On being Mr Wolf on Saturday mornings

A couple of Saturdays ago I found myself being awoken at 08:00 by an alarm I couldn’t remember setting. I lay in bed for a few moments toying with the idea of returning to sleep knowing full well that I’ve inherited my father’s inability to lie in. By 09:00 I was showered and shaved and working my way through a long list of neglected emails and admin. This was going to be a productive Saturday.

At 09:30 the phone rang. I didn’t recognise the number. Ordinarily I would have let it ring out but something compelled me to answer.

Carry on reading here.

On Casting the Safety Net

You can bring yourself up to date with the 4th instalment of my BMJ Blog here.

Where have all the good sales assistants gone?

As we slalomed around several incredibly over sized pushchairs parked throughout the baby department of a well-known triliteral high-street store - the very same store that Londoners are warned to mind out for as they get on and off the tube - we noticed a dearth of sales staff. Our task was to find an outfit for a friend's now not-so-newly-arrived baby. I decided to wade through the sea of pushchairs and see if the cashier could shed some light on this.

Me: Excuse me...there don't seem to be any sales staff on the shop floor.
Cashier: [with an expression that suggested this was quite a normal state of affairs] Oh right.
Me: We just wanted to see if this [holding up a stripey baby jumpsuit] was available in the 3-6 months size.
Cashier: I don't know where they [presumably referring to her co-workers] all are.

In due adherence to shopping protocol I thanked her for her assistance.

Tube Piercings

Whilst riding the tube back home the other day I witnessed perhaps the most surreal of my underground journeys to date. Imagine a relatively packed Northern line train between Chalk Farm and Camden Town stations. To the left of me were sat two drunk middle-aged women (MAW) who, speaking in tandem, were trying to verbally restrain their even more inebriated friend sat opposite them. Directly in front of me was sat a rotund American man (AM) with a camera dangling from a lanyard around his neck. He was smiling inanely. To his left was a gentleman (GM) in a beige linen suit, holding a well-thumbed (bordering on brittle) paperback book in one hand, sharing the same hand with an arm of his spectacles which he twiddled endlessly. The seat to my right was free. The train stopped at Camden Town.

As soon as we were moving again I noticed that the dynamic inside the carriage had palpably changed. I looked up from my own book and noticed the most drunk of the women dropping her oversized aviator sunglasses to fix a gaze on my new next-door neighbour and subsequently point him out to her not-drunk-enough-to-not-be-embarassed colleagues. Everyone else was intently staring at the chap sat next to me (CSNTM). I glanced at him almost out of obligation and noticed he was sporting an incredible array of facial jewellery with almost every pore skewered by some form of metallic contraption. His mohican hairstyle and tartan clothing didn't help him blend in.

AM: (Looking at CSNTM.) Do you mind if I take of a photo of you sir?
CSNTM: (In an unexpectedly soft, almost inaudible voice) Erm...well...if you have to, but it's been a busy day...
AM: No, no. I don't have to. It's just that...you're worth taking a photo of.

(CSNTM's not impressed but too polite to refuse this intrusion. In the meantime, GM interrupts)

GM: (In a crisp home counties accent) Now hold on a moment. (Looking towards CSNTM) You're a work of art! You're expressing yourself through what you've done to yourself. You're an artist! He (pointing to AM) wants to appreciate your work. Let him photograph!
CSNTM: Well...I am an artist. Oh, ok then.

Amidst the resultant surrendering of the usual tube protocol of not making eye-contact or conversation with anyone whatsoever, the carriage inhabitants dissolved into several streams of chatter. The far-from-sober women revealed they were returning from a wake, AM was on his way to a musical, GM returned to his book and CSNTM brought a welcome reprieve from the cocoons we inhabit on the undergound.

Decisions, decisions

My task yesterday was to convince a precocious 6 year old lad recovering from leukaemia to have an injection. Not usually too taxing a requirement as these kids have been subjected to more pin pricks than even the most elderly of tailors. This particular injection was different though. It had to be given intramuscularly i.e. in an arm or bum. In a bid to empower him I offered him the choice. He eventually opted for his posterior. Next we had to decide on a side.

Me: Which bum do you want it in? Left or right?
Kid: Ermmm...ermmm...which bum?
Me: That's right.
Kid: Ermmm...my mum's bum!

A case of mistaken identity

During a particularly busy night shift last week I was summoned to the delivery suite. The midwives wanted me to attend because the baby was being born through thick meconium and being vacuumed out with a ventouse, placing it in a higher category of risk than a 'normal' birth. I flipped into emergency mode and proceeded at breakneck speed to the labour ward.

I entered the room in question purposefully and strode towards the resuscitaire in anticipation of the newborn. As I passed the labouring woman and introduced myself I caught site of what I imagined to be her baby being delivered and the old alarm bells started ringing. In fact my internal siren was blaring. The baby appeared deformed, inhuman, almost alien-like in its lack of distinguishing features. I started rummaging through my mental archives for syndromes and conditions that could result in such an appalling condition. I was considering calling my registrar to join me in what was turning into an incredibly delicate and potentially intensive situation.

My feelings must have made themselves evident by breaking through to the exterior as the midwife asked me in a concerned tone:

"Are you alright doc? You look a bit shocked!"

The question prompted a swift re-evaluation of the scenario and metaphorically (and maybe even literally) stepping back I noticed that a baby was already lying on the mother's chest trying to hold on to the vestiges of its nine months of symbiosis. The penny suddenly dropped. I turned to the midwife and exclaimed:

"That's the placenta isn't it?!"
"It sure is doc. It sure is." She replied, triggering off a crescendo of warm laughter.

My bleep went off again and I left one moment of surreality for another.

The Heart of the Matter

I was asked to review a baby today who had been noted to have a heart murmur the previous day. On entering the room I noticed two women and the dozing baby. One was in traditional Indian clothing and the other wasn't. The former transpired to be the mother, the latter, her sister-in-law.

S-i-L: Oi! The doctor's 'ere to check the baby innit.
Mother: Yeah I know. I've been up all night worrying. Is the murmur still there?
Me: I'll need to have a quick listen to baby's chest to check.

I approached the baby and carefully manipulated its clothing so as to allow my stethoscope to rest on its chest. While doing so I somehow missed the gender cue apparent in the overwhelmingly pink apparel.

Me: He looks like he hasn't a care in the world!
Mother: Did you just call her him?
Me: Oh! So I did...
S-i-L: Don't worry innit. We call her it.

The murmur had disappeared and both ladies were mightily relieved. It remained oblivious.

Alcoholics Anonymous

There is a health food shop situated in the new (and uninventive airport lounge-like) main entrance building at my hospital. For the last week they've been running a half-price sale and even they must be surprised at the number of people that have suddenly developed a fondness for dried prunes and fig juice.

I jumped on the bandwagon by using the opportunity to sample their temptingly packaged ginger beer. An FOTB colleague who was watching my purchase with initial amusement and then growing shock felt compelled to confirm a nagging doubt

FOTB: Ginger...beer?
Me: Yes, ginger beer
FOTB: Beer. You are drinking alcohol?
Me: What do you reckon?
FOTB: It is beer?
Me: You know I'm a teetotaller. Putting that aside though, if I was going to start knocking back grandma's old cough medicine, it'd be pretty outrageous to start in full public view, in a hospital, on duty, don't you think?
FOTB: So it is not beer?
Me: Something like that

The Tale of the Dry Nappy

The conversion of the NHS from an institution of noble aims and aspirations to a flogged mule of service-provision has had unexpected consequences. Gone are the legendary days of zombie-like doctors stumbling along corridors 72 hours into their latest shift courtesy of the European Working Time Directive. However, also gone are the expressions of gratitude and appreciation that would make the zombie feel like its work was worthwhile. Patients (deservedly) have rights but rights now far outweigh responsibilities (and medicine is not the only sphere where this holds true). The niceties that lubricate such relationships have been discarded and replaced by litigious expectation.

During a busy shift I can see upwards of a score of patients. You try and provide a caring, personal service but, with the likes of 4-hour targets, can't help feeling a little overstretched and hope that you're not holding back a smile or sacrificing banter for pure functionality. This is highlighted further by the fact that the patient does not have twenty doctors they are obliged to consult - you are the only doctor they will see. Your experiences of that particular on-call may blend into a montage of signs, symptoms and treatments but for the patient (and their family) that episode will have an individuality and significance.

I only came to appreciate this last weekend during a weekend of night shifts. I was asked to review a baby by the midwives, who having passed urine after birth had now gone for 36 hours without wetting a nappy. They assured me he was still opening his bowels and were certain it hadn't all got mixed up in the noxious concoctions babies' rear-ends can produce. They'd even left pieces of strategically placed cotton wool inside the nappy to capture any traces of moisture for posterity.

I consulted my registrar and trudged up to the postnatal wards to reassure everyone involved in what was rapidly developing into an anuric frenzy. I spotted the Arabic name on being handed the patient notes and greeted the baby's mother who was visibly anxious. Almost immediately her expression changed to one of pensiveness and then a look of recognition.

Arab Mother: Dr Mohammedali?
Me: Erm....No, Dr Mehrali.
Arab Mother: Yes, Yes. Dr Mehrali!

The panic siren was now sounding and the red lights flashing in my mind as it desperately tried to recall the source of the familiarity.

Arab Mother: (Now in broken English and Iraqi Arabic) You treated my son for asthma two years ago. He was very sick. May Allah reward you with goodness!

As she said this she deftly donned an almost opaque niqab or full-face veil. I began to recall the case, one of the first cases I saw after qualifying from medical school. The little boy was experiencing a moderate asthma attack which responded well to treatment - nothing remarkable there - but what made the encounter stand out was his parents' tolerance (and I think appreciation) of my broken Arabic with which I falteringly explained his condition, treatment and prognosis.

Me: Ah yes. I'm surprised you remember. How is your son?
Arab Mother: All praise is due to Allah! He is well.

I went on to examine the new addition to their family and lo and behold the baby's nappy was wet and a lesson was learnt.

Birmingham Burning

Late one evening last December I had my first encounter with Her Majesty's Police Force - an altogether surreal experience from which I think I'm fortunate to have emerged unscathed, my dentition still intact.

I'd completed a busy on-call and wasn't overjoyed at the prospect of delaying my return home by having to detour past Blockbusters to return an overdue copy of Shark Tale. The DVD was returned. The fine was paid. Mission completed. As I drove back home I impressed myself with the stealth and guile of my driving, culminating in managing to just sneak through a notorious set of traffic lights.

I continued over the roundabout and towards my destination when I caught sight of the unmistakable flashing lights in my rear-view mirror and heard the wailing siren of a police car. Being the dutiful citizen that I am, I remained in the left lane of the dual carriageway and beckoned the police car past, only to notice it slide in behind me and return the beckoning gesture. I drove on, innocently unwilling to accept that they could possibly be interested in me and my stealthy, guileful driving.

Eventually the relevant portion of my cerebrum accepted the possibility and I slowed to a halt. The police car stopped about ten metres behind me and the passenger door opened, revealing an Oompa-Loompa in police gear. He was the shortest, most hyperopic PC imaginable with a suitably disporportionate hat. He waddled towards my car. I wound down the passenger window hesitantly.

Ooompa-Loompa: Good evening sir (in a lisping Brummie accent)
Me: Hello officer
Oompa-Loompa: Any idea why we've pulled you over this evening, sir?
Me: Erm...sorry, but I've absolutely no idea officer
Oompa-Loompa: No idea (he muttered to himself). Well in that case can you join me in the squad car please sir?
Me: Is that really necessary?
Oompa-Loompa: It most definitely is.

After querying whether to leave my engine running; lights on/off; keys in car or with me; I joined the Oompa-Loompa and we walked towards the squad car. In the dim light I could just about make out the driver of the police car and he looked like a fairly sizable individual. I entered the back of the car and realised that the driver's neck was about the same size as my waist.

Big Cop: Good evening sir
Me: Good evening
Big Cop: Can you think why we may have stopped you sir?
Me: As I told your colleague, I'm afraid I really have no idea.

Big Cop looked at Oompa-Loompa

Big Cop: He has no idea

They shared a sly glance followed by a barely perceptible grin.

Oompa-Loompa: Do you regularly drive through red lights sir?
Me: (Rather alarmed) Erm...no, not really. No, never.
Big Cop: Well you just did.
Me: I could swear the light was amber
Big Cop: It was close. Perhaps the closest I've seen. But you jumped the light.
Me: It really wasn't my intention.

My tired face must have betrayed the overwhelming feeling of apprehension I was attempting to hide.

Big Cop: Don't worry sir. We're not going to prosecute or anything like that. This is just a gentle Christmas warning.
Me: (Obviously relieved) Ah. That's very kind of you. Much appreciated.
Oompa-Loompa: Lot's of people drink at this time of the year. You wouldn't be a drinker would you sir?
Me: No. Never touched the stuff.
Oompa-Loompa: Good
Big Cop: Good. We just need to run some of your details through our databases.

Oompa-Loompa proceeded to relay my name and number plate to some central office. In the meantime, Big Cop reached down to the area between the gearstick and the handbrake and fished out an odd looking piece of rubbish, almost like an ear of corn. He held it up to the light in the car where I got a chance to inspect it too.

Big Cop: I wonder what that could be?

It looked strangely familiar to me. Almost anatomical. Hang on. It was anatomical. Unable to restrain myself,

Me: It looks like a tooth!

I exclaimed

Big Cop: (Re-examines the item and looks towards Oompa-Loompa) Ha Ha. Must have been a scuffle in here eh?

He wound down his window and quickly threw the molar into the darkness. At this point I began to perspire and had visions of Rodney King being battoned to death flooding my thoughts. As a gut reaction I pulled the door handle only to realise that the door was safety-locked and could only be opened from the outside.

Oompa-Loompa: (Looking back towards me) In a hurry to get going sir?
Me: (Cue nervous laughter) Yes. It's been a long day and I'm feeling quite tired. It'd be nice to get home and unwind.
Oompa-Loompa: We know the feeling sir. I'll tell you what. Why don't we let you on your way? We'll follow you until your details are cleared then we can all go our separate ways.
Me: That sounds reasonable.

The Oompa-Loompa let me out of the car, I drove off in mine, was tailed a short distance and soon we did go our separate ways.

Czech please

It was recently my turn on the rota to spend the best part of a week performing baby checks - a routine examination that all newborns are subjected to before they make their way home.

I picked up my next set of notes and noticed the obviously Eastern European sounding name. As I introduced myself to the mother she asked if she could feed her baby before its MOT. I obliged and agreed to return after I'd seen the other babies.

On returning I noticed that the respectable, bespectacled mother had now been joined by an imposing looking, frankly brutish character who I assumed to be the father. He sat in the corner of the room, looking around menacingly. Clad in a white vest, exposing his heavily tattooed (and enormous) biceps, he was obviously a devotee of the Bruce Willis school of fashion. The tattoo on his right bicep was alarming: a full-length depiction of a tribesman in bushman dress holding a spear.

Anyway I re-introduced myself and started examining the remarkably cute baby boy. As is my manner, I asked the mother a routine set of questions while putting the baby through its paces.

"Did you experience any complications during pregnancy?"
"Do you suffer from any medical conditions?"
"Did you take any medications over the last 9 months?"

Dad was silent throughout all of this. His silence was intimidating. His hulking presence, even more so.

"Is there a family history of any medical problems?"

Before mum could even answer, Mr Willis sprang into life.

"VOT?" he boomed
"erm...Is there a family history of any medical problems?"

He mumbled an incomprehensible sequence of consonants to his wife and replied,

"NO. BABY, HEALTHY. ME, HEALTHY. FAMILY, HEALTHY. MY MOTHER 82, HEALTHY. MY FATHER 85, HEALTHY. DRINK WHISKY. WE FROM CZECH REPUBLIC. YOU KNOW IT?"

In a desperate bid to connect with the family patriarch I nodded and enquired about the tattoo.

"ME. HUNTER." he eloquently replied.

I continued the examination now under Mum and Mr Willis' gaze. As I drew things to a close and reassured them both as to their son's health, dad had a question for me,

"EYES VOT COLOUR?"
"Blue", I responded.

He smiled broadly as if my medical skills were only now confirmed.

My Weekend

I've been politely requested to ensure the blog is updated on a more regular basis. The lack of an online presence has not been a convoluted ploy to create the facade of being busy but the direct result of actually being busy. Now that things have settled down, mehrali.com can breathe again.

I spent last weekend on-call at night on the neonatal unit. This involves keeping an eye on the tiny pocket-sized babies on the intensive care unit ensuring they're not misbehaving and the unpredictable element of attending deliveries on the labour ward. Being part of such a personal moment of peoples' lives still strikes me as somewhat surreal and as with most tasks it doesn't take long to find the harmonic frequency that you resonate along and go through the motions.

I was jilted from this steady state over the weekend though when requested to carry out a task not usually part of the paediatrician's armoury: a mother asked me to recite the adhan for her baby boy. This entails reciting the Muslim call to prayer near the infant's ear with a view to introducing it to the core tenets of the faith. The recitation, at risk of sounding morbid, takes on a more symbolic role though and can leave you feeling quite humbled - Muslim tradition dictates that a newborn child has the adhan recited to it whereas the prayer for the deceased is not accompanied by a call; philosophers have surmised that the adhan recited to the baby is in fact the call to its funeral prayer, alluding to the brevity of life.

All this heavy stuff got me thinking about a book I reviewed a while ago and haven't returned to since - When You Hear Hoofbeats, Think of a Zebra by Shems Friedlander.

His extensive travels combined with a profound understanding of the spiritual dimension of Islam render him a most able guide towards the elusive domain of self-knowledge. A noble and essential goal, for Imam Ali has said “Whosoever knows himself knows his Lord.”

The title of the book neatly encapsulates its aims; our total immersion in the dunya has conditioned us to imagine horses when thinking of hoofbeats. Friedlander’s objective is to encourage the reader to see things in a different manner – akin to lateral thinking, but exercising the heart and not the mind. To achieve this, Friedlander punctuates his readable text with stories. Daniel Goleman, one of the key proponents of EQ (emotional quotient), says of stories, they ‘have a unique power, an ability to make their points without marshalling the mental resistance that more sharply reasoned rational appeals often raise. Knowledge is best transmitted through rational means, speaking directly to the mind. But wisdom strikes to the heart when it is carried in a tale.’ The late Idries Shah was instrumental in introducing this predominantly Eastern art form to the Western audience via the ‘exploits of the incomparable Mulla Nasruddin’.

The realisation that ancient methods of instruction have something concrete to offer the modern world of fuzzy logic is illustrated by a recent paper published in the British Medical Journal, ‘The power of stories over statistics’. The author ponders why stories are so powerful and suggests two reasons: a biologically hardwired predilection of the brain for stories (compared to other forms of input) and the role of the storyteller. How many times have you sat through a lesson or a lecture and emerged with little to show for it? Yet on other occasions either because of a particularly quirky or gifted narrator, or due to the resonance of a particular analogy, the relevant point can be recalled vividly. Goleman sees the methodology as ‘the antidote to what has been called “psychosclerosis”, hardening of the attitudes.’

The book is divided into twelve sections: eleven brief expositions and a ‘gift’ from the author in the form of a letter from Imam Ali to his son extracted from Nahj al-Balagha. Each section presents new concepts but maintains a degree of repetition enabling the reader to constantly revisit the author’s core themes: Allah (swt) and death.

The author urges us to be mindful of Allah (swt) and proposes that the only means to do so is to interrupt the monotony of our lives by introducing adventure. This is not necessarily in the form of jungle-trekking and white-water rafting, but to a much milder degree. Our days can tend towards a repetitiveness which desensitises us to creation. These Groundhog days ensure we lose our connection with our Creator, who manifests Himself through creation. By stepping back and doing things even slightly differently, we can re-establish the ontological chain that connects everything with God, and reawaken ourselves to His presence.

The author tells us of an old dervish he once met in Madinah who told him that ‘life is a gift that consists of three days and two are gone’. It is with such simple yet multivalent anecdotes that Friedlander gives impetus to the text and immediately follows this jolting of the heart with practical measures that can be readily implemented. Thus he moves spirituality from the world of intellectualisation – chin-rubbing and beard-stroking – to the world of pragmatism and action. The work is impregnated with hadith and axioms of scholars, giving the charm a seal of authenticity.

A descendant of the Prophet (saw) is reported to have said ‘Worship is not merely frequent prayers and fasting. True worship is contemplation on Divine matters’. Friedlander appreciates the value of such wisdom and emphasises that ‘action is not just five prayers a day’. However, the author also appreciates that this is easier said than done, especially with the dunya forever presenting new charms to lure people back to their old ways. ‘If we can just say, “I’m turning on the television, and the television is turning me off”, how long will we watch?’ He does not advocate a monastic lifestyle of seclusion, but urges restraint from total detachment from reality. It may surprise you to note that the psychophysiologist Thomas Mulholland has found ‘that after just 30 seconds of watching television the brain begins to produce alpha waves [that] are associated with unfocused, overly receptive states of consciousness… In fact, Mulholland's research implies that watching television is neurologically analogous to staring at a blank wall.’

Perhaps the most engaging aspect of the book is its advice regarding relationships with others, which are classified as private, personal or professional. We all realise that the most important sphere is the private – reserved for those dearest to us, foremost of which is Allah (swt) – yet we spend the most time in the other spheres. Friedlander suggests means of redistributing this subconscious misallocation. Central to the thesis is the need to appreciate creation – including fellow humans – in order to truly love the Creator. Others act as vital mirrors of our own qualities. A notion that culminates in our own souls reflecting the Divine attributes. Key to this is abolition of the ego via the correct use of words. There is a reason ‘why Allah has placed our words in a mouth that imprisons them by rows of teeth, hard teeth that clamp shut. And lips that seal the mouth.’

I found the book enlightening and have since re-read it, a gesture previously reserved for William Dalrymple. Inevitably, a review can serve only to whet the appetite or sour the palate, but as a final note, any book that draws to your attention the fact that the palmar creases on your hands spell 81 and 18 in Arabic numerals, which amount to 99, and yet we continue to perform misdeeds with these same hands is surely worthy of at least a cursory perusal and maybe even of becoming a companion for life.

Night shifts as a tool for introspection - who'd have thought!

Eavesdropping 2

Not really eavesdropping as the conversation involved myself but as there's already an 'Eavesdropping 1' post, why curtail a potentially highly successful and lucrative book deal?

Sat at a restaurant in Manchester's over-hyped self-christened curry mile AKA Wilmslow Road I don't know what overcame me but I decided to order a Chicken Toofan [sic] which had four chillis alongside its name to indicate capsaicin content (inversely proportional to actual flavour). When the chicken blocks smeared with tomato paste and chilli powder arrived, I rapidly realised that a carbonated beverage would be wise. Having ordered the drink I waited and waited whilst emptying the tanker of tap water alongside me.

As the amiable waiter (W) began clearing the table I (LA) made an enquiry:

LA - You forgot the Coke.
W - [Taking slightly longer than normal to compute a simple piece of information eventually breaks into a broad smile] Thank you sir. Thank you very much.

As he tidied away the crockery he stopped before leaving the table and turned,

W - Thank you. Dessert please?
LA - I'll have the bill please.

Lost in translation?

Eavesdropping

A couple of months ago I met up with my sister for a pizza in town. Sitting at the table adjacent to ours were a couple of college students: a waif-like girl (G) and a boy (B) who couldn't decide whether he was more interested in her or his mountain of pizza slices.

B - Are you sure you don't want some pizza?
G - Nah. I'm on a diet innit.

[B proceeds to maul his buffet meal while G looks on, having ordered nothing.]

B - So what's your favourite meal then?
G - Oh that's a tricky one...hmmm...I don't know.
B - If you had to choose something that was your number one food...
G - Ok.Ok. It's gotta be Filet-o-Fish. Man, that is delicious. In fact, I love Filet-o-Fish.
B - Really? Qasme I think it's rough. Why do you love it?
G - Oh man. I can't explain it. It's different to liking something. Like, you know, I could like a guy cos he has a nice bag but you don't know why you love something. You just do. It just tastes so different.

[Some silent munching ensues]

B - Have you noticed me before?
G - Yeah, in science innit.

Marburg Virus

Here's a mugshot of the villain responsible for the recent outbreak in Angola. They say you can develop an impression of someone by knowing their friends and family; Marburg virus is a cousin of Ebola!

An electron micrograph of the Marburg Virus (courtesy of I Love Science)