Wednesday 31 August 2011

They're just words.

I keep trying to write. I have boxes full of scribbled half thoughts on the back of bus tickets. Pages and pages of getting It out. Pulling it out of my head, cajoling it out, and trapping it down on paper so I can look at it this way, and that. My mind works on paper, captured thoughts revisited. I'm steeped in other people's words - book on book of ideas and stories - trying to see through all this paper to the few grains of truth that connect it all together.

There is so much that I want to share, but I can't cut through all of these words to communicate.

I am frustrated. I'm having problems articulating (and swallowing). Brain fog regularly robs me of words, but this is different. My voice is drunk and slurring, stumbling and uncertain, especially when I'm tired. I have been particularly conscious of it back at placement - communication is so much a part of what I do.

It's another aspect of control that has fallen away. Fainting, throwing up, giving way. Jerking, shaking, grunting. My body insists on making its presence known, its difference apparent. Now you will lie down, no you can't eat that, I want to jump and bounce and twist. One long lesson in going with the flow.

I feel vulnerable when I can't hide behind words. I am afraid to speak in case the sounds that come out aren't right, aren't acceptable. My control and my mask are being shredded. God, it's scary. I can't 'pass' anymore as non-disabled. Not invisible anymore, for all the good and bad of that.

I'm doing some studying, some reading. I'm listening more. I can't help but wonder if it's not some cosmic lesson telling me to shut up because I talk too much.

I play with communication on placement. Written information, diagrams, trying to get the most infomation from the least questions. Using silence and touch, when appropriate. Studying how my presence interupts or enhances the doctor-patient conversation, how formality and professionalism blend with the personality of both parties. What do I hold back behind my professional distance, and does that limit how patient-centred my approach can be? How do I vocalise the 'elephants in the room' when someone insists they've come because they "can't sleep", but they seem to be saying that the sleeping tablets help their anxiety? Which words build barriers, and which break them? Is it ever appropriate to say "me too", or would showing true compassion render that unecessary?

This feels like just another experiment in communication, not having the words to make them see past the stick or the random movements, or the chair. Letting people see me, react to me, and not feel the need to explain. Working out when it is really important for me to open my mouth, and when it's just noise.

Tuesday 30 August 2011

First day back =)

A quick post, but a happy one!

I hadn't realised just how terrified I'd been about starting this placement until I got home today and noticed that the sick feeling I've been carrying around for weeks had gone. So far the placement seems well-organised, the building is new and pretty easy to navigate (although the doors are on the heavy side) and there's a room I can leave my wheelchair overnight which also has air-conditioning, which will be a godsend (I get really overheated on the wards, and it makes me sound and feel like I'm drunk). Simple things make such a difference.

[I have a big brute of an NHS bog standard manual which I can self-propel on polished, flat, indoor surfaces for short periods of time (think browsing in a shop, or moving between beds on a ward round). I can take it in and leave it in the hospital (I can't manage it outside on my own and I can't afford to get a taxi every day until I get my DSA) so that I will have the option for parts of the day that normally involve a lot of standing around, such as ward rounds and bedside teaching. When my lightweight chair arrives I will hopefully be able to use it for the whole working day and I'll be able to manage short distances outside on the flat as well.]

I'm a bit nervous about how people will react, but I'm in a small unit with only a few other students, so I'll be a bit sheltered until I get used to it. It's totally worth it if it makes placement easier to manage.

Monday 29 August 2011

Culture Shock

When I call myself disabled, I am talking about my identity and my experience, I am allying myself with other disabled people whatever their impairment, and I am claiming my place in a community built on shared history and common language. It is personal, it is political, it is cultural.

It also has its uses. It's a shortcut to explain to people that I need that seat on the bus, that they have a legal obligation to make this lecture accessible to me, that I'm taking the lift and not the stairs.

I claim this word with pride, and some find that hard to understand. People have done their best to tarnish it, to use it as a synonym for scrounger, object of pity, incapable - to make it my fault, or my tragedy.

For so long I couldn't say it out loud, in case someone said what I was telling myself in the wee hours of the morning : "You're not sick enough to be disabled. You're just lazy. Get your shit together."

After yet another doctor refused to listen, refused to acknowledge, refused to act, I took my first shaky steps. Found myself a walking stick that was pink and shiny. I came out.

A friend showed me how to wheel, joyfully. Another how to stand up for my needs. My love tells me every day that I'm beautiful - that my bendy, breaky, bruisy body is beautiful - her words have soaked in to each cell and for the first time in my life I am not at war with myself.

My beautiful, complex body is not flawed. It is not an intrinsic failure. It is not appreciated, not accepted, not expected, and this is my disablement.

The finality of 'disabled' scared me before I realised that a word doesn't change who I am - just gives me a fresh perspective on my experience. That a label doesn't become my whole identity - just gives me a name to part of myself that's been their all along. I don't have to be 'bad enough' to use this word, I don't have to fit the stereotypical image it conjures - just acknowledge that I have something in common with this community, that I am part of it.

These are all the things I mean when I say that I am disabled, but it's not what people hear. It's not what people see when they watch me wobble along with my stick.

I don't know how to translate my thoughts, how to share the powerful and prophetic words I read about justice and equality. I don't know how to show my friends the strength I have found through working together with other people 'like me'. I want to communicate more coherently that we cannot separate our own favoured branches of inclusivity or accessibility : "If you have come here to help me, you are wasting your time. But if you have come because your struggle is bound up with mine, then let us work together"*.

And yet my words seem to get stuck in a filter somehow, to become jumbled and stripped of nuance. Culture shock.

Sometimes I think that we can change the world with these conversations - these whispers of a world that could be if we learn that love is far more radical than tolerance, that acceptance for nothing more or less than what we are is life-changing, that capitalist ideas of reciprocity are too shallow. If we could only find the words.

*Aboriginal activist group, Queensland, 1970s

Sunday 28 August 2011

T'will all be alright

With term starting tomorrow, I am starting to panic a little bit about how I'm going to cope. My mobility is worse, and worsening, since my last placement and both of the hospitals I'm placed at this year year are huge. My fatigue is slightly more under control these days (hooray!) but I'm really worried about uni setting it back, especially because finals are at the worst possible time of year for me, fatigue wise.

So here is a a post to myself - a post about how to take care of myself, of ways to make myself feel better.

1) Take care of the lovely mrs. Have plenty of not medic-medic or carer-caree time. Tell her often that everything will be fine. Play with daft cat often.
2) Sleep. Stop work at a sensible time, journal before bedtime, be fastidious about night-time pain management, have catch-up naps naps at the weekend.
3) Drink cherry and cinnamon tea, cointreau hot chocolate and mulled cider. Plenty of water, and salt.
4) Be sensible with my energy. Pace as much as possible without becoming a hermit. Don't feel guilty about the cleaner. Be assertive about my access needs on placement. Take it slow and steady.
5) Read something non-medical - funny, easy, familiar. Listen to an audio book snuggled under a blanket. Sing along to Sgt Pepper. Watch BBCThree nonsense and silly films.
6) Phone lovely people. Go for walks (/wheels) and talks with the mrs. Have people to stay, go to visit notsofaraway best friend. Give plenty of hugs.
7) Don't get cold! Wheat bag, big fluffy dressing gown, electric blanket, woolie socks, hot water bottle, nights in front of the fire.
8) Remember all the reasons I love medicine. Revise in ways that keep it interesting. Don't go near the library in the medical school, and avoid talking about revision with anyone else. It is not worth the inevitable panic.
9) Eat proper food what is warm and has veggies in. Plenty of mashed potato and daal and plum crumble. And porridge for breakfast.
10) If things get bad - rest, cut back, get help. Don't let it build up. Talk. Keep the med school in the loop.

The bottom line is that my health is important. I would rather be well and fail than to burn out passing, so I need to act like it, and not let guilt, or panic or the fact that other people still think they're invincible convince me not to. It could all go really quite pear-shaped otherwise, when it very much needs to all be alright in the end.

Friday 26 August 2011

News Stories : Doctors with Visual Impairments

Over the last few years there have been several stories in the national press about disabled doctors or medical students. Most seem to focus on those refused entry to medical school or jobs because of their impairment, although there are a few "Dr Suchandsuch is a surgeon even thought he's in a wheelchair!!!?!". A lot of these stories make for sobering reading, and show the variety of attitudes that are held about disabled doctors, by both patients and colleagues.

The first story I would like to draw your attention to is that of Dr Jemma Saville, who acquired a visual impairment during her time at Southampton medical school. She has shared her story in her own words here on the BMA disability pages, please go and take a look. Dr Saville was unable to find a job after graduating, despite having provisional GMC registration.

"Disabled doctors have so much to give; granted that with a disability you can’t fit into all areas of medicine. I know I can’t be a surgeon, and I don’t want to be. But the system should recognise people’s strengths, and play to them, not just quash anyone who can’t do every single thing. Every person and every doctor has strengths and weaknesses, and disability is just an extension of this. In closing the doors to people with disabilities, the doors will be closed to all sorts of amazing talent..."

She wants to train as a psychiatrist, a field that she believes would play to her strengths, but this has not been possible for, I imagine, two reasons :
1) Concerns over patient safety / her ability to do the job
2) The design of the training programme after medical school

The first point I will not go in to - I believe that if a medical graduate, their medical school and the GMC all consider them capable of proceeding, then it is not anyone's place to argue otherwise.

However, it makes clear what I have found to be true in my trawling of the internet - there is a lot of prejudice and ignorance surrounding the idea of doctors with visual impairments. It provokes some of the most extreme views. For some reason folk seem less able to understand that there is a spectrum of visual impairment - they seem to understand that concept much better in relation to something like mental health problems*.

The (very) general(ised) view seems to be that "if you can't see, of course you can't be a doctor" - which I would argue shows ignorance of both visual impairment and the nature of the medical profession. (Although add 4 little words " the current system", and you probably have a not-unrealistic idea of the current state of affairs - for example, see this news story as an idea of the kind of adaptations that are possible) The clincher of such arguments is "and they'll always need to have someone with them to look at stuff so it's inefficient" - but in an age of holistic, multidisciplinary, patient-centred care, no one clinician would be expected to do everything anyway. Very little of my training has been to do with sight - far more to do with communication, with problem solving, with knowing how to react when the [bad word] hits the fan.

The concept of "limited registration" whereby Dr Saville could, for example, be licensed to work as a psychiatrist, but not a surgeon, doesn't exist in the UK (at least, it happens in practice, but it is not part of the regulations governing the licensing of doctors). It happens in parts of the States, I think. There are advantages and disadvantages - namely reassuring everyone that noone's trying to do anything they can't, and not wanting to ghetto-ise a group of doctors or make their license somewhat second class.

My second point was linked to the design of post-graduate training in medicine. You've already explored with me the challenges of trying to fit my non-standard self into a one-size-fits-all training system. Having a national application system is good in some ways - it streamlines the application process by avoiding filling out numerous applications and it is standardised which (is supposed to) reduces bias. My major problem with the system (other than such a heavy weighting being placed on a set of ridiculous questions) is this :

In order for the system to work a set number of 2 year posts have to be created out of the need for various numbers of doctors to staff various wards in various specialities. Once these posts have been created, it makes the system hugely difficult to navigate as a "non-standard" applicant.

For example, in order for Dr Saville to complete her 2 foundation years all in psychiatry (besides drawing up obvious questions about what the minimum general skill set is that you need to acheive before passing on to specialist training, and whether you could get enough exposure to other specialities - no system of the body existing in a vacuum) it would involve chopping and changing up to 6 other roles, which have at that point already been advertised and applied for as is (because under the current system Dr Saville would not have been able to disclose her needs until after the point at which she had been offered a "standard" role). The same will be true, for example, when I apply to complete my foundation years on a less than fulltime basis - other roles will have to be created or adapted to "fill in the gaps" for me.

From all of the peope I have talked to, and the stories I have read where I can find them, it seems that folk have a much easier time - in terms of work - when they acquire an impairment later on in their training or career. It is not unusual, for example, for those organising specialist training to deal with less-than-fulltime arrangements, as by that point a lot of doctors are having children. Colleagues are much more likely to make an effort with adaptations for someone who is already a known and respected part of the team. Of course this is not always the case, but it seems to be the general pattern.

There are many stories like this, many thousands who have been rejected by our profession at whatever stage. I don't know how to make change - I don't know how to make medicine an accessible career, or how to make the NHS an employer that delights in the diversity of its workforce. I'm just reminded of the words of Kaliya Franklin and The Broken of Britain :

"Alone we whisper, together we shout"

On which topic, I had some interesting chat with my disability advisor today about how we could start a conversation between medical students who are disabled or living with chronic illness at my uni. I think it has potential to be quite exciting. =)

Would you like to write a blog post about your experiences as a medic who is disabled, living with a chronic illness or a carer? Leave a comment or email disabledmedic[funnyatthing]

*That is not to say, unfortunately, that there is not prejudice surrounding mental health problems in the medical profession. Indeed, I have experienced more stigma among medics than in any other sphere, except perhaps the church.

Tuesday 23 August 2011

Dr Internet

Another issue I've seen both sides of over the last year or so is that of patients diagnosing themselves over the internet.

Doctors attitudes towards a patient who's been consulting Dr Internet seem often to be put down to "a little knowledge is a dangerous thing", but - as with anything - as someone who straddles the divide it feels infinitely more complicated.

As a patient, I don't think I would have a diagnosis now if it wasn't for Dr Internet. My condition is genetic, and as such I've always had it, and with the retrospectoscope I can see its stamp on my life from birth. However, it was joint pain that made me start looking for a diagnosis, but more than 2 years after first mentioning this to my GP nothing had happened. It wasn't until an internet friend mentioned her sister's diagnosis that I'd even heard of my condition, but within 5 minutes of googling I was convinced that it was the explanation for my joint pain and a lot else besides.

My GP was not convinced by my research, and it took a further 8 months for a rheumatologist to confirm my suspicions. She diagnosed me, told me there was nothing she could do for me, and discharged me. If it wasn't for the online support group I had found, I wouldn't have known that my condition was genetic or associated with other symptoms than the joint pain. Or really anything else about it. And yet, every time I try to share what I know with any of my doctors, they get really weird. Like I'm trying to undermine them.

I am honest with my GP. If I know something about my condition that he doesn't then I'll say so. Not in an "haha, I'm smarter than you" way, in a "if I don't tell you this it'll be a waste of time for both of us" way. I have consistently tried to get him to read one, simple BMJ article about the management and associated problems of my condition, but to no avail. So I continue to be the one out of the two of us who knows anything about it, and he continues to ignore that fact. My GP is far from being the only doctor who treats me that way.

It's the whole "well if you have all the answers why did you bother to come and see me?" / "I didn't spend years of my life training only to be replaced by a machine" / "if we both have the information what is my role?" thing. And I understand, really, despite my frustration.

We are not trained to deal with this situation. My medical school is fairly progressive, and it has never been mentioned. We are encouraged to respect a patient's experience of their own condition (although in my opinion this isn't talked about enough) but I have only rarely been encouraged to respect a patient's knowledge about their condition. Sometimes when we discuss sharing information with patients, we are taught to first draw out from them what information they already have, but in my experience medics are not good at this part unless we're breaking bad news.

When I am informed it disrupts the role that he has been taught to play as doctor, and it disrupts the role I have been taught to play as patient. There is always going to be an element of this for any medic who is consulting another doctor for treatment, but it is also true for a lot of individuals with longterm health problems - especially those with a rare condition who are used to dealing with doctors for whom they are a "once in career".

But, role disruption is not the only answer, and doctors are not unreasonable for being wary of Dr Internet. I am not naive. I too have seen the patients who come in with a sheaf of printouts about plague or whatever.

The lack of proper media education most of us received at school or thereafter is a really big deal. We are inclined to believe whatever we read, unless we have the resources to read critically. There is a lot of medical information on the internet, and a lot of it is nonsense. But Mr Jones might not know that. Mr Jones is not medical, he has no system for sifting the quite interesting from the potentially dangerous.

For this reason I believe that it is of supreme importance to realise that a lot of patients will have googled their symptoms, and will google the latin name you attach to their symptoms. A very good doctor I worked with suggested to patients "the law of one click" - don't go further than one link away from a reputable website.

Know how to direct your patients to good-quality information on the internet. In my experience, certainly for more rare conditions, this is best provided via condition or symptom specific support organisations, as more generic websites (such as the NHS health A to Z) can be based on outdated or over-simplistic information. However I think the NHS website has some great resources and you should encourage your patients to interact with it =)


Phew! That was a long one... I thought that tomorrow I might start looking at some news stories about disabled medics - they raise some interesting issues.

Joining the dots

I hate phonecalls. I hate them.

Phoning my mother I can manage (although apparently not often enough), but phoning someone I don't know is like torture. It is one of the more debilitating remnants of my mental health issues.

Oddly enough, making calls on placement isn't an issue if it's work-related (e.g. "hey, I'm a medical student on ward 6 returning a page for Dr Wotsit because he's in surgery right now" = fine), but if it's in relation to myself it's different (e.g. "hey, I'm a medical student starting a placement with Dr Wotsit on Monday and I'm wondering where I should meet him" = horrible).

One of the worst things for me since my mobility and self-care have become more and more limited is that I feel like I'm constantly on the phone - making appointments, phoning ahead to future placements to explain my needs (because as I will no doubt mention again, the system my med school has in place of communicating my needs to placement supervisors is [bad word]), phoning to ask for information on particular services and how I can be referred to them etc.

There is another post to be written about acquired versus congenital (from birth) impairments, and this is not it. I fall someone in between anyhow, because although I have a genetic condition, I was not aware of its effects for a long time. To me, the single worse thing about acquiring an impairment, is that noone tells you what you should do next*.

When the consultant diagnosed me with my condition early this year she discharged me. She provided no information about what I was supposed to do now - nothing about social services, benefits, occupational therapy, university disability services - nothing. She discharged me back to my GP who didn't mention any of them either.

I was lucky, in some ways, because I was aware of these services, now. I had become aware of my eligibility for most of them when I figure out my diagnosis via the internet just over a year ago. Still, awareness of them isn't worth much when the mound of paperwork proffered by some agencies and the refusal to become involved without 'official' diagnosis by others, means that they aren't really an option.

I've been eligible for certain help since long before I started uni because of mental health problems, but I wasn't aware of it. Again, GPs, psychiatrists, therapists, teachers and the medical school all failed to make me aware of the services that were available to me as a disabled person.

I guess they all assumed someone else would mention it. I also believe that a lot of those people didn't consider me disabled until I began to develop physical problems.

I think an overwhelming factor connecting all of these individual failures to signpost (if you will) was ignorance. I don't think that most medical professionals are truly aware of who is eligible for what help, where they can find that help and what hoops they have to jump through to get it. That is a massive problem.

Some days it feels like the system is deliberately opening up cracks for me to fall through. I spend hours sitting on the phone chasing down the next person who might have some answers - but those answers always hide behind more phonecalls, more paperwork and more assessments from people I've never met.

If it was just a little bit easier...

But there's no point even finishing that sentence. It's only going to get harder with cuts and changes and reshuffles.

Please don't think I've forgotten my blessings. I hold them in my head and incant them like a spell. I remember every day that so many others are bearing more of the brunt of this system than me, that others face systems far more rigid and uncaring.

I just can't shake the feeling that it's all about to come crashing down on my head. I think the word is overwhelmed. I spent this afternoon making phonecalls, and I will spend tomorrow doing the same. None of them seem to get me anywhere, but a girl can dream.

How have you dealt with the endless hoop jumping that seems to come with being disabled? Have any organisations helped you to deal with it all? Leave a comment or email disabledmedic[funny at thing]

*This may be less relevant for impariments such as spinal cord injuries which tend to involve some kind of systematic, inpatient rehab - although I imagine still implies to a greater or lesser extent

Thursday 18 August 2011

Hi =)

After an impromptu blogging holiday (probably bad for my blog stats, definitely good for my soul) I'm back. I'm 2.5 weeks into my 4 week holiday - I was thoroughly refreshed by a week long event run by the charity I'm a trustee of (lots of very interesting access chat, which I'll come back to) and now we're getting our teeth into a proper pre-finals clearout. It's immensely cathartic, and we've got rid of a lot. Seriously - about 100 books and several bags of assorted other stuff. De-cluttering is one of my favourite activities. I'm trying, day by day, to live more simply - it's healthy in so many ways.

Anyhow. Sensible stuff tomorrow, I promise - who's for a ten top tips for a proper clearout? You thought I was joking...

So, you have a few days off, the flat is a bit of a state, you've run out of space and a bit of a list of DIY chores has built up. It's time for a bit of a non-spring clean (unless you are reading this in the spring, in which case, nobody likes a show-off.

1) It's easier with a friend (and more pleasant). Ideally, if you're a spend-an-hour-arranging-a-drawer kinda person, your friend will be a get-the-room-looking-tidy (and-shove-the-mess-in-a-cupboard) kinda person. It's far easier for a friend to sort that box under the bed into 4 piles - destined for memory box, keep, throw/recycle, charity shop - and for you to just go through the piles they've made.

2) Be systematic. Before you start, give yourself 15 minutes to wander round the flat / house and make a brief list of what needs done (e.g. : bedroom - quick tidy up, clear out bookshelves, clear out boxes under the bed, switch bookshelf for chest of drawers...). Don't get too caught up in this, and be realistic about what time you have.

3) Be systematic part 2. Go through the list with the highlighter and highlight the big jobs and those you're least looking forward to. It's easy for every 'find a new mirror for the sitting room' to consume tidying time. Start with the biggest / least fun job - it'll feel good when you get it done.

4) Be systematic part 3. That being said, it's immensely satisfying to take one room at a time, because seeing the gleaming tidyness of the sitting room will help prod you through the bathroom cabinet. If taking this approach, tackle the biggest / most put off job in the room first, and then start in the corner furthest from the door and work back towards it.

5) Come back to things. If you're getting too bogged down in a big job (for me it's spending hours making the entire contents of a drawer sit at right angles to each other...) or you can't decide whether you're quite ready to get rid of a certain book, put it down and come back to it. It works for bastardly exam questions, and it works for a clearout, too.

6) Piles are your friend (not the bottom kind). Clearouts get messy pretty quickly. I would recommend starting a bin bag, a paper recycling box, a memory box, a charity shop box and an 'inbox' (things that need action taken on them) before you start. To save energy, tidy things into piles (e.g. needs to go back to the kitchen, supposed to be on bookshelf in the hall) or into these boxes rather than running back and forth with each item.

7) BUT don't leave the piles to grow into mountains by the end of the day. Every time you take a break (we'll get onto that) move the relevant piles wherever they need to go. If that room's already been tidied, put the stuff away. If it's not, put it somewhere you won't trip over when you get round to it. Ditto, don't accumulate thousands of boxes to take to the charity shop, every day or two, take some stuff round, or ask them to come and collect.

8) Be sensible. Tidying is hard work. Take regular breaks, fuel properly and be aware of how you're carrying out each task (are you standing to do something that could be done sitting, attempting to do something that's epic hard for you but easy for your flatmate or lifting from the back and not the knees?).

9) Switch types of job. Switch between physically heavy and less physical tasks (e.g. hoovering and sitting down to sort out stuff in the boxes under the bed, assembling flatpack, folding clothes). You don't have to finish each job before switching to the next - I often run two tasks in parallel, switching every few minutes.

10) Be nice to yourself =) Many things fall under this point, including what's above, but most importantly - don't beat yourself up if you don't get everything done that you wanted - any amount of clearout is great, and you can carry on little by little at weekends or evenings. In that spirit, reward yourself at the end of the day - a lie down with a wheat bag, a Cointreau-spiked hot chocolate or a nice bath (or all all three!).

Does anyone else enjoy clearing out, or am I strange in that regard?

Monday 1 August 2011

The "Joys" of Packing

I used to quite enjoy packing. I like making lists, I like ticking things off lists. I especially like ticking things off the list as I repack to come home, because noone else does, so it makes me feel smug.

I have always packed light. My mother left me to pack for myself for my first Brownie pack-holiday with only these words for advice "only pack things that you will use". Wise words indeed. For some reason, my obsessive adherence to this rule has led to a genuine anxiety about being the person on any given trip with the biggest bag. Psychoanalyse that...

Think through the day step-by-step - gather toiletries, a few Tshirts, one book for every 2 days, enough pairs of knickers for until you get home / get to use a washing machine. If camping, grab waterproofs and a sleeping bag, and that's you pretty much done. My second packing rule is "make sure you have the essentials - those necessary to get you where you're going (passport etc) and those necessary to keep you alive while you're there (meds) - anything else you can buy when you get there (subclause : and you can always wash your knickers in the sink if you run out)".

My third rule emerged during my DofE expedition when, for some bizarre reason, I ended up carrying the tent, the stove and, after a while, someone else's bag : "only pack what you can carry and pack smart so that the load is balanced".

My ability to pack was greatly enhanced by my time at boarding school. My house mistress taught me that "rolling is better than folding", and indeed, I am now excellent at stowing socks in impossibly small spaces.

These four pieces of wisdom stand me in good stead now. My carrying is not so good anymore. A modest sized hiking rucksack with a couple of books topped up with clothes is about my limit on a good day. On a bad day I have been known to try and exercise my Matilda-esque mind control techniques to move a heavy bag along a station platform.

The problem that I had while travelling back from my elective yesterday was that I left significantly more disabled than I arrived. On the way I could manage to carry the cat in her box for short periods, along with my rucksack, on the way back I really shouldn't have carried anything. I'm paying for it today.

So, here I am, repacking. It's a slightly different process these days. I feel less secure in my ability to pack only what I need. I'm anxious about my ability to carry anything, and anxious about leaving something behind that I need for comfort. It's less about squashing stuff in, and more about streamlining. On the way to my elective 1/3 of my rucksack was full of meds. I need to take cushions, splints, the stick of wonder, wheat bag and hot water bottle (they both help with different kinds of hurting) blah blah etc blah.

Tomorrow I will employ the technique perfected yesterday - cat in a box on a wheelchair that this wobbly bod will use as a walking frame. And we're only taking one bag between us so my rib will take less of a pounding.

Now, if you'll excuse me, three skirts are flirting with my attention and only one will make the cut... decisions!