The mark of Kane

In hobbles Adam, a man plainly in distress. So much so that he's had to bring Eve along, just so he can lean on her. He's bent double, and obviously struggling with severe back pain. Eve crosses the room and sits, but Adam elects to remain, standing hunched at the end of the desk, grimacing in a pantomime of pain that mimics a Greek mask of tragedy.

Through anguished gasps he manages to tell his tale, with Eve contributing when it all gets too much. He was lying on the floor, prone rather than supine, watching the TV and minding his own business, when he was thunderstruck by a searing pain in his back. Eve takes up the narrative and points out that this pain was occasioned by Kane, their eldest boy, blundering into the room, tripping over dad's trailing legs and landing full force with the point of his elbow right in the middle of Adam's back-- somewhere around L4-S1 for those in the know about such matters.

Four days on and Adam is still in anguish. So I offer to examine him, and stand to walk behind him for a delicate prod. Sure enough he's exhibiting quite a lot of tenderness to touch, but mainly out wide, away from the crucial bones of the spine. These exams are usually easy enough to do through a t-shirt or similar, but since this month Amdridge has been temporarily twinned with Arctic Greenland, everbody's arriving swathed in layers, so to get my anatomical bearings I've had to ask Adam's permission to lift them to have a proper look. As I do I can't help but notice the fetching tattoo he's sporting, right at the pint of impact. In a calligraphic Gothic hand the artist has spelled out his son's name. Verily the mark of Kane.

"Badges, badges?.... "

Yes it's complete the quote time on the old caseblog again. The above comes from one of my favourite movies, see if you can come up with the line that follows, whilst I tell you a tale of woe.

Mac' was in his seventies, and was a true Celtic patriarch. He had a large family and they in turn have gone off to have large families of their own, but most have not gone that far away, so their tight knit "clan" is always on hand to gather round in times of adversity. A few years ago Mac' developed a malignant disease, and it was treated, but by the time it had been staged it was on the cards that it had spread and would be reappearing sometime, somewhere.

(Cleverer docs than your humble interlocutor have ways of telling this, by looking at the histology of the "primary" tumour, the degree to which it has invaded the surrounding tissue and the extent of involvement of lymph nodes nearby for example.)

Late last year Mac' developed some tummy trouble and a little pain. Shortly after this he developed jaundice, and it was pretty clear that the disease had come back. He had a couple of speedy consultations with the oncologists, and started treatment which he and we all knew to be palliative. The clan duly gathered, and it was plain that he was going to be well supported and cared for, and we slipped into an easy routine of checking in now and again to see all was well, and letting him steer his course through what we all knew, but never said, was to be his final illness. This was his choice, and we worked hard to respect it.

There are times when you really don't need to ask a question to know the answer. Mac's whole demeanour and approach to his symptoms let us know he knew he was running out of time and really wouldn't appreciate us jabbering on about it. He wanted to get on with living his final days, not confront what came after. In his last week he finally had to admit that there was a little more pain that he was willing to put up with and accepted the offer of a morphine syringe driver to give him small regular trickle doses of opiate, rather than having to rely on intermittent administration of oral medication.

At the time of his recurrence he was introduced to the "Badge Nurse" who looks after terminal illness. From then on he had little to do with them, really neither needing nor wanting their input. Still we are supposed to offer "Gold Standard" care these days and so the badge nurse took it upon themself to visit from time to time. Returning for the first time in a month just after New Year, said nurse, noting the deterioration, pointed out rather too bluntly to Mac' that he was not long for this world. The "clan" politely thanked them and showed them the door.

Twenty four hours later Mac' had died.

He was ready and had no need of the information. What should have been an elegant decline into the everafter has been marred for his remaining family and they are profoundly unhappy. Still at least our "Badge Nurse" can tick a box on their "Gold Standard" protocol :-(

So where did everybody go?

Even readers far from these shores might have noticed that Dear Old Blighty in general, and Ambridge in particular, have been experiencing a little local difficulty with the weather. Here it hit on Tuesday, and shows little sign of clearing up until well in to next week. The result has been chaos on the roads, dire prognostications over our ever more fragile supply chain for simple necessities like fresh veg and gas as well as grit for the roads. Oh, and a sudden fall in demand for our services.

On any given day our surgery will offer fifty plus "emergency" appointments for use that day only and for urgernt need. And on any given day most of these will be filled. Not so this week. Indeed fewer than half that number have been required. So either everybody has suddenly got better, has gone elsewhere or has revised their opinion of what "emergency" means. I'm guessing it's the latter. No, I'm sure it's the latter-- after all we're all guilty of doing the same when it suits us.

Working in hospitals in the 80s it was apparent when there was a major sporting event everybody stopped wanting urgent attention. I worked over the Live-Aid weekend, and at least one Royal Wedding, and for the hours those events were on screen life in hospital became very quiet. The same used to happen when blockbuster movies were first broadcast on TV, but in these days of mutliple channels and instant DVD release that seems no longer to happen.

It's not particularly surprising that events, be they popular or merely inclement, affect our behaviour, but I am fascinated at the extent to which they can alter our perception of "urgency".

Another year over...

... and lest face it, '09 hasn't been all that special. This can be a miserable time of year at the best of times, as I think I might have mentioned a time or two lately, and it's been noticeably worse this year. Over the past two weeks every surgery has seen at least two or three young adults in floods of tears as the dam bursts and they finally have to admit that they might really be depressed. Mostly it's been on a background of lost employment, failed relationships, mounting debt, and for many, a looming fear of homelessness of of having to go back to living with parents. Even this morning, in my last surgery of the year there have been another handful.

At times like this I am extremely grateful to be doing the job that I do in the place that I do it, but these are problems I'm powerless to directly influence. I can suggest that my poor victims try to throw themselves into something that they used to enjoy doing, that they try finding an outlet to talk about how they're feeling, and that they take the pills I'm about to offer them. What they need is a guarantee of a job, a prince / princess charming-- or at very least a kissable frog, a sizable lottery win, and a place of their own, and none of these things are in my gift.

So today I'm counting my blessings, and hoping that for all of us 2010 will mark an up-turn.

Thank you so much to all of you who read this nonsense, and all the more to those who are moved to comment. You really do all go a long way to keeping as sane I am ever likely to be. All the very best to all of you in the year to come, and God bless us, every one!

I'm dreaming of a white...

... sandy beach, sitting on a sun bleached deckchair, sipping ice-cold beer from a condensation covered glass, basking in thirty degree heat, and as far removed from the seasonal tyrrany of tinsel, turkey and kitsch that has become the Great American... er British Christmas.

If it seems like months now that we've been bombarded by ads with every B list "celeb" you can think of exhorting us to buy more food and booze than it's humanly possible to consume let alone enjoy (and lets face it half the crap they're peddling isn't even that enjoyable) that's because the run up to this next fortnight of saturnalian excess began in October. The pressure to indulge is overwhelming, and, not to put too fine a point on it, it's ruining the whole thing. The expectations now for this few days of "quality time" with the family are quite literally crushing, and it's making my punters irredeemably miserable. The only ones who have seemed at all cheerful have been the odd few who are taking this opportunity to jet for for an Antipodean Xmas with barbies on the beach and more sun than you can shake a boomerang at. Frankly I'm envious as hell. It doesn't help that this weekend we had temperatures of -5 centigrade (yes I know it's colder elsewhere, but once it gets anywhere below freezing it's inhumanly cold in my book), but it's more than that.

The expectation heaped onto this next few days is quite unreasonable, and must inevitably end in dissappointment, yet still we are all sucked in, lemming like, to the collective madness. When we come out the other side we'll still all owe tens of thousands to the economy that has tried to kid us for years that we can have something for nothing, the planet will still be melting, however counterintuitive that feels right here, right now, and all the attendant woes of famine plague and pestillence will continue. The unwinnable "War on Terror" will be grinding on its relentless way and our poor long suffering servicemen and women will still be struggling to deliver "peace with honour" in a conflict that offers neither, and will still be constrained to do so on a shoestring budget because we've poured all the cash away bailing out the banks. No so much "the economy, stupid!" as the "stupid economists". And us for believing in their voodoo.

If ever there was a time to take stock and rethink our priorities it's now. Not that we will. We'll all be too busy crowding out the stores and piling in supplies, one third of which we'll not use, and scrabbling around for those last minute gifts for "what's her name down the street that we thought wasn't going to give us anything this year but did".

So let me be the first to wish you Happy Next Christmas!

(Usual VECHN* for the closest guess to the date of my first "Happy Christmas" of the year from a punter)

*If you don't know what this is have a trawl through my misanthropoic back catalogue-- if you can be bothered at all, though I would'nt blame you for not. I'm in such a happy place right now. You can tell right?

It's the most wonderful time...

As the popular song has it. And full of wonder it must be to be sure. You see, for the next two weeks I and my humble wares become the infallible, guaranteed, absolute and only panacea for all ills. After all it's nearly Christmas, so we are transformed for a brief interval into a branch of the Elf Service and gifted healing powers normally reserved for song and fable. Well at least so it holds in the popular imagination.

The only problem is, unlike the jolly old man in red (courtesy of an early 20th Century Coca-Cola ad campaign apparently) we have to treat with all comers, both the "naughty" and "nice". A great many of both sorts crossed the Jesterly threshhold yesterday coughing, clutching sore throats or, more concerningly, grey cardboad vomit bowl "boaters". They all had some form of viral illness and fully expected I'd be in a position to cure it for them on the spot, or at least come up with an antibiotic to do it inside 48 hours so they can be ready for the fortnight long party that has become the "traditional" Ambridge Christmas we've all come to know and loathe... er... love.

And this particular year that's a hard contention to refute. After all viruses are now curable aren't they. There's that magical Tamiflu we've seen being dished out in bucketfulls for the swine flu, so if it's good for that how much the better will it do for a sore throat?

Well Mrs A, since you ask, not much. Indeed I'd not be allowed to prescribe it for Tyrone just now. You see, although he was "terribly ill" half a hour ago, he's now whirling round the consulting room like the Tazmanian Devil and looking even better than I feel. So no, I don't think his bit of a cough was the beginnings of flu, or pleurisy, or pneumonia... and no I don't think he needs Tamiflu, or Antibiotics, or fairydust. In fact I'm pretty sure he'll be fine for Christmas even if you leave him outdoors all day everyday till the big one itself.

And despite having wrapped himself in the paper bedroll like a demonically possessed Andrex puppy Tyrone was not the worst behaved of my little visitors yesterday afternoon. Nor the least ill.

Now it's true there are key events on the calendar that distort normal behaviour patterns and Christmas and New year are amongst the biggest. No-body is allowed to be ill for Christmas. And life is supposed to fantastically re-invent itself at New Year as we all resolve to do more of what we ought and less / none of what we didn't ought. The burden of this latter expectation can be overwhelming and it's no surprise that our colleagues in A&E and Mental Health services dread New Year as those so overhwelmed are bowled over by the tidal wave of their own expectations and driven to the edge of self destruction thereby.

I wonder, has it always been thus? Were the Druids besieged at Stonehenge by long lines of tartan clad celts on the eve of every solstice and equinox looking for a cure for that "bit of a cough" or that "Pilum head sticking out of my chest" before the drunken revels could begin in earnest? I'm guessing so, and if I'm right I'm also slightly comforted by the thought in a way that's rather hard to describe.

Letting go.

I've ranted about this topic before. After events of a week or two ago I might, possibly, be coming to change my view. A little.

Bill was 97. He'd been living in a nursing home for the best part of a decade. It was a nice home, well run, and he was cared for in every sense of the word. To start with he was just a bit older than the average resident, but down the years as faces came and went he gradually became the eldest.

When he went in he was just a bit wobbly on his legs, and a trifle vague on times and dates. Over the time his wobbliness had become worse, but his haziness lifted (largely because his previously unfettered access to sherry was rather more "managed"). Slowly he took to spending more and more of his days in the chair, but remained bright, alert and sociable.

Last year his ticker started playing up, odd missed beats now and again, then runs of palpitations, then the syncopated jazz riffs of atrial fibrillation. This tipped him over the edge and into heart failure-- an increasingly debilitating shortness of breath with attendant ankle swelling-- which he grew to hate, and perhaps to fear. We tried him with digoxin, diuretics and one or two other things with little benefit. In the end his heart just wasn't up for being pushed any harder, and he began to fade.

And so it was that with a heavy heart a few weeks ago I was called in to sit down with him and his family to ask the awful question, "if your heart stops what would you want us to do about that?" The home needed to know, partly because it's good practice these days, but mostly to make sure they could respect his wishes. In the event that we hadn't asked the standard assumption is that resuscitation will be attempted and paramedics will be called. Bill, quite rightly, didn't want any of this for him. As he put it "I had my three-score and ten some time ago and everything else has been interest."

Within a few days of our discussion Bill passed peacefully away with a daughter in attendance. It was almost as though he'd been looking for permission to let go.