Bonne Annee

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

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

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

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

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

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

For want of a nail...

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

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

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

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

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

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

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

Delusions of Grandeur

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

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

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

Where do I sign to get my new Aston Martin?

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

The dog et it......*

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

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

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

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

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

Just don’t tell anyone I asked…..



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

Stop me if you've heard this one before.

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

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

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

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

He dries.

“So have you tried dieting at all?”

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

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

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

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

If you go down to the wood today...

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

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

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

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

Welcome to Tombstone!

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

Now on with the motley….

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

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

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

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

Gosh, look at all these trees!

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

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

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

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

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

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

In which Dr J has a bit of a moan...

This post has been quite hard to write and might be equally so to read. I’m afraid you’ll have to take my word for it that in no way is it intended as a whinge, however it turns out…

Tony called yesterday to update me on his progress. He was effusive in his praise of the surgery, and of the hospital team he was referred to. In charming and measured tones he took me through his last few weeks, from my referral to the initial surgical outpatients appointment just a few days after. Thence to CT scanning and back to a different, oncology, outpatients appointment where they gave him the expected news, that he did indeed have a carcinoma, and that it was too invasive and widespread for surgery. He goes for palliative radiotherapy in the near future.

He appreciates that the prognosis is poor, and yet is quite unreasonably grateful to the team that have made the diagnosis and given him that information. It may sound surprising, but in my experience such innate nobility and generosity of spirit is not at all unusual. Indeed I would go so far as to say I often feel most appreciated* by those patients for whom I can do the least.

Annoyingly, the converse is also often true, and patients for whom one has attempted impossible feats of logistics, who have then accessed the specialist of their , often quite unreasonable, choice and undergone the high tech intervention for whatever problem they have presented, return to moan about delays in treatment, parking problems and the quality of the hospital food. After consultations like this you will find me tearing what little remains of my hair out, and wondering just why it is I heave myself out of bed each morning to come here...


And then Mrs Archer will wander in for a review of her Diabetes and High Cholesterol, and with a twinkle in her eye, and not a hint of irony, hand over a box of Clotted Cream Fantail Shortbread, “for you Doctor, from my holidays…”.

Well at least it helps explain her sugars and cholesterol!


*Such utterly unwarranted appreciation comes with a large slab of guilt on the side.

"The Pills"

Mrs Antrobus has the gout. She had it a few months ago and hobbled along to see Dr Neighbour. He, quite rightly, gave her Indocid (a shiny new Non-Steroidal Anti-inflammatory Drug – NSAID for short). Of course, by new here I mean invented during the latter half of the last century, but in overall terms that’s quite new really.

It worked like a charm for the gout. Only problem, it made poor Mrs A feel terrible: queasy, giddy, sore-tummied, tight-chested, in short pretty much all the listed side effects short of massive and life threatening gastrointestinal haemorrhage. She almost preferred having the gout.

This is a shame, because, and I can speak here from personal experience, when it works and is tolerated Indocid can be a great help. Still it appears Mrs A is particularly sensitive to the side effects of NSAIDs and so we perhaps should avoid them for the future. But Mrs A has the gout. Again. It’s time, to coin a phrase, to “get mediaeval on it’s a**e”. No more Dr Nice-Jest!

You see, for all our modern sophisticated scientific method, sometimes you just have to go the apothecary route. It’s time to wheel out the Autumn Crocus. More properly, time to wheel out that extract of the aforementioned known to our ancestors as colchicine. It’s a difficult drug to use because it can be quite toxic, causing vomiting and diarrhoea. Indeed the dosing instructions contain the comforting advice “take Ye until ye paine hath abayted or peradventure it happeneth that ye patient vomiteth or suffereth an flux of ye bowelf, prithee”, or words to that effect. It’s also a bit of a pain having to go back to prescribing in grains and drachms, but, for all that, it can and often does work every bit as well as the shiny new drugs, and is often better tolerated.

I have this mental image that the drug is prepared by tonsured and habited apothecary friars sequestered in sheds at the bottom of monastery gardens, dispensing antique wisdom and solving the odd ecclesiastical murder. Somehow I suspect this is no longer the case, but it suits my fancy to continue in my delusion, and to delight in turning the clock back a few centuries once in a while.

Prithee.

I read the news today.... oh boy!

A while ago Orchidea asked what it feels like being the harbinger of bad news. What follows is my best attempt at a succinct(ish) reply.


Students these days spend a lot of time learning about 'breaking BAD NEWS' along with other essential communication skills. We old sweats had to pick these things up the hard way. In reality I'm not so sure we didn't get the better deal though. The thing is, there ae just too many variables you need to factor in to being an effective harbinger. In my view it is damn near impossible to role play this particular scenario effectively, simply because none of the actors involved (one hopes) can truly have any concept of the stakes involved.

The dramatic conventions of stage and screen would dictate that each such occasion is played to the hilt, with everyone in the room wearing their heart on their sleeve and the whole spectrum of grief played out in a few short minutes. As with so much else in life, reality is somewhat at variance with high drama, or even with soap opera. Life, even the end of life, is a continuum. Our scene does not begin with the director shouting 'action'. Neither does it end with the close of the office, or house, front door.

Furthermore, a great many of those for whom the bad news is intended are merely having their own impressions confirmed. Granted this is not the case for all, but my own experience has it at a significant majority. Factors such as faith, ethnicity, family support, prior family history, and both the patient and their families past life experiences all need to go into the melting pot.

Next one has to consider the relationships already built up between doctor and patient (be they good or ill), their connection to the wider practice and community, and to their hospital consultants, teams and specialist units.

From all of the above, it should be pretty clear that there can never be a one size fits all approach to the harbinger business, and we risk confusing juniors, having them believe the whole 'Bad News' agenda has been dealt with in half a day of safe and cosy roleplay.

Now, returning to the question, I have two answers that at first blush may seem rather a cop out. I hope I can show you they are not.

The first and simplest answer is 'never good'. I am frequenly accused of having a penchant for stating the bleedin' obvious, but I fear it needs stating anyhow. With all the evidence presented, when faced with a life threatening diagnosis, it can feel rather as though you sit as judge, jury and executioner dishing out arbitrary and summary 'justice'. This feeling can be even worse if, with the 'benefit' of hindsight you feel the diagnosis was in any way delayed. And it can feel worse still if you have come to know the patient very well, or, ironically, not well enough.

Which brings me to the second and rather woolier answer. The act of delivering such a verdict, as previously aluded to, is interactive, with at least two participants. As a result the scene, though it shares a number of common threads, feels different every time.

For the majority of patients as I said before, you are simply confirming their own impression. It takes some pretty spectacular mental gymnastics to live for any length of time with a significant and potentially life threatening diagnosis, and not to at least guess that somthing is amiss. It can, and occasionally does happen, and when it does we can stray into the sphere of high drama.

But for most folk, with most significant diagnoses, you move speedily from 'what' it is to 'how' to make it go away / stop hurting / slow down. This is where one turns from simple messenger to true harbinger.

O.K. I'll admit, I had to go and look it up. I had always assumed the two terms were near interchangable, all be it that harbingers carried more portentous news, harbinging as they commonly do, Doom, or Spring or some other word requiring a capital letter. And so indeed they do, or did, but they do much more than simply foretell an arrival. They are the fore-runners, the attendants sent out ahead of notable personages to prepare the way. It is their job to see to it that shelter is arranged and that provisions will be on hand to sustain and refresh their charges.

So in the imparting of bad news it behoves us to think about the aftermath, and be ready to reach out and offer what shelter and sustenance we can. Where there is hope of recovery, however slight, we must be sure to offer that hope. And where there is none, we must make it plain that there is still much that can be done to offer comfort and support for as long as it will be needed.

And in doing this well, however painful the message can be both to give and, more particularly, to receive, by showing that we can and will always try to prepare the way, it is possible to take some pride in being an effective harbinger.

Party Time!

It had all but escaped my notice, but will come as no surprise to regular readers. This blog is now officially terrible.

It has all the hallmarks, namely; frequent tantrums, regular spouting of meaningless drivel, and an unhealthy fascination with bodily functions. In fact it is just like any other two year old. Sadly though, it is not very likely that it will begin to develop signs of increasing maturity as it moves relentlessly from blog-toddlerhood to blog-kindergartendom.

It has been a fun couple of years on the whole, notwithstanding the attempts of Radio 4 to mess with my mind. I’ve met some lovely bloggy people (in a virtual sense that is) who are far saner and more mature than I can aspire to be, and they and this oeuvre have kept me as close to sane as I am ever likely to approach, so to all my many and varied therapists a big thank you is in order.

Sadly it’s too young for my favourite cake (a “bootlegger cake” made with tons of nuts, a modicum of rum, and a bourbon glaze for those who are interested) so I’ll just have to look after that for it myself, but there are party hats and hooters aplenty, and lots of crisps and e-number laden dainties to ensure another year of hyperactive misadventure for any who care to join in.

Oh, and a ball pool for us all to romp in, so don’t be shy, come and join the party!

Family Practice, a vignette.

Enter in procession Lilly (and teddy in pushchair), Elizabeth (mummy), Freddy (in pram, with attendant whirry jangly spidery mobile thingy) and, riding trail, Nigel (daddy).

The wagons circle and come to a halt in front of the desk. I half expect an influx of the whooping, bareback riding, arrow shooting Sioux Nation, all painted for war and sporting streaming feather bonnets.

Sadly this is not Blazing Saddles and no Sioux arrive. Neither does the revennant divine Madeleine Khan. Disappointed I slog on with the consultation(s).

On this occasion we have a family affair with both Nigel and Elizabeth requiring attention. Lilly spends her time lining up the trucks and passing daddy all the teddies in the room, one at a time whilst he tries to look masculine under a rising tide of faux fur. Freddie lies there, whirring and jangling in a miasma of frequent heroic farts a prop forward would own with some pride, to Elizabeth’s evident and rising embarrassment.

The consultation(s) ended, we begin the process of restoring teddies and trucks to their rightful places, and guiding the fartmobile through a series of complicated manoeuvres that would tax an HGV driver to the utmost. In a few short minutes (well ten to fifteen) the whole family is ready for the road, and off they go, as the sound of galloping palomino stallions draws ever closer.

Risk Management?

A couple of weeks ago Pat had some chest pain. It was unclear if her pain was indigestion, heartburn, or, perhaps, something more serious. But that’s o.k. In these enlightened times we have “pathways of care” to enable us to sift such problems.

So Pat found herself shunted off down the Yellow Brick Road to Oz… er, the Rapid Access Chest Pain clinic. They did a battery of tests, including and exercise EKG*. All were inconclusive.

In case you were wondering, that means that the RACPC has not been able to show that Pat has heart disease. But, in these enlightened times, this does not mean Pat is out of the woods. You see, the way the pathway works, if you have conclusive tests, i.e. proven heart disease, then to get whisked straight from clinic to Cardiology Out Patients to having a stent put in (where possible) before you can say “myocardial ischaemia”. And you get put on lots of drugs to “save” your life.

But if, as with Pat, the tests do not prove you have heart disease, well you still might have it anyhow, so instead of all the tedious mucking about actually making sure one way or the other, you just get put on lots of drugs anyway, “just in case”. Pat has been told she must come and see us to start her meds A.S.A.P. These are to include a beta blocker (recent headlines reporting these drugs are less good at preventing heart disease and so should not be used without a compelling reason) and a statin (to lower cholesterol- can lead to deranged liver function and rarely to muscle wasting).

Now, call me old fashioned, but before I start a patient on long term medication with a significant side effect profile, I would at least like a clear indication, and in the case of the statin a baseline blood test to monitor her liver function BEFORE she starts, so that when her liver function is abnormal on the statin (as it will inevitably be) I can be sure it was in fact normal before the treatment began. The only problem is, poor Pat is now scared she may drop down dead of a heart attack before she gets to start her treatment.

Unfortunately, the RACPC neglected to tell her that though we feel statins are an important part of the preventive treatment for patients with established heart disease risk, even where this is the case (which we as yet have no reason to suspect is so for her) we have to treat eighty patients to prevent one cardiac death.

Somehow we seem to have lost all sense of proportion in managing medical risk. Intriguingly this is happening as we see the drug companies more and more involved in training the Nurse Practitioners who run a lot of the “Rapid Access” diagnostic facilities.

* yes you read it right. I’m actually with the Americans on his one (actually of course it ought to be “epsilon kappa gamma” but EKG has to suffice to save all the mucking about with fonts etc.).

Do I look like a Professor?

I'm thinking of taking the surgery out on the road, to perform under a red and white striped awning with a proper little replica prescenium theatre and some wooden puppets. And a swozzle. (I think that's what they're called, you know the things that make your voice go all "swozzley"...)

Then I could re-enact last night's little closing scene for you.

In they came . Lets call them, for the sake of argument (and yes I really do mean argument here), Mr Punch and his lovely wife Judy.

I should have guessed there was trouble brewing,. After all Mr P was late for his appointment. A mind boggling twenty four hours late for it! Now even my regulars don't expect me to be running that far behind, and Mr P isn't one of them anyway so his tardiness was quite spectacular. Still the receptionists were quite insistent that he really needed to be seen (a bad sign in itself) and so I invited him in.

Now in hindsight, Judy frog-marching him in, he with pained expression, she holding his right arm pinioned half way up his back, might also have been a bit of a "non-verbal cue" as we are trained to call them.

As they sat down I opened with a non-comm ital and cheery "What can we do for you?"

What follows requires the above puppets and swozzle to recount...

Judy-- He's been a very bad Mr Punch. He's not very well at all and he won't come to see you so I've had to bring him....

Mr P (swozzle)-- Oh no I'm not!

Judy-- Don't listen to him, I know all about it. He's been off at the naughty pub drinking lots of naughty beer.

Mr P (swozzle)-- Oh no I haven't!

Judy-- Oooh! He has too, and I need you to tell him to stop it.

Mr P (swozzle)-- Oh no you don't!

And so we went on. Round and round in ever decreasing circles. In the end it became apparent that their relationship (if such it can be called) was a relentless cycle of recrimination and reprisal and had been so for years. She thinks he drinks too much. He thinks she doesn't drink enough. Both may have a point. What they really seemed to need was a referee. I even had the temerity to suggest they see a counsellor about their relationship. As they were leaving, he turned to offer a parting remark.

"We tried that three years ago. they suggested we divorce!"

Now, at the risk of coining a phrase here...


Dr J (swozzle)-- That's the way to do it!

What we did on our holidays....

For one week the population of the tiny Cornish hamlet of St Veep has just been 15% Jests. The cottage was a sumptuous affair, spookily kitted out as an almost exact replica of our own dear Jest Acres, even down to the tea towels and crockery. Not that the tea towels are that surprising really, Cornwall being a much more appealing vista with which to bedeck domestic linens than grimy old Brum and environs…

The parish church was also built in the hamlet even though there are other somewhat larger settlements in the vicinity. At some point in decades past the church yard appears to have been renovated and a number of memorial stones discarded. Some wily former owner of the cottage we rented saw an opportunity there and so the path that leads from the gate to the front door saw us treading over elaborate 1830s copper plate inscriptions remembering Eliza, wife of Joshua of this parifh and the like. Somehow I suspect this simple act of thrift means the worthies so recorded come to more peoples attention now than they would have done remaining in the churchyard. They may also be remembered more widely since the visitors book suggests our recent predecessors in the cottage hale from several different flavours of abroad.

One of the delights of staying in such a small settlement is that for the sake of a five minute drive along one of the narrower Cornish lanes, you get to feel all the advantages of remoteness, without the attendant trekking and so forth. The traffic past our window was more hoofed than wheeled all week .

If you ever find yourselves in this neck of the woods, we can recommend the food at the Ship Inn in Lerryn, though the service is a little idiosyncratic. Still the salad tastes as good off the table top as it would have done on the plate, and the young waiter was ever so willing, if a tad dyspraxic…. The kids would also give the ice creams from the Lerryn village shop an honourable mention.

On the drive down the aforementioned lane from the cottage to the pub we discovered a new sport, Squirrel Racing. Three times during the week as we trundled our nervous way along one of the more single-tracky bits in the Famille Jeste Tour Bus, out from the hedge popped a squirrel. (We think it was the same one, but they may have a relay team in training….) Said squirrel then pelted along the lane alongside us for twenty metres or so before popping back into the hedge. The honours ended 2-1 in favour of the squirrel(s), though one of those was because the cheating little blighter kept weaving in front of us, plainly out of his own lane.

But the uncontested highlight of the week was a magic fifteen minutes on a small boat in Fowey harbour-mouth in the exultant company of a bottle nosed dolphin.

Sadly, already, just four days back in good old Ambridge, the hol’s seem a million miles away and half a lifetime ago. It’s been a bit of a week, But perhaps more of that anon….

All Aboooaaaaaard!

Suddenly this past two days all of Borchester is bathed in sunshine. It feels as though summer might actually be going to put in a somewhat tardy appearance, just on time for the annual Famille Jeste pilgrimage to the land of King Mark. Yes indeed, brothers and sisters, despite having been already absent from this desk for two weeks during what has till now been somewhat ironically termed the “Summer Holidays”, we have yet to travel more than 30 miles from home (saving one very soggy excursion to Legoland—the only Theme Park in Blighty the cadet branch of the family will tolerate, and none the worse for that…).

So this morning, in anticipation of this fact, I have been to the train station in Borchester to book my train ticket for tomorrow morning. You see our travels are to be a two stage process this year through the vagaries of cat care. The advance party leaves by car, well our Big Red Bus actually, this afternoon whilst I am still slaving over a hot surgery. I shall return to an empty nest tonight, ready to crate up our two untamed panthers (well they think they are, and who am I to disabuse them…) ready for their hol’s at the cattery, and having deposited them at same first thing tomorrow morning,* I shall be making my way south to join the remainder of the family on the train.

This weekend, as well as being the first truly sunny weekend in living memory, is a Bank Holiday weekend here, and the last gasp of the school summer holidays, so all of England will be on the move. Indeed form the look of the station first thing, the diaspora has already begun. I pulled up on the concourse to be greeted by a scene from the “Golden Age”. Long-nosed Tourers with vast sweeping wheel arches and running boards a yard wide were dropping off ladies in billowy dresses and improbable hats. Small boys in sailor suits, and girls in pinafores darted up and down the platforms to a clatter of marbles falling from pockets and hoops being batted along with sticks. Blue uniformed porters huffed along behind two wheeled trolleys piled high with hampers and trunks. Then I realized I had turned up at the Severn Valley Railway station by mistake and went next door to the “proper” one.

I even managed to book a ticket on the train I wanted, at the time I wanted, and be in and out of the station inside five minutes (leaving plenty of time to sit and ramble before surgery gets going as you can see). So whilst I am away for the week, once again I donate this space to you gentle readers to comment as you will, and also, this year, to set a hare running.

In a comment on the previous post the charming Orchidea has asked me to write on how it feels being a “Harbinger” where there is bad news to be imparted. I intend to give this some thought over the week and to post a reply soon after. So is there anything else you “always wanted to know about GPs but were too afraid to ask” ? **

Oh, and whilst I'm away would you all mind keeping an eye on Jest Acres for me, the Green Recycling Bin needs to go out on Thursday if it's not too much trouble, and there's a wee bit of milk left in the fridge if you want a coffee or anything...

Much obliged.


* I should probably have pointed out that I won’t be crating them up until it is time to go to the cattery, and not leaving them boxed up all night as my appalling sentence construction might have implied.

** with an affectionate (as in please don’t sue me) nod to the genius of Woody Allen.

Lesions of the Damned

First year in Med School you learn a lot of new words, and learn to redefine a few old ones. As an example, back in the playgrounds of the wild westcountry we used to use “acute” and “chronic” almost interchangeably to mean “really really bad” as in “I’ve got this acute pain in me side. It’s bin there for days an’ it kills” or, “that joke was chronic” *.

You learn that “infarction” means death of tissue deprived of oxygen and is not just a posh way of saying “infection”. And you learn to call anything from a pimple to a tumour a “lesion”, ( rhymes with legion, from Latin laesio “hurting”). It’s a useful word, lacking all precision as it does, thus allowing us to talk about any variation in appearance or texture of skin in erudite fashion without revealing to the punter whether they should be terrified or relieved about the particular “bit” under discussion. It stops callow juniors from blurting out the word “tumour” inappropriately when discussing minor blemishes, or too soon when discussing major ones.

So far this week I have seen one lesion from either end of the spectrum. First came Tony. Tony has been getting steadily worse over the past month or so. He has lost weight, had frequent bouts of diarrhoea and increasing problems with control of same. He looks and feels wretched. Examination sadly confirms a large “lesion” per rectum. It is a tumour, and I have to tell him so. He is expecting the news and takes it phlegmatically. After all he has already had one brush with malignant disease and seen it off. He has also lost one child to another form of malignancy, and, after the awfulness of this, nothing much even comes close. His principal concern is if any proposed investigation and treatment can be out of the way before next years holiday, planned to celebrate a significant anniversary. I do hope it will be.

After Tony came Jennifer, husband Brian in tow. Brian is a bit cross. It seems Dr Neighbour treated Jennifer last week for a “lesion” on her shin. The blemish in question was a small area of non-malignant sun damaged skin or a keratosis. Dr N zapped it with our favourite toy, the liquid nitrogen gun, last week. The thing, far from dropping off in four to five days as she had hoped, has blistered rather alarmingly (as they often do). It needs no further treatment since as the blister separates it will take the keratosis with it naturally. It is best left to do this on its own, but Brian is not at all happy. He wants it out of the way before their holiday in two weeks.

I toy briefly with the idea of introducing him to Tony.



*Paronomasia being after all an aquired taste, even in the playgrounds of the wild westcountry.

The Doldrums

August is a funny month.

Most of the partners at the Ambridge Surgery have school age kids still, and so tend to need to take some time off through July and August for child care / family holidays, which leaves us short handed pretty much all through this month and in to September. Then again, much of Ambridge itself, and indeed its environs, is also on holiday, so the workload also tends to go down. Particularly when our little corner of the midlands can’t compete with the likes of Stratford upon Avon (home of the Immortal Bard) or “Historic Warwick” (their own self appointed soubriquet), for the lucrative UK tourist market.

All in all, two days back from another week at home with the kids, I feel very much becalmed. Which is not so bad, giving as it does, valuable time for catching up on paperwork and preparation for appraisal and so forth.

The only slight problem, stranded as we are in these medical Horse Latitudes, is that we are hosting a new medical student this next few weeks, and there’s so far been nothing very interesting for him to see.

He’s quite an engaging lad really. A bit northern, but none the worse for that, and at least he’s not, as so many seem to be these days, (pause for dramatic effect) a Brummie…

So if any of you happen to be in the area, or are even thinking about passing trough, and could muster up an interesting symptom or two to offer the poor chap, I’d be eternally in your debt. And for once it appears you won’t have to worry about waiting for an appointment.

Postcard from the global village

Today the sun is shining. Summer has finally come to Ambridge and environs (though possibly not for long if the Radio 4 forecast is to be believed). Indeed we now have proper double digit temperatures for the first time in yonkers. Twenty-something in the shade mark you! (That’s in new fangled Centigrade obviously—after all we are not at the South Pole here—although recently one could have been forgiven for thinking so what with all the rains and floods and penguins).*

It’s so warm I’m sitting here in the lunch hour with BOTH consulting room windows open listening to the pulsing chink-chink of a reggae rhythm wafting in from the car park. There must be some law of nature that brings the reggae into full bloom as soon as there are more than four hours of uninterrupted sunshine and twenty-something temperatures if you ask me. In short, barring the absence of a suitably exotic cocktail, and the small matter of an afternoon surgery to be survived (chiz, moan, groan) all’s right with the world.

Which is good, because in the past few days much of the world has been calling in to visit us. So far this week, in no particular order I have seen Black South-Africans, White Zimbabweans, a Kiwi, a few Poles, a Russian, a guy from one of the Baltic nations (sorry can’t now call to mind which), an Uzbek, numerous Pakistanis and Bangladeshis, more than a few Jamaicans (one of whom regales me with a tale of woe about his erstwhile tenants, whom he took to be Chinese when they were in fact illegal Vietnamese immigrants) and even taken delivery of a box of Mangoes from a very kind and appreciative patient who imports them specially for me once a year.

Even ten years ago it would have been hard to imagine such a widespread mix of peoples visiting a sleepy suburban surgery in the heart of England, but nowadays such consultations are increasingly routine. The only thing missing from our little League of Nations is a coach load of Japanese tourists. Oh , no, hold on a minute, first appointment this afternoon, Mr Harunobu, bus driver….


* O.K so I made up the penguins.