Tuesday, October 31, 2006


Today the road to work will be jammed with Headless Horsemen, Ghosts shall roam abroad, and probably here to. Tonight is THE night for things to go bump. Mainly door knockers, admittedly, clattered by sticky fingered apparitions of tiny horrors demanding sugar "with menaces". Tomorrow the saints shall have their day, though here in Blighty that one manages to slip by essentially unmarked, but tonight belongs to spooks and spectres.

Around this time of year I too often have a restless night when the ghosts of two decades come to visit. They do nothing to threaten, offer no harm, they just seem to feel the need to stop by and renew an old acquaintance, before shuffling off to whatever the hereafter has to sustain them.

Their numbers swell slowly over the years as old friends from this world move on to the next. Many seem content to pass through, let go, and be let go, but some insist on sticking around for some unfathomable reason. I can detect no common thread save perhaps for my involvement in their care before their passing. They are of all ages and have been claimed by a disparate assortment of causes of death, but somehow the connection they made in life has carried forward to the present, and they insist on being remembered.
Allow me to introduce a few. There’s three very small ones all claimed my Microcephaly, a cruel malformation that leaves an infant with just enough brain tissue to survive perhaps a few years, unable to develop beyond total dependence, and prone to fitting and repeated chest infections. At the funeral of one of them they played a Bangles song that I still can’t listen to without welling up.

There are two old soldiers, one who regaled me with crystal clear memories of the Somme, but couldn’t remember what he had had for lunch, and who was still suffering the effects of the mustard gas that had ended his time in the trenches seventy years on. The other had his leg shattered by a machinegun bullet on the first day of the same battle. He was lucky enough to have fallen directly into the hands of the "enemy". Bavarian surgeons saved his leg where his own countrymen might well have not. Later, recovering from his wounds, his hand was shaken by the King of Bavaria. After the war he had a long and distinguished career at the footplate of a locomotive before enjoying a long and happy retirement.

One wag always asked for his appointment with "Dr Pest" with a twinkle in his eye. Consultations degenerated into a sparring of puns, which he seldom lost. Another dour ex-miner with ruined lungs suddenly brightened up one day, and apropos of nothing volunteered that as a lad he had a brief career as a jockey, and had ridden a couple of winners. His tips for the Grand National generally turned out to be absolute donkeys though.

Two ladies, both terminally ill, followed very different paths to their end. One started her pain relief very early in her illness, progressing slowly form intermittent doses of morphine to constant administration through a syringe driver. Still throughout her illness she supervised her household, saw her children through one more birthday each, a Christmas, a New Year, Valentines day, and almost made it to Easter before succumbing to her illness, and this despite being declared "terminal" the summer before. The other lived in constant fear the morphine would hurry her end, and was determined to resist that last step. She tolerated pain rather than accept the fact that this was going to be her final illness, and with grim determination set her affairs in order and slipped gracefully into a coma with minimal interference, fiercely independent to the end.

There are many others. Why they insist on being remembered I can’t say. But they stay with me, and I suspect will continue to do so down the years to come. Now and again they come to visit, just for a night, and then they quietly return whence they came. They ask nothing. It seems remembrance is enough for them. And so I will remember them.

Happy Halowe’en.

Wednesday, October 25, 2006

Loose lips....

used to sink ships apparently. Now they upset grannies. Or one Granny in particular.

"?" I hear you ask so eloquently.

Allow me to explain.

Josh is a mate of mine. He's six now. When he was eighteen months old he had a "turn". He went all clammy and pale and fell over. Mum and Granny didn't think much about it at the time because it was over in a few seconds and he was right as 3.6p (Ninepence in Old Money) in no time. Then, a few months ago he started having "turns" at school. Just one at first (well obviously....) but the next one a month or so after that, then two more in a week. Since Mum was being called out of work on each such occasion both she, and the nice school secretary who had to accommodate Josh in her office (while she fretted in case he "went off on one" before mum came to collect him), were concerned enough to ask for a paediatric referral.

Josh remained the picture of rude good health throughout this time, ate well, grew and developed normally, and other than his occasional "turns", romped about with typical six-year-old vim and vitality. Still a paediatric referral seemed like a good plan, so that's what we arranged.

He came back to see me this week after a plethora of normal tests. The Consultant, a very good and eminently trustworthy opinion, is happy that his turns are not serious and need no further investigation. Granny however is not so sure. The thing is, the nice smart young Doc who saw her with Josh in the clinic told her he could hear a "murmur" that was probably the cause of his turns. His letter says the same, though it goes on to point out that the murmur had gone when the Consultant listened, and that he had explained to Granny that this could happen to "murmurs".

Well, call me old fashioned, but murmurs of a severity sufficient to cause "turns" shouldn't really do that. Indeed they should have much more of an impact on growth and development before the age of six, and probably have been present if not at birth then very soon after.

Now I must have listened to Joshes chest a couple of dozen times down the years and I've never heard a murmur (and still didn't this week as it happens). I know I've listened to a lot of Motorhead and the like down the years, but I can still hear the dropping of a pin at several dozen paces, so I like to think I might have spotted such a thing before now. Likewise I am sure the Consultant has heard a few murmurs in his time, what with being a paediatrician and all, but the nice young Doc in the Pressed White Coat of Diagnostic Loveliness has pronounced, and so now Josh has a "murmur".

For now, the Consultant and I have persuaded Mum that he is fine and no more tests are needed, but I can tell that Granny is not so sure. Which is a shame, because after further discussion with Mum and Josh this week it seems highly likely that his "turns" are actually simple faints, caused by reflex drops in blood pressure when he first leaps up to charge about after being confined at his desk for too long, of after getting up from sprawling about like all six year olds are occasionally wont to do.

Some folk really are just a bit more fainty than others and we don't have to make them all ill. And some heart sounds are just sounds and not murmurs.

Tuesday, October 24, 2006

Sorry to bother you....

Did I miss a meeting?

Every other patient today has been "Sorry to bother me..."

I didn't think I was that irrascible, but a steady stream of recurrent depressives have been sorry to bother me with the impedimenta of their several causes of distress. A couple of chaps were similarly apologetic when presenting with "lumps" that were reassuringly non-malignant, and a lady who might be pregnant, reassured that her right flank pain was only muscular was "very sorry" for wasting my time.

All this sorrow is driving me quietly mad.

As often happens I have had the company of a Medical Student today. I want them all-- the students that is-- to see me as as dear old avuncular Dr J, the peoples friend. Instead, with all these people so sorry to have taken up my valuable time, I'm guessing I'm coming across much more "Simon Cowell" or "Alan Sugar". And I haven't even fired anyone in weeks.

(And even then they resigned and it was nothing to do with me really, just a case of artistic differences that had driven the members of the band apart....)

I think it must be the smart grey suit and somber tie. Well now we've unpacked properly I might be able to wheel out some zanier neckwear for the 'morrow.

If all else fails I could use it to throttle the first person who's sorry to trouble me!

Wednesday, October 18, 2006

The Living Dead

You can tell I'm gearing up for haloween can't you.

Thing is, there have been a few patients recently who could be said to fit that category, including one charming gentleman this morning. They all have one thing in common. A terminal prognosis. That is to say that we have identified in them a condition that will, whatever we do, and unless some other catastrophe intervenes, claim their lives. They have crossed some invisible line between the curable and incurable.

It is very easy for patients and their relatives to hear one message at such a time. "I'm very sorry Mr Bloggs but there's nothing we can do".

Well that's just not true, there's plenty we can still do. For my patient this morning the introduction of steroids have transformed his appetite and his sense of wellbeing. They have also, coincidentally, done a great deal to help his arthritis (not his terminal condition, but a potent source of misery in its own right). In restoring his appetite they have also brought some pleasure back to mealtimes, both for himself, and for his wife who was beginning to doubt her culinary abilities quite unneccessarilly.

He has also been able to have a number of pulses of palliative chemotherapy which have helped at least slow his disease progression. And throughout it all, despite the fear that came with the original diagnosis, he has managed to keep his good humoured nature and positive outlook. We both know that he is already as good as dead given his diagnosis, but he is determined to keep on living, in the very best sense of the word, for as long as he can. And today he reached a landmark.

Back at diagnosis he asked how long the oncologist thought he might have left. She was pretty clear in her prognosis-- a month or two perhaps, probably not six months. That was six months ago, and today he feels fitter than he did back then and is "very happy to have proved her wrong".

Monday, October 16, 2006

Fear of the Dark

It's October in Ambridge. Well Ok, it's October pretty much everywhere else too, but I'm in Ambridge, and it's October here. So with that established we shall move on. Here, as in the rest of Dear Old Blighty, and indeed much of the rest of the northern hemisphere, October heralds three things.

First we see the arrival of the brandy cream in the supermarkets. After all it's nearly christmas you know. Never too soon to stock up on all those festive essentials like brandy cream! (?) I believe Santa has already put in an appearance at some of the more entrepreneurial stores. Soon we shall be heralding the onset of the festive season before the kids have ended their summer holidays.... but I digress.

Second, all the same supermarkets fill with the tacky paraphernalia for haloween. Skull masks and scythes line the shelves, along with additive laden fluorescent orange pumpkin shaped "novelty" sweeties. Teachers must lie awake at night dreading the first week in November when the schools will be full of tiny whirling dervishes hyped up on sugar and e numbers after the outbreak of communal poisoning that is "trick or treat".... but I digress again.

Third, and of more relevance in GP land, the days get shorter and shorter. It seems to start happening all of a sudden. The sun drenched joy of the morning drive to work becomes a gloomy trek through stygian lanes, rain lashed, gale buffeted, and dismally dark. The trip home, instead of a drive westward into the setting sun becomes a night ride into the very jaws of hell itself. (Well, ok, Borchester, but you get the picture). The upshot of this is that a number of my regulars start to get a bit S.A.D. (that's seasonal affective disorder -- not just the ususal random Dr J typing skills).

It starts with a sort of "fin de siecle" ennui, a nameless, free floating dissaffection, but left unchecked can turn into a full blown dose of the moodies, with bleak unremitting depression as the year spirals down the plug 'ole to the shortest day. It can take two or three years to recognize that this is what's happening, but I now have a small cohort of punters who know to "book early to avoid dissappointment". They are all now trotting in to start their antidepressants in readiness, like transylvanian villagers stocking up on the garlic and the holy water before the snows of winter leave them stranded at at risk from the nameless horrors that lurk in wait in the castle on the hill.

Perhaps it's no coincidence that we fill the streets with tiny horrors at the end of the month after all. Or that we try to bribe the same horros to go away with little candy morsels.

Prozac anybody?

Friday, October 06, 2006

Centre of Mediocrity

You would be forgiven for thinking that, Terry Wogan-like, I had sloped off again on holiday for a week. Nothing would be further from the truth.

In reality the cantankerousness of last week carried right on into this week as well. Two consecutive days as duty doc for the practice did little to improve my humour. Our staff in the benign dictatorship that is the Ambridge Practice have been a little fractious. It's peed down with rain quite a lot the past few days. A lot of it on yours truly. In short the whole week has been a bit of a B.

To cap it all a poor lady came in this morning to talk about her outpatient appointment. In September last year she was told she would be seen in clinic in six months. In February, a month before this planned appointment, she received a letter cancelling it, and rebooking it for September this year. Yes you spotted it, that's a bit more than the intended six months. 100% more to be precise. Oh well, she thought, they must be busy and my pain isn't so bad. So she put up with it and didn't tell us about it.

One week before her September appointment date she had another letter. Her September appointmnet was now cancelled and rebooked for November. Oh well, she thought. November's not that far off now. Perhaps it will keep till then. Still she did not feel it important to tell us.

Yesterday came letter number four. So sorry. No clinic date in November after all. Perhaps she could come next April!

Now, when you have not been seen in outpatients for more than 12 months the local health admin will often send you a frosty letter asking if you really need an appointment after all. She must be about due for one of those by now. At last today she thought she might need to let us know what's been going on, or rather, not been going on.

So the chief exec of our NHS Acute Trust will be hearing from me. Shortly. In every sense of the word.

And this is the week the masses took to the streets to "save" the Ambrigde and District General Hospital. Seems in the light of present experience there may not be that much left to save.

I'm off home now.

Will the last one out please turn out the lights.