four bears

My older son is home from university for a day, to get his car serviced and have his twenty one year portrait photograph taken. He is twenty two but is getting around to it after a year of reminding from his mother. Meanwhile, in the last few months, he has lost about fifty kilograms.

We talked about our family history. My son is named for his great grandfather, my father's father, a famous sportsman and successful businessman of his day. He was a lovely man, though I suppose a hard act to follow, with a kindly rounded face and protruding tufts of white hair from his ears which made him look like a cuddly koala. By contrast my grandmother was thin and acerbic. They grew up and met in a goldfields town where his family had a house-moving business and her father was a country policeman who later became Superintendent of Police for the state. He was cheerful and robust while she was demurely pretty. He became the heart and soul of a great sporting club as player, captain, president and patron for over seventy years and was a founding member of our state automobile club. She and her friends founded a society for the benefit of children with cerebral palsy of which she was treasurer for decades. It has developed into one of the largest not-for-profit service organisations in the country, now funded by both government and charity.

They were people with leadership qualities : people who could see a need and work constructively with a group for a common goal without financial reward, over many years. They weren't alone either : their friends worked with them too. I work long hours for the health of our community but I feel myopic compared to the vision of my ancestors.

I look at my son, so handsome now, and wonder, when they look at his portrait, what his descendants will think of these ancient forebears.

Turkish tea glasses

Woke without the alarm. Well. Not sick. No abdominal pain. No fuzzy headache. On time. Competent. Optimistic.

My younger daughter has recovered from her operation.



 My older daughter is back from Turkey and Greece, and she gave me a beautiful set of Turkish tea glasses.

gingko biloba

The sun is shining.
There are new leaves on the trees.







My lost sunglasses have been found.

After only five more days and nights on call I will have a week off.

I no longer feel as though I am just waiting to die.

Hey, that is the best.

weekend off

Friday was busy, with my brief spare time spent organising a Caesarian section for triplets on the Monday morning. Paediatricians and midwives both unhappy but finally agreed.
Woke very early Saturday morning with bowel upset. Had hoped to spend the day looking for a birthday present for my son. Woke again a few hours later and made my way unsteadily to the kitchen where my wife, mother and daughter were sitting, talking about the recent appendicectomy. I found some tablets for the bowel and the rising nausea. Before I could take them I had to run to the bathroom where I managed to get most of the previous night's dinner into the sink with a few concerted efforts. Cleaned up and returned to the kitchen to some worried faces - sound effects were vivid. Crushed my tablets and swallowed them with a little sports drink, hoping they would stay down, and stumbled back to bed.

Woke next at sunset. 

My wife brought me more sports drink which I sipped carefully despite stabbing pains every few minutes. I fell asleep and woke at four a.m., had some more drink then slept again. 

My muscles had no strength. I could barely turn over in bed.

Woke again much later not having eaten for nearly two days but my muscles were working better.Eventually had a light sandwich which my stomach tolerated reluctantly, walked outside then went back to bed.

 A midwife just called to say that the triplets had gone into labour, been transferred to the city and had  been delivered.Outside it is late afternoon. The shadows are getting longer but there is not a cloud in the sky.There is a slight breeze and the occasional chirping of birds. Back to work tomorrow.

A visit to hospital

She was unwell on the first day. On the second day she had enough abdominal pain to stay home from school. The next day the pain was worse so her mother took her to the doctor who thought she might have appendicitis and sent her to hospital. Ultrasound suggested a normal appendix but enlarged lymph nodes.Blood tests were inconclusive.
After my morning clinic I went to the ultrasound department and look at her films with the ultrasonographer. Because she is young and slim the films were very clear. Then I sat and waited with her and my wife in the casualty waiting room until I was late for afternoon clinic. She said she didn't believe she had appendicitis.




Later, the pain became more severe with increasing tenderness over the appendix. She was admitted to the children's ward and given intravenous antibiotics.





 Her mother rang me and asked me to call the surgeon who was still operating in the city. I told him that my wife was concerned since her father had a ruptured appendix at a similar age. He said he would come and remove her appendix.
Theatre was arranged. The surgeon performed a laparoscopy which revealed a normal appendix and enlarged lymph nodes in the nearby mesentery of the bowel - viral mesenteric adenitis.

An enlarged inflamed node can be clearly seen in the mid left of the photograph beneath the instrument holding up the bowel. The appendix was still removed.





When she woke up in the recovery room she said she knew she didn't have appendicitis and apologised to the surgeon for wasting his time and asked if she could have a hamburger. By the time she returned to her bed in the ward she was texting all her friends, then she fell asleep with the phone in her hand.

recovering

It isn't until you start to get better that you realize how sick you have been.

positive thinking

Discussing my daughter's English essay. Positive statements are usually more effective than negative. Better to say that something is rather than that the opposite is not. Thinking that this is one reason why I tend to make mainly positive statements to my patients, especially as many are anxious about the well-being of their baby, or, in gynaecology, fearful of cancer.
Better to say, "The baby is well" than "I can't seem to find any problems with the baby".

Likewise it is undoubtedly better to say "I love you" than "I can't seem to find a really good reason to dislike you"....... or so my wife tells me.

giant strawberry, cucumber, sunset

On call, still have influenza.

true knot, flu

Woken Friday morning by call to labour ward. Instrumental delivery. Then into next room for another instrumental delivery. Then operating theatre, overfull with added emergencies, including miscarriages and an ectopic - removed by linear salpingotomy with conservation of the tube. 

Briefly home for lunch. I went outside for five minutes to practice my service action, still uncoordinated after all these years but worse with a new racquet.

Back to clinic, all new antenatals, then late home for fish and chips alone, feeling unwell, sneezing repeatedly, joints sore,vague headache,uncomfortable throat. Watched television until called again to labour ward. Another instrumental delivery, and again straight to the next room but this time the baby was born unassisted. It was still attached to its umbilical cord which contained a true knot. No harm done in this case but as many as one in ten can die. Such a stark difference in outcomes, perfectly well or dead.

Home again, feeling progressively worse, but unable to sleep easily.

Woke Saturday aching all over, sore throat, painful cough, sinusitis, conjunctivitis, and on call for next three days and nights without support. Stayed in bed most of the day then finally called into labour ward five minutes after getting to sleep. Really struggling now, ears ringing and coughing up sputum. I have influenza. I cannot prevent it because I am allergic to the vaccine, but why does it always seem to happen when I am on call? That is a rhetorical question.

There is a pain in my left eye and temple.

 I am so stiff and sore that I move like the old man that I am.

I will have to cancel my tennis this week.

twins

Twins are considered suitable for vaginal delivery but that doesn't help me relax. It's better if they are both presenting by the head but the second baby can be breech, as in this case. In the absence of spontaneous labour an induction was  booked for thirty-eight weeks gestation.
Even off-duty over the weekend, I found myself thinking about the twins every spare minute, especially the breech, which I knew was larger. I dreamed that the head became stuck. On Monday morning she came in for induction of labour. An oxytocin infusion led into good labour and by mid-afternoon I was called from my clinic for the delivery.
There was quite a crowd in the labour room - patient, partner, three midwives, two obstetric resident doctors, two medical students, two paediatricians and me. My patient, always positive, greeted me cheerfully. I went about my routine, checking all the nursing observations and foetal heart rates then setting up a delivery trolley while chatting a little to the mother about the birth. An ultrasound machine was placed by the side of the bed. Her legs were put in stirrups for better access and this revealed that the first baby was nearly out. It was soon delivered with minimal fuss. Then, while the vagina was still distended, I put my whole hand into the vagina to identify and guide the breech into the pelvis. It disappeared nearly up to the elbow, finding only the baby's hand reaching down into the vagina, threatening to become an undeliverable shoulder presentation if allowed to progress for a few more seconds. I thought perhaps the head was trying to deliver first but a quick ultrasound scan showed that it  was still furthest from the birth canal. However the breech was also fairly high up and would not be encouraged to come down. By this time, still only a minute or so after the first delivery, the second sac had ruptured, the amniotic fluid was rapidly draining away, and there was a serious risk that the baby would become entrapped by the contracting uterus. I had to pull down a leg and do a breech extraction, only by touch. If I pulled down an arm she would need a Caesarian section.Twice I grabbed a hand but managed to push it back. Eventually I found one of the feet and pulled down until the breech started to deliver, first a foot appearing, then the leg, buttocks and back. When the first scapula appeared it seemed that something was blocking further descent. But if the baby wasn't born soon it would rapidly lack oxygen. As I pulled down further a nuchal arm was revealed.
The left arm had become locked behind the head, blocking any further descent like a wedge beneath a door. I pulled the head down as firmly as I could without injuring the neck. It would come no further. I tried to deliver the arm around the back of the head without success; tried to push the head back up the birth canal to free the arm but there was too much resistance; rotated the shoulders one way then the other -   this failed but it seemed closer to the desired result.
The baby's muscle tone was nearly gone. Initially wriggling vigorously, it was now floppy from lack of oxygen. Yet I stopped and gathered my thoughts for the last attempt before it would be too late. Most of the people in the room were talking, mainly about the baby already born, unaware of the increasing drama. I momentarily envied their lack of responsibility and then tried to think. It seemed that the arm was closest to coming free when the head rotated to face the front but that is a position that is usually actively avoided in breech deliveries so I had been stopping the rotation before it proceeded too far. I decided to take it as far as it would go since all other attempts at delivery had failed. The next step would be to deliberately break the arm although I was not certain that would be effective either.
I started again, turning the body around so that the shoulders and head would face towards the front while trying to apply pressure to the inside of the elbow in the hope that it would bend and come out. It worked, then once one arm was out the other was also locking the head. This time I made the correct manoeuvre at once and suddenly the flaccid baby was delivered and handed to the waiting paediatrician. He recovered rapidly but I didn't know if the arm was damaged. No one seemed concerned except for a student midwife who started to faint and had to leave the room.
The mother was happy and excited. Everyone was smiling. I returned to the clinic, shaken by the near miss, disconcerted by how quickly things can deteriorate in obstetrics; how a life can so nearly be lost or permanently damaged. Still trembling, I resumed the mundane repetition of antenatal care. Later I found out that the arm was moving normally. Both twins were well but I wasn't so sure about myself.