Twelve years and counting...

There’s no doubt that as we enter the 25th year of my professional life we’ve come a long way in the intervening quarticentenary*. Two generations of pills have near abolished surgery for stomach ulcers, a tiny bit of wire mesh has gone a long way towards doing the same for bypass grafting. Depression has been transformed by the introduction of SSRIs and the plethora of follow on alternatives. New wonder drugs have been joined by rehabilitated old wonder drugs like Aspirin. Endoscopic surgery and joint replacements are now commonplace and the protracted stays in hospital post op are a thing of the past for the vast majority. Cancers incurable a generation ago are so no longer…. I could go on, and on (stop that nodding there you at the back).

And yet, for all our technological and pharmaceutical accomplishments, as 2008 draws to a close I’m left fearful that we’ve "sold our soul", and ere long Old Nick himself will be paying us a visit to call in his marker. The NHS I joined, for all its evident faults, was a truly National Service. The ethos of the whole organisation was compassionate, aimed at the relief of suffering and the improvement of wellbeing. This morning on Radio 4 we hear of a Kings Fund report highlighting the loss of compassion. This has slowly but surely been eroded by the fragmentation of the service into a vast jigsaw of Trusts each as much determined to protect its borders and boundaries and keep the “undeserving” out, as to hit the targets set for service delivery to those fortunate few “deserving” of its attention. And those targets are all about process. Waiting times , cleaning regimes, infection rates and the like. All of the above are important, but so are the poor bastards stuck on the receiving end.

In the past month I’ve seen patients kicked off waiting lists for surgery because on one screening visit to a N’octor, their blood pressure or blood sugar are not exactly normal according to arbitrary criteria that are almost absurd enough to require that to be fit for surgery you have to be so well as to not require surgery. I’ve heard Doctor Neighbour bemoan the fact that he is unable to arrange a transfer ambulance to get a patient to see a Neurosurgeon at St Elsewhere’s in a nearby city because the Surgeon in question wanted to review them in the A&E department there and the Ambulance trust can only take patients to Outpatients there or to the nearest (Ambridge DGH) A&E but not the St Elsewhere’s A&E because those are the rules. And I’ve seen a patient denied much needed Opiate analgesia because staff at the residential home he lives in cannot find a cupboard to lock his medications in and the rules won’t allow them to do otherwise.

We’ve become afraid to care, and it’s getting steadily worse year on year. Maybe the Kings Fund will turn the tide and 2009 will see a return to the much needed basics. Every Trust in the land has a mission statement that declares in Government approved newspeak their commitment to “patient centred-ness”.

It’s time we all sat down and thought about what that actually means.

*probably not a real word, but should be.

Tis the season.

Sadly not much jollity in evidence in these parts though. One tiny ray of personal sunshine is that Whittards has found a buyer so I sha'nt have t worry quite yet about where ny next 250g of fresh ground Old Brown Java is coming from. I know there's always Taylor's of Harrogate, but it's so much nicer seeing an operative pour the beans out of the tin and into the grinder, whilst solicitously advising that once ground it's only good for a week or two at best, and asking whether the filter I'll be using is paper or permanent (aparently it makes a big difference).

Even the early a.m. run to collect the Turkey from M&S was a muted affair this year. Normally the place is heaving with beaming and avuncular types cheerily queuing for their produce and knocking back simmering goblets of mulled wine. This morning there were a half dozen bedraggled pensioners, a harrased looking suited lady exec and moi. And not a whif of mulled anything. Looking back on 08 it will not go down in the annals of Ambridge as an especially kind year-- and this was before the "crunch". Looking forward 09 doesn't hold out the prospect of being much better.

Still so long as there are Hob Nobs and Java to be had life can't be all bad. And I am as always eternally indebted to those of you who are kind enough to feed back on my ramblings. Your generosity of spirit, and lack of sound judgement, do you all credit, and I wish you all as safe and happy a Christmas and New Year as is humanly possible.

I may well be back before the latter (it's business as usual here Monday through Wednesday) but if not then I hope you will excuse me.

Now I'm just off to google McVities to make sure they are not yet in peril of calling in the recievers, so if you'll all excuse me.....

Catch 22.5

I had another of those Doc Daneeka consultations yesterday. Mrs Yossarian is not happy. She’s been unwell for months, and we’re doing nothing to help her. She tells me so most forcefully. And in many senses she’s quite right, but she implies that we’ve not been trying and that is a little unfair, though woe betide me should I venture to point this out.

“I had a tight chest in the spring and I saw you… you gave me an inhaler, but it just made me worse.”

I tentatively risk asking how.

“Well my chest is still tight now, and it’s burning right here,” she holds a clenched fist to her sternum in a salute reminiscent of a Roman centurion—I mentally hear Russell Crowe intoning Strength and Honour! “and those pills Dr Neighbour gave me did nothing!”

The pills were powerful antacid/ulcer healing drugs. He last prescribed them in the Spring, and for just 28 days. So, I ask again, how long did she take them for?

“Oh I’m still taking them, but they’re no help!”

The logic defeats me. I ask how this can be so, given that they should have run out over six months ago.

“Well my Husband has them too so I’ve been taking his.”

“Anyway after that I got admitted to hospital with chest pain, and they treated me like I’d had a heart attack, but the spray they gave me made everything worse, and I’ve still got this burning” – enter Mr Crowe again stage left. “And all the tests they did have come back normal so they’re no help at all either.”

Now I will concede her that telling her it is her heart, and then telling her it isn’t after all wasn’t entirely helpful, if indeed that is what she was told. Still one might have thought knowing now formally that it isn’t is a good thing. And the cardiologists did actually do quite a lot in helping her to arrive at that point, but again the suggestion that quite a lot has in fact been done gets short shrift. So here she sits, fist clenched tight to her chest, and all set to unleash hell.

And then there’s the final insult. “They made me have statins, and now my legs are really weak and I can’t walk at all.”

How long, I foolishly persist in asking, did she have the statins for?

“About a month, but I’ve been off them for over two months and my legs are no better.”

I hear the ballistae being wound as I venture that stopping the statin ought to have relieved her leg problems by now if it were indeed the cause.

We agree to another blood test to finally absolve the statins, and an ENT opinion about the burning, but I foresee little hope of a breakthrough. I fear Mrs Yossarian’s symptoms are all too likely to have their origin elsewhere that her chest or her legs. Anxiety causes a sensation now referred to simply as Globus—we dropped the old term Globus Hystericus a while ago since the term refers to the awful sensation that you’ve just swallowed half a brick, and has no link to uterine pathology at all. Yes the Hystericus came from the old term Hysteria—a now long discredited diagnostic term. But Globus remains a symptom of the unreassurably anxious, and the one treatment that might alleviate it is the one treatment sufferers cannot accept, namely psychology.

Just occasionally the ENT specialists will be able to persuade the sufferer after an outpatient review but I get the feeling Mrs Yossarian will not take to this advice at all.

Somewhere in the back of my head I hear the sound of pounding hooves.

What's that coming over the hill.... *

Enough navel-gazing for now. Let’s get back to some good old fashioned silliness shall we.

Despite the literary allusion (can it be literary if abstracted from an aural medium I wonder—perhaps it should be “broadcasterary allusion”—or perhaps not….) my own version of Ambridge is in fact far from the rural idyll broadcast daily by Auntie for our listening pleasure. Dormitory Town sub-urban is more the thing if I’m honest. The strange thing is, this does not appear to have impinged on the Mums and Dads of the latest generation of tiny Borcestrians.

There’s been a “bit of a cough” doing the rounds in these parts lately. The sort of cough that leaves tinies choking, gasping, purple and cross. And it’s going on for days on end. Unsurprisingly Mums and a few Dads (you know they’re worried when a sheepish looking Dad is in tow to insist that “something’s got to be done Doc”) have been thronging the waiting room with their wheezing, hacking, retching, puce offspring. The good news is that despite the graphic presentations most are just suffering with the aforementioned “bit of a cough” and some reassurance and symptomatic treatment will pull them through just fine.

Our problem is the traffic management their attendances are occasioning. It seems babies these days are much too precious and fragile to be brought the full fifty yards from car park to consulting room in anything smaller or more dainty than a Sherman tank. Buggies have clearly come on a long way in the umpteen years since the Jests were in the market for one. Gone are the teetering gossamer constructs of yore with their two inch diameter Lego wheels and all the stability and traction of an inebriate hippo on ice.

Nowadays we get mammoth constructs with wheels bigger than a mountain bike, sporting off road tyres, brush cutters and bull bars. The tiny occupants are strapped in tight enough for Saturn V style take-off and re-entry. I’m sure the ones imported by our own share of the Polish Diaspora are in fact just T72s with the turrets removed a few teddy bear stickers applied for that homely touch. More than once I’ve found myself having to strenuously resist the urge to duck and cover as one of these monsters fills the doorframe of the consulting room.

Does anyone have the number for M. Maginot I wonder?


*Hob nob on offer for the correct next line.

Phillip

In case you missed it, today has been World AIDS Day. Good old Radio 4 had a mix of upbeat stories about babies born to positive mothers, and more downbeat warnings that the incidence is on the rise again here in Blighty.

Ambridge has been somewhat cocooned form the ravages of the HTLV. My one brush with the disease was vicarious at best, but none the less tragic for that. Phillip left Ambridge towards the end of the seventies for the bright lights of the big city. He soon hooked up with Terrance. Chef and Actor, they made a fine couple, until Terrance became ill, and started loosing weight and coughing a lot. Phillip nursed him through a protracted and difficult terminal illness before the days of widespread and affordable (at least in the “civilized west”) antiretrovirals. At the onset of Terrance’s illness Phillip was tested and was pronounced clear of infection, but to be certain would have required a second test three months later.

Poor Phillip was too distraught by his partner’s rapidly progressing illness to handle a second test then. Shortly after the funeral he came home to live with his mum. He found work locally and kept himself going, but lived in constant fear. Every cough and every new blemish brought him shaking to the surgery. We talked at length and repeatedly about his fears. We offered him access to a final test for reassurance, though with each passing year and each successful recovery from illness the likelihood that he had contracted the virus became increasingly remote. Still neither we nor the psychologists could reassure him, and he could not face up to getting tested.

In the end, one Monday morning I came in to surgery to find the coroners officer had been on the phone. That weekend mum had been away with her chums, and poor Phillip had given in to his demons and washed down some pain killers with vodka. Though never infected he died as much a victim of AIDS as those many of his friends who were.

I’m not a great fan of “badges” and “ribbons” for this and that. AIDS, Cancer, Asthma or COPD to name but a few, are worth more than just a 365th of our attention, as are the myriad other causes and conditions that don’t get a proper “day” to themselves. And yet, today I’ll be wearing the red ribbon, and thinking of an old friend I couldn’t help.

Help wanted.

Twice this past week I find myself somewhat at a loss to see a way forwards for the folks on the other side of the desk. We appear to have strayed into “irresistible force vs. immovable object” territory and I’m not a all sure how we are going to negotiate it. Allow me to illustrate.

Case one:- “Loose lips….”

Enter Brad’ and Ange’ (names as ever changed to protect the …. you all know the rest). Ange’ had her three yearly cervical cytology done a few weeks ago and the result wasn’t exactly normal. There’s a whole argument to be had about the merits of the whole cervical cytology screening programme, but that’s not for here. The point was that her result, for the first time since she began the screening some fifteen or so years ago, was “abnormal” and showed “borderline changes” in the cells. According to guidelines we need to repeat the sample in six months and if all is well she can move on without the need for intensive investigations, but in the meantime she has to live with the ticking time-bomb of “abnormality”.

And then some Smart Alec at work says to her, “Of course that’s caused by a sexually transmitted disease you know!”

So Ange’ rushes home in an histrionic fervour, beards Brad’ in his lair and starts demanding “How could you?”

The upshot, an attendance to the Ambridge Surgery. We go over the whole Cervical Cytology- HPV- Cellular changes- Cervical Cancer, discussion, but in all honesty our grasp of the precise natural history of this process if hazy at best. They have been together for years, but both had partners before committing to one another, and Brad is quite prepared to swear on all that is holy that since then he has been happily monogamous. Now I accept as a male GP I might be unwittingly biased, but his body language, and indeed the mere fact that he has attended with her on the day, leave me inclined to believe him.

We discussed the fact that despite their long term commitment, should the anomalies in her cells prove to be related to HPV infection, that doesn’t automatically call her man’s fidelity into question, but Ange’ remains visibly unreassured. In the end I have to suggest they seek help from a relationship counsellor as this one chance remark has caused such an apparent rift.

Case 2:- “Love me love my cats”

Sid comes to the chest clinic. He has a cough that has been going on for years. It’s worse when he tries to run, and it’s been deteriorating since Joelene bought her kittens a few years back. He’s tried all sorts of inhaler regimes down the years and none quite gets the job done. So now he’s convinced it isn’t asthma he’s got at all. After all surely the inhalers would have kicked in by now. (I keep telling him not to call me Shirley!)


O.k. so they help him after a run, and they reduce the cough to a minor irritation rather than a constant nuisance, but really if it were asthma they’d have sorted it out by now, Shirley?

We go trough the history again. We look at his peak flow readings, before and after inhalers again. All point to the inescapable conclusion that he has obstructed airways, that get better with inhaler treatment.

In short, Asthma.

So there.

Worse yet, it sounds highly likely that Sid has an allergy to the little bundles of fluff that are now full grown cougar wannabes, who lord it about the house, lolling over sofas and beds, shamelessly indulged like the child substitutes they so plainly are by the otherwise empty nested Joelene. When we have the temerity to suggest we test Sid for cat allergy he ruefully shakes his head—“She’s already told me the cats aren’t going”.

So we try another asthma treatment.

I wonder, is Kofi Annan busy right now?

St Elsewhere's?

You know your appraisal’s going wrong when your appraiser says “You could always think about doing something else…”

After last year, when a commenter rather chided me over the whole “buzzword bingo” concept of appraisal, I decided to do this one cold. This might have been a mistake.

I thought I had prepared my case and supplied the necessary evidence to back up my professed competence, but this year’s appraisal felt somehow so much more joyless than any hitherto, and my appraiser (a new one I’d not met before the day) seemed less interested in the materials I had provided than in her own agenda, namely whipping me in to shape for “revalidation”. It probably didn’t help that I was incubating my annual dose of low grade but highly irritating lurghi come the appointed day. Nor did it help that I had spent forty five minutes completing a twenty minute journey to my place of execution… er appraisal. The fact that the day had not afforded an opportunity for a second cup of Java or any hobnobs at all probably sealed my fate.

As a result I accept I might have come across as a little grumpier and a tad less engaged than I might normally. However it also seemed that the appraisal agenda has changed from a formative mentoring relationship to one of challenge and compulsion. I’m not entirely sure on that point, and accept that I performed badly on the day, but with the benefit of a fortnight of introspection after the fact, this experience was so at variance with the five previous encounters that I await the next with no small measure of trepidation.

And the really sad thing is I’m not at all sure I could, or would want to do “anything else”. I can tell you that next year the bingo will definitely be back on the agenda though.

I’m sorry it took a while to regain my normal equanimity after these events, but I reckon I’m back now, and certainly in no mood to go elsewhere.

A new friend?

Back in January I wrote about an absent friend. Since that time I have seen my old friend Ray a couple of times more, once at home, and later at the surgery, and on both occasions the absence remained a palpable thing. The guide dog Ray had lost was a big personality. When the two of them came in they were always the centre of attention. We kidded Ray it was all down to his chiseled good looks ("One of my friends says I look like Clint Eastwood"), but he and we knew his new found animal magnetism was easily 80% canine. Loosing the big rock-star dog that had been his ten year companion left Ray diminished and contracted his horizons far more than either of us expected it might.

And so it was with some trepidation that I viewed the screen message earlier this week that announced Ray plus "one other" were waiting to be seen. When I went to collect them, instead of the huge, golden maned, long haired Labrador of yore, Ray was escorted by a docile, jet black, short haired shade of a dog. Instead of bounce and slobber I was greeted with equanimity. We processed down the corridor to my office in a far more stately and reserved manner than we had been used to, and once in, the new guide settled himself quietly at his master's feet and watched me cautiously to gauge my intentions and figure out if I was to be trusted.

By the time we were done I think we had achieved a modus vivendi, and I should still be allowed to care for his master for the time being, and on the way back out of the office the carriage of the hound had a more familiar cast to it, and in reception a small flock of admirers began to gather. And again the majority of their attention fell upon the dog. I'm not sure this one will quite achieve rock-star status, but, eleven years on, his quiet efficiency will probably suit Ray better, and it is already clear that he,Ray, is moving on at last.

I was left wondering to what extent this shadow-dog communes with his forebear (or perhaps that should be foredog). I certainly got the impression at points during our consultation that older, more familiar eyes were gazing up from that long dark face.

Perhaps there is something in this reincarnation thing, or perhaps I'm just making a new friend after all....

If the CD player wasn't broken I'd have been listening to Lou Reed.

Once or twice a year you get a perfect morning. Today was one such. The school run was taken by my better half. So I got to head for the surgery a half hour earlier than normal, and today that half hour was especially blessed.

The sun had climbed just high enough not to be dazzling as I headed east out of Borchester, bleaching a near cloudless sky to the faintest blue-white. This in turn was mirrored by the soft blanket of autumn mist that hugged the base of the Ambridge escarpment. Dew drops scattered the field like tiny diamonds, and climbing the escarpment the sunlight pierced the woods at just the right angle to halo the turning leaves in shimmering gold.

What made the ride in all the better was that, being that little bit earlier, I had the route pretty much all to myself right up to the outskirts of Ambridge itself, so that despite apparently dawdling along taking in the sights I was still in early enough to have had a hot steaming Java and a couple of Hob Nobs before returning to the fray.

May you all be so blessed this morning and every morning.

(Needless to say after such a promising start karma blessed me with a morning of Flu’ jabs and crusty toenails—but somehow the residual bonhomie refuses to quite go away).

Grace under pressure.

Around a year ago Grace started to complain of tummy pain. This was before she came to Ambridge. After a few weeks she was unwell enough to need a hospital visit, and there they found a pelvic mass, around the size of a mid term pregnancy. Only trouble was that Grace was pushing seventy years of age and was long past her menopause.

In pretty short order she was told she had ovarian carcinoma. Then that she had inoperable ovarian carcinoma. Then that she had inoperable ovarian carcinoma that was not responding to chemotherapy. At some point in that process she ended up relocating to Ambridge and joined Dr Neighbour’s list.

She has in Dr Neighbour an excellent GP. She also has the input of the best available local Oncologists and Mc Millan Nurses. She also has the Ambridge District Nurse A team on her case. She has little or no pain and has no fears for the future, taking each day on it’s merits, but she has no illusions that this will be her final illness. Lately she has been a bit queasy, and has begun to feel what we English like to euphemistically call “a bit bunged up”. The usual array of laxatives isn’t helping much and neither this past week has repeated enemata from the aforementioned A team.

And so it fell to me as duty doc, a day or two ago, to call on her mid afternoon, to see if we should be trying harder to get things moving. The duty had been a bit busy, so no time for the usual lunch on the hoof for your humble narrator. I needed to examine her abdomen, so she gamely struggled upstairs to get on the bed (one simply does not submit to examinations of that sort on the settee) despite the evident effort it was costing her. I was keen to rule out intestinal obstruction, and as I leant over her “bump” to apply the stethoscope, to my eternal shame, it was my tum and not hers that did the rumbling.

In the end the exam did not reveal immediate concerns and we agreed there was no need for an urgent admission, though a quick Xray of her abdomen might be a good idea to rule out a sub-acute obstruction (believe it or not a fairly precise surgical definition that would have signs evident on said Xray). As a result I arranged for her to go for the pictures that afternoon, and in the event they were clear and we have pulled back from the purgatives and enemata and reassured her that a little feeling of fullness can be expected simply as a consequence of the mass in her tummy, but that so long as it causes no pain and no nasty vomiting she need not fear it.

In the end as happy an outcome as we could have hoped for in the circumstances, and Grace was effusive in her thanks for me not wanting to admit her. And in the midst of all this, as I was arranging for her to pop in for the films to be taken she politely wondered if she might offer me a cup of tea and a sandwich.

Hard to swallow?

Young George is just over one year old. For the past few months he has had an increasingly healthy appetite for solids and is visibly thriving. Or so he was until a few weeks ago. After a couple of weeks of gradual loss of appetite he suddenly stopped eating altogether, and mum and dad began to worry. After three days of nothing but fluids, and diminishing demand even for these, coupled with that most alarming symptom of all, a complete refusal to eat chocolate*, he had put the wind up them both and so they attended, with a still happy and smiling young George in tow.

So far, despite his total lack of enthusiasm for solids the lad was holding his own pretty well, with no signs of rapid weight loss and no real dehydration. He was vomiting after all solids though, and so had really given up trying, and so long as mum and dad allowed him not to eat he was happy, only becoming fractious when they tried to make him.

His tummy was quite soft and not at all tender. There was no worry about constipation or diarrhoea, and on the day I examined him my tummy was gurgling more than his… one of us was definitely in need of chocolate!

Overall he really didn’t seem too bad, but mum and dad were not going to take happily to this suggestion. In reality it appeared little George was suffering a bit of “reflux” with acid flowing backwards from the stomach into the lower reaches of the oesophagus causing heartburn and hence vomiting.

After some discussion his worried parents agreed to my evidently insane suggestion that we try spiking his bottles with an antacid preparation that just might do the trick, before we considered referring him on to the paediatricians. It helped a bit that I have looked after mum since she was little older that her son is now, so with a slight reluctance she and her husband agreed to try my alchemy for a week or so before pressing the panic button.

Two weeks on they came back, all three beaming contentedly, to request some more sachets of the antacid. Young George is back wolfing down everything that’s put in front of him, and most particularly he’s back on the chocolate. There can be no better sign that a toddler is on the mend.

*Regular readers will already be aware that this writer believes Chocolate worthy of it’s own food group and of that food group’s obvious preeminence over all the others.**

** except perhaps the Vodka / Bourbon group that is….

Old head, young shoulders...

Freddy had an asthma attack two weeks ago. He had had a bit of a cold in the morning, but not enough to keep him off school. By mid afternoon school were worried and called Mum to come and get him, and when they arrived at the surgery the poor lad was really gasping for air.

For those to whom this means something he was managing a couple of words between breaths, chugging along at around 50 breaths a minute, using all his accessory muscles, and visibly tiring. For those to whom none of that is especially significant, suffice it to say he was pretty damned breathless.

We whacked him straight on a nebulizer (an air compressor through which we can, and did, aerosolize asthma meds—easier to use and more penetrating than an inhaler for a patient in crisis) which soon sorted out his breathlessness, and packed him off home some forty minutes later with an armful of inhalers, a spacer device (a chamber thingy to put the inhalers into) and some steroid pills, plus all the nebulizer tubing and mask he had just been using for him to play spacemen with when he got home (and to help the Out of Hours docs should they need to get him back on a nebulizer at any point that night).

Mum also went away with clear instructions to look out for a flare of wheeze or breathlessness around four hours later as the nebulizer would be wearing off about then, and if the inhalers didn’t quickly turn him around she knew to call for help straight away. Happily that advice was not needed and, as I discovered today, he was pretty much all better after 48 hours of more intensive medication. All through the consultation though, Freddy looked exactly as you might expect, a pretty scared, rather tiny six year old boy, in need of his Mum.

Not so today.

Today he comes for his review and to plan his treatment from here on. He pulls up his chair, alogside but some distance from his Mum. Today he is immaculately turned out in his school uniform, and not disheveled as when we last met. He has not a hair out of place, and is the living example of calm, composed self assurance.

We agree to try and monitor his asthma with a peak flow meter, and he masters the technique in a couple of puffs with aplomb. Then we need to measure him to see how his result matches with the predicted value for his age and height— “Though I’m not very tall for a six year old you know.” And neither he is, though still tall enough not to present any concerns about arrested development. We also agree he should have a spacer for home and a separate spacer and inhaler combination to keep at school and a peak flow meter for home monitoring.

“You should personalize them with your favourite stickers.” I sagely advise.

“Ooh yes,” says Mum “you could do that in your craft lesson this afternoon.”

“Well,” Freddy draws the word out for emphasis “I suppose I might, but I will have some work to do this afternoon too you know.”

I’m left reflecting that this is a young man who will go far, and also struck by the difference two short weeks and a proper asthma management plan can make.

The N'octor* will see you now...

Last night I was at a meeting where the new GP Out of Hours Provider company were making their pitch. They have been awarded a contract to offer night and weekend GP services to the citizens of Borsetshire starting this October, and so are in the final run up to their takeover.

The mouthpiece for their organization is a tall, chiseled type, with blond and elegantly coiffed locks, in a shiny suit with a lavender shirt and tie. He just oozes “Used Car Salesman”-ness. And his pitch is flawlessly reassuring. Patients making contact out of hours will first be answered by expert call handlers who will speedily ascertain the patients ID and contact details before passing them on to a clinician. If all clinicians are busy and they do not have an over-ridingly urgent problem, then their details will be held until the first such clinician is available to call them back, and their target will be to return these calls within x minutes, where x is a vanishingly small number. Once they have spoken to a clinican, those that need to be seen will be offered a speedy appointment at the nearest centre, or visited at home if housebound.

The new providers are committed to training, and to staff development. They will even help little old ladies to cross the road, pop in at night to fix them their tea and biccies, and tuck them in and read them a story before bye-byes. (Well o.k. I might have slightly embellished the last few points.)

Over all though, an impressive performance by a polished (almost literally so) performer. That is, until we get the specimen rota for the service they are offering. In retrospect (having had the chance to sleep on it I suppose) it should have been obvious from Mr Smooth’s choice of words. Like Humpty Dumpty before him (and I believe as I have also said previously like myself in my turn) Mr S’s words mean what he chooses them to mean. To you and I, hitherto, I suspect the word clinician would have conjured up the image of a proper professional. Probably a Doctor, or, at the very least, a Nurse Practitioner with a higher level of expertise that the standard nursing qualification. It appears to this hallowed band of guardians of the common health and wellbeing we must now also admit the ECP.

“?” you ask, as well you might, and as we all did…

“ECP” says our lad, undaunted. “That’s Emergency Care Practitioner”.

“??” we chorus.

This brave new breed will be at the forefront of our overhauled out of hours services. Without wishing to in any way denigrate this noble calling, the ECP job description is essentially written for a paramedic with a bit of extra training in emergency care—perhaps 2-3 years training after school / college as a minimum, compared to the eight years required of GPs in training.

So, the best advice I can offer the citizens of Ambridge, is to try not to get ill out of hours anytime this winter, as instead of a guaranteed encounter with a GP as we used to offer they are now faced with a one in three chance of being left in the, doubtless entirely capable, hands of an ECP n’octor.


*N'octor-- increasingly accepted contraction for the phrase "Not-a-doctor"

"Tell me why...."

….. “I don’t like Mondays!”

So go the words of the song. And this was the refrain in my head for much of yesterday morning. Churlish of me I know, but there it is.

“But why,” I hear you ask “so irascible this particular Monday?”

I’ll endeavour to tell you, but in doing so I fear I will alienate you, gentle reader, so I ask you not to judge too harshly. The real problem is of course, not Mondays, or even this last Monday in and of itself. It’s what I was doing this particular Monday, in comparison with the preceding couple of weeks.

Regular readers will know that the past fortnight saw the Jest family annual peregrination to the sun (on this occasion on a floating palace around the Adriatic). In essence we have been pampered almost beyond endurance, whilst soaking up the finest sights that the central portion of the Med has to offer. We have braved “La Serenissima” by gondola after hauling ourselves out of bed at Day-Break to witness our arrival in this fairest of cities at a stately pace from thirteen stories up—and if anyone ever offers you the chance to do the same, don’t think twice. We have witnessed the miracle of reconstruction that is the pristine Old Town of Dubrovnik. Our pallid English bodies have braved 36 degree heat in Corfu…. I could rave on at greater length, but even I am coming to hate myself as I do, so I’ll leave it there, but you get the picture.

Mid way through our trip the eldest learned he has aced his GCSEs (the first set of really BIG exams in Blighty for our readers from other jurisdictions) so all is most definitely right with the world. (A “proud Dad” moment for you all there—I’m hoping it will ingratiate me a bit after the alienation possibly engendered by the paragraph above…)

Then we come back to dear old Blighty. It’s cold and it’s raining and it feels like it’s been that way all the time we’ve been away, and will be so all the time until we can somehow get away again. And on Monday morning the surgery goes hopelessly awry as every single patient asks me how the holiday went, just to heighten the juxtaposition.

Still if it keeps up this way we’ll soon be able to get around Ambridge by gondola too, so maybe it will all work out right in the end. Just keep me away from the gun cabinet, that’s all….

Summer outing.

I can’t quite put my finger on what’s the matter, but somehow I haven’t been able to get my head together this past month. There’s definitely something in the wind, but I’m blowed if I can work out what it is, so apologies for the extended leave of absence, and further apologies that it is going to be further prolonged by upcoming hols.

Actually that ought to be Hols with a big “H”, since we are off cruising again which could spell bad news for the Jesterly waistline, and I promise I’ll try not to bore you all too much with countless photo’s of the backs of the family’s heads at various exotic Mediterranean locales when we get back. In the interim here’s a little offering I’ve had on the blocks for a while, since inspiration remains at low ebb right now.

Miranda has been a regular attender to my consulting room for more years than either of us would care to remember. She’s had a hard and demanding manual job and down the years it has taken its toll on her joints, but she complains very little and takes just enough pain relief to keep her functioning at work and “productive”. For the first decade or so of our acquaintance she appeared to be a loner, and quite content in her solitude. Then she began to mention a friend of hers who had recently been bereaved. It turned out that her friend was also a regular at the surgery, though perhaps a little less often than Miranda herself.

A year or so after the bereavement Miranda’s friend moved in with her to help with the rent and save them having to run two separate houses. I know this because Miranda was at pains to point out to me the nature of their association at the time. Down the next couple of years she would make occasional references to her friend during consultations, but often said nothing further about their continued association. Then after five years or so she finally let slip, oh so casually, that she and her friend had become “partners”, whilst looking out of the corner of her eye to see if I looked like I might fall off the chair or start wagging a disapproving finger. I didn’t, of course, and feel I passed something of a test that day.

I suspect you will already have guessed the reason for Miranda’s anxiety but offer the usual EVCHN ™ for the first correct respondent.

Happy Birthday (?)

"What's he doing down there?"

"Dunno. He's got a suit on, and a tie with big bold stripes on it... Looks like he thinks he's power dressing to me. Oh no, he's about to go off on one. He's got that didactic look about him, I've seen it on him before. He's about to have a moan."

"Oh. Right. Think I might skip this one then."

"Hold on. I'll join you...."



Ok now they're gone I'll get on. I'll be trying for levity again soon, but somehow today I just can't seem to manage it-- and no smirking up there at the back, you know that's not what I meant. What follows is drawn entirely from personal experience and my own hazy grasp on reality. It reflects the views of the author and is not intended to reflect the views of any other individual or organization. Neither is is intended to impugn the character, bona fides or intent of any named individual. It's sole intent is personal comment.

It can hardly have escaped anyone in Blighty that our dear old NHS has just turned sixty. In the midst of the somewhat muted celebrations we have seen the publication of Lord Darzi’s latest report intended to set out a bold new vision of service centered on the patient, with talk of “quality” and “compassion”. However it feels, at grass roots level, as though the decision has been already taken to pension the poor old NHS off and giver her job piecemeal to a gaggle of vested interests in the guise of modernization.

This might just be sour grapes of course, because the one vested interest that looks set to be excluded for submitting serious bids in the up coming NHS garage sale is yours truly. Well that is, yours truly and around 35,000 other small time, corner shop, un-entrepreneurial soi disant “entrepreneurs” out here in GP land.

From where I sit this is a bit of a pity. Looking back I realize my association with the NHS began with my very first summer holiday job almost exactly thirty years ago. (O.K. technically it began a lot earlier than that since I have been a patient of the service all my life—but you get what I am saying). It was a fabulous job, pulling X-rays that were over 10 years old and sending the plates for recycling (the silver in the old photographic plates could apparently be reclaimed at a cost that made the whole deal economic, as well as providing funds for the fledgling Doc J’s summer beer money fund).

And from that time to this it is hard to remember a year when the NHS hasn’t felt under threat from some quarter. In the late 70s and early 80s it was the class war and the flexing of union muscle (with a gaggle of us white coated medical students—in direct contravention of the diktat of “Hospital Management”-- brandishing placards on the picket lines in support* of our student nurse colleagues, we being on a grant or financed by mummy and daddy, they working stupid shifts for peanuts as they trained on the job).

In the late 80s we had the setting up of the “internal market” with the promise, still largely unfulfilled two decades on, that the money to pay for the treatment would “follow” the patient, allowing good and popular hospitals to increase their funding at the cost of the “poorer performers”.

The 90s saw tinkering with and eventually wholesale breakdown of the GP contract, with a shift to health promotion, away from out of hours care, into and then back out of fund-holding (where GPs held a “budget” for a tiny fraction of the care of their patients—pretty much just planned surgery and out patient clinic visits). The stated aim was to get the money to start following the patient, but the contractual framework for this was so hedged about with restrictions and caveats that it was very hard to realize, and with the arrival of NuLabour (sic) the whole concept was anathema anyway….

Through the latter half of the 90s and into the Noughties our colleagues in the hospitals have been battered with meaningless targets (along with many that were very worthwhile) and from 2004 on GPland has signed up to a contract that accepted a significant degree of similar targeting. Again much of this, it can be argued, has served to improve standards and give a more uniform quality of service, but it is increasingly ripping the soul out of the profession. And now Lord Darzi's report seems to imply we can re-engineer the entire NHS by chopping it into tiny bits and selling it off in the name of “quality” and “compassion” the two attributes that spring unbidden to mind whenever we think of private enterprise (not).


It really is too bad. To borrow a quote from an unexpected early supporter of a Nationalized Health Service, no less a man than Winston Churchill, the NHS for all its travails has proven to be “the worst form of Health Care provision, apart from all the others.”

I appreciate it sounds the utmost arrogance for any clinician to expect the political class to stump up a mere Hundred BILLION quid and then just step back and leave us to get on with the job, and in reality, as I believe the Darzi reports show, the very last people you want organizing health care provision are clinicians of any type. But I fear the next worst people to do it are the politicians themselves. Neither group can claim to be dispassionate, and nor should they be, it’s not in either one’s job description. But the running of a truly National Service demands the skills a dispassionate and pragmatic observer can bring. Sadly, as we look towards Lord Darzi’s professed vision of the future we are likely to get further fragmentation rather than increased co-ordination and unity of purpose.


Our NHS is sixty this year and yet I fear she will not be around in any meaningful form for her seventieth birthday.


*regrettably our motives might not entirely have been based in proletarian solidarity, but this was an unreconstructed age when Medical Students were predominantly still young men and student nurses were recruited as much for looks as for other aptitudes….

New tricks?

It’s a time of year when the burden of acute illness has dropped, excepting an especially vicious and protracted Hay Fever season. As a result normal surgeries have a little less pressure for appointments and the number of patients attending for routine medication reviews has increased, as they try to get in before the holidays, theirs or mine.

Bill was one such yesterday. He’s eighty years young. Six months ago he had a bit of a scare. He was on the bus, on his way in to town, when he went a bit “funny”. He came to in CCU with a temporary pacemaker making his ticker keep ticking. Shortly after this he was scheduled for the surgery to insert a permanent version. His nurse joked with him that they were going to put the temporary machine in. It’s a box the size and weight of a car battery with knobs and lights and such, and it needs a permanent mains electricity supply. Bill was a little perturbed. Then his surgeon came round and showed him the real one, a little miracle of miniaturization hand crafted in finest clockwork by gnomes in Zurich or somewhere similar. It has its own battery, good for at least five years before replacement. And fits snug and flat in the palm of one hand, with room to spare.

Bill described in detail the procedure of insertion, for which he remained awake, the whole thing being done under local anaesthetic.

“First they put the wires in and I got to watch them go into my heart on a t.v. screen. The the surgeon says “Right we’re going to put the thing in”, and they carved a lump of flesh out of my chest to make room.”

“ I’m glad they didn’t decide to use the bigger machine! After all I’d have looked silly with a wire hanging out of my chest!”

He looked down at the scar after the insertion. It looked surprisingly small given all the carving and excavation that had seemed to be going on. He was more impressed by the blood stained sheet left on the operating table.

A month after the procedure he was back in clinic to have his bionics checked. The pacemaker was working pretty well, but the voltage needed dialling up a bit to get Bill’s heart pounding as it ought. After a couple of electromagnetic tweaks the surgeon was happy.

“There you go Bill. Your heart’s as good as new. You can do anything you want now.”

From the back of the room Mrs Bill’s voice could be heard.

“Don’t even think about it Bill!”

Locum Duty

“Stay away from pills and booze, always use a condom, and nobody goes home with any piercings or tattoos they didn’t already come with, o.k.”

And with this avuncular little homily ringing in their ears my trio of charges shuffled of to be amazed. Later the ringing would have a different cause, but more of that anon.

The time, a week ago last Friday.

The place, Castle Donnington.

The event, Day 1 of the Download Festival.

This was going to the strangest locum appointment of my career. O.k. so it wasn’t exactly a medical appointment. Instead of a Locum Tenens I was standing In Loco Parentis to two of the three teenage lads that had cruised up the midlands motorways with me that morning. All three had just finished their GCSEs and that particular Friday (13th if you were wondering) was their first official day of freedom, and by a staggering twist of fate it coincided with day one of a huge rock festival. The only snag, two of them were too young to get in unaccompanied, and that meant dragging along an oldie. I’m not sure if I was the least objectionable or simply the one with the easiest schedule to rearrange. Whatever the case I got the gig.

As it happens (as regular readers will guess), rock events hold no fear for Dr J. Indeed one of the acts on the bill saw a fledgling Doc at it’s inaugural tour after its Lead Singer and Bassist had split with Hawkwind to form his own heavier, louder beat combo*. I have to admit, as a trip down memory lane (more “memory back alley, after show, wreathed in smoke of a certain characteristic aroma that in time honoured Clintonesque fashion I never inhaled…” in this case) the day was fantastic. I spent it on a splendid pitch alongside the mixing desk, guarding our huddle of foldy chairs and bags of water and sarnies, while the lads milled about a bit, moshed a bit, and we all, at various points in the day, chanted, sang and just plain shouted ourselves silly.

The lads behaved impeccably, turning down spiked drinks aplenty, and enjoying the natural high of the festival environment on its own merits. So whilst it might not be entirely possible to turn back the clock, it's nice to feel there's life in the old dog yet. The only slightly alarming thing was that on the way out the jets passing overhead on approach to the nerby East Midlands Airport appeared to have acquired stealth capability. I now also have a sneaking sympathy for my regulars with their tinnitus.

It's also just possible you're reading the dispatches of the latest recruit to the Kiss Army (though naturally I see myself as Lieutenant-Colonel material at the very least).

* a rare chance to win an electric virtual hob nob if you can name the artiste without resorting to Google or similar... (of course you're all on the honours system here, but I trust you. No really...)


ADDENDUM

Congratulations to The Welsh Pharmacist for correctly identifying the aforementioned Beat Combo and referencing their umlauts. (No I can't do the HTML for individual accented characters either-- life really is too short). As a further enticement two more e.v.h.n's are on offer for the closest guesses to the following;

1-- How long between finding our pitch by the mixing desk and the tap on the shoulder and accompanying "Excuse me Dr J, but can I get a picture with you, cos the missus'll never believe my GP was 'ere otherwise". ( I kid you not, in the midst of all the real Celebrity of a rock festival some hapless souls wanted a pic of your humble narrator!)

2-- Which appointment on the following Monday morning was the first to refer to my appearance in public at the same festival. (Thank God I was only escorting three lads one of whom was obviously my own. Poor kid, there's no denying his herritage looking as he does. )

Cognitive Dissonance

As in “I don’t believe she just said that.”

“Please tell me she didn’t just say that.”

“No really she can’t have just said that. It would be plain wrong of her to say that wouldn’t it?”

And it would, but that, sadly, didn’t stop her.


I know you’re probably all getting fed up of hearing me say this, yet again, like some feeble minded fourth former handing in late homework. (Then again I was such a feeble minded fourth former in what I sadly like to delude myself were the not so distant quondam days.) Still I have to get it off my chest so here goes nothing… Yes dear readers, if any of you have the good grace to still be listening at all, it’s been a bit busy here in Ambridge lately and now it’s not only busy but also enervatingly hot and swathed in toxic killer pollen.

There, now that’s out of the way, back to our little vignette of everyday life in GPland. The tale is of a lady recently retired, who had hurt her neck. The pain had begun six weeks or so ago, she had been prevented from attending the surgery any sooner because she had been staying out of our practice area.

That’s around three thousand miles out of our area.

On a Greek island.

Now devoted as I am to my job, I suspect Dr Neighbour would have a problem with me making home visits to Knossos, so she had been compelled to see a local “Iatre” and then a muscle bound hellenic Adonis of a physiotherapist as a private patient. They had sorted her out quite nicely, but the flight home had flared the pain up again.

Sadly Ambridge is a bit short on Hellenic Adonises, but still from what I could discern her pain is again muscular rather than anything more sinister and would benefit from another physio’s touch. We discussed the options, i.e. a couple of sessions with a private physio’ in a day or two, or an NHS referral, resulting in a few weeks wait.

And then she came out with it, straight faced. “Well I suppose I’ll just have to wait for the NHS physio. After all I’m not working so I can’t afford private physio.”

Now I know there’s been an oil price crisis this past few months, but I’m not aware of any collapse in the global economy that would suddenly put physiotherapy beyond her reach. Surely it can’t just be that all our local private physios are very capable middle aged women.

No, I thought not.

Through the looking glass. (II)*

I dunno, what with all these Bank Holidays we have nowadays it seems we get paradoxically busier. I suppose it might also have to do with having two docs off for half term, and despairing parents looking for things to occupy the kids during the same…

Anyhow, it seems we have survived and so normaller service might soon be possible. Maybe. And after my more recent flights of fancy the weather has gone back to doing what it does best (being horrid) and it’s back down to earth with a bump for poor old Dr J.

Still, it gives me pause to consider another similarity I share with Mr. H. Dumpty, in that, when I use a word it “means just what I want it to mean”. Two instances today serve to highlight this fact.

The first relates to a blood test on a lady who feared she had rheumatism. In the event her blood tests have all returned “negative” meaning of course that they show now evidence of rheumatic disease, so in this sense a “negative” result is a “positive” message to be able to impart.

(Did that last bit sound a bit like that time honoured definition of cricket so beloved of northern tea-towel manufacturers at all? You know, the one that begins “You have two sides, one out in the field and one in. Each man that's in the side that's in goes out, and when he's out he comes in…”)

The second instance came in Asthma clinic. Sebastian is a runner. He also happens to have late onset asthma, and since a flu like illness in November he has had increasing trouble with his wheeze. Annoyingly this has been worse when he runs. We’ve tried a few different changes in meds along the way and the last one has restored his lung function to is previous excellent form. In effect he has lung function readings at 120% predicted, i.e. 20% better than normal. “That’s brilliant” say I, in all sincerity. “No it’s not” he retorts, “ my 100m time is still three tenths off what it was last season.”

Apparently it’s all about perspective.

* See I'm being green and recycling titles now.

In which I kid myself I am Mr D'Arcy.

We do love talking about the weather here in dear old Blighty. Well after all we seem to have so much of it and it’s so much safer than talking about politics, religion, or that other thing…

Here in Borchester it’s not at all uncommon to experience “four seasons in one day”, especially at this time of year. So to have five consecutive days of sunshine and actual warmth last week came as a bit of a surprise. Of course we are now back to “changeable” with “sunny spells” and “showers”, but it was nice while it lasted. Or at least it was for most of us. For one small group of our regular customers it has proved to be a bit of a challenge though.

To explain why, I need to take us back a couple of years. Around that time we got a brand shiny new test to play with here in GP land, the eGFR. It is a whizzy test to be sure. It tells us, by some clever sciency technique too complex for my little grey cells, how well a punter’s kidneys are filtering. This is a pretty useful piece of information, believe it or not. It is especially useful where a customer already has diseases known to muck up kidney function, like diabetes and some sorts or hypertension to name just a couple. And better yet, we have an evidence base of drugs to use to help improve renal function once it is shown to be “failing” as charted by a decline in eGFR.

The only thing is, in screening for other conditions, as we will often do in the elderly, we will ask to look at their blood chemistry (measuring other vitally important chemicals like sodium, potassium, urea and creatinine) and the lab now takes all that chemical soup and uses it to generate an eGFR result, even where that’s not what we were looking for. This in turn has revealed what we have actually known for a long time, but not previously quantified, which is that older folks' kidneys do not filter efficiently. This means that in the absence of any of the scary conditions alluded to above it is still quite possible to have a low eGFR and hence “renal disease” purely as a function of being older. And since we have a lovely evidence base for medicines that will help preserve renal function many of them are ending up medicated.

Now I know you all though sunshine was only medically important in things like rickets (good) and skin cancers and such (bad), but it seems also to have been having an effect on such medicated older patients. The class of drug most widely used in renal protection is the ACE (angiotensin converting enzyme inhibitors). And ACE drugs are known to lower blood pressure, and to do so disproportionately well in the elderly. Taking a little old lady, with “renal disease” (that’s little old kidneys to you and me) and bunging her on an ACE will likely improve her renal function a bit, and could drop her blood pressure a bit more than a bit. Now add in unseasonably warm weather (and them “not casting a clout”, May not yet being out and all) and a sort of "pressure cooker in reverse" effect takes place. So in this past week the surgery has seen a handful of little old ladies having a fit of the vapours as their blood pressure falls to “fainty” levels.

It’s called the law of unintended consequences. Still it’s kind of nice to think I can still cause ladies to swoon at my age….

Wherefore art thou?

In bloody Ambridge, that’s where! He’s been here for a week and he feels rotten. Julie’ has chucked him out, and the prospects for a rapprochement seem pretty slight given that she’s about as far away from here as it’s possible to be and still be in Blighty. Nothing about this oft repeated scene should be that surprising. After all we live in the age of the disposable relationship, so it hardly matters how long they’ve been “stepping out together”. And anyway we’ve all been there at one time or another. It’s a developmental stage entirely normal in adolescence. Even couples we know damn well are going to get back together inside a fortnight have to have the plate flinging, hair tearing, I-never-want-to-see-him/her-again split if their relationship is to be taken at all seriously.

Except that today our Romeo is the far side of seventy and, being male and a bit unrecontructed, to make it to this age he has ended up on a regime of anti-hypertensive and anti-diabetic meds that would stun an average sized elephant (and an African Elephant at that). Of course he still feels sixteen on the inside, and for at least the last week has been getting by on caffeine and adrenaline in pretty much equal quantities without the balancing effects of sleep or a decent meal.

The final upshot of all these shenanigans sees Romeo come within an hairs breadth of a close encounter with the frayed and aging Ambridge Surgery Carpet. You see, not actually being an average sized African Elephant, the combination of anxiety, heartache, anti-hypertensives et al, has left him feeling a bit odd, and in mid consult he comes over all wibbly and threatens to faint.

Twenty minutes later after fifteen of those with his feet up higher than his head, and following a NAAFI strength tea with half a bag of sugar (yes, I know his blood sugar will go up a bit more that would be healthy in the long term, but we're talking emergency resuscitation here-- ask your granny, she'll tell you all about it...), he is restored to something approaching equilibrium. He’s gone off home now for a bit of a rest, a decent feed and the company of a mate. And without most of his anti-hypertensives.

If this story has a moral at all, I guess that it’s this; eighteen or eighty, male or female, if you absolutely have to chuck your significant other, spare a thought for the other poor souls in their GP’s waiting room and let them down gently. It takes a bit more than ten minutes for us to mend a broken heart, and the rest of the queue aren’t always that understanding. *

Thank you all for listening.


* though it is noteworthy that despite all having to tell me about how busy they were and how inconvenient the tardiness of the morning surgery was, not one of them elected to rebook for another occasion. Perhaps they think poor old Romeo will be back….

Off to see the Wizard...

Just as our Colonial Cousins love their Latin we properly educated Englishmen love our Greek, but however your opt to derive it Oedema* / Edema is a serious pain in the arse* / ass. Not literally of course as that would be proctalgia* (sorry, don’t know the proper American term for this though it might contain a G and a W), but I digress comme d’habitude. For those not aware of this beastly complaint, it involves the infiltration of soft tissues with fluid. The precise mechanisms that cause this can be complex, but generally relate to advancing age and failing circulation or to severe inflammation. (Yes it can also be a direct pressure effect on the lymphatic system caused by other nastier diseases or their treatments too, but far more commonly it is just part of getting older.)

At its mildest we see it as a bit of puffiness round the ankles, late on a hot day, and especially after sitting down for a long time (typically on coach trips to “attractions” so beloved of the pre-war generation). From here though it often progresses to a worsening sense of puffiness then tightness then pain and at some point along this continuum there is the awful sensation of squishiness when you walk, and unsteadiness as a result. Add in to this the failing of other senses, that can make tripping all the easier and balancing all the more difficult and oedema can become a thoroughly miserable experience.

Such is the case for Dorothy, who this past four months has been tipped up by the whirlwind described above three or four times. Far from ending up in Oz the first episode put her in the Hospital with rib injuries and a dislocated shoulder. From that time she has become quite reclusive and thoroughly miserable and all through the simple but inevitable process of the accumulation of a half pint or so of water in her feet. Our therapeutic solution to this is to dry poor Dorothy out to reduce the swelling using diuretics. These make her need to pass more water and often with greater urgency, which is itself not great when you fear falling with every step. The problem is the other common “solution” is to apply compression with thick and heavy elastic stockings, which though effective are almost as painful as the swelling, nigh impossible to apply unaided, and Toto aside, poor Dorothy lives alone. So today we have stepped up to a stronger diuretic in the hope that we can get her back into her ruby slippers. We need this to work to restore her confidence and to quite literally put her back on her feet.



* All underlined in wriggly red lines by my rotten American spellchecker.

Back in the saddle...

In the past two days I have seen patients aged from 0 (well ok, 2 weeks) to 102 (with her card from the Queen, sent on her centenary, still proudly on display in her flat). I’ve tried to help a number of young women to avoid unwanted pregnancies, and begun the process of helping one couple who are struggling to make a very wanted baby. I’ve held discussions with young mums about the development and well being of their infants, and one long and heart-searching discussion with the septuagenarian son on a nonagenarian mum who has become non-responsive in a nursing home and looks likely to be entering what will be a short and hopefully painless final illness.

I have seen two dozen sore throats, a handful of bad backs, more than a handful of depressed folk (two just coming back from the brink of self-immolation). I have talked with one chap about a necessary early retirement. I’ve counseled the family of a man undergoing investigations for a scan anomaly which just might be cancer, but is more likely to have been the radiological equivalent of a hair in the gate, ( “yes everything is very probably o.k. but we have to do a scope examination to absolutely sure. Right now the most we can do is hope for the best, but plan for the worst”. A platitude that reassures no-one, but at least the explanation of the process seems to have helped a bit).

I’ve made three routine home visits and two urgents (one of the latter requiring an emergency admission to hospital after a “min-stroke”). I have five referral letters dictated and waiting to be typed. I’ve petted two dogs, three cats and placated a half dozen toddlers.

A couple of my patients this past two days appear to have been left with the impression (quite wrongly) that I can do magic. A handful have left me in no doubt that I am a waste of space and not nearly as good as that nice Dr Neighbour, “why does he always have to be on holiday when I need him so I get stuck with you?”

All in all it’s been a pretty average couple of days, but it feels good to be getting my mojo back. I have no idea where it went, but right now I don’t care, and you’d be pretty hard pressed to persuade me I don’t have the best job in the world.

Except maybe for a Ben and Jerry’s Ice Cream Flavour Tester.

Emergency Service?

Gentle readers, I have to confess to being a bit perplexed by this next diagnostic conundrum. I’m hoping there are some of you out there amongst my varied readership who could help me to unravel it, but before I get going I have to issue a tiny health warning, in that the subject of today’s enquiry is of an hem-hem, Adult nature, as they say. (Well they do if they are Nigel Moleswoth at least). Needless to say, given the usual inane tone of these meanderings, it might not attract a suitably, hem-hem, adult treatment, but then that’s not what you all come here for is it?

In a nutshell the problem is of a somewhat intimate nature, in that a young lady attended surgery last week seeking help with contraception. She was asking for a handful of “morning after” pills*. It seems that her previous GP had hit upon this unusual approach to family “planning” after she presented her rather delicate problem to him a while ago. Perhaps it would help if I explained why such an approach is at variance with accepted practice, before I go on to detail why it had been chosen in this instance.

In effect the “morning after” pill is intended as a single shot treatment for an isolated indiscretion, or failure of other method (principally condoms). To require several such pills suggested an intention to serial indiscretions, which, as health care professionals, causes us some pause for thought. So I had to ask the poor girl why she needed such a “Russian Roulette” method.

It transpires that she has never really been suited to either of the usual varieties of pill through adverse effects such as significant weight gain, or troublesome skin changes. For that reason she had also fought shy of implantable or injectable methods using similar hormones as their basis. As a nullipara (a lady yet to deliver a baby) she is not a candidate for a “coil” either, and, as any fule kno, caps and the wretched “femidom” female condom are about as effective as the old fashioned “hot bath and Gin” method and as spontaneous as a line of Pinter dialogue. And so she and her boyfriend have been diligently trying to use condoms, but about one time in three they burst and she finds herself in need of emergency contraception in the form of the good old “morning after” pill.

So here’s my problem. She and I are both aware that certain substances have a deleterious effect on rubber that can occasion such failures (baby oil being chief amongst these) and she is quite certain that there is no risk of this. She reports that her boyfriend is just “too big”.

Now, having spent many a late night in Doctor’s Messes the length and breadth of the midlands in my formative years, I watched quite a lot of late night Channel Four youth TV. You could guarantee that once every couple of weeks or so some drunken idiot would appear on “The Tube” “The Word” or some other hip and trendy show with “The” in the title, and perform his (yes they were always plug ugly, synaptically challenged herberts) party piece, namely the unrolling of a Rubber Johnny over the top of the unappealing visage to just below the oft fractured hooter. Thereupon said herbert would inhale though his mouth and exhale through his monstrously deformed nose, inflating the aforementioned prophylactic to roughly the size of a London Bus, before it explosively decompressed, sadly leaving the perpetrator unscathed though now adorned by a slightly slimy latex “Alice Band”.

So now I’m wondering just what this couple are doing to occasion such a spectacular failure rate, unless it is just that Boy Friend thinks that the technique described above is the approved method of use?

* for the uninitiated the "Morning After" pill is a monster dose single shot treatment of an oral contraceptive that can be taken anywhere up to 72 hours after an incident of "Unprotected Sexual Intercourse" ** so "Morning After" pill is a bit of a misnomer. Oh, and it used to be two doses of same taken at a twelve hour interval which made it even more so, though not now that both doses have been amalgamated so the name is at least half right these days....

** the acronym is UPSI. There is a trend for naming little girls Daisy round these parts, so I'm looking forward to being able to record my first "UPSI-Daisy" in around 15 years time...

Moan grone droan....

Soul searching is a wretched occupation to be sure, and yet sadly there are times when it becomes unavoidable. For me the past few months have been just such a time, and the truth is I'm far from happy with the conclusions I am reluctantly drawn to make.

You see folks, before you stands a creature as obsolete as the diplodocus, the marsupial lion, the dodo. It appears the job I spent almost half my life training for, and the remainder practicing, is no longer relevant. Family Practice, at least the sort of practice I understood as such, is dead.

The thing that hurts most about this is the knowledge that I and my colleagues have been at least complicit in, if not active proponents of its demise. Never has it been more true that good intentions make for the poorest choice of paving. It matters little how we got here, except perhaps to historians who in years to come may pore over the all too brief social experiment that was the post war Labour administration's establishment of the welfare and national health systems that now lie in tatters. It's what we do next that really matters. So for what it's worth, and for as long as I am able, I shall continue to ply my trade the best way I know how to any who wish to avail themselves of my services.

But with an uncaring, pettyfogging, beureaucratic civil service under a runaway political class on the one side, and an increasingly litigious, narcissistic, solipsistic populace on the other, I'm starting to feel more than a little like Han Solo in a trash compactor.

And the walls keep on closing in.

Just had to share this, lest I forget it....

You get to see all sorts in this job. We are the "window cleaners" of the medical fraternity. And then, just occasionally, you might even brush up against the paranormal. I’ve already told you about our resident reggae loving apparition in a past post, but today I have had a visitation from the Fair Folk.

Yes indeed, gentle readers, today I have consorted with a real life denizen of the land of Faerie. Thankfully one of the Seelie Court, so I think I’ve escaped without ill effect.

Now I’m sensing some skepticism out there, but I can promise you all it’s true. And how, you might ask? Well, because he told me so himself, and without me even having to grasp him by the beard (which was just as well, what with him being clean shaven and all), traipse three times (or should that be thrice to maintain the idiom…) widdershins round a mulberry bush by the light of the silvery moon or anything. Nope, he just came right out with it in the middle of morning surgery, bold as you please.

It transpires this particular sprite had suffered an accident at work. Namely he had barged his shoulder on a doorframe in a desperate attempt to conceal his identity from the mortal he was visiting. As a result he’s bruised his acromio-clavicular joint. In the end we got to do the examination through his T shirt since it had a broad neck, no doubt so he could keep it in place to save revealing his wings and all.

Still it remains the case that today I met with the Ambridge Tooth Fairy. He’s about six feet tall, and answers to the name of Steve* but Tooth Fairy he assures me he is. So when the kids of the Ambridge First School tell you they know for a fact that the tooth fairy has a very deep voice and knows a lot of interesting Olde English words for bodily functions and general Oaths try not to act at all surprised.



* obviously not really "Steve", but he made me promise not to reveal his true name. You’ll just have to trust me it’s something similarly non-descriptly male, and does not end in “-erbell” or in anyway sound floral.

Ecclesiastes Ch3 V1

Over the past couple of weeks it has become increasingly apparent that I need to cut down on the day to day distractions for a bit. I know posting here tends to be erratic at the best of times, and I regret to report that these are far from the best of times for the Ambridge Surgery, or at least for my own little corner of the same…

And so, regretfully, I have decided to place the caseblog in abeyance for a while. It remains my intention to return when I can, but I can’t give you any precise indication when that might be. In the interim rest assured I shall still lurk the bloggosphere, and likely will pop up from time to time in comments pages elsewhere. Feel free to use the comments that follow as you will, I shall be checking them still whilst on hiatus, and I very much hope to be back amongst you all again ere long.

Acquired empathy

Our case for today is a professional gentleman in the first flush of middle age. He has been favourably compared with Daniel Craig* with respect to his chiseled good looks, and likes to think of himself as pretty healthy. In short he is your humble narrator.

“Whatever then can be the matter?” I hear you all ask.

I thank you for your concern, but pleased be assured all is well, or at least soon will be. For now though it appears I have been stricken by a comedy ailment. You know the sort of thing, ailments that are a source of amusement to all but the poor victim. The boil on the bum, or dose of the piles; the glowing scarlet hooter of acne rosacea or alcoholic liver disease; or as in this case the throbbing agony of the hammer splattered thumb or gouty toe.

Yes, ladies and gent’s, your poor old interlocutor has been stricken with the gout. It’s not the first time to be honest. In fact the last bout was only just around Christmas time, though the one before that was a good few years ago. So here I sit, like the plethoric squire in a seventeenth century cartoon, foot held aloft, wincing and any slight movement within three hundred yards whose trajectory might imperil the affected hallux. The good news is, from past experience, both my own and that vicariously obtained, I know it will be gone in a few days and do not then expect it to return anytime soon. Better yet, it seems still to be responding to good old Indomethacin, so no need to seek out the apothecary monks for their Colchicine…

Happily it affects but a single joint, and yet, in so doing, I am given a glimpse into the daily reality of a number of my regular customers who have far more widespread and longer lasting inflammatory joint diseases. And such an insight makes it easier to appreciate just why so many of them are so keen to continue their painkillers, even when it becomes apparent that the anti-inflammatories are slowly but surely rotting their kidneys.

I can’t help thinking they are all an awful lot tougher than me. Arthritis really isn’t for wimps.



* Readers are encouraged to ignore the off camera sounds of Milady spluttering into her tea mug in disbelief… a lad can dream after all.

I give up!

Eddie came to the chest clinic this morning. His asthma is pretty well controlled with his present inhalers, and his lung function is appropriate for his age, and this despite his four decade smoking history. He says he would like to quit, but has tried all the methods available, with no lasting success. Still, this year he has decided to get serious and so, for Lent, he has given up.

Smoking.

Indoors.

Sadly, this behaviour modification has coincided with a bit of an upturn in the weather. In the past couple of weeks, Ambridge has been graced mainly by clear skies and brilliant sunshine or scattered, scudding clouds and a stiffish breeze. So in reality he’s not so much given up as changed venue.

Admittedly that makes it less likely that he will light up first thing, what with the rather frosty mornings such clear skies also cause; or last thing, since it’s still a bit nippy for standing on the patio in PJ’s, dressing gown and slippers. So this in part explains his drop from ten a day to six or seven. The problem is Lent will be up in another three weeks.

I’m also a bit baffled by the logic. Is it somehow more sinful to smoke indoors, polluting your own space, than outside, polluting everybody else’s? Or is God just watching what we get up to inside, knowing he can safely leave outdoors to Her Britannic Majesty’s Government, with their plethora of CCTV cameras and US loaned spy satellites? Or is this a new variation on the “calories don’t count if you’re standing up” argument?

I’m left wondering what other sins it might be safer to indulge outdoors, but, to be honest, so far I’m coming up blank.

The circus is in town.

Most of the time I’m more than happy to make do with a boring old mobile phone. The sort that just makes and receives calls. In fact, if I’m honest, I’m even more content to have the thing switched off in the glove box, or left back on the dresser at home. I know, I’m a grumpy old man, and I don’t care, so just get over it people.

Except that today I really, really wish I had one of those third generation, umpteen megapixel, all singing, all dancing, camera-phone-music-player-teasmade-filofax-blonde-bombshell-PA thingies. Because today I appear to have stepped through the looking glass and come out in Monty-Pythonland. You see, I know it’s not an acid flashback, ‘cos I never had the acid to flash forwards from in the first place, and yet the sight that greeted me on the way in to work this morning takes some explaining, and a picture really would have helped. I’m afraid you’ll just have to take my word for it instead. Still, you know you can trust me. After all I am a doctor….

I sense some of you in the cheap seats at the back getting restless. “Once again we haven’t got a clue what he’s talking about!” I hear you mumble above the background hubbub. I shall, at last, explain.

On the outskirts of town there’s a field (if I repeated this line now I might have a halfway decent beginning for a blues ballad—but we shan’t be going there today). In this field the are some sheep (yes, I know, “with a Baa Baa here an’a Baa Baa there”). So far so normal you might think, and so, on every other day it has turned out to be. But today these same sheep are auditioning for the Cirque d’Ambridge. In short they appear, gathered together in the corner of their field, in a seemingly perfect two-tier ovine pyramid, with a cluster of sheep at the base, and two very haughty specimens, side by side and faced Pushmipullyu fashion on the top tier.* So now you can see why I need a camera-phone.

Oh, and an in-car photographer, ‘cos otherwise all you’d actually get to see here would be a very fuzzy snap-shot of two headless sheepy blobs atop a mound of cotton wool.




*the boringly mundane reality is that the top layer sheep are standing on a very flat, very broad tree stump of an old, long ago felled, oak, with the remainder of the flock gathered in attendance around its circumference, which explanation rather spoils the illusion, but might help in my defense when the men in white coats come calling.

Ars longa...

It’s a rather disappointing discovery to be sure. You see the exigencies of child care have occasioned me to take the middle three days of this past week off. In effect I have worked a two day week, namely Monday and today (Friday). Monday was a moderately busy Duty Surgery day, but the knowledge that this was to be followed by three days at home with the kids reduced the normal stress levels this would entail to near zero. And today, back for just a day before another weekend at home, has felt every bit as good.

I have been at my empathic best. I have explored every patient’s knowledge, expectations and concerns* to the uttermost. Dare I say it, I have even come over all “Peak Practice” on a couple of occasions.

All of which is leading me to the inescapable conclusion that far from being the macho, stress busting 24/7 Dr Kildare of the 21st century, I am in fact far more suited to the occasional commitments of the hobbyist, and well on the way to the pipe and slippers.

I think I feel a bit of a mid-life crisis coming on, and that’s a real blow. Especially since heretofore I was rather hoping to give Metheusala a run for his money, which would put the whole “mid-life” thing almost 440 years too soon.

Bugger.



Knowledge, expectations and concerns-- the "Holy Triad" or the Royal College of GPs, to be explored in every consultation. You know the sort of thing. " I know I've got a sore throat. I expect antibiotics. I'm concerned you won't let me have them."

Solar Power *

It’s been a bad month. You might have been able to tell, what with the total absence of posts and all.

No need to bother with the whys and wherefores. Most folk resident in Blighty might have some clue, although the press coverage of he latest spat between GP Land and Her Britannic Majesty’s Government hasn’t exactly been at the fore-front of the news agenda. Add that to the arrival of a new Student (whom I’m trying desperately to inoculate against the cynicism of my confreres—after all somebody’s got to step up to the plate and keep working to pay for my pension) and a rash of young adults bent on their own self –destruction, and overall the latter half of January through to now has been, in common parlance, “a bit of a bugger”.

And yet today, on the usual drive in to surgery, things somehow feel a little brighter. For one thing, half term is upon us, so no school run and no school traffic. Also all weekend, and again this morning, the sun has been shining, with nary a cloud in the sky. Daffodils are starting to nod in the verges, and a scattering of purple-pink crocuses dapple the floor of our own little wood at Jest Acres.

On the road to the surgery, roughly half way between Borchester and Ambridge, the road climbs sixty metres or so on to the Ambridge Escarpment. It’s a pretty enough stretch of road, but today, under Canaletto Blue skies suffused with the golden glow of the early morning sun, at this spot God is plainly in his heaven, and very little can be wrong with the world.

Governments come and go, as indeed do GP’s, students, suicidal teens and all the other trappings of modern existence. Yet some things still hint to us of eternity and perfection.

And in that context all the distractions of the past month boil away to nothing.




*For those who were wondering Dr J is indeed an unreconstructed hippie and flower-child who's formative years were profoundly affected by the Summer of Love. Not that you'd ever be able to tell nowadays.

One for Dr Freud

Eddie has been having some problems with neck pains. The pains have been with him for years, but until recently he was managing pretty well with regular painkillers. A bit before Christmas the pains got worse so we repeated some blood tests, looking for evidence of arthritis, and an x-ray.

The bloods were quite normal, but the x-ray has shown worn disks in a couple of places in his neck and these will undoubtedly be the cause for his pain. So he will press on with the painkillers. I did offer him physio, but he has tried this before and is not keen.

“I used to come here for it when you had that blonde girl upstairs. We did it three times a week, but I had to give it up ‘cos it hurt too much!”

Then he realized what he had just said, and neither of us could entirely suppress a schoolboy smirk.

Some days here it's just like being on the set of a Carry On film.

Absent friend

Way back when, as one of my first tentative steps in compiling the rolling memoir that you now see before you, I wrote about an old friend and his best friend. My old friend Ray was back again today, this time on his own. Sadly, his best fried succumbed to a heart condition sortly after Christmas and is now serving guide dog duty for the choir invisible.

Ray reminds me that the initial consultation I described in the original post was almost a decade ago now, and yet the passing of his guide and companion still seems way too soon. Throughout the consultation we are reminded of the absence in the room as toys are not fetched to be deposited in either of our laps, and the "whumph" of a slightly pudgy labrador settling at his master's feet for the remainder of the consult is strikingly absent. No bowl of water appears at the door as once it did, and poor Ray is denied the fawning attention of one of our more dog mad reception team that was once his by right.

Happily this hiatus will not last for long as he has already been interviewed with a view to receiving a new companion. But for today we are left mourning the passing of a very special animal.


"The dog is a gentleman; I hope to go to his heaven, not man's." Mark Twain

Winter Wonderland?

Overall it’s hard not to feel a bit swindled. The reports for the preceding forty-eight hours had been full of blizzard warnings for most of the known universe, or at least for dear old Blighty. And to be sure the East Coast did get a bit of a snowy pummeling.

We might have known when first the forecast started to slip from “Thursday” to “… around tea-time” to “… probably after seven”, that we were not to be blessed by so much as a solitary flake. Although actually I might have seen one or two playing fitfully on a chilly gust in the middle of the afternoon visiting round yesterday, or it might have been a slightly tardy post-hogmanay hang-overish sort of thing.

Instead today sees Ambridge submerged in the middle of a damp, clingy cloud of fog, and swept with successive bursts of fine cold drizzle. And the same cold, wet, numbing grip appears to have descended on the minds of most of the locals, or at least most of those attending surgery this past couple of days.


Fair to say, the rot had begun to set in on New Year’s Eve. It’s almost a cliché I know, but I can’t seem to get through a NYE surgery without encountering a least a couple of suicidally depressed patients presenting that day, for the very first time, and wanting everything sorted out right then. This year was no exception and it has sort of set the pattern for the past few days.

O.K. the high drama of NYE has been replaced by the dawning realization that we’ve all got another whole year ahead of us, so the actual impetus to self immolation has receded. Instead consultations seem to alternate between the flat, affectless and moping on the one hand, and the jittery, agitated, “free-floating” anxious on the other.

I can’t help noticing some of the patients seem a bit down in the dumps too.