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.