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)
*****************************

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.