Dr Jest's Caseblog

I wouldn't get too excited, but...

2011-12-30T16:34:00.003Z

"Crikey, two posts in under a month-- what's he playing at? You wait months and months and nothing at all, then this..."

"Shh I think he's trying to say something!"

"Well I for one am not holding my breath so there!"

(And you're right not too. It's been a bit quiet round here of late I know, but here goes...)

As you can probably gather 2011 has hardly been a vintage year at Jest Acres. In fact we’ll none of us be too unhappy to see it go. There have been times this year when it’s been hard to string a coherent thought together, let alone get anything down on the page—virtual or literal. I miss writing hugely, but for large chunks of this year the words just wouldn’t come. There have been moments and punters worthy of anecdote, but it’s just not been possible, and for that I apologize to those of you who might have stopped by from time to time.

I’m hoping for better things in 2012, though if we’re to start looking after 25% of the inpatient population in addition to doing the day job (as one boffin seems to think we ought, to the rapturous reception of Mr Lansley among others) that might be a trifle ambitious. Whatever the case I’m determined to try harder to put virtual pen to paper as it were.

I hope ’11 was good to you all, and whether or not, I hope ’12 will be fantastic for us all. There’s a lot of doom and gloom about pretty much everywhere at the moment, but despite it all there is much to be grateful for (among many other blessings I’m especially looking forward to sampling some home made Mars Bar Vodka over the New Year holiday—if I survive I’ll report back).

So a slightly early Happy New Year one and all, and I’ll be back, soon I hope, to see you all next year.

East of Eden

2011-12-14T15:10:00.002Z

Whether you take it as revealed truth or allegorical myth there’s something compelling about the argument that we live in a flawed and imperfect world. Perfection is there to be striven for, but it’s unrealistic to expect that we shall get there alone. We allow in our oral histories that transcendence *is* possible, but only to a very few very special individuals, and then generally with the help or agency of some higher power. For the rest of us East of Eden is where we are expected and expecting to remain—in this life at least.

Indeed, if anything just now it feels we’re heading further and further east, away from calm, plenty and fulfilment as each day passes. Perhaps it doesn’t help that it’s winter now for real in Ambridge, after an Autumn so mild half the bulbs at Jest Acres seem to think it’s Spring again, but the old Crystal Ball resembles more a Snow Globe than anything else looking to the next year or two.

In the midst of all this gloom and angst we get a bizarre assertion in the news today. 24,000 deaths a year could be avoided if diabetes were treated better. With a token apology for pedantry, avoided? Really? Now I know modern medicine is pretty hot stuff, but I’m not aware of any innovation potent enough to permit us to avoid death. It’s not clear from the reporting whether this is a verbatim quote of a grandiose claim or just sloppy journalese, but I fear I have to disappoint you all. The best we can attain for now is a deferral, which in the colloquial idiom “ ain’t nothin’" but I fear falls far short of the alleged outcome.

I’m also a little uncomfortable at the assertion that there’s some kind of blame to be attached in each of these 24,000 “un-avoided deaths”. It’s almost certainly true that a great many could be helped to look after their diabetes better and in so doing delay or avert death from this condition, but it is equally the case that a number of them would prefer to be let alone, not seeing a prolonged existence as desirable for any of a number of reasons, some well thought through and some, to external scrutiny apparently frivolous.

I worry that in seeking to target this group of patients for “better” care we risk trampling on their autonomy. This is an increasing trend in all areas of modern patient care, where we are pressed to treat to a target—evidence based for sure, but paying little or no regard to the individual on the receiving end.

This is in no way to suggest that trying to offer better holistic care would be a bad thing, and if by so doing patients can be engaged and encouraged to try a bit harder to reach the targets then this can only be a good thing, but where like Mme. Voizin in Chocolat there are patients who know their choices are unhealthy, but opt to continue to indulge, accepting a shortened rather than an impoverished span, who are we to deny them.

Where there's a Will...

2011-06-03T13:33:00.001+01:00

Peggy was in today. She’s well into her eighth decade and in pretty good shape. She survived a cancer diagnosis – going through surgery then chemo and radiotherapy and follow-on operative procedures all over ten years past, and has never looked back. The surgeons have told her she’s cured and she hasn’t needed follow up in more than three years.

Today she’s in to talk about a minor injury, sustained a week or so ago, and healing nicely, so no need to worry. And yet... worried she is.

How do I know? She tells me so—though she did look far more apprehensive that the minor injury warranted so I had already guessed as much.

And why? Not through the injury, and not from her past health scares. No today she is worried because last week she and Jack visited their solicitor and made their Wills. As she put it “We’d never made a Will before, and now I have I’ve got to face up to the fact that I’m going to die.” It’s as though the simple act of making a testamentary disposition has opened wide the door to the Grim Reaper, The Fourth Horseman, The Pale Rider (no not Clint—the real one*). In short she has had to formally acknowledge her mortality.

What impresses me most is that after everything she went through ten years past it hadn’t even entered her consciousness that cancer was something she might not survive. Her faith in the undeniably excellent care and support she was given then, and for the years after, had allowed her not to have to do so. She’s a little surprised that she feels this way now, but I can reassure her it’s something I’ve seen many times before and so, far from cracking up, she’s displaying a normal if utterly irrational response to the feelings generated by this simple act of forethought.

I’ve tried to calm her fears by telling her that to the best of my knowledge there is no hotline from Hades to the offices of the legions of probate solicitors worldwide, and especially none here in Borsetshire. At least I hope not.

*That said, these days Clint is looking his venerable age, and might pass in a dim light for the Bony Fingered Wielder of the Scythe.

Re-Assura-nce ?

2011-05-23T19:21:00.003+01:00

O.k. I know I’ve not been around much lately—or indeed at all, for months. I know there’s a lot to say right now, and not having a voice with which to say it has been a huge frustration, but sometimes words just elude me. So I’m grateful for an email from a friend that gave me a prod to try again.

I fear it’s polemic time, but since I imagine so many of you have drifted quietly away in the long silence perhaps I won’t end up boring too many people. I should also point out that the email came over two weeks ago, so I fear this is not the best place to come for an answer to any queries you may have. Certainly it’s unlikely to be the speediest :-(

So on to the email. My friend was talking with a consultant who revealed the following;

“Apparently the PCT are refusing to fund all 3 monthly hospital reviews, and have been for some time (ie before Coalition took over) The hospital are still arguing about this, to get the PCT to accept those patients they put on pathways exempted from the GP's…”

I have to say the same is true, in some form, in our own PCT and likely in almost every PCT in the country. The reasons for this are many and complicated and though driven by finance are not purely dictated by the bottom line. What we have to bear in mind is our fractured, battered, beloved but struggling NHS has been through six decades of continual change. This change has been technical and clinical every bit as much as financial.

So, how dare a PCT dictate to a consultant when and how a patient should be reviewed? Well the first motivation right now will undoubtedly be financial. Each encounter of a patient with any hospital or “hospital-supplied” service since at least the early 1990s has carried a price tag. So the initial encounter at outpatients generates a bill. There is then a tension between hospital and PCT, both of whom have a primary statutory duty to deliver a balanced budget which overrides any other duty they may have. So more hospital outpatient reviews means more money for the hospital, and a bigger drain on PCT resources.

In the time I’ve been in family practice the level of care and expertise available in the community has gone through a quiet revolution. Pretty much everyone, including our consultant colleagues still see general practice as a sleepy medical backwater of two surgeries a day and a round of golf in between. Anyone who has had any regular dealings with their GP surgery over the past decade or more will know that things aren’t like that anymore. At least they will if they take a quick look around. First, it’s likely that their surgery has a number of doctors rather than just the one or two that was the norm in the first few decades of the NHS. Next, as well as the normal surgery appointments there are likely to be dedicated clinics for a number of conditions including diabetes, heart disease, asthma and COPD as well as “lists” for minor operations ( a rarity in 1990 and near universal by 2000) wart treatment, travel clinics, counseling, physio, and in some of the more adventurous, even “alternative” therapies like acupuncture, chiropractic and a host of others. (True in remoter and more deprived areas not all of this will be so, but even there the GP is still likely to be offering a range of services that thirty years or more ago would have been the preserve of the hospital).

All of this activity is also funded by the PCT. So if the PCT can agree diabetes reviews as an exemplar, in practices, for a fixed price well below that of the hospital, and if the practice is geared up to provide a service at least as good as that of the hospital for the vast majority of punters, why would they opt to have these patients reviewed in hospital or hospital led outpatients? Particularly when the service commissioned from General Practice is a “block contract” paid per capita and not per encounter. But there’s great deal more to this than mere finance. Any regular user of hospital services will tell you that they seldom get to see the same doctor two clinics running, because of the way hospital careers and training are organized, and because the minimum realistic interval between appointments is many months. In practice a GP will generally take a lead role in a given clinical area and will be rather more available. When patients are stabilized and well managed yearly or six monthly reviews will generally be the norm and these could be delivered in either setting, but in Practices the team doing the reviewing will de facto be smaller and longer in post, and so likely more consistent, delivering better continuity and with a greater hollistic knowledge of the patient. And when things are more complex practices can generally respond if needed in a day or two and review in a week or two, where the only option available to the consultant would be admission or “urgent” outpatients which—in this locality at any rate, could be anywhere upwards of 4 to 6 weeks.

This is not to deny that there are some, rather iller and more complex patients who genuinely need more frequent hospital care, and for them the existing system is undoubtedly flawed, to the unending frustration of Consultants and GPs alike.

There was another point raised in the email, “(h)is other interesting information was that here the GP's refer to a private company called Assura as well as the NHS. He pointed out that many of the local GP's have significant shares in Assura and therefore a clear conflict of interest…”

Here’s where things start to get complicated and not a little murky. Before I start I must declare an interest in that our locality has services provided by Assura in which every practice in our consortium are partners.

Assura was started some years ago as a commercial supplier of outpatient style services to GPs run by GPs. They have grown down the years and to the best of my knowledge now continue this model and also help practices with premises development in a model similar to PFI. They tend to develop local services as stand alone ventures—franchises if you like, in joint ownership with GPs, and often engage some of those same GPs who have developed particular expertise, alongside Consultants and other practitioners as appropriate, to provide the service. Their services can range form Physio to Dermatology to Orthopaedics to name but a few. I believe they have also been involved in tendering to offer out of hours GP services as well but cannot be sure if they presently run any.

True they are a “private provider”. So are many others currently offering care and services under the NHS umbrella. And true they provide services in partnership with local GPs, and invite referrals from those same GPs. However, to be able to provide such services they are obliged to tender in an open market to the PCT who commission the service, in competition with other providers, NHS and Private Sector, and stringent attention is paid in that tendering process to cost benefits and to potential “conflicts of interest”. So much so that it can take anything upwards of 18 months to 3 years for tender to gain official sanction.

This is the shape of our modern NHS and current reforms look set to oblige commissioners to look not just to NHS-allied organizations like Assura, but also to the wider marketplace, opening the door for strictly commercial private sector providers who will not have either the tradition of engagement with the NHS nor the public service ethos that alliance with GPs who are grounded in the existing systems carry in their “DNA”. One of the consequences of these new arrangements in our locality has been an increase speed of access to specialist opinions for patients who would otherwise have had to pay personally to see a consultant privately. Under these arrangements the PCT is paying the franchise and the patient is seen as an NHS patient. I wonder if this has some bearing on my friends’ consultant’s concerns over conflict of interest?

That sinking feeling...*

2011-02-16T16:48:00.003Z

I suppose it had to happen sometime. The word is out. There are times when consultations don’t go so well. Like any other human interaction a slight misread of body language, an ill chosen word or a momentary friction between personality types derails things and the express train of therapeutic discourse and discovery goes hurtling off down the wrong track, or smashes headlong into the buffers.

(Yes yes I know derailed trains don’t do either of the above in reality, but it’s my train set and it follows my rules ‘k? ‘K.)

I’ll be the first to admit to my share of disasters, but I hope that I recover most of them before any lasting harm is done to the therapeutic relationship. And though you might not believe it of us as a group, we all try our best not to put our size nines in our mouths too often, or to deliberately rub our patients up the wrong way.

After recent discussions with friends, both face to face and “virtual” (you know who you are) I’m a little worried that sometimes the poor souls of the receiving end of such consults then feel they’ve been labelled, and somehow singled out from the rest for “special” attention. So allow me to set the record straight.

There are times when the doctor-patient relationship dysfunctions, and continues to dysfunction repeatedly and serially over a sustained period. To be non-PC about it terms like “Heartsink” and “Quack” get bandied about and a rift opens between patient and the profession as a whole.

Let me be quite clear about this—though the term and the concept of the “heartsink” patient exist and I’m perfectly certain that the equal and opposite concept of the “heartsink” or “quack” doctor also exist, from where I sit the terms loose currency through overuse. In a career of over 25 years responsible for the care of upwards of 14,000 patients on a day to day basis, and with a dedicated personal list of over 2,000 patients theoretically entirely my own in that they have named me their personal physician by registering on my list, I can’t think of even a handful of patients whose name would instil in me that feeling of apprehension implied by the term. Yes I have many patients who at times test my patience, just as I’m sure there are even more patients whose patience I test from time to time. That doesn’t amount to the same.

One bad consultation, even a run of awkward encounters doesn’t amount to the same thing. Indeed often you have to negotiate a period of awkwardness until you achieve an understanding as with any other interpersonal relationship. Patients know how they feel, even if they don’t intuitively know why. Problems arise when the way they express their symptoms, feelings, fears and apprehensions isn’t heard or isn’t interpreted correctly, or appears to have been ignored and disregarded.

If we can be grown up enough to acknowledge this and back track a bit and try over mostly we can make progress and though we may not be destined to be firm friends we can work together—after all it’s the patients who do all the heavy lifting in any therapeutic process barring the most trivial. We might prescribe the meds, the lifestyle changes or perform the operations, treatments, manoeuvres needed to fix things, but the punters have to take the pills / advice and adapt to the aftermath of the procedures. If we get it wrong first go we have to have the trust of the recipient that our next effort will be better. It’s when this breaks down, and stays broken that we risk loosing an effective therapeutic relationship. At that point the majority of patients, quite sensibly decide that it’s time for them to find another doctor—who will hopefully understand them and their needs better. Sometimes it behoves the doc to suggest this perhaps by means of a personal recommendation.

Where we risk sliding into a longer term “institutional” dysfunction that ends in mutual “heartsink” is where a patient runs through a series of such dysfunctional relationships, or feels trapped within one, ongoing and without possible exit. It’s easy then for patients to feel abandoned, doc’s to feel their well intentioned advice is ignored and for both sides to give the impression either that they’ve stopped trying or are completely disinterested and merely going through the motions.

* anybody else know where I nicked the title from? EVCHN on offer as per usual.

Addendum: For the counterpoint see this from Anna. (Thanks Anna).

You can't get better...

2011-01-26T14:49:00.005Z

O.K. so it's not quite the speedy revival I was hoping for. Still perhaps if I aim for a post a month for now that will do? Well it might have to. And to be honest I'm not sure you're going to like this one. Still here it is...

This week saw the publication of the Health and Social Care Bill, the road map for the much heralded changes to our health services in Blighty under the present administration. You'll notice I've omitted the word National and the capitalization. The thing is, it's hard, sitting here, to see the coming changes as anything other than the final nail in the coffin, ending the pretence that we have such a thing as a unitary "National Health Service" at all.

Ever since devolution, health in Scotland, Wales, and Northern Ireland have been devolved too (in fact the Scots had their own service even before that), but these four separate services still cannot really be regarded as truly national even within the definition of the "home nations" that make up our fractious little "United Kingdom".

Even before this the rot had started with the experiment that was "Fundholding" where GPs held a tiny proportion of the NHS budget to buy operations for their patients from hospitals. The vast majority of these operations were still performed in the NHS (soi disant) but already the "internal market" had hospitals (later "Trusts") vieing with one another for the cash. And even then a small proportion of procedures were shuffled sideways to the private sector on the basis that they could be done quicker and at no more cost to the taxpayer.

This hypocrisy was swallowed hook line and sinker by the monster that was the incoming faux "Nu" Labour administration. Competition and choice became holy writ, and so they remain. True, levels of investment in health went up, and at last we reached a level comparable to other developed economies. Sadly that increase was built on the foundations of decades long underinvestment, so although current spend might be comparable, past investment has been anything but and our infrastructure remains woefully inadequate as a result. Worse yet, dear Gordon found a splendid way of burying the cost of new infrastructure in the PFI scheme where we, the humble taxpayers, sign up to a 30 year mortgage every we time we want a new hospital / surgery / clinic, and said facility is built, operated, and owned (for gods sake) by private enterprise. So not so much mortgage as "rent" then. And at the end of the 30 year term what happens to the infrastructure? (No that's not rhetorical-- I'm pretty sure the builders will own it and our successors will be renegotiating the lease, but I'm not 100% sure).

Oh but then there was even worse to come. ISTCs anybody? Well some of you might have been treated in one. Most PCTs have one. Remember our old friends choice and competition? Well to enshrine them in our hearts PCTs were compelled to establish Independent Sector Treatment Centres. Yes Independent Sector-- "Private" to you and me. Set up by the NHS and awarded fat contracts for surgical procedures and outpatients. They bussed in Consultants from far and wide. Mostly from the expanded EU and Scandinavia, all thoroughly decent chaps and impeccably qualified, but with no grounding in the workings of the NHS. They were guaranteed income for operations and creamed off all the "easy" cases. They did good work, but on fitter, younger, less complicated patients. Anyone who crossed their threshold with a sniff of a raised blood pressure, wheezy chest or high blood sugar was politely declined and sent back to wait for the NHS "proper" to sort them out. And remember the "guaranteed contracts"? Well they meant that in a year when they didn't perform the required number of procedures contracted, they got to keep the money anyway. And all paid for by the PCT and therefore the NHS. And if, and when one of their patients did become more complicated, they were shipped out of the ISTC and back to the local hospital to be sorted by the NHS consultants who had been denied the opportunity to treat their initial problem by the establishment of the ISTC.

Add to that the lunacy of ever more micro-management of contracts and setting of targets as Nu Lab imploded and our poor PCT colleagues have spent much of the last five years running around in ever decreasing circles. And now we get the Health and Social Care bill. Where once we had fundholding, now we get GP Commissioning, and instead of 10% of the NHS budget we get something approaching 60-70%. We're still mortgaged to the hilt with hospitals we don't own, and now every "provider" of NHS services is going to be compelled to become, or to join, a "Foundadtion Trust". Where prices for specific treatments were set nationally now these trusts will be at each others throats striving to win contracts, and now we get the added imperative to consider, when contracting, "Any Willing Provider". Until now the assumption in contracting has been that the NHS family is the "Preferred Provider" and so when bidding for contracts for NHS services, Trusts could presume their bids would be considered ahead of any other. Now that protection is gone and not only will thrusts be at one anothers throats, they will do so with wolves circling the fold ready and waiting to pick off the choicest prey.

And the best bit, the absolute best bit... PCTs (the health service managers we've all derided for all these years, but who have done the best they could to shield us from the twin madnesses of the Department of Health and the Foundation Trusts) have been told that they must continue to run the show for the next year or so whilst GPs gear up to becoming managers themselves, knowing that at the end of their term, they will vanish. Some will doubtless be reabsorbed into the new commissioning bodies or the overseer NHS Commissioning Board which will be there to insure the Commissioning consortia are working properly. But with massive cuts in funding for NHS management demanded throughout the restructuring, many more will be looking for jobs elsewhere, just at the time the Private Sector "wolves" are seeking a foot in the door.

The NHS I joined in the early 1980s gave me freedom to refer patients anywhere in the system, based on their need as that system was bought and paid for in its entirety as a monolithic state run enterprise. Since the foundation of the PCT my freedom to refer has been constrained, in large part, to the county I work in, and to the two or three Trusts my PCT contracts with and preferably to the hospitals we are shackled to by PFI contracts. With commissioning, all the early evidence suggests my freedom to refer will be constrained still further. "National" no longer applies. Even "Local" is beginning to look dicey. True for most of my patients, most of the time, this won't mean a lot. Right up to the point it means their hip replacement will be done by Kwik-fit as the cheapest willing provider!

16.ii.11 Addendum.
In a similar vein just seen this which you might like to read. Not sure I agree 100% but there's some honest to goodness venting going on and much truth. (Thanks to BG for tweeting the link).

Resurgam?

2010-12-31T16:17:00.002Z

Looking back 2010 hasn't really been a vintage year has it?

Well, no matter. 2011 is just around the corner, full of promise. Even in this new found age of austerity there's much to look forward to, both personally and professionally. New challenges to be met, places to go, people to see.

It's easy to look to the year ahead with trepidation, and I've spent most of the last three days doing just that. this arbitrary date on the calendar looms large for the bereaved, the anxious, the dispossessed, but hope is there to be had, and sometimes we need someone else to point that out for us.

As a political ploy Dave's "Big Society" is a bit of a non-starter-- as a friend of mine quipped yesterday, the difference between the Big Society and the Big Issue is that nobody buys the Big Society-- but the fundamental decency of our fellow men that would underpin it is still there and will, I fervently hope and expect, come to the fore in the months to come. *

So, wherever you are, and whatever your plans for tonight, I hope you give Oh-Ten a splendid send off and Oh-Eleven a roaring welcome. I hope to be back rather more next year, and I look forward to hearing all your news as time unfolds.

We shall, as ever be firmly installed in front of the Hootenanny, and we'll be raising a glass to you and yours, and us and ours.

Cheers to you all, and Happy New Year.

*Woohoo. "Big Society" three times in one sentence! Thesaurus- Schmesaurus say I.

Not only... but also....

2010-11-26T08:42:00.003Z

So-ho. You all though last post would be a flash in the pan didn’t you. Go on, admit it, you know you did. Well to be honest so did I a bit. You see you, well I, make these resolutions to try to do better, to stay more engaged, to put down just a few words each day until you get to something postable... and then real life chucks great dollops of stuff at you, well me, or your tiny little butterfly mind flits onto something else and here we are three weeks on and nothing to show.

Anyhow, in the flurry of quite unexpected, and stunningly over generous comments to my last outing, my friend Bendy Gir l set me a sort of a challenge, which I shall now attempt to answer. If you’ve not met her before you owe it to yourselves to do so now. Go ahead, click the link and have a browse, I’ll still be here when you get back.

It seems our heroine has started a “revolution from her bed” as she says. And there follows a small contribution from your humble interlocutor about two friends of mine. As regular readers will know whilst the following stories are “true” they are composites of more than one individual’s experience in each case and reflect the “patient experience” rather than identifying an individual.

So with all of that said, first let’s meet Dud. Dud has worked in light industry all his life. Of course by light industry we only mean not building steam engines or other very very heavy things. He’s worked with metal in heat and dust and smoke for years. He’s also been partial to the odd fag, to be sure (American readers take note: Fag = cigarette in “proper” English like wot is spoke in Ambridge), and as a result of all of these factors he’s developed that persistent shortness of breath that is COPD. He needs three inhalers several times a day to get by. That hasn’t stopped him working well past retirement age, his skills being too valuable to the company to loose. A few months ago his chest took a bit of a nosedive, he started coughing a lot more and he ended up in hospital. While he was in the nice docs did a chest x ray and found a nasty looking “shadow” at the top of one lung. Dud put two and two together, decided he wasn’t liking the arithmetic and quickly persuaded them to let him home without a lot more testing and probing. He’s on oxygen, is comfy, and is looking forward to sitting up for nights on end to watch the test matches from Down Under. We haven’t talked about his diagnosis, because we don’t need to. In the end the only thing he’s worrying about now is how much his treatment is costing and whether he deserves it!

Pete lives in Penny Hasset, a stones-throw from Ambridge. He’s been barman, cleaner and general factotum to the Penny Hasset Working Men’s club for decades. Though never a smoker he’s worked around smokers for most of his working life. From quite an early age he was identified as having bronchiectasis. This, for the uninitiated, is a poorly understood condition of susceptibility to recurring destructive chest infections that slowly but surely erode the normal architecture of the lung, leaving in their wake cavities which fill with phlegm which in turn render the sufferer more susceptible to infection. Three years or so back Pete had a really bad infection—bad enough to warrant admission to hospital with pneumonia. While he was there he developed respiratory failure and came home with both oxygen and night time ventilation. Against advice he went back to work. He lasted six months before I prevailed on him to be signed off. He was gasping, and the lifting his job entailed was patently far too much for him. Three months after signing him off the benefit docs asked him in for a medical, where they asked him a few questions, got him to do a few trivial physical jerks, and passed him fit to return to work. This despite me filling in a form explaining his need for long term oxygen therapy and night time ventilation.

So Pete gamely struggled back to work. At least by now there was a smoking ban so his working conditions were a little better, but come the following winter he had another exacerbation, a long spell off work, and finally lost his job. Thus far I’ve been able to persuade him he really ought not be looking for another, and again thus far, the B.A. docs appear to have seen sense and have accepted my latest report and stopped hassling him.

So there you have it. Neither Pete nor Dud would have chosen to be where they are now, and neither has asked not to work when they were capable. Indeed both have rather struggled on when reason would have suggested they ought not. And I could name you a dozen others in a similar position. All present talk of making it more profitable to work than rely on benefit may sound very noble and high minded in the marbled halls of power, where hard graft means having a lot to read and a few late meetings to go to. It completely misses the enormous efforts made by the likes of Pete and Dud to keep going against the odds, and any move to impoverish them is little short of scandalous and should be relentlessly pointed out for the evil narrow minded bigotry it is. I sincerely hope this is not what Dave and his cronies are about to do, but somehow I'm expecting to be disappointed.

Crikey _ _ *

2010-11-10T14:51:00.002Z

Well, blow me down, here we all are in November. We are all here, right? I mean it's not like I've neglected you at all is it? Well not *really* neglected. Well I didn't *mean* to. Er...

Perhaps I'd better stop digging now eh?

Would it help if I said I'm sorry to have been away for so long and that I never meant to. There were lots of times when I sat down to put finger to keyboard, but the words just wouldn't come. There were even a few when the words just wouldn't stay away, but there was no time to tap them out-- rather fewer to be sure, but a few. Anyhoo-- if there's anybody still out there just let me say again, and for the record, I'm sorry for not keeping in better touch.

So there you have it.

Now what was I going to say....

Oh, yes, crikey!

~Er, that's where we came in-- why doesn't he just get on with it? ~

~Don't ask me. I only stopped by to water the plants!~

~Shhh shhh shhh shhh, it looks like he's going to say something in a minute...~

~well it's about blooming time if you ask me...~

Sooo Mondays...

~What does he mean Mondays-- it's Wednesday isn't it?~

~Shhh, don't scare him off he's only just come back!~

... well perhaps more this past Monday, but in GP land Mondays are funny days. People save stuff up for Monday, or get sent up by the nice out of hours docs after an encounter at the weekend, or wake up at the start of a working / school week feeling a but the worse for wear, and need to be seen stat...

~ooh hark at him going all E.R. on us~

.. just in case it's the killer lurghi, or Green Monkey Disease or whatever. In a nutshell Mondays always loom that bit larger on the GP calendar, unless they are Bank Holidays, in which case the immediately succeeding Tuesday gets promoted to honorary "Monday-with-knobs-on" status.

And so it was two days ago the the gods of Mondayness struck and blighted the surgery with a cloud of despondency. The whole day was a catalogue of grief and woe. I should have known it was going to go ill when the first three patients all moaned bitterly about having their blood pressure checked. Now it's never entirely comfortable having your pressure checked in the vice like grip of the sphygmomanometer (500 points in Scrabble if you can position it right) but on Monday apparently not only was the cuff extra squeezy, it was also "too cold"!

Like the rest of the building.

No heat on over the weekend means it takes till Wednesday duty surgery for the building to thaw, and last weekend was a tad "Parky" as they say. (And yes this is a Wednesday duty surgery and I'm feeling far more toasty thanks for asking). In the end though parkiness was going to be the least of the problems presented.

After coffee a couple came in to talk about the death of their son. it was sudden and unexpected, and there is nothing to say in such a consultation that isn't, however well intended, a platitude. The best you can do is to make sure the bewildered, bereaved and struggling couple in front of you know that you really mean it when you tell them you'll be here for whatever, and whenever they need you. Not an easy sell now we're closed weekends and evenings.

We spent a half an hour going round the houses, with me trying-- vainly, and inevitably so-- to persuade them they have nothing to blame themselves for. In reality this is true, of course, but in the messed up milieu of "feeling" and "emotion" it is anything but. There are always a thousand "what ifs", easy to ask and impossible to answer. We covered a few, and we'll cover some more as time passes, but sometimes, even when it's inadequate "stuff happens" is the only response.

From here it's how you pick up the pieces that matters. We'll help as best we can, and they have family and a phone number to call that will open up the doors to more and better support that I can provide. And my door will remain open for them for as long as it takes, but it all feels so woefully inadequate.

The rest of the day plods on with a succession of intractable depressives, horrid sore throats and one comedy ailment-- a poor chap who pulled his back when he was jolted by the shock of poking himself too hard in the ear with a cotton bud. Now he knows why the ENT boys say never put anything in your ear that's smaller than your elbow (go on try it, you know you want to try putting your elbow in your ear-- not you Bendy Girl if you're still out there, you just might make it and then I'd feel terrible).

And then with grim inevitability, in comes a girl to talk about the death of her mum. Of course you have to bear in mind that in this context a girl is anyone more that five years younger than me-- what with me still being so youthful and all, but here even at forty-mumble she's still her mum's little girl and always will be, even with mum suddenly no longer here. The perspective is different, but the consultation is very much the same. Mum had been ill for some time, and her end was not perhaps quite so unexpected, but that hardly makes a difference as anyone who's been through this will tell you.

There are days when I feel barely adequate to the task. And somehow they are mostly Mondays.

* fill in the missing letters for a fabulous virtual prize.

Does you does or does you don't...*

2010-08-03T10:34:00.002+01:00

So we hover on the threshold of a brave new world, of which doubtless much more later—unless of course that nice Mr Lansley ponies up my share of the £70Bn all in one go, in which case I might soon be blogging from the Cayman’s. Somehow I think not though so you might all be putting up with me for a bit yet.

One thing we’ll not be missing from the old regime is the ceaseless buggering about with targets they like to call “micro management”. One of the weirdest of these was something they liked to call “Access” where the Holy Grail was that punters in need could get to see a doc within 48 hours. This was for us a nonsense, since punters that need to see a doc get fitted into a duty surgery appointment same day. Bit of an un-missable target then, or so one would like to think. Still we spent a happy year or three making monthly submissions to the PCT to prove that this was what we were doing, boxes duly got ticked and we all carried on our merry ways rejoicing.

Or so I thought until last week. For last week in walked a very shaky Susan. She’d not been to see us in over a year, so I was a bit surprised when she said she had come for a repeat of her anti-depressants, also not issued in over a year. I gently inquired as to the reason for the gap in treatment. It transpired that Susan had been seeing Dr Neighbour regularly for her combined anxiety and depression symptoms up until a year ago. Then the Cllr Dan Archer Memorial Car Park and Pizza Franchise just over the road from the surgery was closed “for maintenance”. This meant Susan having to park on the far side of town and walk through. Given the agoraphobia that was a large part of her presentation, this proved physically impossible for her, so she just stopped coming, and waited, indoors, for a year, for the CDAMCP&PF to reopen, so she could start attending again.

Of course no amount of measuring “access targets” can spot a patient like Susan falling through the cracks. I’m not sure anything else in our current armamentarium will either. You see we’re very good at pulling up people we think are over-using their meds, but we tend to the view that punters who stop filling scripts and coming to see us are either better or have moved on to other avenues for help. In common parlance it’s “a bit of a bugger”, and it rather puts all that silly target nonsense in the shade. Access indeed.

* I know it's unfair to readers in other juristictions, but an EVCHN to the Blighty based reader who can spot both the inane reference, and the sublime progenitor (the original song that is) for today's title.

Yesterday*

2010-06-25T02:38:00.002+01:00

Spike came in this week for a chat. Nothing special in that really. We meet four or five times a year now to tweak his meds, catch up with the doings of the clever doctors in his various clinics, and the not so clever apparatchiks in the DWP.

Mostly what he needs me for is certificates to verify his status and the odd re-jig of his painkillers. The interesting bit is his status. You see Spike is a Revenant.
O.K. not the sort you need to fend off with garlic. Indeed Spike can walk quite happily abroad in the daylight. He can do it in Blighty too, and does, mostly, though not without a constant reminder of his if not unique then certainly uncommon circumstance. Oh and you can see him in mirrors too, in case you were wondering.

The difference between Spike and those other more spooky returners from beyond the veil is how he got here. Some time ago he was working in a factory. Having worked there pretty much all his adult life he reckoned he knew what he was doing, so when colleagues needed a hand unloading something big and hefty and made out of steel (sorry my grip of the technicalities here is perhaps a tad fuzzier than would be ideal), he stepped up, like always, and lent them a hand—in fact both hands and the whole rest of himself—as he had countless times before. This last time things went a little less than well, and in no time Spike found about half of himself pinioned under the hefty thing. In took something over an hour, cranes and such, and expert paramedics to extricate him.

In that time Spike drifted away for a while, and when he came too he was hooked up to all sorts of exciting contraptions which were re-expanding the lung that his rib fractures had collapsed, holding his leg back together, and supplying the pain relief he was going to need pots and pots of before he would be ready to try to move at all. Nobody said much at the time, but for a little while he had been what,in less technically gifted times might reasonably be called a bit dead.

It’s taken a while, but he’s now back on his feet and this week we got to discuss the various absurdities of his current position. Like anybody left disabled, either by health or injury, Spike has had to be assessed, and has become, like Schroedinger’s celebrated cat before him, a thing of percentages. Apparently, to the DWP he’s now only roughly 33% of his former self and in a bizarre twist, according to his employer’s solicitors he’s responsible for being so in a roughly similar proportion, since it wasn’t in his job description to help out his mates, and he wasn’t wearing the approved safety kit.

All Spike knows is it hurts him to walk now. Not much, but enough to stop him getting out and about like he used to. He can walk the dog, a bit, and do the garden, sometimes, but as for getting back to work, he’s still a long way off. Then there's sleep. Between nightmares he’s fine, and no he wouldn’t like sleeping pills and no the counsellor lady hasn’t helped a lot. And as to the hospital, a nice sister in ITU who had seen him through the worst asked him last month if he realized how lucky he was to have cheated death, like this was something to be instantly and unhesitatingly grateful for, despite loss of livelihood, and severe limitation of many of the functions he suffers that we all take for granted.

Spike knows, in a sense, he has been lucky, or at least luckier than he might have been, but her well intentioned comment really hasn’t helped. He now feels guilty about the bitterness and the sheer panic that sometimes overwhelm him when he’s transported back to his time on ITU or worse to the day it all happened and his old life ended.

So I tell him that’s o.k. and that for 1/3 of a Spike he’s doing pretty well and day by painful day he’s getting better. Who knows, soon he might even make a 1/2 Spike, and even now in his diminished and revenant state he’s still more of a man than some I look after who are notionally whole. And so we decide that this afterlife isn’t so bad after all, but he’s quite right when he says we should all be so lucky...

* I know this is a bit of a reach, but Virtual Hob Nob on offer if you link post and title-- you all know the drill by now I hope;-)

Of coffee and Hob Nobs.

2010-06-22T07:43:00.002+01:00

So, I managed to keep this blog entirely free from politics all through the election... admittedly by the simple expedient of failing to comment on anything at all for the duration, and all through the tawdry aftermath for good measure. In all honesty things are a bit grim in Ambridge right now, so there’s not been a whole lot worth sharing, and really no time for sharing it all with you poor long suffering souls.

So colour me astonished when I received, through the comments of this shambling mess of a “journal”, a request from a publisher to review a book about my craft, written by an esteemed colleague known to probably nearly the entirety of the UK GP community. Consider the foregoing a declaration of interest. What follows is not exactly a paid endorsement, but I did receive, and am thoroughly grateful for, a copy of the said volume. All that said, I took this assignment with more than a little trepidation.

The thing is the author, one Dr Tony Copperfield (actually a collaboration of two practising GPs) is well known for his bi-weekly column on the back page of our Trade Paper “Pulse” where his worldly wise musings on the absurdities of the job, the relentless push for “evidence based medicine”, the inanities of the Contract, the Departmental Diktats and the lunacies of the PCTs (our immediate managers) never fail to raise a wry smile and a sardonic chuckle. But to let him loose on an unsuspecting public—would this be wise? I had my doubts.

I suppose at this point I should mention the book in question, “Sick Notes. True stories from the front lines of medicine.” It’s published by Monday Books and you can find it here.

Having received and devoured my copy I’m happy to say that this collection of Dr Copperfield’s writings strikes just the right note. The wit and the sardony (I know it’s not a proper word but it definitely should be) are still there, but leavened with stories of old friends and worthy adversaries in the form of Airfix Man (I defy you to read this snippet without at least the beginnings of a lump in the throat) Mr Nickleby (guess where Dr C goes for many of his pseudonyms), and Rebecca Bagnet, along with snipes at the political dimensions of health care, the PCT, the profusion of forms and hoops and brain dead rituals that seem solely intended to stop us doing the job. Along the way you will discover the central role of coffee and Hob Nobs to the functioning of any well regulated family practice and you’ll learn a lot about how UK General Practice operates... er, consults.

If you read this book you’ll discover why your GP adopts that strange far away look when you take him or her a little list, or begin with “I don’t see you often...” or end with “While I’m here....” . Dr C is indeed divulging some trade secrets, but he’s giving you a user’s guide to your GP into the bargain. Or at least he is if you live in this sceptered isle. Because Dr C practices here in Dear Old Blighty his descriptions of our working environment and the challenges it presents are very time and place specific, but the stories he tells of his patients and their woes are universal. And though the style is tongue in cheek the book is billed as a work of non fiction, and so it is. Not all of the events portrayed may have happened exactly as presented, but however much they stretch the credibility, believe me when I tell they happened, and they’ve almost certainly happened to your GP too. (I would have dearly loved to have been at the meeting where he and his partner presented the PCT with their newly “imagineered” Universal Referral Form.)

I suspect this book will be regarded as something of a niche market publication, but I hope it manages a wider circulation, and if I have one wish it is to make it compulsory reading for all PCT managers and Chief Executives. Indeed I’m thinking of passing my copy on to our own Beloved Leader, assuming it’s still in a fit state when my partners have done with it. I get the feeling there is a real gulf of understanding between our two disciplines, and I think Tony Copperfield might have give us a means of bridging the divide. So if you’re an NHS administrator, a politician in or aiming for the Health Department, or if you’re remotely interested in the workings of our shared profession, you owe it to yourself to read this book.

And the next time you’re in the surgery why not take along a packet of Hob Nobs for the troops? Tell them Tony sent you.

They’ll understand.

The Judgment Call

2010-04-29T09:00:00.002+01:00

This post comes with a spoiler. There follows a replay a scenario I encounter five or six times a year. It's one of the very few (I hope) red rags that I can't help but charge when they are waved in front of me. I'm disappointed that after twenty years behind this desk I'm no better at handling them, and I know that what follows might well provoke an "equal and opposite" reaction in some readers. Please just take this as a glimpse into the darker workings of the Jesterly mind and not as implied criticism of anyone else.

If having read it you then have insights to share I'll happily receive them, and if you feel moved to "flame" then vent away by all means-- just don't expect a very sympathetic hearing if you do. On the other hand I promise I'll sit on my hands and not bite back.

So, now that's out of the way;

Monday 10.00 Request received to visit to Mrs Grundy.

Monday 13.00 Visit to Mrs Grundy, a lady well past retirement age. She requests visits roughly once, sometimes twice, every month or so. I find her, as I always now find her, seated in her living room, watching TV and with her lunch, three parts eaten, on a tray on top of her trolley / walking aid. Today she's feeling a bit chesty, and as is also often the case, her chest is essentially clear, but she has a nagging catarrhal cough that's been hanging on since New Year. We agree that it's a nuisance, but that she's not unwell, and there's nothing in her presentation that would indicate antibiotics are likely to help at all, and that the linctus she swears by is still possibly her best choice for symptom control. As is now her norm she sits barefoot with slightly puffy ankles and with an arcade of tiny thread veins and capillaries running the length of the outside edges of both feet. She frequently comments on them, but does not do so today. I decide to let this particular sleeping dog lie.

Tuesday 09.35 Request for visit to Mrs Grundy. Carers noted "Swollen legs and blue feet".

Tuesday 12.25 Telephone call to Mrs Grundy. She's aware of the carer's request, but agrees her feet are no different than they have been for the past year or two, and that she would not welcome compression (the only sensible "treatment" option here) even if I were to offer it to her, which she's sure I won't because she's made it very plain how she feels about this before. We talk about her trying to elevate her legs a bit more (something we both know she's unlikely to do-- but feel we have to discuss for form's sake). She thanks me for the call and agrees there's no need for a home visit.

Tuesday 14.40 Telephone call from Mr Grundy Jr complaining that "the Doc refused to visit my mum".

Tuesday 14.47 Mr Grundy unavailable on mobile number given to staff when I try to call back.

Tuesday 15.50 Mr Grundy finally answers mobile and staff put him through. We discuss the fact that his mum's feet have been as they are now for years and were fine in that context as recently as yesterday, and that she herself says they are no different today. "But the carer says she thinks mum's got a thrombosis so you've got to see her". "You know. For peace of mind." I remind Mr Grundy that if he or his mother are unhappy with the service we offer they are at liberty to register her elsewhere. He tells me he thinks he will.

Tuesday 19.00 Visit to Mrs Grundy. Her feet are as they always are and ever are likely to be. There is no evidence of thrombosis, but at least now Mr Grundy can sleep easy in his bed.

The main thought that occurs as I drive away is that I'm being used as a form of surrogate, by a son who is unwilling to engage directly in his mother's care. This would be fair enough were Mr Grundy living and working in Kent or Aberdeen, or Spain, or Florida-- as has been the case with others I look after. But Mr Grundy lives three streets away from his mother, and yet, for all his willingness to complain about the surgery and my approach to his mother's care, she sees me far more often than ever she sees him. I'm left with the disappointing impression that she might almost be better off if he did live somewhere far far away if this is his idea of "caring".

Proper poorly

2010-04-09T08:41:00.002+01:00

Sorry not to have been around much lately. We've been a tad busy in Ambridge, especially this past two weeks, what with the bank holidays and all. Still at least it's starting to look as though spring might at long last be sprung. I'm going to try very hard to keep this space politics free this next month, but I can't promise. It depends how much I'm provoked. For today though a little treat from last week. I'm still not sure exactly what the problem was but I creased up with internal hysterical laughter at two points in the following exchanges. Virtual Lindt Bunnies on offer if you can spot where.

"Wellit'slikethisI'venotfeltwellformonthsnow,Idon'tknowwhatitisexactlybutI'vebeenfeelingreallypoorly,everythinghurtsandI'msotiredallthetimeandIjustwanttofeelbetter,"

"O.k. Where exactly..."

"onlyyouseeit'sbeenmonthsnadIjustfeelsoillandIjustwanttofeelwellagain.Imeanit'snottoomuchtoaskandIthinkIneedsomeantibiotics..."

"Right, so what is it you think the anti..."

"OnlyMrsWotsithadsomewhenshewaspoorlyandnowshe'stonsbettersoIreallythinkyououghttogivemesomenow."

"Yes but before I can I need to know..."

"Imenait'sbeenmonthsnowandIreallyshouldn'tbeleftfeelingthisillallthetimeit'sjustnotright,"

"But..."

"Carryon"

"Well what I wanted to ask was where you thought...."

"Wellit'sjustbeensobadIcan'tbegintotellyou...."

What's so funny 'bout ...

2010-03-08T15:20:00.005Z

.... peace love and understanding?*

I'm struggling to find a way into this post, but once again there's something I need to get off my chest, so for those who prefer not to have to listen to me ranting on at length about a pet peeve, I urge you to look away now.

Right. There we are. Just a few of us left now, so stand by for a little serious spleen venting.

Not long ago I heard from a friend, that they knew someone who held a faith based objection to having their daughter immunized against HPV. Apparently this God-fearing member of the community felt that doing so was giving the poor girl tacit permission to sleep around with all and sundry. I'm sorry but to me this is wrong on so many levels that I had to put finger to keyboard in rebuttal.

And before we go getting carts before horses and saying that dear old Dr J the hippie and flower-child is off on a diatribe about free love and the like, for the record, I'm not. I'll admit to a more liberal interpretation of certain strictures held to more rigidly in other quarters, but there's no such thing as free love, and never has been. Societies order themselves as they will and their mores are adapted to suit the cultural milieu in which they are nurtured, but human animals being as they are behaviour at the individual level is mediated by a whole load of other stuff so that even the most intellectually enlightened and liberal of practitioners of the art can come very easily undone when emotions like jealousy sow seeds of mistrust.

My problem with the position taken by the righteous (self-righteous?) on this is two fold. First, observable evidence tells me that fear of cervical cancer is absolutely not what determines whether a fourteen year old girl has sex. Indeed even fear of pregnancy doesn't appear to enter into the equation for many. There are a great many other drivers that will determine when and if a teenage girl will become (in that most forensically clinical of phrases) sexually active. Peer pressure, alcohol and drug use must be significant actors, as are education and family and social background, and a whole host of subliminal and indeed "liminal" messages from our mass media.

For a few months in the wake of the much publicized Jade Goodie's untimely demise the issue of cervical cancer was very prominent and a great many women sought screening who previously would not have done. I'm not aware that it had any impact on teenage sexual behaviour however.

Putting all this to one side, my second objection is that the main thrust of this argument places all onus on the poor girl, who, as we understand the pathology of cervical cancer, is only exposed to risk by her partner. Granted, more partners adds up to more risk, but outside of a closed community daughters of the most devout families will end up with partners who might not share their up-bringing, or who have come to the religious life late and after a period of youthful experimentation. It is an orthodoxy of Sexual Health practitioners that when you sleep with a new partner then you sleep with everyone that new partner has previously slept with (in a purely metaphorical sense, by and large).

So a failure to vaccinate a young lady against HPV is at best wilfully blinkered and at worst negligent. Worse, it suggests that parents have absolutely no confidence in their daughters, or indeed in their own abilities to educate them and pass on the values that they live by, and hints at attitudes more in keeping with the strictures of the Taliban that the teachings of a God of love and understanding.

* Usual VECHN for first correct attribution of this shamelessly plagiarized title.

Out!

2010-02-24T08:27:00.002Z

It's finally happened. To be honest I'd half expected it, but still it's a bit of a shock to the system. Monday saw us all sitting around the table at coffee time dissecting the events of the weekend, and talk turned to Dr Neighbour's kids who are off doing the now almost compulsory world tour on a break between studies. They're able to keep in touch by mobile (sometimes) and by blog for the rest. Dr N is new to the bloggoshere and has found the whole thing a revelation, being able as she is to keep in touch with the kids adventures almost as they happen, in word and picture as well as (when monnies and signal permit) by voice.

We sometimes forget how much has changed this past decade. Even ten years ago, when a cousin of mine was doing the same thing, mobile coverage was less reliable and relatively massively more expensive, and most of us were still on good old fashioned steam powered dial up connections so the occasional email from Delhi or Addis Abbaba or wherever, was the most we could expect, and the the hard copy photo's pasted neatly into albums when processed and sorted after the prodigal's return.

So there we all were marvelling the wonders that modern tecnology and permanent web connection have brought when, from the other end of the table comes a voice-- "You've got a blog too haven't you Jesty!"

Back when I started this "stream of consciousness" rambling there were precious few medical bloggers, and especially GP blogegrs about. Not so now as a trawl through the blog rolls of some of my fellow bloggers will attest. I've always tried to keep this little corner of the net under the radar a bit, but being blogrolled by these same erudite colleagues means that inevitably one of my partners blundered across the caseblog some time ago, but till now hadn't thought to mention it.

I'm not overly surprised, but confess to being a little dismayed. It's not that I write stuff I think will upset them, it's just that from here on I'll be more directly aware of the presence peering over my shoulder. Right now I'm not sure what I think about that, but I suspect it will change the nature of our interaction in this virtual place, so I'm asking you all, regular and more recent readers, to bear with me while I figure it out.

Still it could be worse. At least I'm not a formerly cash strapped epidemiologist. Then again, I'll never be portrayed on screen by Billy Piper either.

:-(

Are you Joe Public?

2010-02-19T14:46:00.002Z

In a recent email a very good friend of mine asked me to describe my “average” patient in response to a typically flippant remark I’d made. Which got me to thinking—never a good idea as we shall now discover. Inhabiters of this Sceptered Isle will I hope be familiar with the work of the comic genius that is Dave Gorman, a man who, on a drunken whim, set out to find 54 like named souls and in so doing brightened my life considerably one evening a week for six weeks as he described his search with stats and graphs and all sorts. This all happened a few years back, and if you know nothing of Dave or his quest I urge you to seek him out here.

As an homage (or ommmaaaje as I believe it’s pronounced on the other side of the pond) I offer the following.

The first thing to say, is that the “average” patient comes in two distinct but similar incarnations. Let’s call them Routine and Urgent. In an ordinary week Routines outnumber Urgents by 7:1. On a busier week, like this, the ratio is 3:1, though every third Routine is in fact a Semi-Urgent, but for today they will be appearing as Routines (largely because I can’t face doing the additional maths to separate them out). Right, now that's clear on we go.

So, for this week Ms Routine has been assiduous in his attendance, though her gender identity has been perhaps a little uncertain, being as he is 55% female. She’s a pleasing mix of ethnicities being 8% East European 24% Asian and 16% Afro-Caribbean leaving him roughly 52% indigenous to Borsetshire or Expatriate Brummie.

She’s been around 32% depressed—this prolonged cold spell, the recession and pre-election tension all taking a part in this slightly high statistic. He’s also been 16% Itchy—again mainly thanks to the cold, and 24% giddy. For the rest she’s been pretty much equal parts infectious and sprained. Oh, and he’s been 8% pregnant and 40 years old. And called Paul.

Mr Urgent has been, if anything a bit more confused, being 63% female. She’s 25% East European, 6% each Afro-Caribbean and Asian and a surprising 6% Viking. He’s also only 89% here. Her religious observance is confused, being as she is 6% Moslem, 6% Rastafarian and 24% Catholic. As to diagnoses he’s been suicidally low, had a bit of a cough, a nasty stinging when she—er… you know, and he’s been 18% pregnant—and called Samantha. And she’s 37 years old.

So there you have it, Paul and Samantha, Ms and Ms average. I'm sure you all recognize them.

Margot (Four little words.)

2010-02-10T18:24:00.002Z

When Jerry first got the back pain that turned out to be myeloma Margot immediately rallied round, sorted his life out for him and got him to and fro for his chemotherapy like the trouper she undeniably is. After around eighteen months the chemo' was stopped, and the myeloma was declared in remission. Jerry wasn't quite the man he had been, but with Margot's help he got back on his feet and soldiered gamely on for five years before the disease came back again.

Sadly this is exactly what myeloma does. It's the cancer that breaks pretty much all the rules, especially the one that allows chemo' to work. Normally cancers grow more rapidly that anything else in the body. the chemo drugs poison growing cells (which is why they make your hair fall out). It also means you can give doses that will poison just the cancer cells and the hair follicles-- well mainly, and leave the rest of the patient in reasonable nick. Not so myeloma. It grows way more slowly that normal cells and tissues, so to kill it completely we'd have to kill the patients other cells and organs a number of times over, so we have to use pulses of chemo' to contain rather than cure.

In the end Jerry proved unequal to the fight and slid slowly into that good night around six years ago. And poor old Margot, having been utterly solid throughout his illness, finally fell apart. The first couple of years alone were really tough, even the arrival of a couple of grandchildren did little to lift her spirits. Anti-depressants did their bit to hold back the overwhelming tides of grief, and sheer dogged determination hauled her slowly out of the pit.

A couple of weeks ago she was back after an interval of almost twelve months, during which she'd successfully taken herself off the med's and was thriving. We talked it through, and time and the gradual demands of the same growing grand children had worked their inevitable magic allowing her to reconnect with the land of the living. She was smiling, and rightfully proud of herself. Then, just before she got up to leave she innocently asked those four little words, "While I'm here Doc..."

Anyone with any medical training will tell you how freighted with menace that tiny phrase can be. And so it was. She just wanted to mention this little pain she'd been getting in her chest, just for the past few months, just when she was climbing hills or stairs, or, as it's been lately, it got a bit cold.

So now poor Margot's off to see the cardiologist, but she still managed to leave the room smiling-- for the first time in years. I hope it lasts.

The mark of Kane

2010-01-28T07:36:00.002Z

In hobbles Adam, a man plainly in distress. So much so that he's had to bring Eve along, just so he can lean on her. He's bent double, and obviously struggling with severe back pain. Eve crosses the room and sits, but Adam elects to remain, standing hunched at the end of the desk, grimacing in a pantomime of pain that mimics a Greek mask of tragedy.

Through anguished gasps he manages to tell his tale, with Eve contributing when it all gets too much. He was lying on the floor, prone rather than supine, watching the TV and minding his own business, when he was thunderstruck by a searing pain in his back. Eve takes up the narrative and points out that this pain was occasioned by Kane, their eldest boy, blundering into the room, tripping over dad's trailing legs and landing full force with the point of his elbow right in the middle of Adam's back-- somewhere around L4-S1 for those in the know about such matters.

Four days on and Adam is still in anguish. So I offer to examine him, and stand to walk behind him for a delicate prod. Sure enough he's exhibiting quite a lot of tenderness to touch, but mainly out wide, away from the crucial bones of the spine. These exams are usually easy enough to do through a t-shirt or similar, but since this month Amdridge has been temporarily twinned with Arctic Greenland, everbody's arriving swathed in layers, so to get my anatomical bearings I've had to ask Adam's permission to lift them to have a proper look. As I do I can't help but notice the fetching tattoo he's sporting, right at the pint of impact. In a calligraphic Gothic hand the artist has spelled out his son's name. Verily the mark of Kane.

"Badges, badges?.... "

2010-01-15T10:07:00.004Z

Yes it's complete the quote time on the old caseblog again. The above comes from one of my favourite movies, see if you can come up with the line that follows, whilst I tell you a tale of woe.

Mac' was in his seventies, and was a true Celtic patriarch. He had a large family and they in turn have gone off to have large families of their own, but most have not gone that far away, so their tight knit "clan" is always on hand to gather round in times of adversity. A few years ago Mac' developed a malignant disease, and it was treated, but by the time it had been staged it was on the cards that it had spread and would be reappearing sometime, somewhere.

(Cleverer docs than your humble interlocutor have ways of telling this, by looking at the histology of the "primary" tumour, the degree to which it has invaded the surrounding tissue and the extent of involvement of lymph nodes nearby for example.)

Late last year Mac' developed some tummy trouble and a little pain. Shortly after this he developed jaundice, and it was pretty clear that the disease had come back. He had a couple of speedy consultations with the oncologists, and started treatment which he and we all knew to be palliative. The clan duly gathered, and it was plain that he was going to be well supported and cared for, and we slipped into an easy routine of checking in now and again to see all was well, and letting him steer his course through what we all knew, but never said, was to be his final illness. This was his choice, and we worked hard to respect it.

There are times when you really don't need to ask a question to know the answer. Mac's whole demeanour and approach to his symptoms let us know he knew he was running out of time and really wouldn't appreciate us jabbering on about it. He wanted to get on with living his final days, not confront what came after. In his last week he finally had to admit that there was a little more pain that he was willing to put up with and accepted the offer of a morphine syringe driver to give him small regular trickle doses of opiate, rather than having to rely on intermittent administration of oral medication.

At the time of his recurrence he was introduced to the "Badge Nurse" who looks after terminal illness. From then on he had little to do with them, really neither needing nor wanting their input. Still we are supposed to offer "Gold Standard" care these days and so the badge nurse took it upon themself to visit from time to time. Returning for the first time in a month just after New Year, said nurse, noting the deterioration, pointed out rather too bluntly to Mac' that he was not long for this world. The "clan" politely thanked them and showed them the door.

Twenty four hours later Mac' had died.

He was ready and had no need of the information. What should have been an elegant decline into the everafter has been marred for his remaining family and they are profoundly unhappy. Still at least our "Badge Nurse" can tick a box on their "Gold Standard" protocol :-(

So where did everybody go?

2010-01-08T09:56:00.002Z

Even readers far from these shores might have noticed that Dear Old Blighty in general, and Ambridge in particular, have been experiencing a little local difficulty with the weather. Here it hit on Tuesday, and shows little sign of clearing up until well in to next week. The result has been chaos on the roads, dire prognostications over our ever more fragile supply chain for simple necessities like fresh veg and gas as well as grit for the roads. Oh, and a sudden fall in demand for our services.

On any given day our surgery will offer fifty plus "emergency" appointments for use that day only and for urgernt need. And on any given day most of these will be filled. Not so this week. Indeed fewer than half that number have been required. So either everybody has suddenly got better, has gone elsewhere or has revised their opinion of what "emergency" means. I'm guessing it's the latter. No, I'm sure it's the latter-- after all we're all guilty of doing the same when it suits us.

Working in hospitals in the 80s it was apparent when there was a major sporting event everybody stopped wanting urgent attention. I worked over the Live-Aid weekend, and at least one Royal Wedding, and for the hours those events were on screen life in hospital became very quiet. The same used to happen when blockbuster movies were first broadcast on TV, but in these days of mutliple channels and instant DVD release that seems no longer to happen.

It's not particularly surprising that events, be they popular or merely inclement, affect our behaviour, but I am fascinated at the extent to which they can alter our perception of "urgency".

Another year over...

2009-12-31T13:50:00.002Z

... and lest face it, '09 hasn't been all that special. This can be a miserable time of year at the best of times, as I think I might have mentioned a time or two lately, and it's been noticeably worse this year. Over the past two weeks every surgery has seen at least two or three young adults in floods of tears as the dam bursts and they finally have to admit that they might really be depressed. Mostly it's been on a background of lost employment, failed relationships, mounting debt, and for many, a looming fear of homelessness of of having to go back to living with parents. Even this morning, in my last surgery of the year there have been another handful.

At times like this I am extremely grateful to be doing the job that I do in the place that I do it, but these are problems I'm powerless to directly influence. I can suggest that my poor victims try to throw themselves into something that they used to enjoy doing, that they try finding an outlet to talk about how they're feeling, and that they take the pills I'm about to offer them. What they need is a guarantee of a job, a prince / princess charming-- or at very least a kissable frog, a sizable lottery win, and a place of their own, and none of these things are in my gift.

So today I'm counting my blessings, and hoping that for all of us 2010 will mark an up-turn.

Thank you so much to all of you who read this nonsense, and all the more to those who are moved to comment. You really do all go a long way to keeping as sane I am ever likely to be. All the very best to all of you in the year to come, and God bless us, every one!

I'm dreaming of a white...

2009-12-21T10:42:00.002Z

... sandy beach, sitting on a sun bleached deckchair, sipping ice-cold beer from a condensation covered glass, basking in thirty degree heat, and as far removed from the seasonal tyrrany of tinsel, turkey and kitsch that has become the Great American... er British Christmas.

If it seems like months now that we've been bombarded by ads with every B list "celeb" you can think of exhorting us to buy more food and booze than it's humanly possible to consume let alone enjoy (and lets face it half the crap they're peddling isn't even that enjoyable) that's because the run up to this next fortnight of saturnalian excess began in October. The pressure to indulge is overwhelming, and, not to put too fine a point on it, it's ruining the whole thing. The expectations now for this few days of "quality time" with the family are quite literally crushing, and it's making my punters irredeemably miserable. The only ones who have seemed at all cheerful have been the odd few who are taking this opportunity to jet for for an Antipodean Xmas with barbies on the beach and more sun than you can shake a boomerang at. Frankly I'm envious as hell. It doesn't help that this weekend we had temperatures of -5 centigrade (yes I know it's colder elsewhere, but once it gets anywhere below freezing it's inhumanly cold in my book), but it's more than that.

The expectation heaped onto this next few days is quite unreasonable, and must inevitably end in dissappointment, yet still we are all sucked in, lemming like, to the collective madness. When we come out the other side we'll still all owe tens of thousands to the economy that has tried to kid us for years that we can have something for nothing, the planet will still be melting, however counterintuitive that feels right here, right now, and all the attendant woes of famine plague and pestillence will continue. The unwinnable "War on Terror" will be grinding on its relentless way and our poor long suffering servicemen and women will still be struggling to deliver "peace with honour" in a conflict that offers neither, and will still be constrained to do so on a shoestring budget because we've poured all the cash away bailing out the banks. No so much "the economy, stupid!" as the "stupid economists". And us for believing in their voodoo.

If ever there was a time to take stock and rethink our priorities it's now. Not that we will. We'll all be too busy crowding out the stores and piling in supplies, one third of which we'll not use, and scrabbling around for those last minute gifts for "what's her name down the street that we thought wasn't going to give us anything this year but did".

So let me be the first to wish you Happy Next Christmas!

(Usual VECHN* for the closest guess to the date of my first "Happy Christmas" of the year from a punter)

*If you don't know what this is have a trawl through my misanthropoic back catalogue-- if you can be bothered at all, though I would'nt blame you for not. I'm in such a happy place right now. You can tell right?

It's the most wonderful time...

2009-12-15T15:50:00.002Z

As the popular song has it. And full of wonder it must be to be sure. You see, for the next two weeks I and my humble wares become the infallible, guaranteed, absolute and only panacea for all ills. After all it's nearly Christmas, so we are transformed for a brief interval into a branch of the Elf Service and gifted healing powers normally reserved for song and fable. Well at least so it holds in the popular imagination.

The only problem is, unlike the jolly old man in red (courtesy of an early 20th Century Coca-Cola ad campaign apparently) we have to treat with all comers, both the "naughty" and "nice". A great many of both sorts crossed the Jesterly threshhold yesterday coughing, clutching sore throats or, more concerningly, grey cardboad vomit bowl "boaters". They all had some form of viral illness and fully expected I'd be in a position to cure it for them on the spot, or at least come up with an antibiotic to do it inside 48 hours so they can be ready for the fortnight long party that has become the "traditional" Ambridge Christmas we've all come to know and loathe... er... love.

And this particular year that's a hard contention to refute. After all viruses are now curable aren't they. There's that magical Tamiflu we've seen being dished out in bucketfulls for the swine flu, so if it's good for that how much the better will it do for a sore throat?

Well Mrs A, since you ask, not much. Indeed I'd not be allowed to prescribe it for Tyrone just now. You see, although he was "terribly ill" half a hour ago, he's now whirling round the consulting room like the Tazmanian Devil and looking even better than I feel. So no, I don't think his bit of a cough was the beginnings of flu, or pleurisy, or pneumonia... and no I don't think he needs Tamiflu, or Antibiotics, or fairydust. In fact I'm pretty sure he'll be fine for Christmas even if you leave him outdoors all day everyday till the big one itself.

And despite having wrapped himself in the paper bedroll like a demonically possessed Andrex puppy Tyrone was not the worst behaved of my little visitors yesterday afternoon. Nor the least ill.

Now it's true there are key events on the calendar that distort normal behaviour patterns and Christmas and New year are amongst the biggest. No-body is allowed to be ill for Christmas. And life is supposed to fantastically re-invent itself at New Year as we all resolve to do more of what we ought and less / none of what we didn't ought. The burden of this latter expectation can be overwhelming and it's no surprise that our colleagues in A&E and Mental Health services dread New Year as those so overhwelmed are bowled over by the tidal wave of their own expectations and driven to the edge of self destruction thereby.

I wonder, has it always been thus? Were the Druids besieged at Stonehenge by long lines of tartan clad celts on the eve of every solstice and equinox looking for a cure for that "bit of a cough" or that "Pilum head sticking out of my chest" before the drunken revels could begin in earnest? I'm guessing so, and if I'm right I'm also slightly comforted by the thought in a way that's rather hard to describe.

Letting go.

2009-12-07T12:17:00.002Z

I've ranted about this topic before. After events of a week or two ago I might, possibly, be coming to change my view. A little.

Bill was 97. He'd been living in a nursing home for the best part of a decade. It was a nice home, well run, and he was cared for in every sense of the word. To start with he was just a bit older than the average resident, but down the years as faces came and went he gradually became the eldest.

When he went in he was just a bit wobbly on his legs, and a trifle vague on times and dates. Over the time his wobbliness had become worse, but his haziness lifted (largely because his previously unfettered access to sherry was rather more "managed"). Slowly he took to spending more and more of his days in the chair, but remained bright, alert and sociable.

Last year his ticker started playing up, odd missed beats now and again, then runs of palpitations, then the syncopated jazz riffs of atrial fibrillation. This tipped him over the edge and into heart failure-- an increasingly debilitating shortness of breath with attendant ankle swelling-- which he grew to hate, and perhaps to fear. We tried him with digoxin, diuretics and one or two other things with little benefit. In the end his heart just wasn't up for being pushed any harder, and he began to fade.

And so it was that with a heavy heart a few weeks ago I was called in to sit down with him and his family to ask the awful question, "if your heart stops what would you want us to do about that?" The home needed to know, partly because it's good practice these days, but mostly to make sure they could respect his wishes. In the event that we hadn't asked the standard assumption is that resuscitation will be attempted and paramedics will be called. Bill, quite rightly, didn't want any of this for him. As he put it "I had my three-score and ten some time ago and everything else has been interest."

Within a few days of our discussion Bill passed peacefully away with a daughter in attendance. It was almost as though he'd been looking for permission to let go.

Mothers and Daughters.

2009-11-28T23:40:00.004Z

Friday was an odd day. It's the long run up to Christmas that starts in earnest this weekend with German Markets seemingly springing up all across the land and traffic into all our major town centres gridlocked as we flock to see how our continental cousins do Festive. (More sausage and gluhwein than turkey or beer and a lot of carved wood apparently).

Then there's the flu jabs-- not only the "normal" ones this year, but also the added thrill of pandemic jabs, which pretty much everybody seems to want but for which the target population is at variance to some degree with the other jab. Still in our neck of the woods it's proving popular. We gave 500 last week, and filled another 500 clinic appointments within 2 hours of opening them up. It's almost as though we were offering tickets to see Robbie Williams.

But this Friday was mainly odd because of a couple of encounters that made it plain that the rules of normal behaviour had been suspended for the day. and this weeks before the Lord of Misrule has his annual outing.

Exhibit One: Jocasta.

A precocious young lady of ten. She has eczema, and a month ago kindly young Dr Neighbour decided it looked a bit nasty, and needed treating for infection as well as the more normal inflammation of the eczema itself. This isn't uncommon. Eczema itches. When it itches we scratch. When we scratch we break the skin, bugs get in and a low grade infection adds itself to the misery of the eczema. Mixing an antibiotic into the cream is a far more effective way to tackle this than to opt for "systemic" antibiotics (that's the ones you take by mouth -- or sometimes in a drip) which might eventually work, but are far more likely to fuel resistance and generate side effects.

Sadly Jocasta's eczema looked every bit as nasty on Friday morning as it did a month ago. "How could this be?" I wanted to know-- "Didn't the cream work then?"

"Well we didn't use it" says Mum. "Jocasta said it made her legs sting!"

"Oh dear, so how long did you try it for before you sopped it then?" a reasonable question I felt, but both Mummy and Jocasta gave me that look that suggested I had suggested they go drown sackfulls of puppies.

"Well we only tried it the once. After all she said it stung!"

So we've agreed that poor Jocasta is going to try to be brave, in the hope (firm expectation on my part) that the cream will not only stop singing very soon, but might even do as intended as clear the infection. a;;owing the eczema to settle in its wake.

Exhibit 2: Cissie.

An urgent request for a home visit mid afternoon. Cissie's daughter has been to stay for the last 3 weeks. Cissie will be 90 in a couple of years, and has been left all alone after her husband's passing many years ago. Her daughter lives a long way off the patch, but came to stay when Cissie, normally fiercely independent, got a bit confused, as often happens when folks beyond "a certain age" develop a urinary tract infection. Antibiotics and three weeks of regular meals have worked wonders for her and she's fitter and better nourished now than she's been for a year or two. Daughter has a pressing engagement elsewhere this weekend, but brother is on his way and will be arriving before bedtime.

Daughter has also managed to arrange carers to call twice a day to help Cissie with getting up and going back to bed. She even tried to get her to consider meals on wheels, but after trying one Cissie was less persuaded on that front and would prefer to keep making her own arrangements, which she is in fact now quite capable of doing again. Still for over a week Cissie has been independent and Daughter has simply been helping her sort out the arrangements. And the Friday lunchtime Cissie refuses to eat, starts leaning heavily on the walking frame, takes herself off to the back parlour and refuses to speak to her daughter at all.

When I visit there's no apparent cause for this sudden "turn for the worse". Indeed Cissie is quite polite with me and wonders rather what all the fuss has been about. She does in the end allow me to gently check her out and confirm that she has neither water infection, flu, or any other cause of acute ill health. Neither has she suffered a stroke or any other insult to her frame as can occur in old age. The simple fact is that Cissie would far rather be cared for by Daughter then Son and wanted to make this plain without saying so. I'm pretty sure she's got the message.

Pretzel logic.

2009-11-23T10:59:00.002Z

Once every couple of months or so there's a boffin or a group on Radio 4 shouting the odds about how they can save the NHS pots of cash but keeping folks out of hospital. Last week it was the turn of the Alzheimer's Society. I'll admit to only having caught a small part of the piece, but these things are fairly predictable in their content, intensely well meaning, and woefully wrong in their assumptions, and the thing that really strikes me is, received entirely uncritically by reporters who are otherwise presented as amongst the most enquiring minds of their own or any other generation.

If I have the figures slightly wrong I apologize, but the thrust of the argument is unaffected. It seems the Alzheimer's Society had done a piece of work which suggested that at any given time a large number of hospital beds were occupied by dementia sufferers who might be better cared for at home. the number might have been as high as 1 in 4 but certainly at least 1 in 10. Now it's true that in a number of disciplines, notably general medicine, a great many inpatients are taken on to the ward and then kept longer than is medically necessary because of complex social factors, and dementia would be one of the most common of these. This means that dementia sufferers cannot be discharged as easily, needing as they often do, more community care and support, which is seldom available freely and on demand. Such discharges require planning. Planning is seemingly impossible across a weekend, and is seldom practicable on a Friday, and so these poor "long-stay" patients often stay a week or more longer than is needed simply to accommodate "Social Care".

Please don't get the impression here that I'm disparaging the organizers or providers of social care either. i know first hand how hard their job is, squeezing a quarts worth of service from a pints worth of resource is not easy at the best of times. To expect them to do so at short notice, particularly at weekends when office support has evaporated, would be plainly unreasonable.

The upshot, patients with complex care needs tend to stay loner in Hospitals. This is an eternal verity. Now the Alzheimer's Society quite reasonably argue that with better input in the home admissions could be prevented, and discharges facilitated. But those resources are currently sadly lacking, and if we think the health budget is poorly funded, our social services colleagues gaze in envy from the"blasted heath" of close on a decade of "efficiency savings".

Lets assume for a minute, that some Fairy God-Social Worker were to wave a wand and overturn this to provide the network of carers and support staff we need. Let's then assume that the service they supply can kick in at the first hint of a crisis and prevent all unnecessary admissions. Let's further assume the 1 in 10 figure (which I still believe is an overestimate across the entire UK hospital population, but that's an argument for another day perhaps) is correct.

So, if every one of those patients who was in hospital could instead be cared for at home, we could reduce the hospital population by 10% overnight. If we allow that there is no-one else in line to occupy those vacated beds then we could have a whole load of spare capacity in the NHS hospitals estate. That being the case it would be a simple arithmetical exercise to close 1 in every 10 hospitals, thus saving the NHS pots of lovely cash.

To paraphrase a currently very popular Meerkat-- "Simples!"

I don't know much about art....

2009-11-12T16:02:00.003Z

We've a very genteel nursing home on the patch. It's taken over an Edwardian era Vicarage and converted it to accommodate the residents in the rooms formerly devoted to staff and family, using the larger reception rooms for dining and lounging very much as you'd expect. It's a good one. You can tell because your never greeted by an unsavoury aroma when you cross the threshold-- regular visitors to such establishments will know exactly what I mean, there are always staff on hand to greet you, and always with a smile, and none of the residents is left to wander wraith like through the halls and stairwells.

It's also apparently run by people of quite unsound mind. They commissioned a local artist (also a patient of mine as it happens) to bedeck their common areas with what our family has always referred to as "Muriels". Vasty paintings of trellised vines and frolicking Putti interspersed with little snippets of inspirational text . All very tasteful, but neither Vicarly nor especially Homey, but not without it's own idiosyncratic charm. But this is far from the limit of their artistic pretensions.

Being an Edwardian era property the home has grounds which though obviously landscaped ab initio, had been let go a bit before the present occupiers took root. So they decided to do them up a bit and have a sculpture park. You know the sort, all concrete Lions and Dishevelled and Deshabillee Nymphs and Graces. Indeed the portals to the establishment are guarded by two resplendent sprawling "marbled" Lions of fierce and noble mien who look like they've been there since time immemorial.

Now I've not visited for a few months-- they're good enough that I seldom have to except to welcome new residents who have opted to join our list, or to review the med's of those of our patients who have been lucky enough to fetch up there-- yes Dr Field et al, some of us really do go out and review our patients med's you know (sorry just a bit of a snit about today's Radio 4 News coverage, if you've not heard it it really doesn't warrant repeating now-- forgive the intrusion). So today I was especially pleased to see they've installed a new sculpture pride of place in the centre of their lawn.

There, atop a noble plinth stands a life size "bronze" of a sheepdog. Fair enough I hear you say. Nothing wrong with a statue of dear old Shep surely? And you're quite right, except....

This dog has his forepaws planted foresquare on the rump of a rather startled looking sheep, his hind legs splayed wide in classic leap-frog pose as he vaults over his ovine charge, ears flapping away behind him.

After spotting this I chuckled all the way back to the surgery, and I only hope, when my time comes, they find me someplace just as quirky to spend my dotage.

Speaking truth unto power.

2009-11-06T12:09:00.003Z

Never an easy thing to do for sure, but lately it would seem it has become near impossible. For residents of these fair isles the story of poor Professor Nutt will likely be familiar, but for the rest of you Auntie will fill in the blanks.

It seems the Prof. has been a bit fed up with his political masters apparently failing to hear anything he has had to say on his specific area of expertise, so he has made one public comment too many for them and has been given the push. Now I agree that advisors must advise but politicains must finally decide. That's what a representative democracy is all about, but when political and evidential approaches to an area of public policy diverge as radically as they now appear to in the "difficult" area of drugs there comes a point where the advisors become superfluous and we end up with an approach based on "public opinion". It seems Mr Mackie really is setting HMG's current drugs policy and reasoned advice is deemed unnecessary and inadvisable.

In the long run this damages the credibility of the policy as presently voiced, and calls the judgement of our political representatives into question. If the policy is determined not on the evidence of actual risk, but on some otehr grounds, those grounds need to be far better and more clearly articulated to have credence. If the present classification system is more moralistic than scientific then so be it, but at least let's acknowledge that and move on.

I'm told the Grauniad has suggested that we have moved from "evidence led policy" to "policy led evidence" in this area, and this seems to have been an increasing trend across government for at least two decades, and not just here in Dear Old Blighty or on this lone issue. So perhaps it's time we dropped the figleaf the "advisory" committees lend to policy formulation and let the whole shooting match be determined by focus group and the "Court of Public Opinion".

After all things worked so much better when we had hanging, flogging and transportation to fall back on.

Insomnia

2009-10-22T09:48:00.003+01:00

Both Moon and Pleiades are gone,
The mid-night hours crawl on and on,
And I lie down to sleep, alone.

These are not my words, but a rather rough and ready translation of a poem that speaks across two and a half millennia by the "divine" Sappho. It talks of quiet solitude, loneliness and above all of insomnia. O.K. I'm inferring the loneliness, but the rest is there, and the sentiment is a raw and immediate now as it was then. She was writing in a time when being awake in the middle of the night meant lying hour after hour in engulfing darkness, waiting out the turn of the earth, longing for either the light of dawn or the relief of sleep.

Anyone who has ever had problems sleeping will sympathize. At least now we have it a little easier. We can have light at the flick of a switch, we can divert our ears from the slow sure thump of our pulse beat with tunes on our ipod, or all night poker / roulette / bingo on the telly. We might even get back up, rifle the fridge for tit-bits, or boot up the "machine" and surf away the hours to daylight.

And for a night or two any or all of the above can be a comfort. But after longer than this, the latter day insomniac will end up feeling every bit as wretched as the poet of antiquity and the myriad fellow sufferers down the years inbetween. Small wonder then that some of our oldest remedies have been hypnotics in one form or another, or that they remain among the most commonly prescribed items even now. Yet the real remedy for our shared affliction comes more often from within. If we're not sleeping then something is preventing us, and unlocking what that is, and processing it holds the key to restoring calm and rest. That and switching to De-caff.

Easy, eh?

Mirror mirror

2009-10-15T23:32:00.004+01:00

Last week saw the annual ritual that was my appraisal. In past years I have tried to spice this up by soliciting buzzwords to shoehorn into the conversation. This year I thought it was time I grew up a bit, so I tried to do this one cold. My appraiser this year was a colleague from somewhere the far side of Felpersham, and a year or two older than myself. We spent an afternoon dissecting the year just gone and trying to read the runes for the year to come. As with all public servants dependent on the public purse we expect to be asked to do more with less, but we both agree we've been here, or somewhere pretty close to it before.

Overall then, not too bad, and although I missed the opportunity to inject the odd piece of inappropriate jargon or old rock lyric into the conversation, we parted on good terms, we even got round to talking about poor Albert. And I've got my buzzword for next year from the process itself. Indeed every GP in the country will have the same buzzword ever after as we progress from appraisal to licensing and re validation, and that word will be "reflection". I'm thinking of having a silver spandex suit made up for next time, or a top hat adorned with mirrors like Noddy Holder used to wear.

I know I'm getting on a bit, and I've also been known to wax a bit cynical from time to time, but the new system, in its current format (which may still change) will have us recording every educational activity we pursue at least twice, and preferably three times. First to show we did it, then to show we thought about it, then if possible, to show that when we'd thought about it we did what we thought we ought having done it, and thought about it. Clear?

It's absolutely right and proper that we hold our practice up to scrutiny, and that we try to show that we are continuing to strive to be the best that we can. I'm just not quite sure this new endlessly recursive method is entirely the best. Still it's a very small price to pay for the privilege of holding a licence to practice medicine.

The only other problem I have, is that all this professional introspection can rather become a habit, and it's starting to spill over into life outside the surgery right now. I'm discovering I've got a little way to go to becoming a zen master.

Time to dust off the old relaxation technique methinks, well after a nice fruity claret anyhow.

Memento Mori

2009-10-13T15:08:00.002+01:00

I have a photo on my wall of a young man. He wears a serge uniform and a sam brown belt and stands in front of the engine of his SE5a fighter aircraft. Every now and again someone asks me who he is and I tell them. Only twice in the fifteen years he's been up there has anybody come in and told me who he is before asking me why he's on my wall.

He's no relation, though I would have been proud to claim him as one. He is my "memento mori". His presence reminds me that whatever I do, or do not do, time will march on. However much I triumph or fail in this life, in a couple of generations, or less, none of it will amount to much. In his day poor Albert was rock-star famous. The picture I have of him is one of a few iconic images that are well know to aviation historians, and yet, in fifteen years, and with all the thousands of people that have passed through my room, in that time only twice has he been correctly identified.

He tells me that all you have to do is keep turning up, climbing into the hot seat and doing the best you can until time or circumstance take it away from you. And he tells me that however important, famous or extra-ordinary I might feel, were I to come back in 50 or 100 years people would have a problem remembering I'd even been here.

It's perhaps a bit of an odd choice, but this aviator of the last century helps to keep me grounded, and at the same time, in a very small way I help to keep his memory alive. But even when neither of us are here and none can recall us, life will go on for those that come after. And this can sometimes be a comfort.

Once upon a time...

2009-10-08T14:48:00.002+01:00

This post is in reaction to a sudden upsurge in followers, two of whom, I think, are still in school and looking to a career in medicine. Now I know this blog has violent mood swings about the whole GP / NHS experience, so I'm a little humbled to think they might be interested in what I have to say.

So kids, if you're still out there this one's for you.

A generation ago (at least) a thirteen year old lad came to a sudden, astonishing realization. He wasn't suited for the Army as he'd always imagined -- too independent of thought and slovenly of habits. No what he wanted to do even more than blow people apart, was to learn how to put them back together again. So suddenly he had to transform from an indifferent classics scholar to a scientist. Still at thirteen not too hard to do, and so by O level he had made up enough ground to pass the sciences well enough to go for A levels. (I won't tell you my grades-- you'd laugh. But O levels really were harder than GCSE's or so I like to kid myself)

A levels on the other hand were something else again. Biology I could do. After all it's a "talky" "feely" sort of a science. Chemistry I just about grasped, but Physics was so far beyond me it was embarrasing. In the end I scraped some kind of a grade for it, but the thing that saved my bacon was a biology "Special Paper" or "S level" designed for the brightest and best candidates to really show off what they knew. Thanks to a brilliant tutor and a couple of lucky questions I aced it.

Which was just as well. I'd spent a school career mooching about in the cadets, shooting the odd rifle and fiddling with the odd radio (boys toys for the soldier wannabe) but couln't do sport, played no musical instrument and had no meaningful outside interests. I did spend a month one summer working in a Cheshire Home and learning a heck of a lot about "caring" and "disability", and I had a summer job in the NHS recycling old X-ray plates (yes I know they're all electronic now, but back "before the flood" they were proper photographic plates and could be recycled to reclaim the silver). I'd also managed to witness an autopsy thanks to my Dad, and talk to a professor of nephrology who knew my granny. And that, dear readers, was the sum total of my preparedness for the wide world of medicine. That and Alan Alda in M*A*S*H, and the "Doctor in the House" series off the telly. (You'll probably need to ask your folks-- closest I can get would be Zach Braff, which isn't all that close to be honest).

Then I went to med school, on a grant, topped up by the generosity of parents and grandparents, and five years later emerged the poised polished clinician you see before you now, and my overdraft for my five years of student life was cleared by my first paycheck.

When I look at the sacrifices this generation has to make just to be in the running to get to med-school, and at the debt they can expect to leave with on graduation I am filled with admiration that they even want to try. So to any and all of you prospective medics out there who stumble across this, I wish you all every success and hope that you have as much fun in your chosen profession as I have had thus far in mine.

"This is the end.....

2009-10-01T15:17:00.003+01:00

.... beautiful friend."

It's dark. Insects chirrup in the underbrush. Muffled explosions, miles off, punctuate their fretful murmurings. The night belongs to Charley.

Somewhere a jangling guitar picks out a sparse twanging tune, a handful of notes at a time. Drum and organ whisper underneath a plaintive vocal that speaks of loss, despair and dark dark urges.

Yes, beautiful friends, we are in a far from happy place, and the sense of foreboding if anything is building out here in the boonies. And I know I'm flogging the metaphor to death here, but I can't help it. Somehow Jim just speaks to me right now.

Anyhow, now that I've got your attention, I'm not really talking about a war a generation ago and half a planet away. I'm bemoaning my plight here in Ambridge as usual.

And why?

Permit me to explain.

Exhibit A; A policy statement from a health minister, repeated I believe at party conference that patients will be free to register with a GP anywhere they damn well please and bu**er the geography. Now much as I would welcome the chance to care for patients of all origins and ethnicities, registering patients domiciled on Orkney would seem a bit stupid. Yes I know busy commuters and politicians have a hard time of it prioritizing their health above their oh so important trough snouting... er, working activities, but freedom to register anywhere, I mean really have they no common sense? Anyone who has any experience of front line primary care will tell you this notion is a junkies charter. Any addict has just been told he/she is free to roam the country at will registering here, there and everywhere, and demanding that all important codeine / methadone / valium script. Even if they only manage a week's worth everywhere they register, in just one day on an average inner city bus route, they should be able to score enough gear for a month of Sundays. Bloody brilliant. Sorted! (Or so I believe the vernacular has it).

Exhibit B; Choose and Book. An IT based appointment booking system that will allow a patient to book their own appointment with a specialist they choose at a time and in a hospital of their choice. Sounds fantastic. And when it works, is fantastic. When it works. But how do you know which specialist to choose. Or which hospital to go to. If only there was somebody you could ask...

Exhibit C; Two Week Wait. Patients suspected of having a cancer diagnosis should have to wait no more than two weeks to see a specialist. Quite right too. And again, to be fair, when it works it works well. But witness a call I had today. Two days ago I made such a referral, on the same day I saw the patient concerned. Today the "Two Week Wait" clerk is on the phone declining to accept my referral. They've offered the patient an appointment but she's going to be away for a week starting 13 days from now and won't be able to take it, so please would I not refer her until she's back, in three weeks time. Only the cancer czar has told them they've got to book the appointment within 14 days and they can't..... "Now just supposing I do this, and then in three weeks when I am permitted to re-refer, you still can't give her a slot inside 14 days, what would happen?" I ask politely. "Well then we'd have to refuse your referral again." So no, sorry I'm not taking my referral back, it needs sorting.

Believe it or not there are plenty more exhibits. And that's before Gordon, or Dave, or even (should pigs take wing) Nick start wielding the axe we all know is coming.

If I'm sounding a tad cynical today I apologize, but that last little circus act has really got to me and reading the runes things are looking pretty bleak.

Still, maybe they'll look better after a cup of tea eh?

What do you think?

Sister Morphine

2009-09-25T16:03:00.002+01:00

This weeks BMJ has the Rolling Stones song reviewed as its "Medical Classic", in a slot generally reserved for worthy tomes like "The Conquest of Pain" or medical novels like "The Citadel". I'm a bit miffed, because I'd already decided on it for the title of this follow on post from the earlier post on heroin. Not actually miffed enough to change it though you'll notice.

The thing is it rather fits what I've got to tell you. Not so much the song as the title to be honest. You see Mick and the boys were rather reinforcing what I had to say last time with their plaintive song about addiction, but this time I want to point out the undoubted therapeutic value of this much maligned drug.

For years Morphine has been a "back of the cupboard" "painkiller of last resort" "fit only for the dying" sort of a drug. True there has been increasing use of morphine drips for post operative pain in recent years (these days even administered at a rate determined by-- of all people-- the poor soul who has the pain). And as suggested, Sister M and her bigger beefier cousin Diamorph' have been the mainstay of end of life pain relief since Hippocrates was in short chitons. Anyone with any involvement in such care will recognize the beatific change in countenance that comes when a pain ravaged patient finally achieves symptom control through their tender mercies.

There's a lot of guff talked about the "Doctrine of Double Effect" that implies it's o.k. to administer potentially lethal doses of opiate to relieve pain. Given methods of administration widely available for at least three decades this has never been a part of my reality or that of my patients. Used correctly opiate analgesics kill one thing and one thing only. Pain. Abuse and overdose are not and have never been therapy and should not be allowed to confuse the issue.

Once every eight to ten years we are sold a new "miracle" non-opiate pain killer. They tend to be derived from some species of anti-inflammatory, are heralded with a vast fanfare, tried with enthusiasm but many of us, and within twelve to eighteen months turn out to be no better than, more expensive than and often more toxic that all non-opiate analgesics that have gone before them. Then they disappear of dwindle to a background, occasional, niche painkiller for when everything else (except morphine) have been tried.

Recently we have had to appreciate that a whole class of painkillers-- the non-steroidal anti-inflammatories, can do bad things to aging kidneys, making them hard to use in severe arthritis (which is precisely where you might want to be able to use them). So the poor punters are left with paracetamol plus or minus a bit of codeine. This seldom works, but it's rare that a patient will welcome the offer of a tiny dose of morphine to help give back their pain control.

Which is a shame.

A day in the life....

2009-09-22T09:58:00.002+01:00

The BMA are keen for us to invite MPs into our surgeries at the moment. must be something to do with the looming election. I'd invite ours, but a nearby practice has beaten us to it, and after my recent run-in with Alan I'm not sure how keen they would be anyhow. So instead I'll open the doors to all of you, my loyal readers for a little snapshot of an average day at the Ambridge Surgery.

8.00-- Surgery opens. Dr Neighbour (an insomniac workaholic) starts consulting-- he will consult until 10.30, break for admin and for coffee at Coffee Time (c) The Ambridge Surgery 2000. He will then consult again from 11.30-12.00. Mean while the Duty Doc from yesterday afternoon (your humble interlocutor) will turn on the Surgery Mobile-- the contact for all urgencies from 8.00 to 8.45 when the surgery switchboard will swing into operation. The ringtone and the wallpaper on said phone he will not immediately recognize as they have been reprogrammed by his offspring. Thus every mornig urgent calls can become a little whimsical voyage of discovery-- it's odds on the poor supplicant caller will be heralded by "The Macarena" or the latest Motorolla Death Metal ringtone. The Duty Doc is powerless to prevent or alter this.

9.00 Dr J begins consulting after an idyllic drive through the Borsetshire lanes, accompanied by the plangent strains of the Macarena, punctuated by updates on "Our Wayne's" vomiting. Our Wayne (aged 22 and still living with Mum) is invited to attend mid-morning for an examination.

Morning Surgery I

In no particular order we see and try to help;

two survivors of severe trauma (one abused by a relative from age 7-- over 40 years ago, but still grappling with the fallout, one still being abused by an ex patrner who is about to receive an injuction in the hopes that this will make him stop),

one wheezy babe in arms who is otherwise quite well, though mum takes some convincing of this,

a patient with a chest so bad they require night time ventilation but remain desperate to be able to get back to work,

a patient made psychotic by amphetamines,

a man in an Aircast Boot (imagine Robocop in pale blue plastic) after ankle surgery who just needs a note for work-- and something for the pain,

an expectant mum six weeks off delivery for a check up and a chat about some mechanical chest pains she's been getting because of the pregnancy -- she's not an Ambridge native and has no family within 300 miles so she's also feeling a little isolated and apprehensive which makes her worry more about her chest pains,

Our Wayne, looking a bit green around the gills and in the grip of a touch of food poisoning after a dodgy curry (and around a gallon of Lager) last night,

a couple of "Flu" victims who felt iller on tamiflu than with "flu"-- so probably not then,

a man in need of gluten free bread who's in a rush to get home again before his demented wife (not our patient-- she has kept to her old surgery for the past 40 years and he sees no reason to change her registration) takes it into her mind to wander or to try to set the house on fire.

11.00 Coffee Time (c) The Ambridge Surgery 2000. Half an hour set aside for all the docs and the management team to meet and chat. Sometimes we actually get around to chatting about the punters-- more often movies, kids and knockabout comedy one liners...

11.30-12.20 Morning surgery II

6 more punters with a random assortment of ailments. One requiring urgent hospital admission for a possible embolism which puts the rest around 15 min's behind.

12.20 (but really 12.35) Driving License Renewal Medical.
HGV and PCV (that's lorries and busses to you and me) drivers need a five yearly license medical. 20 minute exam and form filling exercise. Passes without incident.

13.00 Home visits. Two today that will take us to 14.00 and lunch. On the way one lady with nasty pain after shingles last month. We had hoped Zovirax would have headed this off, but no such luck, so now we will need top notch pain relief, probably for a few months-- drat. T'other had come over "all unnecessary" this morning and in the end turns out to have cystitis-- a powerful confuser of little old ladies (and indeed little old men, though less often for reasons too boring for here and now). At least she should be better after 3 days on antibiotics.

14.00 Lunch. Life being too short to make sandwiches, Mr Sainsbury is called upon to provide and does so admirably, which takes us to 14.15 and...

14.15 Phone calls (5) of which three count as "worried well" and two relate to consultations a few days back and effects of the pills therefrom. Then repeat prescriptions 25 to sign and 10 or so to be updated and reprinted for signature.

Now, when I was a lad repeat prescriptions usually ran to a blood pressure pill or two and the odd painkiller. Nowadays most repeats are for 4 or 5 items, which for the over 50s will more than likely include a statin, aspirin, at least 2 blood pressure lowering agents, something for heartburn, and one or two items to overcome the side effects of the other meds, so they warrant a bit of scrutiny, even when they look routine.

15.00 Afternoon Surgery
3 straight hours consulting. We don't break for Tea, so the machine on the desk supplies a steady stream of Java straight to the Jesterly mug-- well from the jug on the hotplate at least...
The surgery will be pretty much a reprise of the morning, or will, once a week, be an all comers "Duty Surgery" for really urgent sore throats and ingrowing toenails-- o.k. I may be exaggerating, but the definition of urgent is mutable depending on which side of the desk you're sitting. To be fair last duty surgery saw me admit three patients urgently to hospital where often I can go months without admitting anybody-- in the words of the song "it goes to show you never can tell".

18.00 Notional end of afternoon surgery, often overtaken by events so average end of surgery closer to 18.20 (worst this year so far closer to 19.05).

18.20-? catch up on calls, write up home visits, stare blankly at the walls waiting for the caffeine buzz to wear off enough to be safe to drive home.

Scattered through the day will be emails (professional and personal) and on any given day, laughter, tears, births, marriages and deaths, blood, sweat and tears. In short about as much fun as you can have with your clothes on and staying within the law.

Not quite the two surgeries and an afternoon on the golf course in between of yester-year that everybody still assumes to be the norm.

Still I wouldn't want it any other way now would I.

Drugs 'r bad, M'kay!*

2009-09-16T13:51:00.003+01:00

Except when they're good. Some can be both. I've recently been asked by a friend for a response to the suggestion that we import Swiss style "Shooting Galleries" to the U.K. for injecting heroin users. I have to start by admitting absolutely no expertise in this area, but some experience in caring for drug users working towards withdrawal trough the substitution of methadone or subutex for their heroin. I'm also a big fan of it personally** for its proven role in pain control.

So, all that said, what about these shooting galleries then?

The answer I'm afraid, is complicated. Taking it one step back for a moment what about injecting users then? What do we know, and what have we been taught to believe?

We know it's bad. It must be, after all it's against the law and has been like forever hasn't it? Well not quite, only really from about 1920, and only a "Controlled Drug" in Blighty from around 1971.

Well O.K. it must be really bad for your mental helath yes? Well perhaps, though probably a lot less so than amphetamines and later "mood enhancers". All the punters I've seen with drug induced psychoses have been using amphetamines.

But it kills people! Well yes, no arguing with that, but because of prohibition we have only the sketchiest guesstimates of how many heroin users there are, so we can't say how many as a percentage, though instinct suggests its likely fewer than either alcohol or nicotine do. Overdoses are dangerous, but speak more to the despair and lack of hope that many users experience, of which their drug use if but one symptom. Inadvertent overdoses have happened when uncut drugs have been supplied, so that instead of a 90% talc (or worse) 10% heroin dose users have ended up taking 100% pure junk. Every avoidable death is a tragedy so arguments over relative risk seem specious in that context, but it probably remains the case that of all the drugs we chose for "recreation" heroin is a long way off being the most harmful.

The reality is that prohibition has created a lot of the problems we face right now. Heroin is addicting. To feed a habit costs money, but to have a lifestyle acomodating heroin is likely to imply a level of chaos that precludes a high or regular income. Hence to feed the habit users either deal or steal. Then we catch them and lock them up with dozens (or hundreds) of other dealers and stealers, so they learn how to do it "better". To keep them sweet we turn a blind eye to their continued use in stir-- after all at least they're off the streets, and heroin won't make you violent...

Then there's the "once a user always a user" myth. We have a number of users who have successfully quit not just injecting, but all illicit drug use. The trick is to "normalize" their care so they can be seen in the surgery without all and sundry knowing what they are here for. With a good rapport, a clear prescribing policy, and a willingness to accept change we can make opiate use so boring that clients will glady turn their backs on it, sometimes just for a time, but sometimes for good. Attending our surgery and not a "drug service" is a door back into the mainstream for some and it's this as much as the methadone substitution that gives them the push to move on with their lives and break out of the loop.

So, shooting galeries then?

Well on the plus side we get controlled dosing, reliable and affordable supply, sterile technique to avoid the harm of unsafe injecting and even perhaps a way in to accessing services for may users who are at present excluded precisely because they are "choosing" to continue to inject which will rule them out of admission to the vast majority of rehab systems.

On the minus side we get state sponsored addiction, less pressure to end a demonstrably harmful habit and a system likely to be too rigid to allow the chaos that is the lot of many current injecting users.

Were it to be made to work it could do a lot of good. The U.K is not the C.H. any more than it is the U.S.A. and any attempt to import techniques from another culture needs a lot of thought, but it appears on balance to be an import worthy of consideration.

* time to revive the tradition of the Virtual Chocolate Hob Nob for the first correct attribution.

** but not "personally" obviously.

Four More Years?

2009-09-15T19:32:00.002+01:00

Looking back it appears I've been at this lark for four years now. I'm the first to admit things have been a bit patchy lately, and at present rate of progress will do well to see out the month, let alone another glorious year, and looking around the "'sphere" I'm beginning to feel a bit nervous. Seems four years in, blogs can start to get a bit time expired and dwindle away to nothing. This simply wont do. I've barely got enough material here for a chapter, let alone a sidesplitting Herriot style memoir or two to see me right in my dotage.

At this rate I'll need to start recycling material rather like a certain teller of Tales of Boy Wizards to see out the time to retirement, only I'm not allowed to go bumping off characters just to revive interest in the franchise now am I?

So if any of you dear, fantastically loyal, vastly talented readers have any amusing GP related anecdotes you're happy for me to shamelessly plagiarize, you know what to do.

Seriously though, four years in, although it's a bit neglected, this old place is still home. I do intend to keep going at whatever rate time, inspiration and real life will allow. After all it's been my safety valve when things get me all hot under the collar, it's introduced me to a fine bunch of people, some nearly as mad as I, and it's done wonders for the old ego, just to know a few of you out there actually want to stop by and read this stuff.

So here's to another fun packed year ahead, and god bless us every one!

Oi, stop chucking all them bloody spears!*

2009-08-24T10:24:00.003+01:00

Right now I'm feeling a bit like Michael Caine playing Lieutenant Bromhead in Zulu. The first wave of the attack has passed and the troops are seeing to the revetments and mealie bag barricades in anticipation of the next wave. Happily thus far, the hospital isn't on fire.

Now you're all sitting there wondering what the hell I'm rambling on about. That's o.k. Sometimes I wonder myself. But no, this time there is a point, honest.

I'm talking about the "Swine Flu". The reason I haven't so far is because early on in the pandemic we were a bit busy preparing, like Michaels tiny band of Red Coats, piling up the barricades. Then it all went a bit berserk, with assegais flying about all over the place... er, the phones ringing off the hook, mainly with the "worried well" but in amongst these a fair few who were poorly. Due to an appaling coinicidence of timing Ambridge was hit with a bit of a summer cold bug just as the flu hype was really getting going which didn't help. In the end we peaked with something over 50 flu related calls a day in addition to our normal workload, which doesn't sound a lot until you figure that's three full additional surgeries worth, with each call needing at least ten minutes to triage and advise, and with a number ending in additional home visits.

Just when it looked like the dam was about to burst the National Flu Line, which had been promised, then posponed, then rushed into service anyway, started, and the calls went away, almost overnight. Then I went on hols, and now I'm back and all is calm again. The only snag is they tell us to expect it back in the autumn. Perfectly timed to coincide with the expected seasonal flu taking off. Since we have no tool for discriminating between the two, things might just get exciting again soon. Especially since this latest outbreak has rammed home to the whole contry that Flu is a significant and occasionally fatal illness (which it undeniably is), and also that it is "treatable" with Tamiflu (which is, sadly, far from true).

So here I sit, and just one question remains. Is it time to learn the words to "Men of Harlech" then?

* Rather disappointingly he never actually said that in the film, but I tend to the view that he should have ;-)

An open letter to the rt hon Alan Milburn MP

2009-07-22T18:59:00.002+01:00

Dear Alan,

I can call you Alan, right? After all, in our egalitarian, best of all possible worlds, society I’m allowed. No glass ceilings here eh?

What’s that you say, disproportionate numbers of professionals come from moneyed backgrounds? And I’ll bet it’s more now than it was a few years ago. And I bet it’ll be more still in another few. And why? Well it’s obvious isn’t it? The universities are all shameless elitists who have it in for “ordinary” kids like you and me. They’ve erected this “glass ceiling” of yours to keep us in our place, yes?

Well no actually. You did that. You, with your failed policies and your failing government. I notice you had to slink away from health a few years back after wrecking that, and now you want to have a go at higher education. Well heaven help them. You see they didn’t put the ceiling there. You and your cronies did that all by yourselves. Whilst you were collectively milking a crooked system that “froze” your pay, quite wrongly I might add, and made up for it by doling out the swill in the expenses trough (and no I nether know nor care if you personally were implicated, this is satire and not libel), you thought it would be a good wheeze to introduce student loans and tuition fees.

Worse, yet, in your anodyne “no-failure” “non-competitive” school system you devalued the grades awarded in the bizarre system of GCSEs that teach pupils how to sit exams, not how to acquire knowledge. Now the universities, faced with a torrent of straight A students, have to find other ways of selecting the brightest and best. Applicants need at least a Grade 8 instrument (but we don’t do music or instruments in school), a Captaincy of a County XV or XI (but we can’t do rugby or cricket—we sold the field) and a plethora of other qualifications or aptitudes beyond what school can offer in normal hours (but we only have to teach the national curriculum).

A medical student qualifying this year will have, on average, a student loan debt approaching £50,000, sorry, didn’t you quite get that, I said FIFTY THOUSAND POUNDS. Lawyers and accountants might owe slightly less, but will still need to obtain post graduate qualifications in order to actually pursue a career in their degree subject, which they will pay through the nose for, with far less guarantee of a job at the end because you’ve blown all our money fighting “terror” and shoring up failed banks. Overall the medics have it easy don’t they.

So how dare I, a privileged member of this moneyed elite dictate to you, a veteran class warrior and striver for equality? Well you see my roots are about as working class as you can get. I was lucky enough to get to a grammar school, and to have grandparents who wanted badly enough for me to be the first of my family to go to University. The same is true of three of my four partners. You’re right, the students I teach now all have at least one professional parent, but it’s not their fault, and it’s not their University’s fault either.

This is the world you made. I imagine you all started with the best of intentions, but you’ve screwed up so badly it almost defies belief. Still you’re not in it for the long haul are you? A few soundbites and then it’s on to the next brief, or the wilderness of opposition where you can say what you like and damn the consequences. Or if it gets too hot again, back you can go to the bosom of your family. But if I were you I wouldn’t spend too long mulling over my dubious achievements when the time comes, or I might end up very tempted to take a long walk off a short pier.

Resurgam!

2009-06-19T19:16:00.002+01:00

To paraphrase Arnie. There's a bit too much Real Life going on right now so don't expect much for a month or two, but I aim to be back soon as I can.

Honest.

Trust me.....

The adventure of the midnight feast.

2009-05-28T15:29:00.004+01:00

Lunchtime sees and urgent request to visit an old friend, put in by the District Nurses. When Nurse Gladys visited him this morning his blood sugar was through the roof. Not good. Especially since he's just out of St Elsewhere's after an op for diabetic complications. So I don my deer-stalker and round I zip, expecting the worst. The last time we did this I ended up having to admit him to the hospital, culminating in his surgery, a three month stay on the ward and a radical overhaul of his treatment.

Today couln't be more different. He's fine. We repair from the dining hall to his new flat in the poshest warden controlled accommodation in Ambridge (another consequence of his recent admission was the move here) for a private chat. He hasn't felt so well in ages, no symptoms to suggest any acute illness that would account for his sudden surge in blood sugar. His appetite is fine. His chest quite clear. No evidence of urinary infection, Swine Flu or other attendant lurghi whatsoever.

"So why," I gently probe, "the high sugar this morning?"

There's a pause. A pregnant pause, where the pregnancy is headed for the delivery of triplets.

"Well," he owns, finally,

"You see,

It's like this....

Last night I had a craving for the biggest bag of chips I could get. Lovely they were, all smothered in salt and vinegar. Just the job!"

Then he grins.

I nag him half heartedly about watching what he eats and then we chat about the cricket for a while.

He's going to try to be good again now, and Nurse Gladys will watch his sugars for me.

So. Another mystery solved, and yes, it appears the answer was alimentary. Now, where's my Meerschaum?

Just passing....

2009-05-19T18:33:00.002+01:00

It's not much fun being eighty. Or so says Eric. He's just had a spell in hospital. Nothing scary. He thought he'd got a tummy upset, but it turned out to be constipation.

(When you've been bunged up for long enough you get a thing called overflow, which makes it look like you've got diarrhoea-- and that's the last we'll hear on that subject today if it's o.k. with you)

Just before he went in I'd had a visit from Doreen, Eric's neice. She's been looking after him since her aunty, Erics wife, died eight or so years ago. Every day, rain or shine, high days and holidays included, she's been calling on him morning and evening, cooking, cleaning and generally fending for him. She's all the family he's got left, and so it falls to her.

She had called in to say she was getting worried about him. He was a lot more cantakerous than usual, and had taken to stopping in bed for hours on end, refusing to get up. We had agreed that I would find a pretext for calling on him-- just to give him a bit of a check-up. Under no circumstances was I to mention that Doreen had been to see me. Then, the day before the appointed "check-up" visit, he went and got himself admitted.

In the end it's made my job a lot easier. Since he's had this seemingly trivial problem sorted out he's been a lot better, but he still greets Doreen every morning with a cheery "'Wish I was dead!" She's nearing the end of her tether with him and we're going to be needing to find him a lot more support soon, if only to preserve her sanity, so having a pretext to do a review visit on discharge was too good an opportunity to pass up.

Today we've sorted out his med's and he's agreed I can call again to see how he's getting on in a couple of weeks. In her absence he can't sing poor Dorren's praises highly enough-- though I'm sure it's never occurrred to him to actually tell her to her face. She's calling back later in the week to see how I got on, so perhaps I can do it for him-- though I mustn't let on to him that we're talking. He's not quite ready to think about letting anybody else in, but if Doreen can be persuaded that she could start letting him know it's time for her to pass the baton on, he just might be. Before she goes to the wall for preference.

It's a complex web to unravel, and none the easier when none of us can articulate half of what's needed, but if we get it right Eric might just be a bit happier to carry on living for a bit yet, and Doreen might even get a chance to start.

Lucky I was "just passing..." Eric's gate this afternoon ;-)

Just another day at the office...

2009-05-15T19:23:00.000+01:00

Sometimes you can go for months without incident. Other times, a bit like London Busses, everything comes along at once. Seems we’re going through one of those phases in our neck of the woods. Thankfully, thus far the “Flandemic” has not lived up to its billing.

Yet.

We expect the next big scare in November or December, unless something quite bizarre happens in the interim. For now the daily email updates are moving to once or twice a week, and the planners really do seem to have a strategy in place. Whether the plan will survive more than half the work force being laid low themselves, or kept at home looking after kids/ elderly relatives who cannot care for themselves, remains to be seen. Still there is a plan.

No, this morning saw a string of genuinely troubled individuals facing potentially or already determined life threatening illness. Once again, by mid morning the surgery was more than an hour adrift with no prospect of catching up. After three patients already watching the sands of time draining from their own personal hourglasses at an alarming rate, came a mum bereaved not once, but twice in the space of six months. Her distress was etched almost bone deep on her face, and there was absolutely nothing to say except “hang in there” and “you will survive this”. I’m not sure if I was saying this for her or for myself to be honest, but after half an hour she was cried out enough, for now, to keep putting one foot in front of the other for a bit longer.

After a ten minute pause, and a half a bucket of Java, we got the show on the road again, and the rest of the day passed without incident. The poor souls who had had to wait around in our waiting room with not even drying paint to watch for amusement (all diversionary materials having been carted off and incinerated to remove possible vectors for the flandemic), were amazingly good natured, and by mid afternoon there was more laughter than tears accompanying the ebb and flow of the afflicted coming trough the hallowed portals.

Still not a day I’ll be forgetting in a hurry, or wishing to repeat any time soon. But I can’t help thinking, for all that, that I’m the one who’s got it easy here.

A visitor from the future...

2009-05-02T02:18:00.002+01:00

Earlier this week I met Yuri for the first time. His record states he’s been in Ambridge for nigh on five years, but so far, after an initial attendance to register, and a couple of visits to Dr Neighbour for minor ailments, he’s not troubled us at all. Looking at him, it wasn’t hard to see why. It’s not that he’s particularly tall, but he’s certainly solid. The urban combats, spetsnaz style black and white striped t-shirt and high laced paratrooper boots certainly created an impression. Then there were the bulging muscles. Yuri hasn’t so much "built" his body as hewn it from living granite. His biceps put the rather weedy Jesterly frame to shame, and the suppressed aggression he exudes suggests that one false move and he could snap my neck like a dried twig. A long dead, especially brittle twig.

Happily, our own little corner of blighty hasn’t yet succumbed to the attentions of a Ray-Ban shrouded oligarch and his own private army. Yuri just came here to work, and to carry on his very impressive hobby lifting ludicrously heavy things for fun, and the odd bit of bag pummelling. Sadly, now he’s been earning for a bit, he’s found himself seduced by the powers of the Dark Side. A "mate" at the gym introduced him to chemical supplements—hormones to you and me. Androgens and anabolics.

The only trouble is, after six months of this he’s been getting some chest pains, which have him fretting. Still he’s been for an EKG back in the Motherland, and it was normal, so he’s a bit less woried now. I tentatively prod where he says it hurts. I could almost swear as I jab his left pectorals there’s a clank. I foolishly suggest we try to provoke his pain with a few resisted movements starting with his shoulder. I cling on to his elbow and ask him to lift it above shoulder height as I press down. He lifts his arm and my feet clear the deck by a good couple of inches. There’s not even a flicker of discomfort.

I decide against asking him to do the reverse move, pressing down with the elbow point whilst I try to prevent him. I value my spine, and like it just the length it is. It helps hold me up.

Still after a bit more of an exam we decide the pain is most likely a minor strain. I prescribe him some 3-in-1 and a referral to Cyberdyne Systems if he doesn't get better. Steroids, it appears, don’t do much for the 800 Series Terminator. Still, I imagine he'll be back.

Credo

2009-04-24T00:18:00.000+01:00

Witnessing wilful self-destruction is never easy. Watching someone plumb the depths of alcoholism, or push the oxygen supply aside to light up with hands made uncontrollably trembly by the drugs needed to keep breathing because of the damage that same act has inflicted down decades is a living hell for those charged with care of loved ones so afflicted, and a kick in the teeth to those that try to treat them.

It’s often hard to take a step back and reserve judgement. But we are not them, we’ve not seen what they’ve seen, or done what they’ve done. We all have our vices, (Hob Nobs might spring to mind perchance) and we all sometimes take a road we know we ought not, just "to see what it’s like". Fortunately for many of us, we get turned around before a wrong turn gets us hopelessly lost, and that can give us some empathy for those less fortunate.

The thing I’m finding more difficult right now is finding that same empathy for those that opt to take a wrong turn on purpose. This winter Blighty has seen a Mumps outbreak. Most of the victims are young adults who were born a year or two too early to be caught in the initial MMR campaign of the late 80s. Some have been children held back from immunization because of a false fear placed in their parents minds by a tub thumping campaign based on widely discredited science about a supposed danger form the combined MMR vaccine.

The fall out from this was hopelessly bungled by the same politicians that told us BSE could never affect humans and by a scientific and medical establishment that failed to articulate clearly enough the counter argument. In the first flush of controversy it is easy to understand why some parents opted to hold back, but we are still finding MMR uptake rates lower than they need to be after all this time, and whilst I’m usually the first to champion the rights of the individual, I’m a little less keen on the right of the individual to remain wilfully and dangerously uninformed. Especially when it is not they, but their children who will bear the brunt of their decision.

In my time in Ambridge I’ve also witnessed patients cut off from family and community for an act so seemingly trivial as accepting a life saving blood transfusion, on the grounds of religious dogma, and others choosing to die, or being condemned by relatives to, for want of the same. I’ve also witnessed patients with curable, or at least remittable malignancies place their faith in crystals and carrot juice rather than hospitals and medicine, and have to endure unnecessary agonies and speedier exits as a result, all through some blinkered perspective that classed all allopathic medicine as bad because they had a bad experience once with Dr X or Hospital Y.

Mankind truly is everywhere born free, but some make pretty odd choices for their chains, and their blinkers.

Dogging?

2009-04-15T18:31:00.003+01:00

As I traversed the Ambridge Gyratory System* the other morning I was struck by the contents of the large estate car in front. Two gormless lop eared Labradors gazed benignly out at me, until the car hung a left and disappeared down the ramp to the Councillor Dan Archer Park and Play Area.

Walkies, it seems, have become "bit of a drivies". Man's best friend no longer has to turn out attached to a leash and walk to the park before getting to zoom about like a lunatic chasing a tennis ball. Now Fido can expect to be chauffeur driven there and back again, and spend ten or fifteen minutes wheezing about after some fuzzy, squeeky monstrosity from the pet shop that looks like a failed genomics experiment and has none of the roll or bounce potential of the good old b-a-l-l (sorry felt the need to spell it out just in case any dogs were listening).

I worry slightly that as soon as they develop a playstation controler adapted to the canine paw, instead of a drive to the park, poor pooch will be parked in front of the doggy version of Doom or Quake, and left to get on with it. It's no wonder our pets, like their owners and their owners kids, are facing an obesity crisis.

There's just one word for it really.

Barking.

* The ring road hemi circumnavigating our fair town, not the 1970's Jazz Fusion Combo of the same name.

Clock watching

2009-04-07T18:47:00.000+01:00

You might wonder why, should you ever have cause to see a personal medical attendant, you spend ages sitting in a waiting room , browsing decade old National Geographics and the like. Perhaps a quick snapshot of this afternoon’s surgery will help explain.

15.00 Enter first patient. Young adult male. Suicidally depressed and in crisis. After a bit of a chat, we manage to tease out the principal cause, agree a management, with antidepressants and the safety net of a ring back any time offer, and fix a two week follow up appointment.

15.30 Enter second patient (appointment 15.10). He’s been drinking a lot lately—just fluids, not alcohol, after all he is only 14—and he has to get up a few times a night to pee. No he hasn’t brought.. but yes he can do a specimen. We find a pot. He pees. The stick shows he’s passing glucose syrup. We find a glucometer and prick his finger. His glucose is 24, or roughly four times normal. We agree he should go to the hospital and get started on insulin. This needs a phone call to arrange.

15.55 Enter third patient (appointment 15.20). She’s worried. She had a car accident a few days ago. Thing is she can’t remember it. She can’t remember if she ought to remember it. She plainly hasn’t had a significant head injury. She’s not had seizures in the past. We’ve no reason to think she has had one this time. Bur we’ve no convincing reason to think she hasn’t. She’d quite like to know, so we agree she needs a brain scan and a referral to a gerontologist for more clever tests. In the meantime I have to advise her not to drive anymore—not a problem right now, since her car has been written off, but still she needs to be advised.

16.20 Enter fourth patient (appointment 15.30). She needs to renew her annual repeat prescription for high blood pressure. So far her BP control has been o.k. Then this week she was told she might loose her job soon. And so might her husband. And her BP control has gone a bit wonky….

16.45 Enter fifth patient (appointment 15.40). “You’re running a bit late today—did you nod off for a bit?”

18.33 Enter DS Carter and WPC Watmough. Seems grabbing a punter by the neck and squeezing hard amounts to assault.

Hard to believe I know. Still at least Broadmoor might be a bit quieter.

Playing the percentages.

2009-03-24T13:08:00.002Z

I’m perplexed. The game I’m in is all about communication, or so I’m continually told, and continue to tell the poor benighted Med Students that draw the short stray and have to make the trek out to Ambridge for final year community based medicine teaching.

Overall I flatter myself that that is one thing I’m not too bad at. If you want a fourteen point differential diagnosis for possible causes of a raised serum custard level you might do better with that nice Dr Neighbour—he’s got Medical Membership you know—but if you want your actual diagnosis explained then I reckon I’m yer man alright.

Now, this year, as every other this past four years, I and my confreres have been surveyed. In short for a couple of weeks around New Year and carefully worked out demographically accurate sample population from our surgeries were given questionnaires to rate us and our practice on.

We have just had the results, and sure enough my mean score for 10e (How well the Dr explained your problems or any treatment that you needed?) was a respectable 86%. I also got 83% for 10d (How well the Dr involved you in decisions about your care?).

Before we get too carried away the national mean for those two parameters, throughout the U.K. was 83% and 81% respectively, so not to be sniffed at at all. Still I must confess to being mystified, since despite these encouraging stat’s 11a lobs a dirty great spanner in the works. The self same population that gave those ratings, when asked in 11a (After seeing the Dr today do you feel able to understand you problem(s) or illness?) only muster a rating of 67% where the U.K. average is 69%.

So there you have it. Despite 3% better explanations than the average, and 1% more involvement my punters are ending up 2% less clear about their problem(s) or illness than their peers. Colour me 100% baffled.

On a brighter note Mrs Antrobus was in today. At 80 plus she had an umbilical hernia repair in the winter, and is now fully recovered. For the first time in almost a decade she has a flat tum, and can see her belly button. She’s so delighted she even asked her surgeon if she can get it pierced now—“Y’know, like that Brittney?”

Passsing through

2009-03-17T19:20:00.003Z

Sorry to have been away so long. Not much to say, and no voice to say it in "blogger's laryngitis" if you will. There's plenty of stuff going on, but it's all pretty dull and uninspiring and I wouldn't want to inflict it on you good gentlefolk.

On the plus side we have sun and daffodils in Ambridge and at Jest Acres. On the minus we have a frenzied month of audits and compliance checks to finish the contract year so we can get paid. None of this is especially threatening, just mind numbingly tedious.

Somehow the regulars have also captured the zeitgeist and have been relentlessly dull and unimaginative in their presentations lately, so there's not much fun to be had there either. If anything amusing or interesting is actually happening here, it's not happening to me, so if you've got anything zany, philosophical, whimsical or perplexing to share, I'd be eternally grateful. If not I'll just go back to lurking, and spying on you all in the bloggosphere for a bit. just wanted to stop by and let you know I'm still around.

Just as an indicator of how low we've sunk, Hob Nobs are off, and I'm having to get by on Custard Creams.

Festina Lente

2009-02-16T19:03:00.001Z

We could all learn a thing or two from the good burghers of Halberstadt. I learnt late last week from my good friends on Radio Four, that these fine folk have embarked on a monumental work set to far surpass and little local difficulties we might be experiencing in the developed world at the moment. In the midst of present financial and political turmoil they have begun a concert whose ambitions will, if completed, span generations, if not epochs.

As we all fret and worry about the fragility of the economy, witnessed locally by the flurry of job losses in the midlands car makers and their attendant parts suppliers, they gathered last week to witness the playing of a new chord in this concert. The chord began but and eyeblink (as I believe the literal translation of a German term would have it) ago in 2003. It will change every 18 months or so, playing steadily throughout the intervening span on the organ of St Burchard’s Curch. Played to its completion the piece should last around 640 years.

That’s right, YEARS.

The time chosen is significant as it reaches forward in time as far as the founding of St Burchard’s reaches back. In those intervening 640 years we have gone from illuminated manuscript to internet, and from horseback through horsepower to spaceflight. The way has been strewn with calamities, market crashes, wars and pestilences to be sure, but equally with triumphs in art, music, medicine and technology unimaginable to the Halberstadters of yesteryear.

I have a new thing to add to the list of “things to do before I die”, and this one should be there for generations of Jests yet unborn to do likewise, whatever befalls us inbetween. And for roughly twenty generations, should we all be lucky enough to be able to participate, and should the concert get to run its allotted course, we could all claim to have been present at the same event. A thought I find both humbling and ennobling. I doff my cap’o’bells to the fair city of Halberstadt and its visionary folk.

A mile in another man's shoes?

2009-02-06T18:40:00.002Z

We moved to Ambridge late in 1990. Our first winter here was a proper Winter with a capital “W”. For four weeks we had a meter long icicle hanging off the corner of the conservatory at Jest Towers, and our poor late lamented moggy (then a spry young two year old) could wade chest deep in snow like a little ginger Bismark.

One especially icy Saturday saw Dr Neighbour and I abandon our attempt to drive home from the duty surgery at the foot of Lakey Hill, after some pillock had jack-knifed his artic’ across the road. Instead we stumped up the hill and back to Jest Towers afoot, like Pooh and Piglet tracking woozles—only stopping at the top of the hill for a reviving medicinal port in the now demolished Lakey Arms. When we made it home we ended up calling Radio Ambridge, to warn the punters there was little point calling on the duty doc that weekend as his car lay abandoned and almost all roads were impassable anyhow. Later that afternoon (once the “medicine” had worn off a bit) we went back with spades and dug Dr Neighbour’s car out, and let our newfound Radio chums know we had restored normal service. Since then Ambridge winters have been a bit of a damp squib—though often very damp indeed to be sure.

Until now.

This week we have fallen pray to a new meteorological phenomenon, the “Snow Event”. Indeed, we have had two such thus far, and can apparently look forward to another on Sunday. On the minus side it’s made all the roads hereabouts really slippy so driving has been a bit of a pain. On the plus side it has made all the roads hereabouts really slippy, so the schools have been closed and nobody has been mad enough to venture out to work, which has made driving an absolute joy, especially when, as this morning, you get to drive through countryside where every tree and bush stands limned in glittering white frosting, in the special silence that attends fresh fallen snow.

Better yet, when you get in to the office, scarcely later than on a normal day despite the “extreme” weather, everyone is so pleased to see you, and many of the regulars, having take a peep out from under the duvet, have decided they can wait a few more days before coming in and so have cancelled their appointments, making the caseload a little lighter. Intriguingly though one group of patients seems to stick at nothing to come in, those with pre-existing mobility problems. One poor old chap even managed the two mile walk in for a routine review of his Parkinson’s Disease since the busses weren’t running. It’s almost as though the snow doesn’t impinge, or that it is just another and perhaps more trivial challenge to their mobility.

I'm pretty sure they could teach the rest of us a thing or two.

Bust....

2009-01-27T16:33:00.002Z

… and Boom.

Or so it would appear. It’s been a nervous six months for the denizens of Ambridge. Light industry hereabouts had evolved to serve the needs of the midlands car makers through the boom years of British manufacturing industry. Those few that are left are all teetering on the brink of the much bruited recession, resulting in increasing uncertainty, lay offs, redundancies, short time working, and downwardly spiralling incomes for the majority of folk.

Add to that rising fuel costs and the coldest winter on record (well o.k. not quite perhaps, but certainly one of the chilliest I can recall) and it all adds up to a pretty miserable picture. Or so I thought until yesterday morning.

You see, we Yeomen of Borsetshire are a sturdy breed. When the chips are down we rally round and make the best of things, and when, as this year, there’s no cash, no heat and nothing worth watching on the telly, we can make our own entertainment. And it seems we have been. Rather enthusiastically.

And the upshot of all this “entertainment” was made manifest not once, nor twice, but three times in the space of one surgery yesterday morning. On each occasion in strode a confident looking woman (one with sheepish partner in tow) with a particular half-smiling expression. These days I hardly need to ask, but do so, just to observe the formalities, thus;

“Now what can we do for you Ms….?”

And they reply “I’m” (or once “We’re”) “pregnant!”

There follows a round of congratulations, followed by one (well, yesterday three) of the most joyful consultations you can get in this line of work. With the obvious exception, I’m not sure there’s a better way of spending a morning ;-)

On being pleasant.**

2009-01-22T19:14:00.002Z

It’s been an odd week again. The ongoing Ambridge Lurghi hasn’t helped, to be sure, but there’s more random weirdness abroad at the moment to go along with it. A case in point is young Elwood, a precocious little four year old who can already spell “Triceratops” and who has a friend who follows him everywhere, name of Harvey*. Elwood’s ears have been feeling a bit sore lately, so Granny brought the two of them in today.

“Harvey’s been poorly” chirrups the lad as Harvey takes his accustomed place seated beside his bestest friend. Elwood’s feet dangle over the edge of the chair, but as I round the desk I am careful not to step on the altogether larger paws of poor old Harvey.

I mime lifting aside a long lop-ear and gaze into space through my auroscope, a good two feet above the upturned face of young Elwood.

“It’s o.k.” say I “Harvey’s looking fine today, now how about you?” and then little Elwood proffers his own ear for inspection.

“Hmm. Not quite as good as yours I’m afraid,” I address the remark to the spot Harvey’s face should occupy. “I think the lad needs and antibiotic, just to be on the safe side.” We all three nod (Elwood assures me so), and off the two friends go, hand in paw, Granny in tow, clutching a script for Elwood, and the invisible carrot I proffer for Harvey’s trouble. I have a special jar of them on the desk, just for Harvey’s visits. Fortunately, being invisible it doesn’t take up much space.

* names changed to protect the innocent. The Triceratops, however is real.

** E-V-H-Ns (TM) on offer for the derivation as usual.

Learning to take the smooth with the rough.

2009-01-12T17:59:00.003Z

Such is the perversity of human nature that I am starting to fret a little. I’ve become accustomed to a more or less steady diet of woe and misery over the last couple on months. The problem has been another winter of intractable cough bugs, with flu like illness chasers, that seem to have been doing the rounds in Ambridge for ever—or at least since early November.

There’s no denying they have been pretty miserable for the poor blighters who have been afflicted. Problem is they’ve also been pretty un-amenable to medical remedy. This has two effects. First it fills surgeries with a lot of miserable people, all lining up to be told, in so many words, there’s nothing we can do for them. Second, and almost more pernicious, it leaves one with a gnawing feeling of clinical impotence which, left unchecked, can lead to an appearance of uncaring dismissal when presented with yet another poor bastard with the lurghi.

The end result of such a downward spiral is a whole bunch of miserable patients and their miserable medical attendants, all moaning to and about one another. So if there’s anybody out there with a miracle flu remedy they can share there just might be a hob nob or two in it for them from this oppressed and downtrodden GP at least.

And then, today, for no clear reason that I can fathom, all the punters have been being especially nice. You know the sort of thing…

“You’re looking well today Dr J, have you lost weight?”

“I swear you’re looking younger now than the last time I saw you!” (Which was five years ago by the way).

“Thank you for your time. I feel so much better just for talking…”

So why do I sit here waiting for the next bombshell I wonder?

As an aside I heard on dear old Radio 4 at the weekend that the good burghers of Brisbane are teaching relaxation technique to toddlers. I feel vindicated. Someone in Oz has obviously been listening to my inane ramblings. Just remember, you heard it here first. Dr J the visionary!

Did you just hear something then?

2009-01-05T17:21:00.003Z

So that’s it then. New Year rung in in suitable style at Jest Acres after trip to the Panto, New Years Eve banquet in the great hall to follow, concluding with the now traditional sybaritic orgy that is the chocolate fountain, and Jools on the telly in the other room Hootenannying for all he was worth. All in all it went rather well, though the return to a duty surgery on Friday the 2nd was a suitably sobering return to earth.

Still the New Year is off to a suitably surreal start, that if nothing else shows the perils of “copy and paste” correspondence. For a long time there have been parallel moans in U.K. health services. The hospitals moan that GP letters are often a bit sketchy, frequently penned in haste at the bedside as they are, and so are inclined to leave out essential titbits, such as the patients inside leg measurement and so forth. In turn GPs have moaned that the discharge letters thrust into the hand of homecoming patients tend to lack vital, or at least legible, information on trivia like diagnosis, treatment and follow up arrangements. This has, to my knowledge been a settled and steady state for at least three decades. I suspect even poor old Hippocrates had young whipper snappers moaning about the appalling state of the handwriting in his wax tablets down at the Kos DGH.

But over the past three or four years we have moved to printing a lot of the more relevant patient data onto an encounter sheet to attach to our urgent referral letters, and the hospitals have moved to IT generated discharge summaries which are way better than the pro-formas of yesteryear. The problem comes when these IT generated documents are pre-formatted for routine entries of common data, and not edited for those that do not apply, as happened today. Or at least I very much hope that that was the case. Otherwise we have a patient who died in hospital, but was found to have a normal temperature, blood pressure and respiratory rate on discharge from the ward to the mortuary…..

Must go now, it’s dark and there’s a strange tapping sound at the window.

Errr Hello!

Is there anybody there………….?

Twelve years and counting...

2008-12-30T19:01:00.002Z

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.

2008-12-24T18:18:00.002Z

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

2008-12-16T12:42:00.000Z

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.... *

2008-12-08T18:30:00.002Z

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

2008-12-01T19:23:00.000Z

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.

2008-11-24T18:22:00.002Z

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?

2008-11-17T18:12:00.000Z

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?

2008-10-23T09:44:00.003+01:00

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.

2008-10-17T14:46:00.001+01:00

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.

2008-10-10T19:13:00.002+01:00

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?

2008-10-06T18:23:00.003+01:00

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...

2008-09-26T17:12:00.002+01:00

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...

2008-09-12T18:00:00.002+01:00

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...."

2008-09-02T19:30:00.001+01:00

….. “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.

2008-08-12T14:15:00.001+01:00

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 (?)

2008-07-10T11:18:00.002+01:00

"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?

2008-07-02T16:43:00.002+01:00

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

2008-06-23T18:24:00.003+01:00

“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

2008-06-10T18:49:00.002+01:00

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)*

2008-05-30T18:28:00.003+01:00

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.

2008-05-21T14:34:00.003+01:00

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?

2008-05-08T14:43:00.002+01:00

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...

2008-05-06T19:37:00.001+01:00

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...

2008-04-30T19:22:00.001+01:00

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?

2008-04-28T18:24:00.002+01:00

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....

2008-04-15T18:22:00.003+01:00

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....

2008-03-19T19:55:00.002Z

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

2008-03-11T15:41:00.001Z

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

2008-03-04T18:11:00.002Z

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!

2008-02-26T13:15:00.001Z

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.

2008-02-20T12:27:00.001Z

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...

2008-02-15T15:08:00.003Z

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 *

2008-02-11T12:08:00.000Z

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

2008-01-18T11:10:00.000Z

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

2008-01-07T10:44:00.000Z

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?

2008-01-04T15:57:00.000Z

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.

Bonne Annee

2007-12-31T14:28:00.000Z

So this is it then. Goodbye and, more or less, good riddance ’07.

It’s not been a specially great year here in Ambridge. A bit like the Nikkei, we’re closing the year a good few percentage points down. That said there have been highlights, both personal and professional along the way. It just seems they have been significantly outweighed by the lowlights this particular year. As a prime example, the year that began with exuberant chocolate fountains (yes I did mean plural) to a full house on New Year’s Day, goes out to a much more sedate chocolate fondue for five tonight, and for the first time ever we get two New Year celebrations exactly one hour apart, as one of our little flock will be celebrating Bonne Annee in mid exchange visit far away from the familial bosom.

(And if he doesn’t ring us close on the stroke of Minuit local time there’ll be ructions).

So all in all ’07 goes down in the Jest family annals as a bit of a damp squib.

We’re hoping for better in ’08, and despite the preceding misery (“the poor old lad’s come over all Seasonally Affective on us again” I hear you all shout, and you might have a point…) I would like to take the opportunity to wish all who tread here hereafter, the very best of years ahead.

And, of course, as much chocolate as you can comfortably accommodate ;-)

For want of a nail...

2007-12-18T15:42:00.000Z

Ivy has had a bad winter so far. She started coughing and wheezing in October. The cough has never really gone away, and after three courses of antibiotics (the last two with a steroid chaser) it is becoming apparent that her COPD has really taken a significant downturn, and now she is left breathless on minimal exertion.

And then, last Friday she arrived back at surgery in grip of another nasty respiratory virus. It’s still not exactly clear how she made it this far, because she arrived in extremis. Indeed after one look at her I was afraid she was on the verge of a respiratory arrest. With judicious use of the nebulizer we managed to get her breathing rate down to below sixty a minute and removed the awful dusky blue tinge from her lips and tongue, but she was plainly still in a lot of trouble and needed to go in to hospital to get sorted out, or at least to be assessed for oxygen therapy.

Except that there was no way to persuade her to go into hospital.

“You see I’ve got to get home to look after Mr. Tiddles.”

No,Ivy’s surname doesn’t even approximate to Tiddles.

She was, of course, referring to her cat, Mr. Tiddles the little black and white bundle of fluff she calls family. It appears her nearest relative lives about as far away from Ambridge as is possible and still be technically resident in Blighty, and may not be in the best of health either. Her closest neighbour on whom she might call is a sprightly ninety five, but not steeped in the lore of feline husbandry, and anyway “it wouldn’t …be right…. to impose … she has ….problems …enough.” All this between gasps which just go to underscore the imperative of Ivy’s admission to Ambridge General.

And so it is that Mr. Tiddles now has a daily entry in our home visit book for the duration of Ivy’s stay on the wards at A.G.H.

Delusions of Grandeur

2007-11-30T17:00:00.000Z

“He’s ready for you now” Miss Moneypenny nodded towards the office door, marked with typical ministerial frugality with a single letter-- M.

In I went, full of trepidation. Two hours later I emerged triumphant. Horizons had been scanned, forward motion was observed and a jolly nice Macedoin de Fruits analogy slipped in under the wire. All told I had shoe-horned in a grand total of five reader submitted buzz words or phrases. And more importantly, my Double-O status is safe for another year. The denizens of Ambridge can sleep safe in their beds, knowing that Dr J is on watch.*

So thank you to all contributors for your sterling efforts in making this year’s appraisal more amusing. It is possible there will be concerns at NHS management level about my sanity after the report goes in, but there’s probably nothing new in that anyway. I now expect my call up to visit Q branch for some new goodies any day, so just one question remains.

Where do I sign to get my new Aston Martin?

*Although actually of course night work and weekends are no longer in my purview…

The dog et it......*

2007-11-23T17:49:00.000Z

Brothers and Sisters I stand before you full of contrition. The thing is, the servers at work started playing silly buggers. Then things at home got a bit busy for a while. Then there was this whole clinical presentation to the entire practice thing that I had to get ready for Monday last, and finally the dread annual GP appraisal looming for Monday coming. In short these are my feeble excuses for the lack of posts (and comments elsewhere) this past few weeks.

Not that I haven’t been thinking of you all you understand. And now I’m back and already I’m after a favour.

“Bloody typical…” I hear you all muttering, “It’s always Me-me-me with him. We don’t know why we bother… honestly… “ and so forth. And you’re probably quite right. Still you can’t blame a chap for asking, so here goes.

As last year, next Monday morning I am to be appraised. A colleague and mentor will be stopping by for a chat, to try to detect if I have developed any homicidal tendencies since last we spoke. I’m pretty sure I haven’t, so that should be ok, but the whole process can be a bit of a travail. To lighten the mood last year we tried a game of “buzzword bingo”, a little something I shamelessly plagiarized from Blogger par excellence, Greavsie.

So what I’m looking for are a few choice buzzwords for this year. All suggestions gratefully received. Of course if you felt you wanted to submit them wrapped in a ringing endorsement stating how the Caseblog has transformed your sex life, cured that embarrassing little crop of warts, given meaning to an otherwise drab and hopeless existence, or other such fitting tribute, then however much it might embarrass me, you should give free reign to those feelings.

Just don’t tell anyone I asked…..

*excuse supplied to Mrs Badcrumble for non-appearance of homework, circa 1969. (And no we never did have a dog).

Stop me if you've heard this one before.

2007-11-05T10:36:00.000Z

“The thing is…” Nelson pauses for effect, “it doesn’t seem to matter what I do, I just can’t seem to stop putting weight on.”

Nelson has Type II diabetes. You know. The grown up sort. The kind that won’t put you into a coma in just a week or two, and, that seldom requires insulin at the start. One of the problems with this is that, in an effort to get his blood sugars to target, he has ended up on rather a lot of meds. And some of those meds can, paradoxically, cause weight gain. So he may just be experiencing a side effect.

“So,” say I, “what exactly have you tried?” A reasonable request I think you’ll agree. But Nelson’s body language comes over all discomfited.

“Well, I don’t have sugar in my tea anymore. And I’ve started using all those low fat thingies….” At this point his brow creases as he casts around for other lifestyle changes made in the three years or so he has been afflicted.

He dries.

“So have you tried dieting at all?”

The stunned look in reply says it all. It appears he was hoping for a visit from the “Weight Loss Fairies” to magic the excess avoirdupoids away.

And so we agree to give it a go. In the end he is weighing in a good three kilo’s heavier than he was in the spring, and this tips him over into the dread “Obese” category, which, coupled with his diabetes is not the best news. He has a target to make in the next four weeks, and if he can hit or get close to the required 2.5kg weight loss we shall be in a position to start him on some meds that might help (yes yet more meds, Type II Diabetes Mellitus is not for the faint hearted—‘scuse the pun).

If not he gets to go to the endocrine clinic for further advice.

Or we could always send in the Weight Loss Fairies...

If you go down to the wood today...

2007-10-22T19:08:00.000+01:00

The ghost of Monty Python is apparently abroad. Or to put it another way I’ve just had another of those completely surreal consultations that leave me marveling on the vagaries of the human character and chortling quietly to myself.

The first clue that things were going to be less than straightforward was Lynda’s admission right at the outset that she was “… in a bit of a mess.” Lynda is a woman of middle years, and not generally prone to euphemism. The second clue passed me by at first, but on the desk she had deposited her car keys—nothing unusual in that—hanging from a cutesy teddy bear key-ring.

It transpired that a few weeks ago Lynda had an intimate liaison with a “new partner”. Or a good old fashioned one night stand to be more accurate. Some weeks on she was left with a continuing reminder of the same, and requires investigation to rule out STI. We agreed that rather than refer her straight to the GU clinic, to spare her blushes we could initiate investigations here and only refer if we found a complicated case of infection. From her symptoms the most likely culprit remained candida and so the full rigours of the GU clinic might well be unnecessary.

So as I was completing the microbiology form to arrange the requisite swabs, I happened to glance over to where teddy lay resplendent on the desk. There he lay in all his glory. I can assert his masculine gender with some certainty, since there he was hung quite literally “like a bear” and with a “Prince Albert” to boot. Keeping a straight face through the remainder of the consultation was a real challenge I must say…

Welcome to Tombstone!

2007-10-15T18:28:00.000+01:00

First a small matter of house keeping. It appears that after fifteen years the domain that also supplied my email address has been withdrawn. My very kind ISP have supplied me with a shiny new domain of my own and a new mail account to go along with it, so for those who feel the need to know, I can now be reached at “the-doctor-is-in(AT)doctorjest(DOT)co(DOT)uk”

Now on with the motley….

I’ve seen some pretty odd indications for admissions to nursing homes in the past. On at least a couple of occasions we have had to admit patients to a local Home for healing of their pressure sores (it helped that the Home’s matron was at the time an internationally published authority on the subject and a true mistress of her craft, thus disproving the old axiom that “those that can’t teach”).

We have also felt in necessary, on more than one occasion, to admit frail patients to nursing homes rather than to hospital to keep them away from the Jabberwock strains of MRSA or C. Difficile (prn dif-ik-illy not dif-iss-eel it’s LATIN people!). There was even one occasion when I admitted a chap to get him away from the maggots (we are talking real live wigglies here, not the Lovecraftian imaginings of a diseased mind).

Still today’s notification takes things to a whole new level. I have a patient who was recently admitted to a nursing home for her own safety after a fist fight developed between her family and her carers.

From now on I’m thinking of changing the old monicker to Doc Holiday.

Gosh, look at all these trees!

2007-10-10T12:42:00.000+01:00

Bert’s angina has been playing him up. Over the past few years he has been a diligent attender at the CHD clinic, and his blood pressure, cholesterol, glucose et al are all perfectly managed. He takes his allotted and guideline mandated handfuls of pills as required. In short, Bert is a model patient, and he is managed to the last scintilla exactly to protocol.

As a result, he is a bit put out to find his angina back again. It isn’t that severe. He can still manage hills and stairs pretty well. He just has to remember to pace himself a little better. And if he forgets (because inside he still feels closer to twenty eight than to his chronological “pushing eighty”) he gets a short sharp reminder. Given that he had been symptom free for much of the past three years this has come as a bit of an imposition, and he is keen to learn what I am going to do about it.

“These pills are no help at all!” he says, brandishing a green and white packet at me. It’s not one I immediately recognize, and with all the waving I can’t quite manage to read the tiny stick on pharmacy label that would inform me as to which precise anti-anginal medication has been letting him down. I take the packet off him, and call up his current meds on the screen. The box contains his statins (cholesterol meds useful for preventing further deterioration—but not for relieving the pain of angina when it hits). The screen shows he has no regular anti-anginal medication. But then, until the past few weeks he has not has regular angina either…

The screen shows his last script for any angina reliever medication was over two years ago, and this has long run out.

So he leaves with a script for a new spray, and my encouragement that he ought also to continue his statin and other meds as well. He’s also going to have a few follow on tests to make sure he hasn’t become worse, but all the evidence of his last investigations shows things were quite stable within the last three months.

I am a little troubled that both he and we have slightly lost the plot here. After all he did already have angina when he began attending the CHD clinic , and for all the preventives he is now receiving, it remains the case that his pre-existing ischaemia will, from time to time, make itself known, and when it does it is quite o.k. for him to react to this with reliever medication. It seems we both need to learn to see the wood again, as well as focusing on the trees...