Sunday, 6 November 2011
snail's pace
Friday, 4 November 2011
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.
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.
Wednesday, 2 November 2011
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.
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.
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.
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.
Or just twenty years older.
She can't go on forever.
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