Farewell but not Goodbye

 On Monday 24th July the following live blog entry appeared on the Pulse website, together with a tweet from Dr Zoe Norris.


09:37 Doctors are mourning their colleague Dr Kate Granger, who died this weekend as a result of cancer.
Before she died Dr Granger, a specialist in elderly medicine, launched a high-profile campaign for doctors and nurses to be more personable to their patients, by always introducing themselves.
In addition to the #hellomynameis campaign, Dr Granger also successfully raised £250,000 in charitable donations for the Yorkshire Cancer Centre before passing away on Saturday.
Tributes have poured in on Twitter since her husband used the social media platform to announce her death - including from NHS England, the health secretary and GP leaders.

An amazing woman who has accomplished amazing things. Thinking of you all &sending my love #RIPKate#hellomynameishttps://t.co/J4WlYR8V27

— Dr Zoe Norris (@dr_zo) July 24, 2016

I don't imagine after all this time there will be many who will read this (though blogger tells me folk still visit these ramblings from time to time), but I needed to write something.  Like Zoe Norris (a Dr I've not met so far as I know) I am thinking of Kate and her family and colleagues and send them heartfelt condolences.

I was privileged to sit in a seminar room at the BMA Annual Representatives Meeting in Harrogate a couple of years ago to hear Kate talk about the role of social media in her #hellomynameis campaign, and about the vital importance of that simplest of human connections at the start of every encounter we have with our patients. She told us her story, simply and directly and with great humour and like all the best teachers told us things we already knew but often forget in the maelstrom of daily practice.

Too often, as with all the medics and nurses caring for her through the early phase of her illness, we get bound up in the technicalities of illness and its treatment, and risk forgetting both attach to a living, breathing, feeling fellow human being. Practicing outside the hospital I have the luxury of having my name on the door to my room in large friendly letters, but when I'm out and about making house calls (yes occasionally we still do them) I never used to introduce myself. Rather like one of Terry Pratchet's Witches I assumed the whole world knew who I was and ordered itself to my convenience. Since that day in Harrogate I've changed my practice and don't leave people guessing who the occasionally harassed looking  man with a sheaf of notes and bag  is that has just arrived at their door to demand entry.

There are very few people in life I would call inspirational, but Kate was one, and I thank her for reminding me of a simple truth, making me, I hope, a better doctor by that one simple act and everything that stems from it, and wish her and all who love and knew her peace.

A post modern post?

Enter Baz. (In the wild West Midlands names are shortened by the addition of a terminal “z” to the first syllable, i.e. Baz for Barry, Daz for Darren / Darryl, Shaz for Sharron etc).

Baz is resplendent in ironmongery from his studded leathers to his multiple piercings. His piece de resistance is a grommet style arrangement through the left earlobe, that stretches it out to improbable dimensions, leaving a porthole through which the light can stream and whole landscapes are made visible.

Like many here in Ambridge, Baz has been afflicted with a run of colds, coughs, and ear infections pretty much all through the winter. He’s had the odd course of antibiotics here and there with little benefit, and he’s getting more and more fed up with things.

He’s especially worried today about his eardrums. It appears they've been popping and crackling a bit more lately so he wants them looking at again (for the umpteenth time in the past two months). Sure enough they look a bit dull and a bit pink, but not especially bad, and certainly no different to the past three times we've looked at them. I tell him this and he looks skeptical. So I ask him what’s worrying him.

Well, it turns out he’s been talking to his mate down the pub, and his mate reckoned his ear drums might be perforated! 

In praise of Big Brother

I know it’s hard to imagine now, but there was a time before the internets, when Lolcats were just cats and Amazon was just a river. In this dawn of prehistory if you wanted to buy stuff you needed to actually go and get it, or use nineteenth century snail mail technology to order stuff from a big shiny book. Jack was the product of such a world. He filled the gap between store and catalogue, travelling his patch introducing people to wonders not available in either, as a commercial traveller.

Jack sold Widgets to industry, and as such his products were in demand throughout the Midlands, from sea to shining sea, as it were. He was a master of the highways and byways of a huge swathe of territory. Of course all of this was a long time ago, shortly after the demise of the mastodon I imagine. He’s certainly been retired almost as long as I've been plying my trade, and let’s face it, my spring chicken days are far behind me now.

And so it came to pass, a few weeks back, that Jack came to see me, attended by what can only be described as a deputation of concerned looking daughters. The poor chap looked a little sheepish as the spokes-daughter recounted his recent adventure with an occasional embellishment furnished by the other delegates. It appears Jack had decided to take a drive to get his tea, fridge and larder being temporarily depleted. He hopped in the car and headed for his nearest convenience store, but on arriving there realized that it was half day closing and he would have to find an alternative vendor.

This fazed him a little, but he gamely soldiered on. After all, the supermarket wasn't far off so it should be easy enough. The only thing was, it was already dark, so landmarks were hard to find, and in a fog of twilight and perhaps hypoglycaemia, suddenly Jack was transported back three decades and was on the road plying his Widgety wares. So off he went, travelling the highways and byways.

Some hours later the spokes-daughter arrived chez Jack to find him and his car gone. The neighbours recalled seeing him go out late that afternoon and even that he had told them as he went that he was off to fetch his tea. They’d thought no more about it, but now it did seem odd that he hadn't made it back five or more hours after what should have been a twenty minute round trip.

When they tried calling his mobile they could hear it ringing in the house, as he hadn't thought to take it with him, and so after a quick council of war with the rest of the family the police were called and Jack was reported M.I.A. An hour or so later WPC Watmough contacted the by now increasingly frantic family to say her colleagues in another county had Jack safe and sound by the roadside. Thanks to a combination of number plate recognition software and CCTV they had spent a happy time in traffic control tracking Jack’s progress through every major conurbation in Borsetshire and the neighbouring counties that had formed one of his sales rounds all those years back. Of course in the meantime all the factories he had been selling to had been pulled down and redeveloped into housing estates so he’d had no landmarks to remind him where he was or what he was doing.

Sad to say this little escapade has highlighted the increasing severity of Jack’s memory failure and he has had to hang up his car keys for good, but at least the very technology that has all but done away with his occupation served to track him down far quicker that we would have managed in that far off web-free age.

Signs and portents

Medicine is all about two things, symptoms (things the punters tell you about) and signs (things you can identify by inspection and examination). A subtle blending of the two is likely to lead to a diagnosis, or at least a differential diagnosis (like those lists of improbable ailments Dr House loves scrawling up on his ever present whiteboard). This gives you a choice of tests to do to sift out the wheat from the chaff and get on with the business of making people better.

Some of the cooler signs have eponyms, either of the first describer, of the first poor soul to be afflicted and described in the literature. In med-school we all learn great long lists of them, and then later, in professional life, we occasionally get to trot them out to our colleagues to show that we did manage to attend the odd lecture and absorb a little medical lore in between the bouts of carousing for which generations of doc’s-to-be are justly famous, or should that be notorious?

I’ve talked before about having my own stab at medical immortality dashed when a condition new and mysterious to Dr Nieghbour and I turned out to have a catchy though not eponymous descriptor after all. This time I reckon I’m onto a winner though, but I fear it won’t bear my name.

The thing is, it appears I was visited this week by a Dark Lord of the Sith. At least that’s what his mum contends and who am I to argue. The revelation came in the midst of  the said D L o t S’s asthma review. We ask routinely about symptoms and how they are managed, and in so doing D L’s mum let on that she could tell when his asthma was flaring and she needed to up his treatment when he started turning into Darth Vader. So there you have it, I’m the first (to my knowledge at any rate) to describe the Vader Sign, and I therefore claim it as my rightful place in the annals of the history of medicine.

Oh and whilst we’re at it I have another, though I think that might be more widely recognized—“Ice Cream Cough”. It’s surprising how many asthmatic kids cough after eating ice cream. I imagine it’s all down to inhaling colder air as they scoff their Ninety Nines.

Anyhow, returning to the Vader Sign, it puts me in mind of a picture I saw a while back in a commercial art gallery in Brum. Which gives me a chance to link to them and it for your edification. And who knows, if my new Sign catches on perhaps I’ll be able to track down a copy with the attendant royalties.

The ghost of Christmas Past

The year before I moved to Ambridge to take up my present lofty post, I was working in the Second City General Hospital on the wards as a jobbing paediatric SHO. As such I was on call for Casualty for any potential paediatric emergencies. This was the tail end of the eighties, when you could tell the paediatric docs by the brightness and eccentricity of their knitwear, white coats being strictly off limits on the kids wards.

For domestic reasons I liked working Christmas back then, so that Christmas Eve found me resplendent in the jazziest of woolly jumpers prowling the ward and tending the on call bleep. It’s not such a bad time to be working in hospital. The wards were awash with choc’s and biccies donated by grateful parents, and nearly empty of patients- nobody wanting to trust that Santa could seek them out down the overlarge Victorian chimneys of SCGH that looked distinctly uninviting. Especially since this was in the pre-Air-Ambulance era so there was no convenient helipad for the landing of reindeer powered sleighs and such.

We had out fair share of victims of Tinsellitis* in through casualty, but all had been treatable and fit for home, and everything was looking rosy. The only crimp in the arrangements for the festive season was an ambulance strike, which saw the Army out on the streets providing cover using their converted Landrover ambulances. As it happened this may well have turned out a boon since it had, for the first time in years, deigned to snow and then freeze hard all through Christmas week.

And so it came to pass that late that evening the pager went off and I trotted into A&E only slightly redder in the face than in the jersey. A woman had arrived in labour, and the Squaddies hadn't realized the SCGH delivery suite was a couple of miles up the road in an NHS run nursing home staffed by nuns (if you've seen the excellent “Call the Midwife” on the Beeb, you know the sort of place I mean). The poor woman had no transport and had already slipped on the ice earlier in the week breaking a wrist, so she had trudged from her flat in the advanced stages of labour and called the ambulance from a payphone, only to have the Field Ambulance of the 477^th turn up to collect her instead.

The delivery went without incident and without a whimper from mum, and barely any from her newborn infant, and all we were missing were a few animals, shepherds, wise men and guiding stars, but still somehow this particular birth felt special. But then so do they all.

* A seasonal upper respiratory illness occurring in the week leading up to Christmas which, as any parent will confidently assert, is uniquely sensitive to antibiotics.

Hercule, Hastings and “the little blue pills”.

A short time ago a commenter left a request to get in touch about a publication they were planning. It's to be entitled "In Rude Health" and was looking for tales of a slightly risque (yes I know but my HTML isn't up to accents) nature form the NHS. It's hoped it will be out for Christmas and I'd encourage you all to go look for it (though possibly with some caveats as to the content being intended for the adult audience). What follows was going to be a putative entry, but it took far too long to put together and so won't be. Still having made the effort, I thought why not go mad and double my output for the year anyhow. 

So gentle reader, with the same caveats, read on, or look away as befits your own personal circumstance.

Hercule was a dapper gentleman in his mid seventies. He had become accustomed to living alone after the passing of Mme H some years previously after a difficult final illness with disseminated cancer. It came time to “downsize” and so he chose to move in to a local retirement community of sheltered flats overseen by a warden. As is often the case in such communities, Hercule was in something of a minority, living surrounded by ladies of similar age and circumstance, but very few other men. Like some latter day Mr Darcy, this led to him receiving numerous invitations to call on his new neighbours for afternoon tea and canasta. Being well brought up he was happy to oblige and soon developed a wide circle of lady friends. One thing led inevitably to another and soon it was afternoons out to Thés Dansant.

After a few months of this new lifestyle Hercule came in for a check up, and after a routine review of medications he bashfully raised the subject of the little blue pills. He’d heard that such were available for gentlemen afflicted by “performance problems” and wondered if they might be suitable for him. A glance at his record showed no contraindications so we agreed he might give them a try, and he took away his first script for Viagra with the usual warnings about not taking them too often and not to exceed the written dose. It seems Hercule had, in modern parlance, a new partner.

Some weeks later he was back to report a happy outcome. The little blue pills were working a treat and he wondered if he might have some more. Well actually quite a few more. It transpired that Hercule had become something of a celebrity in his small group, and was in high demand with a number of his dance partners. It took some persuasion on my part to limit both the frequency and quantity of his prescriptions.

Captain Hastings was a bluff matter of fact ex Colonial type. He and Mrs Hastings had met in the Raj, and after a lifetime of service in the tropics had retired to live in our neck of the woods. The Captain’s blood pressure was not too good, and his arteries were none the better for a hearty diet of kedgeree and curries. This deadly combination had given him problems “in the bedchamber” much to the chagrin of the Memsahib. So we agreed a cautious trial of the wonder pills, all the more so because of his likely circulation problems, He understood he was taking a risk, but Mrs Hastings was his Queen-Empress and he was not about to disappoint her.

As it happened all went well and the Captain was back to request a regular, but entirely reasonable repeat prescription. Years passed and Mrs Hastings suffered a slight stroke and became confused and prone to agitation, but the one thing that calmed her was the easy intimacy she and the Captain still shared. Shortly after this he developed atrial fibrillation, and I had to tell him we really ought to revisit the suitability of the little blue pills.

The Captain would have none of it. Mrs H would be so disappointed if this one thing left her was taken away. He understood he might be taking a risk, but his son would be there to provide for her in the event that his ticker gave out and for the pair of them it was quality not quantity that mattered for the time they would have left. In the end he persuaded me to continue prescribing. Some time later Mrs H suffered a second and sadly fatal stroke, and from that point on the Captain allowed his prescription to lapse, living on for another few years, content that he had “done his bit” for Queen and Country.

Life and art.

So, it’s been a while. All sorts of reasons why, but none to trouble the dear readers with I’m thinking. Today though, life and art have juxtaposed and that serendipitous event demands to be shared, so here I am, back again.

Les isn’t feeling too grand. The gout he had in the spring looks like it’s left a longer term arthritis which is affecting his thumb, making it hard to do stuff like cook, clean and so forth. He’s also had a cough for ages and is fed up with it. It sounds entirely innocuous but deserves some treatment so we opt for an antibiotic to go with some painkillers.

Then he mentions a bit of trouble with the waterworks, and being a gentleman of a certain age, wonders if he needs to worry about his prostate. In fact he had a test just a few months ago, requested by that nice Dr Neighbour, that he had quite forgotten, and never sought the result for, an it was normal so no real worries, but since he’d also brought “a sample” we do a dip stick test, and the only thing that shows is a bit of glucose.

“ I knew that would be up doc,” he chips in, “only the wife’s just left me and I’m fending for myself now….”

Given that catering isn’t his strong point, and he’s had a bad hand anyway I think I get the picture, but I say how sorry I am to hear it. He looks a bit teary so I ask him if he wants to talk about it. And then it happens. I’m not quite sure if I’m whisked away to a steamy bayou and the insistent strum of a blues guitar, or a gritty northern working men’s club, but life has definitely begun to swerve into lyric, or comedy as he replies,

“Oh no doc, I’m alright with it, just not used to living alone quite yet, but the thing that’s really upset me is that the dog died last week. I really miss that dog!”