We could all learn a thing or two from the good burghers of Halberstadt. I learnt late last week from my good friends on Radio Four, that these fine folk have embarked on a monumental work set to far surpass and little local difficulties we might be experiencing in the developed world at the moment. In the midst of present financial and political turmoil they have begun a concert whose ambitions will, if completed, span generations, if not epochs.
As we all fret and worry about the fragility of the economy, witnessed locally by the flurry of job losses in the midlands car makers and their attendant parts suppliers, they gathered last week to witness the playing of a new chord in this concert. The chord began but and eyeblink (as I believe the literal translation of a German term would have it) ago in 2003. It will change every 18 months or so, playing steadily throughout the intervening span on the organ of St Burchard’s Curch. Played to its completion the piece should last around 640 years.
That’s right, YEARS.
The time chosen is significant as it reaches forward in time as far as the founding of St Burchard’s reaches back. In those intervening 640 years we have gone from illuminated manuscript to internet, and from horseback through horsepower to spaceflight. The way has been strewn with calamities, market crashes, wars and pestilences to be sure, but equally with triumphs in art, music, medicine and technology unimaginable to the Halberstadters of yesteryear.
I have a new thing to add to the list of “things to do before I die”, and this one should be there for generations of Jests yet unborn to do likewise, whatever befalls us inbetween. And for roughly twenty generations, should we all be lucky enough to be able to participate, and should the concert get to run its allotted course, we could all claim to have been present at the same event. A thought I find both humbling and ennobling. I doff my cap’o’bells to the fair city of Halberstadt and its visionary folk.
Monday, February 16, 2009
Friday, February 06, 2009
A mile in another man's shoes?
We moved to Ambridge late in 1990. Our first winter here was a proper Winter with a capital “W”. For four weeks we had a meter long icicle hanging off the corner of the conservatory at Jest Towers, and our poor late lamented moggy (then a spry young two year old) could wade chest deep in snow like a little ginger Bismark.
One especially icy Saturday saw Dr Neighbour and I abandon our attempt to drive home from the duty surgery at the foot of Lakey Hill, after some pillock had jack-knifed his artic’ across the road. Instead we stumped up the hill and back to Jest Towers afoot, like Pooh and Piglet tracking woozles—only stopping at the top of the hill for a reviving medicinal port in the now demolished Lakey Arms. When we made it home we ended up calling Radio Ambridge, to warn the punters there was little point calling on the duty doc that weekend as his car lay abandoned and almost all roads were impassable anyhow. Later that afternoon (once the “medicine” had worn off a bit) we went back with spades and dug Dr Neighbour’s car out, and let our newfound Radio chums know we had restored normal service. Since then Ambridge winters have been a bit of a damp squib—though often very damp indeed to be sure.
Until now.
This week we have fallen pray to a new meteorological phenomenon, the “Snow Event”. Indeed, we have had two such thus far, and can apparently look forward to another on Sunday. On the minus side it’s made all the roads hereabouts really slippy so driving has been a bit of a pain. On the plus side it has made all the roads hereabouts really slippy, so the schools have been closed and nobody has been mad enough to venture out to work, which has made driving an absolute joy, especially when, as this morning, you get to drive through countryside where every tree and bush stands limned in glittering white frosting, in the special silence that attends fresh fallen snow.
Better yet, when you get in to the office, scarcely later than on a normal day despite the “extreme” weather, everyone is so pleased to see you, and many of the regulars, having take a peep out from under the duvet, have decided they can wait a few more days before coming in and so have cancelled their appointments, making the caseload a little lighter. Intriguingly though one group of patients seems to stick at nothing to come in, those with pre-existing mobility problems. One poor old chap even managed the two mile walk in for a routine review of his Parkinson’s Disease since the busses weren’t running. It’s almost as though the snow doesn’t impinge, or that it is just another and perhaps more trivial challenge to their mobility.
I'm pretty sure they could teach the rest of us a thing or two.
One especially icy Saturday saw Dr Neighbour and I abandon our attempt to drive home from the duty surgery at the foot of Lakey Hill, after some pillock had jack-knifed his artic’ across the road. Instead we stumped up the hill and back to Jest Towers afoot, like Pooh and Piglet tracking woozles—only stopping at the top of the hill for a reviving medicinal port in the now demolished Lakey Arms. When we made it home we ended up calling Radio Ambridge, to warn the punters there was little point calling on the duty doc that weekend as his car lay abandoned and almost all roads were impassable anyhow. Later that afternoon (once the “medicine” had worn off a bit) we went back with spades and dug Dr Neighbour’s car out, and let our newfound Radio chums know we had restored normal service. Since then Ambridge winters have been a bit of a damp squib—though often very damp indeed to be sure.
Until now.
This week we have fallen pray to a new meteorological phenomenon, the “Snow Event”. Indeed, we have had two such thus far, and can apparently look forward to another on Sunday. On the minus side it’s made all the roads hereabouts really slippy so driving has been a bit of a pain. On the plus side it has made all the roads hereabouts really slippy, so the schools have been closed and nobody has been mad enough to venture out to work, which has made driving an absolute joy, especially when, as this morning, you get to drive through countryside where every tree and bush stands limned in glittering white frosting, in the special silence that attends fresh fallen snow.
Better yet, when you get in to the office, scarcely later than on a normal day despite the “extreme” weather, everyone is so pleased to see you, and many of the regulars, having take a peep out from under the duvet, have decided they can wait a few more days before coming in and so have cancelled their appointments, making the caseload a little lighter. Intriguingly though one group of patients seems to stick at nothing to come in, those with pre-existing mobility problems. One poor old chap even managed the two mile walk in for a routine review of his Parkinson’s Disease since the busses weren’t running. It’s almost as though the snow doesn’t impinge, or that it is just another and perhaps more trivial challenge to their mobility.
I'm pretty sure they could teach the rest of us a thing or two.
Tuesday, January 27, 2009
Bust....
… and Boom.
Or so it would appear. It’s been a nervous six months for the denizens of Ambridge. Light industry hereabouts had evolved to serve the needs of the midlands car makers through the boom years of British manufacturing industry. Those few that are left are all teetering on the brink of the much bruited recession, resulting in increasing uncertainty, lay offs, redundancies, short time working, and downwardly spiralling incomes for the majority of folk.
Add to that rising fuel costs and the coldest winter on record (well o.k. not quite perhaps, but certainly one of the chilliest I can recall) and it all adds up to a pretty miserable picture. Or so I thought until yesterday morning.
You see, we Yeomen of Borsetshire are a sturdy breed. When the chips are down we rally round and make the best of things, and when, as this year, there’s no cash, no heat and nothing worth watching on the telly, we can make our own entertainment. And it seems we have been. Rather enthusiastically.
And the upshot of all this “entertainment” was made manifest not once, nor twice, but three times in the space of one surgery yesterday morning. On each occasion in strode a confident looking woman (one with sheepish partner in tow) with a particular half-smiling expression. These days I hardly need to ask, but do so, just to observe the formalities, thus;
“Now what can we do for you Ms….?”
And they reply “I’m” (or once “We’re”) “pregnant!”
There follows a round of congratulations, followed by one (well, yesterday three) of the most joyful consultations you can get in this line of work. With the obvious exception, I’m not sure there’s a better way of spending a morning ;-)
Or so it would appear. It’s been a nervous six months for the denizens of Ambridge. Light industry hereabouts had evolved to serve the needs of the midlands car makers through the boom years of British manufacturing industry. Those few that are left are all teetering on the brink of the much bruited recession, resulting in increasing uncertainty, lay offs, redundancies, short time working, and downwardly spiralling incomes for the majority of folk.
Add to that rising fuel costs and the coldest winter on record (well o.k. not quite perhaps, but certainly one of the chilliest I can recall) and it all adds up to a pretty miserable picture. Or so I thought until yesterday morning.
You see, we Yeomen of Borsetshire are a sturdy breed. When the chips are down we rally round and make the best of things, and when, as this year, there’s no cash, no heat and nothing worth watching on the telly, we can make our own entertainment. And it seems we have been. Rather enthusiastically.
And the upshot of all this “entertainment” was made manifest not once, nor twice, but three times in the space of one surgery yesterday morning. On each occasion in strode a confident looking woman (one with sheepish partner in tow) with a particular half-smiling expression. These days I hardly need to ask, but do so, just to observe the formalities, thus;
“Now what can we do for you Ms….?”
And they reply “I’m” (or once “We’re”) “pregnant!”
There follows a round of congratulations, followed by one (well, yesterday three) of the most joyful consultations you can get in this line of work. With the obvious exception, I’m not sure there’s a better way of spending a morning ;-)
Thursday, January 22, 2009
On being pleasant.**
It’s been an odd week again. The ongoing Ambridge Lurghi hasn’t helped, to be sure, but there’s more random weirdness abroad at the moment to go along with it. A case in point is young Elwood, a precocious little four year old who can already spell “Triceratops” and who has a friend who follows him everywhere, name of Harvey*. Elwood’s ears have been feeling a bit sore lately, so Granny brought the two of them in today.
“Harvey’s been poorly” chirrups the lad as Harvey takes his accustomed place seated beside his bestest friend. Elwood’s feet dangle over the edge of the chair, but as I round the desk I am careful not to step on the altogether larger paws of poor old Harvey.
I mime lifting aside a long lop-ear and gaze into space through my auroscope, a good two feet above the upturned face of young Elwood.
“It’s o.k.” say I “Harvey’s looking fine today, now how about you?” and then little Elwood proffers his own ear for inspection.
“Hmm. Not quite as good as yours I’m afraid,” I address the remark to the spot Harvey’s face should occupy. “I think the lad needs and antibiotic, just to be on the safe side.” We all three nod (Elwood assures me so), and off the two friends go, hand in paw, Granny in tow, clutching a script for Elwood, and the invisible carrot I proffer for Harvey’s trouble. I have a special jar of them on the desk, just for Harvey’s visits. Fortunately, being invisible it doesn’t take up much space.
* names changed to protect the innocent. The Triceratops, however is real.
** E-V-H-Ns (TM) on offer for the derivation as usual.
“Harvey’s been poorly” chirrups the lad as Harvey takes his accustomed place seated beside his bestest friend. Elwood’s feet dangle over the edge of the chair, but as I round the desk I am careful not to step on the altogether larger paws of poor old Harvey.
I mime lifting aside a long lop-ear and gaze into space through my auroscope, a good two feet above the upturned face of young Elwood.
“It’s o.k.” say I “Harvey’s looking fine today, now how about you?” and then little Elwood proffers his own ear for inspection.
“Hmm. Not quite as good as yours I’m afraid,” I address the remark to the spot Harvey’s face should occupy. “I think the lad needs and antibiotic, just to be on the safe side.” We all three nod (Elwood assures me so), and off the two friends go, hand in paw, Granny in tow, clutching a script for Elwood, and the invisible carrot I proffer for Harvey’s trouble. I have a special jar of them on the desk, just for Harvey’s visits. Fortunately, being invisible it doesn’t take up much space.
* names changed to protect the innocent. The Triceratops, however is real.
** E-V-H-Ns (TM) on offer for the derivation as usual.
Monday, January 12, 2009
Learning to take the smooth with the rough.
Such is the perversity of human nature that I am starting to fret a little. I’ve become accustomed to a more or less steady diet of woe and misery over the last couple on months. The problem has been another winter of intractable cough bugs, with flu like illness chasers, that seem to have been doing the rounds in Ambridge for ever—or at least since early November.
There’s no denying they have been pretty miserable for the poor blighters who have been afflicted. Problem is they’ve also been pretty un-amenable to medical remedy. This has two effects. First it fills surgeries with a lot of miserable people, all lining up to be told, in so many words, there’s nothing we can do for them. Second, and almost more pernicious, it leaves one with a gnawing feeling of clinical impotence which, left unchecked, can lead to an appearance of uncaring dismissal when presented with yet another poor bastard with the lurghi.
The end result of such a downward spiral is a whole bunch of miserable patients and their miserable medical attendants, all moaning to and about one another. So if there’s anybody out there with a miracle flu remedy they can share there just might be a hob nob or two in it for them from this oppressed and downtrodden GP at least.
And then, today, for no clear reason that I can fathom, all the punters have been being especially nice. You know the sort of thing…
“You’re looking well today Dr J, have you lost weight?”
“I swear you’re looking younger now than the last time I saw you!” (Which was five years ago by the way).
“Thank you for your time. I feel so much better just for talking…”
So why do I sit here waiting for the next bombshell I wonder?
As an aside I heard on dear old Radio 4 at the weekend that the good burghers of Brisbane are teaching relaxation technique to toddlers. I feel vindicated. Someone in Oz has obviously been listening to my inane ramblings. Just remember, you heard it here first. Dr J the visionary!
There’s no denying they have been pretty miserable for the poor blighters who have been afflicted. Problem is they’ve also been pretty un-amenable to medical remedy. This has two effects. First it fills surgeries with a lot of miserable people, all lining up to be told, in so many words, there’s nothing we can do for them. Second, and almost more pernicious, it leaves one with a gnawing feeling of clinical impotence which, left unchecked, can lead to an appearance of uncaring dismissal when presented with yet another poor bastard with the lurghi.
The end result of such a downward spiral is a whole bunch of miserable patients and their miserable medical attendants, all moaning to and about one another. So if there’s anybody out there with a miracle flu remedy they can share there just might be a hob nob or two in it for them from this oppressed and downtrodden GP at least.
And then, today, for no clear reason that I can fathom, all the punters have been being especially nice. You know the sort of thing…
“You’re looking well today Dr J, have you lost weight?”
“I swear you’re looking younger now than the last time I saw you!” (Which was five years ago by the way).
“Thank you for your time. I feel so much better just for talking…”
So why do I sit here waiting for the next bombshell I wonder?
As an aside I heard on dear old Radio 4 at the weekend that the good burghers of Brisbane are teaching relaxation technique to toddlers. I feel vindicated. Someone in Oz has obviously been listening to my inane ramblings. Just remember, you heard it here first. Dr J the visionary!
Monday, January 05, 2009
Did you just hear something then?
So that’s it then. New Year rung in in suitable style at Jest Acres after trip to the Panto, New Years Eve banquet in the great hall to follow, concluding with the now traditional sybaritic orgy that is the chocolate fountain, and Jools on the telly in the other room Hootenannying for all he was worth. All in all it went rather well, though the return to a duty surgery on Friday the 2nd was a suitably sobering return to earth.
Still the New Year is off to a suitably surreal start, that if nothing else shows the perils of “copy and paste” correspondence. For a long time there have been parallel moans in U.K. health services. The hospitals moan that GP letters are often a bit sketchy, frequently penned in haste at the bedside as they are, and so are inclined to leave out essential titbits, such as the patients inside leg measurement and so forth. In turn GPs have moaned that the discharge letters thrust into the hand of homecoming patients tend to lack vital, or at least legible, information on trivia like diagnosis, treatment and follow up arrangements. This has, to my knowledge been a settled and steady state for at least three decades. I suspect even poor old Hippocrates had young whipper snappers moaning about the appalling state of the handwriting in his wax tablets down at the Kos DGH.
But over the past three or four years we have moved to printing a lot of the more relevant patient data onto an encounter sheet to attach to our urgent referral letters, and the hospitals have moved to IT generated discharge summaries which are way better than the pro-formas of yesteryear. The problem comes when these IT generated documents are pre-formatted for routine entries of common data, and not edited for those that do not apply, as happened today. Or at least I very much hope that that was the case. Otherwise we have a patient who died in hospital, but was found to have a normal temperature, blood pressure and respiratory rate on discharge from the ward to the mortuary…..
Must go now, it’s dark and there’s a strange tapping sound at the window.
Errr Hello!
Is there anybody there………….?
Still the New Year is off to a suitably surreal start, that if nothing else shows the perils of “copy and paste” correspondence. For a long time there have been parallel moans in U.K. health services. The hospitals moan that GP letters are often a bit sketchy, frequently penned in haste at the bedside as they are, and so are inclined to leave out essential titbits, such as the patients inside leg measurement and so forth. In turn GPs have moaned that the discharge letters thrust into the hand of homecoming patients tend to lack vital, or at least legible, information on trivia like diagnosis, treatment and follow up arrangements. This has, to my knowledge been a settled and steady state for at least three decades. I suspect even poor old Hippocrates had young whipper snappers moaning about the appalling state of the handwriting in his wax tablets down at the Kos DGH.
But over the past three or four years we have moved to printing a lot of the more relevant patient data onto an encounter sheet to attach to our urgent referral letters, and the hospitals have moved to IT generated discharge summaries which are way better than the pro-formas of yesteryear. The problem comes when these IT generated documents are pre-formatted for routine entries of common data, and not edited for those that do not apply, as happened today. Or at least I very much hope that that was the case. Otherwise we have a patient who died in hospital, but was found to have a normal temperature, blood pressure and respiratory rate on discharge from the ward to the mortuary…..
Must go now, it’s dark and there’s a strange tapping sound at the window.
Errr Hello!
Is there anybody there………….?
Tuesday, December 30, 2008
Twelve years and counting...
There’s no doubt that as we enter the 25th year of my professional life we’ve come a long way in the intervening quarticentenary*. Two generations of pills have near abolished surgery for stomach ulcers, a tiny bit of wire mesh has gone a long way towards doing the same for bypass grafting. Depression has been transformed by the introduction of SSRIs and the plethora of follow on alternatives. New wonder drugs have been joined by rehabilitated old wonder drugs like Aspirin. Endoscopic surgery and joint replacements are now commonplace and the protracted stays in hospital post op are a thing of the past for the vast majority. Cancers incurable a generation ago are so no longer…. I could go on, and on (stop that nodding there you at the back).
And yet, for all our technological and pharmaceutical accomplishments, as 2008 draws to a close I’m left fearful that we’ve "sold our soul", and ere long Old Nick himself will be paying us a visit to call in his marker. The NHS I joined, for all its evident faults, was a truly National Service. The ethos of the whole organisation was compassionate, aimed at the relief of suffering and the improvement of wellbeing. This morning on Radio 4 we hear of a Kings Fund report highlighting the loss of compassion. This has slowly but surely been eroded by the fragmentation of the service into a vast jigsaw of Trusts each as much determined to protect its borders and boundaries and keep the “undeserving” out, as to hit the targets set for service delivery to those fortunate few “deserving” of its attention. And those targets are all about process. Waiting times , cleaning regimes, infection rates and the like. All of the above are important, but so are the poor bastards stuck on the receiving end.
In the past month I’ve seen patients kicked off waiting lists for surgery because on one screening visit to a N’octor, their blood pressure or blood sugar are not exactly normal according to arbitrary criteria that are almost absurd enough to require that to be fit for surgery you have to be so well as to not require surgery. I’ve heard Doctor Neighbour bemoan the fact that he is unable to arrange a transfer ambulance to get a patient to see a Neurosurgeon at St Elsewhere’s in a nearby city because the Surgeon in question wanted to review them in the A&E department there and the Ambulance trust can only take patients to Outpatients there or to the nearest (Ambridge DGH) A&E but not the St Elsewhere’s A&E because those are the rules. And I’ve seen a patient denied much needed Opiate analgesia because staff at the residential home he lives in cannot find a cupboard to lock his medications in and the rules won’t allow them to do otherwise.
We’ve become afraid to care, and it’s getting steadily worse year on year. Maybe the Kings Fund will turn the tide and 2009 will see a return to the much needed basics. Every Trust in the land has a mission statement that declares in Government approved newspeak their commitment to “patient centred-ness”.
It’s time we all sat down and thought about what that actually means.
*probably not a real word, but should be.
And yet, for all our technological and pharmaceutical accomplishments, as 2008 draws to a close I’m left fearful that we’ve "sold our soul", and ere long Old Nick himself will be paying us a visit to call in his marker. The NHS I joined, for all its evident faults, was a truly National Service. The ethos of the whole organisation was compassionate, aimed at the relief of suffering and the improvement of wellbeing. This morning on Radio 4 we hear of a Kings Fund report highlighting the loss of compassion. This has slowly but surely been eroded by the fragmentation of the service into a vast jigsaw of Trusts each as much determined to protect its borders and boundaries and keep the “undeserving” out, as to hit the targets set for service delivery to those fortunate few “deserving” of its attention. And those targets are all about process. Waiting times , cleaning regimes, infection rates and the like. All of the above are important, but so are the poor bastards stuck on the receiving end.
In the past month I’ve seen patients kicked off waiting lists for surgery because on one screening visit to a N’octor, their blood pressure or blood sugar are not exactly normal according to arbitrary criteria that are almost absurd enough to require that to be fit for surgery you have to be so well as to not require surgery. I’ve heard Doctor Neighbour bemoan the fact that he is unable to arrange a transfer ambulance to get a patient to see a Neurosurgeon at St Elsewhere’s in a nearby city because the Surgeon in question wanted to review them in the A&E department there and the Ambulance trust can only take patients to Outpatients there or to the nearest (Ambridge DGH) A&E but not the St Elsewhere’s A&E because those are the rules. And I’ve seen a patient denied much needed Opiate analgesia because staff at the residential home he lives in cannot find a cupboard to lock his medications in and the rules won’t allow them to do otherwise.
We’ve become afraid to care, and it’s getting steadily worse year on year. Maybe the Kings Fund will turn the tide and 2009 will see a return to the much needed basics. Every Trust in the land has a mission statement that declares in Government approved newspeak their commitment to “patient centred-ness”.
It’s time we all sat down and thought about what that actually means.
*probably not a real word, but should be.
Wednesday, December 24, 2008
Tis the season.
Sadly not much jollity in evidence in these parts though. One tiny ray of personal sunshine is that Whittards has found a buyer so I sha'nt have t worry quite yet about where ny next 250g of fresh ground Old Brown Java is coming from. I know there's always Taylor's of Harrogate, but it's so much nicer seeing an operative pour the beans out of the tin and into the grinder, whilst solicitously advising that once ground it's only good for a week or two at best, and asking whether the filter I'll be using is paper or permanent (aparently it makes a big difference).
Even the early a.m. run to collect the Turkey from M&S was a muted affair this year. Normally the place is heaving with beaming and avuncular types cheerily queuing for their produce and knocking back simmering goblets of mulled wine. This morning there were a half dozen bedraggled pensioners, a harrased looking suited lady exec and moi. And not a whif of mulled anything. Looking back on 08 it will not go down in the annals of Ambridge as an especially kind year-- and this was before the "crunch". Looking forward 09 doesn't hold out the prospect of being much better.
Still so long as there are Hob Nobs and Java to be had life can't be all bad. And I am as always eternally indebted to those of you who are kind enough to feed back on my ramblings. Your generosity of spirit, and lack of sound judgement, do you all credit, and I wish you all as safe and happy a Christmas and New Year as is humanly possible.
I may well be back before the latter (it's business as usual here Monday through Wednesday) but if not then I hope you will excuse me.
Now I'm just off to google McVities to make sure they are not yet in peril of calling in the recievers, so if you'll all excuse me.....
Even the early a.m. run to collect the Turkey from M&S was a muted affair this year. Normally the place is heaving with beaming and avuncular types cheerily queuing for their produce and knocking back simmering goblets of mulled wine. This morning there were a half dozen bedraggled pensioners, a harrased looking suited lady exec and moi. And not a whif of mulled anything. Looking back on 08 it will not go down in the annals of Ambridge as an especially kind year-- and this was before the "crunch". Looking forward 09 doesn't hold out the prospect of being much better.
Still so long as there are Hob Nobs and Java to be had life can't be all bad. And I am as always eternally indebted to those of you who are kind enough to feed back on my ramblings. Your generosity of spirit, and lack of sound judgement, do you all credit, and I wish you all as safe and happy a Christmas and New Year as is humanly possible.
I may well be back before the latter (it's business as usual here Monday through Wednesday) but if not then I hope you will excuse me.
Now I'm just off to google McVities to make sure they are not yet in peril of calling in the recievers, so if you'll all excuse me.....
Tuesday, December 16, 2008
Catch 22.5
I had another of those Doc Daneeka consultations yesterday. Mrs Yossarian is not happy. She’s been unwell for months, and we’re doing nothing to help her. She tells me so most forcefully. And in many senses she’s quite right, but she implies that we’ve not been trying and that is a little unfair, though woe betide me should I venture to point this out.
“I had a tight chest in the spring and I saw you… you gave me an inhaler, but it just made me worse.”
I tentatively risk asking how.
“Well my chest is still tight now, and it’s burning right here,” she holds a clenched fist to her sternum in a salute reminiscent of a Roman centurion—I mentally hear Russell Crowe intoning Strength and Honour! “and those pills Dr Neighbour gave me did nothing!”
The pills were powerful antacid/ulcer healing drugs. He last prescribed them in the Spring, and for just 28 days. So, I ask again, how long did she take them for?
“Oh I’m still taking them, but they’re no help!”
The logic defeats me. I ask how this can be so, given that they should have run out over six months ago.
“Well my Husband has them too so I’ve been taking his.”
“Anyway after that I got admitted to hospital with chest pain, and they treated me like I’d had a heart attack, but the spray they gave me made everything worse, and I’ve still got this burning” – enter Mr Crowe again stage left. “And all the tests they did have come back normal so they’re no help at all either.”
Now I will concede her that telling her it is her heart, and then telling her it isn’t after all wasn’t entirely helpful, if indeed that is what she was told. Still one might have thought knowing now formally that it isn’t is a good thing. And the cardiologists did actually do quite a lot in helping her to arrive at that point, but again the suggestion that quite a lot has in fact been done gets short shrift. So here she sits, fist clenched tight to her chest, and all set to unleash hell.
And then there’s the final insult. “They made me have statins, and now my legs are really weak and I can’t walk at all.”
How long, I foolishly persist in asking, did she have the statins for?
“About a month, but I’ve been off them for over two months and my legs are no better.”
I hear the ballistae being wound as I venture that stopping the statin ought to have relieved her leg problems by now if it were indeed the cause.
We agree to another blood test to finally absolve the statins, and an ENT opinion about the burning, but I foresee little hope of a breakthrough. I fear Mrs Yossarian’s symptoms are all too likely to have their origin elsewhere that her chest or her legs. Anxiety causes a sensation now referred to simply as Globus—we dropped the old term Globus Hystericus a while ago since the term refers to the awful sensation that you’ve just swallowed half a brick, and has no link to uterine pathology at all. Yes the Hystericus came from the old term Hysteria—a now long discredited diagnostic term. But Globus remains a symptom of the unreassurably anxious, and the one treatment that might alleviate it is the one treatment sufferers cannot accept, namely psychology.
Just occasionally the ENT specialists will be able to persuade the sufferer after an outpatient review but I get the feeling Mrs Yossarian will not take to this advice at all.
Somewhere in the back of my head I hear the sound of pounding hooves.
“I had a tight chest in the spring and I saw you… you gave me an inhaler, but it just made me worse.”
I tentatively risk asking how.
“Well my chest is still tight now, and it’s burning right here,” she holds a clenched fist to her sternum in a salute reminiscent of a Roman centurion—I mentally hear Russell Crowe intoning Strength and Honour! “and those pills Dr Neighbour gave me did nothing!”
The pills were powerful antacid/ulcer healing drugs. He last prescribed them in the Spring, and for just 28 days. So, I ask again, how long did she take them for?
“Oh I’m still taking them, but they’re no help!”
The logic defeats me. I ask how this can be so, given that they should have run out over six months ago.
“Well my Husband has them too so I’ve been taking his.”
“Anyway after that I got admitted to hospital with chest pain, and they treated me like I’d had a heart attack, but the spray they gave me made everything worse, and I’ve still got this burning” – enter Mr Crowe again stage left. “And all the tests they did have come back normal so they’re no help at all either.”
Now I will concede her that telling her it is her heart, and then telling her it isn’t after all wasn’t entirely helpful, if indeed that is what she was told. Still one might have thought knowing now formally that it isn’t is a good thing. And the cardiologists did actually do quite a lot in helping her to arrive at that point, but again the suggestion that quite a lot has in fact been done gets short shrift. So here she sits, fist clenched tight to her chest, and all set to unleash hell.
And then there’s the final insult. “They made me have statins, and now my legs are really weak and I can’t walk at all.”
How long, I foolishly persist in asking, did she have the statins for?
“About a month, but I’ve been off them for over two months and my legs are no better.”
I hear the ballistae being wound as I venture that stopping the statin ought to have relieved her leg problems by now if it were indeed the cause.
We agree to another blood test to finally absolve the statins, and an ENT opinion about the burning, but I foresee little hope of a breakthrough. I fear Mrs Yossarian’s symptoms are all too likely to have their origin elsewhere that her chest or her legs. Anxiety causes a sensation now referred to simply as Globus—we dropped the old term Globus Hystericus a while ago since the term refers to the awful sensation that you’ve just swallowed half a brick, and has no link to uterine pathology at all. Yes the Hystericus came from the old term Hysteria—a now long discredited diagnostic term. But Globus remains a symptom of the unreassurably anxious, and the one treatment that might alleviate it is the one treatment sufferers cannot accept, namely psychology.
Just occasionally the ENT specialists will be able to persuade the sufferer after an outpatient review but I get the feeling Mrs Yossarian will not take to this advice at all.
Somewhere in the back of my head I hear the sound of pounding hooves.
Monday, December 08, 2008
What's that coming over the hill.... *
Enough navel-gazing for now. Let’s get back to some good old fashioned silliness shall we.
Despite the literary allusion (can it be literary if abstracted from an aural medium I wonder—perhaps it should be “broadcasterary allusion”—or perhaps not….) my own version of Ambridge is in fact far from the rural idyll broadcast daily by Auntie for our listening pleasure. Dormitory Town sub-urban is more the thing if I’m honest. The strange thing is, this does not appear to have impinged on the Mums and Dads of the latest generation of tiny Borcestrians.
There’s been a “bit of a cough” doing the rounds in these parts lately. The sort of cough that leaves tinies choking, gasping, purple and cross. And it’s going on for days on end. Unsurprisingly Mums and a few Dads (you know they’re worried when a sheepish looking Dad is in tow to insist that “something’s got to be done Doc”) have been thronging the waiting room with their wheezing, hacking, retching, puce offspring. The good news is that despite the graphic presentations most are just suffering with the aforementioned “bit of a cough” and some reassurance and symptomatic treatment will pull them through just fine.
Our problem is the traffic management their attendances are occasioning. It seems babies these days are much too precious and fragile to be brought the full fifty yards from car park to consulting room in anything smaller or more dainty than a Sherman tank. Buggies have clearly come on a long way in the umpteen years since the Jests were in the market for one. Gone are the teetering gossamer constructs of yore with their two inch diameter Lego wheels and all the stability and traction of an inebriate hippo on ice.
Nowadays we get mammoth constructs with wheels bigger than a mountain bike, sporting off road tyres, brush cutters and bull bars. The tiny occupants are strapped in tight enough for Saturn V style take-off and re-entry. I’m sure the ones imported by our own share of the Polish Diaspora are in fact just T72s with the turrets removed a few teddy bear stickers applied for that homely touch. More than once I’ve found myself having to strenuously resist the urge to duck and cover as one of these monsters fills the doorframe of the consulting room.
Does anyone have the number for M. Maginot I wonder?
*Hob nob on offer for the correct next line.
Despite the literary allusion (can it be literary if abstracted from an aural medium I wonder—perhaps it should be “broadcasterary allusion”—or perhaps not….) my own version of Ambridge is in fact far from the rural idyll broadcast daily by Auntie for our listening pleasure. Dormitory Town sub-urban is more the thing if I’m honest. The strange thing is, this does not appear to have impinged on the Mums and Dads of the latest generation of tiny Borcestrians.
There’s been a “bit of a cough” doing the rounds in these parts lately. The sort of cough that leaves tinies choking, gasping, purple and cross. And it’s going on for days on end. Unsurprisingly Mums and a few Dads (you know they’re worried when a sheepish looking Dad is in tow to insist that “something’s got to be done Doc”) have been thronging the waiting room with their wheezing, hacking, retching, puce offspring. The good news is that despite the graphic presentations most are just suffering with the aforementioned “bit of a cough” and some reassurance and symptomatic treatment will pull them through just fine.
Our problem is the traffic management their attendances are occasioning. It seems babies these days are much too precious and fragile to be brought the full fifty yards from car park to consulting room in anything smaller or more dainty than a Sherman tank. Buggies have clearly come on a long way in the umpteen years since the Jests were in the market for one. Gone are the teetering gossamer constructs of yore with their two inch diameter Lego wheels and all the stability and traction of an inebriate hippo on ice.
Nowadays we get mammoth constructs with wheels bigger than a mountain bike, sporting off road tyres, brush cutters and bull bars. The tiny occupants are strapped in tight enough for Saturn V style take-off and re-entry. I’m sure the ones imported by our own share of the Polish Diaspora are in fact just T72s with the turrets removed a few teddy bear stickers applied for that homely touch. More than once I’ve found myself having to strenuously resist the urge to duck and cover as one of these monsters fills the doorframe of the consulting room.
Does anyone have the number for M. Maginot I wonder?
*Hob nob on offer for the correct next line.
Monday, December 01, 2008
Phillip
In case you missed it, today has been World AIDS Day. Good old Radio 4 had a mix of upbeat stories about babies born to positive mothers, and more downbeat warnings that the incidence is on the rise again here in Blighty.
Ambridge has been somewhat cocooned form the ravages of the HTLV. My one brush with the disease was vicarious at best, but none the less tragic for that. Phillip left Ambridge towards the end of the seventies for the bright lights of the big city. He soon hooked up with Terrance. Chef and Actor, they made a fine couple, until Terrance became ill, and started loosing weight and coughing a lot. Phillip nursed him through a protracted and difficult terminal illness before the days of widespread and affordable (at least in the “civilized west”) antiretrovirals. At the onset of Terrance’s illness Phillip was tested and was pronounced clear of infection, but to be certain would have required a second test three months later.
Poor Phillip was too distraught by his partner’s rapidly progressing illness to handle a second test then. Shortly after the funeral he came home to live with his mum. He found work locally and kept himself going, but lived in constant fear. Every cough and every new blemish brought him shaking to the surgery. We talked at length and repeatedly about his fears. We offered him access to a final test for reassurance, though with each passing year and each successful recovery from illness the likelihood that he had contracted the virus became increasingly remote. Still neither we nor the psychologists could reassure him, and he could not face up to getting tested.
In the end, one Monday morning I came in to surgery to find the coroners officer had been on the phone. That weekend mum had been away with her chums, and poor Phillip had given in to his demons and washed down some pain killers with vodka. Though never infected he died as much a victim of AIDS as those many of his friends who were.
I’m not a great fan of “badges” and “ribbons” for this and that. AIDS, Cancer, Asthma or COPD to name but a few, are worth more than just a 365th of our attention, as are the myriad other causes and conditions that don’t get a proper “day” to themselves. And yet, today I’ll be wearing the red ribbon, and thinking of an old friend I couldn’t help.
Ambridge has been somewhat cocooned form the ravages of the HTLV. My one brush with the disease was vicarious at best, but none the less tragic for that. Phillip left Ambridge towards the end of the seventies for the bright lights of the big city. He soon hooked up with Terrance. Chef and Actor, they made a fine couple, until Terrance became ill, and started loosing weight and coughing a lot. Phillip nursed him through a protracted and difficult terminal illness before the days of widespread and affordable (at least in the “civilized west”) antiretrovirals. At the onset of Terrance’s illness Phillip was tested and was pronounced clear of infection, but to be certain would have required a second test three months later.
Poor Phillip was too distraught by his partner’s rapidly progressing illness to handle a second test then. Shortly after the funeral he came home to live with his mum. He found work locally and kept himself going, but lived in constant fear. Every cough and every new blemish brought him shaking to the surgery. We talked at length and repeatedly about his fears. We offered him access to a final test for reassurance, though with each passing year and each successful recovery from illness the likelihood that he had contracted the virus became increasingly remote. Still neither we nor the psychologists could reassure him, and he could not face up to getting tested.
In the end, one Monday morning I came in to surgery to find the coroners officer had been on the phone. That weekend mum had been away with her chums, and poor Phillip had given in to his demons and washed down some pain killers with vodka. Though never infected he died as much a victim of AIDS as those many of his friends who were.
I’m not a great fan of “badges” and “ribbons” for this and that. AIDS, Cancer, Asthma or COPD to name but a few, are worth more than just a 365th of our attention, as are the myriad other causes and conditions that don’t get a proper “day” to themselves. And yet, today I’ll be wearing the red ribbon, and thinking of an old friend I couldn’t help.
Monday, November 24, 2008
Help wanted.
Twice this past week I find myself somewhat at a loss to see a way forwards for the folks on the other side of the desk. We appear to have strayed into “irresistible force vs. immovable object” territory and I’m not a all sure how we are going to negotiate it. Allow me to illustrate.
Case one:- “Loose lips….”
Enter Brad’ and Ange’ (names as ever changed to protect the …. you all know the rest). Ange’ had her three yearly cervical cytology done a few weeks ago and the result wasn’t exactly normal. There’s a whole argument to be had about the merits of the whole cervical cytology screening programme, but that’s not for here. The point was that her result, for the first time since she began the screening some fifteen or so years ago, was “abnormal” and showed “borderline changes” in the cells. According to guidelines we need to repeat the sample in six months and if all is well she can move on without the need for intensive investigations, but in the meantime she has to live with the ticking time-bomb of “abnormality”.
And then some Smart Alec at work says to her, “Of course that’s caused by a sexually transmitted disease you know!”
So Ange’ rushes home in an histrionic fervour, beards Brad’ in his lair and starts demanding “How could you?”
The upshot, an attendance to the Ambridge Surgery. We go over the whole Cervical Cytology- HPV- Cellular changes- Cervical Cancer, discussion, but in all honesty our grasp of the precise natural history of this process if hazy at best. They have been together for years, but both had partners before committing to one another, and Brad is quite prepared to swear on all that is holy that since then he has been happily monogamous. Now I accept as a male GP I might be unwittingly biased, but his body language, and indeed the mere fact that he has attended with her on the day, leave me inclined to believe him.
We discussed the fact that despite their long term commitment, should the anomalies in her cells prove to be related to HPV infection, that doesn’t automatically call her man’s fidelity into question, but Ange’ remains visibly unreassured. In the end I have to suggest they seek help from a relationship counsellor as this one chance remark has caused such an apparent rift.
Case 2:- “Love me love my cats”
Sid comes to the chest clinic. He has a cough that has been going on for years. It’s worse when he tries to run, and it’s been deteriorating since Joelene bought her kittens a few years back. He’s tried all sorts of inhaler regimes down the years and none quite gets the job done. So now he’s convinced it isn’t asthma he’s got at all. After all surely the inhalers would have kicked in by now. (I keep telling him not to call me Shirley!)
O.k. so they help him after a run, and they reduce the cough to a minor irritation rather than a constant nuisance, but really if it were asthma they’d have sorted it out by now, Shirley?
We go trough the history again. We look at his peak flow readings, before and after inhalers again. All point to the inescapable conclusion that he has obstructed airways, that get better with inhaler treatment.
In short, Asthma.
So there.
Worse yet, it sounds highly likely that Sid has an allergy to the little bundles of fluff that are now full grown cougar wannabes, who lord it about the house, lolling over sofas and beds, shamelessly indulged like the child substitutes they so plainly are by the otherwise empty nested Joelene. When we have the temerity to suggest we test Sid for cat allergy he ruefully shakes his head—“She’s already told me the cats aren’t going”.
So we try another asthma treatment.
I wonder, is Kofi Annan busy right now?
Case one:- “Loose lips….”
Enter Brad’ and Ange’ (names as ever changed to protect the …. you all know the rest). Ange’ had her three yearly cervical cytology done a few weeks ago and the result wasn’t exactly normal. There’s a whole argument to be had about the merits of the whole cervical cytology screening programme, but that’s not for here. The point was that her result, for the first time since she began the screening some fifteen or so years ago, was “abnormal” and showed “borderline changes” in the cells. According to guidelines we need to repeat the sample in six months and if all is well she can move on without the need for intensive investigations, but in the meantime she has to live with the ticking time-bomb of “abnormality”.
And then some Smart Alec at work says to her, “Of course that’s caused by a sexually transmitted disease you know!”
So Ange’ rushes home in an histrionic fervour, beards Brad’ in his lair and starts demanding “How could you?”
The upshot, an attendance to the Ambridge Surgery. We go over the whole Cervical Cytology- HPV- Cellular changes- Cervical Cancer, discussion, but in all honesty our grasp of the precise natural history of this process if hazy at best. They have been together for years, but both had partners before committing to one another, and Brad is quite prepared to swear on all that is holy that since then he has been happily monogamous. Now I accept as a male GP I might be unwittingly biased, but his body language, and indeed the mere fact that he has attended with her on the day, leave me inclined to believe him.
We discussed the fact that despite their long term commitment, should the anomalies in her cells prove to be related to HPV infection, that doesn’t automatically call her man’s fidelity into question, but Ange’ remains visibly unreassured. In the end I have to suggest they seek help from a relationship counsellor as this one chance remark has caused such an apparent rift.
Case 2:- “Love me love my cats”
Sid comes to the chest clinic. He has a cough that has been going on for years. It’s worse when he tries to run, and it’s been deteriorating since Joelene bought her kittens a few years back. He’s tried all sorts of inhaler regimes down the years and none quite gets the job done. So now he’s convinced it isn’t asthma he’s got at all. After all surely the inhalers would have kicked in by now. (I keep telling him not to call me Shirley!)
O.k. so they help him after a run, and they reduce the cough to a minor irritation rather than a constant nuisance, but really if it were asthma they’d have sorted it out by now, Shirley?
We go trough the history again. We look at his peak flow readings, before and after inhalers again. All point to the inescapable conclusion that he has obstructed airways, that get better with inhaler treatment.
In short, Asthma.
So there.
Worse yet, it sounds highly likely that Sid has an allergy to the little bundles of fluff that are now full grown cougar wannabes, who lord it about the house, lolling over sofas and beds, shamelessly indulged like the child substitutes they so plainly are by the otherwise empty nested Joelene. When we have the temerity to suggest we test Sid for cat allergy he ruefully shakes his head—“She’s already told me the cats aren’t going”.
So we try another asthma treatment.
I wonder, is Kofi Annan busy right now?
Monday, November 17, 2008
St Elsewhere's?
You know your appraisal’s going wrong when your appraiser says “You could always think about doing something else…”
After last year, when a commenter rather chided me over the whole “buzzword bingo” concept of appraisal, I decided to do this one cold. This might have been a mistake.
I thought I had prepared my case and supplied the necessary evidence to back up my professed competence, but this year’s appraisal felt somehow so much more joyless than any hitherto, and my appraiser (a new one I’d not met before the day) seemed less interested in the materials I had provided than in her own agenda, namely whipping me in to shape for “revalidation”. It probably didn’t help that I was incubating my annual dose of low grade but highly irritating lurghi come the appointed day. Nor did it help that I had spent forty five minutes completing a twenty minute journey to my place of execution… er appraisal. The fact that the day had not afforded an opportunity for a second cup of Java or any hobnobs at all probably sealed my fate.
As a result I accept I might have come across as a little grumpier and a tad less engaged than I might normally. However it also seemed that the appraisal agenda has changed from a formative mentoring relationship to one of challenge and compulsion. I’m not entirely sure on that point, and accept that I performed badly on the day, but with the benefit of a fortnight of introspection after the fact, this experience was so at variance with the five previous encounters that I await the next with no small measure of trepidation.
And the really sad thing is I’m not at all sure I could, or would want to do “anything else”. I can tell you that next year the bingo will definitely be back on the agenda though.
I’m sorry it took a while to regain my normal equanimity after these events, but I reckon I’m back now, and certainly in no mood to go elsewhere.
After last year, when a commenter rather chided me over the whole “buzzword bingo” concept of appraisal, I decided to do this one cold. This might have been a mistake.
I thought I had prepared my case and supplied the necessary evidence to back up my professed competence, but this year’s appraisal felt somehow so much more joyless than any hitherto, and my appraiser (a new one I’d not met before the day) seemed less interested in the materials I had provided than in her own agenda, namely whipping me in to shape for “revalidation”. It probably didn’t help that I was incubating my annual dose of low grade but highly irritating lurghi come the appointed day. Nor did it help that I had spent forty five minutes completing a twenty minute journey to my place of execution… er appraisal. The fact that the day had not afforded an opportunity for a second cup of Java or any hobnobs at all probably sealed my fate.
As a result I accept I might have come across as a little grumpier and a tad less engaged than I might normally. However it also seemed that the appraisal agenda has changed from a formative mentoring relationship to one of challenge and compulsion. I’m not entirely sure on that point, and accept that I performed badly on the day, but with the benefit of a fortnight of introspection after the fact, this experience was so at variance with the five previous encounters that I await the next with no small measure of trepidation.
And the really sad thing is I’m not at all sure I could, or would want to do “anything else”. I can tell you that next year the bingo will definitely be back on the agenda though.
I’m sorry it took a while to regain my normal equanimity after these events, but I reckon I’m back now, and certainly in no mood to go elsewhere.
Thursday, October 23, 2008
A new friend?
Back in January I wrote about an absent friend. Since that time I have seen my old friend Ray a couple of times more, once at home, and later at the surgery, and on both occasions the absence remained a palpable thing. The guide dog Ray had lost was a big personality. When the two of them came in they were always the centre of attention. We kidded Ray it was all down to his chiseled good looks ("One of my friends says I look like Clint Eastwood"), but he and we knew his new found animal magnetism was easily 80% canine. Loosing the big rock-star dog that had been his ten year companion left Ray diminished and contracted his horizons far more than either of us expected it might.
And so it was with some trepidation that I viewed the screen message earlier this week that announced Ray plus "one other" were waiting to be seen. When I went to collect them, instead of the huge, golden maned, long haired Labrador of yore, Ray was escorted by a docile, jet black, short haired shade of a dog. Instead of bounce and slobber I was greeted with equanimity. We processed down the corridor to my office in a far more stately and reserved manner than we had been used to, and once in, the new guide settled himself quietly at his master's feet and watched me cautiously to gauge my intentions and figure out if I was to be trusted.
By the time we were done I think we had achieved a modus vivendi, and I should still be allowed to care for his master for the time being, and on the way back out of the office the carriage of the hound had a more familiar cast to it, and in reception a small flock of admirers began to gather. And again the majority of their attention fell upon the dog. I'm not sure this one will quite achieve rock-star status, but, eleven years on, his quiet efficiency will probably suit Ray better, and it is already clear that he,Ray, is moving on at last.
I was left wondering to what extent this shadow-dog communes with his forebear (or perhaps that should be foredog). I certainly got the impression at points during our consultation that older, more familiar eyes were gazing up from that long dark face.
Perhaps there is something in this reincarnation thing, or perhaps I'm just making a new friend after all....
And so it was with some trepidation that I viewed the screen message earlier this week that announced Ray plus "one other" were waiting to be seen. When I went to collect them, instead of the huge, golden maned, long haired Labrador of yore, Ray was escorted by a docile, jet black, short haired shade of a dog. Instead of bounce and slobber I was greeted with equanimity. We processed down the corridor to my office in a far more stately and reserved manner than we had been used to, and once in, the new guide settled himself quietly at his master's feet and watched me cautiously to gauge my intentions and figure out if I was to be trusted.
By the time we were done I think we had achieved a modus vivendi, and I should still be allowed to care for his master for the time being, and on the way back out of the office the carriage of the hound had a more familiar cast to it, and in reception a small flock of admirers began to gather. And again the majority of their attention fell upon the dog. I'm not sure this one will quite achieve rock-star status, but, eleven years on, his quiet efficiency will probably suit Ray better, and it is already clear that he,Ray, is moving on at last.
I was left wondering to what extent this shadow-dog communes with his forebear (or perhaps that should be foredog). I certainly got the impression at points during our consultation that older, more familiar eyes were gazing up from that long dark face.
Perhaps there is something in this reincarnation thing, or perhaps I'm just making a new friend after all....
Friday, October 17, 2008
If the CD player wasn't broken I'd have been listening to Lou Reed.
Once or twice a year you get a perfect morning. Today was one such. The school run was taken by my better half. So I got to head for the surgery a half hour earlier than normal, and today that half hour was especially blessed.
The sun had climbed just high enough not to be dazzling as I headed east out of Borchester, bleaching a near cloudless sky to the faintest blue-white. This in turn was mirrored by the soft blanket of autumn mist that hugged the base of the Ambridge escarpment. Dew drops scattered the field like tiny diamonds, and climbing the escarpment the sunlight pierced the woods at just the right angle to halo the turning leaves in shimmering gold.
What made the ride in all the better was that, being that little bit earlier, I had the route pretty much all to myself right up to the outskirts of Ambridge itself, so that despite apparently dawdling along taking in the sights I was still in early enough to have had a hot steaming Java and a couple of Hob Nobs before returning to the fray.
May you all be so blessed this morning and every morning.
(Needless to say after such a promising start karma blessed me with a morning of Flu’ jabs and crusty toenails—but somehow the residual bonhomie refuses to quite go away).
The sun had climbed just high enough not to be dazzling as I headed east out of Borchester, bleaching a near cloudless sky to the faintest blue-white. This in turn was mirrored by the soft blanket of autumn mist that hugged the base of the Ambridge escarpment. Dew drops scattered the field like tiny diamonds, and climbing the escarpment the sunlight pierced the woods at just the right angle to halo the turning leaves in shimmering gold.
What made the ride in all the better was that, being that little bit earlier, I had the route pretty much all to myself right up to the outskirts of Ambridge itself, so that despite apparently dawdling along taking in the sights I was still in early enough to have had a hot steaming Java and a couple of Hob Nobs before returning to the fray.
May you all be so blessed this morning and every morning.
(Needless to say after such a promising start karma blessed me with a morning of Flu’ jabs and crusty toenails—but somehow the residual bonhomie refuses to quite go away).
Friday, October 10, 2008
Grace under pressure.
Around a year ago Grace started to complain of tummy pain. This was before she came to Ambridge. After a few weeks she was unwell enough to need a hospital visit, and there they found a pelvic mass, around the size of a mid term pregnancy. Only trouble was that Grace was pushing seventy years of age and was long past her menopause.
In pretty short order she was told she had ovarian carcinoma. Then that she had inoperable ovarian carcinoma. Then that she had inoperable ovarian carcinoma that was not responding to chemotherapy. At some point in that process she ended up relocating to Ambridge and joined Dr Neighbour’s list.
She has in Dr Neighbour an excellent GP. She also has the input of the best available local Oncologists and Mc Millan Nurses. She also has the Ambridge District Nurse A team on her case. She has little or no pain and has no fears for the future, taking each day on it’s merits, but she has no illusions that this will be her final illness. Lately she has been a bit queasy, and has begun to feel what we English like to euphemistically call “a bit bunged up”. The usual array of laxatives isn’t helping much and neither this past week has repeated enemata from the aforementioned A team.
And so it fell to me as duty doc, a day or two ago, to call on her mid afternoon, to see if we should be trying harder to get things moving. The duty had been a bit busy, so no time for the usual lunch on the hoof for your humble narrator. I needed to examine her abdomen, so she gamely struggled upstairs to get on the bed (one simply does not submit to examinations of that sort on the settee) despite the evident effort it was costing her. I was keen to rule out intestinal obstruction, and as I leant over her “bump” to apply the stethoscope, to my eternal shame, it was my tum and not hers that did the rumbling.
In the end the exam did not reveal immediate concerns and we agreed there was no need for an urgent admission, though a quick Xray of her abdomen might be a good idea to rule out a sub-acute obstruction (believe it or not a fairly precise surgical definition that would have signs evident on said Xray). As a result I arranged for her to go for the pictures that afternoon, and in the event they were clear and we have pulled back from the purgatives and enemata and reassured her that a little feeling of fullness can be expected simply as a consequence of the mass in her tummy, but that so long as it causes no pain and no nasty vomiting she need not fear it.
In the end as happy an outcome as we could have hoped for in the circumstances, and Grace was effusive in her thanks for me not wanting to admit her. And in the midst of all this, as I was arranging for her to pop in for the films to be taken she politely wondered if she might offer me a cup of tea and a sandwich.
In pretty short order she was told she had ovarian carcinoma. Then that she had inoperable ovarian carcinoma. Then that she had inoperable ovarian carcinoma that was not responding to chemotherapy. At some point in that process she ended up relocating to Ambridge and joined Dr Neighbour’s list.
She has in Dr Neighbour an excellent GP. She also has the input of the best available local Oncologists and Mc Millan Nurses. She also has the Ambridge District Nurse A team on her case. She has little or no pain and has no fears for the future, taking each day on it’s merits, but she has no illusions that this will be her final illness. Lately she has been a bit queasy, and has begun to feel what we English like to euphemistically call “a bit bunged up”. The usual array of laxatives isn’t helping much and neither this past week has repeated enemata from the aforementioned A team.
And so it fell to me as duty doc, a day or two ago, to call on her mid afternoon, to see if we should be trying harder to get things moving. The duty had been a bit busy, so no time for the usual lunch on the hoof for your humble narrator. I needed to examine her abdomen, so she gamely struggled upstairs to get on the bed (one simply does not submit to examinations of that sort on the settee) despite the evident effort it was costing her. I was keen to rule out intestinal obstruction, and as I leant over her “bump” to apply the stethoscope, to my eternal shame, it was my tum and not hers that did the rumbling.
In the end the exam did not reveal immediate concerns and we agreed there was no need for an urgent admission, though a quick Xray of her abdomen might be a good idea to rule out a sub-acute obstruction (believe it or not a fairly precise surgical definition that would have signs evident on said Xray). As a result I arranged for her to go for the pictures that afternoon, and in the event they were clear and we have pulled back from the purgatives and enemata and reassured her that a little feeling of fullness can be expected simply as a consequence of the mass in her tummy, but that so long as it causes no pain and no nasty vomiting she need not fear it.
In the end as happy an outcome as we could have hoped for in the circumstances, and Grace was effusive in her thanks for me not wanting to admit her. And in the midst of all this, as I was arranging for her to pop in for the films to be taken she politely wondered if she might offer me a cup of tea and a sandwich.
Monday, October 06, 2008
Hard to swallow?
Young George is just over one year old. For the past few months he has had an increasingly healthy appetite for solids and is visibly thriving. Or so he was until a few weeks ago. After a couple of weeks of gradual loss of appetite he suddenly stopped eating altogether, and mum and dad began to worry. After three days of nothing but fluids, and diminishing demand even for these, coupled with that most alarming symptom of all, a complete refusal to eat chocolate*, he had put the wind up them both and so they attended, with a still happy and smiling young George in tow.
So far, despite his total lack of enthusiasm for solids the lad was holding his own pretty well, with no signs of rapid weight loss and no real dehydration. He was vomiting after all solids though, and so had really given up trying, and so long as mum and dad allowed him not to eat he was happy, only becoming fractious when they tried to make him.
His tummy was quite soft and not at all tender. There was no worry about constipation or diarrhoea, and on the day I examined him my tummy was gurgling more than his… one of us was definitely in need of chocolate!
Overall he really didn’t seem too bad, but mum and dad were not going to take happily to this suggestion. In reality it appeared little George was suffering a bit of “reflux” with acid flowing backwards from the stomach into the lower reaches of the oesophagus causing heartburn and hence vomiting.
After some discussion his worried parents agreed to my evidently insane suggestion that we try spiking his bottles with an antacid preparation that just might do the trick, before we considered referring him on to the paediatricians. It helped a bit that I have looked after mum since she was little older that her son is now, so with a slight reluctance she and her husband agreed to try my alchemy for a week or so before pressing the panic button.
Two weeks on they came back, all three beaming contentedly, to request some more sachets of the antacid. Young George is back wolfing down everything that’s put in front of him, and most particularly he’s back on the chocolate. There can be no better sign that a toddler is on the mend.
*Regular readers will already be aware that this writer believes Chocolate worthy of it’s own food group and of that food group’s obvious preeminence over all the others.**
** except perhaps the Vodka / Bourbon group that is….
So far, despite his total lack of enthusiasm for solids the lad was holding his own pretty well, with no signs of rapid weight loss and no real dehydration. He was vomiting after all solids though, and so had really given up trying, and so long as mum and dad allowed him not to eat he was happy, only becoming fractious when they tried to make him.
His tummy was quite soft and not at all tender. There was no worry about constipation or diarrhoea, and on the day I examined him my tummy was gurgling more than his… one of us was definitely in need of chocolate!
Overall he really didn’t seem too bad, but mum and dad were not going to take happily to this suggestion. In reality it appeared little George was suffering a bit of “reflux” with acid flowing backwards from the stomach into the lower reaches of the oesophagus causing heartburn and hence vomiting.
After some discussion his worried parents agreed to my evidently insane suggestion that we try spiking his bottles with an antacid preparation that just might do the trick, before we considered referring him on to the paediatricians. It helped a bit that I have looked after mum since she was little older that her son is now, so with a slight reluctance she and her husband agreed to try my alchemy for a week or so before pressing the panic button.
Two weeks on they came back, all three beaming contentedly, to request some more sachets of the antacid. Young George is back wolfing down everything that’s put in front of him, and most particularly he’s back on the chocolate. There can be no better sign that a toddler is on the mend.
*Regular readers will already be aware that this writer believes Chocolate worthy of it’s own food group and of that food group’s obvious preeminence over all the others.**
** except perhaps the Vodka / Bourbon group that is….
Friday, September 26, 2008
Old head, young shoulders...
Freddy had an asthma attack two weeks ago. He had had a bit of a cold in the morning, but not enough to keep him off school. By mid afternoon school were worried and called Mum to come and get him, and when they arrived at the surgery the poor lad was really gasping for air.
For those to whom this means something he was managing a couple of words between breaths, chugging along at around 50 breaths a minute, using all his accessory muscles, and visibly tiring. For those to whom none of that is especially significant, suffice it to say he was pretty damned breathless.
We whacked him straight on a nebulizer (an air compressor through which we can, and did, aerosolize asthma meds—easier to use and more penetrating than an inhaler for a patient in crisis) which soon sorted out his breathlessness, and packed him off home some forty minutes later with an armful of inhalers, a spacer device (a chamber thingy to put the inhalers into) and some steroid pills, plus all the nebulizer tubing and mask he had just been using for him to play spacemen with when he got home (and to help the Out of Hours docs should they need to get him back on a nebulizer at any point that night).
Mum also went away with clear instructions to look out for a flare of wheeze or breathlessness around four hours later as the nebulizer would be wearing off about then, and if the inhalers didn’t quickly turn him around she knew to call for help straight away. Happily that advice was not needed and, as I discovered today, he was pretty much all better after 48 hours of more intensive medication. All through the consultation though, Freddy looked exactly as you might expect, a pretty scared, rather tiny six year old boy, in need of his Mum.
Not so today.
Today he comes for his review and to plan his treatment from here on. He pulls up his chair, alogside but some distance from his Mum. Today he is immaculately turned out in his school uniform, and not disheveled as when we last met. He has not a hair out of place, and is the living example of calm, composed self assurance.
We agree to try and monitor his asthma with a peak flow meter, and he masters the technique in a couple of puffs with aplomb. Then we need to measure him to see how his result matches with the predicted value for his age and height— “Though I’m not very tall for a six year old you know.” And neither he is, though still tall enough not to present any concerns about arrested development. We also agree he should have a spacer for home and a separate spacer and inhaler combination to keep at school and a peak flow meter for home monitoring.
“You should personalize them with your favourite stickers.” I sagely advise.
“Ooh yes,” says Mum “you could do that in your craft lesson this afternoon.”
“Well,” Freddy draws the word out for emphasis “I suppose I might, but I will have some work to do this afternoon too you know.”
I’m left reflecting that this is a young man who will go far, and also struck by the difference two short weeks and a proper asthma management plan can make.
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 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….
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