Back to Hackney

The silver-haired rastafarian glanced nervously at the changing traffic lights, rubbing his fingerless-gloved hands together to keep them warm. He turned to me, as if to check if I thought it safe to cross the road just yet. I was heading into (horrible, graffitied, grubby) Hackney Central (the only Tesco within walking distance)to get some groceries for the empty fridge . Just over 24 hours ago, I had been at home in Singapore celebrating Chinese New Year with my family for the first time in seven years. (With a fridge that was far from empty.) Going home always brings on a mix of emotions... [the details of this I have written in my 'real' diary and am too lazy to reproduce] but overall, it was great and I'm glad I went.
It was such a quick trip, it is almost difficult to believe it actually happened, even with a kitchen now stacked high with red-topped jars of pineapple tarts, peanut cookies etc. and nearly a kilogram of kueh lapis in the fridge. So I got my pictures developed in an hour this afternoon (also partly to avoid having to revisit Hackney Central any time soon), just to convince myself it was real.
And it was dark by 17:00. I think I really needed the break even if only for some sunlight in the middle of a miserable grey winter.

Arthur

Arthur (not his real name, but he has got an old man's name) is a one-and-a-half year-old boy who has been given the rather hopeful label of 'global developmental delay'. He doesn't have a particular diagnosis (such as a genetic syndrome or a brain lesion) but he is clearly not progressing normally. He does little other than sit in his cot and stare into space. He is blond-haired and blue-eyed with chubby cheeks. Currently he has got an empyema secondary to an aspiration pneumonia.
I met his mother for the first time today. Unusually for this part of London, she was a slim, bespectabled, middle-aged lady, smartly dressed in a silk blouse, velvet skirt and flat leather boots. As she arrived she cooed to Arthur, and flung her arms around him. "Hello, Arthur daarling!" she said brightly. Arthur remained entirely indifferent. "It's Mummy, Arthur," she said, as if he had merely forgotten who she was in her overnight absence. It all seemed quite tragic. I could almost picture her, in another life, walking Arthur to the Montessori school, in a pressed shirt and trousers with his blond curls slicked back.
I returned later in the day to inject some urokinase into Arthur's chest drain. Now I try my hardest not to subscribe to stereotypes, but there on the bedside table was his mother's copy of today's Observer.

pick and mix selection

..bizarre use of this phrase by one of the MCQ bank websites I was frequenting until yesterday. Felt a bit deflated after the exam (2x 2h30min papers); I just didn't know enough of the answers with enough confidence to believe I'll pass (it's a competitive exam - only the top 30% are allowed to pass). Feel a mite better after consulting my dusty old anatomy text - the thoracic duct does indeed drain into the left subclavian vein - a fact I have not revisted since year 1 of medical school. Now all I have to do is wait 5 weeks to find out if I have to pay another 275 pounds to re-sit.

Made a courgette cake instead of dinner (the thought of cooking a meal and dessert is just a bit much) - sugary playdough-like (due to the erroneous assumption that putting it in at a higher temperature would make it cook faster) confection containing an entire grated courgette. Made MK guess what was in the cake. Unfortunately as he is completely colour-blind, the green flecks (and indeed the green tinge of the cake) did not offer any clues (which was the point). He had no idea. He thought it was a good cake though. Maybe it was a bit of a duff courgette.

Working the weekend again!! T is coming down from Edinburgh this weekend and we were going to watch Daniel Barenboim at the Barbican. Until I remembered I had to work. This (despite my numerous other complaints) is the primary reason why working weekends is Rubbish. And why the thought of having to work weekends for the rest of my life is so depressing I try my best to live in denial of it (hence all the appointments I make that I suddenly remember I can't keep).

At least this time I get to fly home afterwards.

brain rot!

...bit of an odd thought to push its way through at the height of my exam panic (36 hours to go), but I'm suddenly seized with the fear that large swathes of my brain are in danger of rotting away through disuse.
When I recall my teenager-hood, it is usually with much relief that I will never have to live through it all again. But despite the traumas - broken friendships, never being in the 'in' crowd, (perceived?) parental and teacher underappreciation - I have to admit that my mind was almost always sufficiently stimulated. Physics special paper tutorials used bits of my brain that have definitely fallen idle now; I was practising for my piano diploma, submitting poems to an online poetry guild, playing tennis with my dad at weekends, reading books. And I could actually speak chinese. At university (apart from Medicine) I edited a magazine, learned photography, and read the bible for the first time from cover to cover.
Why is it that when we grow up and start work, it all falls to pieces? (Or is it just me?) My work has taken over my whole life, and I flop, drained of energy (particularly if it's been an 08:30 to 21:30 day) into bed each night. It's almost like Charlie in Flowers for Algernon. And it's way scarier than, say, a former athlete losing muscle tone - at least they can keep tabs on it by looking in the mirror. I can't even begin to assess the damage to my neurons caused by more than a year of neglect. This exam with all its memorising has been more mind-numbing than stimulating. (I am conscious that you may have little sympathy for my situation - what? being a doctor not mentally stimulating? - I assure you, it isn't, not much. Emotionally taxing yes, every day. Intellectually stimulating, perhaps once a week.) Am I in the wrong job? Maybe. But I live in hope that the balance will shift...
AND I need to learn something completely new before it is too late!

...you talking to me?

I do a Prolonged Jaundice clinic on Thursdays (my very own list of patients!) and the jaundice bit is easy enough to deal with. The babies are usually referred by a midwife, and they have usually been jaundiced for about 2 weeks. With babies, the general rule is if they are feeding well and growing well, there is unlikely to be anything serious going on. (The rationale being that the most strenuous thing babies do is feed.) Add to that a good number of wet nappies, a few soft yellow poos a day, and you are almost sure to have a healthy baby. There are a few more complex issues of course, like hereditary blood or metabolic disorders. Among other questions, I ask if mom and dad are related (first cousin marriages are common in the Bangladeshi population) and usually just say we need a few drops of blood and we have a standard panel of tests to exclude some rare but treatable causes of jaundice. The questions out of the way, I examine the baby from head to toe. At this point, the mother will inevitably bring up something like "he always vomits after he feeds" or "he keeps pushing the nipple out of his mouth with his tongue". I always feel slightly awkward with these questions. I mean, I know what further questions to ask, and how to exclude anything serious, and I know most of the (textbook) answers, but here's this articulate, middle aged Kurdish woman who has 2 other healthy children asking me (single, childless, still gets asked for ID whenever I buy wine at the supermarket) what to do with her baby. And then I remember I'm a doctor, silly. I wonder how many years it will take until I become a doctor in my own mind's eye.

freak show

What a long 2 days. My mind wanders back to the Diane Arbus exhibition I saw with M at the V&A a few days after Christmas. Her pictures have a (perhaps not unintentional) freak show quality about them. Countless photographers have been fascinated with the idea of finding beauty in the unlovely, but this is the concept taken to an uncomfortable extreme. She went in search of freaks, and, predictably enough, got what she was looking for. Sideshows, nudist camps, and finally, a home containing (by her pictures) mostly middle-aged women with Down's syndrome. At one point, the exhibition blurb reads:

In her photographs, the self-conscious encounter between photographer and subject becomes a central drama of the picture.

That is her problem: self-consciousness. This stands out in particular contrast to the photographs I saw in Edinburgh not long ago at a brilliant exhibition of the works of Henri Cartier-Bresson (same exhibition is currently showing in Amsterdam). Cartier-Bresson's pictures convey a certain love for life. Indeed, he lived to be 95, while Arbus commited suicide aged 41. Now, it may seem I am being unkind to Arbus, but the truth is, her story and the vibes one gets from her pictures remind me alarmingly of myself. My fascination with medicine (and paediatrics in particular) is, at its core, a fascination with the myriad weird and wonderful (not so wonderful if you are the patient of course) things that can go wrong with the human body. Although I am a doctor, I still feel a bit of a voyeur on the wards, and I am sure my self-consciousness (that huge, floundering thing at my shoelaces) shows through my thin doctorly facade. And it is entirely inappropriate, a hundred times more so than it was for Arbus to be wandering around institutes for the mentally infirm with her Rolleiflex.

Pear juice

Bit of an odd day back at work. Having arrived back from Edinburgh at 11pm yesterday (all for the sake of a cheap train ticket!), ended up staying up til 2am (exciting things in the post, including a letter from my 'godfather', who says he hasn't been to central London in 20 years!), then got up at 06:50 to go to work. On arrival, the ward is full of patients but there is no sign of any other doctors. I have been left a sheet with 12 patients' names on that I have never met. *Ben is a 9 year old who has been suffering from diarrhoea for 3 months. He has lost about a stone in weight - his clothes hang off him, and his eyes look sunken. Somehow, his electrolytes are completely normal, and so is his renal function. Inflammatory markers are raised. There is no rash or joint pain and no mouth ulcers. He has no history of recent travel or past history of food intolerance and the rest of his family are well. He is fully immunised. His parents seem pretty cool about the whole thing (cf previous entry) considering he is still pending a diagnosis. The likely diagnoses are 1. infective diarrhoea (including various bacteria, amoebae, TB etc) 2. inflammtory bowel disease 3. coeliac disease (or some other kind of malabsorbtion syndrome). So he's had lots of tests, including a Mantoux, which I watched Dr. M administer. Ben was very brave about the whole thing, as he has been about his entire ordeal so far. He's one of those incredibly sensible kids where you catch yourself speaking to him as if he were 10 years older, when at best he might grasp the facts with no idea the implications.

Anyhow, it was one of those busy, interesting and exhausting days. I went home via Liverpool street, where there is a greengrocers that I have never seen closed (which is very odd considering that I work nights, weekends, and even the new year). I bought 4 chinese pears for a pound, and was very much looking forward to sharing them with my little brother (who is here to stay for a few days) after dinner. Unfortunately in my tiredness and distractedness I accidently left them on the train. Which annoyed me very much until a rather amusing scene popped up in my mind - watch out for it on the news some time tomorrow: someone discovers my "unattended package" and the transport police in their bullet-proof vests rush to detonate it, only to be spattered by pear juice!

A picture of my foe

External diameter: 0.6mm
Length: 19mm
Needle: Siliconised, bevelled, back cut ground stainless steel needle
Catheter: PTFE (Poly Tetra Fluoro Ethylene) / FEP catheter; dual tapered, bevelled tip & siliconized

Instructions: Lay baby on flat surface. Place absorbant towels under chosen limb. Give parent option of leaving the room. Get (preferbly experienced) nurse to hold limb in white knuckle grip (serves both to foil attempts at wriggling away and as a tourniquet) with one hand while fending off kicks/punches from other 3 limbs with the other. Ignore baby's cries. Visualise vein and pin down by stretching skin taut with non-dominant hand. Insert cannula at roughly 30 degree angle (adjust according to how deep/superficial vein appears. Ignore baby's cries. Watch for blood in flashback chamber. Insert a further 1mm, then withdraw needle and advance catheter. Ignore baby's cries. Tape cannula down. Instruct nurse to loosen grip (just enough to allow venous return, but not to let baby withdraw limb). Remove needle. Flush cannula with saline. Tape cannula down with the strongest tape available (check baby isn't allergic!). Ignore baby's cries. Splint and bandage the limb. Release grip and comfort baby. Be thankful that (most) babies have short memories.

Nights misery

The fireworks over Canary Wharf were just visible from the 4th floor of the hospital. The nurses were probably watching it on TV on the ward somewhere, but I prefer to see the real thing, even if through a dirty window in a dark room on my own. It's my second new year in a row where I've had to work overnight. It just turns the whole thing into a non-event, making it feel like I'm stuck in the old year and that yet again, life is passing me by. It wasn't even a busy night on call, so I was deprived even of a sense of purpose, of having to be there for a reason. Had been on nights since before Christmas, had the intervening week off (lonely Christmas 'celebration' with siblings, jet-lagged from being on nights, trying in vain to study for my exam) and then on nights again for new year. My entire cristmas/new year ruined yet again by constant sleepiness and having to miss out on all the best bits, yet feeling under pressure to be 'merry'. I would be, if I could just for once spend the turn of the year with people who care about me.

Spotted!

(: (: very excited! my photos have been spotted by an online gallery that wants to help me put them up for (proper) sale! Despite everything, deep down, I've always really wanted to be an artist. Last chance to buy my work on the cheap!

Punchbag

It will be one of those patients who has had an unusual presentation of a rare disease, with symptoms mimicking something more common and invariably more benign. And now they've developed diarrhoea, or bleeding from some orifice, and we need to take some blood for further tests. "No, you are NOT taking any more blood from my baby," the mother fairly shouts at me. She stands up - her arms planted on her hips, her face stony, eyes burning. It is Sunday, and she vents her frustration at the events of the past week. She feels the doctors are hiding something from her, and keep changing their minds. She demands that I somehow produce the results of all the tests done on Friday afternoon (most of them are microbiology specimens, which will take at least 5 days to return final results). Having seen her child for the first time 5 minutes ago, I am at a loss as to what to say. My task is to take the blood. I have 10 other patients to get through before lunchtime. I decide to do the 'see things from the other person's point of view' thing. I let her go on for a bit. "I can see why you're frustrated," I say, at last. "K* is clearly very ill, and we don't have a certain diagnosis." I am just about to artfully explain the delays and justify the need for further tests (clotting, electrolytes as she is on IV fluid, and stool culture), when she interrupts and lets forth another torrent. Why, if we think K* has an infection, is she not on antibiotics? Why do the doctors tell her one thing and then contradict it? I begin to explain that the commonest cause of infective diarrhoea in children is a viral infection, and that antibiotics do not help a viral infection. "Why didn't they grow the poo for viruses then?" At this point I am exasperated, and return, rather too bluntly, that we have treated her child to the best of our knowledge and that the results of today's tests will help take things forward. In order to escape from the room, I say I will give her some time to think over things and come back later. She shouts after me that no-one is going to take any samples from her child and that's final. In retrospect, I guess she wasn't really interested in the logic behind the decisions, she just wanted someone to shout at, and it happened to be me. I hate my job.

What I saw on call today

...busy but unusually interesting day at work. Too tired to write proper entry, so here's a list of things I saw:
-CSF leak in child with base of skull fracture
-cri-du-chat syndrome
-VACTERL
-paracetamol overdose
-pneumonia
-two PUOs (pyrexia of unknown origin)
-newly diagnosed diabetic - the 7th of 10 children - and her pregnant mom (large orthodox Jewish family)
-lots of babies with bronchiolitis, and
-Dr. X, self-titled 'architect' of the BREATHE trial

Weekend misery
Still not impressed by the fact that the first train into central London tomorrow is at 08:38 when I need to be at work by 08:30. So I have to get up extra early for an extra long commute by BUS just to get to work on a SUNDAY. I miss my bike...

Still on study leave

I miss work (though will probably regret saying this when I am on call at the weekend). The exam is on the 17th of January but I've had to take my study leave now as I will be working lots of nights just before. Am sitting in the flat without any curtains in the windows at the moment as the workmen came round to put the double glazing in today. It's noticeably warmer already. I've also done all my christmas shopping in the last 2 hours without leaving the house (or, indeed, my seat). So its been a productive yet incredibly boring day. Read the Economist over lunch too, as M has a subscription. I like how it's written. Perhaps it is my profound lack of knowledge of economics that makes the magazine so fascinating, but I just get the feeling the BMJ is a whole lot less intelligent.

Lullaby

...just recalling the last time I was taking blood from a 1 year-old. Her (young, very bling) mother was singing to her to try and calm her down. The song of choice? Don't cha by the Pussycat Dolls.

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.