Best of

[a quick btw: New Years Day on call included a 3 and a half hour long appendicectomy where we stood, fully scrubbed and gowned, over the open wound for about 40 minutes while the consultant drove in from home. He eventually left the matted, pus-spangled tip inside the abdomen. Back in the world of Community Paeds today, there is nothing going on (baby check, baby check, baby check) as usual, hence this blog entry.]

In a fit of paranoia (admittedly tinged with narcissism), I've copied and pasted all the text of my old blog safely(?) into a Word file to print out and burn onto CD. Actually I nearly died of boredom reading it, apart from the entries I wrote while on my elective in Canada.

...in fact, according to uncle 9, where there were once forests in Scarborough, there are now Tim Hortons.
- Uncle 9 commenting on the ubiquity of the Canadian donut chain, Toronto, Feb 04

"We never lock the door," she said, "we lost the key about a year ago, probably because we never used it."
- community nurse in St. Anthony, Newfoundland, Feb 04

"I'm cleaning your neck with this alcohol wipe, not because it's dirty, but because we like you to leave hospital smelling of hospital"
- Endocrinology consultant, Edinburgh, Apr 04

"Thank you. I'm glad you did,"
-Sir Simon Rattle, responding to my inane comment that I'd enjoyed his concert with the Berlin Philharmonic. On a BA flight from Berlin, Nov 03 (the only time I've ever asked for anyone's autograph)

"having delivered 3 babies, examined a dead woman, done chest compressions, sat with suicidal patients and so on, one would have thought that it would put my own problems in perspective. i guess (depending on how you look at it) its either a horribly selfish streak or a vital self-preserving streak that keeps alive the belief which i can only express as "the worst possible problem is the one i've got". "
-me, in Nov 03. Some things never change.

Christmas in hospital

"Twas the night before Christmas, when all through the house
Not a creature was stirring, not even a mouse.
The stockings were hung by the chimney with care,
In hopes that St Nicholas soon would be there.

The children were nestled all snug in their beds,
While visions of sugar-plums danced in their heads...."

- opening stanzas from Twas the night before Christmas by Clement Clarke Moore (1779 - 1863)

I think my body clock is finally back in GMT. In short, "twas the night before christmas" and I was at work! Even worse, they've turned our on-call room into the Matron's office so there was nowhere to lie down when I finally got a few hours' break.

You couldn't miss the fact it was christmas on the childrens' wards. Each ward had its own christmas tree, and baubles and tinsel hung from the curtain rails. The hospital porters bearing TPN and blood samples scurried about with fluffy red-and-white hats on. A felt stocking hung at the foot of each bed, often somewhat larger than its sleeping occupant. I spent about half an hour persuading *Ali, a small boy with cystic fibrosis to go to bed. "Santa only brings presents to sleeping children," said his mom, "just ask the doctor". I have a sneaking suspicion she knew Ali would take this literally.

When Ali finally succumbed, an ambulance crew arrived with *Jack, a chubby Vietnamese boy of 4 months and his parents, who spoke little English. He had been lethargic for 2 days, feeding little, and vomiting. They became alarmed when he started passing bright red blood instead of stool. His x-ray (done at the referring hospital) showed dilated bowel loops. I prescribed fluids and antibiotics while my registrar explained (tried to explain) that he would require an air enema, and if that failed would require an operation to reduce the intussusception. His parents looked horrified. "Is it something we fed him?" they asked me, after the registrar had left. (the other, unspoken question was, "help! do you speak vietnamese?") I disappointed them by replying in English, but I did explain as best I could the possible causes. Jack eventually needed a laparotomy and resection of some bowel, but he is making a good recovery.

On Christmas morning, with everything almost miraculously quiet on the baby unit (despite two ventilated premature babies with NEC), I wandered downstairs, and ran right into *Liz, an 8 year old girl with oesophageal dysmotility (and a Hickman line infection). She was wearing tinsel round her pigtails and clutching an unopened present in one hand, and a large drip stand in the other. Her face fell when she looked up to see me. "I thought it would be mom and *Rory," she said, "we always open our presents together."

I was very glad to see *Tom when he appeared at 8:30, and after handing all the patients over to him, I got on my bike and cycled home.

saturday at the christmas market

(no prizes for guessing where!)

originally uploaded by cirrus29.rm.

click photo for the rest of the pictures

before and after

a slap too far

...just a little aside: see what I meant (a couple of posts ago) by repeated predictions of a house price crash that never seems to materialise.

Attended my first Child Protection (CP) Case Conference on monday. It was about a girl I examined several weeks ago - we found linear bruises on her back, legs and arms as well as some old scars. This fitted with her story of being beaten by her father with various objects. I guess I can't really blog about it properly as it's meant to be confidential.

I still come away from CP medicals feeling a bit bruised (emotionally) myself, particularly the physical/emotional abuse ones involving a child and a parent. In the case that went to Conference, it was obvious that the parent had overstepped the mark, on that occasion at least. But there are numerous other cases where the child discloses being beaten but there is no physical evidence. Sometimes social workers enter the the home to find a filthy, overcrowded flat, or a depressed single parent who smells of alcohol. But more often the problem is less obvious (or indeed, there may not be a problem). The home environment looks suitable, the parents are in stable employment, and the children are doing well at school. What is then achieved by having a social worker visit the family fortnightly, forcing the parents to accept 'family support services', or even prosecuting the parents? In an intact family with evidence of adequate resources(which seems a relative rarity in these parts), do the benefits of protecting the children from suspected physical and emotional damage justify the cost of straining family relationships? Certain high profile cases mean that agencies tend now to err very far on the side of caution. While I agree completely that a high index of suspicion is required until all the relevant information is gathered, I think it is also important to back down when investigation reveals that the that child is, on the whole, well cared for. I know hitting a child in this country is illegal etc. but strong family relationships (even if a bit dysfunctional) must hold some currency.

Autumn sunshine

a blast from the (recent) past

little update on Bike - he's now fitted out with brand new tyres - kevlar-lined, no less!

Bit of an interesting baby clinic today (never thought it possible!) - trying to get a portuguese interpreter at 5pm, and seeing *Esther again. (will save my gripes/anecdotes re: interpreters for another post) Esther is an "ex-prem" - a baby who was born prematurely and (typically) spent time on the neonatal intensive care unit. She is on home oxygen, and today mom has brought the travel-sized cylinder, which sits snugly in the undercarriage of Esther's pushchair. It's been 5 months since Esther was born - she was on NICU when I was working there. She didn't stick much in my memory as she was a pretty typical admission - delivered by emergency caesarian section at 28 weeks (ie 12 weeks early) due to intrauterine growth restriction (IUGR) with reversed end-diastolic flow (i.e. very bad placental insufficiency - see link). Admittedly, my contribution to her intensive care was mainly in the form of clumsy phlebotomy at 2 a.m. She did fairly well though, and she's as big as a smallish 8 week-old (which is her corrected age - with premature babies, you count from their expected date of delivery for the first couple of years) now, and smiles and gurgles etc. It's all too easy to take it for granted though.

The IUGR 28-weeker who sticks in my mind never made it out of NICU alive. I was on call the night *Mohammed should have been born. The registrar and I were bleeped urgently to Labour Ward to attend an impending caesarian section. We had the nurses ready an incubator, while we ran over (labour ward at our hospital is stupidly located in a different building from the neonatal unit) with the 'crash bag' (a shiny green backpack containing nearly everything you'd find in the back of an ambulance but in miniature). We arrived to find an empty operating theatre. A midwife waddled up to us; "they are refusing the operation," she panted. We peered into the room - a small and extremely angry Bangladeshi man was hunched in one corner, while the obstetrician - a tall black lady with an imperious mien, was flanked by two burly and irate midwives. The man's heavily pregnant wife lay on a bed in the centre of the room. She was not in labour; they had come because she hadn't felt the baby move in 3 days. "You cannot take the baby out now," said the man, it's too early! We just want scan to see if baby is OK, then we go home." His wife murmured something in Bengali (she didn't speak English, but seemed to understand a fair bit). We retreated to the midwives' office, but it didn't sound any prettier from there. Finally the obstetrician gave up, but invited my registrar to say her piece. I thought she did rather a good job, explaining what a 28-weeker was like and what could be provided at NICU, and emphasising that the baby could die if we didn't act soon. I could see the woman's eyes light up. The man was unmoved. We left them to give them time to come to a decision. Eventually, they packed up and left. Mohammed was born by emergency caesarian section when his mother developed pre-eclampsia 2 days later. He was born in poor condition, and remained comatose and floppy despite resuscitation.

I HATE LIVING ALONE

now I know why all the little old ladies get depressed and stop eating
life is not worth living without company

in reverse order

I reckon there's enough to learn about housebuying to make a GCSE. They should knock useless subjects like Home Economics (I still ended up poisoning myself every week when I first went to uni) and Design and Technology off the curriculum in favour of something like Practical Money Management, including a Housebuying module. I mean, its just the sort of dead boring yet essential subject you shouldn't have to spend your free time educating yourself on.

So I'm pulling out of buying this flat as have discovered in retrospect that I can't actually afford it. I simply (embarrassingly) made a mistake in the maths. Not looking forward to facing a half dozen irate people (solicitors, mortgage brokers, estate agents) tomorrow (well, at least it'll be over the phone), but it wasn't my fault!! I was forced to teach myself off the internet in the space of a few months about the process of housebuying, and it's only in the last week that I've grasped the finer points and it's all started to make (admittedly partial) sense. Everyone you turn to for advice has a different thing to say, and most of these people are only interested in extracting money from you. To make things worse, completely irrational things happen in the housing market - for example, if you search Guardian Money for articles on house prices, you can find nearly identical articles on an impending price crash dating from 2002, 2004 and early 2006. Of course, all of them were wrong.

The other thing that's all backwards is that this is turning out to be completely different from how I imagined it would be. I am (mostly) happy as a doctor because it's what I'd wanted to do from the age of 11, so in that respect at least, life has turned out as I imagined - sometimes even better (more interesting and rewarding) than imagined. But (like many girls, I'm sure) I'd also imagined I would be married and starting a family by the time I'd hit the age I am now. And I imagined I would be buying a house together with someone, and it would be a happy thing, not something quite as fraught and lonely as it is turning out to be. I tapped two incomes equal to my own into an online mortgage calculator just for fun, and the amount you'd get would comfortably buy my dream home - even here in London.

I don't think of myself as someone who pines for comfort and material things, but I have (unpleasantly) surprised myself with the kinds of living conditions I am not willing to put up with (no ex-council flats, no high-rises, no low ceilings, clean tree-lined streets, near a tube etc). I guess I have turned out to have more exacting standards than I thought - but for now I can't afford them.

oh no

would you believe, I've had another puncture. I was just about to get on my bike this afternoon when I noticed the rear wheel (my freshly installed new inner tube!) was completely flat AND had a large, shiny nail sticking out of it. One more time and I'll be a qualified bike mechanic.

Bit of an eventful day today. Called the estate agent first thing in the morning to make an offer on a flat I saw for the second time yesterday evening. Then walked to a nearby primary school for my first ever clinic as School Doctor.

It was more complex than I imagined. The 3 patients were all boys of 5 or 6 years old, and accompanied by their moms.
KM age 6
referred for follow-up by previous school doctor, having been discharged from the Child Development centre in 2005. referred (separately) by the school Special Educational Needs Co-ordinator (SENCO) due to
1. short attention span and disruptive in class
2. unable to read, write, draw, count or name colours or shapes
At the end of the session, the SENCO and I both wondered if he might have ADHD.

BI age 5
referred by class teacher for
1. "pees and poohs his pants"
2. developmental delay
He was a small, slightly odd looking child, who it turned out, had as few words in Turkish as he did in English.

HF age 6
referred by class teacher for
1. disruptive behaviour in class
2. "speech problems"
"but he is capable and shows ability"
He was a bright boy with a lisp who had arrived from Nigeria not long ago.

Each of these took about an hour. While I was speaking to the SENCO afterwards, my phone rang - it was the estate agent. The sellers would take the flat off the market for 2500 pounds more than I had offered. I felt a bit swamped at that point, so said I would call him back.

15:00 Child protection medical
This was the point I discovered my bike tyre was flat. So I set out on foot, fingering my phone with indecision. How many flats is one supposed to see before one commits? What if a better one doesn't come along? What if I buy, and then one does?

I had to examine 2 siblings who had witnessed domestic violence involving a knife and the severing of fingers. They were already on the child protection register. It was the first time I had to do a medical by myself.

I'd already had a really hard day (as in, with high emotional involvment, which is the aspect of medicine I find most draining and difficult) and the worst was to come. I was late, because I had allowed ample time to cycle to the clinic, but not to walk. I needed to make a decision on this flat. I wish I could have deferred it to a day when I was doing boring things, like baby clinic. I called a few people for advice, but their phones were all on answer phone. For a moment, I felt bizarrely alone in the world. I rang the agent back and agreed to buy the flat.

can she fix it?

My bike is a bit of a joke at the best of times. With only 3 speeds (slow, very slow, and a middle speed which doesnt actually change the gear) and a metal frame and that clatters at the tiniest bump in road, it's not the meanest machine. So when I came off a curb (at the edge of London Fields) with a loud bang (at 9pm on thursday, after an evening on call), I thought nothing of it and cycled on. It seemed a particularly gruelling ride, and the hypochondriac in me started to wonder if I should perhaps register with a GP afterall, if only to get an FBC, thyroid function tests, and maybe an LDH and a Mantoux as well. Imagine my relief(!) to discover, panting from carrying the green beast up a flight of stairs, that the back tyre was almost entirely flat. I'd been amazed to that point that I'd not had a puncture before, given the number of broken bottles I've cycled over since acquiring the bike (the road to bethnal green seems perpetually lined with broken beer bottles and it's often a choice between going over the broken glass and getting run over by an oncoming bus).

So I had the cheerful task today of figuring out how to change a rear bicycle tyre - the guy at the bike shop had regarded me suspiciously when I had asked for a 26x1 3/8 inner tube and "those plastic things you pry the tyre off with" (I still don't know what they're called) and when I didn't know what kind of valves I had. "Bring the bike in if you can't manage," he'd said. It was oddly satisfying to prove I could do it without help, and having cleaned the chain as well, the bike's as good as (probably better than!) new. It did take me more than an hour though.

Nights misery - no. 12?

why??? why - when nights in my opinion are the worst kind of misery that can masquerade as Work - do I have to work the longest night of the year? life is unfair.

It's official

...Hackney has been declared worst place in Britain to live. Living and working in Hackney, I'm at once reassured that I'm not mad (or alone) in thinking that things are pretty rubbish here but also slightly offended - since becoming a community doctor here (though this is, of course only until february), I do feel in a (albeit miniscule) way responsible for the quality of life of Hackney residents.

I opened my email at work today to find a message from the Mayor of Hackney himself. "Crime is down by 22%..." it read, "the greatest decrease in London. Our schools are improving..." It went on to encourage recipients to write to Channel 4 in protest, or send an email of encouragement to the local council. "Wear your 'i love Hackney' badge with pride," it said. My what? Curious as to how to obtain one, I clicked on the link to the council's website. Must get the T-shirt.

first time I...

ok quick post as have to get up at 6:45 again tomorrow

Met a friend's two year-old daughter in Boston, who can read(!) and count to 100 in both English and Chinese. She's a clever little thing, and gathers new knowledge at an astounding rate. It reminded me of how much enjoyment I get from learning new things myself. (and also that not all 2 year olds are like the (too often) rather sorry examples I see in clinic). In the past week I have

-found out that I've passed the first part of my membership exams (at last!)
-done my first child protection medical (and written the report that will go to social services and the police)
-attended my first conference (unfortunately it's been rather uninspiring - I have definitely been put off community child health for good)

will (or more likely won't) elaborate on the above if/when I get time

As seen on TV

Pumpkins
Originally uploaded by cirrus29.rm.

...back to work after a week's break in Boston (and environs). For the latter part of our stay one of the couple's (we were there ostensibly to photograph a wedding) friends put us up at her apartment on Elm Street. It was a suburban street straight out of the movies - brightly coloured wood-panelled houses, each with the star-spangled banner hanging over the porch, weather-worn chairs and metal mailboxes with red flags on. Some had pumpkins put out for halloween. We went to a baseball game - where they actually sang 'take me out to the ballgame' - and stopped by a pumpkin patch with some monster pumpkins.

press "1" now

Did I mention my job was repetitive? I think I should send in a robotic stand-in. It would have a smiley, baby-friendly face and a built-in weighing scale heated to 37 degrees, and a growth-chart reader.

"Good morning Mrs. Lopez. How are you? [pause] Have you had your own 6-week check with your GP?" [Mrs. Lopez mutters something about not being registered with a GP] "Not to worry. Many families move house around the time of having a new baby. Do register with a GP as soon as you can. Does your baby smile back when you smile at him? ["oh, yes," says Mrs Lopez] "Good. Does he follow your face with his eyes? [pause] Does he startle to a loud noise?" The standard 6-week review questions over, the Child Health Surveillance Bot would then play a recording explaining the benefits of the BCG vaccine and why we offer it to all babies in Hackney. "Do you consent to your baby having the BCG?" Mrs Lopez answers in the affirmative. "Please place your baby's left upper arm against the Injection Module" The robot's screen replaces its Smiling loop with a short video clip showing the correct position for the baby. A 26 gauge needle is inserted intradermally at precisely 0.1mm below the surface of the skin and exactly 0.05ml of BCG injected. As Mrs. Lopez comforts and dresses her baby, the Bot says: "have you any further questions for me?" "Yes," says Mrs. Lopez. The Bot cuts in: "you now have 5 options: if you wish to discuss your baby's growth and nutrition or any feeding problems, please press 1. If you wish to discuss nappy rash, thrush or any other skin problems or lesions, please press 2. If you are worried about your baby's breathing, please press 3. If you wish to discuss vaccinations, please press 4. If you intend to refuse a vaccination, please press 5." This last button would deliver a nasty electric shock. [I've had several encounters with parents refusing their childrens immunisations, but that is another story!]
Did I mention my job was repetitive?

professional MOM

We have a lot of acronyms in community paeds - there is CCC (complex communication clinic), CHC (child health clinic), PAC (physical assessment clinic), DAC (developmental assessment clinic) and LAC (looked-after children) clinic. This last one I attended today. Looked-after children are children who are under Care Orders, many of whom live with foster parents. They might have been abused, or their parents might be mentally ill or in prison. All of them need Medicals, theoretically within 28 days of the Order being issued. (not always possible in practice - I am told we have a backlog of about 70)

I saw a lovely little Vietnamese boy today. He was accompanied by 3 adults: mom, tall with dyed brown hair, silver high-heeled sandals and a couple of nasty keloid scars; mom's 'friend', a short middle-aged vietnamese woman with chipped red nail polish; and foster mom, an overweight white woman with straw-like hair scraped back into an Essex facelift and a chunky gold pendant - MOM in capital letters encrusted with fake diamonds. Just in case we didn't know who she was. But she had a kindly face, and seemed very sensible - she'd obviously done this all before.

Which got me thinking - why do people become foster parents? They are paid a small sum of money for their trouble, but I am told it is barely enough to feed the child in question. (on the other hand, they do get tax breaks) Is it pure altruism? Some fostering organisations would have you believe so:

"if you are able to guide and support and care for the children we place with you, you will not only have achieved something remarkable for yourself, you will have changed lives for the better - forever." -Community Foster Care

The truth is that fostered children have a dismal outlook (I suppose the quote above is qualified with an 'if'). I guess even biological parents are not completely free of selfish motivation for having a child, and adopters can sometimes be looking for something to fill a void in their own lives. But why would someone make a career of taking in a series of damaged children?

didn't I say that already?

After an art-filled weekend (I highly recommend both this and this)I returned to work on monday to find a large wooden model of an erect penis in the middle of my clinic room table. It took a minute for me to realise this must have been left by the Family Planning people, and was in fact not incongruous with its surroundings at all. I shoved it into one of the drawers and hastily set up my clinic stuff - opthalmoscope, measuring tape, toys, a baby book, and the BCG vaccination kit. Halfway through the clinic, I found myself saying to one of the moms "and so I've explained to you about the BCG injection..." and she stopped me and said "no, you haven't." And she was right. I'd repeated myself so many times in one morning that I believed I had. Child Health Clinic is incredibly boring. It is so repetitive I think I might die of repetition.
I think it was Tolstoy who said "all happy families resemble one another; but each unhappy family is unhappy in its own way." In the same way, well children are all the same (or, at least, require the same treatment) but ill children are each ill in their own way. Which (by a rather skewed inversion of this observation) makes well children rather boring to deal with. Which is why I've had no patients worth blogging about lately. I know the value of child health surveillance etc but it's becoming increasingly hard to get out of bed in the mornings - to go and see lots of well kids and repeat myself a hundred times. But I suppose it could be worse - I don't envy the person whose wooden penis model that was.

space pens!

One of the disadvantages of working in Paediatrics is that my supply of free pens has run dry. (There are, of course, some who disagree with accepting such bribes from the drug industry, but that is another story) As everyone in hospital seems to be 'borrowing' and then 'losing' each others pens all the time, it was handy to have an endless supply of cheap (free!) pens. Also, much of a junior doctor's time is spent writing - I would go so far as to say that it was possible to do my job without a stethoscope, but impossible without a black ballpoint pen. Every admission means at least 2 pages of writing (including diagrams if there are injuries or a rash), and a ward round means 2 paragraphs each in about 10 sets of notes. Each discharge requires a GP letter - this is handwritten onto a self-carbonating form. And then there are the prescriptions, procedures to document, consent forms etc etc. So my pens never last long.

Yesterday I unearthed two old pens that dad gave me when I was in my initial years at medical school. Though long used up, I had kept them because they had been excellent pens, and their casings felt particularly solid. Unscrewing one, I read the print on the spent cartridge: "#PR4 BLACK MEDIUM BK1 #3 400 For Refill Send $4.00 U.S. To FISHER SPACE PEN CO. Boulder City, NV 89005, U.S.A." Sending away by post for a refill - how quaint! I figured if they were real 'space pens' they must have a website by now. So I Googled it and ordered a couple. And they've arrived! Can't wait to try them out on some blood-spattered specimen bottles.

...take 50 nurses

Foulden Road from our window this morning

There is a new childhood immunisation programme rolling out across Britain , which on paper looks simple enough: the introduction of universal vaccination against pneumococcus, and a re-jigging of the meningitis schedule. The problem is this: 4500 babies are born annually in Hackney, and more arrive from overseas each year. A significant proportion of their parents do not speak or read English. Worst of all, the central computer system cannot automatically generate appointments for all the targetted infants, and not all the local GP practices have computerised records. Add to that 50 overworked nurses (gathered in a room on a hot afternoon to hear about the changes) and you have a potent brew. This is admittedly my first glimpse of public health at ground level, but I can begin to see that policy does not translate at all easily into practice. The presentation is (I feel) rather succinct, yet, 5 minutes after the speaker (one of my consultants) has explained something, a hand goes up somewhere and someone either asks a question that has already been answered, or brings up some (usually valid) practicality. The meeting drags on, the heat becoming oppressive. There are jibes at the Department of Health people - "obviously they haven't seen a real patient in ages". So these are our troops; a roomful of tired, sweaty ladies armed with boxes of leaflets, refridgerators full of small glass vials, and lots of needles.