saturday night on whitechapel

"paediatric trauma team to resus, paediatric trauma team to resus" my bleep crackles to life at 2 in the morning. What are children doing up at this time of night is the inevitable thought as one runs down the corridor toward A&E. A 14 year-old has been stabbed - once in the leg and once in the pelvis. He is just conscious, smells strongly of alcohol. His heart rate is 37 a minute - in other words, he is stoned. The team move swiftly; he is examined, blood taken, xrays etc. Then a plaintive voice from behind the curtain: "I was stabbed too." Another boy, who had accompanied the first, and is equally inebriated, shows off his war wound. At this point, I am sent away to Majors as a child with sickle cell anaemia has arrived. It is *Jermaine again, who has come in with excrutiating pain in his abdomen and groin. Before I have finished examining him, another patient is sent over from Adult Majors. It is a 17 year-old with cerebral palsy. He is microcephalic, gastrostomy-fed and in nappies, and has been running an intermittent fever for the past 6 weeks. Lyn, th other SHO sees him. I fail to put an IV in Jermaine, so he gets some morphine orally and is sent upstairs to the ward.
My bleep has by now gone off about 5 times; would I come and see a child who has developed blisters on her arm? One of the teenagers with cystic fibrosis needs a new cannula and he is refusing to have it put in by anyone but me (just because I had been lucky and gotten it in first time the night before). The 5 month old on HDU is needing more oxygen, could I come and see her?

last night of the poms

...not that I am rooting for Australia in the Ashes. Just that I may not be as British as I thought I was. Went to Proms in the Park - that plebeian adjunct to the institution that is the Last Night of the Proms - with an old school friend. We stopped to pick up ice-cream cones and union jacks - the latter essential for audience participation when the old Elgar came on. Funny how one never notices the words of anthems until one comes to sing them. I know from my time in Edinburgh that the unoffical national anthem of Scotland (Flower of Scotland) is all about giving the English a good kicking; and I guess that is what national identities are about - Us against Them. The words to Rule Britannia I found quite disturbing; ironic that when it was written the British were busy enslaving other peoples halfway around the world. Harmless (and half-drunken) flag-waving fun? Or something akin to Japanese people gathering in a park to sing Kimigayo and wave the Hinomaru?

eponymous syndromes

*Billie died at 6 on Thursday evening. She'd been at it for weeks. Billie had Batten's disease, a tragic condition where the brain and nerves gradually stop working. She had uncontrollable seizures, fitting for hours on end despite a full complement of antiepileptic medication - carbamazepine, phenytoin, Keppra, and a midazolam infusion. I was called at least once a night during her last week by nurses who said "Billie's fitting again, can you come and see her." My heart would sink, because I knew there was nothing further I (or anyone) could do. She was on an amount of midazolam one might use for anaesthesia. Rectal diazepam and paraldehyde had been given, and paracetamol for her fever (presumably from a chest infection). She lay there, a pale, floppy 9-year old in nappies, already dead to the world, her gurgly breathing and the beeping of sats monitors her only communication with it. Her eyelids flickered and her right arm jerked continually. Her mother looked on - her eyes no longer imploring, only resigned to Billie's fate.
*****
There is a little boy named 'Jihad' on the ward at the moment. I shall not describe his condition, but suffice to say it is rare, inherited, complex and life-shortening. Perhaps his parents had in mind a personal struggle rather than a holy war on infidels.
*****

nightmare

quick post before i have to get dressed for work...
rather bizarre episode last night. having done our rounds for the night and sorted out all the new admissions, i lay down on the sofa in the doctors' mess for a snooze. And within the space of those 2 hours, I had a nightmare! i dreamt that i was there, lying on the couch, and ravens were flying in through the open windows, clawing at me, and glaring at me with iridescent eyes. i was trying to defend myself with a battered copy of the Guide to Children's Medicines and a few coffee mugs. then my bleep went off. it was 04:45 and i was indeed on the sofa in the doctors' mess, but there was no sign of any invading birds. i was also relieved that i hadn't actually thrown the coffee mugs at them.

Madhouse

"Do you know what HRT stands for?" asks *Ali, the rotund Egyptian Gynae staff grade. "emm. hormone replacement therapy?" I say, knowing that the answer is most likely going to be some coarse joke. "no, no it's HUSBAND replacement therapy. All the old woman, they take, then replace the husband. haha." Ali retrieves his customary mound of chips and 5 halal burgers from the oven and heads to his room. "See you later, Ali...you should eat some vegetables.." I can't help adding, half in jest and half out of real concern for his coronary arteries.

My flatmates are a motley crew (i was the last to move in, and am trying to move away ASAP); apart from Ali, there's the benign big-haired Portuguese guy, the girl who told me off on my first day here for inadvertently using one of her pans, the Vegetarian med student who sticks "keep off" post-it notes in the fridge, and the one in the room opposite mine who i haven't even met and rather inexplicably avoids looking at me and keeps slamming the door in my face. I discovered yesterday (on talking to The Vege) that she'd had a quarrel with the girl who used to live in my room, and that she hasn't realised that a different person's moved in!

Of course the sickest joke was when my pay came through yesterday - I am earning more than I did as a House Officer, but only just enough to cover the rent on my matchbox-sized room, right down to the last pound. Still waiting for Ching to give notice on her flat so I can move out!! Meanwhile, am attempting to create a friendlier atmosphere by 1) leaving my stereo in the kitchen with a "use as you please" post-it and 2) proposing a shared (vegetarian) meal next week. I don't have particularly high hopes for this (so far Ali and Vege are coming) but one has to try...

Blood

*Jermaine was admitted again last night. His story reads like a fictitious case history for a Medical Ethics tutorial. He is *16, with sickle cell anaemia and recurrent priapism. Besides being an excrutiatingly painful condition, it carries the not insignificant long-term consequence (because of damage to the penile vasculature) of impotence. In patients with sickle cell disease, priapism is treated with an exchange blood transfusion. The logic is that by removing sickled cells and replacing them with normal (donor) ones, the vessels will unblock, and the symptoms resolve. However, Jermaine's parents are Jehovah's Witnesses and priapism is not life-threatening, so the usual caveats surrounding children of such parents and blood transfusion do not apply. On this occasion, the issue appears to have resolved itself.

If you are fluent in both Thai and English and live in East London, it seems you could make a small fortune. Our hospital switchboard lists on-call interpreters for Bengali, Hindi, Urdu, Cantonese, Vietnamese, Turkish and Sylheti (in reality, these are 4 women who speak 2-3 languages each), but none of them speaks Thai. A couple of weeks ago a 2-year old was admitted with extensive bruising and a rash over his arms and legs. His platelet count was about 20 (less than 1/6 normal) so the most likely diagnosis was idiopathic thrombocytopenic purpura (ITP), which in very young children usually resolves on its own with time. However the blood film showed a few abnormal white cells, so leukaemia could not be ruled out, and we needed to take a bone marrow aspirate. Now try explaining that to parents who speak about 10 words of English between them. We had no choice but to hire a professional Thai interpreter - at a cost of 200 pounds an hour!

East Enders

[for anyone who's wondering what's been happening to me since mid-july: I've moved to a new city, started a new job (in a new specialty and in a more senior position) and someone close to me has moved 500 miles away. Also, have lost my internet connection in the process and they are trying to charge me 70 pounds to reconnect! Am off sick today so have time to write at last.]
*******

I stepped out of the hospital yesterday to shouts of "Mang-GO!" "mango-mango-MANG-GO!!" My throat had been scratchy all day, and the thought of sweet, slippery mango going down it drew me toward the grocer's. The stall is manned by 3 Hajis, and among its wares are miniature aubergines, giant jackfruit, grapes, tumeric, and many fruit and vegetables that I don't even know the names of. The said mangoes look and smell tantalisingly ripe. The eldest Haji beams at me through his thick cataract glasses. "What you like?" he asks. "Can I have 2 mangoes please?" I say. "Oh no," he exclaims, sounding almost offended. "No 2 mangoes! We sell BOX! This box 2-pound, that box 3-pound." "Oh." I say, realising of course, that they cater for the (much) extended Bangladeshi family. Observing my dismay, he tries to console me: "nevermind, you buy, keep in fridge." He pauses and notices that I am not impressed by his suggestion and am on the verge of walking away. "Make juice!" he says, exasperated. I make do with a 1 pound bag of oranges instead. It must weigh about 3 kilograms.

Whitechapel market consists of a row of tarp-and-steel stalls that spring up each morning from out of the backs of white Transit vans. My walk to work between Stepney and Whitechapel is never dull, what with grocers and mobile-phone-unlockers setting up to the left of me, and Halal butchers and shops with all the latest Bangladeshi fashions to the right. City slickers in pinstripe suits scrurry in the direction of St. Mary's Axe (better known as The Gherkin) and the financial district, which looms to the west. To the east are Ilford and Essex. All this makes for an interesting collection of patients - but more about my patients another time...

How to take blood from a baby

First, send its parents out of the room.
Amir* is a 9-week old baby boy who has been losing weight since his mother stopped breast-feeding him at 6 weeks. He is now back to his birth weight. He lies in his cot sucking contentedly on a dummy. His baby-gro hangs off him, as does his very skin. He is missing patches of hair from where scalp veins have been cannulated before. Danny*, the senior SHO, knots a small piece of gauze around Amir's arm as a tourniquet. He is crying even before the needle has come out of its sterile packet. Danny bends the tiny wrist forward until the hand is almost doubled back on the arm. The needle pierces his skin and he bawls. He kicks with all his might, but Danny has got his arm pinned to the cot with two fingers.
We finally get into a vein on the third attempt. The veins are so delicate and collapsible that you have to just wait and let the blood drip out. Amir stops crying and takes the dummy in his mouth again. He seems to have forgotten the whole ordeal.

Bad news for Mrs. B

"You know what the problem is with Mrs. B?" says Dr. K, in a typical ward round aside "She just sits. Like a pudding." It's not a generous comment, but it is obvious what he means. Mrs., or rather, Dr. B (she is a retired physician) isn't looking too bright these days. We have been trying to explain the importance of her being on warfarin to prevent further strokes. She doesn't appear to understand. The next day, the Physio comments that she has difficulty following simple instructions. "See, a pudding," says Dr. K. I am given the task of performing a mini-mental state examination. She scores 23/30, which is way below normal for her age (late 60s)and level of education. We check the report on the MRI scan she had in May. There are multiple small cortical infarcts - tiny strokes affecting the bits of the brain important for language and calculation. Just in case, we check her thyroid function and folate too. These prove normal. The diagnosis is vascular dementia. How do you tell someone (who is still cognitively intact enough to care)that they have dementia? That they will become progressively less intelligent and eventually become dependent on others for all activities of daily living? How do you tell their family?
I asked her husband if he had had any concerns about her memory lately? Had she seemed 'not herself' at times? He appeared at first to be in denial of the obvious. She did not seem to comprehend - or perhaps did not want to. Until suddenly she said, "so it's not going to get better then? the writing, the counting..." her eyes searched me for some reassurance. "It's not to say that nothing can be done to help things, I said. "Like you can write things down to help you remember, and the Physio gave you a walking frame." We both knew nothing could be done to halt the loss of intelligence, the eventual loss of dignity and self. How awful to feel one's own mind failing, yet have enough of it left to worry about the consequences.

too hot to string a sentence

its 29 degrees and there is no ventilation in my room apart from a wide-open window but the air outside is muggy and still

London on Saturday  

Warning to all would-be medical students

We had 4 sixth-formers on work experience today. And a medical student as well. Unfortunately for them I was in an incredibly foul mood from having worked all weekend. I was particularly abused this weekend by some nurses who had the collective intelligence of a woodlouse. I managed to muster just barely enough niceness for the patients and their relatives, but had none spare for anyone else. It's one of those 'I wish I did Architecture' days. Or any job where you get all your weekends (or at least all your Sundays) off. The warning is this: a career in medicine means you will have to work at LEAST one weekend a month for the rest of your life. This month I have worked 2 out of 4 weekends. No amount of life-saving or gratitude from anyone, or intellectual satisfaction, or money is worth giving up 2 weekends a month for. And that is not to mention how ungrateful people can be. Too many bright, promising young people become doctors through parental/societal pressure, or simply lack of imagination, and lack of effort toward finding out about other career options. So if you are 18 and reading this, consider your options carefully. A career in medicine does NOT give you 1. Money (I get around on a borrowed bicycle and can't even afford a mortgage on a one-room flat) 2. Respect (see previous entries re: rude/racist patients) 3. Intellectual satisfaction (if you want that, become a proper scientist; Medicine is primarily an Art) 4. Emotional/spiritual gratification (on the contrary, most weekends on call leave you emotionally wrecked). What is left? I guess it is the same masochistic gratification that a marathon runner aspires to.

time to move on

last month as a house officer and I am getting thoroughly bored of my job now. Did my first sucessful lumbar puncture this afternoon. Nice clear cerebrospinal fluid dripping out of the hollow needle and into sterile pots ready to send to Oxford. Spilled a little on my trousers. (this is why i always use Bio detergent!) "Ok, it's all done. How are you doing?" The patient replies in the affirmative. "You might get a headache, so we usually say to lie down for the next 4 hours. We'll tell you as soon as we get any results." "Thank-you, doctor."
Saw a lady with haematemesis (vomiting large volumes of part-digested blood) and aspiration (having some of it go down her lung) yesterday when on call. Knew what to do and went through all the motions without really having to think. (Even the talking to the patient and empathising with distraught relatives is second nature. If only dinnertable conversation were this simple!) Organised tests for a patient to go onto the lung transplant waiting list. Wrote up some chlordiazepoxide for a patient withdrawing from alcohol, Piriton for a rash, blood gas then oxygen and salbutamol for a man in respiratory distress. Obtained permission from some grieving relatives for a post mortem on a man with cancer of unknown primary. We've had a load of moribund patients lately and as a result i've had to go to the mortuary a lot too. (it's right next to the canteen, so you drop by to see the corpses at lunchtime) It's all becoming routine. It's a drag to get out of bed in the mornings to do all this stuff all day. How can i be so bored with it all so soon? I'm looking forward to being a bit out of my depth again come August.

"Ah! Brrreathe the Scaaw-Ishh airr!"

My exact thought articulated by a skinhead in a Scotland rugby shirt, stepping off the train from King's Cross. A shower in soft Scottish water, a freshly made bed in a spare room in Marchmont. A sunny day at a cool 20 degrees. A lift to church; kids from creche all grown up. Old friends from university; someone who actually remembers it's my birthday this week. It's like coming home...

And now I'm back in Reading and it's back to work for another 12 days in a row. ):

homework

My first day off after working 12 days in a row (particularly demanding as we've had a run of patients presenting with hypercalcaemia due to cancer of unknown primary - but that's another story) and I've got homework! I've got to do a case presentation on Monday. This is how it goes: 23 year old lady from Zimbabwe presents with a 3-month history of weight loss (10kg), painful joints and muscle weakness. Her only past medical history is a miscarriage two years previously. She had a negative HIV test then. I went down to medical records to get the notes myself, and when looking through them, was amazed at the number of complex tests she had had in the space of about 3 days. My own contribution was arranging an urgent echocardiogram when a pericardial effusion was seen on high-resolution CT. She also had lung function tests, nerve conduction studies and a bronchoscopy. One ward round entry states "patient exhausted after today's investigations". The eventual diagnosis was of mixed connective tissue disease. In addition, an HIV test was positive. So the second bit of my presentation is on HIV and autoimmune disease. A quick look on pubmed reveals that this is in the 'case report'/ J Exp Med realm (i.e. vanishingly rare/ newly noticed). Unfortunate for the patient but pretty fascinating stuff re: T cell suppression etc. Takes me back to my BSc year - probably the last time I actually had to use my brain (day to day medicine is pretty brainless). I miss that.

minutiae

Whoever said 'the devil is in the detail' could have had my job in mind. Patient has INR (International Normalised Ratio-a measure of bleeding time) of 9.0 (9 times normal). Easy - give him intravenous vitamin K. But it falls to me to put in the intravenous cannula. He has tiny, delicate veins and paper-thin skin. Every time I put the needle in, it draws blood, and then, he squeals with pain, moves, and the needle goes right through the vein, leaving a haematoma the size of a golfball. Seven purple golfballs later, the cannula is finally in and I write up the prescription. "Thank you, doctor," he says. Not at all.

This had me in stitches so I had to record it for posterity: "If you fart at school, you have to shout "safety!" and then you have to run and touch the nearest door handle. Otherwise you could get beaten up." - My little brother, on the goings-on at a certain public school for boys

No offence but....

I was on a ward round with *Jo, my registrar, when one of our patients remarked carelessly to her: "your lady colleague there looks like she should still be in school." It's the sort of thing I've come to ignore (or my day would be filled with annoyances). But Jo snapped back immediately: "How rude! She's been through long, hard training to get to where she is today."

It reminded me of some other nasty/ignorant comments I've had:

"I'm really grateful to all you Filipinos - where would the NHS be without you?"
(several erroneous assumptions there...)

"Nurse! I need a bedpan! NUUURSSSSE!"
(usually a gaffe by the same patients who call white male nurses 'doctor')

"Which part of China do you come from?"
(Huddersfield!)

"You look far too young to be a doctor."
(Would you say this to your financial adviser? or your lawyer?)

and of course, anything that begins with
"No offence but...."
(most of these don't bear repeating!)

Day 3 on Rheumatology

Ward 2 appears to be staffed mostly by a bevy of camp male nurses of various nationalities. *Emilio swaggers up to the nurses' station. "Guess what?" he croons. "I'm off to New York and we're staying in a 4-star hotel!" "Who are you going with?" asks *Michaela, a female nurse who is about 6 feet tall and looks like a man. "Oh, Curtis, of course!" Eyelids flutter all round.

Battle Hospital is a strange place. The block across the carpark is literally a pile of rubble. Within Ward 2 there are a few disused bays where not only the paint, but the lights and other fittings are peeling off the walls. I arrived on the hospital shuttle bus, and almost missed the stop. More prominent than the sign with the name of the hospital on is a large placard: "For Sale". In an operation called "Consolidation", the remaining departments are to be moved across town to be become part of the Royal B. Meanwhile the small community of nurses, physios, security guards, doctors, cleaners etc. that remains struggles to offer modern medicine within what can only be described as little more than a ruin. This is not to say Battle is a nasty place to work - I rather enjoy the fact that it is a small hospital and that you are a person here rather than a bleep number.

Dr. K, my new consultant, is a bit of a character (I guess they all are). We're looking at a chest x-ray, and he goes: "hmm... the lungs look fairly clear.. well, there might be a bit of shadowing in the bases, but then, she's Big and Fat." He says this with complete nonchalance. Later, he muses "all these old, crumbly patients, they sit there going nhgh nhgrgh nhgrg (mimics demented old men chattering)..." then he interrupts himself - "mustn't say that, I'll be next (he looks in his 60s). My old man, he was like that when he died. You know, I used to be quite rude when I was younger..."

..so am back home. There's not a lot to do here, merely to melt in the 35-degree heat. The fact that I've only about 2 people to catch up with reminds me of how unpopular I was at school. The old house looks the same, and the volume of suicidal poetry I composed as a morose 14 year-old remains in the bottom of the drawer - right where I left it more than 10 years ago.
Am feeling very rested though, as mom and dad are spoiling me as usual. The Diesel bag I usually use for work looks pristine now that mom has finished with it (the stains from various patients' body fluids washed away). Clothes return washed and ironed and meals just materialise. I could get too comfortable...