Adventures in Dunking

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

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

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

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

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


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

Home thoughts from afloat II

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

A tale of two cities.

Barcelona and Firenze

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

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

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

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

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

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

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

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

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

Home thoughts from afloat I

Sorry but access aboard is limited so no time to handle comments. Still hope you like the following.

Last night threw up a conundrum we wouldn’t have faced at home. More of that later, but for now here follow Dr J’s first thoughts on the cruising lifestyle.

As you are all aware this was an unknown quantity until three days ago. We brought to it a lot of expectations born out of prejudice, hearsay and popular culture. They have been confirmed and confounded in equal measure but all things considered and without even making landfall yet, we are having a whale of a time!

Yes there are an awful lot of very well to do, fairly elderly folk aboard, but there’s lots of us commoners too, and way more kids than we were expecting. So much so that our littlest has made a few friends already, and will be taking to the stage with some of them this afternoon in a show they are putting on in the theatre. Mainly I suspect to an audience of proud parents and doting grandparents for sure, but some seasoned veterans seem to be prepared to turn out to almost anything so we shall see. Her elder brother, being a reticent teenage lad is so far keeping his powder dry, but as a growing lad is whole heartedly enjoying the catering arrangements which are both plentiful and sumptuous.

The staff are unerringly and perpetually cheery. This is astonishing given the varying degree of respect they are shown by some of our fellow travellers. They are also almost all, excepting the "White Suits" from Asia. Indian waiters and chefs. Phillipina waitresses, bar staff and maids. It could feel depressingly colonial if they weren’t all so thoroughly charming and engaging.

Formal nights are not the dread occasions we were expecting. They are just as much fun as the less formal, but we all get to dress up like Penguins or Peacocks *. I presume this is so that if we were unfortunate enough to hit something and sink rescuers would think it odd to see penguins this far north, or peacocks this far off shore and would flock to our assistance. But despite the formal attire, and the "nice" table manners, the atmosphere is relaxed and friendly throughout.

But we have faced one challenge thus-far. Namely, what is the correct wine to serve with "Toad in the Hole". We settled for a very chirpy Beaujolais Villages, but I think we missed a trick. I am now convinced we should have gone with good old fashioned ale instead. After all a dish of such taste and refinement needs hops!

Got to go now. There’s a Picasso and a Chagal in the art auction today and I need to stop the kids from putting a bid on!

What Ho!


* Really, of course, that should be Peahens, but the display makes them all cross dressers for the night….

Sailing

This is it. We are off aship this weekend so posting is unlikely for a couple of weeks. If you're very good I'll tell you all about it when we get back. In the meanwhile, pull up a chair, help yourself to a coffee and a hob nob, and use this space as you will.

A bientot.

S3 MHA 1983

Some while ago we met Carly. I speculated that her recent cutting behaviour represented one end of a spectrum, where the "self harm" was an act of frustration taken out in the infliction of a little pain with ony minor and quickly repaired damage to the self. Yesterday I was called on to visit Ed in the local psychiatric hospital. Ed is right at the other end of that spectrum.

Ed first became ill around ten years ago in his late teens. He became withdrawn, quiet, and a bit "Goth". Then he sarted not wanting to go out at all. He kept looking behind him on those rare occasions when he could be persuaded out of the house. Then he stopped eating out. Then he stopped eating. The other lads on his estate were "picking on him". They looked at him "funny". They were "trying to kill" him. So was his mum.

He got very scared and took some pills and ended up in hospital. A psychiatrist was called and he was relieved. He took some meds and got a bit better and went home. Where he stopped the meds, began withdrawing again, got ill again and needed admitting back to the psychiatric hospital again, this time under the compulsion of a "Section", that part of the Mental Health Act that can require patients to be detained in hospital to be assessed and/or treated.

Being obviously paranoid he was assumed to be schizophrenic and treated as such. He got better again. Better at covering up his symptoms enough to be let home again anyway. As I said, this all began about ten years ago. In the interim he has had two longish spells of regular antipsychotic medication. He put on lots of weight, felt very dopey, even became diabetic as a result. But he stayed "better". Except that his fixed fears about the kids he had grown up with, and even his own mum conspiring against him never went away. And the "medicines" he was being given were making him ill. Small wonder he continues to think we are trying to poison him.

Since his paranoia stubbornly refused to lift along with his other symptoms the psychiatrists began to question their diagnosis / management earlier this year, and I was called on to examine Ed with a view to him being detained in hospital whilst his medication was stopped (something of a first for both of us). In the end it became apparent that he was not willing to go in to hospital voluntarily and we had little option but to section him again. His meds were stopped. He realpsed. He went back on medication and shortly after went back home, exactly the same as he had been.

Until last month.

He cut his left wrist. As in, cut it down to the bone, taking out a couple of flexor tendons along the way. He was admitted to the general hospital, but declined repair surgery. He was re-sectioned and admitted to the psych ward. A couple of weeks later he absconded and went out to play with the traffic. The traffic won and he went back in to hospital with a couple of broken bones. Now he's back on the psych ward and today I had to visit him there to apply Section 3 of the Mental Health Act 1983. This requires him to remain in hospital, and to receive treatment, for up to six months. He and I have done this little dance a time or two now, and we both know the likely outcome even as we sit down for the interview that will "decide" the matter. This time he tells me he was distracted and didn't see the cars. And the cutting? Well that was ages ago and he'll get the tendons fixed when he's back home, no problem.

Problem is, like a latter day Yossarian, if he saw the cars he was trying to kill himself and needs sectioning for his own protection. If he was so distracted he didn't see them his illness caused an accident and he needs sectioning for the protection of others. The outcome was never really in doubt. I think he accepts this. But on the way out of the interview room he asked me to assure him that he will be allowed to see the medication he is to be given before they inject him with it, so he can know just what he is being given. It is the only thing I can do for him before I sign my copy of the section paper and I do it with a heavy heart. The problem is I know he will continue to believe the nurses are poisoning him, and in a sense he is right. We can argue it's for his own good, we can argue it is for the good of others, but it remains the only, utterly imperfect, option we have.

I stand there state appointed judge, jury and executioner, depriving a man of his liberty with a stroke of a pen. This is a far from arbitrary act, and it is entirely necessary, but these are decisions I continue to loose sleep over. And then, just to rub it in, on my way out the door to the ward is locked and the nice lady on reception is away from her post, so I buzz in vain to be let out.

For a few short minutes I get a glimpse of Ed's world for the next six months. Then it's back to the car and on to the next visit...

All at sea.

The latest Paediatric Grand Rounds are published here and are as usual well worth a look. Brilliant quiz with some excellent posts behind it, and a small contribution already seen here. I commend it to you all wholeheartedly.

On to more mundane matters. I am posting this early so that the week does not run away with me before I can....

You see Famille Jeste are about to step back in time to somewhere around the mid 1930's.

How, I hear you ask.

Well, we are standing as companions to an elderly couple on a cruise. So for two weeks starting this Sunday Dr J will be afloat, living the life of Riley. There are however a few things that are bothering me. The point is I know all about these cruise larks. I've seen the movies, and even read some of the books. So I know there are certain things that will be expected of me whilst aboard ship. Here is the list I have come up with so far. If there are others I have missed perhaps some of you wiser readers might care to contribute.

I presume that I shall be called upon to use my finely honed diagnostic skills to assist the onboard authorities in solving at least one, probably more than one, murder. ( I will of course be looking for Butlers or other disgruntled employees, ex-employees, or jilted lovers of the victims to pin the rap on).

I also anticipate being embroiled in a plot to save a well to do nephew from the scheming of an aged aunt to marry him off to an awfully nice but frightfully dim gel. (We have resolved to spend the entrire two weeks afloat greeting all our fellow passangers-- and especially any Americans we come across-- with a cheery "What Ho!").

I assume I will spend much of the voyage fending off the romatic advances of a stunningly gorgeous heiress, (especially now I have the "Thomas Magnum" style Hawaian Shirt Lady J has bought me for the Tropical Theme Night).

Lastly, I worry that I will be called on to paddle to an isolated desert island, towing Lady J and the offspring, as the vessel slips tragically below the waves never to be seen again. Once on said island I fear the social order will be turned on it's head and my family will be seduced by the wiles of a former butler into an alternative lifestyle that removes me from my righful place at the centre of the household.

Still, all of the above are compensated for by the prospect of round the clock pampering, feeding, and liquid refreshment, and the chance to visit some places not hitherto subjected to the depredations of Clan Jest.

*You probably won't believe this but I have just completed a medical exam for a bloke who used to be a chef on the very ship we shall be sailing on!*

Pip pip!

Quiet here innit?

There is a god of general practice. He is a proud and a vengeful god. And his ears are everywhere.

The observant among you will have noticed a hiatus in the customary output this past week. The thing is I am busy corrupting youth again. For two whole weeks I get to weave my spell on the young and impressionable mind in my charge, selling them a carreer in Family Practice, enticing them away from the Nasty Hospital. This leaves less time for posting and severely strains the Dr J batteries, but in the best of causes. Like I keep telling them I need someone to help pay my pension....

As I said at the top, there is a GP god. A warped individual with the sense of humour of a leprechaun. He watches and listens out for such occasions, and then sends his minnions to do his twisted bidding.


Take the duty surgery. (I wish somebody would). As a general rule the surgery is a procession of minor, self limiting, ailments with the odd bigger problem thrown in, but all of it fairly standard stuff. Till the student sits in. Then we have a freak show of bizarre foreign object insertions, sexual misdemeanours, haemorrhoids, and homicidal / suicidal depression. Often all in the same patient. Such was the case on Wednesday.


So I was dreading todays Duty surgery. Second this week (covering for a holidaying partner) and me dreading a reprise of Wednesday's shennanigans. But, by lunchtime today the duty surgery was pristine on the screen. A neat and tidy row of gleaming white unbooked appointments. Even after a Chronic Disease Management tutorial and a "Ward Round" at the local nursing home the screen was as shiny and white as before. For the first time this year the duty surgery had not one appointment taken by 15.00.

Then the poor sacrificial lamb went and opened it's mouth. It used the "Q" word. On a duty day! I'm sure there was a chittering laugh from just outside the window. And the dogs of GP hell were unleashed.

The phone didn't stop ringing. A flurry of bizarre and complex written queries floated down out of the ether, ambulance men wanted to drag unwilling patients kicking and screaming to A&E for having the temerity to trip over en route to the loo and needed "The Doc" to referee.

Still, it's over now and I'm off for the weekend, so overall not too bad a week.

Quiet even.

Did anyone hear laughter then?

DNAR

Enter the District Nurse Team Leader *no-- not to the Dambusters March or 633 Squadron* clutching a sheet of paper with a half inch thick red border. This is my least favourite American Import. It is a DNAR.

Do-Not-Attempt-Resuscitation Form.

The patient she wishes the DNAR to apply to has lung cancer, pneumonia, severe arthritis and a number of other ailments. Despite this he is relatively well symptom controlled, but visibly fading. In the past week he has gone from ambulant to bed bound, and from eating and drinking normally to nil by mouth. He is plainly terminally ill after a life well lived, and is not at all distressed except when people try to make him leave his house to go into a nursing home.

Unfortunately he is now almost totally dependent, and so requires round the clock carers since he is estranged from his family (who wanted him to go into a nursing home). Under the terms of their contract the Round-the-clock-Care-Agency (TM) oblige their staff, all former nurses, to pound the chest of any "client" they find to have died on their watch. Unless they are covered by a DNAR.

Sooo here I am on a Friday afternoon talking to a dying man, reminding him of the fact, and asking him if he would like the nice lady to attempt resuscitation should the inevitable occur over the weekend.

This sucks.

He gets reminded of the fast fading light. And all to meet some contractual stipulation imposed by an unfeeling bureaucracy intended to keep the PCT out of the courts. I am still at a loss to understand just how this poor man's care has been enhanced by today's little mise en scene.

Sadly, these days, his is a relatively simple case. At least he has a diagnosis and a prognosis which are fairly clear cut. This is not intended to sound callous. I feel for all my terminal patients, and do my level best to palliate all the symptoms of their final illness, but consider for a moment patients with a more protracted, less predictable course. COPD, Heart Failure, any of a dozen Neuro-degenerative diseases.... even Rheumatoid Arthritis. All have the potential to cross over a tipping point to become "terminal". So when and how should we be having the DNAR chat with them.

It is all too easy for that little talk to turn into the bleakest message you will ever hear. Worse than diagnosis. Worse even than a terminal prognosis. It implies something along the lines of "Sorry old chap, but we feel it's time we gave up on you. Perhaps you'd like to think about doing the same eh, there's a good fellow."

When my time comes, however it comes, I would far rather decisions to resuscitate or not were made at the time and not logged in advance. There may be some grey areas, but most decisions can be arrived at with the application of a little common sense at the time and given the circumstances then prevailing.

I pity the poor fellow who gets to bring me my DNAR for signing up. I think I might start practicing my "Henry Fonda" act now in readiness.

The wonderful thing about Tiggers.....

My good old friends on Radio Four tell me the Home Office is warning that we are about to be inundated with Eastern Europeans, stealing our jobs, filling our hospitals with their elderly and infirmed, crowding out children from our schools... raping, pillaging, that sort of thing. It seems they all bought into the whole counter-revolutionary capitalist propaganda we bombarded them with for decades and actually feel that "The West" or in this instance Dear Old Blighty, is the land of milk and honey, so now they actually have freedom of movement and are joined to us at the hip via the EU they are going to up sticks and relocate the whole of Poland inter alia to SW1.

*cough*

Now to me this is a cause for celebration. To think that I live and work in a land that is so highly regarded that almost the whole world wants to come and join me is quite the most fantastic news. It almost helps me to forget that I now apparently live in a "Rabbit Hutch" according to at least one fellow blogger. (No I'm not going to elaborate. I believe she knows who she is...). Or it might just be the usual protectionist hyperbole stewed up by the "chattering classes" aided and abetted by the Barking Nutter Party an UKIP.

*cough, cough*

Yes, what is it?

*You promised us Tiggers, then you started ranting and using all those posh words, and then you mentioned Rabbits House but still no Tiggers.*

Yes, I know, just try to be a bit patient will you, and do stay away from that hunny, it's medicinal and very expensive you know....

Now, where was I? Oh yes. The Ambridge experience of Eastern European migration.

We have had a small Polish community nearby since the last Great European Unpleasantness. As they got older and intermarried with local gels the character of the community became a little diluted, and there was a small schizophreenic subgroup of Polish refugess sons and daughters marrying the Italian offspring of fomer POWs as they found their shared Catholicism more of a bond than their previous national allegiances, surrounded as they were by the heathen Borsetshire yeomen.

That little community has been quite stable for almost six decades now and is thoroughly integrated. Shortly after I joined the practice we had a new influx. Again refugees. This time from Kosovo. They were a rag tag bunch of single young men and a few older men with families. They had horrors in their heads they could not tell us about. But as the years have gone by and the children have started in local schools, the men found work and an intriguing "working man's" vocabulary of colloquialism and invective, they too have been integrated, excepting the ones who have been deported.

*Ahem-- don't mean to worry you, but there's a small rather sticky looking yellow bear here that wants you to get to the point*

Yes, sorry. Nearly there I promise.

Now, as our erstwhile janitor would attest, we have seen an influx from Poland in the past couple of years. Mainly young adults in excellent health. Some with young families, but mostly all still single. They speak fractured English for sure, but hey, you should hear my Polish... and they do menial jobs for wages the locals won't take. Often two or three jobs all at once (well in shifts obviously, but you know what I mean).

But in their flats they continue to speak Polish, drat them. And especially so to their three year old offspring apparently. I know. Honestly. Whatever are they thinking, talking their own language to their own children. They'll have the Home Office to answer to 'ere long I'll warrant.

*what is the right emoticon for a sticky bear scowl? Whatever it is, insert it here if you will*

My point is.... and we would honestly have got here quicker if it hadn't been for the constant interruptions, looking at nobear in particular, nor the anonymous reader who indulged him, they then bring said Polskiphone (if that's not a proper word it should be, so there) to the Big Scary Doctor. Now, I imagine kids of that age in Poland are looked after in much the same way they are here. Namely jabbed at almost every available opportunity. This must make a trip to the Doctor quite scary enough, but when the Doc then won't even sooth your fears in a way you can understand, how much the more frightening must that be?

So when little Jaroslaw was brought by mum today because he had been coughing all night, he was tired and fractious and scared.

How could I tell? Well the rise in decibels of his plaintive cries as I got within jabbing range was a bit of a clue, even to my non-polskiphone ear. So, enter out hero. A little plush Tigger with magnetic paws long since surplus to requirements at home. Now I consult with him on all my difficult toddler patients. He guides my stethoscope, and confers with me on the findings, or claps himself to their collar / hair braids / other convenient appendage.... and hangs on for grim death whilst I go about my work. And the beauty of this is that he works in all cultures. Even for kids brought up in lands where there are real tigers to be had.

I'm not quite sure if little Jaroslaw was delighted by Tigger or just stunned to see a grown man, and alleged professional, pratting about in such an unseemly manner, but my colleague and I got the job done in total and acquiescent silence thereafter.

Tiggers truly are wonderful things.

*ahem*

Yes, as are Pooh, Piglit, Eeyore, Rabbit, Wol, Kagna, Blot, Smudge, and all the others.

Gotta go now.
Bizzy.
Bacsun.

*Wot he forgot to tell you wos that Paediatric Grand Rounds are up herehttp://drfleablog.blogspot.com/2006/07/fleas-three-ring-circus.html and he's in them again*

*Personally I can't see what all the fuss is about but then perhaps if I had brain instead of fluff and sawdust...*

Yes. Thankyou.

But they are, and they're jolly good to. You should take a look if you're interested, or if you're laid up after, say, trapping a toe in the door of a DeLorean.

It's ok they're herbal....

We seem to have lost our way somewhere. All the surveys done show that people trust Doctors much much more than Politicians. Except when it comes to one of the key things we do. Therapeutics.

I'm willing to admit we can often be our own worst enemy here. As in the folowing:

1995-- "Oh yes Mrs Grundy, this HRT is just the thing for you. It'll protect your bones and your ticker. You should probably be on it forever, or at least for the next ten years...."

2005-- "Oh no Mrs Grundy, we only recommend HRT for a year or two, IF you really can't manage the flushes. No it probably won't help your bones or your ticker, and it might give you cancer...."

The problem is our relentless struggle to be "evidence based". As a junior doctor with all the latest advances that medical science had to offer it used to drive me mad when "old fogey GPs" stuck to a very limited and very outdated therapeutic armamentarium. Now I'm driving the next generation of bright young things mad in their turn.

Down the past decade there have been a number of high profile "voltes faces" in therapeutics like the HRT debate so elegantly precised above (I thank you). It seems every analgesic invented since paracetamol comes in to a fanfare as the safest bestest and most wonderful. Most are a bit better that what we had before, but then dissappear in a flurry of litigation when it turns out they might also be a tiny bit poisonous. We've been promised an alternative anticoagulant to warfarin for thrombosis treatment, that would take away the need for nasty blood tests every 3-4 weeks, for years but still so far nothing....

So the sharks in the Herbal industry step in. Well if it's herbal it's natural so it must be ok mustn't it. And anyway you can buy it from the Health Food shops so that proves it. And the chemists often sell it too....

It may be true that St John's Wort is effective in relieving depression in some. It also messes with many orthodox treatments for other health problems in ways that we can't entirely predict because no-one has done the rigorous asessment it would have had if it had been brewed in a vat... but hang on how precisely do they get the herby stuff into the pill / capsule / goo? Still you know what I mean. It's natural. It didn't need chemists to "build it". ('cos God beat them to it)

In truth, herbs are some of our oldest drugs. Chemists have helped us to tidy them up a bit as aspirin or digoxin or tacrolimus (yew trees used to treat cancer and horrible skin disease). They take away all the icky organicky bits and leave use the pure therapeutic agent. Then they study it to see what it does. Not so the Herbalists.

Christine, a lady of a certain age, heard that HRT might not be that fab a long term option. She went to the health shop and got some "Phyto-oestrogen" containing Black Cohosh pills. The she started to itch a bit. Then she went a bit tanned looking. In November. Having never left dear old blighty.

We talked about her herbal treatment and looked at her liver function as a result. Sure enough she was jaundiced . This was around five years ago. Google couldn't assoiate Black Cohosh and liver disease. Neither could the Hepatologists we sent her to see. So she carries a doiagnosis of "Autoimmune Hepatitis". After a recent Uk and EU health warning I am no longer so sure this diagnosis is correct.

She stopped taking the stuff anyway, and her liver function is stable. But I can't help wondering if her "health supplement" hasn't left her far from healthy. And because it's "only" herbal, I doubt very much if there's anyone she could pursue for a legal remedy for any inury it gave her.

So next time you find yourself in the health food shop looking at the supplements, have a quick look on the label. If it claims great things but offers no warnings think long and hard before you buy, and don't assume for a moment it's going to better or safer than "orthodox" treatments. We may not know everything about the newer treatments we use, and we may change our minds about them. Often. But at least we are looking at them. There's even a formal reporting system applied to new or relatively untried drugs to make us think a bit harder before we use them. There's nothing similar for Herbal Remedies.

After all they're only natural aren't they.....

Ancient Wisdom

A non-medical post for a change. See what going on Holiday does for you!

And for those that were worried I managed a whole week away without being "outed" once. The fact that it was almost too hot to move and so we spent all day most days in either the pool or the air conditioned bar might have had something to do with it... but whatever the reason a week free of unsightly scars and blemishes and tales of medical catastrophe was most welcome.

As a family we Jests are a pretty unadventurous lot. It took us until last year to brave a non-anglophone holiday with the kids (then aged 9 and 12) unless you count a dismal weekend in EuroDis' some while back, but that's hardly non-anglophone really and anyway it was cold and horrid and half taken up with airport delays and I really don't want to talk about it so there.

We had such a great time last year that we rebooked the same week at the same resort for this year, right at the start of the kids summer hol's, on an island in the Aegean. It's been blissful, if hot, as I said. It was also lovely to arrive back there to be welcomed in the restuarant by our waiter from last year, the redoubtable "George", as though we had never been away. We had very much hoped he would still be there (our little one had quite a thing for him last year-- now supplanted by Captain Jack Sparrow, but I'm specifically not allowed to tell you about that). She's now 10 and he is probably close to 60, very small, and very dapper, and his English is flawless, though he enjoyed teaching her little bits of Greek last year and she enjoyed using them again this year. And the most amazing thing was that he had truly remembered us after all that time and all the people he must have seen in the interim.

This holiday we also got to discover that he is a true philosopher. We flew out last Wednesday, to return yesterday, and we ate in the restaurant every evening except Tuesday when we had a planned excursion which precluded it. That meant that on Monday evening we had to tell George that we would not be needing our usual table ( yes, after just two weeks total spread over 12 months we had a usual table!) the next night and so Moday was our last night in his care.

He looked at us, very concerned, and said, "Only the one week? Still, it's better than nothing eh?"

Earlier in the week we saw him chatting to a three year old lad that had been left at the table by his mum for a moment while she went to get him another drink. George walked up to the table whistling much to the lad's delight. George looked at him and said "Can you whistle?" the lad shook his head. "Then you must learn!" he replied.

The tradition of Sophocles and Plato is in safe hands.

And yes we had a fantastic week, thanks for asking.

The Doctor is Out

Yes folks. Last chance to touch the screen for healing for a week or so as I'm off to the sunny Aegean on hols for a week on Wednesday. Feel free to use this space to chat amongst yourselves whilst I'm gone. But before I go I have an observation and a question.

First the observation. Going on holiday can be a challenge. Mr Angry posted today about the profusion of "Doctors" with PhDs but not medical degrees. To be proper about it they have earned an academic title that dates back to antiquity and just refers to their learned wisdom. Thye have earned it and deserve to enjoy the benefits of their title. But I feel I must warn them that claiming it as an honourific comes at a price.

Before we had kids I could travel incognito as a "civil servant". Sounds just boring enough to kill all conversation and allow the repost "and what do you do?", deftly changing the subject avoiding any comeback. The thing is, even before I qualified any slip re my secret identity was an invite to the most excruciatingly embarrasing ordeal. Don't believe me...

Xmas
1980 (ish)
Dr J (then undergrad' J) takes a job behind a bar somewhere in the Wild West Country over the hol's.

All is well for the first week. Then the Landlord's cousin (an hardened drinker) discovers from the Landlord the secret identity of the fledgling Doc. Cue the public display of the worldst most awful and awe inspiring hernia scar to the very loud if somewhat slurred accompaniment "Whaddaya fink a' that then Doc?" as he yanks his trews down to his ankles and pulls his not so tidy whities to one side. For the next two weeks yours truly was bombarded with questions about hysterectomies, gallstones, cystitis... you name it, I got it, often to similarly inappropriate visual displays. It was a relief to get back to Med School, so since then, on hols and in social settings with strangers you'll find mild mannered cub reporter (well civil servant in this case) Clark Kent standing in for Dr J.

Now we have kids I'm generally outed within the first couple of days, and again the discussion of subjects far better left to the privacy of the confessional resumes. Now don't feel that I'm complaining. I love what I do, and am generally more than happy to offer an opinion on just about anything, but it is nice to be off duty once in a while. Also it staggers me that on hearing that one little six letter word many people seem to shed all inhibitions to talk about and indeed on occasions to display bits of themselves they would never normally bring in to a polite conversation.

Which brings me to my question.

From time to time I am called upon to examine lady patients chests. Often, this can be safely limited to a brief application of a stethoscope to the back with clothing simply untucked and lifted. This I feel quite ok to handle in surgery as part of the normal routine, but sometimes, as today, a full examination in a state of undress is required. In accordance with current practice I no longer do these exams unaccompanied and so patient and I will move into the treatment room and sister will stand in as a chaperone throughout the exam. But, with a disrobed female patient laid on the couch, during the chest examination, where is it safe to look?

Over close inspection of the breasts sounds pretty obviously intrusive. Eye contact seems an equally obvious no no. Closed eyes is open to all sorts of misinterpretation (though I will often do this when trying to listen to chest sounds as I find it helps me to concentrate better -- whatever the age of gender of the patient before you go all funny).

So ladies, help me out here. What's a poor boy Doc to do?

Happy Holidays (well for me anyway). See you all next week.

Play nicely.

Making the cut.

An expression in common parlance among those who favour what Sam L Clemens allegedly termed "A good walk spoiled". It's something to do with surviving the first few rounds of a competition so as to be allowed to play for the title / prize on the last few days I gather.

It's also what brought Carly to the surgery yesterday. Not that Carly, in all her fifteen years on the planet to date, has ever, in so far as I am aware, been near a Niblick. The problem with Carly is cutting. Specifically, last weekend she wanted to go out late. Mum and Dad said no, so she stropped off upstairs, took a glass fragment, and used it to carve a succession of parallel lines in her left forearm. It now transpires she has been doing this on and off for the past six months, often as a "social" activity with a mate of hers who finally "outed" them both to her own mum last week.

So here are mum and Carly. Carly wondering what all the fuss is about. We tend to label cutting, along with overdoses of tablets and booze, and breaking things, as "acting out" or "attention seeking" behaviour, but the present attention is plainly not what Carly was looking for. In the whole consultation (which lasted nigh on twenty precious minutes) she probably uttered no more than half a dozen words and offered a few disconsolate shrugs. I never got to see her eyes from beneath the brim of the baseball cap that stayed firmly welded to her head throughout. It's safe to say rapport was not established, and not for want of trying. I even asked mum to step out for a few minutes to give her a chance to express heself, but she was plainly disengaged and even talk of psychiatric referral didn't really bother her.

I did manage to get a look at her arm. Five days on there were four very neat, very faint lines on the inside of her forearm. They are healing fine and were never deep enough to leave a permanent reminder. Unless she has been very lucky it looks like Miss Carly knows just how much pressure to apply not to leave a scar. And if her friend hadn't said anything I'm not sure mum would have been any the wiser. But now we have a dilemma.

Mum has freaked. Her little girl is carving herself up which "can't be normal" and Carly won't talk to either of us to help figure out if she has a problem or not. I actually suspect not, but with nothing more to go on I have had no option but to accede to mum's request for a specialist referral.

Many primitive cultures have rites of passage way more painful than anything Carly has so far attempted. If Dan Brown is correct grown men and women practice self mortification now in the name of faith every bit as much as in the Middle Ages. All Carly and her peers have to look forward to is the cringeworthy American import that is the High School Prom. I'm sure in America they are fine, no, hold on, actually I'm not, but that comes from a prejudicial view fostered by the media, and the envy of someone who is the product of an all male education,but the thing is, watching British kids trying to be American is every bit as painful for us parents as it must be for the kids.

It is just possible that Carly, her mate, and the many hundreds of other teens engaged in similar rituals are inventing their own rites of passage. I'm just not sure whether the speciallist referral is an integral part of it or not.

What I do know is that Carly has now made the cut, and is progressing to the next round.

Marley's Ghost?

By way of a change here follows a story about the surgery, rather than the docs or the patients. When I joined the partnership many moons ago we were one of four practices working out of a 1960's vintage Health Centre. The building was on it's last legs, and, being part of the local NHS estate, maintenance was beyond our purview and seldom happened. Within four years the changing nature of Primary Care led us to need more space, but there was none to be had, leaving us with no option but to move out. It was than that we relocated to the present tastefully renovated and extended older property in Ambridge*.

We know it dates from at least the 1920's. We have a bit of wood from one of the replaced sash windows dated 1926 by the then chippy. (We're now almost all UPVC for good or ill). The car park replaces what may have been an even older srtucture which had become very shabby before we had it pulled down.

It's a lovely place, with big consulting rooms and a massive reception / waiting area. We've even got a great big Library and Conference Room upstairs. And we've got a ghost. No really we do. Honest.

How do we know... allow me to ellucidate.

Shortly after we moved in, with all our hi tech computers, cupboards full of mind altering drugs and the like, our burglar alarm started going off. Nothing too sinister in that you might think, but every second or third day, always between 01.00 and 03.00 and requiring the duty partner to be called out to search the premises for miscreants, it began to wear a bit thin. Very quickly. And nothing was ever taken-- ecept for the time some scallywag wandered upstairs and made off with our VCR in broad daylight while the surgery was full of people and the alarms no on, but that's another story.

The alarm company tried to suggest it was down to spiders wandering across the i.r. sensors. But then one of the girls, coming in to unlock early one morning, caught sight of a grey man in the corridor, only for him to vanish when the lights went on. From that point on we knew our practice was haunted. The girls now have a name for the poor soul. Gareth. Apparently it goes with Ghost. He's now a permanent feature of practice life and folklore. I wouldn't be surprised if we start inviting him along to our christmas outing.

He goes through phases. Some years he hardly puts in an appearance. Others, like now, he seems ever present. And this week our practice manager has made a discovery. It seems dear old Gareth is a reggae fan, as is she. He has been spotted skanking to the beat among the chairs in the waiting room of a morning, but only to the steel pulse that is reggae.

So not only do we have a Ghost, but a well cool Ghost at that.


*I'm sensing a future in Estate Agency if the Day Job ever falls through.

Unfinished Business

Friday was what my dear departed granny would have termed "A bit of a B' ".

One patient in particular posed problems that were not immediately solvable. Siobhan, a single mum not in the first flush of youth, had had a "funny do" eight days before. It had left her with a funny feeling in her right arm and leg, very tired, and perhaps a bit weak down the same side. She has high blood pressure and had a similar funny turn three years back which got better in less than 48 hours.

Investigations then were all normal, so she takes meds for BP and a daily aspirin and was well until this latest turn. Still there's enough here to make me worry about stroke. So I had to worry her. Unfortunately she hadn't read the "Stroke Care Pathway" and so, thoughtlessly, she had not made any childcare arrangements so I couldn't just send her straight in for work up by the physicians. Some people just don't think things through do they ;-) .

First I tried to call the Medical Registrar to see if there was any way to get her booked for her MRI without all the bother of "the pathway". Switchboard at the hospital tracked him down, but "We can't put you through on this line, do you have a mobile?"

*!*

No. Or at least not on me. I don't generally need one in surgery. If I do bring it in the kids just use it to update me on their missing sports kit / flute / lunch pass / lunch... so I don't do that any more.

"O K we'll get him to ring you back."

Siobhan was ok to wait for a while so I asked her to take five while I saw the next punter. Five turned in to sixty five and still no call back, so we agreed she should go home to await my call.

Twenty minutes later surgery was over and I called my friends on the hospital switchboard and finally got to speak to Med Reg. He's a locum and has less clue what to do than me. We agree to try to get Siobhan up to the Medical Assessment Unit as soon after she has completed the afternoon school run as possible,

So I now ring her back, and get diverted straight to answerphone. Leaving messages in such circumstances can be ticklish. What if it's not her that gets to pick up the message? What indeed if it's not even her phone?

I ring again to make sure I've dialled the right number. I have. It's the same message. So I leave a "George Smiley" type message vague enough to not let ant cats out of any bag, but clear enough (I hope) to make it clear that I need her to call me back.

She doesn't. So I go home, late, worrying.

Monday morning and there she is at reception when I come in. We reprise Friday's consultation and try again. This time all works to plan and she departs surgery for MAU within twenty minutes, referral letter in hand. Later she calls back to say she has had her initial x ray and bloods done and waits for an MRI date, but has been let home to continue to care for her inconvenient children.

I can't help feeling we ought to be able to do this better, but there isn't an arm of the pathway for "Single mum" or for "Carer for elderly demented spouse" or any of a dozen other little wrinkles that make the "Stroke Care Pathway" inappropriate for a great many patients who might be in need of it.

Do not adjust your set....

I may have to apologise to my old friend the controller of Radio Four. Regular readers (bless you all) may recall a running spat I had with Radio Four, and particularly the Today Programme, a few months ago. They appeared to have taken over the collective consciousness of the citizens of Borsetshire so that every little health problem mentioned over the airwaves immediately presented to me in surgery, and without any of thos affected having heard the news reports in question. Well after yesterday it appears it might have been me all along. Apparently I have psychic powers verging on the supernatural. I've thought it through and it's the only explanation that makes any sense...

I'm feeling your skepticism here, but once I have recounted the events that follow, I am sure that even you, gentle reader, will be convinced of my newfound ability.

Oh yes you will!

*teeters precariously on the brink of Panto before pulling us back to relative sanity*

There, glad that's all behind me....

*somewhere off in the distance the screams of hundreds of children all frantically pointing- only to be ignored*

It all begins, as so many of these posts do, with the drive in to work. I like the drive. Leafy lanes, thrashy music, and time for thinking. The kids have been left behind at school, the mobile is either off or inaudible (Jethro Tull's "Aqualung" at eleven on the car stereo), so there are few distractions (sheep and pigeons excepted).

This particular drive in I am pondering asthma. And it strikes me that the past decade or so has seen the presentation of asthma change quite a bit. The condition remains the same, i.e. cough and / or wheeze depending on age. What appears to have changed is the number and frequency of acute exacerbations. In the good old days we used to just have two broad treatments to offer, relievers (like Ventolin) that relieved wheeze quickly only to wear off after about 4 hours, and preventers (steroids like Becotide) that reduced the severity of attacks and helped prevent them in the longer term.

But, preventers need to be used all the time, and the inhalers are not nice to take, often being quite "peppery" on the tongue. Worse still they have sife effects -- sore tongue and hoarse voice, and they are "steroids" which in may people's books make them nasty. Especially when their use, and indeed the use of the relievers, is banned in certain compettetive sports unless you have a "note from the doctor". Add to that the fact that most of our new asthmatics tend to be children, so we are asking mums and dads to give their little darlings something with all the appeal of nerve gas, and it's no wonder preventers meet with a degree of resistance.

In the past this led to significant under treatment and fairly frequent exacerbations. Especially when there were lots of viral coughs about or the air was very cold / hot / polluted. During these episodes, surgeries would be full of wheezy, coughy people all queueing up for a "go" on the nebulizer- a wizzo machine that makes an aerosol of medication that you can breathe, spaceman-like, through a mask. This is a huge hit with the seven to twelve year olds, a source of terrour to the pre-schoolers, and a monumental pain in the wossname to the rest of us. But it does help turn around exacerbations. That and bucketfuls of steroid tablets.

Anyways, in the past few tears other inhalers and pills have become available that bridge the gap between prevention and relief. These (drugs like Salmeterol and Montelukast) have made a big difference to tolerability of treatment and symptom control. This has meant we have seen fewer severe exacerbations and our nebuliser instead of seeing constant use has been relegated to a hidey hole under the sterilizer most of the time.

Back in the car Jethro Tull have moved on to the Dambusters march* as I am musing that we seldom seem to need the nebuliser anymore. So guess what I had to do for three patients yesterday morning....

So there you have it. Convincing proof I think you'll find the power of my immense intellect to forsee the future and influence human behaviour. Now if only I could put it to good use.

So go on. How many of you are now thinking about chocolate digestives then eh?

*name that album for a bonus point.

House!

Mike was married to Betty something over four decades ago. They had their daughter Emma around ten years later. She took up with the "wrong sort" and had a babe of her own very young. Her "partner" then took off, but not before inflicting injuries on his daughter that left her wheelchair bound for life. Emma was at first suspected of complicity and so her daughter was taken in to care, only to be adopted very soon after by Mike and Betty. As soon as permitted by the authorities Emma moved back to the family home and was re-integrated into her family.

Then Betty contracted colon cancer. After a protracted illness she passed on some time ago. During her illness Emma suddenly became empowered. She learned to drive and found steady employment, to Betty's eternal pride. So for a couple of years now Mike, Emma, and Emma's daughter have lived together in their small house surrounded by the comforting presence of Betty's legacy.

Mike has never seemed to suffer the negative symptoms of bereavement and today I think I learned his secret. He spends his afternoons surrounded by a posse of attendant widows at the Bingo. And when he can he goes fishing.

So often men bereaved after a long relationship seem to founder, but Mike has found the perfect mix of extended support and solitude. It's way better than anything I would have to offer him, so today we just reviewed his inhalers, he imparted the secret of life, and we agreed to meet again next year for more of the same. Unless he wins the £1M jackpot and departs these shores for the Cayman Islands in the interim of course.

Dress codes.

Before I get cracking a couple of "notices".

First it is my pleasure to announce that the Paediatric Grand Rounds for 1.6 have been published at shinga's site http://breathspakids.blogspot.com/ and include a couple of posts from yours truly plus a host of fascinating food for thought I really wish I had written. Hopefully even non-medics will find a lot of this as interesting as I have. Thanks to Shinga.

Second, this could well have been a ranty post all about the wicked Mrs Hewitt, who this weekend implied that GPs represent Private Healthcare provided to the NHS. Whilst it is the case that GPs are generally subcontracted "corner shop" partnerships contracted to provide GP services to the NHS, this is a million miles form being "Private Practice" in the context of the interview she was giving. True private primary care provision vests in large outfits such as US style HMOs. We have never seen such a thing in Blighty, and I hope and pray we never do. Ask any American for their opinion of HMOs and you will see why. So for now my only response to Mrs Hewitt is to say "How very dare you!" and to bet that I'll still be in my job when you have been sacked from yours. Oh and at my charge out rate for "Private work" she now owes me £50 for the response.

But I'm not going to rant today. Instead there have been a few incidents over the last week or so that have me pondering dress codes.

The past couple of weeks have seen Borsetshire bathed in sunshine. Daily temperatures are rising nicely into the high twenties, or seventies / eighties for non metric readers. In response Drs J and Neighbour have abandoned ties and gone "shirt-sleeve order". This has attracted some adversecommentt from our manager and newly elevated senior partner, but we both figure our regulars would rather see us cool and collected than plethoric and distracted. Still it does leave me feeling a little bit out-of-uniform, as though abandoning the neck-wear is the start of some slippery slope to loss of professional identity. So I find myself compensating with the draped stethoscope "St Elsewhere's" look as popularized in the eighties by the TV series of that name. Any opinions on the tie / no-tie/ no-tie-but-draped- stethoscope conundrum gratefully accepted.

Next we have the sandals and socks debate. It's something british blokes seem to have real issues with. We were at a lunchtime gathering of Lady J's work colleagues this weekend. It was, as previously noted, pretty warm, so shorts and sandals seemed the right look. Now I know bare british manly toes are seldom a thing of beauty, but socks and sandals seems to defeat the whole object. Hence the Jest toes on full public display. This was a surprise to at least one attendee resplendent in beige socks beneath his sandals. At least on this one I know where I stand, and I shall not be moved. Maybe it would be better if I painted the nails though? Then again, perhaps not....

And last but not least, the White DJ*. It was the boat club dinner this weekend. A "black tie" do. Funny how that phrase has stuck though the majority of ties on display (we are talking bow ties here by the way) were anything but black, mine own included. The best was a resplendent rainbow tie and cummerbund combination worn by the biggest rower in the club, but I digress.... As I was saying, for the dinner the proper formal-wear was required, so out of the moth infested depths of the wardrobe comes the Dr J DJ. It's traditional, black, single breasted and shiny collared. It's also very heavy, and twenty eight degrees in the shade (which rather neatly is eighty two in fahreheit). So off I go to my tailor-- heh --and the assistant finds me a white number, half the mass, but probably twice the price of the black twin left on the hanger at home.

So off to the do. I managed to stop introducing myself to all and sundry with the catchy- "the name's Jest, Doc Jest" and asking for vodka martinis, shaken not stirred, after the merest playful kick on the shin from the eldest. (He's the rower, and was fed up with his embarrassing dad, probably a fair cop). During the course of the evening we got to wondering about the etiquette of black vs white DJ's. Again any thoughts welcomed.

Now that's off my chest normal service may be resumed later this week....


* Sorry but Tuxedo is not a word that belongs in any self respecting Englishman's vocabulary.

Panic

The lovely Shinga http://breathspakids.blogspot.com/ has invited me to make a submission for the Paediatric Grand Rounds next week. All at once I am catapulted back twenty some years to a big drafty lecture hall in the bowels of the "Centre of Excellence" that was St Elsewhere's. There we all were, a gaggle of fresh faced youths (75% male, god-love-us) crammed into an ill assorted collection of white coats, (strangely those destined for Honours always wore the shiniest and best fitting coats too...).

Like a christian being herded in to the Colosseum for the half time entertainment a poor benighted Brummie, often in pyjamas tied up with that frayed white string, would be prodded on to the stage for our edification, and the trial by humiliation would begin.

These grand rounds are not at all like that, and I hope to offer a worthy contribution from a GP perspective. Still I can't help feeling a certain frisson. But this is not the panic of which I speak. Oh no. I can meet even the most eminent of Professor's gaze for at least 10 seconds now before I have to blink.

No indeed. This week I have been intrigued by a juxtaposition of events here in leafy Borsetshire and the wider world as represented on Radio Four's Today Programme.

First the local. We have had a number of calls from worried parents this week. It seems we are in the middle of an outbreak. Maybe this one even qualifies as An Outbreak. It's Hand-Foot-and-Mouth Disease. http://www.patient.co.uk/showdoc/23068750/ For the uninitiated, and all the mums in Borsetshire, this is an essentially trivial viral infection. The illness is both mild and self limiting. But visible. And just possibly a cause of miscarriage if you happen to get really, really unlucky. Because of this whenever we get an outbreak all the nurseries and playgroups in town go into a flat spin and every child with even the vaguest symptom of anything gets sent home, only to turn up in the duty surgery for the usual advice and reassurance. The mere name of it terrifies mums though. They remember the chaos of a few years ago when Foot and Mouth disease led to the wholesale destruction of vast numbers of animals and widespread travel restrictions. I'm sure some of them have visions of us coming to drag their little darlings away to remote outposts and nailing their doors shut with white crosses painted on them as in days of yore. They all seem almost disappointed to find out that it's really not at all serious for their offspring, and indeed, scarcely a danger to the wider populace. The worst impact it has is on the time off they or another family member might need to take to cover their "quarantine" from playgroup.

Now the bigger picture. Yesterday morning the Today programme publicised a news item regarding an open letter sent by thirty eminent immunologists and public health experts calling for an end to the hype surrounding the flawed theory that MMR vaccine is linked to Autism. Later in the day they had a Doc on a talk show (? Jeremy Vine) who was herself still convalescing after contracting measles some six weeks ago. She caught it from a patient. Likely an unimmunized patient. She was at pains to point out that she had never herself encountered a case of measles before, and neither had many of those charged with looking after her. She felt unwelcome as an inpatient because she had a major contagious disease and no-one seemed to know what to do with her.

It has to be six years since we last saw a case of measles (in an adult and contracted abroad) and I too might struggle with the diagnosis it's been so long. There are classical signs and symptoms http://www.patient.co.uk/showdoc/23069075/ but most patients don't read the books or present their symptoms in an orderly fashion. When the epidemic hits, and as things stand it will hit, we are all going to have to relearn measles pretty quickly.

The earlier interview was well handled by the Spokesman for the "gang of thirty" but still the interviewer had the nerve to suggest that by publishing their evidence based call for an end to the "controversy" they were in some way complicit in it! So here's the thing that really troubles me. This week our workload has probably been increased by as much as ten percent by a trivial and short-lived complaint that we understand very well. When measles hits it is hard to imagine we will cope as well.

lost marbles

A thought struck me this afternoon in the middle of a consultation. Jack is comfortably "over the hill" and in recent years has taking to rambling the byways metaphorically speaking. In short his memory is not what it was. Or so he imagines,though he finds it hard now to remember what it was when it was....

Certainly he has progressed along the continuum from Mildly Eccentric in the direction of Dotty, though he remains a long way from Terminally Bemused. So far his personality, and especially his lively sense of humour are reasonably preserved, but the fine details of daily life increasingly evade him. And now he has reached the point where he, and those around him, have decided it's time for something to be done. So I will be referring him to our very nice and very capable psychogeriatrician-- yes that is a job title and not a pejorative-- for an assessment of his memory. There they will ask him a set of stock questions designed to assess his cognitive abilities and recall.

And this is what has got me thinking. There are days when I am sure my nearest and dearest, and maybe even you gentle readers, having heard me rant on at length about the same old stuff for the nth time since breakfast, begin to wonder if I am starting to meander those same byways. The trouble is, I know all those stock questions almost as well as the clinic chaps do. The answers are now essentaially hardwired so I don't need to "take seven off of a hundred and keep going" to know the right number sequence, and I know perfectly bloody well where John Brown* lives thank you very much! So all I've got to do is memorize the name of the new Prime Minister whenever we get one and maybe those of a few footballers, and I'll be safe if the men-in-white-coats chose to pay a call.

So in years to come just how will we assess the failing cognition of GPs, Psychiatrists and others involved in this field of endeavour?

Do tell. I want a head start swotting for the tests.

* The memory assessment includes the giving of an address to be memorized early in the interview with points scored for recalling the name, house number, street and town concerned at the end. A little psychogeriatric in joke for you there. And at no extra cost.

A bit of a do.

This weekend saw the Jests at a family gathering. It combined a significant birthday and a significant wedding anniversary, both falling within this year, for what Bertie Wooster would have termed "ancient relatives". They gathered family and friends around them for a celebratory lunch.

There was splendid food, (the quiche guarded with a fierce intesity by a waitress determined not to allow her largesse to any but card carrying veggies), lovely wine, fizz for the toasts (several, by the time you had covered the bride / groom / birthday / guest speaker etc...) and a general warm hum of happy conversation throughout proceedings (except during the speeches where even the children sat engaged by two racconteurs at the top of their game). Best of all the venue was the function room of a Village Cricket side, and there was a match on, so after the main event we got to sit and soak up some real olde english tradition-- and beer.

Furthermore the occasion has given yours truly another* very tentative claim to fame. Our eldest is learning to fly through school. One of the guests at our table got to hear of this and promptly said, "Here lad, shake my hand." He duly did, being an obliging sort. As he did so the guest (a gent well into his ninth decade) informed him thus, "You're shaking the hand of a man who has shaken the hand of a man who was shot down by Von Richthofen."

It transpires that our new friend was at a seaside resort some time in the late forties or early fifties and came across a man who was there with his wife. This man was rather frail and needed help in getting about on the front. Our friend had been happy to oblige, and the wife explained that her husband had not been quite his old self since he had been shot down by the Red Baron. He then, and we now, have no reason to doubt her veracity, so here I sit, the proud Dad of a lad who has shaken the hand .... as detailed above.

In some sense this gives us a vague tactile link with a significant historical figure and keeps the past alive in a curious way. Books tell you the nuts and bolts of history, but alongside this there persists a rich oral tradition which preserves the more mundane aspects of momentous events. And for a man with a picture of Albert Ball on his wall, that's good enough for me.

*One day, if you're very good, I might tell you all about my other claim to fame. (And yes it is a bit more concrete than shaking the hand of a man who.... )

Good Cop / Bad Cop, and some sheep!

I was going to post about the job interviews we held yesterday. Interesting experience being on the "other" side of the desk, as an interviewer. We were two, plus our practice manager who was along to help thrash out the finer points of contracts, pay scales and the like. We just wanted to get the cut of the candidate's gib as it were.

We are quite new to this having had a stable complement of docs at the surgery for more than a decade. Also we are looking to appoint two half time job-shares this time around which is, for us, uncharted territory. So enter Drs J and Neighbour, like an unholy pairing of George Dixon and Harry Callahan.

Our victims fell into two broad types, power dressed and confident ("Grey" women) or power dressed and timid ("Beige" women). The determinant seemingly being the choice of suit colour. All had impressive CVs. Enough to make me feel more than a bit inadequate in some cases, (till I dug out my old CV and had a bit of a chuckle: "Represented Muggleton Hospital at football" = three games played by the A&E docs against the nurses-- except that for the last game they drafted in all the porters and their husbands and we got thrashed so that was the end of that..... ).

One of the "Greys" got the gig and seemed quite happy so we shall have to see how this bold experiment works out.* So the only question that remains to be answered is which cop you think I was?

Hold on a minute, I hear you cry. You promised us sheep. We're sure you did. They're even in the title, look, just up there....

And so they are. It will not have escaped your notice that the surgery is in a leafy shire county. Borsetshire to be "exact". I've whittered on about the drive to work before. Leafy lanes and wildlife in abundance. Well after spending a large part of yesterday interviewing it rather ate in to my admin time. But today is Lady J's day off and she had "things to do" in town, so she opted to take the big-red-bus and drive the kids in to school this morning. "So you can have the nippy car, go in early and shift the paperwork before surgery..."


Which was lovely. Until I got to within a mile or so of the surgery and hit a tailback. Which is something we just don't have on my morning "commute". As the massive line of cars (at least five ahead of mine!) snaked around the corner the reason became apparent. One man, two border collies rushing about like exocets, and around a gazillion sheep (well more than a hundred anyway-- I may have dozed off momentarily mid count, as is to be expected). They were expertly herded down the lane and round the corner in a matter of ten minutes or so, but somehow after that I didn't have the heart to race in to surgery Colin McCrea style any more, so I wasn't quite as early in as I'd hoped.

If only I'd had my magnum handy......


*In case you were wondering we appointed the first half of the Job-Share a while ago to an old friend of the practice so we know that part will be fine.

Old Friends

By way of a paradigm shift meet Henry and Minnie*, and old couple married in the dawn of prehistory, survivors of recession, war, famine, pestillence..... you get the idea. And throughout it all they have fought like cat and dog, Tom and Jerry, maybe even Itchy and Scratchy!

Their relationship apparently thrives of their ability to contradict one another, or more properly Minnie to contradict Henry. It's easier for her to do now, because in the past five years Old Father Time has accounted for what little hearing war and mining had left Henry. He has aids. You know the sort. Big clunky things that whistle and squeal with alarming regularity. In many ways it's just as well he's deaf enough not to have to hear it!

Minnie has her own agenda. She is desperate to make sure he stays well. The thing is, she was diagnosed with "inoperable" and therefore "terminal" colon cancer some four years ago.

Yes, really, four years.

The diagnosis is quite correct. The prognosis has been appallingly wrong. You might think happily, given she is still around, and really not a lot worse, four years in. But to her that's four years spent on Death Row, waiting for the men with the keys to come for her, to march her off to the chamber, and she doesn't even get to know which day to have her "hearty breakfast". And so she is scared. Not so much for herself, except when she gets a new pain she can't explain**. No, she worries for him.

It doesn't help that like all men of a certain age he is prone to concerns over the working of his bowels.*** In brief he suffers with constipation, despite laxative doses that would bring an elephant to it's knees.**** Of course Minnie's carcinoma began with episodic constipation-- followed by diarrhoea in her case, but still she sees constipation as a "red flag" symptom. So much so that we even investigated poor Henry last year just to reassure her.

It hasn't.

Which brings us back to today. Henry comes in and sits centre stage. After all it is his appointment. Minnie comes in behind him, and takes station, for all the world like a smaller, older, more female Kevin Costner, just behind his left shoulder.

One false move here and I'll feel my hair***** being parted by the bodyguard's katana, I think to myself.

Henry starts to detail in graphic terms his latest struggles with his affliction. All the while Minnie is behind him shaking her head violently whenever she disagrees. Which is most of the time. When he has finished, and before I can shout a response into his least whistly ear, Minnie has her say, and completely revises his presentation. What had been a tale of manly triumph over adversity is instantly transformed into an official history of the first day of the Somme.

They have a stand up row, conducted at 90+ decibels, which she wins. We end up agreeing to give him the treatment she was after for him in the first place. And they leave, hand in hand, smiling sweetly at one another and full of thanks for my kind attention-- or for doing what Minnie asks, which amounts to the same.

Their relationship is founded on the solid bedrock of decades of conflict and a sound appreciation of who wears the trousers.

Even when she's in a skirt.




* usual bogus prize offer for the first respondent to grok the reference.
** which have been mercifully few.
*** what follows has been heavily censored on grounds of good taste and proximity to Dr J's teatime.
**** Aren't you glad this is the edited version?
***** such as is left

It's nice...

...to be nice.

One of the favourite sayings of Mark and Lard in their time on the Radio One lunchtime slot a while back (before I jumped ship and headed for Ambridge). I know they're not there any more, but the saying holds true, and there seems to have been an outbreak of niceness in these parts today.

That's niceness in the warm fuzzy just-been-dipped-in-chocolate way not any of the other frankly rather more unlovely interpretations.

Exemplar one: midway through morning surgery. A woman attended to renew a prescription for eczema. In closing the consultation she volunteered an observation on the professionalism and patience of our reception staff. This is so not the typical view of GPs receptionists that I felt compelled to feed it back to them. The reason for her admiration related to our previously mentioned "Touch Screen" registration that allows patients to check in without the need to queue just for one of the girls to "Arrive" them on the practice system.

To anyone under 60 and with reasonable eyesight this system is a boon as it frees up the staff for things that need face to face contact and reduces their time standing about waiting to check in. Sadly many of our regular attenders do not fit this demographic, so for the past few days there has been a line of shuffling bemused patients at the screen needing help adapting to the new arrangements. The team have borne this with their customary aplomb, and this morning they were recognized for their efforts. Cue warmth and fuzziness.

Exemplar two: Roy has been struggling to come to terms with the loss of a parent some while ago. By December last he was plainly clinically depressed and in need of chemistry as well as counseling. He dabbled with antidepressants on and off until last month. More off than on in reality. Last month we had "The Talk" and he was finally persuaded to stick with the Prozac for a while. He has managed it. Life still has very few cherries to offer in his personal bowl, especially since he "celebrated" a significant birthday during the month which only served to amplify his sense of loss. Still he acknowledges that he fared much better for having had the meds. He is even willing to continue the course and to return for review in a couple of months. Meantime his recovery is giving him the necessary momentum to actively seek to better his prospects by looking for an apprenticeship. Again at the end of the consultation he took his prescription and headed for the door. As he reached the threshold of the consulting room he looked back at me and said "Thanks very much for this" nodding towards his script. Something that hardly ever happens for ANY medication and least of all for antidepressants.

Doubtless my normal whinging tone will be restored in the fullness of time, but just for today I'm doing very nicely thank you for asking.

A new string to the bow?

I am pleased to report that Dr J has been awarded one half of the prestigious Work-Greavsie franchise. The following post will detail the new working arrangements that will obtain for the duration of this franchise.

Dr J will be available for General Greavsie Services (GGS) within the contracted hours of the New Greavise Services Contract, which is to say between 08.00 and 18.30 Monday to Friday. Outside these hours cover will be provided by the Borsetshire Greavsie Deputizing Service.

As an addition to the above we shall be launching “Greavsie Direct”, a 24 hour nationally available helpline. This can be reached by dialing 0845 4GREAVSIE (0845 44732743). Here call handlers with the help of a sophisticated computer program* will be able to advise you which of the six new Greavsie franchises you require.**

In line with the National Enhanced service under the NGS contract all posts will henceforth be monitored for quality. Spelling will be improved by a target 50%. Use of parentheses will be kept to and absolute minimum*** and swearing of any kind will result in a £1 donation to the Swearbox.

In line with locally negotiated arrangements all references to "Barbarella" and " the Barbies" will be replaced by acceptable substitutions for the duration of the franchise.

Any queries can be directed to OFFGREAVE the new Office for Greavsie Standards ****

* They DO NOT just spin a bottle. Honest.
** Calls may be recorded just for laughs. All calls charged at 50p per minute. Average length of call 25-90 minutes. Remember to get permission of whoever pays the bills.
*** Replaced by multiple asterisks. See I know it’s not Asterixes so there.
**** (NOT to be confused with ****) Address available on application.

Pratting About

Or "Wart Treatment using Liquid Nitrogen" as our clinical system would have it.

As an humble houseman it was my job, once a week, to book in around twenty patients on a Wednesday afternoon for "Cryosurgery" with a Consultant Oncologist. Some had skin cancers. Many did not. They had warts or Naevi (little red spots to those of you of a non-medical persuasion). They had all had to take half a day off work for the privilege. All had to be checked in by a gormless specimen just out of med school (yours truly), then get into a gown (no, really, they did) and go to an operating theatre for their "surgery".

The theatre had to have a nurse and an orderly to hand, and the Great Man Himself to do the "operation". Or in other words to squirt the offending body part with liquid nitrogen for anything up to thirty seconds. If you had a few spots treatment could last for whole minutes. Some patients needed fortnightly visits for a while to erradicate bigger blemishes.

For at least fifteen years we have had N2 here on tap. We have a special zappy flask for it to go in, with a great big trigger thingy. When you squeeze it Nitrogen zaps out with a fantastic hissy noise straight on to whatever you point the nozzle at. It's brilliant.

So now when our punters come in with a little annoying blemish we can zap them on the spot (geddit?) with no need for all that mucking about referring for "operations". An especially satisfying job for all concerned on a hot day. Plus you get to prance about the corridors with the flask zapping it in the general direction of the staff, PCT managers, the cat etc whilst shouting "Freeze!" in your best SAS impersonation. Even the older wiser partners have been known to walk about with it twitching the trigger to make a satisfying "puffer train" effect with clouds of vapour and a satisfying accoustic accompaniment from the nozzle.

As a generation of final year medical students will also attest, it's the most spectacular way to remove chewing gum from the surgery carpets.*

* Something they all get asked on their induction here. Please don't tell them though. It would spoil the fun!

Danger Man

Henceforth I wish be known as Danger Man. I am also considering submitting a claim for Hazard pay. Strangely this has nothing to do with our practice being engaged under the new(ish) "Violent Patient Scheme" to take on the care of an individual who was known to visit their former practice "tooled up", as I understand the vernacular would have it. No indeed. Under this scheme we are in fact far safer since we will only be seeing this individual under controlled circumstances in a secure room in A&E and with a security presence.

No, my problem is far more prosaic. It all revolves around the luchtime home visits. I've never really considered these a particularly risky part of the job before. There have been a couple of occasions when on a call out to the Chavvier end of town I have warily gripped stethosocpe and script pad a little tighter, but most of the local hard types know full well that I know their mums so that's generally ok. It's the getting to and fro that is now exercising my mind.

In the past two days I have seen five cases of "Whiplash Injury". No not that kind.... the sudden acceleration / deceleration of the neck that goes with a car crash. Since these five people are all unrelated and each involved in a separate RTA on Saturday last that means I know of at least five accidents that day. The local GP community numbers around 23 Docs, so if my experience is not exceptional (and I have no reason to believe otherwise) that makes for around 100 RTA related injuries in and around Ambrige last Saturday. Now granted Saturday was a busier day than average with everyone trying to get the lagers from Tescos before the match, but I suspect it was no more than twice as busy as usual, so 50 injuries might be more representative of a "normal " Saturday.

So hold on a minute, that's maybe twenty five actual accidents. On a Saturday. We all know all the really annoying drivers come out on a Sunday, so logically the accident rate is not likely to be less. Weekdays more people at work during the day so perhaps the daily rate will fall by as much as 50% to say 12 per day. So that's 50 accidents at weekends, another 60 the rest of the week and at least two victims per accident, for a weekly toll of around 200 injuries. Plainly not all are severe, and many may not make it in to surgery or A&E at all making this a conservative estimate to say the least.

And yet, knowing all this, as they must, the PCT expects me to venture into the maelstrom five days a week to tend to the needy.

Lucky I did that Tank Driving course a year or so back. Now then, just how much would a Warrior set me back.....

Murder 2

I assume there is such a thing as second degree murder to differentiate it form manslaughter or "Murder One" (as booked by Danno on a weekly basis some time ago).

What I do know is that there is definitely such a thing as second degree sunburn, but that just doesn't grab the attention at the head of a post somehow. It's got Sam and Kirsty's attention though.

Sam went to the pub at the weekend to watch the match. (Sorry that should of course have read "The Match"-- with apologies to any Paraguayan readers). He had a few lagers. Celebrated the result, if not the second half performance, and wended his merry, or at least tipsy, way home. It was a nice afternoon so he went out in the garden and fell asleep in the chair. Fortunately for him he had kept on his sacred red jersey, but his aqulline nose took the full force of the afternoon sun for a couple of hours whilst he snoozed. He now has a schnozz worthy of the late lamented Jimmy Durrante. And as they say round these parts "It kills".In fact, though he now has one of the all time comedy ailments, he has escaped lightly comapred to Kirsty.

Kirsty is, as they say, a big lass. She is big in every respect of the word, and has the sort of ample figure described in inches and repeated letters of the alphabet. This asset in tune with current fashions was displyed to its fullest advantage on Sunday.

How do I know this?

From the burns now evident. Celtic heritage and blistering sunshine (quite literally in her case) do not go well. And yes, sure enough "They're killing" too.

It seems Noel Coward was right about the "Mad dogs and Englishmen". It's as though there's something "soft" about using sun protection. I'm willing to bet that if you asked sunburn victims like Sam and Kirsty to stand in front of an electric fire till if started to burn they would hit you. Likewise they might demur if asked to service a nuclear (that's pronounced "new clear" by the way) reactor without the benefit of protective clothing. And yet, because it's just dear old Sol beaming down on us it must be ok.

Generations of Aussies and Kiwis will tell you different. They could teach us a thing or two about sun protection, but untill they do surgeries up and down the land will be full of Sams and Kirsties today, and likely for a few days to come. I tell you it's murder out there!

Well a Bird Bird Bird....

... Bird is the word!*

Morning surgery started a bit late this morning, so this post is by way of an apology to the punters. Not that any of them read this blog so far as I know, so if you see them you'll have to tell them for me.

"Why so late starting?" I hear you ask.

"Has there been some life threatening medical catastrophe that claimed your attention?" er... no.

"Perhaps you had to stop good samaritan like at the site of an accident?" well... not exactly.

"Well we're sure you must have a good reason so please tell us why don't you?"

I thought you'd never ask.

The lanes between Borchester and Ambridge have been idyllic this week. (Except on Tuesday night when torrential rain turned them in to rivers for a good six hours, but that's another story...) This has made the drive in to surgery a real treat, and the drive home even more so, Tuesday excepted obviously.

This morning was no exception. I was about half way here, "Shine On You Crazy Diamond" thundering out of the stereo**, not a care in the world. Suddenly the sun was blotted out as a fell beast passed overhead. The temperature inside the car must have fallen by a couple of degrees easily, and then the fell beast landed forty yards or so ahead of me in the middle of the single track lane. The earth shuddered at its impact. I'm sure the cd skipped a beat or two.

Easing off the throttle I ended nose to beak with the biggest pigeon I have ever seen. I refute utterly any suggestion that there was a slamming on of breaks and a wailed expletive to accompany Dave Gilmore just as he was getting to a good bit. Those streaks of rubber were already there, honest...

Somewhere in the background the soundtrack changed. There was a frantic strum of a guitar, followed by an Ennio Morricone tinkly music box effect, then the wailing trumpet of doom. We were in a stand off of epic proportions. (Just as well there was no other traffic on said lane this morning really.) Now, a word of advice should you ever find yourself in a similar position. Never try to outstare a pigeon. In the first place, they are stupid. In the second, they don't blink.

So, all dignity now in tatters I started up the engine again -- what me stalled?-- surely not. Then, to compound the humiliation, I indicated to pass the pigeon! As I vered right to pass it, it waddled right staying just in front of the car. I cancelled the indicator and pulled back in. It waddled left and stayed, as though fixed by tractor beam, directly in front of me.

By now Signor Morriconi's trumpeter had passed the impossibly high, impossibly long note, and the strings and massed guitars were hammering out the reprise of the theme tune. I indicated and pulled out again. "It" wadlled ahead of me matching course precisely. I have now determined that pigeons waddle at a stately 1.5mph if you are interested.

It was like stepping back 100 years to the time when motor vehicles had to be preceded on the public road by a man carrying a flag. Beetles were strolling down the side of the road overtaking me and thumbing their proboscises in disdain. Or at least they were until one became breakfast for the Pidgeonator.

Ha! It was distracted. I knew better than to signal my intent by now, so, taking my life in my hands I vered sharply past the thing, gunned the engine and sped past it, and on to victory.

Roger Waters sang "How I wish you were here!". The day was back on track. Civilization was saved once more. And only ten minutes behind.

And what have we learned. Well, I for one am not cut out to be a pigeon fancier. It's good to know these things. If nothing else it's one more hobby to cross off the list of potential diversions come retirement.

* Prizes for the nearest contestant in the "How old is Dr J?" sweepstakes.

** (I seem to have caught this form Greavsie) That's the last clue you're getting.

Parental Indignation

Teenagers, eh.

It's quite ususal to see boys, even in their late teens, brought to surgery by their mums. It's well known, and generally true, that teenage lads don't communicate well, or, often, intelligibly to us older types, without a mum present to translate.

It's not unusual to see girls also brought by their mums, at least up to age 16, though often not for much longer after that... if the consultation starts with daughter looking at her shoes and mum saying "I'll tell him shall I?" you can bet it's going to be about "Pills" or "Periods". If it starts with mum saying "You'd better tell him..." they're going to be pegnant. Any other introductory remark and you know it's going to be a normal consultation about ordinary stuff. They still sit there and look at their shoes though.

The ones you have to watch out for are the ones where you get Shoe-Gazey-Teen and Mum and Dad. These will always go badly. With the lads it will be "Drugs" or "Madness" which very often ends up being "Drugs" too, though not always. With the lasses there's a whole spectrum to choose from. There's "Not eating", "Binge Eating", "Self Harming", "Drugs / Booze", or, as this morning;

"Pregnant and on Drugs".

An hour later they left, still apparently talking to one another, though there was a tense stand off 30 minutes in when Dad wanted to talk all about STIs, just to put the boot in a bit more. Unfortunately I didn't have time to ask him to go back to his room for time out (1 minute per year of his age and he'd still be there now!). Five minutes had to suffice, during which he could still be heard huffing and puffing Big-Bad-Wolf-like from the other side of the door....

In reality the daughter, though perhaps a little unrealistic in her expectations, has accepted an urgent antenatal referral to at least seek counselling, assures me she has not "used" since she found she was expecting, and seems to have managed to cling on to a slim thread of self esteem so far.

I find it interesting, and perhaps a tad dissapointing that the one near constant all all such "three handed" consultations is the parental indignation at the position they find themselves in.

Breast is Best

As the fifty percent of the population who don't actually have their own to play with would aver almost to a man.

So why do I find myself prescribing milk powder to a 13 week old infant this afternoon? The answer is complex and small "p" political but here we go...

Society increasingly expects women to play a full part in working as well as domestic life. Indeed for most couples there is a need for both partners to work simply to service the silly prices we pay for our accommodation and chosen lifestyles. Furthermore we define women still as much, if not more, by how they look rather than by their other capabilities. Then, when they have children we worthily spout on about how important it is that they breast feed and devote all their time to baby as though all the other stuff ceases to be important.

In my limited experience this is not a universally popular message. Some women are denied the option as their milk production fails to establish properly, but the vast majority are so denied either because of financial necessity or through personal choice, to preserve their shape,or to resume their other roles in society. Thus in our "enlightened" society of "equal opportunity" far too many babies are rapidly put on powdered milk.

It's logistically much easier to cart about bottles of formula than to breast feed on the hoof as it were. This is partly because our climate here in blighty is seldom conducive, but mostly because society still tends to go all "Benny Hill" around breast feeding women, instead of giving them the help and support to make it easier to do.

Then there's the whole "getting single mothers back to work" thing. This leaves many younger less experienced mums feeling pressured to return to employment far sooner that is right for them or their children.

Ah say the "Guardian Readers", they could always express milk to give in a bottle if they wanted to continue to feed naturally and work. Any mum who has tried this will regale you with horror stories about "milking machines" and awkward damp patches in best blouses etc... It might be a short term expedient for some, but is hardly a sensible life choice.

So we come back to poor little George. I don't know exactly why his mum was unable to breast feed, and now it hardly matters since that option is now lost to him anyhow. After a few weeks on ordinary formula feeds he was increasingly fractious and difficult. His health visitor advised mum to try switching to soya milk and he improved dramatically. So it seems he may be lactose intolerant (as indeed was his mum). But soya milk, used for lactose intolerance, becomes a medicine as well as a food, and so is prescribable.

So there you have it.

Daughter of Eurynome

I see lots of kids in the course of a normal day in practice. They tear around the room howling like banshees. They tip the lego bricks all over the carpet and use them to make rayguns (or worse). They line up the cars in neat rows all across my desk, howl and screach when approached, laugh at my jokes (if they know what's good for them), or sit cringing in abject terror next to mum or dad throughout the consultation....

In other words they carry on just like kids everywhere.

Not so Grace.

Her parents must have been struck by some bolt of inspiration six years ago when they named her. She is otherworldly, and for ten minutes this morning I was captivated. Dressed in a simple white dress and white woolen cardigan she stood in front of my desk smiling and co-operative.

The consultation was entirely unremarkable. She has had earache for a few days after a cold, but is actually now almost better and needs no treatment, Mum just wanted it checked. But throughout her visit she was calm and stillness personified. Grace indeed.

To be fair her brother was equally well behaved and remained quietly in the background fingers twitching away on the Gameboy, but otherwise entirely unobtrusive. This must be what seeing children was like all the time back in the 1950s, but nowadays it was utterly remarkable and truly enchanting.

Bloody Politicians!

Dr J has come over all op-ed again. Apologies in advance.

This may also seem a tad disloyal since I sit here in a position funded out of general taxation and working to all intents and purposes in government service, subcontracted as I am to the Dept of Health. Still, I'm moved to say it again. Bloody Politicians. More specifically in this case the UN.

You see, they've been having a conference this week. On HIV and AIDS. Only they are now bickering over the text of the final "agreement". It seems some members don't like reference to gay men, prostitutes or drug users in the document. It might look as though the text condones "illegal activity" in some countries. Then there's the USA. They're ok with the whole at risk groups thing apparently. They just don't want any reference to needle exchange schemes for drug users. It goes against their whole Volstead era prohibition attitude.

So, no mention of at risk groups then, and no mention of some of the most effective interventions to avoid spread of the disease. And they wonder why the pandemic is a crisis of global proportions.

Sounds like time and money well spent to me.

Not.