The closing act

I'll start off with a joke:  What's orange and sounds like a parrot?  I'll give you the answer at the end.

So, it's my last night in Tunisia. It's been quite a trip - highs, lows, mediums, and everything in between. I took some photos along the way, which you can see here.

The highlight of the last week was the arrival of Steph, which brought even more sunshine to an already extremely sunshiny place. She got here on Friday evening with a bottle of vodka in tow, as is her wont, and we used it to have a bit of a knees-up with my friends here. I showed here round some of the highlights of Tunis on Saturday and then we headed off down the coast to Hammamet, where we stayed in a beautiful hotel on the beach. We ate a lot of food, read improving books, played water polo and generally had a merry old time. So merry in fact that we forgot to leave and helped ourselves to a whole other day of free stuff. Bonus. Then as quickly as she arrived she was gone again - off to the ferry port to go to Sicily and thence on up to Croatia and Outlook Festivities. A flying visit to be sure, but wonderful to see her after a whole month apart. We're reconvening back on the boat on Sunday, assuming it's still afloat.

Also on Friday was my departure from work. There were no patients as usual, so I spent the day chatting to all the doctors and nurses, swapping phone numbers and facebook details (it always seems odd to me that when you do this you just give someone a piece of paper with your name written on it). I'll miss them all but I probably won't miss the department so much! Adjusting back to life in the NHS is going to be quite a challenge - must remember to wash hands, use clean equipment and seek consent!

Back at the hostel people are slowly disappearing. Not in a sinister or mysterious way; they're just going home. About half have already gone, but it's OK because the other half are partying with even more reckless abandon in order the keep the level of noise and disruption pretty much constant. To be honest I'm a little bit bored of the routine here and I'm looking forward to coming and home and seeing some of my proper friends. That's always one of best bits about going away. I've made some good friends here though and I now have contacts in hospitals all over Europe and elsewhere, which may well come in useful for further travels in the future. Of note is an offer to go and work in Burkina Faso next summer, which sounds extremely interesting.

Anyway, tonight I'm just chilling here I think, reading my latest book - Never Let Me Go, by Kazuo Ishiguro (so far brilliant). I've just been out for my last run (not ever, I hope - just here in Tunis), which was beautiful as usual although not as peaceful as I have become accustomed to on account of THE END OF RAMADAN! Just as I prepare to go home, the madness has finally finished. Today is Eid ul-Fitr and so it's party-time, although unfortunately not for us. We were hoping for big street parties etc., but apparently it's a really family-oriented affair and everyone's holed up in their houses. So much so that absolutely everything is shut and so we can't even buy food to have our own party. Still, I hope they're all having fun without us.

Tomorrow I have the day free to hang out in Tunis, although I don't have any particular desire to do so. I might swing by the centre just to see how it is with stuff open during the day but mostly I'll just be slowly making my way airportwards to catch my flight in the evening. I get back around 11 pm I think, and then it's back to uni on Thursday. I was supposed to start today but hopefully they won't have noticed.

So I suppose it's so long and farewell! Thanks for reading and hopefully I'll see you all in person soon.

All the best.

PS: A CARROT!

Behçet's disease

Yesterday I learned all about Behçet's disease, which is a condition that affects blood vessels and is particularly prevalent in this part of the world. It brought up an interesting ethical dilemma about which Tunisia and Britain have markedly different viewpoints.
The patient was a 30 year-old woman who was a university lecturer, happily married and physically active. She presented with a mild stroke affecting her brainstem. Both the location of the infarct and fact that she had a stroke at all were unusual; however investigations did not reveal anything untoward and she was sent home with aspirin. A few weeks later she suffered another stroke, also affecting her brainstem; this one was more serious. The brainstem is involved, amongst other things, with communicating information between the main part of the brain and the body, and the effect of the second stroke was that, although the "thinking" part of her brain was unaffected, her ability to move and feel the rest of her body was impaired. The doctors were still unable to find any cause of the stroke and she was once again discharged by the neurological team. A few weeks later she suffered yet another stroke. This one knocked out essentially all ability to control or feel the rest of her body; although she could see and hear what was happening around her, she could communicate only by blinking her eyes. A kind of "locked-in" syndrome.
Anyway, finally she was diagnosed with  Behçet's disease, which explained the strokes - the disease had led to damage to the walls of the vertebral arteries, which meant that clots were forming there, breaking off and becoming lodged in the small arteries that supply the brainstem. She was started on corticosteroids, colchicine and thalidomide to reverse the damage and try to avoid any further strokes.
Unfortunately after three months of treatment it was discovered she was four months pregnant. You'll probably recognise one of the drugs I mentioned as being a definite no-no for growing foetuses and actually all three are ones to avoid if you're pregnant - especially during the first trimester. So; here comes the ethical dilemma. The Tunisian doctors decided that due to the likelihood of developmental damage to the foetus and also because of the mother's inability to look after the child once it was born (although her husband was still around), they would carry out an abortion without her consent. They were mystified by my view that they should, at the very least, have involved the mother in the decision, and felt that it was really a no-brainer that the baby needed to go. Maybe their approach has its benefits but it seems inconceivable that that would ever happen in the UK, and it must have been a horrible experience for the patient, who - we assume - had full mental capacity throughout.

Sahara baby!

Last weekend we went to the Sahara, which was really hot and sandy but also wonderful. Just look at some of the things that happened:

Pretty sweet eh? The highlight was definitely finding the "Exquisite Funny Bicycle" right at the end ("Completely new to come to the market"), but also of note were the following:

We went to El Djem to see the third largest Roman amphitheatre ever built, which really is very big indeed. It could seat 35,000 people when it was built 1,800 years ago and continued to do so (not all the time, but if it wanted to) until the second world war when it was unfortunately blown up. Shame. It is still extremely impressive though and you can just imagine what it must have been like to sit there and watch some lions ripping a load of slaves apart.

After that we headed on down the coast to Tataouine, stopping off to check out a giant salt lake on the way. As the name suggests it was a giant lake of salt. Very salty it certainly was, although it's not really clear to me how it got there. Something to do with evaporation I imagine. Anyway, Tataouine is pretty cool, at least relative to the surrounding desert, which is blisteringly hot. It's an oasis, supplied by a mysterious waterfall which comes flying out of a cliff just up the road. We arrived just in time for sunset, which we saw by camel-back and was spectacular. It turns out my steed was a racing camel, which made the journey much more exciting - not to mention uncomfortable - than it would otherwise have been. (They're pretty serious animals, are camels, and I have nothing but respect for them; however comfortable they are not). We also had a go on some quad bikes, which were significantly more comfortable and also faster even than my racing camel. Several people crashed theirs into sand dunes and each other but miraculously no-one died, and shortly afterwards we found ourselves safely ensconced back in our posh hotel, replete with swimming pools, giant buffet dinner thing and BAR. The bar was something of a novelty, so we made the most of it, seeing the night out playing dangerously enthusiastic drinking games in the pool.

The following morning we headed out into the desert with some maniacs in 4x4s and drove around insanely quickly. When we weren't doing that we stopped to vomit and look at interesting things, such as the set of Star Wars - The Phantom Menace. We also rolled around in sand dunes a lot and went to sit in the waterfall.

Another evening of hotel-based merriment ensued, closing with the pre-fasting breakfast which is served to all the Muslim guests at 3 am. I'm almost certain we did a pretty good job of convincing the staff that we were Muslim. Almost certain.

The next morning we began the long journey home, passing through Kairouan on the way. There is nothing of interest in Kairouan but they do make excellent sweets.

And so another weekend ended. Just one more week of work to go, and then Steph arrives on Friday for some further adventures. Good times!

Much love to all. 

Twelve gold bars

Cracking puzzle this:

You have twelve gold bars, which look identical. However one of them is the wrong mass - it could be too heavy or too light. You also have a set of scales, of the "pan balance" variety, which you can use to compare the mass of two selections of bars. You are allowed to use the scales three times. Devise a strategy which will allow you to identify the incorrect bar, and also tell me whether it is too heavy or too light.

Good, interesting, productive medicine!

Had an absolutely cracking day yesterday. I decided I was fed up with working in internal medicine and that I'm not going back there ever again. It's dull and nothing ever happens. Instead I joined my friend Seve in the Emergency Room, which was really excellent. It was very exciting and things were happening literally all of the time. I went around introducing myself to all the doctors, who were very welcoming and basically said that I could hang out wherever I wanted and check out what was happening. I started off in surgical admissions, where I saw loads of gruesome things, including some cracking examples of Charcot's foot (everyone here is diabetic, and this is a common complication). A number of taxi drivers were also in evidence - this must rank as the most dangerous profession here by far! One of them had a particularly impressive head wound, which needed fixing. Then there was a guy who had been vomiting blood, who was subjected to what seemed to me to be a needlessly barbaric investigation. Basically they said they couldn't do an endoscopy (camera-into-stomach-have-a-look-aroundy) as that is done in the gastroenterology department and it's not possible to transfer people (!). Instead they stuck a tube up his nose and down his throat, poured a load of saline down it until he vomited it all up again into a pot, and then had a look what was in the pot. It looked really brutal, especially as the intern doing it clearly didn't quite know what she was doing! After that ordeal I headed over to the medical bit to see what was happening there.
Again, many things. There was a guy having an asthma attack, a couple of heart attacks, pancreatitis, septicaemia; all sorts. I actually got to do some real practical stuff like listening to people's chests and tapping their stomachs, and I correctly identified a case of aortic insufficiency! Wonderful - it was the first really properly good day I've had in the hospital, and reaffirmed my desire to go into emergency medicine.
The other exiting/terrifying thing that happened was in the critical care ward (although "ward" is perhaps generous; maybe rather "room" or ever "cupboard"). When Seve and I went in there was a nurse there who told us about the only patient they had at the time - a 65 year-old man with congestive heart failure. He was unconscious and on a ventilator, and was generally not in a good way at all. The nurse left after a while and we stayed to look at his notes and charts. After a few minutes we noticed his oxygen saturation start to fall - from 98%, down to 95, then 90, then 80. Alarms began to sound. The guy groaned once and they lay still. Our attention turned to the ECG monitor, where something was happening... The trace jumped up and down, with the heart rate flying upwards to peak at 250 bpm. Then it flat-lined. JESUS CHRIST. WHAT DO WE DO?! CHEST COMPRESSIONS? ADRENALINE? WHERE'S THE DEFIBRILATOR?! Seve, cool as a cucumber, says, "Don't panic - I've seen this before. I know what to do". He calmly walks over the the monitor and gives it a solid thump, whereupon everything comes back to its proper state. "Loose connection", he says.
In the evening a few of us headed out to a beach/hill combo just outside Tunis to have a quick swim and then watch the sunset, which was spectacular. I needed Steph there really, as the romance of the moment was wasted a bit on the three boys I was with. We still tried though. Here are some pictures:

Afterwards I went out for a few drinks (one tea, one coffee - CRAZY) with a couple of the doctors from the internal medicine department. I feel a bit guilty about jumping ship and joining emergency medicine but they seemed pretty relaxed about it and appreciated the fact that their chosen specialty was basically dull as dulldadulldulldull. Then it was home to bed, after watching Black Swan, which is very good.

Today I have had another equally brilliant day in the emergency room, but I will avoid boring you with any more medical details. I'm just off for a power nap before Spanish dinner ce soir, followed by a football match. Good times.

Karaoke

Turns out the lure of karaoke really does depend heavily on being incredibly drunk. Here, we have been to two different karaoke bars this week and tried to get involved using tea and cake as fuel. Surprisingly quite a few people had a crack at it but it really does sound terrible if you're still more than 75% conscious... 

This shit isn't optional

In response to some comments I have recently received I should like to make it clear that reading this blog every single day is one hundred percent compulsory. This isn't like any other website, and it's even less like every other piece of published material in the whole world - you can't just choose to partake or otherwise as you please; this shit is for absolutely everyone to read RIGHT NOW, on pain of death. And anyone who isn't reading this - I hope you're prepared for the consequences. There will be a test on the contents the moment I get home and anyone who doesn't cut the mustard will no longer be my friend and/or wife.
I insist that absolutely everyone take an immediate and vivid interest in me and everything I do because that is the only reason I am writing this shit. GET USED TO IT.