Compatibility

The boyfriend says to me: "I love it when I clean my teeth after you, you squeeze the toothpaste tube out all nicely for me." We are so perfect for each other!

Stone cold sober and very aware of it

I have been doing cover this week - my usual 9-5ish and then covering the wards until the night staff begin at 9.30. Last night I was bleeped.
"Hello, this patient is not looking well, will you come?"
"Umm, sure, where are you?"
"XXX ward."
"OK what's the patient's name? What's wrong with her?"
"XXX. She had a pleural tap earlier, and she's looking so pale, and she's not breathing right."
"What's her respiration rate?"
"Er, not sure, but not much..."
(Giving up) "OK, if you could get a set of observations now, I'm on my way."
I get there. There's noone around so I just head to the patient. She's on her bed, slumped back, looking pale and limp. Her husband is next to her, not doing anything, just looking a bit worried. I ignore him. I put my hand on her shoulder and ask her if she's ok. She moans and pauses for ages and ages, says she's tired. Her respiratory rate is 8. I put my head around the curtain and get an obs machine. I do the sats first. They're 89 - not terrible, but less than they should be. By this time a nurse - a good one, not the one that called me - comes in to the curtain and asks if I'm ok. I ask her to get some oxygen. Her blood pressure and pulse are ok. Her pupils are small. I do a quick examination of the rest of her, concentrating on lungs, but find absolutely nothing wrong. The nurse comes back. She says "How much oxygen do you want doctor?" I am taken aback for the smallest of seconds at the fact she's asking me with such sort of respect. "10 litres." I say with confidence, not for any particular reason. She puts the mask on and her saturations very quickly come up to 99. I check the drug chart. She's been given 60mg of morpine in the last hour. A lot for a little lady. I go out, interrupt the nursing handover (ah, the reason why noone was with her) and ask the lady's nurse, the one who called me, to draw up some naloxone. "Na ... naxalo ... what?" "Naloxone, you know, the antidote to morphine." "Naxalone?" I get the BNF and open it at the page and give it to her, and write it on the drug chart and give it to her. "I'll check, I don't think we have any ..." "Umm, I really think you do have it, any wards would really - might you go and check?" She goes. I bleep my SHO, cos even though I'm pretty sure it's a morphine overdose, I have never dealt with it before and I was scared. The SHO says she'll come straight up. I go back to the patient. She's still so drowsy. The nurse comes in with the little vial. I'm thinking should I give it? but then my SHO comes in. She does a quick exam. "Yeah, give the naloxone." she says, not really looking worried. I push it in. It's amazing. The lady takes some deep, deep quick breaths and starts getting all jittery, as if she's been switched on. "What is this? I'm feeling so sick, what is this? What did you do?" I reach for a vomit bowl, put it under her face, and I smile. It was so fun. I explain to the lady and her husband what had happened, and said I was sorry for ignoring him earlier. I said we'd keep a close eye on her, but she would be fine. She thanks us. It was fab! Maybe next time I won't need the SHO... ;-)

The House of God

Two of the patients on the ward are now only in hospital because they broke their osteoporotic bones whilst an inpatient for other problems. I don't describe them as gomers, but they sure went to ground. The House Of God is as relevent as it ever was. And Rule 13 will always be my favourite.

Bodies by Jed Mercurio though - this is my book of the moment. Blistering, visceral, disgusting, beautiful, genius. One of my friends maintains that he is a twat for feeling this way about medicine. But I think the training, and especially the work, has the potential to change who a person is to a huge extent. And I don't think it's often a positive change. Positive in the sense that they can function better as doctors, maybe, but I think everyone in medicine loses a certain amount of compassion and empathy. It's survival. I know I have. Things still have the ability to get to me - Pale Boy a few posts back - but it's not often now.

A quick rant

The Boy has just finished his obligatory time sheets to ensure that he is keeping to the European Working Time Directive. He is truthful on the form. He is called into the Clinical Director's Office to explain why his time management skills are not allowing him to leave on time. This makes me pissed off - if there is not enough staff, meaning he has to stay until 7 or 8, surely that means that they need more staff, not people leaving early to keep to timesheets. Why lie on forms? Why do them in the first place if you are not going to believe a result that doesn't go their way? What good will this do the patients? The only people it is going to make happy is the managers who can then say that they don't have to pay him for the extra hours, or hire extra doctors. If they are expecting us to lie so we can be underpaid and overworked, nothing will change.
Anyway, enough of that. I am really liking the people I work with. I have met some real stonkers since I started, but everyone in my team is beautiful. They are nice to patients, nice to each other, and even almost always nice to the nurses, which is rarer than you might think. Even the seniors! My SHOs all went to teaching this afternoon, leaving me alone on the ward with 20 patients. I asked the registrar if it would be ok to bleep her if I had any questions. She said I could bleep her any time about anything I wanted. And I am getting used to the different consultants. The one that insists on everyone being treated for a UTI, no matter what. The one I have to never present any patients under the age of 60. The one who I have to not wear low tops with otherwise I won't get eye contact. ;-)

Things you really don't want to see in hospitals, #1

One of your patients with dementia and urinary retention, who you'd spent a long time catheterising with a long term catheter, walking out of his room at 6pm, minus that crucial little tube, with blood dripping. Oh dear. Ummm, operator, could you tellme the number for the on call urology reg?

Some of my favourite quotes so far

"I used to use StopandGrow to stop me biting my fingers. You know what works better? Rectals. I just don't want to put it in my mouth any more."
-one of the other new F1s

"You want some Glicazide to go with that?"
- my SHO to my Registrar when he cut himself a hunk of chocolate cake (do I need to say I'm doing an Endocrinology rotation!)

I've finished my rotation in the Medical Admissions Unit and I'm starting with my Endocrinology. I've learned more in three weeks than in six years of medical school. I am terribly afraid pretty much all the time. The smalles victories take on epic proportions, like when I examine someone and find the same things as the seniors. Like when the nurses ask me to do something - prescribe something, speak to the family of a patient, whatever - and I can actually do it.

I seem to have developed an invisible wall around me that stops me getting upset as I was. I can almost feel things bouncing off. I am aware of things that would have floored me before I started medical school. I have seen people ill and in pain and I am so calm. I saw someone go into cardiac arrest and die five minutes into my first shift and I was fine, I just got on with my work afterwards. I started to get terrified that I was completely emotionally numb, really genuinely worry I had lost all compassion! Then it happened - 21 years old. Feverish. And ravaged by tumours. I felt them under my hands. His white, white skin was clammy. I did every test I could think of. I spoke to his Mum about everything I was doing. I asked the seniors if I was doing things right. They suggested a few more things. So after only a day of treatment for his infection, he went back home. To be treated palliatively. He kissed me on the cheek as he walked off the ward. I cried all the way home.

Number of fingers in a rectum: 1
Number of catheters in a penis: 2
Number of needles stuck in veins: more than I can count

So with my favourite stethoscope, my favourite pen, and a bucketload of fear, I have tramped the wards for the first time as a real true doctor. I was unlucky with the rota and have started off on nights on "medical take" - I have to help look after the problems that aren't for the surgeons, like babies, broken bones and appendicitis. It means suicidal people, heart attacks, and chest infections - translated into para od, MI, and LRTI. I have been prescribing medications for real. I have been writing in notes and signing my name doctor, and answering my bleep and saying I'm a doctor. It's like I've been looking down on someone else doing all this, it feels surreal and very strange! That could be the sleep deprivation, or as it's referred to, "the jet lag". I feel I have learned more about real medicine than medical school ever taught me. Two things: firstly, the days of spending as much time as I felt like with patients are over. I hate to have to feel like I am limited in time when I'm talking to people. Secondly, the nurses know more than me about everything.

We have a few hours of teaching every week.The first week was death. We had the coroner talk to us about death certificates, the head of palliative care talk to us about the Liverpool Care Pathway (the principles of looking after people who are dying) and finally the chaplain. He's quite young, and hilarious, and completely adorable. Not in a horrid happy-clappy way. In a genuine way. "The chapel is on the seventh floor," he says. "It's non-clinical. It's dark, There are pillars to hide behind. And I promise, if I see any of you sitting there in a huddled lump, I won't come up to you and say "hello my daughter, what can I do for you?" I may arrange a flower or two, just so you know I'm there." Isn't that wonderful?
I have the day off tomorrow. I'm doing nights for the rest of the week. Hopefully it will go as well as this week has gone.

Signing

A General Surgery clinic, years ago right at the beginning of my clinical training. I had been assigned the Professor of Surgery at the large teaching hospital that I had been placed. He was a formidible man - an obviously talented surgeon - the go-to guy that everyone relied on to rescue the sickest patients from their bleeds and cancers and perforations. I respected him so so much for his dedication and exacting standards, even if it meant feeling very very stupid for a lot of the time! I still am glad it was my first rotation, as he drummed into me what high standards I should keep for myself.

However, he was in medicine for the excitement of his surgery and his research. He didn't really like patients, and was interested in them only as a potential cut. So when a deaf man came into the clinic, I grimaced inside. I knew exactly how this was going to turn out.

"God, deaf! You take a history, I don't have time for this."

I dutifully go. Begin by calling out his name in the waiting room - mentally slap myself. Go up to him and touch his arm to get his attention, then say hello. He smiles and comes with me to the room. I say hello again, trying to be as friendly as I can. I ask "do you lip read?" whilst pointing at my lips. He understands, but shakes his head, and gestures with his hands that he just signs. I get out my notebook and we do the whole history by paper.

I find the surgeon again and present the history of the man's problems. He listens, comes in, and speaks loudly to the man - "Where is your pain?" The man makes the gesture that I am sure he has made every day of his life - hand to ear, shaking his head. As Prof asks each question, I show the man where I wrote the question in my notebook. Prof carries on examining the man. Explains what he thinks may be wrong in the same load slow voice, finishing with "So go for an ultrasound now, I'll see you again." The man looks at me, a little confused by now as to why this man keeps on talking to him. Prof leaves. I look at the man, trying not to mirror his amusement and rolling of eyes. I get out my notebook again.

So, this is why I am doing sign language classes! I have had very very little success with remembering anything at all so far, but I have read it takes years. Also, to actually do any good and to be able to take a history, I would need to get really quite fluent. Maybe one day.

I got a crush on Obama

http://www.youtube.com/watch?v=phBBnxXJdoM

This is like a joke to me! Is this really going to make anyone think any better of McCain? Is anone that stupid?

A shadow

I am shadowing the doctor I will be taking over from in 2 weeks. She's from Eastern Europe and says she is shocked every day at the dirt of the hospital.

Best quotes: My new consultant - "What's the most important thing for this patient? Placement. Ever read "The House of God"?"

The F2: "The most important thing you will learn is what to do with the dying."

Wondering what to do with a patient with strange symptoms - F1 - "Get House on the phone." Registrar - "Oh, he'll just say it's lupus." F1: "It could always be lupus."

Also, I found out I am on call on my first day, next Wednesday, which means that I will be clerking patients in from A&E, and carrying the cardiac arrest bleep. Dear God! I am nowhere near old enough for this! I just don't know how to prepare for it.

Too posh to push

I was so interested to read the G2 today about how many obstetricians would actually opt for a caesarean. This follows a report last week about how midwives are trying to decrease epidurals even more, by trying to make people pay for them.

I was lucky enough to deliver babies during my Obs and Gynae rotation. I saw a lot of births, natural and caesarean. I would go for a caesarean in a heartbeat.

From the other side of the clipboard

I've been reading an old edition of the Student BMJ about how it can be a really positive experience to be an inpatient for a while. It made me remember how a matter of a burst appendix when I was applying to medical school was something that actually taught me a lot.

Firstly, how it's absolutely astonishing how little I felt I saw any medical person. I met the surgeon once, after the operation, for about 30 seconds. That's it! His juniors came round occasionally, not even once a day, and never asked me how I was. I felt rather abandoned! And when my cannula tissued, my hand was growing steadily bigger for a day filling with antibiotics and looked white and horribly unhealthy, and it took about 24 hours for anyone to come. I would have taken it out myself if I was an inpatient now, but then I was still scared of doctors. I hope that when I start I will try to remember that patients are scared of their disease, scared of their pain, scared of my needles, scared of my drugs, maybe even scared of me and my colleagues!

Nice little earner

The NHS has a surplus of more than £1.6 billion this year yet hospitals in the UK stand to make £3.5m in total from charging their first year junior doctors. The charge is equivalent to a 20 per cent pay cut, it has been calculated by the
BMA.

- Daily Telegraph, 8th July 2008

I sit in my newly furbished living room as I type. The house still smells of its new paint and new carpets. (Light cream - I wonder how long they will stay that way!) and I am thrilled to be here. It's 5 minutes from the hospital and it's half the price I paid for half the space in London. I love it. But if you'd told me until 3 months ago that I would not be living at the hospital I would be working at, I would be very suprised. But I've gone to the private sector.

I would have been expected to pay £485 a month for one small room in a block if I had gone for the hospital accomodation- that's more than I paid for my room in Marylebone! People in my position last year didn't have to pay a thing.

I don't think junior doctors are special. I don't think they deserve a free ride. But with people already being put off applying to medical school because it is too expensive, salaries for the first year should not be cut into to such an extent for such ridiculous charges.

And still, just across the Severn:

The Welsh Assembly Government has announced that free accommodation will continue in Wales, yet hospitals in the rest of the country will begin charging first year doctors for their rooms when they start next month.

- Daily Telegraph, 8th July 2008

Little Miss Doctor!

Well who would have thought it? I actually made it through medical school. Am feeling quite fragile from the Finalist Ball and lots of champagne etc since. I remember a few months ago, I was talking to one of the junior doctors on the firm I was attached to. I said I wasn't sure whether to go to the ball - it was bloody expensive and there was another party going on. She said I should definately go. She said "It's the only time in your life you're going to feel like a somebody. This summer will be the best time of your life, cos you'll start work and realise a doctor's life is shit and you'll be treated like a nobody!" Yeah, good pick me up! Also not making me feel that much better is that I know the girl who is doing the job I'll be taking over from, and she hates the hospital and the job and the NHS so much she is going abroad to continue her training, joining the ranks of British junior doctors who are swelling the ranks of the antipodean medical profession. Ho hum.

But seriously, I have job lined up. A house with the boy. Things are looking good!

In the midst of exam hell

I try to tell myself I'm still alive and a real person despite the fact I have been doing nothing for months except attempting to turn myself into someone I'm not - ie a confident future doctor. I wake early early in the mornings, with my head full of dreams full of patients that I have seen over the past few years, ones that are probably still alive, ones that are dead. In all the dreams I am disappointing people. And they are more real to me than the exams are.

"You take a really sleepy man, Esme, and he always stands a chance of again becoming a man with all his fac-with all his f-a-c-u-1-t-i-e-s intact."

-JD Salinger

Patients who have made my day, #2

Doing Obstetrics last year. One of my favourite rotations in medical school. Pretty girl, first baby. So excited. Boyfriend and Mum, so excited. Suddenly, baby's not doing so well. People come in and out the room, surround the bed. Told that she would need an emergency caesarian. Right now. Paediatricians woken up. Theatre prepared. Obstetric Registar awaits with scrubbed hands, crossed in front of him (the way they do to avoid touching anything). Crying from pretty girl and boyfriend, Mum being soothing. She's bought into theatre. Midwife says to Dad "scrubs in there if you want to come in." Points, leaves. He changes, comes out pulling the top over his head. Comes into theatre. Mum sits outside the door, staring in front of her. Pretty girl is quiet now but her mouth is shaking. Then suddenly, so so quickly, there's a wet little baby crying. He's completely fine. Given to the paediatricians, deemed hunkydory. Given to pretty girl. Midwife looks over her shoulder at me - "Go tell Mum if you want." I go outside. She's there, she stands and I will never forget the look on her face. I knew then, looking at her, that despite her calm before, she was expecting the worst and thought I was going to say her daughter/grandchild was dead. I made my face break out in a smile and said that her daughter and grandson were doing really well and everything had gone fine. Her face crumpled. She sat down again very quickly. I put my arm around her, feeling her woolly jumper and sweat on her neck. I told her she could see him in a minute. She cried and cried.

People who lead ...

BoJo is mayor of the city I live in. No, he is not a "legend". No, he is not "hilarious!". No he is not "harmless". He is a bumbling idiotic toff, homophobic, racist, and why he was voted in is a complete mystery to me.
http://www.youtube.com/watch?v=CcgrZs4GXv4

I'm keeping my fingers crossed for Barack Obama though!

Patients that have made my day, #1

My favourite thing about medicine is the wonderful people I meet. There have been so many occasions where patients have absolutely cracked me up, or made me smile, or inspired me, and I can never believe how sharply these people's faces are still engraved in my mind.

Taking a history from a cute little girl, about 4ish, and her Mum. She does this little fart. Mum goes, in mock shock but smirking, "What was that!" Little girl shouts gleefully: "MY STINKY BOTTOM!" Oh my Lord, I laughed.

Things that I didn't know about medicine before I started

• How many people in hospital are there, not because they are in actual need of the services hospitals provide, but because the provision for them in society is so inadequate. This mostly includes elderly people with nowhere to go that will care for them. These patients are often turfed to hospital from the bad nursing homes.
• How bad some nursing homes can be. Also, just as much, how good some nursing homes can be.
• How hard nurses work, for so little respect and appreciation. And how good nursing care is as important, maybe more so, than good doctors.
• How many patients are not listened to by their doctors. It seems so basic to me. I think it was William Osler who said "Listen to your patients. They are giving you the diagnosis".
• How little explanation patients get from their doctors and other health professionals. I remember one clinic with a vascular surgeon, with a middle aged man who came in because of claudication (where you get pain in the legs when you exercise, becuase the blood flow isn't sufficient.) He said, at a very fast pace. "Yeah, you've got quite significant claudication. Probably atherosclerosis. I'll send you for a doppler. When we get the results you might need an angioplasty for that." Patient: "Sorry, what?" Doctor: "Angioplasty." Slower and clearer as if he didn't hear. Patient, seeing the doctor was pissed off : "How do you spell it? I'll look it up." The patient looked at me. I looked at the doctor, becuase I didn't want to piss him off. He shrugged and went to do paperwork at his desk before the next patient. I took the opportunity to tell the patient quickly about what the words meant. I would hate to become santimonious, but really, I hope I never forget that not everyone has been to medical school, and that it doesn't make people stupid to not know what all the terms I have spent six years trying to cram into my head.
• Just how much your lifestyle and money and education affect your health, not advanced medicine. I don't mean in this country - around the world.
• How little resources and time are given to palliative care in this country. It's shockingly underfunded. So many doctors I speak to don't even see the importance of the whole speciality. Doing Oncology a few months ago, I spent time in the hospice next to the hospital. Funded charitably. Staffed by volunteers.
• How rare it is for even the best doctors to do more than delay death a short time. In many ways it's a losing battle.
• The only lifelike character on Scrubs is Dr Kelso.
• How much influence big pharma has on research, attitudes, and prescribing habits, how sneaky and underhanded the propaganda can be, and how this is accepted by most.
• How brave most people are in the face of losing their health.

There are some days I will miss London

Feeling bogged down in the library with the work I'm doing for finals - book upon book - I walked down the road to the Wellcome Trust for their exhibition on death and dying. Also, I am in the middle of my Oncology rotation, and have spent time in the hospice next to the hospital in the last few weeks, having been taught and told a lot about death recently. Entering the plush building, I am greeted by an introduction to the exhibition explaining how our ancestors were much more in touch with their feelings about death than today's society is - they describe it as one of the last taboos. The exhibition is pictures of people in hospices in Germany, big, beautifully taken black and white pictures - shortly before and shortly after they died. A small note next to the two pictures explains a little about their life, and about how they were and what they said about their coming death. Very moving, most were calm, resigned. The exhibition didn't shy away from describing the fear and desperation of some of the people - these were the ones I found most moving, the words of my favourite poet, Dylan Thomas, running unbidden through my mind. Rage, rage .... Two expensive black folders, with thick cream paper, lie at the exit for people to write in. I loved to read what they said. Many saying how moving it was. Many saying how grateful they were that someone had the courage to present it. A 9 year old girl writing that she was very interested and grateful for someone telling her a little about "what it was going to be like". A doctor writing that he tries to give people "a good death". A man writing that he was going to go home and make love to his beautiful wife.

I walked out, feeling pretty washed out but with a small feeling that I had the beginning of quite a new thought - that death can be a pretty life-affirming thought, and fear of death is perhaps fear of life, and not making of it what you want.

The tall glass buildings of Euston Road shine down on me as I leave. The traffic noise assails me. I walk back to the libary to continue my reading.

I've been lucky enough to get the job that I wanted as an F1 (a junior doctor, the first job a doctor does after graduating). Many of my friends have not, particularly the ones that wanted to work in London. But I am one of the lucky ones. So that's really great, the new system has worked for me.

I have, however, just recieved the papers from the hospital I will (if I pass my finals!) be working at. They are going to charge me £485 a month for staying in the hospital accomodation, which would mean more like £550 with council tax and bills. Not in central London, not in London at all, not a big house, not in a nice area of town, not even a nice building. No, just a room. One room! For this price, in the city I will be working in, you could rent a house for this price. Considering I will be moving to the same hospital as the boy, we can get a mortgage for a three bedroomed house - for about £600-£700 a month between us. How can they possibly justify these prices? I always saw myself living in hospital accomodation, even if you did have to pay for it. But there's no chance that this makes any sort of financial sense at all. I don't understand how they think that this is reasonable.

Another reason that this has got everyone pissy is that last year (or the year before that in some places) junior doctors didn't have to pay for accomodation at all. This amounts to getting on for a 20% pay cut. I don't think I am special because I am going to be a doctor. I don't think I am any more deserving than another profession. But without any consultation to cut effective pay by 20% - I don't believe that this is fair.

One of my favourite blogs, http://nhsblogdoc.blogspot.com/ , has just done a great piece on this - even showing a picture of a typical hospital accomodation. One I stayed in in December I had to clean the cockroaches out of my room, and the bathroom. The one I have at the moment has boards over some doors warning me about asbestos. I'm off to propertyfinder.com.

These hands ...

... have stitched up cuts

... have, as Turk says, been so far inside someone's abdomen I couldn't even see them

... have held bowls for patients to be sick in

... have palpated countless chests and abdomens

... have stuck needles into countless arms to take blood

... have been inside people's mouths, noses, ears, vaginas and bottoms

... have been covered in blood, vomit, sweat, poo, urine and amniotic fluid

... have catheterized three bladders

... have delivered two babies

... have held patient's hands

... are, along with my eyes, my most prized posession

End of A & E

I'm done with Emergency Medicine for the time being. Not for long, as I have enjoyed it so much I don't think I'm going to be able to stay away! I'm starting Oncology next week after a full week off for Easter - I haven't been given so much Easter for a long time!

I had a preview of Oncology recently though. One man - comes in, as his family had insisted on it. Quite non specific about what's wrong, over the last few months he's been breathless, pale, and very sweaty at night. His white cell count was 102. You'd wonder what was going on if the white count was over 10 - 102 is stupidly, ridiculously high. He turned out to have leukaemia. Another man - the day after - came in after collapsing. He had been breathless, and was coughing uncontrollably. I listened carefully to his chest and froze my face to not let my concern show. (I have a terrible weakness of being very expressive, loads of people have told me that.) His right lung sounded so sick - no pleasant whoosh of air. Just ominously quiet sucking, cracking sounds. He turned out to have a really large tumour in his lung. This really got to me, these two patients in succession that I had seen the worry in their faces, and their family's, increase as their time in A&E dragged on. I was crying silently in the toilets by the end of Wednesday.

So winding down from A&E I am far far away from the city, staying with my parents and the boy, surrounded by farms, where I am woken by chickens and lambs, where the buses go every 3 hours and stop at 6pm. Where the church and village hall are the social centres and people buy vegetables and animals from each other. Where the silence is so deep it feels noisy after living in the big smoke. When we weren't living abroad in the Middle East (we followed Dad's job) I spent much of my childhood around here, and took it for granted. Now I savour every second I'm here. Where people aren't rushing, where it's dark and so silent at night, where everyone knows each other, and likes that they know each other. It's so delicious, I can almost taste it.

Blues and Twos

I've been out with the paramedics this weekend. When I was younger, when I wasn't being a juvenile deliquent, I wanted to be a paramedic. This weekend made me realise how much I would have enjoyed it. Saw some great cases, including a little 8 year old boy who'd fallen from a tree and had a huge nail, foot-long piece of wood attached, through his foot. The paramedics were so great to him. So friendly and jolly, and defused the rather stressed situation in an instant. After a few puffs of Entenox he was giggling away and complaining about his ruined trainers. Bless him!

A & E

"Outside a new day is dawning. Outside surburbia's crawling everywhere."
-Kim Wilde
Doing A&E at the moment. In an area of the city where even the name of the place is a buzzword for middle-class. But I love every second. It's an almost palpable pleasure to be somewhere so organised that patients honestly don't have to wait more than an hour, even for very minor stuff, and for anything serious it's immediately. If they need a specialist to see them, they get seen. If they need to have a scan, they get scanned. It's delicious! The NHS really can work!
I lov every second of A&E. It's brutal and ugly and beautiful and visceral and it's so interesting compared to other specialities. I think I'm going to at least try to go into it as a speciality. You meet fascinating people - from the self-confessed landowner who had cut his hand on his chainsaw and joked that he should be greeted with a bottle of Moet every time he comes as his taxes alone pay for the place. Tee hee! What a prat! To the alcoholic man, fitting from withdrawal, trembling involuntarily under every touch of my hand. To the woman from Myanmar, who didn't actually know the difference between an A&E and a GP. To the childs arm so broken from a trampoline tumble that he had a new right angle in his forearm. To the endless numbers of elderly people with so many things wrong that I take up pages and pages writing it all down. To the motorbiker, who had been hit by a car, who ended up getting 8 stitches from me in his elbow and knee. Love it.

Home and jet lagged

Back in the UK after a BA flight (wonderful as ever - although very Indianified with biryani instead of the regular rectangle of meat and steamed vegetables, and Bollywood on the screen!) after what has been the best holiday ever. I am missing so many things about India - the friendliness and sense of humour of the people, the random sights you see everywhere, the food! But hot showers have never felt so delicious, and actually being able to sleep at night in my own bed is pretty awesome too.
I have also come home to a fab suprise - I have got the exact F1 job I wanted for next year! So after all my stressing about how terrible MTAS is, it's come through, at least for me. I start in August, if I pass my finals, and I am so so excited. I cannot wait. xxx

Waking and baking in Goa

I'm currently in Palolem in southern Goa. I fly to Mumbai tomorrow and I can't believe I ever have to leave this place. I know all the criticisms - that it's touristy, that it's not real India. That's true! But it's still such a fun place, I've had an absolute blast. The people here are just so interesting, there's a very weird mixture of hippies, party animals, and stoneheads. There is so much weed here, it's smoked so openly in the bars and everything. And the pubs and clubs are so mad, hence the fact that I am hungover as hell! As well as this, the beach is gorgeous, all the beach huts and bars don't detract from it. It's a wonderful curved bay, with some islands near the coast, and the whole place is fringed with palm trees. And yesterday we started our evening by watching the sun set from a balcony of one of the bars. I tried to capture just how gorgeous it was with this picture - aren't the colours incredible!

My beach hut is great as well - it's called Dreamcatcher and it's so peaceful. It's run by these great guys who are so cool and as genuine hippies as I have ever met, and one of them played the guitar for us yesterday evening before we went out. He played beautiful acoustic versions of '"Visions of Johanna", "House of the Rising Sun", and, randomly, "Roxanne" which actually worked really well! Everyone in the bar stopped to listen and it was a wonderful moment.

I said I didn't want to go home. He said why didn't I stay. I said I had to go home. And then he said - you don't have to do anything. If you want to stay, stay. What are you going home for? I told him about uni (he seemed quite suprised that I might be a doctor in the summer - I don't think I had been looking or acting very GMC - congruent!) I thought about it. So many of the people here come and never leave. At the moment, I want to do the same more than I would have ever thought possible.

But I'm off to pack my things now. My life doesn't give me the option of the hippy trail at the moment.

Kochi, Kathakali and houseboats

I am currently overlooking the ridiculously busy Mahatma Gandhi Road in Ernakulum, in an internet cafe that could not be more stuffy if it tried! Busy preparing myself for a mammoth train journey to Goa leaving in about 2 hours - overnight, about 14 hours, and the AC coaches were full so it should be "quite humid, madam" according to the people at the train station. Should be an experience! But I have just come from a travel agents where I gave in and bought a flight from Goa to Mumbai to save myself another overnighter. Only about 40 pounds so not exactly breaking the bank!

Fort Cochin was lovely - we arrived in the early morning and watched people fish at the beach, followed by awesome breakfasts and jazz music surrounded by reassuringly wierd modern art at the Kashi Art Cafe. That evening we watched a Kathakali performance - it's a traditional Keralan art form, a mixture of theatre, singing, art, mime, religion, all sorts! Characters are made up with bright colours and fantasticly huge costumes, and tell religous stories. The one we saw was based on the Mahabarata. It involved five princes, all married to the same woman. In a bet, they lost their wife to an evil King and made to serve him. She refuses, and says she will not wash her hair again until it can be washed by the blood of the evil King. One of the brothers, the most powerful, kills the evil King in a dramatic fight and graphically pulls the entrails out and eats some, and brings the blood and washes the hair of his wife. He then feels guilty and confesses to Lord Krishna that he has killed many of the people of the evil King. Lord Krishna forgives him and says that he has fulfilled the role that God wants him to fill. I wonder what the moral of this story is! But the whole thing was actually wonderful to see, with the makeup and costumes and really expressive dancing.

Despite the heat, humidity and incessant horns and traffic of Ernakulam, I am feeling fabulously chilled out from a night spent on a houseboat slowly, peacefully trawling through the backwaters of Kerala. On many "things to do before you die" lists - I can see why. So calm, the light reflecting the banks and trees - coconut, banana and mango mostly - onto the still waters. This is my favourite picture I took in India - I am taken back to the wonderful peaceful backwater life every time I look at it. The local villages at the side of the water with people laying out old-fashioned fishing nets. Watching the sun set and the stars coming out was awesome too, and the food was delicious - coconut curries, spicy vegetables and fresh chapatis were laid out, with loads of fresh fruit, which added up to loads more than we could possibly eat! The most wonderful thing about it was about how it gave me an unparalleled chance to just slow down for fully 24 hours. When I'm travelling - in general I guess - I don't really tend to just stop and watch the world go by and it left me feeling so calm.

Mysore

Our elective at the rural hospital is now over, and we arrived in Mysore for a week of seeing the different programs dealing with urban poverty and health. We arrived on Saturday, and as there were not really any opportunities for having a night out in the Nilgiris hills, we went to the club at Hotel Santhosh The Prince. Sunday - recovering from the club at Hotel Santhosh the Prince. And then yesterday we went to spend the day at the Holdsworth Memorial Mission Hospital. We had been warned not to expect to much from the hospitals here but actually I was pleasantly suprised - it seemed to be well run, with extremely knowledgable doctors who took us on rounds with them and told us all about the patients - saw many very nasty looking ulcers (from diabetes which is so common here), tuberculous meningitis, assaults, burns, and one thing more common than all - organophospate poisoning (a type of pesticide.) Not something that would have crossed my mind to read up on before coming, but apparently the hospital sees about 3 or 4 a day. The doctor obviously went on about the treatment and the medicine of it. But he spoke at length on the social reasons behind it. They are mostly farmers, apparently, hence the easy access to this rather nasty poison, and they can't keep up with the pace of production nowadays, get into debt, and see no way to survive in the country or the city. "The human face of globalisation." said the consultant, pointing at a limp, ventilated man in the ICU. . His wrists were bound to stop him pulling out the tube if he woke up. But pulling my eyes off him, I appreciated the effort that had gone into the development of this hospital - it's clean, reasonably cheap compared to many other private hospitals (although the government hospitals are the only option for many people), and seemed like they really cared. As you go in you are greeted by the daily bible quote above your head.. Yesterday it was Proverbs 15:3 - "The eyes of the Lord are in every place, keeping watch on the evil and the good."

Today we went to the organisation, RHLP, who work to improve all aspects of the lives of people who work in the slums - education, health, human rights, sanitation, work, gender equality. Quite an eye opener. There are 80 slums in Mysore. 4000 in Banglalore. And in Mumbai - well, just less than half of the 16 million people live in slums. The figures are mind-boggling. I came away humbled by the work that they've done. Mostly by hearing about the homes they have set up for street children. I asked to visit, I hope to go later this week to see for myself and to bring them any supplies that I can afford!

Now back to the Green Hotel - one of the nicest places I've stayed! Not for the luxury - it's fairly basic - but for the eco-friendliness, the food, and the gardens, breathtaking at night when the lights come on and twinkle all around you.

Sickness and health and all things in between

One of the biggest differences in the medicine that happens here is the fact that people leave health problems alone a lot longer than they almost always would in the UK. This means people are, as a rule, a lot sicker when they come in than I'm used to. Just today, perhaps 3 hours ago, the doctor we were doing rounds with was called away to see a patient that had just come in, sent from another, not quite so well equipped hospital nearby. He looked reasonably ok - elderly, a little thin and frail, a bit breathless. The nurses had taken one look at his chest X ray that had just been taken at the other hospital and got the doctor. He had a completely collapsed left lung. I mean completely! The X ray was just blank one side! I was astonished. I listened to his chest with my trusted Littman and sure enough, no sounds at all from the left lung. So bossman doc put in a chest drain to let the air out. He was admitted. He had been going around with a collapsed lung for a week.

And another one I'll always remember is the little boy, 6 years old but looked more like 3 or 4. He was really drowsy, not really very responsive at all. He had sickle cell disease, and his spleen was absolutely enormous. As with every patient, I looked at his fingernails, eyelids, and tongue for signs of anaemia. We always are told that you can tell if someone's very anaemic if these are pale. I've only seen them look noticeably pale a handful of times, but his were white. Even his tongue - actually white. When he stook this blanched little organ out at me, I almost jumped! His haemoglobin was 2.9 (supposed to be more like 10 in children). I've never heard of one so low - I actually thought that you wouldn't survive an Hb like that. After a blood transfusion (from one of the members of staff - I discovered quickly that there isn't a working central blood bank in this area. All the things we take for granted!) and a couple of medications, he was right as rain. I was thrilled to see him get better quickly, of course, but despite that I was desperately sad to think that many of the "sicklers" (as they are known) don't live to very old here. As "Haemoglobin" by Placebo ran through my head, I watched him leave the hospital up the lane, little hand in hand with his Dad.

With aching legs she sits and types

"Yoga, an ancient but perfect science, deals with the evolution of humanity. This evolution includes all aspects of one's being, from bodily health to self-realization. Yoga means union - the union of body with consciousness and consciousness with the soul. Yoga cultivates the ways of maintaining a balanced attitude in day-to-day life and endows skill in the performance of one's actions."

- B.K.S. Iyengar

We've been doing yoga classes at the nearby centre every morning at 6.30. This is going to sound like the biggest cliche, but it's the best way to begin the day that I know of. It's dark when we get there but as we start, the sun rises over the mountains and makes the sky go a delicious yellow. The light comes through the windows and lights us with a Vermeer-like glow. I'm feeling very healthy - although that could be the diet that's exclusively vegetarian with no desserts!

On an aside, I'm awfully glad to read about how Barack Obama is doing so well. I'm not a huge fan of anyone in American politics (sorry if that sounds too cynical!) but I think he's the best hope there! I read the funniest article in the Guardian today . http://www.guardian.co.uk/g2/story/0,,2249501,00.html It made me chuckle! But yes, I generally don't think much of many US administrations dating back a while. I'm reading "A Prayer for Owen Meany" at the moment - John Irving's best book, in my opinion - and it's amazing how if you substitute the word Vietnam for Iraq you would have a story that could be about now! But hey, here's hoping Obama gets in and does some of the great things he's promised.

Reinvention

I remember the rotation I did just before I came here. It was a horrendously busy A&E and I did actually quite enjoy the placement - I've always loved A&E for it's excitement and brutality! But there was this one night - about 3 in the morning. A boy - he didn't look 18 - came in with a gang of friends effing and blinding and saying he'd been stabbed. Of course he was seen that second by the most senior doctors there. It was found, though, that the "massive fucking machete!" had barely broken the skin on his thigh and he was not even bleeding any more. A good examination found nothing else of note all all and there was absolutely nothing else wrong with him. I was going to put a few stitches in - two at the most - when I saw a woman coming in by ambulance saying she couldn't breathe. Not just saying it - she looked it too. She was bought into "resus" - where all the monitoring and equipment is for sick patients. She was attached to a monitor and I saw ST elevation, (the tell tale signs of a heart attack), and she very quickly went into VF (for the non-medics - it means your heart is still moving and making electical activity but is not pumping blood. Basically it means you might be able to shock it back into rythym but if not you are dead). I was there as the bossman doc had asked me before to cannulate (put a drip in her arm for medications) so I saw them attaching the defib (the thing people use when they saw "clear!"). I saw them shock her and shock her. I saw the line on the monitor go flat. I felt her broken ribs crunch beneath my hands as I did CPR. After not all that long they stopped and went to speak to the family. I went out to stitch up a thigh (the job of talking to relatives in these circumstances alone is as yet awaiting me.) He yelled at me - "Why the fuck do they need so many doctors in there? Don't they know I've been stabbed! This is the worst hospital ever! I'm going to so complain about this shithole!" I apologised, and said I was really sorry to keep him waiting, and was really calm and nice to him, but he wasn't listening. He wasn't waiting more than 25 minutes.

The reason I have written about that incident was because it was an example of the kind of stuff that makes me think that teaching is a good career option. But the thing that maybe I like most about this trip is how it is reigniting some feeling of purpose and hope about medicine that I thought I had lost. The staff who work for the organisation here are so inspirational in how they are trying, and succeeding, to improve the health of a neglected and downtrodden, yet so fascinating and kind, people. I was becoming so cynical and downright depressed about medicine, what with horrid arrogant doctors, and an unbelievably frustrating health system, with patients that hated being in hospital (often understandably!) and who gave the staff nothing but abuse. Not to mention MMC / MTAS / UKFPO - whatever it is they are calling it these days - which has got the morale of doctors and medical students at an all time low. But here, I remember the 17 year old who went off smart and funeral-suited and trembling to her medical school interviews - a long time ago now - hoping beyond hope that the as yet unknown interviewers would see how much she wanted to be a part of medicine and how much she thought she would be able to do for people, and allow her to join their hallowed club. I haven't remembered her for a while - but now I'm thinking again how much I enjoy medicine. I hope to remember this to see me through finals - I think I'll need to to avoid going mad!

On weddings and random diseases

...or as I'm discovering, not so random. In one outpatient session, I saw leprosy and measles. It's the first time that I've seen either. The girl with measles caught my eye as soon as she came in. During my paediatrics placement, we were told, incessantly, that the most important thing that we should take from the rotation is being able to tell a sick child by simple observation. When I did my paediatrics, I don't really think I ever saw a very sick child in outpatients. Parents bring them in to A&E at such an early stage in England. But she caught my eye because she looked sick. There's no other way to describe it. Anyway, she was admitted and she's doing reasonably well.

And there was a lady with leprosy. Her hands were mutilated by this most strange of diseases - her fingers were shortened and bent, with the classic white patches as well. The fascinating illnesses I'm seeing here astound me - the diseases I read about dutifully for exams but never see are walking through the door and presenting themselves to me.

Lots of TB as well, but doing work in the city where my medical school is means that sadly even in England this is not anything new. TB, along with other emerging and re-emerging infections, is again rearing its head to remind us that we live in a pretty precarious balance with nature. I have a very good friend who lived in one of the most notorious areas of the city who got TB. He was trying to figure out where on earth he got it, but I told him that you don't always have to be anywhere exotic to catch TB now.

I spent Thursday night staying in one of the tribal villages staying with the local people. It took almost an hour to walk to, through acres and acres of tea plantations and palm trees. The hospitality was astonishing. They piled heaps and heaps of rice and daal and all sorts on my plate, and despite my pleas didn't touch any food themselves until they were sure I had been well and truly stuffed. And they gave me and the other student a room to ourselves when they really didn't have the room for it. I did my best to tell them that I didn't need so much room but they wouldn't hear of it. They made us chai after chai, and lit a fire so we weren't cold. The next morning they boiled water before we even woke up so we had warm water to wash our faces. I was humbled! And the kids! they followed us round in their bare feet (sometimes more was bare!) and smiled and laughed and delighted in my obviously hilarious attempts at Tamil and my camera and my watch. It was lovely to see their energy and enthusiasm that I don't think I ever had as a kid!

And on Sunday we were invited to the wedding of one of the nurses that works in the hospital. We all dressed in saris and again felt so welcome! It was a traditional tribal ceremony with the very very old dancing and music - the drums and pipes they were playing were so rythmic and hypnotic and everyone was dancing. And the scenery just couldn't be bettered - in their house surrounded by tea plantations looking out over the valleys of forests. It was stunning.

Tribes

"He who has health has hope, and he who has hope has everything."

- Arabic proverb

The hospital that I'm working in was set up primarily to provide access to healthcare for a previously rather neglected area of rural South India. One of the things that attracted me to this place was that it would be an opportunity to see and really get to know people in the tribe and see how they live. It's been absolutely fascinating. The people lived in quite a lot of isolation in this mountainous area and I have never seen a way of life that's had so little influence by "Western" culture. They live in the most splendid surroundings - covered in palm trees, endless tea plantations, eucalyptus trees grow so tall on the hilsides. Dark mountains frame the whole area.

So one of the things the hospital has organised are people, trained from the tribes themselves, to become health workers. It's not really a formal qualification or anything, but they go around the villages, weighing children to make sure they are not malnourished, taking blood pressures, testing for diabetes, following up on illnesses like TB, and one of the most important parts of their jobs - health education. Concentrating on areas that cause a lot of the health problems; for example, they might educate people about child nutrition (as many of the children here, for many reasons, are very underweight) , anenatal care and childbirth (as death in childbirth - of mother and baby - used to be a lot more common than it is now!), recognising the signs of an ill child (to make sure they get early treatment) and generally trying to help people understand the hospital and what happens there. So I have been out with them three times, "into the field" as we call it, with the health workers. It involves miles of walking in the sun, between all the villages. Last Wednesday we covered about 8 or 9 miles, seeing the most remote villages, many times that don't even have roads. I feel so lucky to be able to have seen these places - I get the impression that life hasn't changed much for thousands of years. Living off the stunning land, in the mountains that their family has lived on for countless generations.

The people organising the hospital have gone to great lengths to make it approachable - like almost all the staff there are people from the tribes. And they don't rely on written material for anything as most of the tribal people can't read at all. The health education is mostly word of mouth, and pictures. This is what I like most about this project - it's not just people from outside, say a Western country, that come in and put programs in place that just aren't understood or trusted by the local population. It has a real grassroots feel - like it's owned by the community. I really feel that the community trusts what goes on at the hospital and aren't scared of it any more.

I think I can tell this from how people treat me. They smile and are so happy when they learn I am staying there. (Sometimes they even know without me telling them, there aren't many white people around here for any other reason!) They tell me stories about how they were helped there. It makes me hapy to be part of something so special.

Oh and we rode an elephant yesterday at one of the nearby wildlife sanctuaries. Pretty awesome!

Incredible India

"In India, I found a race of mortals living upon the Earth, but not adhering to it, inhabiting cities, but not being fixed to them, possessing everything, but possessed by nothing"

- Appolonius Tyranaeus

OK, so this is the first time I've been in India. It's fascinating. The whole place is teeming with life - all sides of life. I think in all the places I've been this is the one where I have seen bare humanity in all its brutal horror and in all its shining glory. A land of contradictions like nowhere else I have seen - ornate, bristling wealth alongside some of the most desperate poverty I have seen outside Africa. And so head-fuck random - on the bumshaking 8-hour drive from Cochin (a fairly big town in the laid-back southern state of Kerala) to the hospital where I'm on elective, I saw temples sixty foot high, children playing cricket in the road, padi fields with the light on the water making it shine like it was made of light, banana trees, lakes and rivers, big dusty towns, and once, opening my eyes to see an elephant walking alongside the car so close I could have reached out and touched it. I gasped in genuine delight and the driver rolled his eyes with a little smile on his face, like London taxi drivers do when tourists stop and take pictures of themselves next to red English postboxes.

In the beginning was the word ...

Well hello and greetings! Decided to join the information autobahn and start posting my random musings for all and sundry to see.

I guess what made me want to start writing is that at the moment I'm on elective. (For those unfamiliar with the ins and outs of medical education, it's the time that medical students get off, usually near the end of the course, from teaching and are able to choose where to go for 2 or 3 months - as long as it's vaguely medical). I'm in very rural South India at the mo, in the only internet cafe for many miles, and I feel like I want to get some of the experiences down somewhere - it's so intense and wonderful and so many things that I hoped to be able to share some of that. Who knows, I may forever be condemned to Google obscurity.

Anyway, hey to you all, dear reader, if you are there. Enjoy.