Encouragement

The road to Lochranza, Isle of Arran (that's rain on the lens!)

Consider it pure joy, my brothers, whenever you face trials of many kinds, because you know that the testing of your faith develops perseverance. Perseverance must finish its work so that you may be mature and complete, not lacking anything. [James 1:2-4]

I've tried to keep my two blogs separate; I'd wanted this one to be more of a log of cases, with perhaps the odd comment on hospital life or medical news. But I still haven't got a job for 1st August; it feels a bit like careening towards the edge of a cliff, and I can't help being just a little pre-occupied.

I asked my consultant to comment on my CV yesterday, and he was really helpful. The best thing he did was to give me a copy of his own CV. Quite apart from providing a template, it helped put things into perspective. Despite being an excellent doctor, he's not had an easy route to becoming a consultant. It all made me feel rather... embryonic. But also less depressed.

Been here before

Blogging from Edinburgh, where am currently on leave - have spent the last couple of days frantically filling in job applications (Glasgow, Manchester, London, Sussex). But we are off to the Isle of Arran tomorrow, on bikes! ( :
(expect pictures in my next post!)

I guess I shouldn't get too upset about the whole jobs debacle. (old link for those unfamiliar with the issue) 10 years ago, I was forced to make applications to medical schools in several different countries before finally gaining a place in Edinburgh. And I am grateful for that.

Four Easy Pieces

The dentist offered to extract the offending wisdom tooth. I decided I could live with one gum infection a year - give me a course of augmentin over the risk of facial nerve injury anytime.

Walking home from the dental surgery, I realised I had just seen the 'other side' of the consultation. Less than 24 hours earlier, I had been trying to convince a 13 year-old and her mother that she should get part of her brain removed (that is, emphasising that they must attend the neurosurgery appointment this time), and then wondered why they were so reluctant about it.

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We've had a run of patients with "severe seizure disorder, global developmental delay, recurrent respiratory tract infections" discharged back to us from the paediatric intensive care unit (PICU) recently. Despite the fact that they do very little (mostly sit or lie motionless waiting for the next Physio session, or for the sats monitor to go off and a nurse to come running with a suction catheter) they make pretty demanding inpatients. A combination of repeated PICU admissions and limb disuse and spasticity means their veins are almost impossible to cannulate - and they always seem to be on a cocktail of intravenous antibiotics. They don't eat - they are fed by gastrostomy, and may also be on the ketogenic diet for seizure control. Some don't pee - requiring intermittent bladder catheterisation. The weekly consultant ward round (it is only weekly because most of the other inpatients are either undergoing neuro-rehabilitation or are under other paediatric teams) begins to resemble a ward round in Geriatrics.

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I left work at nearly 11pm yesterday. My sunday shift ended at around 9, but because it had been a busy week (9 sick/fitting inpatients instead of the usual 3 neuro-rehabs, 2 lumbar punctures under GA and all the usual clinics) I hadn't yet dictated my clinic letters. I knew that my week of leave would be guilt-tinged if I left them, so I deposited my cycling stuff in the office and went across the road to get a biriyani. (bit of a dilemma choosing between the 4 Bangladeshi takeways on the junction) So I've faxed off my EEG requests and my Opthalmology referrals, and all my patients' GPs shall soon be updated on their headache/seizure/etc management.

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It is ironic that just as I am in a specialty that really interests me, and working with a great team who make me feel valued, I may soon be out of a job. I've not fared at all well in the MTAS lottery, and have been crying myself to sleep every night. I decided at the age of 11 that I wanted to be a doctor, and have worked extremely hard at it since. I have a first-class intercalated degree, and am published in two international medical journals, though I only graduated in 2004. I am coming to the end of a clincal rotation that has given me a rich experience in paediatrics in a colourful part of London, and have only one remaining postgraduate exam to pass. Please give me a chance. I have so much to offer paediatrics, to offer medicine, to offer the world (maybe) - if only I could get some proper specialist training.

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Chickpeas and black pudding

Youee and I made a birthday cake for Ching! A shameless fusion of two Nigella Lawson recipes, it tasted somewhat better than what Youee thought the book's illustration was.

A piece of medical history

Fascinating article in the Observer Woman magazine today about Carl Djerassi, the inventor of the Pill.

I took the official 'bride getting ready' shots for T&R's wedding yesterday. Here's a selection: (just a few of about 120)

not having a fit

“Call for you,” said the switchboard operator, in her usual drone. “Hi, this is Mrs. Berkenstein*,” a shrill voice with a decidedly Germanic accent crackled down the line. “I’m *Nathaniel’s mother. Is this *Sally?” “No, it’s Sam, I said,” rather taken aback at being bleeped before 9 in the morning on my first day as Paediatric Neurology SHO by a patient’s mother. Nathaniel is a 6 month-old boy with infantile spasms. His mother had phoned for a repeat prescription – steroids, ranitidine and pyridoxine. She said Sally (the previous person who was in my job) used to fax the prescription to her local pharmacist.

Before I’d had the chance to sort out her request (and right in the middle of clinic), I had another call from a mother: “*Jacob’s school has sent him home because he was going blue around the mouth and rolling his eyes to one side. We saw Dr. *Ahmed last Tuesday and he increased Jacob’s medicines but he is fitting more now. We don’t want to come into hospital again, what do you advise?” I asked her some further questions, but it was impossible to assess the child without actually seeing him. I explained this to her, but she was adamant; “the team have always given advice over the phone in the past,” she insisted, before admitting that the current situation was a new one. I guess one of the luxuries of being a junior doctor is that when you have your back to the wall, you can always wriggle your way out by saying you’ll speak to your consultant and get back to the patient.

Jacob eventually came into hospital and an EEG confirmed increased seizure activity. A blood gas showed a partially compensated metabolic acidosis – in his case it could be due either to the ketogenic diet or intercurrent infection, so we started him on antibiotics and sodium bicarbonate.

Quite apart from all I was learning about seizure disorders, it was interesting to meet these mothers in person. Both were petite Orthodox Jewish ladies, dressed in the usual garb of loose, dark-coloured long-sleeved blouse and black below-knee skirt, dark tights, chunky black loafers and a hat or headscarf worn at all times. Beneath all that, they looked impossibly young (I’d estimate early twenties, certainly significantly younger than myself) and vulnerable. Speaking face to face with them was absolutely fine – they were both gracious and articulate, and though understandably concerned about their sons, were by no means overly anxious or unreasonable. Perhaps the scary telephone persona was a kind of “take me seriously or else” act.

all change

Am quite liking my new job - we had clinic all day on tuesday, and I saw (and made decisions about) patients with conditions ranging from the commonplace (migraine without aura, suspected absence seizures) to the exceedingly rare (cat eye syndrome, mitochondrial electron chain complex 4 deficiency). Nearly lost my voice dictating all the clinic letters afterwards. Today was slightly duller - 5 patients on the ward round, a psychosocial meeting, and having to grapple with really stupid computer-programmed theatre lists that won't let you put a patient on the list who does not have a surgeon for a consultant. Whoever designed it didn't figure that there are other reasons to have an anaesthetic apart from surgery. Have to be in at 08:00 tomorrow to clerk in the patients for lumbar punctures and manometry under general anaesthetic. Should be interesting to do though. Not inspired enough to blog properly about individual patients at present.

diagnosis? (or, I'm not feeling so good)

Just to catalogue my symptoms so far:

-lethargy, malaise and ?depression - about 3 months
-pain in both calves - 14 days ago, for 3 days, resolving spontaneously
-generalised myopathy and ?rigors- 10 days ago, for about 3 days, resolving spontaneously
-leucopenia (neutrophils 1.6, lymphocytes 0.60); Hb 13, but i'm on a multivitamin with iron in it
-raised d-dimers (exact level not known to me)
-morbiliform rash all over body, including palms, soles and face, with mild bilateral conjunctivitis - 7 days ago, for about 3 days, resolving spontaneously (slightly itchy, resolving with cetirizine)
-lymphadenopathy, mainly cervical (smooth mobile nodes about 2cm) - last 7 days
-pain, stiffness and swelling in joints - small joints of hands and feet, both ankles, both wrists and both knees. stiffness for about an hour in the mornings, difficulty walking and turning doorknobs - last 3 days, worst today

Differential diagnosis:
1. viral infection - possible viruses include parvovirus B19, EBV (common, fits all symptoms and I am at risk due to occupational exposure to lots of children)
2. rheumatoid arthritis (but is not associated with rash, also peak age of onset = 5th decade); or other connective tissue disease
3. hypothyroidism (also not associated with rash, but could explain all other symptoms and is commoner in females)
4. lymphoma (unlikely due to leucopenia and normal blood film, but peak age of incidence =3rd decade)

Therefore if the symptoms continue after next week, I suppose I should get someone to take blood from me for
-repeat FBC and film, U&Es. LFTs, TFTs, ESR, CRP, ANA. antidsDNA and rheumatoid factor
The question is how soon to do them. Maybe I'll give it 4 to 6 weeks.
Meanwhile I shall be taking ibuprofen regularly.

The GP didn't do much for me apart from providing a sick note. I had hoped he would at least examine my joints, but he didn't seem interested. He also didn't seem to know that parvovirus infection can cause raised autoantibodies and ESR (and therefore those tests would be completely useless at distinguishing between 1. and 2. at this point). I think I might feel better if I could just stop being (my own) doctor for 30 minutes.

Shooting (digital) in Hackney

...am not sure street photography is particularly good practice for shooting a wedding. Am also coming to hate this kit lens. Lastly, am having some trouble processing my pictures due to a dodgy laptop screen which makes everything look really washed out. If you find the colours too saturated/garish please comment! (Any other comments welcome too)

"sign here..."

Signing for a delivery will never be quite the same.

"This is female infant of HS, born at 30+5 weeks, maternal pre-eclampsia, IUGR, RDS, ventilated for 9 days. On Day 16 of life became septic, blood cultures and CSF cultures grew staph aureus, so is on flucloxacillin. 2-day history of abdominal distension and non-bilious vomiting. Chest x-rays show a cystic structure above the level of the diaphragm, possibly a diaphragmatic hernia, possibly a staph pneumatocoele. She's currently self-ventilating in 1 litre of oxygen, cardiovascularly stable, nil by mouth, on 120ml/kg/day 10% dextrose with additives, antibiotics - cef, met and fluclox. There you go, sign here," said the transport team doctor. He offered me the Neonatal Transport Team notes and a black ballpoint pen, in the same way a DHL deliveryman might.

I squiggled my 'work' signature on the dotted line, signifying that our unit had accepted the transfer. I've been at 'handovers' like this before, but am not usually the most senior person there, so this was the first time I've signed for a baby. It was a rather odd feeling.

New toy

[or, An interlude for some photographic geekery]

Way back in 2001, the Canon EOS 1D was the latest in professional digital SLRs. It boasted a resolution of 4.15 megapixels and cost about 1500 pounds. By 2003, the first 'amateur enthusiast' digital SLRs had appeared, but were still way beyond my student budget. When, as a house officer, I received my first paycheque, I promptly spent a large portion of it on a digital camera - but not an SLR. In the intervening years, the performance of affordable digital SLRs has pretty much caught up with their film equivalents. But eventually it was other things that tipped the balance - film processsing is becoming increasingly expensive, and without access to a darkroom, the fun of (and control afforded by) developing pictures myself is gone. And so it's goodbye to the old digital camera, and hello to my new canon EOS 400D.


a picture of my old camera taken with the new one

Of course, my old film camera is far from retired (not least because of the large hoard of film sitting in the back of my wardrobe), and the two can even share (some) lenses. But I think the digital one is going to see more use, if only because the not-so-good shots can simply be deleted.

it's in! (or, an ER moment)

First time I've successfully intubated a baby at the first try. It was a semi-emergency one too. The baby (an ex- 28 weeker weighing 1.5kg) was breathing at about 100/min and was rapidly tiring out, so needed to be put back on a ventilator. She was oxygenating ok though - until the suxamethonium went in. Her sats dropped to about 50% and her heart rate started to fall. The registrar took over bagging, and we turned the pressures gradually up. Though her chest was moving, the oxygen simply wasn't getting from her lungs to her bloodstream. "We'll just have to go for it," she said, handing me the laryngoscope. I'd let on that I was inexperienced, but had not mentioned I'd never actually been successful before (just in case they didn't let me do it). As it happened, the laryngoscope slid in easily over the (paralysed) baby's tongue. First the oesophagus, with the orogastric tube running down it, came into view. I moved the scope anteriorly, obtaining a perfect view of the vocal cords. I took the endotracheal (ET) tube (size 3.5) in my right hand (the laryngoscope is a left-handed intrument), asked the nurse to apply pressure to the cricoid, aimed for the chords, and there it was, in! Once the circuit was reconnected to the ET tube, the baby's chest moved beautifully. My first intubation. And nobody guessed it.

the other cases (notes for myself)

3 year-old filipino girl post PEG-insertion
known epilepsy usually on phenobarbitone, global developmental delay
called urgently to see due to prolonged fitting
airway ok, highflow O2 by facemask; IV in situ
no lorazepam on ward; given 5mg rectal diazepam
fitting continued; 0.1mg/kg lorazepam - fit terminated
o/e reduced air entry on left side
CXR - lung fields clear; marked scoliosis towards left. bloods - NAD
phenobarbitone level - within normal limits; reviewed by Neurology team
no further fits; started on 1/3 feeds, building up to full feeds over next 3 days
discharged with supply of diazepam


18 year-old bangladeshi girl
psedo-obstruction, peripheral nutrition-dependent, recurrent central line infections
new hickman line inserted 6 days ago. spiking temperatures
o/e alert, complaining of generalised aches, feeling cold (temperature 38.9)
no focal findings on examination; bounding pulse; imp: septic
bloods inc. cultures taken via hickman line.
already on fluconazole (candida on blood cultures from 10 days ago), amikacin, ciprofoxacin
, vancomycin (various resistant bacteria on previous blood cultures)
paeds gastro consultant phoned at home for advice on changing antibiotics;
?outcome unknown to me (will find out when i get back on day shifts)

15 year-old boy, known crohn's disease
had been admitted 3 weeks earlier due to weight loss and increased abdominal pain but was now getting ready for discharge, nearly up to full feeds.
called to see due to drop in blood pressure to 74/50; also tachycardic and low urine output
o/e drowsy, afebrile; no focal findings apart from tender abdomen (as usual)
2 large cannulas inserted; given 20ml/kg bolus of 0.9% saline
blood taken - raised CRP; neutrophilia; cultures taken despite lack of pyrexia
b.p still low after bolus; further bolus given
next day:
surgical review and contrast study showing stricture of ascending colon. planned for resection and stoma formation this week

5 year-old jewish girl post-tonsillectomy bleed
(2 admissions; once on monday night and once on saturday night)
tonsillectomy, adenoidectomy and bilateral grommets 6 days previously
attended Other hospital with earache; sent home on oral antibiotics. was put to bed only to awaken at 20:00 "covered in blood"
taken to Other hospital, but transferred to Our hospital as operation done by our ENT surgeons
had not been given any treatment at Other hospital!
o/e alert, but lethargic and very pale. blood-stained nightdress
imp: haemodynamically stable, no active bleeding. IV cannula inserted and bloods inc. group and save taken.
phoned ENT registrar for advice: IV co-amoxiclav, hydrogen peroxide mouthwash if active bleeding, IV fluids overnight, may eat in the morning if no further bleeding
discharged from hospital on wednesday, only to return on saturday
complained to mom of blood in throat at about 17:00; small vomits of blood
followed by a large vomit of blood about 18:15
dad said: "it was much worse than monday. the floor was covered and the whole couch was soaked. she couldn't walk straight. I lay her down with her legs propped up, and called an ambulance"
given 20ml/kg saline bolus on arrival to A&E; blood pressure came up nicely. by the time I saw her was alert and chatty. Hb 9.2; G&S already done.
advice as before; cef and met IV; for theatre if further bleeding overnight (this fortunately didn't happen)
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just a few of the patients I dealt with on nights. That's why I'm still tired. I can't really remember sunday (granted I slept for most of it), or yesterday (slept/sleepwalked through that too). Off sick today as feeling extremely run-down. Aches, shivers, and an unspeakable emotional tiredness from dealing with all the (justifiably) anxious parents. My only wish is that someone would ask me (with genuine concern) how I am for once.

refeeding

She was a little blonde waif with tired, pale blue eyes. Her England football jersey (with "Age 5" on the label) hung off her like a baggy nightdress. I've met anorexics before, but never one as young as *Jamie. She was nearly 9 and weighed 18 kilograms. The story was (and anorexics never tell the truth - it is part of the disorder) that she'd been at a talk on healthy eating at school, and had started cutting out crisps and cakes from her diet. One thing led to another, and eventually all she would eat was dry toast and a few sips of water. In the last few weeks she had become moody and had started sleeping in the afternoons. She'd been admitted into hospital to receive nasogastric feeds. My task as the night doctor was to do regular blood tests to check her phosphate, magnesium and calcium levels. These can become deranged when someone who has been starving for some time first receives nutrition - the refeeding syndrome.

It was a bit like taking blood from a very little old person. Her skin was dry and flaky, the veins knobbly and very mobile within her wrinkly arms. Her pulse was slow, at about 45/min and her blood pressure extremely low. The blood test results showed she was going into kidney failure, most likely from being so dehydrated. She hadn't had a wee for 36 hours. I dithered for ages about starting intravenous fluids - I didn't want her to be attached to too many lines for a prolonged period, but I also worried about giving her the fluid all at once (as a 'bolus') because of the risk of heart failure. I eventually opted for the latter, under close observation. It turned out to be the right decision.

Over the next few nights, her feeds were increased, and the frequency of blood tests decreased. She perked up dramatically, and on the fourth morning, sat up and smiled at me. She's got a long way to go, though. I'd thought that childhood anorexics had a better prognosis (in adults about 50% never recover and of these just under half die), but I've looked it up and it seems under-11s are significantly worse off.

12,000 junior doctors march through central london

If only they knew

*Musa is a 15 year old Bangladeshi boy, though the nurses on the children's surgical ward refer to him as "that man". He is of short and squat build, but has copious facial hair and bushy eyebrows shaved off in stripes at the ends. Maybe there is something about being advanced in puberty at an early age (though not pathologically so in his case) that brings out the worst in teenage behaviour. He was arrested by the police for suspected drug dealing, and was knocked to the ground in the scuffle, breaking a tooth and bruising the side of his face. He was drowsy and couldn't remember things afterwards, so was brought into hospital with a suspected head injury. A CT scan was normal, so it was the usual - referral to social work and neuropsychology - the surgeons weren't interested in his case.

Over the next day, he recovered and continued to be very polite to the nurses. Every time I saw him he would make up a new complaint calculated to keep him in hospital - first it was double vision, then it was a headache and nausea, then pain in his gums. I made the appropriate referrals, but was frankly getting a bit sick of the whole thing. I recalled Dr. M, one of the consultants, who would give any local teenager coming in with a suspected drugs offence, or even self-harm a good telling off in Bengali. Eventually Musa's old notes arrived, and I discovered he had been in hospital after similar incidents twice in the last 3 months.

I was annoyed because we had 5 very sick premature babies on the neonatal surgical unit that I had to look after as well. These babies had sepsis or necrotising enterocolitis, and were on ventilators. Then I had the fleeting idea of bringing Musa on to the Unit - perhaps if he saw the tiny, fragile babies he would realise how valuable his own life was, and how he was repeatedly and carelessly putting it in danger. But I couldn't of course. The parents (even the teenaged ones) would be horrified at the sight of a burly hoodlum in a hospital gown on the baby unit. Then again, perhaps it would be useful for them to meet Musa - 'this is what your baby could become, if you're not careful' the sight of him would say.

Why I like House

Having followed ER since the first episode of the first season (when Carter was a medical student, and before I was a medical student), I've really gone off it lately. It's become too much of a melodrama and doesn't make you think anymore. An early episode featuring a case of methaemoglobinaemia sticks particularly in my mind. But ER just bores me now.

House MD on the other hand, is a different kettle of fish. It's all about solving the case. It is a fantasy world of medicine, where the crack team flits from specialty to specialty, and have all manner of complex investigations at their disposal. Despite the ostentatiously modern setting (compared to the Victorian hospital building where I work anyway), it is made fundamentally of the same stuff that inspired Conan Doyle to create Sherlock Holmes.

Ever notice that House takes on a disproportionately large number of paediatric cases? That is what attracted me to paediatrics in the first place - the same presentation in a child can imply a much greater number of differrential diagnoses than in an adult. The relationships - whether emotional or genetic - between the child and his parents can heavily influence the course of investigation and the outcome.

The last (and slightly guilty) thing I like about House is that he is often not just blunt, but frankly rude to patients - and gets away with it. I've been sorely tempted so many times (but obviously always think better of it), that it's such a relief even to watch a fictional doctor do it on screen. I particularly like his approach to the vaccine-refusing parent (season 1 episode 2) - it's a situation I've been in many times (and may I add that the scenario in the show is very realistic), and I've often had to suppress an urge to respond in the manner House does!

who turned the gravity up?

am post-nights again. typing this is tiring my fingers out - literally - and my head keeps lolling back into the sofa. It's hard to describe post-nights tiredness. It's a bit like being severely jet-lagged, plus having run several miles when out of physical condition, plus gravity having been turned up to 3 or 4Gs while you weren't paying attention, and the air turning to treacle. The worst bit is you have to resist sleeping, because you need to work the next morning, so you need to sleep at night, not during the day. That's why I always seem to end up blogging post-nights - and even that feels like physical exertion. Well that, and also that Stuff tends to happen at night. Any parent of a small child will vouch that sick children seem to become feverish more often at night.

*Lucy is 10 year old girl with mild asthma who had come into hospital for the removal of a small omental cyst. At 9pm, she became suddenly short of breath. The immediate thought was that something had triggered her asthma, so we put her on nebulisers. She was sweaty and pale, barely able to prop herself up. She was breathing rapidly, her upper chest drawing in a couple of inches with every breath. This was visible under her clothes, and her torso made an odd rocking movement, as she was splinting the lower half of her chest - possibly from the post-operative pain, but also possibly from pneumonia, a diagnosis suggested by her high fever. Beneath the oxygen mask she wore an expression of pure terror. Worried she might be tiring, I did a capillary blood gas - it showed she was holding up for the moment. We took blood cultures, started antibiotics and got her transferred to the high dependency unit. A chest xray confirmed our suspicions. (She was much better 24 hours later.)

hardly a case worthy of House, I suppose. But more on that next time....

A quick turnaround

I arrived for Thursday's night shift already exhausted from staying up late the night before and then not sleeping during the day. I'd been spending that time usefully, of course - completing my online job application form.

Halfway through the handover, my bleep crackled to life. I waited for it to say "good evening..." - when they say 'good evening' you can relax because it means it's the nightly test call. But instead, it deadpanned: "you have been fast bleeped to A&E". My registrar and I jumped to our feet and ran down the 4 flights of stairs and the long corridor connecting the Mess to the back door of Children's A&E.

In the resuscitation bay was *Brandon, a 2 year old boy, lying stiff and unresponsive with his eyes deviated to one side. The A&E nurse was giving him some oxygen with a facemask. His mother had driven him to hospital after waiting half an hour for an ambulance that had failed to turn up. He was either having a fit, or had just had one. For the moment, he was breathing on his own. He looked pale and was cold round the edges, but had a good heart rate. Someone had already inserted a cannula. His mother sat at the foot of the trolley, looking appropriately anxious.

She said they had been at a motor show, and she'd bought him a hot chocolate. He appeared to choke on it, started coughing and spluttering and then went all stiff. She called an ambulance immediately, but was told they were 'busy'. After 30 minutes, when they hadn't arrived and her son hadn't come round, she decided to take things into her own hands, piling her 6 year old and 2 year old in the back seat and driving as quickly as she could to our hospital, where the boy had been admitted only 2 weeks before with a febrile convulsion.

My registrar thought he might still be fitting, so gave him some lorazepam. Meanwhile I took over at the head of the trolley, anticipating that his breathing might become erratic once the drug kicked in. Meanwhile, the blood gas result came back, showing that he was retaining carbon dioxide. His muscles relaxed a little and he blinked. But at the same time, his breathing slowed, and then stopped. I bagged him, while one of the nurses crash called the anaesthetist. Unfortunately, because I don't usually get to do it, I'm not very good at bagging and ended up giving him quite a lot of air in the stomach as well as the lungs. Luckily he started to come round and fought off the mask. His saturations improved. Then he became sleepy again, though he remained pink.

We decided to get him in the CT scanner while he was subdued, to check for a mass lesion or bleeding in the brain. To cover the possibility of meningitis/encephalitis, he was to be started on ceftriaxone, erythromycin and acyclovir. The scan was normal, and so were the blood test results that had come back so far. The chest x-ray was clear. At this point I was called away to see another patient in A&E - a 1 year-old with bleeding gums. Overnight, Brandon went on to have a lumbar puncture, and then a fluid bolus because he hadn't produced any urine for several hours. He was admitted to the high dependency unit.

The next morning, he looked like a completely different child. When we came to his bed, he greeted us with a smile and excited baby chatter, which turned to frustration as he tried to pick up his toast, but failed because both his hands were in bandages - he had had a cannula inserted into each hand in A&E the night before. He looked so well that the consultant stopped the antibiotics and sent him home with an appointment for an outpatient EEG.

Best of

[a quick btw: New Years Day on call included a 3 and a half hour long appendicectomy where we stood, fully scrubbed and gowned, over the open wound for about 40 minutes while the consultant drove in from home. He eventually left the matted, pus-spangled tip inside the abdomen. Back in the world of Community Paeds today, there is nothing going on (baby check, baby check, baby check) as usual, hence this blog entry.]

In a fit of paranoia (admittedly tinged with narcissism), I've copied and pasted all the text of my old blog safely(?) into a Word file to print out and burn onto CD. Actually I nearly died of boredom reading it, apart from the entries I wrote while on my elective in Canada.

...in fact, according to uncle 9, where there were once forests in Scarborough, there are now Tim Hortons.
- Uncle 9 commenting on the ubiquity of the Canadian donut chain, Toronto, Feb 04

"We never lock the door," she said, "we lost the key about a year ago, probably because we never used it."
- community nurse in St. Anthony, Newfoundland, Feb 04

"I'm cleaning your neck with this alcohol wipe, not because it's dirty, but because we like you to leave hospital smelling of hospital"
- Endocrinology consultant, Edinburgh, Apr 04

"Thank you. I'm glad you did,"
-Sir Simon Rattle, responding to my inane comment that I'd enjoyed his concert with the Berlin Philharmonic. On a BA flight from Berlin, Nov 03 (the only time I've ever asked for anyone's autograph)

"having delivered 3 babies, examined a dead woman, done chest compressions, sat with suicidal patients and so on, one would have thought that it would put my own problems in perspective. i guess (depending on how you look at it) its either a horribly selfish streak or a vital self-preserving streak that keeps alive the belief which i can only express as "the worst possible problem is the one i've got". "
-me, in Nov 03. Some things never change.

Christmas in hospital

"Twas the night before Christmas, when all through the house
Not a creature was stirring, not even a mouse.
The stockings were hung by the chimney with care,
In hopes that St Nicholas soon would be there.

The children were nestled all snug in their beds,
While visions of sugar-plums danced in their heads...."

- opening stanzas from Twas the night before Christmas by Clement Clarke Moore (1779 - 1863)

I think my body clock is finally back in GMT. In short, "twas the night before christmas" and I was at work! Even worse, they've turned our on-call room into the Matron's office so there was nowhere to lie down when I finally got a few hours' break.

You couldn't miss the fact it was christmas on the childrens' wards. Each ward had its own christmas tree, and baubles and tinsel hung from the curtain rails. The hospital porters bearing TPN and blood samples scurried about with fluffy red-and-white hats on. A felt stocking hung at the foot of each bed, often somewhat larger than its sleeping occupant. I spent about half an hour persuading *Ali, a small boy with cystic fibrosis to go to bed. "Santa only brings presents to sleeping children," said his mom, "just ask the doctor". I have a sneaking suspicion she knew Ali would take this literally.

When Ali finally succumbed, an ambulance crew arrived with *Jack, a chubby Vietnamese boy of 4 months and his parents, who spoke little English. He had been lethargic for 2 days, feeding little, and vomiting. They became alarmed when he started passing bright red blood instead of stool. His x-ray (done at the referring hospital) showed dilated bowel loops. I prescribed fluids and antibiotics while my registrar explained (tried to explain) that he would require an air enema, and if that failed would require an operation to reduce the intussusception. His parents looked horrified. "Is it something we fed him?" they asked me, after the registrar had left. (the other, unspoken question was, "help! do you speak vietnamese?") I disappointed them by replying in English, but I did explain as best I could the possible causes. Jack eventually needed a laparotomy and resection of some bowel, but he is making a good recovery.

On Christmas morning, with everything almost miraculously quiet on the baby unit (despite two ventilated premature babies with NEC), I wandered downstairs, and ran right into *Liz, an 8 year old girl with oesophageal dysmotility (and a Hickman line infection). She was wearing tinsel round her pigtails and clutching an unopened present in one hand, and a large drip stand in the other. Her face fell when she looked up to see me. "I thought it would be mom and *Rory," she said, "we always open our presents together."

I was very glad to see *Tom when he appeared at 8:30, and after handing all the patients over to him, I got on my bike and cycled home.

saturday at the christmas market

(no prizes for guessing where!)

originally uploaded by cirrus29.rm.

click photo for the rest of the pictures

before and after

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.