fell asleep again

Every night I need sleep more but I take less. Every day I think I will collapse. I promise myself an early night but let the time slip by until there are five hours then four hours then only three hours left before I must get up. I know I will suffer but cannot help myself.;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll';lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll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unexpected finding

Overweight, heavy smoker, abdominal and pelvic adhesions, persistent complex but small ovarian cyst, unsuitable for open surgery, not yet had children, planning to remove cyst by laparoscopy but if too difficult then for removal of the whole ovary. She will still have one ovary left, fertility conserved.
 First on the list. Late start. Difficult access but safe entry. Uterus and both ovaries fixed deep in the pelvis by adhesions. Anaesthetist won't allow steep head down position due to poor oxygenation so bowel and abundant fat obscure access.
Eventually mobilise the uterus and affected ovary only to find, unforeseen, that the other ovary is much more enlarged. This was not detected by scans before the surgery. This means that at least one ovary must have successful removal of its enclosed cyst. I set out to remove the larger cyst, planning to remove the whole of the smaller ovary if successful in preserving the first one.
The ovary is laid open, draining an unpleasant milky fatty fluid and then a clump of hair, but the cyst capsule will not come free. It is thick, tough and densely adherent to the ovarian shell. Since the smaller ovary almost certainly contains the same type of cyst then at least one of them must be removed without also removing or irreversibly damaging the surrounding ovary. Slow progress is made while the anaesthetist repeatedly warns that the patient's  life is in jeopardy if the surgery continues much longer. If the procedure is abandoned incomplete then firstly there will be a large raw surface which will attract adhesions to the bowel but worse, the exposed inside of the cyst will continue to release its irritating contents into the pelvis and abdomen. I work feverishly under constant threat of  termination of the procedure. I cannot just stop and try again another day as the anaesthetist is unlikely to agree to further surgery and a half-completed operation will cause adhesions which will make any further procedure even more difficult and dangerous.
The instruments find the thick irregular cyst hard to grasp, repeatedly slipping off, constantly being replaced, but slowly the cyst is removed with the poor battered ovary saved. All I need to do is remove the other ovary with its cyst inside but the anaesthetist's patience has expired.I am forced to withdraw with the original cyst untouched after two and a half hours of frustrating surgery. Half of the remaining theatre list is cancelled and by the time it is finished (including removal of an ectopic pregnancy) it is time to start my afternoon clinic.
As I arrive for the clinic my secretary asks me if I can see a sick elderly lady who has come a great distance to see me on the wrong day by mistake.I can't say no so the clinic is an hour late before it has started. But surprisingly the day improves.
Despite the stressful beginning, all the afternoon patients are delightful. My feelings of persecution gradually fade.
 I remember that it is Friday. After the last consultation I pick up fish and chips on the way home.

 I have the weekend off.

morality

Listening to the car radio. There is a discussion about morality and religion. Two of the faithful wondering if it is possible to have morality without belief in God. I was thinking that it would be clever to say, considering the historic enormity( look it up ) of the sins of organized religion, that I wonder if it is possible for both morality and belief in God to co-exist. Perhaps that is unkind.

It is such an intolerable burden to be aware of our own mortality that we look for comfort and consolation wherever it is offered, even in impossible beliefs.

But God help anyone who questions them.

drive by

I drive through a little town every day on the way to work, usually thinking only of the day ahead.There is a small bridge over a tiny stream with a few trees before a short stretch of road with five houses on one side and four on the other. Then today, late as usual, I noticed how pretty it is at this time of year.

short list

When I know that a patient will not be coming to theatre or clinic, I try to hide it from my secretary but she usually finds out and fills the gap with another patient. I have already done the elective Caesarian Section from tomorrow's theatre list. She won't be able to replace it at such short notice - so tomorrow I should finish operating early enough to be able to have lunch.

Ikeepfalling asleep

continuity problems

Would like to go to sleep but almost certain to be called into the labour ward soon. Slow progress. Variable decelerations. Epidural.
Unable to sleep so thinking about one of my obsessions.
I'm not sure how to define it. The real self.
If I think that I am me then am I definitely me? I think therefore I am -  but am I me or someone or something else?
I could be psychiatrically deluded....how do I know that I am sane?
When I go to sleep I stop being me. When I wake I recreate me. If I was to wake as someone else I wouldn't know. When I am woken by a phone call, at first I have no identity, just a concept of a role. I help people somehow....


Huh. Fell asleep and then called for an emergency Caesarian section, but not the one I was waiting for. Now it's after five am and still waiting for a call. Just the faintest light in the eastern sky but the birds are already awake.

If a science fiction transporter was possible would it really be the same person who re-materializes at the destination point? It seems unlikely that the same atoms would be used to re-create the body at the end of the journey so at the least it would be a body made of entirely different materials but which still feels as though it is the same individual. This is not necessarily a radical idea since the atoms which constitute our bodies turn over with the passage of time while we continue to feel like ourselves. But what if the transporter failed to "dematerialise" the original person...just simply reproduced the pattern at the destination? The original body would be utterly unchanged, would feel like its normal self, and yet another body would exist at the other end which feels as though it is the same being. However the original subject would have no perception of the thoughts and sensations of this second entity and could die without being aware of it at all. They are not the same person. Dematerialising is simply killing the original person while creating an exact but distant copy which thinks it is the original.If a person had been transported a number of times they could be useful from a strategic point of view and the resulting creature would consider itself the same, but it would be a copy of a creature that was a copy of a creature, going back to the original, all of whom had been killed and no longer existed.

This is the same argument for the concept of "downloading" one's "consciousness" into a computer network. It is theoretically possible to create a set of parameters which is sophisticated enough to be indistinguishable from human intellect and which might possibly consider itself to be the same as a human prototype, But the original human could live and die unaware of the "thoughts" generated by such a program. Thus if you "downloaded" your consciousness it still wouldn't be you. No immortality there.

What if an all-powerful being had only just created me, including an imagined memory of my entire life to that point? I wouldn't know - I could have only just come into existence now. This very moment could be the first instant of my existence.
Or this one.

When I wake for the inevitable next call will I really be me?  As my groggy mind searches for focus I often feel as though I have only just come into being, not sure who or what I am, but perhaps good for helping people somehow.

ectopic

Just about to pick up my daughter from school when the the phone rings. The director of casualty has an ectopic, stable but with internal bleeding. Pick up daughter while patient is prepared for theatre. At laparoscopy nearly a litre of free blood is aspirated. Bleeding from the affected tube will not settle so it is removed.
Later I eat meat pies.

surprise

              New slimline Venetian blinds.                                                                                                          

                                                                                         

                                                                         Flowering pear.

Bee on a flower.
                                            

get-go

Don't get me started.

I want to have dementia

Yesterday was my father's birthday. He died in1981. I want to have dementia so I can think he is still alive, so I can think that I could talk to him again at any time. I want my childhood back.

miscarriage

A typical first antenatal visit. A high school English teacher. I like her. We talk about the books her classes are studying while I fill in the repetitive forms. A medical student is sitting in the consulting room with us. Her husband is on a job, driving his truck, and her first child is with a babysitter. The questions finished, tests ordered, we go into the examination room to check the progress of the pregnancy, at eleven weeks gestation according to an ultrasound scan three weeks earlier.She lies on the examination couch. I squeeze gel onto her lower abdomen and place the probe on her skin. It takes a few seconds to orientate the scan picture but an embryo is quickly seen.

The embryo is the right shape but seems faded. Perhaps the settings are turned down. A quick check shows normal settings and the embryo seems under developed for eleven weeks. Perhaps the dates are wrong, but they shouldn't be if she had an ultrasound only three weeks ago. I pass the scanner back and forth over the image of the embryo as these thoughts rapidly coalesce. I hope its not a miscarriage. No heartbeat can be seen. Maybe I'm wrong. The colour Doppler probe cannot demonstrate any blood flow either. I haven't said anything yet. She must be starting to wonder if there is a problem. I keep scanning in the increasingly unlikely hope that a heartbeat will be found. I have to tell her. 


I summon my courage for the coming ordeal and say without inflection, " I can't find a heartbeat." Instantly, her face turns pale as she asks me what I mean. I have to say that the hoped-for baby is dead. I have to find words to say something that will ruin her day, her year, her happiness, her confidence; to say something so devastating that she will probably remember it in full emotional detail for the rest of her life. I have to find a way to be kind while offering no hope at all, because she needs to be sure.

"I'm sorry. You've had a miscarriage...probably two or three weeks ago."

Now her cheeks flush as though  with shame or embarrassment and, without crying, tears roll freely down her cheeks. " How can that happen ? How can it...but it was fine at the ultrasound...I still feel pregnant..." And then a distant stare, numb despair. I talk.

I tell her it isn't her fault. No cause is usually found. She will have to tell people what has happened. They will try to console her. If you haven't had a miscarriage it seems kind to point out the good things - young and healthy, can try again, already have lovely child. To a woman who has just lost a pregnancy(I know I have said this before) this sounds like " Don't stress. You may have been careless, but you've still got one left and you can always try again so you should stop worrying about it." People will imply that she will 'get over' it, or even 'find closure'. I warn her that this will happen and that people (well, women really - what man would talk to her about the loss of a pregnancy ?) really mean well and just cannot understand unless it has happened to them.
 I tell her she is not supposed to get over it. She will never forget the brief  deeply affecting life of her lost child. Whenever she thinks of it she will be upset all over again and that is how it should be.No one can make her pretend she no longer cares - because when people ( women ) console her it sounds as though she is expected to give up the precious memory, when that is all she has left of her pregnancy. It is a relief to know she can keep at least this much.

She says it is too awful. I agree.

I tell her that she will probably think of little else for some time. Then small gaps will appear in the relentless sadness before she remembers and then feels guilty for forgetting for a short time. Longer gaps will appear. She will laugh without remembering to feel guilty.One day she might feel the urge to make plans. She can't give up her life forever but there is no strict time limit for grief.

She shouldn't be surprised if her partner/husband reacts differently. Men don't usually want to talk over emotionally painful events but it doesn't mean they don't care. It isn't a criticism or a judgement of her, although she could ask him to simply listen even if he doesn't want to talk. Painful but shared experiences should bring a couple closer together. The irrational guilt that we all feel when something bad happens should be understood and not allowed to cause disharmony.

She asks when she can try for another pregnancy. It is tempting to try to get pregnant at once, to try to fool the emotions into believing that nothing was lost. However, there is a higher likelihood of a significant postnatal depression if that path is taken. In fact, overall, the incidence of depression is just as high after a miscarriage as after a stillbirth. This seems surprising if you think that an embryo is too small to have had as much emotional impact as a later pregnancy, but it has already had a large effect. To the mother it isn't an embryo but a baby. She knows when it will be born, what year it will start school, which of her friends will have a child which will be born at the same time of year and grow up at the same time. Names have been dreamed of for years. New rooms may be needed, even a new car. No other child can ever be born at that time. It cannot be replaced. It is unique. Its life must be mourned properly. I am prepared to answer her question.

She can try to conceive another baby when she feels she can cope with another miscarriage.

Plans are made. A possible curette discussed. But she has not even had time to tell her husband. She will talk with him, her friends and family then call me with a decision. She leaves to pick up her other child from the creche before going home to go through it all again.

The medical student has been quiet but supportive. She says that this was the last clinic of her term and she didn't expect anything like this. She had a tutorial on miscarriage the previous week and no one had described how upsetting it was. Tears glisten in her eyes.

I am an only child. My mother had ten miscarriages after me, as late as twenty four weeks. She is eighty five years old and I know she hasn't forgotten any of them.When I am alone I sit for a while and think of her.

art

Over time I have found an increasing desire for significance in my personal environment.I appreciate the functional and mildly decorative qualities of the inside of our house. I contributed to their design. However, I have come to want more than bare walls, albeit in a shade of pale rose pink applied to encourage a feeling of warmth, on an architectural background of a truncated modern version of an historic building style.

I want art.

Hell, I don't even know what art is.
I have read that art is "the product or process of deliberately arranging items (often with symbolic significance) in a way that influences and affects one or more of the senses, emotions, and intellect." (Wikipedia) Actually, that's a good description of what I've been looking for. I want some items arranged in a way that will affect one or more of my senses, emotions or intellect. I probably don't want them on the floor or the ceiling. I suppose the walls are the traditional place for art for a good reason - you can look at their artistic offerings easily and without tripping over them.
I asked my wife what she thinks of as art. She said "Paintings."

Shelley Esaak, an art historian, says that art is "form and content." The form contains the elements of art  ( colour, value, space and line ), the principles of design ( balance, contrast, emphasis and proportion ) and the physical materials used by the artist. The content includes the intention of the artist, the actual realization of that intention and the reaction of the observer to both the intention and the actual representation.
Enough intellectualizing, I want some paintings. They should be attractive, interesting and reveal the personality of the artist. They should communicate and stimulate.

Perhaps I might get one of those paintings of a sad kitten with big eyes.

mortality

Tired. Slept well last night but still tired. I keep thinking that I could have something wrong with me.

As a doctor I try not to be a hypochondriac but I know too many people who have developed serious illnesses at my age. Leukaemia, lymphoma -  both can make you tired, although eventually some sort of lump will appear. Two of my mentors died of a stroke at about my age, not that there is likely to be much warning of that.

You see a lot of illness and death as a young doctor, but I first saw a dead body when I was eighteen. I had just proudly gained entry into a medical course and I wanted some money for a holiday, so my father arranged a job for me as an orderly at the cancer hospital where he worked.
I suppose there wasn't a great need for my services. Perhaps the job was more a favour to my father. In any case I was placed at the front entrance of the hospital. My job was to meet the new arrivals and escort or wheel them to their ward or clinic.The head orderly had been a porter at a famous hotel and he believed that one should never be seen sitting down. So I stood to attention at the front doors for up to eight hours a day, broken by rare trips to the wards with patients.
Standing still is not hard for a short time. After about half an hour the soles of your feet feel a little uncomfortable. You shift position a little, raise one foot then the other...then walk to the other side of the door. If you are caught too far from your post, you are chastised. If you do it again you are told that your pay will be docked. So you stand on the spot.
The soles of your feet start to throb after an hour or two, and yet the day has barely begun. By lunchtime you can think of nothing else. A trip to the ward is blissful. You dawdle back as slowly as possible, but before long your feet feel like enormous insistent throbbing lumps. You can think of nothing else. It is hard to believe that such a simple duty could be made into endless days of torture, so when I was offered an alternative I accepted without hesitation.
The mortician, technically an orderly, was taking leave. A temporary replacement from among the orderlies was required. As a group, it was thought by the other orderlies that, since I was a medical student, it might be educational for me to do the work. In principle, and in view of my newfound relationship with my feet, I tended to agree. And so I was taken to the mortuary and instructed in my new employment.
I was shown how to remove the internal organs from the larynx to the bladder and rectum using a scalpel to make an incision from each shoulder to the base of the sternum then vertically down to the pubic bone. The organs were placed in a large dish for the pathologist to examine later. Then the thoracic and abdominal cavities were filled with scrunched up pages of a large broadsheet newspaper and the incision sutured with a running stitch of string so that funeral arrangements would not be delayed. Leftover organs were later poured into a garbage disposal sink. When I first saw the procedure I tried to maintain my external composure. Internally, I had the sensation that my brain was being sucked out of my skull leaving me without the capacity to frame a response - my own reciprocal "out of body" experience. I was clearly emotionally unsuited to the task but there was no option to turn back now.
A new body was brought into the mortuary and I was left alone to do the job. People say " I have never felt so alone." Well, this was one of those occasions. There was no time pressure so I waited.
Waited for inspiration, for courage. Hoped for escape. The waiting made it more difficult to face the procedure. I can still remember the smell of dead body and disinfectant and the feeling of unreality. Then, like an automaton, I simply pulled back the sheet and did the squelching, cartilage-crunching ,nauseating operation. And then the next, and the next. Eventually I became hardened to the experience but now I was socially isolated. Previously a few people would sit with me at lunchtime. Now no one came to my table. No one would make eye contact. I had become a pariah.
The experience was overlaid with the fact that my father was in remission from his metastatic bladder cancer which hung over our close tiny family like a shroud. In short, I probably didn't cope as well as I thought at the time. It might also at least partly explain my erratic behaviour in the first two years of my medical course.

To handle a corpse is not quite the same as seeing a person die, however. This didn't happen until my intern year, on a rural placement.
The hospital was more than three hours from my family home, which was a rented apartment that I shared with my parents and my girlfriend. My father was coming closer to the end, only a few months away as it transpired, although he was still managing the palliative care patients at the cancer hospital. He was functioning normally on two hundred and forty milligrams of morphine every four hours but the stress level of the household was rising. My girlfriend, also a medical student, left me at the beginning of the new term, although we eventually limped on with our relationship for another two years.
I was emotionally and geographically isolated, and generally sad, but still enthusiastic for the work.
The hospital was run by the radiologist and the GP's.There was a medical resident - me - and a surgical resident who looked after the inpatients and treated the casualty presentations.

 The first day that I arrived on the ward it seemed quiet and empty of staff. As I explored the ward I became aware of a rhythmic sound from one of the rooms.As I came closer I could hear counting from one to five then the sound of blowing air repeated over and over. When I reached the source of these quiet but persistent noises I found two middle aged men leaning over a man of similar age lying on a bed. One was was performing cardiac compressions while the other was squeezing a bag of air into the lungs after every fifth compression of the sternum. Seated in a bedside chair, a middle aged woman was calmly knitting. I asked if I could help.One of the men, both local doctors I later learned , suggested I come back when they were finished.
The patient was their colleague who had suffered a cardiac arrest. His wife was the calm knitting lady.Apparently it had happened more than once before and, as on this occasion, he survived. But it was a somewhat surreal introduction to the hospital.

Not long after this I was called to see a man in casualty with atypical chest pain. His ECG was unremarkable so a chest X-ray was arranged. Since I wasn't busy I decided to watch his X-ray. There was some delay, so I stood beside his trolley chatting with him. He seemed a nice man; I was enjoying the conversation. Suddenly, he began to lift his head and shoulders up while making a loud frightening roaring sound. I had done six years of medical training and two thirds of an intern year but I had no idea what was happening. His face was engorged with blood. The veins in his neck were bulging fit to burst. I felt that I should be doing something. I asked him what was wrong but got no response. I tried to take his pulse but it wasn't possible to feel anything with his rigid trembling roaring condition.
I called for help but no response. I didn't want to leave him like this. I ran a few steps down the corridor and called again then returned at once, as he started to quietly sink back down. Now I could check his pulse - nothing at the wrist, nothing in the neck. I finally realised that this was a cardiac arrest and climbed up onto the trolley to do the CPR. I seem to recall it went on for a long time without any response, even after help arrived with the appropriate equipment. Eventually the resuscitation was abandoned. I was sweating, disappointed and disorientated.
I had been to cardiac arrests before and they were exciting. I always wished that I could be the one at the centre of the procedure. It looked important and, to be honest, fun. But this had not been fun. A nice man had died. Despite my extensive training I had been powerless to help him. On reflection I think perhaps he may have had a massive pulmonary embolism, in which case there was never a chance of a successful resuscitation. I don't think I ever found out the diagnosis. He may not have had an autopsy at all, as it is often simply recorded as cardiac arrest "due to coronary artery disease."  In similar circumstances I know I have made such guesses as a resident doctor in order to spare the family an unwanted intervention by the coroner. It has been written that pulmonary embolism is a more common cause of death than the official records indicate. Despite this, he is the image that comes to my mind when I think of a cardiac arrest. I have been taking low dose aspirin since I turned forty for that reason, even though my risk profile suggests it is more likely to give me a stroke than to save my life.

While writing this I have done two consecutive clinics without a break including an emergency Caesarean section and another run to the labour ward for a two and a half litre primary post-partum haemorrhage. It is odd but I no longer feel tired.

seen on sunday morning in town

And at home:

another dawn

Called to see VBAC for poor progress. All internal hospital doors are shut for fire drill.

Decide to do Caesarian section at eleven fifteen.

Get home at one thirty. Asleep by three. Called for retained placenta at five thirty.
Drive home into the dawn again.

Sleep from seven thirty to eight thirty.
Wake up after one hour.
Eh.

normal

Antenatal clinic on a sunny afternoon.
Generally in pregnancy blood pressure is normal if the diastolic level (the bottom number) is below ninety. A patient's partner was worried because her blood pressure was eighty five. He asked me if I was concerned.
I said no.
He said, "But the midwife said that it is getting high."
I told him it is like the speed limit: if the limit is ninety then eighty five is ok.You don't get a ticket just for being close.
As we spoke, sunlight lit up the office wall. A warm breeze wafted through the open window.
In the middle of winter, that isn't normal.

nothing to nothing

Nothing. Drifting.
No.... something. Little. Sound?
Not important. Stay unconscious.
Still there. Something. Bad feeling. Climb. Against gravity. Through darkness. Pulling in my ......brain.
Phone. Not loud enough. Other phone. Sleep call. No escape.Squint. Dark. Reach over, unplug mobile, and answer.
Dress in sleep. Don't want to lose sleep. Maybe hang on to sleep. Maybe quiet delivery then home and sleep. Down stairs: concentrate, don't fall. Garage door loud. Lights on. Start car and drive out.
Empty road auto-pilot dream then hospital park, entry code, up bright light stairs. Maternity ward. Try to sneak in quietly. Midwives at desk look up, say nothing. Walk into gloomy labour room. Not my antenatal patient. Try to speak. Introduce myself with clumsy words.
Yes, hello, fucking get it out. Just get it out. It out. Out.
Pleeease.
Permission to examine. Fully in pelvis. Fully dilated. Direct OP. No epidural. Vacuum cup.
Get it out!
Please push.
I can't do it.
Please push. Baby's heartbeat is very slow. Please push.
Nnnnnngh ! I can't do it!
Push some more. Baby needs to come out now.
Nnnnnngghh !
More.
 No !
More.
No !
Push !
Do what the doctor says, dear. You can do it. Come on. Do your best.
No ! No ! Nnnnnngghh ! Nnnnnngghh ! No ! That's all !
Push ! Stop talking and push !
Glare. Nnnnnngghh !
That's it dear. It's coming down.You're nearly there.
I can't....nnnnnngghh ! I can't......nnnnnggh ! It hurts ! Nnnnnnggh !
The baby's coming out. It's coming out !
Ow, I'm fucking splitting ! It hurts....can't.....owwww !
Here's your baby, dear. Look at your baby. What have you got?
Is it all right? Is it OK? Why isn't he breathing? What's wrong ?
The baby's fine,dear. Lovely and pink. Why don't you see what you've got while the doctor helps the afterbirth out?
It's a boy ! It's a boy !
Would your partner like to cut the cord?
Just a few stitches and then it's all over dear. Just let the doctor fix you up. Look at your boy. What are you going to call him? Who do you think he looks like? Did you already know it was a boy?
Slip out. Raise hand silent hello and goodbye to midwives at desk. Down stairs. Car. Drive.
Wide awake. Adrenaline aftermath. Fine tremor. Drive into garage. Up stairs. Wife asleep.Dark.
Wide awake. Ears still ringing. Close eyes. Lay awake. Think of things. Try to relax. Lie still.
Wait.
Wait long time.
Still awake. Should I look at the clock? Do I need to get up soon? Don't look. Try to sleep.
Going to be a really busy day. Going to struggle with tiredness. How much sleep would I get from now?I wonder what time it is? Don't look.
Still awake.
Awake.
Maybe two hours?
Awake...sleepy.
Heavy head.
Tired...drifting.
Nothing.

hand crafted

Woke early, for a Sunday, had a shave and shower, and drove into the city with my youngest child. She chose her ideal outfit for a day visiting two markets and a quilting exhibition. We talked as we drove.

She said she loved autumn for its warm days and cool nights; summer for the heat; and spring for the fresh new leaves and flowers. I thought about it and decided that I liked this time of winter because just when everything seems so barren the new buds are already swelling on the branches and early flowers have begun to bloom.

Conversely, this reminded me of the principle that I first encountered in The History of The Decline and Fall of The Roman Empire by Edward Gibbon (a book which opens with beautiful prose unmatched in modern writing): the idea that the seeds of decay are already growing at the height of success. This is often referred to by the coaches of champion sports teams. It requires greater effort to keep succeeding than it did to get there originally. My daughter surprised me by saying that this is also true of relationships. They need continuing work - especially when everything seems to be going at its best. So true in theory, but aren't we all inclined to be a little lazy after reaching our goals? So few relationships flourish after the exciting early days.

We arrived at the first market, large and rural, with many produce stalls, as well as the usual art, craft, clothing and jewellery.

Then we moved further into the heart of the city. The next market had more art and higher prices but better quality too.

We ate, then walked along the river to a quilting and craft exhibition. No photography allowed. There were many beautiful handmade works of art, many of which could be reproduced using a kit but it seems that only my wife, who is an avid and skillful knitter, has the patience for such activities. We bought some ribbons for my daughter's hair, then left, crossing over to walk back along the strangely deserted opposite side of the  river with its unappreciated public artworks,

and old bridges.

As we walked, an old couple passed us - still holding hands after all those years.