Typography?

Greetings from Ambridge-sub-Aqua. Once again the Am has broken it’s banks and is lapping at the back door of the surgery whilst the Koi Carp are disporting with the Mallards on the car park, the bigger ones with a decidedly hungry look about them, making me worry if there are such things as “man eating cyprinidae”.

On a side note apparently Koi is Japanese for carp, so in back translation that makes them “Carp-Carp” which sounds a bit like a stammer. Apparently Koi is also a homophone for the Japanese word for love, which must make for some interesting conversations in Japanese fish mongers and the like.

But, as usual, if you can have a “usual” in a journal as infrequently updated as this, I digress, even within my digression.

Sorry.

I’ll try to get back on track.

Despite the recent downturn in the weather, nothing is keeping the faithful of Ambridge -s-A from our door, and those that can breach the sandbagged parapet and make it “over the top” continue to delight and challenge in equal measure. A week or two back saw two consecutive consultations with diabetic patients about their med's. Both are proper old-school Type 1 diabetics, the sort that go from well to desperately ill and needing insulin in a matter of a few days.

Sophie, the first of the two, is a veteran, having been diabetic for almost as long as she can remember. She has her med's all figured out, is supremely confident to adjust dosing according to her sugar levels, which she monitors by finger prick four or five times a day. By all accounts, and looking at the lab bloods for confirmation, her sugars are near perfect and she is completely well. She has even had her flu jab and made the point that, as with insulin, if you relax the muscle injected, it doesn’t hurt at all—a tip worth passing on the 750 or so punters that will be in this Thursday for the fourth round of our flu campaign this year. I’m thinking of getting some “Sophie Says Relax” T shirts made.

Nick came next. He’s rather less self assured than Sophie. He hates testing and injecting, but then he’s only been at it for a couple of months, having been rushed in to hospital acutely unwell at the onset. He knows what he’s taking and the dose is still changing. Understandably his sugars are all over the shop when he tests them and he’s finding it all a bit demoralizing. He needs his flu jab, so we sort it there and then, but he winces despite my admonition that he must relax. (Easy to say when you’re the one holding the needle eh?)

We are being encouraged to put new patients in touch with more experienced “expert” patients to improve their knowledge of their condition, its impact and treatment in the hope that this will yield better outcomes. Diabetes is at the forefront of this approach and Nick could certainly do with some of Sophie’s wisdom.

The only problem is, that despite being diabetic for almost half a lifetime, Sophie is only six years old, and Nick is in his early twenties. 

(Oh, and yes, Sophie did come in with her Dad, but she did all the talking and was plainly in total control of her condition and its treatment.)

Florence lives!

As you will know it is my lot to have dealings with the Ambridge and District General Hospital and its mother institution the Borchester Royal infirmary on a regular basis as part of my day job. In this repeated exposure it has been all too easy to become accustomed to their working practices and assume that these are "industry standard" throughout our fractured and beleaguered "National Health Service".

In short I've become used to an attitude of expedient management-- a "sort and shift" mentality if you will, that does as much (well, little) as is needed to "stabilize" a patient in the "Assessment Unit" or if absolutely unavoidable, the ward, then boot them home to be sorted out from home either through Out Patients, or, increasingly often, by the practice team, doing what would normally have been done by the admitting medical, surgical or other specialist team as appropriate.

In part it's been our fault for accepting that this is the status quo, but it's also a mark of a prevailing attitude in our cash strapped area the patients are the enemy, to be kept out of hospital at all costs (or more accurately on the flawed assumption that being kept out "saves" the cost of a bed). Of course these savings never truly accrue since an empty bed is just a bed available for somebody else to occupy, which they pretty much inevitably do.

Over the past year we have had occasion, as a family, to have dealings with the Dreaming Spires University Hospitals Trust on a couple of occasions. Sadly the latest had the unhappiest of outcomes, but the prevailing attitude of the hospitals we have had to deal with, the care lavished on us and the expectation that a patient remains the centre of attention, the recipient of genuine care and attention and not an inconvenience, has been startling.

It has been all too easy to accept that the traditional virtues of caring have been ground out of the system by relentless “make-work” target setting and an obsession with counting things, but looking, as I have had to, further afield, whilst those targets still apply elsewhere, the bunker mentality does not and patients are still that, namely “sufferers” deserving of support through adversity, and not either commercial transactions to be shifted in bulk to maximize income, or threats by their mere presence to the meeting of targets for maximum trolley waits or other nonsensical metrics.

It is probably no coincidence that the DSUHT is well funded where the A&DGH and BRI are financial basket cases, so I can't help wishing that, with the same expedience with which I relocated the "surgery" to Ambridge all those years ago when this blog was a mere babe in arms, I could wave a wand and relocate again to the Dreaming Spires. But until I can the poor Ambridge & District can expect me to be on their case on a weekly basis to remind them of what they used to be about and should be again.

It saddens me greatly to have to say this, but I fervently hope that in the event that I or those closest to me have the misfortune to be ill and in need of hospital care, we can contrive to do so in the land of the Dreaming Spires and not here in apparently idyllic Borchester.

Animal Magic

So, not quite sure where July went if I’m honest. Seems real life might have been just a bit too frenetic. Also not quite sure what the month ahead has in store excepting a week on a costa, soaking up rays and studiously not worrying about Ambridge. Or GCSEs. (Not for me you understand, at least not directly so… suffice it to say I’ll be keeping a number of digits crossed for a couple more weeks.)

That said last week was a rare joy—if not a once in a lifetime event. You see last week we became a tiny part of what would turn into a little bit of history. It can’t have escaped notice that Dear Old Blighty has been having a Sports Day thingy going on. You can tell it’s hugely important because our Beloved Leader has been popping up all over the shop, feting this potentate and pandering to that panjandrum and begging Vlad not to break his fingers in the small spat we’re having over Syria.

Happily he stayed away when we went to Greenwich to see something truly magical. It had been months coming and planned with nigh on military precision. Last Thursday famille Jest decamped to the Ibis hotel in London’s Docklands—right next to the Excel centre where a great deal of grunting and straining has been taking place. We hotelled amongst pretty much all the officials there to oversee the various martial disciplines taking place in the exhibition centre turned Olympic venue. Friday morning saw us up early and breakfasting in their lofty company, but we were not off to see Kick Boxers, Judo-ists or what have you, it was just the nearest affordable room we could get to Greenwich, where the horses were strutting their stuff.

After breakfast we trekked by DLR (a sort of over-ground tube), Tube proper, and then by hoof to the park. En route the atmosphere was extraordinary. London, and especially Docklands, has a reputation that suggests outsiders might not always be entirely welcome, but that couldn’t have been farther from the truth. Everywhere was bonhomie in full flow. The most exuberant exponents were, without doubt, the Games Makers, strange people in pink bibs with at least one giant foam hand apiece, but everywhere you looked there were smiles and cheery waves and we were left with the impression that nothing would have been too much trouble.

Greenwich Park was extraordinary, from the vertiginous grandstands bedecked with the flags of seemingly every nation (and a few that were obviously made up), to the arena itself with its highly ornamented “sheds” for the judges, its little topiary embellishments and its manually operated, gnome height, white picket fences, to the high tech wizzo zipwire camera high above the action beaming its signal to the giant screen that was just a few tens of yards from our seats in the gods.

And there it was that we all sat for the better part of a day, watching horses dance. No really. It’s called dressage apparently, and it has since turned out that at least three of my compatriots are pretty good at it. We were watching heats, but even there it was evident that they knew a thing or two about it, as did all the riders we saw, after all they are the best few dozen exponents of the art on the planet. Each was required to follow a set routine of manoeuvres from trots to carousels to zigzags… even the salutes at beginning and end were marked. There was no questioning the evident skill of all the riders, or the levels of excellence in training of their mounts, but there were a few special performances that stood out. 

Every pair—rider and horse, ran through the routine in the right sequence. Barely a horse miss-stepped—so much so that the twice in the whole day they did there were suppressed gasps from the crowd, who otherwise sat in pin-drop audible silence throughout each ride, reserving the hooting and hollering until well after the end of each effort. And though sections of the crowd hooted louder for their own national team the whole crowd responded to every contestant.

Within all of this there were a handful of horses that stood out. For the others the routine was plainly well practised and well executed, but somehow still looked mechanistic. For the few special ones it was evident there was more to it. I mean it when I say that we watched horses dance. Dance, and float and pirouette with balletic precision.

In our overly cynical, over hyped, over commercialized world, it’s nice now and again to be reminded that there is genuine magic to be had out there, and for the past couple of weeks our little island has had more that its fair share. The spirit of the crowd on the trek home was if anything even more effortlessly cheery. If we could keep one tenth of that spirit alive when the last visiting contingent of supermen/women and indeed horses depart for their respective countries, that would be a legacy beyond price.

I feel privileged to have been allowed to be a small part of it in person, and I look forward to the day I have  grand-kids to tell all about the day I saw the horses dancing.

Communication is the problem to the answer... *

The Blobshire General Hospital

London Road

Blobcester

Blobshire

Dear Dr Jest,

Your patient, Miss Archer attended our unit today.

Presenting complaint;                            Personal

Assessment;

Diagnosis;                                             29E: Gynaecological Conditions – other

Treatment:                                            511: Medication – oral

Outcome;

So ran the letter that wung (or is that winged, wang… er…) its way to my electronic in-tray yesterday. It seems all those hours spent on communication skills at the Big Hospital are not practised in the far flung frozen wastes of Blobshire, or at least not in their General Hospital.

You have to give them some credit I suppose. They’ve managed to compile a discharge note and forward it to the right GP at least, but sadly it’s of approximately no use. At least not as a clinical communication anyhow. What this is, in effect, is a glorified invoice. 

You see Blobshire is some distance from our own dearly beloved Ambridge, and our paymasters are unlikely to hold a contract with them for services of any kind, "personal" or otherwise. So if Miss A felt the need for medical attention whilst there on a visit, her treatment will have to be paid for, after the fact, by our own PCT sending a wad of fivers to the Blobshire Acute Trust. To do this our PCT will require evidence of treatment being carried out, which is where we came in.

Disappointingly even the codes are no help. Our 29E is “Pain- Sensation- other” and makes no mention of any gynae’ problem, all the codes before and after it having to do with various types of limp. And on our system 511 doesn’t even exist, so I’m really none the wiser. Sadly as it appears Miss A was not assessed at all, and had no outcome recorded, I can only imagine what happened to her a few nights back on the mean streets of Blobcester.

Still all is not lost, I missed off my absolute favourite bit of the letter. Without, so far as I can glean, the font being so devoid of expression as to make irony improbable, any hint of the same, the communiqué concludes thus:

“If you require any further details, please contact us on the above number.”

* You all know what's on offer by now. EVCHN to the first correct attribution.

Striking a pose.

In twenty days and for the first time in my career, it looks as though I may be called upon to take some kind of industrial action. Aunty says I’m going to be on strike, but that’s not quite right. If I’m doing anything “disobedient” I’ll be doing my level best to make sure it won’t inconvenience the good burghers of Ambridge, and a great many of my colleagues up and down the country will be doing likewise.

Also according to Aunty, this action is all about my pension. And on a technicality there they have it a little closer to the truth, but if they bothered to actually ask any pertinent questions, and then bothered to listen to the answers, they might appreciate there’s a whopping great iceberg of seething malcontent of which the pensions issue is the tiny bit you can see. Still why let the facts cloud a good argument eh? 

The whole pensions argument is a thorny one to be sure, and for anyone out there in the private sector sitting anywhere below top executive “Golden Parachute” grade must wear very thin indeed. Still at the risk of sounding like a seven year old in the playground, what Dave and his cronies are trying to pull is “just not fair”. They say that pension provision is unsustainable, and yet our pension contributions, you know the pay we have stopped to cover our future liability, pay into the treasury roughly £2bn MORE that the pensions take out every year. That’s money abstracted from the scheme by HMG for other purposes. Or put another way TAX (if you’re feeling charitable) or theft if you’re not. Robert Maxwell did something similar a while back but because he was a baddy it was bad. When it’s that nice Dave, and his pal George, somehow it’s o.k. (And yes Tone and Gordon were up to it to, this isn’t a party political point).

Anyhow, that’s the status quo ante, but now Dave and George want a bit more, and at the same time they want to hang on to all our contributions a bit longer too, since we’d only squander them on fripperies if we were allowed to retire too soon. This on its own rankles a tad. And yet, on its own, I very much doubt it would have prompted my colleagues to vote for industrial action in their thousands.

The thing is, as has been droned on about at some length, both here and other-where, our paymasters and rulers have rather lost the good will of the profession. Tone and Gordon playing fast and loose with the contract started the process, true.  Lansley’s back of a fag packet re-organization after we were PROMISED no top down re-structuring, and the appalling mess they’re making of its implementation (a mess so scary they’ve had to veto releasing the “risk register” for fear of frightening the horses) are way more important and way more worrying to those of us who wish to see a true National Health Service for our kids and theirs and so forth even unto the seventh generation and beyond.

The tiny problem with that is that you can’t hold a ballot for industrial action on an abstract concept, so we are left like disenfranchised barons attempting to force bad old King John to Runnymede on the issue of the unfair abstraction of our lands and chattels.

If you care about your surgeries, your hospitals, your lovely district nurses and midwives wobbling about on their sit-up-and-beg bikes and all the other paraphernalia of the only vaguely successful stab at socialized medicine in the known universe (excuse the hyperbole) I urge you to see past the whole “fat cat pensions” thing and think about why the B.M.A. for the first time in a generation has seen fit to hold a ballot at all. And if you’d then like to lend your weight to the campaign, why not email Dave*, George, Andrew , and your own MP to tell them so. 

If you’d like to do it weekly, even daily till they get the message then so much the better. And on 21^st June I shall make a point of being on hand to see urgent cases whether they come bearing hob nobs or not. I’m just saying… ;-)

*seems you might have to write to Dave. 

Try

House of Commons, London, SW1A 0AA
Tel: 020 7219 3475
And remember to sign off “LOL”
I'm told he likes it.

Testing times?

A couple of weeks ago I had the pleasure of Brian’s company. He’d been at the golf club the night before at one of their legendary social functions. These functions used to be a simple excuse for a night of bacchanalian excess, but in these times of scrutiny and accountability even the hallowed portals of the Ambridge and District are not sacred and every function must serve an higher purpose. To that end the committee had invited in someone to do a bit of “health promotion” and offer “screening” before they sat down to their fifteen course banquet with attendant wine list, port and cigars to follow and brandies after the Loyal Toast.  

If you are detecting a hint of irony here I fear it was utterly lost on Brian.

In any event the screening on offer posed us a bit of a problem. It seems that Brian was informed his test (a P.S.A. allegedly) was “high”.

And that was all.

No advice about symptoms, no suggestion of what to do next, indeed no quantifiable information on what “high” might mean in “pounds shillings and ounces” *. Apparently the same was true for a few other stalwarts of the A&D, but fortunately they will be off bemusing their own medical attendants as none of them saving Brian are registered with us.

So what to do now? Well P.S.A. is a notoriously fuzzy test at the best of times. It’s undoubtedly captured the zeitgeist of those men, like Brian, of a certain age, and many attend seeking the “reassurance” of a quick test, on the assumption that a “low” result will ward off the spectre of prostate cancer. And here we run into a few difficulties.

The test measures a chemical put into the blood by an “unhappy” prostate. The problem is the source of prostatic disquiet could be anything on a spectrum from infection through inflammation to cancer. There had been hopes a few years back that it might prove useful as a test for the latter, but the test is just too imprecise to be useful and indeed the prevailing wisdom is that the potential harm of the number of unnecessary biopsies and other procedures that would arise from using it as a screen far outweigh any benefits it might provide in identifying new cases of prostate malignancy.

Needless to say, just because the medical establishment, hampered as it is by a need to evidence practice, doesn’t view the test as a good thing, doesn’t mean, now the Djinn is out of the bottle and the movers and shakers of groups like the A&D up and down the country won’t engage the services of the 21^st century equivalent of the Snake Oil salesmen of old. So it is that they end up buying in unproven services from unscrupulous predators, keen to turn a fast buck at the expense of the anxious and ill informed, all from the best of motives. But this leaves Brian with a bit of a problem. Now he’s had a “screen” and it is “high”, but he has no symptoms of prostate disease.

I’ve offered him an examination (not described here for the sake of the squeamish—fans of Billy Connoly will know what I’m talking about though) but for now he has declined. Do we repeat the test, and if so when, and what do we do if it comes back raised again.

He’s agreed to go away and think about it for a while, and knows to come back at any point if he starts developing symptoms that suggest his prostate is unhappy, but I’m not sure he won’t be back asking for a lab test at some point in any event.

*EVCHN for attribution as usual.

Brand X

Enter Jamie, from his Nike trainers to his fashionably oversized baseball cap (I’m guessing it has some other appellation, but am too unhip and disinterested to go looking—but you all know the sort) festooned with its own logo (which again I “should” know, but again can’t really be bothered enough to go looking) he is every inch (or centimetre for the younger reader) an Ad Man’s dream.

Now I know I’m old, and grumpy, and horribly uncool, but I can’t be doing with all this branding. In the good old days, when life was austere—and I mean properly austere, not the austerity-lite Dave and George are enacting, we were glad to have shoes of any sort—let alone trainers, and trousers that came to within four or five inches of the floor without having to have extra bits let in. Labels were things you cut out of the back of your jumper to stop them itching, not “accessories” to blazon every spare surface.

Well o.k. there was the year every red blooded male child hankered after a pair of hiking shoes with a compass in the heel and a “bear paw” tread, but that was essential survival gear for when you found yourself trapped behind enemy lines, a fate more common for the average eight year old back then, when the average eight year old was allowed, nay expected, to play out in all winds and weathers and states of enemy occupation… but I digress.

On this occasion Jamie (who’s closer to sixteen than eight by the way) was accompanied by a worried looking Cathy (his mum) and after a cheery Jesterly “What ho!” she prompted him to roll up a letter strewn sleeve to reveal the forearm underneath. It transpires Jamie’s forearm has a hole in it. Well more a crater than a hole—it has a base. A mainly greeny-grey rather septic looking base, with angry looking red edges all around. It’s around 2-3 millimetres deep, and self inflicted. A few nights before, Jamie and some mates had been out braving the Biblical floods getting out of their heads on scrumpy and howling at the moon (traditional country pursuits in these parts). For some reason they then decided to do a spot of branding of their own, and one by one heated a lighter to a glowing white heat before jabbing it, now unlit at least, onto their own forearm!

On the plus side, in the modern era of antibiotics the resulting sepsis can be easily treated, and the circle is no bigger than the blunt end of a pencil. On the minus side it looks deep enough that it can’t but heal with a substantial and rather ugly looking scar. Unlike the brands he’s wearing now, but will be too cool for himself in a year or two, this one will be for keeps. He says he’s not unhappy, he wasn’t “self harming” in that sense, and that it was just a “lark”, and for now I think I believe him, but I hope this isn’t the start of some new and scary trend. Somehow it feels far nastier that the present dual fetishes for piercings and ink.