How much does a banana cost? (And other considerations of imperialism and inhospitable glaciers)

My trip to the Southern Glacier, Sólheimajökulll was cancelled last minute.

Frustrating.

That’s the way of the world. Things don’t always play-out as we would like.

So, Iceland, what I have I learned?

My brother keeps telling me that they ‘hate Israel.’

Strictly Jordanian dates only.

My reply had been that lots of countries hate Israel.

He was keen for me to find-out the reason for the antipathy.

I haven’t asked anyone.

‘Hey, Olaf, why do you guys hate Israel?’

‘Eh?’

I suspect some of this has to do with Lutheranism.

I understand, mostly by inference and by standing outside austere churches and cathedrals that this is the major Christian denomination on the Island.

Martin Luther was the man who posted his writs at Worms, who rallied against the flouncery of Catholicism with its purchases of favours and indulgences.

Better to maintain a direct connection with God, than navigate priests, their Latinate rituals, and ceremonies.

Well, I perceive, and please don’t let this offend you if you are a Lutheran and you know more about these things than me, that this leads to a form of self-righteousness.*

Purity of purpose and spirit.

Akin to the way in which Icelanders have adopted renewable energy.

They have tapped into the geothermals to generate electricity, water and heating and, where that is not available, hydroelectric.

They drive electric cars.

I haven’t seen any Priuses although lots of Teslas, Hyundais and Kias.

Their cars move through the streets with a strumming of winter tyres, equipped with metal spikes to manage the ice and snow (no slippy, slidy early mornings for them).

Yesterday I ran past the central Reykjavik cemetery.

Dull stones, names etched for remembrance.

No angels.

OK.

I’m not trying to run-down the population.

I have not met anyone beyond casual shop, hotel, and restaurant interactions.

Although when you live in an area of purity (the tap water tastes amazing – it is filtered through volcanic rock) you, I suspect anticipate this of others.

(This makes the American tourists, sorry for more generalisation and offence, extra loud and intrusive).

And with this approach the anticipation of fairness, equality, and flatness of hierarchy (the gap between the rich and poor is less here than the US, UK or yes, Israel, although it is still significant – the top 5% of people own 50% of the island).

And why not fairness towards the Palestinians?

And there is the problem.

I suspect.

And, who knows, perhaps they love Israel here.

This is my commentary on my brother’s recent Googling.

Or maybe it is the Jews.

Everyone hates a Jew.

Do they not?

Ironically, I didn’t begin this blog with an expose of my biases and prejudices.

I wanted to talk about Imperialism.

The Icelanders have not been colonialists – like the English, French, Spanish and Americans.

(Leif Erikson’s attempt to settle North America didn’t last).

They have scratched-out an existence on the barren soil, contending with winters, volcanoes, and all sorts.

And what is the point?

Well, everything is expensive.

Perhaps double the price of food, drink, and clothing than the UK.

So?

It’s an island; they import everything.

Yes, OK. So too is the UK.

Admittedly this is a remote island with a tiny population. 370,000 or thereabouts.

That is a factor.

Another I suspect, going back to the start of the blog and the Israel – Palestine conflict.

The island in its long history has been colonised or ruled by Denmark and Norway. It gained independence only in 1944 (taking advantage of the war and the German occupation).

It has therefore a history of occupation, of outside control, like Scotland, Ireland, or India.

And, like all previously oppressed people it has a fierce sense of independence and a preference to avoid profiteering from the labour of others (the colonised).

All this combining perhaps, (with Luther) to what you see today.

It is a country built of necessity of grit and determination.

Sure, the bananas are expensive.

So what?

Everything is expensive.

If you take an approach that precludes an exploitation of others.

What is the cost of a banana?

I’ll tell you.

OK, I won’t. You can read How bad are bananas? (Mike Berners-Lee).

And, to return to Israel.

If there has ever been a colonised country it is the Holy land.

The list of occupiers is long.

Assyrians, Babylonians, Greeks, Romans, Byzantines, Crusaders, Ottomans, British…

And the timeline of those occupations, depending on your historical view goes back thousands of years.

This likely relates to the independent attitude of Israel and the Israelis.

Combining the cost of bananas with imperialism and Jewish autonomy.

All before breakfast and, on holiday.

You have my apologies.

Good day.

xxx

What did I do with my cancelled day?

I ran, swam, and walked.

Better to keep moving.

Avoid standing still.

Or you might freeze.

xxx

*Just so as to be clear and, to represent my person-centred credentials; when I refer to groups, I am alluding to the notion of the people rather than the people. Once you have met one Icelander, Scot, Jew, so the saying goes, you have met once Icelander… People are distinct from person. We is not me although you are you.

Heightened index of distractibility & surviving the Nazis.

Now, a shift to something different.

When I was in my early 20’s I was very interested in the writer, Colin Wilson.

He is the former Peterborough man who after leaving school at 16, went to work in a chemical factory then travelled down to London in the early 1950’s. This followed with him writing a classic of the early Angry Young Men generation, The Outsider. Different from Camus’ L’Étranger, although with parallel themes.

This was a work investigating the place of outsiders in art and literature. He wrote it whilst sleeping in a tent on Hampstead Heath, spending his days in the British Library.

A similar activity in 2023 would get you locked-up or sectioned.

I was reading Oliver Burkeman’s book, Four Thousand Weeks, last night and came across a quote by the French Philosopher, Henri Bergson.

It took me back to a moment when, sitting in the Student’s Union in Dundee with my Phil, in conversation, we touched on the meaninglessness of life. When I say touch, it was more of a glance. A passing brush with the notion that proved so very terrifying we immediately changed the subject (wandering off to Waterstones, Virgin, or up Law Hill).

The notion that the aspiration or the thought is more valuable than the thing is steeped in the roots of Stoic Philosophy.

The obstacle is the way.

Apologies for the nihilistic bent of this blog.

I don’t think it is Burkeman’s intention.

Interestingly, in a different vein, he mentioned the effect of intergenerational trauma on him and his family.

They are obsessive planners.

They would drive me crazy. (The feelings would almost certainly be mutual).

Bergman claims that much of this followed his grandmother’s experiences of escaping Nazi Germany just after Kristallnacht. Consequent upon the family’s meticulous planning, they escaped in time. (He describes them popping champagne bottles on the boat – suspect his family were not of my lumpen origins). This has been passed down through the years as a religious observance of the rules of forward planning.

Like my notion of the Anxious Jew.

The laid-back Jews were extracted from the gene-pool by Amalekites, Assyrians, Babylonians, Romans, Lithuanians…

He covers this too (in a roundabout way) – discussing the notion of focus and distractibility.

I am very distractible.

If I am to read a book in public I almost aways require silence or headphones/earbuds. Most recently I have taken to playing brown noise.

I remember as a child, my mum could read a book with lots going on. My brother Lloyd is the same. Not I.

OK, we are different.

And yet, my distractibility whilst mostly frustrating is a useful tool for survival. I will sense the pounding of the horses’ hooves before it is too late. Others will be someplace else, in their heads, that is.

Back to human all too human.

It is hard to escape.

It’s a palaver.

xxx

Apologies for not describing my American/Eurasian tectonic snorkel from yesterday (dry-suits at 2 degrees C) – in the clearest water. Visibility is reckoned at 100m (I can’t see that far out of water!). Floating is like moving through liquid glass. A fish (trout? Char?) passed beneath me; sunlight shattered on volcanic boulders. It was very cold. My socks stayed dry.

To the glacier this morning.

Silfra fissure

Update…

Tour cancelled. Weather apparently too severe for tourists to visit.

Gutted.

The only trip I had really wanted to do during this holiday was to the glacier.

Off to the swimming pool.

Iceland, Israel and four Dorits

This will be an unusual one.

I don’t intend to convey a message or reveal a truth, merely to explain where and why I am. And yes, four Dorits.

It began during Covid. Maybe 2020.

I had an inkling to visit my brother who lives in Israel.

At the time, Israel was far ahead of the UK in its Covid programme (which country wasn’t?), and I thought I could use my citizenship to gain entry. Not for any reasons beyond seeing my family.

Given regulations at the time, I knew I wouldn’t gain entry with my UK passport, and so, I applied to the Israeli Embassy to renew my Israeli one; last used in 90’s.

The reply came that as so much time had passed since my last visit, I would need to attend the Embassy in London with a valid plane ticket.

The logistical complexity (book and take annual leave, purchase ticket, and arrange trip to London) proved too much, and I called-off the trip.

Fast-forward to this February and I again had itchy feet for the Holy Land; I have only seen my brother for one day in the past five years.

I learned that I no longer required a plane ticket, just to present myself at the embassy.

I booked a slot, and the visit was arranged.

Why the hassle of getting an Israeli passport when I could fly using my British one? Well, Israel has a law that if you have an Israeli passport, you need to use it to enter and exit the country.

There must be a reason for this, perhaps related to security or demographics, I don’t know. Anyway, previously when I had visited, I was in and out with my UK passport. I knew I was bending the rules, yet I managed to outmanoeuvre security and get in and out without too much delay.

As I had flagged myself to the embassy only a few months before, I was wary of this strategy and thought I should do it properly.

And so, my visit was planned. A trip to London pending.

I called the embassy to check logistics.

‘How long will I be in the embassy?’ (Wanting to fit-in a trip to Foyles).

‘That is difficult to say.’

‘Will I get my passport at the time?’

‘It can take up to five days.’

‘No quicker?’

‘That depends.’

‘On what?’

‘Matters beyond my control.’

‘Is there anything I can do to speed the process?’

‘That depends.’

‘On what?’

… You can guess what came next.

My appointment was only two days before my flight (I, king of the last minutes saw a risk that I might not have a passport and might not be able to travel.)

‘Sorry, I don’t think I will make it,’ I told my brother.

And so, I cast my net (I still had 5 days leave ahead)

And yes, Iceland.

Here I am.

Reykjavik hotel. Scheduled for a snorkelling session in a few hours. (Yes, snorkel, I’ll report the story if I survive).

And the Dorits?

Well.

In my life I have encountered four Dorits.

There is Dickens’ Little Dorit. I haven’t read the book and couldn’t manage the dramatization.

Then there is Dorit Rabinyan, the Israeli Novelist. I have mentioned her before. She set one of her books in Magdiel, a small village outside Hod Hasharon and, the location of my middle school, Tali.

The third Dorit was a girl in my class at school.

I can’t remember her surname.

She was one of those girls, I remember, tall for her age. Thick glasses, unwashed hair and acne.

I recall her distress at not scoring 100% in Maths.

She tolerated me.

The final Dorit was reached via an investigation of Iceland.

Dorit Moussaieff is married to Iceland’s former President, Ragnar Grimsson.

Born in Jerusalem of Bukharin descent she moved to London as a girl and joined in her family’s jewellery design business before relocating North.

Dorit’s entry in Wikipedia mentioned her 2006 encounter with Israeli border police.

At the time, she was leaving Israel using her British passport and was stopped at the border.

An international incident followed.

And that could have been me.

Perhaps they tightened the regulations. (Possible).

Perhaps she was talking loudly in Hebrew. (Probable).

Who knows.

Four Dorits across England, Israel, and Iceland.

Last night, I dreamed of a trip to Herzliya beach, down from Sidni Ali, with my childhood friend Addy; now Elor. We discussed Bukhara.

He introduced me to Bukharans and their famous lisp.

As a child he was privy to all sorts of arcana.

xxx

I survived the swim.

Sidni Ali Mosque, Herzliya.

Mindful

I have been agitated.

Mind full of itchy & scratchy

Like the hives that appear after nettles.

I once whipped my back with nettles.

To relieve the pain of strain from climbing a wall at CentreParks.

We travelled with Wendy, and I remember competing with little children until muscle shred and spasm stopped me.

It was the year I worked in Rotherham as a registrar.

The year I discovered rectal diclofenac.

I remember the nightshifts, unable to sit or lie (the pain), walking the wards until dawn.

I remember layers of ice coating the BOC oxygen supply.

Like the water hydrant I saw last night.

Little did I know that this would lead to an exclusion on my income protection (no early retirement with a musculoskeletal injury for me).

The aggravation,

Has, I think stemmed from my lone-ness.

I am holidaying in Iceland.

A solo trip, the first since my 20’s.

Back then, energised by adventure I would strike-up conversations, embark on adventures – Pere Lachaise, Marseille, Luxor and the Charles Bridge. The domestication of my 50’s has kept me still. It has been me and my family, the way I like it.

And now, here I am.

Me and an island of strangers.

A hodgepodge of Icelanders, English, Americans and Chinese.

Yesterday, a Spanish couple on the airport transfer talked non-stop for 45 minutes.

I find in my isolation a heightened sensitivity to sound and the conversation of others.

Last night, shortly after arriving, I jogged around Reykjavik. (March & light until 9).

Me, the road, ice, dead grass and some scattering geese.

I think of all the ways our minds sabotage us.

Here, I write in the hotel reception, brown noise playing through noise-cancelling earbuds.

You see, too much alone time and I become lonely; other people and I am overwhelmed. A social catch-22.

I reflect on something I read recently.

‘How will I know if they keep Kosher?’

‘Don’t worry, Orthodox Jews are like Vegans, they will let you know.’

At breakfast, the chef rushed to the front desk; a girl with allergies had arrived.

‘No milk.’

I don’t know if lactose intolerant or properly allergic.

‘I can eat that and that and that,’ she pointed.

By the time I had finished my cinnamon swirl, I knew too much about the girl’s intestines.

At times like these, I think of mindfulness and mental health.

I recall square (box) breathing.

This, when you inhale for four seconds, hold for four, out for four and hold for a final four seconds. Sixteen seconds of mindful attention to the breath. Keep doing this and your internal dialogue will start to dissipate.

Like those images of dreams in Inception.

We often forget about the maintenance of mental health until it is too late.

You see, our psyches are like muscles. They strengthen with practice, repetition, and training.

Rely too heavily on drink, drugs or thrill-seeking and you will be let down; your mind will not sustain a health body.

Work the spirit! (Not the boozy variety.)

And, how?

Invest in yourself.

‘Me time’ it’s called.

Doing things that are for you and no one else.

For me, my time is reading and running and swimming and blogging and listening to podcasts.

I have a heck of a lot of me.

How much me depends on you and your needs.

For some this would be too much aloneness.

Some, those chatterers amongst you require more dialogue, discourse, for me, silence is it.

There is giving too.

The gift of giving.

It is better to give than receive, so said Jesus.

If you let me give you the substantial, this will complete me.

‘I don’t need/want your…’

Think about it.

And love and time with others, and sleep and good food.

Avoid too much refined sugar.

A little honey, OK.

A guide to life, as if I know what I am doing. As if.

I began with the Mindfulness.

This is focusing and avoiding the wandering.

Mind-wandering.

Is what it is to be human.

It is also detrimental to our psychological health.

Our dreams are mind wandering.

They take us on an unconscious journey of healing.

And where would we be without?

I’ll end here, there is too much to do.

What was it you said?

Oh, I forgot you already told me that…

Imagine, always remembering.

We call this eidetic.

Events, places, and times, frozen by indelible recall.

Every phrase, gesture, and nuance locked in.

Imagine. Always, always, forever.

And then, you have

AI

For this is the ultimate robot device.

Computers, just like elephants never forget.

Although silicone isn’t of herbal value,

It is fixed in time and space.

And, it is the forgetting that makes us human.

It is the gaps that we fill with creativity,

Novelty

That makes us, us.

The person out of view,

Our shaded blind-spots.

It is the leaps of imagination,

The ersatz steps, the staccato shuffle that bears the stamp of humanity.

I am, because I fill-in the gaps between then, and now and tomorrow.

Our illogicality, our irrepressible need to join the dots.

Here I am, and tomorrow who knows?

The last lecture

I remember the book,

by           

Randy Pausch.

The Last Lecture.

He was an American Computer Scientist.

the book

discussed his final years,

and his parting lecture with students

before he died from pancreatic cancer, age 47,

Fortunately,

The circumstances of my last lecture are not so bad.

I just fell-out,

grew apart.

A flaky relationship.

Over the years, I have been teaching medical students.

It is central to the role of being a doctor.

You treat and care and you teach.

Some might focus on the data or study the numbers.

That’s not me.

This lecture, I have been giving since 2004. That is, almost 20 years of students. The majority of whom have now progressed to becoming doctors, consultants, GPs, and academics.

Most will not remember even a scintilla of my lecture.

The neural connectome will have died before they leave their seats.

Poof. Lost in a race to memorise facts and figures, to cram adequate information to pass the next test or assessment.

Over the years the students have changed.

Yes, I have changed too, although they more than I.

At the beginning, there were no computers.

Now, most sit looking not at me, instead at their laptops.

(I am a visual thinker and lecturer – I rely on pictures rather than words).

I don’t know what they see; it is perhaps the PowerPoint I am projecting on the wall, it might be Wordle or the Guardian Crossword (unlikely, aren’t they Boomer pastimes?). They might be Googling ‘hospitalisation’ or one of my other catchphrases although most of what I teach is not very sophisticated.

On Monday I began with the tale of Hillel the Elder, who, to paraphrase, sometime around the year 1 AD/CE was approached by a Roman who asked, ‘Explain to me the Torah standing on one leg and I will become a Jew’ (or words to that effect; (Why one leg?) The aspiration I imagine was deprecation).

Hillel replied, ‘Treat others as you would have them treat you, that is the Torah, the rest is commentary; go and study.’

I thought this was a risky start (?too Jewish) although I prefaced it with an allusion to the Golden Rule which most children are taught in Primary School and encompasses Judaism, Islam, Christianity, Hinduism and other mainstream beliefs (not Nazism, Mr Sunak). It is the truism that maintains peaceable societies. (It is also the be-all and end-all of my approach to medicine and healthcare – see here).

I couldn’t tell if there was a connection.

A couple of students in the front row, two young men, one with a curly bob were animatedly talking throughout my introduction.

I flashed-forward a decade and imagined them strutting around a hospital wards, missing the point as they seemed to miss it now.

When I asked them to not talk, they stopped although one started to furiously type on his keyboard.

This year I felt a disconnect like no other.

Previously, there was something, eye contact, smirks, grimaces, or laughter at my jokes.

It felt like talking to a wall.

Like Zoom when everyone has their cameras switched-off. Only, I was standing in a sweaty hall.

My lectures or talks are always bound with interaction, questions and answers, discussion.

Nada.

It was hard to determine whether they were not interested or didn’t care.

I rambled.

At one point I started coughing.

The air was so dry, it was blocking my throat.

I hadn’t brought a drink (All the lecturers bring drinks, my son, later told me).

I was struggling to speak.

Cough. Cough.

‘Does anyone have a drink?’

I asked.

Again, blank faces.

A void.

I coughed more, was struggling to talk.

‘OK, I will see how far I can go,’ I added.

Eventually a young woman brought me a drink.

A smidgen of compassion.

Do unto others…

I continued.

I took the students through definitions and explanations of age and ageing, of falls, frailty, dementia and delirium, person-centred care, hospital admission avoidance and the harms of hospitalisation.

I described my patient who had waited almost three hours, lying on the ground outside her house waiting for an ambulance; she developed hypothermia in addition to her broken hip.

I shared my experiences of staff mis-naming patients, getting them wrong, misconstruing their preferences, what matters.

I showed my photo of M’s room in the care home (below), the quintessence of person-centred care (see here)

More emptiness.

Hollow.

I left feeling empty.

At the start, following Hillel, I even explained to the students that my iCloud had disappeared and I had created the whole lecture from scratch over the preceding weekend.

An image flashed of my lying on the ground, choking perhaps on a Ronald Reagan peanut and the crowd watching me turn blue.

Yes, I have changed; the students have changed more.

And this is not their doing.

This is me and the rest of our society.

When millennials think of the future, and they perceive our worries, our woes, our existential dread that is worse than the Cold Ward nuclear threat I experienced at their age.

They are faced with a selfish self-serving government, a society that allows the minority to flourish and everyone else to sink, that prices them out of the housing market, that has removed retirement and replaced it with zero-hours Deliveroo.

On Thursday night I watched the Channel 4 documentary Undercover Ambulance. You might call it a tragedy of the NHS. In which a young Ambulance Medical Technician, undercover, revealed the breaks, the people like my patient who waited so long they died, the patients lining the hospital corridors, the collapse of a world-leader.

The film ended with his resignation.

I wonder what he is doing now.

A few weeks ago, I asked the young doctor working with me, ‘Did you imagine it would be like this in the UK?’ ‘No’, he replied. I don’t know if he grew-up in an India that still romanticises the UK or he personally chose to focus on other things.

I haven’t given-up on teaching.

I’ll continue one-to-one.

I have already approached the Ambulance Service.

No one wants to read negativity.

Apologies.

What can you expect from a blog called ‘The last lecture’?

It isn’t all doom and gloom.

The chaos has created opportunities for working and caring in different ways (Check-out our Virtual Ward) although I suspect it is the majority, the mainstream that remains tangled.

And this is the uncertainty into which these young are developing, moving towards; not the naïve idealism of ‘wanting to help people’ that was (and is) my motto.

‘What do you want?’ I should have asked.

‘An interesting lecture,’ they might have replied.

/

Post-blog caveat.

Sitting in Kwik Fit.

The valve of my car tyre is broken*. Hissing air, only inflated by the twiddly cap.

Young guy, fiddling with phone.

Old man, walking stick, struggling with door.

Young guy helps older guy.

No question.

Just active, respectful, do unto others.

I wonder.

/

*Valve fixed.

Two front tyres need replacing. Slow puncture in third.

I’ve been driving a death-trap.

Sigh.

Why Israel is not an Apartheid State & a risky date acquisition

For Yael &

Fond memories.

This is not a historical argument,

It is not the absolutes,

It is my take.

A month ago, I visited Waitrose in Sheffield.

Outside, a group of middle-aged, middle-class, mostly white men and women were protesting.

Asking me not to purchase Israeli dates.

Yes, dates, tamar (תמר) in Hebrew.

It seems that Waitrose, and later, I discovered, M&S, sell dates from Israel.

Other dates are available; I have a box of Jordanian ones in my cupboard.

When I told my daughter she was angry,

She saw-through the patina of self-righteousness these fair-weather warriors displayed,

‘Of all the shops to protest, they chose Waitrose!’

The reference was to Waitrose being the only shop in Sheffield to sell Kosher food.

And yes, BDS

Or,

Boycott, divest and sanction is,

Antisemitic.

It singles-out Israel as the worst of the worst, the one to dodge, avoid at all costs.

It is the one nation in the world to be called (in 2023) an Apartheid State.

An allusion to

South Africa.

And when I hear this, I take offence.

I can’t help myself.

To start, let’s ask, what was Apartheid?

My understanding, from reading Biko, Mandela and Paton

It was a system functioning in South Africa that separated whites from blacks,

Strict laws kept the races apart,

A racialist divide that influenced every aspect of life.

A system based upon inequality, inequity.

With skin colour and parentage as the basis.

One which caused untold suffering, indignity, and pain to millions.

I am not an expert in this field,

So don’t shoot me if I get something wrong, this is just my interpretation (one, that you could argue, I should let lie, but there you go, that’s me).

My sense of the end of Apartheid was the lines of voters snaking across our TV screen as I sat in an unheated house in Dundee with Callum and Afghan. It came with the Truth and Reconciliation committee, with Mandela’s election to president.

All that.

You can’t underestimate the significance of that moment that sent waves across the planet, directing us towards a new future, our present modernity.

And Israel and dates.

My brother, an Israeli (so am I – yes, this article is a biased), tells me it was a former member of Pink Floyd who started BDS.

Again, sorry, I haven’t researched, although I know Roger Waters was recently shouting at the UN about the evils of Israel.

Yesterday I listened to a Podcast about the Talmud, Rabbi Woolf, a Chassid living in New York related some stories, he discussed the tiny nature of Israel, it’s place on the map and questioned why, of all the nations of the world, Israel and her people are picked-upon, singled out as the ultimate baddies with date sanctions.

This is an argument taken by many, ‘Why us? Look at them,’ and yes, there is something in this.

The population of Israel is approximately 10 million (Arabs, Jews, Druze, Christians, Bahai and so on), as a percentage of the world that is miniscule.

The ratio of 1 to 1000 (approx!) suggests an inequity of spotlight.

No one has asked me not to purchase Russian dates (supposing they exist – suspect not), for example. I haven’t seen an anti-war protest in the last six months; the World Cup was held in Qatar this winter, billions of dollars flowed into the Qatari Royal Families coffers; Joe Lycett threatened to burn some money.

The argument is not that there is nothing bad happening in Israel, that the Palestinian situation is not awful, that the poverty and violence of the Gaza strip is not appalling, but, why, should Israel be singled-out.

Part of the answer can be found in the Passover Seder, the ceremony held in parallel with Easter; the five questions are traditionally asked by the youngest child in the family, with the signature being, ‘Why is this night different from all other nights?’ (The answer can be found in the Haggadah).

Why focus on Israel when there are so many other bad countries out there?

What is different?

What is unique?

A usual trope is, ‘You stole the Palestinian’s land,’ this, an oversimplification of geography and history doesn’t work.

Sure, there was a Palestine governed by the British, before that the Ottomans, before them the Crusaders and the Romans, before them the Greeks and the Persians.

People have been fighting over the thin strip of land at the end of the Mediterranean for thousands of years.

‘We had it first’ doesn’t wash as an argument as you then must ask, ‘Who are we?’

I can’t or won’t get into the details, although if you want a well-balanced argument, listen to Darryl Cooper’s Podcast – he tells the history in incredible (20 hours) detail.

Should we give Australia back to the Aboriginal people? America to the Native Americans? South America? Brazil, Peru, Mexico to the Incas or Aztecs?

We could run some mitochondrial genomics and determine who should go where and who should be in charge.

I don’t want to be facetious; it is a serious question.

Who owns the land, who are the people?

No, we can never say.

Another argument for or against Israel is that it is occupied by immigrants, the Palestinians are the ones who should be in charge.

Again, a story told to all Jewish children relates to the exiles, the expulsions of the Jews from Israel to Assyria then Babylon then the listless moving of our people from Africa to Europe to America, the removals from England, Spain, Portugal, the Pogroms, the Holocaust.

The plant, the Wandering Jew is named after us, or we it; this works both ways.

No, I can’t tell you the history of the Palestinian People as well as I can tell you my own and yet, I don’t hear anyone saying, ‘Don’t buy Palestinian dates,’ either.

The history, as I say is long and convoluted.

Israel became a state in 1948.

With the declaration of Independence there followed the Israeli War of Independence (the Nakba, النكبة according to Palestinians = catastrophe). Followed soon after by a series of wars that cost the lives of many.

1948 was a few short years after the liberation of Bergen Belsen.

The Jewish psyche has been scarred by intergenerational trauma.

We don’t see things as clearly as we might.

In 1948, the Israeli state’s declaration of Independence set-out a mandate to treat people equally, regardless of their religion. Yes, it is the Jewish state (just as Britain is a Christian state), but there was space and protection for Christians, Muslims, and others.

Israel is a democracy.

Elections are held and people vote, the requirement being they are a citizen of Israel.

Race or religion does not influence who can vote.

If you are unwell in Israel and need medical attention, whether you are Jewish, Muslim, or Christian, a doctor will help you, and they too might be Christian, Muslim, or Jewish; if you are in a hospital ward you will lie in bed beside someone of a different faith.

Jewish, Christian, Druze and Muslim communities in some parts of the country live separately, from choice, as happens across the world, some cities have mixed populations with people getting-on regardless of their ethnicity, skin colour or God. They shop in the same shops, go to the same schools, beaches, swimming baths, hairdressers.

This is not Apartheid.

Yes, there is a problem.

The Palestinian people live in poverty, they are disenfranchised, they do not have freedom of movement. The West Bank is run by the Palestinian Authority and the Gaza Strip by Hamas; two islands of populace that represent a nexus of the BDS’rs ire.

Most don’t have an answer.

There was the two-state solution, there is the current right-wing ‘pretend they aren’t there’ – neither are realistic.

Hamas doesn’t want Israel to exist. They call for its destruction, with the most common image being that of pushing Jews into the sea. (For Israel, a long-thin strip of land this is apposite.)

A state of war exists between Gaza and Israel. I don’t know the solution which is a stalemate and like most situations across the planet is not about the poor people on the street who struggle to make ends-meet, more about the rich and the powerful and their plays for control.

This isn’t Apartheid, it is two people forced into a stalemate by inadequate leadership.

The abuse of the children, the soldiers, at the borders, the guards, the indignity, the border crossings, and so on, are often given as arguments in favour of the Apartheid argument.

Let’s face it, people can be shites.

Armies often consist of young people, in certain areas, conscripts who are made to don uniforms and gift a proportion of their time to serving their country.

There are abuses of power.

Yes, I said it.

Israeli soldiers can and do behave atrociously towards Palestinians, often caught on camera by Human Rights Watch and others.

I am not defending this.

Yesterdaty, my daughter, quoting, I think The Guardian, informed me that one in a hundred police officers in the UK were facing criminal charges last year.

This doesn’t mean all police are bad.

Last weekend when I was protesting in support of the Rotherham Asylum seekers, some of the people abused the police when they asserted their rights to control movement (stopping a fight) – ‘pig’ ‘fascist’ were shouted. And, no, the police in the UK are not fascists (although there are probably some fascists who are police, there are likely more police who believe in democracy, equality, and human rights).

One or a hundred bad eggs is not Apartheid.

If you are an Arab living in Israel, a so-called ‘Israeli Arab’ you can become elected to the Knesset – the Israeli Parliament.

This does not happen in an Apartheid state.

Yes, Israel has many things wrong.

It has elements of American society that have spoiled the original aspirations for a ‘light unto the nations’ – 21st Century consumerism, Netflix, social media, and big business don’t fit with socialism.

Is the US better? The UK? France? Nigeria? Argentina?

I am not aware of a utopia on our planet.

I don’t know a place, even amongst the Scandinavians where everything is wonderful, there are no bad people, no criminals, manipulators, or cheats.

We are human, our planet is controlled by humans with all their flaws.

This blog has likely not changed anyone’s opinion.

It wasn’t my intention. I tend to be an expresser of ideas rather than a changer of minds.

The next time someone tells you not to buy an Israeli date, please think, please consider that the date is innocent.

Please consider the individual is either misled, confused or ignorant.

They are protesting Israel because they can, because they see a simplistic explanation of right and wrong. Israel bad, Palestine good.

Anyone who considers the world in this black and white fashion is missing the point.

Emily isn’t her real name.

Emily isn’t her real name.

I introduced her to our medical student on Friday.

She is rake-thin,

with wizened skin

From almost a century of cigarettes,

She shuffles from room to room on a dusty walker,

Her mobility scooter

askew

In the corner of her room.

I’ve mentioned her before,

She of the parakeet

Coco.

Now deceased.

I said,

She used to have a bird, Coco, now dead.

That’s a shame, said the student, although I am relieved

She continued, I’m terrified of birds.

And the conversation,

The moments in time that morning,

The stillness of the late winter air,

We discussed recent events of Emily’s life.

Her recent falls

Her near-death first-wave Covid,

Her dizziness,

Aches and pains,

Struggle for breath.

She is a survivor,

A crenelated being who is built to last.

And I think,

Had she died,

two years ago,

As so many did,

This conversation would never have happened,

She would had moved into incinerator dust,

Only the memories of those who knew her

at the back of the minds,

Her story would have vanished

Another old woman

Would now be

Zimmering through the tiny bungalow,

And I,

What would I have?

Not those moments,

Not this.

It would have been an un-ocurred sadness,

I flicker in time and other things.

Person-centred care and self-love

I remember, maybe ten or eleven years ago, my children introducing me to the ‘Golden Rule.’

Do you know it?

It’s age-old and runs along the lines of do unto others as you would have them do unto you.

At the time I thought, ‘I know that, was it Jesus? Didn’t know it was a rule.’ And moved-on.

Fast forward a decade and I have just finished reading Irvin Yalom’s The Spinoza Problem.

Spinoza, for those of you who don’t know, was a 17th Century philosopher.

I was going to call him Jewish philosopher (he was) although things went awry for him in his mid-twenties.

At the time, his thoughts were so radical – claiming there is no supernatural god, no life after death, no heaven or hell, no miracles – life only consisting of matter that is one with nature.

This was when they were burning people at the stake for heresy, so you can imagine it went-down like a lead-balloon in the religious exiled Jewish Portuguese community living at the time in Amsterdam (they had previously been booted out of England (burned alive in York), then Spain (Queen Isabella of Columbus fame & the Inquisition) then forced to convert or die in Portugal).

Spinoza was subject to a ‘Cherem’ (חרם) which is a Hebrew word meaning exclusion. He was ejected and rejected by the community, he was made as if never to have existed and not to exist. If a friend or relation walked past him, he would be blanked, send him to Coventry, as it were.

Spinoza went on to write books that were centuries ahead of their time, an early precursor of the Humanist movement which sees the goal of life as caring for and supporting other people (viz the Golden Rule).

(As a clue for what is coming, years ago I used to teach a course to the medical students – ‘Humanistic Geriatrics’)

In the novel, Yalom recounts Spinoza telling the tale of Rabbi Hillel.

Hillel lives in 1st century Israel, dying around 10 AD/CE, famed for his intelligence and compassion.

One day, a Roman soldier came to Hillel and said he would accept Judiasim only if he explained the Torah to him whilst standing on one leg. (No idea why he asked this, also uncertain if it was Hillel standing on one leg or the Roman); Hillel responded, ‘What is hateful to you, do not do to your neighbour. That is the whole Torah’ (all the Jewish rules and commandments and narrative)’ (or words to that effect – I paraphrase).

Yes, the Golden Rule.

And yes, Jesus (or whoever wrote the Gospels) borrowed this theme.

The Golden Rule runs through most religions, East and West.

As a reciprocal concept, it is a fundamental of society.

You can’t live with others without this philosophy.

There is a neo-Nazi idea that the rule is wrong. Say no more.

What does this have to do with Person-Centred Care?

If you know me, you will be aware that Person-Centred Care is my central philosophy; it certainly applies to the way I support patients. That is, seeing the person, not the disease, seeing the whole, not the parts.

It is, I recently realised, one and the same as the Golden Rule.

Care for others as you would have them care for you.

Voila.

And so, we have a congruence of this gargantuan idea and the way to practice care.

There is a critique of the Golden Rule in that, what you might want to do to you – perhaps whipped with nettles if you are of that mind-set, is not necessarily what others want. And, yes, this is true.

Another principle of Person-Centred Care is the person is the expert.

I, as a doctor might know all about diabetes or asthma, you as the person with the condition know all about you. What you know about you is always far more than I can know about the dry technicalities of disease, even with a lifetime of experience.

My life, my experiences have come full circle as, I discovered, when my kids talked about the Golden Rule, and I was surprised to hear it was a thing. I hadn’t realised that I too had received the same teaching when a child.

It was in bible class in Israel; the quotation ‘Ve ahavta le-re-echa ca-mocha’ (ואהבת לרעך כמוך) (Leviticus 19:17-18) – was drummed-into us. I never fully understood the words, despite the drumming. I knew that ‘Ve-ahavta’ meant, ‘and love’ and the final segment, ‘ca-mocha’ meant ‘like yourself’, I didn’t know what ‘re-echa’ meant, and so the phrase was obsolete (as a Jewish child you learn by rote lots of obsolete phrases you don’t fully understand).

And now, thanks to Google and technology, I have learned the ‘re-echa’ is your ‘friend, peer or companion.’

And so, I too was taught this at a young age.

Without full understanding I adopted the principle and can recall as a precocious 13-year-old dreaming about ideas of love and hate and beauty and conspiring a theory of universal value.

Without understanding the phrase, I had been indoctrinated.

No bad thing.

Ironic however when you look at the Land of Israel today, as it struggles with democracy, led by a right-winger who, if the narrative plays-out will be left with Iran as its closest ally.

How odd the twists and turns.

I talked with my brother last night; he lives in Israel. He too is worried about the situation. He sees the country sleepwalking towards right-wing religious totalitarianism. ‘We had Brexit and Boris’ I empathised.

‘At least we still have tomatoes and cucumbers,’ he replied.

Life is a circle without circumference.

Avoy.

Genug.

Black Swan

A black swan event is something unusual or unexpected.

It’s a book by Nassim Nicholas Taleb

It is also a song by Thom Yorke.

And a movie starring Natalie Portman.

I discussed this with my daughter recently.

She said,

‘I know.’

As your children grow, they gain knowledge.

When previously you could amaze them

with a fact or nugget of arcana

They now

Will have already Googled, absorbed, and analysed.

They develop,

acquire minds of their own

With stuff only known to them,

Ideas of their time, their generation.

The black swan was one; I found her at my swimming lake in lower-Barnsley.

Black swans do not usually reside in Barnsley

They are Australian.

Our common variety,

Mute swans (loud when upset)

Are white,

Like dust,

Silken, creamy

An often-exaggerated whiteness against a muddy lake.

My daughter and I saw the only other black swan in my life

This summer

As we

Sailed down the Thames on a windswept barge.

Me too cold in my t-shirt,

I squeezed into her hoodie for warmth,

Wearing it back to front

Like a surgical gown.

It seems these birds likely escaped from captivity and settled in the north,

Having been transported from Australia as curios.

Who knows, some might have flown,

Lost their way and the eternal sunshine.

Last week’s Blindboy Podcast discussed ageing and the loss of youth,

Culminating in a reflection of the artist

Misplaced, psychologically incongruent in a London pub

Dressed accidentally as Eminem.

Should I wear more fashionable clothes?

I asked my daughter yesterday

As we walked through central Leeds,

Past trendy shops and protests in support of Iranian women.

You’re 50, you don’t need to dress fashionably.

I don’t want to look like an old man, like I am past-it.

My daughter assured me that I didn’t look like an old man and my clothes are fine.

We moved-on.

Blindboy discussed bleaching his hair last year when he was distressed,

profoundly anxious.

I remember as a young man, shaving my hair as an act of self-abuse,

An attempt to gain control

When living the opposite.

Similar experiences pass through the minds of adolescents who self-harm.

I can’t do anything

I have no money

No friends

I can’t go anywhere

I can cut.

I am not an adolescent psychologist although I imagine this is some of the context.

A sense of self, of autonomy, of power over your actions or inactions is fundamental to emotional wellbeing.

See the youth’s speeding on their motorbikes?

They are tasting independence.

If independence is not given it is often taken,

Either constructively or with negative consequences.

As we grow, age, mature,

So too, do our children,

If we are lucky.

They move-away,

find new friends and interests.

Develop a language, a toolkit of terminologies that are outside our own.

And this is good,

This is how it should be.

This is the way of the world.

And, black or white swan,

We should celebrate their futures.

R-E-S-P-E-C-T

Remember the song?

From The Blues Brothers.

Aretha Franklin in the diner.

Respect is odd.

Lots of people over the years have died because of either perceived or actual

lack of respect.

Back in the day,

If you met someone of higher status

In China,

You were expected to kowtow to them.

This is literally

Get on your knees and bow, demonstrating your subservience.

There were issues at the time of the Empire

Pushing opium

Where moustachioed Victorians would not oblige

Much unhappiness ensued.

And, on the street.

Gang member to homie to whatever term is used nowadays,

Not doffing the cap

or backing down

or averting the eyes

leads to

stabbing

or gunshot.

And, yes, our patients,

How do we respect them?

How do we demonstrate our appreciation of their humanity?

Or, is the process one-way?

I am always very conscious when I speak with a patient

Whether I call them

Mr Cohen

Or Albert

Mrs Shleperstein

Or Gloria.

Usually,

Actually, always, when I use the first name, and I accidentally say, Dr Kersh, I always follow-up with, Rod Kersh, the doctor from… More often if I call them by their first name, I will purposefully, if they know me, say, ‘It’s Rod Kersh,’ If they don’t, ‘It’s Rod Kersh, doctor from…)

Anyway.

My plan is to offer respect to the patient and almost always they return it.

Nothing more and nothing less.

Occasionally I am treated with suspicion, particularly if I am cold-calling someone to talk about their raised blood pressure – it is hard to disentangle the genuine from the fraudsters and payday loan sharks.

And, respect.

I see you, you see me. Remember Avatar?

Yet, how often does this fragment, dissemble?

On Friday I gave an international lecture to nursing students.

Sounds grand, eh?

I was talking to a class at the University of the Highlands and Islands. Based in Inverness.

The discussion focused (or should or was meant to) on dementia. Yes, I did cover the relevant components although every slide or two, I returned to person-centred care (PCC).

At the start, I asked the group of a 100-odd Mhari’s, Catriona’s, Angus’s and Colins, whether they had heard of PCC. There was an impressively positive reply. (10 years ago, this would not have happened), so, yes, a move in the right direction. And yet, I kept returning to this. The focus of seeing a patient as a person. Not just a person, a person then a patient, an individual then a disease, Rod or Tom or Fred then the Asthma. Not the demented Gloria, and not even, Gloria the dementia sufferer, Gloria who has dementia.

The talk veered into Stoicism.

Greek and Roman.

The obstacle is the way and that kind of thing.

Why people living with dementia prefer this to ‘suffering.’

Funnily, 10 or so years ago, I wrote a dementia strategy for Doncaster Hospital which was lauded at the time.

In an early draft, demonstrating my ignorance, I used the ‘suffering’.

My friend Wayne Goddard aka Peter Kay, put me right.

He didn’t explain why, but it made sense.

Only more recently have I understood the deeper meaning.

Which is, that suffering is a choice.

So, says Epictetus.

We do not suffer externally. It may be cold (the water), there may be pain or discomfort; the experience is however internal, it is what we do with the experience that matters.

The same stimulus in different circumstances can yield different perceptions.

Sunlight can be great, to the same person with a migraine, hell.

The world is what you make it. Our perceptions create everything. Suffering is a choice. You can live with dementia, even when the disease eats-away at you, nibbles your personality, your good humour, your sense of self. Suffering must not and should not be imposed.

And that is the living. That is why we, the doctors, nurses, brothers and sisters are in a position to support the person with dementia or cancer or lung disease; we can enable them to live with their condition, to understand that they are themselves and most of who they are is them, the disease is a component, it may be continuously expanding its influence, but with support, they can continue to shine, to be, until the end and, even afterwards, the focus can be on the person’s 85 good years before the dementia, not the awful three or four last.

And back to respect.

There is a common phenomenon in healthcare where those living with dementia are perceived as lesser, not quite whole. Perhaps the thought by the doctor or nurse that the disease is the person, not a part of the individual and with this notion passes respect, passes the niceties of human interaction, respect, the waiting to hear what another has to say before expressing your opinion, the decision to act without sharing, the notion, ‘They have dementia, they have broken their hip, demented (people/zombies/others) don’t feel pain they say, and yes, they have not said they are in pain, here, give them a couple of Annadin’ (You or I would be screaming for morphine).

Older people frequently, even without the label of a life-limiting disease, are offered less respect than others, than the young, the working-age. Because of their immobility, hearing, or visual impairment they are considered lesser and the shared decision making that should be core to every clinical (and human) interaction is removed; Let’s move Ralph (dementia, 89) to ward A, then, B, then C (he won’t know/complain, then, let’s send him to care home D. Don’t worry, you don’t need to tell or ask him, he has dementia, he wouldn’t understand or know the difference.

He is, not quite human is what is being expressed.

A rephrasing of human all too human.

Not quite human.

And back to respect.

Without respect we have little.

We are molecules random in Brownian motion.

We are scattergun.

The purpose and meaning of our actions are diminished.

Today we should not have to sing about r-e-s-p-e-c-t, it should be a given. We know and understand enough about what works and what does not. We know that disempowering a person is harmful to their ego, is damaging to their sense of self, has adverse outcomes, makes a person depressed and anxious, reduces their white cell count – forces them into themselves and away from recovery.

Respect.

It’s all about respect.

Without respect we are lost.

With respect we can aspire to greater things.

With a notion of equality, we don’t have men inflicting violence on women and consequently other men (the former almost aways comes first).

In a health or social care system that views people as equals, regardless of their protected characteristics or those which aren’t protected (he’s just got wax in his ears, he is not hearing impaired; we don’t need to adapt to accommodate) we have some hope, without we will fail.

Please… Write to me.

I don’t write many letters these days.

Emails, I compose at an incredible rate, but pen to paper, no.

In correspondence with other doctors and patients I word-process although more often I use email. Short and to the point.

In a recent document shared at work, my eyes were opened.

All this is interesting as beforehand I had some inverse learning.

Not sure if that is the best term, it was something one of my trainees demonstrated to me, in other words I learned from someone I am training.

There is nothing wrong with this and day to day existence is composed of the adoption of information and knowledge from many sources.

On this occasion, I had been reviewing a letter the doctor had written.

It was a letter to the patient.

The patient’s doctor had been copied-in.

Within healthcare the most common mode of conveying information about patients is from doctor to doctor.

Those of you who have ever had a hospital appointment will be familiar with the sequence of events. Your GP writes something about you to the hospital doctor, the hospital doctor sees you in clinic (often calls you on the phone for an assessment) and writes a letter back to the GP with their conclusions, diagnosis and/or management plan.

Here is a short example:

///

Dear Dr Hyde,

Thank you for asking me to see Jemima P in my clinic. As described in your letter, she presents with episodic anomalous carotid dysfunction.

I could not find a cause for this although she reports drinking 30 units of alcohol a day and she smokes.

I have explained that her condition is incurable, and she will likely die in the next five years if she does not change her ways.

I have discharged her from clinic.

Yours sincerely,

Dr Jekyll

Honorary Professor of Carotid Dysfunction,

Department of Cardiology

Babylon University.

Babel.

///

No, this is not real, there is no such disorder and Jemima doesn’t exist, however this type of letter is commonplace.

Doctors frequently write as if they are living in the 1950’s. It is doctor as expert, patient as object. If they are lucky the letter will be copied to the patient, if not, the patient, Jemima, will have to wait for her GP to contact her to discuss the cigarettes and alcohol, or she might need ring the surgery to speak with reception to be told, ‘No, we haven’t received a letter yet.’

A inefficient and ineffective way to help people, to, ‘make people better’ as has always been my aspiration (if possible!).

I won’t critique the letter, suffice it to say, it contains jargon, it is talking about Jemima as if she is not a real person, it is cold, indifferent, and paternalistic. All things we have learned over the years are ineffective in… making people better.

Doing to a patient cf. doing with.

My trainee’s letter was something like this:

///

Dear Hieronymus,

It was a pleasure to meet you and your wife at home today.

We discussed some of your recent concerns and you described the way in which you become dizzy whenever you change your position from sitting to standing.

I measured your blood pressure and found that this drops from 145/70 when you are lying in bed to 80/40 when you are standing. When this happens the amount of blood reaching your brain is inadequate and you become dizzy. On one occasion you mentioned collapsing in the kitchen*.

Normally your blood pressure should rise a little when you move from sitting to standing, with you the opposite happens…

… Yours sincerely,

Dr Amanda Snippet

CC Dr Jordan River, The Practice, Rift Valley, Tinseltown.

///

Do you spot the difference?

This letter, which is in no way the letter my trainee wrote, but in a similar vein treats the patient as a person, an individual; she clarified when meeting him that he was OK to be called Hieronymus and not Mr Bosch, she conveyed the story (history) back to the patient, providing them with information that they can check or clarify for inaccuracies, ‘I didn’t pass-out in the kitchen, it was the living room’ for example. In this instance a trivial difference, in others, more significant. (We plan to amputate the right hand).

When doctors write letters they usually proof-read for accuracy and content. No one will proofread a letter better than a patient; they will find errors of fact that another might miss – the conversation is about them and their body after all.

And the letter also contains an explanation to the patient about their condition (and what will be done, etc) – this saves the patient ringing the GP and waiting, the letter is copied to the patient’s GP with specific instructions to, ‘Please continue the medicine I have started,’ for example.

This is person-centred care.

I have been banging the drum for over a decade. (Before that I didn’t have a name for what I was doing/promoting).

Taking the patient and regarding them as intelligent, autonomous entities, part of their medical condition, empowers, it involves them, stops them being a bystander to an active participant, it respects their insight and intelligence, it places the GP a little on the back-foot, it makes the letter writing more difficult as it is a significant change of the way of doing things.

And, why not?

Healthcare sort of works for most people most of the time.

When it goes wrong it can be a disaster.

This is a step towards inclusion.

Reading my trainee’s letter I was curious, ‘Writing to a patient, how odd!’ I thought.

Shortly after I received the document which you can find here.

It presents the argument for changing the way we communicate and correspond with patients.

It calls for better informed patients, a shift of the power-balance, away from ‘papa-says.’ It is an undoing of paternalism towards equality and inclusion.

Our patients are asking to be informed, it is our job not just to investigate, diagnose and treat but to engage and explain.

Today, how many doctors and other clinicians are writing letters to their patients and copying the GP?

The numbers are small.

We need to grow the movement.

Shift the balance.

Hasta la Victoria!

Many, many clinicians I know already practice person-centred medicine, this is not a criticism of them. The others (who likely don’t read this blog) know who they are. Beware! Change is coming.

*For more on this medical condition – postural hypotension, see here.

The Chuckle Brothers, Rotherham heroes.

Satori in the quicksand, the dimishing returns of a hospital admission

Oh-oh! MUD!
Thick, oozy mud.
We can’t go over it.
We can’t go under it.
Oh, no!
WE’VE GOT TO GO THROUGH IT!

And so, it begins.

Michael Rosen’s words from We’re going on a bear hunt seem apposite.

A couple of weeks ago I had a satori.

That is, a sudden moment of realisation, awakening.

It relates to my purpose, or, rather role as clinician and what I should be doing and how I should be deployed.

In many respects, this is not new. For the past 20 years I have been working to support the care and wellbeing of older people.

I know… Older people. Who would want to spend time with them?

This was the shock I encountered in my 20’s when announcing my intention to a room of relatives at the conclusion of a Passover Seder.

You are all old. I told them.

A moment of realisation.

It’s a truism; the greatest source of ageism is old or, older people.

I don’t know why. It is perhaps the secret of a healthy long life – never consider yourself old. Be young at heart. Your joints may ache, your vision may dim, but so long as your essence is in your teens, you will keep going.

And so, my focus is supporting older people.

Disease, time, and accidents are all major impediments.

In many respects you can’t do much to stop time; you can mitigate accidents by being careful although that can take away the fun and uncertainty from life which is what living is about (isn’t it?) and disease, well, it comes, it can also be mitigated but there is a limit. Yes, take your flu and Covid vaccine – none of these are one hundred per cent. Measure your lipids, take your statins, and regulate your blood pressure – none of this will stop the heart attack, only slow its advance.

How to stop time…

If pneumonia or diabetes are coming, they will eventually get you, no matter your oropharyngeal health or body-mass index.

And so, much of this is responding, easing the passage. Prescribing the antibiotics and hoping a person has enough ‘cheshek’ internal energy to overcome the inanition, recover and keep going. Mostly we do, sometimes we don’t, and that, is life.

This wasn’t intended as a treatise on ageing, more a statement on mud.

Or my current thoughts on quicksand.

Quicksand, mud, and custard are non-Newtonian fluids. They are liquids that are also solids.

There is likely more to the physics than my simple description, you get my gist. If you have big enough feet you can run across a pool of custard; if you dally you will sink.

And so, hospitalisation for older people.

My realisation had been the disproportionate harm that befalls older people when in hospital.

For years I have been working to keep people well and at home or in their care homes.

Before Covid I took a colleague round the care home I support; she was surprised at the number of patients I had completed a ‘Please reconsider admission’ form.

The form, devised by me, this doctor and another colleague has operated locally as a moment of pause for out of hours GPs and paramedics when assessing an older person.

It says, ‘When ‘Herman’ becomes unwell, please consider the potential harms of admission to hospital. If Herman can be supported at home, please ensure this happens. If Herman is very unwell and likely not to recover, please provide him with palliative care at home. This is what Herman wishes. Please respect his aspiration.’

Or words to this effect.

The letter started as what I called my ‘Sherlock Letter’ as the template was based on a letter from Dr Watson concerning Sherlock Holmes.

In many parts of the UK this has been superseded by ReSPECT which stands for, Recommended Summary Plan for Emergency Care and Treatment. It is the same thing, just more official.

Anyway.

My colleague was surprised that I had completed the form for people who appeared fit.

‘Fit’ in my world can be misleading.

I exist in a realm of frailty and ill health, of dementia, delirium, falls and disorientation.

And so, my realisation that keeping people out of hospital if it can at all be avoided is almost always in their best interests.

This has never been as true as during the Pandemic and in the subsequent ‘failing NHS’ years.

Yesterday, I introduced our medical student to a patient who had been our Typhoid Mary. Her GP, working at another surgery, had (IMHO), admitted her to hospital during Covid – she was constipated. She returned to the care home a few days later with the infection and seven residents died.

This is extreme and most hospital admissions are only harmful for the individual, yet with infections as they are, anything can happen.

And so, to the quicksand.

Until now, most of the effort invested in the support of older people who land in hospital has been focused on either a) stopping them becoming damaged from hospital – preventing falls, pressure ulcers or hospital acquired infection and, b) getting them out of hospital once the antibiotics, transfusions or investigations have completed.

I am focusing on the latter.

Once an older person is in hospital the process of hospitalisation begins.

When I started my blog (2015), this wasn’t really a word – it has subsequently entered the mainstream.

It is the process of becoming a hospital patient with all the risks and associated hazards.

Recently, it has included the hours waiting on the kitchen floor after a fall, waiting for the ambulance, the hours outside A&E (in the back of ambulance), the hours inside A&E waiting to see a doctor and all the palaver involved in moving to a hospital bed – finding a ward, changing nursing and medical teams, repetition of events and so on.

If I am admitted to hospital I am likely to survive, unless, the cause of my admission is something very bad e.g. massive heart attack; if someone living with frailty is admitted (in other words, an individual who perhaps is low in body weight (less than my 90Kg – many of my old folk weigh less than half of me), struggles to walk, to dress or even feed themselves) their chances of getting back home are far less and, when they do, they are likely to be diminished – further loss of weight, reduced ability to care or support themselves, to walk, to stand. These are the harms of hospitalisation, the harms of wearing PJs for a couple of weeks when you are 90 years old (prior to Covid, a national campaign ‘End-PJ Paralysis’ was growing in momentum; it has become lost in all the worry about contagion, infection and isolation.

And so, there is huge effort invested in supporting people to leave hospital.

This is the quicksand.

It is easy to get-into, less so to get out.

‘Chest pain’ you shout and before you know it, leads are attached and you are on your way to the cardiac catheter lab (which is great if you are having a heart attack), the way in is easy (although frequently delayed as above), it is the getting-out that is tricky.

Not just the arranging, preparing, and sorting of take-home medicines, outpatient appointments and transportation, for the older old, it is the assessments for moving and handling – how to help the previously independent older man get out of bed using a transfer aid ‘Rotunda’ or a sling or hoist. (Every doctor should sit in a hoist to understand the helplessness our patients encounter, frequently daily – the enforced passivity and its harms).

If it takes 1H (H being a unit of healthcare energy) for a person to get into hospital, it takes 100H to get them out.

And so, the necessity to ensure that only those who should be in hospital should be in hospital.

This might seem straightforward.

‘The people who are in hospital need to be in hospital,’ but no.

Remember the cliché, every hammer sees a nail? Well, every hospital doctor sees a vein that needs cannulating, blood testing and antibiotics giving.

‘They fell.’ Says the junior doctor.

‘Urine infection,’ says the senior.

‘Antibiotics?’

‘Yes, better give then something strong.’

And so, it begins for the person who fell over their cat. What they need is a new light in their pantry not intravenous Cefuroxime.

People have a belief that when a hospital doctor says ‘heart attack’ or ‘pneumonia’ they indeed have these diagnoses. The reality is opaque.

Yesterday I had an odd experience.

I looked at one of my patient’s legs and informed the nurse, ‘I think it’s a basal cell carcinoma.’

Her grand-daughter who was sitting behind me leaned-in, ‘It looks like a squamous cell to me,’ she said, ‘I am a dermatology nurse.’

My point being, had the relative not been present, I would have written in the record ‘probable basal cell carcinoma’ that would have become the narrative; someone with a little more insight and perhaps better eyesight changed the plot.

Thus, one doctor might say ‘chest infection’ another ‘bronchitis’ another ‘pneumonia’ and a fourth, ‘chest clear, probable urine infection.’

People don’t realise the imprecision of medicine. It’s like that. It is complicated and uncertain, and this is the world our parents and grandparents discover when they leave A&E and are pushed along a corridor, skinny shins exposed, slumped on a trolley.

The extraction is the hard part and is why avoiding admission is so much more effective.

Keeping someone at home is not without cost.

It might equal 5 or 10H (using my earlier system) – yet this is 20x more efficient than allowing the other processes to play-out.

And yet we probably invest half an H.

Covid ended to a greater or lesser extent GP home visits, the Tory, austerity and all that has gone-on in the past decade (swingeing bureaucratisation of primary care) has eaten away at much of its added value, of relationship-based medicine of, ‘Yes, Tony often complains of chest pain, it’s is his hiatus hernia’ vs ‘Tony has chest pain – dial 999.’

Continuity of care is (to my mind) the most precious component of modern healthcare & it has been diminished.

The demolition started in the 2000’s with the introduction of the European Working Time Directive and has become worse with time. Tory put the nail in the coffin.

‘I see you,’ says Neytiri.

This, a fundamental of James Cameron’s alternative universe is the perception of one by another, the acknowledgment of their essence. By my encountering you, I am forever changed, as are you and that change continues, it grows and develops over time. (It is a bit of Ubuntu too).

A clinical relationship is the same; more profound for those of us working in the community, outside of hospital where we know our patient’s streets, houses, the pattern of their carpets, the names of their dogs. (Rudy, Goldie, Sandy, Brian).

And this the satori.

I have decided to leave the processes already established in helping people out of hospital (that 100H) and to spend my time, my focus on the admission avoidance, on keeping people well, on ensuring treatments and support are available in the community.

Yesterday (which was a normal busy Friday) I discovered one of my patients had been admitted onto our Virtual Ward.

93, she is an independent woman.

‘She’s probably been admitted,’ confessed her GP.

On closer examination of her clinical record, not only had she remained at home, but she had also received a detailed assessment by my team.

I visited her, she is getting better. She doesn’t need a moving and handling assessment to determine whether it is safe for her to sit in a chair – she is in a chair; she has her living room window to watch the day’s goings-on, she has her TV remote to hand and her medicines within reach, she was dressed in her usual old-lady garb, and all was well.

Simples.

Beware the bog!

What is understood. Understood. Standing under. Capisce?

What is the difference between what I understand,

Between what I say

What you hear,

And what you interpret.

What I intend,

And what you perceive?

It is obvious to me that you are the only one who…

Sentence trails-off.

I used to know someone who over-used obvious.

This demonstrated her lack of perception,

Her insensitivity.

The irony being,

Her

Obvious which operated on an intellectual level

Was an example of her lack of the emotionally obvious.

Is obviousness the source of what is wrong?

What is apparent to me

And I believe should be to you.

It is the basis of communication.

You speak

I do not hear.

I cannot hear

I will not listen

My mind is elsewhere;

Noise-cancelling headphones

Hidden

Underneath my Beanie.

The words that leave my lips

Intend one thing

And the Babel translates into another.

I ask you to go left, you turn right.

When doctors speak, they frequently fail to communicate their intentions.

Mostly, because they are talking a different language.

That of medicine is far-away from the everyday,

of you or me or the ‘man’ on the street.

The individual a Channel 4 journalist interviews,

‘What do you think of Sunak/May/Johnson/Truss’ announcement today?’

Blah blah.

Usually one person supporting, another opposing and a third, on an altogether different page, ‘Everything is smaller/dirtier/broken/delayed these days.’

Recently a colleague told me they had clearly communicated to me.

I hadn’t understood. I had missed the point, either not listened or read the intention. It was a miscommunication.

We miscommunicate all the time.

I can’t help returning to Heathcote Williams’ Mokusatsu. Have you read it?

It is my most referenced poem.

If what is said is what is meant and what is meant is what is understood, we will all get along.

Instead, there is obfuscation.

In 1945 it was bombs exploding over Hiroshima and Nagasaki, today it is Putin’s intentions.

In 1844 Samuel Morse sent the first electronic communication.

It said, ‘What hath God Wrought’ (And yes, the rest is history).

‘Mum, remember your cancer scare?’

The narrative that a family carries for decades.

When, the reality was, a doctor over-investigating, mis-interpreting results, signs, or symptoms.

In healthcare there are the black and whites, for example, the presence or absence of Covid.

Beyond this, in the netherworld are chest infections, heart attacks and cancer, all of which exist on a continuum.

‘No, it was pneumonia, not a chest infection.’

‘Severe angina not a heart attack.’

‘A benign growth, not malignant; yes, a growth we still need to cut-out.’

It seems half of society hears one thing and understands another.

This is the basis of Brexit, our mixed-up electoral system.

Look anywhere and democracy is in free-fall.

Politics, polemics, demagoguery combined with Twitter and Facebook.

People disbelieve what they see, doubting the existence of good or bad, pursuing a flat earth and making fools of themselves, although they believe it is you or me who is the fool for trusting Biden or whichever individual holds a meter ruler and advises the length of a piece of string.

‘No, a yard! A foot! A furlong!’

‘I like cubits…’

And so on.

And on.

How do we find a common language?

The system of communication that existed before Babel.

Before God decreed that misconstruction would be our standard?

The humans built the tower to reach heaven or God and their punishment to forever live in perplexity, to hover above or alongside the dark matter.

And what was that early divine inspired language?

What did Adam say to Eve?

Sorry to disappoint, Rabbi Eliyahu, it wasn’t Hebrew or Yiddish.

Ask Netanyahu, he will show you the power of double-speak.

Nor was it Latin or Greek.

Perhaps that early mode of communication was silence.

Gesture, smiling and hand-signalling.

It would have made everything more straightforward.

You can’t build a weapon of mass destruction with a thumbs-up or down.

Here we are.

Most believe their world is the world, their sense of a many worlds to look away.

And here, I hover,

Not quite off the ground,

Not quite floating in space,

Not quite wet or dry.

I hear the rain.

It is after six on a Saturday morning.

My wetsuit is on the table, ready for donning.

This week a news article revealed the dangers of cold-water pulmonary oedema, particularly a concern for women.

The Facebook group were worried.

‘I’m hanging up my neoprene,’ Said one.

Another, ‘You’ve got to die from something.’

The sanguine and the certain.

If only we knew.

Me, I will take my chances.

I will appear odd or bizarre or confused.

An anomaly on the horizon.

I will do my best to represent reality,

And, if I fail,

It wasn’t my fault.

Approaching Bambi

I am listening to a new podcast.

It’s called Ologies.

Presented by American writer, Allie Ward, it discusses the world of Ologies. Yes, like Beatie (BT) of 1980’s telephone adverts, ‘He got an ology!’ (How times and tastes have changed.)

In the current episode, Thanatology, Allie interviews death expert, Cole Imperi.

I am not sure whether her qualifications would stand-up to UK scrutiny, she does however know what she is talking about.

Cole runs a company that supports those who are dying, the bereaved, working with undertakers and those affected by death. She is a death doula plus.

I recommend.

Please don’t be put-off by Allie’s asides, you will grow to appreciate them.

The section that interested me the most was when Cole and Allie talk about talking about dying. The way to engage people in conversations relating to death.

It is something I do every day.

You might say it is an area of my expertise.

Let’s face it, talking about ‘death’ isn’t light. It isn’t banter. It’s about as heavy as it gets.

And this is the problem and where I have seen it done wrong and where Cole has it right.

She suggests talking about death as the way you would approach a deer in the forest.

If you barge-in, you will scare it away.

If you take your time, perhaps taking a circuitous, roundabout route, phasing with the environment, and slowly, slowly changing your position, you might not spook animal.

And so too with death.

‘Do you want to be resuscitated in the event of your cardiopulmonary arrest?’

Is how some doctors start the conversation.

Or even, ‘If you die, would you like us to treat you?’

There are an infinite number of possibilities.

For the most, the best way is to talk to the person, establish rapport before going straight for death.

And yet, as you know with many of the people you have encountered in life in general, some just can’t stop themselves from blunderbussing.

Their noisy footsteps, loud conversation and boorishness loosen a wave of unrest that unsettles even the most stoical.

Go slow, take you time.

A tangential approach is best.

One, tailored to the person and the circumstance.

Yes, person-centred.

What works for me won’t work for you.

If you have had one conversation about death, you have had one conversation about death.

Even I, an expert gets it wrong.

Death and dying.

Please listen.

Here is a link.

A death foretold.

I am running.

January.

Pitch-dark.

Headtorch lighting the way,

I emerge to the road.

Headlights shine

Dazzling,

A gap

I spring and cross.

My ankle twists.

I tumble

torch,

flying from my head.

Seconds that pass

Allow a car to approach.

It hasn’t seen me.

I am inert, organic

It crushes.

A flash

& all over.

Winter cannibalism, a theory of economics, healthcare, and D:Ream

Healthcare staff working in the late 90’s and early 00’s will be familiar with the airplane analogy.

Sometimes a double-decker bus was used.

This supposedly equated either (depending on who was talking and their level of cynicism) to the numbers of patients harmed or killed in US and UK hospitals every day.

The UK planes and buses were proportionately smaller than those in the US, where everything is bigger and better, or in this instance, fatter and worse.

This is my first blog of 2023.

A decade ago, we stopped using these terms to reference harms in healthcare. I am not sure why. I suspect there was because there was an impression that the care provided by the great hospitals in our different nations had somehow become safer.

If you look at any number of graphs produced by healthcare organisations, things did seem to improve – fewer falls, hospital acquired pneumonias and that kind of thing.

As with all measurements, it is what you record and how you record it that is the basis of the data which can be obfuscated.

A decade of Tory austerity followed by three years of Covid in the UK have undone all that.

No one is still singing the Labour Party song of the 1990’s ‘Things can only get better.’

Well.

If I haven’t demoralised you too much already, I would like to return to planes.

I’ve not flown in one in a while although I am constantly assured, they are the safest way to travel.

I think that was a reason doctors and improvers in care latched-on to them ‘we want to be as good as the aviation industry.’

A noble aspiration although flawed in that passengers and patients although both subjects of systems that are built to assure their safety, are dramatically different in that, if a passenger freaks out on a plane, armed guards will tackle them to the ground and silence them. If the same happens in hospital we can’t, don’t and wouldn’t do that.

That is just one example.

There are more.

I’ll let you imagine.

For those who have been watching the TV or reading the news in the UK they will have noticed there is a crisis in our country.

Healthcare (or better, health and social care) is in meltdown.

Years of deconstructing the care sector – taking millions of pounds from councils and stripping people of autonomy, layering-on bureaucracy, crashing the economy and behaving like oligarchs has created a tin-pan mess.

This has recently been reflected in an article in the Emergency Medical Journal. Essentially, for every five hours a patient waits in A&E in the UK, one in 82 people will die unnecessarily in the following 30 days.

One in 82 you think. No bad odds. When you consider the hundreds of thousands of people admitted to hospital in the UK you might think again. And this is for the people who might benefit from admission. If your admission is avoidable or unnecessary – if, for example, your carer didn’t turn up (started new job at Lidl that morning) (Better pay, terms and conditions) and you were stuck in bed and maybe tried to get up and fell and bumped your head but were fine, but stuck, and called an ambulance and are, let’s say, to confuse, 82 years old, and a little discombobulated, you have a risk of being admitted.

In some care homes in the UK there are ‘no lifting’ policies that prevent staff from lifting a person who has fallen; the corollary is, if you are 82, or 92 and fall in a nursing home you might have to remain on the floor for six hours before an ambulance picks you up. By that time, you are so traumatised the paramedics think, ‘Better take you to hospital to get you looked over’ and five hours waiting outside A&E, then 10 hours to be seen by a doctor and 20 hours waiting for a bed. The person is half-gone before the day is done and all because a policy document.

I am on my soapbox.

I’ll step-down.

I’ll get back to planes.

For the past ten years or so, hospitals have adopted a system of alerts borrowed I think from the ambulance service who in turned borrowed from the army – it is called ‘OPEL’ – (Operations Pressure Escalation Levels) with different numbers and colours indicating the level of pressure on their system.

In hospitals, when things become bad (as they are constantly now) they are on OPEL level four, yes, you guessed, colour black.

This means there are more patients coming through the doors of the hospital than going home. There are not enough beds, people are waiting, operations are at risk of being cancelled and the system is under ‘pressure’ (as the managers say).

No one wants to be poorly when the system is operating at level 4.

It means, your heart attack or stroke treatment is likely to be delayed.

This in turn means death of heart and brain cells.

Handicap, disability, or death that would not have occurred if the system was at level 2 or 3 (consuming its own smoke, so to say).

When the black flag is raised, there is a response in most hospitals in the UK.

‘We are at level 4, cancel all unnecessary activities, all hands to the pump (what you do on a ship when it is sinking, I was informed this Christmas)’

And so, what follows is what happens when humans panic.

They run around shouting ‘black’ ‘level 4’ ‘action!’

This, for those of you familiar with the lore of my blog is when the amygdala (almond) fires, creativity ceases, and people shift to survival (fight or flight) mode.

The managers go to A&E and the admission units and stand around, trying to help; the cardiac staff who aren’t doing cardiac things because their cardiac theatres are shut because the operations are cancelled go to the medical unit and offer their support, ‘What can I do?’ They ask an exasperated nurse who is running around, which further stretches the bandwidth of the poor nurse who in turn snaps, ‘help!’ or ‘I don’t know!’ or ‘we are fine.’

The manager or cardiac technician go home later that day, ‘I helped in the emergency department today,’ ‘Very good their children nod with approval.’ (Or, I went to A&E and was told they didn’t need me… fancy!)

The Emergency staff deflate with insomnia, too many sweets, alcohol, or other things.

It’s not very healthy.

And yet, this play is being enacted across the UK constantly.

I can guarantee it.

Do you know an NHS manager? Asked them what happens when things are black in a hospital.

Well.

And this is my point (finally, and where I return to planes).

I have done the same.

‘It’s awful, can you help?’

I cancel my meeting, my paperwork or whatever and try to help.

I often get in the way of people who are doing their job at the limit of their abilities, stretched beyond elasticity and the difference I make is minimal.

The meeting was cancelled, it will be rescheduled for next month and whatever fantastic plans I had to save the world will be postponed.

It is a maladaptive process.

It is the immune response that takes-out the pancreas and creates diabetes. Antibodies doing what antibodies do with negative consequences.

It is not the antibody’s fault, it is the system, there is something awry.

And, equally, I am not suggesting an immunological response to the busyness.

It is a matter of economics.

Last night, after dinner, my daughter was practicing her economics revision for her soon to take place GCSE mocks.

‘What is the economic problem?’ My son asked.

‘It’s the presence of limited resources to meet unlimited wants’ She responded without pause. I am sure she will be the next Jeffrey Sachs or Yanis Varoufakis.

Supply and demand.

When we freak in the hospital, we are supplying more staff to areas that are already fixed, they have a finite number of trolleys, x-ray machines and blood pressure pumps, this (my daughter tells me is called ‘inelastic’) we don’t look at the supply.

The supply, for the most is people arriving at hospital either via ambulance, their GP, their families, or rarely public transport.

Many of these people are older. Many, although potentially ill don’t have an emergency. Or rather the emergency happens after 24 hours in a stretched A&E – the emergency wasn’t the fall, it was the result of the waiting, the dehydration, the pressure sores and so on.

We need to look at the supply.

Our current model, flipping back to the planes, rushes to the scene of the crash and tries to rescue as survivors (?victims) as possible.

We wait, wait, wait, until the crash, perhaps in the Andes or a remote place in the Indian Ocean (to add flavour) and invest time, effort, and resources in patching up those for whom the worst has already happened.

We spend no time at all on checking whether the plane or the passengers are fit for flight. We let them board regardless.

It is easier to prevent a fall before a fall has happened (you look at those who have already fallen (risk-stratify), who are frail, older and very high risk for falling again) and do something about it – provide a rail in their bathroom, stop the culprit medicine. Our current model waits for the fall which happens in a difficult to reach place, waits for them to be rescued then tries to patch them up.

Our system is upside down.

I am not suggesting that we shut the hospitals.

It will be a while before cardiac and orthopaedic surgeons can safely operate in the field, rather, we change the focus, the emergency response.

When the system reaches shit/fan the extra staff should be out with the ambulance crews supporting people at home. Taking the x-ray machine to the person who has fallen, ruling-out a fracture and letting them get on with their day (perhaps also simultaneously doing all you can to prevent a future fall) (Yes, this technology exists – no one is game to work with me on it).

It is me, rather than flouncing around A&E, rushing out to the nursing home with my suture kit. It is me or my colleagues, spending time talking with those at most risk of admission (many of whom don’t want to go to hospital, who know, if they go to hospital, it will only because they are too ill to refuse and will likely die there) and agreeing alternative admission plans.

It is enacting our virtual ward – providing care that is equivalent to the hospital in the home.

This week I met a woman who was very ill.

She was breathing fast; her oxygen levels were low and she’d only managed to drink 100mls of fluid by four pm.

‘I think you might need to go to hospital.’

‘No!’

‘OK, if you promise to drink as much as you can, I will see you tomorrow.’

The next day she was better. She had managed 1400mls. Not as much as an intravenous infusion in hospital but without the risk of snagged cannulas, stopped drips and unnecessary tests and transportation (her last hospital admission had not gone well).

It might sound like I am knocking hospitals – I am not. I will be the first person to ask to be taken to the emergency department for a primary angioplasty when my heart attack happens. It is just, that now, by the time I reach the hospital, my heart will have started to fail, and it might be too late because the system is topsy turvy.

We need to look at the airports not the crash sites.

Stretching the analogy, perhaps even the travel agents.

‘I want to fly to Honolulu.’

‘Do you know the price of insurance?’

The cost of the insurance in the UK doesn’t exist, the cost is the price of the inadvertent harm created by disjointed systems.

GPs, hospitals, community, and ambulance services not working together. Fractured by the limitations of GDPR; as the data companies make a mint, we are dying. Something needs to be done.

Yes, it is toppling the government, general strike, it is a re-evaluation of our fractured system, but first it is using what we have differently, it is responding in an alternative fashion, it is doing differently to what we have already done.

No more crashes in the Andes please.

I’ve had enough of cannibalism.

I write with no agenda, let’s see what happens. Epstein, Maxwell & Gasprom effects on Yoda the tortoise.

My usual listening/reading experience is:

Walking dogs – Audiobook (fiction, sometimes fact)

Running – Podcast (fact, usually history)

Car – Podcast (different to running)

Bed – Book (fiction)

In-between times – phone, Guardian, sometimes Twitter

Maybe I am overdoing it.

I should rationalise. Cut down.

Given these complications, I carry with me a jumble of fact and fiction. Occasionally my dreams are mixed-up, Bosch-like, at other times this variety helps maintain my balance.

I sometimes pick-up obscure facts, at others, I carry fictional narratives into my self-talk.

I am sure I’m not alone.

Most recently I completed Darryl Cooper’s series on Jeffrey Epstein and, before that, his analysis on the war in Ukraine.

It is these two Podcasts that have left me unstuck.

To the extent that I question whether I am being radicalised, whether the content is taking me too far down the warren that is American Alt-Right, not that I am entirely certain what Alt-Right is, just, that it isn’t good. It would have been considered treyf when I was a child.

Here it is.

I will start with Ukraine and my take-home messages.

We, that is, you, me, the West have been given a narrative of the war in Ukraine that tells a story of Russian aggression towards Ukraine. It is an ancient story, good (Ukraine) versus bad (Russia).

Perhaps, given the complicated nature or the shear muchness of our everyday lives we seek simplicity, when offered a solution that is a 1000 pages long or a one-page summary we will almost always opt for the side of A-4.

And so, the war.

Cooper’s interpretation (and apologies if I have this wrong, you can always listen yourself if you have a few hours spare) is that the war relates to NATO expansion fuelled by US weapons manufacturers influencing US politicians. It is a business. The more war, the more bombs dropped, and missiles fired the greater the profits, to the extent that the $x Billion support packages provided by America are actually loans based upon Imperial domination. All of which threatens Russia and its borders.

Did you know that prior to the Russian annexation of Crimea it was used as a peaceful Russian naval base (paying $97 Million/year to Ukraine for rent). The narrative at the time was to expel the Russians, removing their access to a warm water port (one that doesn’t freeze in the winter) and disabling their naval capability.

Is all this true? I am not sure. I have Googled and investigated many of the facts and yes, what I can access does appear to be accurate, although, the frustration is, it’s difficult to determine whether the sources I have accessed are themselves Alt-Right.

OK, maybe this is true. Maybe it hasn’t been Russian aggression solely, rather, US and the ‘West’s’ move to expand NATO, sell ballistic weapons and limit Russia’s sphere of influence (access to trade, etc.)

This I guess is potential. It is understandable and, I don’t think my writing this will place me on a CIA watch-list. (Although writing ‘CIA watch-list’ might).

It is important to remember that underneath the billion-dollar profits (made by Western arms manufacturers) there are people, predominantly Ukrainians, many of whom have lost everything – their lives, homes, and livelihoods. And the rest of the world although perhaps most significantly Africa where grain supplies have been disrupted. (In the UK we worry about our cost-of living crisis, we aren’t facing starvation).

None of them asked for any of this and none of them will benefit.

And now, Epstein.

Jeffrey Epstein, for those of you unfamiliar with his story was an American paedophile, rapist, and sex-trafficker. Those facts are certain. As to his day-job, whether he was a businessman, financier, or philanthropist is less clear. He died, supposedly by his own hand in an American Prison (the three video cameras malfunctioned, the two guards feel asleep on watch).

The sub-story that Cooper tells is one of a privileged upper class, although that is perhaps not the term as these guys don’t drive around in Rolls’ Royce’s and live in stately homes, they fly from A to B in helicopters, private jets and live on their own islands, they are the uber-rich, the multi-billionaires who have proliferated in the last-half of the 20th and early 21st century. Not all of them are exceedingly wealthy, it should be stated, some are just powerful – leaders of nations, politicians, royalty and so on.

The common theme, being, many of them were friends of Epstein.

Some of them are more obvious than others – Bills Clinton and Gates, Les Wexner, Trump, Prince Andrew, Ghislaine Maxwell. These are the ones in the headlines who spent greater of less time on one of Epstein’s private islands (he had two in the American Virgin Islands) (yes, like a Bond villain) – his jet was called the ‘Lolita Express’

Much of this is so fanciful that you imagine it is made-up.

(Last night’s running Podcast – ‘Jesus the history’ with Dominic Sandbrook and Tom Holland argued that many of the gospels had to be true as the stories are so fanciful no one would make them up.)

The details, in the most are available via Google.

Cooper quotes instances of child abuse in Belgium, the US and the UK where important people have quashed, derailed, or influenced investigations.

You know about Jimmy Saville. What about Cyril Smith, or the Kincora Boys Home or Marc Dutrox in Belgium?

He, Cooper, suggests a cabal of unimaginably rich men who pay their way through corruption and vice, who use people, particularly young women for their entertainment and return to their day jobs of defrauding nation-states.

Surely none of this is true.

And yet, Robert Maxwell (Ghislaine’s dad) was likely an Israeli agent, likely murdered by the Mossad, he may have been a double or triple agent. When he died, he took with him half the Mirror’s pension-pot of his thousands of employees. And Bill Clinton has been accused of three, perhaps four accounts of rape, all disputed except Monica Lewinski and, I don’t need to tell you about Trump.

It is a nefarious never-world, one controlled by distorted values and unimaginable privilege.

This doesn’t mean that every very very rich man is caught-up in fraud or sexual abuse, just, that some are. And some manage to pay their way out of their troubles – non-disclosure agreements and the like.

Am I paranoid?

Derailed?

Am I slipping towards the Right?

I wonder whether I should even post this as it suggests I have been taken in.

I tried to investigate Darryl Cooper and found nothing.

If you search, on Google of Duck Duck Go, you won’t find much. He has his Podcast, Martyrmade and another he runs with Jocko Willinck, former US Navy SEAL and all-in action man.

Jocko has a Wikipedia page, Cooper doesn’t. there is so little about him, he must actively wipe the page.

You can find a series of Tweets he released after Biden’s election on the likelihood of the presidential vote having been corrupted (used by Trump as evidence to support his allegations), but little else.

He reveals he worked for the US Department of Defence in a previous job.

It is said about the Kabbalah that one should not commence study unless you are into your middle-age, when you have a sense of yourself and the world that can withstand the corrupting influence of knowing too much.

I am at my middle age, and I don’t intend to reach into Kabbalah although it feels I have gone too far already.

And yet, I want to understand, I want to know what I should be thinking, not what people want me to think.

It is difficult.

At times too much.

On a more concrete note.

Yesterday we had our Christmas/Channukah dinner.

The dining room warmed-up to the extent it tipped our tortoise out of hibernation.

He emerged bleary-eyed.

I fed him some tomato and cucumber.

Remember Plato’s Allegory of the Cave?

For Yoda (tortoise) his Cave (tortoise table) is the world, dependent upon the heat generated by my central heating (dependent upon Russian and Qatari gas prices).

I worry I shouldn’t have fed him (hibernation begins on an empty stomach) and yet, he appeared hungry.

Have a good week.

Dickens speaks to Marx who is in discussion with Harry Leslie Smith. They reach a compromise.

It was the best of times and the worst.

Happy families are all alike; every unhappy family is unhappy in its own way.

Call me Ishmael.

Some starting clichés.

It is Dicken’s that strikes a chord.

Yesterday, I was talking with a group working to improve the lives of people living with dementia.

I mentioned our Virtual Ward.

This, the provision of care that is as good (likely better) than hospital care, the difference being, this support is provided in a patient’s own home.

For those who have dementia (and their families and carers) this is a godsend.

For those affected, hospital is often the final common pathway to loss of ability, function, and independence.

Care at home, supported by family, overseen by specialists in the care of older people is the panacea.

Maybe I am over-egging.

For the average person who has Alzheimer’s or Vascular Dementia, hospital admission, no matter where, is frequently the start of the end.

Covid did away with the notion of dementia friendly hospitals – facemasks and infection control measures have taken-over.

(Yesterday, I asked an old woman what she wanted (admission to hospital or a return home.) The nearby paramedic was surprised, ‘She’s got dementia,’ he said too loudly. ‘I do not have dementia!’ Responded the woman.)

This is the good. (The Virtual)

It is, indeed, very good.

The best thing in a long time.

If you flip the coin, there is no portcullis, you reveal an institution in its death-throes.

Destroyed by those vouchsafed to protect it.

Yes, the NHS and the Tory.

Sure, the Tory has never liked the NHS, it is too leftie, too socialist, democratic, and yet, it is central to UK political debate; it is locked-in to our psyche.

And today, paramedics and ambulance drivers across the country are striking.

Earlier this week it was nurses.

The train drivers who help the nurses and paramedics get to work are striking too, as are the postal workers and teachers who sustain our society.

The fissures are becoming cracks.

The narrative hangs by a thread.

The media, lapdogs of big-business are wavering.

Unsure who to support.

Attack the nurses, paramedics (and shortly doctors) or prop-up the failing government. A party of shams and miscreants.

It is not a difficult calculus.

And yet, one keeps you fat, the other thin. (Financially speaking).

For most it is straightforward. For the oligarchs not.

Recently a paramedic described to me the futility of their role.

‘You wait outside the hospital for five hours, the patient is traumatised, you drop her off then set-off to pick up another old woman who has fallen.’

The cycle begins again.

It must feel like this for the nurses too.

You try to care for too many patients with too few staff, you go home and repeat.

Life expectancy in the UK is falling.

Admittedly it is falling faster the less you have in the bank.

Passivity.

We are the consumerist society that is a stronger opiate than religion.

We, that is you and me and everyone we know should be in the streets in protest.

Mass rallies should be everywhere.

Perhaps the futility of our previous actions has corrupted our DNA.

We, the mutant children of Bevan, of the Welfare State have failed to recognise the cancer.

I must be careful.

Too much negativity and readers will switch-off.

Perhaps that is behind the passivity.

Society’s metamorphosis.

We are either the caterpillar (consumerism) or the chrysalis (dormant, waiting).

Our wings are stiff. Bent out of shape, cramped from too much Netflix or Hooch.

Let us organise.

Let us come together and say, Enough is Enough.

We can’t wait two years for another election that will likely be gerrymandered by whomever will benefit financially.

There is a trope from the 1920’s of the little boy or girl asking their father, ‘Daddy, what did you do in the war?’

The same applies today.

Remember Harry Leslie Smith.

‘Daddy, what did you do when they were deconstructing the Welfare State? The NHS? Asylum? The right to protest or strike? The economy? The EU?’

Indeed, what did you do?

I’ve got it. A grand unified theory! (thank you Dr Feynman).

That is an over-statement.

It is the link between Trump, Johnson, and Bolsonaro, all the biggies, the multi-million moguls who ride slipshod over the rules and regulations.

I’ll take you to Dostoevsky.

I was reminded of this after listening to Darryl Cooper’s Podcast ‘The Underground Spirit’.

He compares the lives of Dostoevsky and Nietzsche.

Specifically, elements such as the scene with the horse in Crime and Punishment and the conception of the Superman.

Both men experienced similar acts of cruelty, barbarity towards an old horse that shaped their future lives, both men wrote about the Superman, the over-man or uber-mensch.

This isn’t someone with laser eyes, faster than a locomotive, with flowing cape, more, an individual for whom the rules of society do not apply. They are out of time, out of the restrictions that limit us normals.

If I drive too fast in a restricted zone, I will receive a parking ticket. An uber-mensch will receive the same ticket, the difference being, I’ll fret, the uber will remain focused on their mission, whatever that may be.

Moving forwards when I refer to the supermen – really, super-people, I’ll call them ubers. Again, not because they are such amazing physical or physiological specimens, more because they have crafted an existence that is outside the laws and conditions that affect us, everydayers.

And the point?

Well, it is an explanation of much of what happens in the world today.

There are us. That is, the 99.9999 per cent of people who work, who turn up at the hospital when we break a leg, who wait, who surf the internet in our free time looking for inspiration or reduced prices on clothing or other unnecessary items who study, work and rest as per the hours of the day, who button our own shirts and pull-on our own pants, without servants or maids or helpers, who must negotiate the filling-in of online forms, all the day to day chaff that is being an adult in the modern world. And then there are the 0.0001 per cent.

Don’t try to calculate the number, I made it up. It is to make a point.

The guys whose pockets have been lined by the World Cup, who profited astronomically from the pandemic who are the tech giants. Mostly men with yachts and multi-storey, multiple-site homes, with security details, their own jets and private airports who exist a little like God, in a time and space outside everyday experience.

I mentioned the Darryl Cooper Podcast. Currently I have been listening to his series about Jeffrey Epstein. The possibly murdered, possible suicide who money-laundered and dealt big-time in the sexual affairs of children and young women, aided, and abetted by Robert Maxwell’s daughter.

In the series he mentioned Cyril Smith.

Remember him?

The oversized Liberal Democrat (in more ways than one) politician.

My sole recollection is of his struggle to fit through the underground gates in London, such was his girth. Oh, and he was a paedophile. Protected by State for decades until the revelations after he was dead.

It is perhaps too easy to slip into a conspiracy-theory mindset, believing there is a Bond-like villain pulling the strings, manipulating. Too easy to imagine Zionists or Old White Men in ivory towers scheming, coordinating the next steps in the saga that is Global Warming (not a climate crisis to them). (The folk who have purchased over-sized plots of land in New Zealand, thinking ahead).

No, no, it isn’t as coordinated as that.

There are bad people, or perhaps good people who are bad or good people who behave badly, thinking they are good, whatever. It is perverse.

It is too complicated to be part of a system.

I know this for sure as I work in a complex system that is healthcare. I see the best made plans of mice and men.

It is those who, having mastered the cognitive dissonance I mentioned yesterday, rise to the top, who can compartmentalise their ideas of what is good and bad, acceptable, or not.

Who are emotionally congruent nursing their baby when they oversee, accept or acknowledge the deaths of others.

It is Stalin and his million deaths.

It is you and me as statistics.

As points on a curve that are not representative of humanity, but to name a collegiate blog, ordure.

In Crime and Punishment, Raskolnikov demonstrates very well his failure of uber-dom. He senses guilt, he feels the burden of the murder, it is destructive.

He is not one of the guys who can appear on TV or on the cover of a glossy, smiling and pretending their innocence. He has the idea, but his honesty is too great.

Well-tuned psychopath. Not me. Not I.

Time-lord, manipulator of right and wrong, of truth and reconciliation, or remorse and regret.

The finite, the stopgap, the end of all things.

My solitary Tweet is lost, yours shakes a mountain.

My power is internal, it comes around and destroys only me, yours sends waves across the planet, echoes without end.

You can hire and fire.

You are bulletproof.

Beyond, above, around.

Omniscient, omnipresent.

Your listening devices are tuned-in, you have listeners who listen to the listening, who oversee the watchers, who manipulate the moment.

You are the comic-book hero who sups Kool-Aid.

You are the first and last.

We humans, so fragile.

The beating of a heart.

The passage of minor electrical currents through microscopic pathways of the heart; organs that perfuse, that push and pull oxygen to brains that exist beyond the complexities of the universe, capable of achieving the greatest and the worst, able to beat an old woman senseless for the pennies in her purse or thieve the pension of a million, able to deceive and explain with sincerity the essence of our hearts. We are the good and the bad. We are the under-men and the overmen, the boy, the girl, child, innocence and experience, the teacher, and the student. Able to listen without speaking, talk without hearing, we are obfuscation, confusion and manipulation, organised crime and disorganised government, we are the staffer who phones in sick, whose duvet-day costs the lives of a family, whose wrinkle or ripple in time is the start of a movement that impels others to drop out or not bother turning in, the break of dawn and the setting sun and all that is in between. The ice, frozen underfoot that fractures, that quakes from money-making, misguided fracking, the burning, oil and gas substrate that fuels the economy that gets you to work or home on time when the strikes are not in the way and you, you sitter outside of time know that none of this affects you, you anti-pleb, sit nicely, chauffer driven car, Mercedes or other, funnelling you along the one-way streets in the high and low country. Caviar and only made for you foodstuffs that resemble fish and chips and salt and vinegar crisps the way black is white and white black, the yin and the yang, the swinging pendulum of forget-me-nots. You can’t change the seasons although you can holiday in your holiday home in the capitals of the north or south, you can navigate the world, Olympian, like the game is only starting and you make the rules.

Fin.

Why did granny die? They killed Gran. After Priestley. (A redo, 26/11/22)

Seven in the evening Elsie reaches for the remote.

She falls.

Eight O’clock, Sandra, carer, should have arrived.

She left that day

To work

In Aldi.

No notice required

As none is required of her boss

To bin her.

She is zero hours

Gig economy.

Elsie on the floor seven until eight the next morning.

In pain.

A puddle of urine.

Cold.

Carpet burns on knees and elbows

as she has struggled to stand,

Eventually giving-in.

Heating is off overnight,

Austerity and all that.

Gaynor, carer #two arrives, find Elsie, she calls an ambulance.

Ambulance reaches Elsie by one in the afternoon.

It is a busy day

and

only life

or limb.

Threatening get priority.

Little old ladies are put to the bottom of the stack;

A virtual pile of clinical priority.

Can I have an ambulance? An old woman has fallen.

Is she breathing?

Yes.

Is the moving?

Yes.

Is her injury threatening to life or limb?

No, she is in a lot of pain.

Can you call the GP?

I’ll never get through (Tory lack of NHS investment)

An ambulance will be dispatched.

When?

Can’t say. Call us back if things change, here is your reference. Goodbye.

All this time, getting on for 16 hours, Elsie remains on the floor.

‘Don’t move her’

Gaynor is told.

‘Nothing to eat or drink’

Gaynor ignores this,

Offers Elsie tea and a digestive.

Ambulance arrives

Transports Elsie

To the local hospital.

X Royal Infirmary, we will call it.

XRI is full.

No room.

Too many patients arriving and not enough leaving.

Logjam.

Backlog.

Call it what you like,

Time and space collude to create a situation.

Elsie waits outside the A&E for three hours.

The paramedics talk with her,

Administer intravenous fluids into her blue veins,

Pain relief

And time.

Eventually Elsie is moved to the A&E

She is triaged

Processed,

Moved from stretcher to trolley.

X-rayed, pin-pricked and palpated,

Stripped of her dirty clothing

And hospital gowned,

She waits.

The last time Elsie was in hospital was 50 years before when her son was born.

The lights and noise and busyness of people rushing overwhelms.

She is left alone in a corridor.

No bays for Elsie.

We are full you see.

Elsie is incontinent.

She lies in her wet.

Embarrassed,

Ashen,

She hates herself and wants to die.

She feels pain and indignity.

She feels the darkness growing.

No beds.

Or there are beds,

Yet those beds are occupied by other patients who should not be in hospital,

They should be elsewhere,

Mostly home.

People cannot get home as following their three day or two-week stay, with them being old and frail, the trauma of the experience so profound (A&E and people like Elsie re-live this trauma seven days a week, 24 hours a day), they are diminished, their autonomy has weakened (institutionalisation), their ability to walk, eat, toilet has disappeared overnight, as will happen to Elsie. A process of clinical infantilisation has begun, the seventh age of decrepitude.

To return home, these folk require carers.

Carers like Gaynor and Sandra who is now working at Aldi on the living minimum wage (£10.90 an hour), a beyond the minimum (£9.50) she was earning as a ‘carer’.

Please care for our old and vulnerable yet we will not care for you, you are on your own, managing your finances, your bills, your future.

And so, thanks to Brexit and yes, Covid did not help, there are not enough carers in the country.

Consequently, old folk remain in beds for days and weeks longer than necessary.

The Tory claim to build, was it, 40 new hospitals? A pipedream, wholly unnecessary, when what was required was to allow people decent wages and job and housing security.

And yet, you, the Tory, doesn’t grow rich on the happiness of others, it is the contracts awarded to multinationals that line their coffers.

Elsie is moved to a ward; her inpatient stay is uneventful (see below).

She waits three weeks to return home.

Gaynor (the one who hasn’t gone to Lidl) has been allocated a different old lady, it will be someone else when Elsie gets out, like being released from prison.

During this wait, Elsie deteriorates, hospital acquired pneumonia then a pressure ulcer and a fall on the ward.

All this time she is diminishing, fading.

Her family visits.

She does not recognise them.

It is the delirium. A shade falling over, taking her away. A dark tunnel.

The night before the day of discharge Elsie dies.

She was an old woman after all, and old women die these days.

A sequence of events, initiated by, let’s ask?

Was it Brexit that led to a fall in the numbers of European workers available to support our job market (I am told our island is too ‘full’ small for all these Poles and Romanians, I don’t agree), or, was it the Covid, Climate Crisis and the mis-treatment of animals in a wet marked in Wuhan, or maybe the overcrowding in Chinese cities that process the world’s tat, sold on Amazon at a Prime price. Maybe it was the middle managers who do too little. Who lack the ability to create systems to undo the burden of Tory austerity that makes the energy companies rich and Elsie and her friends shiver in bed at night; it could have been the A&E department for working inefficiently, too much chatter and banter between those nurses and doctors, the inspector observes; none of this creates capacity, none of this finds a solution to support Elsie who when she fell, just fell, didn’t break any bones; a helping hand to return her to the chair would have sufficed and life might have continued. Maybe Sandra, through her lack of professionalism killed Elsie – a kind of indirect manslaughter. What about the bosses who previously ran teams of carers, supporting with pension and personal development who have allowed those folk to trade places with casual workers. Who can blame Sandra for wanting to earn a little more dough when the price of milk and eggs and cheese has skyrocketed? Who killed Elsie? Was it her son for not forcing her to move-into his large house? Maybe granddaughter Emily whose noise and bustle discouraged Elsie. What do you call murder of a grandparent, not parricide, who knows, not something to contemplate. Recent evidence has shown, the longer an older person lies on the floor and the longer they spend in an A&E department the greater the likelihood of their dying. Who killed Elsie? Does it matter? Stalin called one death a tragedy, a million a statistic. Is Elsie a dot on a graph or a person, a tragedy, or a decimal point?

It could have been different.

We live in an age of unimaginable wealth.

More money and prosperity has never before existed.

A little less greed and everyone would be fine.

Something is wrong with the minds of those in power in the UK.

Some say it is that they didn’t receive enough love as children. Perhaps the long days at boarding school mangled their brains. Switched-off empathy. What killed their compassion? What made them think of ‘me’ rather than ‘us’ – they will laugh at Ubuntu and wonder why England are ejected from the World Cup (a prediction).

Little nation, little island; sing me to sleep.

A final fling of the football, at the back of the net, into the hands of the goalie & a soupcon of Nietzsche.

I am sitting at home.

Downstairs I hear the drone of football.

Supporters cheering

The World Cup

Opponents

Argentina

and

France.

You see,

I have been paying attention, a little.

It is 2-2 and they are moving into extra time.

Look at me!

A proper pundit,

Afficionado.

Alan Hansen, not.

I remember

As an 18-year-old realising

The centrality of football talk

to Glasgow dialogue.

Once or twice, I tried to join-in

Before accepting my fate. (Sit quiet and pretend you are listening).

Early-on in the championship

after

Jo Lycett and his cash non-burning

And my complaints about

Human rights,

My daughter expressed her hope that England would lose.

Why lose? I asked.

The more England win, the more domestic abuse.

Men, getting drunk and beating women.

My daughter is a very switched-on 16-year-old.

I was also aware at that age

Although of different things.

I focused on Apartheid,

I read,

I lived through the start of AIDS.

‘My mum won’t let me drink that water,’ said a friend, ‘She doesn’t want me to catch AIDS.’

The ignorance was profound.

Apartheid was Nelson Mandela, Steve Biko and Rivonia.

Cognitive dissonance is when

You see, experience, or believe one thing but do another.

It is taking a stance against abuses of power

Against cheating

Fair play they say in football

And yet

Acknowledging the bribes and back-handers that took the game to Russia and now Qatar.

It is telling someone you love them

As you lash-out with a punch,

Or passive aggression.

It is inverting,

It is lying.

I popped into the room earlier,

Sans glasses

The players a blur.

One of the French footballers dived,

He pretended

Before an audience of how many millions

And was given a yellow card.

Naughty, naughty.

The lessons we tell our children

The multitudes watching,

Is not not to cheat

Not to find shortcuts or workarounds that save money but cost integrity,

It is, not to get caught.

Don’t get caught

And you will be OK.

And if you are shown to be lying, double-dealing, manipulating,

Just say no,

It isn’t so,

Our politicians provide regular masterclasses in this perversion

As we,

The masses?

Believe,

‘I don’t lie, I don’t cheat, surely not.’

Ever tried to manipulate a parking ticket or tax bill?

It doesn’t work,

We are under-people,

We don’t know the ways of the uber-mensch.

And if we perchance

Believe ourselves to be

Other,

We will fail.

Squeeze the capsule and empty the contents on to their sugar puffs. The 21st century balm.

You can open the capsules

The email arrived last week.

It was on the heels of the panic relating to Strep A.

Nationally, there has been a scare.

The information that two years ago just as many children died from the same infection was overlooked.

Every sore throat in every child has resulted in a trip to the GP or A&E.

We worry about the after-effects of Covid on our children’s immunities.

Swabs,

Anxious waiting

Antibiotics or not.

I don’t want to downplay the worry parents have been experiencing

Or the tragedy of the children who have died.

And yet,

Our newspapers

and broadcasters

Have been selling the story.

If it bleeds it leads

Goes the mantra.

The greater the tragedy the more

people will tune-in and turn on.

And so,

The country has run out of Amoxicillin.

The yellowy liquid you will remember as a child.

Banana or strawberry flavour.

The people in power

Who we long ago stopped trusting

Remind us,

‘There are plenty of antibiotics, it is a matter of logistics’

And,

No one believes them.

We live in a world that has gone beyond post-truth

Into cynicism.

Everyone for themselves.

We are diminished,

We pull-on our Oodies and go to bed early

To save on heating.

We limit our mileage,

Our spending

Our gifting

As the country is shrinking.

First the downsizing of Brexit and now the death throes.

‘Don’t be such a pessimist’

I am told.

My patient was chesty.

His breathing rate had increased.

His heart rate was up, oxygen levels down.

He is an old man who has dementia.

He is nursed in bed and struggles to swallow.

One option would be,

‘His time has come, let’s keep him comfortable,’

The other,

‘Let’s treat.’

An hour later I was told the chemist had run out of Amoxil syrup,

All he can swallow.

I reconsidered and prescribed Clarithromycin.

I was in luck,

Or perhaps he was.

In the medical journals they are advising doctors to guide parents to open Amoxycillin capsules and sprinkle them on food or mix with a drink to help the tots who are too small for pills and tablets.

Another patient this week was struggling.

He has deteriorated after falling down a flight of stairs.

He is in his 80’s.

Dialling 999,

The family were asked whether the call was urgent,

Whether they really needed an ambulance,

Whether he could wait.

They covered him with a duvet

(Fortunately, he has a wife or he’d likely have died.)

They turned-on the radiator,

Repositioning his feet to avoid burns.

After five hours the ambulance arrived

Then a wait to get into A&E

And

A

Wait to be seen once on a stretcher.

Sixteen hours later he was in a hospital bed,

Scans of his brain and spines having ruled-out a fracture or a bleed.

He was, in the parlance of 21st century healthcare a ‘Cat 3’

I’d never heard of the categories before this year.

It is how the ambulance service triages our calls.

Cat, or category one, is a blue light, when you have collapsed and aren’t breathing.

If you are lucky, a person on a motorbike will arrive promptly, defibrillator at the ready. If you are less fortunate you will wait.

The target is to arrive within eight minutes.

Recently only five per cent of calls have reached the victim within that time.

In the stochastic language of healthcare, ‘time is brain’ and, by eight minutes following a cardiac arrest, for the average person, the brain is well-into the process of its death, good CPR will help.

My patient was Cat 3 or maybe 4, this is, ‘non-urgent, get to them when you can.’ This is frequently, commonly, an older person who has fallen, broken hip or not.

The ageing tsunami has been approaching this country for decades and yet we haven’t prepared. Like the pandemic, it was coming, it was inevitable and yet, everyone chose to do other things.

The numbers of doctors training to specialise in the healthcare of older people (the discipline that helps maintain independence, reduces falls downstairs and avoids category threes and fours) is understaffed and diminished, it doesn’t feature adequately in the training of doctors or nurses and the system is, fractured.

NHS doctors, nurses, and therapists are retiring at a faster rate than they can be appointed. Retirement ceremonies have become passe.

By this week my patient was home although his wife was struggling. She is providing 24/7 nursing care. He is in bed, he can’t walk, she is solely tending to his continence, nutrition, hydration, washing, dressing and emotional needs.

There is no care.

That is, domiciliary care. The young (often) men and women (oftener) who visit to support the old and diminished at their homes.

Nationally, there are thousands of people trapped in hospital, they used to be called ‘bed-blockers’ before that term was outlawed. They are ready for home yet there is no support in the community.

My patient was somehow sent home without this care, hence his wife, in crisis. I found myself negotiating between a social worker and my patient’s wife, ‘How much money do you have in your bank?’ I was asked to ask. A moment of exquisite anguish and we are talking savings accounts.

Like my patient and his wife, domiciliary care is in crisis. There are not enough people willing to take-on this physically and emotionally demanding role on a zero-hours, minimum wage basis. Better to work for Lidl or Aldi, you often hear.

And, if you decide to take such a job, there will be no holiday pay, no travelling expenses, no on the job training or progression. You will work and work and if unlucky, people will complain.

Where are all the carers? They are either servicing Reece-Moog’s castle or have returned to Romania or Poland. Brexit was the nail in that coffin, thank you.

‘Bloody hell,’ you say, ‘This is depressing.’

Apologies.

And don’t get me started on the war in Ukraine (fascinating Podcast available here which explains America’s role in all that has happened – transpires, the aspiration to get rich on arms exports through participation in NATO plays a major role in the crisis) or even the protesters I dodged yesterday outside Waitrose as I popped-in to purchase some Christmas chocolates, ‘Ban Israeli dates,’ they shouted, in Yorkshire middle-class English. I wanted to scream. Instead, I bought two packets of Medjoul.

Perhaps I am over-sensitive,

I should rest,

Switch-off,

Read a good book

(Tomorrow and Tomorrow and Tomorrow, Gabrielle Zevin is fantastic).

Or get back to the water.

Yesterday I swam in a frozen lake.

The first time in my life (one degree centigrade).

Not recommended for the weak of heart.

Such was my zeal,

I front-crawled into a sheet of ice,

Lacerating my cheek.

Where do we go from here?

Dan Carlin,

The doyen of historical podcasts describes society’s rise and fall with the image of a flight of stairs,

The ascent is people trudging up in clogs and heavy work-boots, the toil, the sweat, and struggle of our ancestors as they establish the wealth or fortune on which our society (if you are lucky and live in the developed world) versus the velvet slippers that walk down as things fall-apart, as the deterioration, the softening of too many luxuries takes away our forefathers grit.

We are sliding fast.

How to stop this descent?

Somehow ‘Vote Labour’ doesn’t seem adequate,

Not that we will have the chance for another two years,

By then where will we be?

How far will the wrecking have gone?

Eat organic, walk to work, turn-down the heating, avoid airlines, don’t buy certain categories of dates or Bamba or Bisli, none of this will get you very far.

I suspect the only response can be mass protest and a general strike, like the nurses and the rail workers, postmen, paramedics, schoolteachers, and colleagues.

And yet, it doesn’t seem that anyone is noticing.

The media aren’t interested.

Not enough blood, you think.

The protests too small to make the evening news.

We worry about the World Cup, ignoring the Qatari abuses of human rights and equality, looking the other way, ‘I’ll buy those Jordanian dates instead,’ you say, a balm to your confused conscience.

I’ll Tweet my way out, you think. And no, that won’t get you anywhere, will not make any difference (Musk will see to that).

The nihilist in me is emerging.

Perhaps I need some more ice.

Cold water in my face or down my back.

That’ll do it.

Thermostatic analysis

It is seven degrees inside my house.

This morning the car registered minus four.

In the lake we were advised by the keeper of temperatures the water was four or thereabouts.

Afterwards, the neoprene of my bootees having temporarily stuck to the frozen ground, pain shot through my fingers as blood and sensation returned.

When the planet reaches 1.5 degrees of warming all hell will break loose.

Wildfire, drought, famine, war, species extinction.

I sit in the cold, bobble hat and thick jumper typing.

My dogs are oblivious.

Perhaps we should be more like them.

Memories of Mrs. Slocombe & Blind spots in health and care.

Today a patient called me a pussy.

I did not know what to say.

The conversation went something along the lines of,

-Do you know who I am?

-Yes, you’re that man, the first time I saw you I called you something.

-Mum, don’t say that word! Intone her daughters

-What, I can’t remember, I say.

-Well, I said…

-No! shouts her husband

By now point I am laughing.

-Go on, it can’t have been that bad.

-Pussy. I called you a pussy.

-When we first met you, we thought you were Irish. When you said you were from Glasgow, D. called you that word. (Says the husband)

-Pussy. She says again.

-I laughed.

-You laughed then too.

-I don’t remember.

This conversation was my establishing whether my patient D. was confused or to what extent her dementia had deteriorated.

It transpired; her recollection was better than mine.

My memory is frequently patchy. I do not have dementia.

Dementia is more than memory, it represents changes to a person’s mood, behaviour, personality, rationality, and mental processes. What happened five minutes or five days ago is only a fraction of the whole.

-Pussy, I thought, how odd.

Shortly afterwards I visited another patient, we will give her the initial R.

I slipped my shoes off and sat in the warm living room. R was at one end, her daughter between us.

-You can remove your mask, said the daughter.

-I’m not allowed, I replied.

-Mum lip-reads.

-In that case. I kept my distance.

At first I couldn’t remember my reason for visiting R; after a quick leaf through the digital record, aided by R and her daughter, ‘You have come to tell me when I am going to die. I haven’t long left.’

‘I think you will be OK, you look very well,’ I replied, before the story had unravelled.

My patient had been well until a recent admission to hospital where a critical narrowing of one of her heart valves was discovered.

‘You need emergency surgery,’ she has been informed.

The week before she had been independent, driving, cooking, cleaning, and, all that goes with a normal life.

The period of hospitalisation was complicated by an episode of delirium.

‘We are not sure whether we should operate (on your critical heart condition) given the level of confusion, if we do and it goes wrong, you could be worse off,’ the corollary being, ‘You might have a fixed heart but a failing brain.’

The team allowed R’s confusion to settle – recovery from delirium can take weeks or months.

They reassessed.

‘Still too confused,’ they said, ‘No chance of an operation.’

And, my patient was left with a death sentence.

‘Your heart will deteriorate, and you will die,’ she was told.

She was provided a letter that would ‘keep her out of hospital.’

The letter was an advance care plan, the type of document I often complete, with full understanding of the implications. This, I didn’t feel had been done very well. My patient had been guided into an existential limbo and she was terrified.

During the conversation I couldn’t help thinking that R was, despite the numbers associated with her memory scores, very bright, orientated and alert, engaging appropriately with the conversation, keeping-up with the discussion.

All a little odd.

The hospital doctors had subjected R to something called ‘a MoCA’ (Montreal Cognitive Assessment) which, different from the chocolatey coffee is a standardised memory test.

Here is the test. You could google and test yourself if you like.

Many people (me included) don’t like the MoCA as it is quite difficult and often scores people worse than they are. The definitive cognitive assessment if call the Addenbrooke’s Cognitive Exam ‘ACE’ which is much more detailed (it takes longer to complete, hence the frequent reliance on shorter assessments) (Ironic, when the determination of an individual’s cognition, essentially a major component of their personhood can be decided with such flimsy analysis. (We would not accept the same for heart or lung conditions))

Something was odd.

I decided to do my own test.

‘I know the doctors have already checked you, is it OK if I ask you some more memory questions?’ I asked, ‘Sure, she replied.’

My test is the 6-CIT, (Six-item Cognitive Impairment Test) a questionnaire out of 28 points, where the lower the score the better.

R scored 26. This suggests significant confusion.

And yet, she wasn’t confused.

Odd.

It was then I realised, or by the middle of the test, that R’s memory is fine. It is her communication or language skills that are wrong.

She has aphasia. She was labelled with dementia when her disorder is different.

Aphasia is a neurological condition, usually following a brain injury from a stroke or trauma that impairs a person’s ability to either understand (receptive aphasia) or express (expressive aphasia) language. Some people have both. (If you are interested, you can read Sheila Hale’s book, ‘The Man Who Lost his Language‘ written about her husband John).

I am sensitive to aphasia as my mum had this condition.

Visitors to her flat would see pictures on the living room wall of me and my siblings in our graduation outfits with our names stuck on the frames.

Even before my mum’s stroke she would jumble our names, calling me my sister or brother’s names. The stroke made this worse.

Mum would struggle to find the right word (expressive) although mostly she understood what was being said.

This, for mum was a terrible disability as language, conversation and socialising was one of her superpowers. Mum could talk with anyone at any time about anything. She was forever warm and engaging and never stuck for something to say.

It is not uncommon for people experiencing aphasia to be considered stupid or demented by doctors, nurses, and others.

The principle of ‘ask questions first’ and judge later is frequently ignored in the busy-ness of our post-Tory NHS.

Dementia is a distinctive, progressive ‘neurodegenerative’ condition of the brain – Alzheimer’s or vascular dementia, for example.

Aphasia is usually fixed, static, often following a stroke there can be recovery (with the appropriate therapy or support).

It is also not uncommon for people with visual and hearing impairment to receive diagnoses of dementia. ‘I’m not stupid, I am ignoring you’ kind of t-shirt joke, not that this is very funny.

During Covid, many memory assessments were conducted on the phone, often a doctor or nurse talking to an older person who has poor hearing, the diagnosis erroneously reached.

What to do?

A sine qua non of the care of older people and patients is the phrase ‘time and space’ – providing this allows a patient to decompress and relax, it allows the doctor or other clinician capacity to think.

The urgency of the moment often impairs our cognitive abilities.

‘Slow down, you move too fast, better make the moment last,’ says the song, and this is true of most human interactions.

I have arranged some further tests for my patient and contacted the speech therapists.

The cliché ‘with great power comes great responsibility’ is associated with Spiderman. Doctor, nurses, and others in similar positions also have great power to influence another’s life, we often forget the associated responsibility.

Funereal wave. Suspension of belief.

It is a wave

washing over,

as wrinkled toes

tip

and touch the seabed.

It laps your shoulders

and head,

fizzes and falls.

You are tossed

against it.

There are two stages of life,

before and after

the death of your parents.

Before, you are a child

then

an orphan.

For some this happens suddenly

for others

the process is gradual.

a cancer

a dementia

a protracted deterioration.

Frailty, organ failure or senescence.

There is before.

There are the phone calls

at incongruous moments,

that spark fear.

Is this it?

You ask,

Is this the call?

Some

live in the shadow.

Others manage

To maintain a state of innocence.

With me,

I have an internal guilt

That associates any unanticipated

summoning,

‘Could I talk to you,’

Or,

‘Please come to my office,’

Or even,

‘May I speak to Mr X’

‘What can it be?’

‘What cata-strophe?’

Some of us live in this state of suspended

fear.

Or angst.

Always presuming the worst.

A tenterhooks Umwelt.

The warrior is ready for an attack at any time.

The anxious man is ready for the tiger that never comes.

See the difference?

And, when the call does come, ‘We have some bad news,’ it is a relief. The worst has happened, ‘Your dad died last night, we did everything we could,’ or, whatever platitudes, explanations, narrative. With ‘died’ you stopped hearing, with that word you have moved-on, with that quotidian slap everything is different. Now you are a man. Now you are responsible. And even after this trauma, after the subsequent haze, you still hope, even when you know or have seen the reality, the death, the mottled body, the same irrational self which carried you along all kinds of worst-case-scenario fantasies. When the phone rings you still imagine, this time it might be mum or dad, a shift from beyond, a distortion of reality, and why not allow this fiction? Is it improbable, unlikely, impossible? We humans have an inborn tendency to fancy, the scratch-card unreality check, ‘Maybe this one is the winner,’ or the self-delusion, ‘I can stop drinking, smoking, obsessing when I like,’ says the addict to their parent/sibling/partner; humans love delusion, it is us at our best and our worst, it is suspended belief, the search for the miraculous, the supposition of magic or unreality.

Before and after are the same.

When before is after,

After is before.

Life always races forwards.

In the town of Otsuchi in North East Japan, there is a wind-telephone. An old fashioned rotary not connected to any network or exchange. The phone box was installed after the 2011 tsunami to provide survivors time and space to connect with those who were lost, who in a moment were taken away by the giant wave. Those who use the phone know that their husbands, wives, mothers or fathers are gone, their bodies disappeared and yet, over the years more and more people have travelled to this garden to engage with those no longer alive. It is a gimmick for sure, but one that allows people to express themselves in ways that might not be comprehensible to those who have not experienced this loss, ‘Hello, mummy, I just wanted to say I miss you.’ No need for extended narrative, the sentiment is powerful the message concise. The phone never rings and there is no call-tone, it is a fragment of a world lost, that of the analogue, of the wired connection and exchanges, more tangible than our Samsung or iPhone.

For more on the topic, listen to this 2016 TAL Podcast.

the empty bed & the red dahlia

I imagine

the woman.

The week before

She’d been out in the cold.

A nasty wind

blew.

Perhaps too much shopping

Too many people

Coughing and sneezing.

She fell ill.

Admitted to hospital

They do all the right things.

Ill,

but not critical.

Oxygen

and

Intravenous antibiotics.

At one point

The intensive care doctors

Consider

Taking her for more,

For ‘escalation.’

They determine

‘She’s not unwell enough. OK for the ward.’

And so,

She lays in bed,

Slowly recovering.

Yet,

sometime,

At some point,

She doesn’t.

Rapidly, she becomes confused.

Disorientated,

Struggling with the oxygen,

The drip, the cannula,

Her bedclothes are too hot or tight

The plastic pillow wrapper

Causes her to sweat,

The noise, a rustling

Agitates.

Two am

a doctor is called.

More fluids,

discussion with the middle-of-the-night

Microbiologist

suggests

Stronger stuff,

More powerful antibiotics

To address the decline.

Catheter inserted.

She struggles.

Bloods are taken

Three attempts,

was it four?

Eventually, she calms

and dies.

Something happened.

She slipped away.

One moment breathing,

The next,

not.

A futile attempt at resuscitation

As, by the time the nurse

finds her,

Growing cold,

Five am,

She’s gone.

Nurse calls her husband.

can’t get through.

‘Hello, it’s Jan and Jack, we can’t come to the phone right now. Leave a message…’

You, her son is second in line,

yet,

For reasons not altogether clear,

your phone doesn’t ring.

It is six am now.

Sunday.

You aren’t woken.

No message on your phone,

No ‘missed call.’

Time passes.

The body is moved to the mortuary,

The nurses having

Washed her,

Removed the needles and tubing,

Last-offices

This is called.

And off to

Rose Cottage

Or whatever euphemism

They use for the place

Where bodies are stored.

The intervening hours are not straightforward.

There is a change of shifts of nurses

and doctors, porters, technicians, and support workers.

The ‘handover’

The message from nurse Karen to nurse Polly to call you or your dad

is missed,

lost in the rambunctiousness of a Sunday morning.

By eleven

you

and your dad

arrive.

Someone else

Is in your mum’s bed.

Where is mum?

You think.

Dread.

‘Where is mum?’ You ask, ‘they must have moved her,’ wistful thinking.

You see the nurse

And her pallor

Reveals all.

The bed that was empty

The drama overnight

Is meticulously recorded in the notes,

And yet,

You, your dad,

Have been missed,

Forgotten.

A slip of the pen

of an action

On a too long to-do list.

The bed is occupied

by another older woman

grey-haired

patterned blue hospital gown,

>Property of…<

asleep.

As the hospital works overtime,

Over-overtime,

The patients keep coming,

The emergency department struggles,

There are inadequate resources within the system,

A rubber band snapped

Its recoil, gone.

And,

Who is to blame? (#tory #brexit #fate #butterfly?)

Who

Is the fall-guy?

Who picks up the pieces of

Your mum’s distant suffering?

The twist of fate

And genetics, environment, and time

That aligned.

No one really.

One of those things.

Death and an empty bed.

beds

don’t stay empty for long,

Hotbeds.

Hot beds

They call them on miniature submarines

Where sailors in shifts,

Sleep in rotation.

River flowing, breathing.

^^^^

This poem is a tribute to M.

M was a lovely old woman, in her 90’s.

She had been dying for the past six months,

progressively

Fading.

Every time I visited,

Letting myself-in via the key-safe

Code 1929

For her year of birth

And negotiated the no-longer used lift

On the steep narrow stair.

I would find her asleep.

‘M, it’s me, doctor, how are you?’

She would waken,

Smile,

‘Thank you for coming,’ she would always say.

In response to, ‘How are you?’

‘A little better.’

She never moaned

never complained.

One day I showed her a photo of the dahlias in her front garden.

her husband had planted them years before

And now,

Restricted to indoors, she was unable to see them

(although,

thoughtful neighbours dead-headed and brought her cuttings).

She smiled.

I don’t know what she could see,

Whether cataracts or poor vision interrupted,

Yet she thanked me again.

She was a good soul.

A ‘gutte-neshoma’ my mum would say,

The word in Yiddish.

And,

On the final Friday,

As I popped in.

1929, then stairs and

her bed was empty.

She had died in the night.

The room was silent.

It took me a moment to realise

the meaning,

To understand.

She had left.

Her smile was gone.

She had died in her sleep,

And the house was empty.

Still.

The carers and nurses diverted to others,

The world moves on

And just my memory,

My reflection.

Tangled in safety-nets, a healthcare odyssey.

I am calling for a reconsideration of safety-nets.

Don’t worry,

I am not planning

On a change of career

To tight-rope walker

Sans net,

Not my thing

At all.

(Although, being a doctor or nurse is daily walking a tightrope, especially during these times of austerity when we are encouraged to do more with less.)

Safety-nets are core to the life of doctors, nurses, therapists, and paramedics working outside of hospital. Less so for those on wards.

When you are a doctor on a ward-round, you don’t tell every patient, ‘If you are feeling unwell again, call me.’ As, there is an assumption, if you are well, especially in 2022, you won’t be in hospital, and second, if you are unwell and become more unwell, don’t consider calling the doctor – that is the nurse’s role. The nurse can call the doctor, not the patient; that is the hierarchy in a hospital, no matter how flawed or flattened. And, finally, the assumption, if you become more unwell, we, the hospital staff, that is, the nurses and nurse support workers, will detect your deterioration. You don’t have to do anything, as our measurements, our hourly pulse, blood pressure and other checks will detect any concerns. You, the patient, can lie-back, become passive; if old, allow the hospitalisation/institutionalisation/deconditioning to do its thing. (Heck, in hospital, as part of your shift to passivity, we will bring your food and drink, we will wash, dress, feed, and toilet you, all for free.)

Outside of hospital, in the community, which is, Primary Care – your GP as well as all the interconnected services that maintain health and wellbeing beyond the hospital walls, district nurses, specialist nursing and therapy teams who visit you at home, in your own bed when you can’t leave the house, have a different agenda.

First, I guess, because you are ‘at home’ there is an assumption, that no matter your level of disability, there is some ab-ility, some things you can do for yourself, and there is the matter of autonomy. As you are not a hospital patient, you, yourself retain some responsibility for doing what the doctor or nurse says or asks, such as, ‘call me if the pain returns.’ This, indeed, otherwise called a safety net, is how care outside hospital operates. It is useful for those occasions when a doctor hasn’t a clue what is wrong, ‘I am sure it is nothing serious, call me if it gets any worse or doesn’t go away,’ or, if the patient plan is uncertain, ‘Take these antibiotics, if you don’t see an improvement in 24 hours, call me.’ Kind of thing. (Acknowledging the difficulty inherent in ‘getting through’ to some doctors in 2022.)*

At another level there are the first or emergency responders, or those from secondary (specialist care) who might see you in your home. Like me. Although, I don’t want to give myself as an example as I am not an extensive safety-netter.

Imagine you are old, you fall, bang your head.

An ambulance is called.

The paramedic checks you over, no obvious damage, no bleeding, loss of consciousness, weakness down one side.

‘You seem OK, if you start vomiting, your headache gets worse or doesn’t go away, you become confused (etc), call 999.’

This is the safety-catchphrase.

For staff visiting care home residents, ‘If Nora becomes more unwell, ring 999.’

This is the problem.

For a variety of reasons. Principally it conveys a lack of confidence to the patient and/or their carer, as in, ‘I think this is the problem, although, I might be wrong, in which case, call someone else.’ It is a form of delegation of responsibility, such as, ‘If things deteriorate, it’s not my fault, it’s yours, call an ambulance if you are worried.’

And, it is a hand-over to discontinuity.

This is a reference to continuity of care.

This is the essence of primary care.

The relationship developed between a patient and their primary care doctor or nurse over time.

The same man or woman who knew you when you were a child, who is supporting you with your parent’s decline.

The doctor who knows where you live, who knows your family, your story.

The knowledge inherent in this continuity, remembering, for example, that you don’t like needles or work nights and need an early appointment or don’t always answer the phone on the first call, are elements of personhood, the acknowledgement of the complexity of another, that is as important as knowing the guideline for management of condition x or y.

This continuity is an infinity that relates to human connections and relationships that cannot be replicated by the episodic nature of emergency responders.

When you are ropey, calling 999 will get you a response that sees you as a citizen, a human with a unique anatomy and physiology, yet with parameters that are measured against the average:

‘Your blood pressure is 85/50, we need to take you to hospital.’

It is protocol and algorithm.

It doesn’t know that your blood pressure is always low and even when you say, ‘My blood pressure is always low,’ you aren’t believed or trusted (what do patients know?!), the paramedic finds another reason to follow the protocol, ‘Yes, that may be the case, however you have just fallen, we should get you checked-out,’ and so it goes.

So, it goes with a transfer to hospital, the waiting, the doctor, or nurse who says, ‘85/50, we had better take some blood and give you a drip; hold-on whilst we arrange an x-ray, ECG and scan of your heart. Sorry, you said your blood pressure is always low. Let’s see, shall we.’

Continuity of care versus emergency response.

They are difficult to reconcile.

And this is what is relinquished with the safety-net.

The safety-net functions 24/7 – that is its magic. If at three in the morning you experience further chest pain or breathlessness and don’t call an ambulance, that is on you, the doctor you saw earlier is absolved. Without that catchphrase, you can blame someone else, although, if the chest pain heralds a cardiac arrest and you die, no one will know.

It is tricky.

What I am asking is that people think when they safety-net.

They consider the implications.

Of the message conveyed.

Most patients want their clinician to have a degree of confidence (not cockiness or arrogance).

Part of the therapeutic interaction is reassurance, is taking the burden of worry from the patient and placing it on your shoulders.

And this, is how it should be.

If you don’t agree, or even if you do, if you are in doubt, call an ambulance. I am sure the crew will be pleased to see you.

Take care readers.

Wish me well with my three-degree swim.

*Yes, the Tory government over the past 12 years has supported the progressive destruction of the NHS/Primary Care, selling large chunks to the private sector, avoiding the relevance of continuity of care (imagine, an effective, efficient health service (like we had) isn’t a great money-spinner, one that lacks efficiency, that arranges tests, investigations and treatments that are not necessary, is a fantastic way to boost your income or profit) – see USA healthcare (or think of your vet).

discontinuity of care

I just called / pieces of a man

I just called

To say

Hello.

To check

On you.

It has been a year

Since he died.

You are not in.

It is Peter’s confident voice

I hear

On the answerphone.

‘Pete and Jo aren’t in, please leave a message.’

Pete’s voice so strong,

The bounce,

Energy,

Vigour

Still audible

Across time.

I am sorry he’s gone.

This is based upon my recent experiences phoning a patient’s wife.

I had met the patient a few days earlier.

He is a shell.

In a care home. He is not able to engage in conversation.

A few broken sentences,

Not fixed in place or time

Are all that he can say.

I try to connect,

And,

Not even eye-contact is feasible;

Most patients responding to my smile,

For this man

Its magic was absent.

And the voice

On the phone,

Not ‘Pete’

Yet,

Just as confident

As full of life and humour and energy

Was still present,

A ghost

A shadow

Of the man.

The snippets,

Voice recordings

And audio,

Even writings

Are elements of our immortality

That will last beyond our decline.

Football, tory intransigence & virtual reality head-sets

This morning I was listening to another

This is History

Podcast

Tom Holland

&

Dominic Sandbrook

are running a World Cup series.

When I first saw

‘World Cup’

I moved-on.

Enough is Enough after all,

As we say

In England

That being the slogan

Of one of the movements

Bringing together the trade unions.

As in, enough is enough

With our lives shrinking, diminishing

At a time

When the oligarchs

Loosen their belts

And gain pounds,

Expanding their girth.

In the spirit of recent blogs,

I thought

You can’t criticise Qatar

And FIFA

Without the facts

Joe Lycett on Twitter

Is one thing

And

So,

I listened.

Most of the podcasts – they are running 32,

Are not about football

Rather, the countries at the competition

Iran, Croatia, Germany, Tunisia (Carthage!), Uruguay, Costa Rica, and Australia so far

Telling histories of those places.

Germany was represented by the White Rose

The Anti-Nazi movement of 1942 started by Willi Graf, Kurt Huber, Christoph Probst,  Alexander Schmorell, Hans Scholl and Sophie Scholl.

They tell Hans and Sophie’s story.

It is worth a listen.

(Incidentally, I’d never heard of the White Rose until two weeks ago when reading Ian McEwan’s Lessons; I’d thought the narrative fictional until my daughter described her GCSE history homework, on the White Rose. I later sent her the podcast, to discover her English teacher had also shared the podcast. B’shert, or as Jung would say, ‘spooky’)

Yesterday and today, I listened to the history of the World Cup, Nothing about the Tupamaros of Uruguay or Somerton Man.

1978, the World Cup was in Argentina (during the ‘dirty war‘). At the time ruled by an ultra-right-wing junta; It is unclear how many people were ‘disappeared,’ perhaps 30,000 critical of the government, vanished by means of torture, assassination or bloody murder.

An anecdote from the games was that dissidents were held at the Argentine Navy Mechanical School in Buenos Aires – where they were tortured, before being killed.

The school was close enough to the El Monumental stadium for the prisoners to hear the cheers of the spectators.

On one occasion the guards took the prisoners round central Buenos Aires to witness the jubilation, the lack of concern for them and their situation and the state of the country in general.

Oddly, they were taken for a pizza, I imagine not handcuffed but guns pointing, to see the events, a dig at the futility of your actions, ‘You will not defeat us, you are defeated, you shout injustice, liberty, we should ‘football,’’ or words to that effect – I paraphrase from my imagination.

And the same today.

Qatar with multiple human-rights abuses, the treatment of the itinerant workers, women, LGBTQ groups and others is, ignored.

‘Let’s focus on the game’ say the teammates.

‘Don’t bring politics into football.’

I despair.

‘They won’t allow me to wear the arm-band, it’s OK, it is all about winning,’ says the England midfielder of his Pride badge.

I shout, no, it is not about winning, it is not about football, it is a crisis of the moneyed minority dictating to the rest, it is the corruption of UEFA or FIFA or whatever the organisation with its deep pockets and covert operations, its behind the scenes deals for liquified gas and manipulation of currencies, weapons trades and backroom agreements to look the other way, it is part of what is wrong with our society when people are able to trick themselves into believing that ‘look the other way’ is OK, as food and house prices rise, rents increase and more and more are made homeless or unable to step-up. It is covering your eyes and ‘as if’ not to peeking. It is the reason, after 12 years of tory austerity people are prepared to accept more, ‘So long as it’s not in my back yard,’ dump your pollutants, poison your seas, rivers and land, erode the soil, destroy the air and environment so long as I can get to Tesco, so long as I can pretend everything is OK, so long as you don’t expect me to vote for you or change my opinion. I worked hard to get where I am and those people on the dole, on the charity, foodbanks, sitting in café’s to stay warm, they are the chaff, they do not matter; it is my pound (albeit weakened against the Dollar/Euro/Pseta) and its purchasing power that counts; I will watch Strictly or The Bake Off or other reality TV, and, when the programmes are over I will don my VR headset and pretend I am in the Caribbean or at the football itself, travel to Qatar without the cost of the flight, sitting in my mouldy cell (I’ve still not turned-on the heating, she says with pride). Cough, Aspergillus spores, cough; I don’t mind that this is killing me, I will keep going, I will remain on track, I will buy my football stickers even though I need to borrow money to get the whole set. And enough.

It is this glue,

This stickiness

That stops progress

That prevents change.

Apathy,

Intransigence,

Fatigue.

Poor me another drink,

Soothe me

Comfort me,

Don’t face me with facts.

A version of reality where millions are able to cognitively split what they know (human right abuses, etc) and pretend that bright green grass (Ultra HD 4K) grows in the desert; a demonstration of failed congruence, a representation of what is is what is not and truth is post truth and just because I tell you the vaccine won’t kill you is a reason for you to believe the vaccine will make me shed the virus and kill more people, just because you don’t eat meat is a reason for me to consume more, magnetic fields we repel logic. (For more, see here.)

How to win amidst the chaos, the hullaballoo?

Let’s go swimming.

It was 8C yesterday,

Maybe colder today.

Revelation #1 & the day I was kicked-out of Waitrose

I know I should have known

There were people out there

Who see the world

differently.

It is self-evident

It is

What it is

To be human,

To have a pair of eyes and ears

And the ability to process.

Last Sunday

My daughter and I visited some houses in South Central Doncaster.

Nothing like the LA equivalent,

It is stone-built houses

A quiet estate,

From the 90’s.

Mostly , two or more cars on the drive,

Double-glazing

And well-kept lawns.

We were supporting the local Labour Counsellors,

establishing

Who might vote Right or Left or not at all.

‘If there was an election tomorrow, how would you vote?’

We asked.

The responses were mixed.

Many,

I prefer not to say.

Others,

It won’t be your lot!

And one,

I am Tory, the wife and kids, Labour.

A microcosm of English society.

For some of the time we followed

Ed Miliband,

Former Labour leader

And current Shadow Secretary for Climate Change and Net Zero.

Most constituents were welcoming,

pleased to see tall-Ed,

Shaking hands and smiling,

Chatting

In the gloaming.

Some less keen.

One family expressed the entire

Fox News

Daily Mail

Brexit playbook.

Everything from ‘the immigrants’

To NHS managers

And the ‘you are all the same’

Ed handled it with the skill

Expected of an experienced politician,

Showing empathy

And trying to understand despite

Their intransigence,

Their passive-aggression.

It was this family, the man,

Early afternoon, pyjama bottoms

And his wife,

At his side

Agreeing,

Provoking,

Needling,

Stirring,

Who I found most interesting.

I surround myself with like-minded people.

At work, where those minds potentially diverge (viz. here),

We focus on patients and care,

For others,

I block them.

On social media

I follow those who think alike

Who see the world similarly.

Tweet after tweet

Is either the wonders of nature, NHS and healthcare, or Tory Memes.

I exist in a bubble,

A cocoon that I have cultivated.

Is this nurtured version of reality healthy?

Part of my motivation for existing within this buffer

Is my lack of resilience.

Exposed to the brutality of Trump or Johnson or Farage,

I couldn’t cope,

I would fail.

I need this defensive perimeter

To protect my ego.

And yet,

It affects my world view.

I see one side of the coin

And the other

Is stuck to the floor. (Remember the Candid Camera joke?)

Part of the reason for the success of Brexit

Was the Left’s reluctance

Refusal or inability

To countenance the arguments of those on the Right.

As a medical analogy,

It is like fighting a disease

at the same time

Pretending it does not exist.

It will sooner or later get you.

And they got us.

52 to 48.

Voila.

And, hence,

To win

We must embrace not only diversity

But those with differing views

We must try to understand

Their motivations,

The antecedents of their behaviour,

Without which we

Will be stuck.

In Swedish quality improvement parlance,

We must invite those we might not like, to the table,

Sit down and break bread.

Two-step with the dancers we would prefer to leave as wallflowers.

In Plato’s allegory of the cave,

The people spend their lives dancing before the fire,

Their image,

Their perception of the shadows as being reality is a misconception

They are a fragment of what is what.

Bruce Lee in Enter the Dragon,

Slaps the student’s head,

It is like a finger pointing to the moon; don’t <slap> focus on the finger or you will miss all the heavenly glory.

We are fixated on the finger

As the firmament is too big,

Too vast,

Too frightening to comprehend.

My next steps?

I need to embrace those who are different to me,

The loud

The cynical,

The bombastic

Opinionated.

Someone filled with the zeal of an anti-vaxing

No.

Afraid that’s not me,

Someone with bigger cojones is required for the job.

>>I have<<

I have lost the thread of this blog as at the moment of typing ‘job’ a ‘partner’ at the café asked me to leave.

I’ll explain more below.

Although

Perhaps

Maybe

As the I Ching says

A journey of a thousand miles begins with a first step

I shouldn’t seek to snuggle-up to the trolls/right-wingers and creeps inhabiting the Twittersphere,

Incremental change is better than massive failures,

I will have a go.

Watch this space,

Although

If my mind is stolen,

and I acquire a Union Jack tattoo, you will know the experiment was a failure.

So, what happened to me?

It’s Friday morning.

I took my daughter to school in Sheffield and thought I would pop in to Waitrose for a coffee in the café and write my blog.

Everything started well.

I arrived just after 8 and the staff were still setting-up so I found a seat and started writing.

I got into the flow.

Yes, this happens to me frequently as I type; time and space stop and I become absorbed. It is active mindfulness, it is supposedly good for my mental health.

Well, the time passed. It was a little cold. I put-up my hood and continued writing.

I was joined by one man, otherwise the place was empty.

By 830 a ‘partner’ approached me, ‘Are you meeting someone or going to have a drink?’

‘Sorry, what do you mean?’ I asked.

‘This isn’t a communal space, you need to buy a drink or leave.’

As blunt as that.

I informed him I was going to buy a drink (I didn’t go into explanations of flow-state) and decided to leave.

I saw security standing just behind him.

The place was empty.

I was riled.

I thought of the potential confrontation with someone less able to stand-up for themselves (I tried), or maybe someone with depression or an old man or woman sheltering from the cold; I felt confronted by an unexpected toxic masculinity. Was it my hood? My laptop? Backpack? Were it America and a similar situation, I could have ended-up dead.

Yes, I was kicked out.

I went back in and spoke to the manager and explained how annoyed I was.

They offered me a free coffee.

I decline and left.

I get it; they don’t want riffraff spoiling their café. And yet, it is cold out there, we have a fuel and cost of living crisis, and they sell overpriced crap. It just doesn’t tally.

Would Aldi kick me out?

Do Aldi have cafes?

Who knows.

Who cares.

Crisis, alert, no beds!

We have a thing in the hospital, it is called a Level-4 Bed Alert.

When this is announced, it advises staff that there are more patients scheduled to come-in to the hospital than there are beds.

(Were the hospital a sink, the drain would be blocked and the water-level rising).

It is a sign that the Emergency Department has too many patients, an indicator the ambulances are stretched as they wait to offload the sick and injured.

With the alert, staff are directed to move-away from so called non-clinical duties and focus on discharge, this is the process of moving patients out of the hospital to make-way for the new.

It is an organisational cry to arms.

Once upon a time these alerts were unusual.

Now they are daily.

I saw something on Twitter yesterday suggesting that the NHS is now at the bottom of healthcare systems in the developed world.

Yes, we are better than Yemen, Syria, Azerbaijan, or Iraq, but they do not really count.

For years I have tried to convince the hospital management to formally communicate this situation to others, principally primary care, or GPs. (It goes-out on Facebook and Twitter although most GPs and sick patients aren’t tweeting during their crisis or in a morning surgery).

You see, it is my contention that although GPs are only responsible for admitting a minority of patients directly to hospital (most arrive via 999), given the bed crises, they are unable, like in the old days to see an old man with pneumonia and send him directly to a bed on the admission ward.

When I was a junior doctor, we hated GPs sending patients directly to us as this meant we would have to organise blood tests (take the bloods ourselves, insert a cannula if required), x-rays and ECGs. In other words, it created more work for the ‘medics’ – those on the wards, but was better for the man with pneumonia as he wouldn’t have spend time on a stretcher in A&E.

Nowadays as there are never available beds the patients are almost always sent to A&E.

This means, for our man – let’s call him Old Adam, the process for getting to that well-made hospital bed would be, Call GP – speak to receptionist – wait for GP to call back – ask for home visit – GP goes out to review* – Old Adam tells GP about their symptoms, their chest is sounded, ‘You might have pneumonia,’ is announced; ambulance is called – ambulance reassess Old Adam, ‘Any allergies?’ Take Adam to A&E, Adam waits in ambulance outside A&E (cold in the winter, too hot in August), he speaks to a triage nurse, then a practitioner (nurse or medical), ‘Any allergies?’ Again. Bloods are taken, ECG, chest x-ray, cannula, intravenous fluids, and antibiotics, call the medical ward, wait for a bed, 15hours later Adam reaches the medical ward (and the medical doctor), ‘Any allergies?’ and so on.

It is a fershleptibobemyse as my dad would say, that is, Yiddish for, a long and convoluted old granny’s tale.

Our system is complex and there are multiple steps and checks and governance assurances along the way.

Recent evidence has demonstrated the longer a patient such as Old Adam spends waiting in the emergency department, the greater the chance of him dying.

None of this kerfuffle is communicated to the GP, ‘I think you need hospital.’

The GPs often worked in hospital 20 years ago or more, long before the Tory NHS demolition derby.

Many are unaware of the pain and sometimes indignity facing the patients (as Old Adam waits on that stretcher, in hospital gown, bottom or testicle peeking-out, he needs the toilet, ‘Just go in your pad,’ he is told.)

It the start of a gradual descent.

Some GPs are aware of this process, not because they have witnessed it recently themselves, but, because their patients tell them.

Old Adam: Please don’t sent me back to hospital, it was awful, the noise, the lights, the food; daily blood tests, urine measurements, pin-prick blood sugars, temperature, and blood pressure.

And yet, we have few alternatives.

I hadn’t intended to talk about the anticipated virtual ward in my area – the NHS has announced plans to open so-called virtual wards across England this winter; these will provide (supposedly) ‘hospital-level care in a patient’s home’** – millions of pounds have been spent developing systems and processes, recruiting additional staff (there aren’t any – remember the Brexit workforce crisis?).

Let’s see what happens.

The virtual ward will only succeed if GPs and paramedics possess the facts.

‘Adam, the hospital is on level four; that means you will have a very long wait if I send you to hospital. We could give you treatment in your home. Which would you prefer?’

Old Adam falls off settee in his enthusiasm for the alternative.

I haven’t carried the narrative of this blog particularly well.

I had intended to describe the lack of joined up working across our health and social care system.

This is where although at a certain level social workers, doctors, nurses and administrators communicate, at another, on the shopfloor, these conversations are often not happening.

We, given our hunter-gatherer brains, exist within a tribal monoculture. Us and Them.

There has been a recent move to recreate the way care is delivered across ‘systems’ that is different towns, cities, and communities, with greater collaboration.

Moving away from a ‘Sheffield’ ‘Doncaster’ or ‘Barnsley’ patient toward the concept of a ‘South Yorkshire’ patient.

South Yorkshire is the major conurbation, in the South of England’s largest county, with the four towns and cities (Rotherham is the other) mostly mixing and merging – one day we might become a megalopolis.

It is not uncommon to hear the doctor, social worker or commissioner announce, ‘Old Adam is a Rotherham patient, that pathway doesn’t apply, it is only for people from Sheffield.’

(Old Adam lives on a street in Rotherham, one end of which is in Sheffield, you get the idea) – maps are artificial, manmade boundaries like race and class that work to divide rather than bring us together.

The new plan, called ‘Integrated Care Systems’ is for us to integrate.

No more Sheffield or Barnsley, rather, South Yorkshire Patient, it is like a line from Imagine, John Lennon’s vision of the Universal.

Maybe when GPs and hospitals and social workers realise that they are not separate, that they are all pushing in the same direction and that the wellbeing of the Rotherhamite or the Doncastrian is equivalent and within the context of a holistic humanity we will get somewhere.

For now, the Level Four is an alarm (not a literal one) that sounds in the hospital and the common good is over the fence.

Flipping this on the head, you could take the R Moog argument that adversity, especially for the ‘man on the street’ is good, as it not only toughens them up, separates the wheat from the chaff and drives innovation, just, as the people rushing to purchase Oodies in place of central heating are contributing to a reduction in global warming.

No, I don’t believe that.

Yes, Mr Moog, your actions will kill lots of old folk this January.

Your polemic will tear us apart, it will drive the divide.

We shall overcome, Old Adam sings to himself as he let’s go of his urine, too afraid or ashamed to ask for help, too tired or weak to shuffle off the stretcher, the noise and hubbub of the corridor (no room in a bay) are too much for him. A notch off his dignity and his life.

*In many areas of the UK, instead of GPs visiting their old and frail patients at home, visiting services are sent, this is nurse and paramedic practitioners (mostly) who, don’t know the patient, don’t have access to the 80 years of their medical and family history, check a blood pressure, heart rate, and say, ‘Adam, you aren’t well, I am sending you in.’

It is another spicule of Tory defenestration of the NHS.

** Can you see the picture of me on this link?

I am a Tory! (& the trouble with memes)

Driving home last night with my daughter, Eminem was on Spotify.

The Real Slim Shady.

‘May I have your attention, please?
May I have your attention, please?
Will the real Slim Shady please stand up?
I repeat, will the real Slim Shady please stand up?
We’re gonna have a problem here?’

She said it reminded her of Spartacus.

Spartacus?

You know, Spartacus!

What do you mean?

Well, ‘Who is Spartacus?’

Oh, yes, the movie. I didn’t know you had watched it.

No, I haven’t, it was an episode of Outnumbered.

Who was Spartacus? She asks.

A gladiator then Roman Slave. He led a rebellion. (I don’t mention Kirk Douglas/Issur Danielovitch – a cultural reference too far).

Interesting.

My daughter gets many of her cultural references from TV.

Her favourites are Outnumbered (Hugh Dennis and co), The Office (USA), Big Bang Theory, The Gilmore Girls (According to Bonnie Tsui a favourite of Gulf War Veterans) and Friends.

This is generational.

Thanks to DVD then streaming, she has watched these programmes over and over.

I have spent hours in her company as Ross or Sheldon or Michael drone-on in the background.

None of this has much to do with today’s title.

Someone said this in a meeting.

I am unapologetically left of centre. On some matters more left than others. This seems to happen as you age and become part of the establishment with more invested in yourself than in society, with thoughts more focused on the practical, maybe it is a lifetime of six-am starts and too long days at the computer.

Nevertheless, I am always critical of the current government. Even when someone tries a justification. ‘Boris was great in his support of Ukraine’ kind of thing. No… One right doesn’t undo a hundred wrongs.

And so, it is with the health service.

I gather there is to be more money invested in the NHS following this week’s budget.

This money is a drop of urine in an Olympic Swimming Pool. It will soon disappear; the water will be safe by this evening.

It is demonstrable on virtually every measure that the Tories have done more harm to the country and NHS in their 12 years than any of Reece Moog’s wildest childhood fantasies.

I remember in 2008, as the markets were crashing, a conversation with a senior NHS leader, ‘Bad times are coming.’

She retired before it started to fall apart.

And there is more.

Are you all ready for this winter? For January and February, the darkest months?

When I think of reducing life-expectancy and A&E waits and that old woman who lay under a tarpaulin for 15 hours waiting for an ambulance (broken hip) and the cancelled operations and the outpatient waits – 12 months to see a doctor, two years for your operation and the nurses and doctors trying to balance five simultaneous tasks, given the post-Brexit workforce catastrophe and the cost of living crisis and the failing planet and our poisoned rivers and seas and the dispossessed youth and the homeless, you see where I am going.

And it sometimes happens during meetings, when I am analysing the situation and reflecting on root-causes that I suggest, either ironically, ‘This has nothing to do with the Tories,’ or more succinctly, ‘It’s the fault of Tory,’ that recently, at one meeting, the person chairing said, ‘I am a Tory.’

I didn’t have a response.

I was thinking, ‘Eh?’

Yes, I was embarrassed that I had brought-up the potentially taboo (my dad, a former Freemason would always tell me one of their rules, ‘Never talk about money, politics or sex’). Well, although I have never mentioned sex in a meeting, politics, is hard to avoid.

What do you tell the patient?

Yes, there is a 12 month wait for your appointment. Yes, there is a wait to join the waiting list. Yes, you might wait for the waiting list and not meet the criteria and find yourself off the list.

How do we explain what is happening?

It is possible I misheard my colleague.

Perhaps she said, ‘I hate the Tory’ which was mangled by Teams.

Perhaps, who knows.

Maybe she should take credit for her openness.

It is hard to find anyone airing their political allegiances around here.

In the US, people used to have bumper stickers proclaiming whether Republican or Democrat. I am not sure whether in the days of hire-purchase this still follows. In the UK this is not a common way of demonstrating your political leaning.

I only know one other public Tory. I haven’t asked her if she thinks differently now the cracks have become fault-lines. I daren’t.

And yet, there are millions out there.

Millions who perceive the world as a threat, who see the poor as a drain, immigrants, refugees, asylum seekers as lesser than less, there are multitudes who prefer to consider their own nest egg, who want more and more for those who have less and less.

The over-stuffed, the over-fed, the rich, the misled, the easily swayed.

No, I am not making new friends with this blog.

No apologies.

And, had she said, ‘I want the Albanians/Africans/Syrians out of here, Rwanda the sooner the better,’ would I have stayed silent? Yes, I was perhaps wrong with my political allusion when discussing the care of older people, and yet.

Argument in my experience doesn’t take you far. It is two opposing forces colliding, it tends to create more energy for resistance with greater fallout and destruction.

Years ago, I described the martial art of dementia. This makes me think of the scene at the start of Enter the Dragon, where Bruce Lee tricks the cocky South African into climbing into a rowing boat on the way to Han’s Island.

‘It is the art of fighting without fighting,’ he smiles.

It is not uncommon, when working with those who have dementia for your realities to collide.

‘Have you seen my mum?’ Asks 95-year Molly, ‘I need to find her, I saw her through the window.’

There are classically three responses.

You can say, ‘Molly, you are 95, your mum is dead, you have dementia, you live in a care home, sit down.’

That is one way, not the way to do it.

Or, you could say, ‘Molly, your mum is running late, she will be here shortly,’ this is a white lie or half-truth (she is running 50 years late) – no real harm although the principle of lying creates a precedent that is pernicious and detrimental to most relationships (In my experience).

Or you could use ‘diversion’

‘I haven’t seen your mum, would you like a cup of tea,’ or, ‘I am not sure where your mum is, where did you grow up?’

This is called diversion and distraction.

It is acknowledging the other and using your skills to manoeuvre in another direction. It almost always works (unless the person is in a state of heightened arousal – the trick here is to back-off and give time and space, or, if their dementia is too advanced for verbal communication, in which case, more subtle physical interaction might be required – using tone of voice, body language, smiling, eye contact, and so on).

With strategy 1, the ‘mum is dead’ the most common response is escalation, ‘My mum is dead?’ with more upset or, ‘My mum IS NOT DEAD!’ Leading to more anxiety, fear and escalation.

I don’t recall how I managed the ‘I am a Tory.’

I suspect I used diversion.

Maybe I should have replied, ‘I am Spartacus!’

Have a good weekend y’all (even the Tory).

Two or three roads diverged in a yellow wood, now and then.

I know it’s a cliché, yet, I have long been fascinated with Robert Frost’s poem, The Road Not Taken.

This is, I believe associated with my interest in time travel.

Two roads, sliding doors.

That kind of thing.

I also know that some people, perhaps most don’t think this way. They not interested in what might have been.

I sometimes wonder why.

One theory relates to my life trajectory.

I have taken twists and turns that my peers did not.

At age 12, I moved from a suburban existence in the South Side of Glasgow to live for five years in Israel. At 16 I moved back to Glasgow, to a red sandstone tenement.

At that age, I left school, shifting from the basketball courts of Ostrovsky High to the smoking common room of Langside College then to Dundee University.

I had plans to become a neurosurgeon, then a paediatrician then a psychiatrist then an emergency medicine doctor before settling with geriatrics, the care of older people.

At each twist and turn in the road, my interest was keen.

Recently, I have been listening to Elizabeth Day’s podcast How to Fail.

Today she was talking with Gloria Steinem, yesterday, Bernadine Evaristo. Last week, Benjamin Zephaniah, Michael Rosen, and Jarvis Cocker.

The theme of the podcast for guests to present three failures that have shaped their lives, and eventual successes (for Jarvis, falling out of a window, Bernadine, not reaching Australia by car).

Elizabeth Day herself is unusual. The daughter of an English surgeon, she grew-up in Northern Ireland, went to secondary school in England, is a journalist and writer with a clipped English accent that reminds me of Katie Derham. (You can find out more from this podcast)

I was thinking this morning of the failures that have shaped me.

As of this evening, I remain uncertain.

Perhaps my failure to become a neurosurgeon (schoolboy aspiration) or a psychiatrist (more mature interest) were instrumental in making me who I am.

On two occasions, I applied to train as a GP in Sheffield. I was rejected twice. I now work partially in primary care (and I think I am doing a reasonable job) which is a partial vindication.

For decades I used to dream of being a martial artist. For those of you familiar with my blogs, Bruce Lee was and remains a hero. I followed his philosophy and physical exploits.

Between the ages of 13 and 17 I had a passion for Karate. It occupied my thoughts and imaginings. It mostly fell apart with my return to the UK and an inability to find a club that would accommodate me. Well into my 30’s and perhaps 40’s I used, in my mind’s eye, to imagine myself performing rapid-fire Jackie Chan-style mawashi-geris.

In my middle years I frequently considered an earlier life-trajectory, which would have been to join the Israeli army and become an officer (as all my closest school friends, except one did (his tenure in the IDF was short-lived)).

I used to imagine myself as an undercover operative, using my knowledge of Hebrew and English to infiltrate the enemies of the state and win covert operations.

On a trip back to Israel after I received clemency from the Prime Minster (Rabin) I met-up with my old school friends. They were serving their time, one in the submarines, another as a naval commando and a third doing something secret.

We went walking along the Jordan river (or perhaps the Banias). I turned around and they had all disappeared. I couldn’t find them. They had performed a military-style vanishing act, only to reappear five minutes later, in the undergrowth. I still don’t know why they did it.

I carried that with me. Perhaps I could have learned a lesson in stealth. Not much use as a doctor, although who knows.

Was my not becoming an Israeli soldier a failure? My mum was pleased I became a doctor. I imagine perspective is important.

In my early 30’s I fell off my bike.

I was run over by a tram in Sheffield.

For anyone who is familiar with tram tracks, they are a hidden threat for cyclists.

It was a Tuesday morning. I was cycling to Sheffield Medical School to deliver a lecture on older people. It had been raining. I was cruising along Hillsborough Road when a tram came up behind me (they are silent). The tram tooted its horn, I moved laterally, and my wheels jarred into the track. I flew over the handlebars, and it ran over me.

Afterwards, when I visited the police headquarters to collect my mangled bike, they showed me a video of the event (the trams carry forward-facing cameras). It was as dramatic as it seems.

I was knocked out and taken to A&E with a fracture skull (the same department where I was working) – anecdotally, as they were going through my belongings one of the consultants found my stethoscope and said, ‘I think the man is a doctor!’ – amazing they didn’t recognise me. Perhaps there was too much blood.

I failed to give that lecture although I later re-scheduled and thanks to the generosity of a drug rep, provided pizza for the students (I did the lecture in the evening).

The scar and the incident have been with me all these years. My children have an aversion to bikes. I remember my son, three at the time visiting me in the resuscitation bay.

Two roads. This way or that.

I could have died and then what?

As a young boy, perhaps five years old, I remember a trip to Largs (a resort on the banks of the Firth of Clyde). I was paddling on a slipway. I couldn’t swim. My mum caught me as I was wading out. I gather from the concrete landing there was a severe drop off. I carried the thought of my drowning for many years.

Had I drowned, the story would have ended.

Had I not travelled to Israel in 1985 who knows. I suspect I would be a down in the mouth Glaswegian with high blood pressure.

My mum had a brain tumour in 1990. She almost died. What would have happened to my life course had she not survived? By then I was on a trajectory for medical school. Would my chosen specialism have been different?

What is the value of this reminiscence?

Or is it reflection?

Or supposition.

There is no past. Only now.

The past informs our present. It makes me the person I am today and will become tomorrow. If not A then there would be no B, or the C would be alternate.

A mathematical truism.

I have written about some of the antisemitism I experienced as a young boy in Glasgow in the 70’s. In primary five I moved to the Jewish school, Calderwood Lodge. Another fork in the road. I still experienced bullying, just a different kind.

Much of my experience relates to my existential outsider-ness.

What makes an outsider? A stranger?

A Scottish, Jewish, Hebrew speaking Israeli. A Scotsman in Yorkshire. A duck out of water. Where to begin? Where will it end.

Does it matter?

Just another existence that will be snuffed out when the time comes.

On Elizabeth Day’s Podcast, I have heard two of her guests (Michael Rosen and Gloria Steinem) talking about death, its meaning and significance. Their conclusion, that even though a person has gone, so long as their memory continues they are still with us, their existence matters and continues.

Here is to the day I am forgotten.

Be well and perhaps contemplate your own failures or forks in the road.

Thirty years ago and counting. 90’s reminiscence.

Last week I was talking with my son about the past.

He asked whether I thought things were better 30 years ago.

30 years ago, I was 20, my son’s current age. (He’s 19).

Better is vague.

It encompasses multitudes.

Bad, better, best?

We didn’t finish the conversation.

Perhaps there was too much to say or maybe the answer would have been too bad.

The moment passed.

We might have been talking about music.

30 years ago, which would be the 1990’s.

I was 20, in my second year of university. Worrying about psycholinguistics and staying warm.

Today, warmth is another issue.

In the 90’s I had little money and sometimes had to decide between Iceland frozen drumsticks and a night out with friends. It was all a false economy. I was lucky and I didn’t know it.

Today, as I write, winter 2022, the temperature outside is seven degrees centigrade. In the house it is a little warmer. We are opting to restrict the heating, perhaps out of solidarity with those who can’t afford to heat, but also out of an acknowledgement that by heating the house we are burning hydrocarbons which are overheating the planet.

All of us wear Oodies indoors.

I sense the dogs are cold. I haven’t asked them what they think about austerity. They wouldn’t understand the war in Ukraine or the rising sea temperatures.

Last week I finished Noah Hawley’s latest book ‘Anthem’

It is supposedly one of the first major post-Covid novels to come out of America.

On several occasions, I asked myself, ‘Why am I doing this (reading)? It is so depressing.’

It is a dystopia, set in an alternative modern America with Republican and Democrat ideologies even more fractured that we see on TV. The country simmers on the brink of a civil war that does indeed spark and the planet is so far beyond the tipping-point that everything, everywhere is on fire. Fire or flood. It is no Candide.

If you ask the social psychologist Steven Pinker the same question as my son, he will tell you that the world today is the best it’s ever been. He has a glass that is so half-full that the Kool-Aid is spilling over the rim.

He cites examples of global literacy, especially for women, child infant mortality rates and deaths during wars as out time being the best in human history – ancient or modern.

And yes, if you are a woman living in Saudi Arabia, I gather they are considering letting you drive to the supermarket without a male chaperone, but still.

And, if your house was one of those hit by a Russian or Iranian rocket in Donetsk last week or your mum, dad, sister or brother are dead following an atrocity you might not concur.

30 years ago, there was no iPad, iPhone and the internet was perceived as a source for good. The World Wide Web was in its infancy and not dominated by advertising and click-bait data collection. Apple, Google, Twitter, and Facebook were all starting out or not yet conceived, their first steps towards world domination still part of Gate’s, Brin, or Wozniak’s onanistic dreams.

Now social media has overtaken democracy. It has created Bolsonaro, Trump, Johnson, and Netanyahu.

We live in post-truth times where every scientific fact is doubted and second-guessed, where conspiracy theorists occupy the soundwaves and people believe anything.

Chesterton said, in one of my favourite quotes, ‘When people stop believing in God, they don’t believe in nothing, they believe in anything.’

And so, the religious fundamental right in America either believe in God or they believe in armed resistance. They don’t believe in logic or reasoned discussion, they worship the ‘God King’ (Hawley’s allusion to Trump in the novel) and they see only what they want or are told to see, black and white and grey become relative terms that exist in the eye of the beholder.

In 1819, Schopenhauer wrote a book entitled, ‘The World as Will and Idea’ containing the concept, ‘The world is my idea’ in that, it is in my head, it is from me; there is no you or other, only my constructs. Our perceptions create the reality. And yet, there is something called fact, unless you suspect fact is a distortion of truth and someone is trying to hoodwink you to steal your freedom, have a vaccine or pay more tax.

In the 1990’s I had little money, but I did not feel particularly poor. Conspicuous wealth wasn’t something I noticed or paid much attention to.

I don’t remember mega-cars that exceed the value of a home. I don’t remember reality TV or vox pop news channels. As far as I know we didn’t fret too much about the food we ate or the water we drank (see above re Iceland drumsticks).

Animal welfare and the death of the insects was not a mainstream worry.

In the 90’s more people died from heart disease and stroke than today. I can quote this with confidence.

At the weekends (and sometimes on Thursday nights) I would drink too much and dance until three. The clubs were filled with clouds of cigarette smoke. Today the numbers of those smoking in the UK has dropped massively (Labour Government). Now you are much more likely to die from old age or dementia than a cardiac arrest or a blocked coronary artery. Joy.

30 years ago, or a little after, I worked in an A&E department in North London. There was no such thing as trolley waits or bed breaches, the NHS manager’s concept of ‘flow’ ‘discharge to assess’ and ‘right to reside’ were still glimmers in the eye of NHS England’s orgiastic fantasies.

I remember patients waiting 20 hours to be seen by a doctor. I remember beds in the emergency department with people trying to sleep as they waited for a place on a ward. (These were the dying days of Thatcher’s England).

Today, people are routinely waiting more than 20 hours to see a doctor. You might wait eight hours (in agony) at home for an ambulance to arrive, then there is the wait in the car park (was miserable this summer for already dehydrated people). Patients are not waiting. They are leaving the departments across the UK and going home as 15 or 20 hours is too long to wait. They are dying in their beds instead. Unnecessary, avoidable deaths that are a consequence of Tory austerity and a systematic deconstruction of the NHS.

In the 90’s Rabin (my now long-dead, assassinated hero) and Arafat shook hands outside the White House. Today, Netanyahu has become Prime Minister of Israel, a lurching to the Right that causes me despair. The electorate forgetting the fraud, cheating and bullying, opting to worry about their own petty self-interests, the devaluing of a once exemplar society, a proposed light unto nations is dimming.

In the 90’s Dolly the Sheep was born, and Diana was killed in mysterious circumstances. Today you can spend £100 and find-out your genetic makeup, we have Charles on the throne. A perversion? An inversion?

We had dreams of a Genome Project that would introduce personalised medicine, an aspiration for person-centred treatment where I would receive Cholesterol lowering drug X which was specifically tailored for my genotype.

Instead, we have, take this pill, and hope for the best. If a thousand people take this medicine for a thousand years, a hundred extra people might live a year longer. Statistics as evidence of effect. OK if you are average.

In the 90’s the Soviet Union fell apart and lots of new nations were born with long-names and obscure capital cities – Kyrgyzstan, Azerbaijan and Moldova are some.

Today Russia is trying to undo some of that independence, influencing the region and flattening Ukraine.

In the 1990’s the world seemed to make sense. Now it is obscure. Motives and explanations for actions are mysterious. Why does Putin do what he does? Why does he use such long tables? Is the phallic allusion necessary? Why the bombs? Why the refugees? Why, why, why?

A poor person in Moscow, London or Athens is just as poor as they were 30 years ago. The social safety nets have if anything diminished. Food banks have stepped-in in the UK to assist, just as the government has stepped-out.

Supposedly the gap between the rich and the poor has grown. Although does it matter if you have $1 and someone else on the planet has a billion or a zillion $’s? you are still hungry and cold, and they are still on their private helicopter.

You will die when you are 40 or 50, from TB or heart disease or violence and they will be artificially maintained into their 90’s. MRI scanners, regular health checks and fitness coaches alongside good food and clean water will keep them going as you age beyond your years and die in discomfort (on the back of an ambulance).

Ultimately, we all decompose at the same rate. Our dust is the same dust. The atomic number of the particles in the sand we leave behind is identical.

When I was 20, I didn’t worry too much about the environment. I was aware of global warming and the Ozone layer depletion. I got on with my day, however.

I don’t remember the news being so depressing.

Bill Clinton and Monica Lewinsky were messing about in the Oval Office. We have our current tranche of trashy leaders.

Why, despite at times amazing acts of insight, intelligence and compassion are we so stunningly poor at choosing leaders?

In the UK, America, or Brazil, out of the millions, is this the best we can do? In China, out of the billion, we have Xi Jinping who won’t condemn Putin? How, why?

The 90’s was quite a decade. And the 20’s?

Is there value in this analysis?

An exponent of Mindfulness would say, ‘Just focus on the breath.’ That is easy when you aren’t too cold or hungry or afraid or dead.

I think the world is worse than 30 years ago. Not that it matters. Who cares what I think or type or write?

Of as much importance as the facts that are denied by the majority or the minority.

This morning I plan to open water swim.

I don’t know the temperature of the water. I suspect it will be chilly.

30 years ago, I didn’t know about open water swimming. I suspect in those days you could enter a river, or the sea surrounding the UK and not risk cholera, shigella or campylobacter.

OK.

We have Netflix and there have been thousands of movies, films, songs written since the 90’s. It isn’t all bad. I didn’t have the life I have now in the 90’s. I had parents but no partner or children. I had no car; the freedom of my bike was restricted. I couldn’t type my thoughts into a blog and were I to walk the dogs, I couldn’t listen to a Podcast.

Let’s end with Zen.

There is no good

or bad.

There is,

there was,

there will be.

Enjoy your Saturday.

Time on my hands – Pour passer le temps.

The clocks have swung back an hour.

Blindboy was complaining about this the other week.

He reckons it causes problems for women.

His argument was that some women are put-off by running in the dark and with the closing-in of winter and its further hastening by the enactment of DLST society isn’t helping.

There is more to this narrative, and you will have to listen to other Blindboy Podcast episodes to get a better understanding of his approach to concepts such as toxic masculinity, chauvinism, inequality, and sexism. Let’s just say, he is, I believe, on the right side of history.

And yet, because of all this jiggery-pokery with time and clocks, it is lighter in the morning.

I will soon don my winter-layer wetsuit and head-out into the waters of the Dearne Valley, dodging pike, pebbles, and elodea.

My dogs are fed, they are quiet and resting.

I have an hour to go.

How often do we find time on our hands?

My experience is usually either inadequate hours in the working day to squeeze-in all that I need and want to do or otherwise periods of ennui, torpor where there is the time, the capacity but my will is lacking.

Fortunately, the more I exercise, the more active I am, the better my ability to manipulate time in my favour and so, when there are gaps I can either chill or do.

You might not be interested, and this could potentially be over-sharing. Since March I have been getting fit. It has been a post-Covid, return to my levels of action of a decade ago.

Something happened in my 40’s that took me out of the running – both literal and figurative.

20 years ago, I ran the Sheffield Marathon. There haven’t been many since as the hilly city (like Rome, it has seven hills – it even has the Peace Gardens which can give the Trevi a run for its money (on a hot day)) – from recollection a man died that year from overheat and cerebral oedema.

It wasn’t the fear of a swelling brain that put me off running, merely the demands of work and family, life getting in the way of life.

I don’t have any regrets.

I was 50 this week and I feel better than I have done since I was in my 20’s.

I guess, had I been active the past decade I might now be looking for a knee-joint replacement. You can’t undo the past and there is no value in such reflection. Unless that is, you have some way of travelling into the past.

Has anyone read Stephen King’s 11/22/63? It is the story of a man who travels back in time from modern-day ?the 2000’s to the 1960’s to prevent JFK’s assassination. I loved it. There is a Netflix too.

Ever since I watched Back to the Future in 1989, I have adored the concept of time travel.

I remember watching the first in the trilogy at my brother’s house in Cubert, Newquay. A strange memory for one whose grasp of the past is at best patchy. I recall being entranced, pulled-in to the notion of time-loops and quantum experiments . Ah the good old days. More recently I watched If I hadn’t Met You which played to my romantic inclinations.

Enough.

Off to swim.

Have a good week everyone!

Rod’s VO2 Max!

Heraclitus, Zen & Il Gattopardo

To stay the same everything must change.

That is,

For you

To remain

In the same place,

In the same state

across time,

Then everything else must alter

Unless that is,

You change a little

and as

The increments of progress encroach

upon you

The world’s altering will be less.

You can’t put your hand in the same river twice

as

The water is moving

and

Life is a flux.

Me now is different

To me tomorrow

or yesterday.

The moment doesn’t exist

It is, then it isn’t,

A puff of smoke and gone.

When up is down, down is up.

If you stand

On the escalator and look down,

You are up.

As you descend,

Up

becomes down

You have reached the bottom.

Life goes on

And that is it.

Mild Cognitive Impairment, dementia, and a happy patient.

This week I contributed to a patient’s happiness.

It is hard to quantify the effect a doctor’s actions on their patient.

For example, ‘I am afraid the results aren’t good,’ is not something to buoy the spirit and neither is, ‘Let’s see what the surgeon has to say.’

Doctors can be prophets of doom.

Occasionally it is, ‘The biopsy was clear,’ which is of course positive, although, in the world of the geriatrician, for that is me, our swing-o-meter tends to tip in one direction.

This week I had a different experience.

It began with a local scheme to improve the care of people living with dementia.

In different localities (mostly towns or parts of cities across England) the commissioners, that is, the people responsible for divvying-up the money sent to them from Central Government, develop schemes to incentivise GPs, mostly with an eye on the issues of particular concern in that area (the health problems of Brixton might be different to those of Brighton or Bermondsey, for example).

Where I live, we have a ‘dementia and mild cognitive impairment’ scheme, called a ‘LES’ which stands for Locally Enhanced Service.

And, this is my problem, and the basis for this blog.

I have written lots on the topic of dementia over the years. It is one of the areas of medicine that I think I know about, as to whether I am an expert is for others to determine, let’s call me a specialist. For the most, I think I know what I am talking about when I talk about dementia.

Mild Cognitive Impairment, usually shortened to ‘MCI’ is something else.

I’ve never liked MCI.

MCI is a diagnostic criterion (similar in my mind to ‘borderline personality disorder,’ as in something that only a particular kind of doctor could think-up as a label for another human being) that is as vague in its definition as it is to be the individual receiving the appelation.

Dementia is easy.

Dementia is a disease affecting the brain which is progressive – it worsens over time, and it eventually affects all elements of a person’s self. Their personality, memory, mood, interests, and so on. There are various patterns, as in, Alzheimer’s disease and Posterior Cortical Atrophy, although essentially, everyone who had dementia is different to everyone else; it is, you could say, the quintessence of an individualised disease.

Mild Cognitive Impairment is less so.

What is it?

To explain, let’s talk about what happens to everyone as they age.

As you get older, certainly after your 20’s or 30’s, everything starts to fall away, for some (like me) it’s your hair, for others, the first niggles of arthritis, chronic diseases sneak-in like COPD and type 2 diabetes. Your concentration, focus or short-term recall is blunted, you are no longer as quick on the uptake. Tiny wrinkles form. Hair grows in unexpected places.

All this an uphill struggle towards, well, death, that we hope will come somewhere in our 80’s.

Alongside all this disintegration (despite your growth in possibly knowledge and skill) is a slowing of cognition. Your mental processes are less agile. You forget more, you are less able to jump from thought or action one to two to three.

(Accepting that this falling-off for some happens in their 50’s or 60’s or later – for exceptions to the rule, please see Benjamin Zephaniah or Uri Geller).

The outcome with respect to memory is a slowing, a limiting, a shortening. We call this healthy ageing. Perhaps the effects of too many cigarettes, whisky shorts, or head injuries.

This is not a disease, it is the human condition, part of the quid pro quo for keeping going.

For some, the ageing process is accelerated, not as bad as in Progeria, more like when you have a reading speed on Audible that is 1.2 times the normal. You finish the book ahead of others.

‘He looks 70,’ might be said of a person in their 50’s who has had a rough ride.

And so too with memory or cognition, that is, all the processes inherent in your sense of self.

This condition, where an individual’s memory is worse than expected for their age but not a) progressive and does not b) interfere with the person’s quality of life or ability to live autonomously is, Mild Cognitive Impairment.

MCI is also not progressive beyond the super-added effects of ageing that we all encounter.

The science says that ten per cent of people diagnosed with MCI will progress to develop dementia, just as a certain proportion of people in their 40’s and 50’s who have aching joints will progress to develop crippling arthritis.

Ageing and disease processes combined.

Now, back to the LES.

The LES stipulates that doctors working in primary care (GPs and others) will review each of their patients who have a diagnosis of dementia once a year.

This, as far as I am concerned is great and I’d advise perhaps a more frequent assessment.

The complication arises when the request was attached to reviewing people with dementia and MCI.

It is called the ‘dementia and mild cognitive impairment LES’

This is a bit like putting people with bipolar disorder (major psychiatric illness) in the same grouping as people with mild depressive illness (so called, minor psychiatric illness) (You’ve got to love those (mostly American) psychiatrists and their love of placing people in diagnostic boxes).

And so, if you don’t know the difference between dementia and MCI, when someone sees a patient, it is easy to fall into the perception that the person has dementia rather than MCI.

People are often diagnosed with MCI in memory clinics, ‘Your memory is not as bad as someone who has dementia, you have MCI.’

And yet, they were referred to the memory clinic which they perceive as the dementia clinic and it is hard for them to get over this, to realise that although they are in the clinic with people who have dementia, that is not what they have.

Clinic visits are full of heightened emotions and anxiety and especially during Covid when many of these assessments were undertaken on the phone, the full meaning of the outcome does not pass to the patient.

When someone shouts ‘Tiger!’ you don’t necessarily wait to hear the ‘has gone’. We are hardwired to the bad stuff.

And so, it was with my patient.

She has MCI.

She thought she had dementia.

I met her and explained all that I have just written – perhaps in fewer words and with less cynicism.

And so, my patient, and her husband left the clinic, with a carefully jotted piece of A4 on which I illustrated what I have just said. (With my new birthday pen).

‘What can we do?’ They asked.

‘Look after your blood pressure, your diabetes and keep mentally active’

They went away happy.

Another case of de-diagnosis.

Papa

I visited my patient yesterday.

He is from Alloa.

In the Lowlands of Scotland.

A tall,

Former miner

Now ageing gracefully.

His grandson was there

And his red-headed great-grand daughter.

She sat colouring as I sounded

The old man’s chest.

‘Papa, I’ll pop to the chemist.’

Said the grandson.

He refers to himself in the second person

as Papa too,

As in,

‘‘What were you thinking, Papa?’ She asked,’ He might say.

His grand daughter

That is.

His family, close-knit

Like a finely woven

Fabric.

And me.

My grandfather

Was Papa too.

And I wonder whether this is a Scottish thing

Beyond the affectations

Of the English upper-class,

As in Papa. Like Nicole in the Clio advert of the 90’s.

Papa. With two flat-A’s.

A doubling-up of Pa.

And the links that connect us with our pasts

That hang

By a weakening thread

To our present.

He & she, me, thee & thon

We talk so much of

He

As God

Yet,

When you think about it

God is surely,

If they exit,

Bigger than man.

Their remit

Must

at the very

Least,

Be man and woman.

And isn’t

She

Both He and She?

Doesn’t

That word

sustain the

Essence of both?

And

What of they or them or

Thon?

Third or

Non-gendered spirituality

Is surely

Beyond the binary

Beyond the box

That Western Society

Permits

Or

Accepts

Or

Understands

?

Dear reader,

apologies for my diversion into poesy.

The short form is all I can accommodate in these winter morning

pre-outdoor swim.

Cold morning, 70’s flashback & white dog shit

Four degrees outside.

14 in.

My daughter is dressed for school

And wearing her fluffy red dressing gown,

Just like I did

In the 70’s.

I used to share a chipped white Dimplex

With my brother.

It would straddle our rooms in an attempt to maintain the heat.

The ice

On the inside of our windows

a reflection of its failings.

I don’t remember the cold.

Although

When I think of cold

I think of that ice

And I think of

Billy in Kes, as he’s pulled out of bed by his brother

of the skinny boys standing, shivering on the football pitch

or in the shower

Cold

It goes to the bones.

As a student I knew the cold

With a poor diet I would cough and sniffle through every winter.

Now

I am a man

The world is different

Yet there is this undoing

A reversion to the world of 50 years ago.

It is familiar

And not a place to visit.

It is red bills

That are demands for the gas and electricity

It is winter of discontent

It is Grundig TV with whiteouts and loops over and over

And white dog shit

And the state we are in.

Where have all the bibles gone? (Can be sung to the melody of ‘Where have all the flowers gone? By Peter, Paul and Mary.)

Where have all the bibles gone?

It used to be a thing

I saw

When staying

at

Hotels and hostels

& similar types

of places.

In every

Bedside drawer

There would be a brown or blue

Gideon

Bible.

‘Look,’ I said to my daughter, ‘In your bedside drawer!’

‘It’s empty,’ she replied.

They seem to have disappeared.

and,

Did you know,

That Gideon

The biblical

Soldier, judge and prophet

Determined who would fight alongside him

Through the water test?

They guys who knelt

And scooped water from the river

With their hands, were out

And those who lay,

on the bellies and lapped ‘like dogs’

were, in,

For it was thought

That the kneelers were idolaters

Kneeling at every Tom, Dick, or Harry.

The belly layers,

Were the full-on, monotheists,

The, ‘No God Before Me’ folk.

Myself,

I would have taken to my knees. Anything to get out of a bloody battle.

And still,

I don’t know where the bibles have gone.

Thinking about a newsy mystery: Why are Gideon Bibles vanishing from hotel nightstands? — GetReligion

The state we are in, your future and mine. Echoing emptiness & uncertain tomorrow.

‘Thank you very much for working hard. For keeping the lights on, for running the buses, delivering the post, and cooking our food. For teaching our children, caring for our old, tending the sick, for maintaining the roads and building our houses. Thank you very much for manning the phones, selling our groceries, and stacking the shelves, for cleaning our windows, removing our waste, and recycling, for policing the streets and extinguishing your fires. For driving the trains, processing your applications, and fixing the radiators. For being around and your self-sacrifice when Covid struck (as we spent £££ on our friend’s useless PPE), when others were out partying, for tidying-up after that party and keeping the electricity-on. Thank you. Thank you very much.’

And now you have the cold.

You need to delay switching-on the heating, despite the October chill.

‘Don’t worry, you are saving the planet!’

No holiday this year. Postpone for another.

And then, for the poor. When you are struggling. We will make it worse. We will stick in the knife and twist.

We will make you homeless.

You will surf the sofas of friends or if your family is small, we will allocate you a bed in a hotel for 28 days before moving you on. We will help you look for unaffordable housing far from your family and friends, we will move you on or evict if the landlord demands.

We will charge you more for gas and electricity.

We will force you down a pathway of despair.

We will make you smoke or drink or eat too much or too little.

Hang you out to dry and leave you in the rain.

We will look at your children and acknowledge their physical, social, and mental health challenges and then turn away and let you get on with it.

When you seek help, we will create systems of such complexity that no one who enters can ever arrive or find their way out. We will make Kafka laugh.

It is the worst of times and the best of times if you are sitting on a million with a secure pension and paid-off mortgage. It is the worst of times if you are young and setting-out. We will inflate your rents and destabilise your pound.

Want to save? Pay of your debts first.

Want to study? Let us have your money. We will lend you some. Pay it back before you start living.

We will turn the screws and crush you.

We will generate a false sense of grandiosity when our monarch dies and leave you sitting in the gutter.

It is all good. If you are one of us.

Not so for you, but that is OK.

You have told us what you want time after time.

When the writing was on the wall, we read between the lines and did what was necessary.

You voted to leave, and we took you away.

You chose not to vote, and we took advantage of your time on Twitter or TikTok. We manipulated you as rats in a maze or hungry rabbits.

We played and continue to toy with your lives, your self-exposed innocence.

We set the rules and change the game if there is any sign of equality or shift towards a positive outcome that is not our own.

We will stop you complaining.

We won’t let you protest or demonstrate or stop the traffic.

You can blow your whistles and bang your drums so long as the noise doesn’t interfere with our going about our business.

We will use our money wisely and make a handsome return.

We will vulture invest and asset strip and enjoy our time in the sun or the snow. We need to see the glaciers before they are all gone. Don’t worry, you can always catch up on Netflix. You can spectate as we live our lives.

We can watch the planet burn or sink or drown, we will observe the levels of pollution the thickening of the air, the disappearance of habitat, of tillable earth, we will be OK.

We are moving to where the air is fine, and we will move again if necessary. We might consider Mars, when you have sorted-it out, when you have tested the air and the gravity and the system failures.

We will spend your money, for your money is ours and, you don’t really have any.

We will leach off your existence and grow mighty.

You will wither.

Hey. Christmas is coming.

Another distraction.

Don’t worry, it will soon be over.

#enoughisenough

Enjoy your week. Get a booster.

An unusual half hour – just a sharp scratch.

It has just gone 1230 on Saturday morning.

I have a 30 minute lunch break during the Covid and Flu clinic.

I don’t normally have breaks for lunch and today, true to form, I am munching my nuts and high-speed blogging.

I usually blog first-thing on a Saturday and Sunday morning.

Those are my open-mind times, when I have access to my creative unconscious. That part of me that is hidden during my medical masquerade.

Who am I? Blogger or doctor? Doctor or blogger?

I have been blogging for nearly eight years. I have been a doctor for over 20, I guess my day-job trumps my hobby.

Today we have been vaccinating.

One shot of two-in-one Moderna and one of four-in-one Flu. Resistance to six viral entities in two arm punctures.

There were four of us scheduled to vaccinate although we have found we can work faster than anticipated so we have let some folk home early; we have called some patients in early too – we are to get home ahead of time.

Last week I went round the care home and stabbed the oldies; that was Covid. Some in the arm, some in the leg (those who have too little deltoid muscle). I did a re-run on Thursday for flu (I opted to give them separately for their ageing immune systems – not evidence based, but that is not how I roll.)

I was surprised how many of the residents remembered my visit the preceding week.

‘I’ve already had it!’

‘Oh, no, that was the Covid. This is the flu.’

Most gave-in and let me stab.

A couple said no.

Two had the Covid but not the flu.

A bit of a mishmash.

One old man called me a ‘baldy bastard’ after the Covid, he was one of the flu-Refusniks.

Another old man shouted, ‘You F@ing bastard.’ He had both.

I get where they are coming from and don’t blame them.

Just a sharp scratch.

Ha.

There is a prize for anyone who guesses what is going on in this photo.

Anxious Jew Redux, Professor Ian Robertson & Blindboy

Today I listened to a fantastic Blindboy Podcast with the Scottish Psychologist Ian Robertson.

Please listen. Here.

Actually, maybe read this then decide.

I don’t I believe have much success with my Podcast recommendations. I can but try.

So.

Anxious Jew.

I have written about this a few times.

It is at the intersection of epigenetics (which my Biologist son tells me I misunderstand) and the effects of multigenerational trauma.

The trauma of the Jewish people, those whose families spent centuries moving around from shtetl to shtetl in Poland and the Pale of Settlement related to their precarious existential situation, with the possibility of Cossack or other raid, rape and pillage, expulsion, and blood libel. (And let’s not forget the Holocaust).

The most anxious Jew would be the one who said to his family, ‘I am worried about the way Boris and his friends are looking at us today, I think another pogrom is brewing, let’s leave.’

The anxious Jew’s genetic predispositions and behaviours would have been passed to their children and so on.

Like the way in which we evolved the fight or flight response in Eastern Africa.

The laid-back Jew, well, they would have to take their chances, perhaps relying on other talents/abilities or face wipe-out.

Back to the blog.

Blindboy and the professor discussed the roots of anxiety and more generally the medicalisation of, I suppose you would call it, maladaptive states of being.

Doctors are great at diagnosing or assigning diagnoses. It is something that makes many of them very happy. It provides the doctor with certainty, a finite box in which to place their patient and to focus treatment – antibiotics, pain killers or anti-depressants. (I am sure there is a dopamine release every time a doctor signs a prescription).

It is in many instances a reversion to the paternalistic medicine that did more harm than good. (How many people have reached a diagnosis of whatever their condition through shared decision making?)

‘I believe you are experiencing anxiety; how do you feel about that?’

vs

‘You have anxiety’

‘You are an anxious person’

Or, Diagnosis: Generalised Anxiety Disorder.

I saw a very good example of this recently.

A colleague referred me a patient.

He conducted a dementia assessment on the phone and assigned a diagnosis of ‘mild cognitive disorder’ in the patient’s notes.

Not something I would recommend (telephone diagnoses or cognitive assessments).

He then referred the patient to me.

Somewhere along the lines the description became ‘dementia patient.’

I saw the guy at home. He is as sharp as a tack. He is writing not just one but two books. OK he got the .com and .co.uk mixed-up on his email address; he is in his 80’s.

Another patient I saw labelled with dementia and placed on a dementia unit in a care home despite not having dementia; a reckless doctor wrote this in his hospital notes, and it stuck.

I could go on further about all that is wrong with this component of medicine which I feel in general likely reflects a degree of sloppiness.

I will instead focus on anxiety.

If you look-up the DSMN-5, the psychiatrists user-guide for diagnoses, you will find all-sorts of anxiety diagnoses, you will also find other conditions such as borderline personality disorder, anankastic personality disorder, narcissism and so on.

The trouble with diagnoses is that they stick.

Last week I saw a 94-year-old woman who had the diagnosis ‘miscarriage’ on her medical notes. Yes, important, but not that relevant to her struggles with increasing frailty.

You carry them with you, even if not inaccurate they become self-fulfilling prophecy.

‘It’s not me, it is my personality disorder that is making me do this to myself.’

Is a good example.

It facilitates learned helplessness.

It perpetuates.

‘You have a personality disorder because your mum had one, and, oh, you are living in poverty and your dad left home.’ (Nothing to do with inequality, lack of opportunity, inadequate housing or austerity.)

The podcast indicates the problem with such ideas.

It discusses neuroplasticity. The reality that people can change. Can turn their lives around and become something different to the imprint delineated by their parents when they were a child.

Neuroplasticity is the brain’s ability to remodel. Everyone knows that you can’t re-grow brain cells. If they are damaged, that is it, they aren’t like your liver or skin. And yet, neurones don’t work in isolation, they work through networks, through countless linkages and interconnections with other cells; these pathways or circuits can be regrown, can reform and can change not just how we think but who we are, how we feel.

If you think, ‘I am an anxious guy,’ that is how it is, you will be less likely to consider your potential. Same with, ‘I am shy,’ ‘I lack confidence,’ ‘I am a terrible public speaker,’ ‘I am dull.’

Whatever.

This I believe is a fundamental difference between the psychological approach proposed by Robertson (and Blindboy) and that espoused by modern medicine.

Ironically what the professor and Blindboy say is not new. It dates-back to the origins of Greek and Roman thought, and the teaching of the Stoics.

Eg Seneca ‘We suffer more in our imagination than in reality’

Is that enough?

Have I explained myself adequately?

I don’t think so.

Please listen to the podcast! Here is another link.

If you don’t listen, you will be missing-out on an inspirational discussion.

NOTE! If you want to miss a slightly dull section of the podcast, skip forwards to 18 minutes.

pogrom | Cultures Contexts

Be well and have a good week; I am off for a swim (and some CO2 regulation). (You will need to listen to understand that reference) 😄

Cognitive dissonance, the NHS, Virtual Wards, and the rest of the shit that is going down

I attended an online NHS England conference on Thursday afternoon.

The conference focused on the development of Virtual Wards.

Virtual Wards are a newish concept in the UK, providing hospital-level care for people in their own homes.

There is a lot to this, and I don’t want to get too much into the nitty-gritty as that will take me on a tangent away from my topic – my cognitive dissonance.

So, Virtual Wards are scheduled to start-up across the UK this year. Some wards have been running for years.

Essentially, if you are old and frail or have a chronic chest condition and experience an exacerbation (a worsening) you should have the option (in certain circumstances – there is always small print), to receive your care at home rather than hospital.

I’ll focus on frailty as that is my area.

If, for example, you are 90 and you fall at home and perhaps have a chest infection, you will have two options; A&E = 5 hours waiting for ambulance, 2 hours outside A&E waiting to get into the department, 8 hours waiting to be seen by a doctor, 12 hours waiting to move to a hospital bed, 3 to 21 days receiving treatment with associated hazards – hospital acquired infection, deconditioning, falls, institutionalisation and perhaps never getting home again as you are too worn-out from the experience to live alone again or:

You fall, a nurse arrives within 2 hours at your home, you are assessed, I review you either virtually or in person in your home, therapists, social workers, pharmacists, and others come to you; treatment is initiated, and you are back on your feet in a few days.

Yes, the choice is obvious.

The NHS has put lots of money into kick-starting these wards. (For this year).

The idea is that people will receive care in their homes, with better outcomes and associated reductions in pressure on the ambulances, hospitals, and social care.

All of this is good. Some of it is great. There’s a risk people will lose the opportunity of receiving specialist hospital care – things might get missed, although if you are 90, you possibly want things missed (you don’t want that unnecessary MRI scan or colonoscopy).

At the conference there was much positivity.

Indeed, lots of this is moving towards my dream-state of providing high-quality care for older people that doesn’t require the precarious process of hospitalisation. (If you want to know what is bad about hospitals, search ‘hospitalisation’ on my blog site or Google, ‘almondemotion’ and ‘hospitalisation’. You will soon see.

So, many people were upbeat. There was an enthusiasm, an exuberance. Excited tweets were liked and shared, the whole social media shebang.

And, yes, it is genuine, there are good things.

And this is my point.

This is the dissonance.

Cognitive dissonance is the tension associated with holding two conflicting concepts or ideas in your mind.

You see, for all this modicum of good, there is so much bad.

Setting aside the waits I described above (which one of my patients experienced recently), there is the medicalisation or specialisation within healthcare, there is the sleepwalking towards a computerised system, where, for example, the pressure on GPs to ‘sort’ patients is so great, they are forced into shortcuts, which translates in many instances as, my 90 year old woman not getting to see a doctor in her home.

I heard last week that many older people have given up calling their doctor as they can’t cope with the telephone conversations, the lack of a person, struggles to hear, catch or recall what is being said, the sense that they are not important enough to get to see their doctor or nurse in person.

The processes that started during Covid have continued. Most patients haven’t seen a doctor in two years.

The hospital clinics for older people, those living with frailty and cognitive impairment are still run on the phone.

Doctor A calls patient B.

‘Hello, it is doctor A, how is your pain/breathing/stomach/bowel/etc?’

‘Oh, everything is fine.’

‘I will see* you in six months’            

*Speak to you again in six months and have an equally superficial/transactional interaction.

I even recently read in a patient’s notes the following:

‘Called patient for telephone appointment. There was no answer. Patient has not attended the appointment. See again in six months.’

This attitude will ruin us all.

And outside the NHS, beyond the ambulances that take 20 minutes to reach someone experiencing a cardiac arrest (too late) or the 18 month waits for surgical procedures – hip and knee replacements, the day of the operation cancellations (‘Sorry, we don’t have any beds’), or the associated issues with social care, where people do not want to work in the field as the pay and working conditions are so poor, beyond this, is the knowledge that today, somewhere in the UK an old person will die as they can’t or won’t turn on the heating for fear of not being able to pay the bill.

Those in government function in a cesspit of lies, deceit, manipulation, and self-interest.

The planet is failing. Forget 1- or 3-degrees global temperature rises; we are facing a run-away state of global collapse where the only people who will be OK are the billionaires building secure complexes in New Zealand for the end of times.

The polluted seas and beaches, the inability of younger people to rent or buy houses – living with their parents into their 30’s as the property market is a mess of profiteering.

The starving Polar Bears.

The disappearing insects.

The desertification.

Loss of soil.

Covid.

Hyperinflation.

Inequality.

Putin.

Yes, the list is long.

It is easy to become carried-away with negativity.

And this is my point.

How do I balance some of the good things with all the bad?

How do I carry these conflicting thoughts in my mind?

The term Schizophrenia literally means ‘split-mind’ – is that the only way to remain sane?

(See, ‘Mad to be Normal’ by RD Laing).

Perhaps sequestering my emotions, to allow myself some capacity to appreciate what I have.

Any thoughts?

Positive mental attitude?

Self-help books or groups?

Cocaine/Cannabis/Alcohol/Amazon/Netflix?

My current remedy is to run and swim (first winter swim of the season for me today, picture), blog, read fiction and focus on my patients, doing my best for them at the moment of my encounter without considering the x10,000 others who are not getting the care, treatment or support they require and deserve.

Funnel your vision.

Narrow the focus, one tweet at a time.

What a stramash.

First swim of the winter!

Bullying techniques, the lost photography of Vivian Meier, Jew-bugs & etc.

Last night I watched a fascinating documentary about the American Nanny/Photographer Vivian Meier – Finding Vivian Meier (Netflix).

Yes, that wasn’t a typo. She worked as a Nanny, looking after well-to-do American children for most of her adult life and in-between or frequently at the same time was a photographer.

How Vivian Maier, the Enigmatic Nanny Who Took 150,000 Photographs, Found Her Place in History | Smart News| Smithsonian Magazine

The story begins with the chance discovery of a box of photonegatives by John Maloof who made the documentary and spent several years exploring Meier’s unusual life.

I won’t describe the film here; please go and watch it on Netflix if you are interested. It is only around 90 minutes long.

You might now wonder why the title, or its relevance to Vivian.

I am not sure.

Watching last night somehow made me think about my own life experiences. Who I am, what has led to me being and behaving as the person I am today.

The documentary attempts in as much as it is possible to understand Meier’s personality and motives. Why, for example, did she take so many photos? Upwards of 100,000 yet never show them to anyone, why did she work as a nanny when she has enough talent as a photographer to make this a career? Why did she speak with a pseudo-French accent when she was born in New York? Why the floppy hats? Why all the trinkets? Why the self-portraits?

Exhibition Review: Vivian Maier and Stephan Vanfleteren: Capturing Life — Musée Magazine

We don’t know and is it likely we will never discover her entire back story.

What made me?

Last week I was out for a meal at a pub in the tiny village of Wortley. I had fish and twice-fried chips. The conversation meandered onto the topic of racism. I tried to explain the origins of my recent blog ‘slap in the face’ alongside my perceptions (or not) of racism.

I talked about my own small-scale racist experiences growing-up in Glasgow. I was most frequently called chocolate boy as each summer would roll-around and my skin would brown, and my pale-skinned (peely-wally) classmates would burn. There was the occasional Jew-bug, and my family were convinced one of my teachers disliked me (Mrs Firth) because of my Jewishness.

As a 20-year-old I once bumped-in to Mr Firth in the newsagent’s, Fletchers. I stared at her for a second then walked away. I didn’t know what to say or do. She would wear her hair in a tight bun that progressively greyed with age.

When I attended the Cubs (precursor of the Boy-Scouts) again there was a suspicion that latent racism was at play. I was never clear about the details although it was something my family discussed. One explanation was their repeated misspelling and mispronunciation of my surname.

Vivian Maier: Milton Keynes hosts first UK exhibition - BBC News

Ironically, two weeks ago when some photos I took of a recent trip to Florence were published in the local Jewish newsletter, they manage to mangle my name there too. I don’t think they were being racist. Most likely incompetent.

No, I am not sure that people have been particularly racist towards me, although it is impossible to know what is inside peoples’ hearts.

Now, bullying, yes, I have been bullied.

Have I been bullied because of my looks and my religion or something else? Hard to determine.

I was bullied at primary school in Glasgow. I was probably bullied when I lived in Israel.

None of this really kept me down although it likely shaped my behaviour, my sense of self and level of confidence.

The first adult bullying was around 2000 when a consultant at work, in my first job as a doctor made my life a misery. In hindsight I think he probably bullied everyone who worked for him – he was a bit of a bastard. An awful surgeon too. The next doctor I worked for; another surgeon was also quite an arse. I remember him inviting all the junior doctors on my team to a Christmas party and not asking me. He gave me a hard time. (Blindboy would call him a ‘prick’).

Sorry for the swearing.

8 Clues to Better Street Photography in the Works of Vivian Maier | Learn Photography by Zoner Photo Studio

Fast-forward eight or nine years and I was bullied by another doctor when working in Barnsley. This was in the early years of the internet and email. He sent me a PDF explaining that I was the worst doctor he had ever met, and I should leave medicine and never return; he didn’t quite tell me to go and kill myself although that was implied.

Then a gap of perhaps a decade and my most recent encounter. He was a guy who tried to micromanage me and managed to crush my spirit.

It took me years to recover.

Is this level of bullying unusual?

Well, first I should provide a definition.

From my own learning, bullying is not a thing. You can’t calculate or weigh it as it is subjective. It is determined by the victim.

It is possible that one person’s bullying is another’s ribbing or joking or extreme-rough play.

Yes, I am sensitive, my skin, whatever its colour is thin. If you say something mean to me, I will likely listen, take it in and think about it. A lot.

Last week (it was a busy seven days) my daughter reported her English teacher asking her to remain behind at the end of the lesson. Her response was the same as mine would have been, ‘Crap, what have I done?’

He wanted to complement her on the homework she had submitted.

For me, no matter how many positive experiences I have I always think the worst. If you say, ‘Can I have a word with you?’ No matter the context, I will hear, ‘You have done a bad, bad thing, I want to tell you how very bad.’

I related this to a colleague at work (also last week!) I had said something similar to her. She was unfazed. I could tell by her expression that she took the ‘Let’s talk about that later,’ or whatever I said, as it was intended.

I asked, ‘When you hear things like that doesn’t it make you feel anxious?’

She replied, ‘Why would I feel anxious?’

The thought had not crossed her mind.

She is a Stoic. Marcus Aurelius would be impressed.

I am not.

I am the opposite of Stoic. Not sure what that might be, perhaps ‘victim’

As to why I am the victim, I don’t know.

Some of it relates to my sensitivity.

Part of this is my personality.

Forgive me for who I am or am not.

I have an innate sense of justice.

When things are wrong, I find it difficult to sit on my hands. I question. I challenge. It gets me into trouble.

Within months of my first consultant appointment in 2007 in Doncaster Royal Infirmary, I was upsetting the establishment, challenging the status quo, the variability of patient care and experience, the behaviours, and attitudes of colleagues.

‘You aren’t making any friends,’ a fellow doctor once told me.

I didn’t reply, although I should have said, ‘I can’t help it!’

That didn’t lead to bullying although there were clashes.

I am the man with the itch who scratches.

It is part of my temperament. Who I am.

Apologies for being me.

I am almost 50.

I wonder if there will be future bullying instances ahead.

I think it likely.

As to how to avoid the bullies or the racists or the bad people, I am not sure.

I can’t keep my head down; it is unfortunately sticky-uppy.

Bullying in 2022 UK is more of a thing. It is more acknowledged, and I might have a better grasp of what to do or how to handle the attacks.

The thing about bullies, for I haven’t really talked about them or their motives in this blog is that although the systems are becoming more sophisticated (In work we have ‘freedom to speak up’ and several anonymous ways to report concerns), the bullies themselves are becoming more cunning, the subtlety of the interaction can skew the response, the fear of appearing paranoid or neurotic can influence your actions. It is likely these people aren’t going anywhere any time soon. The racists will be hanging-around too.

Vivian Maier -Street Photographer - The Eye of Photography Magazine

All photos by Valerie Meier.

If you enjoyed this blog, I have written almost a 1000 others, why not search back through my site?

Take me to your specialist!

Thank you to Limp of the Limp Cabbage and Soggy Chips blog for your reply to Saturday’s write-up.

I talked about the ups and downs of permanent pacemakers.

Limp considered the pros and cons of the future direction of medicine, which is super and supra specialists versus the old ways of the family doctor.

The person who knows your kidney inside out versus the person who knows you inside out and by inference, relatively less about your kidney. Or kidneys.

All this ties-in neatly with Friday night when I was a little rude to my brother.

Fridays are when I work in primary care. Not as a GP, rather the general practice’s specialist (tautology?) who does his best to practice holistic medicine. A generalist specialist. Or a specialist generalist.

Fridays are by far my hardest day of the week. Working 7 am to 7pm is not unusual. Some of the GPs work even longer days. (I know the people who can’t ‘get to see the doctor’ presume they are sitting around playing Wordle; this is not the case. They are working flat-out to help as many people as they can.)

Anyway. I was exhausted.

My brother texted, ‘Do you know a good specialist in London for my friend who has a sore neck.’

I was tired, I replied, ‘Afraid I don’t know anyone in London. Has she seen her GP?’

‘She has seen everyone. GP useless. Can she contact RCP?’

‘RCP?’

‘Royal College of Physicians’

‘Are you drunk?’

…

‘If she has an ongoing problem she should go back to her GP. If she wants to go private, suggest Google.’

‘OK.’

WhatsApp is not the platform for communicating sensitive information. It can result in misunderstanding. I was tired. I went to bed shortly afterwards.

I had wanted to reply, ‘What sort of pain? When did it start? What makes it worse?’ And so on. These are standard doctor-trying-to-find-out-what-is-wrong questions.

I guess I was frustrated at the ‘GP is useless’ and the ‘RCP’

I accept that some doctors are not very good.

We are tested by the Bolam Standard which says we must be as good as the average, no better, no worse.

In a population of doctors most are OK, some are great, some are awful. They are human.

The same logic applies to generalist as much as specialists.

Within ‘good’ (whatever good is – it is very dependent upon your perceptions and expectations) is a continuum between the specialist’s special knowledge and their holistic tendencies.

Most of us, if ill would rather have a good specialist who approaches you holistically. At least, that is my recommendation.

Patients in the UK at least, and many other countries are not usually offered a choice (unless they make a lot of fuss, complain, and so on and then they are often sent through a ping-pong lottery of doctors trying to avoid their complaining ways).

I’d interpreted in my fatigue, ‘Her GP is useless’ as ‘All GPs are useless’ and, perhaps, ‘UK doctors are useless’ (He lives overseas where things are supposedly better. My friend who lives in Australia tells me that healthcare is fantastic Down-Under too, particularly in comparison to my failing system (he reckons).)

The British tend to self-deprecation and in an aspiration towards continuous improvement are not afraid to surface their flaws.

Contrast this with Americans and their national pride.

I think the NHS is fantastic.

It is one of the best healthcare systems in existence.

It offers treatment to patients, free at the point of delivery, regardless of their wealth, race, or religion. It is democracy in action.

It is being eroded by the Tory Government. It is being underfunded and stretched beyond the point of reasonable elasticity.

It is this necessity to do more continuously with less that forces the ‘good’ doctors into a corner, pushes them towards the average in order to survive.

Yes, I shouldn’t have asked my brother if he was drunk (he is not a big drinker). His suggestion of going to the Royal College was however so left field that I didn’t understand.

My response of GP then Google is exactly what I would do if I had a problem that wasn’t going anywhere. I might, depending on the situation email a doctor directly after doing some research, again, I am not a layperson.

I can’t imagine an equivalent situation where someone would ask, ‘Do you know a good lawyer/mechanic/accountant’ in a country of 60 million people.

And even if I did know someone in London who ‘does necks’ (there isn’t as far as I know such a thing as a neck specialist – could be a neuro or orthopaedic surgeon, a physiotherapist, neurologist*, anaesthetist, or psychiatrist) who is to say that they would be good.

As they say, ‘Good is the enemy of Great’

I just don’t know.

It is a lottery.

If you are lucky to have a GP who has been your family doctor for the past few decades, someone who gets you when you are up and down, who knows your mum, dad, and siblings. Who understands your social context, who knows where you live, that is something to treasure. Someone who listens and understands, someone who acts when necessary and watchfully waits at other times.

Doctors are finite. They are human. Most after 30 or 40 years retire and live short retirements. If you are lucky and live to be more than 40 your will need to find another doctor. The lottery will then restart.

If you don’t like waiting a year for your hip replacement or you don’t like the referral system or the way the hospital manages or treats you or your kidney, the best action is to email your MP, if they are Tory and tell them what is wrong, that way, when they say, ‘I thought everything was fine,’ you have evidence. It will however likely not do you much good.

(Don’t tell the MP that you are unhappy with the doctor/nurse/hospital – tell them their party sucks otherwise they will just shift the blame to that struggling doctor/nurse/hospital.)

Almost a thousand words into this blog and I have not told you what to do with your sore neck or where to go with your health concerns – generalist or specialist.

Like everything in this life, it is a lottery. You can influence the odds by doing your homework, ‘Please refer me to Dr X, I hear she is very good.’ That might work although depending on the referral management system in your hospital, specifically asking for X might get you nowhere, or you might meet X’s registrar (doctor in specialist training) who is average or even bad compared to X.

Crap shoot.

Lottery.

I appreciate that none of this is reassuring.

Interestingly, if you read Alfred Adler and his thoughts on early childhood experience / trauma, you will realise that many people who become the best doctors, nurses and other clinicians do so because of early experiences where they have felt helpless at the actions (good, bad or otherwise) of the healthcare system.

Their life works frequently determined by a sense of powerlessness.

This influenced, I am sure, the numbers of students applying to study medicine during Covid.

Most of us can’t become doctors.

Last thought?

It is 730 on Sunday** morning. I will shortly be heading out to swim in the 10 degrees of Yorkshire September. I am doing everything I can as I enter my 6th decade to stay fit and healthy.

Don’t complain about your doctor until you have done everything you can to help yourself.

(Accepting that some things – MS, Parkinson’s disease and cancer are dependent upon your environment and genetics, nevertheless, there is stuff you can do.)

Take care and have a good week.

Physician heal thyself' may be impossible task for a psychiatry profession in crisis

*For functional disorders, you might want to read Suzanne O’Sullivan’s book, ‘It’s all in your head’

** I wrote this Sunday, today is Monday – Queen Elizabeth’s Bank Holiday. (I am watching the service with the sound switched off in order not to hear all the ‘Blessed Father/life everlasting/eternal’)

*** Also just seen my first ‘God Save the King’ – I noted that Harry’s lips didn’t move.

**** I love the pipers.

Today is the day of Elizabeth’s funeral. A rethink.

Last week I wrote a blog expressing my feelings relating to the death of the Queen.

(Again, sorry, is it, ‘The Queen’ or ‘the Queen’ not ‘The queen’ or ‘the queen’?) (The auguries of English grammar, enabled us to at one time to rule the seas and half the planet.)

I have just re-read, and I stand by what I said. I get grief, I get mourning, I don’t necessarily understand the concept in relation to someone I do not know, never met, was very, very old when they died and probably had the fullest life of anyone.

OK.

Let’s re-think that last sentence.

Did HRH (appreciate this could be His or Her, you know where I am going her, please infer) lead a full life?

Over the past couple of days, I listened to The Rest is History podcast dedicated to HRH.

Tom Holland is clearly a Loyalist/Royalist, a lover of the establishment, Dominick Sandbrook, I suspect less so. Nevertheless, over two hours they provided a solid account of HRH’s life.

From the background of her becoming Queen, through to her marrying Philip (National austerity wedding – only seven wedding cakes, honeymoon The New Forest), the Commonwealth (originally The British Commonwealth of Nations then The Commonwealth of Nations, and now, just, the Commonwealth.)

Inside The Queen and Prince Philip's wedding: pictures & facts | Tatler

HRH through the default of her uncle’s renunciation and her dad’s premature death from lung cancer was made monarch in 1952. As we all know. (Although they covered up George VI’s lung cancer for decades. Imagine if that he been promoted? The stigma that could have been undone.

In asking whether HRH had a full life, the podcasters describe her early desire to ‘live in the country with dogs and horses.’

Yes, she did get a ‘country residence’ and yes, she did have dogs and horses, although the impression is that she would have liked to use her great wealth to join the landed gentry (Hooray’s) in their parties, shindigs, safaris and getting drunk or drugged-up.

This was one example.

Another was the description of Elizabeth as a young girl at the Palace peeking out from behind the curtains at all the those outside and imaging the lives they lead, wishing perhaps she could taste a little of the life of a commoner. (Pulp Ear Worm warning!)

The historians talked about HRH dancing with the President of Ghana, Kwame Nkruma in 1961 (a staunch republican) an act which appalled the South Africans. The time she drove the Saudi Prince around Balmoral or visited Saudi itself and was granted honorary male status to circumvent the necessity for women to be hidden away producing babies.

queen-dancing

HRH supposedly supported sanctions against Apartheid South Africa; Thatcher didn’t let it happen (until later) (Does anyone remember not eating South African oranges back in the day?)

So, yes, there was the good.

There was the pomp and ceremony. The Royal Lineage. The Crown. The life-long dedication to the nation (and the Commonwealth).

And yet, there was so much she did not do.

And here, this is from my narrow lens. From my assessment of the papers or the TV news or occasionally Twitter.

She could have shucked the protocols, she could have held William and Harry’s hands at their mum’s funeral, she could have done away with much of the formality, she could have undone the protocols and expressed her feelings about the different Prime Ministers and their actions, whether Blair and Iraq or Johnson and his lie after lie.

Prince William, Prince Harry open up about how they learned ...

All of this is entangled with the idea of what it is to be English. (Which I am not).

And it is Englishness that unsettles me.

People talk about triggering words or phrases.

Seeing the English flag is a trigger for me.

What effect does it have on the people in our concentration/migrant camps?

New Covid outbreak at third UK immigration removal centre | Immigration and asylum | The Guardian

Seeing the Landed Folk (or not seeing them, wealth allows anonymity) is a trigger for the inequalities in the country.

The history of fox hunting in Britain

The privilege inherited through birth is a trigger for social inequity.

English stiff upper lip is also a trigger for suppressed emotions, for doing what is considered right rather than what is right.

Yesterday I sat with my daughter and watched the Queen lying in state. People filing past. Some saluting, others bowing or curtseying. The occasional namaste. The odd person was crying. Old soldiers, young men, and women. Mostly dressed in regular clothes, nothing representative of mourning. I looked for someone I knew but saw no one.

A few Hasidim shuffled past without bowing.

It was a melange.

One of my colleagues from work went with her daughter. I didn’t see her, and I don’t know if she got to shuffle past (haven’t check FB update).

In my last blog I mentioned Paddington. This followed the national request for people to stop taking jars of marmalade to the palace. (Take them too your food bank instead) I never actually saw the CGI segment. I didn’t see the Olympics opening ceremony. I never participated in the Jubilee celebrations.

Perhaps I am a poor subject.

The Royals thinking, ‘Thank goodness there aren’t more like this geezer with his overly sentimental and leftist blogs!’

And yet, and yet.

When I was younger, I had the choice to move away from the UK. Heck, I could have gone anywhere in Europe, or with my medical degree perhaps anywhere in the world. I chose to remain. And now, I am too old to emigrate. The Australians or Canadians wouldn’t have me.

When I was much younger my family took me to live in Israel. I was for five years a Scottish person in Israel. Prior to that I had been a Jew in Scotland. Now I am a Scotsman in England.

Camus would have had a field-day with my sense of identity.

How many other outsiders are pondering their place in the world?

How many others are inside looking out and wondering, ‘Why don’t I fit in?’

Wishing, ‘If only I could feel what they are feeling.’

Remember the young Elizabeth behind the curtains?

During The War TS Elliot visited Windsor Castle to read The Wasteland.

The story is that the Royals spend most of the reading giggling.

The paradox.

Inversion? Perversion?

I keep thinking Land Rovers.

I think Dutchy Organics.

Purveyors of fine foods to HRH.

It’s a jumble.

I will use today to reflect on my own family. On those I have lost. My own personal mourning.

We still have freedom of thought.

A Man in Kazakhstan Held Up a Blank Sign to See if He'd Be Detained. He Was. - The New York Times

When your batteries are running low, turn down the lights. Permanent pacemakers and other medical follies.

I have a patient.

He is an old man.

I have written about him before. He had a dog called Rover.

A few years ago, he experienced funny-dos.

It is hard to say whether this was before or after he developed his first symptoms of dementia. I suspect afterwards.

He used to live alone, and the diagnosis of dementia is notoriously tricky in people who live by themselves and who don’t have any close family to pick-up on the initial symptoms – the changes in mood and behaviour, the forgetfulness, the lapses in routine.

I was not his doctor at that time, although for whatever reason, he had been falling.

I suspect he ended up in A&E at some point and was later found to have a slow heart rate. He was duly provided with a permanent pacemaker.

Pacemakers are small electronic devices, about the size of two 50 pence pieces that are placed underneath the skin of the left chest wall with wires connecting through the arteries to the heart that transmit electrical impulses in the event of the heart slowing.

Pacemaker: Types, Procedure, Precautions, and More

Like marathon pacemakers, their role is not to win the race but to facilitate its completion.

I have never placed a permanent pacemaker although I have done a few temporary ‘wires’ which through the five years of my specialist training were probably the area of medicine I feared the most.

This is an aside and I suspect (and hope, although possibly doubt) that such procedures are no longer undertaken by those who are unskilled.

Every so often, perhaps several times a year, a patient arrives in A&E with a profound slowing of the heart, the two most sinister types being ‘complete heart block’ where the ventricles beat at around 30 times a minute and a patient is unwell, lightheaded, with low blood pressure and so on, and, asystole, which is essentially death, when the heart stops.

ECG: Cardiac Asystole

Asystole – not good.

In these situations, a pacemaker can help prevent deterioration or death.

The catch-22 was that as these have always been quite uncommon events, it was difficult to gain expertise in the procedures.

Cardiologists place pacemakers all the time and are the experts.

In many hospitals in the UK, as there are so few cardiologists they don’t work out-of-hours, that is after six during the week and at weekends; it is at these times (usually 2am) that the on-call medical registrar would be summoned to have a go.

The procedure involves sticking wires either into the subclavian vein, just below the clavicle or the femoral vein in the groin and feeding a long wire all the way to the heart, traversing the atria, through the tricuspid valve to the right ventricle, then further fiddling to find the spot at which the electrical conductivity enables an effective beat, tying things down, attaching the patient to a battery and exiting.

Pacemaker therapy 1: clinical indications, placement and complications | Nursing Times

If you only do this procedure once every year or two you can imagine the difficulties in gaining competence. (You know where the wire is positioned as radiographers send live-x-ray feeds to a black and white monitor and the patient is attached to a continuous ECG).

Thinking about this gives me the chills.

Nowadays most hospitals have on-call cardiologists who will do this procedure instead of relying on a hapless medical registrar (worth finding out before you have your heart attack).

Anyway, my patient had a pacemaker placed some time ago.

The batteries last up to 10 years, so I imagine that was when it was done.

Fast-forward a decade and he now has advanced dementia. He is living in a care home. He is a private man. He becomes very upset when people are in close physical contact with him.

People who have pacemakers mostly have annual battery and function checks arranged by the cardiology department.

Recently, I received a message that my patient’s battery was running low.

When this happens, pacemakers are a little like Apple devices, you cannot just replace the battery, you have to have a new one installed (also an issue for environmental pollution globally).

Placing a pacemaker is tricky. It can take an hour or so, you must lie still; you need to be happy with cardiologists fiddling with you. Not something my patient could now tolerate.

As an energy saving step, the pacemaker team turned-down the sensitivity of the pacemaker (this can be done remotely via the internet or Bluetooth) (another blog is the follies of having your pacemaker hacked).

The pacemaker will now only fire if my patient’s heart rate falls to 30 instead of 50 beats per minute, a significant reduction in battery usage.

Like switching your phone to ‘battery saver’ mode, or perhaps setting your home to 17 rather than 19 degrees by adjusting your central heating. (Hello, winter 2022/23).

Ultimately, however the pacemaker will run out of power. The battery will be flat. (As to why the manufacturers don’t create self-charging pacemakers is a separate conspiracy theory related to the profit made by selling a whole new device every five to ten years).

In discussion with the pacemaker team, we established that my patient probably didn’t need it. They can do special calculations to establish how often it is used and what might happen if it isn’t used.

And this takes us back to the original consideration.

There is a widely held belief that medicine is a science. When a doctor says x, y, or z, that is the case.

‘You have pneumonia’

‘You have cancer’

‘You need a new hip’

‘Take this tablet’

The reality is that none of this is necessarily black and white.

Most of it is a murky grey.

A patient informed that they have a bad chest infection might have pneumonia and vice versa.

I have another patient who was told twice she had cancer when she didn’t.

Medicine prescription advice is based upon the output of randomised controlled trials that demonstrate the benefit of a drug for a population of people, for example, if 100 people take drug A for 10 years, 10 people will avoid experiencing a heart attack. The other 90 would have been fine without the drug.

The statistics apply to populations not people, and you, if you are the man or woman with the dicky heart or bladder or brain are an individual. Medicine and you is a clash of individuals and the collective. (Not considering the financial analyses undertaken by the economists of NICE).

And so, to my patient.

The conversation with the pacemaker people was that as he will be very upset if we try to change the pacemaker, it will be OK to let the battery run-down as after 10 years he probably doesn’t need it.

I can think of several non-medical analogies.

After driving your car for 10 years you discover that there were no airbags or perhaps after flying to Spain you learn that the pilots were drunk, or asleep or in the mile-high club.

It is easy to dupe us.

This is the success of Trump, Boris, and Bolsonaro.

We are gullible. We are genetically programmed to believe.

We follow instruction and command.

Let’s face it, we are human.

We are all too human!

And there are frequent occasions when humans are not smart.

Seeing is not necessarily believing.

My advice?

Don’t always believe what you read or are told*. Don’t accept anything on face value. Challenge, discuss, seek to understand what is underneath or behind.

Be well.

blakey

*This week I was caught-out by fake-news. ‘People are forced to cancel funerals scheduled for Monday. It’s outrageous,’ I told my family. I’d read this on Twitter. Yes, it is fake news. Careful what you tweet, or blog.

Slap in the Face / To a Louse

Anyone who knows me will know that I am not a night owl.

I am writing this blog at night.

It is after nine.

Son is downstairs watching Better Call Saul.

The dogs are at my feet.

Anne is still not home from a long day at the surgery.

Daughter is upstairs completing homework.

A family idyll.

Yesterday my friend Phil commented on a poem I wrote four years ago.

I will stick it to the bottom of this blog.

It was a night in Dundee.

A guy whacked me in the face. I have the scar today.

My memory of the event had been that we were walking home, it was two or three in the morning, the two guys crossed the street, and one punched me. It felt like a lump of lead hitting me in the face.

In the poem I said the attack was unprovoked.

Phil in his recollection feels the attack was provoked, by his ‘brown skin and long hair, and you with your distinctly semitic looks.’

How odd.

This event was perhaps 30 years ago.

All this time and I had not considered there to have been a racist component to the incident.

I had been existing in a bubble of naivete.

Not naïve to the fact that sometimes people dislike me because of my Jewishness, which I think is subtle, but to the concept that a random stranger might go for me in that context.

Shortly before or after this event, Phil and I travelled to Israel.

This episode was full of comic moments.

We met-up with some of my old school friends. We were probably 20 or 21 at the time.

My friends were either still in the Israeli army or had just been released.

Very different life experiences (Dundee University vs Israeli Defence Forces).

We were struggling to barbecue steaks on a small fire on the banks of the Sea of Galilee (Lake Tiberias). I remember the meat being too tough to eat.

My friend J, who was originally from South Africa, had made some off-hand comments, racist slurs; I had sort of tuned out to that (yes, I know I shouldn’t, but this was a long time ago and I was younger.)

I remember Phil taking Jake aside and telling him how he felt about the use of his racist language.

It was a weird moment but in hindsight it made me think.

I reflect now.

I consider my whiteness or perhaps semitic-ness or Jewishness and the way in which that is a step away from Phil’s life experiences.

I always considered Phil, Phil. His greatest distinction being his Southern-ness, not his race or colour. (His mum was from St Helena).

And here again in Dundee with the attack.

I hadn’t considered race or skin-colour a component.

It was more evident to Phil.

During the pandemic I had an encounter with the doctor who was at the time my divisional director.

He was talking about the risks of Covid to people from ethnic minorities. He explicitly excluded me from that.

I didn’t argue the point.

I see myself as of minority status – Scottish Jew in Yorkshire is itself an anomaly.

Covid disproportionately killed Jewish people although it is unclear whether this related to the Orthodox Jews in some parts of the world ignoring regulations to socially distance or a genetic predisposition.

How we perceive ourselves and how others perceive us is at the core of what it is to be human.

As Robert Burns said, ‘O wad some Power the giftie gie us / To see oursels as ithers see us!’

I sometimes think I am dumb (as in not very bright).

I miss the obvious.

It takes a slap in the face and 30 years to ring the bell.

Thanks Phil.

Be well.

x

How I got my scar…

I have a little scar on my right eyebrow.

It used to be,

When I was younger,

That people thought I had done it myself;

shaved,

Mimicking some sort of gangster-rap style.

No, no.

It was a Thursday night,

walking back

with Phil, Nick and co

from…

was it Fat Sam’s?

Slammed in the face

by a guy

walking towards us.

out of nowhere.

Unprovoked.

Broke my nose,

Split my eye.

Now I am older,

And

Obviously

Not styling my eyebrows,

I guess,

There is an assumption of scar.

Perhaps I should shave the other one

and see

What comments I get?

The Queen, the queen is dead. Long live the.

Yesterday, whilst driving to London with my daughter, we passed one of the bus signs with a picture of The Queen and 1926 – 2022.

It got me thinking.

No. I had been thinking since I heard the news on Thursday.

Somehow my kids knew what had happened before the official announcements.

Millennials have a super-sense that goes beyond the establishment’s reach.

My relationship to the Royal Family.

I have no relationship.

If I did, I would be a Royal myself.

And, even as I start writing this blog and consider whether Queen should be capitalised or lower-case, as with royal or Royal, I am not sure whether I should be writing this.

I worry that as I am not adopting the tone of reverence that appears to have swept the country, I might be singled-out as a bad-egg. A problem person. A disrespecter.

At different times through my life, I have been considered a problem person, so, let’s go with that.

Yes.

Reflecting on all the mourning.

Yesterday, several meetings scheduled for the coming week were removed from my diary. Because of the death of The Queen.

For those of you reading this overseas, all the bus-stops and other digital adverts that traditionally advertise soft drinks and car insurance have flipped to a picture of The Queen.

The BBC Radio 6 is playing acoustic and other mellow music sans dialogue.

Yesterday I received emails from the hospital, our chief executive, the British Geriatric Society, the British Medical Association, the Royal College of Physicians as well as my daughter’s school announcing their sorrow and grief.

Sure, this for me and the country is a one-off.

It is just that I don’t get the fuss.

Yes, HRH was head of the Church of England, she was our monarch, she was around for a long time. She was, to all intents and purposes a good woman.

The photo of her sitting alone in church during Covid at Philip’s funeral comes to mind.

As queen mourned alone, UK gov't staff held parties: Report | Boris Johnson News | Al Jazeera

I remember as a child stories of her turning-off lights in Buckingham Palace to safe electricity.

And there was Paddington.

I never watched HRH’s Christmas Speech. The Queen’s Speech. Sorry.

I don’t speak The Queen’s English.

HRH appears on every five or ten pound note I spend. I don’t do that anymore, I use Apple Pay.

When I was a small boy, attending Langside Synagogue in Glasgow (now converted into a house), there was to the side of the Bima the prayer for the royal family. I might be wrong, although I am sure I can remember when they added, then, I suspect deleted Diana from the prayer.

Here I reflect, ‘How odd,’ Judaism, the apotheosis of a monotheistic religions somehow allowing a prayer to the Royal Family into the forum.

Ffynone Synagogue, Ffynone Road, Swansea | Coflein

I never met HRH. I’ve never been to Buckingham Palace.

I have a problem with Landed Gentry.

I struggle with the British system of privilege.

For me, the biggest blot against Keir Starmer is the ‘Sir’ in his title.

I have sung the Proclaimer’s song, ‘In recognition’ to myself too many times.

And I question the ten days of mourning.

Here, I will say it.

I was not upset when I heard HRH had died.

I didn’t feel much at all.

As a doctor I probably encounter more suffering, death and dying that most.

I remember Diana’s death. I was sitting with Anne in a pub in Inverness.

I was shocked. The nation was devastated. There weren’t any instructions as to how to behave. Emotion was explicit.

Diana, died in a horrible accident, she was young, a do-gooder, almost anti-establishment with two young children.

HRH was 96. She lived a full and productive life. Her experiences are beyond the imaginings of most ordinary people.

Why the sorrow?

When I am driving past former patient’s houses, where those I have known have lived, I have a moment of reflection, sorrow at their absence, their passing, particularly if they were what I perceive as ‘young’ when they died. Mostly people who had cancer. Occasionally conditions such as Parkinson’s or the one man I thought about yesterday who had a rapidly progressive form of Motor Neurone Disease.

The first time I met him he recited a Robert Burns poem. I’d just dropped in to see how he was.

In our world there is so much suffering. So many children dying, murders and atrocities. I think of Ukraine. I think of our struggling planet. The old men and women who this winter will not be able to pay for heating or electricity, who I am sure will be found cold and dead in double coats, huddled in darkened living rooms.

The point of a long productive life when it has passed is to celebrate the occasion.

I am sure the doyens working inside the BBC will get to this point eventually once they stop talking about themselves and showing-off their own sorrow.

I have long been a Republican and now is not the time or place for me to discuss such thoughts.

As people have said, HRH was someone’s mum.

I have never appreciated false emotion. An abhorrence for pretence has been at the core of who I am since I read The Catcher in the Rye as an adolescent.

I feel I am living in a country drowning in pretence.

A pretend grief. A behaving the way they think they should behave for purposes of not being called out.

This has been an odd blog.

I guess that is what you expect from me.

I am in London to meet my family. It is a mini reunion. We are not all here although those who could make the journey will be in attendance. We plan to spend the day at Kew Gardens.

I am sure there will be pictures of HRH on the underground.

I don’t know what else to expect.

There is more I wanted to say.

I reflect on the death of David Attenborough. When it comes. You see, it will come. We are mortals after all, even someone with God-like status. I am sure that will be a celebration.

I remember Mandela’s death. Did they have ten days of mourning in South Africa? What more, what less could or should have happened?

Let’s face it. I am living in the United Kingdom.

Britannia ruling the waves.

The Empire although diminished still resonates through the Commonwealth.

Last month I watched the Commonwealth games. Britain did very well. I wonder why.

A parting thought.

Supposedly our current PM met HRH two days before she died.

That to me is the saddest aspect of all of this.

Did HRH see our country deteriorating into the morass of populism that it is today? Did she reflect on her meetings with previous Prime Ministers and think, ‘OMG, who is this woman?’

Perhaps not. Perhaps there have been worse.

When Rishi and Truss were having it out in the hustings, I am sure I wasn’t the only person to think, ‘This is worse than Boris.’

Yes, our county is in a mess. Poverty is increasing, children are not being fed, old people will literally freeze this winter (unless we have a climate related warm season), we have fallen out of Europe, inequality is bigger and better than in almost any country in the world except America. Nobby the Yorkshire Polar Bear experienced the hottest day on record.

These are all things to mourn.

A life well lived is something to celebrate.

Nobby the polar bear arrives in Doncaster after 1000-mile journey | ITV News Calendar

Hooliganism and cheddar cheese sandwiches

I have had a short blog break. Apologies to anyone who missed me.

As I haven’t written in a while, I have a backlog of things I’d like to discuss.

I thought I would start with one of the most recent.

Hooligans.

And cheese.

My dad was a regular guy.

He never did anything too extreme (beyond parachute jump in the 1950’s – revealed to the family one Rosh Hashanah and thirty years later drive his green Peugeot from Israel to Glasgow with my mum as co-pilot (in the days before satnav and Waze)).

During his working years he was regular in his habits; getting up early, cup of milky coffee, cigarette, a throaty cough as he left the house, revving the car twice before setting-off. All those kinds of things. He like novels about sailing ships. He was a bibliophile and a lover of watches (as am I) (ships don’t do much for me).

And he liked cheese sandwiches.

For decades his staple working lunch was a cheese sandwich. Cheddar. Mostly my mum would make them for him. White bread in the 70’s, moving towards wholemeal later.

He never grew tired of them. I have I think perhaps inherited a similar tolerance for sameness in food.

This takes us back to the hooligans.

That is a joke on a joke.

A joke to make you wonder where I was going with hooligans (a ‘hook’) and a joke from the company called Huel who manufacture meal replacements.

The company, founded in 2014 by Julian Hearn of Aylesbury, is on a mission to encourage more people to adopt their diet. Not one intended for weight loss or muscle building, instead to save the planet.

Hueligans.

That’s what they call themselves. Jokingly. (Huel derived from ‘Human Fuel’)

Huel is a diet replacement which comes in liquid, powder, and chew-bar form. The intention being that you can eat one of their preparations instead of a meal.

Why would anyone do this? You might wonder.

Well, in case you hadn’t noticed, our planet (or more precisely, the ecosystem) is on life-support.

We are running out of resources. Too many people eat too much meat (some eat hardly any). Our food comes from cattle, poultry and other animals that are fed unsustainable diets (rainforests chopped down to grow crops, water used to water plants where there is inadequate rainfall, nitrate run-off that pollutes rivers, and so on).

Consider how much water is required to grow an Avocado (2,000L for 1Kg) or a watermelon (377L).

(Something to reflect when you can’t use your hosepipe) (much of the UK is in drought today) (Climate Crisis effect).

If you are reading this and still eat animal-based foods on most days of the week you are contributing to the problem. The depopulation of fish in the sea, the horrible ways in which animals are raised then slaughtered.

slaughter house

And don’t get me started about the harm a Double-Mac does if eaten regularly to you coronary or cerebral arteries.

super-size-me

Huel sees itself as part of the solution.

It is a vegan wholefood, in that it contains appropriate amounts of fat, carbohydrate and protein as well as vitamins, etc to replace food.

It is gluten free.

It comes in a variety of flavours – chocolate, vanilla, cinnamon swirl (?!)

Huel is not proposing that we eat just their food. (That wouldn’t be balanced or tolerable), instead it is recommended as a meal replacement. Perhaps lunch.

They suggest that by drinking or chewing a Huel bar for lunch you will save time in food preparation and potentially eat an improved diet (rather than white bread (high carb), cheese (animal suffering) and crisps (bad fats).

Most of us who are working eat our meals at our computers.

Yesterday, in the busy-ness of primary care, for lunch, I managed two lumps of Gouda (a love of cheese runs in the family), a pear, three organic carrots an apple and a container of mixed-nuts.

It didn’t really fill me up although it is probably better than an M&S or Tesco meal-deal.

Drinking a Huel would have been a more balanced supplement; and I could have got on with my work more easily (difficult to engage in sensitive conversations with patients when crunching carrots).

I know some of you will think this terrible. ‘He should be taking a break! He should be resting to recharge! We become less productive working without a time-out!’

Sure. This isn’t the reality of being an NHS doctor in 2022. Maybe in 1922. Oh, we didn’t have the NHS back then.

What about the monotony? Another question.

Well, I take you to my dad.

Cheese sandwiches for 30 years.

People do these things.

In some ways it is like Barak Obama’s shirts. If you only have white, you don’t need to spend time or effort working what to wear (my interpretation is theatre scrubs). It is off the shelf. This is off the shelf food.

Suffice it to say I haven’t started Hueling. Yes, there is a Wikipedia joke about, ‘After a week of Huel I wanted to Huel.’

Let’s face it, the world is changing.

Huel proposes not to eat their food all the time. It suggests sitting down for dinner with your family in the evening.

The dietary requirements of humans are complex and difficult to replicate (ask any dietician) and, yes, we do need some variety. (Suspect my dad could have had my mum’s roast chicken for every meal.)

Please don’t go all Matrix on me. Futuristic notions of space-meals or sci-fi hot-pot. We aren’t there yet. We can still pop down to the shops and buy some fruit and veg. Unfortunately, it is often of questionable provenance. Do you know how much pesticide is used? How many antibiotics are pumped into your beef/lamb/burger/sausage? What about growth stimulants? How much fear did that chicken experience just before its head was chopped off (as it watched it pal being decapitated)?

All things to consider.

Have I recommended this to my patients?

Not yet. I don’t know enough about it although I plan to research (I know a team of dieticians who will have their own opinions).

Have a good day.

matrix

I am scared, proper anxious. Paranoid ideas and worries about the American.

The past week I have been monitoring my posts.

I suspect lots of bloggers like me check their statistics. This is a facility within WordPress, the software I use to publish this blog; it tells you how many people have accessed (not necessarily read) your blog and their country of origin (or VPN*). In other words, it gives you an idea of what is happening, nothing more. I can’t for example identify individual readers, who has accessed which blog, that kind of thing.

Screenshot 2022-08-24 at 10.23.24

And this is the origin of the fear.

Most of my readers are from the UK.

I have very little idea as to how the internet works – a techno-luddite as far as understanding URL’s and technology goes. I know that my laptop connects via Wi-Fi and that signal goes to a satellite in space and data is stored in a freezer near the North Poll.

There is a whole layer of stuff beyond my understanding, like the Matrix, there is a code running which can explain everything, at depth.

I’ll get back to my fear (I don’t necessarily worry that some people have a profound insight into computers, I have a reasonable understanding of humans.)

The fear is that someone, perhaps an individual, has been reading my blogs. (Isn’t that the point of blogs, that someone will read them? I will explain!)

The stats appeared the day I published my blog about My American Wife. The title also included ‘Jesus’ – these are perhaps the hooks that raised an eyebrow in America.

Now, I know that the USA is a big country and there are lots of people living there (or living in the rest of the world and using a US VPN) (the latter being less likely, although anything goes in my paranoid head).

It is also likely that America has its normal distribution of the good and bad, the crazies and the normos, just like everywhere.

The problem is, I have been reading most recently Ruth Ozeki who has a certain take on the American Mid-Westerns and currently Dean Koontz.

Yes, I know that Ruth and Dean are not natural literary bedfellows, that is the way it has gone.

My first Dean Koontz book was ‘The Watchers’ which amongst other things involved a dog with advanced intelligence who was pursued by some desperate people with guns.

I am currently on book four of five of the Jane Hawk series. Jane is a former FBI agent, whose Navy Seal husband recently killed himself through a nanobot brain control mechanism that is being rolled-out across America to manipulate people in influential positions or eliminate those (on the ‘Hamlet list’), who might get in the way of the revolution.

Yes, it is fanciful. Einstein the word-processing dog in The Watchers was kind of wacky too, although the plot seems to draw you in.

Well, Koontz writes about the surveillance capabilities of the FBI or the CIA or Homeland Security or the NSA. I don’t really know which is which. Suffice it to say, if one or all these guys are after you, they will find you and sort you out.

I am not suggesting that my reader in America works for the National Security Agency (although they might), and I don’t think that person or persons has accessed my computer and is monitoring my keyboard taps or is glaring at me through my laptop camera; but still. I have a wild and potentially paranoid imagination at the best of times.

All of this is a paradox.

You see, I am essentially a quiet guy. I like my silence and alone time. I am an introvert by nature who would rather read a book or walk the dog than attend a party. I value my privacy, not to the extent that I would ‘conceal carry’ as in the Koontz world (carry a hidden gun under my loose-fitting jacket to protect me from those who might invade my liberty or personality) but, enough to make me cautious and quiet at times.

This is of course a paradox as I am writing and for the past seven years have been writing a blog about some of my inner-most thoughts (I have previously considered, if you took all my blogs and plugged them into a computer you could probably recreate me or at least second-guess my next move). (Have I written enough blogs for that AI to write future blogs? Interesting thought).

(I was once advised by a colleague, ‘I know more about you than you think,’ in reference to my blogs. Not sure what they meant. Kind of chilling).

Anyway, I worry.

As most all paranoia, it is not based purely on fantasy.

A few years ago, there was a sudden spike in my stats from a reader in the UK. Hundreds of my blogs were accessed/read in one day. Shortly after I was reprimanded at work for making the hospital look bad. (It was bad, so was I, I was suffering psychologically and likely portraying some of the negative aspects of my experience in a particularly harsh light) (Things are much better now, both with me and the hospital).

Perhaps I have said too much.

I should ignore my American reader and hope that they are either a nice person who is interested in almonds and emotions or, if they are employed by a US counter-espionage-spy agency they will realise that I am on the benign end of the spectrum and move-on.

Who knows.

I don’t anticipate a nano-web of brain-bots will seek-out my cortex any time soon, although, you never know.

paranoia-by-getty-images-56cb36495f9b5879cc540a97

*VPN – Virtual Private Network – software that enables to you be in country A and it appear that your computer is in county B; useful if you are trying to access websites that are limited or banned in your country.