It's finally happened. To be honest I'd half expected it, but still it's a bit of a shock to the system. Monday saw us all sitting around the table at coffee time dissecting the events of the weekend, and talk turned to Dr Neighbour's kids who are off doing the now almost compulsory world tour on a break between studies. They're able to keep in touch by mobile (sometimes) and by blog for the rest. Dr N is new to the bloggoshere and has found the whole thing a revelation, being able as she is to keep in touch with the kids adventures almost as they happen, in word and picture as well as (when monnies and signal permit) by voice.
We sometimes forget how much has changed this past decade. Even ten years ago, when a cousin of mine was doing the same thing, mobile coverage was less reliable and relatively massively more expensive, and most of us were still on good old fashioned steam powered dial up connections so the occasional email from Delhi or Addis Abbaba or wherever, was the most we could expect, and the the hard copy photo's pasted neatly into albums when processed and sorted after the prodigal's return.
So there we all were marvelling the wonders that modern tecnology and permanent web connection have brought when, from the other end of the table comes a voice-- "You've got a blog too haven't you Jesty!"
Back when I started this "stream of consciousness" rambling there were precious few medical bloggers, and especially GP blogegrs about. Not so now as a trawl through the blog rolls of some of my fellow bloggers will attest. I've always tried to keep this little corner of the net under the radar a bit, but being blogrolled by these same erudite colleagues means that inevitably one of my partners blundered across the caseblog some time ago, but till now hadn't thought to mention it.
I'm not overly surprised, but confess to being a little dismayed. It's not that I write stuff I think will upset them, it's just that from here on I'll be more directly aware of the presence peering over my shoulder. Right now I'm not sure what I think about that, but I suspect it will change the nature of our interaction in this virtual place, so I'm asking you all, regular and more recent readers, to bear with me while I figure it out.
Still it could be worse. At least I'm not a formerly cash strapped epidemiologist. Then again, I'll never be portrayed on screen by Billy Piper either.
:-(
Wednesday, February 24, 2010
Friday, February 19, 2010
Are you Joe Public?
In a recent email a very good friend of mine asked me to describe my “average” patient in response to a typically flippant remark I’d made. Which got me to thinking—never a good idea as we shall now discover. Inhabiters of this Sceptered Isle will I hope be familiar with the work of the comic genius that is Dave Gorman, a man who, on a drunken whim, set out to find 54 like named souls and in so doing brightened my life considerably one evening a week for six weeks as he described his search with stats and graphs and all sorts. This all happened a few years back, and if you know nothing of Dave or his quest I urge you to seek him out here.
As an homage (or ommmaaaje as I believe it’s pronounced on the other side of the pond) I offer the following.
The first thing to say, is that the “average” patient comes in two distinct but similar incarnations. Let’s call them Routine and Urgent. In an ordinary week Routines outnumber Urgents by 7:1. On a busier week, like this, the ratio is 3:1, though every third Routine is in fact a Semi-Urgent, but for today they will be appearing as Routines (largely because I can’t face doing the additional maths to separate them out). Right, now that's clear on we go.
So, for this week Ms Routine has been assiduous in his attendance, though her gender identity has been perhaps a little uncertain, being as he is 55% female. She’s a pleasing mix of ethnicities being 8% East European 24% Asian and 16% Afro-Caribbean leaving him roughly 52% indigenous to Borsetshire or Expatriate Brummie.
She’s been around 32% depressed—this prolonged cold spell, the recession and pre-election tension all taking a part in this slightly high statistic. He’s also been 16% Itchy—again mainly thanks to the cold, and 24% giddy. For the rest she’s been pretty much equal parts infectious and sprained. Oh, and he’s been 8% pregnant and 40 years old. And called Paul.
Mr Urgent has been, if anything a bit more confused, being 63% female. She’s 25% East European, 6% each Afro-Caribbean and Asian and a surprising 6% Viking. He’s also only 89% here. Her religious observance is confused, being as she is 6% Moslem, 6% Rastafarian and 24% Catholic. As to diagnoses he’s been suicidally low, had a bit of a cough, a nasty stinging when she—er… you know, and he’s been 18% pregnant—and called Samantha. And she’s 37 years old.
So there you have it, Paul and Samantha, Ms and Ms average. I'm sure you all recognize them.
Wednesday, February 10, 2010
Margot (Four little words.)
When Jerry first got the back pain that turned out to be myeloma Margot immediately rallied round, sorted his life out for him and got him to and fro for his chemotherapy like the trouper she undeniably is. After around eighteen months the chemo' was stopped, and the myeloma was declared in remission. Jerry wasn't quite the man he had been, but with Margot's help he got back on his feet and soldiered gamely on for five years before the disease came back again.
Sadly this is exactly what myeloma does. It's the cancer that breaks pretty much all the rules, especially the one that allows chemo' to work. Normally cancers grow more rapidly that anything else in the body. the chemo drugs poison growing cells (which is why they make your hair fall out). It also means you can give doses that will poison just the cancer cells and the hair follicles-- well mainly, and leave the rest of the patient in reasonable nick. Not so myeloma. It grows way more slowly that normal cells and tissues, so to kill it completely we'd have to kill the patients other cells and organs a number of times over, so we have to use pulses of chemo' to contain rather than cure.
In the end Jerry proved unequal to the fight and slid slowly into that good night around six years ago. And poor old Margot, having been utterly solid throughout his illness, finally fell apart. The first couple of years alone were really tough, even the arrival of a couple of grandchildren did little to lift her spirits. Anti-depressants did their bit to hold back the overwhelming tides of grief, and sheer dogged determination hauled her slowly out of the pit.
A couple of weeks ago she was back after an interval of almost twelve months, during which she'd successfully taken herself off the med's and was thriving. We talked it through, and time and the gradual demands of the same growing grand children had worked their inevitable magic allowing her to reconnect with the land of the living. She was smiling, and rightfully proud of herself. Then, just before she got up to leave she innocently asked those four little words, "While I'm here Doc..."
Anyone with any medical training will tell you how freighted with menace that tiny phrase can be. And so it was. She just wanted to mention this little pain she'd been getting in her chest, just for the past few months, just when she was climbing hills or stairs, or, as it's been lately, it got a bit cold.
So now poor Margot's off to see the cardiologist, but she still managed to leave the room smiling-- for the first time in years. I hope it lasts.
Sadly this is exactly what myeloma does. It's the cancer that breaks pretty much all the rules, especially the one that allows chemo' to work. Normally cancers grow more rapidly that anything else in the body. the chemo drugs poison growing cells (which is why they make your hair fall out). It also means you can give doses that will poison just the cancer cells and the hair follicles-- well mainly, and leave the rest of the patient in reasonable nick. Not so myeloma. It grows way more slowly that normal cells and tissues, so to kill it completely we'd have to kill the patients other cells and organs a number of times over, so we have to use pulses of chemo' to contain rather than cure.
In the end Jerry proved unequal to the fight and slid slowly into that good night around six years ago. And poor old Margot, having been utterly solid throughout his illness, finally fell apart. The first couple of years alone were really tough, even the arrival of a couple of grandchildren did little to lift her spirits. Anti-depressants did their bit to hold back the overwhelming tides of grief, and sheer dogged determination hauled her slowly out of the pit.
A couple of weeks ago she was back after an interval of almost twelve months, during which she'd successfully taken herself off the med's and was thriving. We talked it through, and time and the gradual demands of the same growing grand children had worked their inevitable magic allowing her to reconnect with the land of the living. She was smiling, and rightfully proud of herself. Then, just before she got up to leave she innocently asked those four little words, "While I'm here Doc..."
Anyone with any medical training will tell you how freighted with menace that tiny phrase can be. And so it was. She just wanted to mention this little pain she'd been getting in her chest, just for the past few months, just when she was climbing hills or stairs, or, as it's been lately, it got a bit cold.
So now poor Margot's off to see the cardiologist, but she still managed to leave the room smiling-- for the first time in years. I hope it lasts.
Thursday, January 28, 2010
The mark of Kane
In hobbles Adam, a man plainly in distress. So much so that he's had to bring Eve along, just so he can lean on her. He's bent double, and obviously struggling with severe back pain. Eve crosses the room and sits, but Adam elects to remain, standing hunched at the end of the desk, grimacing in a pantomime of pain that mimics a Greek mask of tragedy.
Through anguished gasps he manages to tell his tale, with Eve contributing when it all gets too much. He was lying on the floor, prone rather than supine, watching the TV and minding his own business, when he was thunderstruck by a searing pain in his back. Eve takes up the narrative and points out that this pain was occasioned by Kane, their eldest boy, blundering into the room, tripping over dad's trailing legs and landing full force with the point of his elbow right in the middle of Adam's back-- somewhere around L4-S1 for those in the know about such matters.
Four days on and Adam is still in anguish. So I offer to examine him, and stand to walk behind him for a delicate prod. Sure enough he's exhibiting quite a lot of tenderness to touch, but mainly out wide, away from the crucial bones of the spine. These exams are usually easy enough to do through a t-shirt or similar, but since this month Amdridge has been temporarily twinned with Arctic Greenland, everbody's arriving swathed in layers, so to get my anatomical bearings I've had to ask Adam's permission to lift them to have a proper look. As I do I can't help but notice the fetching tattoo he's sporting, right at the pint of impact. In a calligraphic Gothic hand the artist has spelled out his son's name. Verily the mark of Kane.
Through anguished gasps he manages to tell his tale, with Eve contributing when it all gets too much. He was lying on the floor, prone rather than supine, watching the TV and minding his own business, when he was thunderstruck by a searing pain in his back. Eve takes up the narrative and points out that this pain was occasioned by Kane, their eldest boy, blundering into the room, tripping over dad's trailing legs and landing full force with the point of his elbow right in the middle of Adam's back-- somewhere around L4-S1 for those in the know about such matters.
Four days on and Adam is still in anguish. So I offer to examine him, and stand to walk behind him for a delicate prod. Sure enough he's exhibiting quite a lot of tenderness to touch, but mainly out wide, away from the crucial bones of the spine. These exams are usually easy enough to do through a t-shirt or similar, but since this month Amdridge has been temporarily twinned with Arctic Greenland, everbody's arriving swathed in layers, so to get my anatomical bearings I've had to ask Adam's permission to lift them to have a proper look. As I do I can't help but notice the fetching tattoo he's sporting, right at the pint of impact. In a calligraphic Gothic hand the artist has spelled out his son's name. Verily the mark of Kane.
Friday, January 15, 2010
"Badges, badges?.... "
Yes it's complete the quote time on the old caseblog again. The above comes from one of my favourite movies, see if you can come up with the line that follows, whilst I tell you a tale of woe.
Mac' was in his seventies, and was a true Celtic patriarch. He had a large family and they in turn have gone off to have large families of their own, but most have not gone that far away, so their tight knit "clan" is always on hand to gather round in times of adversity. A few years ago Mac' developed a malignant disease, and it was treated, but by the time it had been staged it was on the cards that it had spread and would be reappearing sometime, somewhere.
(Cleverer docs than your humble interlocutor have ways of telling this, by looking at the histology of the "primary" tumour, the degree to which it has invaded the surrounding tissue and the extent of involvement of lymph nodes nearby for example.)
Late last year Mac' developed some tummy trouble and a little pain. Shortly after this he developed jaundice, and it was pretty clear that the disease had come back. He had a couple of speedy consultations with the oncologists, and started treatment which he and we all knew to be palliative. The clan duly gathered, and it was plain that he was going to be well supported and cared for, and we slipped into an easy routine of checking in now and again to see all was well, and letting him steer his course through what we all knew, but never said, was to be his final illness. This was his choice, and we worked hard to respect it.
There are times when you really don't need to ask a question to know the answer. Mac's whole demeanour and approach to his symptoms let us know he knew he was running out of time and really wouldn't appreciate us jabbering on about it. He wanted to get on with living his final days, not confront what came after. In his last week he finally had to admit that there was a little more pain that he was willing to put up with and accepted the offer of a morphine syringe driver to give him small regular trickle doses of opiate, rather than having to rely on intermittent administration of oral medication.
At the time of his recurrence he was introduced to the "Badge Nurse" who looks after terminal illness. From then on he had little to do with them, really neither needing nor wanting their input. Still we are supposed to offer "Gold Standard" care these days and so the badge nurse took it upon themself to visit from time to time. Returning for the first time in a month just after New Year, said nurse, noting the deterioration, pointed out rather too bluntly to Mac' that he was not long for this world. The "clan" politely thanked them and showed them the door.
Twenty four hours later Mac' had died.
He was ready and had no need of the information. What should have been an elegant decline into the everafter has been marred for his remaining family and they are profoundly unhappy. Still at least our "Badge Nurse" can tick a box on their "Gold Standard" protocol :-(
Mac' was in his seventies, and was a true Celtic patriarch. He had a large family and they in turn have gone off to have large families of their own, but most have not gone that far away, so their tight knit "clan" is always on hand to gather round in times of adversity. A few years ago Mac' developed a malignant disease, and it was treated, but by the time it had been staged it was on the cards that it had spread and would be reappearing sometime, somewhere.
(Cleverer docs than your humble interlocutor have ways of telling this, by looking at the histology of the "primary" tumour, the degree to which it has invaded the surrounding tissue and the extent of involvement of lymph nodes nearby for example.)
Late last year Mac' developed some tummy trouble and a little pain. Shortly after this he developed jaundice, and it was pretty clear that the disease had come back. He had a couple of speedy consultations with the oncologists, and started treatment which he and we all knew to be palliative. The clan duly gathered, and it was plain that he was going to be well supported and cared for, and we slipped into an easy routine of checking in now and again to see all was well, and letting him steer his course through what we all knew, but never said, was to be his final illness. This was his choice, and we worked hard to respect it.
There are times when you really don't need to ask a question to know the answer. Mac's whole demeanour and approach to his symptoms let us know he knew he was running out of time and really wouldn't appreciate us jabbering on about it. He wanted to get on with living his final days, not confront what came after. In his last week he finally had to admit that there was a little more pain that he was willing to put up with and accepted the offer of a morphine syringe driver to give him small regular trickle doses of opiate, rather than having to rely on intermittent administration of oral medication.
At the time of his recurrence he was introduced to the "Badge Nurse" who looks after terminal illness. From then on he had little to do with them, really neither needing nor wanting their input. Still we are supposed to offer "Gold Standard" care these days and so the badge nurse took it upon themself to visit from time to time. Returning for the first time in a month just after New Year, said nurse, noting the deterioration, pointed out rather too bluntly to Mac' that he was not long for this world. The "clan" politely thanked them and showed them the door.
Twenty four hours later Mac' had died.
He was ready and had no need of the information. What should have been an elegant decline into the everafter has been marred for his remaining family and they are profoundly unhappy. Still at least our "Badge Nurse" can tick a box on their "Gold Standard" protocol :-(
Friday, January 08, 2010
So where did everybody go?
Even readers far from these shores might have noticed that Dear Old Blighty in general, and Ambridge in particular, have been experiencing a little local difficulty with the weather. Here it hit on Tuesday, and shows little sign of clearing up until well in to next week. The result has been chaos on the roads, dire prognostications over our ever more fragile supply chain for simple necessities like fresh veg and gas as well as grit for the roads. Oh, and a sudden fall in demand for our services.
On any given day our surgery will offer fifty plus "emergency" appointments for use that day only and for urgernt need. And on any given day most of these will be filled. Not so this week. Indeed fewer than half that number have been required. So either everybody has suddenly got better, has gone elsewhere or has revised their opinion of what "emergency" means. I'm guessing it's the latter. No, I'm sure it's the latter-- after all we're all guilty of doing the same when it suits us.
Working in hospitals in the 80s it was apparent when there was a major sporting event everybody stopped wanting urgent attention. I worked over the Live-Aid weekend, and at least one Royal Wedding, and for the hours those events were on screen life in hospital became very quiet. The same used to happen when blockbuster movies were first broadcast on TV, but in these days of mutliple channels and instant DVD release that seems no longer to happen.
It's not particularly surprising that events, be they popular or merely inclement, affect our behaviour, but I am fascinated at the extent to which they can alter our perception of "urgency".
On any given day our surgery will offer fifty plus "emergency" appointments for use that day only and for urgernt need. And on any given day most of these will be filled. Not so this week. Indeed fewer than half that number have been required. So either everybody has suddenly got better, has gone elsewhere or has revised their opinion of what "emergency" means. I'm guessing it's the latter. No, I'm sure it's the latter-- after all we're all guilty of doing the same when it suits us.
Working in hospitals in the 80s it was apparent when there was a major sporting event everybody stopped wanting urgent attention. I worked over the Live-Aid weekend, and at least one Royal Wedding, and for the hours those events were on screen life in hospital became very quiet. The same used to happen when blockbuster movies were first broadcast on TV, but in these days of mutliple channels and instant DVD release that seems no longer to happen.
It's not particularly surprising that events, be they popular or merely inclement, affect our behaviour, but I am fascinated at the extent to which they can alter our perception of "urgency".
Thursday, December 31, 2009
Another year over...
... and lest face it, '09 hasn't been all that special. This can be a miserable time of year at the best of times, as I think I might have mentioned a time or two lately, and it's been noticeably worse this year. Over the past two weeks every surgery has seen at least two or three young adults in floods of tears as the dam bursts and they finally have to admit that they might really be depressed. Mostly it's been on a background of lost employment, failed relationships, mounting debt, and for many, a looming fear of homelessness of of having to go back to living with parents. Even this morning, in my last surgery of the year there have been another handful.
At times like this I am extremely grateful to be doing the job that I do in the place that I do it, but these are problems I'm powerless to directly influence. I can suggest that my poor victims try to throw themselves into something that they used to enjoy doing, that they try finding an outlet to talk about how they're feeling, and that they take the pills I'm about to offer them. What they need is a guarantee of a job, a prince / princess charming-- or at very least a kissable frog, a sizable lottery win, and a place of their own, and none of these things are in my gift.
So today I'm counting my blessings, and hoping that for all of us 2010 will mark an up-turn.
Thank you so much to all of you who read this nonsense, and all the more to those who are moved to comment. You really do all go a long way to keeping as sane I am ever likely to be. All the very best to all of you in the year to come, and God bless us, every one!
At times like this I am extremely grateful to be doing the job that I do in the place that I do it, but these are problems I'm powerless to directly influence. I can suggest that my poor victims try to throw themselves into something that they used to enjoy doing, that they try finding an outlet to talk about how they're feeling, and that they take the pills I'm about to offer them. What they need is a guarantee of a job, a prince / princess charming-- or at very least a kissable frog, a sizable lottery win, and a place of their own, and none of these things are in my gift.
So today I'm counting my blessings, and hoping that for all of us 2010 will mark an up-turn.
Thank you so much to all of you who read this nonsense, and all the more to those who are moved to comment. You really do all go a long way to keeping as sane I am ever likely to be. All the very best to all of you in the year to come, and God bless us, every one!
Monday, December 21, 2009
I'm dreaming of a white...
... sandy beach, sitting on a sun bleached deckchair, sipping ice-cold beer from a condensation covered glass, basking in thirty degree heat, and as far removed from the seasonal tyrrany of tinsel, turkey and kitsch that has become the Great American... er British Christmas.
If it seems like months now that we've been bombarded by ads with every B list "celeb" you can think of exhorting us to buy more food and booze than it's humanly possible to consume let alone enjoy (and lets face it half the crap they're peddling isn't even that enjoyable) that's because the run up to this next fortnight of saturnalian excess began in October. The pressure to indulge is overwhelming, and, not to put too fine a point on it, it's ruining the whole thing. The expectations now for this few days of "quality time" with the family are quite literally crushing, and it's making my punters irredeemably miserable. The only ones who have seemed at all cheerful have been the odd few who are taking this opportunity to jet for for an Antipodean Xmas with barbies on the beach and more sun than you can shake a boomerang at. Frankly I'm envious as hell. It doesn't help that this weekend we had temperatures of -5 centigrade (yes I know it's colder elsewhere, but once it gets anywhere below freezing it's inhumanly cold in my book), but it's more than that.
The expectation heaped onto this next few days is quite unreasonable, and must inevitably end in dissappointment, yet still we are all sucked in, lemming like, to the collective madness. When we come out the other side we'll still all owe tens of thousands to the economy that has tried to kid us for years that we can have something for nothing, the planet will still be melting, however counterintuitive that feels right here, right now, and all the attendant woes of famine plague and pestillence will continue. The unwinnable "War on Terror" will be grinding on its relentless way and our poor long suffering servicemen and women will still be struggling to deliver "peace with honour" in a conflict that offers neither, and will still be constrained to do so on a shoestring budget because we've poured all the cash away bailing out the banks. No so much "the economy, stupid!" as the "stupid economists". And us for believing in their voodoo.
If ever there was a time to take stock and rethink our priorities it's now. Not that we will. We'll all be too busy crowding out the stores and piling in supplies, one third of which we'll not use, and scrabbling around for those last minute gifts for "what's her name down the street that we thought wasn't going to give us anything this year but did".
So let me be the first to wish you Happy Next Christmas!
(Usual VECHN* for the closest guess to the date of my first "Happy Christmas" of the year from a punter)
*If you don't know what this is have a trawl through my misanthropoic back catalogue-- if you can be bothered at all, though I would'nt blame you for not. I'm in such a happy place right now. You can tell right?
If it seems like months now that we've been bombarded by ads with every B list "celeb" you can think of exhorting us to buy more food and booze than it's humanly possible to consume let alone enjoy (and lets face it half the crap they're peddling isn't even that enjoyable) that's because the run up to this next fortnight of saturnalian excess began in October. The pressure to indulge is overwhelming, and, not to put too fine a point on it, it's ruining the whole thing. The expectations now for this few days of "quality time" with the family are quite literally crushing, and it's making my punters irredeemably miserable. The only ones who have seemed at all cheerful have been the odd few who are taking this opportunity to jet for for an Antipodean Xmas with barbies on the beach and more sun than you can shake a boomerang at. Frankly I'm envious as hell. It doesn't help that this weekend we had temperatures of -5 centigrade (yes I know it's colder elsewhere, but once it gets anywhere below freezing it's inhumanly cold in my book), but it's more than that.
The expectation heaped onto this next few days is quite unreasonable, and must inevitably end in dissappointment, yet still we are all sucked in, lemming like, to the collective madness. When we come out the other side we'll still all owe tens of thousands to the economy that has tried to kid us for years that we can have something for nothing, the planet will still be melting, however counterintuitive that feels right here, right now, and all the attendant woes of famine plague and pestillence will continue. The unwinnable "War on Terror" will be grinding on its relentless way and our poor long suffering servicemen and women will still be struggling to deliver "peace with honour" in a conflict that offers neither, and will still be constrained to do so on a shoestring budget because we've poured all the cash away bailing out the banks. No so much "the economy, stupid!" as the "stupid economists". And us for believing in their voodoo.
If ever there was a time to take stock and rethink our priorities it's now. Not that we will. We'll all be too busy crowding out the stores and piling in supplies, one third of which we'll not use, and scrabbling around for those last minute gifts for "what's her name down the street that we thought wasn't going to give us anything this year but did".
So let me be the first to wish you Happy Next Christmas!
(Usual VECHN* for the closest guess to the date of my first "Happy Christmas" of the year from a punter)
*If you don't know what this is have a trawl through my misanthropoic back catalogue-- if you can be bothered at all, though I would'nt blame you for not. I'm in such a happy place right now. You can tell right?
Tuesday, December 15, 2009
It's the most wonderful time...
As the popular song has it. And full of wonder it must be to be sure. You see, for the next two weeks I and my humble wares become the infallible, guaranteed, absolute and only panacea for all ills. After all it's nearly Christmas, so we are transformed for a brief interval into a branch of the Elf Service and gifted healing powers normally reserved for song and fable. Well at least so it holds in the popular imagination.
The only problem is, unlike the jolly old man in red (courtesy of an early 20th Century Coca-Cola ad campaign apparently) we have to treat with all comers, both the "naughty" and "nice". A great many of both sorts crossed the Jesterly threshhold yesterday coughing, clutching sore throats or, more concerningly, grey cardboad vomit bowl "boaters". They all had some form of viral illness and fully expected I'd be in a position to cure it for them on the spot, or at least come up with an antibiotic to do it inside 48 hours so they can be ready for the fortnight long party that has become the "traditional" Ambridge Christmas we've all come to know and loathe... er... love.
And this particular year that's a hard contention to refute. After all viruses are now curable aren't they. There's that magical Tamiflu we've seen being dished out in bucketfulls for the swine flu, so if it's good for that how much the better will it do for a sore throat?
Well Mrs A, since you ask, not much. Indeed I'd not be allowed to prescribe it for Tyrone just now. You see, although he was "terribly ill" half a hour ago, he's now whirling round the consulting room like the Tazmanian Devil and looking even better than I feel. So no, I don't think his bit of a cough was the beginnings of flu, or pleurisy, or pneumonia... and no I don't think he needs Tamiflu, or Antibiotics, or fairydust. In fact I'm pretty sure he'll be fine for Christmas even if you leave him outdoors all day everyday till the big one itself.
And despite having wrapped himself in the paper bedroll like a demonically possessed Andrex puppy Tyrone was not the worst behaved of my little visitors yesterday afternoon. Nor the least ill.
Now it's true there are key events on the calendar that distort normal behaviour patterns and Christmas and New year are amongst the biggest. No-body is allowed to be ill for Christmas. And life is supposed to fantastically re-invent itself at New Year as we all resolve to do more of what we ought and less / none of what we didn't ought. The burden of this latter expectation can be overwhelming and it's no surprise that our colleagues in A&E and Mental Health services dread New Year as those so overhwelmed are bowled over by the tidal wave of their own expectations and driven to the edge of self destruction thereby.
I wonder, has it always been thus? Were the Druids besieged at Stonehenge by long lines of tartan clad celts on the eve of every solstice and equinox looking for a cure for that "bit of a cough" or that "Pilum head sticking out of my chest" before the drunken revels could begin in earnest? I'm guessing so, and if I'm right I'm also slightly comforted by the thought in a way that's rather hard to describe.
The only problem is, unlike the jolly old man in red (courtesy of an early 20th Century Coca-Cola ad campaign apparently) we have to treat with all comers, both the "naughty" and "nice". A great many of both sorts crossed the Jesterly threshhold yesterday coughing, clutching sore throats or, more concerningly, grey cardboad vomit bowl "boaters". They all had some form of viral illness and fully expected I'd be in a position to cure it for them on the spot, or at least come up with an antibiotic to do it inside 48 hours so they can be ready for the fortnight long party that has become the "traditional" Ambridge Christmas we've all come to know and loathe... er... love.
And this particular year that's a hard contention to refute. After all viruses are now curable aren't they. There's that magical Tamiflu we've seen being dished out in bucketfulls for the swine flu, so if it's good for that how much the better will it do for a sore throat?
Well Mrs A, since you ask, not much. Indeed I'd not be allowed to prescribe it for Tyrone just now. You see, although he was "terribly ill" half a hour ago, he's now whirling round the consulting room like the Tazmanian Devil and looking even better than I feel. So no, I don't think his bit of a cough was the beginnings of flu, or pleurisy, or pneumonia... and no I don't think he needs Tamiflu, or Antibiotics, or fairydust. In fact I'm pretty sure he'll be fine for Christmas even if you leave him outdoors all day everyday till the big one itself.
And despite having wrapped himself in the paper bedroll like a demonically possessed Andrex puppy Tyrone was not the worst behaved of my little visitors yesterday afternoon. Nor the least ill.
Now it's true there are key events on the calendar that distort normal behaviour patterns and Christmas and New year are amongst the biggest. No-body is allowed to be ill for Christmas. And life is supposed to fantastically re-invent itself at New Year as we all resolve to do more of what we ought and less / none of what we didn't ought. The burden of this latter expectation can be overwhelming and it's no surprise that our colleagues in A&E and Mental Health services dread New Year as those so overhwelmed are bowled over by the tidal wave of their own expectations and driven to the edge of self destruction thereby.
I wonder, has it always been thus? Were the Druids besieged at Stonehenge by long lines of tartan clad celts on the eve of every solstice and equinox looking for a cure for that "bit of a cough" or that "Pilum head sticking out of my chest" before the drunken revels could begin in earnest? I'm guessing so, and if I'm right I'm also slightly comforted by the thought in a way that's rather hard to describe.
Monday, December 07, 2009
Letting go.
I've ranted about this topic before. After events of a week or two ago I might, possibly, be coming to change my view. A little.
Bill was 97. He'd been living in a nursing home for the best part of a decade. It was a nice home, well run, and he was cared for in every sense of the word. To start with he was just a bit older than the average resident, but down the years as faces came and went he gradually became the eldest.
When he went in he was just a bit wobbly on his legs, and a trifle vague on times and dates. Over the time his wobbliness had become worse, but his haziness lifted (largely because his previously unfettered access to sherry was rather more "managed"). Slowly he took to spending more and more of his days in the chair, but remained bright, alert and sociable.
Last year his ticker started playing up, odd missed beats now and again, then runs of palpitations, then the syncopated jazz riffs of atrial fibrillation. This tipped him over the edge and into heart failure-- an increasingly debilitating shortness of breath with attendant ankle swelling-- which he grew to hate, and perhaps to fear. We tried him with digoxin, diuretics and one or two other things with little benefit. In the end his heart just wasn't up for being pushed any harder, and he began to fade.
And so it was that with a heavy heart a few weeks ago I was called in to sit down with him and his family to ask the awful question, "if your heart stops what would you want us to do about that?" The home needed to know, partly because it's good practice these days, but mostly to make sure they could respect his wishes. In the event that we hadn't asked the standard assumption is that resuscitation will be attempted and paramedics will be called. Bill, quite rightly, didn't want any of this for him. As he put it "I had my three-score and ten some time ago and everything else has been interest."
Within a few days of our discussion Bill passed peacefully away with a daughter in attendance. It was almost as though he'd been looking for permission to let go.
Bill was 97. He'd been living in a nursing home for the best part of a decade. It was a nice home, well run, and he was cared for in every sense of the word. To start with he was just a bit older than the average resident, but down the years as faces came and went he gradually became the eldest.
When he went in he was just a bit wobbly on his legs, and a trifle vague on times and dates. Over the time his wobbliness had become worse, but his haziness lifted (largely because his previously unfettered access to sherry was rather more "managed"). Slowly he took to spending more and more of his days in the chair, but remained bright, alert and sociable.
Last year his ticker started playing up, odd missed beats now and again, then runs of palpitations, then the syncopated jazz riffs of atrial fibrillation. This tipped him over the edge and into heart failure-- an increasingly debilitating shortness of breath with attendant ankle swelling-- which he grew to hate, and perhaps to fear. We tried him with digoxin, diuretics and one or two other things with little benefit. In the end his heart just wasn't up for being pushed any harder, and he began to fade.
And so it was that with a heavy heart a few weeks ago I was called in to sit down with him and his family to ask the awful question, "if your heart stops what would you want us to do about that?" The home needed to know, partly because it's good practice these days, but mostly to make sure they could respect his wishes. In the event that we hadn't asked the standard assumption is that resuscitation will be attempted and paramedics will be called. Bill, quite rightly, didn't want any of this for him. As he put it "I had my three-score and ten some time ago and everything else has been interest."
Within a few days of our discussion Bill passed peacefully away with a daughter in attendance. It was almost as though he'd been looking for permission to let go.
Saturday, November 28, 2009
Mothers and Daughters.
Friday was an odd day. It's the long run up to Christmas that starts in earnest this weekend with German Markets seemingly springing up all across the land and traffic into all our major town centres gridlocked as we flock to see how our continental cousins do Festive. (More sausage and gluhwein than turkey or beer and a lot of carved wood apparently).
Then there's the flu jabs-- not only the "normal" ones this year, but also the added thrill of pandemic jabs, which pretty much everybody seems to want but for which the target population is at variance to some degree with the other jab. Still in our neck of the woods it's proving popular. We gave 500 last week, and filled another 500 clinic appointments within 2 hours of opening them up. It's almost as though we were offering tickets to see Robbie Williams.
But this Friday was mainly odd because of a couple of encounters that made it plain that the rules of normal behaviour had been suspended for the day. and this weeks before the Lord of Misrule has his annual outing.
Exhibit One: Jocasta.
A precocious young lady of ten. She has eczema, and a month ago kindly young Dr Neighbour decided it looked a bit nasty, and needed treating for infection as well as the more normal inflammation of the eczema itself. This isn't uncommon. Eczema itches. When it itches we scratch. When we scratch we break the skin, bugs get in and a low grade infection adds itself to the misery of the eczema. Mixing an antibiotic into the cream is a far more effective way to tackle this than to opt for "systemic" antibiotics (that's the ones you take by mouth -- or sometimes in a drip) which might eventually work, but are far more likely to fuel resistance and generate side effects.
Sadly Jocasta's eczema looked every bit as nasty on Friday morning as it did a month ago. "How could this be?" I wanted to know-- "Didn't the cream work then?"
"Well we didn't use it" says Mum. "Jocasta said it made her legs sting!"
"Oh dear, so how long did you try it for before you sopped it then?" a reasonable question I felt, but both Mummy and Jocasta gave me that look that suggested I had suggested they go drown sackfulls of puppies.
"Well we only tried it the once. After all she said it stung!"
So we've agreed that poor Jocasta is going to try to be brave, in the hope (firm expectation on my part) that the cream will not only stop singing very soon, but might even do as intended as clear the infection. a;;owing the eczema to settle in its wake.
Exhibit 2: Cissie.
An urgent request for a home visit mid afternoon. Cissie's daughter has been to stay for the last 3 weeks. Cissie will be 90 in a couple of years, and has been left all alone after her husband's passing many years ago. Her daughter lives a long way off the patch, but came to stay when Cissie, normally fiercely independent, got a bit confused, as often happens when folks beyond "a certain age" develop a urinary tract infection. Antibiotics and three weeks of regular meals have worked wonders for her and she's fitter and better nourished now than she's been for a year or two. Daughter has a pressing engagement elsewhere this weekend, but brother is on his way and will be arriving before bedtime.
Daughter has also managed to arrange carers to call twice a day to help Cissie with getting up and going back to bed. She even tried to get her to consider meals on wheels, but after trying one Cissie was less persuaded on that front and would prefer to keep making her own arrangements, which she is in fact now quite capable of doing again. Still for over a week Cissie has been independent and Daughter has simply been helping her sort out the arrangements. And the Friday lunchtime Cissie refuses to eat, starts leaning heavily on the walking frame, takes herself off to the back parlour and refuses to speak to her daughter at all.
When I visit there's no apparent cause for this sudden "turn for the worse". Indeed Cissie is quite polite with me and wonders rather what all the fuss has been about. She does in the end allow me to gently check her out and confirm that she has neither water infection, flu, or any other cause of acute ill health. Neither has she suffered a stroke or any other insult to her frame as can occur in old age. The simple fact is that Cissie would far rather be cared for by Daughter then Son and wanted to make this plain without saying so. I'm pretty sure she's got the message.
Then there's the flu jabs-- not only the "normal" ones this year, but also the added thrill of pandemic jabs, which pretty much everybody seems to want but for which the target population is at variance to some degree with the other jab. Still in our neck of the woods it's proving popular. We gave 500 last week, and filled another 500 clinic appointments within 2 hours of opening them up. It's almost as though we were offering tickets to see Robbie Williams.
But this Friday was mainly odd because of a couple of encounters that made it plain that the rules of normal behaviour had been suspended for the day. and this weeks before the Lord of Misrule has his annual outing.
Exhibit One: Jocasta.
A precocious young lady of ten. She has eczema, and a month ago kindly young Dr Neighbour decided it looked a bit nasty, and needed treating for infection as well as the more normal inflammation of the eczema itself. This isn't uncommon. Eczema itches. When it itches we scratch. When we scratch we break the skin, bugs get in and a low grade infection adds itself to the misery of the eczema. Mixing an antibiotic into the cream is a far more effective way to tackle this than to opt for "systemic" antibiotics (that's the ones you take by mouth -- or sometimes in a drip) which might eventually work, but are far more likely to fuel resistance and generate side effects.
Sadly Jocasta's eczema looked every bit as nasty on Friday morning as it did a month ago. "How could this be?" I wanted to know-- "Didn't the cream work then?"
"Well we didn't use it" says Mum. "Jocasta said it made her legs sting!"
"Oh dear, so how long did you try it for before you sopped it then?" a reasonable question I felt, but both Mummy and Jocasta gave me that look that suggested I had suggested they go drown sackfulls of puppies.
"Well we only tried it the once. After all she said it stung!"
So we've agreed that poor Jocasta is going to try to be brave, in the hope (firm expectation on my part) that the cream will not only stop singing very soon, but might even do as intended as clear the infection. a;;owing the eczema to settle in its wake.
Exhibit 2: Cissie.
An urgent request for a home visit mid afternoon. Cissie's daughter has been to stay for the last 3 weeks. Cissie will be 90 in a couple of years, and has been left all alone after her husband's passing many years ago. Her daughter lives a long way off the patch, but came to stay when Cissie, normally fiercely independent, got a bit confused, as often happens when folks beyond "a certain age" develop a urinary tract infection. Antibiotics and three weeks of regular meals have worked wonders for her and she's fitter and better nourished now than she's been for a year or two. Daughter has a pressing engagement elsewhere this weekend, but brother is on his way and will be arriving before bedtime.
Daughter has also managed to arrange carers to call twice a day to help Cissie with getting up and going back to bed. She even tried to get her to consider meals on wheels, but after trying one Cissie was less persuaded on that front and would prefer to keep making her own arrangements, which she is in fact now quite capable of doing again. Still for over a week Cissie has been independent and Daughter has simply been helping her sort out the arrangements. And the Friday lunchtime Cissie refuses to eat, starts leaning heavily on the walking frame, takes herself off to the back parlour and refuses to speak to her daughter at all.
When I visit there's no apparent cause for this sudden "turn for the worse". Indeed Cissie is quite polite with me and wonders rather what all the fuss has been about. She does in the end allow me to gently check her out and confirm that she has neither water infection, flu, or any other cause of acute ill health. Neither has she suffered a stroke or any other insult to her frame as can occur in old age. The simple fact is that Cissie would far rather be cared for by Daughter then Son and wanted to make this plain without saying so. I'm pretty sure she's got the message.
Monday, November 23, 2009
Pretzel logic.
Once every couple of months or so there's a boffin or a group on Radio 4 shouting the odds about how they can save the NHS pots of cash but keeping folks out of hospital. Last week it was the turn of the Alzheimer's Society. I'll admit to only having caught a small part of the piece, but these things are fairly predictable in their content, intensely well meaning, and woefully wrong in their assumptions, and the thing that really strikes me is, received entirely uncritically by reporters who are otherwise presented as amongst the most enquiring minds of their own or any other generation.
If I have the figures slightly wrong I apologize, but the thrust of the argument is unaffected. It seems the Alzheimer's Society had done a piece of work which suggested that at any given time a large number of hospital beds were occupied by dementia sufferers who might be better cared for at home. the number might have been as high as 1 in 4 but certainly at least 1 in 10. Now it's true that in a number of disciplines, notably general medicine, a great many inpatients are taken on to the ward and then kept longer than is medically necessary because of complex social factors, and dementia would be one of the most common of these. This means that dementia sufferers cannot be discharged as easily, needing as they often do, more community care and support, which is seldom available freely and on demand. Such discharges require planning. Planning is seemingly impossible across a weekend, and is seldom practicable on a Friday, and so these poor "long-stay" patients often stay a week or more longer than is needed simply to accommodate "Social Care".
Please don't get the impression here that I'm disparaging the organizers or providers of social care either. I know first hand how hard their job is, squeezing a quarts worth of service from a pints worth of resource is not easy at the best of times. To expect them to do so at short notice, particularly at weekends when office support has evaporated, would be plainly unreasonable.
The upshot, patients with complex care needs tend to stay longer in hospitals. This is an eternal verity. Now the Alzheimer's Society quite reasonably argue that with better input in the home admissions could be prevented, and discharges facilitated. But those resources are currently sadly lacking, and if we think the health budget is poorly funded, our social services colleagues gaze in envy from the"blasted heath" of close on a decade of "efficiency savings".
Lets assume for a minute, that some Fairy God-Social Worker were to wave a wand and overturn this to provide the network of carers and support staff we need. Let's then assume that the service they supply can kick in at the first hint of a crisis and prevent all unnecessary admissions. Let's further assume the 1 in 10 figure (which I still believe is an overestimate across the entire UK hospital population, but that's an argument for another day perhaps) is correct.
So, if every one of those patients who was in hospital could instead be cared for at home, we could reduce the hospital population by 10% overnight. If we allow that there is no-one else in line to occupy those vacated beds then we could have a whole load of spare capacity in the NHS hospitals estate. That being the case it would be a simple arithmetical exercise to close 1 in every 10 hospitals, thus saving the NHS pots of lovely cash.
To paraphrase a currently very popular Meerkat-- "Simples!"
If I have the figures slightly wrong I apologize, but the thrust of the argument is unaffected. It seems the Alzheimer's Society had done a piece of work which suggested that at any given time a large number of hospital beds were occupied by dementia sufferers who might be better cared for at home. the number might have been as high as 1 in 4 but certainly at least 1 in 10. Now it's true that in a number of disciplines, notably general medicine, a great many inpatients are taken on to the ward and then kept longer than is medically necessary because of complex social factors, and dementia would be one of the most common of these. This means that dementia sufferers cannot be discharged as easily, needing as they often do, more community care and support, which is seldom available freely and on demand. Such discharges require planning. Planning is seemingly impossible across a weekend, and is seldom practicable on a Friday, and so these poor "long-stay" patients often stay a week or more longer than is needed simply to accommodate "Social Care".
Please don't get the impression here that I'm disparaging the organizers or providers of social care either. I know first hand how hard their job is, squeezing a quarts worth of service from a pints worth of resource is not easy at the best of times. To expect them to do so at short notice, particularly at weekends when office support has evaporated, would be plainly unreasonable.
The upshot, patients with complex care needs tend to stay longer in hospitals. This is an eternal verity. Now the Alzheimer's Society quite reasonably argue that with better input in the home admissions could be prevented, and discharges facilitated. But those resources are currently sadly lacking, and if we think the health budget is poorly funded, our social services colleagues gaze in envy from the"blasted heath" of close on a decade of "efficiency savings".
Lets assume for a minute, that some Fairy God-Social Worker were to wave a wand and overturn this to provide the network of carers and support staff we need. Let's then assume that the service they supply can kick in at the first hint of a crisis and prevent all unnecessary admissions. Let's further assume the 1 in 10 figure (which I still believe is an overestimate across the entire UK hospital population, but that's an argument for another day perhaps) is correct.
So, if every one of those patients who was in hospital could instead be cared for at home, we could reduce the hospital population by 10% overnight. If we allow that there is no-one else in line to occupy those vacated beds then we could have a whole load of spare capacity in the NHS hospitals estate. That being the case it would be a simple arithmetical exercise to close 1 in every 10 hospitals, thus saving the NHS pots of lovely cash.
To paraphrase a currently very popular Meerkat-- "Simples!"
Thursday, November 12, 2009
I don't know much about art....
We've a very genteel nursing home on the patch. It's taken over an Edwardian era Vicarage and converted it to accommodate the residents in the rooms formerly devoted to staff and family, using the larger reception rooms for dining and lounging very much as you'd expect. It's a good one. You can tell because your never greeted by an unsavoury aroma when you cross the threshold-- regular visitors to such establishments will know exactly what I mean, there are always staff on hand to greet you, and always with a smile, and none of the residents is left to wander wraith like through the halls and stairwells.
It's also apparently run by people of quite unsound mind. They commissioned a local artist (also a patient of mine as it happens) to bedeck their common areas with what our family has always referred to as "Muriels". Vasty paintings of trellised vines and frolicking Putti interspersed with little snippets of inspirational text . All very tasteful, but neither Vicarly nor especially Homey, but not without it's own idiosyncratic charm. But this is far from the limit of their artistic pretensions.
Being an Edwardian era property the home has grounds which though obviously landscaped ab initio, had been let go a bit before the present occupiers took root. So they decided to do them up a bit and have a sculpture park. You know the sort, all concrete Lions and Dishevelled and Deshabillee Nymphs and Graces. Indeed the portals to the establishment are guarded by two resplendent sprawling "marbled" Lions of fierce and noble mien who look like they've been there since time immemorial.
Now I've not visited for a few months-- they're good enough that I seldom have to except to welcome new residents who have opted to join our list, or to review the med's of those of our patients who have been lucky enough to fetch up there-- yes Dr Field et al, some of us really do go out and review our patients med's you know (sorry just a bit of a snit about today's Radio 4 News coverage, if you've not heard it it really doesn't warrant repeating now-- forgive the intrusion). So today I was especially pleased to see they've installed a new sculpture pride of place in the centre of their lawn.
There, atop a noble plinth stands a life size "bronze" of a sheepdog. Fair enough I hear you say. Nothing wrong with a statue of dear old Shep surely? And you're quite right, except....
This dog has his forepaws planted foresquare on the rump of a rather startled looking sheep, his hind legs splayed wide in classic leap-frog pose as he vaults over his ovine charge, ears flapping away behind him.
After spotting this I chuckled all the way back to the surgery, and I only hope, when my time comes, they find me someplace just as quirky to spend my dotage.
It's also apparently run by people of quite unsound mind. They commissioned a local artist (also a patient of mine as it happens) to bedeck their common areas with what our family has always referred to as "Muriels". Vasty paintings of trellised vines and frolicking Putti interspersed with little snippets of inspirational text . All very tasteful, but neither Vicarly nor especially Homey, but not without it's own idiosyncratic charm. But this is far from the limit of their artistic pretensions.
Being an Edwardian era property the home has grounds which though obviously landscaped ab initio, had been let go a bit before the present occupiers took root. So they decided to do them up a bit and have a sculpture park. You know the sort, all concrete Lions and Dishevelled and Deshabillee Nymphs and Graces. Indeed the portals to the establishment are guarded by two resplendent sprawling "marbled" Lions of fierce and noble mien who look like they've been there since time immemorial.
Now I've not visited for a few months-- they're good enough that I seldom have to except to welcome new residents who have opted to join our list, or to review the med's of those of our patients who have been lucky enough to fetch up there-- yes Dr Field et al, some of us really do go out and review our patients med's you know (sorry just a bit of a snit about today's Radio 4 News coverage, if you've not heard it it really doesn't warrant repeating now-- forgive the intrusion). So today I was especially pleased to see they've installed a new sculpture pride of place in the centre of their lawn.
There, atop a noble plinth stands a life size "bronze" of a sheepdog. Fair enough I hear you say. Nothing wrong with a statue of dear old Shep surely? And you're quite right, except....
This dog has his forepaws planted foresquare on the rump of a rather startled looking sheep, his hind legs splayed wide in classic leap-frog pose as he vaults over his ovine charge, ears flapping away behind him.
After spotting this I chuckled all the way back to the surgery, and I only hope, when my time comes, they find me someplace just as quirky to spend my dotage.
Friday, November 06, 2009
Speaking truth unto power.
Never an easy thing to do for sure, but lately it would seem it has become near impossible. For residents of these fair isles the story of poor Professor Nutt will likely be familiar, but for the rest of you Auntie will fill in the blanks.
It seems the Prof. has been a bit fed up with his political masters apparently failing to hear anything he has had to say on his specific area of expertise, so he has made one public comment too many for them and has been given the push. Now I agree that advisors must advise but politicains must finally decide. That's what a representative democracy is all about, but when political and evidential approaches to an area of public policy diverge as radically as they now appear to in the "difficult" area of drugs there comes a point where the advisors become superfluous and we end up with an approach based on "public opinion". It seems Mr Mackie really is setting HMG's current drugs policy and reasoned advice is deemed unnecessary and inadvisable.
In the long run this damages the credibility of the policy as presently voiced, and calls the judgement of our political representatives into question. If the policy is determined not on the evidence of actual risk, but on some otehr grounds, those grounds need to be far better and more clearly articulated to have credence. If the present classification system is more moralistic than scientific then so be it, but at least let's acknowledge that and move on.
I'm told the Grauniad has suggested that we have moved from "evidence led policy" to "policy led evidence" in this area, and this seems to have been an increasing trend across government for at least two decades, and not just here in Dear Old Blighty or on this lone issue. So perhaps it's time we dropped the figleaf the "advisory" committees lend to policy formulation and let the whole shooting match be determined by focus group and the "Court of Public Opinion".
After all things worked so much better when we had hanging, flogging and transportation to fall back on.
It seems the Prof. has been a bit fed up with his political masters apparently failing to hear anything he has had to say on his specific area of expertise, so he has made one public comment too many for them and has been given the push. Now I agree that advisors must advise but politicains must finally decide. That's what a representative democracy is all about, but when political and evidential approaches to an area of public policy diverge as radically as they now appear to in the "difficult" area of drugs there comes a point where the advisors become superfluous and we end up with an approach based on "public opinion". It seems Mr Mackie really is setting HMG's current drugs policy and reasoned advice is deemed unnecessary and inadvisable.
In the long run this damages the credibility of the policy as presently voiced, and calls the judgement of our political representatives into question. If the policy is determined not on the evidence of actual risk, but on some otehr grounds, those grounds need to be far better and more clearly articulated to have credence. If the present classification system is more moralistic than scientific then so be it, but at least let's acknowledge that and move on.
I'm told the Grauniad has suggested that we have moved from "evidence led policy" to "policy led evidence" in this area, and this seems to have been an increasing trend across government for at least two decades, and not just here in Dear Old Blighty or on this lone issue. So perhaps it's time we dropped the figleaf the "advisory" committees lend to policy formulation and let the whole shooting match be determined by focus group and the "Court of Public Opinion".
After all things worked so much better when we had hanging, flogging and transportation to fall back on.
Thursday, October 22, 2009
Insomnia
Both Moon and Pleiades are gone,
The mid-night hours crawl on and on,
And I lie down to sleep, alone.
These are not my words, but a rather rough and ready translation of a poem that speaks across two and a half millennia by the "divine" Sappho. It talks of quiet solitude, loneliness and above all of insomnia. O.K. I'm inferring the loneliness, but the rest is there, and the sentiment is a raw and immediate now as it was then. She was writing in a time when being awake in the middle of the night meant lying hour after hour in engulfing darkness, waiting out the turn of the earth, longing for either the light of dawn or the relief of sleep.
Anyone who has ever had problems sleeping will sympathize. At least now we have it a little easier. We can have light at the flick of a switch, we can divert our ears from the slow sure thump of our pulse beat with tunes on our ipod, or all night poker / roulette / bingo on the telly. We might even get back up, rifle the fridge for tit-bits, or boot up the "machine" and surf away the hours to daylight.
And for a night or two any or all of the above can be a comfort. But after longer than this, the latter day insomniac will end up feeling every bit as wretched as the poet of antiquity and the myriad fellow sufferers down the years inbetween. Small wonder then that some of our oldest remedies have been hypnotics in one form or another, or that they remain among the most commonly prescribed items even now. Yet the real remedy for our shared affliction comes more often from within. If we're not sleeping then something is preventing us, and unlocking what that is, and processing it holds the key to restoring calm and rest. That and switching to De-caff.
Easy, eh?
The mid-night hours crawl on and on,
And I lie down to sleep, alone.
These are not my words, but a rather rough and ready translation of a poem that speaks across two and a half millennia by the "divine" Sappho. It talks of quiet solitude, loneliness and above all of insomnia. O.K. I'm inferring the loneliness, but the rest is there, and the sentiment is a raw and immediate now as it was then. She was writing in a time when being awake in the middle of the night meant lying hour after hour in engulfing darkness, waiting out the turn of the earth, longing for either the light of dawn or the relief of sleep.
Anyone who has ever had problems sleeping will sympathize. At least now we have it a little easier. We can have light at the flick of a switch, we can divert our ears from the slow sure thump of our pulse beat with tunes on our ipod, or all night poker / roulette / bingo on the telly. We might even get back up, rifle the fridge for tit-bits, or boot up the "machine" and surf away the hours to daylight.
And for a night or two any or all of the above can be a comfort. But after longer than this, the latter day insomniac will end up feeling every bit as wretched as the poet of antiquity and the myriad fellow sufferers down the years inbetween. Small wonder then that some of our oldest remedies have been hypnotics in one form or another, or that they remain among the most commonly prescribed items even now. Yet the real remedy for our shared affliction comes more often from within. If we're not sleeping then something is preventing us, and unlocking what that is, and processing it holds the key to restoring calm and rest. That and switching to De-caff.
Easy, eh?
Thursday, October 15, 2009
Mirror mirror
Last week saw the annual ritual that was my appraisal. In past years I have tried to spice this up by soliciting buzzwords to shoehorn into the conversation. This year I thought it was time I grew up a bit, so I tried to do this one cold. My appraiser this year was a colleague from somewhere the far side of Felpersham, and a year or two older than myself. We spent an afternoon dissecting the year just gone and trying to read the runes for the year to come. As with all public servants dependent on the public purse we expect to be asked to do more with less, but we both agree we've been here, or somewhere pretty close to it before.
Overall then, not too bad, and although I missed the opportunity to inject the odd piece of inappropriate jargon or old rock lyric into the conversation, we parted on good terms, we even got round to talking about poor Albert. And I've got my buzzword for next year from the process itself. Indeed every GP in the country will have the same buzzword ever after as we progress from appraisal to licensing and re validation, and that word will be "reflection". I'm thinking of having a silver spandex suit made up for next time, or a top hat adorned with mirrors like Noddy Holder used to wear.
I know I'm getting on a bit, and I've also been known to wax a bit cynical from time to time, but the new system, in its current format (which may still change) will have us recording every educational activity we pursue at least twice, and preferably three times. First to show we did it, then to show we thought about it, then if possible, to show that when we'd thought about it we did what we thought we ought having done it, and thought about it. Clear?
It's absolutely right and proper that we hold our practice up to scrutiny, and that we try to show that we are continuing to strive to be the best that we can. I'm just not quite sure this new endlessly recursive method is entirely the best. Still it's a very small price to pay for the privilege of holding a licence to practice medicine.
The only other problem I have, is that all this professional introspection can rather become a habit, and it's starting to spill over into life outside the surgery right now. I'm discovering I've got a little way to go to becoming a zen master.
Time to dust off the old relaxation technique methinks, well after a nice fruity claret anyhow.
Overall then, not too bad, and although I missed the opportunity to inject the odd piece of inappropriate jargon or old rock lyric into the conversation, we parted on good terms, we even got round to talking about poor Albert. And I've got my buzzword for next year from the process itself. Indeed every GP in the country will have the same buzzword ever after as we progress from appraisal to licensing and re validation, and that word will be "reflection". I'm thinking of having a silver spandex suit made up for next time, or a top hat adorned with mirrors like Noddy Holder used to wear.
I know I'm getting on a bit, and I've also been known to wax a bit cynical from time to time, but the new system, in its current format (which may still change) will have us recording every educational activity we pursue at least twice, and preferably three times. First to show we did it, then to show we thought about it, then if possible, to show that when we'd thought about it we did what we thought we ought having done it, and thought about it. Clear?
It's absolutely right and proper that we hold our practice up to scrutiny, and that we try to show that we are continuing to strive to be the best that we can. I'm just not quite sure this new endlessly recursive method is entirely the best. Still it's a very small price to pay for the privilege of holding a licence to practice medicine.
The only other problem I have, is that all this professional introspection can rather become a habit, and it's starting to spill over into life outside the surgery right now. I'm discovering I've got a little way to go to becoming a zen master.
Time to dust off the old relaxation technique methinks, well after a nice fruity claret anyhow.
Tuesday, October 13, 2009
Memento Mori
I have a photo on my wall of a young man. He wears a serge uniform and a sam brown belt and stands in front of the engine of his SE5a fighter aircraft. Every now and again someone asks me who he is and I tell them. Only twice in the fifteen years he's been up there has anybody come in and told me who he is before asking me why he's on my wall.
He's no relation, though I would have been proud to claim him as one. He is my "memento mori". His presence reminds me that whatever I do, or do not do, time will march on. However much I triumph or fail in this life, in a couple of generations, or less, none of it will amount to much. In his day poor Albert was rock-star famous. The picture I have of him is one of a few iconic images that are well know to aviation historians, and yet, in fifteen years, and with all the thousands of people that have passed through my room, in that time only twice has he been correctly identified.
He tells me that all you have to do is keep turning up, climbing into the hot seat and doing the best you can until time or circumstance take it away from you. And he tells me that however important, famous or extra-ordinary I might feel, were I to come back in 50 or 100 years people would have a problem remembering I'd even been here.
It's perhaps a bit of an odd choice, but this aviator of the last century helps to keep me grounded, and at the same time, in a very small way I help to keep his memory alive. But even when neither of us are here and none can recall us, life will go on for those that come after. And this can sometimes be a comfort.
He's no relation, though I would have been proud to claim him as one. He is my "memento mori". His presence reminds me that whatever I do, or do not do, time will march on. However much I triumph or fail in this life, in a couple of generations, or less, none of it will amount to much. In his day poor Albert was rock-star famous. The picture I have of him is one of a few iconic images that are well know to aviation historians, and yet, in fifteen years, and with all the thousands of people that have passed through my room, in that time only twice has he been correctly identified.
He tells me that all you have to do is keep turning up, climbing into the hot seat and doing the best you can until time or circumstance take it away from you. And he tells me that however important, famous or extra-ordinary I might feel, were I to come back in 50 or 100 years people would have a problem remembering I'd even been here.
It's perhaps a bit of an odd choice, but this aviator of the last century helps to keep me grounded, and at the same time, in a very small way I help to keep his memory alive. But even when neither of us are here and none can recall us, life will go on for those that come after. And this can sometimes be a comfort.
Thursday, October 08, 2009
Once upon a time...
This post is in reaction to a sudden upsurge in followers, two of whom, I think, are still in school and looking to a career in medicine. Now I know this blog has violent mood swings about the whole GP / NHS experience, so I'm a little humbled to think they might be interested in what I have to say.
So kids, if you're still out there this one's for you.
A generation ago (at least) a thirteen year old lad came to a sudden, astonishing realization. He wasn't suited for the Army as he'd always imagined -- too independent of thought and slovenly of habits. No what he wanted to do even more than blow people apart, was to learn how to put them back together again. So suddenly he had to transform from an indifferent classics scholar to a scientist. Still at thirteen not too hard to do, and so by O level he had made up enough ground to pass the sciences well enough to go for A levels. (I won't tell you my grades-- you'd laugh. But O levels really were harder than GCSE's or so I like to kid myself)
A levels on the other hand were something else again. Biology I could do. After all it's a "talky" "feely" sort of a science. Chemistry I just about grasped, but Physics was so far beyond me it was embarrasing. In the end I scraped some kind of a grade for it, but the thing that saved my bacon was a biology "Special Paper" or "S level" designed for the brightest and best candidates to really show off what they knew. Thanks to a brilliant tutor and a couple of lucky questions I aced it.
Which was just as well. I'd spent a school career mooching about in the cadets, shooting the odd rifle and fiddling with the odd radio (boys toys for the soldier wannabe) but couln't do sport, played no musical instrument and had no meaningful outside interests. I did spend a month one summer working in a Cheshire Home and learning a heck of a lot about "caring" and "disability", and I had a summer job in the NHS recycling old X-ray plates (yes I know they're all electronic now, but back "before the flood" they were proper photographic plates and could be recycled to reclaim the silver). I'd also managed to witness an autopsy thanks to my Dad, and talk to a professor of nephrology who knew my granny. And that, dear readers, was the sum total of my preparedness for the wide world of medicine. That and Alan Alda in M*A*S*H, and the "Doctor in the House" series off the telly. (You'll probably need to ask your folks-- closest I can get would be Zach Braff, which isn't all that close to be honest).
Then I went to med school, on a grant, topped up by the generosity of parents and grandparents, and five years later emerged the poised polished clinician you see before you now, and my overdraft for my five years of student life was cleared by my first paycheck.
When I look at the sacrifices this generation has to make just to be in the running to get to med-school, and at the debt they can expect to leave with on graduation I am filled with admiration that they even want to try. So to any and all of you prospective medics out there who stumble across this, I wish you all every success and hope that you have as much fun in your chosen profession as I have had thus far in mine.
So kids, if you're still out there this one's for you.
A generation ago (at least) a thirteen year old lad came to a sudden, astonishing realization. He wasn't suited for the Army as he'd always imagined -- too independent of thought and slovenly of habits. No what he wanted to do even more than blow people apart, was to learn how to put them back together again. So suddenly he had to transform from an indifferent classics scholar to a scientist. Still at thirteen not too hard to do, and so by O level he had made up enough ground to pass the sciences well enough to go for A levels. (I won't tell you my grades-- you'd laugh. But O levels really were harder than GCSE's or so I like to kid myself)
A levels on the other hand were something else again. Biology I could do. After all it's a "talky" "feely" sort of a science. Chemistry I just about grasped, but Physics was so far beyond me it was embarrasing. In the end I scraped some kind of a grade for it, but the thing that saved my bacon was a biology "Special Paper" or "S level" designed for the brightest and best candidates to really show off what they knew. Thanks to a brilliant tutor and a couple of lucky questions I aced it.
Which was just as well. I'd spent a school career mooching about in the cadets, shooting the odd rifle and fiddling with the odd radio (boys toys for the soldier wannabe) but couln't do sport, played no musical instrument and had no meaningful outside interests. I did spend a month one summer working in a Cheshire Home and learning a heck of a lot about "caring" and "disability", and I had a summer job in the NHS recycling old X-ray plates (yes I know they're all electronic now, but back "before the flood" they were proper photographic plates and could be recycled to reclaim the silver). I'd also managed to witness an autopsy thanks to my Dad, and talk to a professor of nephrology who knew my granny. And that, dear readers, was the sum total of my preparedness for the wide world of medicine. That and Alan Alda in M*A*S*H, and the "Doctor in the House" series off the telly. (You'll probably need to ask your folks-- closest I can get would be Zach Braff, which isn't all that close to be honest).
Then I went to med school, on a grant, topped up by the generosity of parents and grandparents, and five years later emerged the poised polished clinician you see before you now, and my overdraft for my five years of student life was cleared by my first paycheck.
When I look at the sacrifices this generation has to make just to be in the running to get to med-school, and at the debt they can expect to leave with on graduation I am filled with admiration that they even want to try. So to any and all of you prospective medics out there who stumble across this, I wish you all every success and hope that you have as much fun in your chosen profession as I have had thus far in mine.
Thursday, October 01, 2009
"This is the end.....
.... beautiful friend."
It's dark. Insects chirrup in the underbrush. Muffled explosions, miles off, punctuate their fretful murmurings. The night belongs to Charley.
Somewhere a jangling guitar picks out a sparse twanging tune, a handful of notes at a time. Drum and organ whisper underneath a plaintive vocal that speaks of loss, despair and dark dark urges.
Yes, beautiful friends, we are in a far from happy place, and the sense of foreboding if anything is building out here in the boonies. And I know I'm flogging the metaphor to death here, but I can't help it. Somehow Jim just speaks to me right now.
Anyhow, now that I've got your attention, I'm not really talking about a war a generation ago and half a planet away. I'm bemoaning my plight here in Ambridge as usual.
And why?
Permit me to explain.
Exhibit A; A policy statement from a health minister, repeated I believe at party conference that patients will be free to register with a GP anywhere they damn well please and bu**er the geography. Now much as I would welcome the chance to care for patients of all origins and ethnicities, registering patients domiciled on Orkney would seem a bit stupid. Yes I know busy commuters and politicians have a hard time of it prioritizing their health above their oh so important trough snouting... er, working activities, but freedom to register anywhere, I mean really have they no common sense? Anyone who has any experience of front line primary care will tell you this notion is a junkies charter. Any addict has just been told he/she is free to roam the country at will registering here, there and everywhere, and demanding that all important codeine / methadone / valium script. Even if they only manage a week's worth everywhere they register, in just one day on an average inner city bus route, they should be able to score enough gear for a month of Sundays. Bloody brilliant. Sorted! (Or so I believe the vernacular has it).
Exhibit B; Choose and Book. An IT based appointment booking system that will allow a patient to book their own appointment with a specialist they choose at a time and in a hospital of their choice. Sounds fantastic. And when it works, is fantastic. When it works. But how do you know which specialist to choose. Or which hospital to go to. If only there was somebody you could ask...
Exhibit C; Two Week Wait. Patients suspected of having a cancer diagnosis should have to wait no more than two weeks to see a specialist. Quite right too. And again, to be fair, when it works it works well. But witness a call I had today. Two days ago I made such a referral, on the same day I saw the patient concerned. Today the "Two Week Wait" clerk is on the phone declining to accept my referral. They've offered the patient an appointment but she's going to be away for a week starting 13 days from now and won't be able to take it, so please would I not refer her until she's back, in three weeks time. Only the cancer czar has told them they've got to book the appointment within 14 days and they can't..... "Now just supposing I do this, and then in three weeks when I am permitted to re-refer, you still can't give her a slot inside 14 days, what would happen?" I ask politely. "Well then we'd have to refuse your referral again." So no, sorry I'm not taking my referral back, it needs sorting.
Believe it or not there are plenty more exhibits. And that's before Gordon, or Dave, or even (should pigs take wing) Nick start wielding the axe we all know is coming.
If I'm sounding a tad cynical today I apologize, but that last little circus act has really got to me and reading the runes things are looking pretty bleak.
Still, maybe they'll look better after a cup of tea eh?
What do you think?
It's dark. Insects chirrup in the underbrush. Muffled explosions, miles off, punctuate their fretful murmurings. The night belongs to Charley.
Somewhere a jangling guitar picks out a sparse twanging tune, a handful of notes at a time. Drum and organ whisper underneath a plaintive vocal that speaks of loss, despair and dark dark urges.
Yes, beautiful friends, we are in a far from happy place, and the sense of foreboding if anything is building out here in the boonies. And I know I'm flogging the metaphor to death here, but I can't help it. Somehow Jim just speaks to me right now.
Anyhow, now that I've got your attention, I'm not really talking about a war a generation ago and half a planet away. I'm bemoaning my plight here in Ambridge as usual.
And why?
Permit me to explain.
Exhibit A; A policy statement from a health minister, repeated I believe at party conference that patients will be free to register with a GP anywhere they damn well please and bu**er the geography. Now much as I would welcome the chance to care for patients of all origins and ethnicities, registering patients domiciled on Orkney would seem a bit stupid. Yes I know busy commuters and politicians have a hard time of it prioritizing their health above their oh so important trough snouting... er, working activities, but freedom to register anywhere, I mean really have they no common sense? Anyone who has any experience of front line primary care will tell you this notion is a junkies charter. Any addict has just been told he/she is free to roam the country at will registering here, there and everywhere, and demanding that all important codeine / methadone / valium script. Even if they only manage a week's worth everywhere they register, in just one day on an average inner city bus route, they should be able to score enough gear for a month of Sundays. Bloody brilliant. Sorted! (Or so I believe the vernacular has it).
Exhibit B; Choose and Book. An IT based appointment booking system that will allow a patient to book their own appointment with a specialist they choose at a time and in a hospital of their choice. Sounds fantastic. And when it works, is fantastic. When it works. But how do you know which specialist to choose. Or which hospital to go to. If only there was somebody you could ask...
Exhibit C; Two Week Wait. Patients suspected of having a cancer diagnosis should have to wait no more than two weeks to see a specialist. Quite right too. And again, to be fair, when it works it works well. But witness a call I had today. Two days ago I made such a referral, on the same day I saw the patient concerned. Today the "Two Week Wait" clerk is on the phone declining to accept my referral. They've offered the patient an appointment but she's going to be away for a week starting 13 days from now and won't be able to take it, so please would I not refer her until she's back, in three weeks time. Only the cancer czar has told them they've got to book the appointment within 14 days and they can't..... "Now just supposing I do this, and then in three weeks when I am permitted to re-refer, you still can't give her a slot inside 14 days, what would happen?" I ask politely. "Well then we'd have to refuse your referral again." So no, sorry I'm not taking my referral back, it needs sorting.
Believe it or not there are plenty more exhibits. And that's before Gordon, or Dave, or even (should pigs take wing) Nick start wielding the axe we all know is coming.
If I'm sounding a tad cynical today I apologize, but that last little circus act has really got to me and reading the runes things are looking pretty bleak.
Still, maybe they'll look better after a cup of tea eh?
What do you think?
Friday, September 25, 2009
Sister Morphine
This weeks BMJ has the Rolling Stones song reviewed as its "Medical Classic", in a slot generally reserved for worthy tomes like "The Conquest of Pain" or medical novels like "The Citadel". I'm a bit miffed, because I'd already decided on it for the title of this follow on post from the earlier post on heroin. Not actually miffed enough to change it though you'll notice.
The thing is it rather fits what I've got to tell you. Not so much the song as the title to be honest. You see Mick and the boys were rather reinforcing what I had to say last time with their plaintive song about addiction, but this time I want to point out the undoubted therapeutic value of this much maligned drug.
For years Morphine has been a "back of the cupboard" "painkiller of last resort" "fit only for the dying" sort of a drug. True there has been increasing use of morphine drips for post operative pain in recent years (these days even administered at a rate determined by-- of all people-- the poor soul who has the pain). And as suggested, Sister M and her bigger beefier cousin Diamorph' have been the mainstay of end of life pain relief since Hippocrates was in short chitons. Anyone with any involvement in such care will recognize the beatific change in countenance that comes when a pain ravaged patient finally achieves symptom control through their tender mercies.
There's a lot of guff talked about the "Doctrine of Double Effect" that implies it's o.k. to administer potentially lethal doses of opiate to relieve pain. Given methods of administration widely available for at least three decades this has never been a part of my reality or that of my patients. Used correctly opiate analgesics kill one thing and one thing only. Pain. Abuse and overdose are not and have never been therapy and should not be allowed to confuse the issue.
Once every eight to ten years we are sold a new "miracle" non-opiate pain killer. They tend to be derived from some species of anti-inflammatory, are heralded with a vast fanfare, tried with enthusiasm by many of us, and within twelve to eighteen months turn out to be no better than, more expensive than and often more toxic that all non-opiate analgesics that have gone before them. Then they disappear or dwindle to a background, occasional, niche painkiller for when everything else (except morphine) have been tried.
Recently we have had to appreciate that a whole class of painkillers-- the non-steroidal anti-inflamatories, can do bad things to aging kidneys, making them hard to use in severe arthritis (which is precisely where you might want to be able to use them). So the poor punters are left with paracetamol plus or minus a bit of codeine. This seldom works, but it's rare that a patient will welcome the offer of a tiny dose of morphine to help give back their pain control.
Which is a shame.
The thing is it rather fits what I've got to tell you. Not so much the song as the title to be honest. You see Mick and the boys were rather reinforcing what I had to say last time with their plaintive song about addiction, but this time I want to point out the undoubted therapeutic value of this much maligned drug.
For years Morphine has been a "back of the cupboard" "painkiller of last resort" "fit only for the dying" sort of a drug. True there has been increasing use of morphine drips for post operative pain in recent years (these days even administered at a rate determined by-- of all people-- the poor soul who has the pain). And as suggested, Sister M and her bigger beefier cousin Diamorph' have been the mainstay of end of life pain relief since Hippocrates was in short chitons. Anyone with any involvement in such care will recognize the beatific change in countenance that comes when a pain ravaged patient finally achieves symptom control through their tender mercies.
There's a lot of guff talked about the "Doctrine of Double Effect" that implies it's o.k. to administer potentially lethal doses of opiate to relieve pain. Given methods of administration widely available for at least three decades this has never been a part of my reality or that of my patients. Used correctly opiate analgesics kill one thing and one thing only. Pain. Abuse and overdose are not and have never been therapy and should not be allowed to confuse the issue.
Once every eight to ten years we are sold a new "miracle" non-opiate pain killer. They tend to be derived from some species of anti-inflammatory, are heralded with a vast fanfare, tried with enthusiasm by many of us, and within twelve to eighteen months turn out to be no better than, more expensive than and often more toxic that all non-opiate analgesics that have gone before them. Then they disappear or dwindle to a background, occasional, niche painkiller for when everything else (except morphine) have been tried.
Recently we have had to appreciate that a whole class of painkillers-- the non-steroidal anti-inflamatories, can do bad things to aging kidneys, making them hard to use in severe arthritis (which is precisely where you might want to be able to use them). So the poor punters are left with paracetamol plus or minus a bit of codeine. This seldom works, but it's rare that a patient will welcome the offer of a tiny dose of morphine to help give back their pain control.
Which is a shame.
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