Professor Clouseau and the Science of Shadows

I’ve been ill for the past few days so I wasn’t going to work. A low fever, malaise, a general ill feeling. Exactly the kind of mood that doesn’t inspire any thoughts of work. My friend Subroto in Australia diagnosed it as an allergy to work. He had it himself. Apparently it’s a global epidemic.

However, three days is more than enough to cure one of any imaginary allergies. I went in this morning to find the senior resident beaming at my arrival.

“Dr KK! Where have you been? We haven’t seen you for so long!” he exclaimed boisterously as he hugged me.

“I haven’t been feeling well, Dr Anwar,” I mumbled incredulously. He wasn't usually this demonstrative.

“Oh? So sorry to hear that,” he commiserated. “How are you feeling now?”

“Much better, thank you.”

“Good.”

I put my bag in the doctors’ room and joined Dr Salman for pre-rounds.

“How’ve you been?” he asked me. “I wanted to call you last night to see how you were.”

“Then why didn’t you?” I shot back genially.

“Oh, I was busy in the ICU. We had a patient who started bleeding into his lungs and we had to put in chest tubes, first on one side, then the other. Then he developed renal failure and we had to do dialysis. It was a long fight. I came home at three this morning.”

“Did the patient make it?”

“No, he expired early this morning. I wanted to call you to join me. You would have found it very interesting. ICU practice is very exciting.”

“Thanks, maybe next time.”

“Oh, if it isn’t my buddy, Dr KK!” I heard a voice behind me. “How are you feeling now?”

“Much better, thank you, Dr Faraz. How are you?”

Dr Faraz was one of the junior residents on the team. He was new to nephrology, coming in a few days after I did, but Dr Faraz was a keen worker and more than made up for his lack of knowledge with long hours and thoughtful questioning on rounds. He was also one of the more amiable people on the team, subject to random outbursts of poetry and gluttonous discussions on food.

“I’m fine, thank you,” I replied. “How are you?”

“Good, thanks.”

“What have you eaten lately, Dr Faraz?” I teased him.

“We had aloo gosht yesterday,” he said mournfully. “But today the cook’s made chicken. You must join me.”

“Aloo gosht? That’s good food. You don’t like aloo gosht?”

“I do but only at home,” he explained. “You must understand. There is a difference between home food and hostel food. At home palak gosht tastes like palak gosht. Here I think the cook uses grass instead of spinach. The taste is very different. Same with aloo gosht.”

I started laughing.

“No seriously,” he assured me. “It’s not like home. But then, what would you know? You eat at home all the time.”

“Very true. I have eaten in a hostel for five years though. I understand where you’re coming from.”

“Good! Ok, it’s time to work,” he said, gearing up. “It’s Professor Clouseau doing rounds today.”

We all went back to our patients. Professor Clouseau was one of the senior consultants in the department. His real name wasn’t Clouseau, of course, but he reminded me so much of the character from the Pink Panther cartoons that I decided to call him that. Like his namesake, Professor Clouseau was also a quiet, unobtrusive person, completely unimpressive until he started teaching you. And then fireworks would go off inside your head. It wasn’t just that he knew a lot, which he did, but that he asked all the right questions, and in such a way as to guide your thinking as a physician and inspire you to acquire knowledge. After rounds with him, all you wanted to do was to go home and study.

Dr Salman and I were reviewing the progress of a patient that had been admitted with fever a few days ago. She had come in unconscious and comatose and slowly, over the course of a week or so, had managed to recover slightly on an aggressive antibiotic regimen. The progress however had been shortlived as she had slipped back into unconsciousness over the last two days. We were trying to locate the source of the infection.

“It could be a central nervous system infection. Or maybe an infection from the Foley’s catheter or the central line in her subclavian vein,” said Dr Salman listing the possibilities.

“How long can you keep a central line in?” I asked.

“Ideally, you should take it out after 72 hours,” he said. “But here in Pakistan most of our patients can’t afford this. So we keep it in indefinitely. It’s a risk factor for sepsis but we have to take that risk if we want to keep dialyzing the patients. They’re reluctant enough as it is to go on dialysis and if we don’t even do this, then we’re just inviting misery for them.”

I knew what he was saying. Over the past month or so, I had seen countless patients refuse dialysis. It seemed preposterous at first. They were in a nephrology ward, suffering from renal failure, a lot of it end-stage renal disease where their kidneys had stopped working, and yet the moment you brought up dialysis, it was like you were asking for permission to chop off their nose.

“No, doctor sahib, not dialysis!” they recoiled at the very mention of the word.

“Why not? It’s a perfectly safe procedure. And you need it. Without it, you will only be making things worse for yourself.”

“No, I will get better on medicine. Just give me the medicine and I will get better. I don’t want dialysis!”

“But why not?!” It was exasperating.

“I don’t believe it works.”

“What???”

“I think it will make me more ill than I already am. Please, doctor sahib, just give me the medicine and pray for me and you will see. I will get better.”

“Ma’am, if you were going to get better with just medicine, we would have been delighted to offer you just that. But the situation cannot be controlled simply by medication any more. You need to get rid of all the waste product accumulating in your body and dialysis will do that for you. Otherwise they will just go on building up.”

“I don’t want dialysis. Please.”

It was like talking to a brick wall. Quite often we would have to have two or three different people coming in to talk to the family and explain the need for dialysis. To be fair to them, I understood their concerns. Dialysis was very expensive. Each session costs about two thousand rupees and most of these patients need two sessions a week for an indefinite period of time. It can be tremendous burden on the family, especially in our patient population that came mostly from the lower socioeconomic classes. Still, if it was between saving your life or saving your money, the choice should have been to save your life. Anybody could see that.

“How is she doing?” Professor Clouseau had joined us.

“Not very good. She’s slipped back into the coma again. We need to do a lumbar puncture to see if there is a CNS infection,” Dr Salman replied.

“How long have the lines been in?” Professor Clouseau asked.

“It’s been a while,” Dr Salman told him.

“Ok, take the central line out and send the tip for culture. Also the Foley’s catheter.” He turned to me. “Bacteria colonise these surfaces and seed the bloodstream with infectious particles. You’ll notice that whenever the nurse injects something through the line, the patient experiences a spike of fever. That’s the bacteria being released into the system.”

“How soon should you take the Foley’s catheter out?” I asked.

“The risk of colonization is 10% per day. So in ten days, there is a 100% chance that the catheter has been colonized. How long as it been in, Salman?”

“About two weeks.”

“Take it out. What about antibiotics?”

Dr Salman explained that she was getting powerful, broad-spectrum antibiotics.

“But there’s a cost issue, sir,” he said. “The relatives say it is very expensive for them.”

Professor Clouseau turned to the attendant.

“We realize the treatment is expensive but we don’t have a choice. If we don’t treat like this now, we may lose the patient.”

“It’s difficult, doctor sahib,” the lady said in a quiet voice.

“I understand, ma’am, and we’re careful not to prescribe any overly expensive drugs. But you must realize that this is no ordinary infection. It’s not like a sore throat where you can scrimp on antibiotics. If we make any more concessions to the treatment, we’ll be doing nothing for the patient.”

The lady didn’t reply.

“It’s difficult practicing like this,” Professor Clouseau said, turning to me. “We have to use sub-standard drugs with poor bioavailability. The patient has several sources of infection. Cultures may reveal the need for powerful antibiotics but we can’t give them because the family can’t afford it. So we have to make do with second-line agents. It’s like shooting in the dark.”

He picked up the X-ray and examined it.

“Nothing in the chest right now.”

“Is that a lesion in the right upper lobe?” Dr Faraz asked, pointing to a hazy rounded opacity in the right lung.

“Looks like an old tuberculosis lesion. You can see the calcification in it,” he explained. “What are the four radiological densities, Faraz?”

Dr Faraz didn’t say anything.

“Radiology,” the Professor said smiling, “is the science of shadows. All objects have a density that attenuates oncoming radiation. What are the four radiological densities you can see on a chest X-ray?”

“Bone?” Dr Faraz ventured.

“Yes, good. And what else?”

“Air?”

“Yes, air, water, bone and metal.” Professor Clouseau summed up. “Whenever you see a lesion, ask yourself what density it corresponds to and you will be able to identify it more easily.”

We smiled. He made it sound so easy.

“Alright, on to the next patient.”

It was a long round. Twenty five patients on the ward and ten to fifteen minutes on each patient. Three hours hours later we were all exhausted as the Professor relieved us to run our patients’ orders. I went back to the nursing counter to help Dr Salman with a discharge summary. Dr Faraz came over.

“What are you doing for lunch?” he asked.

“Going home,” I teased.

“Ah, yes,” he said dolefully.

An attendant came up to us.

“Excuse me, doctor sahib?” he addressed Dr Faraz.

“Yes?”

He handed over two packs of intravenous antibiotics. They were the foreign, expensive kind.

“My mother passed away this morning. She doesn’t need these any more. If you could please give them to someone who needs them?” he said.

Dr Faraz looked at me.

“I think I know what to do with these,” he said, grinning.

A Day in the Life of

It was the day before Eid and we had just finished rounds. There was a festive mood in the wards as the doctors were going home to celebrate with their families. We have four doctors in our ward and two are from out of town. They were the ones most excited as they rushed about doing their tasks so they could get the earliest bus out.

I walked into the doctors’ room to collect my bag. It had been a relatively long day with a non-productive working round so I was looking forward to going home, taking a nap and then getting some studying done. The week before I’d traveled all the way up to the inner city to get the latest copy of Parveen Kumar’s Textbook of Clinical Medicine and it was lying on my desk, all glossy with the scent of the fresh paper and promise. I couldn’t wait to start reading it.

As I slung my bag over my shoulder, Dr Salman, one of the senior residents, came in.

“Where do you think you’re going?” he said, grinning at me.

“Home?” I ventured.

“No, you’re not,” he said. “You and I have some discharge summaries to fill out.”

I groaned inwardly. Discharge summaries are the bane of any resident’s existence. Filling them out involves a long and tedious process of reading the patient’s file, going through pages and pages of hastily scribbled residents’ notes and then extracting the relevant details of the patient’s stay in the hospital. It was irritating work but Dr Salman had been teaching me regularly these past few weeks and it was the least I could do to return the favor.

“Sure,” I said.

We sat down at the nursing station with a stack of files. My first case was a lady we’d admitted for fever a month ago and her file was as thick as a brick. Just jotting down the salient features alone would take an hour. There went lunch. Beside me, Dr Salman was hacking through his file as well as simultaneously fending off attendants’ requests about what they could feed their patients.

“But she hasn’t eaten all night. How can she take her medicines?”

“Your patient is in uremic acidosis. It doesn’t matter if she doesn’t eat. We need to take care of her renal failure first.”

“But if she doesn’t eat, won’t she become weak, doctor?”

“We’re taking care of that through the IV glucose infusion. As soon as we correct her renal failure, we can start giving her something to eat.”

“Whatever you say, doctor,” the attendant said skeptically. “You know best.”

I smiled at the exchange. This being Lahore, food was a major concern here, even on the wards. Attendants associated eating with well-being and took any opportunity they had to feed their loved ones. It meant they would get better. But to have one attendant after another coming up to you, testing various dietary regimens against your clinical knowledge, could be very trying. A lot of the patients were critically ill and it didn’t take much to see that feeding them wouldn’t solve their problems. It took some patience to help explain all this repeatedly to the attendants and, to be quite honest, it wasn’t their fault. We worked in a government hospital and most of our patients came from lower middle-class socioeconomic backgrounds were the education levels weren’t very high. To them it was all confusion, no matter how many metaphors we worked urea and electrolyes into, and food and prayer was the only way they could deal with the situation.

“The problem is education,” Dr Salman echoed, speaking my mind. “The families aren’t very educated and so they can’t understand. It’s not like this in Western hospitals. There patients are very educated.”

Dr Salman had a curious habit of directing every conversation, whether it be the details of peritoneal dialysis or an evaluation of compression fractures, towards a treatise on the inadequacies of the government healthcare system. He himself had done his undergraduate medical training abroad, in Russia, and was used to working in a more organized setting. So any time any thing went wrong, and even sometimes when it didn’t, he would point out to me the failures of the system we were working in and how things were better abroad. When I first started working with him I found this habit a bit disconcerting, this constant comparison, but as time went by I got used to it and put it down to a chronic, albeit benign, malcontent nature. He was a good teacher and a very skillful member of the team and I enjoyed working with him.

“Are you done?” he asked me.

I looked at the mess of notes in front of me. “No, give me an hour and I’ll have them ready for you.”

“Alright, let me know when they’re done and then we can go and get some lunch.”

Lunch? Just over an hour later I was done.

We went back into the doctors’ room where Dr Salman pulled out a tiffin from his bags and proceeded to unpack his lunch. He was on call that night and his wife had probably made him a hefty Lahori meal.

He pulled out some sandwiches and cake.

“What?! Just this!” I exclaimed, only half in mock disbelief. “What kind of Lahori are you?”

“Who said I was from Lahore?” he said, smiling at me.

“Oh? Where are you from?” I said.

“Have you heard of Sheikhupura?” he asked.

“Yes, that’s close by.”

“Ok, have you heard of Nankaana Sahab?”

“Yes, where the Sikh visitors go.”

“Exactly, that’s where I am from. My father is a schoolteacher there.”

I looked at him in surprise. From his foreign education and his inscrutable movie star looks, I would never have guessed.

“So where do you live in Lahore?” I asked, quickly trying to conceal my reaction.

“We live in a rented house in Model Town. We are five, three brothers and two sisters. Three of us are doctors,” he said with some pride in his voice.

“Do they also work here?” I asked.

“No, not here. My eldest sister is a gynaecologist at another hospital. I’m the second one. Then a brother who is doing his internship. Then a sister, she is training to be a clinical psychologist. And last, a brother, who is a dialysis technician.”

“Our parents had a small plot of land. Seven acres. They sold that to send my sister and I to Russia. But when we came back and started our internship we were only paid four thousand rupees a month. I am the eldest and I had to support my family. You know how expensive it is to live in a city like Lahore. I took on two extra jobs, working at a private hospital in the evening after my regular job and then at another dispensary for two hours after that.”

I could only stare at him.

“It was a difficult time. For five years I worked liked this, sometimes up to twenty hours a day. I had to because I was supporting my family. I couldn’t start my training because I had no money. All the time I was running after money.”

“But things have become easier now. We managed to set up an arrangement with a private hospital here so that I have a good fixed income. Also, my younger brothers and sisters are educated now and can support themselves. Last year, my eldest sister got married.”

“Now I have some time so I can pursue my education. Last year, I started this training position in Nephrology. They don’t pay me anything here so I have to work at the other hospital but working here gives my experience some credibility so I can take the qualifying exams. Even today, before coming here, I went to do rounds at the other hospital early in the morning because I was on call here and wouldn’t be able to attend to those patients until tomorrow afternoon.”

“Here, try some of this. Let’s see if you can tell what it is made of,” he said, pointing to a small cake.

I broke off a piece and tasted it. The sharp, sweet taste of ghurrh erupted in my mouth.

“It’s ghurrh,” I said. “And what else?”

“Crushed rice. This is my favorite. My mother sends it from home. My stock is about to finish now so I will tell her to make some more.”

He smiled. “I’m sorry for keeping you. It’s Eid tomorrow. Go home.”

“Oh, no, it’s my pleasure,” I insisted. “If you need me to help you with anything else, just let me know.”

“Alright, after you finish, we can go and do the lumbar puncture on Bed 20,” he said, picking up on my enthusiasm for doing procedures.

We finished our lunch and went over to Bed 20. The patient was a young girl with Alport’s syndrome, a rare form of hereditary renal disease associated with nerve deafness. Saba had a family history of Alport’s syndrome, having lost two elder brothers to the disease. She herself was in uremic encephalopathy and we needed to do a lumbar puncture to rule out any other infectious process. Dr Salman was an expert in ward procedures.

We placed the child in the correct position, flexing her spine so that the intervertebral space would open up and allow us access into the spinal canal.

“We normally insert the needle lower down, where the spinal cord tapers off, so that we don’t accidentally puncture it,” he revised for me while simultaneously cleaning the area with antiseptic solution.

“Whenever you’re doing a procedure, the idea is to be very comfortable and relaxed. Tensing up only increases the chances of a mistake. When you panic you are more likely to inadvertently injure the patient. So relax whenever you do a procedure.”

He infiltrated the space with local anesthetic. The child winced.

“The needle we use is usually a 20-gauge. The 22-gauge is too narrow and flexible and the 16 and 18 sizes are too thick. 20 is the perfect size.”

He slid the needle smoothly into the interspinal space.

“There, I’m in. I can feel the resistance give way as soon as I’m in the canal. Now all we have to do is wait for the fluid to come out.” He placed a vial under the open end of the needle and waited patiently for the drops of cerebrospinal fluid to drain out.

“A lot of residents get very tense about this procedure. There’s nothing to get tense about. It’s a very simple procedure. And the more you practice, the easier it gets.”

“You do it very well,” I remarked. He made it look very easy.

“It’s because I’ve done so many. When I was working at the private hospital, I was the only person doing all the ward procedures. So I got a lot of exposure. You name the procedure and I’ve done it.”

I smiled. I could definitely believe that. I’d seen him put in a central line, a catheter that goes into the jugular vein, and, again, he’d made it look like child’s play.

“I was going through the records of the private hospital recently. They keep a record of all the procedures performed by the doctors there. In the six years that I’ve been working there, I’ve done 3500 central line placements.”

Wow.

“So now, it’s very easy for me.” He closed off the vials and removed his gloves.

“Okay, now go home,” he said. “It’s almost eight in the evening. Eid mubarak. Thank you for helping me.”

“No, thank you, Dr Salman,” I said gratefully, “Eid Mubarak.”

Perspective

“No, I don’t want the line!” she sobbed.

I stood by her bedside, dumbstruck by her tears. “But Faiza, it’s just a Foley’s catheter. You won’t feel any pain. It’s a routine procedure. We do it all the time.”

Faiza was a young insulin dependent diabetic we had admitted for renal failure. The diabetes had damaged her kidneys and her nerves, including the nerves to her bladder, so that it couldn’t sense when to empty and ended up retaining abnormal amounts of urine. Urinary stasis is a common cause of urinary tract infection and our team had planned for Faiza to have a Foley’s catheter inserted into her bladder so that we could drain the excess urine. Women are more prone to urinary tract infection than men, anyways, even without diabetes, and with Faiza’s current renal failure, it was important that we protect her from infection.

But she wouldn’t have a word of it.

“I don’t care! I don’t want a line! Please tell them not to put a line in!” she cried to her mother.

I was lost. Faiza was usually a quiet and amiable young girl. Every time we came by on rounds, she would sit up, and listen patiently to our discussion, not understanding much but still attending respectfully to our inquiries. The chart said she was twenty but Faiza didn’t look older than twelve and the chubby cheeks and swollen appearance only added to the impression of youth.

“What are you afraid of, Faiza?” I asked, trying to be reasonable. “If you’re worried about it hurting, I promise you it won’t hurt. We use a local anesthetic while inserting and it’s all over in a few minutes. You won’t even feel it.”

“No! I don’t want the line! That’s it!” she refused adamantly.

“It’s a very common procedure, A lot of the patients on the ward have Foley catheters. It’s not a problem at all. Look around you.”

And as soon as I turned around to show her, I realized what a terrible mistake I had made. All around us were beds with old, chronically ill patients, hooked up to a vast assortment of IV lines and dialysis bags. Some had central lines peering incongruously out of their jugulars. Others were swollen and bloated, stepping in and out of uremic stupor as their kidneys failed to excrete the waste their bodies had accumulated. To a young girl it must have looked like death.

“You told me to stop drinking water, I did that. You told me to cut down on my salt, I did that. But I’m not going to let you insert the catheter!” she sobbed indignantly.

I finally understood. To me, a Foley’s catheter was merely an appliance I used to treat a patient’s symptoms or manage a pathology. But to Faiza, it was a violation of her body. A humiliating exercise that meant she was no longer in charge of her private functions. She didn’t want to give up her self-respect and was fighting resolutely for it.

“If I refuse to let you insert it, what will you do?” she challenged me.

“If you don’t want to have the catheter, we won’t put it in. We won't do anything you don't want us to,” I reassured her. “Here, look at this,” I said, pointing to the note in her chart where the previous resident had documented her refusal after his counseling had also failed.

“Yes, I don’t want it!” she said, seizing the chance. “And I want to go home. It’s Eid next week and I need to make new clothes. Tell the doctor I have to go home.”

Later in the day when we came over to round, the attending physician tried once more to convince her to get catheterized and he met with the same steely resistance that I and my colleague had. Faiza refused persistently and finally we decided to manage her symptoms medically and arrange for a drug to be brought over from Karachi.

As the team went ahead to the next patient, I turned back to her, unable to suppress a smile. “Mubarak ho!” I whispered congratulating her. “You won’t be getting the line after all.”

“Khair mubarak,” she said, smiling back.

Eating Crow

I made my peace with Nurse Squeaky today. She's one of the nurses on our ward, a little daft and petulant - if I were making a detective movie, she'd be perfectly cast as the dim-witted secretary who scoffs cream buns all day - and we'd fought last week over band-aids. I'd asked for one for one of my patients and she told me they didn't keep any. So I went over to check with another nurse, just to make sure. Squeaky heard me and came over. "Don't you believe me?!" I said I did but it's common practise to use band-aids in a ward and maybe the other nurse had some. "Well, we don't use them here!" she snapped, leaving me wishing for a gun I could load up with iodine bullets and shoot her with.

That was last week.

This morning we were standing around the nursing counter, chatting before rounds. The nurses were busy collecting syringes and vials to do their appointed blood draws. On an impulse, I asked Nurse Squeaky, who was sitting in front of me, to let me do the draws, since I wasn't very comfortable with it. "Sure," she said. And picking up her stuff she took me over to a patient and started teaching me the whole process. How to pick veins, how to tell the difference between veins and tendons, which vials to use for which tests. And all this without the slightest residue of malice from our previous argument.

It was quite humbling.

Later in the day, a patient went into cardiac arrest. A resident shouted the code and we went over to assist in the CPR. Squeaky ventilated the patient while I set myself up over the chest and began performing compressions to try and revive the heart. As I heaved back and forth, pressing into the patient's sternum, I heard Squeaky quietly reciting a prayer for the patient. It was an innocuous gesture and in the frenzy of the moment I'm not sure how many people noticed it but it took me completely by surprise. I'm ashamed to admit it but I simply hadn't thought Squeaky capable of such gentleness. Working with sick patients, you sort of become immune to the emotional catastrophes that affect them and their families. Death is merely the end-point of all possible therapeutic intervention and a signal that your utility has ended. Nothing more. And yet here was a nurse who even though she knew she couldn't do anything for her patient, still had the compassion to offer a prayer for their well-being.

I'm not sure what to say to that. Sometimes, in our more petty moments, we form impressions of people that end up doing a great deal of injustice to them. It's very easy, and gratifying, to do but it ends up belittling our worth as human beings. We miss out on some very rich possibilities of human connection. And that's always something to regret.

How cool is that . . .

A florist's on Main Boulevard called Bloody Phools . . .

When I Grow Up . .

I want to be a Professor of Medicine.

Seriously, academic medicine rocks my socks. Having been away from it for the past three years or so, I'd forgotten how cool working in a teaching hospital could be. There is a structured environment, an academic culture that supports your learning. Morning report, noon lectures, professors' rounds. And most important of all, patient care itself, the individual therapeutic encounter between you and your patient. Because no matter how much you read and learn from others, it's what bring to that therapeutic alliance that exists between you and your patient that really matters at the end of the day. And nothing teaches you that as much as actually doing it. As someone once said, "The secret of patient care is in caring for the patient."

So, I'm working at a teaching hospital these days. It's an awesome experience. I'm part of a team of four doctors, residents at various levels in their training, and together we're responsible for a ward of twenty-five patients. I'm the youngest member of the team, and contrary to popular conceptions, including my own, am being handled with a great deal of kindness. My senior resident is an exceptionally talented, very hard-working young doctor who doesn't mind me pestering her with questions as long as I help her with the scutwork. I got an idea of her dedication one afternoon when we were sitting in the doctor's room after a round. Dr Sabeen was post-call, which means she'd been in the hospital for the thirty or so hours, and was slumped in a chair waiting for the clock to strike so she could go home. We were all tired. It'd been a long round and the professor had grilled us with all sorts of inconvenient questions whose answers we hadn't known so morale wasn't particularly high. A nurse came rushing into the room.

"Dr Sabeen, your patient on bed 12 just crashed." (The patient had gone into cardiac arrest.)

Dr Sabeen leapt out of her chair, raced across the ward and jumping on to the bed, started performing chest compressions while a nurse ventilated the patient. We all followed behind her and watched as she did a few cycles of CPR but it didn't help and the patient passed away. She was a very ill young woman who had severe, widespread infection in her body and had been slowly deteriorating for some time. The prognosis had been a guarded one. And yet, to watch Dr Sabeen shake off her exhaustion and apply herself so ferociously to the resuscitative effort was a lesson in patient care. These things are reflexive responses, acquired through practise and dedication, and it's moments of crisis like these that reveal where you truly stand as a doctor.

Strangely enough though, for all the suffering, ward medicine also has its moments of comedy. Like when you ask a patient who only moments ago was lost to cold metabolic stupor how they're feeling and snap comes the slurry reply, "Fine! And you?" (There's something very touching about that, how people retain their instincts for manners.) Or when the professor looks like Inspector Clousea from the Pink Panther and his assistant like Hagrid, towering behind him solemn and observant, possibly weaving a silent spell so that a pair of doves may rise from the Inspector's lab coat and flutter through the ward. Incidentally though, both Hagrid and Dr Clouseau are superlative teachers and it's a pleasure attending rounds with them. I can only hope that I am as good for my patients as they are for theirs.

Here's wishing you all a great new year!