Wednesday, August 23, 2006

Home thoughts from afloat I

Sorry but access aboard is limited so no time to handle comments. Still hope you like the following.

Last night threw up a conundrum we wouldn’t have faced at home. More of that later, but for now here follow Dr J’s first thoughts on the cruising lifestyle.

As you are all aware this was an unknown quantity until three days ago. We brought to it a lot of expectations born out of prejudice, hearsay and popular culture. They have been confirmed and confounded in equal measure but all things considered and without even making landfall yet, we are having a whale of a time!

Yes there are an awful lot of very well to do, fairly elderly folk aboard, but there’s lots of us commoners too, and way more kids than we were expecting. So much so that our littlest has made a few friends already, and will be taking to the stage with some of them this afternoon in a show they are putting on in the theatre. Mainly I suspect to an audience of proud parents and doting grandparents for sure, but some seasoned veterans seem to be prepared to turn out to almost anything so we shall see. Her elder brother, being a reticent teenage lad is so far keeping his powder dry, but as a growing lad is whole heartedly enjoying the catering arrangements which are both plentiful and sumptuous.

The staff are unerringly and perpetually cheery. This is astonishing given the varying degree of respect they are shown by some of our fellow travellers. They are also almost all, excepting the "White Suits" from Asia. Indian waiters and chefs. Phillipina waitresses, bar staff and maids. It could feel depressingly colonial if they weren’t all so thoroughly charming and engaging.

Formal nights are not the dread occasions we were expecting. They are just as much fun as the less formal, but we all get to dress up like Penguins or Peacocks *. I presume this is so that if we were unfortunate enough to hit something and sink rescuers would think it odd to see penguins this far north, or peacocks this far off shore and would flock to our assistance. But despite the formal attire, and the "nice" table manners, the atmosphere is relaxed and friendly throughout.

But we have faced one challenge thus-far. Namely, what is the correct wine to serve with "Toad in the Hole". We settled for a very chirpy Beaujolais Villages, but I think we missed a trick. I am now convinced we should have gone with good old fashioned ale instead. After all a dish of such taste and refinement needs hops!

Got to go now. There’s a Picasso and a Chagal in the art auction today and I need to stop the kids from putting a bid on!

What Ho!

* Really, of course, that should be Peahens, but the display makes them all cross dressers for the night….

Saturday, August 19, 2006


This is it. We are off aship this weekend so posting is unlikely for a couple of weeks. If you're very good I'll tell you all about it when we get back. In the meanwhile, pull up a chair, help yourself to a coffee and a hob nob, and use this space as you will.

A bientot.

Wednesday, August 16, 2006

S3 MHA 1983

Some while ago we met Carly. I speculated that her recent cutting behaviour represented one end of a spectrum, where the "self harm" was an act of frustration taken out in the infliction of a little pain with ony minor and quickly repaired damage to the self. Yesterday I was called on to visit Ed in the local psychiatric hospital. Ed is right at the other end of that spectrum.

Ed first became ill around ten years ago in his late teens. He became withdrawn, quiet, and a bit "Goth". Then he sarted not wanting to go out at all. He kept looking behind him on those rare occasions when he could be persuaded out of the house. Then he stopped eating out. Then he stopped eating. The other lads on his estate were "picking on him". They looked at him "funny". They were "trying to kill" him. So was his mum.

He got very scared and took some pills and ended up in hospital. A psychiatrist was called and he was relieved. He took some meds and got a bit better and went home. Where he stopped the meds, began withdrawing again, got ill again and needed admitting back to the psychiatric hospital again, this time under the compulsion of a "Section", that part of the Mental Health Act that can require patients to be detained in hospital to be assessed and/or treated.

Being obviously paranoid he was assumed to be schizophrenic and treated as such. He got better again. Better at covering up his symptoms enough to be let home again anyway. As I said, this all began about ten years ago. In the interim he has had two longish spells of regular antipsychotic medication. He put on lots of weight, felt very dopey, even became diabetic as a result. But he stayed "better". Except that his fixed fears about the kids he had grown up with, and even his own mum conspiring against him never went away. And the "medicines" he was being given were making him ill. Small wonder he continues to think we are trying to poison him.

Since his paranoia stubbornly refused to lift along with his other symptoms the psychiatrists began to question their diagnosis / management earlier this year, and I was called on to examine Ed with a view to him being detained in hospital whilst his medication was stopped (something of a first for both of us). In the end it became apparent that he was not willing to go in to hospital voluntarily and we had little option but to section him again. His meds were stopped. He realpsed. He went back on medication and shortly after went back home, exactly the same as he had been.

Until last month.

He cut his left wrist. As in, cut it down to the bone, taking out a couple of flexor tendons along the way. He was admitted to the general hospital, but declined repair surgery. He was re-sectioned and admitted to the psych ward. A couple of weeks later he absconded and went out to play with the traffic. The traffic won and he went back in to hospital with a couple of broken bones. Now he's back on the psych ward and today I had to visit him there to apply Section 3 of the Mental Health Act 1983. This requires him to remain in hospital, and to receive treatment, for up to six months. He and I have done this little dance a time or two now, and we both know the likely outcome even as we sit down for the interview that will "decide" the matter. This time he tells me he was distracted and didn't see the cars. And the cutting? Well that was ages ago and he'll get the tendons fixed when he's back home, no problem.

Problem is, like a latter day Yossarian, if he saw the cars he was trying to kill himself and needs sectioning for his own protection. If he was so distracted he didn't see them his illness caused an accident and he needs sectioning for the protection of others. The outcome was never really in doubt. I think he accepts this. But on the way out of the interview room he asked me to assure him that he will be allowed to see the medication he is to be given before they inject him with it, so he can know just what he is being given. It is the only thing I can do for him before I sign my copy of the section paper and I do it with a heavy heart. The problem is I know he will continue to believe the nurses are poisoning him, and in a sense he is right. We can argue it's for his own good, we can argue it is for the good of others, but it remains the only, utterly imperfect, option we have.

I stand there state appointed judge, jury and executioner, depriving a man of his liberty with a stroke of a pen. This is a far from arbitrary act, and it is entirely necessary, but these are decisions I continue to loose sleep over. And then, just to rub it in, on my way out the door to the ward is locked and the nice lady on reception is away from her post, so I buzz in vain to be let out.

For a few short minutes I get a glimpse of Ed's world for the next six months. Then it's back to the car and on to the next visit...

Tuesday, August 15, 2006

All at sea.

The latest Paediatric Grand Rounds are published here and are as usual well worth a look. Brilliant quiz with some excellent posts behind it, and a small contribution already seen here. I commend it to you all wholeheartedly.

On to more mundane matters. I am posting this early so that the week does not run away with me before I can....

You see Famille Jeste are about to step back in time to somewhere around the mid 1930's.

How, I hear you ask.

Well, we are standing as companions to an elderly couple on a cruise. So for two weeks starting this Sunday Dr J will be afloat, living the life of Riley. There are however a few things that are bothering me. The point is I know all about these cruise larks. I've seen the movies, and even read some of the books. So I know there are certain things that will be expected of me whilst aboard ship. Here is the list I have come up with so far. If there are others I have missed perhaps some of you wiser readers might care to contribute.

I presume that I shall be called upon to use my finely honed diagnostic skills to assist the onboard authorities in solving at least one, probably more than one, murder. ( I will of course be looking for Butlers or other disgruntled employees, ex-employees, or jilted lovers of the victims to pin the rap on).

I also anticipate being embroiled in a plot to save a well to do nephew from the scheming of an aged aunt to marry him off to an awfully nice but frightfully dim gel. (We have resolved to spend the entrire two weeks afloat greeting all our fellow passangers-- and especially any Americans we come across-- with a cheery "What Ho!").

I assume I will spend much of the voyage fending off the romatic advances of a stunningly gorgeous heiress, (especially now I have the "Thomas Magnum" style Hawaian Shirt Lady J has bought me for the Tropical Theme Night).

Lastly, I worry that I will be called on to paddle to an isolated desert island, towing Lady J and the offspring, as the vessel slips tragically below the waves never to be seen again. Once on said island I fear the social order will be turned on it's head and my family will be seduced by the wiles of a former butler into an alternative lifestyle that removes me from my righful place at the centre of the household.

Still, all of the above are compensated for by the prospect of round the clock pampering, feeding, and liquid refreshment, and the chance to visit some places not hitherto subjected to the depredations of Clan Jest.

*You probably won't believe this but I have just completed a medical exam for a bloke who used to be a chef on the very ship we shall be sailing on!*

Pip pip!

Friday, August 11, 2006

Quiet here innit?

There is a god of general practice. He is a proud and a vengeful god. And his ears are everywhere.

The observant among you will have noticed a hiatus in the customary output this past week. The thing is I am busy corrupting youth again. For two whole weeks I get to weave my spell on the young and impressionable mind in my charge, selling them a carreer in Family Practice, enticing them away from the Nasty Hospital. This leaves less time for posting and severely strains the Dr J batteries, but in the best of causes. Like I keep telling them I need someone to help pay my pension....

As I said at the top, there is a GP god. A warped individual with the sense of humour of a leprechaun. He watches and listens out for such occasions, and then sends his minnions to do his twisted bidding.

Take the duty surgery. (I wish somebody would). As a general rule the surgery is a procession of minor, self limiting, ailments with the odd bigger problem thrown in, but all of it fairly standard stuff. Till the student sits in. Then we have a freak show of bizarre foreign object insertions, sexual misdemeanours, haemorrhoids, and homicidal / suicidal depression. Often all in the same patient. Such was the case on Wednesday.

So I was dreading todays Duty surgery. Second this week (covering for a holidaying partner) and me dreading a reprise of Wednesday's shennanigans. But, by lunchtime today the duty surgery was pristine on the screen. A neat and tidy row of gleaming white unbooked appointments. Even after a Chronic Disease Management tutorial and a "Ward Round" at the local nursing home the screen was as shiny and white as before. For the first time this year the duty surgery had not one appointment taken by 15.00.

Then the poor sacrificial lamb went and opened it's mouth. It used the "Q" word. On a duty day! I'm sure there was a chittering laugh from just outside the window. And the dogs of GP hell were unleashed.

The phone didn't stop ringing. A flurry of bizarre and complex written queries floated down out of the ether, ambulance men wanted to drag unwilling patients kicking and screaming to A&E for having the temerity to trip over en route to the loo and needed "The Doc" to referee.

Still, it's over now and I'm off for the weekend, so overall not too bad a week.

Quiet even.

Did anyone hear laughter then?

Friday, August 04, 2006


Enter the District Nurse Team Leader *no-- not to the Dambusters March or 633 Squadron* clutching a sheet of paper with a half inch thick red border. This is my least favourite American Import. It is a DNAR.

Do-Not-Attempt-Resuscitation Form.

The patient she wishes the DNAR to apply to has lung cancer, pneumonia, severe arthritis and a number of other ailments. Despite this he is relatively well symptom controlled, but visibly fading. In the past week he has gone from ambulant to bed bound, and from eating and drinking normally to nil by mouth. He is plainly terminally ill after a life well lived, and is not at all distressed except when people try to make him leave his house to go into a nursing home.

Unfortunately he is now almost totally dependent, and so requires round the clock carers since he is estranged from his family (who wanted him to go into a nursing home). Under the terms of their contract the Round-the-clock-Care-Agency (TM) oblige their staff, all former nurses, to pound the chest of any "client" they find to have died on their watch. Unless they are covered by a DNAR.

Sooo here I am on a Friday afternoon talking to a dying man, reminding him of the fact, and asking him if he would like the nice lady to attempt resuscitation should the inevitable occur over the weekend.

This sucks.

He gets reminded of the fast fading light. And all to meet some contractual stipulation imposed by an unfeeling bureaucracy intended to keep the PCT out of the courts. I am still at a loss to understand just how this poor man's care has been enhanced by today's little mise en scene.

Sadly, these days, his is a relatively simple case. At least he has a diagnosis and a prognosis which are fairly clear cut. This is not intended to sound callous. I feel for all my terminal patients, and do my level best to palliate all the symptoms of their final illness, but consider for a moment patients with a more protracted, less predictable course. COPD, Heart Failure, any of a dozen Neuro-degenerative diseases.... even Rheumatoid Arthritis. All have the potential to cross over a tipping point to become "terminal". So when and how should we be having the DNAR chat with them.

It is all too easy for that little talk to turn into the bleakest message you will ever hear. Worse than diagnosis. Worse even than a terminal prognosis. It implies something along the lines of "Sorry old chap, but we feel it's time we gave up on you. Perhaps you'd like to think about doing the same eh, there's a good fellow."

When my time comes, however it comes, I would far rather decisions to resuscitate or not were made at the time and not logged in advance. There may be some grey areas, but most decisions can be arrived at with the application of a little common sense at the time and given the circumstances then prevailing.

I pity the poor fellow who gets to bring me my DNAR for signing up. I think I might start practicing my "Henry Fonda" act now in readiness.

Tuesday, August 01, 2006

The wonderful thing about Tiggers.....

My good old friends on Radio Four tell me the Home Office is warning that we are about to be inundated with Eastern Europeans, stealing our jobs, filling our hospitals with their elderly and infirmed, crowding out children from our schools... raping, pillaging, that sort of thing. It seems they all bought into the whole counter-revolutionary capitalist propaganda we bombarded them with for decades and actually feel that "The West" or in this instance Dear Old Blighty, is the land of milk and honey, so now they actually have freedom of movement and are joined to us at the hip via the EU they are going to up sticks and relocate the whole of Poland inter alia to SW1.


Now to me this is a cause for celebration. To think that I live and work in a land that is so highly regarded that almost the whole world wants to come and join me is quite the most fantastic news. It almost helps me to forget that I now apparently live in a "Rabbit Hutch" according to at least one fellow blogger. (No I'm not going to elaborate. I believe she knows who she is...). Or it might just be the usual protectionist hyperbole stewed up by the "chattering classes" aided and abetted by the Barking Nutter Party an UKIP.

*cough, cough*

Yes, what is it?

*You promised us Tiggers, then you started ranting and using all those posh words, and then you mentioned Rabbits House but still no Tiggers.*

Yes, I know, just try to be a bit patient will you, and do stay away from that hunny, it's medicinal and very expensive you know....

Now, where was I? Oh yes. The Ambridge experience of Eastern European migration.

We have had a small Polish community nearby since the last Great European Unpleasantness. As they got older and intermarried with local gels the character of the community became a little diluted, and there was a small schizophreenic subgroup of Polish refugess sons and daughters marrying the Italian offspring of fomer POWs as they found their shared Catholicism more of a bond than their previous national allegiances, surrounded as they were by the heathen Borsetshire yeomen.

That little community has been quite stable for almost six decades now and is thoroughly integrated. Shortly after I joined the practice we had a new influx. Again refugees. This time from Kosovo. They were a rag tag bunch of single young men and a few older men with families. They had horrors in their heads they could not tell us about. But as the years have gone by and the children have started in local schools, the men found work and an intriguing "working man's" vocabulary of colloquialism and invective, they too have been integrated, excepting the ones who have been deported.

*Ahem-- don't mean to worry you, but there's a small rather sticky looking yellow bear here that wants you to get to the point*

Yes, sorry. Nearly there I promise.

Now, as our erstwhile janitor would attest, we have seen an influx from Poland in the past couple of years. Mainly young adults in excellent health. Some with young families, but mostly all still single. They speak fractured English for sure, but hey, you should hear my Polish... and they do menial jobs for wages the locals won't take. Often two or three jobs all at once (well in shifts obviously, but you know what I mean).

But in their flats they continue to speak Polish, drat them. And especially so to their three year old offspring apparently. I know. Honestly. Whatever are they thinking, talking their own language to their own children. They'll have the Home Office to answer to 'ere long I'll warrant.

*what is the right emoticon for a sticky bear scowl? Whatever it is, insert it here if you will*

My point is.... and we would honestly have got here quicker if it hadn't been for the constant interruptions, looking at nobear in particular, nor the anonymous reader who indulged him, they then bring said Polskiphone (if that's not a proper word it should be, so there) to the Big Scary Doctor. Now, I imagine kids of that age in Poland are looked after in much the same way they are here. Namely jabbed at almost every available opportunity. This must make a trip to the Doctor quite scary enough, but when the Doc then won't even sooth your fears in a way you can understand, how much the more frightening must that be?

So when little Jaroslaw was brought by mum today because he had been coughing all night, he was tired and fractious and scared.

How could I tell? Well the rise in decibels of his plaintive cries as I got within jabbing range was a bit of a clue, even to my non-polskiphone ear. So, enter out hero. A little plush Tigger with magnetic paws long since surplus to requirements at home. Now I consult with him on all my difficult toddler patients. He guides my stethoscope, and confers with me on the findings, or claps himself to their collar / hair braids / other convenient appendage.... and hangs on for grim death whilst I go about my work. And the beauty of this is that he works in all cultures. Even for kids brought up in lands where there are real tigers to be had.

I'm not quite sure if little Jaroslaw was delighted by Tigger or just stunned to see a grown man, and alleged professional, pratting about in such an unseemly manner, but my colleague and I got the job done in total and acquiescent silence thereafter.

Tiggers truly are wonderful things.


Yes, as are Pooh, Piglit, Eeyore, Rabbit, Wol, Kagna, Blot, Smudge, and all the others.

Gotta go now.

*Wot he forgot to tell you wos that Paediatric Grand Rounds are up here and he's in them again*

*Personally I can't see what all the fuss is about but then perhaps if I had brain instead of fluff and sawdust...*

Yes. Thankyou.

But they are, and they're jolly good to. You should take a look if you're interested, or if you're laid up after, say, trapping a toe in the door of a DeLorean.