Panic

The lovely Shinga http://breathspakids.blogspot.com/ has invited me to make a submission for the Paediatric Grand Rounds next week. All at once I am catapulted back twenty some years to a big drafty lecture hall in the bowels of the "Centre of Excellence" that was St Elsewhere's. There we all were, a gaggle of fresh faced youths (75% male, god-love-us) crammed into an ill assorted collection of white coats, (strangely those destined for Honours always wore the shiniest and best fitting coats too...).

Like a christian being herded in to the Colosseum for the half time entertainment a poor benighted Brummie, often in pyjamas tied up with that frayed white string, would be prodded on to the stage for our edification, and the trial by humiliation would begin.

These grand rounds are not at all like that, and I hope to offer a worthy contribution from a GP perspective. Still I can't help feeling a certain frisson. But this is not the panic of which I speak. Oh no. I can meet even the most eminent of Professor's gaze for at least 10 seconds now before I have to blink.

No indeed. This week I have been intrigued by a juxtaposition of events here in leafy Borsetshire and the wider world as represented on Radio Four's Today Programme.

First the local. We have had a number of calls from worried parents this week. It seems we are in the middle of an outbreak. Maybe this one even qualifies as An Outbreak. It's Hand-Foot-and-Mouth Disease. http://www.patient.co.uk/showdoc/23068750/ For the uninitiated, and all the mums in Borsetshire, this is an essentially trivial viral infection. The illness is both mild and self limiting. But visible. And just possibly a cause of miscarriage if you happen to get really, really unlucky. Because of this whenever we get an outbreak all the nurseries and playgroups in town go into a flat spin and every child with even the vaguest symptom of anything gets sent home, only to turn up in the duty surgery for the usual advice and reassurance. The mere name of it terrifies mums though. They remember the chaos of a few years ago when Foot and Mouth disease led to the wholesale destruction of vast numbers of animals and widespread travel restrictions. I'm sure some of them have visions of us coming to drag their little darlings away to remote outposts and nailing their doors shut with white crosses painted on them as in days of yore. They all seem almost disappointed to find out that it's really not at all serious for their offspring, and indeed, scarcely a danger to the wider populace. The worst impact it has is on the time off they or another family member might need to take to cover their "quarantine" from playgroup.

Now the bigger picture. Yesterday morning the Today programme publicised a news item regarding an open letter sent by thirty eminent immunologists and public health experts calling for an end to the hype surrounding the flawed theory that MMR vaccine is linked to Autism. Later in the day they had a Doc on a talk show (? Jeremy Vine) who was herself still convalescing after contracting measles some six weeks ago. She caught it from a patient. Likely an unimmunized patient. She was at pains to point out that she had never herself encountered a case of measles before, and neither had many of those charged with looking after her. She felt unwelcome as an inpatient because she had a major contagious disease and no-one seemed to know what to do with her.

It has to be six years since we last saw a case of measles (in an adult and contracted abroad) and I too might struggle with the diagnosis it's been so long. There are classical signs and symptoms http://www.patient.co.uk/showdoc/23069075/ but most patients don't read the books or present their symptoms in an orderly fashion. When the epidemic hits, and as things stand it will hit, we are all going to have to relearn measles pretty quickly.

The earlier interview was well handled by the Spokesman for the "gang of thirty" but still the interviewer had the nerve to suggest that by publishing their evidence based call for an end to the "controversy" they were in some way complicit in it! So here's the thing that really troubles me. This week our workload has probably been increased by as much as ten percent by a trivial and short-lived complaint that we understand very well. When measles hits it is hard to imagine we will cope as well.

lost marbles

A thought struck me this afternoon in the middle of a consultation. Jack is comfortably "over the hill" and in recent years has taking to rambling the byways metaphorically speaking. In short his memory is not what it was. Or so he imagines,though he finds it hard now to remember what it was when it was....

Certainly he has progressed along the continuum from Mildly Eccentric in the direction of Dotty, though he remains a long way from Terminally Bemused. So far his personality, and especially his lively sense of humour are reasonably preserved, but the fine details of daily life increasingly evade him. And now he has reached the point where he, and those around him, have decided it's time for something to be done. So I will be referring him to our very nice and very capable psychogeriatrician-- yes that is a job title and not a pejorative-- for an assessment of his memory. There they will ask him a set of stock questions designed to assess his cognitive abilities and recall.

And this is what has got me thinking. There are days when I am sure my nearest and dearest, and maybe even you gentle readers, having heard me rant on at length about the same old stuff for the nth time since breakfast, begin to wonder if I am starting to meander those same byways. The trouble is, I know all those stock questions almost as well as the clinic chaps do. The answers are now essentaially hardwired so I don't need to "take seven off of a hundred and keep going" to know the right number sequence, and I know perfectly bloody well where John Brown* lives thank you very much! So all I've got to do is memorize the name of the new Prime Minister whenever we get one and maybe those of a few footballers, and I'll be safe if the men-in-white-coats chose to pay a call.

So in years to come just how will we assess the failing cognition of GPs, Psychiatrists and others involved in this field of endeavour?

Do tell. I want a head start swotting for the tests.

* The memory assessment includes the giving of an address to be memorized early in the interview with points scored for recalling the name, house number, street and town concerned at the end. A little psychogeriatric in joke for you there. And at no extra cost.

A bit of a do.

This weekend saw the Jests at a family gathering. It combined a significant birthday and a significant wedding anniversary, both falling within this year, for what Bertie Wooster would have termed "ancient relatives". They gathered family and friends around them for a celebratory lunch.

There was splendid food, (the quiche guarded with a fierce intesity by a waitress determined not to allow her largesse to any but card carrying veggies), lovely wine, fizz for the toasts (several, by the time you had covered the bride / groom / birthday / guest speaker etc...) and a general warm hum of happy conversation throughout proceedings (except during the speeches where even the children sat engaged by two racconteurs at the top of their game). Best of all the venue was the function room of a Village Cricket side, and there was a match on, so after the main event we got to sit and soak up some real olde english tradition-- and beer.

Furthermore the occasion has given yours truly another* very tentative claim to fame. Our eldest is learning to fly through school. One of the guests at our table got to hear of this and promptly said, "Here lad, shake my hand." He duly did, being an obliging sort. As he did so the guest (a gent well into his ninth decade) informed him thus, "You're shaking the hand of a man who has shaken the hand of a man who was shot down by Von Richthofen."

It transpires that our new friend was at a seaside resort some time in the late forties or early fifties and came across a man who was there with his wife. This man was rather frail and needed help in getting about on the front. Our friend had been happy to oblige, and the wife explained that her husband had not been quite his old self since he had been shot down by the Red Baron. He then, and we now, have no reason to doubt her veracity, so here I sit, the proud Dad of a lad who has shaken the hand .... as detailed above.

In some sense this gives us a vague tactile link with a significant historical figure and keeps the past alive in a curious way. Books tell you the nuts and bolts of history, but alongside this there persists a rich oral tradition which preserves the more mundane aspects of momentous events. And for a man with a picture of Albert Ball on his wall, that's good enough for me.

*One day, if you're very good, I might tell you all about my other claim to fame. (And yes it is a bit more concrete than shaking the hand of a man who.... )

Good Cop / Bad Cop, and some sheep!

I was going to post about the job interviews we held yesterday. Interesting experience being on the "other" side of the desk, as an interviewer. We were two, plus our practice manager who was along to help thrash out the finer points of contracts, pay scales and the like. We just wanted to get the cut of the candidate's gib as it were.

We are quite new to this having had a stable complement of docs at the surgery for more than a decade. Also we are looking to appoint two half time job-shares this time around which is, for us, uncharted territory. So enter Drs J and Neighbour, like an unholy pairing of George Dixon and Harry Callahan.

Our victims fell into two broad types, power dressed and confident ("Grey" women) or power dressed and timid ("Beige" women). The determinant seemingly being the choice of suit colour. All had impressive CVs. Enough to make me feel more than a bit inadequate in some cases, (till I dug out my old CV and had a bit of a chuckle: "Represented Muggleton Hospital at football" = three games played by the A&E docs against the nurses-- except that for the last game they drafted in all the porters and their husbands and we got thrashed so that was the end of that..... ).

One of the "Greys" got the gig and seemed quite happy so we shall have to see how this bold experiment works out.* So the only question that remains to be answered is which cop you think I was?

Hold on a minute, I hear you cry. You promised us sheep. We're sure you did. They're even in the title, look, just up there....

And so they are. It will not have escaped your notice that the surgery is in a leafy shire county. Borsetshire to be "exact". I've whittered on about the drive to work before. Leafy lanes and wildlife in abundance. Well after spending a large part of yesterday interviewing it rather ate in to my admin time. But today is Lady J's day off and she had "things to do" in town, so she opted to take the big-red-bus and drive the kids in to school this morning. "So you can have the nippy car, go in early and shift the paperwork before surgery..."


Which was lovely. Until I got to within a mile or so of the surgery and hit a tailback. Which is something we just don't have on my morning "commute". As the massive line of cars (at least five ahead of mine!) snaked around the corner the reason became apparent. One man, two border collies rushing about like exocets, and around a gazillion sheep (well more than a hundred anyway-- I may have dozed off momentarily mid count, as is to be expected). They were expertly herded down the lane and round the corner in a matter of ten minutes or so, but somehow after that I didn't have the heart to race in to surgery Colin McCrea style any more, so I wasn't quite as early in as I'd hoped.

If only I'd had my magnum handy......


*In case you were wondering we appointed the first half of the Job-Share a while ago to an old friend of the practice so we know that part will be fine.

Old Friends

By way of a paradigm shift meet Henry and Minnie*, and old couple married in the dawn of prehistory, survivors of recession, war, famine, pestillence..... you get the idea. And throughout it all they have fought like cat and dog, Tom and Jerry, maybe even Itchy and Scratchy!

Their relationship apparently thrives of their ability to contradict one another, or more properly Minnie to contradict Henry. It's easier for her to do now, because in the past five years Old Father Time has accounted for what little hearing war and mining had left Henry. He has aids. You know the sort. Big clunky things that whistle and squeal with alarming regularity. In many ways it's just as well he's deaf enough not to have to hear it!

Minnie has her own agenda. She is desperate to make sure he stays well. The thing is, she was diagnosed with "inoperable" and therefore "terminal" colon cancer some four years ago.

Yes, really, four years.

The diagnosis is quite correct. The prognosis has been appallingly wrong. You might think happily, given she is still around, and really not a lot worse, four years in. But to her that's four years spent on Death Row, waiting for the men with the keys to come for her, to march her off to the chamber, and she doesn't even get to know which day to have her "hearty breakfast". And so she is scared. Not so much for herself, except when she gets a new pain she can't explain**. No, she worries for him.

It doesn't help that like all men of a certain age he is prone to concerns over the working of his bowels.*** In brief he suffers with constipation, despite laxative doses that would bring an elephant to it's knees.**** Of course Minnie's carcinoma began with episodic constipation-- followed by diarrhoea in her case, but still she sees constipation as a "red flag" symptom. So much so that we even investigated poor Henry last year just to reassure her.

It hasn't.

Which brings us back to today. Henry comes in and sits centre stage. After all it is his appointment. Minnie comes in behind him, and takes station, for all the world like a smaller, older, more female Kevin Costner, just behind his left shoulder.

One false move here and I'll feel my hair***** being parted by the bodyguard's katana, I think to myself.

Henry starts to detail in graphic terms his latest struggles with his affliction. All the while Minnie is behind him shaking her head violently whenever she disagrees. Which is most of the time. When he has finished, and before I can shout a response into his least whistly ear, Minnie has her say, and completely revises his presentation. What had been a tale of manly triumph over adversity is instantly transformed into an official history of the first day of the Somme.

They have a stand up row, conducted at 90+ decibels, which she wins. We end up agreeing to give him the treatment she was after for him in the first place. And they leave, hand in hand, smiling sweetly at one another and full of thanks for my kind attention-- or for doing what Minnie asks, which amounts to the same.

Their relationship is founded on the solid bedrock of decades of conflict and a sound appreciation of who wears the trousers.

Even when she's in a skirt.




* usual bogus prize offer for the first respondent to grok the reference.
** which have been mercifully few.
*** what follows has been heavily censored on grounds of good taste and proximity to Dr J's teatime.
**** Aren't you glad this is the edited version?
***** such as is left

It's nice...

...to be nice.

One of the favourite sayings of Mark and Lard in their time on the Radio One lunchtime slot a while back (before I jumped ship and headed for Ambridge). I know they're not there any more, but the saying holds true, and there seems to have been an outbreak of niceness in these parts today.

That's niceness in the warm fuzzy just-been-dipped-in-chocolate way not any of the other frankly rather more unlovely interpretations.

Exemplar one: midway through morning surgery. A woman attended to renew a prescription for eczema. In closing the consultation she volunteered an observation on the professionalism and patience of our reception staff. This is so not the typical view of GPs receptionists that I felt compelled to feed it back to them. The reason for her admiration related to our previously mentioned "Touch Screen" registration that allows patients to check in without the need to queue just for one of the girls to "Arrive" them on the practice system.

To anyone under 60 and with reasonable eyesight this system is a boon as it frees up the staff for things that need face to face contact and reduces their time standing about waiting to check in. Sadly many of our regular attenders do not fit this demographic, so for the past few days there has been a line of shuffling bemused patients at the screen needing help adapting to the new arrangements. The team have borne this with their customary aplomb, and this morning they were recognized for their efforts. Cue warmth and fuzziness.

Exemplar two: Roy has been struggling to come to terms with the loss of a parent some while ago. By December last he was plainly clinically depressed and in need of chemistry as well as counseling. He dabbled with antidepressants on and off until last month. More off than on in reality. Last month we had "The Talk" and he was finally persuaded to stick with the Prozac for a while. He has managed it. Life still has very few cherries to offer in his personal bowl, especially since he "celebrated" a significant birthday during the month which only served to amplify his sense of loss. Still he acknowledges that he fared much better for having had the meds. He is even willing to continue the course and to return for review in a couple of months. Meantime his recovery is giving him the necessary momentum to actively seek to better his prospects by looking for an apprenticeship. Again at the end of the consultation he took his prescription and headed for the door. As he reached the threshold of the consulting room he looked back at me and said "Thanks very much for this" nodding towards his script. Something that hardly ever happens for ANY medication and least of all for antidepressants.

Doubtless my normal whinging tone will be restored in the fullness of time, but just for today I'm doing very nicely thank you for asking.

A new string to the bow?

I am pleased to report that Dr J has been awarded one half of the prestigious Work-Greavsie franchise. The following post will detail the new working arrangements that will obtain for the duration of this franchise.

Dr J will be available for General Greavsie Services (GGS) within the contracted hours of the New Greavise Services Contract, which is to say between 08.00 and 18.30 Monday to Friday. Outside these hours cover will be provided by the Borsetshire Greavsie Deputizing Service.

As an addition to the above we shall be launching “Greavsie Direct”, a 24 hour nationally available helpline. This can be reached by dialing 0845 4GREAVSIE (0845 44732743). Here call handlers with the help of a sophisticated computer program* will be able to advise you which of the six new Greavsie franchises you require.**

In line with the National Enhanced service under the NGS contract all posts will henceforth be monitored for quality. Spelling will be improved by a target 50%. Use of parentheses will be kept to and absolute minimum*** and swearing of any kind will result in a £1 donation to the Swearbox.

In line with locally negotiated arrangements all references to "Barbarella" and " the Barbies" will be replaced by acceptable substitutions for the duration of the franchise.

Any queries can be directed to OFFGREAVE the new Office for Greavsie Standards ****

* They DO NOT just spin a bottle. Honest.
** Calls may be recorded just for laughs. All calls charged at 50p per minute. Average length of call 25-90 minutes. Remember to get permission of whoever pays the bills.
*** Replaced by multiple asterisks. See I know it’s not Asterixes so there.
**** (NOT to be confused with ****) Address available on application.

Pratting About

Or "Wart Treatment using Liquid Nitrogen" as our clinical system would have it.

As an humble houseman it was my job, once a week, to book in around twenty patients on a Wednesday afternoon for "Cryosurgery" with a Consultant Oncologist. Some had skin cancers. Many did not. They had warts or Naevi (little red spots to those of you of a non-medical persuasion). They had all had to take half a day off work for the privilege. All had to be checked in by a gormless specimen just out of med school (yours truly), then get into a gown (no, really, they did) and go to an operating theatre for their "surgery".

The theatre had to have a nurse and an orderly to hand, and the Great Man Himself to do the "operation". Or in other words to squirt the offending body part with liquid nitrogen for anything up to thirty seconds. If you had a few spots treatment could last for whole minutes. Some patients needed fortnightly visits for a while to erradicate bigger blemishes.

For at least fifteen years we have had N2 here on tap. We have a special zappy flask for it to go in, with a great big trigger thingy. When you squeeze it Nitrogen zaps out with a fantastic hissy noise straight on to whatever you point the nozzle at. It's brilliant.

So now when our punters come in with a little annoying blemish we can zap them on the spot (geddit?) with no need for all that mucking about referring for "operations". An especially satisfying job for all concerned on a hot day. Plus you get to prance about the corridors with the flask zapping it in the general direction of the staff, PCT managers, the cat etc whilst shouting "Freeze!" in your best SAS impersonation. Even the older wiser partners have been known to walk about with it twitching the trigger to make a satisfying "puffer train" effect with clouds of vapour and a satisfying accoustic accompaniment from the nozzle.

As a generation of final year medical students will also attest, it's the most spectacular way to remove chewing gum from the surgery carpets.*

* Something they all get asked on their induction here. Please don't tell them though. It would spoil the fun!

Danger Man

Henceforth I wish be known as Danger Man. I am also considering submitting a claim for Hazard pay. Strangely this has nothing to do with our practice being engaged under the new(ish) "Violent Patient Scheme" to take on the care of an individual who was known to visit their former practice "tooled up", as I understand the vernacular would have it. No indeed. Under this scheme we are in fact far safer since we will only be seeing this individual under controlled circumstances in a secure room in A&E and with a security presence.

No, my problem is far more prosaic. It all revolves around the luchtime home visits. I've never really considered these a particularly risky part of the job before. There have been a couple of occasions when on a call out to the Chavvier end of town I have warily gripped stethosocpe and script pad a little tighter, but most of the local hard types know full well that I know their mums so that's generally ok. It's the getting to and fro that is now exercising my mind.

In the past two days I have seen five cases of "Whiplash Injury". No not that kind.... the sudden acceleration / deceleration of the neck that goes with a car crash. Since these five people are all unrelated and each involved in a separate RTA on Saturday last that means I know of at least five accidents that day. The local GP community numbers around 23 Docs, so if my experience is not exceptional (and I have no reason to believe otherwise) that makes for around 100 RTA related injuries in and around Ambrige last Saturday. Now granted Saturday was a busier day than average with everyone trying to get the lagers from Tescos before the match, but I suspect it was no more than twice as busy as usual, so 50 injuries might be more representative of a "normal " Saturday.

So hold on a minute, that's maybe twenty five actual accidents. On a Saturday. We all know all the really annoying drivers come out on a Sunday, so logically the accident rate is not likely to be less. Weekdays more people at work during the day so perhaps the daily rate will fall by as much as 50% to say 12 per day. So that's 50 accidents at weekends, another 60 the rest of the week and at least two victims per accident, for a weekly toll of around 200 injuries. Plainly not all are severe, and many may not make it in to surgery or A&E at all making this a conservative estimate to say the least.

And yet, knowing all this, as they must, the PCT expects me to venture into the maelstrom five days a week to tend to the needy.

Lucky I did that Tank Driving course a year or so back. Now then, just how much would a Warrior set me back.....

Murder 2

I assume there is such a thing as second degree murder to differentiate it form manslaughter or "Murder One" (as booked by Danno on a weekly basis some time ago).

What I do know is that there is definitely such a thing as second degree sunburn, but that just doesn't grab the attention at the head of a post somehow. It's got Sam and Kirsty's attention though.

Sam went to the pub at the weekend to watch the match. (Sorry that should of course have read "The Match"-- with apologies to any Paraguayan readers). He had a few lagers. Celebrated the result, if not the second half performance, and wended his merry, or at least tipsy, way home. It was a nice afternoon so he went out in the garden and fell asleep in the chair. Fortunately for him he had kept on his sacred red jersey, but his aqulline nose took the full force of the afternoon sun for a couple of hours whilst he snoozed. He now has a schnozz worthy of the late lamented Jimmy Durrante. And as they say round these parts "It kills".In fact, though he now has one of the all time comedy ailments, he has escaped lightly comapred to Kirsty.

Kirsty is, as they say, a big lass. She is big in every respect of the word, and has the sort of ample figure described in inches and repeated letters of the alphabet. This asset in tune with current fashions was displyed to its fullest advantage on Sunday.

How do I know this?

From the burns now evident. Celtic heritage and blistering sunshine (quite literally in her case) do not go well. And yes, sure enough "They're killing" too.

It seems Noel Coward was right about the "Mad dogs and Englishmen". It's as though there's something "soft" about using sun protection. I'm willing to bet that if you asked sunburn victims like Sam and Kirsty to stand in front of an electric fire till if started to burn they would hit you. Likewise they might demur if asked to service a nuclear (that's pronounced "new clear" by the way) reactor without the benefit of protective clothing. And yet, because it's just dear old Sol beaming down on us it must be ok.

Generations of Aussies and Kiwis will tell you different. They could teach us a thing or two about sun protection, but untill they do surgeries up and down the land will be full of Sams and Kirsties today, and likely for a few days to come. I tell you it's murder out there!

Well a Bird Bird Bird....

... Bird is the word!*

Morning surgery started a bit late this morning, so this post is by way of an apology to the punters. Not that any of them read this blog so far as I know, so if you see them you'll have to tell them for me.

"Why so late starting?" I hear you ask.

"Has there been some life threatening medical catastrophe that claimed your attention?" er... no.

"Perhaps you had to stop good samaritan like at the site of an accident?" well... not exactly.

"Well we're sure you must have a good reason so please tell us why don't you?"

I thought you'd never ask.

The lanes between Borchester and Ambridge have been idyllic this week. (Except on Tuesday night when torrential rain turned them in to rivers for a good six hours, but that's another story...) This has made the drive in to surgery a real treat, and the drive home even more so, Tuesday excepted obviously.

This morning was no exception. I was about half way here, "Shine On You Crazy Diamond" thundering out of the stereo**, not a care in the world. Suddenly the sun was blotted out as a fell beast passed overhead. The temperature inside the car must have fallen by a couple of degrees easily, and then the fell beast landed forty yards or so ahead of me in the middle of the single track lane. The earth shuddered at its impact. I'm sure the cd skipped a beat or two.

Easing off the throttle I ended nose to beak with the biggest pigeon I have ever seen. I refute utterly any suggestion that there was a slamming on of breaks and a wailed expletive to accompany Dave Gilmore just as he was getting to a good bit. Those streaks of rubber were already there, honest...

Somewhere in the background the soundtrack changed. There was a frantic strum of a guitar, followed by an Ennio Morricone tinkly music box effect, then the wailing trumpet of doom. We were in a stand off of epic proportions. (Just as well there was no other traffic on said lane this morning really.) Now, a word of advice should you ever find yourself in a similar position. Never try to outstare a pigeon. In the first place, they are stupid. In the second, they don't blink.

So, all dignity now in tatters I started up the engine again -- what me stalled?-- surely not. Then, to compound the humiliation, I indicated to pass the pigeon! As I vered right to pass it, it waddled right staying just in front of the car. I cancelled the indicator and pulled back in. It waddled left and stayed, as though fixed by tractor beam, directly in front of me.

By now Signor Morriconi's trumpeter had passed the impossibly high, impossibly long note, and the strings and massed guitars were hammering out the reprise of the theme tune. I indicated and pulled out again. "It" wadlled ahead of me matching course precisely. I have now determined that pigeons waddle at a stately 1.5mph if you are interested.

It was like stepping back 100 years to the time when motor vehicles had to be preceded on the public road by a man carrying a flag. Beetles were strolling down the side of the road overtaking me and thumbing their proboscises in disdain. Or at least they were until one became breakfast for the Pidgeonator.

Ha! It was distracted. I knew better than to signal my intent by now, so, taking my life in my hands I vered sharply past the thing, gunned the engine and sped past it, and on to victory.

Roger Waters sang "How I wish you were here!". The day was back on track. Civilization was saved once more. And only ten minutes behind.

And what have we learned. Well, I for one am not cut out to be a pigeon fancier. It's good to know these things. If nothing else it's one more hobby to cross off the list of potential diversions come retirement.

* Prizes for the nearest contestant in the "How old is Dr J?" sweepstakes.

** (I seem to have caught this form Greavsie) That's the last clue you're getting.

Parental Indignation

Teenagers, eh.

It's quite ususal to see boys, even in their late teens, brought to surgery by their mums. It's well known, and generally true, that teenage lads don't communicate well, or, often, intelligibly to us older types, without a mum present to translate.

It's not unusual to see girls also brought by their mums, at least up to age 16, though often not for much longer after that... if the consultation starts with daughter looking at her shoes and mum saying "I'll tell him shall I?" you can bet it's going to be about "Pills" or "Periods". If it starts with mum saying "You'd better tell him..." they're going to be pegnant. Any other introductory remark and you know it's going to be a normal consultation about ordinary stuff. They still sit there and look at their shoes though.

The ones you have to watch out for are the ones where you get Shoe-Gazey-Teen and Mum and Dad. These will always go badly. With the lads it will be "Drugs" or "Madness" which very often ends up being "Drugs" too, though not always. With the lasses there's a whole spectrum to choose from. There's "Not eating", "Binge Eating", "Self Harming", "Drugs / Booze", or, as this morning;

"Pregnant and on Drugs".

An hour later they left, still apparently talking to one another, though there was a tense stand off 30 minutes in when Dad wanted to talk all about STIs, just to put the boot in a bit more. Unfortunately I didn't have time to ask him to go back to his room for time out (1 minute per year of his age and he'd still be there now!). Five minutes had to suffice, during which he could still be heard huffing and puffing Big-Bad-Wolf-like from the other side of the door....

In reality the daughter, though perhaps a little unrealistic in her expectations, has accepted an urgent antenatal referral to at least seek counselling, assures me she has not "used" since she found she was expecting, and seems to have managed to cling on to a slim thread of self esteem so far.

I find it interesting, and perhaps a tad dissapointing that the one near constant all all such "three handed" consultations is the parental indignation at the position they find themselves in.

Breast is Best

As the fifty percent of the population who don't actually have their own to play with would aver almost to a man.

So why do I find myself prescribing milk powder to a 13 week old infant this afternoon? The answer is complex and small "p" political but here we go...

Society increasingly expects women to play a full part in working as well as domestic life. Indeed for most couples there is a need for both partners to work simply to service the silly prices we pay for our accommodation and chosen lifestyles. Furthermore we define women still as much, if not more, by how they look rather than by their other capabilities. Then, when they have children we worthily spout on about how important it is that they breast feed and devote all their time to baby as though all the other stuff ceases to be important.

In my limited experience this is not a universally popular message. Some women are denied the option as their milk production fails to establish properly, but the vast majority are so denied either because of financial necessity or through personal choice, to preserve their shape,or to resume their other roles in society. Thus in our "enlightened" society of "equal opportunity" far too many babies are rapidly put on powdered milk.

It's logistically much easier to cart about bottles of formula than to breast feed on the hoof as it were. This is partly because our climate here in blighty is seldom conducive, but mostly because society still tends to go all "Benny Hill" around breast feeding women, instead of giving them the help and support to make it easier to do.

Then there's the whole "getting single mothers back to work" thing. This leaves many younger less experienced mums feeling pressured to return to employment far sooner that is right for them or their children.

Ah say the "Guardian Readers", they could always express milk to give in a bottle if they wanted to continue to feed naturally and work. Any mum who has tried this will regale you with horror stories about "milking machines" and awkward damp patches in best blouses etc... It might be a short term expedient for some, but is hardly a sensible life choice.

So we come back to poor little George. I don't know exactly why his mum was unable to breast feed, and now it hardly matters since that option is now lost to him anyhow. After a few weeks on ordinary formula feeds he was increasingly fractious and difficult. His health visitor advised mum to try switching to soya milk and he improved dramatically. So it seems he may be lactose intolerant (as indeed was his mum). But soya milk, used for lactose intolerance, becomes a medicine as well as a food, and so is prescribable.

So there you have it.

Daughter of Eurynome

I see lots of kids in the course of a normal day in practice. They tear around the room howling like banshees. They tip the lego bricks all over the carpet and use them to make rayguns (or worse). They line up the cars in neat rows all across my desk, howl and screach when approached, laugh at my jokes (if they know what's good for them), or sit cringing in abject terror next to mum or dad throughout the consultation....

In other words they carry on just like kids everywhere.

Not so Grace.

Her parents must have been struck by some bolt of inspiration six years ago when they named her. She is otherworldly, and for ten minutes this morning I was captivated. Dressed in a simple white dress and white woolen cardigan she stood in front of my desk smiling and co-operative.

The consultation was entirely unremarkable. She has had earache for a few days after a cold, but is actually now almost better and needs no treatment, Mum just wanted it checked. But throughout her visit she was calm and stillness personified. Grace indeed.

To be fair her brother was equally well behaved and remained quietly in the background fingers twitching away on the Gameboy, but otherwise entirely unobtrusive. This must be what seeing children was like all the time back in the 1950s, but nowadays it was utterly remarkable and truly enchanting.

Bloody Politicians!

Dr J has come over all op-ed again. Apologies in advance.

This may also seem a tad disloyal since I sit here in a position funded out of general taxation and working to all intents and purposes in government service, subcontracted as I am to the Dept of Health. Still, I'm moved to say it again. Bloody Politicians. More specifically in this case the UN.

You see, they've been having a conference this week. On HIV and AIDS. Only they are now bickering over the text of the final "agreement". It seems some members don't like reference to gay men, prostitutes or drug users in the document. It might look as though the text condones "illegal activity" in some countries. Then there's the USA. They're ok with the whole at risk groups thing apparently. They just don't want any reference to needle exchange schemes for drug users. It goes against their whole Volstead era prohibition attitude.

So, no mention of at risk groups then, and no mention of some of the most effective interventions to avoid spread of the disease. And they wonder why the pandemic is a crisis of global proportions.

Sounds like time and money well spent to me.

Not.