Chickpeas and black pudding

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

A piece of medical history

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

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

not having a fit

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

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

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

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

all change

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

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

Just to catalogue my symptoms so far:

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

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

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

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

Shooting (digital) in Hackney

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

"sign here..."

Signing for a delivery will never be quite the same.

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

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

New toy

[or, An interlude for some photographic geekery]

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


a picture of my old camera taken with the new one

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

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

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

the other cases (notes for myself)

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


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

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

5 year-old jewish girl post-tonsillectomy bleed
(2 admissions; once on monday night and once on saturday night)
tonsillectomy, adenoidectomy and bilateral grommets 6 days previously
attended Other hospital with earache; sent home on oral antibiotics. was put to bed only to awaken at 20:00 "covered in blood"
taken to Other hospital, but transferred to Our hospital as operation done by our ENT surgeons
had not been given any treatment at Other hospital!
o/e alert, but lethargic and very pale. blood-stained nightdress
imp: haemodynamically stable, no active bleeding. IV cannula inserted and bloods inc. group and save taken.
phoned ENT registrar for advice: IV co-amoxiclav, hydrogen peroxide mouthwash if active bleeding, IV fluids overnight, may eat in the morning if no further bleeding
discharged from hospital on wednesday, only to return on saturday
complained to mom of blood in throat at about 17:00; small vomits of blood
followed by a large vomit of blood about 18:15
dad said: "it was much worse than monday. the floor was covered and the whole couch was soaked. she couldn't walk straight. I lay her down with her legs propped up, and called an ambulance"
given 20ml/kg saline bolus on arrival to A&E; blood pressure came up nicely. by the time I saw her was alert and chatty. Hb 9.2; G&S already done.
advice as before; cef and met IV; for theatre if further bleeding overnight (this fortunately didn't happen)
*****************************

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