Fourth-order Rainbow?

I read the articles here and here with great interest.

The photograph below was taken on the 6th of May 2010 at 1900 in Rochdale, Greater Manchester, UK. I believe that I may have captured the first ever photograph of a fourth order rainbow with my Nikon D90 over a year ago.

This is a low resolution image of the original photograph. As you can see, even without enhancement, the fourth order rainbow is clearly visible. This is a crop of the centre of the image above to better show the fourth-order rainbow.

This image has been edited to increase contrast and colour saturation.

9 hours

... up and down and this is perhaps the only half-decent picture I got from Ben Nevis. Loch Eil in the background.

Psychiatry, so far

And I'm halfway through my stint in psychiatry already. Barely 2 months to go before I (hopefully) rejoin a proper medical ward. And it's not that psychiatry isn't enjoyable, seeing 4 patients a day and being able to go home on time (or early!) is most definitely a welcome change from running around the ER trying to persuade doctors from other specialties that my patients really are theirs, and trying to persuade my registrars that I'm not a total idiot. I usually succeed, on both counts.

There is a learning curve to psychiatry, no doubt about that. However, after 2 months of seeing patients on my own and only running to my consultant for help when I really need to, I've sort of settled in.

And I don't like it.

The only physical contact you'll ever have with a patient is the initial handshake before the consultation. Sometimes, there's a handshake after. Occasionally (last week), you have to stab a guy in the ass with a needle to administer some medication that he doesn't really want to stop him from clawing the eyes out of every patient and staff member on the ward. At least I'm not the one trying to pin him down and shouting 'Any time now doc!'.

And the there's all this talk about the 'mental state exam'. Important words are thrown about: appearance, behaviour, mood, affect, risks, harm, perceptions, thoughts, insight, cognition etc. I was told quite early on that someone else reading your notes should be able to go into the waiting room and pick out your patient from the crowd. Seriously? Don't take it seriously. As another doctor told me: 'Just cover your ass'.

I've taken numerous psychiatric histories. I've talked to patients about their childhood, hobbies, likes and dislikes, aspirations, feelings, partners, parents, children, finances, associated physical health issues, sleep patterns, dreams; well, almost everything in their lives up to the point when I see them. And somehow, I feel further away from the person who is the patient than I've ever been in my entire medical career (which hasn't been that long). Somehow, by knowing everything about the patient, there is no connection anymore. Sounds paradoxical, but most certainly feels real.

And then we come to weekly small group discussions, otherwise known as Balint groups. A group of doctors, mainly psychiatry trainees (which I'm not) come together and someone talks about a patient they've seen and the rest of the group with the aid of a facilitator is supposed explore the patient-doctor relationship and emotions involved. Somehow though, it's become more of a speculation exercise about how the patient got into into his current situation and not so much about how the doctor has (or has not been able to) connect with the patient. Maybe I'm just too insensitive to realise how this should be helping me 'connect', or as a colleague helpfully put it (still not sure if I understand it), 'it's like a controlled mind-fuck'.

Maybe it's because I have to keep telling patients things like 'It's going take a few weeks (sometimes 6 to 8) for the medication to kick in and maybe you'll start feeling better. 'Maybe'. I've come to loathe this word that I've most definitely overused. It's almost a lie a lot of the time. And then you say something like, 'If that doesn't work, we'll increase the dose. If it still doesn't work, we'll need to find something else that hopefully does. But it will be a few weeks before we can try something else. Why do they take so long to work? Well, for those who are interested, there's an excellent paper on the subject (http://bjp.rcpsych.org/cgi/content/abstract/195/2/102). Which is so not frustrating, regardless.

Am I actually helping anyone in this specialty? I don't know. Some patients thank me. Some thank me regardless of how the consultation went. Some even shake my hand again. Some break down and cry. Some get angry. Some don't tell me anything. Some tell me they want to kill themselves. And there was this one chap who wanted to kill someone else. That was slightly disturbing. Most were on medication, some on more than one. Does medication help, I don't know. I haven't been here long enough to find out on my own. I suppose with psychiatry being such a large specialty medication HAS to help, right? Please tell me it does, I've been prescribing all week.

I'll be so glad to get back into MEDICINE. Only 2 months to go. The Force is with me.

Kinder Scout, Peak District

First it was misty and cold.
At least it wasn't snowing.
The ridge of Kinder, mist included. Compulsory, if anything.

Rocks. And the prospect of a nasty fall.
And then the sun came out. We headed down this way, enjoying the sunshine.

And realised that we had to head back up, and it was now unbearably warm.

But it did give us the opportunity to have a look at the ridge again, with less mist and more sun. I'm told that there is supposed to be a waterfall where the sheep is.

The 'river' bed which supposedly leads to the afore-mentioned 'waterfall'.

The trek back, in the blissful sunshine.

Prayers

One tsunami and some freaks think it's a sign from god. Some even think they indirectly caused it and are happy that god answered their prayers. I wonder how many monotheists were among the victims. Obviously their god didn't love them enough.

Thank who?

So this dude is brought into the ER almost moribund. Not really responding, tachypnoiec, looking quite dry.

Really unwell. So...

Oxygen on, blood pressure cuff on, chest leads on, pulse oximetry, cannula in, some blood for the lab, fluids in, arterial stab, slightly acidotic, oxygen levels ok, low CO2, high anion gap, blood glucose 29, second cannula in, more fluid in, chest radiograph shows consolidation in the right base, insulin sliding scale up, some IV benpen and levo, patient gets better, starts talking, refer medics. Well done team.

A textbook case of DKA.

Patient's relative starts thanking god for saving this chap's life. 3 relatives join hands with the patient and proceed to give thanks to the lord.

Reviewing a patient in the next bay, separated by a shelf and a curtain, I'm obliged to hear everything they're saying.

God is thanked for saving a life. God is thanked for being benevolent and merciful. God is thanked for his kindness and infinite wisdom.

Yep. No thanks to the paramedics, nurses, or doctor. Seriously. If god really wanted to save a life, he should have done it at the patient's house and not in the ER at 0200.

I'd like to see a 'faith' healer work on a DKA patient. If you can make 'crippled' people walk, treating DKA without insulin should be child's play.

And whenever something bad happens to a patient, it's never god who gets the blame.

You want to know why? Try going to your attorney and ask him to sue god for 'killing' someone. He'll tell you it's much easier to sue the hospital, the staff, and the potted plant in the waiting room.

And don't even bother telling me that god works through doctors, nurses and paramedics. I have considered the premise and I find it offensive. Very. I work through me.

God didn't send me to medical school.

God didn't buy me medical books.

God didn't bless me with good senior doctors who continue to educate me.

If you're offended, go pray.

May the Force be with you. Because if there is a god, he isn't. His masterplan is all worked out and he isn't supposed to interfere.

And why is god a he? Why is he never a she? Oh I'm sorry, is that offensive? Next time you want a doctor, go put on a lab coat and see if he'll work through you.

Fabese

Yes, fabese, defined by the urban dictionary as fatally-Jabba-the-Hutt-obese.

I'm not talking about 250 pound people here; I'm talking about people who weigh about as much as the average bear, about 250 kilos.

Sometimes, people who weigh that much can be a little hard to treat in the ER. Difficulties that may arise include:

1. Finding suitable bed for such individuals. Normal hospital beds start to sulk at the prospect and usually die when faced with such a burden.

2. Moving said patient, who may be unconscious, onto the bed, from err, the floor? or another bed? or from a bariatric chair? It took more than a dozen of us the last time.

3. Finding a suitable vein to insert a cannula or to draw blood from. Adipose tissue, while being an excellent insulator, makes it difficult for us to identify suitable veins. And um, if we miss, it's not because we aren't good at it, it's because you're, um, 'fat'.

4. It is almost impossible to check for abdominal tenderness, masses, shifting dullness, or a pulsatile abdominal mass. The last means you're totally fucked if we can't find a vein, or two. Also means a couple of extremely tired junior doctors should they manage to open you up in time.

5. Because you can't see your own feet, you can't tell us if the unpleasant looking ulcers there are getting worse. Hell, you can't even tell us if the horrible, fungal rash in between the layers of your abdomen is getting better.

6. You smell. Although I have to agree that it's not your fault that a cat crawled into a crevice after a rat and couldn't find it's way back out again; it's the rat's.

7. The toilet cries after you visit. The cleaners cry too, but they're being paid, at least. If you've done your number two in bed because you're unconscious, then the nurses and the health care assistants cry. The doctors just look smug and pretend to be busy. The junior doctors are sometimes forced to get involved though; it takes more than one to roll you on your side.

8. They don't seem to realise that it won't hurt for them to live off their 'reserves' for a while. And on that matter, they ask for TWO packs of sandwiches, not one, TWO!

No, seriously. Some are plump, and that's fine. Some are fat, and that's okay. Some are obese, but they can't help it. The fatally obese though, are a different matter. Surely you realised something was wrong when you couldn't get through a door without great difficulty. Or that you needed crutches to get to the kitchen because your knees are arthritic and give way when you try to walk even though you're only 30. Or that you haven't left the house in years. Or that you can't wash between your butt-cheeks because, um, it's a little out of reach? Or that you can only wear XXXXL sweat pants and even that's stretching it.

And the list goes on.

So, I guess what i'm trying to say is, well, help yourself. If you can't, at least realise that you need help and talk to someone. Also, bariatric surgery is free in this country if you meet the criteria. Bah.

May the Force be with you.

(note: I may be wrong about how much the average bear weighs)