enough

The week before Christmas I wanted to stop work and retire.

 I was too busy to eat. The other part time obstetrician refused to work. I had to prepare for Christmas, a meal for nearly twenty people, and presents still to buy. On the Thursday I admitted that I couldn't cope any more. Words were spoken and somebody took my place. That night I was finished. I have never given in to pressure before but I didn't feel well and I had only one day to finish shopping for presents. All the fresh food for the meal would need to be purchased the following day, the day before Christmas.

The shopping was a failure. I couldn't think. I was exhausted, short of breath. There were aches in my muscles and abdominal spasms like hunger pains. I gave up. At home I felt nauseated and went to bed, waking with nausea throughout the night. Next morning I brought up everything I had eaten for the previous  two days. I couldn't get out of bed.

The day before Christmas is a blur, spent sprawled in bed. Occasionally, my oldest daughter or my mother would bring me a tablet or some fluid. I had dishes planned which couldn' t be made but my daughter collected the turkey and brought fresh vegetables and fruit. I slept. My son drove to the city to bring his mother home for a day.

After sleeping for a day and a night, I awoke early on Christmas morning and put the turkey in the oven. My daughter and her boyfriend had already stuffed the bird so it was ready to cook, but I didn't have the energy to do any more. All those vegetarian dishes would have to be shelved. Then people started to help, to share the work, and a selection of dishes were prepared to make the meal a success. I don't think I should have been handling food anyway as it was uncertain whether I had food poisoning or gastroenteritis.

The presents were opened in a good spirit then the guests arrived. The meal was very good though I didn't eat much, and the gathering was worth the effort.

raining in the morning

a vegetarian meal

a rainbow formed after a late afternoon storm

the most intense rainbow I have seen

the end of a good day

Now I have been on holiday for a week which seems like no time at all. I am bringing my wife home today. In two days we are going to the beach for another week then I must return to work.

 I don't know if I can keep working. It is too hard.

an old girlfriend

An old girlfriend rang a few days ago to arrange a meeting while she is in the state visiting her numerous family for Christmas. We were together for nearly six years. She was attractive, intelligent, athletic and decent. It is legend in my family, since I am not a very private person, that she eventually told me that she wouldn't marry me if I was "the last person on earth". Poor girl. She made an exasperated statement many years ago as a young woman and it lives on in the wife and children of an old partner. But for me it was a humbling life experience which I needed and deserved. The experience demonstrated to me that I am not an attractive show pony but a work horse who is only valuable by a continuing contribution to the common good.

But bridges were mended, a new way of relating was developed to assuage my aching loss and her kindly pity. She is the godmother of my more troubled but very talented son. However I have not seen her for a few years, not even a picture. I don't know how age has treated her though I suspect, given her powerful determination, that it will be with some kindness. Which makes me wonder how I will be judged. Ridiculous that it should matter, that I should care what a relative stranger should think about me, but she is a messenger from my past, one of the few who can validly judge the life I have created both physically and morally.

I had such an arrogant belief in my destiny, sadly unsupported by an adequate work ethic. I would be the doctor who knew more, who cared more, the parent who understood their children the best, those beautiful confident quietly amazing children who would expand the greatness of my family. Children who would only eat healthy food, play regular sport, study without anxiety, and never watch television: in essence, correct my own failings. Actually, I have been very lucky with my children, but then I married well.

Am I thin enough?

Kjelland forceps

 I want to talk but I don't have time this week. The clinics are overbooked - I haven't had a meal in daylight yet, and the other obstetrician has taken sick leave so I have been on call continuously. My wife has been in hospital for her usual pre-Christmas stay so I haven't been able to finish shopping for presents and for the meal for nearly twenty people. I have not had enough sleep.

On a positive note I have done two Kjelland  forceps deliveries which were perfect for a posterior position under epidural and unable to push. The baby is stuck then once it is rotated into the anterior position it flexes, narrows the effective diameter of the head and slides out easily.
However, there are definitely traps when using rotational forceps. Disasters have occurred. Some women have an android or funnel-shaped pelvis which is wide enough at the inlet but narrows progressively as it descends. Initially labour progresses very well and everyone is optimistic but it becomes slower and slower as the head squeezes tighter and tighter until the cervix is nearly or actually fully dilated. Abdominal examination seems to indicate that the head is no longer palpable and therefore it is safe to do an instrumental delivery but the head is almost always in a posterior position with the head facing forwards, thus only the little face is easily felt and the bulk of the head is missed because it is not at the front. Thus it is not appreciated that the head is too high for safe delivery. On vaginal examination the marked moulding into the pelvis and the oedematous scalp extends the length of the head and gives the misleading impression that it is further down than it is. Then, for a perfect storm, the obstruction of labour eventually results in an abnormal foetal heart rate which requires urgent delivery. Under severe pressure the obstetrician can be easily trapped into trying an unwise forceps delivery, usually Kjelland forceps because the head is always posterior so rotation is required. Labour has become long and painful so there is usually an epidural which weakens pushing so forceps are usually chosen over the vacuum cup. After applying the forceps the heart rate often plunges catastrophically, but the head does not fit so there is no descent with the usual force. At this point it seems that there is no alternative but to pull very hard and that is when the baby can be injured. The obstetrician is upset, trembling and with tears in their eyes as it dawns on them that they are now in the middle of an obstetric disaster which will never end.
That is why some hospitals simply don't use rotational forceps, but they are sweet when used with care.

So, very little sleep last night managing  a vaginal birth after previous Caesarian section. Then abnormal foetal heart rate, onset of vaginal bleeding and head in posterior position, probably due to her epidural,  but not quite suitable for delivery. Anxious parents, midwives and obstetrician. I slowly prepared for an instrumental delivery until the head was genuinely low enough, then applied the Kjelland forceps, rotated the head and delivered a healthy baby.

By this time the sun was rising and sleep unlikely when I finally got home.

busy

Busy antenatal clinic. No time to waste or I will be late for my tennis final tonight. The best of the worst - the play-off for teams that didn't reach the real finals. In the middle of it all I have to run to labour ward for severely abnormal foetal heart rate and deliver a baby by vacuum rotation and descent. I love the Kiwi vacuum cup.

modelling

I don't understand modelling. Wearing clothes just doesn't seem like a job. Yes, you might say, but a model must also be thin.

Then, if she can talk as well, she might aspire to be a celebrity.

sun break

 Ran up to labour ward to deliver a baby known to have a serious brain abnormality to a mother with intellectual disability. I ran through sunshine and wished I could stop there a while.

On the way back to clinic I sat on a bench in the sun for a few minutes even though I was late.

I was thinking about the baby.

the voice

Running late in clinic then called urgently to theatre to help with a difficult Caesarian section. Sitting down in the changeroom to pull on my overshoes when I hear the voice again.

Who am I?

trust

The result appeared without elaboration among the usual pile of pathology reports. I felt nauseated.
She had first come to me nearly two years ago for management of a cyst on the left side of the pelvis. She had placed her trust in me when I decided not to operate. I believed that it was benign. On ultrasound it was simple, thin walled, mobile and without any increased blood flow. Her other ovary was easily seen, small and normal in appearance. She had been told that the left ovary had been removed in a long and difficult operation which suggested, first, that the cyst should not be ovarian, and second, that surgery in that area might carry a greater risk of serious injury. As a final reassurance her Ca 125 antigen was normal, only 4.
Now it was1460.
I rang the laboratory to find out if there could be an error, but they couldn't check before her appointment the next day which by coincidence had been booked months ago for routine review.
Guilty and upset, I couldn't sleep.
Next day, when I called her name in the waiting room, I could instantly see her distended abdomen, though she was unaware of its significance. In the consulting room I explained my concern about the result then performed an ultrasound scan. She was indeed distended with ascitic fluid, most likely due to ovarian cancer, but the original cyst was still there, unchanged, floating free in the watery milieu.
It was not my fault. My relief made me feel unworthy as I prepared to make arrangements for the treatment of her coincidental carcinoma of the opposite ovary. It was no relief for her.

this and that

Saw a young woman with intellectual disability who had uncontrollable epilepsy associated with areas of cerebral atrophy.  She has been free of seizures since excision of a temporal lobe and hippocampus three years ago.They are hoping I can help with her constant slight urinary incontinence. It is probably a cerebral problem, but all possibilities are being investigated.
Asked if she had ever had sex she said, "He tried but he couldn't do it."
Although twenty three years old  she attended with her guardian who asked her why he couldn't do it. She said, "Because I didn't let him." This was all news to her guardian - I think they might have more discussion on the way home.

Too busy for lunch then ran to the labour ward for a GP having a difficult delivery. The head was nearly on the perineum but the vacuum cup kept detaching while the baby's heartbeat was difficult to detect. The patient had an epidural so couldn't push very well. The head had rotated enough to apply forceps which still required some effort as the shoulders were stuck. After some manoeuvres the large baby was delivered in good condition with the perineum intact. No tear but a lot of tears.
After the birth,the patient's mother said that she had watched me deliver her other daughter with forceps only two weeks ago. I thought she looked familiar.

hug

Just delivered my tennis teammate's wife. He gave me a hug after the delivery.

rainbow and cherries

An electrical storm rampaged through tonight, cutting the power repeatedly, and then it left a rainbow.

One end.

The middle.

                                                   










                                                                                                           

                                                                                     

                                                                                                                   The other end.      


 It freshened the trees.

Sunburst Gleditsia

Ruby Lace Gleditsia
                                                                                               


                    It formed rivulets down the driveway.                                                  

Looking back the sun was setting,

while an unusual light glowed in the wake of the storm.

Walking back to the house I found cherries on our tree for the first time in fourteen years.

blood

Delivery by GP at seven thirty p.m.. Called me at eight thirty. Bleeding. Not stopping. Had oxytocin, ergometrine, misoprostol, but possibly still some placental tissue in the uterus, so arranged removal of retained tissue in theatre.
Patient very pale but apparently blood loss is only a litre. I don't believe the measurement and ask for a blood transfusion asap. The anaesthetist agrees. Under anaesthetic a small piece of placental tissue is removed along with large blood clots. The midwife rings to say they measured a further three litres in the bucket. She certainly looks pale but there is no further bleeding and blood is on its way. I leave her with the anaesthetist and GP and go home.
I cannot sleep so I read my book - Birdsong - about the first world war. It is very graphic and gory. I feel as though I am soaked in blood. At one a.m. the phone rings. The bleeding has recommenced. More blood and misoprostol is ordered. Arrangements for transfer to the city are begun while I come in to to insert an intrauterine balloon.
The balloon is not easy to insert properly. It is inflated and deflated repeatedly until finally it is in good position. The bleeding stops. She has now lost over four litres. Blood is smeared on my white shirt. I sponge it off then go home when the emergency transport team arrives. She is pale but still conscious.
Later, reading in bed to wind down, the book ends in a mixture of bloody defeat and unlikely optimism. I turn off the light at five a.m..
At seven the city registrar rings for further information. The patient is still ok. I sleep for a little longer then  
go to work in the clinic. While I am seeing my first patient there is a phone call from the patient who had the cervical laser treatment. She started bleeding five hours after the treatment, hasn't been able to sleep and has soaked two bath towels with blood. I ask her to come in at once.
On the examination couch copious blood clots are removed from the vagina and the cervix exposed. I was hoping for a single bleeding vessel but there is just a general ooze which I oversew with a nylon suture then add Monsel's solution and silver nitrate. There is only a slight residual bloodstained discharge but I am concerned about a further bleed. She will ring me in a few hours with her progress.
The clinic continues without lunch.

new laser

Laser: Light Amplification by Stimulated Emission of Radiation (electromagnetic radiation, i.e. photons).

Tried it today. Second hand but still expensive. It works well though the case was difficult due to bleeding.

Now to see if funding is approved or buy it myself.

sunny day

Everything is better when the sun is shining.

enough

I am tired of it all.
My wife hates Christmas. It is only November but it has started already, so predictable.
Nurses are striking. My major case was cancelled. I can't judge but everyone seems to want conflict.
I don't know if  I am tired or depressed, if I need a holiday or medical treatment, retirement or a kick in the backside. I just don't feel like working.

I have been thinking about motivation, thinking about our neurological reward system. I imagine that, every time we act, we ask it if it will make us feel good. I wonder if I can ignore it and continue to do what I have planned, or perhaps that is still the reward system in action - telling me that there is more pleasure in following the plan. Or, perhaps I can ignore the reward system for a while but will suffer the consequences later, such as depression or lack of drive. Maybe that is what is happening now after working too much for too long.
 Or maybe it's just Monday again.

early start

Late to sleep as usual then woken at four by the resident. There was a noise and I knew it was important. I consulted my brain which said not enough sleep yet. I knew I had to do something before the noise stopped. I jumped out of bed determined to do the right thing and still couldn't understand what was happening but found the source of the noise. I grabbed it hastily and realised it was a phone. I pressed the button to answer.
A woman with identical twins and a history of three previous Caesarian Sections was in probable early labour but the cervix was closed. She did not want to try for a vaginal birth but could wait at least a little while. I asked if we could take her to theatre an hour before the start of the scheduled list to cause the least disruption. I went back to sleep then woke early for the operation. As soon as I was up the resident rang to say the anaesthetist refused to do the case for another hour: now there was starting to be a little concern about the possibility of the labour progressing too much when a repeat Section had been agreed, but there seemed no point in arguing with the anaesthetist who, if I pressured him, would probably just delay until he got his way anyway. I went back to bed.
The phone rang again. The operation was going to start as originally scheduled, in just ten minutes time. The nursing supervisor had called the Medical Director who had spoken to the anaesthetist who had reluctantly agreed. I raced to get dressed and rushed to the hospital, changing again quickly for theatre to find that preparations for the operation were not hurried at all. Eventually we commenced half an hour before the usual list was rostered.
There are genuine risks in this situation. The chance of an abnormally adherent placenta is significantly greater after three Caesarians, and further worsened by a lowish anterior placenta - much more likely to grow abnormally into the old uterine scar and result in heavy bleeding, which is already a greater risk in a twin pregnancy. A hysterectomy was a real possibility but, in the event, the placenta came away cleanly and bleeding was minimal.
Small but healthy identical twin boys were handed to the paediatrician then routine uterine closure was begun. Before I could finish I was called urgently to the labour ward for a baby with a heart rate of only fifty. While my resident completed the abdominal closure I delivered another baby by vacuum rotation then traction, and perineum intact. I returned to theatre to change for my busy day of antenatal clinics and looked in on mother and babies -

After a long day, I travelled to another town for night tennis, losing my singles in a tie-break to one of our recent medical students. Perhaps I was a bit tired.

inner city

Went to an inner city artists' market on my own, looking for a present for my younger daughter. The graffiti is a striking feature of the nearby area. Overall it gives an ugly impression to a visitor. Tagging is definitely puerile and disfiguring: messy, egocentric and unimaginative. However, there is both art and heart in street art,
                             large scale

medium scale

and small.

There was sculpture

and some hidden sadness.

                                     In the market I bought some photographs of graffiti.

dawn

Noisy birds again. Must get some sleep.

snail's pace

Woke early and found this gastropod working hard while everyone else was asleep. It had travelled a long way by the end of the morning.

clinic

A midwife with Chronic Fatigue Syndrome having her third baby under five. She is not feeling tired any more.

A thirty year old child care worker in her second pregnancy, anxious but brave after the unexplained loss of her first pregnancy last year at only fifteen weeks. Her husband is large and heavily tattooed but gently considerate of his delicate wife.

A young couple having their second child after their first baby died of septicaemia at four weeks old, two years ago. The infection started soon after the delivery but was not recognized as anything other than mild respiratory distress. The baby was observed without active treatment until it was too late to save it. He survived for nearly four weeks but the initial organ damage was too great to overcome. She is pale, pretty and level- headed. Her husband is a little overwhelmed. I am requesting information from the three hospitals that managed the child but I am not expecting an enthusiastic response. Medical Directors are reticent to say much when the outcome is poor.

First antenatal visit for a young woman whose mother was my patient many years ago but committed suicide while waiting for surgery. She was also my neighbour and we talked about her mum - a lovely selfless woman. She will miss her support when the baby is born.

Bartholomew Mosse lecture

I worked in Dublin for eighteen months in a famous and historic hospital, one of the first "Lying-in" hospitals in the world. At my interview I was asked what I thought of Ireland. Since I thought there was no chance of getting the job, I had been to the equally historic pub over the road from the hospital and had a pint of Guinness. I told them that I thought the beer was very good and I had already rung my wife and told her that I had drunk a pint in an Irish pub. They were amused, and I wondered if that was why I was selected. Six months later the Master (elected to be in charge of the hospital every seven years) told me that one of the other candidates had a reference from Sir Malcolm T.,the doyen of British obstetrics, to say that he was the best resident he had ever had. The Master said that they didn't want someone who knew he was that good so they chose me instead  - the advantages of mediocrity.
Every year the hospital would invite a famous speaker for a lecture to celebrate the founder of the hospital. I attended in the two hundred and fortieth year of the institution, honoured by the presence of one of the creators of in vitro fertilization. This was followed by a formal dinner for all the medical staff. Drinks were served with each of the numerous courses. Calls were made for speeches. I had secretly prepared an epic poem in rhyming verse mentioning all the well known members of staff. I stood up when the audience were properly lubricated and announced my intention to speak. It was a lengthy and hallucinogenic tale in the tradition of Alice in Wonderland, well received by the party. When I finished, Professor Browne leaned over and spoke to me for the first time. He said,"You surprised me." Afterwards those who wished to continue the evening grabbed bottles from the tables and repaired to the residents' lounge.
Here my memory becomes a bit hazy. I can remember my slender young wife bouncing up and down on the ruddy-faced Master's knee as the music played amid general uproar. The hospital pathologist deliberately tipped a glass of red wine into our illustrious guest's lap for reasons unknown, then they both left abruptly. And the paediatric senior registrar had turned a pale shade of green so I suggested he head back to his room. He was found face down on the cold stone floor of the corridor next morning with his pants round his ankles having tried to prepare for the toilet but failing to stay conscious for the conclusion. He said he had no memory at all of the previous night.
Now I understood why I had been selected for the job.

next day

My large patient eventually had prostaglandin gel last night for induction of labour then intravenous oxytocin this morning. She started to bleed after three hours, and not yet in established labour. After seven hundred ml a Caesarian Section was arranged. Due to her size(BMI>55) there were delays but eventually the baby was delivered in good condition. The placenta was marginally low with bleeding from beneath its lower edge. When it was removed there was heavy bleeding from the lower uterine wall. I have seen this before and tried to oversew the bleeding area without success , eventually removing the uterus entirely, but this time it seemed to work. Measured blood loss was two and a half litres so blood transfusion was begun. She was given multiple treatments to contract the uterus as it was repaired.Soon after , both mother and daughter were fine but for a moment I had been about to perform a hysterectomy. Now she will be able to have more children if she wishes. None of her problems were due to her weight but it would be nice if she was a little smaller next time.
Back to clinic, two hours behind.

public holiday

Booked to see thirty two reviews and two new antenatal patients on a day when no one else is working.
Woken at six to start the day with an emergency Caesarian Section for a heavy smoker admitted on the night before with a kidney infection - flank pain and heavy nitrites in the urine. She also had a productive chest infection. Foetal monitoring detected a slow foetal heart rate and decelerations with contractions. The baby girl cried vigorously at delivery.
Labour ward is empty but I am prevented from inducing labour for a high risk patient at term who has had repeated small placental abruptions, and has already been postponed twice. She weighs nearly one hundred and sixty kilograms. The theatre staff fear she may have a complication when they have reduced resources but tomorrow they will have elective surgery and a whole new range of obstetric complications to deal with as well.I believe they are being punitive over her weight, but they wouldn't admit it.They will feel no remorse if she has a major abruption while she is waiting but I have been overruled by the Medical Director.
Now for the clinic.
External cephalic version( turned a breech around): the only case of interest. Then review after review. Slower and slower as the day progressed, until the clinic finally petered out, no longer caring about much at all.

white shirt

I bought my white shirt from a local supermarket twenty years ago. It is a little worn but still serviceable. I'm not sure what it means that I still wear it. Am I a proud conservationist or simply stagnant? Am I a model of consistency or too scared to face change?
Or just twenty years older.

My mother ironed it for me.
She can't go on forever.

microbrewery

Invited to an October beer celebration at a new small brewery.
Not sure if it will be outside; the weather is wet. Perhaps we should stay home.

But the rain clears.

Friends drop in to see us off.

We drive to the brewery and try a variety of their specialty products.

My daughters share a seat and chat.

Later we eat at an Afghan restaurant and come home. Despite my protestations my wife drives. I have theatre in the morning but after the daytime drinking I must admit I feel a little flat.