There There

Life's A Beach

2012-02-15T02:05:00.002Z

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

2012-01-21T14:43:00.000Z

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

2012-01-13T00:47:00.003Z

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

2012-01-06T00:03:00.001Z

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

2012-01-02T23:23:00.002Z

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

2011-11-25T09:36:00.001Z

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.

Ed is Dead

2011-09-29T11:35:00.001+01:00

Tuesday was a very disjointed day. First of all I saw a patient who the paramedics say was confused. And she seemed confused - she looked dishevelled, smelled of urine, and kept talking about having her eyes checked. But like a lot in medicine, you need to try and put a number on it. And for that we have the abbreviated mental test score - 10 questions which make sure you know roughly where, when and what is going on. We use it quite a lot, and these days I don't even look it up because it's so ingrained in my brain. The other day I was asking an old man who the current Prime Minister was, when I noticed that J in the next door cubicle was doing the same thing but a couple of questions behind. I wondered if his patient was cheating by trying to hear my patient's answers...

Anyway, my lady knew the year, her age, the dates of world war two, and even managed to remember the made up address that I gave her to recall. (Incidently, if there is a John Smith at 12 Church Street anywhere in the country, I'm very sorry for giving all these old folk your details.) But her story didn't quite match up with what everyone else said, or with the pressure sores that hinted at a fairly long period on a hard floor. I realise at this point that I don't know the end of this story - I sent her to the medics for further investigation. The medic wondered if she wasn't confused, did she really need admission? I know medics need to provide some resistance to all the vague, "off legs", not-specifically unwell rubbish that comes their way, but the alternative is for me to say that it is perfectly ok for an old lady to spend the night on the floor without really being aware of it happening. Goodbye! I hope she sleeps better tonight in the house she lives alone in.

Well, I thought she quite obviously needed to come in and be investigated beyond the 4 hours I am generously given. Of course, I didn't see her until after she had been in for 2 hours already. She hadn't had anything done by this point, and I wasn't able to bleed her. I asked a nurse to see if any of them could bleed her, only she asked someone else who forgot about it and so once I came back from my 20-minute-meeting-that-went-on-for-an-hour nothing had happened. So now we had 40 minutes before she breached, and nothing had been done.

At this point the sisters start to prick up their ears. What is happening to her? Where is she going next. Refer, refer, refer! But she hasn't had any investigations or treatment! Who cares about that? Bad things will happen if she stays in the department for long enough to check her x-rays. When I raised this, the sister got in a huff. "Why don't you do the bloods, instead of standing there doing nothing?"

Doing nothing? I've been trying to do three things simultaneously! There is a girl with a pneumothorax waiting for me to stick a needle in her chest just metres away. But after a few moments of my trying to defend myself, it was clear that none of this mattered to this sister. I was an arrogant doctor just expecting things to be done, who didn't understand that nothing matters more than the 4 hour rule. Nothing I could say could vindicate me in his eyes.

Fortunately, the lovely M was in overall charge. She gently asked me what had happened, and I explained. She tried to see what could be done to make sure it didn't happen again, without apportioning blame. I probably wasn't entirely blameless - I could have handed it over to another doctor whilst I was out of the department to get things done. But it still happened that she left the department before I could see her x-ray or blood results. Which has a knock-on effect on the medical service and makes me feel like a rubbish doctor.

All of which is to say that the 4 hour rule is the bane of my life. But later I got to aspirate a pneumothorax, which was awesome, and the patient was really sweet and lovely. I explained all about the aspirating needle thoracotomy or whatever it's called, before telling her that basically I was going to suck out the air outside her lung which was causing the problem. With a big syringe. Medicine can be quite simple a lot of the time.

Then there was teaching, and then a drunk man who wee-ed on my shoes. All very bitty, and I didn't really see that many patients. The other thing I took from the day was the minor injury teaching from the emergency nurse practitioner. "

I think it's sacrilegious that we're taking away all the most enjoyable aspects of emergency medicine from doctors, and just leave you with the crap. You really need to kick up a fuss about it."

And she's the second ENP I've heard express this in a week. Whereas consultants just sigh and say, "That's a shame." Which is the other problem with my day job. Otherwise I love it. I promise.

Hold On To Yourself

2011-09-22T00:23:00.001+01:00

Yes, well maybe you should just quickly listen to a gorgeous bit of Nick Cave and the Bad Seeds. Go on, I'll wait for you while you youtube or spotify or whatever it. "Hold On To Yourself."

So, I have to get up in 6 hours, but my mind is going rather fast and I hoped that writing a bit more rambly internet nonsense would slow it down a bit and allow me to sleep that much sooner. Plus this allows me to keep up with my plan to update weekly.

Not that I have anything to write about. Since I last wrote I have been enjoying a short period of rostered time off, rudely cut short by a course that I had to go to today. Most of my time off I have spent either studying, or feeling bad about not studying. As the reality of the enormity of my workload over the next 3 months slowly hits me - I read the introduction to one of my study books this week which said, "Trainees need to appreciate that this exam represents a substantial undertaking, typically requiring 9 months' revision time (or the order of 1000 hours)" - I wonder if there is any chance that I will get through it successfully. If I fail the exam this time, I have another 6 months before I can sit it again which means that I have roughly 9 months to revise for the second sitting, in which case I have planned it all about right. Gosh, I'm organised.

One of my mentors on today's course was an anaesthetist, who gave me the usual banter for being an A+E trainee.

"Ah, all the A+E trainees go through anaesthetics, and then decide to switch sides. And so they should to, it is by far the best specialty. Or do you enjoy the warm feeling that anything you do to your patients, there is someone in the hospital who could have done it better."

Charming. But then my own boss and education supervisor said as much to me a few weeks earlier as part of her introduction to ACCS.

"The funny thing about A+E training in the UK is that trainees spend 2 years not doing any A+E at all, and so we lose quite a lot of them to anaesthetics, which is a shame."

So there you have it, perhaps I am destined for anaesthetics after all. Most of the delegates on this course are F2s, and most of them have their careers neatly planned out already.

"Paediatric surgery. Or failing that adult neurology. That's where my interests lie."

Ah yes, the humourless individual who is talking about where his interests lie, only 13 months into being a doctor. It would be interesting to do a prospective study to see how many people end up doing what they wanted to do when an F2. It is when you're supposed to choose after all. Perhaps I'm the stupid one. I certainly will be if I end up switching to anaesthetics after all that internal wrangling about becoming an A+E wannabe.

Apparently on day 2 of this course we get to put chest drains (tube thoracotomies to my American audience) into sheep carcasses, so I'd better get well rested in preparation for that. So I'll bid you adieu and see if sleep will come to me now. And if I ever put a chest tube in one of your relatives, you'll know that it won't be my first time. Because I'll already have done it to a dead sheep. Maybe even twice.

Lost a girl

2011-09-14T13:13:00.003+01:00

My mother always tells my sister off for saying "like" too often. But now it turns out that I'm just as bad, and "like" is the word that I use most frequently here on this page. Perhaps I am just such a poetic soul that I use similes like Keats and Larkin having a picnic together in St James' Park. Or maybe I'm basically, like, just a teenage girl, or, like, um, I dunno.

I'm now five weeks in to my new job, and one thing that I have been fighting hard to resist yet still frequently hear myself saying is, "When I was in New Zealand..." and "At my last hospital, we...." Every hospital has its own systems and quirks, and it must be hugely annoying for old staff to hear from new employees all about how marvellous things were where they used to work, and how much better their hospital did things compared with this one. But at the same time, the differences are quite pronounced and they are not usually where I expect them to be. Nor are they always bad, just different and comparing them is quite interesting. To me anyway.

I suppose I should just keep the comparing to inside my head, but since I keep failing that I'll try quickly to write about them here and hope that it gets it out of my system.

The main difference is the presence of consultants. In NZ we had 3 consultants on the floor from 8am-6pm during the week. At the weekend it was 2, and on late shifts (4pm to 1am), again it was 2. One of those consultants would invariably stay until things became quiet in the small hours of the morning. In the UK there is only ever one consultant on the floor and, depending on who it is, they frequently spend the time hiding in their office.

Along the same lines is the juniors. My average shift in NZ was staffed by three registrars, one house officer, and during the day one or more staff grades. Apart from the house officers, everyone was an emergency trainee and thus wanted to do emergency medicine. Not everyone was senior, but to be a registrar you had to have done at least 2 years as a house officer and they liked at least 6 moths of EM. In the UK there are between 3 and 6 SHOs on the floor and occasionally one registrar or staff grade. So most of the bodies on the shop floor are juniors who don't want to do A+E as a career, and many of whom are in their second year as a doctor. Now the good thing about this is that it means that lots of junior doctors are getting a taste of A+E which is an invaluable experience and one that I think should be a mandatory part of every F2 year.

Again, along the lines of senior support and again varying according to person is the way the floor is run. In NZ we were rostered on to different parts of the department (kids, majors, resus etc.) which meant we got an equal experience of the different parts of an ED. The consultant in overall charge would keep an eye over the whole department and move staff if necessary, and every shift began with a handover giving us a chance to discuss all the patients in the department at that time. It also meant that things were more regularly handed over and we were more likely to go home on time. Nothing as developed as that exists in my new hospital, which means that it is easier to do what I want and cherry pick the things I need doing for my training (a good thing) but I'm sure that it means thing run less efficiently overall. This is probably a more hospital specific thing, because my first taste of A+E came in a children's hospital where things were very efficiently run.

So, really all of those come from the fact that emergency medicine in the UK is a very new specialty, and just a bit more established in Australasia. A positive difference is that thrombolysis for strokes (a relatively new treatment) is far more developed a service here than in NZ, and it runs incredibly smoothly at my new hospital. Other things I've moaned about are the relative lack of opportunity to do procedures, the attitude of medics to A+E and of course the politics and pressure surrounding the four hour rule. It all makes my job feel more like a triage service, deciding as quickly as possible whether a patient needs admission and to which specialty before fighting tooth and nail to persuade the SHO acting as gatekeeper to accept the referral.

And the nursing staff seem to put pressure on us to do that NOW NOW NOW!!! Most nursing staff are lovely, and work with us to keep the department flowing. But one really riled me the other day when she arrogantly answered my complaints of feeling like this by saying, "Well, I can usually tell within 5 minutes with a patient whether they need admission or not." Not the point! My job isn't, "does this patient need admission or not?" My job is, or at least should be, to diagnose patients as best as I can and to treat them, within the emergency setting. But no, this nurse would not see it that way and continued stating the same thing again and again until I had to just stop talking to her and pretend she hadn't rudely crashed in on a conversation I was having with someone else.

Anyway, I do honestly believe that in the years to come emergency medicine in the UK will grow and we will become more established and take on more and more acute work. Hopefully not too much minor injury stuff will be taken by ENPs (nurse practitioners) and UCCs (Urgency Care Centres - GP run) because otherwise we emergency trainees will lose the chance to learn about stuff that really is bread and butter emergency medicine. But that's just my opinion, and ENPs and UCCs represent a cheap way to reduce A+E waiting times, so will always be popular with management types. My sister had a bad experience with an ENP a month or so ago, so I feel a bit down on them at the moment.

I've decided that I need to write more often, but shorter and more snappy entries rather than the longer, rambling "The thing about A+E is..." entries. So I'm going to try. And you have the right to suspend judgement until you actually, like, see it happen. Happy reading to both my regular readers!

So Young

2011-09-14T11:50:00.002+01:00

Yeah, I'm listening to Suede. What of it? What's it to you? I've only got 30 minutes before I have to leave to work for a night shift, give me a break. Bernard Butler wrote some genius guitar bits long before he started propping up the careers of Duffy and Kate Nash. Exactly. Animal Nitrate, come on!

Tonight is night 2, and it's also my last night, which is an added bonus. On Monday I have a study day, which initially I didn't think I'd be able to go to, but then my boss decided that I should go, pulled some strings and hey presto! I have a trip across the city to look forward to in place of two nights. It's my second set of nights, and once again I'm not doing the full number.

Also once again - my nights have been unsupported. One of the F2s that was on last night has already noticed that "nights are all about who you're on with" and that's true. I don't feel too unsafe when unsupported at night - after all managing sick people is a fairly generic exercise in oxygen, IV fluids and ordering every investigation under the sun and calling for help. The med reg is at the end of the phone, and probably enjoys the moribund blue call more than the usual raft of rubbish that they wade through on an average night. The problem is learning. You just don't learn anything when you're on nights on your own. There is a lot of stuff you come across in A+E that you don't really see anywhere else, and if you don't have anyone experienced in A+E to guide you through it then you aren't really going to going to learn how to deal with it. Piles for example. I remember the first time I was confronted with haemorrhoids. I didn't have a clue! I wasn't even entirely sure that I had diagnosed them correctly having never seen them before.But J was in the waiting room with me, and a crash course in A+E haemorrhoid management ensued and now anyone terrified by the painful lumps hanging out of their back end who meets me in minors will meet a confident assurance of what they need to do to make things better.

Last night I just had two brand new F2s and a locum who could have been anyone as far as I knew. But that's still better than nothing - even having someone to bounce your thoughts off is something.So how about the 50 year old woman with two weeks of chest pain. It was in the whole of her chest, she wailed, as she clutched the two massive sides of her chest together in a fairly violent gathering motion. Maybe that's what was precipitating the pain... How long have you had the pain for? Two weeks, on and off. Does it make you feel sick? Yes, doctor, vomiting lots but not now. When then? Four months ago. But I asked if the pain makes you sick? Sometimes. How many times? Lots and lots, four months ago. But now she has diabetic injections which have stopped the vomiting. Ok...

Do you feel breathless with the pain? Yes, sometimes. Do you get palpitations with the pain? Yes, sometimes. Does it come on when you exert yourself? Yes, sometimes. Do you ever get the pain at rest? Yes, sometimes. Does the pain ever make your right foot feel colder than the rest of your body and give you a tremor in your left little finger? Yes, sometimes, doctor.

The thing is, you look at ladies like this, and you know that they're not sick. You know that a second blood test is a waste of everyone's time. But if you are wrong, and she arrests on the way home, you have all of your notes where you have to write that she answered in the affirmative to every question that you asked and as such admitted to every risk factor in the book. And you don't have leg to stand on. These patients seem like minor irritants during the daylight hours, but frequently they can become crazy, stressful, insurmountable impossibilities if you lose perspective once the sun is down.

On the plus side, last night things became tranquil around 6am and I went for a wander around the hospital site just as the sun was rising. The air was crisp and all around me everything was quite and still. Wisps of red cloud had been painted on the deep blue of the early morning sky and the first golden shards of sunshine were shooting between the leaves of the trees by the road. I took a deep breath and felt happy to be alive.

I went back into the waiting room - empty except for a man who had been walking on a broken ankle for over a week - and shared my experience with my colleagues. One of the nurses told me to stop being so chirpy at the end a night shift.

X-ray

2011-08-25T20:47:00.007+01:00

Hi, Hi, Hi, Hi...

The new job, as everyone has been asking me, is fine. Thank you. It has been a slightly slow, protracted and painful start, beginning with unsupported nights and followed by 10 days of rostered, prescribed annual leave. Those few chaotic shifts felt more like an aberration and then normal service was resumed - back to the alarm that could be slept through, and the sunny afternoons filled with good intentions but not much else.

Now things are a bit more regular, and the hard graft of learning a new hospital's quirks and systems, guidelines and priorities begins. Around the same time I have to get to grips with the curriculum of a training post complete with WBAs, DOPs, CbDs, Mini-CEXs, MSFs, ACATs, CAPs, Summative assessments, Formative Assessments and ARCPs*. There is an exam to sit, courses to attend, and an audit to complete. Sometimes I'll be seeing and treating patients. I think.

But the people, of course, it is all about the people. And so far, the people are lovely. The nurses, the rehab team, the registrars, the consultants, I haven't met many that I don't like. And that, of course, is why I like A+E. The consultants are like J, who shook my hand and introduced himself by his first name, before showing me how to put a chest drain in by "the Cape Town method."

(I got a DOPs out of it.)

One thing about the whole curriculum and exam and training and stuff is that hopefully it should make me progress in my career a little. Not that I would change anything about what I have done with the past 2 years, but the fact remains that if I had stayed at home and done core medical training then I could be a medical registrar by now. And then I'd have to know some stuff. Like, about medicine. I'd review F1 clerkings, and run arrests and be asked to see nearly dead surgical patients. I'm just saying, there are people who graduated the same year as me out there in that position. Then again, they could well be sitting around thinking to themselves, "I thought I'd feel like I knew stuff by the time I was a registrar..."

Enough philosophising. I reckon I know a little bit more than most F2s. Although A is one of those super confident F2s that seems to have taken to A+E like a duck to water. Smug git. "In actual fact alcohol is protective in a paracetamol overdose." I'm sure I knew that. Actually, I'm not even sure if it's true. He was probably just making it up and sounding confident. I far prefer sweet little N, who apologises before asking the consultant's advice on every patient she ever sees. That's my kind of person - racked with insecurity and terrified of missing something, and yet also too lazy to do any kind of real studying to cover the lack of knowledge that those insecurities are based on. I wonder what she wants to do with her life?

"I really fancy going to New Zealand next year."

Let me quickly mention the end of the Bolivian trip, just to sort of bring an end to that side of things. La Paz as a city was much like many of the other cities we had visited in Bolivia and South America. Like most capitals it is big, built up and busy, although it's settings in the mountains gives it something over most. Mostly it was the base for some wonderful experiences.

First was the death road cycle. Whilst it sells itself as the world's most dangerous road, the only worrying statistics are from the days it was the one main road in the area and there were no barriers. Now it's only really used for bike riders, who get to ride down 64km downhill amongst some incredible scenery.

The other big event was climbing Huayna Potosi, which is the mountain in the photo above. This took three days, including one night going to bed at 18pm with 17 of us sleeping in a room smaller than most people's bedrooms, in order to set out at 2am the next morning. Climbing on snow and ice at that altitude is possibly the hardest thing I have ever done. To be absolutely gasping for air after 10 footsteps, panting as if you had just sprinted 10 miles, is not a comfortable feeling. But then you stagger across the final vertigo-inducing ridge and reach the summit just as the sun is rising... and you are on top of the world. 6088m high, looking out across creation in the red morning light. It's breathtaking.

* None of these are made up.

Sorry With A Song

2011-08-10T15:36:00.007+01:00

Medicine is all about numbers, so here is the summary:

3 days of induction lectures.
3 night shifts
2 of the 3 nights were without any senior support (Welcome back to the NHS!)
8 cans of caffeine energy drinks
2 pens at the end of shift on Tuesday morning. Which was 1 more than I started with, so that's a definite plus.
1 patient who came in at 3am because she was itchy.
1 computer system that defies understanding...
10 days rostered off post nights.
22 new SHOs. 4 are GP trainees, 1 is an anaesthetics ACCS person, 16 are F2s and only 1 is an A+E trainee. And that's me.

So not the best way to start. Nights are always a bit of a drag, but when you're understaffed and no-one around can really tell you how things work then it doesn't make the simple job of seeing patients any easier. Fortunately the sister on was lovely, and as always nurses are the driving force behind the department. They were all excellent and so I just did as I was told like a good junior A+E doctor.

Everyone keeps asking me if I'm one of the new F2s, and I keep wanting to say yes, partly because there's little functional difference between F2 and ST1 (both SHOs in old money) and so it sounds like you're splitting hairs just to big yourself up, but also because I feel a bit apprehensive about my ability after 8 months off so I'd rather lower people's expectations than raise them.

Anyhoo, I'm writing to tell you about Potosi, which has the exciting distinction of being the highest city in the world at 4090m altitude. It is a pretty little city full of narrow alleys and old colonial buildings, overlooked by the all important Cerro de Potosi mountain beneath which is the silver mine which has dominated the city's history since colonial times.

The buses in Bolivia were a little different to the luxury coaches we had got used to in Chile and Argentina. We had seen some really questionable 1960s buses on the roads with people hanging out of windows and loud Andean music blaring in their wake, so in the end we were quite relieved that our bus was a step up from that, and the journey was short enough to pass in relative comfort. We stayed in the Koala Den hostel which was charming and comfy, and did good breakfasts.

The dilemma we faced in Potosi was whether or not to visit the silver mine. This is a real, working silver mine, not just a museum and being in a less developed country like Bolivia means that health and safety isn't quite as well thought through. The lonely planet was pretty negative about it as an experience both ethically and in terms of safety, which left us feeling fairly apprehensive. But people who had done it painted a different picture of an unforgettable experience, and no-one knew of anyone that had come to any harm. So we went for it, choosing a company run by a cooperative of miners.

First, they took us to the market to buy gifts for the men down the mine, which included dynamite, juice and the ubiquitous coca leaves. Next we headed to the refining plant where they turn the rocks into some more silvery rocks, which then go off to the proper refinery to be made into rings and ipods and such like. And then the mine...

The mine is dark, close, alternating boiling and freezing, dusty and goes on and on and on. And this is where the miners work, day in day out, chewing on their coca and saying hello to the tourists. The first guy we met in his little hole in the wall works on his own, chipping out rocks by hand and carrying them out on his back at the end of the day. Then we met groups, who utilise the carriages on rails that occasionally came roaring down the tunnels, sending everyone scuttling to the sides to cling to the walls.

Everyone works as part of a cooperative, so that they sell their silver at an agreed price and so get paid depending on how much they mine. Their wage is significantly higher than the Bolivian average, so the young men are still turning to the mine for work in large numbers. One of the groups we saw had 3 generations of the same family in it. The guide showing us around was himself a miner who learnt English. He then reeled off a number of slang and swear words that he had learnt from previous groups, so we taught him some kiwi slang and he was happy as.

Overall it was an experience, and an unforgettable one, but I was very glad to get out into the evening air and gaze over the city as the stars came out. I hope that tourist visits help the miners, after all what else can you do when confronted with such inequality?

From Potosi we got a taxi to Sucre, which is the judicial capital of Bolivia and used to be the only capital of Bolivia until the most recent president moved the seat of government to La Paz. With there being 8 of us now (we had been up to 10 in Potosi with Ash and Ed rejoining with Dave and Jen, but then we lost Lucy and Lynn), 2 taxis ended up being cheaper than the bus, and since it was less than 2 hours away, that's what we did.

Sucre is another very attractive, former colonial city with a far more relaxed feel to it than La Paz. We stayed in the exceptionally lovely Hostal de Su Merced, and spent the first evening just having a few drinks on the fantastic roof terrace overlooking the city. There was no big trip or event in Sucre, but we did have a nice relaxing few days in amongst the shops and restaurants (and pharmacies - some people wanted to buy valium for the long coach journeys!). One of the best meals was at the central market, where we all ate some spectacular Bolivian chorizo. We tried to get some culture, but the museum we wanted to go to was closed for refurbishment so we just went to another cafe instead...

Next, and last stop for me, was La Paz.

She Wants

2011-08-04T20:36:00.007+01:00

Nothing but induction at work, so let's see if we can't crack this...

San Pedro de Atacama (this hardly seems fair given how much time I gave to Buenos Aires!) is a tiny little town with free wifi in the town square. It seems to exist today mostly for the nearby geysers, moon valley and Eduardo Avaroa National Reserve, so in other words it's a small desert town that looks much like you expect a lot of poorer areas of South America to look like with simple buildings and dusty roads, but everyone you pass is a gringo and a tourist. One of the smaller shacks was actually a North Face shop.

That's not to say it isn't without its charm, or benefits. Eating out was excellent, and the tour of moon valley, dune-boarding and then the drive into Bolivia were incredible. I could see it getting a bit odd for the locals though, and I suspect you wouldn't want to stay there more than a week max.

Moon valley is at the edge of the desert, and is difficult to describe so I'll just refer you to the photo at the top. The guide who took us around had a geology degree and was explaining it all very well, but clearly rocks just don't stay in my mind and all I remember is him saying that they don't mine salt there any more because of the high arsenic levels! Anyway, we stayed out for the sunset, and the world looked very beautiful at the time.

The next day saw a change of personnel; Ash and Ed went on to Uyuni to meet Dave and Jen, whilst Sarah, Lucy, Lynn and I stayed in San Pedro to meet Mike and Jess. It was Mike who persuaded me to try dune boarding, which was super fun, but did result in my camera going somewhat defunct. Kinda my fault for taking it to somewhere where there is nothing but sand (asking for trouble?), but at least the electronics continued to work and I didn't lose any video that I had already shot. Also, I was rubbish at sandboarding. And got tired walking up the dune time and time again.

So, the crossover into Bolivia. We did a three day trip through the national park, which is located at an altitude of between 4200 and 5400 metres. The six of us were taken in a jeep by "Johnny", who definitely spoke more English than he let on, but generally let Mike (whose Spanish is superior to the rest of ours) translate. We saw mountains, red lakes, hot springs, flamingoes, volcanoes, desert plains and rocks shaped like trees. Much of it is like another world, and all of it is breathtaking. The altitude gives an extra edge to everything, starting with Mike and I racing each other to see who got more out of breath fastest, and ending with everyone playing cards in the refuge in an average of 6 layers. I can't remember what the guides said the temperature dropped to, but I think it was at least -10°C, maybe even -20.

On Day 3 we arrived in Uyuni, and saw the train cemetery, where a lot of dead trains live. After the obligatory climbing and photos we headed to the famous salt flats. I have never been anywhere like this before; as far as you can see is flat and covered in thick salt crystals. Nothing but white for miles and miles and miles. So what else can you do except take a lot of geeky photos which play around with perspective? We had people climbing out of marmite jars, standing on people's hands and waiting to be eaten on a spoon. I'm sorry I can't really put any here.

When we arrived in Uyuni, the power was out and the sole cash point was empty! Fortunately someone had dollars, and the hotel wasn't expensive. We ate at a Mexican restaurant, with the lights coming on midway through. Uyuni is another town that exists mostly for the tourists, and so we made a fairly quick getaway after one night. Still it was a comfortable night, and after all the expensive hostels of Chile and Argentina it was nice to have cheap, posh hotels to look forward to in Bolivia.

John Taylor's Month Away

2011-08-02T23:02:00.003+01:00

You will of course be dying to know who I like from the Mercury Prize nominee's this year, and I am more than delighted to tell you that I like a lot of them. Elbow, of course, go without saying, and PJ Harvey I mentioned a few weeks ago. Metronomy are the authors of probably my favourite song this year, "Everything Goes My Way", and of course I haven't been able to keep away from the brain virus that is "Someone Like You" by Adele. So, basically I'm going to go very arbitrarily for King Creosote and John Hopkins, mostly because my Mother liked it whilst I played them in the kitchen the other day. I'll try to pretend Tine Tempah never happened...

"But they should recognise him. He's popular" (Julia)

Nope, I reserve my right to music snobbery and Tine Tempah is a rapper who is objectively not very good at rapping. OK, just think about that for a second. "Pass Out" is as empty a piece of creativity as its subject matter. On that track, the aforementioned Mr Tempah speaks, quite slowly, about what it is like for young people today to go out partying. Among his more astute observations on his subject matter are that he has so many clothes that he "keeps some at his aunts house," and that "I been Southampton but I've never been to Scunthorpe". The latter, evocative image, allows me to picture Mr Tempah as the sort of person that has been to Southampton but hasn't been to Scunthorpe. This helps me understand what he is trying to communicate more easily.

In between such incredible wordplay, Tine manages to rhyme "out" with "out" repeatedly whilst encouraging binge drinking and the poor treatment of women. But you know, the loop is quite catchy, so that hardly matters does it?

Anyways, we are now just hours away from the 3rd of August 2011, which is of course national change-over day.

*Fanfare*

F1s become F2s, F2s move on to more grown up things (or not, if they're like me), core trainees go up a number, and newly qualified doctors get the super terrifying experience of their very first day on the wards. Most hospitals do everything they can to ease them in gently, which usually involves keeping every other doctor in trust induction all day so that the brand new doctors get the whole hospital just to themselves!

So, in other words I have reached the restart of my languishing medical career without finishing my travelling tales. Hmmm. Not really sure what to do now. I've already spent half this post ranting about an unimportant pop star, so it kind of feels a bit late to describe the cross from Chile to Bolivia. I could write down my advice to the new doctors? It's not that exciting though, and it's what any junior doctor will tell you.

Rule 1: Take regular breaks and never skip meals. The busier you are the more important this is.
Rule 2: Be nice to nurses. Actually, make that be nice to everyone. And learn everyone's names. Nurses, physios, OTs, phlebotomists, ward clarks, pharmacists - all fantastic allies to have.
Rule 3. Do one thing at a time.
Rule 4. Never be afraid to ask for help. This includes when you feel out of your depth with a patient, or when you're just swamped by little things. Ask a less busy fellow F1.
Rule 5. Write stuff down. It helps you remember it.
Rule 6. Don't feel bad about handing stuff over. The person on nights is there to work. Plus they're fresh, and you're knackered.

I can't think of anything else. Well I can, but nothing that general or succinct. I suppose most importantly is to remember to enjoy it. I loved my F1 year - suddenly you're not in the way but you're a super important cog in this massive force for good that is the hospital. You get to interact with people all day, you have fantastic job security and pretty good pay and it's rarely boring and frequently rewarding. We really are very lucky to do the job that we do.

Anyhoo, I met my new boss today, and found out a bit more about my job. Of the 8 middle grade positions on the rota, only 3 are currently filled. This has the downside of meaning that the department is frequently understaffed, but the upside (says my boss) that I will get the chance to step up and take on more responsibility. Um... At least we have a full regiment of juniors, and clearly if London is struggling to fill it's registrar posts then I should find it quite easy to get an ST4 job in 3 years time. The other good news is that A+E bods do all wear scrubs and trainers (YES!) so I will be buying new trainers with my first pay check. The less good news is that my "acute medicine" block will involve me being a bog standard medical SHO, either in endocrinology or cardiology. Never mind - that's not until February. I don't know if it would have been better to start in medicine to get it over with first, but it's not my choice and either way I will end up doing the same amount of everything overall.

All just speculation. I also have a roster now, which is very unlike my NZ roster. The annual leave is built in, so that we have a very heavy 3 weeks, only then to get almost 2 weeks off every 5 weeks. It will be interesting to see how that works in practice. It was nice with the last roster never having more than 4 days on in a row, but then only ever having 2 days off at a time meant that you could never use the time off to do anything too exciting. This roster also clearly tries to have it so that there are more doctors around at certain, usually busier, times which is probably better than during my time in NZ.

Three days induction and then straight into nights. The new boss apologised for that, which was nice of her.

Good luck everyone.

Clarion Call

2011-07-14T10:11:00.006+01:00

I doubt I ever gave much of a shout out to Delphic back in the day when they were new and hip and exciting - I tend to only like bands before or after they are cool - but I've been giving the album a proper run through again, and it's really, really good. I definitely prefer it to the other indie-dance types like Friendly Fires or, heaven forbid, the Klaxons, probably because it's heavier on melody and harmonies and hits that euphoric atmosphere that dance music can give so perfectly on the head. The title track, "Acolyte" is particularly good, as is "Clarion Call".

Anyway, today is quite an exciting day because this afternoon I'm going for an induction type thing at my future hospital. Mostly it's just HR and payroll and other types of evil, ("This is how to wash your hands") so I doubt it will be a particular exultant experience, but that said it still gives me the chance to see the place and decide whether or not the hospital and I are likely to fall in love or just have to work together with mutual distaste. So stay tuned for that.

With less than 3 weeks to go, I had better crack on with the travelling tales. The Elqui valley, which was a short bus journey from La Serena, gets over 300 days of sunshine a year. Clearly the inhabitants are just far more sensible that the rest of the globe who put up with all colours of unpleasant weather. Incidentally, on the bus journey they were playing Mel Gibson's "Apocalypto", which is possibly the most ludicrously violent film ever produced. Hardly bus journey type material, when we were all struggling with travel sickness as it was. I think Lucy was the unlucky person to be suffering with sickness sickness by this point, so she sat in front of the television screen.

The valley itself has a very dramatic landscape, as you would expect of a valley in the Andes. It is overlooked closely on both sides by hulking great sandy peaks and runs like a thread of mediterranean green through these giants, dotted throughout with small villages set amidst perfectly ordered vineyards. In short, very pretty.

Our hostel was also very pretty, set in the very picturesque Pisco Elqui. We spent the rest of that afternoon enjoying the famous sunshine and swimming (not for very long) in the world's coldest ever swimming pool. I went in first, but Ash actually did lengths! Crazy.

That evening we arranged to go to an observatory in the hills, where the light pollution is minimal and the stars are able to shine through. At one point when we were in the van of the guy who picked us up I couldn't help but wonder if we were being kidnapped - we had just got into his unmarked vehicle without asking for any evidence that he was from the observatory - especially after he stopped in a random village and asked us for the money for tickets. But it proved unfounded and we had a wonderful tour of the sensational night sky from a lovely lady with impeccable English. Wonderful.

The next day we had lunch at the place where they make pisco (a distillery? refinery? piscoery?), whilst Lynn and Ed took turns in being sick. Then it was a quick dash for the bus which landed us back in La Serena, ready for the night bus up to San Pedro de Atacama.

Hello Sunshine

2011-07-11T17:11:00.003+01:00

So...

Puerto Varas was lovely, and the other big thing we did there was kayaking, and whilst we were kayaking we got to look at sea lions. I say we, it was actually we boys and them girls went on an exciting expedition to a volcano and a waterfall which was only half successful. I forget the exact details.

We got the night bus to Santiago, which was actually a close run thing because we ended up at the wrong bus station. Why a town that small needed more than one bus stations is beyond me, but at least being small there was a short distance between the two and we didn't miss anything. Phew. In Santiago we stayed at Happy House hostel , which was lovely. At first it was full of 14 year olds and being ageist (as we have already established) I was a bit worried about being kept awake by their noisy existence. But then they left and we were pretty much on our own in the whole big, clean, well decorated, free wifi-ed place except for an old German couple who had triplets at home. (I'm not making any of this stuff up.) It was obviously a slow season for the hostel, because when they found out when we were leaving they decided to move their barbecue night forward, and it was then that Ed and I spent the evening chatting to the German couple, who had just retired and were doing a big trip to celebrate. Then we went to play pool in the kitchen, and I was rubbish except for getting a lucky break and potting the black. When I was supposed to pot the black that is.

Anyhoo, the other night we went out for sushi, which I enjoyed. The others went on for a big night out, but Sarah, Jess and Lynn and I managed to escape (I forget why we wanted to) which involved an excellent bit of espionage on Sarah and Jess's part. Ash and Mike wouldn't let Sarah go, but then Jess said she wanted a goodbye hug which allowed them both to run for it. Lynn and I just watched and laughed from across the street.

I can imagine people liking Santiago when they live there. It's a nice size, there are nice parks and the subway system is very good. (All parts of a good city in my book). But really, all it has to distinguish itself from other big cities is the smog, and the smog is not a good thing. There are mountains overlooking Santiago which would give it an amazing dramatic backdrop, except you can't see them. If you stare hard you get a vague outline, but really mostly all you see is smog, smog, smogsmog. What I'm basically trying to get across to you is that there is a lot of smog there. There are also the usual churches, cafes where the waitresses wear very little to serve "coffee and legs", a good authentic English pub with a phone box as its entrance, a big statue of Mary up a hill, and smog.

The other thing we did in Santiago was go to an exhibition of bodyworks in an out of town shopping mall, which was mostly memorable because of how long it took us to find it, and then once we had found it to find where you could buy tickets and then where the entrance was. "Donde es entrada?" No-one had a clue what we were talking about. Bodyworks is that dude who dissects and preserves human corpses to show their anatomy, and none of us had done anything medical for a while...

From Santiago we went to Valparaiso, which is the second city, built on the coast by some mountains which give it a dramatic rise from the seafront. It is famed for it's art and bohemian culture, and the definite highlight was wandering around the "outdoor museum" which was full of some beautiful, beautiful street art. After wandering around we found a cafe which was essentially someone's living room, but still had a lovely atmosphere and made a relaxing end to our day. The lowlight was the worst meal out I have ever partaken in. My tuna sandwich was 60% water, and the coffee's were sachets of instant and a mug of hot water.

The other bad thing to happen in Valparaiso was the start of the stomach bug. All 6 of us ended up vomiting, one by one over the next week, each victim going down just as the previous one was recovering. Sarah went first, the night before we left Santiago. Lucky for her the bus journey was only 2 hours, but it still wasn't at all enjoyable for her. I was next, meaning I spent the second day in Valparaiso lying on the couch as close to the bathroom as possible and dosing. I was feeling better by the evening though, and the next journey wasn't too bad. Up to La Serena, just in time for Ash to hit the ground spewing.

Ash was hilarious when he was sick. It was like, "I will not tolerate illness" and he just powered through, claiming to have fully recovered just 3 hours after his first trip to the bathroom at the bus station. The rest of us went to the beach and the supermarket, and I can't say that I remember much about La Serena beyond that. The hostel we stayed in was nice though, with a very friendly proprietor, which was good because it was another place where the night bus arrived horrendously early. In fact we spent the first few hours in the town in bed.

Next, we were off to the Elqui valley, which I really did love, so we'll be positive about that!

Little by Little (Caribou remix)

2011-07-02T08:43:00.006+01:00

I've just joined Twitter, because my friend in the jungle said that it's a good way to keep up with bands and the news and everything. I should clarify that I mean my friend, who I was speaking with whilst in the jungle as opposed to my friend who actually resides in the jungle having been raised by mosquitos (how would he know about twitter?) Also, something that's mentioned so often in the media surely deserves at least a quick look, so I've signed up and am giving it a quick trial.

Anyway, Twitter offers you to attach your website or blog to your account, and I'm not sure if I should because I don't think anyone except my parents and my brother read this page these days (only they have stuck around as the posts become longer and more rambling, and the periods of silence more prolonged) and part of me would like to keep it that way. Of course part of me longs for fame and recognition, a book deal and an offer to write a screenplay based on my experiences, but I keep that part in check and continue to write mostly for myself and enjoy the fact that it's easier to stay anonymous and therefore write with impunity if no-one knows that you are writing and all of your bad grammar and nonsense gets lost in the wash of an internet that is already saturated with both.

Which brings me neatly on to Bariloche, which was our first experience of the foot of the South American Continent and Patagonia. It's also called 'The Lake District', which means that I've now visited two different lake districts before setting foot in the original, much lauded version in my own country. So I'll try to put that right once I'm done with the Thai rainy season.

Anyway, Patagonia is beautiful and I really hope that I can spend more time there in the future. As I mentioned before, the climate suits me perfectly and the potential for trekking, and boating, and skiing and just gazing at such a glorious piece of creation fills me with joy and I sincerely hope to spend a lot more time there once I'm done with of America, Canada, Brazil, Central America, Southeast Asia, The Trans-Siberian express, South Africa, Eastern Europe and the parts of England that I haven't seen yet. Not too sure where I'm going to fit a job in amongst all that...

We arrived at the bus station and squeezed into two tiny taxis. Our hostel was beautiful with wooden floors and friendly staff and a perfect setting right on the lake. The girls stayed in a 3 bed apartment at the top, which gave us the chance to cook for ourselves whilst we stayed there, which was good in terms of economy and also health because South American restaurants do tend to serve mostly grilled meat and bread or some other carbohydrate. On the first night as we walked back to the hostel we were lucky enough to witness a spectacular array of colours in the sky just as the sun went down, and I began to feel very happy that we were staying in this beautiful town for at least 3 nights.

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On our first full day in the town, Ed and I resolved to make the most of our time and got up early to go to the tourist information office to ask where the best trekking was to be had. The first lady had perfect English, and listened patiently to my Spanish question before telling us that it was a different tourist office that dealt with maps and trekking. So off we went to the correct tourist information office, and the lovely lady there told us all about Frey. Once back at the hostel we overheard the proprietor telling other guests exactly what we'd left at the crack of dawn to find out.

A short bus journey ensued, and then we were off, starting from a small ski village, deserted until the snow arrives. The autumnal colours were brilliant, and the lake at the top was a beautiful setting to rest our weary feet and eat before we started on the way down. We were joined by a Norwegian guy who planned to work at the refuge at the top of Frey, and as such did the same long trek with his 75 litre rucksack on. We offered to take turns with it, but he said that he planned to do this journey multiple times and therefore needed the practice. The girls looked on admiringly.

I forget the exact order of the next few days, but one of them was spent relaxing in the town and another was spent cycling around El Circuito Chico, a picturesque journey which was gruelling during the climbs and exhilarating during the descents. I remember the place that we stopped for lunch mostly because it's the only restaurant I've seen built from a disused petrol station. The girls didn't cycle, but rode horses around a similar area and we spent the evening debating who had gotten the best views during the day. We did eat out one evening, only so that we could try the steak and cheese fondue that had caught Lynn's eye. It was pretty good, although Lynn said that she did better at home.

The next day we got the bus to Chile, and in particular to Puerto Varas. Crossing the border was an experience, as Sarah had a sudden panic that she was in effect smuggling marmite and peanut butter into the new country. She ticked "no" on the declaration, and then crossed it out and ticked "yes, I am carrying foodstuffs". She then crossed this out, and invented her own box specifically for peanut butter and marmite. It was with great trepidation that we watched the sniffer dogs wander through our bags (I had a sachet of soup in my shoe that I forgot about, but they didn't find it), before Sarah decided she had better get out the two jars of condiment and throw herself on the mercy of the customs officials. They were quite interested in the marmite, and it wasn't until Ed offered to eat some that they seemed convinced that it was, in fact, food, but otherwise they just laughed at us and made Sarah fill in a new form. Smooth sailing after that, over the mountains and into the thin line of a country that is Chile.

Puerto Varas was in fact build by German immigrants, so it has an altogether more Bavarian aesthetic which suits it's green Patagonian setting very well. It's also overlooked by a massive, conical volcano which gazes at you ominously from across the lake on a clear day. Being the first of May, and a Sunday absolutely nothing was open except a small coffee shop and a little "supermarket" just down the road from which we were able to fashion a reasonable meal from a pumpkin, pepper, some rice and the soup sachet that I had smuggled in.

The hostel we stayed at was Casa Azul, which is one of the nicest places I have ever stayed in anywhere. The kitchen and living area were so homely, the rooms so simple but comfortable with lovely little touches, and the German owner so friendly that I lost all faith in the lonely planet because it didn't even list the place. We only found it because it was in a free guidebook called "Get South" that we had picked up, and found it the nearest to the bus station. That evening the owner put on the David Attenborough series, "Planet Earth" for us on his plasma screen and chatted to us until we went to bed.

I'm conscious that I'm running out of time to write these travel-journal entries, but also concerned that this entry is already far too long to be quickly read, so I'll sign off here, and be glad that at least we've got to the second country of the trip!

Who Cares What The Question Is?

2011-06-24T12:32:00.003+01:00

Occasionally I joke that it's going to be a bit odd that a lot of the people I went to medical school with and a lot of the people that I was an F1 with will be big grown up registrars when I eventually return to the much-cherished NHS, but really there isn't a single fibre of my being that has any doubts that the past 2 years out of the system hasn't been the right thing to do. Medicine is 95% about experience, and I have 18 months extra experience than most of the other core trainees that I'm going to be starting with in August. Also, I got to live in New Zealand for a year and a half, and spend the past 3 months circumnavigating the globe.

Anyway, what made me think of this is that at the moment I'm really excited about medicine and going back to work again, and I can't imagine that I would feel this energised and motivated if it weren't for the past 6 months off work. Let's see if it lasts till Christmas. When presumably I'll be on nights...

So, Mendoza then. A pretty, greenish, biggish city with a Mediterranean climate, and happily only 2 hours away from San Luis. At this point we slowed down a little and had 2 nights in this warm, relaxed place, staying in a hostel with a massive group of English Gap Year kids. "Yah, yah, darling, I'm flying to Thailand in June. I'm literally so excited for Asia." It literally was just like that. The word literally has literally never been quite so used and abused as by those 18 year old. Especially the one with the terrible moustache. Max, I think his name was. Sorry Max.

Anyway, we found a company called Bikes and Wine, which lived up to it's billing fairly well. There was a little village just outside Mendoza called Maipu, where we were given bikes and a map and left to tour the wineries. The whole area was beautiful, with tree-lined avenues and vineyards backed by snow capped mountains in the distance. Cycling through the sunshine, stopping to taste wine and tour vineyards is a sensational way to spend a day, and it wasn't just the wine. One vineyard had an excellent restaurant where we stopped for lunch and another sold all manner of chocolates and liqueurs. All in all an excellent day, and I was still cycling in a straight line by the end of it.

When we got back, the very sweet Gap Yah girl Anna asked us if we got "totally lashed?" There was an awkward silence before I said, "Um, no... We're over 25." "Oh," said Anna, "I hope I'm still getting lashed when I'm 25." Everyone told me off later for being a bit mean about the poor gap children. Which I suppose I was, although mostly I just held my tongue as I heard these newly unaccompanied children spout the nonsense that only 18 year olds can spout. But then I expect people in their 30s would probably be very scathing of everything I say and do. Although that probably has little to do with age...

That evening we learnt to Tango. A Danish dude translated the Spanish into English for us, making me again ashamed of being so hopelessly monolingual. It's not easy, especially for the men who are supposed to lead the women around the floor in extremely tight steps without stepping on your partner's toes. But it was fun, and a quintessentially Argentinian experience.

The next day we just laid around in the sunshine by the pool, and it was lovely. I snuck out for lunch at MacDonald's, only to be caught by Ash as I walked back to the hostel. My love of junk food became a bit of a joke amongst the group, along with my propensity to nearly lose anything remotely important at every opportunity, Ash's 5 page emails to the American girl he met in Buenos Aires, Lynn and Lucy's amazing ability to buy all flavours of tat wherever we went, and Sarah's general grumpiness with everyone.

Anyway, that night we headed off to Bariloche, and the cold weather that kept me smiling. It's quite tragic how happy I am in the cold. I don't think it's normal, although Ed told me he felt the same way. I'll talk about that more next time.

The Tallest Man, The Broadest Shoulders.

2011-06-20T16:38:00.002+01:00

Of course, as I get further away from all this stuff that happened, the less detail I shall remember it in, the shorter these posts shall become, and then on the 3rd of August normal service shall be resumed...

Believe that if you will. I'm going to have to be sitting exams, so it probably will become quite regular as procrastination suddenly gives writing an added shine. But now we're talking about San Luis, and arriving at the 5'o'clock when everything's dark and everyone sane is asleep. Still plenty of stray dogs around at 5am, but then there appears to be no shortage of stray dogs anywhere in South America. I'm not the biggest fan of rabies, and therefore of these strays, so it was with quite some irritation that I had to hang around two girls who used every opportunity to name, adopt and stroke every stray anywhere in their vicinity. Towards the end of the trip the sound of, "hello doggy!" or worse, "hello gorgeous!" was beginning to make me want to hit something, girl or canine. And don't complain to me that you've got fleas, or that you're hand is now too filthy to eat ice cream. Go and tell "William" and see if he apologises. Grief.

So, that's a fairly good appropriation of the mood we were all in as we sat in the cafe and waited until it was late enough to make our way hostel-ward. To amuse ourselves, we ended up putting effervescent vitamin C tablets straight into our mouths and let them fizz on our tongues.

The point of stopping in San Luis was Sierra de las Quijadas National Park, where we had heard there were dinosaur footprints. This meant leaving the hostel as soon as we arrived, and getting on another bus which dumped us by the side of the road, seemingly in the middle of nowhere. It was around this time that I started feeling quite apprehensive, but seeing as I hadn't contributed to any planning or decisioning on the trip for a couple of days I didn't want to say too much.

We walked in the direction that we hoped the dinosaurs were in, which just happened to coincide with the direction two confident Spanish-speaking tourists were heading. Before too long, we came to a ranger's station, and the ranger came out to greet us. Now, he spoke no English, and you already know what our Spanish is like. ("When English people say 'Poqueno', that usually means almost nothing"). I had made good progress with Maria, but then failed to use Spanish often enough, and besides she and I hadn't ever got on to dinosaurs or footprints.

"Where can we get a guide? We want to see the dinosaur footprints. Will you guide us?"

Ed was trying to convey what we were saying through sign language, but stopped when it got to Dinosaur. A pity really, because we'd already compared dinosaur impressions and his wasn't bad.

So, it turned out the ranger was just explaining that it was a 6km walk down to the next station where there were toilets, a restaurant and guided walks. And in trying to explain this simple sentiment he had to endure English people demanding guided tours from him, and half a dinosaur impersonation. In the end we were picked up by a dude in a minibus, so we didn't have to walk far at all.

There were two guided walks, one which took in the footprints but little else, and one which went right down into the valley and took in a lot of scenery. We chose the latter, which didn't please everyone, but probably was the right decision. It turned out you couldn't get too close to the footprints, and the scenery in the valley was just spectacular. I was particularly happy, because all the time in cities had been leaving me a bit cold, whereas I find long walks amongst stunning natural surroundings a total joy. You can see from the photo, that it's somewhere between the Grand Canyon and Sion national park for it's views and its rock formations, but whatever it is it was beautiful and I really enjoyed it.

The guided walk was also in Spanish, but we were able to get the gist of the guiding and enjoy all of the walk. Then we did have to walk 6km back to the road, and flag down the bus as it passed. All this went completely smoothly, and before long we were sunburnt and exhausted in the centre of San Luis. Our hostel was terrible - humungous, uncomfortable dorm room with half of the lockers broken and no internet facilities. They also charged us extra for early check, although I thought that was fair enough. That said, it was the only real bad hostel experience we had.

San Luis though, for all we thought it was a bit of a nothing town that just happened to be near a national park, turned out to be a charming and pretty place with a fantastic night market in the square (at least there was a market there and it was night) and one of the best meals out of the holiday. I will blame tiredness for the fact that I walked out of the restaurant without my bag which had laptop, camera and passport in it. Thank goodness for observant friends. Sadly, that wasn't the only time they were called upon. It's fairly miraculous how little I lost actually. That, along with the stray dogs was another of the themes of this holiday. I'm really sorry Mum. If it makes you feel better, all my valuables are locked in a draw in Thailand.

Cordoba

2011-06-01T05:20:00.003+01:00

Last order of business in Puerto was another trip to the police station to get a report for Sarah's iPod. No tourist police or interpreters in Puerto, she and I managed to muddle through nevertheless. It's interesting to see how easy it is to make yourself understood in these kind of circumstances, even though none of them spoke a word of English. A point to your ring finger to ask if you're married, miming of earphones which Sarah was determined to point out cost £100, and raised eyebrows when we said we were "Medicos". Really? You? Both? Doctors?

Lunchtime came, and it was time to board a new bus, now on to Cordoba. Ash and Ed got up early to spend more time at the Falls, and were rewarded with blue skies for their photos, but they did cut it a bit fine with the bus. Still, we were all loaded on and in place when the bus pulled away and made for Argentina's second city.

After about 4 hours on the road, the bus stopped. Protesters weren't allowing any bus or lorry past. People were getting out of vehicles and walking the other way. Should we be going that? We didn't have a clue. We couldn't walk back to Peurto, but there was another little town a bit further back. Isn't it better to stay on the bus? The bus driver told us it could take another 5 hours before they let us passed. We got on with playing cards to pass the time.

Eventually we got going, although now we were 6 hours behind schedule. Not the end of the world, but because it was 6 hours later that we picked up the meals for the passengers, it meant we were woken at 4 a.m. to be served ravioli in a meat sauce. Gluten free Sarah was not impressed... Neither was I though, Ravioli has to be pretty good to be woken up at 4am for.

We got in fairly late the next day to Cordoba. We hadn't booked anywhere to stay because nowhere would let us book in advance for just one night of the easter weekend. But then, when we rocked up in the city, all the places we phoned were now full. Fortunately the lady at the tourist information took pity on us and rang around a number of places for us, and we took the last 6 beds at turning point hostel just a few blocks away.

Cordoba is quite a pretty place - lots of good looking architecture and a nice park. It's supposed to be a real student city, with over 20 universities or something like that. That evening we wondered around until we found somewhere to eat - we went for an "English" pub, called Golden's which wasn't really an English pub at all although the food was good, and we had some nice Patagonian beer. Then I think we just went back to the hostel and drank more beer, because the hostel gave each of us a free litre bottle of a beer called Cordoba. We also played cards for a while too.

The next day we wandered around the cathedrals and the museums, and sat in a few different cafes. I wanted to spend longer in the park, where there was a cool sculpture made up of 200 coloured rings, one for each of Cordoba's bicentennial. Instead we went to an art gallery, which was fine, but what can you write about another art gallery?

I suppose it's coming across that I don't have the strongest memories of Cordoba as a place, but that's partly because we were rushing about at this point staying only a night in each place. I do remember Ash and Sarah going off to have secret chats during the afternoon, and Lucy and Ed seemed to be getting pretty deep as well. "Are we all 15 again?" I wondered, as I sat on a bench in the (very lovely) main square, shooting the breeze with Lynn.

I also remember the hostel had bed bugs. Not good - I woke up with a very neat line of bites just above my left elbow which itched like crazy. I told the dude on the desk, and he didn't seem to know what significance that had to him. He was German, but spoke English with an American accent, so I already had a fairly low opinion of him.

Another night, another bus. This time is got us to San Luis, and this time at 5am. But more on that later.

Written On The Forehead

2011-05-30T02:40:00.003+01:00

I'm currently sitting by gate 11 at Santiago airport, where my time in South America is about to come to an end. And so far I've only just written about my first week in just one city, so I'm not sure I'll finish this before August when my new job starts and I get to write whimsical nonsense about a brand new hospital. Still, I've got two hours before departure - I left in plenty of time just like my mother said - so let's get on with things.

So yeah, PJ Harvey. Her new album is rather brilliant. I haven't been this struck on anything on first listen for a long time, but this is really beautiful. I'd check it out if I were you...

Thinking back, we were rather lavish at the start of this trip. I've already mentioned the constant eating out, but we also decided that we would go for the proper first class, totally flat bed bus for the trip up to Puerto Iguazu - the town on the Brazilian border which it looks like Argentina has stretched out an arm to grasp at. Or at least we would have, but there were only 4 spaces available, so Ash and I took the slightly less lavish option where the beds reclined to a very restrictive 160 degrees. In the end that was the only "Total Cama" bus that we took, so I never found out how comfortable they were, or how nice it was having your own TV screen and entertainment system. But from what the others said, it was very nice.

Anyway, bus is the way to get about in Argentina, and there are a myriad of bus companies to choose from. In fact, when Ash and I saw a bus that said "Puerto Iguazu" due to leave 5 minutes before ours was, we assumed it must be our bus, and that we had made a mistake. Nope, they just really are that frequent. We found the right bus, strapped in for the night and awoke many miles further north where the weather is much hotter and the mosquitos much more fierce.

Puerto Iguazu isn't actually a bad town, given that it pretty much just exists for the big, massive waterfall just a few miles away. There is a fair amount there, and it's even famous for it's nightlife - something we didn't experience given our tight schedule. All I remember is seeing a poster promoting "the only pub crawl involving 3 different countries!" which made me roll my eyes.

The first thing that Ash saw when we stepped off the bus was the others. Suprising given that we had left an hour before them, but not at all a bad thing. The first thing they told us was that Sarah had had her ipod stolen. So that's half of us falling victim to light fingers with in 4 days. Nice one Argentina. Apparently she had fallen asleep having put it on a shelf just next to the door. We all vowed to be a bit more careful from then on...

Anyhoo, we checked in to the hosteling international hostel which wasn't at all shabby, although they didn't have a key to let us lock our dorm room which was a bit annoying. As mentioned, the schedule was tight, so we wasted no time in getting the bus from the town, to the national park.

Just like the Grand Canyon, no photo or video or description can ever do Iguazu Falls justice. I remember walking along the walkway to the viewing platform, and noticing how everyone who was walking the other way was dripping wet. The power of the thing is overwhelming, and the mist it throws up soaks you through and stops you from seeing to the bottom which gives the cool illusion of being bottomless. It is so big, so powerful and just stunningly, stunningly beautiful. Even if you get bored looking at the waterfall then there are plenty of butterflies, turtles and beautiful birds to snare your wonder.

There is a train in the park that takes you to the various viewing platforms. There's also a boat to an island, but sadly the river was too high to get over there on the day that we went. I was happily filming a pelican that I had spotted in a tree, when suddenly I was yelled at to run to catch the train. Ash and Ed didn't run, so we all got separated, which wasn't the worst thing because they ended up on a different route so got slightly different photos. One of my favourite photos is of a tiny little waterfall which is just around the corner from the main one. It just makes me wonder why I bothered taking it. "Here is a fairly normal sized waterfall that just happens to be around the corner from one of the world's largest." Ooooh.

So that's kinda it. We saw the waterfall, and it was beautiful and humbling. I took photos, and got a bit wet. Then I crammed onto a crowded train bench, where a fat person was trying to get away with taking up two seats. No luck buddy, for either of us it seems. That night we went to a "parilla", which is what Argentina prides itself on - the best barbecue/grills. And it was pretty good. Then we stayed up late playing cards with fellow travellers, who taught us the game that would keep us occupied for the next 6 weeks. In between hands, Joe (who taught us the game) told me all about how he wasn't going to settle down now that he was 32, just because society told him to. I nodded, mostly because that's what you do when people that you don't know spout life philosophy at you.

And now they're bording my flight. So I'd best get on. Next stop Auckland again! Woo! In the travel story, we went to Cordoba next. So, you have that to look forward to.

Leaving Buenos Aires

2011-05-20T21:28:00.003+01:00

The next few days in Buenos Aires followed a pattern. I spent 3 hours learning Spanish from Maria, from Barthelona in some of BA's loveliest cafes. Maria is a film student who is teaching Spanish in her spare time to earn cash. I got spectacularly lucky given that I was the only one in the class, and so she just made me speak Spanish, whatever I wanted to say or ask, for those hours for 4 days. Cafe Tortini was one, notable for being the oldest cafe in Argentina and making a conscious effort to be dripping with culture. (I had a pepsi.) Another was in a beautiful bookshop, which was easily my favourite. It made me want to open a cafe of my own, full of books that people can just pick and peruse as they sip on kiwi-style flat white coffees...

In the afternoons I tried to get some sights in and Buenos Aires isn't short on sights. Above is the Recoletta Cemetery, where dead people get bigger rooms than I did in my 4th year at University. Another was an art gallery, where sketches by Picasso on torn pieces of notepaper are framed because they are Picasso. Otherwise there were some very beautiful pieces - one that sticks in my mind was a wooden bench whose wooden slats twisted and snaked across the gallery at its far end. Very cool.

In the evenings I met up with the other three, and we went to different places for dinner. Usually we went with what we found, but after a couple of less than exciting food experiences we decided to turn to the lonely planet. Sarah led us confidently in the certain direction through Palermo, announcing, "At school I once won an award for orienteering. I am an excellent mapateer." When we retraced our steps about half an hour later we realised that it was just as she announced this that we had taken a wrong turn.

In fairness to her the restaurant we were looking for had shut down. (That's -2 points to the Lonely Planet at this point.) We did find a beautiful little place whose name I can't remember, but we all had gorgeous dishes. My lamb and lemon risotto was a sensation, and we still thought it was the third best thing that our table was served. So that was a hit, as was the Sushi place on Thames the next night, but there were also misses too. Italian restaurants litter the streets, but I don't remember ever being impressed by one. Funnily enough, the only restaurant that we ever had to wait for a table at was when we were trying to eat after midnight - as I've said, the city lives for the night.

On Thursday, Lucy arrived and on Friday, Lynn arrived. So now we were a group of six. Which, when we met other travellers often led to:

"So, how do you know each other?"
"Well, I know Sarah, who knows Ash, who knows Ed, who knows Lucy, who knows Lynn."

But we were all very firm friends within a few days, and I enjoyed travelling with that group a lot. I suppose if you're all doctors, all who worked in NZ for a bit and all who fancied travelling around South America then you're bound to find something in common. Ed and Lynn are even going home to start ED training in August...

I've called this post leaving Buenos Aires so I suppose I should get to where we got the bus to Puerto Iguazu. Two things of real significance happened in our last remaining days, and they kind of overlap so I'll try to be brief but I could easily write a whole post about both. The first happened in two parts, and that was going to see Boca Juniors play Tigre at "La Bombenera". The first part was buying tickets. We already knew that the party hostel did a transport and match package for AR$300, but thought we'd see how much the tickets cost on the door so got the subte to as near Boca as we could and walked to the stadium on a mission of information. We found the shop, and asked about tickets. Unfortunately they don't just sell tickets to whoever walks up to the door. They sell normal seats to club members (and they have twice as many members as seats) and they sell tourist packages complete with box and champagne for far-more-US-dollars-than-we-had-any-intention-of-paying.

"Or you could buy tickets from one of the touts. That fat dude on the door is pretty good, his tickets are usually genuine."

We went across to a nearby cafe. Did we want to buy from a tout? Even if they were recommended by a staff member in the club shop? We were uneasy, but after a pack of crisps and a pepsi we decided that "when in Rome" (or as we've taken to saying "Cuando in Rome") we would hand over AR$200 for something that quite clearly said AR$40 on it's face. "You may as well take them all for now Steve," said Ash, thinking that it would be easiest and safest.

The tickets turned out to be with the away fans, which I suppose served us right. Argentinian fans are renowned for their passion and the atmosphere at the games, but we were more concerned about their reputation for violence at the games when we found out where our tickets were. But we got our "seats" early, near the police and near the exit. They weather was beautiful and the exceptional thing about the the Bombonera is that even up on the second or third tier you still feel like you're right on the touchline. Only Ed and I really knew or cared much about football, but we all loved the game, which finished 3-3, and the atmosphere was every bit what we had heard it would be. We bumped into a Brazilian dude who had the same tickets as us, and watched the game with him. It was awesome, and who knows how dangerous it really was?

So, on to the second event, which was being robbed. Ugh. We had moved to a new hostel for the last few days, and I had helped the other 5 move their stuff. I had just been back to the party hostel for my big bag and was walking alone with it for possibly the first time since I had arrived in Buenos Aires (barring the time when I crossed the road from Mundial to Party hostel). By this time I had walked home at 3 a.m. without feeling scarred, so I had a feel for BA as a safe city (which in the grand scheme of things it still is, particularly when compared with, say, London.) I was only two blocks away when someone threw some vinegar or something foul over me. Oh yes, I fell for that trick. The one that is detailed quite specifically in the Lonely Planet. The woman walking beside me looked concerned. She tried to speak to me about it, and I was quite happy for the chance to practice my Spanish. "It's fine," I said, "I'll sort it in a moment." "But it's everywhere!" she said, looking unhappy about letting me walk away in such a state. She persisted, so I finally put down the big rucksack to take a look. It was all over the rucksack, and down my jeans, and she did have a tissue in her hands, so I thought a quick wipe down couldn't hurt.

As I quickly wiped my bag down and she helped, another passer by stopped by us. "Oh dear, that's not nice!" he said to me, in Spanish. "It's fine, it's nothing", I replied as the lady moved on to wiping down my jeans. "No, no," said the man and offered his water and more tissues to help. "Are you dutch?" he asked me as I wiped. "English," I said. "And you speak Spanish?" he asked. "A little, I'm learning." I replied, all the while thinking how nice strangers could be. The lady had finished my jeans at this point and walked off as the man chatted to me. We didn't say much more, and he offered me his bottle of water as a goodwill gesture, and I carried on down the street.

About 10m down the street, the gears in my mind finally clicked into place. "Why would people throw stuff on me in the first place? Hang on, isn't that a trick to... Uh-oh, where's my wallet?"

Neither the man or woman was anywhere in sight, and besides, running with a 95 litre rucksack isn't that easy. I kicked the wall, annoyed with myself for being so stupid, and with people for being such bastards. I went to the hostel and vented my fury. Worst of all to my mind, we had lost the Boca tickets that we had spent the morning getting. My cards and my money were nothing, my friends had also lost AR$200 each too through my mistake.

I cancelled my cards. It took 3 Skype calls (why is nothing easy when this kind of thing happens?) but fortunately no money was taken in the meantime. Ash had had his wallet lifted on the tube a few hours earlier, and the perpetrators got away with £800 and $1200 Kiwi before he convinced himself he hadn't just misplaced it and checked his bank account. All in all I didn't lose much, and I was lucky enough to have kept my kiwi cards separate so money wasn't an issue either. Ash did a lot worse, and seemed a lot less annoyed than me! But still, being robbed sucks, and it wasn't until a day or so later that my faith in humanity and sense of humour returned.

The trip to the police station was funny. We went to the tourist police where "over 40 languages are spoken." The first police dude didn't speak English and heard us try to explain what had happened in broken Spanish (to be robbed was not a verb that Maria and I covered) for about 20 minutes before fetching his colleague who had lived in London for 7 years. Thanks. The second policeman was a chilled out dude, who gave us a number of options. Getting a translator to come with us to the appropriate local police station depending on where we were robbed would take hours. He could instead pretend that we had been robbed nearby and send us sooner to the nearest police station with one translator, or he could pretend we had just lost our wallets and issue a report right there and then. He even offered to change the date, incase our insurance needed the report to be issued within 24 hours!

But I suppose it's all a game. There are plenty of pickpockets, and pinning individual crimes on them isn't what it's about. I only got as far as, "They threw some vinegar on me..." before he stopped me with, "It's an old trick." We both know we're there so that we can claim on insurance. But still...

Anyway, that was Monday, and later on I bought a Boca shirt to remember the good experience from that weekend. We bought more tickets on match day from the same tout. I'm collecting my new cards in New Zealand. Monday evening saw us on the night bus to Iguazu and the fun times continued.

More BA

2011-05-12T13:06:00.000+01:00

Probably should pick up the pace, but either way I doubt I'm going to finish this before I get home, so we'll see how it goes.

Hotel Mundial (let's get into travel guide mode) is right in the centre of town between two big plazas. Plaza del Congreso has the congress building and lots of statues (and, by the way, a small internet cafe), and Plaza del Mayo has a big museum and a big red house called Casa Rosada. (Translation - Big Red House.) So, it's as central as anything in Buenos Aires, which is ultimately rather meaningless because BA is huge and everything is a fair old walk away from everywhere. We got fairly au fait with the taxis, although that combined with eating out every night meant that BA has been far and away the most expensive leg of this trip so far.

Otherwise, the hotel was fairly standard for a 3 star hotel. Clean, decent breakfast included, friendly staff although my room was a little bit poky. Still, I've never seen the point in staying somewhere overly luxurious - I was only planning to sleep and shower there. If the hotel's so nice, why go outside? And in that case, why come to Argentina?

Anyhoo, the next day we walked towards the Dique (little inlet - bit like a river) where we had drinks, and later lunch, and saw some turtles on the rusting wreckage of some old boat. We also got to the parks, and then to the ecological reserve which is just by the sea (pictured). One beach smelt horrible, and there was a bloated dead fish amongst all the rubbish. The one in the photo was a lot nicer, and we sat chilling for a relaxing few hours, whilst more joggers went around and around.

In the evening we went out for steak, again in Palermo, which was delicious before we hit the bars in celebration of Sarah's birthday. Imaginative souls that we are, we ended back at the same square as the previous night. Somewhere in the course of the night, Ash ordered tequila, which came in a ridiculously big glass (heading for 100ml) and tasted very sweet and strange. But it was Sarah's birthday, and we were being gap year kids, so I went with it and somewhere along the way - either the steak or the tequila although I really didn't drink much else - I ended up spending the next 24 hours throwing up in a serious attempt on the world vomiting record.

So that was that day. Sarah was also vomiting so perhaps it was the food.

Sunday wasn't a complete write off as it turned out. I was fine after some anti sickness pills, and felt pretty human again by the evening. So in this said evening we went to watch Il Trovatore at Teatro Avenida. We bought the tickets the day before - very reasonable - but something got lost in translation so we ended up with standing tickets, which wasn't too bad and we found somewhere to perch for the second act anyway. Also lost in translation was the story of the opera, which is apparently notoriously hard to follow even for Spanish speakers. Still, the music was exquisite and plans were made to go to more classical concerts once I'm back home...

So, I didn't run on Sunday because I was sick, and then I didn't run on Monday because I had to move my stuff to the new hostel. I chose the hostel mostly because it was 100m from hotel Mundial. Milhouse Avenue is definitely a youth hostel, and I definitely felt like a grumpy old man hoping that the kids didn't make too much noise with their nightly parties. Still it very well decked out, provided every imaginable service, and the bar/common area was beautiful and deserted before midday. The poor kids need their sleep...

Now (I hope this isn't too long or rambling) both Ash and I booked our Spanish lessons through STA travel. I tried to book the same one as the others but it turned out to be fully booked. The guys turned up on Sunday to two different, but both equally closed and empty addresses for their Spanish school and had to book a hostel for that night. (Their school included accommodation.) I turned up at the time and place for my Spanish "on the move" and waited an hour in Bar Britannica, harassed the staff a little but did not find any sort of Spanish course. This was despite a Spanish vocabulary now of over 7 words. So two Spanish schools, two sets of incorrect information. I emailed them later, and found out that Maria had been told a different time and place, but would happily give me the extra lesson on Friday. STA generally are great, but that wasn't too impressive. However it was amusing watching Ash striding around with his massive rucksack, convinced that he knew where it would be, and re-reading the information 20 times a minute, looking for the all important extra clue in the symbols on the page...

I spent the rest of the time on Monday afternoon wandering around San Telmo, which is the arty part of the city. There were two people dancing the tango at the beautiful Plaza Dorrego, the streets are cobbled along many of the roads, and Parque Lezama was a nice, green, shady place to sit and read for a bit. At some point I even stumbled upon an English pub which made me laugh. I didn't go in though. Didn't fancy going for the British stereotype. "When abroad, look for the most English thing possible and sit in it. Bien."

In the evening I brought the rest of the guys back to Plaza Dorrego, and we had a fairly forgettable meal in the plaza - by which I mean I've forgotten if the meal was any good or not, but I did enjoy the ambience of the square and the jazz trio that played us through the night until we all went home.

Up to the dorm. Earplugs in.

Palermo et al

2011-05-10T14:49:00.004+01:00

Palermo is the posh area to the north of the "microcentre" of Buenos Aires. My Spanish teacher, Maria, rolled her eyes when she heard that we headed straight for the affluent, bohemian land of bars and restaurants on our first full day in BA. "I loved it when I arrived in BA, but now I can't stand it..." she said with her beautiful Catalan lisp.

Not really sure where I was aiming for, I had set off on a route that would take me through the gardens. There are a number of these and they are very green and pretty and filled with statues and joggers. "This is clearly the place to run," I thought, as I strode through the sunshine. The rucksack I've travelled with for the past 5 years is pretty big, and so when I had packed everything I thought I'd need for this trip, I found that I still had plenty of space. Rather than think, "Great, my rucksack will be lighter, and I will have room incase I need to buy anything when I'm out there," like a rational person, I instead thought, "Well, I may as well pack my running shoes given that I have room to use up," and so began my intention to run in a number of South American cities.

My plan to meet my friends in Plaza Italia had crystallised as I reached the Jardins, and so I took a left, and headed in the direction of the plaza. Buenos Aires is full of these Italian style squares, very pretty and usually with a number of statues (see previous post). I took a few photos (which I seem to have lost...) and some video, and then sat down with the lonely planet and read all about BA whilst I waited for Sarah, Ash and Ed to turn up. Reading the LP is a bit like reading a menu - something about them turns my mind into a sieve, and I am unable to retain any of the information that I read. I read about all the hostels and restaurants in the area, and yet when the others turned up, I couldn't tell them a thing...

The four of us went for lunch in one of the first cafes we found. I ordered a chicken sandwich (because it was one of the few things that I understood on the menu) which turned out to be a quarter chicken in a baguette. No salad, no sauce. Fortunately most cafes in Argentina serve you bread whilst you wait, so I had plenty of bread to eat with my chicken and bread. And coca-cola - unsuprisingly the second most recognised English words on the planet. Sarah - who is gluten free - had been learning the all important phrase. "?Hay comida sin trigo?" - Is there anything without flour? She ate quite a lot of eggs in Buenos Aires...

Ed and Ash, it turned out, had both learnt Spanish before, which made life a little easier. The four of us wandered around Jardin Botanico Carlos Thays before heading back to our hotel to get changed for the evening. At the hotel I had my first experience of "boxercise" - the less said about which the better to be honest. I didn't need to join in - I was planning to run in the next few days.

We headed out for food around 7p.m. which is practically the morning by Buenos Airean Standards. This city lives for the night it seems, with restaurants empty until 10p.m. and the streets still full at 3a.m. We found our way to the wonderful Plaza Corteza (aka Plaza Serrano a photo of which is above) and found a bar with a balcony where we spent the rest of the day drinking caipirinhas and eating. Again going for the safe option I ended up with a hamburger, which, again, turned out to be meat in some bread. A theme seemed to be developing, and I can't say my opinion of BA as a city of culinary delights ever really improved. It has many virtues as a city, but its eateries cannot be said to be one of them.

Still, Corteza was a lovely place with a beautiful ambience, from which we shot the breeze and watched the hustle and bustle of the so-called Palermo Soho (there's also a Palermo Hollywood apparently...) from a balcony overlooking the square, where the street vendors were packing up and the many bars were coming to neon life. We stayed until around 11pm (I hadn't slept since the plane remember), before getting a taxi home, checking in to the hotel properly, and reflecting on how exciting this pseudo-gap-year was becoming...

Supercolider - (new free Radiohead song) or What's New, Buenos Aires?

2011-05-02T02:45:00.005+01:00

Hola todos.

So, I'm currently in Santiago, having left for Latin America almost 4 weeks ago. So what better time to start my exciting, if slightly hazy, account of the Latino road on which my friends and I have been travelling? The short answer to that is, of course, 4 weeks ago. Well I'm sorry, but right now is my final offer.

And so it was, on the evening of the 7th of April, I kissed my mother goodbye at Heathrow airport, and boarded BA flight 205 to Buenos Aires. For once I'd learnt from my, now fairly extensive, long haul flight experience and checked in on-line as soon as possible and booked myself an emergency exit row seat - i.e. one with lots and lots of leg room. And so the 18 hours to the Argentinian capital was passed in relative comfort, chatting to an Argentinian-Dutch couple, and South African-Italian air hostess. Being plain old English is quite dull sometimes.

Immigration, Baggage reclaim, Customs... All very smooth, and an exciting new stamp sits alongside the others in my now slightly battered passport. I head to the "remises" - pre-paid taxis. These aren't the cheapest option, but given that I did not speak one word of Spanish beyond "Que Pasa!", I decided that I might struggle with the shuttle, plus this way I was delivered straight to my door.

Soon I was speeding through the outskirts of Buenos Aires, and getting an idea of just how humungous this city is. Also how European/Western it feels. I'd heard that Buenos Aires was once fabulously rich, the location of the world's only Harrods' outside Knightsbridge, but then I had also heard about a recent economic collapse, and Latin America in my mind was only slightly ahead of Africa in the development stakes.

Completely wrong. Aside from a few more security guards on shop doors, BA could be any European capital. The streets bustle with every kind of person, the blocks tower over you boasting impressive European architecture, and the roads... Ok, Buenos Aires is like nowhere else I've ever seen when it comes to driving, except perhaps Mumbai. Portenas (BA citizens) are nuts! Like proper, crazy, every-inch-is-up-for-grabs, insane. You couldn't pay me to drive along any of it's quietest, one-way streets. Two cars would cut me up on the inside every time I took a second to look in the mirror. I couldn't watch the roads whilst we were in any of the taxis in case my heart stopped. True.

Anyhoo, I dumped my luggage at the lovely hotel Mundial, and set about wondering how I was going to get in touch with my friends given my aforementioned non-existant Spanish. I tried texting from my English number - no reply. That was all of my ideas exhausted there and then, so I started to wander around to get a feel of BA as a place. (I passed 7 music shops in a row.) This might strike you as a trifle disorganised, but I was just excited that I had somewhere to stay that night given that I once arrived in Melbourne, having lost my backpack in Sydney Airport, at 10p.m. the night before the Australian open with nowhere to stay. So I felt I was doing relatively well this time.

I found an internet cafe, and discovered that the Spanish word for internet is, conveniently, internet. "Internet?" I timidly inquired of the man on the desk. "Quince" he grunted back at me. A lucky guess took me to number 15, and everything ran very smoothly. I logged onto Facebook (which, if you do from another country checks that you are you by asking you to identify photos of your friends. This is quite fun, until you realise one of your friends has been tagged as a pile of pigs in multiple photos...) and found a message from my friend Sarah. "Where shall we meet you? My phone isn't working. Ash's number is 07xxxxxxxxxx."

I texted Ash, and then took care of the pressing matter of telling my mother that I was safe, and she could watch TV again without any fear of hearing reports of a plane crash or British tourist being stabbed at the baggage reclaim. Then I wrote a message in reply to Sarah.

"I've arrived and dumped my stuff at our hotel. If you get this in the next 30 minutes, I'm at the internet cafe on Hriyen Yrgroin, which is just up the road from the hotel by all the statues."

It turned out that I wasn't on that road at all, but also, and this is something that Ash was keen to point out again and again once we did meet up, Buenos Aires is full of statues in every direction. And just after sending this, I received a text message from Ash telling me to meet them in Palermo, so I wasn't there for the next 30 minutes either.

At this point, I suspect you are wondering why I didn't just ask for my friends at the hotel, given that we were all staying at the same place. To which the simple answer is stop being so clever and listen to the story. And stop questioning how suitable a doctor I am.

Anyway, I set off for Palermo, which it turns out is an hour's walk away. I payed for the internet cafe - around 5 pesos - with an 100 peso note, which did not please the owner at all. "Spanish, spanish, spanish," he said irritably, which I didn't really need any help understanding. I made the face for, "I am most terribly sorry sir, but regrettably I have only just arrived in Buenos Aires, and am only in possession of 100 peso notes. Please forgive my English incompetence," which, again, he seemed to understand. "I really need to learn some basic Spanish," I thought to myself, and set off in the wrong direction.

20 minutes later, and now walking happily in the sunshine and the correct direction, I received a text message from Sarah. "Where are you?". They were still at the hotel, and their earlier message was just to let me know of their intention to go to Palermo and not, as I thought, informing me that they were already there. Having received my Facebook message, the three of them were wandering around the area looking for an internet cafe along the very long road that I had incorrectly informed them that I was on. "Nearly there!" I informed them cheerfully in reply. At this point, Sarah, who I used to live with, carried on thinking that it would probably be a miracle if they found me in Buenos Aires that day, whilst Ash and Ed began to get a picture of what kind of person they were dealing with.

Finally, they told me to meet them in Palermo, in Plaza Italia, which I thought was the plan all along. I made it to Plaza Italia, and sat in the Sunshine, happily reading the lonely planet, putting on blue suncream and wondering if I could possibly look more like a tourist. An hour later, we did all meet, and had a lovely afternoon in Palermo, which I will tell you about next time.

Ciao!

Salute Your Salution

2011-03-24T20:36:00.007Z

You will of course remember that the plan at this point was to pimp myself out as a locum of all trades - an excellent plan thwarted by the need for an elusive piece of paper which says what I've been saying all along: "I do not, as yet, have a criminal record." This is annoying because I am missing a big money making opportunity, and because I have to live with my mother saying "I told you so". And to be fair, she did - I didn't apply for work as early as I could have. But then again, maybe my heart wasn't in it - starting any new job is never fun, and that's pretty much how working as a locum is all the time. I've got my savings, the travel plans did not depend on my earning power.

Anyhoo, I'm currently watching "Junior Doctors: Your Life In Their Hands" which is a new programme on BBC three. The Big British Castle has decided to follow 3 F1s and 5 F2s in Newcastle with cameras, and put the results on to the television, complete with voiceover to rank up the drama. "If Jon doesn't run down this corridor, everyone in the hospital could die."

Yes, well... I can't say I'm loving it as a TV program - most of the time I just laugh at its sensational style and indulge my music-geek tendencies by naming every song used as incidental music. But still, I keep watching. We're on episode 5 now.

I guess it's hard for me to judge it objectively as TV. Essentially it's my day job made into entertainment for the BBC's youth channel. I do wonder if it needs a voiceover though. Half the time it's stating the obvious, and a lot of the time it's overstating the drama. "Kia has to decide whether he wants to go down a medical or a surgical route, and soon." Then he chose paediatrics.

I know I speak the language so it's easy for me to work out what's going on, but I can't help but think that not being entirely sure what an ECG is (most people know that it's the heart, right?) doesn't really matter and like everything the interest comes out of the human drama as patients and juniors cope with whatever the big, bad hospital throws at them. I sort of wish they would let the story tell itself. You could see it Suzi's eyes that her confidence was knocked when a patient wouldn't listen to her and threatened to put in a complaint. Having a man's voice say it over and over again really didn't add anything.

But what do I know. Of course it's all very recognisable, because it is real young people doing the real job. The self-doubt, the feeling of wanting to pack it all in after a bad day, the buzz after a busy day that went well so that the hours flew by - they are all expressed fairly eloquently. Suzi, in A&E gets all the best stories of course, so no doubt that I've chosen the best specialty...

It is making me long to get back to work. I am excited with my travel plans, but at the same time there is a part of me that wishes it was August now, and I could be getting stuck in to a new hospital, and the joyous ED life. And then I can get back to moaning, and considering other careers...

Call Me a Rainbow

2011-02-27T22:22:00.003Z

One of the things that worries me about me, is how good I am at doing nothing. It's a real skill. Tonight at church I was talking to someone about my plans for the next few months. "Well," he said, reasonably, "you can't sit around for six months doing nothing, can you?"

Well, I've thought about this, and I'm pretty sure that I could. I'm not saying that I think I should sit around for six months doing nothing, or that I wouldn't be heading towards despondency at the end of it, but I still think that my inertia would easily allow it to happen. I haven't worked for over 2 months now, and it's amazing how quickly your day fills up. I haven't had any time to write the blog, as you will have noticed. For a start there is getting up, and by the time I've finished that it's practically lunch time. And then by the time I've made the decision about what to do with the afternoon it's too dark to do it, and soon after it's time to go to bed again. I suppose once upon a time I must have fit a job into that hectic schedule somewhere, but I'm really struggling to see where.

But on a more serious note, I am enjoying this break, and I am doing quite a lot - reading, writing, running, music, video-editing, visiting friends - and since I haven't stopped for 8 years I think I almost deserve it. That's the kiwi influence of course. One of my kiwi friends is taking 6 months off to study for MRACP (Australasian Physicians). Plenty just take 6 months off because they fancy it. And who wouldn't? After 6 months they're welcomed back into the system with open arms. Buyers market you see.

Not so the NHS. "HAVE YOU EVER HAD MORE THAN 4 WEEKS OFF WORK?!" said page 4 of my application form this year. And just underneath, "IF YOU HAVE ANSWERED YES, JUSTIFY YOURSELF IN LESS THAN 12.5 WORDS!" Well, that's certainly winsome. I hope I never have to justify this period of unemployment. Although I'd only need 3 words. "Felt like it". "Fancied a break". I wonder if I'd get an interview...

I've had two interviews in this round of the awfulness. They went better than last year. I spent ages reading about interview stations and questions, preparing my flawless, spontaneous sounding answers for why I wanted to train in ED, where I see myself in 10 years time, what the difference is between audit and research (answer - one they have forced me to do, and one they haven't forced me to do just yet.) I even re-read this old page to get ideas for examples of when I showed good team playing skills, and when my communication skills made a difference to the outcome of the Nobel prize. Despite it all, I felt hideously under prepared, aware that any unusual question probably could and would throw me.

I sat down outside the first station, and wondered how I could feel no more confident than this time last year. "Clinical scenario". The one I fell down on so badly last year. The one I hadn't really thought to revise for. Not really sure why now...

Well, it went ok. I missed one fairly obvious thing, and rambled a bit through the interpretation of the blood gas, but I think I said everything I should say. "A, B, C, easy as 1,2,3." But then they asked me what other investigation I'd want on a patient presenting with chest pain. "Um... an echo? Not in the acute setting. Um..."

I have never, ever in clinical practice forgotten to get an ECG. Mostly this is because ED nurses tend to do them when anyone aged over 50 sneezes. You don't need to ask for them, they just happen! How did I forget this? Same problem as last year - I'm in a suit in box overlooking a football pitch, not in a resuscitation room with a patient in front of me.

There were presentation stations at both interviews, one asking me about which city in the world I'd most like to visit. I'm not too sure how that assessed how good an ED physician I would make. Not complaining though, I thought it went quite well as a station! Another one asked me about ED training, and the four hour rule. I knew most of it - I'd done my homework. One or two things I fudged through, but mostly I was ok.

Since then it has been waiting. I've had all the interviews I can have, it's over for the year. (Why they can't have twice annual recruitment I don't know). Every morning has been a horrible ritual of hope and fear as I do anything as drastic as check my email. Nothing. Day after day. I know how the system works this year. People can hold offers. I could hear "yes" any day, but wouldn't hear "no" until some time in April. Neither interview went spectacularly, and I'm far more used to being rejected than accepted. I'm expecting some difficult decisions about the future in between my getting up and having lunch come May.

And then came Thursday. And the offer for ACCS CT1. And my mother jumping around the room. And my excitement reading through the website about ED training, knowing that that would be me in August.

So that's the next 3 years sorted! I can tell you that, God willing, in the near future I will be able to tell you about 6 months as an ED SHO, 6 months as a medical SHO (yeuch...) 6 months as an anaesthetic SHO and 6 months as an ICU SHO. Exciting stories will abound from my trauma rotation for 6 months, and my children's ED for 6 months. Um, kinda feels like I've done a lot of this before...

But I'm so excited. Really, really, really ecstatic. It's such a relief, leaving limbo behind. Now, I just have to make sure that I don't spend the next 6 months just sitting around doing nothing. Would it really be so bad?

Coffee and TV

2011-01-06T00:30:00.004Z

My camera is broken, and my laptop is on it's last legs, so that's why I haven't been putting photos up at the top of the posts. So, when I join the legion of smug apple-mac losers, and find somewhere that will mend olympus lenses I will get back to adding some colour to proceedings. As we all know, appearances are everything...

So, nothing doing here really. I had a great Christmas, a barbeque with many fellow orphans, and Christmas lunch with a very lovely family. New Year was rather good as well, although I was exhausted as we got a ferry back home at 6am just as the 2011 sun was rising...

In the mean time I am trying to prepare for my imminent departure. This involves selling my life, preparing for interviews, looking for work back in the UK and enjoying the last few days in which I live at a house with a pool in the summer. I'm also going to have to remove some of the sweet as kiwi-isms from my vocabulary for fear of looking like a weirdo once I get back home.

Anyway, I thought I would tell you about an arrest that made quite an impression on me. I don't really know if this is unusual, but I've been to very few arrests that were actually arrests - as in, the person's heart had stopped beating. I've been a doctor for over 3 years now, and been through plenty of simulation senarios on dealing with patients whose hearts aren't beating in any meaningful way. I've been to plenty of crash calls as well, where a patient is fitting, or has had a bit too much morphine, or looks like death. This is the only real life crash call that I have been to where everything played out like an ALS senario.

The emergency bell started, the overhead sign said that it was coming from triage. Usually this means that the emergency is in the car park. There were already a few people crowding around a car as I approached, and the consultant called to me to get a trolley. I did, and we man-handled the patient on top of it, and started to run towards resus. He was pale and sweaty, unresponsive and wasn't breathing. I ran ahead to prepare the resus room, and get the drugs that we were likely to need.

We get him in, and attach him to the monitor. Ventricular fibrillation. We already know he doesn't have a pulse. This is one of the arrest rhythms that you can shock. So we do. Nothing happens. Someone starts pumping on his chest to keep the blood circulating whilst his heart isn't up to the task.

The consultant is here, and quickly takes charge. Everyone is now in the room, medics, intensive care, charge nurse, resus nurse, orderly, and a couple of other ED registrars. We get access, but can't get blood - not that suprising given that he doesn't have much of a circulation. I am tasked with getting blood from his groin. All the while we are on rotation with the chest compressions - this, believe me, is a tiring job and it is a struggle to last more than a minute or so.

Up at the patient's head, S is having trouble securing his airway. He is trying to bite the tube. Fortunately we are getting oxygen in with a bag and mask, although this is far from ideal.

The boss asks me to get a history from the daughter who brought her father to ED. She is beside herself just outside the room, desperately trying to contact any family she can at 2am. Her recently perfectly ok father is dying just a few metres away from her, so she doesn't take that kindly to being quizzed. I try to stay matter of fact about the whole thing, and give her all the time she needs to shout her frustrations. I get what I need from her - the story is no surprise. He awoke with chest pain, asked her to drive him to hospital and then collapsed in the car.

Back in resus, the resuscitation effort is still in full swing. This is a well run arrest. Everyone knows who is in charge, everyone is being given a role. People doing chest compressions are being changed every two minutes. We have access, a history, bloods and a gas, he has been given the correct drugs. Every two minutes he gets another 300J of electricity. It's exciting, it's eventful, it's kinda fun being with everyone in a focussed, high pressure environment. I'm enjoying this arrest.

Only now it has been going on for over 30 minutes, and the chances of recovering his cardiac output are dropping after every cycle. The consultant has to make the decision to call it a day. He calls the family in, so that they can witness us doing every thing we can for the last few minutes. They are beside themselves. One daughter grabs her father's hand and pleads with him to stay with them.

And then we have to stop.

"I'm so sorry, Mrs _, we just can't restart your husband's heart. We've done all we can."

The cries from his assembled family are devastating. The tears are in my eyes now, as I type this, just remembering the hopelessness expressed in their howls of anguish. How could I have been enjoying myself just a few minutes ago?

We leave them with him. It's hardly my first thought as I walk away from the scene, but other patients have been coming in at a usual rate and four of the ED doctors have been taken up with this arrest for the best part of an hour. There is a long list of patients waiting to be seen. The day job calls, normal service recommences. It feels pretty rubbish if I'm honest.

I Want the World to Stop

2010-12-28T02:47:00.003Z

Good day everyone. As you all most probably know, I have quit my job and will be heading back to the sub-zero paradise that is the UK. Why you ask? Well, let me tell you that I have no real idea, no real plan and no confidence in my decision making ability at all. Also, you may like to know that it's raining here. Like, properly pouring...

Anyhoo, I do have some exciting plans for the next few days. Northland, Capital country, hopefully even a few days in Oz. Somewhere amongst my busy new life as an unemployed bum I need to polish my interview skills or maybe just give up on medicine altogether. The applications are in, I have spouted as much nonsense about my personal skills and attributes as I could manage, all the time resisting the urge to write, "please can I have a job, please, please, please!" before hitting submit.

"I have a blog that my Mum says she likes, although mostly she just corrects the grammar..." That probably is my number one achievement to date. Anyone want to give me a book deal based on this rambling nonsense? You don't have to pay me, I'd just like to say I had something published, something that I initiated and blah, blah, national level, blah, blah, blah, first author, blah blah buzzword, blah blah, completed the flipping cycle.

So... with no medicine to write about, and the end of the year fast approaching, I really have no choice but to tell you my exciting, comprehensive and well thought out views on the year in music. Try to quell your excitement kids, the best albums of 2010 in my humble music-geek opinion were... (in less than 2 sentences each, and my favourite song for you to find yourselves on the internet)

Belle and Sebastian Write About Love - Belle and Sebastian
Yeah I love them. To the point where my enthusiasm for the incredible songwriting, lyrical perfection, gorgeous melodies and sublime arrangement seems to put everyone else off. (Or at least that's the only conclusion I can come to...)

Try: I Want the World to Stop

The Suburbs - Arcade Fire

16 tracks long, without a single note of filler. Beautiful big-band indie - it has the same aesthetic as the other two Arcade Fire records but manages to be a big step up at the same time.

Try: Modern Man

End Times - Eels

One of 3 Eels albums in the past 18 months - this one appears to be about divorce so it's pretty bleak. Fairly standard Eels stuff otherwise though.

Try: Little Bird

Flaws - Bombay Bicycle Club

Gorgeous, gorgeous, gorgeous acoustic album from yet another band that have acomplished a lot more than me at an irritatingly young age.

Try: Flaws

Broken Bells - Broken Bells

When you hear about an album by Danger Mouse and James Mercer from the Shins and you think it should be spectacular. Sadly, this is only very good.

Try: The High Road

Forgiveness Rock Record - Broken Social Scene

Another excellent ensemble piece from a big Canadian band. Always inventive, always interesting.

Try: All in All

Plastic Beach - Gorillaz

Plenty of people have heard this album so not too much to say. They put on a good show in NZ the other day - I think this album is hit and miss, but then the hits are spectacular.

Try: Stylo - sorry but it's so good.

Invariable Heartache - KORT

I make no bones about loving Americana and Country music - and this record of Nashville covers is wonderful. Two beautiful voices, over aching bare arrangements.

Try: Invariable Heartache

I Speak Because I Can - Laura Marling

Clearly an immense talent, the thing I love about Laura Marling is that as I've listened to the album different songs have stood out to me each time. Beautiful songs, beautiful voice.

Try: I Speak Because I Can

Life is Sweet! Nice to Meet You - Lightspeed Champion

Not the best voice in the world, but proof that the strength of your songwriting is ultimately what matters most. I sing them all day long.

Try: Marlene

Blood Like Lemonade - Morcheeba

Morcheeba back together in their original form - wonderful stuff. Always finding the most gorgeous, chilled groove and what a voice...

Try: Even Though

If I Had a Hi-Fi - Nada Surf

An album of covers by another band I love. Gets on the list just because the title is a pallindrome.

Try: Enjoy the Silence

High Violet - The National

Very understated, haunting stuff and a vocalist who could melt any heart. A bit like how I think Tindersticks should sound.

Try: Anyone's Ghost

Together - The New Pornographers

I always feel a bit bad telling people that I like The New Pornographers - I mean they make some of the cleanest rock music around. Anyway, they're another one of those big Canadian ensembles, and this is a very good album.

Try: Crash Years

We Are Born - Sia

I love Sia for many reasons, not least her voice, but also because she is so good at so many different styles of music - this is the most upbeat she's ever sounded - and manages to make being a singer look like such fun. She's about the only musician that my whole family enjoys.

Try: The Fight

Beachcomber's Windowsill - Stornoway

I'm a sucker for harmonies, and for melody. A bit like Fleet Foxes, but Scottish and with less irritating, obtuse turns in their songs.

Try: Here Comes The Blackout...!

Tourist History - Two Door Cinema Club

"Something Good" is one of my favourite songs of the year. They have some awesome, lively tunes that make you want to jump around, but don't quite manage to keep interest for the whole album.

Try: Something Good

Becoming a Jackel - Villagers

I love the voice, I love the songs, excellent arrangements, and all very consistent for a debut album. Blindsiding.

Try: The Pact - I'll Be Your Fever (Only because I've gone on about Becoming a Jackel and Twenty-Seven Strangers before...!)

Oddblood - Yeasayer

Using possibly every instrument on the planet, whilst tying it all together with excellent songs, gotta love Yaysayer.

Try: O.N.E.

There are other albums that I'm still getting into, by bands I already know I like. The Bees, Alabama 3, M.I.A., Black Francis. I'm also just trying out Warpaint - the song "Undertow" is stunning.

So that's that. If any music magazines or newspaper supplements want to offer me a job, then you'll see from the above that I have far too much time on my hands...

At the Bottom of Everything

2010-12-06T00:32:00.002Z

Apologies again to the loyal fans. You must both be very annoyed. But December has kind of snuck up on me this year. I mean, I understand that it usually follows the 30th of November, but the weather is getting warmer, I haven't bought an advent calender and at no point in November did I hear any Slade or Wizard Christmas songs so I find it hard to believe that Christmas is less than 3 weeks away.

Things are happening. I have resigned. I have a date in January that I have to be home for. The application process that caused me so much pain without any gain last year is just beginning. I have tentative plans to work as a locum for a few months once I'm home, before heading off travelling the world for a few months. South America is the next continent I have to try out I think...

Work carries on, and I am left with the sad fact that I have absolutely loved my job for the past 6 months, and that is something that I can't really ignore when I consider which specialty I want to train in. Not an easy decision - I've been a wannabe anaesthetist for quite a while and the downsides of ED are glaringly evident. Yesterday is a good example of this - I was working for the third Sunday in a row, the department was heaving. The first two patients that I saw had been assaulted whilst out on a Saturday night. The next girl I saw was having a miscarriage, but I couldn't tell her that for sure. She will have to wait a couple of days for her scan to tell her what we both already suspect.

Next up was a drug seeker. She had been in the day before, refusing any kind of investigation but demanding a presciption.

"Give me methadone."
"I can't give you methadone."
"Isn't this a hospital?"
"No, this is the emergency department. We don't keep methadone."
"Well then, give me morphine."

And so on, through morphine, and codeine, and a whole other host of other drugs of abuse. Meanwhile she was trying to light up in the waiting room. In the end my consultant had to get involved in kicking her out.

And then the trauma. A drunk driver crashes into a ditch after driving away at high speed from the police officer that tried to pull him over. His 3 passengers are all thrown from the car. I have to accompany one to CT, but whilst we're there her friend starts trying to die in the scanner and we're held up for ages, whilst I get drawn in to trying to keep this other girl alive. The driver has a few scratches on his face, and that's it. I do find trauma more interesting and exciting and there is often more that we're able to do as we try to get people stable enough for theatre where the real life saving treatment happens. But you still have to deal with 18 year olds who can't be saved, whose injuries are just too horrific. You still have to see the faces of their relatives whose worlds have just been ripped apart when you tell them that their daughter/sister/cousin has been taken to ITU and things don't look good.

But the fact remains. Bad days aside, I really really enjoy working in ED. I'm keeping an open mind, but at this point I'm definitely a convert. And so that is what I will be applying for. Hopefully with more work and a less blase attitude, plus the availability to apply to the second round, I should be telling you all about being a first year core trainee this time next year.

Grumpus

2010-10-13T09:37:00.002+01:00

So, where were we?

This weekend, a lady went to reverse her car out of her driveway. As she slowly edged out onto the road, she went to brake and accidentally hit the accelerator instead, speeding backwards into a parked car. Shaken, she tried to edge the car forward again, in so doing drove straight into a tree.

"What state was the car in afterwards?" asked the young emergency doctor who came to check her over once she had arrived in ED. Not a completely stupid question, it was one I was taught to ask after, "Did the airbags deploy?" when taking these car crash histories.

"Well, it was a bit shorter than before," the patient's daughter deadpans, having accompanied her mother in the ambulance to the hospital. She is having trouble looking her mother in the eye, and when she does it brings tears to her own, and she looks away quickly. It is this daughter that tells me that the whites of her mother's eyes have been yellow for almost a month. She is also covered in spider naevae - two tell tale signs of fairly advanced liver disease.

"How much do you drink?" I ask her directly. "Well, I had a glass of red wine this morning, and a few to drink the other night for my birthday. But we don't drink on a regular basis, do we?" She looks at her husband for confirmation, and he duly supplies it. "No, we're not big drinkers," she says with confidence, and she doesn't even flinch.

But I know that the levels of alcohol in her blood are many times over that of the legal driving limit in NZ (itself double that of the UK.) I also know that her liver isn't working the way it should be. I tell her this, and she shakes her head in bewilderment. I decide not to press the issue, and check her head to toe for injuries.

I ask my consultant for an opinion on her head wound - it's pretty small but bleeding a fair amount and the edges aren't opposing. "Yeah, I'd stitch that. And make sure you check her clotting." He has already picked up on her high alcohol level and liver signs. So when I tell him that she denies drinking any large amounts, he goes straight back to see her and confronts her with the parts of her story that don't add up.

I come back later with the suture trolley - everything I need to stop her head from leaking scarlet. The family (2 sons are here as well) say that they're ready now, and urge me on. I put in the local anaesthetic, wash out the wound and get the first stitch in, and am just starting on the second when she begins to weep and weep.

"I wish I was gone! That would be better for all of you."
"No Mum! That's not what any of us want. We just want you to be honest with us."
"I just don't want to hurt you!"
"You're hurting us when you lie to us. Can't you see that?"
"I'll be honest with you from now on. But you must believe me that I only had a glass of wine this morning. That's God's honest truth."
"Mother, your alcohol levels were four times the driving limit. It's just not medically possible." The disappointment in his voice is unbearable. I'm struggling not to cry at this point, focusing fiercely on the 5.0 Ethilon suture in my hand.

"Both the doctors could tell as soon as they walked in the room about your drinking, and they've never met you before. We all know about the flask that you carry around."
"Well, a couple of sips of it, but other than that it was just 1 glass!" She's pleading now.
"You see, it comes out bit by bit! You're still not being honest with us!"
"I'm sorry. I'm so sorry!"
"Keep your head still, the doctor's trying to put the stitches in."

I had already tried to make this point, mostly as a ruse to remind them that I was still there and was hoping that they could keep the personal secrets and family tragedy until after her scalp has stopped bleeding.

"You know why I drink, don't you?"
"Yes Mum, I know."

"Hannah hates me, doesn't she."
"No Mother, I don't hate you. That's why I'm the only one who's been honest with you all these years." She's sat in the corner, speaking to the curtain.

Seriously? I've even got a sterile drape over your head. Can you not keep all this in for just a few more minutes?

I don't mean to sound flippant or uncaring. And to that end, I'm a bit stuck as to what to write about next. She is going to go back to AA, and she is going to get sober this time. Her family are all behind her. She's going to do it for them. "Well, um, I came to tell you that your head scan is normal and that I can't find any other injuries." That's my reply to these momentous statements. In my head I'm wondering how many times they've me made before. She thanks me for my help, and I explain that she needs her liver tests repeated in a week. I doubt I'll ever see them again, but I hope she does get better this time. Driving into a tree could be the best thing that's happened to her recently.

I've got some other head wounds I could tell you about. I've had 3 in the last 2 weeks and you know how much I love stitching. One was an old lady who was completely bonkers, and absolutely pouring blood out of the tiniest cut on her head. Two stitches later and it stopped abruptly. "I really didn't expect that to work so well," I confided to the nurse, and then left him to clean up all the blood that she was now lying in.

And then there was a kid on ketamine. So now I was stitching in front of my boss, who was giving the ketamine. "Quickly, I don't want to have to give him any more," she told me, at which point I knocked over the stool and hit my head on the overhead light.

Now ketamine is a wonder drug for these cases, because it causes dissociative anaesthesia. Patients aren't unconscious in the conventional sense, so their blood pressure doesn't drop and their airway doesn't collapse. They are aware, supposedly, but the pain doesn't bother them. Somewhere along the line this makes their eyes go absolutely crazy, constantly wandering all around the room and when you are stitching just a few centimeters from a frantically roving eyeball it can be a bit unnerving. In fact, I'd say it was the second most distracted and unnerved that I'd been whilst stitching a head wound in the last few weeks.

Reel Life

2010-09-07T09:59:00.003+01:00

Hello. How are you this fine - depending on your perspective - spring evening/autumn morning? I still haven't really got my head around this upside down seasons thing that the Kiwis insist on doing. Spring in September? Don't they know anything? Soon they'll be announcing all the Summer's New Year Parties... Weirdos.

Anyhoo, how's things? Did the NZ earthquake make it onto the UK news? Not that it affected me, smug and safe on the North Island with it's 50 odd volcanoes. Living abroad does remind you how inward looking countries are. I always tell the story of how the top story in New Zealand when I arrived was, "The debate over whether Wanganui should actually be named Whanganui rages on!" but leave out the fact that the top story I left behind was about a prank phone call that backfired just a little...

But then I was chatting to a South African man (no-one here is actually Kiwi it seems...) whilst he was having a lumbar puncture. I was supervising, not sticking, so whilst the house officer was busy concentrating on the tiny space between his vertebrae, I was trying to distract him from what was going on in the small of his back. So, naturally we ended up talking about the excitement that peppers New Zealand current affair on a daily basis, at which point he sighed and would have looked down at his feet were he not already forced into that position by the procedure. "Kiwis don't know how good they have it, in this beautiful country of theirs," he said sagely. "Would they rather the daily tales of Johannesburg? Streams of shootings, stabbings and rape?"

No news is good news. Or, as the media seem to interpret it, good news is not news. At least the Kiwis have plenty of good things to report about the All Blacks at the moment, although again I doubt that anyone in the UK will have heard about it. I assume that my Mother hasn't heard about earthquake, seeing as I'm yet to receive the phone call checking that I'm still alive...

I was trying to imagine being in ED when something major like that happens. I know there are protocols and things, getting extra hands on the floor and claiming extra space for patients, but I wonder what it would be like to be on the floor, feeling the earthquake and just as you are recovering from the shock of a 7.2 force ground-shaking yourself, having to think about the hoards that are doubtless on their way. Would you kick out the guy who called an ambulance at 5am because he couldn't sleep? Suddenly the beds are full of trauma, which is what all ED doctors prefer anyway...

We had a good night the night before last. "Good, ol' fashioned, vintage ER work," as our American consultant put it when he arrived the following morning, taking up his classic stance of legs apart, hands together and leaning forward. Someone falls down a ravine, takes most of the skin off his scalp but miraculously escapes any other injury. Kid takes a knife to the neck which amazingly misses everything important and he strolls into triage holding his jacket rolled up over the gaping wound. It's not often someone strolls into the resuscitation room, so I walked in with an eyebrow raised. "Why's he come to re...s'ah I see." Airway, Breathing, Circulation...

My personal favourite was the man who had broken his ankle after 24 cans of beer. 24! "I was celebrating Father's day," he explained, and I didn't have the heart to tell him that Father's day was, in fact, tomorrow. Not that he would have remembered anything I said to him at this point. Anyway, his ankle was in pieces and I was looking forward to trying to put those pieces in the best possible position, when the orthopaedic registrar waltzed in and told me that what I was planning was unnecessary and that all I needed was to put his foot in a neutral position. The patient was drunk enough that he barely needed any sedation, so it all went very smoothly. "Lean into it with your belly," adivised the ortho reg and then mocked me for not leaving the imprint of a six-pack. Ahem.

The reason why I enjoy this story is of course because he came back to me after the repeat x-rays, confessing that I was right, and he needed another push. So you see, I did learn some orthopaedics back in the day... How does that mastercard advert go again? Plaster cast, $30 dollars. 40mg Propofol, $130. (I'm making all these up by the way.) Post-reduction film, $12.50. Beating an orthopod at his own game...

Well, I enjoyed it anyway.

Twenty-Seven Strangers

2010-08-07T06:24:00.004+01:00

I'm going to go out on a limb here, and suggest Becoming a Jackal by Villagers as the most deserving winner of the Mercury Music Prize this year. That particular song really reminds me of Love which is definitely no bad thing. This song, Twenty-Seven Strangers, has that quality about it that makes you think that you've heard it before on your first listen which either means it's a brilliant song or they have just actually copied someone else.

To be fair, I haven't really given Corinne Bailey Ray or Biffy Clyro a proper listen yet so who knows, I might really be blind-sided by either record and change my mind. I Am Kloot is a band that I've admired for a very long time, ever since I saw them live supporting Turin Brakes and the lead singer John Bramwell introduced every song by saying, "This song is about *whatever the song was about*... and disaster!". He also put the song "Morning Rain" in my head, which was nice of him as it's a very pretty song. I'm going with Villagers though, because I love the dude's voice whereas I Am Kloot's harsh Mancunian tones are just a little off putting. Just a little.

Anyway, that's two whole self-indulgent paragraphs on what my little sister scathingly refers to as "Stephen Music". As in, "Ugh, this is such Stephen Music. No-one else likes this kind of thing!" That was her response to I'll Have to Dance with Cassie, by God Help the Girl. But I love the song, in part because I feel warm inside when I hear lyrics like;

"Rarely does the dream boy come along,
He don't exist,
A lover with the candour of a friend."

Plus it's my blog, so there.

Which brings us neatly on to one of the up-sides of shift work. Monday to Sunday this week I will have only worked 3 days. Yup, 3 days. The dreaded 12-days-straight is a dim and distant memory, 15 hour shifts are a thing of the past and all the while I have trainers on my feet. Not that ED is a slacker's job - I usually sneak in a 20 minute break each shift for food but other than that I'm at it solidly for the whole 10 hours. Some days in medicine, we had finished all our work in the first hour and I spent the rest of the day in the mess considering flushing my pager as a means of ensuring that it wouldn't bleep at me for the next 7 hours. So it's hard work, but there is ample free time. Just no-one to spend it with. And miraculously, this page starts getting multiple posts each week...

Okay. Now, one of the things about leaving your comfort zone is that it makes you feel rubbish a lot of time. Just 3 short months ago, I was the dream medical house officer; good at my job, efficient, never flustered and even able to step up above my duties if and when called to do so. Now I am an inexperienced, junior ED registrar, and I am not at all good at it. Forget straight forward clinical ability, I don't think I ask for help in a very efficient manner, and I'm not even aware of half the stuff that I don't know. It's a bit of a drop, and needless to say not brilliant for your self-esteem in winter time on day seven of a really unpleasant cold.

But then last night I had a really good shift. I had a gynae case - gynae of course being my personal zone of terror and inexperience - and it went quite smoothly. I felt as if I was getting to grips with some of these things and that all of those unpleasant, out of my depth, heart sink moments had added up to me learning some stuff. So the whole case made me feel better, even though it must have made the woman involved feel terrible as I was most likely treating her for a miscarriage.

I was thinking about this the other day, after writing about my "Hooray! Pneumonia!" moment. I diagnosed another pneumonia and again I felt pretty happy about it. How twisted have I become? I doubt the patient, nor his family felt particularly jubilant about things as they stood. But I was just glad that I wouldn't have to find another source for his fever, and in particular I wouldn't have to subject him to a spiky needle at the base of his spine and tell him that he had meningitis. Winner! I can give you a diagnosis, I can explain the treatment and what is likely to happen. And I know how much worse it could be. Miscarriage? I was worried about an ectopic pregnancy! Miscarriage is nothing - I see it all the time and it often doesn't even need admission to hospital.

But of course miscarriage is not nothing. It's a horrible diagnosis after the excitement that this woman must have had on finding out that her little girl would most likely have a new brother or sister, accompanied by guilt and wondering why she miscarried and if it would ever happen again. Coming to ED is not nothing for a lot of people, and I wish I was better at being an ED registrar so that I could make their experiences better, and didn't have to leave so many of them waiting around for senior review. But then, do you know another way for me to get good at it? Answers on a postcard.

Failure

2010-08-02T02:24:00.004+01:00

With a negative title like that it might well be worth reminding you that I gave up on thinking of clever blog-post titles a long time ago, and the title of each post is always just the name of the song that I happen to listening to as I start writing. The ipod is on shuffle, so a few minutes later and you would have been confronted with "A Long and Sleepless Night" which may or may not have been more relevant and definitely less true. Perhaps I should listen to more upbeat music...

And perhaps I should save my illnesses for work days. Actually, illness is a bit of a complete overstatement - I have a cough and a sore throat and I would not have called in sick in my current state. It does feel like a waste of an off day however, especially now that the sun is shining (and the song has changed to "Head On.") One of my flatmates, S, has had a cough for almost 4 weeks now. I asked her the other day how long she would have to cough for before she went to the emergency department. I can't remember her answer but she hasn't been yet.

If other people were more like her then I would often be much less busy. "Just thought I'd better get it checked out, Doc" the friendly ones say when I tell them that they're fine and doing the right thing. "Can't I at least have an x-ray?" say the slightly less friendly ones, and the downright rude tend to open with, "We pay all this money for this hospital, and still end up waiting 4 hours to be seen. It's disgusting."

That same patient had broken his arm... three weeks ago. And he downright refused to have it put in plaster, ray of sunshine that he was. You do what you can.

I'm not too good at the waiting room patients. I've done orthopaedics, and kids, and a fair amount of medicine so I'm fairly happy with all those bits and pieces. The man with the sore foot in the waiting room I'm a bit unsure about. It's probably nothing, but people usually want a diagnosis not "probably nothing." I'm never desperate to involve the boss in what is most likely not anything, but I suppose it's the only way to learn. Plantar fasciitis - the medical term for probably nothing. Actually no, it's pain in the foot that they think is the soft tissues being irritated. The cure is rest, rest and some more rest. I probably could have guessed at that...

I also felt quite rubbish in the resus room yesterday. I don't really know how much to play my "baby reg" card in those situations. And yesterday I was on with a boss who is more of the "it's quicker to sort it out myself" mentality than, "if I do it for him, he'll never learn". So when he saw a blood test that was compatible with death yesterday before I'd had the chance to look, he wasn't best pleased. "If you're going to do these tests, you need to follow them up," he warned me, "so what are you going to do with him?"

Fluids and oxygen. Try to get his temperature above 30 degrees centigrade. Look for infection in the obvious places. Scan his head and his belly. I got there eventually, but not in the kind of concise way that inspires confidence. But I'm new at this! You're the one training me - can't I have a little bit more leeway during my first ever 6 weeks as an ED trainee?

The patient took a turn for the worse in the CT scanner, and I missed all the fun and games that ensued. I was busy persuading the medics that they wanted to take another collapse query cause. Probably nothing...

The day before I did have fun with a crazy lady, who sat there talking whether there was anyone there or not. Crazy or not, she did have these pearls of wisdom for me.

"You're how old? 26! Wait until you're older, then marry a young wife and enjoy life. I don't understand all this changing of partners that goes on these days. Why can't you just fight, and then wait until you like each other again, and fight, and make up, and fight and make up. That's commitment. I've been married 60 years, and we fight, and commit, and fight, and commit, and fight and commit."

Less fun with her committed husband, who had nowhere to go without her and adult children who couldn't possibly have him to stay in his hour of need because they had people coming for dinner. True.

By Some Miracle

2010-07-22T03:53:00.005+01:00

The last couple of photos that I've posted are from a disposable camera which my sister used because she forgot to bring any camera of her own to New Zealand. We gave it to a Kodak shop in Wanaka who made it into a CD for us. Digital photography is all well and good, but crystal clear images aren't always exactly what you want and there's a really nice tone to the shots we got. Although there are also quite a few with a finger over the lens...

Anyhoo, what can I tell you about now that I seem to be doing this a bit more regularly? I'm still not great at doing useful things during these off days. This morning was good - good long skype chat to my brother - but since then I have made pancakes and listened to stuff on the internet. I've got things to do, but it's difficult to know where to start with them - do I put my clothes straight into the washing machine from the floor, or do I put them in the dirty clothes basket first?

I think that I need a routine. Every off day I have I will set an alarm, and then do certain things that invariably need doing. Once I'm finished, hopefully I will be in a frame of mind to do useful things, or I can study until dinner. Then I have the evening to go out or catch up with whatever rubbish band I'm into at the time, and learn more about them than I know about medicine. Yeah... I'll start that tomorrow. Today's a lost cause I think.

Work continues. Is ED the way forward? Or will I be reclaimed by anaesthetics? Or will I pack it all in and open the beach cafe from which I can write my TV scripts? I was on with the kiddies again this week. (I say week - it started on Saturday afternoon, and ended on Tuesday) I enjoy being on the kids side, after all my first experience of ED was in a children's hospital - it's familiar territory. Plus there are paediatricians just next door in case I get stuck or someone sick comes in.

Sometimes it's a bit isolating. On Saturday for example the adults side was hectic whilst the paeds side was just ticking over. This meant that the bosses had their work cut out for them complete with car crashes and everything so had no choice but to leave the under 18s to me, whereas usually they would stick their head in from time to time and even see a kid or two if they felt so inclined. And paeds aren't the best people to ask about little fingers that were trapped in doors. Mostly I have coped, however, and only one child has cried at the sight of me.

I'm trying to think about any cases that stand out for me. The most embarrassing moment of my medical career so far happened whilst I was mid-phone call to the surgical registrar. Suddenly I realised that my ability to tell left from right had deserted me, and the boy I was trying to refer to her as possible appendicitis actually had pain on the side of his belly without an appendix. "I think I'm going insane," I confessed to the surgeon on the end of the line, who thankfully was nice and able to see the funny side.

The other case that I remember was a 6 year old who had sliced his foot open on a metal draw. He looked over my shoulder with curiosity in his eyes, as I unbandaged his foot and prodded gently with my gloved finger. Didn't even flinch, either then or when we put the IV line. I couldn't help but wonder if sedating him (with ketamine - interesting) to stitch it back up again was overkill given how brave he had been up to that point. But we did, and the other reason that he sticks out in my mind is because those four sutures really lifted my mood. Tragic really, how therapeutic closing a wound with nylon thread can be.

I was less impressed with the 9 year old who cried when I looked up his nose. Kids have nosebleeds! Why should I have to see them in an emergency deparment! It's just a torch - there's no way it's hurting you. Keep your head still! I'm not enjoying this either - do you see me crying? Suck it up.

Other than that there were the usual games of "hunt the fever", "One episode of diarrhoea is not an emergency" and "Of course it hurts when you bend your finger back playing netball." I did enjoy fixing a 2 year old's pulled elbow. It's an injury that only kids can do and one that you can fix on the spot simply by gently twisting their arm. My student had seen her first and become very confused about what was wrong. One subtle click later, and I was a witchdoctor in his eyes. The grandfather was suitably impressed too - it was one of the warmest handshakes I've ever received.

So it turns out that paediatrics for 4 months was easily the most useful job that I've done so far. Learning how to approach well kids and sick kids and worried parents has turned out to be a valuable skill. A good day in kids ED makes me wonder why I hated paediatrics so much, but then I remember - parents, procedures and paediatricians. *Shudders*

Not much other news. Music-wise Sia's new album is quite different again, but still very good. She deserves to be huge, but I worry that if she becomes huge then I will like her less. I got an email from the BBC saying that they won't be closing BBC 6music which is great news. I still have decisions about my future to make. Next August isn't too difficult - I'll be applying to ED and anaesthetic training somewhere near where I grew up - it feels like the right time to return. If I only get one, then it's decision made. If I get both, then it's decision put off for a few months. If I don't get either then... Well, neither is the most competetive specialty and there are promises of national appication schemes and clearing programmes, and I won't be as naive going into this year's applications. Hopefully it won't come to that. If it was purely about medicine, then I would stay in NZ.

The, as yet unmade, decision is about what to do between December - when the current run ends - and the aforementioned August. The options:
1. Another run in the NZ ED.
2. Something else.

That could be why it's a hard decision to make. I'm tending towards option 2, but it's somewhat ill-defined. I'd like to go home for a bit, and then probably after interviews do something else. Something in Africa maybe. I need some ideas really. Perhaps I'll get internet searching now.

Here Comes The Blackout...!

2010-07-16T02:40:00.004+01:00

This will interest nobody, but I have seen two films recently which were both brilliant, and which both made excellent use of The Velvet Underground song, "Oh, Sweet Nothing." It features in the most tragic scene of Away We Go, and in one of the funniest scenes in Zombieland.

I know! Exciting right? Imagine how I felt when I was watching Zombieland, laughing my face off, when suddenly I got to hear one of Lou Reed's finest in a film for the second time in a month! It was a good time, and was by no means a sign that I spend too much time listening to pointless music or watching stupid films, and should spend more time with textbooks trying to become better at my job.

So yes, fantastic holiday - thanks for asking. Lovely to have the youngest sister out to visit, although it has made me feel homesick and loath to go back to work. Such is life, especially when skiing and the South Island are involved. New Zealand really is a spectacular country - I know Julia was impressed, even though her first thoughts of the hills surrounding Dunedin airport were, "Why have we travelled to the other side of the world, just to visit Wales?"

Well... Generally I'm pretty good at leaving work at work and not worrying about things once I get home. My flatmate is less good at it, which means she often comes home and needs reassuring that she didn't miss cauda equina syndrome on that patient, and that even if she had she was asked to review the patient by the orthopaedic team to assess potential causes of her delirium, and that cauda equina syndrome is really the orthopods' area of expertise so stop worrying! But every so often a patient stays with me, and I need reassurance from any medic-type friend. There is one girl who has stayed with me from the nights just before skiing, and I really don't think I could have done anything different, but the whole thing doesn't sit well.

She came in with a headache. Oh, and she had been vomiting every morning for the past week. And she hadn't had her period this month, but that wasn't that unusual for her. It was obvious that she didn't want to be there, didn't want to talk to me, but her mother had dragged her. "Could she be pregnant doctor?" her mother asked me again and again. Um... Am I the best person to answer that? I've only just felt her pulse - I need a bit more information.

So, an 18 year old with a headache - and now it's taken a different turn. I have to ask her mother to leave, so that I can trust the answers I get when I ask her about her sex life. They definitely don't pay me enough. "No. Definitely. No chance." She looked me in the eye, and I believed her. Sucker.

I see someone else while I'm waiting for her blood tests. My boss asks me about her, looks up her tests and tells me that - yup - she's pregnant. And given our population, I have to do a pelvic examination and swab her for chlamydia. This takes time to set up and be properly chaperoned, and all the while her distraught mother is stalking me through the department. "Is she pregnant doctor? Is she? She is, isn't she?" Yes, yes she is, but I really, really have to tell her that first. But of course, my hesitation and refusal to answer yes or no have already told her everything that I know. Why did I think I liked ED - there's none of this in anaesthetics...

So now my job is simple. I have to tell an 18 year old that didn't want to come to ED that her life has changed forever. I have to explain to her that as a bonus, she has won her first ever pelvic examination which will be done not in a beautifully set up, experienced, comfortable gynae clinic but in an emergency department by a young, inexperienced, male emergency trainee. I have to ask her as gently as I can if she wants to tell me, or a social worker if she'd prefer, about any abuse that she's been hiding. I have to arrange, at midnight, her clinic appointment to ensure that she's properly followed up, and all the while I must remember that she came to me with a headache and that pregnant teens get meningitis too...

And even now, I just feel desperately sorry for her. There was such a sadness to her eyes, and I think that that is now what keeps me turning the thing over in my head. A&E just wasn't the place for her, but people just don't seem to understand that - where else would her mother have taken her? What more could I have done? What could I have done differently - not picked her chart up and let someone else deal with her.

I know of departments where my job would have been only to note that she was pregnant and get the obs and gynae team to sort out the rest. I do think that that is a lot better from the patient's point of view. But there is a culture sometimes surrounding ED that that is being work shy. Probably her GP would have been the best person for the job, but I suppose the whole experience can never be pleasant from her point of view.

It is difficult dealing with all the bits and pieces that you know should be dealt with by other people - not because you're work shy but because you're simply not set up for dealing with it. Plenty of things that present to ED don't need treating, they just need watching to make sure they right themselves. But as a busy department run by doctors on shifts, we aren't in a place to follow these people up. How about the man who came in at 3am because he had been itchy for 2 months? "I can't afford my GP" he confessed to me - GP's charge in NZ you see.

I hope that's not all too heavy, or gory for you. Any other ED trainee would read this and thing, "Big deal! I see three of those per week." I think I'm pretty numb to it all these days - all in a day's work. Death and the disgusting - 5 years of training to have the privilege of asking people about their bowel habits and for them to answer me conversationally rather than look at me like a pervert and walk quickly away.

"So, shall I have a look at this haemorrhoid that you've just described to me?"
"Why yes doctor, let me drop my underwear for you right now."
It's a weird life.

2010-07-01T10:00:00.002+01:00

The photo thing is all well and good, trying to make my blog look a bit more colourful and professional and not just the ramblings of someone who thinks that he has a computer so should be heard. However, because I've been keeping all my photos on a seperate hard drive that is all the way over there and requires plugging etc. it does mean blog posting is just a bit more effort and I think that could be why I've not been writing as much recently. So, no photo this time, but that's mostly because I have to leave for work in 40 minutes, and then I'm on holiday tomorrow and wanted to write in the short time I have left before I'm gone for 2 weeks. Otherwise you would have thought I'd disappeared off the face of this earth, dear non-existant reader.

I guess the main news is the new job. Between the two jobs I went to do a couple of weeks of anaesthetics, because it was the job I was supposed to be doing anyway and I thought it would be useful with anaesthetics still being the career I hope and expect to end up in. Possibly, maybe. So now I have 2 weeks anaesthetics and 2 weeks ED under my belt, and everything is as clear as mud. Which doesn't matter of course - decisions schmecisions - I'll just see which way I fall and I know I'll enjoy either. Drifting into things, like medicine and emigrating, has served me well so far so I see no reason to change it.

Anaesthetics was ok. Yeah, just ok. The main problem was having to get up crazy early, find the anaesthetic coordinator who was invariably stressed and busy, and try to explain that I was the anaesthetic house officer that they weren't getting but could I please hang around with someone in theatre today. So that put a downer on it. The things I like about anaesthetics were still there - the drama of theatre, the hands-on practical bit, wearing trainers to work. But there was also the sitting around, watching another appendicectomy, made worse by feeling a bit weird for being there in the first place.

Contrast that with ED, where I'm now a registrar - like a proper trainee of whom things are expected - in a really lovely, well run department and I still get to wear trainers to work. You see why it's not really a fair test, but why also it's not helping me try to decide what to do with my life. But like I said earlier, I'm 25, I'm ok with that.

This week I'm on nights, which is the shift for which the bosses go home. Tonight, if any resuscitation cases come in, it's primarily up to me to do the life saving bit. There are medical and surgical and other ED people around, so I'm not properly alone. But still, the first call comes to me. Scary, huh. 39 week pregnant lady comes in with a heart rate over 200 and a low blood pressure? That's me. Yes, me, dragging the med reg in for help and begging the obstetric registrar to come down and monitor the baby for me. And then I gave her atropine, and magicked her heart back to a more sustainable speed.

That's about all that's come in so far. The usual chest pains, asthmatics and people who really should know better than come to an emergency department at 3am. I can just about handle those. Nights in ED are better because they don't have a lot of the things that make other nights so horrible. The shifts are shorter, they are better staffed and so less lonely, and there is no ward round at the end of it just when you need your bed. No ward rounds ever - what a thing! You medics and surgeons are putting yourselves throught it for no good reason...

OK, time constraints mean I need to end here. I can ponder my life choices some other time. I haven't even got onto the dilemma of whether to stay and do a year of ED here in NZ, or to leave in December (height of summer remember) and find something else exciting to do with this year.

Stay tuned. But don't get annoyed at me if it's 6 weeks before the next post. But feel free to get jealous of me on the ski slopes next to Lake Wanaka.

Marlene

2010-05-27T07:27:00.007+01:00

Yeah, I'm listening to Lightspeed Champion, what of it? He's unpretentiously brilliant. Not many people you can say that about now are there. Check him now, thank me later.

So, let's review the top five candidates for the firing squad this week:

1. People who cram themselves into a crowded lift and then get out one floor up or down.

2. Actually people who take the lift for one floor in general. The stairs are right there, what are you?

3. Whoever or whatever has made my laptop hard disc full. My music and documents take up around 20gig, and the folder called "programme files" takes up 10 gigabytes. What on earth is taking up the other 40 gigabytes of memory, and how do I get rid of it? I spent the evening un-installing programmes that I don't use the other day, and still the message pops up telling me that my disc is "dangerously full". Dangerous to who exactly. Are you telling me that it might explode as I type?

On an unrelated note, my housemate managed to elevate a child's heart rate this week (which she needed to do) by telling him that he had a headache because his head was about to explode. Ethical and effective.

4. My patient, who had a fantastic Mr Men type name which, quite frankly, he didn't live up to. I spent ages explaining his test results to him, and what the plan was next. He grumped out at spending another night in hospital (free, full-board, with not just room service but bed service) and signed his self discharge. Great end to my day yesterday, but hey, it's one less on the list.

5. Every journalist that's being knowing about coalitions and how they're doomed to failure. People working together with people with whom they disagree for the common good is how the rest of the world works, it's about time the people who run the country caught up and did something not petty and sensible. I reserve my right to be hopeful and optimistic that this really is a new era in politics, where jeering at people who have different points of view from you is done away with.

So, now that all that negativity is out of the way, what can I tell you? I have a job. That's good isn't it? I'm going to be an emergency medicine registrar. Registrar here means what "specialist trainee" is supposed to mean back home, so I'm not suddenly a big middle grade. Still it's said to be a big step of responsibility forward, and it is in a new hospital, both of which are making me feel more apprehensive than excited. Ugh, unfamiliarity. New places, people and systems to get used to - I'm not a fan.

But on the plus side, back to wearing trainers to work! And no 14 hour days. No hitting 6pm and realising you still have 4 hours more to work. In ED you just slog it out solidly for your time, and then you're off home, visiting the post office during opening hours.

The current UK crop are heading home, and quite sad about it too. One older, more experienced Irish friend told me I had made the right choice, and though you know it wasn't a choice, I really felt like I knew what he meant. This is a fantastic path that I've been forced on to. Medicine is all about experience anyway, who wants to give in to the careerists and their world of exams and audits? That's not to say I don't miss my mother, and friends, and Radio 4, and autumn (kind of a non-event here) and TV with fewer adverts, and good bread, and central heating/double glazing. But life as an English doctor in NZ is cool. I'm cool.

But I'll miss those who are going, particularly my wonderful housemates. We all just randomly moved in together, and seem to have ended up as practically family. It could have all gone horribly wrong, but we got spectacularly lucky. The new flatmates have a lot to live up to.

Who shall I tell you about? It's been a stressful couple of weeks, starting to wind down now. I was getting pretty fed up with medicine to tell you the truth. How about the alcoholic who has pickled his brain at the tender age of sixty something. My uncle turned 60 this year, 60 is damn young. He's going to sit around for a while, because he's too young to get funding for any help at home, and yet he can't cope on his own. It's going to take some intense rehab, and charity funding to get him home. Each morning we go and see him, and add nothing. Nothing we can do, just waiting.

And possibly the saddest case I've seen. Again, a lady in her 60s. My consultant tells me that she was an active, outgoing woman just 10 years ago. Now she is ravaged by a mystery illness to the point that she doesn't have the strength to lift her own head up. The experts can't agree what exactly is wrong with her, only the general kind of illness it is. "Parkinsonian" they say sagely, giving a scientific name to an unknown quantity that is a bit like Parkinson's disease.

What that must do to a person's mental state, I just don't know. But this lady has taken to moaning. She calls the nurse every 10 minutes over nothing. On our morning ward round she has a list, and we can do nothing about any of those things. She has a quiet voice, so we struggle to hear what she wants, and then we struggle to do anything about it. And then we, her carers, start to resent her. And there it is. I resent a woman who needs my help, who sits in constant, 8 out of 10 pain unable to shower herself or get out of bed without help. And the nursing staff resent her as well. Everyone agreed that it was a relief when she was discharged this week.

I can do something for most of my patients, but you see why I prefer stitching wounds and pulling fractures. But then again, I was reminded this week why I used to think I would be a psychiatrist. I was reading a patient's old notes, including a consult with a psychiatrist. When a psychiatrist assesses someone, it's their job to explore them as a whole person. Their childhood, their family, their emotions, their history. This psychiatrist had heard the story of this lady, and it was more interesting than a lot of fiction that I have read. People just are, fascinating. The simple drama of someone's life, told in their own unreliable, simplistic way. Psychiatry is a specialty which forces you to look at the whole person.

And on some level, so should general medicine, and emergency medicine. But of course it doesn't work out in practice, because that person needs IV access and adenosine stat and who their father re-married is probably best left for another time. And our lady with pancreatic cancer doesn't look like she'd take too kindly to me asking about her childhood. I assume it's the accent, but she makes me repeat everything I say to her, and being the flippant human being that I am I'm usually embarrassed by what I've said by the time it comes to repeating it.

Paradise Blues

2010-04-28T07:10:00.007+01:00

There is a new big screen in the handover room in ED (I go back there from time to time) and I was asking various senior ED nurses and doctors what it's for. Some say that it is for handover, in which case it is completely unecessary because the room is small enough to see a small screen from every corner. Others say that it is for x-rays, in which case it is completely unecessary because there is a special x-ray viewing room in ED which is dark with 2 high resolution monitors. So, it seems likely that it is unecessary and that no-one is really even sure why it's there. Money well spent.

If senior clinicians in ED don't know what it is there for, it begs the question, who ordered it? Perhaps it was delivered to the hospital by mistake, and someone is having to make do without a giant TV whilst simultaneously trying to work out what to do with 5,000 packs of 22 gauge needles. Perhaps they ordered plasma, and got a plasma-screen by mistake! Anyone? No?

Another annoyance, this time in the field of wrecking any hope of a career that I might once have had (Travel writing here I come!). I found a training job due to start in February 2011, which would be the ideal time for me, and although I was apprehensive I applied for it mostly because I found it on the last day that they were accepting applications. Well, they emailed me to invite me to interview, on the day before the interview. Um, I live in New Zealand. That's kinda not possible on most days, even with the 12 hour time difference. It's even less possible on a day when Heathrow airport is closed and thousands of people are stranded abroad. I emailed them to gently remind them of my address, which they already had, and suggest a phone interview.

The email address that I was given to reply to resulted in an instant reply: "Deaneryperson is on annual leave until Monday 26th of April. For all urgent matters please email Otherdeaneryperson." Bearing in mind that I had less than 36 hours between receiving this email and potentially attending an interview, would it not have made sense not to put Otherdeaneryperson's email address in the email in the first place?

Well, in between exciting New Zealand news about girls stealing a pop singer's hat, we occasionally get word of overseas goings on and apparently there is some sort of election going on back home? I can't vote because I didn't get around to registering as an overseas voter in time (it was a long form, ok?) so I don't have to try to figure out any sort of political opinion until way after May 6th.

I'd find it quite easy to know who to vote for locally if I were back home, but I really don't know who to root for nationally. Given that I've just recounted three stories of how deep incompetence runs in the human condition, I don't tend to get too angry at politicians for honest mistakes and I can't see it as a reason to choose or reject any party. They're all people at the end of the day, and to suggest that they have a monopoly on greed, stupidity and all round malificense is just plain wrong.

But if I were voting, what lines should I vote along? Should I vote along healthcare lines, given that this is where my expertise, humble as they are, lie? Well, both Labour and the Conservatives pledge increasing private involvement in the health service, and increasing patient choice. Both want to try to make the NHS more of a market place, which so far has been very costly and not that effective. The people that want the NHS run as a business tend to also condemn NICE for suggesting that an expensive cancer drug which only improves life expectancy by months, and has questionable evidence behind it, isn't the most efficient use of resources. Government provided universal healthcare is never going to be a profit making scheme, but it's something I believe in absolutely.

How about voting along Christian lines? There are various people that would tell me what, as a Christian, I am supposed to think on what they have decided are the only important issues. Show me the verse in the bible that says that a 7 day old embryo has a soul. And why should agreeing with someone on a relatively small print issue trump whether or not I agree with them about free speech or economics?

But suppose I was about to lose my job because I was refused to do something that I honestly believe to be wrong? Forcing your beliefs on others is not tolerant. That news story scares me. A Tory MP was saying something very reasonable about whether a B&B is a public service in the same way a High Street Hotel is. But the media see a story about "banning gays", when in fact he is saying important things about "I think we need to allow people to have their own consciences."

So basically, I want to vote for someone who thinks that the NHS should be run by healthcare workers and become independent like the Bank of England, for someone that guarantees the rights of Christians to their conscience and churches to employ only Christians, and who holds to socialist ideals and is suspicious of big business and the media. Oh, and I think that they should only want to govern for one term, because they care more about doing the right thing (e.g. protecting the enviroment)than how the economy is doing. Abolishing slavery wrecked the British economy, and yet is one of the proudest moments of our history.

So, is there anyone that I can vote for?

It's just what I think. I'm probably wrong - I was pretty incompetent the last time I had a leadership role. I'm not even sure that I'm interested in what I think. I'll stick to correcting my 4th year student when she pronounces clerking the way that it's spelt, rather than "clarking". And feeling good when I make a patient laugh, before feeling really bad because she's very short of breath and I've just triggered a coughing fit.

Hope In The Air

2010-04-18T06:09:00.005+01:00

No-one appears to have told my face, but I am undeniably in my mid-twenties. What with emigrating and having a real job and everything I suppose I have to face the fact that I am now a proper grown up person, of the kind who is trusted to look after not only his own passport but also his younger sister's, and the kind whose first thought when he notices that his camper van park is full of gap year kids is, "I hope that they don't make too much noise."

And the fact that Laura Marling is four years younger than me doesn't help. I think that was the real reason that I didn't like her so much first time around - she had written and released a very high quality album by 19, whereas I have been writing a song about procrastination for 7 years. But, I've swallowed my pride, and this time I am well and truly in love. Anyone that can sing the word "daughter" with such perfect, unforced diction is a wonder in my humble reckoning.

So, you know how much I love my job, and how thankful I am to be in my profession? Well, how great a job must travel writing be! I've been in the South Island for the past 10 days, touring in a camper van amidst the beautiful scenery and just relaxing at the end of a bungy rope and underneath a parachute. My guide for the past two weeks has been the lonely planet, and, well, some people wrote it. They got paid for it and everything. Spending weeks and weeks in beautiful places, trying out every available activity and eating at every available cafe and restaurant and then writing about it - that was their occupation. 10 days wasn't really long enough for such a wondrous place, especially with the distances we had to cover. (I'm not complaining, it meant we packed loads in.) But the lonely planet writer's only mission was to get a comprehensive feel of each and every place in the South Island. The longer in Queenstown the better. Is there a downside to that job?

Ok, well let's pretend that the hospital is a local attraction and I'm writing about it. Hospitals make it into the lonely after all. You know, the best title I could come up with for "my life as a situation comedy", which would exist if I were to write more than 2 pages of it, was "Job's I'd Rather Do". That's not very good, is it? Bad on at least two levels. "Hospitology" was worse though. But even now that I'm thinking about it again, all I can come up with is rubbish, and "JIRD" seems better in comparison...

To business then. I've been back a week, and you know what? I'm enjoying medicine. I like the people, and I know the systems. It makes for a contented if not challenging or earth shattering existence. We've hit the grinding part of the rota though. Take (i.e. admitting) on Tuesday, Saturday/Sunday and then take this Thursday. And the patients usually oblige to become complicated and stay in for longer, so we're getting pretty roundly whipped. Lady in her 70s with diarrhoea and vomiting? Out with a couple of days of IV fluids? Try ICU with a query ischaemic guy...

But we soldier on, and I stay 2 hours late, and I'm shattered when I get home, but I don't hate it. Give it a few weeks and we'll be finishing at 9 again. It doesn't seem the most efficient way of running things, but then again I wonder if it isn't. Most people seem to prefer it this way - we're more efficient when we're stretched, but we're not always stretched so we don't burn out.

Today we went round quickly in the morning. We assured the lady who had swallowed very, very small pieces of glass that we were sure that they hadn't travelled out of her stomach and into her brain. Yes, even though she had a headache. And even if they had, as I said at the MDT meeting, we wouldn't know how to treat that. She'd probably have to go to neurosurgery or something.

I tried to explain the difference between a Dutch accent and a South African accent to my registrar. And we had a new trainee intern, which gave me someone else to tell that my registrar and her fiance (another med reg) are going to be married at the hospital, by our medical director. He used to run 3 acute teams, and he has 2 specialties, I'm sure he must be legally allowed to marry people. I've been telling this joke for 4 weeks now, and I'm really not getting bored of it. A (my reg) is...

And then there were coconut and white chocolate muffins in the cafeteria for coffee. When they wrote my weight on my hand for my two bungy jumps, I decided that the time for weight loss had come again. Then there were muffins, and they persuaded me that it could wait another week.

Then back to the motley crew. A few more sent home with "All the best" written on their discharge summary. One Maori patient with a lung problem was discharged. Maori patients are visited by Maori Health whilst in hospital in NZ. One of K's patients used to get really stressed out by them, thinking that she had to have something new to say to them each day. "Pretend to be asleep," was K's advice.

And each time they come, they write in the notes that they have been, and that they offered support, and that we should carry on with our medical management. Um... thanks. There's Pacific health too, and Asian support services. They're often quite useful with language barriers. And in NZ it's true, there are health and social problems that particular affect Maori, and Pacific Islanders. But I'm not convinced that were I admitted that I'd want UK support services popping along, asking how my illness was affecting me as an Englishman, and asking if I wanted any specifically British support. They serve fish and chips on a Fridays anyway, I feel all of my cultural needs are met. The tea machine is kept nearby, I can listen to Radiohead songs to lift my mood. If the doctors could use a bit more irony around me, then that would be appreciated, but otherwise I feel that they're being pretty sensitive to my cultural background.

The High Road

2010-04-01T10:08:00.009+01:00

Speaking of places, and things, I suppose I should mention my recent low output. It has been low. I'm not really sure why. That's just how things go sometimes. Sometimes you're up, sometimes you're down. Sometimes you're putting off proper work, sometimes maintaining a journal of medical things feels like a chore. Sometimes your brother reads it, sometimes your mother does. Both get weekly emails so should stop complaining.

Sometimes your team has only four patients. Yesterday we had finished the ward round by 9, with no real jobs with which to occupy ourselves for the rest of the day. Hmmmm. So, kinda blissful. But then... We've been through our rough patch, so hitting the quiet patch is welcome. Maybe it even helps us through the rough patch, and somehow makes the whole process more efficient. Maybe, maybe. Basically I don't want to complain about how much time I spent in the RMO lounge yesterday watching test match cricket.

So instead I will complain about nurses. Remember how 3 years ago, or whenever it was that I last wrote here, I was making long work of explaining the difference between being team based now and ward based back in my younger days? Well, team based means lots of wards, and therefore lots of nurses. And I miss the ED nurses. I lived in a small department, I got to know them all. We spent night shifts playing "Would you rather..." and one of them stopped talking to me because I didn't bring back any Percy Pigs from the UK as I had promised. I was chatting to one of them about the Big Day Out music festival, when she said that she would feel a bit old to be going, and I said she shouldn't because even people my parents' age go to music festivals, and she laughed at me for ages because she took that to mean that I thought she was my parents' age. I tried digging myself out of that one, but you know what happens if you keep digging...

I miss banter with the nurses. I like knowing who to speak to about my patients because I know the nurses names and what they look like (and who I trust.) It's good to go back to ED, and chat with KA about what facepaint I should wear to a facepaint party. (Spiderman). It's less good when, last time, one of them came up and asked me if I was orthopaedic. Do I look orthopaedic? Am I wearing scrubs, and avoiding ED like the plague/like an ECG? Was I not just talking to you about a medical patient 5 seconds ago? I am deliberately forgetting your name...

The issue with the nurses on the ward is that I have to deal with as many as I have patients, and it's so difficult to get to know them. They too have to get to know 30 junior doctors, as we all have patients on all wards. So no banter, and many more problems communicating with them about the patients we both look after.

So that's one downside. The same is true for the physios, OTs, SALTs and Social Workers of course. On the upside, I'm enjoying the team. Good banter with the bubbly registrar, and cordial relations with the quietly spoken consultant. And the other day, I accidently wore trainers to work, and had a great day because my feet were so comfortable. And I had to shake the feeling again that the only reason I'm drawn to the two specialties I'm considering is because you get to wear trainers all day in both...

I'm off to sleep in preparation for the long day that I'm planning to use to celebrate Good Friday. People call it Easter Friday over here, which sounds clumsy to my ear. So, happy Easter Friday to all of you UK folk that are 12 hours behind me, have a lovely Easter, and who knows I might write again after my holiday and trip to the South Island which is less than a week away.

And yes, I have been listening to Broken Bells, and yes you should too. They are the Shins and Dangermouse for goodness sake! Get a grip.

Eat That Up, It's Good For You

2010-03-02T05:28:00.006Z

Post number 50 then, and I thought it was time to add some colour to preceedings. The first photo is the view from the bottom of Mount Taranaki (also known as Mount Egmont), and the second is the view from the top. It took 4 hours of walking, clambering and sliding down screet slopes and around 12 litres of water but we made it, only to be told that we had climbed the second highest mountain in the North Island, and that the highest, Mount Ruapehu, has a cafe at the top of it...

So that was the weekend, off discovering myself. Turns out I'm a fairly unfit 25 year old. I'm off caffeine and alcohol for lent by the way, and my friends took both chocolate and rum (seriously) up the mountain so I think I deserve extra points for not giving in to temptation at 2500 meters. All I took was blue suncream, and still managed to miss my ears and parts of my face. But sunburn, grazed legs and quads that have refused to work for the past two days aside, it was a great day and well worth it for the view and the feeling at the summit.

Medicine then, and after all my complaining about job switching every 4 months during F2 I have come to NZ for 3 month long runs. I'm back on Gen Med, and trying to see the benefits. Um, there's a nice view from the ward...

Well, medicine is always good experience and a good place to study for the exams I'm having to think about after my spectacular failure in ST (specialty training) recruitment this year. Just because I already know that Gen Med isn't for me, doesn't mean I can't make the most of it and learn as much as I can. And NZ is a good place for medicine - it's small so the medicine stays very general, and the mix of populations makes for good pathology. So I'll just have to work on my "I'm not finding this 5 hour ward round boring or tedious!" face and use the days where I have finished all my work by 11am productively.

What can I tell you? Well, in the UK whenever I worked in medicine my jobs were all ward based. This meant that I had to look after which ever patients landed in the beds on my ward. In my hospital in NZ I'm team based, so once a week the team and I admit whoever needs admitting and look after them until they go home or are transferred or whatever.

Ward based has the advantage of sharing the load evenly between the teams and the juniors, and also means that all your patients are in one place and the nurses always know who to ask (bug) about the jobs. Team based has the advantage that whoever you admit, you see all the way through their admission, and if you can discharge people quickly there are days when you have no patients and a relaxing day in the library/doctor's lounge.

Both of my medically inclined housemates felt that they prefer team based. I was tempted to stick up for ward based because it means that seeing all of your patients doesn't involve a 10 mile trek and 12 flights of stairs - although in the old days hospitals were operating at a lower capacity so could put all of one teams patients in one place rather than wherever there is a bed, quick now before someone else gets it!!! I was once the victim of ward based when a moribund patient whom I knew nothing about suddenly turned up in a side room that I had responsibility for, with no handover or clue that she had a high fever and blood pressure in her boots and no IV access... All because she had had one episode of diarrhoea, and the trust was a bit touchy about the spread of C. Difficile.

In NZ there is no C. Diff. Well, practically none. There's also almost no heroin or cocaine here - all part of the advantages of being such an isolated country. There's also no hanging around waiting for funding for rest homes, so there are far fewer patients "medically cleared" but still in hospital for "social reasons". I think it's because it's all privately funded.

So those are some of the differences. The drugs we are allowed to use are slightly different too, because there is an agency called Pharmac decides which drugs it will and will not subsidise, which means I only tend to use one beta-blocker because Metoprolol is the one that Pharmac has decided to fund. If I prescribed Bisoprolol, which is the beta-blocker that I was most familiar with in the UK then the patient has to pay full price for it.

Other than that the medicine is medicine, and I need to make the most of it.

Who Cares What The Question Is?

2010-02-09T00:27:00.008Z

"Writing about music is like dancing about architecture"

In a largely successful bid to annoy myself, I've been reading various publications' "Top Albums of 2009" lists. The main difference this year is that Spotify puts much of this music instantly at my fingertips, and so I'm in more of a position to form my own opinion.

Opinion? I think you'll find here that objectively, Merriweather Post Pavilion by Animal Collective was the best album of 2009. It's certainly been a recurring theme in all of these definitive lists. Which makes me wonder how many people heard a number of albums last year, and thought, "Yes, that is my favourite album of all those that I have heard this year." It seems a theme that often these albums will get a "pretty good" review when they are released, only to be heralded as better than all those albums that got 5 hundred stars come the end of the year.

Elbow are a good case. I love Elbow, and think that their third album "Leaders of the Free World" is possibly my favourite album ever. It didn't fair too well in end of the year lists back in 2005. "Seldom Seen Kid" is also wonderful, but fairly similar and by no means a grand leap forward. But for some reason (Mercury Music Prize?) it featured in almost every critic's top 10 list last year... A lot of it seems to be whoever is new, and whoever is vogue at the time. Do you remember Arctic Monkeys? They released an album this year, pretty much on a par with all their previous work whilst trying out new ideas. I haven't found it on any lists as yet...

Anyway, no-one really cares which my favourite albums of 2009 were, but it's my blog so I'm going to tell you anyway. So, in no particular order:

Mumford & Sons - Sigh No More
Possibly my favourite - to be fair I haven't been listening to it for as long as some of the others. For a list like that to be fair, I think you'd have to wait 5 years before creating it. That's an interesting idea actually...
Anyway, this is sublime folk, consistently memorable, melodic songs performed with passion. And they're from West London, although appear to have accomplished a fair bit more than me...

The Decemberists - The Hazards of Love
It sounds a bit pretentious, with a "prelude" and everything, but then I have a real weakness for this Americana/Alternative Country sound.

Jamie T - Kings & Queens
Didn't like him first time around, but when I read a good review of this album I decided to give it a try and was quickly hooked by the milk-bottle percussion and atmospheric guitar sounds of the first track "368". The vocal delivery stops grating once you get used to it, and really there isn't anyone else that sounds like this, is there?

Animal Collective - Merriweather Post Pavillion
Not entirely sure how I feel about this record. I love "Summertime Clothes", and always love bands that use a lot of harmonies. But, a bit like TV on the Radio, I can see that they're good and understand why they're praised, but I admire them rather than love them.

The Yeah Yeah Yeahs - It's Blitz
In my snobbish ways, I tend to like bands like this before or after they're popular, which could explain why I like Karen O and band again now. But these songs are so catchy, with the kind of energy that makes you strut around the room when you listen to them.

The Mummers - Tale to Tell
I loved this album first time around - it's melodic and orchestral and very much to my taste. I still like it a lot, but it's a bit lacking in depth. Still, the singer has a pretty voice, and the songs are strong. If I was being a critic, I'd say something like "Tindersticks meets Bjork". Yeah.

Wilco - Wilco
Wilco are a band I should love - I adore Lambchop, and Wilco come up as "similar artists". But I don't, and I'm not particular sure why. They have good sound, and this album is my favourite of theirs so far. Good songwriting usually wins the day.

Florence & The Machine - Lungs
Tipped for great things, people had mostly got bored of her by the end of the year - or at least that was my perception of things surrounding Florence. She tends to over sing, but you can't really argue with songs like "Dog Days Are Over."

Kasabian - West Ryder Pauper Lunatic Asylum
A band that I never particularly liked before, but I decided to give them another chance after hearing "Where Did All The Love Go", which I still think is my favourite song of the year. Particularly impressive when I saw them at Big Day Out festival.

Sweet Billy Pilgrim - Twice Born Men
A very subdued, mordant affair so you have to be in the right mood for it, but when you are then it's very pretty, very enjoyable misery.

Noah & The Whale - The First Days of Spring
Possibly the least subtle break up album ever, but holds together nicely with some very nice orchestral touches.

Boxer Rebellion - Union
Another possible favourite. The only album I was surprised to see so completely unacknowledged in the lists. They sound a bit like The Editors, but 100 times better with an excellent singer who has an incredible range and real emotion to his voice. There was even a "success against the odds" story, when they had to release it themselves with no budget after their old label collapsed. Anyway, a very atmospheric sound, with soaring lead-guitar lines and a fantastic mix of the melodic with the noisy. Love it.

Hockey - Mind Chaos
There's a real charm to this band, and a real energy to their songs. Check out "Too Fake" and "Song Away" and dance happily around your room.

God Help The Girl - God Help The Girl
I was initially unimpressed by this vanity project from a personal hero (Stuart Murdoch of Belle and Sebastian). But then I was drawn in by the quality of the songs. If you start listening from "If you could speak", you'll see that it's as strong as anything B&S have done.

The Invisible - The Invisible
When I listen to stuff like this, I think that it's a shame that R&B is dominated by the slick production and slimy superstars of today's charts. It has soul, it's funky, and it's all sung by a singer with real richness in his voice.

White Lies - To Lose My Life
iTunes says this was released in 2009, but Spotify says 2008. So not sure if it's a valid choice, but this band has a great sound and some great songs.

Emmy the Great - First Love
Occasionally seems like she's being quirky for the sake of being quirky, but she keeps it interesting and clearly puts a lot of thought into her songwriting. Which is what it's all about...

Gomez - A New Tide
I saw Gomez live this year, and loved every moment of it. This is a band that have been playing together for years, and it shows. What a amazing singer Ben Ottewell is! And they harmonise so perfectly. So yeah, I love Gomez. This album is solid rather than spectacular, but it's Gomez, so I'm happy.

Eels - Hombre Lobo
Again, Eels aren't new or fashionable, so why should this superb album be mentioned on end of the year lists? But it's brilliant - simple songs with clear attention to how the album hangs together as a whole. There can't be many bands with as strong a back catalogue as Eels.

The Horrors - Primary Colours
I was aware of the Horrors without really knowing what they sounded like. Then I made a playlist of all the Mercury Music albums available on Spotify, and this was the one that really surprised me. It glories in its discordance in that arty way, but the end result is a real success.

So that's that. I feel slightly empty now, in that way you do when you've spent the best part of an hour and a half doing something really pointless...

Woke Up This Morning

2010-02-06T00:37:00.002Z

"I just want to be friends. Plus a bit more. Plus I love you."

So, new dream life plan. I live in San Francisco, where all my family and friends have also moved, writing for American TV in the cool cafe that I also own and run and bake cheesecake for.

Joy! Of course, a close second dream life plan is the one where I live in New Zealand, and work in a local ED. And eat cheesecake. I think I might bake cheesecake later...

Fairly average night last night. Many highlights - most involved verifying random claims on Wikipedia. I saw one guy who had been dropped on his head by a friend at an AC/DC concert. This led K to ask me if the lead singer of AC/DC was a serial killer. When R the nurse didn't know, I looked it up on Wikipedia. There was no mention of it in the band's biography, which I think means K might have been right...

I see a lot of head injuries, and hardly any of the patients are knocked out by them. That's real life people - that film you saw where someone was knocked out because a leaf fell on their head is not quite accurate. I'm sure Wikipedia will verify that for me. Hang on...

Anyhoo. I also saw broken clavicle guy, who had a lot of questions. "Should I take my sling off when I put my shirt on." Um... I'm going to go with yes. Common sense in an confident, knowledgable tone. That's what I go for when Wikipedia can't give me the answer. Or when D doesn't come along and tell my patient that 95% of collar bone fractures heal perfectly.

"Well, pretty well. Well, you'll probably have a lump there."
"What stops the 5% from healing?" Again with the questions.
"They almost all heal. Yours will almost definitely heal. Probably."

D's ok. Someone told me not to learn people skills from him. I like K too - he gave me a very enthusiastic greeting last night which made me glad to have made the decision to go to work last night. (It was a close one.) There was a good moment yesterday when D and I were talking yesterday about books. I think it started when a nurse told us about a book called, "The only way to quit smoking" which I thought was a genius title for a book - instant bestseller. Which somehow led to us talking about Harry Potter, and me checking with...um... some website or other to see if J.K. Rowling used to be a teacher. And then D said, "I wonder what I could write a book about." And for some reason I found that absolutely hilarious.

What else did I see yesterday? Not much really. It started so so busy, but the department was pretty much empty by 4am. Such is nights. A man who's soft toys talk to him and tell him to take overdoses of Neurofen Plus. Only he often takes 60 tablets a day, so really 24 tablets yesterday was an under-dose for him. And then he asked me if he should be on methadone to help with his addiction to Neurofen Plus? I went with no. Didn't need to look that one up. I did once like psychiatry, but it will take me many more rejection emails before I think that way again.

Anyway, I must sleep now. Don't think that this regular updating thing is going to last. I usually find that I write about all the funniest stuff when I email my mother, and can't be bothered to type it out again. Which leaves me with various rants about medical careers and stuff, so look forward to that.

Time of Times

2010-02-04T21:57:00.004Z

"If a man speaks, and no woman is around to here him, is he still wrong?"

So, a couple of dilemmas today. Firstly, what should I do about sleeping? I flew back to NZ yesterday - at least I think it was yesterday. I'm a bit confused about days at the moment, what with leaving on Tuesday and arriving on Thursday. And now it's still Thursday in the UK, but Friday where I am, which kind of leads me to the dilemma, because I start work at 11pm today, and only slept for about 5 hours on the plane, despite sleeping tablets. Which 5 hours those were in which time zone is completely beyond me - what with navigating 3 different departure gates over 28 hours, I got a bit disorientated.

Well, of course, the moment I felt most tired was the moment I was trying to make it through passport control and smuggle polo mints through customs. I made it home, and cooked frozen pizza which had the word "gourmet" on the box but square, cardboard chicken pieces on the base. Then I slept from 9pm to 4am NZ time, and now I'm not really sure when I will be able to sleep again, or when I should.

The second dilemma is mostly my own making, a result of my naivity and blase attitude to specialty recruitment this year. 7 applications, 2 interviews and no job. When I sat around discussing my back up choices with my housemate in early January, it seemed completely hypothetical. As if I wouldn't have a job! My plan for my return to the UK was already beautifully complete in my mind.

Bother. What now? The nominal back-up plan was to get a registrar job in ED in NZ. I did enjoy being back in the UK a lot, and I'm not sure I want another year here. I missed Christmas, and birthdays, and my best friend is getting married in November.

There is a round 2 of recruitment, but with it costing £1000 each time a pop home, I'm not sure that that is feasible. So if I do apply again next year, being in the UK would be easier. Score one for trying to find any UK based job. But what would I do in the UK? Being in NZ would mean a training job which would look a lot hotter on the CV and could make job seeking next year a little easier.

Well, at least even though I'm single and jobless, I have no regrets about coming to NZ. In a cliched way, I have found myself. I have discovered that I prefer coffee to tea, and that I love watching DVDs of U.S TV shows. Ha ha! I think I might be American...

Half and half could be the way forward. By which I mean 6 months in NZ and 6 months in the UK. And I still haven't decided if I should give up on round 2 yet. Hopefully my housemates will be back soon and can plan my life for me. Part of coming to NZ was to stick 2 fingers up at the inflexible UK training system, get more experience and enjoy the ride. It was also a way to indulge my lack of ambition and self-drive, which is a worry when I think about applying next year.

Friends are getting engaged and buying houses, and I'm getting left behind and trying to be a child for as long as possible.

I'm also half watching "Definitely Maybe", which is a bit too complicated to be half watched. I've got the subtitles on, so that I can understand more as I half watch it, and amuse myself when it says (Indistinct Chattering) or (Birds Fluttering). Ryan Reynolds seems to have three choices, all of whom are beautiful, although based on looks alone I think Rachel Weisz wins.

Speaking of my American TV addiction, Jenna Fischer is also beautiful. And I'm sure you've noticed that QPR have fired 2 managers this year, and are doing pretty badly. Plus, you will have noticed that I haven't unpacked yet, so I'd better stop doing this and do that...

Do or Die

2010-01-30T14:42:00.002Z

"It all depends on what happens afterwards as to how people regard your behaviour at the time."

The past 3 months of my life have been taken up with applying to "Core Training" posts in the UK. The whole process has been unspeakably horrible, and I'm feeling apprehensive just at the thought of typing about it. Overall, I feel more down than angry about it all. Perhaps the anger will come later as I start to recover from the mental exhaustion. Perhaps not.

Perhaps there's not even that much more to say. I've already done my best to give a fair and balanced description of the dire hoop-jumping horrors we have to go through to carve out any sort of career for ourselves. Probably best not to read the unfair, one-sided version. And though I can quite clearly see how difficult it is for the powers that be to navigate the maze of intractable conflicts that make up junior doctor training in the UK (made all the more difficult by the messy mis-firing of MTAS and MMC) it is small comfort when it could well be my life and career that is messed up.

Sitting here, with no job offers, and only two interviews that I felt went badly it is probably not surprising that I feel rubbish about the whole thing. Perhaps it will all seem worth it if I get an offer in the next couple of days. But what is particularly unpleasant is that I can't help but wonder if working in New Zealand has had a negative impact on my employability in this country. One of the jobs I applied for this year was the same job that I had an interview with last year. No such luck this year, and yet I put so much more effort into the application form. My CV has improved! I promise, really it has! Perhaps more tangibly, one of the deaneries had jobs of the sort I was applying for left in the second round last year. I couldn't apply to that deanery, because I could only be in the country for 2 and a half weeks.

I don't regret going abroad - it has been a fantastic experience all round. But human nature is what it is, and that's where my mind goes. Perhaps I was naive, but I really felt upbeat about my prospects for this year. I had that interview without really trying last year, and now I had what I thought was an impressive year in a different healthcare system gaining experience relevant to the job that I was applying for. I had even hoped that there would be fewer people applying this year because more people would go abroad like I did. My back up plan to stay another year and try again seemed like needless prudence.

Which brings me neatly onto perspective. It has been lovely to be home for these two weeks, catching up with friends and family, and remembering that these are ultimately more important. My back up plan is a pretty good option, tarnished only by the thought of going through this nightmare again next year, although the system is likely to have improved by then according to the BMJ, and I would be better prepared. And it is my sincere and rational belief that the God of the Bible is real, and that he in all things... works for the good of those who love him.

So, not much else medically to say. One of the problems that I had with the interviews was the "clinical scenarios" stations. In one interview, I was presented with the scenario of a 30 year old woman fitting, and I was asked what I would do. Obediently I rattled off that I would check her airway, breathing and circulation (easy as A,B,C...) and call for help. What could I do whilst help is on the way, I was asked. What were my differential diagnoses in this situation?

I don't know why, but I find it so, so difficult to put myself into the scenario and think the way I would think if I was actually confronted with this problem in real life. I knew that there was something I could give her, and I knew that it wasn't an anti-epileptic as such, and I knew that my interviewer was willing me to say this simple word, and yet that word had completely left my brain. Perhaps because of this, I found myself unable to think of many differentials. "I know that you know this," encouraged my lovely interviewer, whilst my heart sank lower and lower and my brain unhelpfully reminded me that this interview was actually quite important.

But so much of my clinical knowledge is wrapped up in the different cues you get from the clinical setting, which were absent in the hotel function room that I was being interviewed in. Sat outside, awaiting the next station, the answer finally came to me. I knocked on the door I'd just left. "I would have given her diazepam!" I exclaimed at my bewildered interviewers. "Yes, well done, thank you," came the solemn reply, and I sheepishly shut the door again.

Just before leaving New Zealand, I met up with a couple of friends who were also applying for jobs back at home. One had had to leave early, leaving two of us to reflect on how good she was, and better prepared than both of us. I related this to my housemate the next day.

"But I'd far rather work with you or R, than with H!" she replied, kindly and honestly. But it was no comfort, I thought as I tried to revise the seven pillars of clinical governance, wondering if knowing the difference between a guideline and a standard (a classic interview question) made me a better doctor.

If You Could Speak

2009-12-23T06:13:00.007Z

"Mrs Plornish was particularly ingenious in this art; and attained so much celebrity for saying 'Me ope you leg well soon' that it was considered in the Yard but a very short remove indeed from speaking Italian."

Isn't that wonderful? A man is able to make me laugh out loud with words that he wrote 150 years ago on the other side of the world. Here I am, looking in on London in the 1820s, whilst being burnt by the Kiwi sunshine of January 2010.

So job applications, broken laptops, sorry for not posting as regularly recently blah, blah, blah. Let's say it's my new year's resolution or something. Spend more time writing nonsense on the internet that no-one reads - actually that sounds like one I could keep. The jogging every day one has been less successful.

ED then. "Emergency Department" seems to be the latest shift in nomenclature for the casualties and accident and emergency departments of the UK and New Zealand. Perhaps it's so that you can laden your opening, "What brings you to the emergency department today?" with extra sarcasm, making the girl with an insect bite smaller the one on your own arm blush and vow not to waste your time further. Perhaps it's because ED sounds cooler, closer to ER, which I suspect American TV owns the rights to.

Whatever, I've taken to calling it ED fairly quickly. "A+E" now sounds clumsy and arcane. I've also taken to enjoying it very much fairly quickly. A good thing, of course, but one which complicates my career planning considerably.

On the surface the two seem quite disperate, but fundamentally they aren't far apart at all. These are the inbetween specialties - halfway between the elegant puzzle solving and slow burning cures of medicine, and the hands on, life and limb saving decision making of surgery. Specialties with less ego, happy to let the glory go to others. Specialties without ward rounds, clinics, and in which you can wear scrubs and trainers all the time.

All arguable, and just the impressions of a small, third year post grad, but I have met similar personality types in both. So, I must decide: Do I enjoy the excitement of resuscitation, the variety of knowing that anything can walk through the door, the practical, seeing and treating that comes with pulling fractures and closing wounds. Remember how people used to ask "How many stitches did he have to have?" when somone had been to Casualty or A+E? Well now it's me sewing those stitches! The 10 stitches holding the skin on that man's arm together- my handiwork. He broke a glass on his arm. I cleaned it up, checked for remaining shards on an x-ray and then fixed him. Clearly I do enjoy it. My question is, do I enjoy it enough to work shifts for the next 8 years, and stay patient with the abusive drunks and attention seeking overdosers.

It's a while since I did anaesthetics properly, and I have applied for anaesthetics training jobs again this year. However, the ACCS programme is designed to produce acute medics, emergency physicians and anaesthetists, so in theory switching shouldn't be too hard. My main concern with commiting wholeheartedly to anaesthetics is that I will get bored after a couple of years putting people to sleep and sitting listening to surgeons swearing at nurses and juniors. The amateur transplants summed it up quite well:

"Everyone wonders what anaesthetists do whilst the patient's asleep.
Everybody wonders what we do for three hours while that machine goes beep.
Everybody reckons we drink coffee and we gossip and we're generally subversive.
Everybody reckons we do crosswords and sudoku's and we chat up all the nurses.

But do you really think that's all we do?
Well let me tell you now it isn't true.

Cause we sometimes check the screen,
and every now and then we write stuff.
And if we have to intervene,
we inject a bit of white stuff.
And we offer to alter the light,
or the height of the bed.
Or fiddle with the radio, change the CD,
we even check the patient occasionally.
And if they move, we turn op the vapor,
and then we go back, to reading a paper."

Well, there is a grain of truth to that. But then, as I explained my dilemma to my current, and very enthusiastic and lovely boss, her subversive colleague kept asking people in the office why they went into emergency medicine. "It was so you could go to the bank on a Wednesday wasn't it?" she demanded, before each witness nodded sheepishly.

Ok, that's it. I'm talking no more about my career dilemmas. Next time I'm going to talk much more about NZ. Although I'm going home for interview next Sunday. Woo.

Place for Us

2009-12-06T05:41:00.004Z

"She says I always criticise her, which is another flaw of hers."

Hello, hello. So, I've started emergency medicine, which was a pretty major reason for me coming out here. I enjoyed my shifts in paeds ED, and thought I'd give it a quick try before committing to anaesthetics. The main questions are, did I like paeds ED for the paeds or for the ED, and will I love or hate shift working? I started on nights, so I'm collating my answer to the second question straight away.

There is a part of me that thinks shift work should be, well, fun. Finishing work as everyone else comes in, going against the traffic, days off during the week, empty shopping streets and not being at work when post offices are open. The camaraderie of the night shifts, and the way it makes you feel you're doing a job where every day is different because, amongst other things, you're working different hours each day! Afternoon shifts allow you to lie in on a work day! I'm easily pleased.

Perhaps it's just me who thinks like this. I'm worried that the reality will be work hanging over me before late starts, so I feel like I can't get anything done, and the death of my social life. But that's the idea of testing it out first, right?

On the plus side, it means that I can score 1-2 points on my application form, under the section "any experience in the ACCS specialties (excluding foundation training)". Oh yes, it's already here. Application form grief. Why can't they just give me the job that I want? Why do they have to make it such an unpleasant hoop-jumping exercise?

"It's a game, you've just got to play it," says my flatmate K.
"If it's a game, then why isn't it fun?" I reply, whilst between us we try to make it sound like organising a hospital touch rugby team shows leadership skills.

It's not a nice experience to confront a question, "Please provide details of outstanding achievements outside the field of medicine.(250 words max)" and to draw a blank. Why can't I just be good at and enjoy things without seeking international accolade? Is grade 6 piano outstanding?

Ugh. It's just my nature to downplay everything I've achieved in life, and so to have to sell myself so shamelessly really grates. And it's to a committee of people ticking boxes en masse, trying to decide if I've shown enough of an interest in anaesthetics to get to interview and the next part of the game. And they do so by reading about which of my audits was the most boring, and the fact that by some fluke I managed to do an interesting project at med school which was presented to the national conference of a royal college. Both of which prove my excellent bedside manner, diagnostic skills and medical knowledge.

The thing that makes me really angry, is that they have made such little progress on the application forms. I am applying for a specialty that is recruiting at a local level. If I want to apply to lots of different parts of the country, because I want the job more than I want any locality, then the application forms are different. Couldn't they have just got together and made one standard application form for the whole country?

The other area in which they have made no progress is giving offers. I have a preference 1, and a preference 2. Preference 2 will be interviewing and giving out job offers 2 weeks before preference 1. Suppose I am successful and get an interview from preference 2, and then they offer me a job straight away. I have 48 hours to say yes or no, not knowing at all how the interview will go with preference 1. I have to either stick with my second choice, which I have, or take a gamble on my first choice and potentially end up with nothing.

It is a horrible way to be treated, and it is a problem that has been highlighted for 3 years running. I appreciate that it is difficult from the deaneries point of view - if everyone holds on to the jobs only to turn them down later then they could potentially end up with no-one to do the work when August arrives. But I feel sure that by now a third path could have been found. The Royal College of Physicians has managed to make applications to core medical training national. Everyone fills out one application form, and chooses their top two deaneries (geographic areas) to apply to. They also list all the areas in order of preference so that there can be a clearing system for those unlucky enough to not get either of their top choices. In one fail swoop the amount of work for both applicant and deanery is slashed, and the system allows people to hold a job until they have heard from both of their top two choices.

The Medical Training Application System was a pretty massive disaster. However this was because of the application form, and the sudden bottle-necking that came about by suddenly offering a limited number of golden tickets and ruining the careers of anyone who tried but didn't get one at the time. The idea of a national recruitment scheme is a sound one, and I wish that people would get their act together.

I also wish that medical bloggers wouldn't moan so much. I mean, grief, we have well paid, fulfilling jobs! So, to stop myself moaning, I'm not going to write anything until the 18th December, which also happens to be when applications close. Fingers crossed.

Today

2009-11-17T08:37:00.003Z

"Choice"

I feel that I should clarify a couple of things from my last post. Firstly, when I talk about medicine, I mean general medicine as a specialty rather than medicine as a profession. Secondly, I have nothing against Dermatology and CER will make a great dermatologist. It's just that I have a lot more contact with acute/general medics and I know the value of a good one.

CER is still back and providing good entertainment. On the downside is the moustache he is growing for charity. "Movember" is massive in NZ, but that is no excuse for the mo-nstrosity that's currently staining his top lip. It needs peroxide to match his hair. Exactly.

On the upside, he's still as needy as ever. "I'm having lunch in the RMO lounge for a change of scenery." Well worth a page. Not sure I need to know your every move. And we've been team clerking this week, which is what we do when there aren't enough patients for us to see so we take it in turns to see a patient with the other person writing the notes. It's quite a good exercise - useful to see someone else take a history and examine, and then have someone watch and critique your own assessment of a patient.

We were team clerking a slightly reticent lady last week, when I got to the background questions and asked her what she used to do when she worked.
"I was a nurse," she replied.
"Oh," I said, in my throwaway manner, "perhaps that's where you got your mistrust of doctors from?!"
"No," she explained, "I developed my mistrust of doctors when my husband was in hospital, and they ignored my concerns about him, and then he died suddenly."

I don't think you can say anything to that. I paused, half mumbled regrets and "sorry", paused again and asked her if she had ever smoked.

The next night I saw her again, now with a diagnosis of a brain tumour, possibly not even a primary. (i.e. she has cancer somewhere else, and it's advanced enough to have built colonies.) She wanted to go home overnight, and I wanted to let her. So I said yes, and then spent the rest of the evening picturing her having a seizure alone in her house, choking on her tongue and not being able to phone for an ambulance... Which is not normal for me - I'm usually pretty good at switching off once I leave the hospital, and distancing myself from patients. I saw her walking around the ward the next morning and breathed a sigh of relief. I had the temptation to embellish her unreasonable demands and threats to walk out if I refused her wish to spend the night in her own bed, but saw it pass because writing lies in a patients notes is a far worse crime than making a mistake and a patient coming to harm from it.

Today we were group clerking again. An English patient - giving us the chance to pine for the old country whilst congratulating each other for leaving and coming to sweet as New Zealand. A 92 year old lady whose legs didn't work when she tried to get up this morning. "I think people should get to 85, and then just press a button to stop," she told us. And then no-one for ages, until I saw a Tongan man who had been to the GP for a refill of his medications. The GP had done a blood test (why not?) and found that he had a pretty massive anaemia.

But then, the story the GP told us on the phone was a bit different. Yes, this man had a drop in his blood count, but the test hadn't been done for over 6 months, so the drop is from before May, and he hasn't had any symptoms. And the "recent hemi-colectomy" turned out to over a year ago.

CER took the call. Low haemoglobin after an operation - surely the surgeons need to see him first? I pointed this out to him once he was off the GP phone. "Well, the surgeons refused him," CER replied, whilst I made various incredulous faces. "We'll see him and triage him to the apporpriate service." "But," I insisted, "couldn't the GP give you an idea where his bleeding is coming from?" Blood doesn't tend to drop as quickly as the GP implied without an escape route, be it in bowel motions or vomit or whatever. CER shrugged, "GPs can't tell you anything here."

I do not wish to slander all Kiwi GPs. I have had some excellent referral letters from very switched on GPs. But I have experienced an overall lower standard. The one that really annoys me is the letter that says:

"Dear collegue,

Many thanks for assessing the above patient.

Yours sincerely,

Dr Cantbearsed"

And there follows a print out of the last 5 consultation notes like a good little computer programme. Well, I do not need to know that you gave him Ceclor for a cold 5 months ago. I do not find consultation notes as helpful as a GP writing specifically to me, the admitting doctor, and telling me what he or she has found and why he or she has been concerned enough to seek admission for HIS/HER patient. And since many GPs here seem to send people to hospital for a second opinion, to resolve themselves of any responsibility, independent thought or the need to examine the patient, I feel the least they could do is write a proper referral letter.

Glass

2009-11-13T10:48:00.003Z

"You shouldn't tell him, you're too easily offended."
"I can't believe you just said that!"

Hello. Here's a quick summary of my non-medical life. Queens Park Rangers are currently 4th in the championship after an excellent recent run of form which included 3 games in a row in which the team scored 4 goals per game.

My favourite piece of Kiwi slang is "choice", a word which I am using at every appropriate (or choice) opportunity, particularly as a response to someone else using "awesome" or "sweet as".

A few choice songs (old and new) that I recommend at present are "Too Fake" by a band called Hockey, "Sunrise" by The Divine Comedy, "Edith" by The Hot Melts, "Intro" by The xx and "Dishes" by Pulp (mostly for the instrumental bit in the middle). And I was just listening to The Aliens, whose first album "Astronomy for Dogs" manages to bypass its terrible title and be quite fun.

And finally, I am currently in love with Little Boots, Tina Fey (in a kinda "I'd like to be married to Tina Fey if I was in my late 30s" sort of way), Beautiful Pharmacist, and Lydia (who is engaged).

So, that's us up to date. Except for travelling - by far the most important part of coming to New Zealand for a year. Last weekend I went to Rotorua, which smells of sulphur thanks to volcanic activity. Nice - fortunately the sulphuric stench is mostly in pockets, and much of the city is able to go by without covering its collective mouth, although that maybe just because you get used to the smell after a while.

Whilst there I went White Water Rafting, Sledging (on rapids), Luging, Zorbing (waste of money), and Quad Biking. We also got some Maori culture, which was a nice change of pace. There are times when I think I would have liked to spend a year travelling, rather than all this rather pointless work...

Although, as we were saying at lunch today, a whole year of travelling would take a lot of stamina. And money. R was saying this, because she had planned to spend 5 months travelling from February time, but now is thinking that she will come back to work for another 3 months. "3 weeks on the South Island, and I needed a holiday!"

True. I felt in need of a holiday all this week following our weekend escapades. Today, I mostly felt altitude sickness, seeing as how I was all the way up on ward 10, pretending to be a normal medical house officer. Dr H moved me today, just as he moved me for 2 days last week, and I got to experience being a normal medical house officer.

It reminded me why I don't really want to be a medic. It's a world of endless ward rounds, passively waiting for everyone to get better, hierarchies and relatively humourless individuals. It is the specialty that gets dumped on, the specialty where men like Mr G end up. Mr G was an nice enough man, who ended up on a monitor because he said the magic word: "Chest Pain". Mr G gets short of breath when he walks from his bed to his toilet and so can't really leave the house. Once he gets short of breath, he often gets angina, usually around 3 times a day. He also has diabetes, so has to inject himself with insulin each day, as well as prostate cancer and osteoarthritis. Writing all his usual medications on his hospital drug chart took the best part of half an hour. No doubt each drug has its own side effects, and is in difficult balance with all of the other chemicals designed to slow his decline.

And what can I offer him? Not much. And why is he in such a state? Smoking, obesity and a lot of bad luck. He will sit in a hospital bed, perhaps at best we will get his medications a bit better so that he can walk to the post box like he used to be able to do, or so that he only gets the chest pain once a week. He will go home, little better than when he arrived.

Medicine does have its upsides - why else would anyone do it? But I don't get enough pleasure from diagnosing, problem solving and building up relationships with your long-term patients.

The reason I'm going into all of this, is because I really, really enjoy my current job. And it makes me think of the noble lot of the physician again, with his extensive and detailed knowledge, quickly called upon by all other specialties to solve the problems that defeat them or fall outside of their narrow focus of interest.

So I'm reminding myself that it is not me. Although CER (my registrar - I've decided Paul was a stupid fake name for him) is excellent at it. Knowledgeable, patient, accommodating but firm enough to turn away GPs that can't examine patients "because I'm a locum", and unflappable even when the referral phone doesn't, stop, ringing. He has his heart set on being a dermatologist. Which will be a waste.

Foux du Fafa

2009-10-28T08:49:00.003Z

"Sounds like something a lamppost could do"

So, whilst we're on medical words, I rediscovered emaciated the other day. Not quite as graphic as its relative, cachectic, but it still has a good visceral quality to it. I'm glad I looked it up before I wrote it in a patients notes, or I would have ended up describing said patient as emancipated, which is something quite different.

Now, until recently, I was managing to fly under the radar in my job. During the previous 3 month run my job was unfilled, and so I think Dr H, the big medical boss dude who runs the general medical handover each morning, had forgotten that the acute medical house officer was even supposed to exist. He used to urge registrars to hurry down to ED to see medical patients if ever Paul, the acute registrar, was away saying, "Until you get down there, no-one will be clerking patients." Yep, just me, Dr No-one, clerking patients all on my own.

I used to ask Paul if I should let him know that I was working for him - he is, in name at least, my supervising consultant. "Nah," said Paul, "probably a good thing to be under the radar for a bit" citing Dr H's love of moving people to cover different teams as and how patient lists demand.

Of course, I work with 3 different teams a day, so I got to know everyone else medical within 2 weeks. People would grin conspiratorially when Dr H would make a reference to the medically-deficient ED, knowing that in actual fact I was the ever present first line of attack each day. You know, once I'd got my coffee from the canteen. Can't be yawning in front of sick people.

And then it happened. "There is no acute registrar today, but there is an acute house surgeon. Stephen is the acute house surgeon, so make sure you use him constructively." So long, Dr No-one. I'm not too sure I like the sound of being used, constructively or otherwise. One week later, and he has tried to move me for the first time. If you cross cover a team, you get an extra $300 for your trouble. Work without a registrar for the day and that's a further $300 in the bank. Work more than a certain number of hours beyond that which you are rota-ed for, and that is more money you can claim. If you want to come in at the weekend and catch up on discharge letters, you can claim for that.

The RMOs (junior doctors) hold a lot of the power here you see. All of the above is notable, in case you hadn't guessed, because it doesn't happen in the UK. Claim? What? Working without a full team? Suck it up. Working late? You're fault for not working fast enough. In fact official management rules are that we shouldn't be working late at all, rather we should drop everything at 5pm and let the on call do all the work we couldn't do for us. No-one works like that, because we all know that ward cover is the most miserable job on the planet already, without being further dumped on.

But Raz, the house officer who I would have been helping, who I think is in his 6th year, and who is universally acknowledged as being a bit of an unscrupulous pain, decided that he didn't need my help. He preferred it the other way around, because then he got the $300, which I didn't mind because I've never been one to do extra work for money. I've never wanted to work extra shifts as a locum, my free time is always more valuable to me than extra money. And so I was back in the ED, seeing chest pain, chest pain and then some knee pain.

Knee pain? Medicine? He was a sweet, though senile old man who was there with his daughter, who was correcting the bits of his history he couldn't remember. The ED senior had said that this man had cellulitis, on account of his hot, red, tender skin. I couldn't find hot,red, tender skin anywhere on this man and I couldn't work out if the ED dude was trying to justify his rather questionable diagnosis, or if this was just a very sensitive case of cellulitis which had vanished in a few hours with 1 dose of antibiotics. He did have a swollen knee though. So I phoned orthopaedics.

"Hmmm. You need to rule out a septic knee (something I knew already, kind of the point of the phone call). Aspirate the knee, get your senior to do it if you aren't happy to do it, or the rheumatology registrar, and if it grows anything exciting, then give us a call back."

What now? Yes I can aspirate knees. I used to do them when I was an orthopaedic SHO. Yep - an orthopaedic member of staff doing the orthopaedic investigation for the orthopaedic problem. Those were the days. Did he just say rheumatology? How desperate to avoid work are you?

But the issue wasn't really could I aspirate the knee or not. I would have, I like procedures. What I needed was someone whose job involves knees to tell me which is the riskier option - to assume that this is a haemarthrosis as the history and examination suggest and not rule out a very dangerous septic joint, or to stick a needle in this man's knee when he takes warfarin so will bleed and bleed and bleed and when it's so deformed with arthritis I can't reliably tell where any landmark are to stick the needle in safely. And so I told the orthopod just that, and asked him if he was nearby. Lazy sod, this particular reg was from the UK as well, but has evidently got too used to the Kiwi way of orthopaedic surgeons doing no work outside of theatre.

Make It Rain

2009-10-17T00:55:00.003+01:00

"The most perfidious way of harming a cause consists of defending it deliberately with faulty arguments."

Perfidious. Why is that word not used more often? How about fitigous? I was discussing that with Paul, my camp English registrar, this week. He thinks it's a medical word, as in 'pertaining to a fit', but Kiwi doctors don't seem to recognise the word fit as being an alternative to "seizure", so I don't think they'll recognise fitigous either, even though it sounds cool. Personally I think it sounds like someone who can't sit still, which could be a medical condition - I forget.

Paul was away for the first 3 days this week. His first action on returning to work was to page me to ask if I wanted coffee - always the sign of a good working relationship. In his absense I spent more time getting to know some of the other Med Regs in the hospital, as and when I wanted advice. There was Rahim, who took a throwaway remark about, "why has the GP referred a patient he clearly hasn't examined?" as a personal insult (he was accepting referrals), which in hindsight it should have been because it was an insanely busy day full of soft admissions. Pete, on the other hand was the consumate senior, efficient, supportive, approachable, good advice.

The career structure is all a bit different over here. When you finish medical school, you are a trainee intern, but you don't do much more than a medical student back in the UK - no responsibility and no on call. Then you become a house officer, which you can do for as long as you like. It is more like the old SHO grade back in the UK, but again I would say it's a more junior position. I suppose that's because we're picking up what the F1 equivalents aren't doing over here.

And so, registrars are also more junior as well. You need no exams to become a registrar over here, just 2 years as a house officer. In other words, I could be a registrar, and many of the registrars are no more experienced than I am. As it is, all the UK doctors have come out to be house officers. Not unusual, because the pay doesn't change between grades, so there are many 3rd, 4th and even 5th year house officers. A lot of the UK doctors do feel a bit frustrated by the fact they are essentially as senior as their middle grades, but are having to do the sort of ward cover that you do as an F1 back home. I'm finding it ok, but only because the job I'm doing - acute medicine - doesn't really fit into the team system so I'm almost a free agent.

If I were to become a medical registrar here, it would mean I was just stuck in medicine for the year. Being a house officer suits what I want from the year medically- a bit of general medicine, some A+E experience and 2 months off at the end of the year to go travelling. I can put up with being a bit more junior for a little while for that. And officially, a house officer is the equivalent grade to what I'd be back in the UK, so that's fine from a CV point of view.

Sorry if that's all a bit confusing. The main point is that it's a bit odd answering to registrars who are at the same stage of training as me. Especially if they're not very good. It also means that consultants have to be around and inquired of a lot more than back home.

Anyway, this week was the week of late presentations. My favourite was an 86 year old lady who had had some chest pain on Monday night, a further couple of episodes on Tuesday before finally coming to hospital on Wednesday morning. Taking her history, checking her ECG and looking at her blood tests it was very quickly apparent that this was the most textbook heart attack that I had ever seen. The pain did everything it was supposed to, the ECG had every classical feature and the blood tests were off the scale. "But I've never had a heart attack before," she explained, "so I thought it was just indigestion. I thought it would just go away. To be honest I didn't even want to come into hospital today".

It was fun phoning the cardiologists and saying, "I've got ST elevation in 5 leads, and a troponin that's too high to be measured." Usually I have to try to sell pathetic little heart attacks because the big, obvious ones miss me and go straight to the coronary care unit. This one was easy, "I'll be down now," said the cardiology reg.

The second man had a weak right arm for, wait for it, 6 days before he finally saw his GP. Even then he didn't come into hospital until the day after his GP referred him. The head scan was subtle, but the radiologist reassured us that with the history, he was happy to call it a stroke. "So I can't go to work tomorrow then?" was the patient's only question.

Corrupted

2009-10-13T10:16:00.004+01:00

"We return now to everyone loves hypnotoad"

So, I was wondering, what makes a patient obnoxious? What is it that makes someone who is sick start mistreating the person who is trying to make them better? Why do some people treat health care staff as the enemy, to be viewed with suspicion and to be kept on a short, demanding leash for fear that they will otherwise avoid helping you if they can?

And what makes someone cake their face in malcoordinated make up? I've not put on much lipstick in my life, but most women who I see wearing cosmetics seem able to colour within the lines. You can probably guess as this gets more specific that it all relates to one person. In case you think it was just me who took a dislike to this Room 101 inhabitant, allow me to present evidence exhibit number 1:

"Please don't admit that man. His wife will drive the nursing staff crazy."

In fact I think the word suicidal may have been used. So you see, all her efforts were counter productive. The more she pushes, the more defensive the healthcare workers become, and the harder she feels she has to push and a viscious cycle ensues...

Speaking of cycles, I bought a bicycle at the weekend. I cycled it home on Saturday, to church and back twice on Sunday and then had biked my way to the hospital on Monday morning. All that physical exercise had put me in a very upbeat mood, despite my aching legs, and I had decided in the sunshine as I looked across at the beautiful view of the harbour that it was going to be a good day. It was busy, but I've always secretly preferred it that way, and the morning was going well.

And then I met them. Unhappy about how long they'd had to wait, they trudged through into the cubicle area of the emergency department. The GP letter had made me roll my eyes as I read of painkillers that had been prescribed for this man's headache but rejected because of various side effects. I'm always slightly suspicious of the person who is having unbearable pain, 9/10 in severity, but won't take codeine because it makes them constipated. If your pain is as bad as you're describing my friend, I think I'd take the constipation...

I knew things were doomed as soon as the man started telling me the history of his headaches, only to be interrupted by his wife, who clearly felt that he wasn't injecting the full amount of drama his problem exists.

"And last time we were in here, we were told by the junior doctor to go home and just expect the headache to go away by itself, which I don't really think is good enough."

Nor would it be good enough, if it were true. However, a consultant review, a provisional diagnosis and a clear follow up plan, most of which had been actioned by this point, is not quite what you described there. And if you will reject all the painkillers we suggest for the meantime whilst we investigate and treat the underlying cause, then what more do you want from us? Yes I'm sure it was the junior doctor who was left to do all the donkey work of discharge and answer all your questions, we tend to get given these tasks by our consultants, but that doesn't mean you were treated inappropriately.

They were here for a CT head. The GP had promised they would come into hospital for a CT head. He should have had a CT head last time, she told me.

Now CT scans are Xray based, and so use a not insignificant amount of radiation. "They decided that it wasn't worth doing a CT head last time." Yes, a highly qualified, experienced medical practioner decided, correctly as it turns out, that your signs and symptoms did not fit with any causes of headache that a CT can detect, and therefore he would rather not give you a large dose of radiation just because you think that a head scan will answer all your problems. The majority of causes of headache will not show up on a scan of your brain, and incidently if I scanned your head I wouldn't find out why you're treating us as if we've been guilty of the most heinous malpractice up until now.

Well, the patient got his CT head. I'm not sure why the registrar made that decision, but there you are. I suppose it wasn't so unreasonable, as this headache was almost 4 weeks old, albeit not constant. But then he had uncontrolled high blood pressure, which was a far more likely cause for his headache than something physical like a bleed or a tumour. The result came back... normal. Who would have thought it! Back to the original plan...

I had phoned the radiology registrar to request the scan, and was told that it would be tomorrow. Fair enough, I said, I couldn't argue that it needed to be more urgent than that, although I wasn't looking forward to telling the patient that he would have to wait until then, possibly in hospital. So, I went to explain the situation to the patient and to his wife. I did it with all the charm I could muster, trying to keep them fully informed and trying to make them feel cared for. I answered her inevitable questions honestly and with a smile. Just when I finished passing on the message that the scan wouldn't be today, the porters arrived to escort him to CT right there and then. Which made me feel like an idiot. Why do these things happen to these patients?

Anyway, she's the exception, not the rule. Most patients appreciate that coming into hospital means waiting around a lot, and trust that we're doing all that we can. I'm not spending the time checking my email, because I can't be bothered to see you just yet, I promise.

My mood was restored by the wonderful American woman who had had a truely terrible ride through hospital earlier in the year, on account of a horrific pair of diagnoses and a hospital acquired infection to boot. Yet here she was again, cheerful to the last, stoic about her trials and making me laugh as she described some of the things that had happened to her, and spoke about her family. We discussed California, and my trips around Sion national park and Josemite, and how I fell in love with San Francisco and would love to work there, and being ex-pats and how I was going to treat her medically this time. And then the sky was clear as I cycled home.

Resistance

2009-10-03T10:50:00.002+01:00

"...his looking so supremely benignant..."

Hello. How's everything? I hope that you're all well. I've missed you too, but you must understand that I haven't had such ready access to the internet up until now. And the last few days I have found it hard to know what to write about because it has been so long. I hope you will accept my sincere apologies.

I've just been looking into moving this page to therethere.blogspot or there-there.blogspot but both of those are "taken". Neither has had anything written on them since 2004, so that hardly seems fair. I think that the current URL is pretentious, assuming and irrelevant, but looks like I'm stuck with it for now. There must be an awful lot of discarded webpages lying around cyberspace, all translated from a series of tiny switches, on or off in a particular formation, which exist in real space somewhere in the world because someone wrote something on a keyboard many miles away and then forgot about it...

Not the most romantic of images. I still don't like the word "blog" you may have noticed. I do however like the word benignant, and the word joyous, so I must try to use them both more often.

All of which is stalling, because I really don't know what to write about. It has been a long time, a lot has happened. I got settled into the new job in acute medicine, moved into a new house full of celts, spent too much time speculating on whether my registrar is actually gay or just really feminine, etc. etc. Just this week I justified 3 consecutive cooked cafeteria breakfasts to myself on the basis that I was about to be on a long day, I was on a long day, or I had just been on a long day. The real reason was just that I had got up late 3 days running, and have a real weakness for hash browns...

It hasn't all been work. Two weeks ago I went to watch the All Blacks beat the Wallabies, which was preempted by the spectacular, firework augmented haka. Around the same time, I explained the basics of how you play rugby to a group of girls... We decided to drive to Wellington in a hired campervan, which meant that we got to see some of the North Island countryside on the way. It also meant that we spent 20 hours driving for a game of rugby and a night out, but that really misses the point.

I have seen a lot of patients. My job is basically the bit that happens right at the start of their stay in hospital, the really acute bit, so I rarely if ever see a patient two days in a row. This has many advantages for me, the main one being that my medicine is a lot sharper than it was 6 weeks ago. The only disadvantage is that I don't routinely see what happens to any of my patients through the rest of their admission. I can look it up in a discharge on the computer system when I have the time, but that's not much of a substitute.

So that's a very basic sample of the last few weeks. I'm really too sleepy right now to add any more, but for now I'm just getting back into the habit... I will write soon, I promise.

A House Is Not A Motel

2009-08-25T09:09:00.004+01:00

"in joy, in joy, knowing the abyss behind"

1 line of Homer there, for my mother.

So, New Zealand then. I don't work for the NHS anymore. A certain nobility is lost. I still feel a bit miffed that a lot of American's are being loud and ignorant about our communist style medical system, but I am out of the employ of the world's 4th largest employer, so I feel less under attack personally. I feel sorry for the Americans who, and I think they must exist somewhere, actually advocate a national health service and look on the shouting conservatives with despair. "Why should I pay taxes to help someone in much greater need's health?" the con-men cry between lies about the UK. We filthy communists shake our heads, and decide that if you need to ask that question, you will never understand the answer to it.

New Zealand then! Get to it! Welcome to the other side of the world. I write at 20:24, enjoying a quiet evening whilst everyone in England contemplates the beginnings of a new day. I am told that if you fly from NZ to Los Angeles, you can arrive the day before you leave. That sounds cool enough to try. Although I imagine 10 hours on a plane is enough to take the wonder out of any experience, especially an experience which ends in LAX. Ahem.

So I arrived 24 hours after I had left. The dictats of time zones meant that I lost Monday somewhere along the line, and so I arrived bright and bleary eyed on Tuesday morning in Auckland airport. I hadn't slept much on the plane, although I had met M and S, two friends from Cardiff, and the three of us had caught up on the past (F)2 years over rum and coke and strange vegetable cracker things at the back of the plane. My lovely hostess met me at the airport, and drove me through the city, allowing me to start trying to answer my mind's question. "What," I wondered, "does New Zealand look like?"

Speaking of inevitable questions, "Why did you come to New Zealand?" is definitely one I need to work on. No-one really asked me, "Why are you going to New Zealand?" before I left. Occasionally I'd get, "to work, or just travel?" but everyone I spoke to about going seemed just to understand or accept without further question that I wanted a gap year, wanted to try being a legal alien or a foreigner for a while, wanted to see what New Zealand looked like, wanted to travel to the other side of the world because it's an adventure and that's a part of what we're here for. But now I'm here, people are asking. People who have done the same thing are asking. That must just be small talk. They must know that the reasons are numerous and none.

"What made you come to New Zealand, aye?" The prospect of sticking you, specifically you, with your cornish grandmother, with this long and pointy spinal needle. That was my lumbar puncture patient from earlier today. He was a nice kid. Very well, but with a splitting headache.
"Do an L.P," said the reg, "I know that the consultant will ask for one." Good to see many things don't change, wherever you practice medicine. This boy had to wait for his CT, then for his LP, and yet I would have bet money when I initially saw him to say that this headache was, most likely, a headache. Meningitis? Space occupying lesion? Sub-arachnoid haemorrhage? Ticked off one by one. You have a headache. But just in case you don't you get to spend the whole day waiting for tests and results. Good to see many things don't change, wherever etc.

Anyway, today was day 2. Friday was induction day, bombarded with information whilst making friends with the other pohms that are here to provide Kiwi healthcare for the next few months. We met some maori people, who explained a bit about maori healthcare and exchanged life spirits with us. (It involved touching noses - I was more worried about exchanging my cold.) The pohms exchanged plans for the year. It seems we all want to disappear in May, so the health board may find itself a bit short staffed nine months from now

Whim and opertunity, and a bit of adventure. That's what made me come to NZ. Well today I worked long hours in an unfamiliar hospital with systems I don't know yet, and it rained on the way in. Then I miss people, and feeling fully relaxed at home, and being real friends with people, not just new aquaintances with everyone. And I'm wondering for a brief moment on the way to work, when the train has made me late on my second day, if I should just quit now and fly home and live off my 2 years of savings. And I sigh to myself, and wish away the difficult part of doing something new, willing myself to see 2 months into the future when I know my job well, live in a room that is mine, start spending weekends in exciting places. Then the day goes well, very well, and I am glad because each day is bound to get easier as everything gets a bit more familar.

"So you're going to New Zealand, that's very Lord of the Rings." That was one of my favourite reactions. "I have come to New Zealand because I've got this one ring that I need to dispose of, and I've heard that Mordor, which I think is on the South Island, is a good place to do it. Meet my friend Sam. "

Not the Only Person

2009-08-15T18:43:00.003+01:00

So, in other news I'm quite enjoying The Rumble Strips at the moment. This is a cool song, has that thing where it sounds like you've heard it before which either means it has that rare immediate quality, or that the band has just copied an old song...

Yes indeed, Spotify is turning me in to an even bigger music geek than usual. I've read a fair amount about Spotify in the press recently, but still most people I talk to about it haven't heard of it. It's an online music library, which lets you stream music straight from the web. It's free, so you have to put up with adverts, but it's still a dream come true for people like me. It has plenty of obscure rock nonsense, which just about sums up my music taste...

And isn't Little Boots wonderful? Seriously, I think I'm in love. For someone to use that much electronica and for me still to like her is quite something, although it might be partly because she's blonde and pretty...

All of which is to say that I've been unemployed for 10 days now, and so don't have anything medical of consequence to say at the moment. Instead I've spent days and days editing the video of our American holiday, so that it now has music and montages and other novelty gimmicks in it. Someone told me I had quite a flair for it, so what with opening a cafe, writing and sponging off my parents, I'm slowly ammassing an array of options for when medicine goes wrong.

Tomorrow I fly to New Zealand. This involves sitting on a plane for 24 hours, so with time differences I don't actually arrive until Tuesday morning. So between trying to find accomodation, starting a new job in a whole different health care culture and arriving in the middle of winter I can't help but feel a bit apprehensive. Excited too, and struggling to really appreciate the fact that I really am completely, actually going for a whole year.

I'm sure I should have more to say on the matter. The Medical Council of New Zealand agent emailed me the other day to say I could come for my registration interview straight from the airport if I wanted to. Um, I'm not sure I want anyone to see me after I've been on a plane for 24 hours, let alone someone who's deciding if I'm fit to work in the country. It could make for a very short trip...

There are 40 doctors coming to Aukland from the UK. 40! Makes me feel very unoriginal. Facebook is also continually attacking me with news of other people saying "...has arrived in Oz" or "...flies tomorrow." It's impressive that so many people have the confidence to take the time out, when there are plenty of doomsayers - surgeons mostly, I've noticed - who say that we'll all struggle to get jobs when we come back. My hope is that even more people will have the confidence to take a year between F2 and specialty training next year, making applying for the job I want that bit less competitive. And who knows, perhaps they will take a few more steps forward in the application process by next year - perhaps there will be an "offers week" so that if you're offered your second choice job before you hear from your first, you won't have to play a monstrous game of "stick or twist" with your career. Fingers crossed.

Anyway, I'm going to have to pack my laptop up now, before going out for a farewell meal with the family. Church tomorrow, and then off to Heathrow in the evening. Wish me luck.

Dishes

2009-08-06T07:59:00.004+01:00

"When a man hurries, the first thing he forgets are his toothbrush and his God."

Today is the second day after the big, fat, medical changeover. My flatmate has left for his new commuter job, getting to call himself CT1, whilst I'm sitting in the lounge getting to call myself unemployed. My littlest sister used the insult, "go write your blog" as a means of dismissal recently, so I suppose it's only natural that I should question what I'm doing right now. Ends and changes make everyone at least a bit reflective, which is probably a good thing because "reflective practice" is one of the buzzwords of the modernising medical careers era.

Changeover day was quite fun for me really. I was on nights - I know! Third set of nights in 4 months! - and tried to argue that since my contract ended on the 4th of August, I should be paid at locum rates for the 9 hours I was to work on the 5th. No such luck, but that particular injustice was easier to take since in the end it was the quietest night ever. I spent the night reading in the mess, wondering if something more momentous was going to happen on my last ever shift as a foundation doctor.

Well, it didn't and I got to ring the "no admissions" bell when I reached handover the next morning. Except I didn't because it wasn't there, which made me reflect on some other stuff, although that mostly related to bells. Anyway, I reflected, there would have been almost no-one to hear the bell since all the old guard had moved on and the new guard were in "Trust Induction". The few registrars who were staying in the department sat around furtively, contemplating how they were to run the wards with no junior staff for the day. One of them got his old stethoscope out, and dusted it down for a few minutes. I sat there in my scrubs, the last SHO standing. The SpR with the stethoscope offered to put in £10 to a communal pot to try and tempt me with cash to stay and cover the wards for them. I replied with four fingers, two on each hand.

And then it was all finished. Trauma and Orthopaedics. Foundation Year 2. Nights. All done. "All the best for New Zealand Steve." Variations on that sentiment. Do keep in touch, let us know if we can help with anything. It's been good working with you. A quick trip to the wards to say goodbye, leave some Roses. Chocolates that is. Goodbye forever. This sentimentality doesn't change the fact that this hospital is low on my list of places to work in in the future.

How has it been as a year? I was confronted with this question during the night, when I used the time to fill out the "F2 feedback form". Negativity poured out of my every pore, as I told them what I thought of the standard of F2 teaching, or educational supervision and mentoring, and of the staff in the office. I told them of my high hopes of working in a teaching hospital with an excellent record on getting people into the specialty training posts they wanted. I told them that the staff at my F1 district general hospital were 100 times more supportive, and that their good record has nothing to do with them. The real reason is that teaching hospitals in popular cities have a higher-than-average cohort to start with.

It comes down to the simple things I told them. Don't go on holiday for the week which includes the deadline for F2 sign off. Don't arrange teaching sessions called "a career in Microbiology" after we've had to put in our applications for our specialty of choice. Make sure your interview preparation sessions happen before the majority of the interviews. Learn our names, please.

I begged myself to think of something positive to say. I have enjoyed my F2 year, haven't I? Well, yes. It's been mixed, but I'm sure the positives have outweighed the negatives. Can I really complain about the lack of support, when perhaps that's just been because I haven't needed any support. My educational supervisor said as much at the beginning of the year. "This is just a formality. I'm only really here if you have any real problems." We're grown ups, doctors even, who shouldn't need bottle feeding. But that is just excusing their lack of support, not a real positive note.

The moment came to rate my placements, and it was odd because in many ways it was the opposite of what I was expecting. You see, I hated paeds, you might have noticed, and yet there was much more to praise about my paediatric placement than my medical placement. In paeds, we had regular, formal teaching which was relevant because we delivered it ourselves, and quality controlled because it was supervised by a consultant. Nothing for F2s in medicine. My clinical supervisor in paeds was lovely, and practical in his help. I didn't really have a clinical supervisor in medicine. The poor old medical department fared badly indeed.

How about me? Did I get a lot out of my F2 year? Am I a good doctor? Better than this time last year? I met with my consultant about a month ago to review my time in orthopaedics, and he was so kind, full of praise for how I'd done. I ran the ward patients very tightly, he said, and he was pleased with how much effort I had made getting to theatre and clincs and to show an interest in the specialty. He finished a glowing supervisors report, and I thanked him profusely. Truth is, he is responsible for encouraging me to engage with orthopaedics. He helped me see that the difference between a house officer and an SHO is really that an SHO should be taking more of an interest.

Shortly before, I had my final meeting with my educational supervisor. Although he also went on holiday during the final week, so I had to get the head of F2 to do it for me. I know her quite well because she is an anaesthetist who has been encouraging me in my anaesthetic ambitions. A bit. Anyway, she was able to finally show what people had been saying about me in my mini-PAT (peer assessment tool). Basically you have to get lots of people who work with you at all levels and disciplines to rate how you're doing as an F2, and why not just try to pick people who you think like you. If you still get a bad score, then I suppose you must be doing really badly. Well, I hate these. I hate hearing what people have to say about me. But why? This time there really was no good reason to fear it. Everything people had said was positive. Very positive in some cases. I suppose I just really feel convinced that I'm not a good doctor, and so I find it suprising to find that a lot of the evidence is to the contrary.

Well, that's far too much reflection for one day. The European Working Time Directive came into force whilst I was at work on Friday night. I was watching it on BBC Breakfast news the next day in the mess, and wondered what it meant for me on nights at the time. I work 91 hours in the week I do nights, although at that precise moment I was spending one of those hours watching TV, so I'm not sure what EWTD would have to say about that. Actually the 91 hour week is allowed to stay, because the magic number 48 is the average across the whole rota over 6 months. On the new, compliant orthopaedic rota the SHOs get a whole week off once they've finished nights.

EWTD did fairly well for press, mostly thanks to Sir John Black, president of the royal college of surgeons, making it his business to highlight that if you have less time then less stuff happens. Training, for example. Less mistakes happen though, says the Department of Health, because everyone's a lot less tired. Anyway, shouldn't you have mentioned this a long time ago? Such as when it was made law, with the support of the Bristish Medical Association?

The thing that gets me is how arbitrary the numbers are. Where does 48 come from? Sir John suggests 56, which is apparently what you get if you work 9-5 with a 1 in 6 out of hours rota. This came out of a survey of members of his college. If 48 hours does prove to be unworkable, it would be nice to know that it wasn't just randomly plucked out of the air before being rolled across the board. I'm afraid I can't find any evidence to the contrary

Anyone can tell that you make more mistakes when you're tired. I know that I am far more likely to miss an IV line at the end of my shift than at the beginning. And Parkinson's law states that work expands or contracts to fill the time available. People will still find the time for their training if they're keen enough. The one thing that is lost on the altar of 48 hours is continuity of care - the same doctors seeing the same patients. The longer I work, the more I am convinced of its importance and the less I am willing to see it go. Getting to know your patients makes the job at lot easier and safer. And it's not just getting to know patients, but getting to know ward staff and seniors better too.

Well that's that. In many ways EWTD is just a big experiment. If it does turn out to be a disaster, it won't take long for things to get back to normal. Some form of opt out will be hastily drafted, and things will go back to the status quo. I'll keep an eye out for what's happening from New Zealand.

After Hours

2009-07-28T23:56:00.002+01:00

"I know that I have swine flu, my blackberry told me so."

So, this time I'm not going to apologise for the abscence of posting, because all I would have to tell over the last 2 and a bit weeks was how much I was enjoying not being at work. It's odd to think how much I appreciate my leave now, the days when having August off was a given are long gone...

Of course, I haven't written for slightly longer than 3 weeks, so that excuse doesn't completely hold. I'm afraid the reasons for that silence are similar to the reasons why I haven't yet got my hair cut, and the reasons why they ironing board is still standing out and proud in my living room. Actually, I think that last one may be my flatmate. I'm refusing to put it away, because he keeps, on, doing, this... Ironing, I mean. It's got a bit weird to be honest. I think he may have a problem.

So, America was wonderful, thank you. I am pleased to announce that I now have a new, sincere ambition to work at some point in San Francisco. Mostly because I want to see if I'd ever stop singing, "If you're going to San Francisco" by Scott MacKenzie if I were to be there for more than a few days. I am less pleased to announce however that I was straight back to work today, 8.15 a.m. sharp, which I'd just like to remind you is quarter past midnight by Pacific time which I think I was still operating on for the trauma meeting.

Not that I had to do anything at all for this morning's meeting. Smile at a few comments about my sunburnt nose. Stare unknowingly at an X-ray of an ankle as someone mentions the word "tri-plane". Hmmmm, should I know that word having done 4 months of orthopaedics now? Probably. Still, at least I'm thinking "medial malleolus" and not "ankle" any more. It's all about knowing the correct words to say in orthopaedics. I mean, what's wrong with pointing and saying, "it's broken, just there". "...Sustaining this closed, neurovascularly intact, transverse, laterally displaced, Salter-Harris classification 2, ring finger metacarpal fracture." Parlez-vous orthopaedic? Impressez-vous le consultant?

Having said that, some consultant don't seem to enjoy that particular game as much as others. Mr E today is a pretty laid back dude. He can see the X-ray. He can see what it is, where the bone is compared to where it should be. Jack is a pretty chilled SHO, happy to admit when he doesn't know something. Good combination really. He even regailed the seniors with tails of "the Hallpike manoever" for benign positional vertigo. What right do orthopods have to look superior when I don't know how many extensor tendons each finger has, when they know so little medicine? Tom had to explain the difference between ST elevation MIs and non-ST elevation MIs to one of the consultants a couple of months ago. They are two different classifications of heart attacks, and pretty basic knowledge for anyone with a medical degree, surely. But then I suppose if you never need to know it for 20 years, why would you remember it?

So, not much to do in the trauma meeting, not much to do on the wards either. I ate a brownie that one of the OTs had made me, because she couldn't remember if it was my last week this week or the previous week. I told her it was next week, but enjoyed the brownie none the less. I went round my few patients, half of whom were still in from just before I went away. One of them I'd told she had better not be there when I get back. I think we both knew that she would be.

"My knee is really tense just here."

Your knee looks exactly the same as the other knee. Go away. You're on all the treatment already.

"Is it really Mrs S. It does look better than when I went away. I'm sure there will be no problem sending you home once you've finished the antibiotics."

Such a joy. And Mark! My favourite manipulative drug addict. Still using the wheelchair that's too big for you and putting pressure on your sciatic nerve which is causing all your problems I see.

"Yeah, but seriously, I've never known pain like it." Neither have I my friend, and incidently I've never injected heroin into my groin either. Why did I leave America? I've already been signed off tor the year... And all I've got to look forward to is nights starting Thursday, finishing Wednesday morning even though my contract ends on Tuesday.

"Thank you for everything Doctor, I hope I shan't see you again."

Wonderful Mrs T, I'm glad to see you go and looking so well. It's been a tough 2 months in hospital for you I know, and I'm glad you've pulled through so well now. Glad we got one final chat, you always did make me laugh.

And that was pretty much my day. I popped back to the wards to check some bloods at 4ish, and they were all improving. Sweet nurse Karen asked me for the 5th time today if I was looking after her patient. Nothing had changed since the first time she had asked me.

And that was today. I checked the rota, and noticed a poster for swine flu education. "Two sessions," it proclaimed, "One for clinical staff, and another for non-clinical staff." What do they teach the non-clinical staff about swine flu? Don't come to work if you have it. Any questions? Yes, you at the back. "Should I come to work if I've got the symptoms of swine flu." No, as I said during the talk, you should not come to work if you have it. Anyone else. Yes?

"I saw someone on TV who knew someone whose second cousin had it. Should I come to work?" No, you should use it as an excuse to extend your summer holiday. Anything else? "Yes, should I eat Pork?" Yes, there is no risk. Even so, I probably wouldn't want to risk my family's health. There's no risk, but I wouldn't want to risk it. So I just won't. Don't know why I asked really...

I don't know anything about Swine Flu. Perhaps I should go to the clinical meeting and find out about it. Perhaps I should get it so that I don't have to do these stupid nights...

Banquet - (Warning: This post may contain Julia)

2009-07-03T22:12:00.005+01:00

"We are here on earth to do good. What the others are here for, I don't know."

I'll admit that I have been a bit slack with my writing recently. Only three posts on this page in June is not good form, and I am seriously behind on chapter 2 of my rather lame novel. I know it's a lame novel because it was inspired by the big brown coat that I tend to live in during the winter months.

My excuse this week is that ever since doing four long days in a row, including an absolutely horrendous Monday, I have not really had the energy to do anything all week. As ever, the problem was not the weekend, but finding the strength for the week after. I had half planned to phone in sick on Thursday and Friday, because I'm owed a couple of sick days from when I was doing nights over Easter. One night I went to work despite a temperature of 38.3. I could still just about stand and I couldn't imagine where they would find someone to cover Good Friday night with only 5 hours notice. But then I told too many people this story, and realised that it wasn't really a feasible plan any more.

So in I went. Someone told me a story about someone they worked with well known for pulling sick days. They had told colleagues that they had tickets to some European football game, and therefore would be "sick" the next day. The colleagues, somewhat annoyed but not wanting to get their friend into trouble, dutifully informed the consultant that this doctor was too unwell to come in to work that day. "Really," said the consultant, "Because I saw him in the crowd at that game on TV last night..."

Now that's unlucky. Someone else told me an anecdote yesterday, about the night switchboard operator sleeping through a crash call, and I tried to tell his story to him today, so perhaps I should stick to what's been happening to me these past few days.

Well, my little sister came to work with me for 5 days last week. Four of them were 13 hour days, so perhaps not the best advert for medicine, but it doesn't seem to have put her off applying next year. She got to meet both of my consultants. The first was his usual rude self. "Are consultants allowed to be that rude to people?" was Julia's question, or something along those lines.

"Who are you then?"
"I'm Julia, I'm a work experience student"
"So you want to be a doctor?"
"Yes, I think so."
"Where do you go to school?"
She told him, not locally.
"So why are you doing work experience here."
"Well, I'm Stephen's sister"
"You're his sister! You want to be like him then?"
(nervous laugh)
"Does he want to be like me?"

Ahem. Meanwhile I was talking to Emma, who told me off for not listening to her. My other consultant was also true to form, taking time in the ward round to explain each of the patients to Julia. Do I want to be like him?

Maybe. Carolyn the nurse was telling us about how she became a ward sister, and then gave it up just to go back to ordinary nursing. That seems to be much more common in nursing than in medicine, where the only way is up until you retire. There are staff grades in medicine, people who have either chosen or been forced to come off the career ladder, but the culture seems to look down on them if anything. Maybe it will change on the back of all the problems with training posts over the last few years. Maybe lots of people will be forced to become staff grades, and then realise that they have a better life than consultants anyway.

It is difficult having students, but it was easier having Julia than most. She was a shadow I could talk to, and who I knew exactly what she wanted to get out of it. Although apparently watching the work I do is more tiring than actually doing it, seeing as she had to go home 2 hours earlier than I did to rest and drink diet coke.

Which meant she missed the arrest. I was just stood by the phone, having answered my bleep when the emergency alarm went off. This usually means someone's got confused in the toilets and tried to turn the light on, but it became apparent that it was something more when some of the nurses started running around in circles and the other more calm nurses grabbed the crash trolley.

Behind the curtain, a 19 year old girl looked deathly pale. "She's gone!" cried one of the nurses, who was still running in a circle and seemed to have lost control of her flailing arms. Well that's helpful I thought, and I started to assess the patient. Not breathing, that's enough to command someone to put out a crash call. I call her name and apply sternal pressure. She starts but doesn't rouse. I'm pretty sure that means she's alive. Airway. Breathing. Circulation, just like you were taught. A strong pulse, what a relief. A morphine drip, now we're talking. Now I'm pretty sure I know what we're dealing with. Take it away, I'm commanding again. I don't usually command, but then a team of nurses aren't usually looking at me for what to do. Get me some naloxone.

An ITU SpR arrives, and thankfully I'm junior again. He also asks for the naloxone, and I feel a bit annoyed that he doesn't know that I've already asked for it. The nurses are just getting it I tell him. Meanwhile, the patient has taken her 3rd breath in 2 minutes. It's fairly clear this is morphine. Panic over. Bit by bit the rest of the crash team begins to arrive. As the patient begins to wake up, most of the team are just standing around watching. Two of them strike up a conversation. "How are you, I haven't seen you for a while." One of the site managers arrives panting. "I was in another building." "That's impressive," I say, "I feel bad, because I was just at the desk."

Not entirely sure that I saved her life, but it's exciting to see how you react in those situations. And interesting to see how others react. I know at least 2 nurses that I wouldn't want around if it were my life at stake, but on the other hand the quiet student nurse with the dark hair was calm and very helpful.

Mykonos

2009-06-23T19:05:00.004+01:00

"He has terrible jet-lag. He thinks it's tomorrow."

Now Fleet Foxes sound like they really should be my type of music, and their album last year won lots of rave reviews. The problem is, I'm just not feeling it. There are a couple of awesome tracks, like this one which isn't even on their stupid album, but the rest of the album is just a bit underwhelming, sometimes even dull.

But the music press always tend to favour new bands, so who really cares. I appreciate Diamond Hoo Ha by Supergrass as one of the best albums of 2008, even if it was roundly ignored by the people who write about music.

Well, that is what I was thinking as I walked to work today, listening to Fleet Foxes. I was also thinking that it's not really worth putting the ear phones in, seeing as I only live 10 minutes from work, 5 minutes if I'm late. My new reg, who I like very much by the way, was telling me about her husband who has recently moved hospitals giving him a 1 hour commute instead of one lasting 2 hours. That's marrying in medicine for you. Young, free and single, I live nearer to the hospital than where she parks her car...

Anyway, I arrived in good time for trauma meeting, albeit after Emma. NCB was in charge today, and I hate to say it but I have warmed to him slightly. Slightly mind, I still think it is terrible that he doesn't routinely see his ward patients. He bought us a drink the other day at the pay-day revue thing. And he even said "Hi Stephen" to me today, without having to look down at my name badge. This man doesn't believe in Christian names usually, so this can only be a good sign. Perhaps I just caught him unawares, so the usual public-school persona wasn't engaged in time...

Such fun. Like I say, I'm getting on well with Emma, the new SpR back from maternity leave, so that's all grand. She's no Carl, but then Carl was just so unique. My other consultant has also switched registrars, although that was just an internal free transfer and the two even have the same name so that's all very easy. I couldn't really complain about the previous Ant, but did he always have to be so serious? That was a joke, no need to turn it into teaching point. And if you recognise it as a joke, perhaps you could laugh, rather than point out the fact that I was being humorous. And then teach me about it. In some ways it would have been easier if he was a grumpy, straight-laced person who looked down on all frivolity in a hospital, rather first impressions were of a friendly, fun and supportive senior. It's just a shame that he turned out just to be supportive. Which is why I can't really complain.

The worst moment was when I heard him talking to his new SHO Tom. "Don't you have a hole punch with you Tom? You should keep all this stuff with you on a tool belt." I was stunned, and slightly saddened. Was it just me? Perhaps I was just so incompetent, that he had to be serious the whole time to cope with all the problems I was causing him. Perhaps he just didn't like my hair. Perhaps Tom is just the perfect SHO, whose many skills include making serious SpRs tell jokes.

Katie agrees with me. "Suprisingly serious," she said, agreeing and looking pleased that I had also noticed it. Katie is the surgical trainee who's also on my team. We are in fact a full team this week, which makes work a bit less relentless. Mike, the final SHO, is back at work after breaking his leg. I had met Mike once before, at a pay day party when he sent his friend over to drunkenly tell me, "My gay mate really fancies you." Well, that's just joyous to know, especially given that we're going to have to work together in the future. But it was a long time ago, and anyway, if I'm honest a small part of me is a bit in love with Katie and I have no problem working with her. All we need is for Katie to develop a thing for Mark and we're away.

It's not really love with Katie, more a slight sense of awe. It's the combination of the fact she's very tall, stupidly buxom, has that surgical self-confidence and aloof-ness that I completely lack, and because in spite of that we get on really well.

Anyway, not really sure where I'm going with all that. None of the patients was particularly eventful today. My 3 month lady is pretty close to death, which makes me feel sad, although she is 93 and has said repeatedly that it's what she wants. My other 2 long term patients are fairly well, one gave me a sweet from the huge selection on her table today. You do understand that part of your problem is that you have very bad diabetic control? I should confiscate those sweets. It's in the patient's best interest.

The alcoholic man was quite fun. He was pulling on his sheets and gown, so that his whole lower half was exposed as I walked in to see him. Good start, sorry to interrupt the conversation you're having with the wall but I need to test to see if you're confused. And that was the start of a remarkably lucid conversation about his injury, his operation and 8/10 on the abbreviated mental state test. He got the day, month, year, prime minister, memory test, recognition of objects all right. The only thing he got wrong was where he was, which might explain why he talking to the wall. Alcohol withdrawal does funny things to your brain.

He was actually quite aggressive with the nurses, and told Emma quite gruffly that he wasn't going to have the operation she suggested. Rick, the male nurse did ok with him, as did I, which made me wonder aloud whether he thought all the female staff members were nurses, and he didn't like nurses, wheras all the male staff were doctors who he had respect for. I should have kept that one inside because Sarah the staff nurse seemed to think I was expressing that as my own opinion, and slapped me sharply on the wrists.

Otherwise that was about it. There was a pointless consultation with a very nice and completely well lady in the farthest part of the other building.

"They're not very friendly over here," complained my consultant. "I don't feel very welcomed. What do you think?"
"Well, they're certainly not a laugh-a-minute like you boss." I replied, suprising myself a bit. He let out a raucous laugh, and perhaps that's why he remembered my first name later on in the day.

In Between Days

2009-06-18T18:34:00.003+01:00

"One isn't exactly brain surgery, and the other is brain surgery!"

Ok, so today I'm moaning about patients. Tom, the other F2 was moaning about patient's relatives. Katie, she's CT1 in case you're following what all these new job titles mean, was moaning about the fact that they're trying to move her to paediatric surgery, even though she had been promised there would only be general surgery after her six month sojourn in orthopaedics. Mike was moaning about the NHS in general. All the other SHOs were away. After a while I started moaning about the computer. Tyher was on nights, so the nurses were moaning about him.

That is more moaning than usual. In my defence I have a couple of patients that are really taking it all out of me at the moment. The first lady is 93, and she has been with us for almost 3 months. She was admitted when I was first doing nights with something called necrotising fasciitis, a condition sometimes called "flesh-eating bacteria". Sadly, that cost her her arm, and everyone expected her to die. She was discharged from ITU with that prognosis. Well, she made a remarkable recovery, (remarkable in that she didn't die, her arm hasn't grown back) but has spent the past 3 months very slowly rehabilitating and developing a myriad of problems which, one by one, have set her back. By this point, her mood is very low and she spends most of the day sleeping. I can't help but think that if I were 93, I would rather have been kept comfortable and left to it.

Well, yesterday there were reports of a rather large loss of blood from her back passage. Nobody could get any sort of blood samples from her to see how much blood she had lost, nor could anyone get any access to give her a blood transfusion. That was a good couple of hours trying to sort her out, but the truth is there hadn't been that much change with her. I have spent so much time and effort with this lady, with little senior support, and we never seem to get anywhere with her. Draining does not even begin to cover it.

Today there was a nurse, who had hot swollen knees. She told me where to take blood from her, then told me that all doctors are rubbish at taking blood because it didn't work where she had told me. I hate it when people tell me that doctors are rubbish at taking blood. Why do people think I want to hear that? It's both flattering and well informed. Doctors are very good at taking blood. When the phlebotomist or nurse fails, who has to take the blood then? Anyway, when she let me just do it my way, I was able to get blood fine. Actually, she didn't let me take it my way, I just decided I was going to ignore her.

"Ok, try this needle over here."
"Um... no."

I was a tad more diplomatic. Just as I was when the medical reg who reviewed her told me that he thought we needed to take a sexual history.

"Has she been s***ing anyone she shouldn't have been. But obviously don't say it like that"

Obviously. Perhaps that was why he hadn't done it himself, even though he had seen her and asked her everything else. So I suppose that's my job now then? While you're at it, anyone whose bowels you want me to manually evacuate?

That was the other thing Tom was moaning about - the fact that we're still having to do all the ward monkey work and learning so little orthopaedics. Such is the lot of a junior doctor. I've said before that I think Tom will end up as an orthopod. He's pretty good. Better than me, although I think that about most people. Anyway, when he's an orthopod reg he'll enjoy the benefits, such as ordering around juniors, and unnecessarily bringing an attractive dancer back to clinic to "monitor her knee", even though there is nothing wrong with the knee. True story.

Soon We'll Be Found

2009-06-12T12:15:00.005+01:00

"Back off Ben - I'm a scientist"

8 weeks have passed, and I am now on the right side of 7 nights. As ever there were a few positives about the week - going to bed whilst at work, taking a week off some of my more difficult, long term patients, shops and banks being open when you're not at work - to name a few. But it is still an 84 hour, often lonely week and you never really know when to eat when you're sleeping during the day. Most people seem to go with continually...

No, I don't dread nights, but I'm glad it's only once every 8 weeks. Nothing too terrible happened during my stint, and a friend and fellow F2 was the surgical night SHO so we could meet up and have "lunch" and coffee at various moments, making the experience a whole lot less lonely. One thing I don't like about orthopaedic nights, which I went into last time, is that the registrar goes home to sleep. I know what things they want to be called in for, so that's ok, but what about people you're just not sure about? For example, one of the conditions they would need to be called in for is something called "compartment syndrome", and it's something I've never actually seen before. I know the theory, but that's no substitute for putting your hand on one so that you never forget what it feels like. One of the symptoms is quoted as "pain out of all proportion." Well, I examined a girl who had had knee pain for 7 days, and from the tears in her eyes and her threats to punch my lights out when I exhaled a bit too forcefully near her leg, her pain was definitely "out of all proportion".

"I've had three children without pain killers, and that wasn't as bad as this pain."

Really? I know that pain is a very subjective thing, and I've never experienced either pain, but that seems to go against an awful lot that I've been taught about both childbirth and twisting your knee a bit whilst out running...

Anyway, I didn't feel the need for registrar support for her. The pain said more about her than about her underlying condition, and even I could tell that, although the nurse seemed to need a bit more convincing. However, there was another girl who had severe pain just after her operation - classic compartment syndrome time - but whose pain didn't quite fit with the diagnosis, and had no other symptoms or signs either. I felt quite confident that I was correct, and that this wasn't compartment syndrome, but quite confident to rule out a condition you've never seen before and which can cost a young person his or her limb doesn't quite cut it. So at night, do you wake the registrar at 2am for him to come in to hospital and supply the 1% of certainty you need to make it to 100%? Would they even come in in that situation? The answer is of course you do, and why should you feel bad about phoning a registrar who gets paid to be on call for a reason? I wish that I was the kind of person who felt that with conviction rather than knowing it in my head but still debating internally for ages before finally making the call...

The actual decision I made was to review her in 1 hour, and let that make the decision for me. If the pain was the same or worse, or she had developed concrete signs (that, believe it or not, could be a medical pun) then I would make the call without any further hesitation. If, as was the case, she was asleep then I could rest easy. Compartment syndrome is not really compatible with sleep.

Not a huge amount else to comment on through my nights. The best story was funny because the man was drunk and the details were so unclear, but it seems as though he had been clipped by a car once, which had then reversed to check he was alright but accidentally run him over again. There was another story involving toe-clips on bikes, which really makes me think that they're not worth the risk. I also got to test out my new plaster cast applying skills at 3am one night.

The A+E reg who was on during the week was absolutely lovely. My general experience of A+E staff is that they are very nice, laid back people which is surprising given the inconvenient hours and even more inconvenient drunk patients. I find myself thinking more and more seriously about A+E as a job. I think personality type does play a big part in choosing your specialty, not only because it gives you an idea of what you would be suited to, but also because you have to spend so much time with other people of that specialty and it makes sense to spend time with people you get on well with. However interesting I find parts of orthopaedics, I'll never be able to swear as fluently or dismissively as the majority of the orthopods or truly enjoy the predictable jokes about whichever blonde house officer is around at the time.

But no, I think A+E would suit me. I have broad interests, prefer to be busy, and I'm calm in a crisis. But the hours, the hours, the hours, and I'm not too sure what an A+E consultant really does day to day.

Whatever happens, I'm looking forward to getting to a specialty which I feel like I fit in to. From this year I have learnt that I could cope with medicine, paediatrics is definitely not for me, and whilst there is a lot about surgery that I like, I'm not really a surgeon and even less an orthopod. All extremely valuable lessons.

Everybody's Gotta Learn Sometime

2009-05-30T14:34:00.004+01:00

As part of my bid to learn something new each year (I've already forgotten most of my sign language from last year) I have been taking clarinet lessons since August. Since I don't seem to have fundamentally changed since I was 7 years old, I do the majority of my practice just before my lesson. Which prompted my flatmate to ask;

"Do you ever get better?"

Harsh. So anyway, isn't the sunshine beautiful? There seems to be a general feeling around that we are due a perfect summer this year, seeing as the last few have been a bit underwhelming. Not that I'm very good at picking up on the "general feeling" these days judging by the fact that the news is still talking about MP's grocery lists or something like that. Why is it so awful? It's fairly universal human nature to try to get the maximum perks out of your employers as possible. I hope that all these angry people have never stolen anything from their offices. And then stolen more when they dropped a stapler in the moat.

For me it always seems to be micropore tape. I don't know how but I seem to accidentally collect rolls and rolls of the stuff, and as such there is a roll currently wedged into the hinges of our kitchen door. What with student debt and European working time directives we don't seem to be able to afford a door stop.

So that's just about all my political views. I have the potential to vote twice in the European elections on June 4th, because my parents have never told anyone that I've moved out so I'm still on the electoral role down in West London in addition to here. My flatmate decided not to register when we moved in here, so all the electoral propaganda is address specifically to me. The BNP leaflet wasn't however, which means that someone had to go around putting them through every one's door. That's not a job I would want.

The leaflet itself is hilarious. Why anyone bothers to talk about the BNP is a complete mystery to me. Perhaps it's because it's the only thing guaranteed to get applause from the audience on "Question Time". "Aren't the BNP awful!" *Everyone claps because no-one wants to look racist* In reality, I don't think anyone could vote for the BNP based on this leaflet.

"No to immigration and unemployment" they proudly declare. I'm sorry but who is saying yes to unemployment? "We've earned the right! Trafalgar, The Somme, Dunkirk, D-Day, The Falklands." Well, I didn't fight in any of those battles, and weren't at least two of them resounding defeats?

Anyway, the reason I'm talking about this leaflet is because there is a picture of a doctor on it saying, "Why I'm voting BNP". Actually the picture is the second picture you get when you search for "Doctor" on google images so I'm quite skeptical if this is a real doctor. "I've seen what immigration has done to the NHS." Stopped it from collapsing is the honest answer to that one, seeing as how the NHS has been propped up by a lot of excellent doctors coming over from the Indian subcontinent. "As a Doctor I want to see an end to health tourists and to make sure British nurses are employed and paid fairly." As an individual who can read, I can already see more flaws in that argument than there are words.

"As a Doctor..." If I say that, does it mean that I'm definitely right? You should ask Anna, who I discharged on Friday after 3 very, very draining weeks. I had a bleep on Friday afternoon, not long after Anna had left the hospital. I dialled the number, and the woman on the other end answered after 2 rings.

"Hello, complaints department."

Well, I haven't asked to complain about anything recently, so I suppose talking to you today is a bad thing. The woman could clearly hear the apprehension in my voice though because she quickly said, "It's nothing bad that you've done. In fact they were all singing your praises." I wish I could have sung their praises though. I got on pretty well with Anna when she was on her own, but her mother was a different issue. Why are you interfering in your daughter's care when she's in her early 40s? And why oh why do bad things happen to difficult patients? If I could have picked any of my patients to develop dysentery and get caught between two orthopaedic teams and get side effects from paracetamol then it would not have been her. I'm sure that if I said anything to Anna's mum beginning with, "as a Doctor, I think..." She would have replied, "As next of kin, who has looked up the side effects of this medication on Google..."

I wonder if Tom, the other orthopaedic F2, was speaking "as a Doctor" when we were talking about Microbiology the other day. We only know the microbiologists by their voices, as they rarely venture out of the laboratory, and we often phone them for advice about patients with anything but the most straight-forward infections.

Me: "Did you ever speak to Mai? She used to use your first name way to much. 'Well Stephen, the thing is Stephen that Stephen these antibiotics Stephen can sometimes Stephen'."
Tom: "I like Vishan, he's always far too enthusiastic about bacteria, which makes me laugh. Oh and Rachel. She sounds fit."

Can someone sound fit? "She sounds like she has brown hair and a freckle just above her right eyebrow." That's not my definition of fit by the way, I'm just trying to mock the idea of guessing someone's appearance by their voice. I did once meet Mai in the children's hospital, and it was a bit strange meeting someone whose voice you knew so well. I remember speaking to her on the first day of Paeds, which confused her no end. "Stephen, I thought you were a medic Stephen?" Sweet of her to remember. I wonder what she thought I looked like based on my voice?

Sister Rosetta Goes Before Us

2009-05-27T18:52:00.002+01:00

"You must never go to bed on a grammatical error."

So, this one made me feel a bit stupid:

(bleep goes off and I dial the number)
Person who bleeped me: "Hello, Dr Graham."
Me: "Uh... No, actually I'm Stephen, one of the orthopaedic SHOs."
Person who bleeped me: "No, I mean I'm Dr Graham, answering the phone..."

Easy mistake to make. Anyway, no-one expects much of orthopaedic SHOs so it's a useful label to hide behind. Those two words (or one word and one acronym) must strike fear into the heart of any medical registrar when they are on call. It means they are either about to be referred something ridiculously simple, or a patient who is nearly dead.

Sorry, that's a bit stereotypical. It's just difficult being an orthopaedic SHO because as hard working and knowledgeable as our seniors are when it comes to bones and the 30 types of screw available for an ORIF, they lean on us completely for the medical side of things. And orthopaedic SHOs are either me - very junior - or wannabe surgeons who want to be surgeons because medicine bores them. I spend a lot of the time feeling convinced that I am missing something on half of my patients, whilst sighing and telling myself that I am horrible and inadequate at medicine and my job.

That said, I was buoyed the other day when the orthogeriatric F1 (orthogeriatrics keep a medical eye on the elderly orthopaedic patients) told me that her consultant had said that she was pleased with me and that I was "more medically minded that most of the SHOs that do orthopaedics." I then expected her to say, "Yes she always says, 'Tom really takes care of his patients'," and I would have had to tell that I am Stephen and that she's thinking of the other F2...

She didn't, but then it's in Dr Bradshaw's interest to say how good I am since I used to work for her and she wouldn't like to think that she had trained me that badly.

So that's medicine. I've been enjoying the orthopaedic side of my job recently. Since I'm not learning anything by trudging around the wards, I've been going to clinics and theatres more recently in an attempt to keep myself interested. Who cares if I won't be an orthopod, both of the careers I'm considering involve orthopaedic patients - it won't be completely useless knowledge. And it has been good, although tragedy is about to strike. My favourite Registrar moves to Swindon next week.

I find myself completely besotted with Carl. Our consultant is a horrible old school surgeon who loves nothing than the performance of mocking his staff with an audience laughing sycophantically at his terrible jokes. Where many would try to laugh and suck up to the consultant, Carl is unapologetically himself. He has a pencil case with his name on it. When he told me on Tuesday that his wife is pregnant, he did so with the air of someone relating what he had seen on TV the night before. "So, it turns out that my wife is having a baby, and..." What! Carl that's huge news, why is that not enough of a story in itself so it needs an "and"?

Crucially, Carl makes me laugh. At myself, at him, at our patients. My other registrar is nice, but it's always strictly business. He uses me like a tourist uses a guide in the foreign land of the wards. Carl seems to enjoy the company, and I don't feel the pressure to go around the patients at the speed of light. When I made the mistake of expecting my consultant to be interested in an old patient of his who had been re-admitted, his reply was "I'm not a miracle worker" and to call me by my last name. Well, when I told Carl this, he laughed for ages and it has now become his catchphrase. Yesterday he told me that anaesthetics would mean that I had to do pain medicine, and then he would refer me all his difficult patients with letters addressed "to the miracle worker."

Carl, I will miss you so much. I am so glad that people like you exist, and that some even become orthopods. Much as I hate you for leaving, I am glad that you are going to a better place, away from the disinterested, pathetic clowning of our consultant, a man for whom I truly have not a single redeeming word to say, and who I would describe as the "nicotin chewing bastard" if I didn't think my mother would disapprove.

(She would tell me that I spelt nicotine wrong.)

Bewitched, Bothered and Bewildered

2009-05-16T00:09:00.004+01:00

"Uncoffined - Just as found."

One of the great disappointments of my working life so far, is that I have yet to love a hospital in the way that I loved the Heath, the hospital in which I was trained. At the time, I thought I would simply love any hospital that I was owned by, the feelings growing deeper as I learned her secrets. It is true that I did have strong feelings for the district hospital that I started out in - if anyone criticises her I can get very defensive. But it wasn't a love affair to rival that of my obsession with the magnificent UHW.

I am in the middle of my second stint in the hospital that currently owns me, and there is little love to be lost in our relationship. I try to look kindly on her charms, such as the spiral staircases in radiology and the secret stairs that lead to A+E on one floor and a cupboard on the next. I also like the fact that the hospital is on a hill, and so has entrances and exits on floors 1,2,3 and 5. I find it a simple joy to take the short cut down the hill to get to A+E from the orthopaedic wards, especially if it's raining slightly.

But no, I am afraid that our relationship is only professional. Working for her is not unpleasant, but I'm looking for more...

So, mildly disturbing nonsense and bad spelling aside, I am struggling to choose between two moments as the highlight of my week. There was the touching moment when I clearly got too close to an 88 year old woman with dementia, who then pulled me in close for a hug and kissed the back of my neck. I'm never normally one to shun affection, but that made me feel distinctly uneasy. She is a sweet old lady though, always sitting contentedly and always beaming when ever anyone comes to see her.

Dementia is possibly the most horrible illness of all, and I find it strange to see it affect people so differently. This lady in particular is covered in bruises because she forgets how easily she falls, and so her zimmer frame stays untouched beside the bed. But she remains cheerfully confused, whilst others become aggressively confused and others use all their energy day and night in hospital beds calling out to whoever walks past. One consultant told me that he thinks each is a reflection on what sort of a person was before their independence was eaten away.

Working in a hospital does give you mixed feelings about growing old. I suppose I see the worst of it, as why would the fit 80 year olds who take the great grandchildren out blackberry picking have anything to do with me? The wife of one patient, who has seen her husband become increasingly anxious and paranoid as he loses his memory, whilst she has had to deal with losing her sight told me at the weekend that she didn't think people should live to 80. Another lady who was sadly readmitted this week has a choice between staying at home, keeping her independence and falling almost every week because of a dodgy knee, and going into a care home and becoming dependent on people. "My children all think they know better than me," she told me solemnly. Mind you, my three sibling and I have known better than our Father for about 20 years now...

What was my other highlight? Oh yes, walking through a door which said "strictly no entry" printed sternly on it, but also commanded me to wash my hands after entering. Which is really what got me thinking about why I don't love my current hospital the way I loved the Heath, even though it has a few wonderful quirks.

The Sea

2009-05-08T20:42:00.008+01:00

I wrote a song called "The Sea" once. It wasn't very good, and I can't remember the chords anymore. This one is much better.

So, Friday is here, one day earlier than expected. Isn't that the beauty of bank holidays? Not only do you get a 3 day weekend, but the next week is 1 day shorter and so the next weekend comes that much quicker.

The thing I can never understand about bank holidays is why they are so randomly spaced throughout the year. Why are there 2 in May, which itself is so close to Easter, but none from September to November? The second one in May isn't really celebrating anything.

Not that bank holidays really mean that much to me anymore. I worked on Christmas day until 1am, and then spent the whole of Easter working nights. But I appreciated this one on Monday. The only thing is it did mean we missed the Monday Xray meeting, and therefore Dr Wakes. He is a really lovely man, but the best thing is what happens when he is surprised by something. (Usually something on an Xray).

"Oh! Crumpets!" "Oh goodness me! Oh Crickets!"

All of which made me a bit disappointed when I did once hear him say, "S**t!" Um, I think you meant to say "Shovels!" Dr Wakes.

Being nice seems to be a bit of a disadvantage in radiology. There are three radiologists in my hospital who can grant requests for MRI scans. Two are nice, approachable and helpful, whilst the third is grumpy and enjoys making people feeling small. I know which radiologist I tend to avoid, and so I imagine he probably gets less work than the other two.

Speaking of radiologists, I found this again the other day, when a student was talking about how he didn't have a clue what specialty he was going to do:

Ha ha! Although it does ignore the 50% of people that choose general practice. And it's not really something you can apply to yourself, but rather something I think other people have to apply to you. How do you answer the first question for yourself?

One thing I will say about the surgeons that I have met in this hospital, is that they don't tend to be mean. And it's not just nice "once you get to know them," three of them are amongst the nicest consultants I've ever met. But then that just makes me wonder why consultants need to be mean at all? I guess some people are just bad tempered. There was a receptionist who turned completely on me the other day whilst I was on call and used her phone to answer my bleep.

"Excuse me, that is an emergency phone. I need it to be kept clear so I can answer it in emergencies. There is another phone over there."

"I'm sorry. It doesn't say anywhere on it that it's an emergency phone."

"Um, this is my phone and I think I know that it's for emergencies."

"No, I didn't mean that, I just meant that most emergency phones are red, so I didn't know not to use that phone."

"Well I'm telling you now that it's for emergencies. Go and use that other phone."

You have to imagine the evil-eyes that she was giving me at the time. But who phones a receptionist in an emergency anyway? Quick! We need someone to staple these papers together! (No offence to receptionists who don't have a fascist streak)

But why are so many consultants mean and grumpy? They are well paid, and should have a fairly good chance at job satisfaction. I suppose many of them were abused as SHOs and students, and so have become student and SHO abusers in return. I suppose some people are just not that nice, and once they get to consultant level they don't really need to pretend to be nice anymore. There are certainly SHOs I know now who have a less than generous attitude to patients and anyone junior to them.

Having said that, I do remember as a student resolving that when I was an SHO I would really look out for students and try my hardest to get them involved. But now that I find myself on the other side of the fence, I see that it's actually much more difficult than that. I have no warning when students come, and even less when they go. And the truth is that I have often found them uninterested, and not that grateful when I do make an effort to include them. When you are busy and only doing dogsbody type work then the last thing you want is a student looking bored simply tailing you.

Perhaps if I ever become a consultant, I will complain about never getting to know my SHOs as they change every 4 months. And anyway, they're not particularly interested in my specialty. Sorry orthopods.