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!

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?

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.

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.

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.

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!"

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.

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.

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?

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.

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.

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.

"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?

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.

A day in the life....

The BMA are keen for us to invite MPs into our surgeries at the moment. must be something to do with the looming election. I'd invite ours, but a nearby practice has beaten us to it, and after my recent run-in with Alan I'm not sure how keen they would be anyhow. So instead I'll open the doors to all of you, my loyal readers for a little snapshot of an average day at the Ambridge Surgery.

8.00-- Surgery opens. Dr Neighbour (an insomniac workaholic) starts consulting-- he will consult until 10.30, break for admin and for coffee at Coffee Time (c) The Ambridge Surgery 2000. He will then consult again from 11.30-12.00. Mean while the Duty Doc from yesterday afternoon (your humble interlocutor) will turn on the Surgery Mobile-- the contact for all urgencies from 8.00 to 8.45 when the surgery switchboard will swing into operation. The ringtone and the wallpaper on said phone he will not immediately recognize as they have been reprogrammed by his offspring. Thus every mornig urgent calls can become a little whimsical voyage of discovery-- it's odds on the poor supplicant caller will be heralded by "The Macarena" or the latest Motorolla Death Metal ringtone. The Duty Doc is powerless to prevent or alter this.

9.00 Dr J begins consulting after an idyllic drive through the Borsetshire lanes, accompanied by the plangent strains of the Macarena, punctuated by updates on "Our Wayne's" vomiting. Our Wayne (aged 22 and still living with Mum) is invited to attend mid-morning for an examination.

Morning Surgery I

In no particular order we see and try to help;

two survivors of severe trauma (one abused by a relative from age 7-- over 40 years ago, but still grappling with the fallout, one still being abused by an ex patrner who is about to receive an injuction in the hopes that this will make him stop),

one wheezy babe in arms who is otherwise quite well, though mum takes some convincing of this,

a patient with a chest so bad they require night time ventilation but remain desperate to be able to get back to work,

a patient made psychotic by amphetamines,

a man in an Aircast Boot (imagine Robocop in pale blue plastic) after ankle surgery who just needs a note for work-- and something for the pain,

an expectant mum six weeks off delivery for a check up and a chat about some mechanical chest pains she's been getting because of the pregnancy -- she's not an Ambridge native and has no family within 300 miles so she's also feeling a little isolated and apprehensive which makes her worry more about her chest pains,

Our Wayne, looking a bit green around the gills and in the grip of a touch of food poisoning after a dodgy curry (and around a gallon of Lager) last night,

a couple of "Flu" victims who felt iller on tamiflu than with "flu"-- so probably not then,

a man in need of gluten free bread who's in a rush to get home again before his demented wife (not our patient-- she has kept to her old surgery for the past 40 years and he sees no reason to change her registration) takes it into her mind to wander or to try to set the house on fire.


11.00 Coffee Time (c) The Ambridge Surgery 2000. Half an hour set aside for all the docs and the management team to meet and chat. Sometimes we actually get around to chatting about the punters-- more often movies, kids and knockabout comedy one liners...

11.30-12.20 Morning surgery II

6 more punters with a random assortment of ailments. One requiring urgent hospital admission for a possible embolism which puts the rest around 15 min's behind.

12.20 (but really 12.35) Driving License Renewal Medical.
HGV and PCV (that's lorries and busses to you and me) drivers need a five yearly license medical. 20 minute exam and form filling exercise. Passes without incident.

13.00 Home visits. Two today that will take us to 14.00 and lunch. On the way one lady with nasty pain after shingles last month. We had hoped Zovirax would have headed this off, but no such luck, so now we will need top notch pain relief, probably for a few months-- drat. T'other had come over "all unnecessary" this morning and in the end turns out to have cystitis-- a powerful confuser of little old ladies (and indeed little old men, though less often for reasons too boring for here and now). At least she should be better after 3 days on antibiotics.

14.00 Lunch. Life being too short to make sandwiches, Mr Sainsbury is called upon to provide and does so admirably, which takes us to 14.15 and...

14.15 Phone calls (5) of which three count as "worried well" and two relate to consultations a few days back and effects of the pills therefrom. Then repeat prescriptions 25 to sign and 10 or so to be updated and reprinted for signature.

Now, when I was a lad repeat prescriptions usually ran to a blood pressure pill or two and the odd painkiller. Nowadays most repeats are for 4 or 5 items, which for the over 50s will more than likely include a statin, aspirin, at least 2 blood pressure lowering agents, something for heartburn, and one or two items to overcome the side effects of the other meds, so they warrant a bit of scrutiny, even when they look routine.

15.00 Afternoon Surgery
3 straight hours consulting. We don't break for Tea, so the machine on the desk supplies a steady stream of Java straight to the Jesterly mug-- well from the jug on the hotplate at least...
The surgery will be pretty much a reprise of the morning, or will, once a week, be an all comers "Duty Surgery" for really urgent sore throats and ingrowing toenails-- o.k. I may be exaggerating, but the definition of urgent is mutable depending on which side of the desk you're sitting. To be fair last duty surgery saw me admit three patients urgently to hospital where often I can go months without admitting anybody-- in the words of the song "it goes to show you never can tell".

18.00 Notional end of afternoon surgery, often overtaken by events so average end of surgery closer to 18.20 (worst this year so far closer to 19.05).

18.20-? catch up on calls, write up home visits, stare blankly at the walls waiting for the caffeine buzz to wear off enough to be safe to drive home.

Scattered through the day will be emails (professional and personal) and on any given day, laughter, tears, births, marriages and deaths, blood, sweat and tears. In short about as much fun as you can have with your clothes on and staying within the law.

Not quite the two surgeries and an afternoon on the golf course in between of yester-year that everybody still assumes to be the norm.

Still I wouldn't want it any other way now would I.

Drugs 'r bad, M'kay!*

Except when they're good. Some can be both. I've recently been asked by a friend for a response to the suggestion that we import Swiss style "Shooting Galleries" to the U.K. for injecting heroin users. I have to start by admitting absolutely no expertise in this area, but some experience in caring for drug users working towards withdrawal trough the substitution of methadone or subutex for their heroin. I'm also a big fan of it personally** for its proven role in pain control.

So, all that said, what about these shooting galleries then?

The answer I'm afraid, is complicated. Taking it one step back for a moment what about injecting users then? What do we know, and what have we been taught to believe?

We know it's bad. It must be, after all it's against the law and has been like forever hasn't it? Well not quite, only really from about 1920, and only a "Controlled Drug" in Blighty from around 1971.

Well O.K. it must be really bad for your mental helath yes? Well perhaps, though probably a lot less so than amphetamines and later "mood enhancers". All the punters I've seen with drug induced psychoses have been using amphetamines.

But it kills people! Well yes, no arguing with that, but because of prohibition we have only the sketchiest guesstimates of how many heroin users there are, so we can't say how many as a percentage, though instinct suggests its likely fewer than either alcohol or nicotine do. Overdoses are dangerous, but speak more to the despair and lack of hope that many users experience, of which their drug use if but one symptom. Inadvertent overdoses have happened when uncut drugs have been supplied, so that instead of a 90% talc (or worse) 10% heroin dose users have ended up taking 100% pure junk. Every avoidable death is a tragedy so arguments over relative risk seem specious in that context, but it probably remains the case that of all the drugs we chose for "recreation" heroin is a long way off being the most harmful.

The reality is that prohibition has created a lot of the problems we face right now. Heroin is addicting. To feed a habit costs money, but to have a lifestyle acomodating heroin is likely to imply a level of chaos that precludes a high or regular income. Hence to feed the habit users either deal or steal. Then we catch them and lock them up with dozens (or hundreds) of other dealers and stealers, so they learn how to do it "better". To keep them sweet we turn a blind eye to their continued use in stir-- after all at least they're off the streets, and heroin won't make you violent...

Then there's the "once a user always a user" myth. We have a number of users who have successfully quit not just injecting, but all illicit drug use. The trick is to "normalize" their care so they can be seen in the surgery without all and sundry knowing what they are here for. With a good rapport, a clear prescribing policy, and a willingness to accept change we can make opiate use so boring that clients will glady turn their backs on it, sometimes just for a time, but sometimes for good. Attending our surgery and not a "drug service" is a door back into the mainstream for some and it's this as much as the methadone substitution that gives them the push to move on with their lives and break out of the loop.

So, shooting galeries then?

Well on the plus side we get controlled dosing, reliable and affordable supply, sterile technique to avoid the harm of unsafe injecting and even perhaps a way in to accessing services for may users who are at present excluded precisely because they are "choosing" to continue to inject which will rule them out of admission to the vast majority of rehab systems.

On the minus side we get state sponsored addiction, less pressure to end a demonstrably harmful habit and a system likely to be too rigid to allow the chaos that is the lot of many current injecting users.

Were it to be made to work it could do a lot of good. The U.K is not the C.H. any more than it is the U.S.A. and any attempt to import techniques from another culture needs a lot of thought, but it appears on balance to be an import worthy of consideration.


* time to revive the tradition of the Virtual Chocolate Hob Nob for the first correct attribution.

** but not "personally" obviously.

Four More Years?

Looking back it appears I've been at this lark for four years now. I'm the first to admit things have been a bit patchy lately, and at present rate of progress will do well to see out the month, let alone another glorious year, and looking around the "'sphere" I'm beginning to feel a bit nervous. Seems four years in, blogs can start to get a bit time expired and dwindle away to nothing. This simply wont do. I've barely got enough material here for a chapter, let alone a sidesplitting Herriot style memoir or two to see me right in my dotage.

At this rate I'll need to start recycling material rather like a certain teller of Tales of Boy Wizards to see out the time to retirement, only I'm not allowed to go bumping off characters just to revive interest in the franchise now am I?

So if any of you dear, fantastically loyal, vastly talented readers have any amusing GP related anecdotes you're happy for me to shamelessly plagiarize, you know what to do.

Seriously though, four years in, although it's a bit neglected, this old place is still home. I do intend to keep going at whatever rate time, inspiration and real life will allow. After all it's been my safety valve when things get me all hot under the collar, it's introduced me to a fine bunch of people, some nearly as mad as I, and it's done wonders for the old ego, just to know a few of you out there actually want to stop by and read this stuff.

So here's to another fun packed year ahead, and god bless us every one!

Oi, stop chucking all them bloody spears!*

Right now I'm feeling a bit like Michael Caine playing Lieutenant Bromhead in Zulu. The first wave of the attack has passed and the troops are seeing to the revetments and mealie bag barricades in anticipation of the next wave. Happily thus far, the hospital isn't on fire.

Now you're all sitting there wondering what the hell I'm rambling on about. That's o.k. Sometimes I wonder myself. But no, this time there is a point, honest.

I'm talking about the "Swine Flu". The reason I haven't so far is because early on in the pandemic we were a bit busy preparing, like Michaels tiny band of Red Coats, piling up the barricades. Then it all went a bit berserk, with assegais flying about all over the place... er, the phones ringing off the hook, mainly with the "worried well" but in amongst these a fair few who were poorly. Due to an appaling coinicidence of timing Ambridge was hit with a bit of a summer cold bug just as the flu hype was really getting going which didn't help. In the end we peaked with something over 50 flu related calls a day in addition to our normal workload, which doesn't sound a lot until you figure that's three full additional surgeries worth, with each call needing at least ten minutes to triage and advise, and with a number ending in additional home visits.

Just when it looked like the dam was about to burst the National Flu Line, which had been promised, then posponed, then rushed into service anyway, started, and the calls went away, almost overnight. Then I went on hols, and now I'm back and all is calm again. The only snag is they tell us to expect it back in the autumn. Perfectly timed to coincide with the expected seasonal flu taking off. Since we have no tool for discriminating between the two, things might just get exciting again soon. Especially since this latest outbreak has rammed home to the whole contry that Flu is a significant and occasionally fatal illness (which it undeniably is), and also that it is "treatable" with Tamiflu (which is, sadly, far from true).

So here I sit, and just one question remains. Is it time to learn the words to "Men of Harlech" then?


* Rather disappointingly he never actually said that in the film, but I tend to the view that he should have ;-)

An open letter to the rt hon Alan Milburn MP

Dear Alan,

I can call you Alan, right? After all, in our egalitarian, best of all possible worlds, society I’m allowed. No glass ceilings here eh?

What’s that you say, disproportionate numbers of professionals come from moneyed backgrounds? And I’ll bet it’s more now than it was a few years ago. And I bet it’ll be more still in another few. And why? Well it’s obvious isn’t it? The universities are all shameless elitists who have it in for “ordinary” kids like you and me. They’ve erected this “glass ceiling” of yours to keep us in our place, yes?

Well no actually. You did that. You, with your failed policies and your failing government. I notice you had to slink away from health a few years back after wrecking that, and now you want to have a go at higher education. Well heaven help them. You see they didn’t put the ceiling there. You and your cronies did that all by yourselves. Whilst you were collectively milking a crooked system that “froze” your pay, quite wrongly I might add, and made up for it by doling out the swill in the expenses trough (and no I nether know nor care if you personally were implicated, this is satire and not libel), you thought it would be a good wheeze to introduce student loans and tuition fees.

Worse, yet, in your anodyne “no-failure” “non-competitive” school system you devalued the grades awarded in the bizarre system of GCSEs that teach pupils how to sit exams, not how to acquire knowledge. Now the universities, faced with a torrent of straight A students, have to find other ways of selecting the brightest and best. Applicants need at least a Grade 8 instrument (but we don’t do music or instruments in school), a Captaincy of a County XV or XI (but we can’t do rugby or cricket—we sold the field) and a plethora of other qualifications or aptitudes beyond what school can offer in normal hours (but we only have to teach the national curriculum).

A medical student qualifying this year will have, on average, a student loan debt approaching £50,000, sorry, didn’t you quite get that, I said FIFTY THOUSAND POUNDS. Lawyers and accountants might owe slightly less, but will still need to obtain post graduate qualifications in order to actually pursue a career in their degree subject, which they will pay through the nose for, with far less guarantee of a job at the end because you’ve blown all our money fighting “terror” and shoring up failed banks. Overall the medics have it easy don’t they.

So how dare I, a privileged member of this moneyed elite dictate to you, a veteran class warrior and striver for equality? Well you see my roots are about as working class as you can get. I was lucky enough to get to a grammar school, and to have grandparents who wanted badly enough for me to be the first of my family to go to University. The same is true of three of my four partners. You’re right, the students I teach now all have at least one professional parent, but it’s not their fault, and it’s not their University’s fault either.

This is the world you made. I imagine you all started with the best of intentions, but you’ve screwed up so badly it almost defies belief. Still you’re not in it for the long haul are you? A few soundbites and then it’s on to the next brief, or the wilderness of opposition where you can say what you like and damn the consequences. Or if it gets too hot again, back you can go to the bosom of your family. But if I were you I wouldn’t spend too long mulling over my dubious achievements when the time comes, or I might end up very tempted to take a long walk off a short pier.

Resurgam!

To paraphrase Arnie. There's a bit too much Real Life going on right now so don't expect much for a month or two, but I aim to be back soon as I can.

Honest.

Trust me.....

The adventure of the midnight feast.

Lunchtime sees and urgent request to visit an old friend, put in by the District Nurses. When Nurse Gladys visited him this morning his blood sugar was through the roof. Not good. Especially since he's just out of St Elsewhere's after an op for diabetic complications. So I don my deer-stalker and round I zip, expecting the worst. The last time we did this I ended up having to admit him to the hospital, culminating in his surgery, a three month stay on the ward and a radical overhaul of his treatment.

Today couln't be more different. He's fine. We repair from the dining hall to his new flat in the poshest warden controlled accommodation in Ambridge (another consequence of his recent admission was the move here) for a private chat. He hasn't felt so well in ages, no symptoms to suggest any acute illness that would account for his sudden surge in blood sugar. His appetite is fine. His chest quite clear. No evidence of urinary infection, Swine Flu or other attendant lurghi whatsoever.

"So why," I gently probe, "the high sugar this morning?"

There's a pause. A pregnant pause, where the pregnancy is headed for the delivery of triplets.

"Well," he owns, finally,

"You see,

It's like this....



Last night I had a craving for the biggest bag of chips I could get. Lovely they were, all smothered in salt and vinegar. Just the job!"

Then he grins.

I nag him half heartedly about watching what he eats and then we chat about the cricket for a while.

He's going to try to be good again now, and Nurse Gladys will watch his sugars for me.

So. Another mystery solved, and yes, it appears the answer was alimentary. Now, where's my Meerschaum?

Just passing....

It's not much fun being eighty. Or so says Eric. He's just had a spell in hospital. Nothing scary. He thought he'd got a tummy upset, but it turned out to be constipation.

(When you've been bunged up for long enough you get a thing called overflow, which makes it look like you've got diarrhoea-- and that's the last we'll hear on that subject today if it's o.k. with you)

Just before he went in I'd had a visit from Doreen, Eric's neice. She's been looking after him since her aunty, Erics wife, died eight or so years ago. Every day, rain or shine, high days and holidays included, she's been calling on him morning and evening, cooking, cleaning and generally fending for him. She's all the family he's got left, and so it falls to her.

She had called in to say she was getting worried about him. He was a lot more cantakerous than usual, and had taken to stopping in bed for hours on end, refusing to get up. We had agreed that I would find a pretext for calling on him-- just to give him a bit of a check-up. Under no circumstances was I to mention that Doreen had been to see me. Then, the day before the appointed "check-up" visit, he went and got himself admitted.

In the end it's made my job a lot easier. Since he's had this seemingly trivial problem sorted out he's been a lot better, but he still greets Doreen every morning with a cheery "'Wish I was dead!" She's nearing the end of her tether with him and we're going to be needing to find him a lot more support soon, if only to preserve her sanity, so having a pretext to do a review visit on discharge was too good an opportunity to pass up.

Today we've sorted out his med's and he's agreed I can call again to see how he's getting on in a couple of weeks. In her absence he can't sing poor Dorren's praises highly enough-- though I'm sure it's never occurrred to him to actually tell her to her face. She's calling back later in the week to see how I got on, so perhaps I can do it for him-- though I mustn't let on to him that we're talking. He's not quite ready to think about letting anybody else in, but if Doreen can be persuaded that she could start letting him know it's time for her to pass the baton on, he just might be. Before she goes to the wall for preference.

It's a complex web to unravel, and none the easier when none of us can articulate half of what's needed, but if we get it right Eric might just be a bit happier to carry on living for a bit yet, and Doreen might even get a chance to start.

Lucky I was "just passing..." Eric's gate this afternoon ;-)

Just another day at the office...

Sometimes you can go for months without incident. Other times, a bit like London Busses, everything comes along at once. Seems we’re going through one of those phases in our neck of the woods. Thankfully, thus far the “Flandemic” has not lived up to its billing.

Yet.

We expect the next big scare in November or December, unless something quite bizarre happens in the interim. For now the daily email updates are moving to once or twice a week, and the planners really do seem to have a strategy in place. Whether the plan will survive more than half the work force being laid low themselves, or kept at home looking after kids/ elderly relatives who cannot care for themselves, remains to be seen. Still there is a plan.

No, this morning saw a string of genuinely troubled individuals facing potentially or already determined life threatening illness. Once again, by mid morning the surgery was more than an hour adrift with no prospect of catching up. After three patients already watching the sands of time draining from their own personal hourglasses at an alarming rate, came a mum bereaved not once, but twice in the space of six months. Her distress was etched almost bone deep on her face, and there was absolutely nothing to say except “hang in there” and “you will survive this”. I’m not sure if I was saying this for her or for myself to be honest, but after half an hour she was cried out enough, for now, to keep putting one foot in front of the other for a bit longer.

After a ten minute pause, and a half a bucket of Java, we got the show on the road again, and the rest of the day passed without incident. The poor souls who had had to wait around in our waiting room with not even drying paint to watch for amusement (all diversionary materials having been carted off and incinerated to remove possible vectors for the flandemic), were amazingly good natured, and by mid afternoon there was more laughter than tears accompanying the ebb and flow of the afflicted coming trough the hallowed portals.

Still not a day I’ll be forgetting in a hurry, or wishing to repeat any time soon. But I can’t help thinking, for all that, that I’m the one who’s got it easy here.

A visitor from the future...

Earlier this week I met Yuri for the first time. His record states he’s been in Ambridge for nigh on five years, but so far, after an initial attendance to register, and a couple of visits to Dr Neighbour for minor ailments, he’s not troubled us at all. Looking at him, it wasn’t hard to see why. It’s not that he’s particularly tall, but he’s certainly solid. The urban combats, spetsnaz style black and white striped t-shirt and high laced paratrooper boots certainly created an impression. Then there were the bulging muscles. Yuri hasn’t so much "built" his body as hewn it from living granite. His biceps put the rather weedy Jesterly frame to shame, and the suppressed aggression he exudes suggests that one false move and he could snap my neck like a dried twig. A long dead, especially brittle twig.

Happily, our own little corner of blighty hasn’t yet succumbed to the attentions of a Ray-Ban shrouded oligarch and his own private army. Yuri just came here to work, and to carry on his very impressive hobby lifting ludicrously heavy things for fun, and the odd bit of bag pummelling. Sadly, now he’s been earning for a bit, he’s found himself seduced by the powers of the Dark Side. A "mate" at the gym introduced him to chemical supplements—hormones to you and me. Androgens and anabolics.

The only trouble is, after six months of this he’s been getting some chest pains, which have him fretting. Still he’s been for an EKG back in the Motherland, and it was normal, so he’s a bit less woried now. I tentatively prod where he says it hurts. I could almost swear as I jab his left pectorals there’s a clank. I foolishly suggest we try to provoke his pain with a few resisted movements starting with his shoulder. I cling on to his elbow and ask him to lift it above shoulder height as I press down. He lifts his arm and my feet clear the deck by a good couple of inches. There’s not even a flicker of discomfort.

I decide against asking him to do the reverse move, pressing down with the elbow point whilst I try to prevent him. I value my spine, and like it just the length it is. It helps hold me up.

Still after a bit more of an exam we decide the pain is most likely a minor strain. I prescribe him some 3-in-1 and a referral to Cyberdyne Systems if he doesn't get better. Steroids, it appears, don’t do much for the 800 Series Terminator. Still, I imagine he'll be back.

Credo

Witnessing wilful self-destruction is never easy. Watching someone plumb the depths of alcoholism, or push the oxygen supply aside to light up with hands made uncontrollably trembly by the drugs needed to keep breathing because of the damage that same act has inflicted down decades is a living hell for those charged with care of loved ones so afflicted, and a kick in the teeth to those that try to treat them.

It’s often hard to take a step back and reserve judgement. But we are not them, we’ve not seen what they’ve seen, or done what they’ve done. We all have our vices, (Hob Nobs might spring to mind perchance) and we all sometimes take a road we know we ought not, just "to see what it’s like". Fortunately for many of us, we get turned around before a wrong turn gets us hopelessly lost, and that can give us some empathy for those less fortunate.

The thing I’m finding more difficult right now is finding that same empathy for those that opt to take a wrong turn on purpose. This winter Blighty has seen a Mumps outbreak. Most of the victims are young adults who were born a year or two too early to be caught in the initial MMR campaign of the late 80s. Some have been children held back from immunization because of a false fear placed in their parents minds by a tub thumping campaign based on widely discredited science about a supposed danger form the combined MMR vaccine.

The fall out from this was hopelessly bungled by the same politicians that told us BSE could never affect humans and by a scientific and medical establishment that failed to articulate clearly enough the counter argument. In the first flush of controversy it is easy to understand why some parents opted to hold back, but we are still finding MMR uptake rates lower than they need to be after all this time, and whilst I’m usually the first to champion the rights of the individual, I’m a little less keen on the right of the individual to remain wilfully and dangerously uninformed. Especially when it is not they, but their children who will bear the brunt of their decision.

In my time in Ambridge I’ve also witnessed patients cut off from family and community for an act so seemingly trivial as accepting a life saving blood transfusion, on the grounds of religious dogma, and others choosing to die, or being condemned by relatives to, for want of the same. I’ve also witnessed patients with curable, or at least remittable malignancies place their faith in crystals and carrot juice rather than hospitals and medicine, and have to endure unnecessary agonies and speedier exits as a result, all through some blinkered perspective that classed all allopathic medicine as bad because they had a bad experience once with Dr X or Hospital Y.

Mankind truly is everywhere born free, but some make pretty odd choices for their chains, and their blinkers.

Dogging?

As I traversed the Ambridge Gyratory System* the other morning I was struck by the contents of the large estate car in front. Two gormless lop eared Labradors gazed benignly out at me, until the car hung a left and disappeared down the ramp to the Councillor Dan Archer Park and Play Area.

Walkies, it seems, have become "bit of a drivies". Man's best friend no longer has to turn out attached to a leash and walk to the park before getting to zoom about like a lunatic chasing a tennis ball. Now Fido can expect to be chauffeur driven there and back again, and spend ten or fifteen minutes wheezing about after some fuzzy, squeeky monstrosity from the pet shop that looks like a failed genomics experiment and has none of the roll or bounce potential of the good old b-a-l-l (sorry felt the need to spell it out just in case any dogs were listening).

I worry slightly that as soon as they develop a playstation controler adapted to the canine paw, instead of a drive to the park, poor pooch will be parked in front of the doggy version of Doom or Quake, and left to get on with it. It's no wonder our pets, like their owners and their owners kids, are facing an obesity crisis.

There's just one word for it really.

Barking.


* The ring road hemi circumnavigating our fair town, not the 1970's Jazz Fusion Combo of the same name.

Clock watching

You might wonder why, should you ever have cause to see a personal medical attendant, you spend ages sitting in a waiting room , browsing decade old National Geographics and the like. Perhaps a quick snapshot of this afternoon’s surgery will help explain.

15.00 Enter first patient. Young adult male. Suicidally depressed and in crisis. After a bit of a chat, we manage to tease out the principal cause, agree a management, with antidepressants and the safety net of a ring back any time offer, and fix a two week follow up appointment.

15.30 Enter second patient (appointment 15.10). He’s been drinking a lot lately—just fluids, not alcohol, after all he is only 14—and he has to get up a few times a night to pee. No he hasn’t brought.. but yes he can do a specimen. We find a pot. He pees. The stick shows he’s passing glucose syrup. We find a glucometer and prick his finger. His glucose is 24, or roughly four times normal. We agree he should go to the hospital and get started on insulin. This needs a phone call to arrange.

15.55 Enter third patient (appointment 15.20). She’s worried. She had a car accident a few days ago. Thing is she can’t remember it. She can’t remember if she ought to remember it. She plainly hasn’t had a significant head injury. She’s not had seizures in the past. We’ve no reason to think she has had one this time. Bur we’ve no convincing reason to think she hasn’t. She’d quite like to know, so we agree she needs a brain scan and a referral to a gerontologist for more clever tests. In the meantime I have to advise her not to drive anymore—not a problem right now, since her car has been written off, but still she needs to be advised.

16.20 Enter fourth patient (appointment 15.30). She needs to renew her annual repeat prescription for high blood pressure. So far her BP control has been o.k. Then this week she was told she might loose her job soon. And so might her husband. And her BP control has gone a bit wonky….

16.45 Enter fifth patient (appointment 15.40). “You’re running a bit late today—did you nod off for a bit?”

18.33 Enter DS Carter and WPC Watmough. Seems grabbing a punter by the neck and squeezing hard amounts to assault.

Hard to believe I know. Still at least Broadmoor might be a bit quieter.

Playing the percentages.

I’m perplexed. The game I’m in is all about communication, or so I’m continually told, and continue to tell the poor benighted Med Students that draw the short stray and have to make the trek out to Ambridge for final year community based medicine teaching.

Overall I flatter myself that that is one thing I’m not too bad at. If you want a fourteen point differential diagnosis for possible causes of a raised serum custard level you might do better with that nice Dr Neighbour—he’s got Medical Membership you know—but if you want your actual diagnosis explained then I reckon I’m yer man alright.

Now, this year, as every other this past four years, I and my confreres have been surveyed. In short for a couple of weeks around New Year and carefully worked out demographically accurate sample population from our surgeries were given questionnaires to rate us and our practice on.

We have just had the results, and sure enough my mean score for 10e (How well the Dr explained your problems or any treatment that you needed?) was a respectable 86%. I also got 83% for 10d (How well the Dr involved you in decisions about your care?).

Before we get too carried away the national mean for those two parameters, throughout the U.K. was 83% and 81% respectively, so not to be sniffed at at all. Still I must confess to being mystified, since despite these encouraging stat’s 11a lobs a dirty great spanner in the works. The self same population that gave those ratings, when asked in 11a (After seeing the Dr today do you feel able to understand you problem(s) or illness?) only muster a rating of 67% where the U.K. average is 69%.

So there you have it. Despite 3% better explanations than the average, and 1% more involvement my punters are ending up 2% less clear about their problem(s) or illness than their peers. Colour me 100% baffled.

On a brighter note Mrs Antrobus was in today. At 80 plus she had an umbilical hernia repair in the winter, and is now fully recovered. For the first time in almost a decade she has a flat tum, and can see her belly button. She’s so delighted she even asked her surgeon if she can get it pierced now—“Y’know, like that Brittney?”

Passsing through

Sorry to have been away so long. Not much to say, and no voice to say it in "blogger's laryngitis" if you will. There's plenty of stuff going on, but it's all pretty dull and uninspiring and I wouldn't want to inflict it on you good gentlefolk.

On the plus side we have sun and daffodils in Ambridge and at Jest Acres. On the minus we have a frenzied month of audits and compliance checks to finish the contract year so we can get paid. None of this is especially threatening, just mind numbingly tedious.

Somehow the regulars have also captured the zeitgeist and have been relentlessly dull and unimaginative in their presentations lately, so there's not much fun to be had there either. If anything amusing or interesting is actually happening here, it's not happening to me, so if you've got anything zany, philosophical, whimsical or perplexing to share, I'd be eternally grateful. If not I'll just go back to lurking, and spying on you all in the bloggosphere for a bit. just wanted to stop by and let you know I'm still around.

Just as an indicator of how low we've sunk, Hob Nobs are off, and I'm having to get by on Custard Creams.

Festina Lente

We could all learn a thing or two from the good burghers of Halberstadt. I learnt late last week from my good friends on Radio Four, that these fine folk have embarked on a monumental work set to far surpass and little local difficulties we might be experiencing in the developed world at the moment. In the midst of present financial and political turmoil they have begun a concert whose ambitions will, if completed, span generations, if not epochs.

As we all fret and worry about the fragility of the economy, witnessed locally by the flurry of job losses in the midlands car makers and their attendant parts suppliers, they gathered last week to witness the playing of a new chord in this concert. The chord began but and eyeblink (as I believe the literal translation of a German term would have it) ago in 2003. It will change every 18 months or so, playing steadily throughout the intervening span on the organ of St Burchard’s Curch. Played to its completion the piece should last around 640 years.

That’s right, YEARS.

The time chosen is significant as it reaches forward in time as far as the founding of St Burchard’s reaches back. In those intervening 640 years we have gone from illuminated manuscript to internet, and from horseback through horsepower to spaceflight. The way has been strewn with calamities, market crashes, wars and pestilences to be sure, but equally with triumphs in art, music, medicine and technology unimaginable to the Halberstadters of yesteryear.

I have a new thing to add to the list of “things to do before I die”, and this one should be there for generations of Jests yet unborn to do likewise, whatever befalls us inbetween. And for roughly twenty generations, should we all be lucky enough to be able to participate, and should the concert get to run its allotted course, we could all claim to have been present at the same event. A thought I find both humbling and ennobling. I doff my cap’o’bells to the fair city of Halberstadt and its visionary folk.

A mile in another man's shoes?

We moved to Ambridge late in 1990. Our first winter here was a proper Winter with a capital “W”. For four weeks we had a meter long icicle hanging off the corner of the conservatory at Jest Towers, and our poor late lamented moggy (then a spry young two year old) could wade chest deep in snow like a little ginger Bismark.

One especially icy Saturday saw Dr Neighbour and I abandon our attempt to drive home from the duty surgery at the foot of Lakey Hill, after some pillock had jack-knifed his artic’ across the road. Instead we stumped up the hill and back to Jest Towers afoot, like Pooh and Piglet tracking woozles—only stopping at the top of the hill for a reviving medicinal port in the now demolished Lakey Arms. When we made it home we ended up calling Radio Ambridge, to warn the punters there was little point calling on the duty doc that weekend as his car lay abandoned and almost all roads were impassable anyhow. Later that afternoon (once the “medicine” had worn off a bit) we went back with spades and dug Dr Neighbour’s car out, and let our newfound Radio chums know we had restored normal service. Since then Ambridge winters have been a bit of a damp squib—though often very damp indeed to be sure.

Until now.

This week we have fallen pray to a new meteorological phenomenon, the “Snow Event”. Indeed, we have had two such thus far, and can apparently look forward to another on Sunday. On the minus side it’s made all the roads hereabouts really slippy so driving has been a bit of a pain. On the plus side it has made all the roads hereabouts really slippy, so the schools have been closed and nobody has been mad enough to venture out to work, which has made driving an absolute joy, especially when, as this morning, you get to drive through countryside where every tree and bush stands limned in glittering white frosting, in the special silence that attends fresh fallen snow.

Better yet, when you get in to the office, scarcely later than on a normal day despite the “extreme” weather, everyone is so pleased to see you, and many of the regulars, having take a peep out from under the duvet, have decided they can wait a few more days before coming in and so have cancelled their appointments, making the caseload a little lighter. Intriguingly though one group of patients seems to stick at nothing to come in, those with pre-existing mobility problems. One poor old chap even managed the two mile walk in for a routine review of his Parkinson’s Disease since the busses weren’t running. It’s almost as though the snow doesn’t impinge, or that it is just another and perhaps more trivial challenge to their mobility.

I'm pretty sure they could teach the rest of us a thing or two.

Bust....

… and Boom.

Or so it would appear. It’s been a nervous six months for the denizens of Ambridge. Light industry hereabouts had evolved to serve the needs of the midlands car makers through the boom years of British manufacturing industry. Those few that are left are all teetering on the brink of the much bruited recession, resulting in increasing uncertainty, lay offs, redundancies, short time working, and downwardly spiralling incomes for the majority of folk.

Add to that rising fuel costs and the coldest winter on record (well o.k. not quite perhaps, but certainly one of the chilliest I can recall) and it all adds up to a pretty miserable picture. Or so I thought until yesterday morning.

You see, we Yeomen of Borsetshire are a sturdy breed. When the chips are down we rally round and make the best of things, and when, as this year, there’s no cash, no heat and nothing worth watching on the telly, we can make our own entertainment. And it seems we have been. Rather enthusiastically.

And the upshot of all this “entertainment” was made manifest not once, nor twice, but three times in the space of one surgery yesterday morning. On each occasion in strode a confident looking woman (one with sheepish partner in tow) with a particular half-smiling expression. These days I hardly need to ask, but do so, just to observe the formalities, thus;

“Now what can we do for you Ms….?”

And they reply “I’m” (or once “We’re”) “pregnant!”

There follows a round of congratulations, followed by one (well, yesterday three) of the most joyful consultations you can get in this line of work. With the obvious exception, I’m not sure there’s a better way of spending a morning ;-)

On being pleasant.**

It’s been an odd week again. The ongoing Ambridge Lurghi hasn’t helped, to be sure, but there’s more random weirdness abroad at the moment to go along with it. A case in point is young Elwood, a precocious little four year old who can already spell “Triceratops” and who has a friend who follows him everywhere, name of Harvey*. Elwood’s ears have been feeling a bit sore lately, so Granny brought the two of them in today.

“Harvey’s been poorly” chirrups the lad as Harvey takes his accustomed place seated beside his bestest friend. Elwood’s feet dangle over the edge of the chair, but as I round the desk I am careful not to step on the altogether larger paws of poor old Harvey.

I mime lifting aside a long lop-ear and gaze into space through my auroscope, a good two feet above the upturned face of young Elwood.

“It’s o.k.” say I “Harvey’s looking fine today, now how about you?” and then little Elwood proffers his own ear for inspection.

“Hmm. Not quite as good as yours I’m afraid,” I address the remark to the spot Harvey’s face should occupy. “I think the lad needs and antibiotic, just to be on the safe side.” We all three nod (Elwood assures me so), and off the two friends go, hand in paw, Granny in tow, clutching a script for Elwood, and the invisible carrot I proffer for Harvey’s trouble. I have a special jar of them on the desk, just for Harvey’s visits. Fortunately, being invisible it doesn’t take up much space.

* names changed to protect the innocent. The Triceratops, however is real.

** E-V-H-Ns (TM) on offer for the derivation as usual.

Learning to take the smooth with the rough.

Such is the perversity of human nature that I am starting to fret a little. I’ve become accustomed to a more or less steady diet of woe and misery over the last couple on months. The problem has been another winter of intractable cough bugs, with flu like illness chasers, that seem to have been doing the rounds in Ambridge for ever—or at least since early November.

There’s no denying they have been pretty miserable for the poor blighters who have been afflicted. Problem is they’ve also been pretty un-amenable to medical remedy. This has two effects. First it fills surgeries with a lot of miserable people, all lining up to be told, in so many words, there’s nothing we can do for them. Second, and almost more pernicious, it leaves one with a gnawing feeling of clinical impotence which, left unchecked, can lead to an appearance of uncaring dismissal when presented with yet another poor bastard with the lurghi.

The end result of such a downward spiral is a whole bunch of miserable patients and their miserable medical attendants, all moaning to and about one another. So if there’s anybody out there with a miracle flu remedy they can share there just might be a hob nob or two in it for them from this oppressed and downtrodden GP at least.

And then, today, for no clear reason that I can fathom, all the punters have been being especially nice. You know the sort of thing…

“You’re looking well today Dr J, have you lost weight?”

“I swear you’re looking younger now than the last time I saw you!” (Which was five years ago by the way).

“Thank you for your time. I feel so much better just for talking…”

So why do I sit here waiting for the next bombshell I wonder?









As an aside I heard on dear old Radio 4 at the weekend that the good burghers of Brisbane are teaching relaxation technique to toddlers. I feel vindicated. Someone in Oz has obviously been listening to my inane ramblings. Just remember, you heard it here first. Dr J the visionary!

Did you just hear something then?

So that’s it then. New Year rung in in suitable style at Jest Acres after trip to the Panto, New Years Eve banquet in the great hall to follow, concluding with the now traditional sybaritic orgy that is the chocolate fountain, and Jools on the telly in the other room Hootenannying for all he was worth. All in all it went rather well, though the return to a duty surgery on Friday the 2nd was a suitably sobering return to earth.

Still the New Year is off to a suitably surreal start, that if nothing else shows the perils of “copy and paste” correspondence. For a long time there have been parallel moans in U.K. health services. The hospitals moan that GP letters are often a bit sketchy, frequently penned in haste at the bedside as they are, and so are inclined to leave out essential titbits, such as the patients inside leg measurement and so forth. In turn GPs have moaned that the discharge letters thrust into the hand of homecoming patients tend to lack vital, or at least legible, information on trivia like diagnosis, treatment and follow up arrangements. This has, to my knowledge been a settled and steady state for at least three decades. I suspect even poor old Hippocrates had young whipper snappers moaning about the appalling state of the handwriting in his wax tablets down at the Kos DGH.

But over the past three or four years we have moved to printing a lot of the more relevant patient data onto an encounter sheet to attach to our urgent referral letters, and the hospitals have moved to IT generated discharge summaries which are way better than the pro-formas of yesteryear. The problem comes when these IT generated documents are pre-formatted for routine entries of common data, and not edited for those that do not apply, as happened today. Or at least I very much hope that that was the case. Otherwise we have a patient who died in hospital, but was found to have a normal temperature, blood pressure and respiratory rate on discharge from the ward to the mortuary…..

Must go now, it’s dark and there’s a strange tapping sound at the window.


Errr Hello!

Is there anybody there………….?