Monday, June 25, 2007

Testing.... testing....

“Never,” admonishes the old, beak nosed, fossil of a medicine professor, resplendent in a pristine white coat at the foot of some hapless victim’s bed in mid Grand Round, “never, request a test to which you do not already know the result!”

We somewhat more shabby looking and infinitely more sleep deprived juniors huddle round the hapless punter’s bedside, gazing at our shoes and wishing that Dr Bloggs hadn’t blurted out the first test that came into his head when the Prof quizzed the assembled company as to what was to be done to our victim next. After the round we would all shamble off to the mess and commiserate with poor old Bloggs, whilst secretly congratulating ourselves that for this round at least we had evaded the basilisk’s gaze.

Then we would have a group chunter about the arrogance of old age and professed professorial omniscience. How could we be expected to diagnose and treat without the freedom to do tests. After all we had sweated and strained for years to train to this point, finally to be given the run of the toy-box that was the path lab, only for our elders and betters to now repeatedly nag at us not to use it.

I’ll warrant that there isn’t a houseman / intern trained in the past four decades for whom the above scenario doesn’t ring true. And yet as I sit here in what I take to be the mid-point of my career, I find myself more and more on the side of the fossils. Perhaps this ossification is just a part of the natural conservatism (very small c for this writer) of advancing age and experience, but it comes more form the increasing realization that the more tests you put otherwise healthy folk through, the more anomalous results you find, and the less you have a clue what to do with them.

As a case in point I offer the following. Our local path lab has recently “enhanced” its level of service by including for free in all liver function tests an assay of an enzyme called (in short hand) Gamma GT. This enzyme is well recognized as a marker for excessive alcohol intake, but sadly it is not at all specific as other forms of chemical challenge to the liver (including many prescription medications) will also provoke a rise in levels.

In these days of health promotion and disease prevention we have a lot of patients on med’s (especially statins) that require regular monitoring of their liver function. In the past six months, since the path lab’s generous “upgrade”, many of them have had their liver function tests reported as “abnormal” as a result of higher than expected Gamma GT levels. Doubtless a number of these patients will have taken our advice about a glass of red wine a day being good for the heart a little too literally, but the majority (we are a sober society here in Ambridge—Eddy and Lillian notably excepted perhaps…) will not. And now they have “abnormal” Gamma GT’s what are we to do with this unasked for knowledge.

We have invited a professor to comment.

An eminent professor from the centre of excellence.

I’ll leave you to guess what his reply was….

Friday, June 15, 2007

Out and about.

Today sees Ambridge temporarily twinned with Transylvania. Vicious forks of lightning stab earthward from the lowering inky black clouds. Great peals of thunder rend the skies. The peasant hordes throng the streets brandishing pitchforks and blazing firebrands-- which is admittedly a bit odd in June in a light industrial suburb, but there you go, it must be the thundery weather (or perhaps the Sale at the Fancy Dress shop in the precinct...).

The rain lashes the windows of the car before being unceremoniously shoved aside by wipers on their highest speed setting. The rain suddenly stops. The wipers flick little steams of sparkling diamonds over already drenched peasantry as they wave their, now extinuished, steaming firebrands at me. The wipers yowl in pain across the now dry screen then degenerate into desultory fart noises till I can flick them back to off.

On the whole I'm rather glad I only had one home visit to make today.

Monday, June 11, 2007

Ambridge invaded.

Indeed, much of Borsetshire, and possibly other neighbouring counties too. We are hosting a delightful group of fourteen and fifteen year old German students on the return leg of this years foreign language exchange, although of course for them German is scarcely a foreign language...

Exchanges have changed a bit since my day when you were farmed off to a family somewhere in the "near abroad" (France in my case, since there was no possibility of a latin or ancient greek exchange-- chiz chiz*) still in short trousies, and left to fend for yourself. These days the poor kids seem to have some cultural thingumy laid on every day and just use their host's places to crash in, except at the weekend.

So this past Saturday saw the gates of Jest Acres thrown open to around a dozen of our visitors and a similar number of their hosts. We were all on our very bestest best behaviour. No Basil Fawltys, no mentions of Minehead**, no "Two world Wars and One World Cup"s. Not that I think the kids would have known or cared what the hell the fuss was all about.

As a baby of a baby boomer, the last great european unpleasentness, and indeed the one before, cast a very long shadow. Not so for this generation. It was wonderful to see them all lounging about on the beatifully manicured lawns (did I mention I'd mown them myself-- no?-- really?) chatting about football, Schumaker and Hamilton, swapping Ipods and generally getting on with being teenagers.

Being parents of a lad, we had not, so far encountered many of his female contemporaries, so those he had invited to our little barbie were as new to us as their German guests. Indeed we had to spend a moment or two sizing each little girlie huddle up come feeding time before knowing whether to speak normally (assuming they were Brits) or slowly and loudly in time honoured tradition (if not). I have to admit to getting it wrong at least once.

And during all this whatever the correct german term for "entente" building, there was I manfully flipping burgers and sizzling bangers on the barbie, wreathed in the heady smoke of carnivore heaven. There can be few jobs more satisfying than hunter gathering a shedload of meat patties, scorching them to an even charcoal black, then watching the resulting mound of meat products disappear. And such caveman cooking needs no language, but crosses all supposed cultural boundaries, taking us all back to simpler times.

And this was when I stumbled across a dichotomy. As recreation there is nothing finer than setting to, firing up a griddle and providing for your tribe and their guests. Yet as an occupation it has become something to look down on.

Sorry, but that was it really. No great revelations or damascene experiences, but a thoroughly pleasant weekend in the company of a bunch of charming teenagers who despite their differing languages had more in common with one another through their use of Ipods, MSN, email the ubiquitous mobile phone et al, than with their wrinkly parents. Somehow I find this massively reassuring. However screwed up the world we have made for them I've got a feeling this next generation are globalized enough to start to put aside our traditional tribalism and get on with the job of sorting it out, or at least of going down in style to some bangin' tunes as the flashes from their camera phones light up the night sky.

* and ** attract the usual cyber-hobnobs for correct provenance.

Friday, June 01, 2007

St Elsewhere's

It’s been a long time since I have had anything to do with hospitals on a regular basis. Yes I’ve attended the odd meeting, visited an occasional patient, and for a few years either side of the millennium our out of Hours co-op sat cheek by jowl with A&E, but in all I’ve not had much call to spend time on hospital wards for yonkers. That all changed recently for reasons that need not worry us for the purpose of this post. Suffice it to say that I have been spending a couple of hours a day on a ward for the past fortnight, with time to observe what goes on, and with a mole on the inside to fill me in on the patient’s perspective.

Some things have undoubtedly changed, gone, for example, are the old “Nightingale Wards” of my medical youth. It’s all four bed bays now, and almost all single sex as well, and not before time either. Though it does rather deprive current inmates of those all too precious “Carry On” moments of yesteryear.

Thanks to the working time directive, perhaps helped along by decades of deficit and finally entrenched by the recent MTAS debacle, Doctors, even callow “Juniors” are now invisible. In two weeks of visits I think I saw a “Housemonkey” once, but it might just have been another visitor with lots of pens in his top pocket…

It seems in Patsy’s modern dependable NHS all the work of the ward is done by super-nursies instead. Not that there’s anything wrong with that per se, but I do rather wonder what has happened to the doctorin’ we used to be allowed to get up to between clinics and theatre lists.

On the other hand there is much that remains the same, and somehow, probably, always will. Rubbish gowns that show your bum to the whole wide world, horrid foam mattresses and pillows seemingly guaranteed to deprive even the soundest snoozer of the last vestiges of a restful kip, shabby flowers in greenish ooze in manky vases….

But the main thing I couldn’t help but notice is just how infantilizing the whole business is. From first thing in the morning to last thing at night the day is regulated and governed just like the Victorian nursery. You are woken at a set time. Breakfast follows. All the food, all day is nursery food, Cauliflower Cheese, Sponge and Custard and so on. And sometimes Nanny is “nice” and sometimes Nanny is “nasty”, but never Mary Poppins. The inmates are almost all and almost always talked to like three year olds by everyone from the Cleaner to the Modern Matron. Visitors command scarcely more respect. And despite the best efforts of Medical and Nursing Schools up and down the land the fine art of communication is abandoned in favour of the tone and ethos of the workhouse that once stood on the same site as the shiny new PFI hospital.

In such a regime the poor benighted inmates shrink visibly day by day, both bodily and emotionally to the same level. No wonder they are all so desperate to get out and reclaim their stolen adulthood.