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Thursday, June 30, 2005

Keeping secrets - medical ethics (III)

"I really want to get home and be with my little baby...but I keep being sick. Why? WHY?"

She looked at me, red-eyed. I had no advice for her. All her tests had come back normal. That very morning, she had been feeling sprightly and so we were going to send her home...but then she vomited again after having a mouthful of cereal - the only bit of food she'd eaten in three days. We'd given her some antiemetics (reduces nausea) which had worked pretty well for her over the last three days, but for some reason, wasn't working today.

I walked back to the nursing station feeling very frustrated, when one of the other patients from her bay hobbled up to me.

"Doctor, doctor..." she whispered, "I've something to tell you about that young lady you was just talking to."

I looked at her curiously, waiting.

"This morning, after you left, me and the others seen her sticking her fingers down her throat to make herself sick, you know. She tried to cover her face with her blanket, you know, but we seen her do it, but we was pretending to be asleep, and we seen what she done, you know. We seen her, we did."

Sirens went off in my head.

I saw, in my mind's eye, her husband bringing the newborn son to the ward to visit her...and she said to him, angrily, "Why did you bring 'im here for?". I had thought she was concerned that the baby might catch an infection.

I was wrong. "Why did you bring it here for?", she had said. It. It.

How could I not have noticed? An unhappy young woman with a 3 week old baby...why, it's postnatal depression.

Later that day (I had to wait until I was less furious with myself and with her - and I had to investigate the truth for myself), I went back to have a chat with her and realised that she was very unhappy but unwilling to admit her problems to me or to anyone else...and I didn't want to confront her with an accusing 'you aren't sick, you are making yourself sick on purpose' approach either. I asked her permission to talk to her husband who would be visiting in the evening. She agreed.

When he arrived, he was all stressed out and almost in tears I waited until he had calmed down and had unburdened all his worries. Then I told him.

Your wife is physically well. But she has been under alot of stress and anxiety, and she is forcing herself to vomit. It is a cry for help. I have not confronted her about this, and she will not admit it to me. I don't suggest that you confront her about it either, but accept that she needs help. She needs to see a counsellor urgently, but I don't have the means to get her one fast enough in this hospital. You need to take her home and get her GP to refer her to a counsellor. She is not going to get better in this ward because we're not doing anything useful for her. Please persuade her to talk to somebody about her problems.

I saw the light dawning in his eyes. He looked more hopeful than before.

We talked a while about antidepressants and counselling, and I told him that all those treatments would only work if she was willing to seek the help...and until then, he would need to be very longsuffering. And it might be good if there was someone else around to sort out household chores, maybe help with the baby and take some of the pressure off her.

As I watched him walk back to his wife, I wondered to myself...have I violated my patient's trust?

A patient has the right to expect that information about them will be held in confidence by their doctors. This is central to the patient-doctor relationship as it builds trust - this is why patients are willing to share intimate details about their life with a total stranger.

As a doctor, I must respect my patient's privacy. I have information about them which is sensitive and I must not disclose information without the patients' consent unless I have proper justification - if disclosure would be in the best interest of my patient or for the well-being of others.

In my case, I had information that would be crucial for her further management and would also affect other people around her. Until she is willing to seek professional help, she would need encouragement, understanding and support from the people at home - not frustration, anger or criticism. I needed her husband to keep an eye out for her, to be aware that there are problems simmering under the surface, to be prepared for the worst (?suicide ?child abuse). If left untreated, postnatal depression can be devastating - especially to the child, who can be severely neglected and unnurtured in those early days of development.

Tenuous reasons, but valid?

If she was not even willing to share this information with me, or even admit it to herself, then who am I to decide to tell her husband?

Have I helped her by garnering family support? Or have I given her husband another barb to torment her with? I could only hope that I'd made the right decision.
I had a call from the husband, two weeks later, thanking me.

And I heaved a sigh of relief.



There is nothing like fresh strawberries. These beauties were handpicked by the In Laws in the morning, and served up in the afternoon, along with homemade scones.

Mmmm...Strawberries with creme fraiche and sugar. Strawberries with melted chocolate. Strawberries pureed with orange juice and bananas and yogurt. Strawberries crushed on top of vanilla icecream. Or just plain strawberries, sweet and juicy, staining fingers, mouths and chins.

And scones, still hot from the oven, crumbly, with thick clotted cream and raspberry jam.

Cream teas are wonderful!

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Tuesday, June 28, 2005


Today MDH and I are going house-hunting. Again. Hope we find something nice this time.

I yearn for the day when we can stop paying rent and start paying a mortgage.

(11 hours later)

So we drove for 3 hours and when we were within 20 minutes of our destination, the estate agent called to say that the owners of the house had bailed on us and gone out of town instead.

AAARGH!!! *scream of frustration*

Unfortunately, that particular property was the only one we were interested in, and none of the other estate agents had anything to instead we had to content ourselves with driving around the town and familiarising ourselves with the roads (and note down places that we could investigate in greater detail after we move into the city).

I was really disappointed about not being able to see the house - although we did drive in front of it to check out the neighbourhood and find out how far it would be from my workplace. It looks nice, but we'll probably have to arrange to see it another day (grr).

I really felt like I had wasted a whole day of annual leave, so MDH allowed me to have a 'grumpy half hour' (I'm allowed one half hour of grumpiness a day), and then we left for home.

We dropped by this beautiful rose garden on the way back - over 300 varieties of 'old-fashioned' roses, all in full bloom, a myriad of colours and scents. It was late afternoon by then, so the fragrance was truly incredible.

MDH and the Aged P found a thrush's nest hidden away under some ivy and amused themselves by making the nestlings pop their little beaks in the air, whistling shrilly. I pottered around admiring the blossom-heavy plants and watching the bumblebees as they whizzed from bloom to bloom, drinking nectar and filling their bags of pollen.

We sat by the fountain in the middle of the garden, listening to the sound of trickling water and enjoying the gentle breezes.

Later on, we wandered by the nearby brook and fed our leftover stale bread to the fish. Occasionally, an overenthusiastic rainbow trout would spring out of the water to catch the crumbs, its flanks flashing yellow red and silver blue in the sun.

Perhaps it wasn't such a waste of annual leave after all...

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Sunday, June 26, 2005

Somewhere that's green

The countryside is a strange, alien place to me. Growing up in Singapore makes me a city girl, at home with skyscrapers, noisy motorways, bright street lamps and parks that you can walk through in 15 minutes flat.

I never really spent much time in the countryside (driving through it in a rented car during family holidays doesn't count) until I came to the UK.

When MDH and I were dating, we once spent two weeks in Devon over Christmas break (separate bedrooms of course! we're very conservative). We'd go for long walks through the frozen fields during the day hours, stargazing at night.

I found that I couldn't sleep at night, and I felt agitated during the day. After a week, I realised why - it was too dark and too quiet at night, and the empty sky and wide open spaces freaked me out.

"Where are all the cars?! Where are all the people"

But I'm getting used to it now, and I am growing to love the countryside, the silence and the solitude.


Thursday, June 23, 2005

I've made a new friend!!

I've just finished reading The Time Traveller's Wife byAudrey Niffenegger. Reading this book made me feel very happy - and I will probably spend the next few days daydreaming about it.

I have favourite books and Favourite Books. To me, a novel is truly exceptional (not just 'good' or 'enjoyable' or 'interesting' or 'cool') when I get so absorbed by it, that even the words on the page seem to disappear and I am watching the scenes through the author's eyes - as if I too am a part of the story. The characters are real to me, and I love them.

I start to associate the book with places I have been and events in my life, each page brings with it a certain scent, a certain taste, a certain piece of music (
Memoirs of a Geisha by Arthur Golden, for example, always evokes the taste of toffee fondant icing and the smell of pastry crust). The book sits on my bedside table for weeks and travels with me in my haversack.

I read the book over and over again, and every perusal is like a reunion with old chums. The cover becomes cracked along its spine from being loved too much and shallow indentations on the pages from being held too tightly on bumpy busrides. It becomes a Favourite Book.

There are many other books that are really excellent, penned by geniuses (
Brighton Rock by Graham Greene springs to mind), but the characters they write about make me feel so ill - they torture me, make me nauseous, even give me headaches - and I can't bear to read them again. These novels do not make it to the status of Favourite Books, or favourite books. I put them on my shelf but in inconspicuous positions (I don't like throwing books away, and I can't give them away either because I don't want to make anyone else suffer). I probably won't recommend them to friends; although if asked, I'd say 'it's really good but borrow it from the library'.

Every time I find another Favourite Book, I feel like I've made a new best friend. And the best thing to do is share a Favourite Book with a friend.

Some of my Favourite Books that are reserved a place of honour on the shelves (in no particular order):
A Wizard of Earthsea by Ursula Le Guin
Captain Corelli's Mandolin by Louis De Bernieres
Many Waters by Madeleine L'Engle
The Last Battle by C.S. Lewis
Pride and Prejudice by Jane Austen
The Princess Bride by William Goldman
Aura by Carlos Fuentes
Anne of Windy Willows by L.M. Montgomery
Emily of New Moon by L.M. Montgomery
The Last Unicorn by Peter Beagle
The Complete Robot by Isaac Asimov
The Little Prince by Antoine de Saint-Exupery
The Moonstone by Wilkie Collins
My Family and Other Animals by Gerald Durrell
These Happy Golden Years by Laura Ingalls Wilder
The Joy Luck Club by Amy Tan
The Complete Short Stories by Saki

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Buy me something pretty

A package arrived for me in the post the other day. I knew it was going to be something really special - when I ripped off the brown paper, there was a small white box tied shut with a black ribbon. Inside it, wrapped in pale grey tissue paper (you can tell something is really special when it's wrapped in tissue paper), was a beautiful mulberry silk slip. Another attempt by MDH at purchasing lingerie - and unlike previous occasions, his choice was absolutely perfect this time round.

Choosing lingerie as a present for the special someone in your life really isn't that difficult, as long as you think '6S'.

1. Soft. Lingerie has to be comfortable and luxurious and sensual. It's difficult to feel sexy if one isn't relaxed - and it's difficult to be relaxed if one is feeling hot, sweaty and itchy. Stick with smooth satins and silks, crisp cottons or cuddly flannels. You have to really want to touch it, to feel the texture of it on your skin. Basques, corsets and anything that includes underwires should be avoided unless you are 100% certain of that person's size and figure (see point 4) - but be warned that she might not wear them often enough to make them worthwhile purchases. Fur, feathers, PVC and leather are all very exciting and sexy, but not much fun for sleepwear and besides, they make a girl look more like a bordello mistress (and she might not be the type - so you'd best play it safe and stick to my advice).

2. Sweet. It's all about the details! Lace, ribbons, embroidery - it all makes a slip look so much prettier, and gives it character, makes it more special. A small embroidered flower here, a dragonfly
applique there, a lace trim, a contrasting velvet bow, a cluster of opaline beads. It not only holds the eye but draws attention towards curves and lines of the body. Keep it delicate, subdued and above all, simple. A row of hook-and-eye fasteners on the back or tiny buttons down the front look amazing but could be a hassle to get on and complicated to get off.

3. Skim. The fabric should skim the body or be softly clinging, not skin tight. She needs room for movement. Besides, less is not more when it comes to lingerie. The ultimate seductress,
Marquise Isabelle de Merteuil, describes her most provocative negligee as one that 'hides everything from the eye, but reveals all to the imagination'. I'm not suggesting that it has to be high necks, long sleeves and cover-your-ankles-you-tramp, but the main body of the lingerie should be opaque or at the very most, translucent. Not transparent. The words 'mesh', 'peek-a-boo' and 'crotchless' should not be in the description.

4. Sizing. Unless you know her exact bra-cup size, try to buy in simple measurements ie. Small, Medium, Large. Pick outfits that allow room for minor alterations - adjustable shoulder straps, ribbon ties, drawstrings or a little bit of lycra or lace in the material. Try to avoid elastics as they sometimes leave marks on the skin.

5. Sets. Matching overgarments (robes, kimonos) or undergarments (french knickers, boycut or bikini panties) would be nice, just for completeness and aethetic appeal (imagine having to wear a tiny black babydoll slip with Bridget Jones type granny pants *shudder*). Some negligees will come with a free g-string thrown in, but I wouldn't advise buying thongs or g-strings unless you already know that the receipient of the garment wears them comfortable. There's nothing worse than a wedgie.

6.Slogans. Girly and fun is the way to go. Something like 'Little Miss Naughty' or 'Sugar and Spice' would go down very nicely. I have a pink nightie that reads 'I have a way with Freudian Slips', emblazoned in tiny black letters.

And there you have it. My guide to buying women's sleepwear. Guaranteed 6S!

PS. MDH bought my lovely new slip from Figleaves, but this site has great stuff too.

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Wednesday, June 22, 2005

An afternoon by the North Sea

Originally uploaded by
Sunshine follows me.

Last week, whilst gallivanting round East Anglia with the Aged P's, we decided to spend an afternoon at the beach.

We followed the Peddars Way - an ancient Roman road along the coast of East Anglia and came across this lovely beach lying in the shade of a stretch brown and cream layered cliffs.

The sun blazed overhead whilst we lazed on the sands, warm and contented, watching the North Sea as it foamed across the shoreline. MDH stretched himself out on the beach blanket and fell asleep. The Aged P's walked up and down the beach, pointing excitedly at seagulls and breathing in the fresh salty sea air.

I amused myself by collecting striped seashells, smooth multicoloured stones and bits of twisted driftwood and dried seaweed, arranging them on the sands in what I hoped was a tasteful Zen-like pattern. I raked the sand around our blanket into neat swirls, thinking of Japanese gardens.

beach boys
Originally uploaded by
Sunshine follows me.
Across the beach, parents had brought their toddlers out to play on the sands. Little boys in shorts and round sunhats dug great troughs in the sand with neon coloured spades, held nets made out of clothes hangers and onion sacks and emptied their treasures into little plastic buckets. Little girls in ribboned sundresses paddled in the water and screamed when the little boys emptied the contents of their buckets - mostly tiny crabs, molluscs and worms - on their laps.

Parents scurried after each child carrying armfuls of equipment - buckets, spades, fish nets, kites, towels, sandwiches, beach balls.

beach man
Originally uploaded by
Sunshine follows me.

Meanwhile, elderly couples sauntered along together, walking hand-in-hand or pushing their partner in a wheelchair.

They perched on deckchairs in little groups, sipping cold drinks and talking about 'young people nowadays'. Some put up windbreaks closer to the sea and sat quietly enjoying a book.

I love the seaside. I love the sea, and I really miss the sound and the smell of it and the feel of warm sand underneath my feet. I wonder if this is because I associate the sea with Singapore, and it makes me feel more at home when I am near it.

It started to get very hot, so the Aged P's bought icecream for all of us.

I had a refreshing strawberry and raspberry sorbet. Yummy!

Originally uploaded by
Sunshine follows me.


Tuesday, June 21, 2005

biju, baby, biju

biju, originally uploaded by Sunshine follows me.

Whilst helping one of the Aged P's to make char siew, I managed to spray some black sauce over my nice pale blue shirt.

So I reckon that it's time I bought myself an apron.

I haven't gotten one yet, but I thought these designer aprons from
biju look really cool. I love the prints on them. And they have matching oven mitts and tea towels as well! Whee!! How cool is that?!




I am getting far too domesticated.


Monday, June 20, 2005


and the living is NOT easy.

What is going on here?! This is the UK for goodness sakes, not Singapore. It's 27 degrees Celsius in the shade and I'm actually sweating. SWEATING!!!

One of the things I love about the UK is that I hardly ever sweat, not even when I'm chugging uphill attempting a one-sixteenth marathon.

This is getting ridiculous. One minute it's
frigidly cold and I'm huddled up under my mac and umbrella like a little mouse, the next it's absolutely sweltering and nary a cloud in the sky.

Summer has only just begun - a late summer, really; it's been so cold up until the last few days. I have a feeling all this climactic disorder can be traced back to the terrible December earthquakes. I distinctly remember that after each of the earthquakes and the tsunami, the temperature out here plummeted and it was freezing. (Meanwhile, Singapore suffered from drought and bushfires.) It got so bad that I spent many a frosty day thinking 'it's far too cold here. I wish I was in Singapore'.

Now it is absolutely sweltering out here. The worst thing is, there's
no air-con anywhere. And so, oddly enough, I'm thinking along the lines of 'it's far too hot here. I wish I was in Singapore'.

In my desperation, I have folded a paper fan which has brought me little relief.

I must be going mad.


Sunday, June 19, 2005

Stopping for tea

Today's cakes
Originally uploaded by
Sunshine follows me.
I love finding these little english tea rooms selling all sorts of homemade cakes and breads. Every little village in England will have one of these family-run shops, a chalkboard propped up against the front window with the daily specials recorded on it.

There's just something so restful to be able to sit in a wooden chair, by a table with a patterned cloth, sipping on a fragrant cup of hot tea and enjoying a gloriously sticky victoria sponge.

MDH ordered this indulgent hot chocolate topped with cream and mini marshmallows and chocolate sprinkles.

I watched as the tea lady took out a huge bar of dark chocolate and a grater to make the chocolate sprinkles, whilst a young lad whipped up the fresh cream.

I ordered a pot of tea for myself and the Aged P's, as well as a toasted teacake (it's more like bread with sultanas in it) and cinnamon butter.

The smell of the cinnamon permeated the air when my teacake was served up, crisp and hot on the outside, fluffy on the inside with a generous smattering of juicy sultanas.

Outside, the cold winds blew over the marshes, the reeds and bulrushes whipping in all directions. We watched the terns and seagulls as they struggled seaward, returning inland to feed their young.

Teacakes and Cinnamon Butter
Originally uploaded by
Sunshine follows me.



It's five past midnight and we have just driven 8 hours across the UK.

Had a lovely week break with the Aged P's who've come over from Singapore for a visit.

Lots to write about but much too tired so here's a little taster of some of the interesting things we came across whilst gallivanting 'round East Anglia.

This picture was taken on a path leading to one of the beaches on Peddars Way. We all had a good chuckle about it, I'd hate to think what would actually happen in a real emergency...!!


Sunday, June 12, 2005


Today's schedule:

0900 - Wake up, clean self, wash up dishes
0944 - Tidy living room, empty bins, change bin liners
1013 - Wake up MDH, tidy living room
1057 - Wake up MDH, tidy kitchen
1100 - Eat breakfast, MDH reorganises spare room
1130 - Vacuum spare room, kitchen and bathroom floors
1146 - Make up spare room bed, MDH eats breakfast
1217 - Mop bathroom and kitchen floor, MDH cleans self and bathroom
1248 - Clean kitchen, MDH takes out the trash
1315 - Wipe down all surfaces, MDH cleans out the car
1357 - Get dressed to go out, check driving directions on internet
1430 - Leave house
1600 - Arrive at Heathrow airport
1703 - Parents finally get through immigration, meet at 'arrivals'
1728 - Pack car to overflowing and drive back home
1911 - Parental inspection of living quarters
1912 - Living quarters meet parental standards, nods of approval
1913 - TSCD and MDH heave sigh of relief

It has been a very busy day.
Parents are unaware of this blog at present - so will have to update as and when time permits for the next few weeks. Hopefully will still be able to update daily - this blogging wheeze is therapeutic!


Saturday, June 11, 2005


TSCD: Hello Mrs T.
Mrs T: Hello Doctor!
TSCD: I see your drip has fallen out.
Mrs T: Yes, you've come to replace it?
TSCD: Yes.
Mrs T: Okay. Don't mind me if I shout - I find that it helps.
TSCD: It's alright. You yell as loud as you want, okay? This will only take a minute. (busies self getting cannulation kit together)
(rustles from other patients in the bay as they get woken up from their sleep)
TSCD: Mrs T?
Mrs T: HELPHELPHELPhelphelp(pauses for breath)HELPHELPHELP!!!
(other patients whispering: do you hear that? That doctor is killing her!)
TSCD: Mrs T!
TSCD: Mrs T, I'm not even touching you yet.
Mrs T: Oh I know, I'm just practicising.
TSCD: Riight. You just carry on then. (starts cannulating Mrs T)
Mrs T: It's okay, I'm taking a rest now. (hums a tune) Have you started yet?
TSCD: (removing needle) I've already finished.
Mrs T: Oh! That was fast! I didn't feel anything at all. HELPHELPHELP
TSCD: What's wrong? I'm not doing anything to you now.
Mrs T: I know, but I just felt like something was missing.
TSCD: (refrains from throttling Mrs T) Ooookay then. You look after that cannula now. We don't want to do this again....(EVER!!!!!)

Mrs T: You're such a nice doctor.

I hate it when they get the last word.



Anusha, originally uploaded by Sunshine follows me.

This 'boudoir of a boutique' has got so many indulgent items. Silk organza, lace-trimmed satin, soft handstitched leather, crisp cotton, intricate beading...oh so luxuriously tactile, a textile heaven, a Swarovski crystal paradise. Perfect for lounging seductively around the house.


Friday, June 10, 2005

Life's little stresses

There are certain stressors in life that are commonly associated with depression or anxiety - like a change of lifestyle (eg. divorce, moving house, new baby) or a significant loss (eg. of a loved one, of a job). Certain household chores rank quite highly as life stressors - doing the laundry is one of them, and at the top of the list of household stresses is changing bed linens.

In fact, a depressed person will eventually fail to look after their own appearance - it's just too much pressure to keep clean and keep their surroundings clean.

Sometimes, when an elderly person is ready to be discharged from hospital, we send a team of occupational therapists and social workers round to inspect the patient's living quarters and to find out if that person is able to cope living independantly at home. A good sign of whether or not a person is coping at home is how tidy the home is - whether the bedsheets have been changed or if they've got clean undergarments.

I find that the state of my surroundings often reflects the state of my mind. When I was studying for exams, my room would become increasingly more chaotic (books everywhere, notes in random piles) as my own stress levels sky-rocketed. I would have to spend some time meticulously tidying up my room before I could concentrate on my work again. By cleaning up and filing away the mess in my room, my own thoughts would also become clearer and more ordered.

I also find that on the days where I have to change my duvet covers, I get really really snappish.

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Thursday, June 09, 2005


A cloudy afternoon with a slight chill in the air. I was feeling rather moody so I decided to go out for a walk to cheer myself up. I pulled on a grey turtleneck sweater, grabbed my purple suede 'Sgt Pepper' jacket and headed downtown.

I was just stopping outside 'Daizylake Comfort & Cake', wondering if I should get a loaf of lemon apricot cake for MDH's tea, when I noticed these two women coming out from the shop opposite.

The shop was called 'Long Tall Sally' which (as you may already have guessed) stocks a range of clothes for tall ladies. The two women who emerged from the depth of that boutique were really Long and Tall. With masses of springy red-gold hair, fair rose petal skin with a just a few cute freckles and slim legs that seemed to go on forever. One of them wore a pair of white capri trousers and a bright yellow tunic that slipped enticingly off one shoulder and was bound at the waist with a chunky braided leather belt. The other one wore a floaty pale green chiffon blouse and a ruffled prairie skirt that ended at mid-calf, with heavily embroidered cowboy boots.

I looked that them with envy - being a petite person, I could never carry off any of the items or any of the colours they were wearing. I immediately felt frumpish, stumpy-legged, sallow-skinned.

How could I ever, (I thought to myself) ever look as exotic as they do?



Dammit, if anyone is 'exotic' around here, it's me.

I'm the girl from the Orient, the raven-haired mystery, the small and fiery goddess! I'm the golden-skinned (sallow-skinned, HAH!), almond-eyed, trim little treat from the Southeast of Asia! I beat off my admirers with my powerful tai-chi skills, I carry throwing stars in my handbag and my skin is thicker than dragonhide but smoother than silk!

Right, I'll show them who's 'exotic'!

And so, head held high and shoulders squared, I breezed past the two giantesses who walked behind me whispering to each other. The wind changed direction and bits of their conversation drifted up towards me..."These oriental girls always make me feel so fat."

heh heh heh heh heh


Tuesday, June 07, 2005

Best Interest - Medical ethics (II)

He was a middle aged man with thick spectacles and a hearing aid. He was jaundiced - almost florescent - and complaining of abdominal pains.

When I say 'complaining', what I mean is that he was holding his stomach, grimacing and whimpering. He never really said very much except to scream uncontrollably and attempt to hurl himself against the wall when I tried to come near to him. The poor man couldn't express himself as he had a rather severe form of Downs Syndrome.

Somehow, we managed to convince him to have an ultrasound scan of his abdomen. His carer was present and we scanned her abdomen in front of him to show him that it was harmless and painless and in fact rather a tickly sort of test. He giggled when the ultrasound probe wiggled around his belly - showing us numerous gallstones lodged all over his gallbladder and a blocked bile duct, the reason for his jaundice and the source of his pain.

Over the few days he was in hospital, he refused to eat or drink anything - too much pain. He was losing weight and becoming terribly dehydrated. He wouldn't let me near him to put in a cannula (cannula = tube into the vein through which a drip can be given) - quite understandably, because he had been cannulated in the past and remembered that it was painful. We gave him antibiotic tablets instead and tried to encourage him to drink water, juice, anything - not the best treatment regime, but the one which was most tolerable to him.

However, the only way to unblock his bile duct and relieve the pain and jaundice would be to do an ERCP.

ERCP = Endoscopic Retrograde Cholangiopancreatogram

This is a test by which one uses a telescope camera (the diameter of this scope is about 1 cm) to look down the gullet and into the stomach and first part of the small intestine - Endoscope.

By doing this you can see the opening of the bile duct in the small intestine. A guidewire is inserted into the bile duct opening and dye is squirted into the opening in such a way that it travels backwards into the duct (Retrograde).

X-ray pictures are taken from outside the body will show the anatomy of that person's bile duct and gallbladder as well as the pancreatic tree, as the dye coats the insides of all these structures, making them visible to the Xray camera (Cholangiopancreatogram). This shows up the exact position of the gallstones as well as the part of the bile duct which has become blocked.

Once the camera is in place, guidewires with scissors and baskets at the end of them can be used to cut the opening of the bile duct, thus allowing the gallstones to escape and be caught in the baskets. A stent is inserted then into the duct (with the help of the X-rays to check the position of the stent within the duct) to keep the duct patent and prevent further obstruction.

Sounds longwinded? It is a longwinded test and rather invasive, as
you can imagine. You probably would find it difficult to keep still whilst someone shoves a bloody great big snake-like object down your gullet, even with sedation.

So how would one go about doing this test on somebody who has Downs syndrome, who can't understand what is going on? (Mind you, sometimes even people of normal intelligence can't seem to grasp
what is going on.) He won't understand what you are doing or why you are doing it, so one can't get him to consent to going ahead with the test, and one certainly can't get him to co-operate.

I couldn't even get him to agree to have a cannula put in so that he could have a drip. I did try with the help of his carer, to say - you need this (pointing at a needle) to make this (pointing at his stomach) get better (pointing at a picture of a happy person). But he just shook and shook his head, and I knew all he was thinking was 'needle = PAIN!!!'.

In cases like these, doctors tend to work in the patient's best interest. The 'Best Interest' rule comes into effect when an adult patient is unable to make an informed decision about his or her treatment. We judge the ability to make an 'informed decision' based on whether a person is able to understand and retain information about his/her condition and consequences of treatment/non-treatment.

Not all Downs Syndrome or mentally disabled patients will have treatment under the 'Best Interest' rule - I have met a few Downs Syndrome patients who were able to refuse treatment on the grounds that they understood what would happen if they did not receive treatment.

Anyway, the day came when my patient would be having his ERCP. The plan was simple. I would sedate him with some tablets, then cannulate him and give him more sedation through the cannula, so that he would be asleep during the ERCP.

Easier said than done.

He took the tablets and became drowsy, but not so drowsy that he couldn't put up a fight when I came to cannulate him. It took 5 people to hold him down, and he still managed to kick two of my helpers in the stomach and jab a nurse in the eye and scream like there was no tomorrow.

I managed to get the cannula in and sedate the poor fellow so that he was snoring away in under 10 seconds...but I really felt like I'd sold my soul. I felt like I had assaulted this poor fellow - 5 people grabbing him and forcing him down whilst a sixth person shoved a needle in his arm. The look of terror on the poor man's face! It was like a horror film.

He got his ERCP and was soon napping quietly in his bed again...and by the next day he was feeling much better and was tucking into his breakfast cereal and fruit juice, ready to go back home again.

Yes, I know he needed his ERCP, and I know he feels better know. And maybe, as a doctor, I might have done the right thing with regards to treatment.

But have I done the right thing with regards to the patient? All I have done is instill in him a fear of hospitals and hospital staff. I look at the bruises on his arms and legs and I know that I was the one who caused them. He will never trust me now, nor any other medical staff. And all he knows about hospital is that it is a place where people hurt you. What will this do for him in the future, if he needs to come into hospital again? Will he mask his pain from his carers in the future in the hope of avoiding hospitals?

If I had done this same thing to a child or an elderly person with dementia? When am I allowed to treat a person against their will? How far am I allowed to go before it's classed as assault? What are the psychological repercussions of my actions?

I feel terrible.


Monday, June 06, 2005

Good or Bad day?

I can't decide if today has been a good day or a bad day.

Started off this morning - a tree fell across the train tracks making me late for work. Bad day.

Replacement train service arrived but broke down halfway. Very late for work. Bad day.

Replacement bus service arrives but not enough buses for all the grumbling passengers. Had to wait for 2nd bus to arrive. Very VERY late for work. Bad day.

Then I got to work and realised that all my patients had been discharged over the weekend so I had nothing to do - went home early. Yay! Good day.

Got home, paid the electricity and credit card bills, did some laundry, washed up the dishes. Felt very virtuous. Good day.

Went to the bank, paid in my cheques, got some money out. Good day.

Went window shopping. Good day.

Walked into a spider's web and ATE a baby spider. Bad day!!! VERY BAD!!!! *pleagh pleagh*

So. 4 'good day' points and 4 'bad day' points. What does that make?



Gotta get the taste of that spider out of my mouth.



Most Singaporeans lead very sheltered lives. We seem to be able to 'block out' all the ugly side of Singapore, especially when it comes to foreign workers - some of whom are often undernourished, ill-treated and have no access to healthcare.

It may be that the majority of foreign workers who live in such poor conditions are actually illegal immigrants, hiding out after hours in the rainforests of Singapore - and I'm sure those hiding spots have been around for years and will probably never be found.

During my medical training, I often went back to Singapore during the holidays and did work experience in the hospitals there.

I once treated a young girl in the emergency department who had been dumped by the side of the road, naked and feverish, in the early hours of the morning by her employer. She was probably from Thailand or Myanmar, and she was wearing nothing but a set of undergarments made from a cheap red lace. An illegal immigrant, a prostitute too ill to work and was therefore expendable - thrown away, left for dead.

Somebody had seen her lying in bushes near the motorway and had called the police. She was so sick with fever that she could barely move or speak. How long had she been lying there? I remembered that it had been pelting down with rain the night before - and tropical rainstorms can be pretty scary.

She looked young - perhaps in her late teens - and frightened (why not? she was in a strange, bright place where everyone ran about sticking needles everywhere and babbling gibberish at her). But her face was wrinkled from stress, crumpled like a wad of paper, and the skin on her body was hanging off her bones. She was probably about nineteen, but life had prematurely aged her fifty years.

Her eyes looked at me and were dull - she'd given up a long time ago. Then she blinked and looked away from me, looking at the ceiling, as if to say "do what you want with my body, I'm sending my mind far away from here". I wondered how many times she had to do that every night.

Had she come to Singapore thinking that it would bring her oppotunity? Or had she been sold out of poverty so that there would be one less mouth to feed? How long had she been living here, like this? Who would go to the jungles to use these prostitutes, knowing the conditions in which they lived, knowing that the money spent would be used to smuggle more girls into the country?

How many girls have died and are buried in those jungles?

And how many are still living there?


Sunday, June 05, 2005

Stopping by the woods

On a snowy evening
Originally uploaded by
Sunshine follows me.

Near the centre of town is a park called 'The Common' - 250 acres of unspoilt woods and heathland. 250 acres is really not that big; one can easily walk round the perimeter of the Common is about 45 minutes.

It's a lovely bit of land. MDH and I have spent many a happy tranquil hour walking through the Common, enjoying the sweet singing of birds and watching the squirrels play in the trees.

However, squirrels and birds aren't the only wildlife to be found in these woods.

MDH once met a man who had apparently been living in the Common with his family. In a tent. This extraordinary gentleman had come into MDH's hospital because he had cut his leg and infection had set into the wound. He didn't seem at all keen to stay for very long, so MDH gave him some antibiotics and sent him on his way, asking him to return in a few days time to 'see how he was getting on'.

Of course, he never came back.

But I'm amazed. MDH and I had thoroughly explored those woods and had never come across any sign of him before. And he had been residing undisturbed in the woods for at least three years! How did he get through the winters? It snowed quite heavily last winter. It reminded me of what Yann Martel said in Life of Pi:

"If you took the city of Tokyo and turned it upside down and shook it, you would be amazed at the animals that would fall out...crocodiles, piranhas, ostriches, wolves, lynx, wallabies, manatees..."

And so it would be with our little 250 acres of woodland.

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Saturday, June 04, 2005


Summer rain
Originally uploaded by
Sunshine follows me.
I got my summer dress on, my coat, my boots and my handbag, all ready to go out for a nice bit o' shopping but it's frigging *RAINING*.

Curse this British Weather.

Rainy Day
Originally uploaded by
Sunshine follows me.

It was all sunny and warm just an hour ago and I was going to get the groceries and then maybe get a cake and coffee at the Java cafe. But no. Now it looks like a blasted heath. I'll just have to wait until it stops.


Friday, June 03, 2005


Nifty, originally uploaded by Sunshine follows me.

I love the detailing on the vinyl pouches and bags by Stitchpixie - nifty designs and colour combinations. Her site has got loads of other treats - vintage clothes, shoes, homewares, jewellery...and the designer's own blog as well, which is worth a read.


Hard Boiled

Coeliac disease is a common condition amongst Europeans. It's basically an allergy to gluten. Sufferers who ingest gluten will suffer from massive amounts of diarrhoea and eventually develop terrible inflammation and ulceration of the intestinal lining. It is imperative that a person with coeliac disease keep to a gluten-free diet, as damage to the intestinal lining not only causes great discomfort, but it also inhibits the absorptive properties of the gut and the person can become seriously malnourished.

Gluten is found in wheat and wheat products such as cereal, bread and pasta. It's easy to find 'gluten free' products in the UK, and most people with coeliac disease eventually become so used to avoiding gluten that they do not really think of it as a problem.

One such person was admitted to my ward and had forgotten to mention his special dietary requirements to the doctors and to the staff. The next morning, I came round to find him staring forlornly at his muesli and toast, looking very hungry.

"May I have boiled egg for breakfast instead?" he said, "I normally have two every morning."

"For sure!" I replied, "I'll let the staff know"

One hour later, I get a call from the nurses who said to me, "The cook is throwing a strop (tantrum) and says that he needs to be seen by a dietician first".

"Ridiculous!" I answered, "The dietician won't be around to see him until after Tuesday!" (It was a 3 day weekend)

"He says if the patient wants a special diet, he'll have to buy it himself from the canteen"

Another hour passes and the nursing sister, executive manager and site co-ordinator call me up and say that the catering services have refused to provide special diet for my patient and that I'll have to put a cannula in him and start up a drip because he won't get anything to eat over 3 days.


So I went up to the ward and wrote up a prescription on the fellow's drug chart:

'Boiled Egg, TT, OD, Mane' (Boiled Egg, Two doses, Once a Day, in the Morning)

We all looked at each other and grinned. The pharmacist arrived on the ward, gave me a wink, and headed off toward the catering department, the drug chart held before her like a shield.

Thirty minutes later, I went to check on my patient and he was sitting there looking forlornly at his two boiled eggs.

He looks up at me and says with a sigh, "I usually have them soft-boiled".


Thursday, June 02, 2005


So today I was sitting in the train waiting for it to depart from the station and in walks this bloke in his late thirties who had been standing on the platform finishing off his cigarette.

I was mildly annoyed at him, partly because he decided to sit right across from me (aargh now I might have to make *eye contact*) and partly because he blew a cloud of cigarette smoke my way which made me cough.

I eyed him with some derision. Trousers with brown scuffs over the knees, old shirt with a frayed collar, water stained boots. Fingernails dirty and cut very short, nicotine stained skin, small scars on the fingertips. A builder or gardener, perhaps. Strange tattoo on the forearm - a golden crown and intersecting hearts and...'A Rhs Neg'?! His blood type? Most unusual.

He reached into his haversack and extracted a battered looking plastic bag containing a magazine, which I assumed would be the latest edition of Playboy or FHM or some such rubbish.

The magazine was called 'Crossstitch Patterns Vol 1'.

He wiped his hands meticulously on his trousers, then opened the magazine and took out a small square of fabric and a small packet containing some needles and coloured yarn. Deftly, he threaded a needle, examined the crossstitch pattern closely and started work.

It was a pretty piece of embroidery - a fairy princess in a pink dress waving a golden wand. He'd obviously been working on this for a while - the picture was almost complete. It would make a fine gift for a little girl - a daughter or a niece.

This hefty, mean looking fellow holding a fine needle in his workworn fingers, making a present for somebody he loves.

He got off at the next stop, carefully putting his project away and tucking it back into his haversack.

The train continued on its way and I watched as he ambled off down the platform. I leaned back into my seat and looked at my reflection in the window, wondering: What do people think when they see me?

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