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.