Poo

...so while Mark is away in Malawi saving/improving the lives of poor African children, here I am in Edinburgh, joining in the fight against....childhood constipation!
Ok, so I also admitted a baby with likely viral meningitis, and a boy who'd had a prolonged seizure. But the second-last patient of the day (in A&E!!) was a 2 year-old with constipation. "She won't eat any fruit and vegetables, doctor," said Father. *Lily hadn't been to the toilet for a week, and when she finally went, she passed "a golf ball", unsurprisingly causing her much distress. After checking for any birth/neonatal/developmental/family history to exclude a pathological cause (e.g. Hirschprung disease, hypothyroidism, neurological causes etc), I gave him the old "it'll take as long to clear out as it did to build up" talk, and went to fetch some Movicol and a "constipation pack". The fact that these ready-made packs exist, particularly in the A&E department, does amaze me somewhat. They contain a leaflet about healthy eating, a booklet with a cartoon Mr. Poo, a Bristol stool chart and diary, and a bottle of bubbles (for toilet time amusement). I hand it to Lily's father, explaining the use of the chart and diary, trying my best to be sympathetic. This is why I didn't like community paediatrics much.

keep praying

The exam was a bit of an anticlimax. After months (and I mean HOURS AND HOURS AND HOURS!!!!!) of preparation, I think I may have exterminated myself on the "video" station. I spent some time on the train back from Newcastle calculating the worst possible and best possible scores, and I think (with a pass mark of 100/120, i.e. 83%) it's going to be a very, very close call. Either I'm going to pass by a couple of marks, or I'm going to fail by the tiniest of margins. So I'm not crying YET. Please let the examiners be kind to me.

The other side of the fence

[24 hours to my exam]

Reading over recent entries, I realise it would be easy to suppose that I am becoming callous (or trying to be) in order to cope with emotional overload. The truth (or part of the truth) is that writing well about one's emotional response to a situation requires one to at least partially relive it. And sometimes that is a luxury I just can't afford. (e.g. when I need to ram hard facts into my memory for the exam)

On the other hand, I have been fascinated of late by the writing of Patient bloggers, such as Tiffany C. I can't remember anymore how I stumbled upon her blog, but it remains one of my favourites. Some entries, such as this one have been particularly helpful with my own approach to patients who are growing up with chronic illness.

The problem, of course, is that not all patients (or parents) are quite so articulate. Being a doctor is sometimes a bit like being a translator. Say you are explaining to parents something like a new diagnosis of Down Syndrome. You have about 20 seconds to assess their vocabulary (medical and non-medical) and likely desired level of detail, as well as their emotional response. If the admitting doctor has taken a detailed social history (e.g. parents' ages and occupations) then you have a leg up - but it can still be risky to assume things.

beyond the pale

[4 days to my exam, so please excuse the poor writing]

We got off to a poor start: I introduced myself, full name as is my custom, and stating that I was the registrar on call. "Our 6 week-old son was in a month ago," the mother said, hoping that I would recall the episode, which must have been pretty harrowing from their point of view. "Maybe you saw another doctor," I said. "No, it was you," she said, certain. "You did a lumbar puncture." I still had no recollection. It must have been during my last stint covering A&E, when I had a run of 'septic' babies (3 or 4 of them) who all needed lumbar punctures. "How is he now?" I asked, hoping to fix things a bit.

Meanwhile, *Mairi lay languidly on the examination couch, her pallor so extreme that she seemed almost transparent. "The doctor said she was anaemic," said her father. I thought that must be the understatement of the century, but decided to get the details straight: "he's done a blood test?" "No, he was going to do one in 3 months."

This was all a bit surreal. Extreme pallor in previously well child, no symptoms apart from 6 to 8 weeks of lethargy (i.e. no source of blood loss). Diagnosis= most likely bone marrow failure= either aplastic anaemia (autoimmune, post-viral etc.) or leukaemia (or other haematological malignancy). In plain English = VERY BAD SIGN

The A&E doctor had managed to get just enough blood for a full blood count.

[argh have to get back to my revision]

Anyway, to cut a long story short, the blood count showed almost no white cells, one blast cell and a haemoglobin of a third what it should be. The consultant haematologist who'd looked at the film came down to A&E in person to give the parents the likely diagnosis, and explain that she would need to take a bone marrow sample to confirm the diagnosis, and that Mairi would have to be admitted to the Haematology/Oncology ward. At that point, father responded with a rather loud "F***!"
Dr. T remained calm; in fact, she said "yes, that would be my thought exactly." This was a good lesson for me, because the last time someone had sworn that way, I was explaining to a father that his daughter had pneumococcal meningitis. And I had presumed his swearing was directed at me; perhaps I had broken the news insensitively. That plagued me for a couple of months. But I knew Dr. T had done a good job. I guess some people just respond that way.

Anyway, back to Mairi. So she was admitted, and had a blood transfusion. I haven't been able to catch up with the rest of her story yet (she's now under Dr. T's team so I haven't seen her).

Middlesbrough

Am writing this from a hotel (motel?) room in Middlesbrough where I am at a Neonatal Conference. (I love my 3G modem!) I have to say, it's not been particularly inspiring so far. I was hoping that it would make Neonatology make more sense at least. My impression beforehand was that despite the surfactant trials being poster child for the Cochrane collaboration, Neonatal medicine was largely witchcraft. Unfortunately, my suspicions have been confirmed. Take phenobarbitone as an antiepileptic in neonates, for example. Phenobarbitone is an old drug (brought to market in 1912). And even when given with a second anticonvulsant, it only stops about 60% of babies fitting, and is not without side effects. Yet it is the best thing neonatologists have for treating convulsions in newborns! What on earth have all the researchers been doing?! The other thing that got my back up was the talk on Science and the abortion debate. Now I signed a petition and wrote to my MP, as a member of the general public, in order to try and influence the parliamentary vote on this issue. The talk was given by a Professor who had been on the advisory panel for the MPs debating the Human Fertilisation and Embryology Bill. Yet he didn't seem to have a personal opinion on the issue at all; he seemed determined to remain neutral. I think such responsibility is wasted on people who don't have a clear system of personal ethics. A Neonatologist should be duty bound to be an advocate for his patients (or potential patients). I would have been less angry had he picked a side; pro-life or pro-choice, I don't care, it was his neutrality that was irresponsible.
Among all the (apparently) big names in neonatology at the conference, I can't help but feel like a teenager indignant at all the 'grown-ups' for messing up. It seems they have got neither the science nor the ethics sorted out.

23 May; posted in retrospect

Bizarrely enough, the reason I've not been writing lately is I've felt a little saturated by the number of other people's stories I'm carrying around in my head. When one first assesses a patient, one "take[s] a history"; obviously this information then forms the basis of the examination and any further tests, and is duly recorded in the patient's notes. What the doctor is then supposed to do with the residual information impinging (sometimes rather disturbingly) on his own thoughts by the end of a 12 hour shift is slightly less clear. It is too easy for others to say, "go home, switch off, do something to relax." 4 years into working life, and I am still struggling to find a balance between empathy and detachment. Sometimes I feel physically sickened by what I've heard and seen. And then I get home, and I can't relax because I've got a clinical exam to study for! I have to read up on the conditions I've seen, and memorise the symptoms and treatments etc because I'm going to be tested on it all in a few weeks. I do go swimming or running or something if I'm on a short day ("short"= 9am to 5pm), but long days or nights (9am/pm to 9pm/am) make even this impossible. The only thing left that is vaguely soothing is doing the ironing; something about the creases coming out, I think.

One thing I learnt on nights last weekend:
A one-year old girl had come into A&E with a short history of poor feeding, crying all the time and her body being "so stiff, it was hard to get her into the car seat". Although her temperature was only 38 degrees, her behaviour (the obvious irritability) made it likely that she could have meningitis. She was otherwise pink and well-hydrated, and her condition was stable. I explained the situation to her parents, and explained that I would need to perform a lumbar puncture. They flatly refused, but did agree that she should be admitted to hospital. I couldn't leave it, so, feeling rather pathetic, I rang the senior registrar. She spent a few minutes with them, then emerged, saying, "get the LP trolley, they're fine with it." "What did you say to them?" I asked. "I said they would never forgive themselves if it turned out to be meningitis and we missed it," she said. Nothing like a spot of emotional blackmail to save the day.

"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.