Just 17

One thing I don't miss at all about adult medicine is having patients several times larger than myself. I had a run of teenagers in clinic today, from the largest 12 year-old I've ever seen (over 6 foot and weighing 85 kilos) , to an autistic 18 year old whose mom has to shave his unruly facial hair.

12 year old boy, learning disability, seizure disorder, behavioural problems. Mom worried about sexualised behaviour ever since started sex education at school. Good school reports but mom struggling to cope with behaviour at home. Mom unwilling to be referred to our pschologists as boy managed to fall out with one over "talking about poo" a few years ago when he was referred for problems with soiling. EEG - no seizure activity but suggests epileptic tendency. Plan: refer to clincial psychology at Big Famous Hospital; start carbamazepine.

16 year old girl, accopanied by mother. headaches since age 6 years; pineal cyst on CT at age 7; thought to be benign. Headaches increasing in severity and occasionally waking her at night. 2 year history of sudden "blackouts" always associated with yawning and stretching. Family history of migraine. Meds: propranolol as migraine prophylaxis - but patient had stopped these herself 6 months ago. Impression: likely carotid body hypersensitivity syndrome; plan: ECG, refer to cardiology. also MRI brain. Adult or paediatric cardiology?


18 year old boy, high functioning autism. Mother opens the consultation by whipping out Certificate of Achievement from vocational taster course and beaming proudly at me. I try to look suitably impressed as she relates that he can walk to the DLR station and get to college all by himself. (but still needs help shaving and supervision bathing). He looks about 20, with marked 6 oclock shadow and scraggly moustache despite it being 3 oclock in the afternoon. Is on fluoxetine for anxiety; mom feels this helps. I wonder if it is appropriate to refer him on to the adult clinic?

And others. When do you refer to adult clinic? I guess the patient attending clinic on their own is always a good sign. It's the age old question. When is one truly grown up? And what matters more, mental or chronological age? Part of the reason teenagers unsettle me is I guess deep down I do feel as if I am still living in much-extended adolescence myself. Each birthday I think, maybe I will feel finally grown up when I....
live independently? - nah, been doing that 10 years now
graduate? - that was a while ago now, but that didn't do it
start work? - that didn't do it either
watch someone die and then have to speak to their relatives? - nope
make a 'good save' that keeps someone alive? - nope, not that either
get married?
have my own children?
become a consultant?
buy a house?
who knows. maybe the moment you stop growing up is the beginning of the end.

FFP2s and AFBs

Like Dr. P is what I want to be when I "grow up" - a respected paediatric neurologist - the Ferragamo shoes would be a bonus. Everytime a parent asks specifically to see Dr. P, she makes me see them. I suppose it works out "well" on all sides - the pushy parent gets "punished" by having to see the most junior doctor on the team, I get practice dealing with difficult parents, and Dr. P gets to sit back and have a coffee.

The last patient on Tuesday's clinic list threatened to be one of these. "Look at her, she's sick," said the father, a burly, bear-like man. "I want to see Dr. P! She said she would see *Amina." Dr. P sat in her consulting room dictating her clinic letters. "You see them," she said to me, ignoring his protests. "When I say I will see you," she said to the man, "I mean one of my team will see you." With that, she retreated behind the door again and left me with the irate parents and their languid daughter. Someone had given her a sick bowl, which she was coughing into.

Amina has epilepsy, which is well controlled on sodium valproate, but because she is approaching puberty, Dr. P had been trying to change her over to topiramate, a less teratogenic drug with fewer undesirable effects. "That topiramate," began Dad, "Amina has been very ill ever since we got to 100 miligrams." They had come to hospital before, with Amina complaining of pain in her chest (an unusual symptom in children), and tiredness. The A&E doctors had told them that topiramate can cause tiredness, and reduced appetite; sometimes even weight loss. "She is not right, we need to stop it. Look, how she coughs!" I explained that topiramate certainly didn't cause chest infections. "How long has she been coughing?" I asked. Since 100 miligrams!" he said, exasperated that I wouldn't acknowledge the link. "And fever too!" I looked back at her previous clinic letter, and calculated that she had had a cough and intermittent fever for three months. This being Whitechapel, I thought immediately of TB. Turned out I wasn't the first to consider this diagnosis - she had attended A&E just the day before, and had been sent home after having a Mantoux test administered. It was already strongly positive. So we admitted her from the Neurology clinic into a barrier-nursed cubicle.

Later that day, I went to see her on the ward. The window blinds were down and a trolley laden with plastic aprons, gloves and FFP2 masks sat outside the door. I put a mask on and pushed the door open. Amina had been a timid little thing before, but now she looked postively terrified lying in bed with the sheets up to her chin, and surrounded by relatives, each with a beaked TB mask on. I bent down and tried to reassure her, but it was difficult, wearing a mask, particularly when I had been examining her closely without a mask on just hours before. Her father looked over at me, and despite the mask I could make out that he wore a completely different expression from the scowl he had had on earlier. "Thank you," he mumbled from under the mask.

the job offer came through 2 days before my birthday

The telephone and the tendon hammer

It was in my second year of medical school that I became fascinated by the workings of the brain, but it was in fourth year that I first decided I wanted to become a Neurologist. I have vivid memory of our first tutorial; the professor perched himself on the edge of his consulting room desk, and began: "In diagnosing epilepsy, the telephone is more important that the tendon hammer." He explained that though neurologists often order large batteries of esoteric tests (like cerebrospinal fluid neurotransmitters and other things that need to be rushed to the lab on dry ice), neurology is no different from any other specialty - a good history (or, in the case of epilepsy, a good eyewitness account) often provides the best clues to diagnosis.

4 years on, and my very own mobile telephone has helped reach a diagnosis of infantile spasms. But not in the way the professor had envisaged. Everyone has camera phones these days, and we often send parents home with advice to try and capture an episode (of what might or might not be a seizure) on camera. Sometimes they return for the follow-up appointment without the child - but with the precious video recording, and appropriate treatment can then be started. I guess this helps particularly in an area like ours, where many parents have a limited grasp of English.

Encouragement

The road to Lochranza, Isle of Arran (that's rain on the lens!)

Consider it pure joy, my brothers, whenever you face trials of many kinds, because you know that the testing of your faith develops perseverance. Perseverance must finish its work so that you may be mature and complete, not lacking anything. [James 1:2-4]

I've tried to keep my two blogs separate; I'd wanted this one to be more of a log of cases, with perhaps the odd comment on hospital life or medical news. But I still haven't got a job for 1st August; it feels a bit like careening towards the edge of a cliff, and I can't help being just a little pre-occupied.

I asked my consultant to comment on my CV yesterday, and he was really helpful. The best thing he did was to give me a copy of his own CV. Quite apart from providing a template, it helped put things into perspective. Despite being an excellent doctor, he's not had an easy route to becoming a consultant. It all made me feel rather... embryonic. But also less depressed.

Been here before

Blogging from Edinburgh, where am currently on leave - have spent the last couple of days frantically filling in job applications (Glasgow, Manchester, London, Sussex). But we are off to the Isle of Arran tomorrow, on bikes! ( :
(expect pictures in my next post!)

I guess I shouldn't get too upset about the whole jobs debacle. (old link for those unfamiliar with the issue) 10 years ago, I was forced to make applications to medical schools in several different countries before finally gaining a place in Edinburgh. And I am grateful for that.

Four Easy Pieces

The dentist offered to extract the offending wisdom tooth. I decided I could live with one gum infection a year - give me a course of augmentin over the risk of facial nerve injury anytime.

Walking home from the dental surgery, I realised I had just seen the 'other side' of the consultation. Less than 24 hours earlier, I had been trying to convince a 13 year-old and her mother that she should get part of her brain removed (that is, emphasising that they must attend the neurosurgery appointment this time), and then wondered why they were so reluctant about it.

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We've had a run of patients with "severe seizure disorder, global developmental delay, recurrent respiratory tract infections" discharged back to us from the paediatric intensive care unit (PICU) recently. Despite the fact that they do very little (mostly sit or lie motionless waiting for the next Physio session, or for the sats monitor to go off and a nurse to come running with a suction catheter) they make pretty demanding inpatients. A combination of repeated PICU admissions and limb disuse and spasticity means their veins are almost impossible to cannulate - and they always seem to be on a cocktail of intravenous antibiotics. They don't eat - they are fed by gastrostomy, and may also be on the ketogenic diet for seizure control. Some don't pee - requiring intermittent bladder catheterisation. The weekly consultant ward round (it is only weekly because most of the other inpatients are either undergoing neuro-rehabilitation or are under other paediatric teams) begins to resemble a ward round in Geriatrics.

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I left work at nearly 11pm yesterday. My sunday shift ended at around 9, but because it had been a busy week (9 sick/fitting inpatients instead of the usual 3 neuro-rehabs, 2 lumbar punctures under GA and all the usual clinics) I hadn't yet dictated my clinic letters. I knew that my week of leave would be guilt-tinged if I left them, so I deposited my cycling stuff in the office and went across the road to get a biriyani. (bit of a dilemma choosing between the 4 Bangladeshi takeways on the junction) So I've faxed off my EEG requests and my Opthalmology referrals, and all my patients' GPs shall soon be updated on their headache/seizure/etc management.

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It is ironic that just as I am in a specialty that really interests me, and working with a great team who make me feel valued, I may soon be out of a job. I've not fared at all well in the MTAS lottery, and have been crying myself to sleep every night. I decided at the age of 11 that I wanted to be a doctor, and have worked extremely hard at it since. I have a first-class intercalated degree, and am published in two international medical journals, though I only graduated in 2004. I am coming to the end of a clincal rotation that has given me a rich experience in paediatrics in a colourful part of London, and have only one remaining postgraduate exam to pass. Please give me a chance. I have so much to offer paediatrics, to offer medicine, to offer the world (maybe) - if only I could get some proper specialist training.

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Chickpeas and black pudding

Youee and I made a birthday cake for Ching! A shameless fusion of two Nigella Lawson recipes, it tasted somewhat better than what Youee thought the book's illustration was.

A piece of medical history

Fascinating article in the Observer Woman magazine today about Carl Djerassi, the inventor of the Pill.

I took the official 'bride getting ready' shots for T&R's wedding yesterday. Here's a selection: (just a few of about 120)

not having a fit

“Call for you,” said the switchboard operator, in her usual drone. “Hi, this is Mrs. Berkenstein*,” a shrill voice with a decidedly Germanic accent crackled down the line. “I’m *Nathaniel’s mother. Is this *Sally?” “No, it’s Sam, I said,” rather taken aback at being bleeped before 9 in the morning on my first day as Paediatric Neurology SHO by a patient’s mother. Nathaniel is a 6 month-old boy with infantile spasms. His mother had phoned for a repeat prescription – steroids, ranitidine and pyridoxine. She said Sally (the previous person who was in my job) used to fax the prescription to her local pharmacist.

Before I’d had the chance to sort out her request (and right in the middle of clinic), I had another call from a mother: “*Jacob’s school has sent him home because he was going blue around the mouth and rolling his eyes to one side. We saw Dr. *Ahmed last Tuesday and he increased Jacob’s medicines but he is fitting more now. We don’t want to come into hospital again, what do you advise?” I asked her some further questions, but it was impossible to assess the child without actually seeing him. I explained this to her, but she was adamant; “the team have always given advice over the phone in the past,” she insisted, before admitting that the current situation was a new one. I guess one of the luxuries of being a junior doctor is that when you have your back to the wall, you can always wriggle your way out by saying you’ll speak to your consultant and get back to the patient.

Jacob eventually came into hospital and an EEG confirmed increased seizure activity. A blood gas showed a partially compensated metabolic acidosis – in his case it could be due either to the ketogenic diet or intercurrent infection, so we started him on antibiotics and sodium bicarbonate.

Quite apart from all I was learning about seizure disorders, it was interesting to meet these mothers in person. Both were petite Orthodox Jewish ladies, dressed in the usual garb of loose, dark-coloured long-sleeved blouse and black below-knee skirt, dark tights, chunky black loafers and a hat or headscarf worn at all times. Beneath all that, they looked impossibly young (I’d estimate early twenties, certainly significantly younger than myself) and vulnerable. Speaking face to face with them was absolutely fine – they were both gracious and articulate, and though understandably concerned about their sons, were by no means overly anxious or unreasonable. Perhaps the scary telephone persona was a kind of “take me seriously or else” act.

all change

Am quite liking my new job - we had clinic all day on tuesday, and I saw (and made decisions about) patients with conditions ranging from the commonplace (migraine without aura, suspected absence seizures) to the exceedingly rare (cat eye syndrome, mitochondrial electron chain complex 4 deficiency). Nearly lost my voice dictating all the clinic letters afterwards. Today was slightly duller - 5 patients on the ward round, a psychosocial meeting, and having to grapple with really stupid computer-programmed theatre lists that won't let you put a patient on the list who does not have a surgeon for a consultant. Whoever designed it didn't figure that there are other reasons to have an anaesthetic apart from surgery. Have to be in at 08:00 tomorrow to clerk in the patients for lumbar punctures and manometry under general anaesthetic. Should be interesting to do though. Not inspired enough to blog properly about individual patients at present.

diagnosis? (or, I'm not feeling so good)

Just to catalogue my symptoms so far:

-lethargy, malaise and ?depression - about 3 months
-pain in both calves - 14 days ago, for 3 days, resolving spontaneously
-generalised myopathy and ?rigors- 10 days ago, for about 3 days, resolving spontaneously
-leucopenia (neutrophils 1.6, lymphocytes 0.60); Hb 13, but i'm on a multivitamin with iron in it
-raised d-dimers (exact level not known to me)
-morbiliform rash all over body, including palms, soles and face, with mild bilateral conjunctivitis - 7 days ago, for about 3 days, resolving spontaneously (slightly itchy, resolving with cetirizine)
-lymphadenopathy, mainly cervical (smooth mobile nodes about 2cm) - last 7 days
-pain, stiffness and swelling in joints - small joints of hands and feet, both ankles, both wrists and both knees. stiffness for about an hour in the mornings, difficulty walking and turning doorknobs - last 3 days, worst today

Differential diagnosis:
1. viral infection - possible viruses include parvovirus B19, EBV (common, fits all symptoms and I am at risk due to occupational exposure to lots of children)
2. rheumatoid arthritis (but is not associated with rash, also peak age of onset = 5th decade); or other connective tissue disease
3. hypothyroidism (also not associated with rash, but could explain all other symptoms and is commoner in females)
4. lymphoma (unlikely due to leucopenia and normal blood film, but peak age of incidence =3rd decade)

Therefore if the symptoms continue after next week, I suppose I should get someone to take blood from me for
-repeat FBC and film, U&Es. LFTs, TFTs, ESR, CRP, ANA. antidsDNA and rheumatoid factor
The question is how soon to do them. Maybe I'll give it 4 to 6 weeks.
Meanwhile I shall be taking ibuprofen regularly.

The GP didn't do much for me apart from providing a sick note. I had hoped he would at least examine my joints, but he didn't seem interested. He also didn't seem to know that parvovirus infection can cause raised autoantibodies and ESR (and therefore those tests would be completely useless at distinguishing between 1. and 2. at this point). I think I might feel better if I could just stop being (my own) doctor for 30 minutes.

Shooting (digital) in Hackney

...am not sure street photography is particularly good practice for shooting a wedding. Am also coming to hate this kit lens. Lastly, am having some trouble processing my pictures due to a dodgy laptop screen which makes everything look really washed out. If you find the colours too saturated/garish please comment! (Any other comments welcome too)

"sign here..."

Signing for a delivery will never be quite the same.

"This is female infant of HS, born at 30+5 weeks, maternal pre-eclampsia, IUGR, RDS, ventilated for 9 days. On Day 16 of life became septic, blood cultures and CSF cultures grew staph aureus, so is on flucloxacillin. 2-day history of abdominal distension and non-bilious vomiting. Chest x-rays show a cystic structure above the level of the diaphragm, possibly a diaphragmatic hernia, possibly a staph pneumatocoele. She's currently self-ventilating in 1 litre of oxygen, cardiovascularly stable, nil by mouth, on 120ml/kg/day 10% dextrose with additives, antibiotics - cef, met and fluclox. There you go, sign here," said the transport team doctor. He offered me the Neonatal Transport Team notes and a black ballpoint pen, in the same way a DHL deliveryman might.

I squiggled my 'work' signature on the dotted line, signifying that our unit had accepted the transfer. I've been at 'handovers' like this before, but am not usually the most senior person there, so this was the first time I've signed for a baby. It was a rather odd feeling.

New toy

[or, An interlude for some photographic geekery]

Way back in 2001, the Canon EOS 1D was the latest in professional digital SLRs. It boasted a resolution of 4.15 megapixels and cost about 1500 pounds. By 2003, the first 'amateur enthusiast' digital SLRs had appeared, but were still way beyond my student budget. When, as a house officer, I received my first paycheque, I promptly spent a large portion of it on a digital camera - but not an SLR. In the intervening years, the performance of affordable digital SLRs has pretty much caught up with their film equivalents. But eventually it was other things that tipped the balance - film processsing is becoming increasingly expensive, and without access to a darkroom, the fun of (and control afforded by) developing pictures myself is gone. And so it's goodbye to the old digital camera, and hello to my new canon EOS 400D.


a picture of my old camera taken with the new one

Of course, my old film camera is far from retired (not least because of the large hoard of film sitting in the back of my wardrobe), and the two can even share (some) lenses. But I think the digital one is going to see more use, if only because the not-so-good shots can simply be deleted.

it's in! (or, an ER moment)

First time I've successfully intubated a baby at the first try. It was a semi-emergency one too. The baby (an ex- 28 weeker weighing 1.5kg) was breathing at about 100/min and was rapidly tiring out, so needed to be put back on a ventilator. She was oxygenating ok though - until the suxamethonium went in. Her sats dropped to about 50% and her heart rate started to fall. The registrar took over bagging, and we turned the pressures gradually up. Though her chest was moving, the oxygen simply wasn't getting from her lungs to her bloodstream. "We'll just have to go for it," she said, handing me the laryngoscope. I'd let on that I was inexperienced, but had not mentioned I'd never actually been successful before (just in case they didn't let me do it). As it happened, the laryngoscope slid in easily over the (paralysed) baby's tongue. First the oesophagus, with the orogastric tube running down it, came into view. I moved the scope anteriorly, obtaining a perfect view of the vocal cords. I took the endotracheal (ET) tube (size 3.5) in my right hand (the laryngoscope is a left-handed intrument), asked the nurse to apply pressure to the cricoid, aimed for the chords, and there it was, in! Once the circuit was reconnected to the ET tube, the baby's chest moved beautifully. My first intubation. And nobody guessed it.

the other cases (notes for myself)

3 year-old filipino girl post PEG-insertion
known epilepsy usually on phenobarbitone, global developmental delay
called urgently to see due to prolonged fitting
airway ok, highflow O2 by facemask; IV in situ
no lorazepam on ward; given 5mg rectal diazepam
fitting continued; 0.1mg/kg lorazepam - fit terminated
o/e reduced air entry on left side
CXR - lung fields clear; marked scoliosis towards left. bloods - NAD
phenobarbitone level - within normal limits; reviewed by Neurology team
no further fits; started on 1/3 feeds, building up to full feeds over next 3 days
discharged with supply of diazepam


18 year-old bangladeshi girl
psedo-obstruction, peripheral nutrition-dependent, recurrent central line infections
new hickman line inserted 6 days ago. spiking temperatures
o/e alert, complaining of generalised aches, feeling cold (temperature 38.9)
no focal findings on examination; bounding pulse; imp: septic
bloods inc. cultures taken via hickman line.
already on fluconazole (candida on blood cultures from 10 days ago), amikacin, ciprofoxacin
, vancomycin (various resistant bacteria on previous blood cultures)
paeds gastro consultant phoned at home for advice on changing antibiotics;
?outcome unknown to me (will find out when i get back on day shifts)

15 year-old boy, known crohn's disease
had been admitted 3 weeks earlier due to weight loss and increased abdominal pain but was now getting ready for discharge, nearly up to full feeds.
called to see due to drop in blood pressure to 74/50; also tachycardic and low urine output
o/e drowsy, afebrile; no focal findings apart from tender abdomen (as usual)
2 large cannulas inserted; given 20ml/kg bolus of 0.9% saline
blood taken - raised CRP; neutrophilia; cultures taken despite lack of pyrexia
b.p still low after bolus; further bolus given
next day:
surgical review and contrast study showing stricture of ascending colon. planned for resection and stoma formation this week

5 year-old jewish girl post-tonsillectomy bleed
(2 admissions; once on monday night and once on saturday night)
tonsillectomy, adenoidectomy and bilateral grommets 6 days previously
attended Other hospital with earache; sent home on oral antibiotics. was put to bed only to awaken at 20:00 "covered in blood"
taken to Other hospital, but transferred to Our hospital as operation done by our ENT surgeons
had not been given any treatment at Other hospital!
o/e alert, but lethargic and very pale. blood-stained nightdress
imp: haemodynamically stable, no active bleeding. IV cannula inserted and bloods inc. group and save taken.
phoned ENT registrar for advice: IV co-amoxiclav, hydrogen peroxide mouthwash if active bleeding, IV fluids overnight, may eat in the morning if no further bleeding
discharged from hospital on wednesday, only to return on saturday
complained to mom of blood in throat at about 17:00; small vomits of blood
followed by a large vomit of blood about 18:15
dad said: "it was much worse than monday. the floor was covered and the whole couch was soaked. she couldn't walk straight. I lay her down with her legs propped up, and called an ambulance"
given 20ml/kg saline bolus on arrival to A&E; blood pressure came up nicely. by the time I saw her was alert and chatty. Hb 9.2; G&S already done.
advice as before; cef and met IV; for theatre if further bleeding overnight (this fortunately didn't happen)
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just a few of the patients I dealt with on nights. That's why I'm still tired. I can't really remember sunday (granted I slept for most of it), or yesterday (slept/sleepwalked through that too). Off sick today as feeling extremely run-down. Aches, shivers, and an unspeakable emotional tiredness from dealing with all the (justifiably) anxious parents. My only wish is that someone would ask me (with genuine concern) how I am for once.

refeeding

She was a little blonde waif with tired, pale blue eyes. Her England football jersey (with "Age 5" on the label) hung off her like a baggy nightdress. I've met anorexics before, but never one as young as *Jamie. She was nearly 9 and weighed 18 kilograms. The story was (and anorexics never tell the truth - it is part of the disorder) that she'd been at a talk on healthy eating at school, and had started cutting out crisps and cakes from her diet. One thing led to another, and eventually all she would eat was dry toast and a few sips of water. In the last few weeks she had become moody and had started sleeping in the afternoons. She'd been admitted into hospital to receive nasogastric feeds. My task as the night doctor was to do regular blood tests to check her phosphate, magnesium and calcium levels. These can become deranged when someone who has been starving for some time first receives nutrition - the refeeding syndrome.

It was a bit like taking blood from a very little old person. Her skin was dry and flaky, the veins knobbly and very mobile within her wrinkly arms. Her pulse was slow, at about 45/min and her blood pressure extremely low. The blood test results showed she was going into kidney failure, most likely from being so dehydrated. She hadn't had a wee for 36 hours. I dithered for ages about starting intravenous fluids - I didn't want her to be attached to too many lines for a prolonged period, but I also worried about giving her the fluid all at once (as a 'bolus') because of the risk of heart failure. I eventually opted for the latter, under close observation. It turned out to be the right decision.

Over the next few nights, her feeds were increased, and the frequency of blood tests decreased. She perked up dramatically, and on the fourth morning, sat up and smiled at me. She's got a long way to go, though. I'd thought that childhood anorexics had a better prognosis (in adults about 50% never recover and of these just under half die), but I've looked it up and it seems under-11s are significantly worse off.

12,000 junior doctors march through central london

If only they knew

*Musa is a 15 year old Bangladeshi boy, though the nurses on the children's surgical ward refer to him as "that man". He is of short and squat build, but has copious facial hair and bushy eyebrows shaved off in stripes at the ends. Maybe there is something about being advanced in puberty at an early age (though not pathologically so in his case) that brings out the worst in teenage behaviour. He was arrested by the police for suspected drug dealing, and was knocked to the ground in the scuffle, breaking a tooth and bruising the side of his face. He was drowsy and couldn't remember things afterwards, so was brought into hospital with a suspected head injury. A CT scan was normal, so it was the usual - referral to social work and neuropsychology - the surgeons weren't interested in his case.

Over the next day, he recovered and continued to be very polite to the nurses. Every time I saw him he would make up a new complaint calculated to keep him in hospital - first it was double vision, then it was a headache and nausea, then pain in his gums. I made the appropriate referrals, but was frankly getting a bit sick of the whole thing. I recalled Dr. M, one of the consultants, who would give any local teenager coming in with a suspected drugs offence, or even self-harm a good telling off in Bengali. Eventually Musa's old notes arrived, and I discovered he had been in hospital after similar incidents twice in the last 3 months.

I was annoyed because we had 5 very sick premature babies on the neonatal surgical unit that I had to look after as well. These babies had sepsis or necrotising enterocolitis, and were on ventilators. Then I had the fleeting idea of bringing Musa on to the Unit - perhaps if he saw the tiny, fragile babies he would realise how valuable his own life was, and how he was repeatedly and carelessly putting it in danger. But I couldn't of course. The parents (even the teenaged ones) would be horrified at the sight of a burly hoodlum in a hospital gown on the baby unit. Then again, perhaps it would be useful for them to meet Musa - 'this is what your baby could become, if you're not careful' the sight of him would say.