive, hurried break. Even if the hospital canteen food had been tastier, you'd still end up choking it down. How can you sit down and relax, even for 5 minutes, when you know you've left people who need attention? And that's assuming your bleep doesn't go off (it inevitably does - I've never so much as eaten a sandwich without it sounding before I've swallowed the first mouthful). I feel so guilty about taking a break for lunch that I have to lie to patients that I am going to see another patient who is sicker. I guess there is a grain of truth in it.

my first death certificate, or a minute's silence for Mrs. B

my first thought was that my stethoscope must be broken - it took a second to remember that i'd been called by the nurses to confirm her death. Mrs. B had breathed her last, and as i peeled back her eyelids in turn, large inanimate pupils met my torch beam.

She had been tucked into bed and a crepe bandage wound round her head to hold her jaw shut. Under the dim reading light, the regulation pink hospital nightdress cast a rosy glow on her gaunt cheeks. A black and white photograph of her husband continued its vigil over her from the tray table. They must have been a handsome couple.

Mrs. B was 70, and had an advanced bladder cancer that had eaten into her vagina - she had bloody, fungating metastases - and blocked off her kidneys, causing them to fail. But as horrible as her disease was, I reckon she had died well. Early on, it was decided that she should have radiotherapy to keep the symptoms at bay, and stents put in to help the kidneys drain. She had a long line put in her arm so she didn't have to endure daily needlesticks for blood tests or medication. When it became apparent that her kidneys were failing despite all the treatment, a 'do not resuscitate' order was discussed while she was still lucid. She looked comfortable until the last, and was alert apart from her final 2 days, during which she drifted into a deepening sleep.

tired beyond description

..have just wolfed down the bagel I got up early to make for my packed lunch - finally, at 10:30 at night! This is the first time I've sat down today for more than 5 minutes without being harrassed from all sides. On the face of it, working 13 hours without a break doesn't seem so bad. But I am tired beyond description. The physical tiredness I can handle. The parched throat and unsettled stomach I can put up with too. But I feel as if all my emotional reserves have been sucked dry. On my way out of the hospital, I got stuck behind 2 porters pushing a large metal laundry cage. It seemed as if they were sneering at me and purposely pushing it just that bit faster than my weary feet could carry me. They laughed, and it was cutting, as if the joke was on me (perhaps it was, but I'll never know). I just burst into tears, right in the corridor, and cried uncontrollably for half an hour. I can't explain it, except that perhaps my usual emotional 'buffer' had been chipped at all day by demanding patients and nurses, and now there was nothing left, the smallest slight could make me crumble.

It wasn't even a bad day. Just madly busy. Apart from my usual ward duties, I saw 8 patients in A&E on my own (normally there is a senior doctor around) - each had to be worked up as if for an operation, bloods taken, IVs started, X-rays ordered. Patients with appendicitis can be particularly demanding - what is technically a very simple clerking is complicated by the fact that the patient is young and has usually never been in hospital before. (and therefore naive to the embarassment, prodding and sticking-with-needles that a hospital admission entails). The patient expects empathy, but not too much. It is quite demanding to project the right balance of "seen it all before, doesn't rattle me" and "of course I care that this is awful for you".

I failed to pass a catheter in a man who was in urinary retention because his penis was blocked off by blood clots. He was literally delirious with pain, but I didn't want to force it (you can create a false passage if you ram it hard enough). "Do you mind if I get up on my feet?" he asked, struggling to right himself with the rails of the bed. "You've only got one foot, dear," nagged his wife, as if reminding him of a forgotten hat or keys. The man had had a hindquarter amputation several years ago, and could barely sit up without assistance. It would have been comical if it hadn't been so sad.

I also put scalpel to skin for the first time today (previously I've only ever stitched things together), to incise and drain an infected sebaceous cyst (i.e. massively oversized pimple) on someone's back. Nasty. But kind of cool.

So it wasn't a bad day. Just a day with a week's worth of work and a month's worth of emotion packed into 13 hours. And no time for food, rest or even water. And the guilt of handing lots of stuff on to the on-call night team. And the guilt of having made people put up with pain, just because I can only see one patient at a time, even if 3 arrive at once! (And plenty of nurses to rub the guilt in.) Right, should get washed and to bed - must be up for work again in 7 hours. Think am so exhausted am becoming slightly euphoric.

why there aren't many women in urology

...too much male anatomy. man of 40 attended A&E with a fractured penis at 6a.m. "I woke up with an erection and rolled over, and I heard - or rather, felt- a click", he said. "This was followed by rapid detumescence" reads the admission clerking. There was a large black bruise on the side of the injury. Whatever the story, he was soon taken to theatre, where the skin of the penis was peeled back, and the rent in the fibrous tissue sewn up.
the morning ward round involves lifting up too many gowns and finding horrible swollen, bruised and variously deformed phalluses. its enough to put you off men for life.

day 5 on urology

-had to bleed all the patients myself because the phlebotomists appear to be on strike
- catheterised a man with a leaky bladder - i hate it when patients ask "have you done this before" i mean, do they think i do this for fun?
-went to theatre to watch D and JM operate - or in other words saw a man transformed into a scrotum by sterile drapes and then sliced open, a gleaming cyst removed, and sewn back together again

i love my job

i love my job
i love my job
i love my job

what can i do to convince myself that that is true? anyone in a full-time job (duh, hence the term) spends so much of their lives working that there must be more to it than a means to an end (i.e. payday). or do i expect too much out of life? perhaps it is routine that dulls the magnitude of each day's accomplishments. i suppose one could say that i helped save someone's life today - 70 year old woman, speaks only Hindi, suddenly becomes short of breath and manages to convey that she is suffering from some chest pain. admitted over the weekend with abdominal pain and vomiting, she is normally on a full compliment of cardiac medication - generally bad news for any patient on a surgical ward. at 11 o'clock - when all the senior doctors are safely away at theatre or in clinic - she starts gasping for breath, goes cold at the peripheries, her distended neck veins pulsing to her ears. that is pretty much what greets me when i get to the ward - i have already asked over the phone for her to be sat up and put on high flow oxygen. she is attended by a student nurse, who helps hold her up while i deftly slide my stethoscope in to listen over the lung bases. she has fluid nearly up to the top of her lungs - in other words, she is drowning in her bed. i order an urgent ECG and some IV frusemide. i've read it in the books and have even seen it done, but this is the first time i am running the show. the presence of the woman's daughter is a mixed blessing - she translates the patient's panting half-sentences, but her presence gives me a tinge of stage-fright. i feel compelled to keep explaining what i am doing - whereas if all i had was an obtunded patient, i could just get on with it. in the mean time, i despatch the student nurse to call the medical SHO. by the time he arrives, everything is under control. the patient is chatting with her daughter, as best she can with the oxygen facemask still on. i guess it was quite a satisfying experience, but it is one that i will soon become used to, and then it will be "all in a day's work" as they say.

am on call again tomorrow. i called in sick for the first time ever today. it was a difficult decision because i felt absolutely dreadful (and was arguably a public health hazard) yet i didn't want to be seen as skiving, particularly as i had been on holiday all of last week. i suppose it is quite ironic that i should have fallen ill while on leave.
it is now evening and my cold is much less fulminant, my head clearer for having slept for much of the day. i was amused to overhear the cleaners going "sshhhh, she's sleeping" in loud stage whispers outside my room as i sat in bed reading. my day of reading (last 3 issues of BMJ, verses from the Bible, last few chapters of The Life of Pi, photography magazines) and dozing has been much more refreshing than my trip to york. in fact, my holiday left me with an inexplicable feeling of emptiness. i barely finished 2 rolls of film (on a usual holiday i easily burn a roll of 36 a day), the 'therapeutic massage' did nothing for me (i am too self-conscious and ticklish), and the guilt that followed the purchase of a new winter coat made me determine not to spend any money on myself for a long time to come. perhaps it was a good holiday in the sense that it made me long for work again?

I love meeting people, and I love a good story, particularly one with vivid description, in the vein of Garcia Marquez. it may seem that medicine and stories don't have much in common, but in fact, a good story is the basis of all diagnosis and treatment. as a doctor you are privileged to obtain from the patient their most intimate details - bowel and sexual habits, what the voices say, what their grandmother died of and so on, and your job is to arrange them to form a coherent story, or 'history' as we say in medical parlance. and, of course, your very listening to the story is the beginning of the patient's treatment. despite all the attendant pressures, i like the role of 'doctor'. outside of work i can be a bit of a social misfit - it can often be a strain to so much as ask a stranger's name, nevermind finding out things about them. but in the hospital i can nearly always say the right lines with confidence. perhaps that is what i miss when i am on holiday.

postscript:
Mr. K was eventually discharged with a diagnosis of Munchausen's syndrome.