Through the anterior fontanelle

I took some cool pictures today - using an ultrasound scanner. Too bad they had to remain in the patient's notes! Premature babies' brains are slightly different in structure to term babies' brains. In particular, they are more prone to bleeding into them, so the babies on the Unit often need cranial ultrasounds. The fact that babies' skull bones are not yet fused means it is possible, by holding the probe over the largest gap between the bones (i.e. the anterior fontanelle), to get an ultrasound image of the brain. Occasionally one finds unexpected malformations of the brain, such as this example (I only have a picture because I presented this case at Thursday's perinatal morbidity meeting):


Even with this poor quality image, it is possible to discern that the lateral ventricles are fused. This is known as holoprosencephaly. In its most extreme form, this results in cyclopia, seen here in a kitten. The baby whose brain is seen in these ultrasound images weighs a mere 480g and was born at 24 weeks' gestation.

a walk down church street

bouncing babies!

The day before my exam, and I am up at 06:45 to go to work - a day as the sole paediatric doctor on the postnatal ward. Our hospital serves an area of London (Tower Hamlets, Hackney and Newham) that boasts Britain's highest birth rates (or for full figures, go to the Mayor of London's website and download 'Borough Fertility Rates'), but I have never felt it quite like I did today. Once again the ward was full, with the overspill housed on the antenatal ward. The spectre of having to do 20 baby checks (mind-numbingly boring after the first 5 minutes; also think: vernix, wee, poo and baby sick) all by myself loomed large.
[baby count: 2]
Imagine my delight when an unsuspecting Swedish elective medical student pitches up at 9 o'clock. "I have to do 4 baby checks," he says, anxiously. Well, you've sure come to the right place, I think to myself. From my previous experience of teaching medical students (teaching them how to examine a breast and then letting them clerk in breast cancer patients), having a medical student actually doubles the time it takes to complete the task. But I enjoy it - I like to think it is not because it makes me feel important. I guess it's nice to have some company (and be outnumbered by midwives about 10 to 2 instead of 10 to 1) and it makes me think about why each step in the baby check (or Routine Neonatal Examination) is important, because I quiz the med students about it (and then embarrass myself when I don't have all the answers, like how long it takes for a Mongolian Blue Spot to fade). Well, he was pretty good, he got the hang of it after just one demonstration, and then was able to help me out.
[cumulative baby count: 6]
A couple of our Native medical students turned up an hour later, in their usual inappropriate attire (large dangly jewellery and !nail extensions!). I have tried to shake my negative impression of the students from our local med school ever since the Fetal Haemoglobin incident (which Ching can tell you about), but have not so far succeeded. If this had been Edinburgh, we would've run out of babies to examine by then, but as we have an unceasing supply (the moment you discharge a baby, a new mother and baby appear in their place. Literally.), these stragglers had plenty of babies to try their hand on. I resisted the urge to chuck the long-nailed student out of the room. They each examined 4 babies, and I signed them off for a job fairly adequately (if incredibly inefficiently) done. I had to secretly go back and redo the ones seen by the long-nailed girl, though.
[cumulative baby count: 14 ]

After lunch, I went over to the Neonatal Unit in search of the registrar to ask his advice about a couple of things from the morning. Instead, I found yet another medical student, who was desperate to fill his baby check quota. 4 medical students in one day?!? This was becoming like ER. He seemed like the keen sort, so I brought him over to the postnatal ward. After 2 babies, I said he could go if he liked, but he said he wanted to do the antanatal ward ones too.
[cumulative baby count: 18]

And that is how I examined 18 babies with the help of 4 medical students.

Inedible Cookies No. 2

Am currently on study leave (hence actual time to spend in front of computer) and have discovered (though coming rather late to it) numerous blogs with amazing pictures of incredibly complex food (I think 'food porn' is the correct term). Here is my (; version (please note the culinary disasters are genuine!):-

Inedible cookies No. 1
On Saturday I craved a sugar-fix, and what better way to raise the blood glucose than to imbibe sugar blended with a load of pure animal fat and refined carbohydrate. A recent trip to Edinburgh stoked my appetite for shortbread, and the website of the self-proclaimed Ultimate Guide to Scotland provided what surely must be a fail-safe recipe. The recipe called for ground rice as well as plain flour, and having none of the former to hand, I substitued raw bulgur wheat.

Ingredients:
200g butter
175g plain flour
50g bulgur wheat
85g caster sugar

When I was working on my BSc thesis way back in 2001, my supervisor once said "a lab protocol is NOT a recipe. You have to follow a protocol to the letter." His advice served me well. Therefore I deduced that the converse must be true, and ignored the details of the recipe completely, sprinkling a few scant handfuls of flour over my creamed butter-and-sugar, and randomly grating the rind of an orange into the mixture, along with the crumbs from a packet of salted cashewnuts I found under my desk, and a tablespoonful of ground cinnamon.

The mixture looked fairly inhomogenous, but came together sufficiently to sit gloopily in the centre of a baking tray. By then I had turned the computer off, so I simply made up the oven temperature. I guessed it to be about 200 degrees celcius, without pre-heating. Shortbread is often thought of as uninteresting and stodgy, but this version was turning out to be anything but. The cookies seemed to come to life and sprawl as they baked, until they coalesced to form a bubbling lumpy pool. It smelled good though. And here is the end result:


My flatmate tried one and it almost broke his teeth.

Inedible Cookies No. 2
3 weeks on, and a little wiser, I cycled to Hackney Central Woolworths to get a measuring jug for 49 pence before embarking on my next attempt at cookie-making. This time, I decided I would study several recipes from those glossy-looking foodie-type weblogs to figure out the correct proportion of fat : sugar : flour. A ratio of 2:1:2 seemed fairly safe, so that is what I used:

Ingredients
250g butter
120g caster sugar
250g flour
zest of 1 lemon
spoonful of greek yogurt
crushed almonds

Ah, the taste of a Mediterranean Summer! A citrusy note and greek yogurt, to make it, like, Greek. These ingredients were quite challenging to blend, not least because I had only a wooden spoon and a flat-bottomed casserole dish with which to mix everything. I nearly got a splinter. The cookies looked OK as they baked. The oven temperature was 180 degrees celcius, preheated this time. Cooking time was 13.3 minutes, the mean time from among the recipes I looked at.

The cookies came out looking ok, but when I bit into one, it was raw in the middle. So I shoved them back in, for another 15 minutes. And the same thing happened. These cookies must have a really high specific heat capacity. So I gave up, removed them from the oven, and finished them with some caster sugar on top.


My flatmate tried one and he says they are better than the last batch. He also mentioned that I should maybe stick to Medicine.

...of very little brain

She looks like Maggie from The Simpsons - bug-eyed with an oversized head, bundled up and lying quietly (thanks to a large dose of chloral hydrate) on the CT table, all 2 kilograms of her. *Amina was born at 24 weeks (a gestational age at which an abortion would be legal - just). She had necrotising enterocolitis resulting in bowel perforation - she had to have a large amount of gut removed and a stoma fashioned. Then she had a bleed into her brain (something preterm babies are prone to), and following that developed hydrocephalus. The bones of her skull (these are not yet fused in babies) are splayed and her eyelids cannot fully close. She also has a port wine stain over her face, like that seen in Sturge Weber syndrome. Today she is having a brain scan. I take her down to CT in the transport incubator, with the help of a nurse. We get lost in the hospital basement. We get a lot of stares. At first, there are 'awww's as people realise it is a baby in the incubator, but their coos soon turn to speechless horror when they see her. Nearly half an hour later, she is finally on the table. We retreat to the control room. She lays remarkably still (she had hiccups on the way), and the pictures show, well, very little brain. The ventricles are huge and the brain is squashed into a tiny rim around the edges. The skull itself is very deformed - although her face is parallel to the table, the scan is almost entirely assymmetrical. It seems almost surprising now that when awake she does pretty much what the other babies do - stretch, kick, suck and cry, and she has (like all of them) her own little personality. What will become of Amina? The statistics do not bode well. She will most likely be severely disabled, and require a series of shunts inserted to drain the fluid from her brain. The only conversation I have had with her parents revolved around them trying to wrangle a letter from the consultant to support their application for a bigger council flat. "we all sleep in the same bedroom", the mother complained, "me, like this (she gesticulates), him, like this, and the three children (two of whom are in the pushchair they have brought) like this." So how (and why) did they conceive again, one inevitably thinks. They never touch Amina or change her nappy. In fact, they appear to share the revulsion of the onlookers in the hospital corridor. I wonder what I would be like in their situation?

3 months down, 3 to go

I think the word was 'karoshi' - Japanese for 'death from overwork'. Had a tune in my head as I was cycling home through insane London traffic - 'bye bye Miss American Pie, drove my chevy to the levy [etc etc] just as it got to 'this will be the day that I die' a police van screeched, with blue lights flashing, right into my path. The first I noticed was that all the other traffic had hung back at the junction and I was strangely alone in the yellow box. It was a bad cannula day today - I get these every now and then - days when every single line I try to put in results in multiple bloody holes in the baby and no intravenous access. There must be some weight in the argument that I should have the day off as in this state I cause more harm than good to my patients. I wish I had some energy left to care. However, only 2 more days to go and I get 2 weekends off in a row! What a treat! I can hardly remember what a weekend is anymore. This job threatens to be the death of me, but I've come this far....

just to set the record straight

Just for those who hate to read about my bad days, (unfortunately those are the ones which drive one to write) may I gently protest that I am allowed them, just like everyone else. And that the main problem with the nature of my job is that being professional involves being compassionate and working with your whole heart in it even when you are exhausted and feel rubbish yourself. Therefore I can only really whinge outside of work.

In addition, I don't hate medicine, I just hate intensive care! I miss being able to talk to my patients, and I hate having to check blood gases and electrolytes every 4 hours AND intensive care attracts (arguably needs) a certain breed of nurse (meticulous to the point of obsession with detail- drives me MAD!). To be fair, it also attracts a certain personality of doctor, and I obviously do not fit the description. Of course, in order to be a good paediatrician, I need to gain as much experience in neonatal intensive care as possible, as i will be encountering 'graduates' from the neonatal unit in my future work. SO this job is merely a means to an end. In addition, I have gained an appreciation for normal human physiology - put it this way: if we had to conciously control our fluid and electrolyte balance, acid-base balance, blood pressure, blood sugar, breathing and heart rates, we would all be dead in a matter of minutes.
I say all this as I am preparing to go to work on Good Friday - I have got 7 consecutive days of 13 hour-shifts ahead of me. I have to cycle as the trains are running a Bank Holiday schedule. (have drawn the short straw and have to work the 4-day easter weekend!). So forgive me if I get a little grumpy as the week wears on.

baby

Was called to Labour ward theatre at 12:00 on Tuesday, just as my shift ended. Have been itching to properly resuscitate a baby since going on the Neonatal Life Support course, so went along, only to discover it was an elective and not an emergency caesarian section. "Is there any particular reason you need a paediatrician?" I asked the midwife. She shoved me into the scrubbing-up room. "The mother does not want to see the baby," she said, in hushed tones and a heavy carribean accent. "I'm sorry?" I said, puzzled. "She is a student, and she wants the baby to be adopted, " the midwife explained. S.P.*, a 20 year old college student, had booked at around 20 weeks' gestation, having discovered that morning at her doctor's that she was pregnant and had not merely been gaining weight. She was on the Pill, and had continued 'spotting' throughout the 20 weeks, so had not suspected anything. She was no longer in contact with the baby's father, who she had met at a London nightclub.

(to be continued)

Nights misery

On nights again. It's amazing how one can be so bored at work when there is so much to do. I guess it just gets repetitive after a while. I miss having patients you can actually talk to. Must keep reminding myself that the little creatures in boxes are actual people. Desperately desperately need some sleep. (am awake now as life goes on - still have exams to study for, laundry to do, holidays to plan, must keep fit etc so can't afford to sleep all day). sorry this is so uninspired.

epilogue

the parents of baby Z (the baby in my last post) handed in a hand-written letter yesterday evening. "Dear Sirs," it began, "thank you for your excellent care of Z. We have spoken to our parents... and they agree that we should set his soul free and let him die peacefully so we may see him again in the next life.....we have agreed that the date to do this should be March 10th."

And so Z's ventilator was switched off, and he was placed in his mother's arms - for the first time. He died within minutes.

Beautiful Freak

Thursday is Academic Day on the Unit, which means we don't do any work until lunchtime (and consequently work like mad afterwards and can't leave until nearly seven... but i'll save that rant for next time). Cotside teaching today was on a tiny, hairy little thing, a baby born at 30 weeks' gestation (i.e. 10 weeks early), unable to breath on his own and with multiple deformities. Having sent all the parents out of the room, we crowded round the incubator. "Now, who's going to help me criticise this baby?" said Dr. J, ending this question in his usual alligator grin. "Look at the feet. The heels are very prominent... they had 5 goes at intubating this baby - he has a micro-oropharynx. His ears are low-set and his fingers overlap - classic clinodactyly. On the xray, he has gracile ribs." Dr. J pauses to remove the nappy. "Now that is a very posterior anus...hang on, it's not an anus!" He gets really excited at this point. "Write in the notes, will you, Ali* (he says to one of the other SHOs) the baby has an imperforate anus and a sacral pit. Those are spinal structures you can see through that hole. What do you think," he turns to the other consultants, "surgical opinion?" They all bristle with excitement. One gushes about the size of the ventricular septal defect he'd found on echocardiography and marvels that it was not picked up by antenatal ultrasound scanning.

The baby is likely to have Edwards syndrome (genetic tests are pending), and will most likely die once he is taken off the ventilator. Meanwhile we try to explain all this to his parents while he serves as an unwitting specimen for postgraduate teaching. But one has to learn somehow. What freaks me out is the consultants. Neonatal medicine attracts a certain kind of personality. It requires an obsessive amount of attention to detail and a deft hand with fiddly procedures. Your patients never talk back, and (usually) possess near-miraculous powers of recovery. However, they come with (usually very distraught) parents and you also have to work with Midwives (another group of bizarre individuals) and Obstetricians. The work never stops because babies are born at all hours and fluctuate almost from minute to minute. So its an admirable job they do. But it gets a bit sad when they start getting excited about anuses being in the wrong place (or, indeed, absent).

the two faces of stoke newington

[once again so much has happened that I haven't had time to blog it, so here's a select list: survived 5 x 13 hr shifts in NICU, was going to blog an anonymised patient list but am too tired at the moment; took a short break in Edinburgh, submitted some pictures to a stock library, can now memorise about 30 minutes worth of Pilates - done purely out of a book and...]

Went rock climbing with my sister - at a castle (yes, literally) in Stoke Newington, discovering a whole new side of Hackney in the process - one where New-Agey (mostly white) couples come to nest, and which contains an entire herd of miniature tame deer in a landscaped park, gastropubs galore and a holistic hair salon. This is perhaps best described in the magazineN16. It truly is (or pretends to be!) a world apart from that of the Hackney Gazette - the latter's top headline today being a case in point: "A PARTYGOER ATTACKED in the street after a night out died of his injuries yesterday..." And all within a half hour's walk from my flat!

grthoyfhdljhss

too tired to type, should be in bed. 4th long day (08:15 to 21:15) in a row (since Sunday - therefore also the 11th day in the row that I have worked without a break), and have another one tomorrow. Am so tired am hallucinating - was convinced that a tall man in a black coat and a green and blue checked scarf was behind me and put out his arm as I unlocked the door (i swear i felt it brush against me), but when I turned around again, there was nobody. Had to stay up to prepare Portfolio for my beginning of job appraisal tomorrow. contains a CV and 'what i hope to get out of this job'. Have seen/done lots of new stuff - intubating babies, putting in long lines (a cannula running from a peripheral vein to near the baby's heart that is so fine it looks like a piece of string), interpreting baby xrays etc. But its all a bit too much. If only I could do all this AND have some rest as well! have done pretty well with having 3 meals a day (even if dinner is a stale croissant or bag of soggy chips eaten on the train home at 22:00), though still do not feel quite right - muscle aches, losing my balance, seeing and hearing things that are not there. etc. ok should get to bed. oh and did I mention I have to get up half an hour earlier nowdays in order to get into work at 8:15 instead of 8:30?! stupid train. so i have to be up again in 6 hours. what i would give for some sleep.

NICU

...stands for Neonatal Intensive Care Unit.

Am still slightly groggy from last night's on-call (my first ever as Neonatal SHO). It was (as first days always are) rather surreal. NICU is (stupidly) located in a different building from the maternity wards, which means that each time I get bleeped by labour ward I have to run across a courtyard and up 2 floors, by which time the baby is either already born, dried and swaddled (which happened 4 times last night) or is in dire condition with no paediatric doctor present (which fortunately has not happened-yet). Being Intensive Care, I didn't get a moment's rest in my 13 hours, as most of the babies were on some kind of ventilatory support and needed blood tests every 6 to 8 hours. At the end of the night, I had to write a summary on each baby, ready for the morning's ward round. And all that is just the routine stuff. Add to that the blood tests for jaundiced babies on phototherapy on the postnatal ward, antibiotics to be given (the midwives, who are trained to give IV antibiotics, won't do this, while I, who have never given them in my life, had to do them all), emergency calls to the labour ward, babies on the Special Care unit (a notch down from Intensive Care), and you are constantly running behind schedule. There are only 2 doctors covering all 4 wards, and I, as the junior (and arguably rather clueless) one am responsible for clearing all the boring stuff.

The nurses were kinder to me than I had anticipated. Charge Nurse (male version of Sister) for the night was an unbelievably camp, middle-aged chinese bloke. From what I hear he is much more laid back than the other Sisters - large, matronly African ladies who run a tight ship. He even ran a blood gas for me. As I made my 'blood round' armed with lancets, capillary tubes and microtainers, the (predominantly Filipino) nurses chattered away in Tagalog.

a tip for the hungry

Just had to blog this, in case you should ever find yourself wandering the streets of Stoke Newington at night with a rumbly tummy and only a pound in your pocket. I have just had for dinner a Lamacun - sometimes touted as 'Turkish Pizza', but more like kebab roll, except it contains a thin layer of minced lamb in a tomato-based sauce instead of slivers of kebab. This is topped with a generous amount of chopped fresh tomato, shredded lettuce, onion, coriander and chilli and the whole thing rolled tightly. It's large as well - nearly a foot long - and quite satisfying, though not exactly delicious and decidedly gastric reflux-inducing. But still, not bad for a pound and quite possibly the cheapest meal in London. Too bad it didn't come in a vege version. S (good friend from med school who is vegetarian) is here to stay (hence the sojourn from the now cozy flat to a Turkish 'restaurant') so I've got some company in MK's absence. And we can even whinge at each other about medical postgraduate exams.

A manual of neonatal intensive care

...my latest purchase. I've heard scary things about Neonatal Nurses - apparently they try to show you who's boss in the first few weeks by bullying you, especially if you are female. I am hoping that by arming myself with some prior knowledge, this period of brutal initiation will be minimal. I have also got a book on Neurolinguistic Programming for good measure. It is with a large measure of trepidation that I look forward to my new job next week.

With the end of another 6 month post, it is time to update the old CV. And another reminder that my life has been completely taken over by Work. I used to do interesting things like edit the med school's magazine and develop pictures in the darkroom. Even academically, my only publication in a journal so far was as a medical student. The audit project I designed in August has all but stalled because I can't seem to get away from the wards for long enough to work on it and medical records won't let me in after hours. I am trying to write a protocol for the management of coma in children, but have only just managed to read a couple of reviews. I suppose I did invest a lot of time in the Exam (which I shall be absolutely devastated about if I fail). But still... And I haven't really settled in London after 6 months. I have moved house twice, have not really met anyone outside of work, have been sporadically to 8 different churches (none of which is quite right), and still HATE east london with a vengeance. Though I did walk past a newsagent's selling the Hackney Gazette, and fantasised for a few minutes about writing to the editor to ask if they needed a resident doctor. I'd love to have my own column, like Dr. Thomas Stuttaford. I imagine they'd want a qualified GP though, not someone 18 months out of medical school.

Back to Hackney

The silver-haired rastafarian glanced nervously at the changing traffic lights, rubbing his fingerless-gloved hands together to keep them warm. He turned to me, as if to check if I thought it safe to cross the road just yet. I was heading into (horrible, graffitied, grubby) Hackney Central (the only Tesco within walking distance)to get some groceries for the empty fridge . Just over 24 hours ago, I had been at home in Singapore celebrating Chinese New Year with my family for the first time in seven years. (With a fridge that was far from empty.) Going home always brings on a mix of emotions... [the details of this I have written in my 'real' diary and am too lazy to reproduce] but overall, it was great and I'm glad I went.
It was such a quick trip, it is almost difficult to believe it actually happened, even with a kitchen now stacked high with red-topped jars of pineapple tarts, peanut cookies etc. and nearly a kilogram of kueh lapis in the fridge. So I got my pictures developed in an hour this afternoon (also partly to avoid having to revisit Hackney Central any time soon), just to convince myself it was real.
And it was dark by 17:00. I think I really needed the break even if only for some sunlight in the middle of a miserable grey winter.

Arthur

Arthur (not his real name, but he has got an old man's name) is a one-and-a-half year-old boy who has been given the rather hopeful label of 'global developmental delay'. He doesn't have a particular diagnosis (such as a genetic syndrome or a brain lesion) but he is clearly not progressing normally. He does little other than sit in his cot and stare into space. He is blond-haired and blue-eyed with chubby cheeks. Currently he has got an empyema secondary to an aspiration pneumonia.
I met his mother for the first time today. Unusually for this part of London, she was a slim, bespectabled, middle-aged lady, smartly dressed in a silk blouse, velvet skirt and flat leather boots. As she arrived she cooed to Arthur, and flung her arms around him. "Hello, Arthur daarling!" she said brightly. Arthur remained entirely indifferent. "It's Mummy, Arthur," she said, as if he had merely forgotten who she was in her overnight absence. It all seemed quite tragic. I could almost picture her, in another life, walking Arthur to the Montessori school, in a pressed shirt and trousers with his blond curls slicked back.
I returned later in the day to inject some urokinase into Arthur's chest drain. Now I try my hardest not to subscribe to stereotypes, but there on the bedside table was his mother's copy of today's Observer.

pick and mix selection

..bizarre use of this phrase by one of the MCQ bank websites I was frequenting until yesterday. Felt a bit deflated after the exam (2x 2h30min papers); I just didn't know enough of the answers with enough confidence to believe I'll pass (it's a competitive exam - only the top 30% are allowed to pass). Feel a mite better after consulting my dusty old anatomy text - the thoracic duct does indeed drain into the left subclavian vein - a fact I have not revisted since year 1 of medical school. Now all I have to do is wait 5 weeks to find out if I have to pay another 275 pounds to re-sit.

Made a courgette cake instead of dinner (the thought of cooking a meal and dessert is just a bit much) - sugary playdough-like (due to the erroneous assumption that putting it in at a higher temperature would make it cook faster) confection containing an entire grated courgette. Made MK guess what was in the cake. Unfortunately as he is completely colour-blind, the green flecks (and indeed the green tinge of the cake) did not offer any clues (which was the point). He had no idea. He thought it was a good cake though. Maybe it was a bit of a duff courgette.

Working the weekend again!! T is coming down from Edinburgh this weekend and we were going to watch Daniel Barenboim at the Barbican. Until I remembered I had to work. This (despite my numerous other complaints) is the primary reason why working weekends is Rubbish. And why the thought of having to work weekends for the rest of my life is so depressing I try my best to live in denial of it (hence all the appointments I make that I suddenly remember I can't keep).

At least this time I get to fly home afterwards.

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.