EXPOUNDING THE REAZLES FOR SNEEZLES AND WHEEZLES

IATROGENIC PANCREATITIS

Wed, 18 Oct 2006 22:40:00 +0000

I admitted a lady this afternoon with a third episode of pancreatitis within the last twelve months. She neither drinks, nor has any gallstones apparent on abdominal ultrasound (which together account for 90% of cases of acute pancreatitis in the UK). She also lacks the remaining rare but recognized risk factors for pancreatitis: trauma, Cocksackie/Mumps infection, scorpion bites, steroids, hypercalcaemia, etc.

The patient has a twenty pack-year history of smoking, and a background of Ischaemic Heart Disease, Hypertension, and Type 2 Diabetes Mellitus. Her list of regular medications includes Simvastatin, Bendroflumethiazide, and Enalapril. Tucked away in the fine print of side effects associated with all three of these drugs, is pancreatitis.

So the suspected culprits have been stopped and will shortly be reviewed. Interestingly, while writing her drug chart from the list of her regular medications on EMIS, I noted she was not currently on either Aspirin or Clopidogrel - rather odd for a person boasting every risk factor under the sun for atherosclerotic disease. A search of the patient's notes revealed a previous gastritis in association with Aspirin. And Clopidogrel?

Causes pancreatitis.

IN AWE

Tue, 17 Oct 2006 23:11:19 +0000

The King Edward VII Memorial Hospital is a 28-bed hospital in Port Stanley, Falkland Islands. It caters to the 2000 civillian and 2000 military residents of the Falklands, and the fishermen of the surrounding isles. All routine and emergency medical services are run from the hospital, and include a helicopter Search & Rescue Service, daily general practice clinics, flying doctor service for rural settlements, an A&E, ITU, and elective as well as emergency surgery.

The doctors that are central to the healthcare system are the kind I can only dream of being, thanks to the Modernising Medical Careers crap which is responsible for the mass confusion surrounding junior medical jobs in the UK. Here, the four GPs, one surgeon, and anaesthetist are together nothing short of a super-hero team. They see, treat, admit, and manage patients with the skill and ability of an entire hospital kitted out with superspecialists of every variety.

I'm particularly awestruck by the surgeon. One man - Pakistani too :-) - and he performs any surgical procedure required - orthopaedic surgery, caesarean sections, reconstruction of a hand following trauma, herniae, appendices, whatever. The limiting factor is not his skill, but the aftercare which is possible in such a setting, and the technology available. And as it's just the one surgeon, I'm the lucky duck that gets to assist on all the procedures. Not that it's brain surgery we're performing, but even an inguinal hernia is more exciting than an organ transplant when you're the one closing rather than the one watching on a remote screen.

PRISON BREAK

Fri, 6 Oct 2006 21:12:02 +0000

Stanley has a prison - a room at the top and a few in the basement of the local police station. Today we went to perform a health check on a man who had done some not very nice things and had accordingly been sentenced to 28 days. Had he been sentenced to 31, he would've been home in 24, with a week off for good behaviour. It was quite a contrast to the UK, where prisons are overflowing.

We left casualty and drove in the government jeep used by the doc on call to turn the corner, blink, and arrive at the station. Chatted with the officers, tried on some hats, looked in two ears, listened to a heart beat, checked the lung bases, squished a belly, chatted with the officers, got into the jeep, blinked, turned the corner, and were back to work in the ER.

Little cottages, multicoloured rooftops, and my Chief Medical Officer waving to everyone as we drive past. I felt a little like postman pat's cat.

MED STUDENT - DOES THE JOBS YOU HATE

Thu, 5 Oct 2006 15:43:08 +0000

The trouble about being in a community as tiny as this is you can't talk about things "in general". The General tends to get offended as in a 28-bed largely empty hospital, there are only specifics.

So I can't tell you the details of the first autopsy I witnessed, how the person died, or about any critical incidents that may or may not have surrounded the event. I might just get away with saying that the closet-sized mortuary is next door to the chapel, and while cleaning up the overspill ran under the door and destroyed the chapel carpet. At midnight, I was sneaking mops from the ward, and jumping up and down on incontinence pads on the chapel floor, trying to soak it up.

Despite its size, the King Edward VII Memorial Hospital does have a range of pathology to boast. On my first day I came across Ramsay Hunt Syndrome, recurrent pericarditis, life-threatening hypercalcaemia, and talcum-power inhalation resulting in ten respiratory arrests overnight. Only one day in theatre so far, but I feel as though I'm going to learn a lot.

SANTIAGO

Fri, 29 Sep 2006 22:42:00 +0000

Wow.

Fourteen (incredibly long) hours over the Atlantic and I arrived in Santiago just after seven am local time this morning. The people are so friendly (or perhaps I´m just out of London?) The keyboards are, however, annoying me; all the punctuation is in the wrong place, and although I can see it, I can't get to the 'at' key.

I had lunch at a lovely sea-food restaurant near my hotel in the district of Vitacura about five miles east of the city centre. Then headed to Parque Metropolitano (apparently the largest city park in the Americas). The map I'm using doesn't really differentiate between motorways and roads that pedestrians can actually walk along, but I survived and eventually got to the centre.

Santiago is snuggled between the Andes and the Coastal mountains, and as you can imagine the views are spectacular. I have two more days here in seven weeks time on my way back from the Falklands, and now have a pretty good idea of what I want to see. Meanwhile, bedtime, as it's a four am start, for a six am flight. More from the Islas Malvinas!

OLA!

Thu, 28 Sep 2006 20:47:47 +0000

Yesterday while shopping for Wellington boots on High Street Kensington, I asked the salesperson whether they would be suitable for walking over uneven terrain. He inquired where I was headed.

"The Falklands," I replied. His eyes widened. Holy crap, I thought. I´m actually heading for the Falklands. Months of planning and preparation, but it only really hit me yesterday!

So I´m now in Madrid, having flown from Manchester airport earlier today, waiting for my flight to Santiago, Chile, where I´ll be spending the whole of tomorrow, and then flying to Port Stanley, East Island, The Falklands on Saturday for seven weeks. I´m so excited! This is my first trip to South America, and indeed the southern hemisphere. I´m itching to get out of the airport though; there´s a whole city outside I´ve never met. The airport itself is pretty but so quiet. It looks a little like an expensive shopping mall just before opening hours.

I´ve booked my luggage through to Santiago but realised as soon as I landed in Madrid that I wasn´t given a luggage tag at Manchester. Let´s hope there´s still a big black suitcase waiting for me in South America!

Only eight minutes until my Internet time expires, so more from across the pond. Of course, those of you who know me know that the actual going across the pond bit represents a slight challenge (flying over water scares me - this has more to do with the sharks in the water than crashing in shark-free water) but I´m armed with the necessary chemicals needed to reduce the chances of my arresting as a consequence of SVT. Sixteen hours to Santiago. Speak to you then.

Mahim x

SPLASH

Tue, 26 Sep 2006 15:45:24 +0000

It started as any other 24hr shift in Labour Ward- as usual the babies had been born just before I got there. The day dwindled, the thermostat in my hypothalamus tangled up around itself in the confusion between icy theatres and tropical baby units. Another c-section, another assist, another procedure I'd logged too many of. Another I didn't get to close.

They walked in almost together. Three colours, three faiths. With only pain, a bump, and their medical student in common, the widowed refugee, the prostitute, and the married student each took to their own room and through the course of the night etched themselves deep into framework of my most vivid memories.

The primip refugee barely made a noise. My broken Arabic would have been an insufficient offering in return for the history I traced through her medical and psychiatric notes. And then I missed the baby; she fell asleep with an epidural at barely four centimetres and I went to assist on a laparoscopic ectopic pregnancy. An hour later I returned to meet her newborn. I asked if she'd named the baby, she shook her head and after a moment's pause asked me mine. "Mahim," I replied, with an Arabic accent that doesn't quite belong in a Persian name. She pondered, dismissed, and smiled. So did I.

Next door the prostitute was wailing for methadone. She was high, drunk, studded with track marks, and accompanied by all the aromas of street life with the attitude of a dissocial rottweiler. She was also in active labour for the fifth time, though she had no idea of the whereabouts of the fruits of the previous four. But she wanted this one, and the combination of heroin, drug-fuelled and logical paranoia, laced with the probability that someone was going to take her baby, was too powerful for any drug or team of medical professionals to overcome.

At 6cm she needed the bathroom. The midwife tried to get her to stay put for just half a minute while she examined her, to make sure it wasn't the baby coming. But there was no way to stop her. The woman made it back into the room as one person, climbed onto the bed on all fours, screamed. And then the baby fell out of her. Stunned, gasping, flaring, drenched in meconium. The placenta followed like a bullet. The cord was cut, the baby wrapped within 30 seconds of her having walked back in through the door. I don't think she knew what had happened. I ran to call paeds.

An attempt to inject the woman with Syntocin resulted in the needle and syringe being hurled at the midwife. Police, security, social services, paediatrics, obstetrics, the senior sister, the medical student watched as the baby was taken away, watched as the mother tried to struggle against "the greater good", watched the most painful sight I've ever had to endure, watched.

And then move on. One room further down and pretend the world is a wonderful place for a young married woman and her husband about to hold their first child while my mind hovered in the space I had walked out from. Eighth procedure of the night. Twenty-three hours into my shift. I knew she carried a blood-borne virus. I know what universal precautions are. But as I delivered the baby's head the world was bathed in red and I tasted blood. My heart stopped. I didn't. I completed the delivery, cut the cord, took the cord bloods, and delivered the placenta. Then I excused myself.

I had been splashed in the mouth and eyes with blood I knew to be H - positive. With trembling fingers I dialled the number for Occupational Health. I stepped out, shocked to find it was daylight. I waited for my eyes to adjust, be a little less blinded. And then I was the patient. Forms, questions, needles, blood, vaccines. Fear. It's easy to forget the latter when you're the (student) doc.

For me it ended well. Follow up was clear at six and twelve weeks. But being told how slim the chances were of my having contracted a disease by this mode was a pitiful means of reassurement; mostly it pissed me off. In my mind, the unlikelihood did little to quell the possibility. Perhaps I'll try and incorporate that into my patient manner.

I left London to go back to my family home after that shift and the Occ Health work up. I was met at the station by the Haematologist Daddy who only waited as long as it took my seatbelt to be fastened to ask whether I cared for the taste of meconium.

There's always room for humour.

TO DONE:

Tue, 26 Sep 2006 13:05:08 +0000

2003 - 2006:

~~Teach the UK's five best Latin & Ballroom teams exactly how to cha~~
~~Medical Elective: Emergency Department, Services Hospital, Lahore~~

Win the 2004 OU Pool League as Captain of the Pembroke College Pool Team - (step aside, UN)

~~Dissertation: Shots in the Dark: The Management of Gulf War Illnesses~~

~~BA (Hons) Oxon, Physiological Sciences~~
~~Pembroke College Oxford~~
~~Move to Imperial College London~~
~~Riding in CABs~~
~~The first clinical year~~
~~Try to bleed a patient watching Thursday night Channel 5, erm, programmes~~
~~The Tsunami~~
~~Find lost security blanket~~
~~Put it away safely~~
~~Reside in a red light area~~
~~Reside in a Dorset Mansion~~
~~Fall in love with London~~
~~See school-friend after eight years~~
~~Miss Ro's wedding~~
~~The realisation that I have the best friends in the world~~
~~Needing them~~
~~Prague & Vienna~~
~~Being reminded that everything happens for a reason~~
Even though I may not find it
~~The earthquake in Pakistan~~
~~Paediatrics~~
~~Psychiatry~~
~~Obstetrics & Gynaecology~~
~~Pathology (exam; not the lectures)~~
~~Crying~~
~~The second clinical year~~
~~Mind the Kap at Earl's Court Station~~
~~Perform first solo surgical procedure~~
~~Reside in a red light area; again~~

HOME AGAIN

Sat, 11 Jun 2005 23:41:51 +0000

It is hard. Stumbling towards a shore I'll never see again, searching lost footprints to find where you left off, knowing I mustn't venture too far - this is where I once drowned.

I remember the scent of oranges, and the fear of urchins. The prayer call that let us know we'd been up all night, your counting in your sleep during the day that confirmed it. I know the winding road too, where the jeep sank and children laughed. I just wasn't looking ahead, I had no need.

I was looking up, at the diamonds that stunned serenity, in a forsaken land I called home. You were never far away.

Now when it rains I smile and think that this was once sacred. We grew up where blue skies took us for granted, and then we each walked out on them. Shit happens. Cut, heal, wither, break. But like the Boomerang you bounce back, and I can see the crags, not so far, and a soft place to perch. I've found the footprints, one big one small. Damn the urchins.

I'm the second to say I don't know where this is going. I'm just glad you're there.

THE BEACH

Fri, 10 Jun 2005 22:00:22 +0000

December 22nd, 1998

I sift the wind for the answers to questions I'm too afraid to ask, as the solutions I yearn for are muffled by the clamour of your pride - a fragment of masochism which pretends to shelter you.

The authenticity of your deceit never ceases to astound, as does my gospel of lies. There isn't anything or anyone we haven't been. In my blindness I perceived your every glance, for in my vanity you are my priority, my self obsession. I am illiterate; I have read every account of your life and though I am fatigued there is no shade of your soul where I haven't rested. I radiated warmth through numbness and responded to every whispered heartbeat. Yeah I'm incoherent, but I've pondered every reflection of your mind. Those simple deliberations and chaotic perplexities. At least their confusion and obscurity make sense.

Searching for you is like seeking corners in bubbles. Their spherical perfection bursts with the tiniest caress. Spectra of illusions are apparent, delusions easy to choose, but their existence is superficial.

I beg you to tell me what I am, as I remain ignorant - a chalcedonic non-chalance clinging to a whim.

The knowledge of experience is a stranger to my heart. Yesterday's ashes from the cremation of dreams born in my own historical fiction are re-ignited by the touch of our gazes. Yet no fire is hot enough not to burn, once more each dormant desire is flamed. This hurt peals with an intense vociference that is silence. Can you hear me?

December 28th, 1998

A perfume of radiance veils my stench of misery to create an aura of adequacy. I try and fill aching voids with memories of passion, but they evolve into reminders of regret. Once more I've dropped the catch, lost the championship of togetherness, but I always make the final.

At dawn I found the corners in the bubbles and bathed in their foam. At noon, the tide threw me against crags whose danger signs I'd ignored. I tried to swim against the current of fate. I drowned. Now the sun has set, and the grains of love are too fine to catch, but my heart still foolishly sifts the wind.