last day

...or rather, Night on this job. Have to get on my bike in a minute (no trains on Sunday evenings - only 1 an hour, and at exactly the wrong time). It's been a horrible time but at the same time it's been good. (insofar as a junior doctor's job can ever be described as Good - one often learns in spite of one's experiences rather than because of them) I know so much more than I did six months ago that yet again, I wonder how I could have thought I knew anything about medicine before.
Also I am fed up with people telling me I look too young to be a doctor, particularly when I have their maternity notes in front of me, and I know for a fact that they are about 5 years younger than I am! I think medical dramas give people the impression that a doctor should look a certain way - female doctors that one can take seriously are either matronly or manly in stature - if you look any different you are fighting a battle for respect for your medical opinion before you've even said hello.

photos!

St. Malo algae covered rocks
Originally uploaded by cirrus29.rm.

...am meant to be preparing a case presentation and a teaching session on Neonatal Tachycardia. However, cannot help looking through my holiday photos! (taken on digital compact camera - you will soon see why) We cycled more than 200km through Brittany/Normandy in the space of 4 days (21st to 25th June). I was meant to be having a week of deskbound days ("supernumerary" where you have to do all the Discharge Summaries that nobody else has had time to complete) but have been made to cover the shifts of those who are taking their clinical exams! So have done 2 long days and have to cover the postnatal ward tomorrow.

China

Watched a fascinating documentary about China's women on BBC2 yesterday evening. As it was produced for a British audience, it probably contained its biases, however the landscapes (both rural and urban) and people were mostly allowed to speak for themselves, and they gave a pretty moving account.

I've never been to China (HK doesn't really count, particularly as I haven't been since 1997), and after seeing the documentary, I'm not sure I really want to. At least not rural China. It would just be too strange to see families who, 4 or 5 generations ago, would have been indistinguishable from my great great-grandparents' families but who now live in a complete time warp. Oh, and also in abject poverty. I don't know how I would react if confronted by a real Chinese villager in the flesh. I wouldn't understand what they were saying, for a start.

Would the villager, if she understood what a fortunate beneficiary of cleverly timed emigration (and shrewd and enterprising recent ancestors) I was, and also if she knew I was a doctor, feel that I had some kind of obligation to my ancestral village? (that is, if it existed - according to some of my relatives on my father's side of the family, everyone either left or starved to death)
I, on the other hand, would feel quite impotent in the face of their many problems, and almost ashamed of my comparatively luxurious lifestyle. Would I even be able to photograph the village in the same way I photograph Hackney?

'it was busy' is an understatement

completed 7 long days on the Unit. We started the week with 9 ventilated babies. We withdrew care on one on saturday and one died on Monday afternoon. By Wednesday, we had a new admission (25 weeker with necrotising enterocolitis who was operated on as an emergency) and yesterday a 23-weeker was born.

one of the more stable babies had a cardiac arrest on saturday. This coincided with the registrar being busy with a recently discharged baby who had been brought into A&E collapsed and me being on the labour ward at an emergency caesarian section. so the nurses got the surgical and transport teams instead. anyway, said baby was down for 45 minutes, had 4 lots of adrenaline, and now has fits.

the only baby who has got any better is a 27 weeker who I weaned the ventilation on over the weekend as the registrar was occupied with the sicker ones. by the time the baby was accidentally extubated while having a chest xray on Monday, I had got her on to SIMV (see mechanical ventilation link 2 entries down) at a lowish rate and had stopped morphine. She's coped well on CPAP and even had some time off on Thursday. It was nice to be able to say to her parents that she was doing well.

Hackney in pictures (or what I did on Tuesday)

More here Colour pictures shot with Jessops SHR 200 (expired 2004), black and white pictures with Fuji Neopan 400CN. Camera: Canon EOS 3000 35-80mm. Minimal manipulation (cropping and levels only) with Adobe Photoshop CS 2.

Yay! It's Monday!

Monday mornings don't come sweeter than when you've worked 4 nights in a row and are let off early from the morning ward round! And someone even thanks you for your hard work! Bit sad, that last comment, but I think one of the problems with hospital medicine is that the work of junior doctors is largely unrecognised. I was up all night with one of the sickest babies (baby from last entry, who died on Friday) yet the thank-you card was addressed solely to the consultant, and the parents don't even know who I am. Instead, on Friday morning, exhausted and hungry from a crazy shift, I was critisised by the consultant for taking blood (from a different baby) from a heelprick instead of a venepuncture (a very trivial point that made no difference to baby). Such is the level of appreciation for my work. Still, I think it was a good set of nights overall (I never thought I would reach the point of saying this, as I am normally ready to shoot myself ten minutes into the second shift).

In short, I have finally got to grips with my job:
1. I can now confidently make small decisions in intensive care, such as weaning or increasing ventilation (and the use and monitoring of the various modes of ventilation available), the use of inotropes in hypotension, correcting pH and electrolyte disturbances etc etc
Here is a taste of the mechanics of ventilation. Note that this site is about Adult ventilation, which is quite different (both in terms of numbers, such as the rates and pressures used, and in the underlying pathophysiology), but it gives some idea of the complexity.
2. I've figured out how to organise all the routine tasks (bleeding all the patients and writing the 24 hourly summary on each - it helps that I now understand what I am writing!) so that there is time to sleep for an hour on the shift (provided the labour ward bleep doesnt go off! I was lucky on 3 of 4 nights) Also helps that I can do things more quickly, like dry off a newborn baby (they are wetter and slipperier than you think!), examine it, wrap it up and hand it to its parents, and write in its notes, all in under 8 minutes (obviously that's the ones that turn out not to need resuscitation).
3. I've learned how to get on the good side of most of the nurses and midwives (though there are a couple who are impossible, and those ones I have learned to avoid)

So life on Nights has become bearable.

help! the baby's not breathing!

Today was supposed to be my half day (finishing at noon - it is the only way the rota remains legal as I will be working 52 hours (4 night shifts) over the coming weekend), but I didn't get away until 3 in the afternoon.

The labour ward bleep went off at about 11 in the morning. "Hello is that the Paed?" said the midwife. (that's what they always say - they get really confused if you answer the phone and say you are a 'Neonatal' SHO) "We are in theatre now, it's a 35-weeker with dextrocardia and situs inversus, and IUGR."
"Are you starting right now?" I asked, as they always seem to call me before the anaesthetist has even turned up to put in the spinal. "We've already started," she said. This was quite inconvenient as the baby was likely to have other congenital abnormailities and to require resuscitation, and she was only giving me 7 minutes' notice. (It usually takes 7 minutes to deliver the baby from the time of first incision at an uncomplicated caesarian section) On hindsight, I should have called the registrar first-off, but I didn't know how bad things were going to be.

I hadn't been able to find any scrubs of the right size in the morning, so it took me another 3 minutes to grab a Medium top (the smallest I could find) and to put on shoe covers and a hat. By the time I got to the theatre, I had just enough time to check the resuscitaire.
Before I knew it, a tiny, floppy bundle the shade of a blueberry had been placed before me. It was the most deformed baby I had seen in my life (believe me I have seen some freaky babies) and it was clearly hydropic. The moment I saw the baby, I asked the midwife to page the registrar immediately. I dried the baby as best I could, gave it 5 inflation breaths, and then more breaths through a facemask. The baby gasped and moved its arms, but then it stopped moving, and stopped breathing. Its heart rate slowed and it turned even bluer. The anaesthetist came over to see if he could help. I tried adjusting the mask on the baby and repositioning its head, but nothing seemed to work. One thing I should have done in retrospect is used higher pressures - something that would have been more obvious had I been ventilating the baby manually. I got the anaesthetist to give some chest compressions. I thought about intubating the baby (something I have yet to do successfully ever) or at least looking down its trachea to see if there was anything blocking the flow of air (possibly meconium or vernix). The baby had an abnormally small jaw and a tiny mouth. I had difficulty even getting the laryngoscope blade in, and when I tried to lift the scope, there was very little give in the jaw. I couldn't even see the vocal cords, but was afraid to pull any harder. So I went back to trying to ventilate the baby through the mask. At the age of 6 minutes (though it felt much longer at the time), the baby was starting to look like a specimen from the pathology museum.
Just as I thought I'd lost the baby for good, S*, my registrar turned up. He's really experienced and it took him 3 trys to intubate. As soon as the tube was in, the baby began to pink up. His heart rate picked up. He was still completely limp though.
Back at the Neonatal unit, the baby had an arterial line put in to check his blood pressure. The first attempt resulted in a wound (from a tiny needle prick) that just would not stop bleeding. The umbilical vein too, oozed for ages. I was allowed to attempt cannulation of an umbilical artery (again something I have never done before), but it was difficult, and I didn't get it in. An echocardiogram (done on the ward using the same machine I took my brain pictures with) showed that the baby's heart was contracting very poorly, and was grossly enlarged.
By then it was nearly 14:00. I headed back to the labour ward to get a full maternal and antenatal history. It turned out that the cardiac anomaly had been discovered 5 weeks ago, and that the Fetal Cardiologists at the Big University Hospital had done a scan and reassured everyone that 'cardiac function [was] normal'. They even went on to say that they planned to see the baby in their outpatient clinic at the age of 4 to 6 weeks! As things have turned out, this was a false (and arguably dangerous!) assurance. I just hope I haven't contributed significantly to the baby's (already) poor prognosis.

Day off

...and I find myself playing Maths teacher to my little brother, who is sitting his GCSEs at the moment. Here he is in a rare moment of concentration:

Through the anterior fontanelle

I took some cool pictures today - using an ultrasound scanner. Too bad they had to remain in the patient's notes! Premature babies' brains are slightly different in structure to term babies' brains. In particular, they are more prone to bleeding into them, so the babies on the Unit often need cranial ultrasounds. The fact that babies' skull bones are not yet fused means it is possible, by holding the probe over the largest gap between the bones (i.e. the anterior fontanelle), to get an ultrasound image of the brain. Occasionally one finds unexpected malformations of the brain, such as this example (I only have a picture because I presented this case at Thursday's perinatal morbidity meeting):


Even with this poor quality image, it is possible to discern that the lateral ventricles are fused. This is known as holoprosencephaly. In its most extreme form, this results in cyclopia, seen here in a kitten. The baby whose brain is seen in these ultrasound images weighs a mere 480g and was born at 24 weeks' gestation.

a walk down church street

bouncing babies!

The day before my exam, and I am up at 06:45 to go to work - a day as the sole paediatric doctor on the postnatal ward. Our hospital serves an area of London (Tower Hamlets, Hackney and Newham) that boasts Britain's highest birth rates (or for full figures, go to the Mayor of London's website and download 'Borough Fertility Rates'), but I have never felt it quite like I did today. Once again the ward was full, with the overspill housed on the antenatal ward. The spectre of having to do 20 baby checks (mind-numbingly boring after the first 5 minutes; also think: vernix, wee, poo and baby sick) all by myself loomed large.
[baby count: 2]
Imagine my delight when an unsuspecting Swedish elective medical student pitches up at 9 o'clock. "I have to do 4 baby checks," he says, anxiously. Well, you've sure come to the right place, I think to myself. From my previous experience of teaching medical students (teaching them how to examine a breast and then letting them clerk in breast cancer patients), having a medical student actually doubles the time it takes to complete the task. But I enjoy it - I like to think it is not because it makes me feel important. I guess it's nice to have some company (and be outnumbered by midwives about 10 to 2 instead of 10 to 1) and it makes me think about why each step in the baby check (or Routine Neonatal Examination) is important, because I quiz the med students about it (and then embarrass myself when I don't have all the answers, like how long it takes for a Mongolian Blue Spot to fade). Well, he was pretty good, he got the hang of it after just one demonstration, and then was able to help me out.
[cumulative baby count: 6]
A couple of our Native medical students turned up an hour later, in their usual inappropriate attire (large dangly jewellery and !nail extensions!). I have tried to shake my negative impression of the students from our local med school ever since the Fetal Haemoglobin incident (which Ching can tell you about), but have not so far succeeded. If this had been Edinburgh, we would've run out of babies to examine by then, but as we have an unceasing supply (the moment you discharge a baby, a new mother and baby appear in their place. Literally.), these stragglers had plenty of babies to try their hand on. I resisted the urge to chuck the long-nailed student out of the room. They each examined 4 babies, and I signed them off for a job fairly adequately (if incredibly inefficiently) done. I had to secretly go back and redo the ones seen by the long-nailed girl, though.
[cumulative baby count: 14 ]

After lunch, I went over to the Neonatal Unit in search of the registrar to ask his advice about a couple of things from the morning. Instead, I found yet another medical student, who was desperate to fill his baby check quota. 4 medical students in one day?!? This was becoming like ER. He seemed like the keen sort, so I brought him over to the postnatal ward. After 2 babies, I said he could go if he liked, but he said he wanted to do the antanatal ward ones too.
[cumulative baby count: 18]

And that is how I examined 18 babies with the help of 4 medical students.

Inedible Cookies No. 2

Am currently on study leave (hence actual time to spend in front of computer) and have discovered (though coming rather late to it) numerous blogs with amazing pictures of incredibly complex food (I think 'food porn' is the correct term). Here is my (; version (please note the culinary disasters are genuine!):-

Inedible cookies No. 1
On Saturday I craved a sugar-fix, and what better way to raise the blood glucose than to imbibe sugar blended with a load of pure animal fat and refined carbohydrate. A recent trip to Edinburgh stoked my appetite for shortbread, and the website of the self-proclaimed Ultimate Guide to Scotland provided what surely must be a fail-safe recipe. The recipe called for ground rice as well as plain flour, and having none of the former to hand, I substitued raw bulgur wheat.

Ingredients:
200g butter
175g plain flour
50g bulgur wheat
85g caster sugar

When I was working on my BSc thesis way back in 2001, my supervisor once said "a lab protocol is NOT a recipe. You have to follow a protocol to the letter." His advice served me well. Therefore I deduced that the converse must be true, and ignored the details of the recipe completely, sprinkling a few scant handfuls of flour over my creamed butter-and-sugar, and randomly grating the rind of an orange into the mixture, along with the crumbs from a packet of salted cashewnuts I found under my desk, and a tablespoonful of ground cinnamon.

The mixture looked fairly inhomogenous, but came together sufficiently to sit gloopily in the centre of a baking tray. By then I had turned the computer off, so I simply made up the oven temperature. I guessed it to be about 200 degrees celcius, without pre-heating. Shortbread is often thought of as uninteresting and stodgy, but this version was turning out to be anything but. The cookies seemed to come to life and sprawl as they baked, until they coalesced to form a bubbling lumpy pool. It smelled good though. And here is the end result:


My flatmate tried one and it almost broke his teeth.

Inedible Cookies No. 2
3 weeks on, and a little wiser, I cycled to Hackney Central Woolworths to get a measuring jug for 49 pence before embarking on my next attempt at cookie-making. This time, I decided I would study several recipes from those glossy-looking foodie-type weblogs to figure out the correct proportion of fat : sugar : flour. A ratio of 2:1:2 seemed fairly safe, so that is what I used:

Ingredients
250g butter
120g caster sugar
250g flour
zest of 1 lemon
spoonful of greek yogurt
crushed almonds

Ah, the taste of a Mediterranean Summer! A citrusy note and greek yogurt, to make it, like, Greek. These ingredients were quite challenging to blend, not least because I had only a wooden spoon and a flat-bottomed casserole dish with which to mix everything. I nearly got a splinter. The cookies looked OK as they baked. The oven temperature was 180 degrees celcius, preheated this time. Cooking time was 13.3 minutes, the mean time from among the recipes I looked at.

The cookies came out looking ok, but when I bit into one, it was raw in the middle. So I shoved them back in, for another 15 minutes. And the same thing happened. These cookies must have a really high specific heat capacity. So I gave up, removed them from the oven, and finished them with some caster sugar on top.


My flatmate tried one and he says they are better than the last batch. He also mentioned that I should maybe stick to Medicine.

...of very little brain

She looks like Maggie from The Simpsons - bug-eyed with an oversized head, bundled up and lying quietly (thanks to a large dose of chloral hydrate) on the CT table, all 2 kilograms of her. *Amina was born at 24 weeks (a gestational age at which an abortion would be legal - just). She had necrotising enterocolitis resulting in bowel perforation - she had to have a large amount of gut removed and a stoma fashioned. Then she had a bleed into her brain (something preterm babies are prone to), and following that developed hydrocephalus. The bones of her skull (these are not yet fused in babies) are splayed and her eyelids cannot fully close. She also has a port wine stain over her face, like that seen in Sturge Weber syndrome. Today she is having a brain scan. I take her down to CT in the transport incubator, with the help of a nurse. We get lost in the hospital basement. We get a lot of stares. At first, there are 'awww's as people realise it is a baby in the incubator, but their coos soon turn to speechless horror when they see her. Nearly half an hour later, she is finally on the table. We retreat to the control room. She lays remarkably still (she had hiccups on the way), and the pictures show, well, very little brain. The ventricles are huge and the brain is squashed into a tiny rim around the edges. The skull itself is very deformed - although her face is parallel to the table, the scan is almost entirely assymmetrical. It seems almost surprising now that when awake she does pretty much what the other babies do - stretch, kick, suck and cry, and she has (like all of them) her own little personality. What will become of Amina? The statistics do not bode well. She will most likely be severely disabled, and require a series of shunts inserted to drain the fluid from her brain. The only conversation I have had with her parents revolved around them trying to wrangle a letter from the consultant to support their application for a bigger council flat. "we all sleep in the same bedroom", the mother complained, "me, like this (she gesticulates), him, like this, and the three children (two of whom are in the pushchair they have brought) like this." So how (and why) did they conceive again, one inevitably thinks. They never touch Amina or change her nappy. In fact, they appear to share the revulsion of the onlookers in the hospital corridor. I wonder what I would be like in their situation?

3 months down, 3 to go

I think the word was 'karoshi' - Japanese for 'death from overwork'. Had a tune in my head as I was cycling home through insane London traffic - 'bye bye Miss American Pie, drove my chevy to the levy [etc etc] just as it got to 'this will be the day that I die' a police van screeched, with blue lights flashing, right into my path. The first I noticed was that all the other traffic had hung back at the junction and I was strangely alone in the yellow box. It was a bad cannula day today - I get these every now and then - days when every single line I try to put in results in multiple bloody holes in the baby and no intravenous access. There must be some weight in the argument that I should have the day off as in this state I cause more harm than good to my patients. I wish I had some energy left to care. However, only 2 more days to go and I get 2 weekends off in a row! What a treat! I can hardly remember what a weekend is anymore. This job threatens to be the death of me, but I've come this far....

just to set the record straight

Just for those who hate to read about my bad days, (unfortunately those are the ones which drive one to write) may I gently protest that I am allowed them, just like everyone else. And that the main problem with the nature of my job is that being professional involves being compassionate and working with your whole heart in it even when you are exhausted and feel rubbish yourself. Therefore I can only really whinge outside of work.

In addition, I don't hate medicine, I just hate intensive care! I miss being able to talk to my patients, and I hate having to check blood gases and electrolytes every 4 hours AND intensive care attracts (arguably needs) a certain breed of nurse (meticulous to the point of obsession with detail- drives me MAD!). To be fair, it also attracts a certain personality of doctor, and I obviously do not fit the description. Of course, in order to be a good paediatrician, I need to gain as much experience in neonatal intensive care as possible, as i will be encountering 'graduates' from the neonatal unit in my future work. SO this job is merely a means to an end. In addition, I have gained an appreciation for normal human physiology - put it this way: if we had to conciously control our fluid and electrolyte balance, acid-base balance, blood pressure, blood sugar, breathing and heart rates, we would all be dead in a matter of minutes.
I say all this as I am preparing to go to work on Good Friday - I have got 7 consecutive days of 13 hour-shifts ahead of me. I have to cycle as the trains are running a Bank Holiday schedule. (have drawn the short straw and have to work the 4-day easter weekend!). So forgive me if I get a little grumpy as the week wears on.

baby

Was called to Labour ward theatre at 12:00 on Tuesday, just as my shift ended. Have been itching to properly resuscitate a baby since going on the Neonatal Life Support course, so went along, only to discover it was an elective and not an emergency caesarian section. "Is there any particular reason you need a paediatrician?" I asked the midwife. She shoved me into the scrubbing-up room. "The mother does not want to see the baby," she said, in hushed tones and a heavy carribean accent. "I'm sorry?" I said, puzzled. "She is a student, and she wants the baby to be adopted, " the midwife explained. S.P.*, a 20 year old college student, had booked at around 20 weeks' gestation, having discovered that morning at her doctor's that she was pregnant and had not merely been gaining weight. She was on the Pill, and had continued 'spotting' throughout the 20 weeks, so had not suspected anything. She was no longer in contact with the baby's father, who she had met at a London nightclub.

(to be continued)

Nights misery

On nights again. It's amazing how one can be so bored at work when there is so much to do. I guess it just gets repetitive after a while. I miss having patients you can actually talk to. Must keep reminding myself that the little creatures in boxes are actual people. Desperately desperately need some sleep. (am awake now as life goes on - still have exams to study for, laundry to do, holidays to plan, must keep fit etc so can't afford to sleep all day). sorry this is so uninspired.

epilogue

the parents of baby Z (the baby in my last post) handed in a hand-written letter yesterday evening. "Dear Sirs," it began, "thank you for your excellent care of Z. We have spoken to our parents... and they agree that we should set his soul free and let him die peacefully so we may see him again in the next life.....we have agreed that the date to do this should be March 10th."

And so Z's ventilator was switched off, and he was placed in his mother's arms - for the first time. He died within minutes.

Beautiful Freak

Thursday is Academic Day on the Unit, which means we don't do any work until lunchtime (and consequently work like mad afterwards and can't leave until nearly seven... but i'll save that rant for next time). Cotside teaching today was on a tiny, hairy little thing, a baby born at 30 weeks' gestation (i.e. 10 weeks early), unable to breath on his own and with multiple deformities. Having sent all the parents out of the room, we crowded round the incubator. "Now, who's going to help me criticise this baby?" said Dr. J, ending this question in his usual alligator grin. "Look at the feet. The heels are very prominent... they had 5 goes at intubating this baby - he has a micro-oropharynx. His ears are low-set and his fingers overlap - classic clinodactyly. On the xray, he has gracile ribs." Dr. J pauses to remove the nappy. "Now that is a very posterior anus...hang on, it's not an anus!" He gets really excited at this point. "Write in the notes, will you, Ali* (he says to one of the other SHOs) the baby has an imperforate anus and a sacral pit. Those are spinal structures you can see through that hole. What do you think," he turns to the other consultants, "surgical opinion?" They all bristle with excitement. One gushes about the size of the ventricular septal defect he'd found on echocardiography and marvels that it was not picked up by antenatal ultrasound scanning.

The baby is likely to have Edwards syndrome (genetic tests are pending), and will most likely die once he is taken off the ventilator. Meanwhile we try to explain all this to his parents while he serves as an unwitting specimen for postgraduate teaching. But one has to learn somehow. What freaks me out is the consultants. Neonatal medicine attracts a certain kind of personality. It requires an obsessive amount of attention to detail and a deft hand with fiddly procedures. Your patients never talk back, and (usually) possess near-miraculous powers of recovery. However, they come with (usually very distraught) parents and you also have to work with Midwives (another group of bizarre individuals) and Obstetricians. The work never stops because babies are born at all hours and fluctuate almost from minute to minute. So its an admirable job they do. But it gets a bit sad when they start getting excited about anuses being in the wrong place (or, indeed, absent).

the two faces of stoke newington

[once again so much has happened that I haven't had time to blog it, so here's a select list: survived 5 x 13 hr shifts in NICU, was going to blog an anonymised patient list but am too tired at the moment; took a short break in Edinburgh, submitted some pictures to a stock library, can now memorise about 30 minutes worth of Pilates - done purely out of a book and...]

Went rock climbing with my sister - at a castle (yes, literally) in Stoke Newington, discovering a whole new side of Hackney in the process - one where New-Agey (mostly white) couples come to nest, and which contains an entire herd of miniature tame deer in a landscaped park, gastropubs galore and a holistic hair salon. This is perhaps best described in the magazineN16. It truly is (or pretends to be!) a world apart from that of the Hackney Gazette - the latter's top headline today being a case in point: "A PARTYGOER ATTACKED in the street after a night out died of his injuries yesterday..." And all within a half hour's walk from my flat!