freak show

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

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

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

Pear juice

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

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

A picture of my foe

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

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

Nights misery

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

Spotted!

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

Punchbag

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

What I saw on call today

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

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

Still on study leave

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

Lullaby

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

Essex boys

Revising for my exam and have just read about cystic fibrosis, which reminds me of a patient I saw the last time I was on nights.
I had a bleep at about 1 in the morning. "I'm sorry," began the nurse (always a bad sign when nurses are apologetic for no apparent reason), "*Damien's cannula has tissued. Can you come and put in a new one?" Damien is a 13 year old boy with cystic fibrosis (CF). He was in hospital for an infective exacerbation and was on intrvenous antobiotics. His Portacath had been removed after it had become infected, and he did not like to admit it, but he was needle-phobic. I arrived on the ward to be greeted with a loud, "Hi Doctor!" He grinned at me from behind the nurses' station, where he was in the middle of ordering a pizza using one of the ward's telephones. He looked about 9, and had a thick fake gold chain round his neck, more little ones around his wrist, and was wearing a basketball jersey over his hospital gown. As Inner City Hospital is in the middle of what seems like Little Bangladesh, the CF kids stand out for being white, and they all seem to come from Essex. "Hi Damien," I said. "Ready for your cannula?" I motioned toward his room, but he swaggered a few steps in the opposite direction, and stuck his head into someone else's. "Hey *Jen," he said, "come and see this." A skinny blonde girl (another CF patient) emerged. She was wearing a pink tracksuit and a similar gold chain around her neck. Damien wanted an audience for his ordeal.
Having finally coaxed him into his room (and banished Jen from it), he stuck his hand out. "You can have one try, there," he said, pointing to a vein in the back of his left hand. I was still trying to get over the surrealness of his manner. Fortunately the cannulation was an easy job (having done loads of thalassaemics with totally shot veins and very dark skin). "Thanks, doc." said Damien, running off to find Jen and his pizza.

It hurts

KT looked a little like a hamster with his swollen parotids. It had started on the left, behind his ear, several weeks after he had returned from Nigeria. His dental hygiene was good, he was fully immunised (DTPs, MMR, BCG, the lot), and he didn't have any sinister symptoms (i.e. of lymphoma). He'd had a couple of fevers, but was otherwise well. On examination there was a smooth parotid swelling on the left, and some cervical nodes on the right. The A&E doctor had sent mumps and EBV serology, but the results were not yet available. Should I order an ultrasound? Did I need to give him a follow-up appointment? I wasn't really sure. I have been plagued by uncertainty in the last 2 weeks. 12 months as a house officer (otherwise known as 'housedog' or 'houseplant'), and then 3 months in haematology in what is essentially the role of a house officer have left me incapable of making my own decisions. I am now paralysed by the fear of doing something wrong - having come close to killing a febrile neutropenic, and prescribing imipramine to some poor kid with enuresis who probably didn't need it. I know that anyone who is junior in their profession must learn by making mistakes, but mine are too painful to bear - children suffer and may even die when I get it wrong. The weight of this has become overwhelming and I am getting nightmares (literally) again, awakening in terror at 3 or 4 in the mornings.
Fortunately, Dr. P (my consultant) came to my rescue, and pronounced that it was a typical case of mumps (which can sometimes occur despite vaccination), which needed no follow-up apart from checking the serology. I felt stupid. I feel almost constantly stupid nowadays. Obviously I need to gain more experience, but it all just seems too painful.

photos

as promised earlier

Whitechapel Market

Am moving house today so will be offline for a while. So here's goodbye to Whitechapel (outside of working hours, that is!) Look out for my photographic study of Council Architecture in East London appearing on my photoblog as soon as I get reconnected...

Kidneys

*Saida is 18 months old and had been suffering from diarrhoea for 4 days. On the ward round she seemed a bit 'flat' - drowsy, pale, floppy, cold round the edges. She had not passed any urine in nearly 24 hours. Her tummy was tender to touch and I thought I could just feel a bladder. She had a smattering of little red spots - petechiae - on her arms, legs and back. She looked septic. Diarrhoea is exceedingly common, and most children recover quickly with rehydration. Sepsis secondary to gastroenteritis in small children is also not unusual. But a couple of things didn't fit, which in retrospect seem to be the most obvious clues. She was hypertensive - one would expect a low blood pressure in shock - and when we did get some urine (with the help of a very fine nasogastric tube as a urinary catheter), it was very frothy (3+protein). We took some blood, but as sod's law would have it, the specimens just sat in the lab and were not processed until I called to hassle them 3 hours later. Meanwhile we gave Saida a fluid bolus (appropriate management for shock but not appropriate for her in retropspect). They rang back to say the child was clearly in renal failure. She was also very anaemic. A blood film showed haemolysis. (for the medical reader: guess the diagnosis) We rang the consultant on his mobile phone, and he rang the Big Famous Hospital to get Saida transferred in case she needed dialysis.

*Shah is a 7 month-old boy who was found to have a dilated ureter (on ultrasound scan) before he was born. He has vesicoureteric reflux - meaning the urine in his bladder goes back up the ureters into his kidneys - and as a consequence has repeated urinary tract infections. His right kidney is scarred and hardly functioning. It will probably never recover. But his left kidney is working, and one can have full 'kidney function' even with only one physical kidney. The problem is he has a terrible urinary tract infection at the moment, and the last time he had one it grew horrid bacteria that were resistant to a large number of antibiotics. We have got him on two broad spectrum antibiotics - one of which is potentially toxic to kidneys - while waiting for the urine culture results.

Stupider and stupider

I used to be fairly intelligent. I used to know things, to grasp concepts quickly, to 'accidentally' memorise people's telephone numbers etc. I used to be good at puzzles. Perhaps it has to do with working nights and not sleeping enough, or the mind-numbing nature of my job, but my mind feels increasingly dull, clouded over. I have an exam in January, but my brain now seems resistant to retaining new information. I used to absorb reams effortlessly at one sitting, but now it is all I can do to memorise the aetiology, presentation, treatment, prognosis of 3 or 4 diseases each time I sit down to read. I can't seem to think laterally anymore; feel stuck in a rut, slow, thick, old.

Early morning existential crisis

At 7 o'clock my bleep went off - unusually, it was the Neurorehabilitation ward. *Mohamed, a 12 year-old recovering from a head injury, was complaining of pain in his chest. "Is he short of breath?" I asked the nurse, immediately thinking of pulmonary embolism or a sneaking pneumonia (being confined to his bed he was a sitting duck for both). "No, his resp rate is 20, temperature 37 (both normal), bp 105/59. Heart rate is 90 and he's a bit anxious." If it was a PE it wasn't a massive one. I didn't have to run.
I'd actually been pleasantly surprised to hear of Mohamed 'complaining' of anything; he isn't one of my usual patients, so the last time I'd seen him was the last time I was on nights, about a month ago. He'd just arrived from India, having fallen 40 feet from some scaffolding while on holiday at his grandparents' house. He was admitted to hospital in India, where they'd pretty much given up on him. There had been no physiotherapy and he was 'not for resuscitation'. They'd made a half-hearted attempt at nutrition - he couldn't swallow, so a makeshift PEG tube (actually a urinary catheter) had been shoved through the skin of his abdomen into his stomach, and he was fed pureed vegetables through it. He was emaciated, unable to speak or move any of his limbs. But he didn't die, so his parents brought him back to London.
I examined Mohamed, and satisfied myself that his chest sounded entirely clear and the pain was most likely muscular in origin. I told him so. I asked him if there was anything in particular he had been worried the pain might be. No, he said, but he had a question for me. "You know, in my religion you have to read the Book, and then you can go to heaven. I am in here twenty-four seven, I don't know... is my God angry with me? I try to memorise the Book, it has 30 chapters, but I have only memorised one..." I paused. "You're asking a difficult question," I said, at last. "It doesn't have an answer I can give you in one sentence. From what I know about what happened to you, it was an accident. And bad things often happen to people who don't deserve them." I waited for him to speak again. "I want the hospital Imaan to come and teach me the Book." he said. He said this with an urgency that made me realise he feared he was dying, running out of time. "Do you remember the last time I saw you? You were in that little room over there, and you couldn't speak." "Yes," he said, "and soon I could point to alphabets on a board." "You're getting better," I said. "We don't know why this happened to you, but you're recovering from it well. I've had a good look at you and I don't think there's anything wrong with your heart or your lungs. I'll make sure someone gets the Imaan to come and see you today, ok?" He nodded.

an unfortunate sequence of events

JD lifted his leg off the bed yesterday (a Sunday - I hate working Sundays). Have been wanting to write about him for days, but have been too self-absorbed lately (multiple unresolved issues in personal life; the spectre of loneliness, the dilemma - limited self-induced heartbreak now or potential soul-destroying heartbreak in the future; a badly timed wedding invitation from an old school friend. Oh, and I hate London).
Anyhow, JD is a 13 year old with sickle cell anaemia, who a few months ago discovered a lump in his neck. A biopsy revealed it to be Hodgkin's Lymphoma. The sparkly New University Hospital was having a few problems with its operating theatres, so he came over to Inner City Hospital on Thursday to have a line inserted for chemotherapy. After the operation he seemed a little slow to get back on his feet, but by Friday morning had sat up and even managed to have a row with his dad. On Friday afternoon I thought he looked drowsy, and a closer examination revealed that he couldn't move his left side - at all. Uncharacteristically for a Friday afternoon (or I am just being cynical), we managed without too much wrangling to get an urgent head CT, which confirmed the worst - JD had had a massive stroke. He'd also had a carotid artery dissection. My job on Saturday was to carry out his second exchange transfusion (read first link for explanation) - this involved cannulating a vein so that JD's blood could be drawn out (manually with a 10ml syringe - gives you thumb cramp) while donor blood was infused into his newly inserted line. It took several hours. I also had to explain things to his mom, which was difficult, as I have only just (now) had the time to read up about stroke in these circumstances. I explained as best I could from my understanding of stroke in adults, stressing that the next 48 hours would be crucial and that JD's final ability/disability would not be evident until weeks or months later.
JD remained in a haze all weekend. His dad turned up on Monday, and having examined JD on the evening ward round and answered a few of dad's questions, was turning to leave when he said "doctor..." I stopped. "Can I have some Pringles?" he breathed, through the right side of his mouth.

an innate defense?

Woke up at 9:00 today with a pounding headache and nausea. Called in sick, but felt so guilty I still went in at 17:00 to do my on-call tonight. I was sure I had set my alarm clock, but while I had adjusted the alarm to 07:00, had accidently neglected to switch it on. I feel (physically) much better for sleeping in (slept until lunchtime today, then tidied up for the first time in weeks). Perhaps if I had set my alarm clock I would have been well on my way to killing myself from overwork. (Certainly came near to collapse on Saturday) I did long days (13 hours shifts) on monday, friday and saturday of last week, would have had one today, have got one on wednesday and one on sunday. With only coming saturday off in what would have been 21 consecutive working days. Perhaps my body is trying to tell me something. I can't win though. Every time I take days off, I have to swap all my on-calls, therefore doubling the on-calls before and after my holiday. So I spend my holiday being ill and then come back to...Hell. Yes, my life at the moment is a living hell - chronic sleep deprivation (by far the worst thing) and trudging up and down corridors with a bleep that goes off continually. Being so utterly worn out on your one day off that you are unable to enjoy the people and things you value in life. I have nothing interesting to say today. Work ceases to be interesting when it becomes all-consuming.

Indignation

..belatedly reading the BMJ from 24 Sept 05, which reminds me how angry I am about the BMA's "neutral" stance on euthanasia. Doctors have a responsibility to take a stand. It is all very well quoting people's experiences of their relatives' deaths, but each bereaved individual has only that to draw on - an intensely personal experience (or at most, a handful of experiences) at the deathbed of someone they love. No matter how strong a lay person's system of religious or ethical beliefs, they simply do not possess enough knowledge of the workings - physiology, pathology, pharmacology etc. of death, and have certainly not seen enough of it (in the setting of home or hospital). In my 6 months as a medical house officer, I saw at least 5 dead or dying people a week; often, I would have to explain things to their families, and help comfort them. I prescribed countless diamorphine infusions and other palliative measures, and have been present both at resuscitations and at discussions of do-not-resuscitate orders. And that's just me as a doctor freshly out of med school. How much richer and more complex must be the understanding of more experienced physicians. And how unspeakably irresponsible of them to abstain from making a public statement for or against euthanasia.

clinic again

Day 2 of Ramadan. *Ahmed, the other SHO on my firm, is feeling the effects of hypoglycaemia. "Aahh!" he groans, "you know, I have this bad headache. I think I need to leave early." I am just about to offer some paracetamol when I remember that he is, as they say, nil by mouth.

I saw three patients in clinic today - still frustrated by my own inefficiency. Everyone else saw between 6 and 10. Although I guess I have the added challenge of fobbing off the dumb bleeps from nurses on the ward (and taking any calls from A&E) so that the registrars can get on with actually running the clinic. I like clinic because it is a team effort. There is a long list of patients (usually 30 to 40) to be seen, in theory, by one consultant and one registrar between 09:00 and 13:00. These are all children with chronic haematological disease (mostly sickle cell anaemia - we have the largest clinic in London), and its attendant effects on growth, development, education, home etc. so there is a lot to discuss with each family. Some patients need vaccinations or blood tests, or letters to the Council regarding housing or Disability Living Allowance, and each patient's GP needs a letter detailing the encounter. In short, it is a lot of work, and we all pitch in. Apart from the new patients (mostly babies diagnosed on newborn screening or new arrivals from Africa or the Indian subcontinent), who Dr. *F sees and enters into his amazing database (more about this another time), it is a free-for-all. Between the 5 of us (supported by 2 specialist nurses, community nurse, educational psychologist, dietitian and a bevy of translators) we somehow give each patient the time required to unpack and address their concerns as well as assuaging ours.

I saw *Kevin, a 5 year-old with sickle cell anaemia who had been in hospital a month ago. He'd come in with pain in his chest, which spread to his abdomen. His urine turned dark red, while he went that ghastly shade that black children go when they are anaemic and jaundiced. We gave him several units of blood, but his blood counts dropped further- the cells were being broken up as soon as they went in. His spleen was enlarged and tender. Eventually he had to have it removed. He's recovered well. Today his mom seemed more worried about the school he'd missed.