a slap too far

...just a little aside: see what I meant (a couple of posts ago) by repeated predictions of a house price crash that never seems to materialise.

Attended my first Child Protection (CP) Case Conference on monday. It was about a girl I examined several weeks ago - we found linear bruises on her back, legs and arms as well as some old scars. This fitted with her story of being beaten by her father with various objects. I guess I can't really blog about it properly as it's meant to be confidential.

I still come away from CP medicals feeling a bit bruised (emotionally) myself, particularly the physical/emotional abuse ones involving a child and a parent. In the case that went to Conference, it was obvious that the parent had overstepped the mark, on that occasion at least. But there are numerous other cases where the child discloses being beaten but there is no physical evidence. Sometimes social workers enter the the home to find a filthy, overcrowded flat, or a depressed single parent who smells of alcohol. But more often the problem is less obvious (or indeed, there may not be a problem). The home environment looks suitable, the parents are in stable employment, and the children are doing well at school. What is then achieved by having a social worker visit the family fortnightly, forcing the parents to accept 'family support services', or even prosecuting the parents? In an intact family with evidence of adequate resources(which seems a relative rarity in these parts), do the benefits of protecting the children from suspected physical and emotional damage justify the cost of straining family relationships? Certain high profile cases mean that agencies tend now to err very far on the side of caution. While I agree completely that a high index of suspicion is required until all the relevant information is gathered, I think it is also important to back down when investigation reveals that the that child is, on the whole, well cared for. I know hitting a child in this country is illegal etc. but strong family relationships (even if a bit dysfunctional) must hold some currency.

Autumn sunshine

a blast from the (recent) past

little update on Bike - he's now fitted out with brand new tyres - kevlar-lined, no less!

Bit of an interesting baby clinic today (never thought it possible!) - trying to get a portuguese interpreter at 5pm, and seeing *Esther again. (will save my gripes/anecdotes re: interpreters for another post) Esther is an "ex-prem" - a baby who was born prematurely and (typically) spent time on the neonatal intensive care unit. She is on home oxygen, and today mom has brought the travel-sized cylinder, which sits snugly in the undercarriage of Esther's pushchair. It's been 5 months since Esther was born - she was on NICU when I was working there. She didn't stick much in my memory as she was a pretty typical admission - delivered by emergency caesarian section at 28 weeks (ie 12 weeks early) due to intrauterine growth restriction (IUGR) with reversed end-diastolic flow (i.e. very bad placental insufficiency - see link). Admittedly, my contribution to her intensive care was mainly in the form of clumsy phlebotomy at 2 a.m. She did fairly well though, and she's as big as a smallish 8 week-old (which is her corrected age - with premature babies, you count from their expected date of delivery for the first couple of years) now, and smiles and gurgles etc. It's all too easy to take it for granted though.

The IUGR 28-weeker who sticks in my mind never made it out of NICU alive. I was on call the night *Mohammed should have been born. The registrar and I were bleeped urgently to Labour Ward to attend an impending caesarian section. We had the nurses ready an incubator, while we ran over (labour ward at our hospital is stupidly located in a different building from the neonatal unit) with the 'crash bag' (a shiny green backpack containing nearly everything you'd find in the back of an ambulance but in miniature). We arrived to find an empty operating theatre. A midwife waddled up to us; "they are refusing the operation," she panted. We peered into the room - a small and extremely angry Bangladeshi man was hunched in one corner, while the obstetrician - a tall black lady with an imperious mien, was flanked by two burly and irate midwives. The man's heavily pregnant wife lay on a bed in the centre of the room. She was not in labour; they had come because she hadn't felt the baby move in 3 days. "You cannot take the baby out now," said the man, it's too early! We just want scan to see if baby is OK, then we go home." His wife murmured something in Bengali (she didn't speak English, but seemed to understand a fair bit). We retreated to the midwives' office, but it didn't sound any prettier from there. Finally the obstetrician gave up, but invited my registrar to say her piece. I thought she did rather a good job, explaining what a 28-weeker was like and what could be provided at NICU, and emphasising that the baby could die if we didn't act soon. I could see the woman's eyes light up. The man was unmoved. We left them to give them time to come to a decision. Eventually, they packed up and left. Mohammed was born by emergency caesarian section when his mother developed pre-eclampsia 2 days later. He was born in poor condition, and remained comatose and floppy despite resuscitation.

I HATE LIVING ALONE

now I know why all the little old ladies get depressed and stop eating
life is not worth living without company

in reverse order

I reckon there's enough to learn about housebuying to make a GCSE. They should knock useless subjects like Home Economics (I still ended up poisoning myself every week when I first went to uni) and Design and Technology off the curriculum in favour of something like Practical Money Management, including a Housebuying module. I mean, its just the sort of dead boring yet essential subject you shouldn't have to spend your free time educating yourself on.

So I'm pulling out of buying this flat as have discovered in retrospect that I can't actually afford it. I simply (embarrassingly) made a mistake in the maths. Not looking forward to facing a half dozen irate people (solicitors, mortgage brokers, estate agents) tomorrow (well, at least it'll be over the phone), but it wasn't my fault!! I was forced to teach myself off the internet in the space of a few months about the process of housebuying, and it's only in the last week that I've grasped the finer points and it's all started to make (admittedly partial) sense. Everyone you turn to for advice has a different thing to say, and most of these people are only interested in extracting money from you. To make things worse, completely irrational things happen in the housing market - for example, if you search Guardian Money for articles on house prices, you can find nearly identical articles on an impending price crash dating from 2002, 2004 and early 2006. Of course, all of them were wrong.

The other thing that's all backwards is that this is turning out to be completely different from how I imagined it would be. I am (mostly) happy as a doctor because it's what I'd wanted to do from the age of 11, so in that respect at least, life has turned out as I imagined - sometimes even better (more interesting and rewarding) than imagined. But (like many girls, I'm sure) I'd also imagined I would be married and starting a family by the time I'd hit the age I am now. And I imagined I would be buying a house together with someone, and it would be a happy thing, not something quite as fraught and lonely as it is turning out to be. I tapped two incomes equal to my own into an online mortgage calculator just for fun, and the amount you'd get would comfortably buy my dream home - even here in London.

I don't think of myself as someone who pines for comfort and material things, but I have (unpleasantly) surprised myself with the kinds of living conditions I am not willing to put up with (no ex-council flats, no high-rises, no low ceilings, clean tree-lined streets, near a tube etc). I guess I have turned out to have more exacting standards than I thought - but for now I can't afford them.

oh no

would you believe, I've had another puncture. I was just about to get on my bike this afternoon when I noticed the rear wheel (my freshly installed new inner tube!) was completely flat AND had a large, shiny nail sticking out of it. One more time and I'll be a qualified bike mechanic.

Bit of an eventful day today. Called the estate agent first thing in the morning to make an offer on a flat I saw for the second time yesterday evening. Then walked to a nearby primary school for my first ever clinic as School Doctor.

It was more complex than I imagined. The 3 patients were all boys of 5 or 6 years old, and accompanied by their moms.
KM age 6
referred for follow-up by previous school doctor, having been discharged from the Child Development centre in 2005. referred (separately) by the school Special Educational Needs Co-ordinator (SENCO) due to
1. short attention span and disruptive in class
2. unable to read, write, draw, count or name colours or shapes
At the end of the session, the SENCO and I both wondered if he might have ADHD.

BI age 5
referred by class teacher for
1. "pees and poohs his pants"
2. developmental delay
He was a small, slightly odd looking child, who it turned out, had as few words in Turkish as he did in English.

HF age 6
referred by class teacher for
1. disruptive behaviour in class
2. "speech problems"
"but he is capable and shows ability"
He was a bright boy with a lisp who had arrived from Nigeria not long ago.

Each of these took about an hour. While I was speaking to the SENCO afterwards, my phone rang - it was the estate agent. The sellers would take the flat off the market for 2500 pounds more than I had offered. I felt a bit swamped at that point, so said I would call him back.

15:00 Child protection medical
This was the point I discovered my bike tyre was flat. So I set out on foot, fingering my phone with indecision. How many flats is one supposed to see before one commits? What if a better one doesn't come along? What if I buy, and then one does?

I had to examine 2 siblings who had witnessed domestic violence involving a knife and the severing of fingers. They were already on the child protection register. It was the first time I had to do a medical by myself.

I'd already had a really hard day (as in, with high emotional involvment, which is the aspect of medicine I find most draining and difficult) and the worst was to come. I was late, because I had allowed ample time to cycle to the clinic, but not to walk. I needed to make a decision on this flat. I wish I could have deferred it to a day when I was doing boring things, like baby clinic. I called a few people for advice, but their phones were all on answer phone. For a moment, I felt bizarrely alone in the world. I rang the agent back and agreed to buy the flat.

can she fix it?

My bike is a bit of a joke at the best of times. With only 3 speeds (slow, very slow, and a middle speed which doesnt actually change the gear) and a metal frame and that clatters at the tiniest bump in road, it's not the meanest machine. So when I came off a curb (at the edge of London Fields) with a loud bang (at 9pm on thursday, after an evening on call), I thought nothing of it and cycled on. It seemed a particularly gruelling ride, and the hypochondriac in me started to wonder if I should perhaps register with a GP afterall, if only to get an FBC, thyroid function tests, and maybe an LDH and a Mantoux as well. Imagine my relief(!) to discover, panting from carrying the green beast up a flight of stairs, that the back tyre was almost entirely flat. I'd been amazed to that point that I'd not had a puncture before, given the number of broken bottles I've cycled over since acquiring the bike (the road to bethnal green seems perpetually lined with broken beer bottles and it's often a choice between going over the broken glass and getting run over by an oncoming bus).

So I had the cheerful task today of figuring out how to change a rear bicycle tyre - the guy at the bike shop had regarded me suspiciously when I had asked for a 26x1 3/8 inner tube and "those plastic things you pry the tyre off with" (I still don't know what they're called) and when I didn't know what kind of valves I had. "Bring the bike in if you can't manage," he'd said. It was oddly satisfying to prove I could do it without help, and having cleaned the chain as well, the bike's as good as (probably better than!) new. It did take me more than an hour though.

Nights misery - no. 12?

why??? why - when nights in my opinion are the worst kind of misery that can masquerade as Work - do I have to work the longest night of the year? life is unfair.

It's official

...Hackney has been declared worst place in Britain to live. Living and working in Hackney, I'm at once reassured that I'm not mad (or alone) in thinking that things are pretty rubbish here but also slightly offended - since becoming a community doctor here (though this is, of course only until february), I do feel in a (albeit miniscule) way responsible for the quality of life of Hackney residents.

I opened my email at work today to find a message from the Mayor of Hackney himself. "Crime is down by 22%..." it read, "the greatest decrease in London. Our schools are improving..." It went on to encourage recipients to write to Channel 4 in protest, or send an email of encouragement to the local council. "Wear your 'i love Hackney' badge with pride," it said. My what? Curious as to how to obtain one, I clicked on the link to the council's website. Must get the T-shirt.

first time I...

ok quick post as have to get up at 6:45 again tomorrow

Met a friend's two year-old daughter in Boston, who can read(!) and count to 100 in both English and Chinese. She's a clever little thing, and gathers new knowledge at an astounding rate. It reminded me of how much enjoyment I get from learning new things myself. (and also that not all 2 year olds are like the (too often) rather sorry examples I see in clinic). In the past week I have

-found out that I've passed the first part of my membership exams (at last!)
-done my first child protection medical (and written the report that will go to social services and the police)
-attended my first conference (unfortunately it's been rather uninspiring - I have definitely been put off community child health for good)

will (or more likely won't) elaborate on the above if/when I get time

As seen on TV

Pumpkins
Originally uploaded by cirrus29.rm.

...back to work after a week's break in Boston (and environs). For the latter part of our stay one of the couple's (we were there ostensibly to photograph a wedding) friends put us up at her apartment on Elm Street. It was a suburban street straight out of the movies - brightly coloured wood-panelled houses, each with the star-spangled banner hanging over the porch, weather-worn chairs and metal mailboxes with red flags on. Some had pumpkins put out for halloween. We went to a baseball game - where they actually sang 'take me out to the ballgame' - and stopped by a pumpkin patch with some monster pumpkins.

press "1" now

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

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

professional MOM

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

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

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

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

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

didn't I say that already?

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

space pens!

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

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

...take 50 nurses

Foulden Road from our window this morning

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

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

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

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

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

Piss poor

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

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

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

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

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

piccies from clinic

...off to a great start - forgot my camera, so my phone (with a <1 megapixel camera) had to stand in. The clinic resembled a small military outpost, with heavy-duty metal grilles over all the windows (as seen in first picture). I manoeuvred my bike round the back, avoiding a hoard of hoodies hanging around the entrance. Middle picture: clock - a free gift from a drug company (nice retro design though) Right: a fan. commonplace in London these days, thanks to the recent heatwave. to the left of the fan is a trolley with the BCG kit on top.

pictures

Have resolved to take one picture of Hackney (or Whitechapel) every day (until I tire of it). Meanwhile, here are more selected holiday snaps. (All taken with Sony DSC-W1 and not manipulated)

'Humani nihil a me alienum puto'

(the motto of The Royal London Hospital. roughly translates as 'nothing human is alien to me' or to remove the double negative - all human troubles are my concern)

09:30
As I lock my bike to what looks like a secure railing outside the health centre, an elderly black man pops his head out of a window 2 floors up. "I wouldn't park there," he says, kindly, "last week someone cut my bike from that fence." I thank him for his advice. But 5 minutes later, I am back in the carpark as the receptionists won't let me keep my bike inside. I lock it right opposite the main entrance in a parking space marked "doctors only". Well, it doesn't say cars only! The road leading to the health centre seems to feature a different "serious assault - can you help?" (or "murder - can you help?") sign every time I cycle past. Minutes later, I am in the thick of Enuresis clinic (i.e. bedwetting 8-year olds); babies are thrust at me while mothers help the 'problem' child undress. Each child needs a full history and examination, urine test (plus sample to the microbioogy lab), and then lots of explanation - mothers are advised not to get cross, and star charts are given out. I've seen this all before as a medical student in Edinburgh, but in Hackney it is not quite the same. A family history reveals that father was tortured in his home country; it transpires that the child sleeps in the parents' bed, along with its younger brother. Mother speaks only Polish, or Albanian. The interpreter is a jumpy young man, who repeats all Dr. D's calm assurances at twice the speed and treble the volume.

11:00
On my bike to cycle to the Child Development Centre (CDC) to observe a Child Protection medical. Most of the referrals are for alleged physical abuse. Even though I have technically lived in Hackney now for 9 months, before this job I had never actually seen any of these clinics - they are all tucked away in the hearts of the many council estates. The CDC (which I expected to be a good-sized multistorey building as all children in the borough with disability are known to the services based there) turned out to be a small brown-brick shack (ok so it has 3 floors, but it is so small that one of the toilets had to be converted to make a treatment room) with an overgrown, locked garden that serves as an open-air storage area for disused furniture, toys, and the doctors' bicycles. I can't really write about the Medical here as it is confidential, but suffice to say it was pretty harrowing.

13:30
Back to 'base camp' for Child Health Clinic. I think I gave about 6 BCG shots (after explanation and examination). All the babies blurred into one after a while. The babies were all happy, bouncy little things, but the moms had various problems ranging from HIV to housing benefits. Some had already fallen out with and separated from their (6 week old) babies' fathers.

17:00
Home time. Community paediatricians certainly work short days, but they are tiring in their own way.

..not to mention

...as an extension from yesterday's post: have not played the piano since I left home to go to med school in 1998. Used to paint and write poetry but have not had time/energy since starting work. Used to read a lot, keep up varied interests, but all this has vanished from my life. Also, because work involves meeting lots of people, my desire for 'alone time' is greater than the urge to go out when I have a day off, with detrimental effects on social life. Working weekends means you can't build new friendships outside of work - e.g. you meet someone one weekend, then you have to work the next two weekends in a row, plus on-calls in between. 21 days later, they have forgotten who you are, and its back to square one.

Post-Weekend Crump

Sank into the sofa after work today (got off at 5) and promptly fell asleep for 1 and a half hours. I have been working every single day since the 24th of July, and did 3 thirteen hour shifts covering paediatric surgery last weekend. What happens when you have to work lots of long days in a row is that your body goes into overdrive mode - you lose the desire to eat, wake up early automatically and feel almost euphoric with exhaustion at the end of each shift. Then, when you get a day off, or a less demanding/shorter day, your body switches back to normal mode, and realises how tired it is. Suddenly, your legs feel so heavy you can't even stand up. (much less do the large, stinking pile of laundry accumulated from working 2 weekends in a row, or get any groceries). I did eventually manage the laundry after my (unplanned) nap, but I think the psychological effects of working so many days in a row are ongoing - when I sleep my mind keeps replaying scenes from work, and I keep waking in the night. The problem is, though utterly exhausted, I am not ill enough to justify taking a day off sick.

what price career success?

My favourite section of the BMJ is the obituaries. At the end of a long week, just at the point where I start to wonder if it is all worth it (having to work weekends for the rest of my life, endless postgraduate exams, the burden of other people's problems etc), the obituaries remind me that it is sometimes possible to achieve great things over a lifetime in medicine. The latest issue of the BMJ contains the obituary of Baroness June Lloyd (this is the obituary as it appears in the Times, as you need a subscription for the online BMJ). If you read it, you will discover that not only was she made a life peer, her image is part of the coat of arms (above) of the Royal College of Paediatrics and Child Health, which she helped found. She seems, on all accounts, to have been an extraordinary woman, almost the kind of person I would look to as a role model for my own career. (I am unlikely to become a Baroness of course, but one has to aim high if one is to achieve anything!) However, I say almost, because of this line: "She did not marry, and is survived by her brother." Last birthday, I was the same age as my mom was when she had me and I can't help but wonder if something has to give at some point. At present my (potential) family life is at a complete standstill while my job takes up close to 100% of my time and energy, and I try to ignore the fact that fertility decreases and the probability of genetic defect increases with maternal age. Would Baroness Lloyd have achieved all that she did if she'd had her own children to look after? Will I be forced to choose between career and family?

whitechapel to nuttall street 2.9km

I've cycled more than 60km in a day before, but the short distance between whitechapel and nuttall street seems to separate two different worlds. On the one hand, what is now familiar to me: the world of hospital medicine - the tyranny of the Bleep, pyjama-ed (or intubated, ventilated) in-patients to be reviewed daily, the weekly clinic list - booked up 2 months in advance. And on the other: community medicine - doctors without prescription pads who work from 9 to 4, health visitors who rule the roost, walk-in clinic patients who turn up either in droves or not at all - and have nothing wrong with them - apart from poverty and unemployment.

On the afternoon of my first day (yesterday), having been given a quick (and uninformative!) introduction, I was told to make my own way to one of the local clinics. It is located on the side of Hackney I usually avoid (see previous post); certainly more Hackney Gazette than N16. The low brick building is run down both inside and out, the windows have rusty metal grilles over them and all the furniture and clinic equipment looks circa 1970. There is a plastic doll (of the horror film variety, but in miniature) on the desk in the clinic room - she is naked and black, and sits next to a tray of orange needles and vials of BCG vaccine.

The first patient is a lovely 6-week old. She is growing well, doing all the things appropriate for her age, and her mother is quite happy with her progress. Dr. J explains and then administers the BCG vaccine. It all seems quite straightforward. The second and third patients are similar. Piece of cake, I think to myself, and then start fretting that I shall be bored of this job by the middle of next week. The next patient is a 7 month old boy who had attended the local hospital with infected eczema a week before, and now had cervical lymph nodes visible from across the room. He is hot and sweaty, but otherwise seems quite content, smiling and babbling at everyone. Dr. J umms and ahhs for ages before finally deciding to send them back to the hospital. I could've done that in about 2 minutes, but as I was only observing, I didn't comment. A 6 month old is brought in whose mother is worried he is not gaining weight. Mother is visibly depressed - she speaks in a soft, low voice, and avoids all eye contact. The (apparently omniscient) health visitor has discovered that the child's father has been seeing another woman - because the second lady has a baby of a similar age, and it is also his. On examinination, there is nothing wrong with the child. In fact, he is manifestly happy and healthy. I wait to see what Dr. J says to the mother. She reassures her that the child is well, but does not attempt to explore the other (arguably the root) problems. I suppose that is a reasonable response - one cannot expect to solve all of everyone else's problems. But at the same time, I was more than a little disappointed. On the one hand, Dr. J did not have the means to treat and follow up a clearly medical problem (likely infected eczema with lymphadenopathy); on the other, she chose not to delve into psychosocial issues which might have an impact on the child in the future. It was not a busy clinic, and my gut feeling was that the mother was simply looking for someone to confide in, even if they did not physically intervene.

I suppose the problem is that the patients (parents) think a community paediatrician is like a GP, but for children. The fact that the clinic is in a local GP surgery only serves to confuse things further. But the remit of a community paediatrician is quite different. There's all the public health stuff (child health surveillance, immunisation) and the legal stuff (child protection) and the ringing round and fixing patients up with the right services (psychologists, special needs coordinators, physios etc etc). All this I know in theory. But the reality of it is much more mixed up than I thought.

last day

...or rather, Night on this job. Have to get on my bike in a minute (no trains on Sunday evenings - only 1 an hour, and at exactly the wrong time). It's been a horrible time but at the same time it's been good. (insofar as a junior doctor's job can ever be described as Good - one often learns in spite of one's experiences rather than because of them) I know so much more than I did six months ago that yet again, I wonder how I could have thought I knew anything about medicine before.
Also I am fed up with people telling me I look too young to be a doctor, particularly when I have their maternity notes in front of me, and I know for a fact that they are about 5 years younger than I am! I think medical dramas give people the impression that a doctor should look a certain way - female doctors that one can take seriously are either matronly or manly in stature - if you look any different you are fighting a battle for respect for your medical opinion before you've even said hello.

photos!

St. Malo algae covered rocks
Originally uploaded by cirrus29.rm.

...am meant to be preparing a case presentation and a teaching session on Neonatal Tachycardia. However, cannot help looking through my holiday photos! (taken on digital compact camera - you will soon see why) We cycled more than 200km through Brittany/Normandy in the space of 4 days (21st to 25th June). I was meant to be having a week of deskbound days ("supernumerary" where you have to do all the Discharge Summaries that nobody else has had time to complete) but have been made to cover the shifts of those who are taking their clinical exams! So have done 2 long days and have to cover the postnatal ward tomorrow.

China

Watched a fascinating documentary about China's women on BBC2 yesterday evening. As it was produced for a British audience, it probably contained its biases, however the landscapes (both rural and urban) and people were mostly allowed to speak for themselves, and they gave a pretty moving account.

I've never been to China (HK doesn't really count, particularly as I haven't been since 1997), and after seeing the documentary, I'm not sure I really want to. At least not rural China. It would just be too strange to see families who, 4 or 5 generations ago, would have been indistinguishable from my great great-grandparents' families but who now live in a complete time warp. Oh, and also in abject poverty. I don't know how I would react if confronted by a real Chinese villager in the flesh. I wouldn't understand what they were saying, for a start.

Would the villager, if she understood what a fortunate beneficiary of cleverly timed emigration (and shrewd and enterprising recent ancestors) I was, and also if she knew I was a doctor, feel that I had some kind of obligation to my ancestral village? (that is, if it existed - according to some of my relatives on my father's side of the family, everyone either left or starved to death)
I, on the other hand, would feel quite impotent in the face of their many problems, and almost ashamed of my comparatively luxurious lifestyle. Would I even be able to photograph the village in the same way I photograph Hackney?

'it was busy' is an understatement

completed 7 long days on the Unit. We started the week with 9 ventilated babies. We withdrew care on one on saturday and one died on Monday afternoon. By Wednesday, we had a new admission (25 weeker with necrotising enterocolitis who was operated on as an emergency) and yesterday a 23-weeker was born.

one of the more stable babies had a cardiac arrest on saturday. This coincided with the registrar being busy with a recently discharged baby who had been brought into A&E collapsed and me being on the labour ward at an emergency caesarian section. so the nurses got the surgical and transport teams instead. anyway, said baby was down for 45 minutes, had 4 lots of adrenaline, and now has fits.

the only baby who has got any better is a 27 weeker who I weaned the ventilation on over the weekend as the registrar was occupied with the sicker ones. by the time the baby was accidentally extubated while having a chest xray on Monday, I had got her on to SIMV (see mechanical ventilation link 2 entries down) at a lowish rate and had stopped morphine. She's coped well on CPAP and even had some time off on Thursday. It was nice to be able to say to her parents that she was doing well.

Hackney in pictures (or what I did on Tuesday)

More here Colour pictures shot with Jessops SHR 200 (expired 2004), black and white pictures with Fuji Neopan 400CN. Camera: Canon EOS 3000 35-80mm. Minimal manipulation (cropping and levels only) with Adobe Photoshop CS 2.

Yay! It's Monday!

Monday mornings don't come sweeter than when you've worked 4 nights in a row and are let off early from the morning ward round! And someone even thanks you for your hard work! Bit sad, that last comment, but I think one of the problems with hospital medicine is that the work of junior doctors is largely unrecognised. I was up all night with one of the sickest babies (baby from last entry, who died on Friday) yet the thank-you card was addressed solely to the consultant, and the parents don't even know who I am. Instead, on Friday morning, exhausted and hungry from a crazy shift, I was critisised by the consultant for taking blood (from a different baby) from a heelprick instead of a venepuncture (a very trivial point that made no difference to baby). Such is the level of appreciation for my work. Still, I think it was a good set of nights overall (I never thought I would reach the point of saying this, as I am normally ready to shoot myself ten minutes into the second shift).

In short, I have finally got to grips with my job:
1. I can now confidently make small decisions in intensive care, such as weaning or increasing ventilation (and the use and monitoring of the various modes of ventilation available), the use of inotropes in hypotension, correcting pH and electrolyte disturbances etc etc
Here is a taste of the mechanics of ventilation. Note that this site is about Adult ventilation, which is quite different (both in terms of numbers, such as the rates and pressures used, and in the underlying pathophysiology), but it gives some idea of the complexity.
2. I've figured out how to organise all the routine tasks (bleeding all the patients and writing the 24 hourly summary on each - it helps that I now understand what I am writing!) so that there is time to sleep for an hour on the shift (provided the labour ward bleep doesnt go off! I was lucky on 3 of 4 nights) Also helps that I can do things more quickly, like dry off a newborn baby (they are wetter and slipperier than you think!), examine it, wrap it up and hand it to its parents, and write in its notes, all in under 8 minutes (obviously that's the ones that turn out not to need resuscitation).
3. I've learned how to get on the good side of most of the nurses and midwives (though there are a couple who are impossible, and those ones I have learned to avoid)

So life on Nights has become bearable.

help! the baby's not breathing!

Today was supposed to be my half day (finishing at noon - it is the only way the rota remains legal as I will be working 52 hours (4 night shifts) over the coming weekend), but I didn't get away until 3 in the afternoon.

The labour ward bleep went off at about 11 in the morning. "Hello is that the Paed?" said the midwife. (that's what they always say - they get really confused if you answer the phone and say you are a 'Neonatal' SHO) "We are in theatre now, it's a 35-weeker with dextrocardia and situs inversus, and IUGR."
"Are you starting right now?" I asked, as they always seem to call me before the anaesthetist has even turned up to put in the spinal. "We've already started," she said. This was quite inconvenient as the baby was likely to have other congenital abnormailities and to require resuscitation, and she was only giving me 7 minutes' notice. (It usually takes 7 minutes to deliver the baby from the time of first incision at an uncomplicated caesarian section) On hindsight, I should have called the registrar first-off, but I didn't know how bad things were going to be.

I hadn't been able to find any scrubs of the right size in the morning, so it took me another 3 minutes to grab a Medium top (the smallest I could find) and to put on shoe covers and a hat. By the time I got to the theatre, I had just enough time to check the resuscitaire.
Before I knew it, a tiny, floppy bundle the shade of a blueberry had been placed before me. It was the most deformed baby I had seen in my life (believe me I have seen some freaky babies) and it was clearly hydropic. The moment I saw the baby, I asked the midwife to page the registrar immediately. I dried the baby as best I could, gave it 5 inflation breaths, and then more breaths through a facemask. The baby gasped and moved its arms, but then it stopped moving, and stopped breathing. Its heart rate slowed and it turned even bluer. The anaesthetist came over to see if he could help. I tried adjusting the mask on the baby and repositioning its head, but nothing seemed to work. One thing I should have done in retrospect is used higher pressures - something that would have been more obvious had I been ventilating the baby manually. I got the anaesthetist to give some chest compressions. I thought about intubating the baby (something I have yet to do successfully ever) or at least looking down its trachea to see if there was anything blocking the flow of air (possibly meconium or vernix). The baby had an abnormally small jaw and a tiny mouth. I had difficulty even getting the laryngoscope blade in, and when I tried to lift the scope, there was very little give in the jaw. I couldn't even see the vocal cords, but was afraid to pull any harder. So I went back to trying to ventilate the baby through the mask. At the age of 6 minutes (though it felt much longer at the time), the baby was starting to look like a specimen from the pathology museum.
Just as I thought I'd lost the baby for good, S*, my registrar turned up. He's really experienced and it took him 3 trys to intubate. As soon as the tube was in, the baby began to pink up. His heart rate picked up. He was still completely limp though.
Back at the Neonatal unit, the baby had an arterial line put in to check his blood pressure. The first attempt resulted in a wound (from a tiny needle prick) that just would not stop bleeding. The umbilical vein too, oozed for ages. I was allowed to attempt cannulation of an umbilical artery (again something I have never done before), but it was difficult, and I didn't get it in. An echocardiogram (done on the ward using the same machine I took my brain pictures with) showed that the baby's heart was contracting very poorly, and was grossly enlarged.
By then it was nearly 14:00. I headed back to the labour ward to get a full maternal and antenatal history. It turned out that the cardiac anomaly had been discovered 5 weeks ago, and that the Fetal Cardiologists at the Big University Hospital had done a scan and reassured everyone that 'cardiac function [was] normal'. They even went on to say that they planned to see the baby in their outpatient clinic at the age of 4 to 6 weeks! As things have turned out, this was a false (and arguably dangerous!) assurance. I just hope I haven't contributed significantly to the baby's (already) poor prognosis.

Day off

...and I find myself playing Maths teacher to my little brother, who is sitting his GCSEs at the moment. Here he is in a rare moment of concentration:

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.