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.

Panoramic mode!!

This weekend I discovered panoramic mode on my camera. Check these out:

Also, check out the showers at our hotel!

       

The first one's a bit terrifying but penguin shower is awesome! Steph, can we have one?!

These works of photographic brilliance were created in Monastir and Sousse, where we went for the weekend. The towns were moderately interesting, although pretty touristified. We stayed in a sweet hotel by the beach just outside of Monastir which gave us loads of lovely food and stuff, so that was nice. 

I feel like I've got the general idea of tourist towns in Tunisia now: Fort, Big tower, Mosque, Trinkets, Done. Probably won't go to any more. Next weekend we're off the the desert, which should be entirely different.

At the moment I'm completely absorbed by the two books I'm reading: "Road to Reality" by Roger Penrose and "The End of Mr Y" by Scarlett Thomas. Both are excellent, so I'm going to leave you now and continue reading. 

Oh, in other news: STEPH IS COMING!! This is really very good news, and will brighten the trip up significantly. Literally as well as metaphorically. She arrives Friday week. Yay!

Bye for now.

Riots and pancreatic cancer

Wow, so London's been pretty mental eh? It seemed a bit inappropriate to be posting here about my exciting travels whilst everyone back home suffered that onslaught of rage, but now that it's all calmed down a bit I can get right back to my self-involved narcissism. You guys are fine, right? If not then man up; it's only a bit of petrol. For God's sake.

Anyway, life here is still lovely. There is hardly any fighting and nothing is on fire, apart from the odd pile of rubbish and some of the taxis. Someone did try to rob me today, but luckily they were very bad at it and failed utterly. Everyone here is very interested in the goings on in London, and people keep asking me about the reasons behind it. These sound pretty pathetic when compared to what happened here in January, and I can see their respect for the UK slowly slipping away as I talk. Talking to people about the revolution is really fascinating, and I've heard a lot of different views expressed. Here are a few of them:

• No-one really knows what to do with regard to Ramadan this year. There was previously a well-defined set of laws that governed behaviour, but people are not sure if they are still in force.
• Despite this, Islam in Tunisia is on the up. The mosques are more crowded than ever before, and strongly religious parties look to do well in the upcoming elections.
• People are intensely proud of what they achieved with the uprising.
• Driving has become significantly more difficult, as well as dangerous. Previously traffic police were everywhere, and would stop you for every minor offence in order to extort some cash. Now people will not stand for corruption, so the police don't bother, and everything is chaos. Take from this what you will.

Of note this week has been a trip to Carthage, the old Phoenician settlement on the outskirts of Tunis. I'm not normally one for ruins - a lump of old stone is a lump of old stone if you ask me. However this place was actually very impressive - you could really get a feel for how it used to be back in the day. The baths were especially good - a huge site, with many of the original pillars and stuff still standing. It must have been quite a sight in its heyday.

We also went to the beach at Bizerte which was great. Huge waves in which to throw oneself about. Almost drowned and smashed my leg up on some rocks. Lovely.

On the medical side, things continue to be pretty quiet on my ward, so I've been casting myself around the wider hospital looking for some action. No-one seems to mind or even notice if you just wander into a ward and start reading patients' notes, and doctors are generally happy to talk to you. It gives them something to do. I ended up in the emergency room on a night shift, working with my new friend Sobhi, which was quite an experience. It's pretty crazy at night - huge rooms full of moaning/screaming/crying people; not enough space for everyone to fit; guards with machine guns maintaining order - and still the doctors spend a lot of time just sitting around chatting! Sobhi's job was basically triage - we had to check new admissions to see if there were likely to die imminently. If yes then we sent them off for treatment; if no then we ordered tests and sent them off to get them done themselves. It's all pretty DIY, in that the patient is given a piece of paper with, say, "Needs a chest X-ray" written on it; they then have to head out into the rest of the hospital to look for the radiology department (no mean feat!) or if they want, to a private clinic that can do it faster; then they come back to the emergency room with the film for the doctor to interpret. 

One poor guy was there with his dad, who has pancreatic cancer. He wanted to speak to the doctor about it, but the doctor was busy so he spoke to me instead. He kept asking me to have a look at the X-ray his dad had just had, which I of course couldn't do as I'm not qualified. Then he wanted me to give my opinion on what his dad's chances were, and how long I thought he might live. Pancreatic cancer's a really nasty one, and in this case it had already spread to the liver and lungs, so he probably has a few months at best; there's no possibility of recovery. However again, I couldn't tell him any of this as I'm not qualified, so I just had to reassure him as best I could that he'd be able to speak to someone about it soon, and that the doctors would do everything they could. He just needed someone to talk to him properly, in the right setting, with their full attention, and give him the information he needs so he and his father can start to prepare for the end. Sadly everyone is too busy to do this; and not always with work.

Another guy had a three inch gash in his head from a fight he'd been in earlier. He needed some stitches and so we headed down to the treatment room. It was like a theatre - amazing! On the way we picked up some more doctors, a few students, some friends and relatives, a couple of security guards and quite a few complete strangers. There must have been thirty of us by the time we got there, all crowded round the patient as he sat in the middle of the room with his head over a dustbin to catch the blood. The doctors decided there was no need for anaesthetic (!) and started sewing, eliciting sharp intakes of breath from the gathered crowd with each pass of the needle. Poor guy. He didn't seem to mind though, and was still and silent throughout. Crazy.

Back at the ranch it's been fun and games every night. Yesterday was traditional Tunisian dinner, served at the end of fasting hours at 7.30 pm. We were encouraged to have a crack at Ramadan just for a day, and not drink or eat anything from 3.30 am. I did pretty well, and only had a peach and some water. It certainly makes the food taste much better! We've continued the "national dishes" theme for dinner on the nights when we have nothing else organised, and have been through Portuguese and Czech since my English offerings last Friday. Nothing's come close to the peanut and coriander swordfish if you ask me. Tonight we're having a cross-cultural offering, with myself, Tall Tomas (Czech republic) and Non-tall Tomas (Slovenia) joining forces. Turkey and potatoes will be the mainstay, and we'll see what else we can rustle up on the side.

Tomorrow morning we're heading off to Sousse and Monastir for the weekend, which I'm sure will be lovely. I'll let you know how it was on Sunday.

Much love to all.  xxx

Some new conditions

Here are some of the conditions I've come across over the last few days:

Takayasu's arteritis

• A vasculitis of large vessels that particularly affects the aorta and its primary branches.
• More common in women and typically presents before the age of 40.
• Typical symptoms include limb claudication on exertion, chest pain and systemic symptoms of weight loss, fatigue, low-grade fever and myalgia.
• On examination vascular bruits may be audible over the carotids, abdominal aorta or subclavian vessels. Unequal blood pressures may be recorded between sides and a murmur of aortic regurgitation may be heard if there is aortic-root dilatation.
• The diagnosis is usually made by vascular imaging.
• Corticosteroids form the mainstay of treatment with the additional use of steroid-sparing immunosuppressive agents for resistant disease. Surgery may be required for established complications.
• Long-term complications are due mainly to arterial occlusion and related damage, including limb ischaemia and renal failure.

DVT in a young male

28 year-old male presented with symptoms consistent with a pulmonary embolism secondary to deep vein thrombosis. Quite unusual in one so young. There was no history of trauma, recent air travel or any other risk factors. Possible aetiologies:

• Genetic
• Factor V Leiden
• Prothrombin mutation
• Protein C or S deficiency
• Antithrombin deficiency
• Antiphospholipid syndrome 
• Associated with SLE?
• Unusual in a young male
• Malignancy

Things that have happened since Thursday

Thursday


Rubbish.

Friday


Amazing. Saw some really cool stuff at work; we had three new admissions overnight so it was all go during the morning. Got to assist with a salivary gland biopsy. By "assist" I mean "hold a tube" but still... It was a bit mental how they did it actually - in particular the environment they chose to operate in, which basically looked to me a lot like the coffee room - loads of crap lying about, flies circling, people wandering in and out etc. The doctor doing the actual cutting and rooting around was at least wearing sterile gloves, but no-one else even washed their hands! The poor patient was barely consented, and then had to put up with us three students peering at her the whole time while the doctor pretty much ignored her obvious discomfort, with no nursing staff to assist...
The whole ethos of medical ethics seems to be really different here. It kind of fits in with their laid back attitude to life and work in general - people basically want to do the bare minimum, and will do anything for an easy life. My friend Chris did a night shift in A+E and even there it was the same - doctors and nurses just sit around chilling while patients suffer. I guess it makes sense that their work ethos applies to the medical profession too, but you kind of get the feeling that if they could just be bothered to work a little bit harder, their patients would really have a much better time! I think some of it is to do with Ramadan - and to be honest, if I hadn't had anything to eat or drink for fourteen hours in forty degree heat, I'd probably be quite keen to take it easy too! Perhaps the rest of the year things are better. Ridiculous idea if you ask me.

Dinner for bloody THIRTY

On Tuesday the Italian couple who are also here on an exchange cooked dinner for the fifteen people who had already arrived. We decided it might be nice to make a kind of routine of it - whenever there's an evening where we have nothing else scheduled, one nationality gets together and cooks dinner for everyone. We have 8 countries represented, which should take us through to the end of the month. So, Chris and I volunteered to go next, showcasing the delights of British cuisine. Unfortunately then fifteen more people arrived and he had to work a night shift, leaving me with quite a task. Luckily it worked out very well. The central market is completely brilliant - a huge warren of meat, fish, vegetables, nuts and spices. Sorted me right out. Then I recruited some minions and we cooked a feast, the likes of which have never been seen before. Literally. Potatoes with honey anyone? Peanut and coriander swordfish? Dates with blueberry yoghurt? Bit weird, but seemed to go down very well. I'm a little concerned that people will be heading back out to the four corners of the globe to tell all and sundry that that's what we eat in England, but hey...

The weekend

Yeah! Weekends! Woo hoooo! It's been great. Tiring, but great. We've just got back from Hammamet, which is a beach resort about 50 miles from Tunis. Really very nice indeed. We lay on the sand, played frisbee (actual proper ultimate frisbee!), read books, chatted, and generally had a merry old time. It got a whole lot merrier when we found the supermarket that sold the BOOZE which we've been without for the last week. We bought pretty much all of it, afraid that it was the only opportunity we might ever have. Then we sat on the beach and drank a whole load of it. Night swimming ensued, revealing that phosphorescent algae stuff in the water! Glowing trails following your hands. Lush. Sunrise followed, as did an enormous buffet breakfast before bed. Sadly forty minutes later I was rudely awakened, rushed out of the hotel, bundled onto a bus, driven down the coast and before you could say, "Shit the bed I feel absolutely TERRIBLE" I was on a BASTARD PIRATE SHIP. Bonkers. You'll be pleased to hear it wasn't one of the scary ones full of machine-gunned mentalists who actually rob people, but it wasn't a whole lot better, I can tell you. The sun was beating down, the boat was heaving to and fro, weird Euro house was playing and men with swords were forcing us all to bloody DANCE. Literally forcing us; as in they threw you into the sea if you refused. Wow. After a while they stopped and then we could jump off really high bits of the boat into the sea, which is always great. After that it was fine.
Now we're all home, eating dates and chilling out before another hefty dose of hospital tomorrow morning.
Good times!

Sidi bou said, Salivary glands and Several hungry foreigners

Yay! It's a competition! Jamie and Charlie are applying themselves to South Africa and have written some words about it or something. Have a look and tell them mine is better if you have a chance.

Here, things continue to happen with frightening speed and regularity. These are just some of them:

Sidi Bou Said


Or something like that. It's really beautiful, on a cliff, looking out over the sea (as if often the case for cliff-based prominences). All the buildings have a blue-and-white colour scheme, although it was difficult to appreciate this since we went there at night. We often go to places at night since everything is closed the rest of the time on account of Ramadan. In the day-time everything moves very slowly and nothing is open, including most of the hospital. Then, at sunset, Tunis turns into a ghost town - literally no-one is around, even right in the centre - not a soul. Everyone's at home stuffing their face, making up for the fact that they've been feeling the plight of the poor during the day. Then, about 10 pm, all hell breaks loose, and continues to do so until 3 am, when everyone races home in time for food, drink and dirty thoughts curfew at 3.30 am. There are crazy traffic jams everywhere at quarter past 3 in the morning.
Anyway, yeah, so we went to this place at night on Wednesday, and hung out in a restaurant on top of the cliffs. It was pretty weird by English-night-out standards - I spent 5 hours there, in the middle of the night, and all I had was a cup of tea and a sandwich. Bizarre, but seemed completely normal at the time. Chatted a lot to my new friends about all and sundry and had a lovely time. The speed of Arabic functionality takes a bit of getting used to - all of us northern European types were really impatient at the start of the week, but now we're getting used to sitting down, waiting for 45 minutes for a menu, waiting another 45 minutes for a waiter, ordering, and then waiting another hour and a half for a completely arbitrary selection of food to appear from the kitchen. It's OK once you get into it.

Thursday


Thursday was a bit shit by all accounts, as is so often the case. I have to go and get on a bus now so I'll have to tell you about it later.

Friday


Was absolutely great. The bus is waiting though..

Godel's incompleteness theorem

There was a lot of optimism at the start of the 20th century regarding the power of axiomatic systems (in particular mathematics) to explain the universe. An axiomatic system is one which does not rely on observation, induction, or anything silly like that - it starts with a small number of axioms which are assumed a priori to be true, and some rules of deduction. Then you can use the axioms and the rules in a flawlessly logical way to prove theorems of the system which are incontrovertibly true. For example, you can find the axioms of number theory here. If you were so inclined, you could use these to prove, for example, that there are infinitely many prime numbers. There is no way of arguing with this proof - it is incontrovertibly true, since all you have done is use logic to work on the axioms. People's optimism stemmed from the fact that they thought the incontrovertible axioms that founded these systems were not just plucked out of thin air, but actually corresponded to something incontrovertibly true about the universe; thus if you selected your system and your axioms properly, you could start to prove things not just about mathematics but also about astronomy, physics, chemistry, etc., in a rigorously logical and incontrovertible way. In other words, you could use pure logic to discover the truths of the universe. (People like Reimann came along and showed that the initial step of choosing axioms that correspond to incontrovertible properties of the real universe is not as easy as it sounds - but that's another story.)
People like Bertrand Russell reckoned that, assuming you'd set up your system properly (i.e. chosen sensible axioms and rules of deduction), you must be able come up with some sort of automated process that would simply apply the rules to the axioms and come out with true theorems. You can see that this is a realistic belief, certainly for the "first level" of theorems - those that you obtain simply by applying one of the rules of deduction to one of the axioms. Then you can just continue using your rules and axioms to work on these "first level" theorems to generate second and subsequent levels of theorems, all of which are guaranteed to be true. Thus - surely - we can reliably generate ALL of the true theorems of an axiomatic system. Perhaps there might be a problem with your automated process where it can get stuck in an infinite loop or something so it might be quite difficult to do this in practice (and of course it might take a very long time) but at the very least all of the true theorems must be "out there" somewhere, waiting for us to discover them.
Well, along came Godel, who wanted to challenge the concept of such "complete and consistent" systems ("complete" because the system contains all the true theorems - i.e. all of the true theorems are "out there" somewhere; and "consistent" because it doesn't have any theorems that are wrong or disagree with each other). He did the following in a very clever and rigorous way, but essentially what he said was this. Consider the theorem which says, "This theorem is not part of your complete and consistent system". There are two possibilities. First, that theorem is true. In that case, what it says is true: "This theorem is not part of your complete and consistent system". Thus we have identified a true theorem which is not part of the system, and so the system is not complete. On the other hand, suppose the theorem is false. Then what it says is false. In other words, in fact it IS part of our supposedly complete and consistent system. In that case we have identified a false theorem which is part of our system, and so the system is not consistent. You can apply this procedure to any axiomatic system with rules of inference. Godel thus proved, in a rigorously logical way, that it is not possible to formulate any axiomatic system which is both complete and consistent. We are never going to discover all the truths about anything at all by using logic alone.
Everyone was extremely disappointed.

Sarcoidosis? Mikulicz syndrome? Benign lymphoepithelial lesion?

Saw a 54 year-old woman today who presented 2 days ago with fatigue, weight loss and exertional dyspnoea. Then a massive lump appeared around her right eye. The doctor explained some things about her but, it all being in French, I didn't catch a lot of it. I think she has sarcoidosis. The swelling around her eye is due to blockage of her lacrimal duct, but it wasn't really clear to me whether this was part of the sarcoidosis. I think they wanted to do a biopsy to see if there was some granulomatous business going on around her eye, which I guess would be supportive of some secondary effect of sarcoidosis. She didn't seem that keen on the idea.
Then people were talking a lot about something called Mikulicz syndrome, which I'd never heard of. As far as I can tell I think this is an (outdated) descriptive term for any swelling affecting the parotid or lacrimal ducts - originally described as a symptom of lymphoma. But then there's some mention of it being a synonym for Sjogren's syndrome... which would usually be bilateral, and involve other stuff like dry mouth and eyes.
Confusing. Tomorrow I will try to find out more..

Shower view

This is the view from the bathroom window, over the city of Tunis:

First day's work

Finally met my host this morning - Asma. She took me to the hospital, where nobody had any idea who I was, and then on to the correct hospital. Found the department of internal medicine where I'll be based, and met the medical team. It's quite a contrast to the London hospitals I'm used to! The whole department is a single floor of a small ramshackle building in the corner of the hospital site, with a broken lift and rubble around the entrance. Off the central corridor are 4 wards, with 6 beds in each; although continuing the "nobody to be found anywhere" theme of Ramadan, very few of these are actually occupied. There's no alcohol gel (or in fact any hand-washing facilities at all), people don't wear gloves, and all the notes are kept in big brown envelopes. There's not really any equipment to be seen other than an ECG machine that look like it might be powered by coal.
There was an awful lot of waiting around, but eventually a ward round happened. Everything is in French or Arabic, one being only marginally easier for me to understand than the other. There was a huge group of people, made up of students of all kinds - medicine, pharmacy, genetics, biochemistry, theology, archaeology. The doctor was pretty good to me, explaining what the management plan was for each patient and asking me questions - although keeping up with the French was tough. We saw all the patients, most of whom are diabetic and are suffering from complications surrounding that. The last patient was more interesting but I'll save the medical details for a separate post.
Everything was over by about 11 am, and people just sort of wandered off, and so I did too. Next week there might be more action apparently, as the head of department is back from holiday. We'll see. For the moment, I'm off to learn about sarcoidosis and Sjögren's syndrome in preparation for rounds tomorrow morning.

Tuesday

Still no sign of my host, so no work today I guess. Spent the morning sleeping (much needed) and then headed into town with one of my new friends, Thomas from the Czech Republic. Saw some really good stuff, including the giant central market (incl. goat heads, giant squid). Then home for another nap (I could get used to this), and then out for a run. Got lost in a desolate urban wilderness of thorns and burning rubble but luckily there was an enormous pack of wild dogs to chase me back out in the right direction. Home for a shower, then a giant meal prepared by the Italian contingent. Pasta and ice cream (of course); delicious. Volunteered to show-case the delights of English cuisine on Thursday night (ha! they've a treat in store). Invented a series of elaborate games to help us remember each others names, then retired to bed.
There's no alcohol anywhere to be had, which is quite refreshing (not least in the mornings). Relying on our un-lubricated social skills in new situations happens so rarely these days! 

The journey out

Friday/Saturday

It all began with Triptych on Friday night, which was wonderful. Good work everyone involved with that. The de-rig at 7 am on Saturday morning was less wonderful, but things soon picked up at the afterparty up at the old Braindrop house in Turnpike lane. Good times. A ridiculous journey back to Bethnal Green was improved somewhat by an enforced stop-over in Iceland where Steph and I bought loads and loads of treats. South Park on the mattress in half-moved-out-of flat closed the day.

Sunday


SHIT THE BED WE HAVE TO MOVE ON TO A BOAT. Up at dawn crack; stuff into boxes; stuff into bags; clean floors; clean walls; clean ceilings; rent van; drive to Clapton; move boat; break boat; fix boat; drive to Bethnal Green; tube to London bridge; collect bikes; cycle to Clapton; find crucial belongings; pack rucsac; teach Steph how to operate boat; beak boat again; fix boat again; drink wine; sleep. Good lord.

Monday


Up at 7 to let Steph out of the marina, then back to boat-bed for a couple more hours kip, although too excited to sleep properly. Finished off a couple of things on the boat (sound system, solar charger, check batteries), then headed off to Liverpool Street for key handover to Steph. Thence to Victoria to get the train to Gatwick, with 3 hours until my flight. Plenty of time, right? Wrong. ABSOLUTE, COMPLETE AND TOTAL CHAOS. The whole of East Croydon is underwater - nothing can penetrate London's new aqueous border. "GO TO SURREY - IT'S YOUR ONLY HOPE". Righty-ho. Slowly - oh so slowly - we crawl our way through South-West London, until finally we make it as far as Reigate. JESUS CHRIST WE'VE LOST OUR CONDUCTOR. Nowhere to be found. Impossible to continue. Must wait for conductor-dispenser van to arrive. Terrifyingly little time remaining until flight leaves from airport far from Reigate. SAVED by insane but wonderful taxi driver with heart of gold, flying through country lanes to Gatwick. Onto aeroplane; tiny glass of orange juice; soggy sandwich. Phew.

Still Monday


We landed in Tunis around 7 pm. Bearing in mind that this is the capital city of one of the most developed countries in the whole of Africa it came as a surprise that absolutely no-one was to be seen, at all. No baggage handlers, no information point people, no HOST TO COLLECT ME AS PROMISED, no metro, no buses, not even any taxi drivers. Turns out this was to become somewhat of a theme around this time of day, on account of Ramadan. Eventually I happened upon a famished taxi driver just on his way back to his family to break his fast, and cajoled him into giving me a ride. Got him absolutely and totally lost, the poor guy  - but we eventually made it to my hostel. He staggered off home. Gave him a generous tip. Hope he made it. The "nobody around at all" thing continued, but I eventually happened upon an empty room which I'm now calling my own and laid down my things.
Suddenly ALL CHANGE. Hordes of medical students from the four corners of the globe returned from the beach. Introductions; too many new names; too many languages; cup of tea; supermarket for supplies; off to town; restaurant for dinner; swapping stories; good times; lovely people; home; bed; sleep. 

Places in Tunis

Here is a map showing where I'm living and working in Tunis:

I live in El Manar 1 and work in La Rabta. They're just about walking distance apart (takes about an hour), but it's pretty tough in daytime temperatures and in work clothes! A taxi is only 2 Dinar (less than a pound) so that's a better option as a rule..

The programme of social events

This is what our hosts have in store for us:

03/08/2011: Visit of Sidi Bou Said (at night)
04/08/2011: Visit of the medina (afternoon)
06/08/2011==>07/08/2011: Weekend Hamamet (50dt)
09/08/2011: Ramadanesque party
11/08/2011: International food and drinking party
13/08/2011==>14/08/2011: Weekend Monastir (80dt)
16/08/2011: Trip to bizerte (afternoon)
18/08/2011: Trip to Carthage (afternoon)
19/08/2011==>21/08/2011: Sahara trip (195dt)
23/08/2011: karaoké(at night)
24/08/2011: visit of bardo museum (afternoon) / Football match (at night) (5dt)
27/08/2011==>28/08/2011: weekend tabarka(60dt)