Freddy had an asthma attack two weeks ago. He had had a bit of a cold in the morning, but not enough to keep him off school. By mid afternoon school were worried and called Mum to come and get him, and when they arrived at the surgery the poor lad was really gasping for air.
For those to whom this means something he was managing a couple of words between breaths, chugging along at around 50 breaths a minute, using all his accessory muscles, and visibly tiring. For those to whom none of that is especially significant, suffice it to say he was pretty damned breathless.
We whacked him straight on a nebulizer (an air compressor through which we can, and did, aerosolize asthma meds—easier to use and more penetrating than an inhaler for a patient in crisis) which soon sorted out his breathlessness, and packed him off home some forty minutes later with an armful of inhalers, a spacer device (a chamber thingy to put the inhalers into) and some steroid pills, plus all the nebulizer tubing and mask he had just been using for him to play spacemen with when he got home (and to help the Out of Hours docs should they need to get him back on a nebulizer at any point that night).
Mum also went away with clear instructions to look out for a flare of wheeze or breathlessness around four hours later as the nebulizer would be wearing off about then, and if the inhalers didn’t quickly turn him around she knew to call for help straight away. Happily that advice was not needed and, as I discovered today, he was pretty much all better after 48 hours of more intensive medication. All through the consultation though, Freddy looked exactly as you might expect, a pretty scared, rather tiny six year old boy, in need of his Mum.
Not so today.
Today he comes for his review and to plan his treatment from here on. He pulls up his chair, alogside but some distance from his Mum. Today he is immaculately turned out in his school uniform, and not disheveled as when we last met. He has not a hair out of place, and is the living example of calm, composed self assurance.
We agree to try and monitor his asthma with a peak flow meter, and he masters the technique in a couple of puffs with aplomb. Then we need to measure him to see how his result matches with the predicted value for his age and height— “Though I’m not very tall for a six year old you know.” And neither he is, though still tall enough not to present any concerns about arrested development. We also agree he should have a spacer for home and a separate spacer and inhaler combination to keep at school and a peak flow meter for home monitoring.
“You should personalize them with your favourite stickers.” I sagely advise.
“Ooh yes,” says Mum “you could do that in your craft lesson this afternoon.”
“Well,” Freddy draws the word out for emphasis “I suppose I might, but I will have some work to do this afternoon too you know.”
I’m left reflecting that this is a young man who will go far, and also struck by the difference two short weeks and a proper asthma management plan can make.
Friday, September 26, 2008
Friday, September 12, 2008
The N'octor* will see you now...
Last night I was at a meeting where the new GP Out of Hours Provider company were making their pitch. They have been awarded a contract to offer night and weekend GP services to the citizens of Borsetshire starting this October, and so are in the final run up to their takeover.
The mouthpiece for their organization is a tall, chiseled type, with blond and elegantly coiffed locks, in a shiny suit with a lavender shirt and tie. He just oozes “Used Car Salesman”-ness. And his pitch is flawlessly reassuring. Patients making contact out of hours will first be answered by expert call handlers who will speedily ascertain the patients ID and contact details before passing them on to a clinician. If all clinicians are busy and they do not have an over-ridingly urgent problem, then their details will be held until the first such clinician is available to call them back, and their target will be to return these calls within x minutes, where x is a vanishingly small number. Once they have spoken to a clinican, those that need to be seen will be offered a speedy appointment at the nearest centre, or visited at home if housebound.
The new providers are committed to training, and to staff development. They will even help little old ladies to cross the road, pop in at night to fix them their tea and biccies, and tuck them in and read them a story before bye-byes. (Well o.k. I might have slightly embellished the last few points.)
Over all though, an impressive performance by a polished (almost literally so) performer. That is, until we get the specimen rota for the service they are offering. In retrospect (having had the chance to sleep on it I suppose) it should have been obvious from Mr Smooth’s choice of words. Like Humpty Dumpty before him (and I believe as I have also said previously like myself in my turn) Mr S’s words mean what he chooses them to mean. To you and I, hitherto, I suspect the word clinician would have conjured up the image of a proper professional. Probably a Doctor, or, at the very least, a Nurse Practitioner with a higher level of expertise that the standard nursing qualification. It appears to this hallowed band of guardians of the common health and wellbeing we must now also admit the ECP.
“?” you ask, as well you might, and as we all did…
“ECP” says our lad, undaunted. “That’s Emergency Care Practitioner”.
“??” we chorus.
This brave new breed will be at the forefront of our overhauled out of hours services. Without wishing to in any way denigrate this noble calling, the ECP job description is essentially written for a paramedic with a bit of extra training in emergency care—perhaps 2-3 years training after school / college as a minimum, compared to the eight years required of GPs in training.
So, the best advice I can offer the citizens of Ambridge, is to try not to get ill out of hours anytime this winter, as instead of a guaranteed encounter with a GP as we used to offer they are now faced with a one in three chance of being left in the, doubtless entirely capable, hands of an ECP n’octor.
*N'octor-- increasingly accepted contraction for the phrase "Not-a-doctor"
The mouthpiece for their organization is a tall, chiseled type, with blond and elegantly coiffed locks, in a shiny suit with a lavender shirt and tie. He just oozes “Used Car Salesman”-ness. And his pitch is flawlessly reassuring. Patients making contact out of hours will first be answered by expert call handlers who will speedily ascertain the patients ID and contact details before passing them on to a clinician. If all clinicians are busy and they do not have an over-ridingly urgent problem, then their details will be held until the first such clinician is available to call them back, and their target will be to return these calls within x minutes, where x is a vanishingly small number. Once they have spoken to a clinican, those that need to be seen will be offered a speedy appointment at the nearest centre, or visited at home if housebound.
The new providers are committed to training, and to staff development. They will even help little old ladies to cross the road, pop in at night to fix them their tea and biccies, and tuck them in and read them a story before bye-byes. (Well o.k. I might have slightly embellished the last few points.)
Over all though, an impressive performance by a polished (almost literally so) performer. That is, until we get the specimen rota for the service they are offering. In retrospect (having had the chance to sleep on it I suppose) it should have been obvious from Mr Smooth’s choice of words. Like Humpty Dumpty before him (and I believe as I have also said previously like myself in my turn) Mr S’s words mean what he chooses them to mean. To you and I, hitherto, I suspect the word clinician would have conjured up the image of a proper professional. Probably a Doctor, or, at the very least, a Nurse Practitioner with a higher level of expertise that the standard nursing qualification. It appears to this hallowed band of guardians of the common health and wellbeing we must now also admit the ECP.
“?” you ask, as well you might, and as we all did…
“ECP” says our lad, undaunted. “That’s Emergency Care Practitioner”.
“??” we chorus.
This brave new breed will be at the forefront of our overhauled out of hours services. Without wishing to in any way denigrate this noble calling, the ECP job description is essentially written for a paramedic with a bit of extra training in emergency care—perhaps 2-3 years training after school / college as a minimum, compared to the eight years required of GPs in training.
So, the best advice I can offer the citizens of Ambridge, is to try not to get ill out of hours anytime this winter, as instead of a guaranteed encounter with a GP as we used to offer they are now faced with a one in three chance of being left in the, doubtless entirely capable, hands of an ECP n’octor.
*N'octor-- increasingly accepted contraction for the phrase "Not-a-doctor"
Tuesday, September 02, 2008
"Tell me why...."
….. “I don’t like Mondays!”
So go the words of the song. And this was the refrain in my head for much of yesterday morning. Churlish of me I know, but there it is.
“But why,” I hear you ask “so irascible this particular Monday?”
I’ll endeavour to tell you, but in doing so I fear I will alienate you, gentle reader, so I ask you not to judge too harshly. The real problem is of course, not Mondays, or even this last Monday in and of itself. It’s what I was doing this particular Monday, in comparison with the preceding couple of weeks.
Regular readers will know that the past fortnight saw the Jest family annual peregrination to the sun (on this occasion on a floating palace around the Adriatic). In essence we have been pampered almost beyond endurance, whilst soaking up the finest sights that the central portion of the Med has to offer. We have braved “La Serenissima” by gondola after hauling ourselves out of bed at Day-Break to witness our arrival in this fairest of cities at a stately pace from thirteen stories up—and if anyone ever offers you the chance to do the same, don’t think twice. We have witnessed the miracle of reconstruction that is the pristine Old Town of Dubrovnik. Our pallid English bodies have braved 36 degree heat in Corfu…. I could rave on at greater length, but even I am coming to hate myself as I do, so I’ll leave it there, but you get the picture.
Mid way through our trip the eldest learned he has aced his GCSEs (the first set of really BIG exams in Blighty for our readers from other jurisdictions) so all is most definitely right with the world. (A “proud Dad” moment for you all there—I’m hoping it will ingratiate me a bit after the alienation possibly engendered by the paragraph above…)
Then we come back to dear old Blighty. It’s cold and it’s raining and it feels like it’s been that way all the time we’ve been away, and will be so all the time until we can somehow get away again. And on Monday morning the surgery goes hopelessly awry as every single patient asks me how the holiday went, just to heighten the juxtaposition.
Still if it keeps up this way we’ll soon be able to get around Ambridge by gondola too, so maybe it will all work out right in the end. Just keep me away from the gun cabinet, that’s all….
So go the words of the song. And this was the refrain in my head for much of yesterday morning. Churlish of me I know, but there it is.
“But why,” I hear you ask “so irascible this particular Monday?”
I’ll endeavour to tell you, but in doing so I fear I will alienate you, gentle reader, so I ask you not to judge too harshly. The real problem is of course, not Mondays, or even this last Monday in and of itself. It’s what I was doing this particular Monday, in comparison with the preceding couple of weeks.
Regular readers will know that the past fortnight saw the Jest family annual peregrination to the sun (on this occasion on a floating palace around the Adriatic). In essence we have been pampered almost beyond endurance, whilst soaking up the finest sights that the central portion of the Med has to offer. We have braved “La Serenissima” by gondola after hauling ourselves out of bed at Day-Break to witness our arrival in this fairest of cities at a stately pace from thirteen stories up—and if anyone ever offers you the chance to do the same, don’t think twice. We have witnessed the miracle of reconstruction that is the pristine Old Town of Dubrovnik. Our pallid English bodies have braved 36 degree heat in Corfu…. I could rave on at greater length, but even I am coming to hate myself as I do, so I’ll leave it there, but you get the picture.
Mid way through our trip the eldest learned he has aced his GCSEs (the first set of really BIG exams in Blighty for our readers from other jurisdictions) so all is most definitely right with the world. (A “proud Dad” moment for you all there—I’m hoping it will ingratiate me a bit after the alienation possibly engendered by the paragraph above…)
Then we come back to dear old Blighty. It’s cold and it’s raining and it feels like it’s been that way all the time we’ve been away, and will be so all the time until we can somehow get away again. And on Monday morning the surgery goes hopelessly awry as every single patient asks me how the holiday went, just to heighten the juxtaposition.
Still if it keeps up this way we’ll soon be able to get around Ambridge by gondola too, so maybe it will all work out right in the end. Just keep me away from the gun cabinet, that’s all….
Tuesday, August 12, 2008
Summer outing.
I can’t quite put my finger on what’s the matter, but somehow I haven’t been able to get my head together this past month. There’s definitely something in the wind, but I’m blowed if I can work out what it is, so apologies for the extended leave of absence, and further apologies that it is going to be further prolonged by upcoming hols.
Actually that ought to be Hols with a big “H”, since we are off cruising again which could spell bad news for the Jesterly waistline, and I promise I’ll try not to bore you all too much with countless photo’s of the backs of the family’s heads at various exotic Mediterranean locales when we get back. In the interim here’s a little offering I’ve had on the blocks for a while, since inspiration remains at low ebb right now.
Miranda has been a regular attender to my consulting room for more years than either of us would care to remember. She’s had a hard and demanding manual job and down the years it has taken its toll on her joints, but she complains very little and takes just enough pain relief to keep her functioning at work and “productive”. For the first decade or so of our acquaintance she appeared to be a loner, and quite content in her solitude. Then she began to mention a friend of hers who had recently been bereaved. It turned out that her friend was also a regular at the surgery, though perhaps a little less often than Miranda herself.
A year or so after the bereavement Miranda’s friend moved in with her to help with the rent and save them having to run two separate houses. I know this because Miranda was at pains to point out to me the nature of their association at the time. Down the next couple of years she would make occasional references to her friend during consultations, but often said nothing further about their continued association. Then after five years or so she finally let slip, oh so casually, that she and her friend had become “partners”, whilst looking out of the corner of her eye to see if I looked like I might fall off the chair or start wagging a disapproving finger. I didn’t, of course, and feel I passed something of a test that day.
I suspect you will already have guessed the reason for Miranda’s anxiety but offer the usual EVCHN ™ for the first correct respondent.
Actually that ought to be Hols with a big “H”, since we are off cruising again which could spell bad news for the Jesterly waistline, and I promise I’ll try not to bore you all too much with countless photo’s of the backs of the family’s heads at various exotic Mediterranean locales when we get back. In the interim here’s a little offering I’ve had on the blocks for a while, since inspiration remains at low ebb right now.
Miranda has been a regular attender to my consulting room for more years than either of us would care to remember. She’s had a hard and demanding manual job and down the years it has taken its toll on her joints, but she complains very little and takes just enough pain relief to keep her functioning at work and “productive”. For the first decade or so of our acquaintance she appeared to be a loner, and quite content in her solitude. Then she began to mention a friend of hers who had recently been bereaved. It turned out that her friend was also a regular at the surgery, though perhaps a little less often than Miranda herself.
A year or so after the bereavement Miranda’s friend moved in with her to help with the rent and save them having to run two separate houses. I know this because Miranda was at pains to point out to me the nature of their association at the time. Down the next couple of years she would make occasional references to her friend during consultations, but often said nothing further about their continued association. Then after five years or so she finally let slip, oh so casually, that she and her friend had become “partners”, whilst looking out of the corner of her eye to see if I looked like I might fall off the chair or start wagging a disapproving finger. I didn’t, of course, and feel I passed something of a test that day.
I suspect you will already have guessed the reason for Miranda’s anxiety but offer the usual EVCHN ™ for the first correct respondent.
Thursday, July 10, 2008
Happy Birthday (?)
"What's he doing down there?"
"Dunno. He's got a suit on, and a tie with big bold stripes on it... Looks like he thinks he's power dressing to me. Oh no, he's about to go off on one. He's got that didactic look about him, I've seen it on him before. He's about to have a moan."
"Oh. Right. Think I might skip this one then."
"Hold on. I'll join you...."
Ok now they're gone I'll get on. I'll be trying for levity again soon, but somehow today I just can't seem to manage it-- and no smirking up there at the back, you know that's not what I meant. What follows is drawn entirely from personal experience and my own hazy grasp on reality. It reflects the views of the author and is not intended to reflect the views of any other individual or organization. Neither is is intended to impugn the character, bona fides or intent of any named individual. It's sole intent is personal comment.
It can hardly have escaped anyone in Blighty that our dear old NHS has just turned sixty. In the midst of the somewhat muted celebrations we have seen the publication of Lord Darzi’s latest report intended to set out a bold new vision of service centered on the patient, with talk of “quality” and “compassion”. However it feels, at grass roots level, as though the decision has been already taken to pension the poor old NHS off and giver her job piecemeal to a gaggle of vested interests in the guise of modernization.
This might just be sour grapes of course, because the one vested interest that looks set to be excluded for submitting serious bids in the up coming NHS garage sale is yours truly. Well that is, yours truly and around 35,000 other small time, corner shop, un-entrepreneurial soi disant “entrepreneurs” out here in GP land.
From where I sit this is a bit of a pity. Looking back I realize my association with the NHS began with my very first summer holiday job almost exactly thirty years ago. (O.K. technically it began a lot earlier than that since I have been a patient of the service all my life—but you get what I am saying). It was a fabulous job, pulling X-rays that were over 10 years old and sending the plates for recycling (the silver in the old photographic plates could apparently be reclaimed at a cost that made the whole deal economic, as well as providing funds for the fledgling Doc J’s summer beer money fund).
And from that time to this it is hard to remember a year when the NHS hasn’t felt under threat from some quarter. In the late 70s and early 80s it was the class war and the flexing of union muscle (with a gaggle of us white coated medical students—in direct contravention of the diktat of “Hospital Management”-- brandishing placards on the picket lines in support* of our student nurse colleagues, we being on a grant or financed by mummy and daddy, they working stupid shifts for peanuts as they trained on the job).
In the late 80s we had the setting up of the “internal market” with the promise, still largely unfulfilled two decades on, that the money to pay for the treatment would “follow” the patient, allowing good and popular hospitals to increase their funding at the cost of the “poorer performers”.
The 90s saw tinkering with and eventually wholesale breakdown of the GP contract, with a shift to health promotion, away from out of hours care, into and then back out of fund-holding (where GPs held a “budget” for a tiny fraction of the care of their patients—pretty much just planned surgery and out patient clinic visits). The stated aim was to get the money to start following the patient, but the contractual framework for this was so hedged about with restrictions and caveats that it was very hard to realize, and with the arrival of NuLabour (sic) the whole concept was anathema anyway….
Through the latter half of the 90s and into the Noughties our colleagues in the hospitals have been battered with meaningless targets (along with many that were very worthwhile) and from 2004 on GPland has signed up to a contract that accepted a significant degree of similar targeting. Again much of this, it can be argued, has served to improve standards and give a more uniform quality of service, but it is increasingly ripping the soul out of the profession. And now Lord Darzi's report seems to imply we can re-engineer the entire NHS by chopping it into tiny bits and selling it off in the name of “quality” and “compassion” the two attributes that spring unbidden to mind whenever we think of private enterprise (not).
It really is too bad. To borrow a quote from an unexpected early supporter of a Nationalized Health Service, no less a man than Winston Churchill, the NHS for all its travails has proven to be “the worst form of Health Care provision, apart from all the others.”
I appreciate it sounds the utmost arrogance for any clinician to expect the political class to stump up a mere Hundred BILLION quid and then just step back and leave us to get on with the job, and in reality, as I believe the Darzi reports show, the very last people you want organizing health care provision are clinicians of any type. But I fear the next worst people to do it are the politicians themselves. Neither group can claim to be dispassionate, and nor should they be, it’s not in either one’s job description. But the running of a truly National Service demands the skills a dispassionate and pragmatic observer can bring. Sadly, as we look towards Lord Darzi’s professed vision of the future we are likely to get further fragmentation rather than increased co-ordination and unity of purpose.
Our NHS is sixty this year and yet I fear she will not be around in any meaningful form for her seventieth birthday.
*regrettably our motives might not entirely have been based in proletarian solidarity, but this was an unreconstructed age when Medical Students were predominantly still young men and student nurses were recruited as much for looks as for other aptitudes….
"Dunno. He's got a suit on, and a tie with big bold stripes on it... Looks like he thinks he's power dressing to me. Oh no, he's about to go off on one. He's got that didactic look about him, I've seen it on him before. He's about to have a moan."
"Oh. Right. Think I might skip this one then."
"Hold on. I'll join you...."
Ok now they're gone I'll get on. I'll be trying for levity again soon, but somehow today I just can't seem to manage it-- and no smirking up there at the back, you know that's not what I meant. What follows is drawn entirely from personal experience and my own hazy grasp on reality. It reflects the views of the author and is not intended to reflect the views of any other individual or organization. Neither is is intended to impugn the character, bona fides or intent of any named individual. It's sole intent is personal comment.
It can hardly have escaped anyone in Blighty that our dear old NHS has just turned sixty. In the midst of the somewhat muted celebrations we have seen the publication of Lord Darzi’s latest report intended to set out a bold new vision of service centered on the patient, with talk of “quality” and “compassion”. However it feels, at grass roots level, as though the decision has been already taken to pension the poor old NHS off and giver her job piecemeal to a gaggle of vested interests in the guise of modernization.
This might just be sour grapes of course, because the one vested interest that looks set to be excluded for submitting serious bids in the up coming NHS garage sale is yours truly. Well that is, yours truly and around 35,000 other small time, corner shop, un-entrepreneurial soi disant “entrepreneurs” out here in GP land.
From where I sit this is a bit of a pity. Looking back I realize my association with the NHS began with my very first summer holiday job almost exactly thirty years ago. (O.K. technically it began a lot earlier than that since I have been a patient of the service all my life—but you get what I am saying). It was a fabulous job, pulling X-rays that were over 10 years old and sending the plates for recycling (the silver in the old photographic plates could apparently be reclaimed at a cost that made the whole deal economic, as well as providing funds for the fledgling Doc J’s summer beer money fund).
And from that time to this it is hard to remember a year when the NHS hasn’t felt under threat from some quarter. In the late 70s and early 80s it was the class war and the flexing of union muscle (with a gaggle of us white coated medical students—in direct contravention of the diktat of “Hospital Management”-- brandishing placards on the picket lines in support* of our student nurse colleagues, we being on a grant or financed by mummy and daddy, they working stupid shifts for peanuts as they trained on the job).
In the late 80s we had the setting up of the “internal market” with the promise, still largely unfulfilled two decades on, that the money to pay for the treatment would “follow” the patient, allowing good and popular hospitals to increase their funding at the cost of the “poorer performers”.
The 90s saw tinkering with and eventually wholesale breakdown of the GP contract, with a shift to health promotion, away from out of hours care, into and then back out of fund-holding (where GPs held a “budget” for a tiny fraction of the care of their patients—pretty much just planned surgery and out patient clinic visits). The stated aim was to get the money to start following the patient, but the contractual framework for this was so hedged about with restrictions and caveats that it was very hard to realize, and with the arrival of NuLabour (sic) the whole concept was anathema anyway….
Through the latter half of the 90s and into the Noughties our colleagues in the hospitals have been battered with meaningless targets (along with many that were very worthwhile) and from 2004 on GPland has signed up to a contract that accepted a significant degree of similar targeting. Again much of this, it can be argued, has served to improve standards and give a more uniform quality of service, but it is increasingly ripping the soul out of the profession. And now Lord Darzi's report seems to imply we can re-engineer the entire NHS by chopping it into tiny bits and selling it off in the name of “quality” and “compassion” the two attributes that spring unbidden to mind whenever we think of private enterprise (not).
It really is too bad. To borrow a quote from an unexpected early supporter of a Nationalized Health Service, no less a man than Winston Churchill, the NHS for all its travails has proven to be “the worst form of Health Care provision, apart from all the others.”
I appreciate it sounds the utmost arrogance for any clinician to expect the political class to stump up a mere Hundred BILLION quid and then just step back and leave us to get on with the job, and in reality, as I believe the Darzi reports show, the very last people you want organizing health care provision are clinicians of any type. But I fear the next worst people to do it are the politicians themselves. Neither group can claim to be dispassionate, and nor should they be, it’s not in either one’s job description. But the running of a truly National Service demands the skills a dispassionate and pragmatic observer can bring. Sadly, as we look towards Lord Darzi’s professed vision of the future we are likely to get further fragmentation rather than increased co-ordination and unity of purpose.
Our NHS is sixty this year and yet I fear she will not be around in any meaningful form for her seventieth birthday.
*regrettably our motives might not entirely have been based in proletarian solidarity, but this was an unreconstructed age when Medical Students were predominantly still young men and student nurses were recruited as much for looks as for other aptitudes….
Wednesday, July 02, 2008
New tricks?
It’s a time of year when the burden of acute illness has dropped, excepting an especially vicious and protracted Hay Fever season. As a result normal surgeries have a little less pressure for appointments and the number of patients attending for routine medication reviews has increased, as they try to get in before the holidays, theirs or mine.
Bill was one such yesterday. He’s eighty years young. Six months ago he had a bit of a scare. He was on the bus, on his way in to town, when he went a bit “funny”. He came to in CCU with a temporary pacemaker making his ticker keep ticking. Shortly after this he was scheduled for the surgery to insert a permanent version. His nurse joked with him that they were going to put the temporary machine in. It’s a box the size and weight of a car battery with knobs and lights and such, and it needs a permanent mains electricity supply. Bill was a little perturbed. Then his surgeon came round and showed him the real one, a little miracle of miniaturization hand crafted in finest clockwork by gnomes in Zurich or somewhere similar. It has its own battery, good for at least five years before replacement. And fits snug and flat in the palm of one hand, with room to spare.
Bill described in detail the procedure of insertion, for which he remained awake, the whole thing being done under local anaesthetic.
“First they put the wires in and I got to watch them go into my heart on a t.v. screen. The the surgeon says “Right we’re going to put the thing in”, and they carved a lump of flesh out of my chest to make room.”
“ I’m glad they didn’t decide to use the bigger machine! After all I’d have looked silly with a wire hanging out of my chest!”
He looked down at the scar after the insertion. It looked surprisingly small given all the carving and excavation that had seemed to be going on. He was more impressed by the blood stained sheet left on the operating table.
A month after the procedure he was back in clinic to have his bionics checked. The pacemaker was working pretty well, but the voltage needed dialling up a bit to get Bill’s heart pounding as it ought. After a couple of electromagnetic tweaks the surgeon was happy.
“There you go Bill. Your heart’s as good as new. You can do anything you want now.”
From the back of the room Mrs Bill’s voice could be heard.
“Don’t even think about it Bill!”
Bill was one such yesterday. He’s eighty years young. Six months ago he had a bit of a scare. He was on the bus, on his way in to town, when he went a bit “funny”. He came to in CCU with a temporary pacemaker making his ticker keep ticking. Shortly after this he was scheduled for the surgery to insert a permanent version. His nurse joked with him that they were going to put the temporary machine in. It’s a box the size and weight of a car battery with knobs and lights and such, and it needs a permanent mains electricity supply. Bill was a little perturbed. Then his surgeon came round and showed him the real one, a little miracle of miniaturization hand crafted in finest clockwork by gnomes in Zurich or somewhere similar. It has its own battery, good for at least five years before replacement. And fits snug and flat in the palm of one hand, with room to spare.
Bill described in detail the procedure of insertion, for which he remained awake, the whole thing being done under local anaesthetic.
“First they put the wires in and I got to watch them go into my heart on a t.v. screen. The the surgeon says “Right we’re going to put the thing in”, and they carved a lump of flesh out of my chest to make room.”
“ I’m glad they didn’t decide to use the bigger machine! After all I’d have looked silly with a wire hanging out of my chest!”
He looked down at the scar after the insertion. It looked surprisingly small given all the carving and excavation that had seemed to be going on. He was more impressed by the blood stained sheet left on the operating table.
A month after the procedure he was back in clinic to have his bionics checked. The pacemaker was working pretty well, but the voltage needed dialling up a bit to get Bill’s heart pounding as it ought. After a couple of electromagnetic tweaks the surgeon was happy.
“There you go Bill. Your heart’s as good as new. You can do anything you want now.”
From the back of the room Mrs Bill’s voice could be heard.
“Don’t even think about it Bill!”
Monday, June 23, 2008
Locum Duty
“Stay away from pills and booze, always use a condom, and nobody goes home with any piercings or tattoos they didn’t already come with, o.k.”
And with this avuncular little homily ringing in their ears my trio of charges shuffled of to be amazed. Later the ringing would have a different cause, but more of that anon.
The time, a week ago last Friday.
The place, Castle Donnington.
The event, Day 1 of the Download Festival.
This was going to the strangest locum appointment of my career. O.k. so it wasn’t exactly a medical appointment. Instead of a Locum Tenens I was standing In Loco Parentis to two of the three teenage lads that had cruised up the midlands motorways with me that morning. All three had just finished their GCSEs and that particular Friday (13th if you were wondering) was their first official day of freedom, and by a staggering twist of fate it coincided with day one of a huge rock festival. The only snag, two of them were too young to get in unaccompanied, and that meant dragging along an oldie. I’m not sure if I was the least objectionable or simply the one with the easiest schedule to rearrange. Whatever the case I got the gig.
As it happens (as regular readers will guess), rock events hold no fear for Dr J. Indeed one of the acts on the bill saw a fledgling Doc at it’s inaugural tour after its Lead Singer and Bassist had split with Hawkwind to form his own heavier, louder beat combo*. I have to admit, as a trip down memory lane (more “memory back alley, after show, wreathed in smoke of a certain characteristic aroma that in time honoured Clintonesque fashion I never inhaled…” in this case) the day was fantastic. I spent it on a splendid pitch alongside the mixing desk, guarding our huddle of foldy chairs and bags of water and sarnies, while the lads milled about a bit, moshed a bit, and we all, at various points in the day, chanted, sang and just plain shouted ourselves silly.
The lads behaved impeccably, turning down spiked drinks aplenty, and enjoying the natural high of the festival environment on its own merits. So whilst it might not be entirely possible to turn back the clock, it's nice to feel there's life in the old dog yet. The only slightly alarming thing was that on the way out the jets passing overhead on approach to the nerby East Midlands Airport appeared to have acquired stealth capability. I now also have a sneaking sympathy for my regulars with their tinnitus.
It's also just possible you're reading the dispatches of the latest recruit to the Kiss Army (though naturally I see myself as Lieutenant-Colonel material at the very least).
* a rare chance to win an electric virtual hob nob if you can name the artiste without resorting to Google or similar... (of course you're all on the honours system here, but I trust you. No really...)
ADDENDUM
Congratulations to The Welsh Pharmacist for correctly identifying the aforementioned Beat Combo and referencing their umlauts. (No I can't do the HTML for individual accented characters either-- life really is too short). As a further enticement two more e.v.h.n's are on offer for the closest guesses to the following;
1-- How long between finding our pitch by the mixing desk and the tap on the shoulder and accompanying "Excuse me Dr J, but can I get a picture with you, cos the missus'll never believe my GP was 'ere otherwise". ( I kid you not, in the midst of all the real Celebrity of a rock festival some hapless souls wanted a pic of your humble narrator!)
2-- Which appointment on the following Monday morning was the first to refer to my appearance in public at the same festival. (Thank God I was only escorting three lads one of whom was obviously my own. Poor kid, there's no denying his herritage looking as he does. )
And with this avuncular little homily ringing in their ears my trio of charges shuffled of to be amazed. Later the ringing would have a different cause, but more of that anon.
The time, a week ago last Friday.
The place, Castle Donnington.
The event, Day 1 of the Download Festival.
This was going to the strangest locum appointment of my career. O.k. so it wasn’t exactly a medical appointment. Instead of a Locum Tenens I was standing In Loco Parentis to two of the three teenage lads that had cruised up the midlands motorways with me that morning. All three had just finished their GCSEs and that particular Friday (13th if you were wondering) was their first official day of freedom, and by a staggering twist of fate it coincided with day one of a huge rock festival. The only snag, two of them were too young to get in unaccompanied, and that meant dragging along an oldie. I’m not sure if I was the least objectionable or simply the one with the easiest schedule to rearrange. Whatever the case I got the gig.
As it happens (as regular readers will guess), rock events hold no fear for Dr J. Indeed one of the acts on the bill saw a fledgling Doc at it’s inaugural tour after its Lead Singer and Bassist had split with Hawkwind to form his own heavier, louder beat combo*. I have to admit, as a trip down memory lane (more “memory back alley, after show, wreathed in smoke of a certain characteristic aroma that in time honoured Clintonesque fashion I never inhaled…” in this case) the day was fantastic. I spent it on a splendid pitch alongside the mixing desk, guarding our huddle of foldy chairs and bags of water and sarnies, while the lads milled about a bit, moshed a bit, and we all, at various points in the day, chanted, sang and just plain shouted ourselves silly.
The lads behaved impeccably, turning down spiked drinks aplenty, and enjoying the natural high of the festival environment on its own merits. So whilst it might not be entirely possible to turn back the clock, it's nice to feel there's life in the old dog yet. The only slightly alarming thing was that on the way out the jets passing overhead on approach to the nerby East Midlands Airport appeared to have acquired stealth capability. I now also have a sneaking sympathy for my regulars with their tinnitus.
It's also just possible you're reading the dispatches of the latest recruit to the Kiss Army (though naturally I see myself as Lieutenant-Colonel material at the very least).
* a rare chance to win an electric virtual hob nob if you can name the artiste without resorting to Google or similar... (of course you're all on the honours system here, but I trust you. No really...)
ADDENDUM
Congratulations to The Welsh Pharmacist for correctly identifying the aforementioned Beat Combo and referencing their umlauts. (No I can't do the HTML for individual accented characters either-- life really is too short). As a further enticement two more e.v.h.n's are on offer for the closest guesses to the following;
1-- How long between finding our pitch by the mixing desk and the tap on the shoulder and accompanying "Excuse me Dr J, but can I get a picture with you, cos the missus'll never believe my GP was 'ere otherwise". ( I kid you not, in the midst of all the real Celebrity of a rock festival some hapless souls wanted a pic of your humble narrator!)
2-- Which appointment on the following Monday morning was the first to refer to my appearance in public at the same festival. (Thank God I was only escorting three lads one of whom was obviously my own. Poor kid, there's no denying his herritage looking as he does. )
Tuesday, June 10, 2008
Cognitive Dissonance
As in “I don’t believe she just said that.”
“Please tell me she didn’t just say that.”
“No really she can’t have just said that. It would be plain wrong of her to say that wouldn’t it?”
And it would, but that, sadly, didn’t stop her.
I know you’re probably all getting fed up of hearing me say this, yet again, like some feeble minded fourth former handing in late homework. (Then again I was such a feeble minded fourth former in what I sadly like to delude myself were the not so distant quondam days.) Still I have to get it off my chest so here goes nothing… Yes dear readers, if any of you have the good grace to still be listening at all, it’s been a bit busy here in Ambridge lately and now it’s not only busy but also enervatingly hot and swathed in toxic killer pollen.
There, now that’s out of the way, back to our little vignette of everyday life in GPland. The tale is of a lady recently retired, who had hurt her neck. The pain had begun six weeks or so ago, she had been prevented from attending the surgery any sooner because she had been staying out of our practice area.
That’s around three thousand miles out of our area.
On a Greek island.
Now devoted as I am to my job, I suspect Dr Neighbour would have a problem with me making home visits to Knossos, so she had been compelled to see a local “Iatre” and then a muscle bound hellenic Adonis of a physiotherapist as a private patient. They had sorted her out quite nicely, but the flight home had flared the pain up again.
Sadly Ambridge is a bit short on Hellenic Adonises, but still from what I could discern her pain is again muscular rather than anything more sinister and would benefit from another physio’s touch. We discussed the options, i.e. a couple of sessions with a private physio’ in a day or two, or an NHS referral, resulting in a few weeks wait.
And then she came out with it, straight faced. “Well I suppose I’ll just have to wait for the NHS physio. After all I’m not working so I can’t afford private physio.”
Now I know there’s been an oil price crisis this past few months, but I’m not aware of any collapse in the global economy that would suddenly put physiotherapy beyond her reach. Surely it can’t just be that all our local private physios are very capable middle aged women.
No, I thought not.
“Please tell me she didn’t just say that.”
“No really she can’t have just said that. It would be plain wrong of her to say that wouldn’t it?”
And it would, but that, sadly, didn’t stop her.
I know you’re probably all getting fed up of hearing me say this, yet again, like some feeble minded fourth former handing in late homework. (Then again I was such a feeble minded fourth former in what I sadly like to delude myself were the not so distant quondam days.) Still I have to get it off my chest so here goes nothing… Yes dear readers, if any of you have the good grace to still be listening at all, it’s been a bit busy here in Ambridge lately and now it’s not only busy but also enervatingly hot and swathed in toxic killer pollen.
There, now that’s out of the way, back to our little vignette of everyday life in GPland. The tale is of a lady recently retired, who had hurt her neck. The pain had begun six weeks or so ago, she had been prevented from attending the surgery any sooner because she had been staying out of our practice area.
That’s around three thousand miles out of our area.
On a Greek island.
Now devoted as I am to my job, I suspect Dr Neighbour would have a problem with me making home visits to Knossos, so she had been compelled to see a local “Iatre” and then a muscle bound hellenic Adonis of a physiotherapist as a private patient. They had sorted her out quite nicely, but the flight home had flared the pain up again.
Sadly Ambridge is a bit short on Hellenic Adonises, but still from what I could discern her pain is again muscular rather than anything more sinister and would benefit from another physio’s touch. We discussed the options, i.e. a couple of sessions with a private physio’ in a day or two, or an NHS referral, resulting in a few weeks wait.
And then she came out with it, straight faced. “Well I suppose I’ll just have to wait for the NHS physio. After all I’m not working so I can’t afford private physio.”
Now I know there’s been an oil price crisis this past few months, but I’m not aware of any collapse in the global economy that would suddenly put physiotherapy beyond her reach. Surely it can’t just be that all our local private physios are very capable middle aged women.
No, I thought not.
Friday, May 30, 2008
Through the looking glass. (II)*
I dunno, what with all these Bank Holidays we have nowadays it seems we get paradoxically busier. I suppose it might also have to do with having two docs off for half term, and despairing parents looking for things to occupy the kids during the same…
Anyhow, it seems we have survived and so normaller service might soon be possible. Maybe. And after my more recent flights of fancy the weather has gone back to doing what it does best (being horrid) and it’s back down to earth with a bump for poor old Dr J.
Still, it gives me pause to consider another similarity I share with Mr. H. Dumpty, in that, when I use a word it “means just what I want it to mean”. Two instances today serve to highlight this fact.
The first relates to a blood test on a lady who feared she had rheumatism. In the event her blood tests have all returned “negative” meaning of course that they show now evidence of rheumatic disease, so in this sense a “negative” result is a “positive” message to be able to impart.
(Did that last bit sound a bit like that time honoured definition of cricket so beloved of northern tea-towel manufacturers at all? You know, the one that begins “You have two sides, one out in the field and one in. Each man that's in the side that's in goes out, and when he's out he comes in…”)
The second instance came in Asthma clinic. Sebastian is a runner. He also happens to have late onset asthma, and since a flu like illness in November he has had increasing trouble with his wheeze. Annoyingly this has been worse when he runs. We’ve tried a few different changes in meds along the way and the last one has restored his lung function to is previous excellent form. In effect he has lung function readings at 120% predicted, i.e. 20% better than normal. “That’s brilliant” say I, in all sincerity. “No it’s not” he retorts, “ my 100m time is still three tenths off what it was last season.”
Apparently it’s all about perspective.
* See I'm being green and recycling titles now.
Anyhow, it seems we have survived and so normaller service might soon be possible. Maybe. And after my more recent flights of fancy the weather has gone back to doing what it does best (being horrid) and it’s back down to earth with a bump for poor old Dr J.
Still, it gives me pause to consider another similarity I share with Mr. H. Dumpty, in that, when I use a word it “means just what I want it to mean”. Two instances today serve to highlight this fact.
The first relates to a blood test on a lady who feared she had rheumatism. In the event her blood tests have all returned “negative” meaning of course that they show now evidence of rheumatic disease, so in this sense a “negative” result is a “positive” message to be able to impart.
(Did that last bit sound a bit like that time honoured definition of cricket so beloved of northern tea-towel manufacturers at all? You know, the one that begins “You have two sides, one out in the field and one in. Each man that's in the side that's in goes out, and when he's out he comes in…”)
The second instance came in Asthma clinic. Sebastian is a runner. He also happens to have late onset asthma, and since a flu like illness in November he has had increasing trouble with his wheeze. Annoyingly this has been worse when he runs. We’ve tried a few different changes in meds along the way and the last one has restored his lung function to is previous excellent form. In effect he has lung function readings at 120% predicted, i.e. 20% better than normal. “That’s brilliant” say I, in all sincerity. “No it’s not” he retorts, “ my 100m time is still three tenths off what it was last season.”
Apparently it’s all about perspective.
* See I'm being green and recycling titles now.
Wednesday, May 21, 2008
In which I kid myself I am Mr D'Arcy.
We do love talking about the weather here in dear old Blighty. Well after all we seem to have so much of it and it’s so much safer than talking about politics, religion, or that other thing…
Here in Borchester it’s not at all uncommon to experience “four seasons in one day”, especially at this time of year. So to have five consecutive days of sunshine and actual warmth last week came as a bit of a surprise. Of course we are now back to “changeable” with “sunny spells” and “showers”, but it was nice while it lasted. Or at least it was for most of us. For one small group of our regular customers it has proved to be a bit of a challenge though.
To explain why, I need to take us back a couple of years. Around that time we got a brand shiny new test to play with here in GP land, the eGFR. It is a whizzy test to be sure. It tells us, by some clever sciency technique too complex for my little grey cells, how well a punter’s kidneys are filtering. This is a pretty useful piece of information, believe it or not. It is especially useful where a customer already has diseases known to muck up kidney function, like diabetes and some sorts or hypertension to name just a couple. And better yet, we have an evidence base of drugs to use to help improve renal function once it is shown to be “failing” as charted by a decline in eGFR.
The only thing is, in screening for other conditions, as we will often do in the elderly, we will ask to look at their blood chemistry (measuring other vitally important chemicals like sodium, potassium, urea and creatinine) and the lab now takes all that chemical soup and uses it to generate an eGFR result, even where that’s not what we were looking for. This in turn has revealed what we have actually known for a long time, but not previously quantified, which is that older folks' kidneys do not filter efficiently. This means that in the absence of any of the scary conditions alluded to above it is still quite possible to have a low eGFR and hence “renal disease” purely as a function of being older. And since we have a lovely evidence base for medicines that will help preserve renal function many of them are ending up medicated.
Now I know you all though sunshine was only medically important in things like rickets (good) and skin cancers and such (bad), but it seems also to have been having an effect on such medicated older patients. The class of drug most widely used in renal protection is the ACE (angiotensin converting enzyme inhibitors). And ACE drugs are known to lower blood pressure, and to do so disproportionately well in the elderly. Taking a little old lady, with “renal disease” (that’s little old kidneys to you and me) and bunging her on an ACE will likely improve her renal function a bit, and could drop her blood pressure a bit more than a bit. Now add in unseasonably warm weather (and them “not casting a clout”, May not yet being out and all) and a sort of "pressure cooker in reverse" effect takes place. So in this past week the surgery has seen a handful of little old ladies having a fit of the vapours as their blood pressure falls to “fainty” levels.
It’s called the law of unintended consequences. Still it’s kind of nice to think I can still cause ladies to swoon at my age….
Here in Borchester it’s not at all uncommon to experience “four seasons in one day”, especially at this time of year. So to have five consecutive days of sunshine and actual warmth last week came as a bit of a surprise. Of course we are now back to “changeable” with “sunny spells” and “showers”, but it was nice while it lasted. Or at least it was for most of us. For one small group of our regular customers it has proved to be a bit of a challenge though.
To explain why, I need to take us back a couple of years. Around that time we got a brand shiny new test to play with here in GP land, the eGFR. It is a whizzy test to be sure. It tells us, by some clever sciency technique too complex for my little grey cells, how well a punter’s kidneys are filtering. This is a pretty useful piece of information, believe it or not. It is especially useful where a customer already has diseases known to muck up kidney function, like diabetes and some sorts or hypertension to name just a couple. And better yet, we have an evidence base of drugs to use to help improve renal function once it is shown to be “failing” as charted by a decline in eGFR.
The only thing is, in screening for other conditions, as we will often do in the elderly, we will ask to look at their blood chemistry (measuring other vitally important chemicals like sodium, potassium, urea and creatinine) and the lab now takes all that chemical soup and uses it to generate an eGFR result, even where that’s not what we were looking for. This in turn has revealed what we have actually known for a long time, but not previously quantified, which is that older folks' kidneys do not filter efficiently. This means that in the absence of any of the scary conditions alluded to above it is still quite possible to have a low eGFR and hence “renal disease” purely as a function of being older. And since we have a lovely evidence base for medicines that will help preserve renal function many of them are ending up medicated.
Now I know you all though sunshine was only medically important in things like rickets (good) and skin cancers and such (bad), but it seems also to have been having an effect on such medicated older patients. The class of drug most widely used in renal protection is the ACE (angiotensin converting enzyme inhibitors). And ACE drugs are known to lower blood pressure, and to do so disproportionately well in the elderly. Taking a little old lady, with “renal disease” (that’s little old kidneys to you and me) and bunging her on an ACE will likely improve her renal function a bit, and could drop her blood pressure a bit more than a bit. Now add in unseasonably warm weather (and them “not casting a clout”, May not yet being out and all) and a sort of "pressure cooker in reverse" effect takes place. So in this past week the surgery has seen a handful of little old ladies having a fit of the vapours as their blood pressure falls to “fainty” levels.
It’s called the law of unintended consequences. Still it’s kind of nice to think I can still cause ladies to swoon at my age….
Thursday, May 08, 2008
Wherefore art thou?
In bloody Ambridge, that’s where! He’s been here for a week and he feels rotten. Julie’ has chucked him out, and the prospects for a rapprochement seem pretty slight given that she’s about as far away from here as it’s possible to be and still be in Blighty. Nothing about this oft repeated scene should be that surprising. After all we live in the age of the disposable relationship, so it hardly matters how long they’ve been “stepping out together”. And anyway we’ve all been there at one time or another. It’s a developmental stage entirely normal in adolescence. Even couples we know damn well are going to get back together inside a fortnight have to have the plate flinging, hair tearing, I-never-want-to-see-him/her-again split if their relationship is to be taken at all seriously.
Except that today our Romeo is the far side of seventy and, being male and a bit unrecontructed, to make it to this age he has ended up on a regime of anti-hypertensive and anti-diabetic meds that would stun an average sized elephant (and an African Elephant at that). Of course he still feels sixteen on the inside, and for at least the last week has been getting by on caffeine and adrenaline in pretty much equal quantities without the balancing effects of sleep or a decent meal.
The final upshot of all these shenanigans sees Romeo come within an hairs breadth of a close encounter with the frayed and aging Ambridge Surgery Carpet. You see, not actually being an average sized African Elephant, the combination of anxiety, heartache, anti-hypertensives et al, has left him feeling a bit odd, and in mid consult he comes over all wibbly and threatens to faint.
Twenty minutes later after fifteen of those with his feet up higher than his head, and following a NAAFI strength tea with half a bag of sugar (yes, I know his blood sugar will go up a bit more that would be healthy in the long term, but we're talking emergency resuscitation here-- ask your granny, she'll tell you all about it...), he is restored to something approaching equilibrium. He’s gone off home now for a bit of a rest, a decent feed and the company of a mate. And without most of his anti-hypertensives.
If this story has a moral at all, I guess that it’s this; eighteen or eighty, male or female, if you absolutely have to chuck your significant other, spare a thought for the other poor souls in their GP’s waiting room and let them down gently. It takes a bit more than ten minutes for us to mend a broken heart, and the rest of the queue aren’t always that understanding. *
Thank you all for listening.
* though it is noteworthy that despite all having to tell me about how busy they were and how inconvenient the tardiness of the morning surgery was, not one of them elected to rebook for another occasion. Perhaps they think poor old Romeo will be back….
Except that today our Romeo is the far side of seventy and, being male and a bit unrecontructed, to make it to this age he has ended up on a regime of anti-hypertensive and anti-diabetic meds that would stun an average sized elephant (and an African Elephant at that). Of course he still feels sixteen on the inside, and for at least the last week has been getting by on caffeine and adrenaline in pretty much equal quantities without the balancing effects of sleep or a decent meal.
The final upshot of all these shenanigans sees Romeo come within an hairs breadth of a close encounter with the frayed and aging Ambridge Surgery Carpet. You see, not actually being an average sized African Elephant, the combination of anxiety, heartache, anti-hypertensives et al, has left him feeling a bit odd, and in mid consult he comes over all wibbly and threatens to faint.
Twenty minutes later after fifteen of those with his feet up higher than his head, and following a NAAFI strength tea with half a bag of sugar (yes, I know his blood sugar will go up a bit more that would be healthy in the long term, but we're talking emergency resuscitation here-- ask your granny, she'll tell you all about it...), he is restored to something approaching equilibrium. He’s gone off home now for a bit of a rest, a decent feed and the company of a mate. And without most of his anti-hypertensives.
If this story has a moral at all, I guess that it’s this; eighteen or eighty, male or female, if you absolutely have to chuck your significant other, spare a thought for the other poor souls in their GP’s waiting room and let them down gently. It takes a bit more than ten minutes for us to mend a broken heart, and the rest of the queue aren’t always that understanding. *
Thank you all for listening.
* though it is noteworthy that despite all having to tell me about how busy they were and how inconvenient the tardiness of the morning surgery was, not one of them elected to rebook for another occasion. Perhaps they think poor old Romeo will be back….
Tuesday, May 06, 2008
Off to see the Wizard...
Just as our Colonial Cousins love their Latin we properly educated Englishmen love our Greek, but however your opt to derive it Oedema* / Edema is a serious pain in the arse* / ass. Not literally of course as that would be proctalgia* (sorry, don’t know the proper American term for this though it might contain a G and a W), but I digress comme d’habitude. For those not aware of this beastly complaint, it involves the infiltration of soft tissues with fluid. The precise mechanisms that cause this can be complex, but generally relate to advancing age and failing circulation or to severe inflammation. (Yes it can also be a direct pressure effect on the lymphatic system caused by other nastier diseases or their treatments too, but far more commonly it is just part of getting older.)
At its mildest we see it as a bit of puffiness round the ankles, late on a hot day, and especially after sitting down for a long time (typically on coach trips to “attractions” so beloved of the pre-war generation). From here though it often progresses to a worsening sense of puffiness then tightness then pain and at some point along this continuum there is the awful sensation of squishiness when you walk, and unsteadiness as a result. Add in to this the failing of other senses, that can make tripping all the easier and balancing all the more difficult and oedema can become a thoroughly miserable experience.
Such is the case for Dorothy, who this past four months has been tipped up by the whirlwind described above three or four times. Far from ending up in Oz the first episode put her in the Hospital with rib injuries and a dislocated shoulder. From that time she has become quite reclusive and thoroughly miserable and all through the simple but inevitable process of the accumulation of a half pint or so of water in her feet. Our therapeutic solution to this is to dry poor Dorothy out to reduce the swelling using diuretics. These make her need to pass more water and often with greater urgency, which is itself not great when you fear falling with every step. The problem is the other common “solution” is to apply compression with thick and heavy elastic stockings, which though effective are almost as painful as the swelling, nigh impossible to apply unaided, and Toto aside, poor Dorothy lives alone. So today we have stepped up to a stronger diuretic in the hope that we can get her back into her ruby slippers. We need this to work to restore her confidence and to quite literally put her back on her feet.
* All underlined in wriggly red lines by my rotten American spellchecker.
At its mildest we see it as a bit of puffiness round the ankles, late on a hot day, and especially after sitting down for a long time (typically on coach trips to “attractions” so beloved of the pre-war generation). From here though it often progresses to a worsening sense of puffiness then tightness then pain and at some point along this continuum there is the awful sensation of squishiness when you walk, and unsteadiness as a result. Add in to this the failing of other senses, that can make tripping all the easier and balancing all the more difficult and oedema can become a thoroughly miserable experience.
Such is the case for Dorothy, who this past four months has been tipped up by the whirlwind described above three or four times. Far from ending up in Oz the first episode put her in the Hospital with rib injuries and a dislocated shoulder. From that time she has become quite reclusive and thoroughly miserable and all through the simple but inevitable process of the accumulation of a half pint or so of water in her feet. Our therapeutic solution to this is to dry poor Dorothy out to reduce the swelling using diuretics. These make her need to pass more water and often with greater urgency, which is itself not great when you fear falling with every step. The problem is the other common “solution” is to apply compression with thick and heavy elastic stockings, which though effective are almost as painful as the swelling, nigh impossible to apply unaided, and Toto aside, poor Dorothy lives alone. So today we have stepped up to a stronger diuretic in the hope that we can get her back into her ruby slippers. We need this to work to restore her confidence and to quite literally put her back on her feet.
* All underlined in wriggly red lines by my rotten American spellchecker.
Wednesday, April 30, 2008
Back in the saddle...
In the past two days I have seen patients aged from 0 (well ok, 2 weeks) to 102 (with her card from the Queen, sent on her centenary, still proudly on display in her flat). I’ve tried to help a number of young women to avoid unwanted pregnancies, and begun the process of helping one couple who are struggling to make a very wanted baby. I’ve held discussions with young mums about the development and well being of their infants, and one long and heart-searching discussion with the septuagenarian son on a nonagenarian mum who has become non-responsive in a nursing home and looks likely to be entering what will be a short and hopefully painless final illness.
I have seen two dozen sore throats, a handful of bad backs, more than a handful of depressed folk (two just coming back from the brink of self-immolation). I have talked with one chap about a necessary early retirement. I’ve counseled the family of a man undergoing investigations for a scan anomaly which just might be cancer, but is more likely to have been the radiological equivalent of a hair in the gate, ( “yes everything is very probably o.k. but we have to do a scope examination to absolutely sure. Right now the most we can do is hope for the best, but plan for the worst”. A platitude that reassures no-one, but at least the explanation of the process seems to have helped a bit).
I’ve made three routine home visits and two urgents (one of the latter requiring an emergency admission to hospital after a “min-stroke”). I have five referral letters dictated and waiting to be typed. I’ve petted two dogs, three cats and placated a half dozen toddlers.
A couple of my patients this past two days appear to have been left with the impression (quite wrongly) that I can do magic. A handful have left me in no doubt that I am a waste of space and not nearly as good as that nice Dr Neighbour, “why does he always have to be on holiday when I need him so I get stuck with you?”
All in all it’s been a pretty average couple of days, but it feels good to be getting my mojo back. I have no idea where it went, but right now I don’t care, and you’d be pretty hard pressed to persuade me I don’t have the best job in the world.
Except maybe for a Ben and Jerry’s Ice Cream Flavour Tester.
I have seen two dozen sore throats, a handful of bad backs, more than a handful of depressed folk (two just coming back from the brink of self-immolation). I have talked with one chap about a necessary early retirement. I’ve counseled the family of a man undergoing investigations for a scan anomaly which just might be cancer, but is more likely to have been the radiological equivalent of a hair in the gate, ( “yes everything is very probably o.k. but we have to do a scope examination to absolutely sure. Right now the most we can do is hope for the best, but plan for the worst”. A platitude that reassures no-one, but at least the explanation of the process seems to have helped a bit).
I’ve made three routine home visits and two urgents (one of the latter requiring an emergency admission to hospital after a “min-stroke”). I have five referral letters dictated and waiting to be typed. I’ve petted two dogs, three cats and placated a half dozen toddlers.
A couple of my patients this past two days appear to have been left with the impression (quite wrongly) that I can do magic. A handful have left me in no doubt that I am a waste of space and not nearly as good as that nice Dr Neighbour, “why does he always have to be on holiday when I need him so I get stuck with you?”
All in all it’s been a pretty average couple of days, but it feels good to be getting my mojo back. I have no idea where it went, but right now I don’t care, and you’d be pretty hard pressed to persuade me I don’t have the best job in the world.
Except maybe for a Ben and Jerry’s Ice Cream Flavour Tester.
Monday, April 28, 2008
Emergency Service?
Gentle readers, I have to confess to being a bit perplexed by this next diagnostic conundrum. I’m hoping there are some of you out there amongst my varied readership who could help me to unravel it, but before I get going I have to issue a tiny health warning, in that the subject of today’s enquiry is of an hem-hem, Adult nature, as they say. (Well they do if they are Nigel Moleswoth at least). Needless to say, given the usual inane tone of these meanderings, it might not attract a suitably, hem-hem, adult treatment, but then that’s not what you all come here for is it?
In a nutshell the problem is of a somewhat intimate nature, in that a young lady attended surgery last week seeking help with contraception. She was asking for a handful of “morning after” pills*. It seems that her previous GP had hit upon this unusual approach to family “planning” after she presented her rather delicate problem to him a while ago. Perhaps it would help if I explained why such an approach is at variance with accepted practice, before I go on to detail why it had been chosen in this instance.
In effect the “morning after” pill is intended as a single shot treatment for an isolated indiscretion, or failure of other method (principally condoms). To require several such pills suggested an intention to serial indiscretions, which, as health care professionals, causes us some pause for thought. So I had to ask the poor girl why she needed such a “Russian Roulette” method.
It transpires that she has never really been suited to either of the usual varieties of pill through adverse effects such as significant weight gain, or troublesome skin changes. For that reason she had also fought shy of implantable or injectable methods using similar hormones as their basis. As a nullipara (a lady yet to deliver a baby) she is not a candidate for a “coil” either, and, as any fule kno, caps and the wretched “femidom” female condom are about as effective as the old fashioned “hot bath and Gin” method and as spontaneous as a line of Pinter dialogue. And so she and her boyfriend have been diligently trying to use condoms, but about one time in three they burst and she finds herself in need of emergency contraception in the form of the good old “morning after” pill.
So here’s my problem. She and I are both aware that certain substances have a deleterious effect on rubber that can occasion such failures (baby oil being chief amongst these) and she is quite certain that there is no risk of this. She reports that her boyfriend is just “too big”.
Now, having spent many a late night in Doctor’s Messes the length and breadth of the midlands in my formative years, I watched quite a lot of late night Channel Four youth TV. You could guarantee that once every couple of weeks or so some drunken idiot would appear on “The Tube” “The Word” or some other hip and trendy show with “The” in the title, and perform his (yes they were always plug ugly, synaptically challenged herberts) party piece, namely the unrolling of a Rubber Johnny over the top of the unappealing visage to just below the oft fractured hooter. Thereupon said herbert would inhale though his mouth and exhale through his monstrously deformed nose, inflating the aforementioned prophylactic to roughly the size of a London Bus, before it explosively decompressed, sadly leaving the perpetrator unscathed though now adorned by a slightly slimy latex “Alice Band”.
So now I’m wondering just what this couple are doing to occasion such a spectacular failure rate, unless it is just that Boy Friend thinks that the technique described above is the approved method of use?
* for the uninitiated the "Morning After" pill is a monster dose single shot treatment of an oral contraceptive that can be taken anywhere up to 72 hours after an incident of "Unprotected Sexual Intercourse" ** so "Morning After" pill is a bit of a misnomer. Oh, and it used to be two doses of same taken at a twelve hour interval which made it even more so, though not now that both doses have been amalgamated so the name is at least half right these days....
** the acronym is UPSI. There is a trend for naming little girls Daisy round these parts, so I'm looking forward to being able to record my first "UPSI-Daisy" in around 15 years time...
In a nutshell the problem is of a somewhat intimate nature, in that a young lady attended surgery last week seeking help with contraception. She was asking for a handful of “morning after” pills*. It seems that her previous GP had hit upon this unusual approach to family “planning” after she presented her rather delicate problem to him a while ago. Perhaps it would help if I explained why such an approach is at variance with accepted practice, before I go on to detail why it had been chosen in this instance.
In effect the “morning after” pill is intended as a single shot treatment for an isolated indiscretion, or failure of other method (principally condoms). To require several such pills suggested an intention to serial indiscretions, which, as health care professionals, causes us some pause for thought. So I had to ask the poor girl why she needed such a “Russian Roulette” method.
It transpires that she has never really been suited to either of the usual varieties of pill through adverse effects such as significant weight gain, or troublesome skin changes. For that reason she had also fought shy of implantable or injectable methods using similar hormones as their basis. As a nullipara (a lady yet to deliver a baby) she is not a candidate for a “coil” either, and, as any fule kno, caps and the wretched “femidom” female condom are about as effective as the old fashioned “hot bath and Gin” method and as spontaneous as a line of Pinter dialogue. And so she and her boyfriend have been diligently trying to use condoms, but about one time in three they burst and she finds herself in need of emergency contraception in the form of the good old “morning after” pill.
So here’s my problem. She and I are both aware that certain substances have a deleterious effect on rubber that can occasion such failures (baby oil being chief amongst these) and she is quite certain that there is no risk of this. She reports that her boyfriend is just “too big”.
Now, having spent many a late night in Doctor’s Messes the length and breadth of the midlands in my formative years, I watched quite a lot of late night Channel Four youth TV. You could guarantee that once every couple of weeks or so some drunken idiot would appear on “The Tube” “The Word” or some other hip and trendy show with “The” in the title, and perform his (yes they were always plug ugly, synaptically challenged herberts) party piece, namely the unrolling of a Rubber Johnny over the top of the unappealing visage to just below the oft fractured hooter. Thereupon said herbert would inhale though his mouth and exhale through his monstrously deformed nose, inflating the aforementioned prophylactic to roughly the size of a London Bus, before it explosively decompressed, sadly leaving the perpetrator unscathed though now adorned by a slightly slimy latex “Alice Band”.
So now I’m wondering just what this couple are doing to occasion such a spectacular failure rate, unless it is just that Boy Friend thinks that the technique described above is the approved method of use?
* for the uninitiated the "Morning After" pill is a monster dose single shot treatment of an oral contraceptive that can be taken anywhere up to 72 hours after an incident of "Unprotected Sexual Intercourse" ** so "Morning After" pill is a bit of a misnomer. Oh, and it used to be two doses of same taken at a twelve hour interval which made it even more so, though not now that both doses have been amalgamated so the name is at least half right these days....
** the acronym is UPSI. There is a trend for naming little girls Daisy round these parts, so I'm looking forward to being able to record my first "UPSI-Daisy" in around 15 years time...
Tuesday, April 15, 2008
Moan grone droan....
Soul searching is a wretched occupation to be sure, and yet sadly there are times when it becomes unavoidable. For me the past few months have been just such a time, and the truth is I'm far from happy with the conclusions I am reluctantly drawn to make.
You see folks, before you stands a creature as obsolete as the diplodocus, the marsupial lion, the dodo. It appears the job I spent almost half my life training for, and the remainder practicing, is no longer relevant. Family Practice, at least the sort of practice I understood as such, is dead.
The thing that hurts most about this is the knowledge that I and my colleagues have been at least complicit in, if not active proponents of its demise. Never has it been more true that good intentions make for the poorest choice of paving. It matters little how we got here, except perhaps to historians who in years to come may pore over the all too brief social experiment that was the post war Labour administration's establishment of the welfare and national health systems that now lie in tatters. It's what we do next that really matters. So for what it's worth, and for as long as I am able, I shall continue to ply my trade the best way I know how to any who wish to avail themselves of my services.
But with an uncaring, pettyfogging, beureaucratic civil service under a runaway political class on the one side, and an increasingly litigious, narcissistic, solipsistic populace on the other, I'm starting to feel more than a little like Han Solo in a trash compactor.
And the walls keep on closing in.
You see folks, before you stands a creature as obsolete as the diplodocus, the marsupial lion, the dodo. It appears the job I spent almost half my life training for, and the remainder practicing, is no longer relevant. Family Practice, at least the sort of practice I understood as such, is dead.
The thing that hurts most about this is the knowledge that I and my colleagues have been at least complicit in, if not active proponents of its demise. Never has it been more true that good intentions make for the poorest choice of paving. It matters little how we got here, except perhaps to historians who in years to come may pore over the all too brief social experiment that was the post war Labour administration's establishment of the welfare and national health systems that now lie in tatters. It's what we do next that really matters. So for what it's worth, and for as long as I am able, I shall continue to ply my trade the best way I know how to any who wish to avail themselves of my services.
But with an uncaring, pettyfogging, beureaucratic civil service under a runaway political class on the one side, and an increasingly litigious, narcissistic, solipsistic populace on the other, I'm starting to feel more than a little like Han Solo in a trash compactor.
And the walls keep on closing in.
Wednesday, March 19, 2008
Just had to share this, lest I forget it....
You get to see all sorts in this job. We are the "window cleaners" of the medical fraternity. And then, just occasionally, you might even brush up against the paranormal. I’ve already told you about our resident reggae loving apparition in a past post, but today I have had a visitation from the Fair Folk.
Yes indeed, gentle readers, today I have consorted with a real life denizen of the land of Faerie. Thankfully one of the Seelie Court, so I think I’ve escaped without ill effect.
Now I’m sensing some skepticism out there, but I can promise you all it’s true. And how, you might ask? Well, because he told me so himself, and without me even having to grasp him by the beard (which was just as well, what with him being clean shaven and all), traipse three times (or should that be thrice to maintain the idiom…) widdershins round a mulberry bush by the light of the silvery moon or anything. Nope, he just came right out with it in the middle of morning surgery, bold as you please.
It transpires this particular sprite had suffered an accident at work. Namely he had barged his shoulder on a doorframe in a desperate attempt to conceal his identity from the mortal he was visiting. As a result he’s bruised his acromio-clavicular joint. In the end we got to do the examination through his T shirt since it had a broad neck, no doubt so he could keep it in place to save revealing his wings and all.
Still it remains the case that today I met with the Ambridge Tooth Fairy. He’s about six feet tall, and answers to the name of Steve* but Tooth Fairy he assures me he is. So when the kids of the Ambridge First School tell you they know for a fact that the tooth fairy has a very deep voice and knows a lot of interesting Olde English words for bodily functions and general Oaths try not to act at all surprised.
* obviously not really "Steve", but he made me promise not to reveal his true name. You’ll just have to trust me it’s something similarly non-descriptly male, and does not end in “-erbell” or in anyway sound floral.
Yes indeed, gentle readers, today I have consorted with a real life denizen of the land of Faerie. Thankfully one of the Seelie Court, so I think I’ve escaped without ill effect.
Now I’m sensing some skepticism out there, but I can promise you all it’s true. And how, you might ask? Well, because he told me so himself, and without me even having to grasp him by the beard (which was just as well, what with him being clean shaven and all), traipse three times (or should that be thrice to maintain the idiom…) widdershins round a mulberry bush by the light of the silvery moon or anything. Nope, he just came right out with it in the middle of morning surgery, bold as you please.
It transpires this particular sprite had suffered an accident at work. Namely he had barged his shoulder on a doorframe in a desperate attempt to conceal his identity from the mortal he was visiting. As a result he’s bruised his acromio-clavicular joint. In the end we got to do the examination through his T shirt since it had a broad neck, no doubt so he could keep it in place to save revealing his wings and all.
Still it remains the case that today I met with the Ambridge Tooth Fairy. He’s about six feet tall, and answers to the name of Steve* but Tooth Fairy he assures me he is. So when the kids of the Ambridge First School tell you they know for a fact that the tooth fairy has a very deep voice and knows a lot of interesting Olde English words for bodily functions and general Oaths try not to act at all surprised.
* obviously not really "Steve", but he made me promise not to reveal his true name. You’ll just have to trust me it’s something similarly non-descriptly male, and does not end in “-erbell” or in anyway sound floral.
Tuesday, March 11, 2008
Ecclesiastes Ch3 V1
Over the past couple of weeks it has become increasingly apparent that I need to cut down on the day to day distractions for a bit. I know posting here tends to be erratic at the best of times, and I regret to report that these are far from the best of times for the Ambridge Surgery, or at least for my own little corner of the same…
And so, regretfully, I have decided to place the caseblog in abeyance for a while. It remains my intention to return when I can, but I can’t give you any precise indication when that might be. In the interim rest assured I shall still lurk the bloggosphere, and likely will pop up from time to time in comments pages elsewhere. Feel free to use the comments that follow as you will, I shall be checking them still whilst on hiatus, and I very much hope to be back amongst you all again ere long.
And so, regretfully, I have decided to place the caseblog in abeyance for a while. It remains my intention to return when I can, but I can’t give you any precise indication when that might be. In the interim rest assured I shall still lurk the bloggosphere, and likely will pop up from time to time in comments pages elsewhere. Feel free to use the comments that follow as you will, I shall be checking them still whilst on hiatus, and I very much hope to be back amongst you all again ere long.
Tuesday, March 04, 2008
Acquired empathy
Our case for today is a professional gentleman in the first flush of middle age. He has been favourably compared with Daniel Craig* with respect to his chiseled good looks, and likes to think of himself as pretty healthy. In short he is your humble narrator.
“Whatever then can be the matter?” I hear you all ask.
I thank you for your concern, but pleased be assured all is well, or at least soon will be. For now though it appears I have been stricken by a comedy ailment. You know the sort of thing, ailments that are a source of amusement to all but the poor victim. The boil on the bum, or dose of the piles; the glowing scarlet hooter of acne rosacea or alcoholic liver disease; or as in this case the throbbing agony of the hammer splattered thumb or gouty toe.
Yes, ladies and gent’s, your poor old interlocutor has been stricken with the gout. It’s not the first time to be honest. In fact the last bout was only just around Christmas time, though the one before that was a good few years ago. So here I sit, like the plethoric squire in a seventeenth century cartoon, foot held aloft, wincing and any slight movement within three hundred yards whose trajectory might imperil the affected hallux. The good news is, from past experience, both my own and that vicariously obtained, I know it will be gone in a few days and do not then expect it to return anytime soon. Better yet, it seems still to be responding to good old Indomethacin, so no need to seek out the apothecary monks for their Colchicine…
Happily it affects but a single joint, and yet, in so doing, I am given a glimpse into the daily reality of a number of my regular customers who have far more widespread and longer lasting inflammatory joint diseases. And such an insight makes it easier to appreciate just why so many of them are so keen to continue their painkillers, even when it becomes apparent that the anti-inflammatories are slowly but surely rotting their kidneys.
I can’t help thinking they are all an awful lot tougher than me. Arthritis really isn’t for wimps.
* Readers are encouraged to ignore the off camera sounds of Milady spluttering into her tea mug in disbelief… a lad can dream after all.
“Whatever then can be the matter?” I hear you all ask.
I thank you for your concern, but pleased be assured all is well, or at least soon will be. For now though it appears I have been stricken by a comedy ailment. You know the sort of thing, ailments that are a source of amusement to all but the poor victim. The boil on the bum, or dose of the piles; the glowing scarlet hooter of acne rosacea or alcoholic liver disease; or as in this case the throbbing agony of the hammer splattered thumb or gouty toe.
Yes, ladies and gent’s, your poor old interlocutor has been stricken with the gout. It’s not the first time to be honest. In fact the last bout was only just around Christmas time, though the one before that was a good few years ago. So here I sit, like the plethoric squire in a seventeenth century cartoon, foot held aloft, wincing and any slight movement within three hundred yards whose trajectory might imperil the affected hallux. The good news is, from past experience, both my own and that vicariously obtained, I know it will be gone in a few days and do not then expect it to return anytime soon. Better yet, it seems still to be responding to good old Indomethacin, so no need to seek out the apothecary monks for their Colchicine…
Happily it affects but a single joint, and yet, in so doing, I am given a glimpse into the daily reality of a number of my regular customers who have far more widespread and longer lasting inflammatory joint diseases. And such an insight makes it easier to appreciate just why so many of them are so keen to continue their painkillers, even when it becomes apparent that the anti-inflammatories are slowly but surely rotting their kidneys.
I can’t help thinking they are all an awful lot tougher than me. Arthritis really isn’t for wimps.
* Readers are encouraged to ignore the off camera sounds of Milady spluttering into her tea mug in disbelief… a lad can dream after all.
Tuesday, February 26, 2008
I give up!
Eddie came to the chest clinic this morning. His asthma is pretty well controlled with his present inhalers, and his lung function is appropriate for his age, and this despite his four decade smoking history. He says he would like to quit, but has tried all the methods available, with no lasting success. Still, this year he has decided to get serious and so, for Lent, he has given up.
Smoking.
Indoors.
Sadly, this behaviour modification has coincided with a bit of an upturn in the weather. In the past couple of weeks, Ambridge has been graced mainly by clear skies and brilliant sunshine or scattered, scudding clouds and a stiffish breeze. So in reality he’s not so much given up as changed venue.
Admittedly that makes it less likely that he will light up first thing, what with the rather frosty mornings such clear skies also cause; or last thing, since it’s still a bit nippy for standing on the patio in PJ’s, dressing gown and slippers. So this in part explains his drop from ten a day to six or seven. The problem is Lent will be up in another three weeks.
I’m also a bit baffled by the logic. Is it somehow more sinful to smoke indoors, polluting your own space, than outside, polluting everybody else’s? Or is God just watching what we get up to inside, knowing he can safely leave outdoors to Her Britannic Majesty’s Government, with their plethora of CCTV cameras and US loaned spy satellites? Or is this a new variation on the “calories don’t count if you’re standing up” argument?
I’m left wondering what other sins it might be safer to indulge outdoors, but, to be honest, so far I’m coming up blank.
Smoking.
Indoors.
Sadly, this behaviour modification has coincided with a bit of an upturn in the weather. In the past couple of weeks, Ambridge has been graced mainly by clear skies and brilliant sunshine or scattered, scudding clouds and a stiffish breeze. So in reality he’s not so much given up as changed venue.
Admittedly that makes it less likely that he will light up first thing, what with the rather frosty mornings such clear skies also cause; or last thing, since it’s still a bit nippy for standing on the patio in PJ’s, dressing gown and slippers. So this in part explains his drop from ten a day to six or seven. The problem is Lent will be up in another three weeks.
I’m also a bit baffled by the logic. Is it somehow more sinful to smoke indoors, polluting your own space, than outside, polluting everybody else’s? Or is God just watching what we get up to inside, knowing he can safely leave outdoors to Her Britannic Majesty’s Government, with their plethora of CCTV cameras and US loaned spy satellites? Or is this a new variation on the “calories don’t count if you’re standing up” argument?
I’m left wondering what other sins it might be safer to indulge outdoors, but, to be honest, so far I’m coming up blank.
Wednesday, February 20, 2008
The circus is in town.
Most of the time I’m more than happy to make do with a boring old mobile phone. The sort that just makes and receives calls. In fact, if I’m honest, I’m even more content to have the thing switched off in the glove box, or left back on the dresser at home. I know, I’m a grumpy old man, and I don’t care, so just get over it people.
Except that today I really, really wish I had one of those third generation, umpteen megapixel, all singing, all dancing, camera-phone-music-player-teasmade-filofax-blonde-bombshell-PA thingies. Because today I appear to have stepped through the looking glass and come out in Monty-Pythonland. You see, I know it’s not an acid flashback, ‘cos I never had the acid to flash forwards from in the first place, and yet the sight that greeted me on the way in to work this morning takes some explaining, and a picture really would have helped. I’m afraid you’ll just have to take my word for it instead. Still, you know you can trust me. After all I am a doctor….
I sense some of you in the cheap seats at the back getting restless. “Once again we haven’t got a clue what he’s talking about!” I hear you mumble above the background hubbub. I shall, at last, explain.
On the outskirts of town there’s a field (if I repeated this line now I might have a halfway decent beginning for a blues ballad—but we shan’t be going there today). In this field the are some sheep (yes, I know, “with a Baa Baa here an’a Baa Baa there”). So far so normal you might think, and so, on every other day it has turned out to be. But today these same sheep are auditioning for the Cirque d’Ambridge. In short they appear, gathered together in the corner of their field, in a seemingly perfect two-tier ovine pyramid, with a cluster of sheep at the base, and two very haughty specimens, side by side and faced Pushmipullyu fashion on the top tier.* So now you can see why I need a camera-phone.
Oh, and an in-car photographer, ‘cos otherwise all you’d actually get to see here would be a very fuzzy snap-shot of two headless sheepy blobs atop a mound of cotton wool.
*the boringly mundane reality is that the top layer sheep are standing on a very flat, very broad tree stump of an old, long ago felled, oak, with the remainder of the flock gathered in attendance around its circumference, which explanation rather spoils the illusion, but might help in my defense when the men in white coats come calling.
Except that today I really, really wish I had one of those third generation, umpteen megapixel, all singing, all dancing, camera-phone-music-player-teasmade-filofax-blonde-bombshell-PA thingies. Because today I appear to have stepped through the looking glass and come out in Monty-Pythonland. You see, I know it’s not an acid flashback, ‘cos I never had the acid to flash forwards from in the first place, and yet the sight that greeted me on the way in to work this morning takes some explaining, and a picture really would have helped. I’m afraid you’ll just have to take my word for it instead. Still, you know you can trust me. After all I am a doctor….
I sense some of you in the cheap seats at the back getting restless. “Once again we haven’t got a clue what he’s talking about!” I hear you mumble above the background hubbub. I shall, at last, explain.
On the outskirts of town there’s a field (if I repeated this line now I might have a halfway decent beginning for a blues ballad—but we shan’t be going there today). In this field the are some sheep (yes, I know, “with a Baa Baa here an’a Baa Baa there”). So far so normal you might think, and so, on every other day it has turned out to be. But today these same sheep are auditioning for the Cirque d’Ambridge. In short they appear, gathered together in the corner of their field, in a seemingly perfect two-tier ovine pyramid, with a cluster of sheep at the base, and two very haughty specimens, side by side and faced Pushmipullyu fashion on the top tier.* So now you can see why I need a camera-phone.
Oh, and an in-car photographer, ‘cos otherwise all you’d actually get to see here would be a very fuzzy snap-shot of two headless sheepy blobs atop a mound of cotton wool.
*the boringly mundane reality is that the top layer sheep are standing on a very flat, very broad tree stump of an old, long ago felled, oak, with the remainder of the flock gathered in attendance around its circumference, which explanation rather spoils the illusion, but might help in my defense when the men in white coats come calling.
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