"Monospots are rubbish"

We've had a run of patients with large neck glands (cervical lymphadenitis) in lately. The first, a 16 year-old who presented with a sore throat and dehydration, had obvious glandular fever. Her glands were so large, her chin had nearly disappeared into her neck. The tonsils were red with exudate, and her liver and spleen were enlarged. Her lymphocyte count was 26. She had a positive monospot (unsurprisingly).
Last night's crop of new patients included a 7 year-old with a left-sided painful neck swelling and an 8-month old with a non-tender 2cm neck lump. Both patients had had monospots sent, to which the consultant said "but monospots are rubbish anyway." So I thought I'd look up exactly how rubbish they are.

I found this on Medscape:

its sensitivity is only 20% in young children. This test is frequently used to assess EBV infection in older children (>5 years-old). It is easy to perform and has a sensitivity of 85% in older children and a specificity of 97% (Peter & Ray, 1998).

here's a more complete answer
ok now i'm bored.

Notes 1

4 day old; unbooked/concealed pregnancy; both parents IVDUs known to social work; NAS on oramorph
reading: associations with maternal drug use: defects including cardiac (esp cocaine), abdominal wall (these associated with SGA baby/placental insufficiency); polycythaemia and increased risk of neonatal thrombosis;
7 month old; bronchiolitis. Both parents smokers.
reading: associations of paediatric respiratory disease with maternal (fewer data available on fathers) smoking; increased incidence of URTI and LRTI including otitis media, pneumonia; risk factor for asthma development

[note confounding factors: J Am Board Fam Pract 14(5):330-334, 2001 - mothers who smoked during pregnancy likely to be younger, and have smaller babies of shorter gestational age; I'd guess they would be of a lower social class also.]

Note the former baby's future does not look particularly bright. But that is another story for another time.

Chatted with Prof I met at conference - advice on how to proceed re: getting into some Proper research. Also with sensible consultant on for Receiving this week, which makes a big difference. Am liking work more this week.

Fed up already

I've never hated work quite so much. Two days back at work, and all I am looking forward to is my next day off. Am hoping it is just the fact that this is Acute Receiving, and I chose the placement specifically because I have less experience in the area, hate resuscitations and the aim was to get it out of the way. But I'm hating it even more than I thought it would. I hate how patients come through, you fix them if you can, refer them on if you can't, and then you never see them again. i.e. there's no continuity; the patients never feel like your patients; it's all just really fragmented and everything takes twice as long because it's impossible to know all the patients. And everyone else seems to be off sick all the time - I acceded to a "request" to cover someone's evening shift yesterday. But I really really wanted to say 'no'.

So I've booked myself a place at a research conference. I hope it's good. Am desperate at the moment for some inspiration; something to remind me that there is more to medicine than unthinking drudgery and ungratefulness from all sides. Otherwise it will be time to start plotting a way out.

A short break in Barcelona

[Click picture for more]

The Toast Sign

The first time I came across the Toast Sign, I didn't recognise it. I was a medical student on the labour ward, fascinated by the sight of nursing auxillaries scurrying about with trays of Tea-and-Toast - only for the mothers who had already given birth, of course.

On call yesterday at A&E, I was asked to see an 8 month-old boy who had come in with vomiting so severe, the A&E doctors thought he might have intussusception. As I approached the curtained cubicle, I heard little crunching noises. Behind the curtain was a pink and rather cheery-looking baby, chewing on some dry toast with his brand new teeth. "He's miles better since they gave him that fluid through the drip," said his mother. "He's back to his normal self," added father. I sent him home with a diagnosis of gastroenteritis.

Fluid balance charts on childrens' wards can often be quite informative. For instance, one of the more bizarre but common breakfast choices on our ward is a packet of Quavers . But you can be sure your patient is very nearly well enough to go home if they've had toast. Especially if they were admitted with tonsillitis. But it also works for patients with pneumonia or even orbital cellulitis. I think I might be on to something. Christmas BMJ here I come.

Random weekend type stuff

A quick, quick one as have to go to bed. Have decided to sacrifice quality (of posts) for quantity as this blog might die out otherwise. So I've got a training number (i.e. a job for the next 6 years and a qualification in paediatrics at the end of it). Just at a time when I'm starting to be less than thrilled with work. But one must be grateful (see other blog).

Made some rhubarb jam completely by accident! Was stewing some rhubarb for crumble and ended up with too much liquid, so poured the remainder off and reduced it. Then put it in a ramekin in the fridge thinking it would make a good meat seasoning only to discover that it had turned into jam by the next morning! So we had some on toast today and tomorrow's lunch shall be a decidedly transatlantic treat of peanut butter and rhubarb jelly sandwiches.

I need a holiday

It's good to be on Days again, though have had two really horrible ones in a row. Have been avoiding blogging as don't feel motivated enough to craft my sentences properly. However need some kind of outlet for the things which have been happening at work so here goes the incoherent account, more for my own records than anyone's reading pleasure. Perhaps I'll go even lazier and put it in point form...

Finished my old job on a night shift on the 4th of March, when two extremely sick children came in at the same time - 07:00, the worst time to be admitted to hospital because that's when the nurses are changing over shifts, so they are all avoiding doing anything. One turned out to have pneumococcal sepsis/meningitis and the other staphylococcal toxic shock syndrome. Both ended up being transferred to Intensive Care. The former patient is now on our ward at the Childrens' Hospital, and will almost certainly be disabled for life. It seems selfish to say in the same breath, but I think I may be traumatised for life from my experience dealing with her (and her family). But of course, a doctor's feelings are of no importance. Just blame the doctor when things go wrong. Even if there was never a chance of intact survival.

So I went from a crazy night shift, to my new job, arriving several hours late for Induction, because I missed the train trying to sort the sick patients out. Then it was work as normal the next day, with no time to recover (one usually gets a day off post-nights) and nobody really to talk to about what had happened in my last night shift. Then I had to do a weekend of nights at my new job without really knowing my way round the hospital. This was all shortly after the whole job interview run (I had three, including one on the day of that fateful night shift, so I basically hadn't really slept from the night of the 3rd or March until the night of the 5th, because they wouldn't let me have any time off). I survived the weekend, but came down with a bilateral purulent conjunctivitis, and a cough (which I still have) so that I lost my voice and physically had trouble trying to call in sick. And then I was on night shifts again from the 17th to the 20th of March. On the 17th I set a new personal record of 13 A&E reviews overnight, admitting 11 out of the 13 patients, some of whom were pretty unwell. Then I had a weekend off, during which we (M&I) saw a terrific Ansel Adams exhibition and watched 'Bleu' from Krzysztof Kieslowski's Three Colours trilogy. I highly recommend both. And then it was on-call for Easter Monday, which left me exhausted and all ready (not) to start another week today. And today was a complete nightmare, involving me running around trying to single-handedly sort out all the patients sent round from A&E to a Surgical ward (where they don't have the appropriate equipment or trained nurses for common Medical procedures such as lumbar puncture) without having been properly resuscitated. Just because all the juniors were either off sick or in Teaching all day and the other registrar was busy with a dying teenager. See, when I whinge about work I just sound like a completely evil heartless person. It's the sort of thing you wouldn't really see in a TV medical drama, like they are in the middle of a big resuscitation and then someone's bleep goes off and they can't find a phone (that isn't in use) to answer it or it's a wrong number. Twice. Stupid things like that that stop you from getting your work done. Or you try and drink lots of water so you have to go to the loo, because that's the only time you'll ever get to sit down. And then there is a combination lock on the staff toilet that you don't know the code to...

And now it's almost April. The last time I looked it was the 2nd of March.

Bright yellow baby

I spotted him from the waiting room, a happy, chubby thing the colour of Bart Simpson. Perhaps I should have noticed then that the whites of his eyes were quite clear. He had attended the ambulatory care unit the week before with a 'viral rash'. On examination, it looked more like really bad eczema. He was otherwise very well, but his colour concerned me. I decided to take some blood to measure his bilirubin level. Just then, one of the staff grades walked by. She's really experienced and was a GP before training in Paediatrics. She took one glance at the baby and exclaimed, "Hypercarotenaemia! I'd put my money on that. Bet you his mother feeds him lots of mashed carrot and sweet potato and organic baby food jars." His bilirubin came back at 6. I swallowed my pride and took my medical students to see him. Sure enough, he was halfway through a sweet potato-based organic baby food jar. My excuse is that I've only ever worked in paediatrics in East London before this job, where you wouldn't see the orangey yellow as they're all Bengali. And they probably don't get organic baby food.

Several hours (and countless wheezy/feverish/vomit-y patients later) , my bleep went off, and it was an ambulance crew with a 6 year old boy in SVT (supraventicular tachycardia). His mother had tried vagal manoeuvres at home, without success. An ECG confirmed the diagnosis, recording a heart rate of 190 per minute. We had the adenosine ready, and I chatted with the boy to distract him while the A&E doctor put an IV line in. "So you're off school for half term then?" I said. He nodded and tried to smile. "What have you been up to today?" "My cousins came and we played on the trampoline (gasp), and then we had tea (gasp) and then we were watching telly (big gasp) and then I had my heart attack," he said, as if it were quite an ordinary thing. Everyone round the bed smiled for about a second and then realised it wasn't funny, he was probably having severe chest pain and feeling very short of breath. Just then, the cannula went in. "OW!" he screamed. The local anaesthetic cream hadn't had time to work. He went all sweaty and pale, and then his heart rate flipped back into a normal rate and rhythm. So we didn't need the adenosine after all. Having a cannula inserted had literally cured him. The funny thing was, the A&E doctor had wanted to put in a yellow (i.e. smallest available) cannula but I argued for a blue (a size up) and won, as adenosine is meant to be given as a fast bolus (i.e. as quickly as possible). Perhaps a yellow wouldn't have been painful enough?

I love being a doctor but...

Feeling a bit jaded and tired; I guess that's why I haven't posted much lately. One of my resolutions (I know it's February, call it a Chinese New Year resolution then) is to be less scruffy for work. My current work attire is either too-big scrubs (even 'Xtra Small' is massive on me) and trainers (when on the neonatal unit or on nights), or a 3/4 sleeved V or round-necked stretchy top (no ironing!) with wide-legged trousers (usually with fraying hems or a couple of rips in the bottom) and cheap 'n nasty loafers. Oh, and I seldom get time to even comb my hair (just tie it back), never mind put on proper makeup in the mornings. Hardly wear my contact lenses either. Now I'm not one for placing much importance on appearances (as you can tell), but even I think I'm starting to cross the line (to 'unkempt') here, and it does reflect the inner goings-on....

This commuting to work + Band 2A rota (i.e. up to 72 hours a week, and on call 2 in 5 weekends) have completely sapped all but Work from my life. There's barely time to eat or sleep adequately. I suppose if one commutes an hour and a half each way, that's 15 hours each week (21 hours if I am working the weekend as well), or, 2 whole working days. Think of all the things you could do with 15 hours a week! That's what I had before (with my 20min cycle each way, that doubled as exercise), and I miss it sorely. I love medicine and am lucky enough to be pursuing my childhood ambition and all that, but I don't think I can live like this for much longer. (Good thing I will be working within walking distance of my flat, and on a 2B rota come March!)

Speaking of which, I had a phonecall from work this morning - one of my colleagues (on the same rota) was found dead at home yesterday evening. I don't know any further details, but if it wasn't an accident I'm sure the stress of this job wouldn't have been helping.

Still birth

It might have been the demographics of Berkshire or perhaps the fact that I covered the Geriatric and Oncology wards as junior house officer on call. Each weekend on call, I had to examine at least 4 or 5 dead people. After a while, it became a pretty normal thing to do. Then I went into Paediatrics.

I hadn't really seen anyone dead in a while; a few extremely malformed or premature babies perhaps, but not anyone who'd ever had half a chance of survival.

The parents wanted to be present while I examined the baby. *Eddie was a term baby, who had been alive and active in the womb until 5 hours previously; then his heart had mysteriously stopped. The obstetricians induced his delivery, but he had already been dead for 2 hours by the time he emerged. He lay in a standard issue cot beside his mother's labour ward bed. He was dressed in a baby-gro and woolly hat, and had been carefully tucked in. The parents had declined a post-mortem, so I was to perform a "detailed external examination".

After conveying my condolences to the parents, I explained "I need to take all Eddie's clothes off to examine him. I need to have a close look at him from head to toe, and stick my finger in his mouth to examine his palate. Then I need to turn him over to look at his back."

His mother nodded. "Leave the clothes for me to put back on," she said. "It might be the last time I get to dress him." Her eyes were dry, but red and cried-out."He's a perfect little baby," she whispered.

Eddie lay still with his eyes closed and lips pursed; he was purply-blue and ice-cold to touch. I removed his hat to feel his fontanelle. I listened for a minute for his non-existent heart and breath sounds. I removed his nappy to find that he was still mid-poo; so I had to wipe his bum in order to reveal his anus. I flipped him over to see his spine, and he was so limp in my hands I worried I might break him. Blood-stained fluid dripped from his mouth as I turned him, and landed on the white sheets. "Sorry," I mummured. Apart from some macerated skin at the neck and near the umbilicus (as to be expected for a stillborn baby), the examination was completely normal. "He is perfect, as you say," I concluded, rearranging his head and limbs into an appropriately baby-like position. Eddie's mom and dad smiled, "thank you."

Thanks mom

It's been about a week since mom left, for the airport at 4 in the morning. I watched from the window, in my pyjamas, willing the taxi driver to come out of his warm cab to help mom with her suitcase, which he did. She looked very small from 4 floors up, and I missed her already.

The flat's still got a touch of shiny, Jiffy cleaness, despite my recent weekend on nights (i.e. 96 hours without doing the dishes or tidying up). It wasn't until a couple of days after mom left that I noticed that everything (which I had literally spent hours scrubbing before mom arrived) was even shinier and tidier than before. Even the inside of the freezer had been neatly rearranged.

It also emerges that mom used to take me to the library daily before I could even talk. Maybe that's why, as far as I can remember, I could always read.
***
Apparently it's that time of year when grey seals come to shore to pup. When mom and youee and ching were here, we went to North Berwick to see if we could spot some. We did, but only by webcam link to the visitor centre, which was a bit rubbish.

On the train back to work after my half-week of leave, I looked up from reading the Metro to see not one, but three grey seals basking, glinting and blubbery in the sun. They had convened on a rocky outcrop not more than 20 or 30 metres from the track. And yesterday, on my way home from a night on the neonatal unit, (and I would've doubted it if this latter had been my only sighting), there they were again, on the same rock, somewhere between Burntisland and Aberdour.

The boy with an ouch in his haggis

The 2 year-old had been admitted with vomiting, and intolerance of his gastrostomy feeds. He also had a high fever that was put down to a red ear - otitis media. A course of co-amoxiclav seemed to be getting on top of things, when I was asked to see him because he had developed some abdominal pain.

*Matt sat on the bed watching the Fimbles on TV. He is small for his age, and was born with multiple anomalies, including a heart defect, which has been operated on, Pierre Robin sequence and an exomphalos, which has not yet been repaired. His exomphalos is covered in a thin skin, or epithelialised, and has been shown on ultrasound to contain part of his liver. The family have christened it his Haggis. One can imagine the resemblance, where it had once been covered in a moist, translucent membrane. I'm personally not a great fan of food analogies in medicine (such as 'cheesy' or caseous exudate, i.e. horrid smelly crumbly stuff issuing from an abscess), particularly before lunch, but I suppose it does help trivialise things.

Matt frowned when he saw me walk in. I knelt by his bed and asked what was wrong. "An ouch." he said, plaintively. "Where?" I asked. "Haggis", he said, pointing to the centre of his tummy. I looked over to his mom, who explained that Matt had been complaining intermittently of pain over the exomphalos over the past 2 days. "But he hasn't bumped it or anything, and it doesn't seem to bother him when he's watching TV." I established that the vomiting was getting less frequent and that he had been passing stool. Mom distracted him with a book while I felt his tummy, which was soft, including the Haggis.

I explained that it didn't seem serious, but that we would keep an eye on things. [APLEY'S LAW: in paediatrics, the further a recurrent abdominal pain is from the umbilicus, the greater the likelihood of an organic cause for the pain] - applying the principle in reverse; bit tricky in exomphalos as the lesion is right over the umbilicus! But on balance if the Fimbles can take the pain away, it's probably not serious. Matt continued to make a good recovery and was discharged home the next day.

too tired

have been constantly tired since August, too tired to do anything more than keep the house tidy and keep myself clean and fed. This rota is so anti-social (working 2 in 5 weekends and split nights) that many of my friends in Edinburgh think I am still living in London! Am too exhausted to write anything. Sometimes I feel as if I might die of tiredness.

Over the Firth

Breakfast (brioche with marmalade and a cup of tea) on the train, with sea view as we go over the bridge - a world away from the view of someone's armpit one gets when commuting in London.

***
Just completed a 1/2 set of nights (they are split 4 and 3, with a week of days in between). Was a bit bemused when the nurses said "that was a busy one"; we only had 3 babies in intensive care and only one ventilated (am used to up to 9 ventilated, and nasty nurses who won't help with the blood gases on principle). But I suppose that is trivialising things a bit; the one sick baby had grade 2-3 HIE, and the only thing he had going for him was he didn't need inotopic support. His oedema, high urine output, plummeting sodium and rocketing potassium, occasional metabolic acidosis and coagulopathy made for a rather challenging maths session at 4 o'clock in the morning. I had more than one "better call the registar" moment, followed by a sinking realisation: "oh, that would be me". I didn't really want to wake the sleeping on-call consultant (a paediatrician rather than a neonatologist) but at 5am I gave up and called her. (having changed the baby's fluids to what I thought would approximate what he needed) She wasn't much help - merely agreed with what I'd done, leaving me to get told off on the morning ward round by the neonatal consultant. "Did you calculate the sodium excretion?" he demanded to know. "And why wasn't the baby weighed?" he asked the nurses, looking decidedly unimpressed. Nurses often don't weigh critically ill babies (because they don't tolerate handling), and the weight obtained is often inaccurate due to all the tubes and lines that can't be disconnected. And I've learned (from previous bitter experience) to avoid contradicting neonatal nurses unless I'm absolutely sure I'm right. I suppose you can't win. I just hope the baby's alright.

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.