Twelve years and counting...

There’s no doubt that as we enter the 25th year of my professional life we’ve come a long way in the intervening quarticentenary*. Two generations of pills have near abolished surgery for stomach ulcers, a tiny bit of wire mesh has gone a long way towards doing the same for bypass grafting. Depression has been transformed by the introduction of SSRIs and the plethora of follow on alternatives. New wonder drugs have been joined by rehabilitated old wonder drugs like Aspirin. Endoscopic surgery and joint replacements are now commonplace and the protracted stays in hospital post op are a thing of the past for the vast majority. Cancers incurable a generation ago are so no longer…. I could go on, and on (stop that nodding there you at the back).

And yet, for all our technological and pharmaceutical accomplishments, as 2008 draws to a close I’m left fearful that we’ve "sold our soul", and ere long Old Nick himself will be paying us a visit to call in his marker. The NHS I joined, for all its evident faults, was a truly National Service. The ethos of the whole organisation was compassionate, aimed at the relief of suffering and the improvement of wellbeing. This morning on Radio 4 we hear of a Kings Fund report highlighting the loss of compassion. This has slowly but surely been eroded by the fragmentation of the service into a vast jigsaw of Trusts each as much determined to protect its borders and boundaries and keep the “undeserving” out, as to hit the targets set for service delivery to those fortunate few “deserving” of its attention. And those targets are all about process. Waiting times , cleaning regimes, infection rates and the like. All of the above are important, but so are the poor bastards stuck on the receiving end.

In the past month I’ve seen patients kicked off waiting lists for surgery because on one screening visit to a N’octor, their blood pressure or blood sugar are not exactly normal according to arbitrary criteria that are almost absurd enough to require that to be fit for surgery you have to be so well as to not require surgery. I’ve heard Doctor Neighbour bemoan the fact that he is unable to arrange a transfer ambulance to get a patient to see a Neurosurgeon at St Elsewhere’s in a nearby city because the Surgeon in question wanted to review them in the A&E department there and the Ambulance trust can only take patients to Outpatients there or to the nearest (Ambridge DGH) A&E but not the St Elsewhere’s A&E because those are the rules. And I’ve seen a patient denied much needed Opiate analgesia because staff at the residential home he lives in cannot find a cupboard to lock his medications in and the rules won’t allow them to do otherwise.

We’ve become afraid to care, and it’s getting steadily worse year on year. Maybe the Kings Fund will turn the tide and 2009 will see a return to the much needed basics. Every Trust in the land has a mission statement that declares in Government approved newspeak their commitment to “patient centred-ness”.

It’s time we all sat down and thought about what that actually means.

*probably not a real word, but should be.

Tis the season.

Sadly not much jollity in evidence in these parts though. One tiny ray of personal sunshine is that Whittards has found a buyer so I sha'nt have t worry quite yet about where ny next 250g of fresh ground Old Brown Java is coming from. I know there's always Taylor's of Harrogate, but it's so much nicer seeing an operative pour the beans out of the tin and into the grinder, whilst solicitously advising that once ground it's only good for a week or two at best, and asking whether the filter I'll be using is paper or permanent (aparently it makes a big difference).

Even the early a.m. run to collect the Turkey from M&S was a muted affair this year. Normally the place is heaving with beaming and avuncular types cheerily queuing for their produce and knocking back simmering goblets of mulled wine. This morning there were a half dozen bedraggled pensioners, a harrased looking suited lady exec and moi. And not a whif of mulled anything. Looking back on 08 it will not go down in the annals of Ambridge as an especially kind year-- and this was before the "crunch". Looking forward 09 doesn't hold out the prospect of being much better.

Still so long as there are Hob Nobs and Java to be had life can't be all bad. And I am as always eternally indebted to those of you who are kind enough to feed back on my ramblings. Your generosity of spirit, and lack of sound judgement, do you all credit, and I wish you all as safe and happy a Christmas and New Year as is humanly possible.

I may well be back before the latter (it's business as usual here Monday through Wednesday) but if not then I hope you will excuse me.

Now I'm just off to google McVities to make sure they are not yet in peril of calling in the recievers, so if you'll all excuse me.....

Catch 22.5

I had another of those Doc Daneeka consultations yesterday. Mrs Yossarian is not happy. She’s been unwell for months, and we’re doing nothing to help her. She tells me so most forcefully. And in many senses she’s quite right, but she implies that we’ve not been trying and that is a little unfair, though woe betide me should I venture to point this out.

“I had a tight chest in the spring and I saw you… you gave me an inhaler, but it just made me worse.”

I tentatively risk asking how.

“Well my chest is still tight now, and it’s burning right here,” she holds a clenched fist to her sternum in a salute reminiscent of a Roman centurion—I mentally hear Russell Crowe intoning Strength and Honour! “and those pills Dr Neighbour gave me did nothing!”

The pills were powerful antacid/ulcer healing drugs. He last prescribed them in the Spring, and for just 28 days. So, I ask again, how long did she take them for?

“Oh I’m still taking them, but they’re no help!”

The logic defeats me. I ask how this can be so, given that they should have run out over six months ago.

“Well my Husband has them too so I’ve been taking his.”

“Anyway after that I got admitted to hospital with chest pain, and they treated me like I’d had a heart attack, but the spray they gave me made everything worse, and I’ve still got this burning” – enter Mr Crowe again stage left. “And all the tests they did have come back normal so they’re no help at all either.”

Now I will concede her that telling her it is her heart, and then telling her it isn’t after all wasn’t entirely helpful, if indeed that is what she was told. Still one might have thought knowing now formally that it isn’t is a good thing. And the cardiologists did actually do quite a lot in helping her to arrive at that point, but again the suggestion that quite a lot has in fact been done gets short shrift. So here she sits, fist clenched tight to her chest, and all set to unleash hell.

And then there’s the final insult. “They made me have statins, and now my legs are really weak and I can’t walk at all.”

How long, I foolishly persist in asking, did she have the statins for?

“About a month, but I’ve been off them for over two months and my legs are no better.”

I hear the ballistae being wound as I venture that stopping the statin ought to have relieved her leg problems by now if it were indeed the cause.

We agree to another blood test to finally absolve the statins, and an ENT opinion about the burning, but I foresee little hope of a breakthrough. I fear Mrs Yossarian’s symptoms are all too likely to have their origin elsewhere that her chest or her legs. Anxiety causes a sensation now referred to simply as Globus—we dropped the old term Globus Hystericus a while ago since the term refers to the awful sensation that you’ve just swallowed half a brick, and has no link to uterine pathology at all. Yes the Hystericus came from the old term Hysteria—a now long discredited diagnostic term. But Globus remains a symptom of the unreassurably anxious, and the one treatment that might alleviate it is the one treatment sufferers cannot accept, namely psychology.

Just occasionally the ENT specialists will be able to persuade the sufferer after an outpatient review but I get the feeling Mrs Yossarian will not take to this advice at all.

Somewhere in the back of my head I hear the sound of pounding hooves.

What's that coming over the hill.... *

Enough navel-gazing for now. Let’s get back to some good old fashioned silliness shall we.

Despite the literary allusion (can it be literary if abstracted from an aural medium I wonder—perhaps it should be “broadcasterary allusion”—or perhaps not….) my own version of Ambridge is in fact far from the rural idyll broadcast daily by Auntie for our listening pleasure. Dormitory Town sub-urban is more the thing if I’m honest. The strange thing is, this does not appear to have impinged on the Mums and Dads of the latest generation of tiny Borcestrians.

There’s been a “bit of a cough” doing the rounds in these parts lately. The sort of cough that leaves tinies choking, gasping, purple and cross. And it’s going on for days on end. Unsurprisingly Mums and a few Dads (you know they’re worried when a sheepish looking Dad is in tow to insist that “something’s got to be done Doc”) have been thronging the waiting room with their wheezing, hacking, retching, puce offspring. The good news is that despite the graphic presentations most are just suffering with the aforementioned “bit of a cough” and some reassurance and symptomatic treatment will pull them through just fine.

Our problem is the traffic management their attendances are occasioning. It seems babies these days are much too precious and fragile to be brought the full fifty yards from car park to consulting room in anything smaller or more dainty than a Sherman tank. Buggies have clearly come on a long way in the umpteen years since the Jests were in the market for one. Gone are the teetering gossamer constructs of yore with their two inch diameter Lego wheels and all the stability and traction of an inebriate hippo on ice.

Nowadays we get mammoth constructs with wheels bigger than a mountain bike, sporting off road tyres, brush cutters and bull bars. The tiny occupants are strapped in tight enough for Saturn V style take-off and re-entry. I’m sure the ones imported by our own share of the Polish Diaspora are in fact just T72s with the turrets removed a few teddy bear stickers applied for that homely touch. More than once I’ve found myself having to strenuously resist the urge to duck and cover as one of these monsters fills the doorframe of the consulting room.

Does anyone have the number for M. Maginot I wonder?


*Hob nob on offer for the correct next line.

Phillip

In case you missed it, today has been World AIDS Day. Good old Radio 4 had a mix of upbeat stories about babies born to positive mothers, and more downbeat warnings that the incidence is on the rise again here in Blighty.

Ambridge has been somewhat cocooned form the ravages of the HTLV. My one brush with the disease was vicarious at best, but none the less tragic for that. Phillip left Ambridge towards the end of the seventies for the bright lights of the big city. He soon hooked up with Terrance. Chef and Actor, they made a fine couple, until Terrance became ill, and started loosing weight and coughing a lot. Phillip nursed him through a protracted and difficult terminal illness before the days of widespread and affordable (at least in the “civilized west”) antiretrovirals. At the onset of Terrance’s illness Phillip was tested and was pronounced clear of infection, but to be certain would have required a second test three months later.

Poor Phillip was too distraught by his partner’s rapidly progressing illness to handle a second test then. Shortly after the funeral he came home to live with his mum. He found work locally and kept himself going, but lived in constant fear. Every cough and every new blemish brought him shaking to the surgery. We talked at length and repeatedly about his fears. We offered him access to a final test for reassurance, though with each passing year and each successful recovery from illness the likelihood that he had contracted the virus became increasingly remote. Still neither we nor the psychologists could reassure him, and he could not face up to getting tested.

In the end, one Monday morning I came in to surgery to find the coroners officer had been on the phone. That weekend mum had been away with her chums, and poor Phillip had given in to his demons and washed down some pain killers with vodka. Though never infected he died as much a victim of AIDS as those many of his friends who were.

I’m not a great fan of “badges” and “ribbons” for this and that. AIDS, Cancer, Asthma or COPD to name but a few, are worth more than just a 365th of our attention, as are the myriad other causes and conditions that don’t get a proper “day” to themselves. And yet, today I’ll be wearing the red ribbon, and thinking of an old friend I couldn’t help.