Essex boys

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

It hurts

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

photos

as promised earlier

Whitechapel Market

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

Kidneys

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

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

Stupider and stupider

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

Early morning existential crisis

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

an unfortunate sequence of events

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

an innate defense?

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

Indignation

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

clinic again

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

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

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

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.