Sandpaper Kisses

It struck me today, and I'm not really sure why it didn't strike me earlier, that it now well over a year since I left New Zealand. Perhaps it's because I bang on about it so much, "When I was in New Zealand blah, blah, blah, blah. Yes I LIVED IN NEW ZEALAND FOR 18 MONTHS AND IT WAS AMAZING AND I MISS IT AND I CAME BACK BECAUSE I'M REALLY CLOSE TO MY FAMILY BUT REALLY BLAH BLAH BLAH DID YOU KNOW THAT AOTEROA IS THE MAORI NAME FOR IT AND IT MEANS LAND OF THE LONG WHITE CLOUD AND DID HOW BEAUTIFUL IT ALL IS, ESPECIALLY THE SOUTH ISLAND. I WENT ROUND THE SOUTH ISLAND IN A CAMPERVAN AND, AND, AND...!

So, surprisingly, people still seem willing to talk to me, although admittedly that may mostly be because I was holding the medical SHO on call bleep quite a lot. This all happened where I work, which is in the UK, where I have been living for over a year. Crazy.

So, general medicine then. Last week I was on call with J, and we got chatting, as you do.

"What do you want to do?"
"Oh, I'm an A+E trainee. I'm one of the few crazy ones who want to do this for a career."
(pause)
"I don't think you and I are going to have very much in common."

But I've got used to it, to the blank looks I get as I make the usual (half) joke about having a short concentration span. I haven't made the one about choosing a career solely so that I can wear scrubs and trainers all the time, maybe because that one a bit too close to the truth and anyway, medics aren't the most humorous bunch.

I say it like medics are all entirely homogenous. And that is because THEY ARE. Medics are all serious minded, intelligent, passive-agressive people who like things done in a particular way and make a virtue of working themselves so hard that their health is affected. (Must, inhale, my food, whilst, walking, to see, the next, patient. Sitting is a sign of weakness!). They also have a tendency to look down on all other specialties and to moan lots, but then again that's true of all doctors in every speciality and I don't want to seem unfair.

All of that was suppose to be a preamble to say that I love my new consultant. Like, properly middle-aged, bald man-crush love him. He's just awesome. He was the consultant on call during my nights on take, and within 10 minutes of him stepping into the department at 11:30pm I had decided that I really, really liked this person and was very pleased to be working for him for the next 6 months. His bedside manner, his decisiveness, the very fact that he was in at 11:30pm and still in a good enough humour to make wry jokes and even laugh at my never-ending flippancy.

Ok, I feel I should talk a bit more about meaningful medical stuff, before this just becomes a post about my undying love for a bald man twice my age. I am beginning to love my hospital too, by the way. I mention it as a reference to the fact that when I used to write this blog as a medical student, it was essentially all about my romantic feelings towards the Heath Hospital in Cardiff. Happy days. We're not quite at that level yet, but this is the strongest I've felt about an unshapely 1970s brick of a place since I qualified.

I don't feel quite at liberty to talk about the specifics for fear of giving away my location, but it has a good number of the things I usually look for in a hospital. It's tall, it's well lit, it has lots of random corridors to places that only exist on certain floors and (probably) only on certain days of the week. It has corridors that my ID badge doesn't give me access to that I really really want to go down. Today I found some offices that were tucked into a really strangely designed corner of the physio gym. It's also crazy busy and has that kind of teetering-on-the-brink feeling, yet all the staff muddle through somehow and feel a kind of loyalty to the place as a result. Also, the main entrance is on level 4. That may sound like a give-away but strangely all three hospitals that I have worked in in the UK have had entrances on levels other than "Ground".

Yes, yes, medical stuff. Um, I saw some patients. Yeah, I definitely saw some patients in the last four weeks. All a bit of a blur to be honest. I spent a lot of time speaking to A+E staff who had noticed that I wasn't in scrubs any more about moving to medicine, not being entirely happy about it but not wanting to be too negative and write it off at the start. But in between that, I definitely saw some patients. I even treated a couple of them, I think. A lot of the time was taken up writing exactly what the A+E doctors had written but in my hand writing, and then filling in a drug chart. And I remember one of the days every single patient that I saw was unable to speak to me either because of dementia or because of language barriers. Not the best day I've ever had...

I led an arrest! I should definitely talk about that. Ok, this is what I'll finish on. The crash bleep went off and D and I were the first doctors on scene. (D and I both moved from A+E to medicine at the same time, so they put us both on nights together - why not?) CPR was happening, but little else appeared to be. D, a wannabe anaesthetist gravitated towards the airway. It was all a bit messy to start with, but we got the pads onto the patient and connected him to the monitor. Asystole. Back on the chest. Give him some adrenaline.

An ICU SHO came in and asked who was leading the arrest. D and I had kinda just come in and done our own thing, but I realised that, really, I was. I was in charge and directing other people as we tried to keep this man alive. I gave a couple of people jobs to do ("Get the notes please! Write stuff down, thanks!) and started to say everything I was thinking out loud, because that's what being in charge means, I think.

"What could have caused this? Hypoxia - well we're breathing for him now and giving him high flow oxygen. Hypervolaemia - can someone stick put some fluids up please and squeeze it. Hypothermia, can someone take a temperature please."
"He's not hypothermic," said the ICU registrar who had arrived at this point.
"Yeah, you're probably right. Hyper/hypokalaemia - unlikely. We're sending a blood gas anyway."

Five cycles later and we still only had asystole. The notes revealed a very sick old man with lots of medical problems. He had been found collapsed and pulseless in his room - no-one knew how long he'd been there for.

The Med Reg was here. I made to hand over to him, so that he could make the decisions. "I don't think there's anything reversible here. I think we should think about stopping. What do you think, Mr Med Reg?"
"No," interjected the ICU registrar. "You're running this arrest. It's your decision."

We carried on for one more cycle (a cycle being 2 minutes of CPR during which you try to treat what is treatable before looking again at the monitor to see what the heart is doing.) Once again, the heart was doing nothing. "Does everyone agree that we stop?" I asked, looking around the room. A pause, then generalised nodding. The flurry of activity dissipates quickly, and before long you are left with a dead body in an empty room.

Afterwards my mind was buzzing, so I had to stop seeing my next patient and just sit and eat some lunch. D came down and we reflected on how it had gone. "I thought you did well," said D, and I thanked him. "Next time we probably need to decide who's running the arrest a bit earlier, and I felt a bit unsure of myself once the Med Reg was there," I said, but generally the experience had given me a lot more confidence to do what I will probably have to do more and more as I edge closer and closer to the dreaded land of seniority.

Life's A Beach

So, I know that you're all questioning my ability to count to two, but as usual my rambling got the better of me and I decided to leave the second case for another post. Which is now...

What with two 6-month stints in ED bookending my 8 month period of travelling and locuming-but-never-actually-getting-around-to-any-actual-locuming, it's actually been just short of two years since I carried any kind of bleep or pager. It is definitely one of the many advantages of Emergency Medicine - no longer a slave to the page - but pretty soon all of the feelings that you used to get when the small box on your hip shouted at you are transferred to a new and equally piercing sound: The sound of the blue call phone ringing...

Of course, I once had a blue call for a man who was just a bit stoned, so it's not always possible to predict what prompts the paramedics to switch their sirens on. Plenty of times the blue calls are the cases that quicken your step and make you excited to be an A+E doctor, but there are also plenty of days when you thought you had everything under control and suddenly 4 blue calls in 3 minutes puts paid to all that and next thing you know the medical student is having to run the trauma call in one of the cubicles in minor injuries.

I remember this particular blue call being fairly ambiguous. Low GCS it said, but that was about all the detail we were given. The Glasgow Coma Scale, for the uninitiated, is the fairly ubiquitous measure of consciousness that aims to help us be a bit more precise about awakeful-ness than, "a bit sleepy - probably hasn't had his coffee yet" or "didn't even flinch when I pulled his toe-nail off". Other than "low GCS", the rest of the numbers were ok-ish, so I wasn't especially expectant that the ambulance service were bringing me something exciting.

The lady that they did bring through the door was not at all right. She was middle-aged, and looked like a respectable, middle-class type but she was acting like a 3 year old. An agitated 3 year old. "Toilet, toilet, toilet!" she moaned, picking at something unseen on her skirt. "I said I needed the toilet! And headache! Stop it, stop it, stop it!"

The story was even stranger. "When we arrived she was GCS about 10," explained the paramedic. "Then she dropped to 3, and stopped breathing. I'm not kidding, I had to bag her for about 2 minutes before she just started again spontaneously." I don't think the paramedic expected my to believe her, but I didn't have to wait long to witness a similar event for myself.

It's strange - one minute I was there on my own, attempting the slow and difficult task of assessing an agitated and confused lady whilst wondering how on earth I am going to get her to lie still enough to have a head scan. Moments later and she was staring blankly into space, air had stopped passing into her lungs and the entire crash team was surrounding us both in a chaos of hyperactivity and opinion.

I should give a few more details. A nurse and I had just helped the patient back onto the bed from the commode, and were just getting her settled in the bed when her face just suddenly went blank and nothing would rouse her. I was fresh from my Advance Life Support course (you have to do them every 4 years), so wasted no time in performing a textbook "look, listen and feel" check for signs of life. A, one of the medical SHOs was walking past the end of the bed, and saw all this happen.

"Quick, put out a 2222 arrest call!" he shouted.
"No, it's ok," I said, " She's got a pulse."
"But she's stopped breathing, don't you want them anyway!" replied the somewhat more sensible A in a slight panic.
"Um... Oh yeah, good point," I replied, and started to ventilate her with a bag and valve mask. (When I recounted this part of the story to my registrar, M, she laughed and called me a cowboy. Because of the "No, it's ok I don't need the crash team" part, not the ventilating part - that part I actually did right.)

Medics, A+E Consultants, Anaesthetists, Site Practitioners, Porters - loads of people come running when you put out an arrest call. Everyone adds their two cents, and you have to repeat the story a few times. Meanwhile, the patient slowly but surely started to wake up again, and breath for herself, and it became apparent that the moment of danger had passed without anyone really needing to do anything. One-by-one they all drifted off until it was just me and A and an ICU registrar left at the bedside.

"So, um, who's going to be looking after the patient now then?" asked the ICU reg. There was silence and a few more people drifted away. "Ooh, ooh, please let it be me!" I said, misjudging the situation a little as one that would appreciate my idea of humour. The ICU reg didn't seem phased by it. "Get a CT scan, and give us a call if you have any more problems," he said. "But what if she becomes agitated again, like before?" I asked, keen to keep the anaesthetically trained person on hand to help with the main problem I had foreseen from earlier. "Um... She seems like she'll stay still for you now, I shouldn't worry. Give us a call if there are any problems." And with that he walked away, and without any particularly big change in the circumstances it was just A and I looking after the patient again. Great.

I took her to the scanner, and fortunately didn't run into any major problems. At some point, I can't remember exactly when, I had a quick chat with the two friends who had come with the patient and had witnessed her collapse. They told me about how she had suddenly clasped the back of her head, cried "Oh my head!" and then wandered off and collapsed a few meters away. So I went into the scanner with a fairly decent idea of what we would see. The scale of it still made us all gasp. Even on the initial run through of the images being compiled on the computer we could see it. Shining out at us at the base of her skull, the unmistakable star-shaped sign of a sub-arachnoid haemorrhage.

SAH. It's a bit like AAA in that we're always trying to rule it out. Anyone comes in with a headache, particularly at the back of their head or particularly if it comes on suddenly and you feel like you must rule out SAH. This was the second case of SAH I have seen, and just like the AAA you knew that something was wrong. Obviously, stopping breathing is a fairly poor prognostic sign even if you do start breathing again fairly shortly after, and no doubt a small SAH would be a lot more subtle and still very dangerous. Still, it makes me wonder what I worry about with all those people who sit there looking comfortable, bright lights all around them, having not even taken paracetamol yet still manage to describe a thunderclap headache that's like "the worst headache ever!"

Anyway, this is one of those half stories, because of course we packed her off to the neurosurgeons in another hospital, and I'm not actually sure how she did. I heard that she crashed again just before going and had to be intubated but I had finished and gone home by then. Not before I had to break the news to her daughter, however. There she stood, about my age, calling her mother's name, asking me what was wrong. I took her to the quiet relative's room, and sat her down. It must have been obvious just by my doing so that the news wasn't good. "We've done a scan of her head, and it's bad news I'm afraid,"  I began, absolutely terrified of doing this badly. At first she just hid behind questions. "What is it? Is it a kind of stroke? Is she in danger now?" Later, though, I saw her break down in the ams of her father, and I saw far too clearly how easily it could have been me. Me, the relative, stood on the other side of that conversation. A few words from a boy in scrubs, and suddenly the world falls to pieces around you.

Met Before

Maybe I got lucky over Christmas - I was on nights but there was party food and then I had 10 days off when my sister came down - but my rostered luck has generally been out this year and I'm about to start a second rotation that will both start and end with nights. Not just nights, but ward cover nights. And yes, I've been watching the new series of "Junior Doctors: Your Life In Their Hands", and it has been reminding me of how unpleasant ward cover is. It is worse when you're an F1, and even the simplest cannula eludes you (small tip: don't go in at 90 degrees to the skin), but even once the simple things become second nature ward cover is still a lonely world and everything seems so much harder with that much less support.

Perhaps it's fear of the unknown again. I've had two 6-month A+E jobs with 8 months off in-between so that's nearly 2 years since I've had to do anything particularly ward based. Outside of the emergency department, the hospital can be quite a tranquil place at night so perhaps it will be quite a refreshing change. Ultimately though, I've done medicine, I've decided it's not for me because I'd rather take shift work and drunks over ward rounds and social admissions, so it's difficult not to just see the next 6 months as something I've just got to grin and get through.

Anyway, tonight I have the night off. I considered picking up a locum shift for the night, seeing how there's no point trying to re-flip my body clock for just 24 hours, but in the end I decided I'd rather stay up blogging and watching DVDs. So here are a couple of cases that stand out amongst the hundreds that I've seen over the last six months, because both had fairly major pathology that we're always told to look out for but don't often see.

The first one I missed. Not a proud moment, but pride is deceitful and I learnt a lot from the case so I will tell it the way it was. I picked up the Cas-Card and saw the presenting complaint at the top. "Back Pain," it said. Not too exciting then. A quick glance at his numbers, and it seemed that this dude wouldn't be too sick or exciting. Then I went to see him.

He was grey, sweaty and his eyes were closed. His wife held his hand, and speaking was clearly an effort for him. The pain had come on suddenly in the night and was across his lower back, he told me pointing out the equivalent location on me. "Which I belief," he lisped, "is where your liver is."

His wife had called NHS direct. "They told me to try to get some paracetamol and ibuprofen and see if they helped," she said. "And did they help?" I asked, marvelling at the fact that one of the sickest looking patients I had seen for a long time had been advised to stay at home, when it had long seemed to me that NHS Direct's blanket advice was "Go to A+E".  "No," said my patient, "it didn't even touch it."

I examined him, and found out that he was sore. Very sore, mostly in his belly. But then, none of his numbers were that bad it. I wrote him up pain relief and went to check his blood results. Nothing too out of the ordinary there either, yet there was no doubt in my mind that this man had some serious pathology and I should be getting the specialists in sooner rather than later.

At this point, I suspect most of my medical readers know what is coming and are shouting at the screen for my license to practice to be revoked. Afterwards the nurse who was looking after the patient casually mentioned that she had always thought he had what he had "just from the look of him." I nodded, and inwardly wished that she had vocalised her belief within my hearing at some point.

I called the surgeons. L, the SHO for the day, initially said yes, then came to see me to clarify a few details. I told her the numbers as she asked for them, but really I wanted her to see him so we could hurry up and scan him or whatever. "He's really, really sick," I said. "But it's not really on," said L, haughtily, "You've referred me a patient, he hasn't had his urine dipped or bilateral blood pressures, and from what you've told me it could well be muscular pain from all his vomiting."

I was meek and apologetic. I didn't make a big thing of the fact that we hadn't got a urine, because he hadn't been able to give us a urine, and shouldn't that be a bit of a sign along with me saying, "He's sick" that he is sick. Junior surgeons are welcome to try to score cheap points over trainee emergency physicians if it makes them feel big, ultimately I just wanted my man seen. I did the blood pressures for her myself, they were normal. "What do you think is wrong with him," she asked me before she went in. "I honestly have no idea," I said.

Well, she felt the pulsatile mass that I didn't press hard enough to feel. We took him to CT, and then to resus after seeing a large, leaking, Abdominal Aortic Aneurysm, or "triple A". Anaesthetists descended, consultants were called in from home and everyone got very excited and the small part that I had to play - missing the diagnosis - was lost in the flurry of activity. He survived, and was discharged about a week or so later.

The next week one of the staff grades, S, told me that the surgeons wanted her to feedback to me that the case was a AAA. I knew that, I told her because I had stayed with the case after calling the surgeons and had been involved after the CT. "Were they annoyed?" I asked. "A little," she said, "but ultimately you still referred it to the right people. It's not like you sent them home or anything." This didn't really comfort me. Whatever NHS Direct said, I don't think there could have been many people who would have looked at this man and thought, "mechanical back pain, take some pain killers and go home." I was, and still am, annoyed with myself for not thinking of AAA. It isn't something I'd seen before, and I'll not likely forget it now - everyone with a hint of back pain that I see now makes me think of it. But still - my constant fears of being a rubbish doctor were given a lot more weight at that point. S shrugged. "Well, I missed a testicular torsion a few months ago, so I think that's worse." She's a sweet one, is S.

Us Against The World

Time marches relentlessly on, and so it is that I find myself less than 3 weeks from Big Fat Rotation Day and the 6 months that I am looking forward to least of my 3 year ACCS life plan. General Medicine.

"How are you feeling about the move to medicine?" I asked D, my fellow ACCSer, whilst we sat and wrote notes together in minors. It's called minors, but it basically just means "probably didn't come in by ambulance" and can include strokes, heart attacks, and every so often a pneumothorax. I had a girl in there the other night whose ceiling had fallen on her head. "Just keep your neck still..." I said trying to remember if the Advanced Trauma Life Support course had said anything about protecting a patient's C-spine when she's sat up in a tiny cubicle shouting at her daughters to stop hitting each other and STAY STILL!

"Apprehensive," said D. "How about you?"

"I'm absolutely dreading it," I replied, rolling my eyes. "I really don't like medicine."

By which I mean I don't like general, hospital based, hierarchical, constantly dumped on, ensnared by patient's social problems, uncertainty filled, intellectual one-up-manship medicine. Obviously I like medicine, but I generally like it to be blue lighted in by an ambulance and then wheeled off to a ward once it's breathing normally again. I had this conversation with M, one of the new registrars, before Christmas and I got a very flat, "No, I love medicine" in reply. Right. That ended that conversation quite quickly.

I find that happens quite often with M. I mean she seems nice, approachable and pro-active and all, and clearly very good at her job (sadly the same can't always be said of the other registrar) but I just don't think we're on the same page. The other day she spent ages waxing lyrical to me (or rather at me) about how she couldn't believe one of the F2s had made a certain mistake, and worse still the locum middle grade had confirmed her in her mistake. "I mean, what am I supposed to do then?" she asked me. And I didn't really know what to say. "Do you know what I mean?" Not really M, I'm still quite junior. I can imagine it's a bit of a stressor, but really I don't know what you want me to stay. And that's just it, most of the time I don't know what she wants me to say. I usually go with the serene but sincere nodding.

You will remember of course that I felt this way (not looking forward to it) last time I had to do a general medicine job, and actually I ended up really quite enjoying myself. I liked my team, and because I was essentially slumming it as an overqualified house officer I was able to take everything quite easily. I doubt this will be the case this time, but I suppose that an English SHO isn't so far above a Kiwi house officer, and perhaps if I like my team then life will be fun. Perhaps I'll enjoy being 9-5 with a regular group of people for a while.

Emergency Medicine continues to have its ups and downs, but I still feel fairly settled in my conviction that it is ultimately what I want to do. The things I dislike about it often relate to me feeling inexperienced and junior, or getting annoyed with myself for allowing myself to be bullied into things by those more confident than me. Monday was a bad day, and I felt pretty rubbish by the end of it. I had two patients who should have been relatively simple except things kept going wrong, and I kept feeling that I should be doing more about it.

The first was a man who had come off his scooter and broken his arm. Fair enough, I can do primary and secondary survey's fairly smoothly at this point. (Push, ouch, x-ray). Clearing his neck was a bit of a chore, seeing as it wasn't sore and unlikely to be broken but the rules said I needed a CT scan to be absolutely super duper sure. I was able to get the scan done fairly quickly however, and then we set about sorting his broken arm. "He doesn't need bloods does he?" said the confident nurse. "Um, yeah, probably not," I said, forgetting for a second that I was capable of independent thought.

Of course he needs bloods! He's come off his flipping scooter and broken a long bone. He could have all sorts wrong with his bloods! What planet are you on, past me? You're the doctor, you've been caught out before, tell the nurse where to go!

Anyway, later I got bloods. Because he started to complain of abdominal pain. But the thing is, by then he had been referred to orthopaedics on account of his long bone having a new right-angle in it. And, as my consultant later pointed out, you refer the patient to orthopaedics, not just the patient's left arm. But the orthopaedic SHO was the super confident, look busy, look busy, Al who used to be an F2 with us. I always liked Al socially, but that didn't stop me from secretly hoping he would get seriously humbled sooner rather than later and become a much better, nicer doctor as a result of it. Anyhoo, he just didn't seem to get the idea that scooter man was his patient now, and he kept threatening to get me involved again. And because he is kinda my friend, I want to be helpful and engaging but I still think that ultimately if he wants to discharge the patient he shouldn't be saying to me, "We're happy to discharge him from an orthopaedic point of view, if you're happy."

No! There is no orthopaedic point of view. I was happy to send you a stable patient who had nonetheless been involved in fairly significant trauma who I expect you to be able to manage as part of a specialty that quite frequently has to be involved in trauma. You may not want to admit him because of his arm, but you are still a doctor and he is your patient and you should decide if you think that medically as a whole person if he is safe to be discharged. Stop being so overbearingly, infuriatingly, cheerfully confident in what you are doing!

I'm sure the patient is fine. I'm sure most of the people I worry about are fine. I'm sure that A never will harm anyone through ignorant overconfidence, though a small part of me thinks (hopes?) that he might. But still, being bullied into situations that I'm unhappy about by overconfident people who are junior to me makes me feel rubbish about myself and makes me wonder if I am really cut out for an emergency specialty which requires you to make difficult calls and lead people in high pressure situations.

The other patient was from Scotland. "Known dementia, more confused than usual" I was informed by the ambulance sheet, before the extremely lucid woman in the bed went on to tell me the date, day, year, place, person and prime minister. Right. I think that whoever sent her in was being a little overcautious.

Just one thing though, her oxygen levels were low with the ambulance. And now I can't get her ABG (the first one I've missed for well over a year), and I'm not even sure if she needs one. I try to ask the consultant, in such a way so that he says that I don't need to go back and hurt the poor woman again. He doesn't buy it. "I think that a blood gas is the single most useful test in this situation." Bother. He was right though, and after all but getting her ready to go home I had to go cap in hand to the sister and let her know that the patient would be breaching because I was making a late referral to the medics with a newly hypoxic patient.

A lot of the time the way you feel has nothing to do with what happens, and feeling rotten to the core on Monday was probably just because I felt rotten to the core on Monday. The last 3 days have actually been really good days from which I have left feeling pretty happy with life, the universe and everything. Tuesday in particular went really well, just one day after coming under an inexplicably black cloud. I just really, really hope that overall I am getting better at this A+E thing that I've chosen for a career.

California

Evening kids. I was recently asked to contribute 5 of my favourite songs to a 2011 compilation album, which was a bit of an honour because the friend who organised it is really into her music, really into what is cool and has been doing it for a few years and this was the first year that I made the cut. So, once the excitement at being asked had faded, I spent the next few weeks trying to work out what music has been cool this year and what random obscure nonsense track would get me the most street cred. All the while I was wondering if I had the guts to just run with "Paradise" by Coldplay and stick two fingers up at the inevitable music snobbery. Yeah, that's right, I'm a Coldplay fan, and I'm not ashamed to admit it.

Anyhoo, the choice of the final five was a fairly arbitrary game of what I hadn't made myself sick of by the deadline, but it was still nice to be reminded that there has been a lot of music that I have really, really enjoyed this year. To that end I put together a playlist of my favourites from 2011, and you must now sit through and read every last detail and over-opinionated raving that I have written about it below before you can do anything else because THOSE ARE THE RULES!

Options by Gomez


It was free, and I haven't listened to the whole album yet (shock!), but it's jaunty and I do love Gomez.

Calamity Song by The Decemberists


The general theme is that lots of bands that I like put out albums this year, so not so many new, exciting discoveries. But this is just the kind of perfect Americana that I can't get enough of.

Age by Lianne La Havas


She was captivating on Jules Holland, but sadly loses something on record. This song shows her at her alone-with-a-guitar best, and doesn't have Willie Nelson rudely interrupting her halfway through...

White Noise by Mogwai


Wins the best album title of the year award hands down with Hardcore Will Never Die But You Will, plus we all need more soaring instrumental guitar music in our lives, don't we?

Sophia by Laura Marling


So far I've found this album by one of my true loves a bit cold and distant and I kinda prefer the wide-eyed innocence of her early stuff. But the voice is still there and as haunting as ever.

Black by Dangermouse and Daniele Luppi featuring Norah Jones


Another slight disappointment - this film score without a film from the usually sensational Dangermouse definitely has more style than substance. This track is one of the few with a good tune as well as Norah Jones behind it.

Wildfire by SBTRKT


He's electronic, ubercool and only performs with a mask, "so as not to distract from the music". Give me a break. It's a good tune though, plus my sister likes it.

Light's Out, Words Gone by Bombay Bicycle Club


Always quite liked this band, and three albums in three different styles of increasing quality is a good omen. Being younger than me annoys me still, though of course as I head towards 30 I'm going to have to get used to it.

Georgia by Yuck


I put this track on in the kitchen, and my mother started dancing around and saying how much she liked it, so that must mean something. I guess there will always be life in the contrast of a strong melody with grungy guitars.

I Don't Feel Amazing Now by Guillemots


I can't help but wonder if Guillemots and Fyfe Dangerfield will languish around forever, constantly trying but failing to reach the dizzying heights of their amazing debut album, a bit like Ian Brown with the first Stone Roses record. This is a gorgeous, heartfelt song better than anything on album number 2 though, so things are looking up.

Forget It by Blood Orange


Is it really different enough from Lightspeed Champion's work to warrant release under another name? I suppose that it's his pretentious decision to make. This is upeat, melodic and has a gorgeous guitar line so was one of the first to make it onto my final five.

Codex by Radiohead


"I'm right in saying that Radiohead's last album is a load of dirgy rubbish, isn't it?" A friend wrote this on my facebook wall a few months after The King Of Limbs was released, which made me laugh as it sounds like I'm an authority on such matters, but in general I did agree with him. But then it's Radiohead, and I'll still generally take their dirgy rubbish over the latest nonsense cool young band that the NME is pushing.

Norgaard by The Vaccines


The latest nonsense cool young band that the NME was pushing (at least they were a year ago...), and I actually really liked them. Especially this track. Enough to have anyone jumping around the room.

The Glorious Land by PJ Harvey


It's already had more than enough praise and awards thrown at it, but I remember being massively struck by "Let England Shake" even on that first listen whilst waiting for my plane in Santiago airport in Chile. This is still my favourite track.

20 Years by Civil Wars


At the end of the day, my taste in music is fairly predictable. I try to mix it up occasionally with some cool electronica by a dude in a mask but ultimately tell me about a couple of American's singing love-lorn harmonies over simple folk guitar songs with a country tinge and I'll be in love before you can say anything about Jackson Five covers.

Abducted by Cults


An awesome track, again making use of the enormous potential of the discordant with the melodic. This one also made it into my final list of five.

My Body by Young The Giant


I've not heard anything else by this band except this song, but it was iTunes' single of the week at some point during the year and I liked it a lot.

Dub Outside by Steve Mason and Dennis Bovell


I keep meaning to give Steve Mason's record a proper listen - he was the main songwriter for the Beta Band who are one of my all time favourites, so I hope he'll be less disappointing than The Aliens. I heard this Dub remix of one of his tracks on 6 music one day, and liked it a lot.

Blackout by Anna Calvi


I think in general Anna Calvi over sings, and that put me off her. This song stayed with me however, and I still think it's one of the year's best.

Woman, When I've Raised Hell by Josh T. Pearson


I won't lie, it's not my favourite acoustic, confessional, break-up album - there's already enough of them and maybe it's just been too long since I was heartbroken but I was left largely unmoved. It's not bad though, and you know what I've already said about American's and finger-picked guitars.

L.I.F.E.G.O.E.S.O.N. by Noah and The Whale


Noah and The Whale will never be my favourite band - the songwriting is too average and the lyrics are too clumsy for me. Just when I feel safe to write them off as middle of the road non-interests, they come up with gems like this. Not something to complain about really.

Sackville Sun by Zoey Van Goey


"I listened to your record and it made me want to jump out a window, but in a good way." Any song that starts like that will never have to work hard to win me over. Sublime. Another favourite five selection.

Don't Wait by The Duke Spirit


A band I have liked a lot in the past, I simply haven't had time to check their new album out. I like this song a lot though, so fingers crossed. It's their usual; tuneful but rocky with an awesome singer.

Bedouin Dress by Fleet Foxes


Again, I like their first record but haven't heard much of the new stuff. I picked a few tracks to listen to when considering my five, just in case, and this one was the most striking.

Hackney Marsh by Slow Club


Current new favourite band, Slow Club tick all the boxes. Melodic, harmonious, inventive, quirky, wonderful songs, poetic and I'm just a little bit in love with Rebecca, who sings.

Everything Goes My Way by Metronomy


Bored yet? I doubt anyone will read this far, so I can write anything really. I'm kinda not sure why I'm writing it really. Nice swingy gate sound at the beginning. Good song.

Little by Little by Radiohead (Caribou Remix)


Proving that there is a tune in there somewhere, this was probably my favourite of all the King of Limbs remixes. Caribou's own stuff is very good too.

Fade Away by The Mummers


An interesting band I would love to spend more time with. I always think I should enjoy this kind of chamber pop more than I actually do for some reason.

Lucky Now by Ryan Adams


The king of proper Americana releases his best record for years. I, for one, am very happy about this.

First Growth by Roots Manuva


I chose some rap, I'm down with the kids. Not his greatest, but I've always got room for Roots.

Honey Bunny by Girls


I was sure it was a case of which Girls track I was going to choose for the festive 50, but after a while I started to get just a little bored of all of them and his voice is very thin and too weak to ever put them up with the best of bands. Sweet sentiment though.

Towers by Bon Iver


I didn't like it, then I thought it was growing on me, now I'm still not sure that I do like it. This song is sublime though. One of those melodies that stays with you for hours and makes you play it on repeat until you physically have to go to work.

The Birds by Elbow


No other band comes close, Elbow are pretty much peerless in my book. There is so much in every song, Guy Garvey is a poet and one of the most soulful singers in the world with an incredible range. 8 minutes of perfection.

Berlin Sunrise by Fink


Another excellent artist with a slightly below par release this year. Also one of the few bands that I got to see live this year which helped the songs come alive a bit more with an amazing stage show. This is a strong closer to the album.

Bats In The Attic by King Creosote and Jon Hopkins 


A real slow burner, but so, so gorgeous. One of my favourite records of the year. Stick with it.

Shake It Out by Florence & The Machine


Quite possibly one of my favourite five songs of the year, but I'm probably too much of a music snob to include something that was sung on X Factor this year. And it gets lost a little in all the shouting towards the end.

Step Out Of The Car by The Boxer Rebellion


Another band I've liked before and just wanted to give a quick nod to in an end of year thing, even though I've given the new record almost no time at all.

Gabriel by Joe Goddard


Something addictive and gorgeous about this relentless tune. It's a nice little loop, and the vocals just soar.

Video Games by Lana Del Rey


Another favourite that just didn't make the list because I thought too many people had heard it and would be bored of it by now. Gorgeous tune, beautifully sung.

New Years Eve by Tom Waits


I found the most recent Tom Waits record solid and consistent all the way through, and a welcome return by one of the most wonderful musicians still writing today, but it was difficult to pick one stand out track. I went for this one because of its vivid imagery, and use of the accordion.

Paradise by Coldplay


It is just so good though. You can say stadium rock in as disdainful a tone you want, but I love this track because it's melodic, well arranged, beautifully sung, and builds to its euphoric payoff with masterful timing. Ooooh-oh, ooooh oh oooo-oh ooh oh.

Trellick Tower by Emmy The Great


Marling may have the voice, but Emma has the warmth in her songwriting and this track cuts me to pieces. I hear, "Praying till my knees don't fold, praying till my hands don't close, praying till my fingers glow, " and I'm back at that riverside, having my engagement ring handed back to me, thinking back on all the hours I spent praying for help to climb the unclimbable tower. Feeling like you are nothing, just a relic of something long gone by.

So three years getting over it all, undone in just one 4-minute, piano led ballad! Thanks for that Emmy The Great, if that is your real name. Puh.

Accept Yourself

New Year, new chance to break all the usual resolutions. So far I'm enjoying 2012, but then again I am yet to get out of bed before 10am...

I think the thing to do is remind myself what I enjoy about writing to the internet. It is the only person who I can talk to about music without their eyes clouding over and their brains subconsciously thinking, "If he loves that band so much, I must hate them just to even things out and stop the world from becoming unbalanced and exploding." I assume that's what's happening. At least, it's the only explanation I can think of for all my friend's and family's total aversion to Belle and Sebastian...

A+E has been ticking over as usual. I did have an epiphany during handover on Christmas morning after working a hideous Christmas Eve night shift. I watched as the Morning Sister approached and greeted the Night Sister:

"Morning Darling! Happy Christmas! How was the night?"

And straight into work talk and handover. So, precisely identical to every other day in which the Sun rises in the East and sets in West (N.B. I was much too busy to look out of the few, tiny windows at work to confirm this), Christmas Day, it turns out is very much like all the rest of Days. The same conversation is had every single morning at 7 a.m. in EDs up and down the country, with the sole addition of "Merry Christmas" to mark the fact that it is December 25th, and most of the Western world has paused for the day to give presents and eat turkey. Incidentally, the fact it was Christmas also didn't stop me from pausing before dating every x-ray request to try to remember the day's date.

"Oh yeah! Christmas Day! How could I forget... 37 times in one night."

But yes, Christmas was lovely, thank you. I had mine on the 27th of December, celebrated by my sister and brother-in-law arriving to complete the set and me staying awake for 30 hours straight. The latter did upset my mother a bit, so sorry about that Mother. I have been off since then, enjoying my first few days of freedom without feeling the compulsion to study every single second available (and then ignoring that compulsion). It has been bliss, soured only by the disconcerting speed with which Friday seems to be approaching. That will be it then - my last twist of the roster before I depart for the evil hierarchical world of General Medicine on the first Wednesday of February. Not really looking forward to that...

But yes, I passed! MCEM Part A. The exam that no-one has heard of! I am now Part A of a Member of the College of Emergency Medicine. I am that much closer to some sort of real, actual career progression - something I have been putting off for the last few years if I'm honest. Turns out I can't sit the next part for a year, which is how long in advance you have to "book" your place. Slightly odd, but there you go. A year to plan all my last minute cramming.

I don't really want to dwell on the suicide attempts that I saw over my festive nights, or the drunks that had cuts on their heads because, what do you know, they tried to strangle their wives of all things! I'm not all that fond of the fractured/dislocated ankle that I relocated beautifully with the brand new orthopaedic F2 (I remember being on the other side of that...) only for him then to swear his heads off at us for cutting off his jeans (the patient not the F2), walk around the department on his broken leg and tear his plaster cast off. I told my brother about it, and he reckoned that I had technically assaulted him by reducing his ankle without his consent, which was exactly what I wanted to hear as I tried to sleep before going back in for more the next night.

But they are the cases that stay with you, and in a perverse way they are a big part of why I love ED work. It's simply never boring, and putting a foot that was at right angles from it's leg back in place with a satisfying "clunk" is definitely worth getting out of bed for. Or staying out of bed for and trying to sleep the next day as the case was.

But it did make me feel like I was growing in confidence. I saw two middle aged ladies, almost identical in presentation on consecutive nights. Both had stories that sounded like acute pulmonary oedema ("fluid in your lungs") but both with signs and stories that didn't quite fit the diagnosis. Both times I went with my gut (something I've always been too scared to do without senior approval), gave the scary infusion and both times they got better in front of my eyes. One of the major flaws of my current department is the lack of feedback given to juniors, and me being me I usually feel massively inadequate, diffident, slow, incompetent and disliked but with no senior input to help me confirm or refute my suspicions. This was one of those few moments where I felt like I could see a clear and concrete marker that I am at least making some progress.

Skeletons

I haven't forgotten you, my 2-5 readers (I'm beginning to lose track...), but as you will no doubt have guessed my free time is now almost exclusively being spent on studying or the kind of time wasting that you think should only take 2 minutes but ends up taking the majority of the day.

The exam is now less than 2 weeks away, so I've given up on my beautiful note taking which got me through about 3 topics in lots of depth and have resorted entirely to practice questions. The problem is, it's tough to find time to study when you work a full time rota. When I met P during one of his medical on calls a few weeks ago (P is the other EM trainee at my hospital) he sighed and said he hadn't even started studying yet, as he found most of his free time was spent crashing into a lifeless heap at the end of a long day on the wards.

Still, it's not inconceivable that he should pass. The exam is "True or False" multiple choice questions, so when I got my mother to try a 4-part-question the other day she actually got a higher score than me. At least it's been quiet enough at work for a few days so that H - an orthopaedic fellow I happen to know from way back when - was doing a locum in our department he had an hour or so to quiz me on the brachial plexus. True. Oh, wait, no False. It's hard to tell because of the way the question is asked...

Anyway here's one for you. In the digestion of protein:

a. Pepsin is inactivated by the acidic environment within the stomach

b. The action of pepsin on protein produces dipeptides

c. Trypsin activates chymotrypsin and elastase

d. Amino acids are absorbed using a Na+ co-transport mechanism

e. The acoustic version of Soft Shock towards the end of It's Blitz! by The Yeah Yeah Yeah's is absolutely gorgeous.

Answers next time. Which will probably be in about 2 weeks.