TGI

Three years ago Sid was taken to A&E with chest pains. There was a flurry of White Coated Doctorly activity, and exercise ECG (negative), Blood tests (all normal), and even, after a brief interval, angiography (wide patent coronary arteries throughout). Despite all of the above he was stuck with a label of Angina and ended up on a plethora of meds, including beta blockers, aspirin, a statin and a diuretic.

The whole process took a couple of months during which he was going to and fro to the hospital, and so was not available for work. This underlined to him the severity of his condition. And yet, throughout it all he carried on smoking twenty a day.

A short while later his heart rate fell catastrophically low, leaving him faint and wibbly all the time. His beta-blockers were duly stopped and he got a lot better. He continued to get chest pains, and so, almost as an afterthought, he was referred to gastroenterologists and had a gastroscopy. This revealed inflammation throughout the stomach and oesophagus-- a common cause of chest pain. So he started more meds for this. The pain got a bit better, but his other meds all continued as before (except his aspirin, given that it causes gastric inflammation) because, after all he had had angina. Still he smoked just as before.

Two years later ( and still with a twenty a day habit) he went to see a new cardiologist. The cardiologist looked at the results, and at the patient, suggested that the pain might not be angina after all, that it would be a good idea if he stopped smoking, and that he might like to see a chest specialist. This really upset Sid, and his wife Joelene. They are convinced he has angina. After all he was told so years ago, and the lack of confirmatory evidence in the interim has no bearing on this. And it's a damn cheek for the cardiologist to tell them he doesn't and then to tell him to stop smoking anyway.

The problem here is the "knee jerk" reaction at the front door of the hospital that attempts to neatly pigeonhole symptoms and channel patients down "pathways" so that independent thought by junior staff can be avoided.

He undoubtedly had chest pain when he went in. It definitely got better after a short interval. Whether the meds truly had anything to do with this is far from proven, but cannot now be disputed after the fact. And now, because his second cardiologist handled his last consult clumsily by daring to mention smoking and not venturing to repeat any of the (previously normal) investigations, rather than being delighted to hear he probably doesn't have angina at all, Sid is now determined to prove the point by seeing a third consultant, and is even less likely to quit the weed.

It's obviously been a cantankerous week, but for me Suid and Joelene, with their millitant smoking habit have hammered in the final coffin nail.

TGI Friday.

Royal bloody college of bloody general bloody practitioners.....

Enter Dr J, back from a house move, and firing on all cylinders. Funny how a few (more) days out of surgery and a complete change of location and routine can recharge the old batteries. So here I have been the last two days, spiffy suit on, (OK you've got me on that one, all the trademark Dr J Smart Cash' togs are probably still in boxes and the suit holder was easier to spot in the post-move morass of brown cardboard) oozing bedside manner.

Goodbye Gregory House, hello RCGP approved Dr Kildare, or as close an approximation as a middle aged grump can get. I have resolved not to curmudge at the punters for at least a week. And I know I haven't told them this, and I didn't see it scrolling across the automated "Call In" system that makes our waiting room so fetchingly resemble Times Square at New Year. But somehow the word is out.

"'Ere old Jesties back-- le's go an' pick a fight wiv 'im!"

How else to explain this afternoon's cavalcade of un-resolvable woes. I swear some of them booked just to have a monty pythonesque "Ten Minute Argument", and at least one of the blighters wanted "the Full Half Hour". It ran something like this:

Ms Blighter "I got this shootin' pain down me arm. Bin there about a mumf."

Dr J (thumbing the intercom) "Janet, a cup of tea for Ms Blighter please, and something sugar free and healthy for her charming little one-- oh sorry Ms, do go on..."

Ms B "Then it goes like forked lightening all over the back of me 'ed"

DrJ "Oh dear. I am so sorry. Here let me take a little look. This might hurt a bit, but I'll be as gentle as I can..."

Ms B "Ow."

Dr J "I haven't started yet"

Ms B "Ow?"

Dr J (rubbing hands to warm them before attempting examination) "Still not yet"

Prod

Ms B "F*****G OW!"

Dr J "So sorry. Here have some tea, there's a biccie to dunk too if it will help. Now then. I think I know what the trouble is. You've a worn disk in you neck. That's trapping the nerve into your arm to cause the pain. Then your neck muscles have cramped up to try to protect it and that's why you have the headache. Lets try you with some decent painkillers, but if they haven't done the trick in a week or so perhaps you might like to see the physio'."

Ms B "Ow! It kills. Bet it's not that wot you said. An' anyway I 'ent seein' no physio wotever you say."

She snatches up the script and flounces out muttering as though I had just acused her of child molestation.

So this is my thanks for beeing all bright and chirpy and Bloody Royal Bloody Collegey.

Two days back and already Gregory is tapping at the door to be let in...

Must resist.

There's a lovely cup of tea here if anyone wants it.....

N.F.A.

We are nearing the end of our two week period of self imposed homelessness. By Friday evening we should have taken possession of Jest Acres and at least begun to move in. The movers have promised we will at least have our own beds back by Friday night even if tons of other stuff has to wait till Saturday.

If I’m being honest we have only really been playing at it. Yes we have spent several nights with all four of us in one room, after eating fast food from one of a variety of outlets. But the kids have had offers of sleep-overs at friends for the end of this week, we escaped to relatives for the weekend, and we knew full well we would have a lovely new home to go to this Friday. Still the experience has been significantly stressful, with predictable squabbles over the length of time “certain people” are spending in the bathroom, mum and dad chatting too loudly when “we are trying to get to sleep” (yeah right), the lack of milk / fridge / decaf tea…… space.

To their credit, despite an increase in whinginess the kids are not at one another’s throats and are about to be spared their enforced cohabitation by the aforementioned sleep-overs. Mum and Dad ( yes that’s us—Dr and Lady J) have held it together with just a few terse words on a couple of occasions. We have been driven mad by the lack of a postal address or landline / answerphone for contact (though mobiles have just about managed to field most of our necessary communications). We have been cheered by the kindness and concern shown by our friends and family, especially the couple who received our change of address card, noticed the hiatus between the move out and move in dates and promptly rang to offer us a meal which we thoroughly enjoyed last night. To do so they even managed to negotiate the fact that all they had was a defunct mobile number for us, by ringing the surgery and leaving me a message!

All in all we have been very lucky. Still if we never see the inside of another “family” motel room it won’t be too soon. And I have a new respect for those of my small flock who have to do this for months at a time. I can well understand how it “does their head in”. It might even make me stop and buy the occasional “Big Issue” from now on, and this years charity xmas cards might just change their focus slightly too.

So if any of you know anyone in a similar position, give them a call and offer a chat, a cup of tea, a meal if you can. You might just save their sanity.

Though admittedly some of us might be beyond help in that regard ;-).

Home thoughts from afloat III

I know we've been back over 2 weeks already, but there are still things to say, and not much happening in surgery so here goes.

"If it's Sunday it must be Roma." It was, and it was, or at least it was about to be. What it actually was to start with was Civitaveccia. Now any schoolboy will tell you (at least any clasically educated schoolboy, anyhow) the port of Rome is Ostia. Well, not any more it isn't. It's Civitaveccia now. I gather that means "Old Town" which, when you're next door to Rome itself seems quite a bold assertion, but since all we got to see of it as we were whisked away by coach were docks, warehouses and cement mixers it's hard to comment really.

Around an hour later we were in Rome proper. In brief we did the Trevi Fountain (where nowadays you get to chuck coins with much smaller denomination that the old "Five Billion Lire" piece); Trajan's, Augustus' and Juilus' Fora; the Flavian Amphitheatre: then, last but not least St Peter's Basillica. Our guide was a fantastically knowledgeable Italian lady who refused to acknowledge the existence of queues, breezing through them and imparting information all the while, from her radio-mike straight to our earpeices, and, from the look of some of our fellow travellers, straight out the other ear in many cases.

We learnt, among other gems, that the huge "Tea Urn" to the right of the Trevi Fountain as you look at it, was sculpted to block the view of a notoriously nosey Barber who kept annoying the sculptor with a daily critique of his efforts as seen from the barbershop window. Also that gladiators had a cushey life most of the time, (apart from when they were actually killed that is). Further, we learnt that when you see a line of people standing about outside an ancient monument or prominent place of worship you should just get out your stick with a glittery bit of ribbon on it, raise it aloft, shout "follow me" to all and sundry, put your head down and just keep walking. Then a few minutes later, explain to your group that the folks coming in behind you look a bit cross because YOU jumped the queue.

She talked about Roman and Vatican history from 700BC to the present day, occasionally stopping to draw breath, and put much of what we got to see into some sort of context. And what we got to see was two milennia and more of monumental architecture designed to affirm that this place we were standing was the undisputed centre of mankind's universe. Standing in St Peter's, having toured the antiquities, the overall impression was of continuity. The Empire might have fallen centuries ago, but the Holy See had moved in, stuck up a building that proclaimed "Under New Management!" and had carried on regardless. The opulence that fills the basillica would have been entirely recognizable to the Caesars, Flavians, all the old Imperial dynasties. It proclaims as loudly as it can that here is the home of all earthly power.

The supreme irony is the sealed door, bricked up for twenty four in every tweny five years, more or less. Once in every generation it is opened for a year of Jubilee, as a call to forgive old debts and renew the faith. Just once. Unless an encumbant Pope decalres an extraordinary extra year to mark some other significant anniversary in the life of the church. The rest of the time the incalculable wealth of the church lies symbolically shut in, cut off from the christian empire that fills its coffers, as remote as the Caesars from the Picts.

Hopelessly Devoted

Our students are often surprised when a “theme” emerges during a surgery. However it works sometimes the fates play quirky tricks and one surgery will have all of our “John Smiths” booked in to be seen one after the other, quite by coincidence, or there will be a stream of pre-schoolers with lego bricks or beads up their noses… that sort of thing.

Yesterday morning it was elder men and relationships.

Three of them.

One after the other.

EM 1 came in to review his repeat medication. Just three items, and two of them for blood pressure. We checked his BP (well within target on this occasion) and I agreed to renew his script for a further twelve months quite happily. He needed a new issue so just before printing I thought I had better check with him about item three, not filled since April. Sildenafil… or Viagra if you need the brand name. Our conversation went a little like this:

Dr J-- So would you like -

EM1 (hastily interjecting)—No thank you!

Dr J -- ? (the TM quizzical eyebrow)

EM1 – I’m not like that Des O’Connor you know.


And that was that. Plainly he didn’t want to talk about it and we moved on to the renewal of his BP meds.

EM2 was widowed eighteen months ago. We reviewed his osteoarthritis and agreed it still rendered him unfit for work. It is likely he will be medically retired in the near future so we agreed to review the position when his employer’s insurers had been contacted. Then he looked a little bashful and said he wanted to ask a “personal” question.

It transpires he has been “dating” again as our U.S. cousins might put it. Nothing too involved, just dinner out on a couple of occasions, but each time when he got home after a pleasant evening of one to one female companionship he has felt terrible. It’s a mixture of guilt and anxiety which he thought was unique to him. He seemed happier after my reassurance that it was not, and that it would be ok for him to persevere if he wanted. Hopefully he now understands the origins of the guilt, and the fact that he has no need to feel so terrible. It’s like he was looking for my approval. I hope he now knows that he has it—but that he shouldn’t need it in any event.

EM3 has been caught like a dolphin in a tuna net. He has Ischaemic Heart Disease. This is well managed by our thoroughly able in house CHD team. This year, as part of our contract we are obliged to screen our “Heart Disease” population for depression as well as reviewing their other CHD risk factors so the nurses asked him the required two question screen… along the lines of “Do you feel sad?” and “No go on, really, do you?”

Indeed he does. But not through his, entirely well managed, IHD. No, his problem is Mrs EM3. She has dementia. It has been progressing for some years and is now increasingly severe. She hardly goes out. She sees old friends as strangers, and strangers as a threat. She declines the offered help and flatly refuses to contemplate respite. Every three to six months in outpatients the Psych’s ask her how she feels. She Says “OK”. They ask her about her memory and she shrugs and chuckles.

All through our consultation he is looking at his watch. She has been left alone at home and he worries she will have left the gas on or microwaved the cat. If he talks to her about his need for help she gets nasty and says spiteful things, or, when it’s really bad, hits him. “But” he says, “we promised each other for richer or poorer, in sickness and in health….”

He knows he is struggling, but “When I look at her when she’s sleeping I KNOW it’s not her fault.” He’s thoroughly trapped. So the next time they see the psych’s he’s going to chime in when they ask how she is, and really tell them. Till now he has felt it’s not for him to comment. I hope he is now persuaded he really needs to.

Happy birthday to me...

.. blog.

It seems this freeform free association rambling I have the nerve to call a blog is about to be a year old. Admittedly, after a fairly tentative start there was something of an hiatus caused by a jesterly crisis of confidence, and the need to sqaure the circle of telling believable stories of GP life without letting any cats out of bags. The upshot has been a relocation of the surgery to leafy Ambridge, and it's all the better for it. Now I get spectacular views over Lakey Hill instead of dreary suburban sprawl, and a cast of characters to die for.

We have seen many aspects of life and health from cradle to grave, (and even beyond) and I have been lucky enough to show off when fabbo holidays have taken me far from dear old Ambridge. It's truly been a lot of fun, and I've also "met" a lot of lovely bloggy people who entertain and amuse me far more than I could ever hope to reciprocate.

I'm still pretty amazed that anyone but me can take the time and effort to wade through any of my incosequential mumblings, but I bless all of you who do. I am even more stunned that some of my less looney submissions have made the grand rounds, both general and paediatric. They share webspace with some truly fascinating pieces that I feel priviliged to have had brought to my attention, and I commend them to you all once again. The latest PGR is now up on Shinga's site here.

There is likely to be another brief hiatus because tomorrow, thanks to the ludicrous way UK property laws work, I and famille Jest become "homeless" for two weeks, between the sale of our current property, the quondam "Jest Towers", and the vacation of our new country seat by its present occupants. I get the feeling living out of a suitcase and blogging might not entirely work, but we shall see.

For now I'm off tonight for a final look at the old pile before tomorrow's move out, and I intend to raise a glass to all of you who have visited in the past year.

Cheers!

Food for thought

Grannies up and down the country must be standing there with crossed arms nodding in grim satisfaction. They've been right all along it appears. Fish really is "brain food". Or so the powers that be in County Durham think. And they're busy generating the evidence to back this up. I gathered all this this morning from my favourite source of "medical" information, the Today Programme on Radio 4.

As I understand it there have been several small scale trials there involving primary school children (so they would need to be small scale then obviously) taking cod liver oil capsules or placebo for a few months. The fishy kids are now outperforming their placebo riddled fellows academically, and spending less time in the naughty corner to boot. (Hopefully the placebo supplied was not the "dangerous" additive laden Killer Blue Smartie then...)

So now they are moving on to trial the addition of omega3 to the secondary school kids. You know, all those stroppy tweens and teens we know and love. Three capsules, twice a day.

The teachers and dinner ladies of County Durham must be made of stern stuff indeed to be prepared to put themselves forward for such a monumental task. Round these parts they won't allow kids to take paracetamol or inhalers for known conditions without notes signed in triplicate by "the Doctor". A few years ago they even threatened not to work in a class with a boy who had a wasp sting allergy that required him to carry an epipen.

Then there's the small business of getting kids who happily chuck down burgers and kebabs to swallow little capsules. Because they're "pills" rather than "food" there is almost no way many will be induced to swallow even one, let alone six a day, every day, all term. Also they are proposing to dish them out at registration so all the truants and latecomers (surely the principal target population for the study) will be self excluded by their normal behaviour. Unless the truancy officers will be supplied dart guns laced with fish oil to stalk their prey with, that is.

I really hope thay can make it work. I really hope it helps to prove the point. It does seem to make sense that a diet rich in vitamins and minerals, complex cabohydrates and proteins, would beat a diet of chocolates, crisps and fizz. Jamie Oliver's much hyped school dinners project really did apear to have an impact on both performance and behaviour.

Which leads me to ask one important question. Why on God's green earth do we feel it necessary to bugger about trying to supplement kids diets to improve performance instead of committing to giving them all a decent school meals service that would do the same, but better?

If we truly "believe the children are our future" (sorry, couldn't resist) then why do we not believe enough to want to invest in that future?

I applaud the intentions of those wishing to conduct the trial. I fear they will not last a week, let alone a term, but I do honestly wish them well. And who knows, if they can prove the point, again, then maybe someone in authority will discover the political will to start feeding kids properly.

Until then, drink up your cod liver oil like good children.

After all Granny knows best!

Adventures in Dunking

Astute readers will have noticed that the NHS in general and GP land in particlar are run on a steady diet of caffeine laden drinks and chocolate coated biscuits. Show me a medic, and I will show you a dunker. We can't help it. There is some mystical attraction between chocolate laden oatmealy things and steamy cups of coffee akin to the pulling power of a Black Hole. It even works when the chocolate is squirreled away in fondant form between slabs of biccie a la Bourbon Creams.

So here I sit, second day back after a two week sojourn. Kids not yet in school so Lady J bravely at home holding the fort. Dr J in the office early to sift through the backlog of letters, reports, weird messages and requests for Methadone scripts from the drug team boys and girls. Being manly and having to "get in early" I eschew breakfast, knowing full well that there are a desk top coffee maker and a trusty biccie tin awaiting me on arrival, and so it is.

The milk is even at the surgery door when I pull up ready for the fray. Without further ado the computer is switched to on. (Yesterday thare was a better than evens chance that it would then go "phut"- not so today. Result!) So off to the galley-- sorry, kitchen-- for the trusty mug. In with a splash of milk, just enough for the trademark Dr J "Grey" coffee, too dark to be brown but not quite the inky blackness of the truly addicted... thence to the tin for a biccie or twain. Oh, ok, three if you must know, but who's counting?

I pop down the biccies on the desk and pour the now steaming java into the waiting mug. The incomparable aroma snakes out and works its caffeiny magic. Suddenly all's right with the world, which, after yesterday, is something of a triumph. Then it happens. The mystical attraction begins, and before I know it half a mug of java is swirling out of the upturned mug and engulfing the biccie pile. I had obviously left them too close in my haste to prepare my libation. And worse, the slick also engulfs the pile of DWP* report requests that have accumulated in my absence, so now all the Benefits Docs will have their suspicions that I am not safe to be let out unsupervised confirmed.

And as a method of dunking it sucks too. The edges get a bit soggy but the middly bit stays too crunchy. Worse still you dare not re-dunk them for fear of the soggy edges dehiscing completely to sludge up the bottom of the mug. So looks like today is all set to be a re-run of yesterday after all. Bum.


*I refer of course to the Orwell inspired rebranded "Department of Work and Pensions"

Home thoughts from afloat II

In the end blogging opportunities didn’t really arise for the rest of the hols, but it left me with loads of ammunition, and, having stepped back in to the predictable shit-storm here at work after two whole weeks away, I think I would rather talk about times just past that work for a while anyway, so here goes.

A tale of two cities.

Barcelona and Firenze

(Why do Anglophones have such difficulty calling for’n places by their proper names? It’s hardly difficult, and it has a Z in it. I like Z’s so there….)

We had a trip out to each on days four and six respectively, and I was left with the following impressions, having never been to either before. Oddly, both cities seem to trace their origins back to early Imperial Rome or there abouts, but they couldn’t be more different.

Barcelona, from my admittedly very touristy prespective, is a brash noisy kaleidoscopic place that owes much more to Gaudi, Picasso and Joan Miro than to the Romans or any intervening cultures. Ok, there is a gothic quarter, with a very grand cathedral, and geese, but the whole city is dominated by the building site that will be Sagrada Famiglia as and when it gets completed.

And what a weird building it is. I can’t help but feel it has been wrecked before it is even completed (and that is still a projected 40 plus years away). The thing is the bits that Gaudi did before his efforts were cut short by a fatal encounter with a tram, all look very organic, with forms taken from nature. There are very few straight edges to be seen and motifs of plants, lizards and fruit combine bizarrely with the biblical images of annunciation, birth and redemption. At the other end of the building some cubist monster has reconstructed the passion all angles and boxes. Now I know I’m getting a bit old and set in my ways, but this mish mash of styles just didn’t do it for me. It’s almost as though the good burghers of Barcelona all went out one night after realizing they had to come up with one arm of their spangly new showpiece cathedral and got the least sober of their fraternity to draw up the plans on an etchasketch.

That said, the “Spanish Village” atop Mount Juic takes tourist kitsch and turns it into art. In one small “village” they have recreated buildings and landmarks from all over Spain, and turned them all into little retail outlets selling marvelous glass, wood and sundry other artifacts (along with killer green apple slushies).

And the whole town abounds with architecture, sculpture and art from the likes of the aforementioned artists, and even Roy Lichtenstein gets a look in with his surreal “Head of Barcelona” sculpture.

I never did Acid as a student, but I get the feeling, having seen Barcelona, I now know what I was missing.

Firenze couldn’t be more strikingly different. A city of high renaissance splendour set out on a grid that would probably have been familiar to its Roman founders. The “wedding cake” Cathedral and churches, clad in particoloured marble, seem to pop up round every corner. The statuary of Michelangelo Buonarroti ( I never even knew he had a surname before…. Duh!) and his rivals and near contemporaries dominate the main square of the city or Piazza Signoreia (ok I know they are all copies now, but they are none the less striking for that) seemingly unchanged since they were first given life by their sculptors. In short the Medici would feel at home if they were zapped back into being there tomorrow. And they’d probably do something about that funny looking policeman with the ponytail too. Call me old fashioned, but if a copper is going to “pack heat” he should at least be man enough to go for the crew cut look as well.

That about wraps it up for this installment. More to follow when time permits….