Psychoneuroimmunology and all that

I wasn’t going to write anything today.

Not many people read my blog about long-distance relationships.

I get all the data.

Nothing personally identifiable just country and number.

Yesterday didn’t seem to connect.

I had one ‘like’ on Twitter – thanks Debbie.

The first time I heard about Psychoneuroimmunology (PNI) was back in 1994 when I was writing my Bachelor’s thesis. The topic was Near Death Experiences (NDE’s). I will cover this in a blog one day although I am not as interested in the subject now as much as I was in my early 20’s.

NDE’s are described by people who either encounter death or come very close, for example during cardiac arrest, shock, anaphylaxis or some other trauma.

There are lots of theories as to what is going-on.

I prefer the one which talks about the stimulation of excitatory neurones in the brain that generate complex hallucinations.

The idea being, or, perhaps the associated idea, is that these experience relate to the origins of the human propensity to belief.

PNI is related as it is the inter-relationship between the psyche, that is, the mind, neurology, or the white and grey matter in your head, including the peripheral nervous system (the nerves running into your eyes, fingers and toes) and, immunology, the body’s defence mechanisms.

If you layer on top of this our recent and growing understanding of the human gut-microbiome, you are getting somewhere, approaching the complexity.

It’s funny.

I remember being fascinated by PNI back in the 90’s. There were a few articles around – this was the dawn of the internet and we didn’t have Google Scholar. I was desperate to find people to talk to about this, I even considered it something I could get into as a career.

It wasn’t big in the UK and I became interested in other things, first medicine then older people.

Jumping forward 15 years, I met at an event Claudius, a South African thinker-cum expert in the work of Jan Smuts, Holism, Spiral Dynamics and PNI.

And now, I am thinking about this again.

There is a developing field of Functional Medicine in the UK, this is doctor and other scientists who are investigating and supporting people who have symptoms that lack an obvious physical cause.

For example, headaches when the brain scans, lumbar puncture and blood tests are normal, odd rashes, tingling in the fingers, unsteadiness, upset bowels and bladder that after extensive investigation look and appear to function just like everyone else’s bowels and bladder, yet they seem to work differently or at least provide the person affected with significant symptoms of pain, urgency, discomfort that other so-called ‘normals’ don’t experience.

This is something I have covered before so I won’t go into the details.

Here is more!

I was talking with my brother yesterday.

He has a hard time.

He is recently retired and struggling with arthritis affecting his hip and back. He has already, in his early 60’s had his first hip replacement and is scheduled for another.

This is all frustrating for my brother, as he has been very active all his life, always, running, cycling, skiing, that kind of thing.

Nothing is particularly surprising about any of this and you might think it odd for me to mention him in a blog about PNI.

Well, you see, despite his new hip and his old bad one and constant, severe pain that limits him and interferes with his sleep, a month ago he was off in the alps skiing. Yes, skiing.

He plays a weekly game of tennis.

He gets out an about on his bike.

And yet, at other times he has terrible, activity-limiting arthritis.

He told me when he was skiing all his pains disappeared.

I reminded him of our mum.

She had awful arthritis affecting both her knees.

Given all her other health problems she was never fit enough for surgery and so she had to put-up with the aches and pains and limited mobility.

Once a week she would attend a social in Glasgow. She loved to dance. She would dance for hours.

I recall, twenty or thirty years ago my mum experiencing terrible feet pain. She found it difficult to walk. I get this as well from time to time. One day, I need to hobble, especially in the morning, other days, nothing.

My mum’s foot pain just disappeared one day.

We have had all the tests. There is no rheumatoid or other funny inflammatory condition, x-rays are normal and all that.

Just pain sometimes and at others nothing.

Very dependent on the circumstances and my mood.

Not necessarily a bad, worried or anxious mood, just, mood. My specific demeanour on the day.

I said to my brother, ‘perhaps your pain is psychosomatic’ – this another name for functional.

He didn’t agree.

I described my hay-fever.

‘That’s caused by pollen,’ he said.

And yet, I have rhinorrhoea, that is, a runny nose that can happen at any time through the year, often precipitated by changes in my mental state. Pollen can affect me, mostly not.

It’s a funny old world.

They say there are as many neurones in your gut as in your brain, just as there are more bacteria in your gut than in your entire body.

I don’t know the specifics and these would be difficult to count, and yet, things are not as they seem.

We tend to believe in a concrete world. In the West at least. What you see is what you get. Spirituality is on the wane. Religious, transcendental or mystical experiences are niche, particularly for concrete thinkers like my brother.

PNI sort of addresses this.

It says that our psychology – what we think, feel and imagine is dependent not only upon our neurones, the electrons zipping through clouds of fat in our bodies but our immunity, all the cell signallers, the cytokines, antibodies and cell signalling-factors that keep us health and can on occasion turn on us, as in auto-immune conditions like rheumatoid or lupus.

We are the finite of our bodies and we are the infinite of our minds.

We are a walking anachronism.

And that explains it.

That we are for the most, at least at times, inexplicable.

We still don’t have enough understanding of ourselves to know what causes what and why we feel the way we do.

It is fine if you can climb into the flow, lose yourself in the TV or football or a book, if you are stuck inside, particularly if you are trapped in your body and the only way out is to walk in circles, that is when PNI strikes, it is when a NDE is an interesting diversion. When functional becomes our everyday.

Go well.

Long distance relationships

I was involved in an unusual consultation this week.

I was sitting with my patient and his wife in their living-room.

My patient has problems with pain and breathing.

His wife has dementia.

He is supported by his son and his daughter, one of whom lives with him, the other in Italy.

That was what was odd.

It began before I entered his house.

I received an email from a colleague the day before.

She had spoken with my patient by phone. There would have been my colleague in the hospital, my patient, his wife and son in the room, his daughter who lives in Italy was on another phone dialled-in.

I’ve described before some of the challenges involved in what have become known as telephone consultations, these, as opposed to the real McCoy, face-to-face, in the clinic, more traditionally associated with the pre-Covid world.

It is very hard. Without access to facial expression, eye-contact, posture and all the rest, understanding your patient can be tough. Add to that the often associated hearing impairment and older person’s difficulty with manipulating hands-free and you can imagine the issues, even before the overseas relative joins.

My colleague gave me a clinical summary, an update of the case. She was looking at something specific, a patch that had appeared on my patient’s lung, found during an incidental scan as part of the assessment for the Covid he had caught in hospital when admitted for something completely different.

When the conversation began, my patient was in the room, sitting on a low-settee, his packet of Old-Holborn rolled-up on a stool, his wife, who only spoke once to my left (‘she’s got Alzheimer’s’ he mouthed when I entered the room) and his daughter first on the old cordless phone, then, when I spotted their iPad, propped on the table to my right. The other son who had been out when I arrived, eventually returned and joined-in, although like all late arrivals, he was on the back-foot, aware or suspecting he had missed something.

This was a long preamble to the topic of long-distance relationships, or more, family scattered around the world.

It seems there are two types.

Those whose who stay close to home, go to school, maybe university and return to live near their parents and the other who because of life, circumstances or work live hundreds of miles away.

When my parents were alive I was the latter.

They were in Glasgow, me in South Yorkshire.

Not that far, four hours in the car, but far enough that I couldn’t attend hospital appointments or help-out around the house. Not quite Italy or Australia but far enough.

As your parents age, for the most they need more support, particularly when their health deteriorates.

Back in the day I would order food via Tesco online, I would speak with doctors and social workers on the phone, it was always difficult.

I imagine my patient and the connection via FaceTime, a gift that didn’t exist when my parents were alive.

I think of my patient and his wife, living together yet disconnected by the unfathomable nature of her dementia.

When I meet patients who have overseas relatives I always try my best to reach-out, to stay in touch. Mostly this works-out. I’ve spoken to people in America, Europe, Asia and Australia. No one in South America yet.

I am always happy to share my email with relatives and patients. The struggle of getting past GP reception and hospital switchboards is, I believe a major impediment to the function of the health service. Email is so much easier. For the most this has worked although occasionally I am contacted in exasperation over issues that I can’t resolve – the problems of care agencies, the cost of over the counter medicines, that kind of thing.

It was a struggle to run the consultation with four people in different places, the patient, his wife, their son, their daughter.

It was a toughie. It took me an hour to unravel what was what, which medicines were which, what had been stopped, started, changed, what he could and couldn’t do, what he understood, what the family understood, the plans for further tests and follow-up.

Yesterday I visited another patient who had that morning received an appointment to see an ENT doctor. They had waited four months for the appointment. The appointment was the day before the letter had arrived. Go figure.

The complexity of our lives, of health and social care is immense. It is overwhelming. Some patients accept defeat and become passive, others keep on going. I am not sure where they get their energy. I guess it is desperation.

The challenge of three or four-way consultations is significant and yet, necessary. Time is the limiting factor, it snaps at your heals, it is you looking at your watch, calculating the travel time between patients, the next meeting, the time to write-up the consultation, and on and on.

Time and space.

This is an aide-memoire to help those caring for people with delirium.

It is also useful as a necessity for getting-on, for survival.

Have a good weekend.

Rod

For reasons of patient confidentiality I have changed some of the details in this blog.

Doctoring, fast and slow.

I wrote this a few years ago.

The world has changed in that time.

There are still the high-speed intuitives and the slow-but-steady detail-orientated folk plodding-through healthcare, inhabiting wards, clinics and operating theatres.

Who knows what is best.

It is easy to say, ‘Improve the performance, faster, damn you! More flow,’ it is harder to demonstrate meaninful person-centred support that makes a difference.

Dr Rod’s Odd Blog (almondemotion)

In my experience I have found three types of doctors;

Those who work very fast, very slow or somewhere in the middle.

This is obvious and logical as human behaviour is divided on the basis of a normal distribution, with most being average.

In life, there are those who work and act quickly; my mum would say, ‘chick-chak’ which I think is a derivation of Hebrew meaning, ‘promptly, without messing about,’ and, those who tend to dilly-dally.

I remember when, as a junior doctor working in A&E, they had a top-ten of patients seen in the six-month period of the rotation. Some colleagues would plough through the numbers, others would move more methodically. The NHS being what it was and is, would usually reward those working at the fastest pace, seeing the most.

I know doctors who carry tremendous workloads, seeing two, if not three times as many patients in…

View original post 1,047 more words

My blood pressure is too high and when I get out of bed in the morning, I almost collapse. What should I do?

Thanks to Nigel for inspiring this blog.

If follows-on from yesterday’s about postural hypotension.

I don’t think, in fact, I am almost certain, no patient has ever asked me this specific question, although it is a thing. It is a condition that is tricky to manage and I suspect, one which is becoming more common, although I am not sure why.

To recap.

Postural hypotension is the opposite of the normal (doctors say physiological) response to changing posture.

Imagine a sucky-straw.

You suck a little and the juice stays at the bottom, you apply more pressure (actually negative pressure) and the juice rises-up, eventually to your mouth. Not enough pressure (or suck) and you don’t get your drink.

Most patients get-it when I explain what is happening although some take a little longer to understand.

All that is fine when your baseline blood-pressure is OK. You only have to worry about the ‘drop’ – what about the situation when you have high blood-pressure (hypertension) and it then drops?

Here is an example:

Norma is a 79 year old woman. A retired post-mistress.

Her sitting blood pressure is 180/90.

When Norma stands, her blood pressure drops to 100/60.

She feels awful and has to sit down again and very gradually rise. If she doesn’t, if she remains standing she passes out. This has happened twice. On one occasion she bumped her head and required eight stitched in A&E.

Norma is prescribed 10mg of Amlodipine. This is a blood pressure lowering drug called a calcium-antagonist.

These are your choices:

You could ask Norma to reduce the Amlodipine to 5mg, although as her baseline blood pressure is 180/90, it is likely to rise further although the drop might be less.

You could ask Norma to take her Amlodipine at bed-time when the effects of the drugs will be most pronounced when she is asleep (although she gets-up in the night several times to help her husband, Albert, 85 who has dementia) and, most people would agree, falling at night is just as bad if not worse than falling during the day.

You could explain to Norma that although her blood pressure is high, the condition that is causing her most upset, that is most interfering with her quality of life, is the drop in blood pressure. You could look in more detail into her blood pressure and determine whether the 180/90 is accurate or spurious (used to call this white-coat hypertension) (nowadays we ask people to home-blood pressure monitor to avoid this).

You agree on the last option.

Norma’s home blood pressure average over seven days is 175/80. Still too high. She still has the ‘postural drop’.

As the doctor there are some options available and I won’t go into the various medicines that can be tried, you could use a different blood pressure lower agent to see if that causes Norma’s blood pressure to fall less precipitously (all these medicines work in different ways).

After lots of trial and error you agree for Norma to stop her Amlodipine.

She monitors her blood pressure.

It remains at 175/80. The drop in her blood pressure is however much less, when she stands it falls to 160/70. Still low, but she doesn’t feel like she is going to pass-out. She feels this is tolerable.

What has happened is that you have taken two problems and reduced them to one.

Norma’s blood pressure is still too high and you both agree that although high blood pressure is not good, in fact, over the long-term it can cause some major problems, it is the low blood pressure which was the immediate threat.

And that is it.

Some patients ask me for help with their problems. They think I can fix everything.

For some, it is apparent that the pain they have had for 20 year is they pain they have, for others, there is always an answer.

I have written before that doctors, physicians like me in particular, often make little difference to a patient’s outcome, it is the interaction, the listening and explanation that helps. We are modern-day shaman. We have university degrees and prescription pads. Compared to the complexity of the human body, the infinite convolutions of the mind and the psyche, we are nothing. We can be good at guiding, advising and reassuring, we can be a presence that helps.

I discovered last week an interesting button on the primary care computer programme. I had known you could estimate a patient’s risk of a ‘major cardiovascular event’ i.e. stroke or heart attack by clicking the button (It’s called QRISK) – this takes your age, blood pressure, cholesterol, diabetic status and so on into account and gives you a predictive percent for the next ten years. E.g. a QRISK of 30% means you have a 30% chance of having a heart attack or stroke over the next decade. Anything over 10% is considered relevant and an indication for statins, tight blood pressure control and so on.

The thing I found is a button you can press that shows the effect of your risk in pictures – here if the risk is 3% (low) and after than 70% (high)

The thing, and apologies, I am getting to the point, is that you can also get a picture for the NNT that is, Numbers Needed to Treat.

People think that by taking their cholesterol medicine it will stop them having a heart attack. It won’t, it will only statistically reduce their risk (which is better than nothing) – if you want to read more, I have a blog on the subject – SEE HERE!

Back to my patient.

She had a raised blood pressure.

Her main concern was the collapses. That was the real and present danger (to use a non-homer Americanism) – the actual threat that was doing her harm and it was this we addressed. Her risk of heart attack and stroke is the same although her risk of breaking her hip and not being able to care for Albert is significantly reduced, the other, the hypertension is a managed risk, one we can monitor and support in other ways.

I hope that helps.

I think Nigel was looking for a short answer to his question. Sometimes it’s more complicated.

Have a good day everyone and let me know your thoughts.

Rod

Every time I stand up I fall over.

Hi folks, I am low on ideas today. I thought I might re-blog this article from a year ago. It seems just as relevant now as ever. Also, please ignore the egotism (Kersh Syndrome) it’s meant to be a joke.

Let me know what you think.

Is this something you have ever encountered in clinical practice or as a patient? Or am I just seeing what I am looking-for?

Be well.

Dr Rod’s Odd Blog (almondemotion)

This is potentially a tricky one as it will blend medicine with an overall philosophical interpretation of what is wrong with some aspects of doctoring.

Where to begin?

I’ll start with the straightforward – a lesson in physiology.

I will not go into the details as they are long forgotten in a brain that was at medical school in the 90’s.

The essence, or the principle is –

Blood pressure keeps us alive.

Our beating heart sends blood flowing around our body, supplying oxygen, nutrients and other important things to our organs.

The two most important (if specialists will allow me to employ some anatomical one-upmanship) is that brain and the heart. Without either getting enough blood for more than a few minutes and you are dead. That’s it.

Not enough blood to the brain you end up with a stroke, your heart, a heart-attack.

The heart pumps the blood…

View original post 1,289 more words

the woods

The woods are deep and dark and there are more trees than anything and finding a map to navigate is difficult as you can’t go left at the ‘big oak’ and know where you are as there are lots of big oaks and some smaller ones are big too. The woods are a metaphor for complexity and entanglement, they represent both the good and the bad, the light and the dark. They are human conscience and consciousness. The woods are the brain and the mind. Within is the treasure and the spoils. They are the Kabbalah. The mystics, sufis and saints. Nietzsche is the woods and so too Wittgenstein. They are the outer-reaches of religiosity. They are madness and enlightenment. Obfuscation. They are the narrative that twists and turns. I become lost in my waking or my dreams. I can lose you or you, me, my person or my body. I can sink into the moss, become one with the treefall. Hansel and Gretel and all things Red Riding Hood. The woods are the plotline, the narrative for adventure. The wolf, wild boar, bear and badger. They are an idyll. They are a nightmare.

The poop you walk past, Navalny and others on standards in society

I’m just back from walking my top-dog Stella.

It is bank holiday Monday which led to a later than usual getting up and out.

There was poop about.

Last night I watched the new Alexei Navalny BBC documentary with my partner Annie.

Not only was the documentary incredible, serious, funny, tragic, absorbing, it also touched on a central element of Navalny’s philosophy – beyond the realisation that the FSB* tried to kill him by lacing his pants with Novichok**.

Towards the end, when Navalny was running a piece-to-camera he described a principle which motivates him, that being, the behaviour you walk past is the behaviour you accept.

And, it struck me that beyond this being a cliché, it is an incredibly profound critique of our lives. Mine and yours.

In many respects the planet is falling to pieces, whether through climate change, the growing divide between the rich and the poor, the haves and the have nots, the war in Ukraine, microparticles of plastic lodged in my lungs and circulating in my blood, lying, philandering politicians, an NHS on the brink of not being able to attend to its basic founding principles, I could go on.

If you want more, Google, ‘Guardian Newspaper’*** and read a few headlines.

It is bleak stuff.

And, how much of it relates directly to your or my behaviour?

Very little.

It is more a chaotic butterfly of cause an effect, a stochastic randomness that nudges the world in a certain direction.

The Monarchs are disappearing too.

I mentioned Annie at the beginning. She has always struggled to walk past dog-poop.

I’d better explain.

Annie and I are dog walkers.

We walk around with pockets stuffed with poo-bags.

If ever our dogs poop, we are standing above them, bags at the ready as their perineum relaxes; down we swoop.

Not all dog walkers are as diligent.

Some places I go there is shit everywhere.

When you see a dog shit you have three options.

You can ignore it, you can walk past and say, ‘There is dog shit everywhere,’ or you can reach in your pocket and acknowledge that the poop is not yours, not your dogs, but pick it up anyway and pop into a bin.

I am sure we have all been in this situation.

This morning there were two non-Stella poops. The first had been on our walk for a couple of days; someone had tied it in a bag and left it by the path, the other was fresh, lying in the open.

I removed them both.

‘Big deal, poop mover,’ you say. Well, it’s not that simple, as anyone who collects poop knows. Sometimes the bags burst. Sometimes it gets on your hands, and, your own dog’s poop on your hands is one thing, an unknown dog’s, well, that is a different matter.

On Saturday I wrote about a meeting run by our director of HR Steve. He talked about oxygen masks and ensuring your physical and mental health is OK before reaching out to help another.

Another management aphorism which he alluded to, and which I recently covered myself relates to the Navalny quote about the behaviour you walk past. If your see a colleague, a doctor or a nurse behaving in an uncivil way (towards a colleague, patient, relative), it is down to you to challenge. Walk past it, look the other way, and the poop is on you as much as it’s on the bully.

Sometimes the connections in life are odd. Unpredictable. Unexpected.

And Navalny.

I’d thought the age of the great leaders had passed.

Like most of my readers, when younger I followed the experiences of Mandela, I thought the days of Obama were behind us, a falling a way to mediocrity.

Navalny demonstrated that there are still people out there who won’t just walk past, but stick their necks out. Volodymyr Zelensky is one. Navalny is another. I’m not sure what it is about the Ukrainian/Russian spirit that inspires this bravery. Maybe it’s the weather, the same cold that blew through Dostoevsky, Chekov and Gogol.

The wind might not have found me, although I commit to more poop scooping.

*FSB – Federalnaya Sluzhba Bzopasnoti

**Novichok – Russian for ‘newbie or newcomer’ – the FSB’s nerve agent of choice.

***Death of the forest moths, Rwanda asylum, Dentists deserting the NHS, PPE scandal, police blocking cycle paths, sewage in the rivers, cataclysmic ocean extinction, 30,000 waiting for cancer treatment, raw sewage in the sea…

Free Speech, Twitter, Elon & Biko

I asked my son last night what he thought about Elon Musk’s purchase of Twitter.

He paused for a moment and first replied that he thought free-speech was good and important, then, that he didn’t think it would make any difference to anything and finally, that as Elon Musk has done so much to promote electric cars that we shouldn’t be too concerned.

It all came-out in one go and I wasn’t sure what to think or reply.

Yes, I agree with free-speech and yes, the world is so obfuscated and yes, he is the electric car guy.

What about bots Tweeting? What about lying leaders? What about the AI manipulation? Either the technology doing what it wants or someone guiding its hand, via algorithms.

Having watched a You Tube with Elon Musk I know he is worried about AI, which suggest that at least he is aware of the problem, although it’s likely that the folk currently at Twitter are just as concerned.

As with most conversations, it ended with my not conveying all that I was thinking, and us drifting-off into the more mundane.

‘And, I don’t use Twitter,’ he added.

And, what about Twitter?

What about Trump’s suspended account?

What about suppression in China or North Korea and the removal of the site in Russia?

What about free-speech and being able to say what you want, when you want, to who you want?

As I was thinking about this blog today, whilst walking the dogs on the damp Doncaster streets, I recalled a previous blog and a book that has influenced my thoughts for decades. It is by Steve Biko, called, ‘I write what I like.’

Younger readers will not know about Biko and they might not have even seen the movie. He was an Anti-Apartheid campaigner who was arrested by South African police and battered to death.

Yes, he wrote what he liked.

I have reflected on my own facility for free-speech. Can I say what I want?

No.

I am bounded by my own internal anxieties and concerns, my consideration of what others might think about me. I am constrained by professional regulations and guidelines. I have patient-doctor confidentiality.

Most of what I think remains inside.

Some people, let’s call them extraverts tend to let everything spill-out. I am not one of those.

This blog is a form of cognitive expiation.

I write what I think people will read and what I think won’t make them suspect I am too unhinged.

Trump Tweeted what he thought.

A recent Netflix documentary, the Social Dilemma, describes some of the problems associated with social media and in particular Facebook and Twitter (other platforms are available and used by younger people.)

Yes, social media was fundamental in Trump’s 2016 presidential campaign. Obama’s campaign has used social media successfully too. It just so happens that my world-view aligns with Obama’s and Trump, well, his contempt for the world will always make me feel sick.

I don’t know the extent to which social media has influenced politics in the UK. It is hard to say, although likely Brexit and BJ being the PM are consequences of programmer manipulations.

Contempt, and I think of Reece-Moog.

I think of that guy who yesterday resigned for watching pornography on his phone in parliament.

I read an interview with his wife yesterday. She was of the opinion that women wouldn’t become involved in the ‘industry’ if they didn’t get something out of it.

I wanted to slap her.

Will Elon Musk owning Twitter make any difference to the behaviours of these people?

No, I doubt it.

I also think of the Tesla super-chargers at the service stations. Most almost always lying half-unused whilst other electric car drivers like me queue to use the one or two public chargers.

I think of inequality.

Recently I watched Jeremy Paxman’s interview with Russell Brand. He (Russell) was explaining why he doesn’t vote, the rationale being that left or right, the system is so corrupt that nothing but a total revolution will make any difference.

I can’t see a revolution any time soon.

Musk buying Twitter is a revolution of sorts although a silent one, brought to life by digital interfaces arguing with one another.

And, as the poem goes, ‘Prices will rise, politicians will philander.’

The inevitability of change. The futility of reflection.

Live for the moment, the here and now. There isn’t anything else.

My thoughts are not my own, they are the run-off, the slough of being alive.

Why bother?

This is Dying Matters Week.

At a meeting last Tuesday, I agreed to write a blog about dying.

I suspect most of you would not volunteer to write about death. It isn’t necessarily on the tip of the tongue. And yet, for me, it is there.

In the past two years I have encountered more death than at any time in my career.

Caring for older people during a pandemic that particularly affects that group is a clear consequence.

It has been awful.

I won’t mention the stoicism demonstrated by sons and daughters who couldn’t be present as their parents lay dying in hospital or care homes, nor the swingeing restrictions on funeral attendance that were in place.

And, dying matters. Does it?

I don’t want to be facetious and quote Benjamin Franklin* and, for most, as our society modernises, progresses and at the edges starts to fail, death has lost its familiarity.

For me it is so commonplace that I have become slick at the discussion.

As a younger doctor, for example, I used to struggle to hold conversations about resuscitation, now, I have a useful set of phrases that seems to make it easy, that seem to enable a dialogue that is not stilted by awkwardness; I mostly talk about allowing a natural death and dying peacefully, a common aspiration.

I rarely mention the consequences of chest compression or discussions with the police or coroner’s officers for those who die naturally but without a document in the home.

You might consider Dying Matters something that is best left for the time it is in front of you, when it is unavoidable, inescapable. ‘I’m only young, I don’t need to consider death,’ you might think, and, for the most, you will be right.

In my experience, many people up to their late-80’s still see themselves as ‘young’ – something happens to those in their 90’s where they realise, ‘I’m getting on.’

And yet, let’s talk about it.

I’ll come back to the old and the sick, those who most commonly die in our society, and focus on how it matters throughout life.

Freud suggested that we can’t imagine our own death.

I’ve tried and I can although it isn’t a comfortable or pleasant.

When I was younger, in my late 20’s or early 30’s, probably when I bought my first house or just after my children were born, I thought briefly about death. I have a will, without which you risk, becoming intestate. Which means that when you die, not only will your family have to cope with the grief of your loss, they will have to struggle with banks and solicitors to finalise your affairs.

I had a head-injury involving a Sheffield tram which also helped.

A little while later, I faced the deaths of both my parents. My dad first, through cardiac arrest on a lonely hospital ward in Glasgow and my mum, eventually, at my request, following arguments with the doctor in charge, through sedation and palliation.

Most of us employ something called magical thinking.

It is the notion that not thinking about something will make it not happen; it is a form of positive mental attitude, which as we know works, and there is the opposite, the consideration that talking or thinking about death too much might make it happen, tempting fate you might say.

In Yiddish there is the term ‘kinnehora’ which is said quickly after people talk about death, it is a way of safeguarding against or cancelling the evil-eye.

The problem is, that if we don’t think or talk about death and dying, it will be forgotten. Time and effort will not be spent ensuring the possibility of a good death.

‘What do you mean ‘good death,’ how can death be good?’ you ask.

As I have said, for the most, death is inevitable. For the majority, death will be accompanied by an old age, for many either dementia, heart disease or cancer will be a cause.

Shining a light on ignorance is a good way to remove its associated harms, talking about death can ensure that people are given an opportunity to know what is happening to them and their relatives.

Recent data in Rotherham has shown that for those dying in the town, only a minority are ‘fast-tracked’ that is, provided NHS funding for a life-limiting condition, indicating a person is in the last three-months of life. And for those who do, for most, their death happens within a fortnight.

This suggests our doctors (it is generally they who are accountable) (and, don’t get me wrong, this isn’t a Rotherham thing, the data is the same nationally) are poor at diagnosing the approach of the end of life.

Diagnosing death by comparison is straightforward, there is no sign of life, no breathing or heartbeat.

You might wonder why doctors are sometimes poor at determining the point at which treatment is futile.

The reasons are complicated and as much to do with our sometimes broken health service that does not respect the importance of patient-clinician (doctor/nurse/therapist) relationships through the growth and maintenance of continuity of care (the doctor/nurse A, then B, then C or D is looking after you phenomenon) as modern medicine’s focus on diagnosis and treatment.

Often the decision to reach a diagnosis overlooks the patient and their wishes with a diagnostic or task-focused goal being of greater importance.

‘I am not sure what is wrong with you but I don’t think you are going to get better,’ versus, ‘Let’s do this test, then that one and that one until we pin-down what is wrong.’

It is hard if you are the patient or relatives to know what to do.

There is an odd phenomenon I have recognised over the years. It is the unlearning that seems to happen in healthcare.

Mostly, when talking with medical students and junior doctors, those in their first few years after qualification, when I ask, ‘Have you ever seen a patient receive treatment which you feel is futile or unnecessary, especially if the patient is obviously dying?’ The majority will respond in the affirmative.

It is not uncommon for patients to realise they are dying, for relatives to think, ‘I am not sure what the doctor is doing, mum is dying,’ and yet, the doctor perseveres with intravenous antibiotics, escalation of observation, treatment and investigation.

This is the lay folk, those without specialist training who appear to see the obvious, whilst those with decades of learning, of post-graduate qualifications and education seem blind.

Perhaps they are too close or too far away to see. Perhaps occupational myopia is a thing.

I don’t as yet have a way to fix this mismatch in perception.

Perhaps that is the point of this blog, to provoke discussion or reflection.

It is easier as I said at the start to talk about something else, and yet, this is too important to ignore, it is too closely related to who we are and what we are doing to postpone.

Let’s talk about death, let’s talk about dying matters.

What do you think?

If you enjoyed this article, there are many more at www.almondemotion.com or you can search ‘almondemotion’ and ‘falls’ ‘older people’ ‘person-centred care’ or ‘end of life’

*Our new Constitution is now established, and has an appearance that promises permanency; but in this world nothing can be said to be certain, except death and taxes. Benjamin Franklin, 1789.

Oxygen masks, paranoid androids and helping others

I attended a meeting at the trust this week. Steve, the director of human resources/people/personnel was talking about the recent NHS staff survey.

This is an annual review conducted by the American consultancy, Picker into the experience of staff working in the NHS. It is one of the biggest staff surveys in the world.

Over the years I have had a mixed relationship with the data collection.

It is designed as an anonymous review of how staff experience their hospital or workplace, their bosses or managers, how confident they feel to do their job, their level of satisfaction, that kind of thing.

In the past I was often reluctant to fill the form in, firstly because I was convinced it wouldn’t make any difference – the ‘why vote?’ argument and secondly, because for the last 20-odd years I have been broadly critical of my employers (not because I am a malcontent, rather I have an unrelenting drive for things to be better), I feared being identified – the form is anonymous although I am not and, working out who the unhappy 30 or 40-something, male geriatrician couldn’t have been that difficult.

The latter is my paranoia. The former my pessimism.

A paranoid pessimist.

Joy.

Well, over the past couple of years, I have matured and thrown caution to the wind and completed the forms.

There is a lot more to it than that, I won’t go into the details as I know a superficial analysis can be misleading and a deep one, is, well, deep and very complicated.

Getting back to Steve.

We were talking on the call about workplace culture and the impression that the way to run a successful hospital, shop, team or organisation is to ensure that your staff feel respected, listened-to and involved, that things are not done to them but with them, that what matters to them is understood and adopted as principles of action.

This often does not happen, yet, having what is sometimes described as ‘Compassionate Leadership’ as your mantra can help the process and move you in the right direction.

It was in this context that we discussed an element of the Institute for Healthcare Improvement’s Quadruple Aim.

I won’t say more about this as I have described it several times in previous blogs – SEE HERE!

One of the aims is for teams, organisations, etc to look after their staff.

This is a transliteration of providing person-centred care not only to the patients or customers but the staff.

Understanding the world through their senses, their perception, feeling their pain and struggle, celebrating their success.

It is compassion, that is, suffering-with those people you lead or support.

And it was here that Steve provided a gem of an anecdote.

Steve said that someone had recently described this to him and he was sharing it with us.

I am sharing it with you.

Most of us will have sat-through pre-flight take-off checks.

You know, where the purser and the flight attendants run through the, ‘Seats upright and tables folded’ spiel.

With this is the, ‘passengers travelling with children, ensure you have fitted your own oxygen mask before helping others.’

The reason for this guidance is that it is no possible to help others if you are unconscious.

Make sure you are OK before assuring the wellbeing of others.

It is the ‘charity begins at home’ motif.

And it is profound.

You see, within the NHS there are lots of caring people.

It is within the NHS Constitution, our, ‘By the people for the people.’

Yes, there are un-caring types amongst the million-odd NHS staff, there is a powerful majority however who care.

And if you care or are a carer, this is frequently your go-to position.

Not so much, ‘When in doubt, act,’ more, ‘When in doubt, care.’

Which is all very well, yet, it is hard if not impossible and potentially inadvisable to care if you are sinking.

If you are sick, physically, mentally or spiritually, it is hard to care.

If you don’t have enough oxygen, the physical or metaphorical kind, it is difficult to dole-out caring and kindness.

And the value of this quote is not so much a useful piece of life-advice, it is also a permission-slip, a note to say, ‘It is OK to not be OK and if you are not OK, you don’t need to use your last drop of energy to make others OK.’

We are human.

We are finite (just as much as we are infinite).

Take the time to pause and ensure your own wellbeing before going after others.

Then you will be in a position to help, to kindle the flame.

Then you can panic that the plane is losing altitude.

Old blog about the staff survey! (with my favourite Picasso)

The Brazil nuts from Brazil

The Boys from Brazil is a book written by Ira Levin in 1976*. Many of you will have watched the Gregory Peck / Laurence Olivier movie from 1978 about a fictional Mengele who has escaped to the jungles of South America and has cloned lots of Hitler children intent on reviving a Third Reich.

Brazil nuts are something different.

This is about the nuts.

I am getting to that age where it is reasonable to think about my health and survival into late middle-age. As a consequence I have reduced carbohydrates from my diet – sweets, sugar, alcohol, bread and pasta. That kind of thing.

I have also adopted an intermittent-fasting regime which my brother got me on to.

As a consequence of not scoffing sweet-salty popcorn or Sports Mixtures I have been consuming more nuts.

Nuts are great although not without metabolic risk as they contain lots of fat.

The other week I learned both that the cultivation of the nut is quite amazing, it is also potentially toxic – something I didn’t at first believe.

Brazil nuts, perhaps surprisingly are mostly grown in Brazil.

The eponymous nut can’t be grown anywhere else as the life-cycle of the tree and the flower that becomes the fruit or the nut (don’t talk to me about fruit/nut/legume/seeds) is dependent for pollination upon a large-bodied bee that is only found in areas of pristine rainforest – the bees can’t survive elsewhere, that’s why you don’t get Brazil nuts from China or California.

Here are some amazing Brazil nut facts:

The fruit takes 14 months to mature after pollination

Some Brazil nut trees are a thousand years old

The trees can grow up to 50 meters tall

The nut-fruit weighs up to 2Kg (falling 50 meters)

The nuts are naturally spread in the rainforest by agoutis, small rat-like rodents.

The nuts which are packed with protein (14%), carbohydrate (12%) and fat (66%) contain the chemical selenium, a micronutrient important for the healthy function of human cells in such large amounts that eating more than eight a day over a period of weeks can result in selenium poisoning. (One small bag of Brazil’s can contain over 300 times the recommended daily amount).

Selenium poisoning can lead to broken nails, a garlicy taste and if you eat lots and lots, death.

The nuts also contain radium (a radioactive element) and barium (a heavy metal) neither of which are very good for you.

There you have it.

Who would have thought?

Brazil nuts.

You can get them coated in chocolate as a sugary snack (not for me).

Rainforest produce.

Intimately connected with the health of Amazonia.

Moderation OK.

Excess, less so.

If you hear someone saying, ‘I’m putting you on a Brazil nut diet,’ worry.

Apart from Nazi clones, falling nuts and selenium poisoning the Brazilian rainforest is a great place.

*Ira also wrote ‘Rosemary’s Baby’ – quite a guy.

Civility, Incivility and being nice

I attended a talk this week given by Emily, the Equality, Diversity and Inclusion lead in the trust.

It was part of a two-day Quality Improvement programme in Rotherham.

Civility isn’t necessarily one of those things you tend to think about, it’s a little like the absence of pain.

When there is no pain, you are just you, getting on with things.

When an arthritic joint flairs or you bump your nose, suddenly, where there was painlessness, you have it.

Civility is the same.

Most of us go about our day to day lives, interacting with others, often, and to my mind, more since the pandemic, with appropriate, pleases, thankyous and patience; allowing the old man to fumble at the till, accepting that people have fallen out of practice with some behaviours.

What is civility?

Well, you will have heard of civil-servants, they are, I guess, those employed to work in roles that maintain the civil or social order, to ensure systems, plans and processes are in place to allow us to live without crashing in to one another, getting our wages on time, paying for what we owe, feeling safe walking home at night, having confidence in the safety of the food we eat and the transport we take. That kind of thing. Providing a magic blanket that most of us don’t think about but which keeps life ticking-over. We call this a civil society. Our civilisation is infinitely complex and precarious and it requires tending. Sure, there is more to be done, and there are many, thanks to Boris and team who fall outside the safety-net, yet, most of us will agree it is better to live within the boundaries of civility than without. (If you don’t agree, perhaps visit Yemen or Syria).

That was a long paragraph describing the obvious.

It is probably appropriate to borrow the terms micro and macro from economics to explain the rationale for Emily’s talk, you see, the macro-civility, we probably don’t need to bother too much about; there are rules and systems in place to keep us right – traffic lights and best-before dates on our food, it is the micro that is trickier.

Micro-civility is at the level of the individual. What I say or do to you.

Again, this is one of those things that we take for granted, particularly in the UK where civility has been honed over hundreds of years.

It is when it is absent that it hurts.

Most of us have experienced this.

Rudeness, passive or active aggression; dismissal, walking into a room and the clique ignoring your presence, being forgotten or overlooked either with or without intention; the emails you send which fall into a blank space, the smiles or eye contact that aren’t returned.

I guess some people are more prone to this than others, that is, receiving the incivility.

It is probably a matter of sensitivity too. If you have thick skin and a mountainous ego, it is easy to shrug-off, if not, less so.

Yesterday, I was out walking with my son and our dogs. I walked past someone who at first I didn’t recognise then was vaguely familiar. It was only when we had each moved-on that I realised who it was. At the time I did the dog-walking, smile and hello; had I known who it was I would probably have stopped for a chat.

I have glasses. My long distance vision has been a victim of age and Covid. Part of this was my not seeing him as I wasn’t wearing my specs. They hurt my eyes.

My dog walking colleague could either have been insulted or not thought anything more of it (he was wearing ear-buds and likely listening to something)(I tend not to talk with folk when wearing my ear-buds), alternatively he could have said, ‘Hi Rod!’ or, it could be that he has equally bad eyesight (he is about my age).

Who knows.

I don’t think that was incivility. That was just the complexity of everyday life.

Previously I experienced repeated bouts of incivility. It was a few years ago, at work.

It was all the usual. Emails that weren’t answered, meetings that I was not invited to or meeting minutes where my contribution was deleted, backs turned and decisions or discussions about me without me. That kind of thing.

In the end, when the bullying was too overt for me to look the other way I crashed and was on sick leave for several months.

That was the effect of incivility which I suspect is beyond not recognising someone on a dog walk.

And here is the point of Emily’s talk.

We live within a fairly clearly defined set of rules and expectations of what is right, what is reasonable and acceptable and what is not. Deviation is easy to spot.

Yet, when this deviation is on the micro-scale, particularly behind closed doors, the victims tend to be at a loss, often flounders, or, at least that is what happened to me.

There is another incivility, the grand-standing type, less common in today’s world of dressing someone down in public, of mocking them for perceived or actual failings or mistakes.

And all of this, what does it matter?

Life is tough. What do we care about a few victims here or there?

When you take these micro-actions and shift them to a health or social care environment, that is when things fall apart.

That is when the rudeness or the aggression from me to you affects you to such an extent that you are no longer functioning, that your judgment is impaired, your resilience diminished. Your thought processes delayed. You make mistakes. Your sleep pattern and health suffer.

Incivility from me to you is as bad as my stabbing you with a knife, just less bloody.

Emily showed us lots of evidence of this from academic studies. The effect of rudeness or incivility. Of blanking, of ignoring, of overlooking.

It shortens the victim’s lifespan, it affects their relationship with colleagues and friends and family. It is a terrible, pernicious thing.

And, yes, it is out there in healthcare.

What to do?

Well, the first is to call it out. To acknowledge that today, 2022, it is never acceptable for incivility to happen, particularly in the workplace, particularly in the NHS.

Incivility is an inversion, a perversion of everything we are aspiring to achieve in clinics and hospital wards.

It is the diametrical opposite of person-centred care, where the person is valued, celebrated.

The in-civil nurse or doctor is a bad doctor or nurse or at least one who has lost their way. Their actions or relationships with colleagues will spill-over to patients and vice-versa.

Call it out and do something about it.

The adage of, ‘the behaviour you walk past is the behaviour you accept,’ rings true here.

Call it out. Escalate. Don’t accept it.

If you see it and are not necessarily the victim, you can act too. If you don’t, your hand is on the knife.

It is as significant as that.

We complain about much in the UK and today, we have more to dislike than ever (Boris, et al) and yet, our society is at the extreme end of civility.

I am certain that behaviours we would not countenance are commonplace elsewhere.

We queue. We say please and thank you. We wait our turn; sure the odd sigh or raising of the eyes, but for the most we are pretty good. Let’s keep it that way and let’s celebrate our decorum, and remain on the look-out.

Florence Nightingale, Florence Synagogue, Dali and palpitations

It’s funny. I was planning to write something about my visit to the Great Synagogue in Florence last week. When, first Googling to get the correct name (make sure it wasn’t the ‘Grand’ or ‘Central’ or whatever) that I accidentally clicked on a link to Florence Syndrome.

Florence has been on my mind follow last week’s trip.

I was going to mention Florence Nightingale*, she of the lamp, as that was the city where she was born in 1820.

In one of the churches there is a small commemorative plaque.

Anyway, fancy there being an associated condition.

It has another name, that is Stendhal (19^th century French novelist) Syndrome, although given the narrative, let’s stick with Florence.

It appears this is a psychiatric, or perhaps psychosomatic syndrome associated with a profound physical response to art (rise in heart rate, palpitations, breathlessness). It would probably make the artist’s day to know that their creation had such an effect .

We often forget that one of the aspirations of art is to connect the physical with the spiritual or the eternal, linking a pen or brushstroke with creativity or imagination.

It is easy, particularly when there is so much art on display in a place like the Uffizi to become inured. ‘Not another Annunciation,’ you sigh, forgetting that for the artist, perhaps during or after the creation of the art there was something special going-on; this was their link between their everyday and divinity.

Art in the current era is so monetised, transformed into postcards, keyrings, and memes that we forget how special it can be.

Imagine a 14^th century peasant seeing a gold-leaf portrayal of a scene from the life of Jesus. In a time, devoid of electricity or even books, the experience must have been transformative.

I remember as a student in Dundee back in the 90’s there was a fashion for 3-D posters; these were images of Marilyn Monroe and beefburgers that when looked at but not looked-at, came alive. I was never able to see them, perhaps I was too grounded.

PS I’ve no idea what this is in this image, if it is inappropriate, please let me know!

Art often aspires to trick us into believing that our perceptions are befuddled and, that what we see is real or what is not real is real. Dali was a connoisseur.

I sometimes wonder what it would be like to travel back in time with my iPhone and show it to someone from two or three hundred years ago. Sure, there would be no connectivity, but until the battery ran-out I’d be able to show them some of the apps and maybe the camera.

I suspect this was a similar experience for those seeing their first Pieta.

In a way, because we are exposed to so much that is beyond our imagination or perhaps our ability to create, TV and movies and cartoons we have forgotten the magic involved in creativity.

I have certainly never diagnosed anyone with Florence Syndrome.

It would be funny if I did…

‘Diagnosis – Florence Syndrome’

‘Treatment – avoid visiting Florence and/or trips to art galleries. Watch more TV’

The irony of this is that I had intended to discuss the synagogue and I have gone nowhere near it.

Such is life.

Here is a picture.

*Interestingly, Wikipedia describes Florence N as a statistician. Who would have thought?

What have I learned, what have I seen?

It has been a busy few weeks.

First, I became infected with Covid.

That started it all off.

It wasn’t a surprise that I caught the virus – all the signs were present, that is, increasing numbers infected, an attitude of acceptance and disavowal by everyone around, confused and mixed-messages – wear a mask here but not here or here, use alcohol gel but don’t forget to wash your hands, symptoms x, y and z are relevant but not a, b, and c.

A perfect storm.

I will perhaps discuss the symptoms I experienced another time, if you are interested, there are no end of articles and blogs describing what it is like to be infected, most from people who were much more unwell than me.

Nevertheless, the infection has passed, and I am getting-on.

Last week I was in Florence.

After some toing and froing by email with the hotel reception desk we were given rooms with views of the river, that is the Arno and that a reference to EM Forster.

We were in the heart of the old city surrounded by cobbled streets and tourists, the same kinds of people, generations apart who have been visiting over the centuries.

We saw sculptures and paintings of the annunciation, the crucifixion, Calvary, the pieta, you name it. Jesus as an idea, as a baby and as a godman resurrected. In gold-leaf, in fresco and oil paint, all shapes, sizes, times and textures.

We learned about the various symbols of birds, flowers, feathers, and items of clothing.

It was an education.

Dante Alighieri, the poet of Florence wrote the Divine Comedy following his expulsion from the city on the 27^th of January 1302. (He is buried in Ravenna; the Florentines have been trying to get his bones returned without success since 1332).

The comedy is not funny. It isn’t jokey at all; Comedy is a literary form contrasted with Tragedy, the former written in colloquial language for entertainment, the latter in a more obscure format for serious consumers.

The Comedy (let’s call it) is divided into three sections over around 14,000 lines that take Dante on a journey, led by the Roman poet Virgil through Purgatory to Hell and onwards to Heaven.

I can’t comment on the work which I have not read, as to whether it is fantastic writing or brilliant creativity although it has stood the test of time.

I gather from reading around, that the story has become particularly famous for two reasons, not necessarily because it was a best-seller when it was published (before Guttenberg (1450’s)) but, because it was a fantastic advertising device for the church, as it describes in endless ways the various tortures, agonies, and embarrassments those who don’t go straight to heaven upon their death experience.

If you commit any one of the seven deadly sins (Pride, Greed, Lust, Envy, Gluttony, Anger & Sloth) – (presumably combo-sins (angry, greedy, gluttonous sloth – I can think of a few of them in the Conservative Party) get you worse punishment) or if you aren’t baptised or up to the moral standards of the church, this is your fate.

It is likely that very few ordinary people read The Comedy when it was written (as most people couldn’t read and those who could would struggle to get a copy), it was two hundred years later when Botticelli after reading the book (or having it read to him, or perhaps the stories related) drew the vision which Dante described did the awfulness of hell become more apparent.

Again, the numbers of people with an opportunity to see the paintings would have been small, no doubt over the centuries, descriptions were passed across the generations, ‘eat your sprouts or you will end up with a backwards facing head’ kind of thing.

All of this was of course great for the church as the only way to get into heaven or avoid being buried alive head-first in boiling pitch was to pray and give the church your cash.

It was an early form of advertising better than anything Saatchi or Apple could have created – a gift that kept giving.

I learned all about of this from Dan Brown after reading the Inferno which is a thriller set in present-day Florence describing Dante’s visions interpreted through the twisted notions of a tech billionaire.

It takes you from the Bobbili Gardens to the Palazzo Vecchio along the Vasari Corridor, all stuff we did or almost did (the corridor isn’t open at present).

We also watched the movie (20% Rotten Tomatoes!) in our hotel (the one overlooking the Arno).

Fittingly the theme of the film (and more accurately the book) is the creation of a novel virus that works to change the world order, to trim-down the human population and create a sustainable world akin to that which existed following the plague of the 1350’s (which in part inspired Dante).

A perfect symmetry.

Couldn’t have planned it better.

Although there were no plague doctors wearing long-nosed masks, everyone in Italy had their own masks, all very different from the laissez-faire of England.

We went to the cinema and had to buy an FFP2 mask, which is a level up from that which doctors and nurses wear in hospitals in the UK (and from the mask which I wore when I most likely caught Covid from a patient).

When I first saw people wearing these masks, my assumption was that they looked like the kind you buy in DIY stores (like those people were rushing to buy at the start of the pandemic), imagining my mask, my China-made, Amazon purchase was better.

Not.

The Italian (let’s call them) masks are much better than the facemasks we wear in the UK. They are more expensive, which is perhaps a reason the government hasn’t proposed them for widespread use, although they are more robust and seem to last longer, they also, because of the way they filter air avoid my glasses becoming misted, which in turn allowed me to check-out the art (fresco, lapis-lazuli, etc)

I don’t know about you, all of this seems very Zen; the narrative is circular, like chicken biting the tail of the snake that is chasing the god that is biting the chicken.

We don’t really move or go anywhere.

In space and time, we stand still.

The past is very much the present and the future, well, anyone’s guess.

Rest easy, my fellow sufferers, there is more to come.

Hospital at home, virtual wards and turning care in the community on its head

Last week I attended the second annual Hospital at Home (H@H) conference. It was online as they are nowadays and representatives joined from the Four Nations as well as Singapore and Australia.

H@H or, if you are living in England, Virtual Wards are the NHS’s latest thing.

Somewhere in Whitehall it recently dawned on the mandarins that we couldn’t keep doing what we have been doing and expect, to survive.

Apologies for the convoluted cliché.

Building more and bigger hospitals in a society that is ageing, in a health and social care service that is supporting more and more people with chronic, long-term conditions, pretending we are still living in the 1960’s is unsustainable.

Not only can the system not continue as it is (trying checking-out the A&E waiting times near you), it has reached a point where the benefits in many instances outweigh the harms.

No one has particularly challenged me over this, although I think it is apposite to mention, my thesis does not extend to shutting-down all the hospitals, rather, it extends to a repurposing of what goes on in a hospital and how the patients are treated.

As an example, were I to develop a brain tumour, let’s go for something relatively benign like a pre-frontal meningioma. If I had one of those, I’d want the neurosurgeon to drill into my brain in the most sophisticated hi-tec operating theatre in the country. I’d hope for cutting-edge diagnostics and infection-free facilities. I would accept spending time in a hospital to gain access to this care and support.

If, however, I was 90 and I fell at home or in my care home and I had a minor bump on my head, the very last place I would like to be taken is hospital. Care in my home, with doctors, nurses, therapists and everyone else I might require to support my recovery and return to independence, would be better in my little house.

You see, there is no Covid in my home, the floors aren’t slippery, I have my favourite mugs and all my clothes. Sure, Blake the dog might get in the way although we could train him. No one would obsess over my length of stay and there would be little chance of a confused fellow patient climbing into my bed in the middle of the night or all the lights on a ward being switched-on at 6am for ‘drug rounds and observations’.

We talk about a health service (which is very good) that is based upon person-centred principles, with the person aka the patient at the core of everything we do, and yet, when you draw graphs of the organisational structures of health and social care organisations, and examine the ebb and flow of money, hospitals tend to sit in the centre (financially if not diagrammatically).

H@H sees an inversion of this.

The plan for Virtual Wards does too.

The proposal is (from memory) 20 beds per 100,000 population, equating to a 50-bedded virtual ward in Rotherham, and lots, lots more in the bigger cities

I haven’t really explained what I mean by H@H.

I’ll give an example of the current state and one which might evolve.

Let’s imagine Albert, 89 years old.

Albert has a new Covid infection, in his late 80’s with all the associated conditions –diabetes, COPD, hypertension, underactive thyroid and ischaemic heart disease.

He has had all three vaccines currently available on the NHS and despite the Covid he isn’t too unwell.

His son asks for a home visit because he has noticed they have become delirious and a little chesty.

As a doctor working outside of hospital you are quite limited by what you can do.

Checking heart rate, oxygen saturations, blood pressure and so on are straightforward.

You can talk with the patient and their family. (If you are a GP you have to rush back to the surgery in 20 minutes to sort all your other patients.)

You can determine a diagnosis and work-out what to do.

The options would are either, wait and see what happens or, call an ambulance (there are in-betweens, for the purpose of this blog, please bear-with).

The doctor calling the ambulance rationalises their actions, ‘I don’t know what will happen to their chest (NB not ‘Albert’, but his chest – a lapse into pathology and medical-speak helps the doctor distance themselves emotionally and psychologically) – it (their chest) might get much worse tonight, he is a little wheezy, could be the start of Covid pneumonitis, I don’t know if he has become dehydrated, sure, he can drink at home, but there is no access to IV fluids, and what if he needs intravenous antibiotics, and, then there is the confusion, and his CRP (test of infection/inflammation) what is that doing? Sure, if he gets much, much worse, he wouldn’t want to go on a ventilator (he told me), yet, he is still quite fit (for an 89 year old with all his health conditions), and, how will he manage, what if he falls?

Just a soupcon of a doctor’s internal dialogue.

The doctor further rationalises, ‘Well, if I call the ambulance and they take him to hospital and A&E check him over (do bloods and an x-ray) and he is fine they can send him home’ (doctor, internally not wanting to concede that trip to hospital will take four hours (ambulance are very, very busy), A&E is rammed, it will take eight hours for him to be seen by a doctor and by the time the bloods and x-ray are back, even if they are all normal it will be too late at night to send him home’) (So, yes, although not openly admitting, ‘ambulance’ means, move to medical ward for a period of time.) (Oh, and, as he has Covid, that is, the Covid ward. No visitors.)

In the conference a team from Northern Ireland presented cases of patients they had supported at home.

One was a man similar to Albert.

He didn’t want to go to hospital, he said he would rather die than go. The H@H went to him.

They provided oxygen, intravenous antibiotics, steroids, Remdesivir. They monitored his fluids his blood pressure and provided extra support for him and his wife. It was a wraparound in the community.

He recovered – he was so grateful he even made a You Tube thank you (played at the conference).

Some of you reading this might be thinking, ‘Ah, but the cost, the logistics!’ and, yes, that care was expensive, and not likely the intensity most patients require who will be supported at home, yet for this man, the alternative would have been death. And, again, ‘Well, if he wasn’t willing to go to hospital he should have been left to die,’ Some might think (but not say), and yes, there is a resource and an economic argument within the ethics of all of that, and yet.

And yet, research recently conducted on H@H has shown that it is overall less expensive than hospital care (which has multitudes of hidden costs) – the saving being, in the region of £2,000 per patient (supported at home rather than hospital).

‘What?! Why aren’t we already doing this!’

Well, a major factor is the model of care we have inherited from the last century, the medico-centric, bigger and better hospitals concept (What was it that BJ said about building 40 new hospitals?)

If we change the focus, the movement of the money, the staff and the resources from hospitals into the community, to develop community services we can achieve the miraculous.

Have a good week.

Analogy

I enjoy analogies.

I find they help me remember.

They are part of a theory I have, when writing or teaching, that, they help ideas stick.

Perhaps not, it is just a theory.

My most recent analogy related to person-centred care.

Yes, I know I should move-on, find something else to worry about, yet, it remains such a central component of everything I do and believe that it is hard to me to shift gear or change focus.

The basis of this is humanism.

To the best of my knowledge, we have not, as yet, discovered another system of belief that supports in an equivalent way outside of the supernatural.

Avoy.

Which I am told is not a Yiddish word, but one which somehow established itself in my subconscious and pops-out every so often. (To me it means ‘oy vey’ and ‘there you go’).

Back to the analogy.

I will use it tomorrow.

I am giving my annual ‘old people’ lecture to medical students in Sheffield.

It was a damp squib last year (if I did it at all, I am not sure, might have been the year before) as I did a Zoom recording.

I hate recording myself on Zoom.

There a technique or a system to employ to bring-out spontaneity in the process; suffice it to say, I haven’t found it and it leaves me feeling wooden. Woollen. Woollen and wooden.

Not a scintillating educational combination.

Tomorrow is face-to-face.

It could be that my daughter will be sitting-in as it is after he school day and the lecture is in Sheffield, so, if I pick her up she can see me in action. Which, to me, is something as none of my family have ever seen me lecture.

‘The analogy, my good fellow, tell us about the analogy!’ You ask. (I read A Room with a View last week & watched the movie last night) (lots of good fellows in Edwardian England).

So, yes, the analogy.

Well, it relates to the concept of care that we provide to patients.

There are different ways of caring.

You can care on the basis of what you think is right, good and proper for the patient (Cousin Charlotte) (Oh, I am EM Forstering this!) – this is doing to.

This is paternalism.

‘You have a cancer, we will open you up, cut it out, a few stitches and all will be well.’

Versus.

Doing with,

That is, finding-out what is important to the person/patient, establishing what they want and working-out how you can use your clinical skills to achieve a goal that is doable by you and desirable by the patient.

There is a whole movement which espouses this approach, it started in Scotland (Ah, the Scots. Sláinte.) and has spread globally – What Matters To You.

All the evidence (and there is much) suggests if you as a doctor, nurse or therapist do something to a patient that they don’t want, i.e. doing to, the outcomes are much worse than doing with the patient.

Logical but surprisingly uncommon in 21st century Western Medicine.

The analogy.

Well,

The first form I used was based upon my daughter’s request for an iPhone.

It went something like this:

My daughter asks for an orange iPhone.
I buy her a black iPhone.
It is as good as the orange iPhone.
It is black.
My daughter thanks me for the black iPhone.
It’s not the orange one.

This was meant to illustrate beyond the realms of pettiness that, if someone wants something, even if you get a thing that is quite similar, if it isn’t what the person wants, if you miss the mark by even a tiny amount, the effect is diminished; you have done to, rather than done with.

The medical equivalent might be the patient agreeing to have their bowel cancer removed.

They wake the next day and the cancer is gone.

They have a stoma.

No one mentioned a stoma.

Yes, they care cured, the cancer is gone, yet, now a stoma.

Maybe it is not right to compare cancer treatment to iPhone purchasing, apologies if I have offended.

For the lecture, after discussing the above with my daughter, I changed the narrative;

I asked for an orange iPhone for my birthday.
My family bought me a black iPhone.
It is as good as the orange iPhone.
It is black.
I thank my family for the black iPhone.
It’s not the orange one.

Subtle change of context;

Easier to use yourself in these things.

I am not sure how this will go down tomorrow.

I wasn’t sure what other cultural reference to use with the students.

I am getting older, by the minute, by the moment, and they, are eternally stuck at 20.

Weird to consider.

I am not sure how teachers do it.

Facing their mortality on a daily basis.

For me, most of my patients are old and getting older with me.

It makes me think of a spacewalk where the tether has snapped; I am drifting off and the spaceship is moving away. It is me or the ship that is moving? Both of us? All is change. You can’t put your hand in the same river twice.

I need to move-on.

Or perhaps stand still.

The Waterboys, Gene Kelly & Worm Moon 2022.

Friday night, I was driving home.

First Southbound along the M1 then on to the M18, followed by an A-road.

The moon.

The moon was big.

Massive.

At first I wasn’t sure whether it was just a full-moon,

Or, whether it was something different.

As the road curved, or trees appeared I would lose-sight,

For, it was low at that time,

Maybe seven in the evening.

I wondered whether other motorists were seeing or thinking the same,

‘Wow, what a moon, is it big or just full?’

Impossible to know.

The sky was bright

As happens on a full-moon, for full it was,

Yet, was it bigger than normal?

Closer to the Earth.

You can’t figure these things at 70 miles an hour.

I thought of the moon’s gravitational effect,

Was it pulling the tides, causing them to rise?

I recalled my brother losing his coveted snorkel

In a particularly high

August tide in Newquay.

I thought of the residents of my care home,

Was it disturbing their mental continence?

Would it influence me?

As I reached Maltby,

I saw a man,

Standing by the side of the road with a camera on a tripod.

‘There, I knew it, it must have been a special moon.’ I thought,

Vindicated.

Eventually I arrived home,

The sky was still clear,

Dark and cold.

‘Have you seen the moon? I asked my daughter.

‘I’m inside,’ she guffawed.

‘Look, look at the moon, it’s huge!’

‘It looks normal to me.’

An hour passed.

My partner returned home.

‘The moon! Have you seen the moon?’

‘Yes, it was massive.’

A second vindication,

But not with my fervour.

And that is it,

That is human perception.

Our existence as a self.

As the multitudes,

As the matinee that is our inner-word.

‘I was grounded
While you filled the skies
I was dumbfounded by truth
You cut through the lies
I saw the rain dirty valley
You saw Brigadoon
I saw the crescent
You saw the whole of the moon.’

Exciting moon facts:

Friday’s moon is called a ‘Worm Moon’ in America, as to why, no one knows; perhaps it is the worms emerging from their winter burrows, perhaps it is other grubs appearing.

The worm moon, which is the last moon of winter is also called the Lenten Moon occurring as it does during Lent, before the spring Equinox (although if it happens after the spring Equinox, it is called the Paschal (Passover/Pesach)* Moon)

Some people call Easter a moveable feast as it occurs at a different time each year depending on the lunar calendar.

For more on the Paschal Lamb, see this blog I wrote!

On Friday (18/3/22) the moon was at 100% illumination in the sky. On that day, the moon was 400,000 Km away from me and 150 million Km from the sun. the light was doing strange things that night.

Brigadoon is a mythical village in the Scottish Highlands. It is said to materialise every 100 years; it is also a 1954 movie starring Gene Kelly.

Human, all too human.

Everywhere the necessity for togetherness,

Everywhere our separation.

It seems grand to start a blog referencing Nietzsche, yet, it seems appropriate.

Within the greatness of humanity, that is, the technological and scientific advances of our age, the artistic and emotional evolutions, is a core of collaboration, of working together towards a greater good, and yet, like a shadow we are haunted by the dark side of our spirit which tears us apart, which forces us into competition and undoing.

This morning I woke to the theme tune to Rocky IV.

That’s the one where the champ is forced into a fight with Captain Ivan Drago, hero of the Soviets. (Actually Swedish actor, Dolf Lundgren).

It came out in 1985 when East versus West filled the headlines.

Today, 40 years later, again, we have East versus West.

MacDonald’s and Ikea withdrawn from Russian cities, the Rouble disconnected from international finance. Bombs in Kyiv.

It is admirable to look up and out and criticise the world around, the naivety of the Russians, Syrians and Byelorussians.

Close-by, the same separateness exists.

In healthcare we have the patient, the monad, the focus of our attention and, all around we have competing disciplines, occasionally coming-together (we call this multidisciplinary working), frequently falling-back on outdated tropes.

Health and Social Care.

The individual’s need is perceived as being related to their health, that is, all that has to do with the beating of the heart and the movement of their physical body and, social care, which is the actions of that body, how it behaves, where it lives, how it washes and dresses itself.

All as if they are independents.

And so too with the mental and physical.

Try speaking to a psychiatrist about the pain in your knee or your disordered bowel, ‘That is a physical health matter, I cannot advise,’ they will tell you, or, conversely, ‘I can’t face the world, I’ve had enough, please help,’ you cry, ‘That, my dear patient, is a matter of your mind, I will find you a good mental health professional. (6-week wait). Let me know if you have any more chest pain.’

These microcosms of health and wellbeing seem laughable, yet, they are all too true, and, they are the basis of what makes us human.

We see the world and our little sphere of influence, beyond that is a blur, an existential myopia.

I live in South Yorkshire, there are a half a million or so souls hereabouts, living within the borders of Sheffield, Doncaster, Barnsley and Rotherham, and here too the barriers exist. Try registering with a doctor if you live at the wrong end of the street, ‘I am afraid your address is outside our boundary,’ or even more difficult, requesting a disabled parking badge or attendance allowance, ‘You have a Rotherham GP when you live in Barnsley, that’s a problem.’

It is ‘The computer saying no,’ on a grand scale.

Humans build the computers and create the algorithms, it is the fault of the people not the machines.

‘They make a desert and call it peace,’ perhaps it is the complexity of relationships that are too difficult.

We have evolved to get-on with our close families and our clan. The human mind can’t compute mega-cities; it needs to close-down. This is also likely why we struggle with leadership in the modern era – people aren’t constructed to function at such scales, consequently you get arseholes – Putin, or charlatans, Johnson.

I feel like a broken record, raising the banner of person-centred care, as if this is a panacea.

And yes, it is.

It is the method for stripping away the nationality, nationalism, the mental and physical health, the care, the social workers and medics, getting under the skin, rub rosa, to the person.

The human that is all too human.

Vulnerable and uncertain in an unpredictable world.

Or is this but a fata morgana?

Stripping away, hacking at the unessential, to the core of who or what we are.

This is the transparency I encounter when I visit patients at home, in their poorliness or vulnerability, on their death-beds, in their terminal loneliness.

Everything else is a joke.

I will keep looking, I will keep aspiring to unity, to unification, to the oneness that is so very obvious yet so hidden away.

All my love, without the wax.

Black-belt medicine

When I was younger I spent a few years as a Karateka.

That is, an exponent of the martial art of the open-hand (Japanese; kara = open, te = hand, ka = practitioner).

Between the ages of 12 and 16 I was entranced, caught-up in the mystique, the thrills and spills.

I should write a blog about this one day as it was a memorable time, with my first Sensei Michael Aleko, who later became a Hollywood graphic artist and my last, Douglas Paul who knew the art of Shukokai ‘body blocking’ and had previously spent time working as a mercenary in Southern Africa.

The thing with Karate, and I am not sure if this is the case with other youthful activities, the repetition of the actions, the time spend inside your head imagining all the blocks and punches generates thoughts that remain with you long after you have moved-on, grown stiff and out of condition.

What I mean by this is, even when I was 32, a lifetime after I had stopped wearing the gi, I would still conduct imaginary battles in my mind’s eye. Fantastic jumps and spins, defying gravity and common-sense.

These were never translated into actions, the dreams were of a 16 year old with a 16 year old’s abilities inside a 30 or 40 year old body.

Too many hours watching Enter and The Way of the Dragon.

Too much reading Bruce Lee.

I was talking about martial arts yesterday.

It was a Saturday morning medical student lecture, run online and arranged by students from King’s College and Cambridge.

Very prestigious.

They seemed to find me via an article I had written for the Journal of the British Geriatric Society about the speed of doctors on ward rounds.

I talked all about my experiences as a doctor who a few years ago fled the confines of the hospital ward and the strictures of in and outpatient sessions, to the freedom of the open road.

Jack Kerouac would have been proud.

In the talk I presented my ideas relating to white and black belt medicine.

I have covered something along these lines before in discussing the management concept of wicked and tame problems.

If you want to read that you can go here.

For me, the difference between the two belts and their equivalents in medicine can be described as transactional and transformational care.

The first, the former, is the white belt.

It is the doing the do, following the recipe-book, Googling your condition and following the instructions.

The instructions can be straightforward self-care ‘rest, apply ice and elevate’ in the event of a sprain, through to the most sophisticated robot or laser-guided surgery, extracting clots from the brain’s posterior-circulation (yes, they do that nowadays).

In the tame/wicked world, the issue of how you remove the clot from the basilar artery had a clear beginning and end, the start is the patient with sudden onset of symptoms, maybe dizziness and the end is the clot gone and the patient recovered.

None of this is underestimating the in-between, complex public health messaging (that gets the patient to hospital in time), the skill of the diagnostician, the logistics of the hospital or care system and the operator who removes the clot, supported by nurses, therapists, technicians.

It is likely, barring nuclear or environmental disaster that humans will continue progressing medicine in this direction, undertaking the miraculous.

That’s white belt.

Seems black belt to me, you might think.

Well, I am not trying to diminish the skill of the scientists or operators, the professors and academics who underpin all of this, it is just, that ultimately, I might be able to sit in front of a computer, press a button and receive a diagnosis, then call a number and the treatment happens.

It is finite. Doable. Within the limitations of physics and technology.

And what of black belt?

Well, that on the spectrum is wicked.

It is the thorny side of medicine.

Medicine that has dirty nooks and crannies where human error, personal preference, economics and individual variation lurks.

It is the patient who does not follow the rules, who smokes and drinks too much even after their life-saving bypass, it is the old woman who prefers to cling to her furniture rather than mess around with the shiny new Zimmer Frame bought for her by the family, it is the man with diabetes who loves a big-mac and hides his Metformin under the cupboard thinking the GP notice. (HbA1c doesn’t lie).

It is the prettiness and ugliness of getting more for less, or rationing health resources and providing sustainable care, it is convincing those people who administer the medicine or the apply the dressing that they should continue to care, day after day.

Black belt medicine is realising that the evidence-based guidelines for the management of hypertension or vascular disease or cancer reflect the opinions of academics, the statistical determinations of thousands, not the whim of the individual.

It is the caring and kindness, the compassion (yes, you can suffer with your patient), the love and support, the creativity and imagination to think around difficult problems. It is the skill of communication, being able to sense the subtleties of eye contact, tone of voice and rate of breathing that indicate worry or surprise or fear.

It is the infinite possibilities of what is means to be healthy or sick, happy or sad, angry at the state of your health, with mis-directed frustration that can be perceived as rudeness or antagonism which is in reality fear.

The best doctors, nurses, therapists, carers and support workers get this.

They see the whole of the person.

The enormity of the situation.

It isn’t necessarily something that can be taught or learned or bought, it requires focus, time and commitment. It is tapping-in to the humanity of the process of care.

In the world of martial arts, the supposed cycle is that of the student starting with the white belt and through struggles, practice and time, the white darkens to become black. It isn’t the stepwise progression sometimes bought from the shop.

In the spirit of holism, the beginning is the end.

The master once he or she arrives discovers the simplicity, they revert to white.

We contain multitudes.

There are innumerable cliches that work to describe this journey.

I’ll end with an anecdote then a poem.

One night, maybe ten years ago I was on call.

A young doctor on the ward phoned me with the story of their patient, a 48 year old man, admitted with chest pain then vomiting. He was bringing-up blood. We call this haematemesis. The most common cause an ulcer. The doctor was worried by the amount of blood and the patient’s condition.

At this time when was working in Doncaster, there were not enough gastroenterologists to run an out of hours service, the system was to call Sheffield.

‘Can I speak to the gastroenterologist on call.’ I asked the operator.

‘Putting you through, it is Dr X tonight.’

‘Hi, is that Dr X? My name is…’

‘It’s Professor X. You woke me up.’

He gave me a hard time, he wouldn’t accept the patient (transfer from Doncaster to Sheffield) – in his opinion it could wait until the morning.

The patient survived.

This was a guy pretending to be togged-out in black but wearing white.

The patient’s anxieties were not addressed – he continued to vomit, neither were my fears or those of the doctor on call on the ward.

The patient was a number, a statistic, a hazy three in the morning representation of instability.

This is from one of Bruce Lee’s books, I can’t remember which – I think he took it from (I believe) an ancient Chinese source;*

‘He who knows not and knows he knows not, he is a fool, shun him,

He who knows not and knows he knows not, he is simple, teach him,

He who knows and knows he knows, he is asleep, awaken him,

He who knows and knows he knows, he is wise, follow him’**

*There is a suggestion that this is nothing to do with Bruce Lee, regardless, it carried me through my early teens.

**Don’t over-analyse, please get on with your day.

Be well.

Rod

Holidays

I am famously last-minute.

If you know Myers-Briggs, you could guess the last letter of my type.

Despite this propensity, I almost always get things done on time.

The argument to myself and those around me who wonder why I am not doing anything when I should be preparing is that I am thinking (worrying) about it.

This might seem like an excuse – it is a genuinely held belief

Although there is nothing to see, I am confident my unconscious mind is working away in the background.

It might not.

It could be that whatever I do, this blog, for example, is generate in the nanosecond before I type.

What comes first? Thought or action? Thought about thought then action?

This might seem unrelated to holidays, yet, that is where I am.

Easter is coming-up.

I overcame every form of conceivable inertia to book my leave.

I’ve still not decided where to go.

It will be my daughter and I as partner will be working and minding the dogs and son is down-south learning to scuba.

The original thought was Israel, to see family, perhaps witness the Easter and Passover preparations.

The flight operators have considered this too and pushed up the cost of ticket.

Well, that, and there is the pollution.

The damage international flights causes.

You know that argument.

And now, Ukraine.

What does that have to do with my holiday?

Well, it isn’t fear of venturing into Europe, if there is a nuclear war, it won’t matter where we are.

It is the guilt of coming-across refugees.

‘Hello, I am Rod, checking out the sights. So, your entire belongings are in that suitcase? You are fleeing the bombs? Your dad is back home, being starved-out? Your granny is back home too, lapsing in and out of a diabetic coma as insulin supplies have disappeared. My hotel is very nice. I am on holiday. Life is tough.’

Whether I go on holiday or stay at home and feel guilty, this will make no difference to those suffering.

I read a Guardian article yesterday indicating the proposed plans (why not actions?) for accommodating refugees in the UK.

I could open-up my house.

The thought is easier than the action and nothing is happening yet.

I could send some money to DEC.

I’ve done that already.

I could send more.

I could send all of the money I have in the bank and it is likely it would make little difference to the bombs that are falling.

The situation of helplessness is numbing.

I could wear a little yellow and blue solidarity badge.

I can’t imagine that will make much difference.

I have written before about the Latin root of compassion –

Suffering-with.

I want to show compassion.

Compassion doesn’t help the lack of Salbutamol or Amoxicillin.

Covid led to major interruptions to family time over the past two years.

We managed away to the Hebrides in the summer but not much else besides.

I owe it to my family (we are all off in the second week of my leave).

Staying at home and brooding won’t do anyone any good.

Watching Channel 4 news neither.

Oh, the challenges of a privileged Western Existence.

The problems of having too much.

I appreciate some, perhaps most will consider this self-pity.

‘Get on with it!’ They might say.

I kind-of want to shout this to myself.

And after the worries about Covid and the environment and Russian Oligarchs has passed, what remains?

I could head-off to the Highlands. Find somewhere remote, leave phone and computer behind and disconnect for a fortnight. (Family, books and dogs are all I’d take) (& food).

Is that the answer?

Active disconnection.

It might do me some good.

It might help me recharge for whatever future faces us.

I might become a doctor more able to provide compassionate, timely care to those in need.

I could get-over myself.

My mum – for International Women’s Day 8 March 2022

My mum

Would pass thread through the eye of a tiny needle and perform what she called invisible stitches.

It was what all the ladies wanted.

The middle-aged women would call-in at our house

Requesting alterations

to aid their

spread,

their girth expansion

from the time in-between diets.

Mum would sit at her Singer sewing machine,

The whirr of the electric motor

and the mechanised

bobbing

up and down,

As the stitches appeared

and fabric was transformed.

By the time I was old enough, in the 80’s,

Mass-production

had removed the necessity to make your own clothes

although

I remember

My mum matching patterns to material,

Sketching-out with

Tailor’s chalk.

Triangular, smooth, and white,

that was no good for drawing.

I still have beside me a set of pinking-shears,

So called scissors,

named after the flower,

with zigzag blades

designed to stop fraying,

also, no good for paper.

And,

Big heavy shears

For cutting fabric,

Formal and sharp

and,

Heaven forbid I’d be caught playing with them

For fear of blunting the edge.

I also have the wooden yardstick

With bronze tips at the ends

and inch-long segments,

No use for measuring much

In my metric world.

Mum would record the inside leg

and waist

circumference

of the men and women,

People she mostly knew.

family friends

and acquaintances.

A long, white tape, she would sometimes hang around her neck,

When not in use

I would roll it up,

The plastic creaking

as I tightened.

Seamstress,

Dressmaker,

are the proper terms

Although she always thought of herself

as a sewer.

a doer of alterations.

It was focused,

lonely work.

Hours spent at the machine,

leaning over the table.

As she grew older

and her eyesight diminished

It became harder

for her to see the needle,

The placement of the pins became more difficult.

When I was little, I played with her pincushion.

A gift from my brother.

It was a red-silken dome with green threads running from the centre.

Oriental figures, with tight black hair

At the end of the rows.

Miniatures

Monitoring the sharp things.

I would take pleasure in

Plunging the pins in and pulling them out,

feeling the stuffing give-way.

I still have, somewhere,

In a drawer,

The red-retriever duvet and pillowcase cover,

She made for me when I was six.

There is nothing else left.

Drowning in data, in war.

There is a link you can find on Google that tells you the frequency of words appearing on the internet.

It’s called Google Trends.

It is a thermometer of what is happening, who is saying or typing what about whom.

Keywords. Covid, Trump, Ukraine.

the only positive being that Mr T is a flatline

It’s hard to think of anything positive to investigate.

What has been good?

It mirrors life, it’s hard not to get bogged-down in the bad stuff.

Many of us, me included have a natural propensity for thinking black.

Sure, there can be bright moments, but the tendency is certainly in the direction of the not so good rather than the opposite.

Perspective.

Interpretation and analysis.

The causes are likely long and complicated, a mixture of nature and nurture.

Last night, perhaps the result of too much sushi, I had some hyper-real dreams. In one, I was looking at photos my brother had sent me (In the post? Online? Who knows).

They were old pictures, the kind you find in albums from before the 90’s.

These were different in that when you looked at them, they allowed for a telescopic zoom inwards. You started with the photo of a confused scene and with the looking you were taken to a corner of the image that was expanded and magnified.

In one, I saw a small boy, floating inside an inflatable ring. He was maybe three. Black tousled hair. He was me. He was in the water beside a boat. Other people, his family were at a distance.

The analysis, midst dream, was, ‘How could they leave a little boy to float in deep water inside a ring, all by himself? What if he slips through? He can’t swim, he will drown.’

A dream-thought, everything at once.

I am reading the Beekeeper of Aleppo by Christy Lefteri.

In one scene a boy, Muhammad falls in the sea, the protagonist Nuri jumps in to save him.

I am also in the middle of Babi Yar (Babyn Yar), the autobiographical account by A. Anatoli of the events that happened in 1941 with the German invasion of Ukraine.

This was where the Russians bombed the TV tower in Kyiv this week.

It is a ravine outside Kyiv where Nazis led tens of thousands of innocent men, women and children, mostly Jews, but also Ukrainians, Gypsies and Russians to their death.

Lining them up and machine gunning them, covering them with sand and machine gunning more. The soldiers would walk across the dead and dying and shoot anyone who was still alive.

There is a scene in that book where the writer and his friend are swimming in a lake, his friend fails to surface and is rescued near death by a Ukrainian soldier.

Death by drowning.

I finished Dan Brown’s third novel, The Lost Symbol this week.

It also features a scene where Robert Langton the Harvard professor of symbology, hero of The Da Vinci Code amongst others is drowned in a box by crazy guy called Mal’akh.

I need to stop the reading.

When I watch the news, Ukraine looks like it is drowning.

An manmade tsunami.

Every image worse than the next.

The world looks-on.

We fear World War 3.

We fear for the moral basis of our existence.

We fear crazy men who remain in power for too long, who climb to the top ensuring multiple mutually assured mechanisms of destruction for anyone who might threaten them.

We hope for a putsch or a coup.

Good luck with the hoping.

The world is drowning and the landscape is changing and it is hard to perceive a cup half-full, to bring a positive spin to the news updates.

The mess is ever increasing in size and complexity.

Runaway train.

Whatever image you fancy.

Covid, we thought that was bad.

On the graph of all graphs, that is old news.

What is for tomorrow?

The cost of loneliness (Roubles, dollars or robots?)

Some of you will know that I am a regular dog walker, mostly twice a day, if time and the weather is good, more often.

I am also a little nosey.

Not a peeping-tom or a voyeur. I keep my eyes open.

As with everything in life, I am attracted to the familiar.

The familiar I see is carers coming and going.

Some individually, others in pairs. There is an occasional nurse.

I notice the key-safes. The ramps and hand-rails.

I see through the living room windows the (almost always) old woman, sitting alone in arm-chair, Zimmer frame and the diminished indoor light.

I see the loneliness.

Or, at least, I imagine it.

The carers will come once and up to four times a day, they will come in pairs if there are special concerns, for example, if the person, who is almost always old, needs assistance moving in and out of bed or their chair.

By the time there are two carers, the person is often incontinent.

It is hard to train your bladder or even bowels to operate to the variable regimen of an organisational rota. The calls might be 6, 12, 4 and 8. With every visit there will be latitude. Daisy at no 10 might take a little longer, Francis might be in hospital (no visits that day), carer Rebecca might be sick, and so on.

It is very possible that these old folk are not at all lonely.

They possibly enjoy the solitude.

Solitude is however, at least in my experience, something of a choice. I choose to be alone, I choose to avoid the party or the gathering, and so, I dedicate time to myself. Every day, for regular or intermittent periods, is not a choice, it is an imposition, secondary to the falling apart of society. The move of children and grandchildren to population centres for work or lifestyle, the death of partner or spouse.

This kind of solitude is forced upon us.

And we know the death of a husband or wife has an immediate and medium-term effect on the surviving partners’ wellbeing and life expectancy.

I am unsure whether the moving away of son or daughter has been measured. It is bound to have a similar effect.

And the death of friends, no matter the size of your social circle, if you are buddies for long-enough, there will eventually be only one person left. You might think yourself lucky to be the survivor, the one left behind. Kind of lonely though.

What are the alternatives?

Covid was a death-knell to the alternatives.

This was one of the indirect harms of the pandemic.

There is a trope that Death walks at a certain speed. So long as you walk more quickly you are safe. Covid has slowed-down many people. Some it has brought to a complete stop. Housebound and then bedbound situations make it easy for Death to get you.

There are groups and clubs. Online if you are savvy, switched-on and able, they call it Social Prescribing, when you try to address your loneliness by calling the GP too often. These teams direct you, signpost to places of support and engagement. Useful alternatives to anti-depressants, opiates and alcohol, although frequently ineffective.

And so, the old woman, grey living-room light, the reflection of daytime TV in her specs. I can’t hear and I only glimpse for as long as it takes my dogs to pull me towards their next stop.

In some countries they have built retirement villages, a means to creating a social environment where people can live semi-independently. We have a few areas in Rotherham constructed upon a similar premise, in my experience, the social butterflies engage and connect, many others sit, waiting.

And the final common denominator of living in care. Institutionalisation. Move to the care home. If you are ‘self-funding’ that is, you have money in the bank or property to sell, this is often a straightforward transition.

For those reliant upon social funding there are multiple obstacles to overcome, for the most, the lonely dependent person has to prove that they can no longer cope living alone before this is considered. Often a trip or two to A&E followed by an inpatient stay after falling is enough to tip the balance; certainly if you are confused.

Criteria are determined by checklists – if you tick enough boxes you will be allowed-in, that is for the NHS or the social care departments to pay for your living expenses, if not, you stay in hospital or another temporary facility until you have deteriorated to the extent that you tick more boxes.

Apologies for the cynicism. This is how it appears to me.

For some, moving into care is the worst thing imaginable. Worse than death, worse than a plague. Being allowed to sit for hours alone in their front room with TV and pads for the toilet is considered more desirable than ‘care’.

Some of this bias is I imagine based upon peoples’ own experiences of care in the 50’s and 60’s in the UK when their parents and grandparents were in a similar position. Yes, those environments – NHS long-term care facilities were truly awful. (Have you watched this video yet?).

The world is different and although there are some dodgy care homes, most are good if not great.

In the past year, something like 1000 care homes have closed in the UK, the costs of insurance, inability to recruit or retain staff, the Covid vaccine conditions of employment and the wages (more in Amazon without the emotional baggage, I hear) has led to a decline in the options available.

Yes, it’s Brexit and the Tories and all that.

And, what would I want?

I find it hard to imagine the time or the situation where I would want to move into care.

My current head sees my independence. My ability to move when and where I like (albeit within the constraints of the dogs), I have my family and work and things are fine. My bowels and bladder are fine.

Who knows.

Suddenly in the middle of life is a condition of unexpected catastrophe that changes everything. No one knows when this will be.

We work towards the mantra of ‘home first’ – this being the notion that when an older person falls (most often) or becomes unwell (they often fall, then become unwell because of an unnecessary and prolonged admission to hospital), the ideal outcome is for them to return home.

Home First.

What if home is a broken TV and carers who don’t appear to care or who are unable to engage or relate to you, who don’t speak your language or appreciate your sense of humour (or irony)?

What if home is a prison and even hospital is considered a step-up?

Home, home first, that is the chant you will hear in NHS circles.

Home is best.

People are less likely to fall or become ill at home, they are in a familiar environment which is particularly important for those who have dementia or cognitive impairment.

What if the reason the person has fallen or has become unwell is because they are at home, alone, lonely day in and day out?

The cost.

Home costs less than 24 hour care, residential or nursing.

And what is the cost of that older person failing?

What is the cost to them?

A current NHS obsession is to create ‘virtual wards.’ These are systems that allow people to be unwell, yet supervised by clinicians when they are in their own homes.

Gadgets attached to arms and legs send continuous transmissions of heart beat, respiratory rate and oxygen levels. Some will monitor temperature and steps taken in a day, others will alert you if the person has fallen.

Teams of staff will soon fan-out across the country to provide this extended care, the intention of which is to allow people to be poorly in their own homes rather than in hospital, something I 100% endorse.

Will it help loneliness?

‘Loneliness is not a medical condition.’

‘It’s not a social problem.’

The managers might say.

‘It is existential.’

Opines the philosopher.

What to do?

If you are lucky someone might buy you a talking doll or purring cat or wriggling puppy to keep you company. A.I. that is meant to bridge the gap between having someone to hold your hand and being alone.

These technologies only seem to work if you have dementia or are adept at fooling the people who have bought them for you that they work.

One patient recently attempted to resuscitate her (toy) baby when the batteries ran-out.

Surely we can do better?

I saw the horror of mechanised flame-throwers en route to Ukraine yesterday.

We have the technology, the sophistication to create these devices but can’t fix loneliness.

What a world.

What a time.

I sometimes joke that we need robots.

I am not sure whether I would get on with a robot in my loneliness. I suppose that would depend upon the algorithms.

Man or woman, Irish or Australian?

Years ago I wrote about the Israeli trend to employ women from the Philippines to look after their pensioners – the idea being that it would cost less to employ such a woman (I didn’t see any men what I was last there) than putting the old person into care.

I don’t know if that system is still operational.

Let’s face it, we have a problem that has no easy solution.

And yet, soldiers march along darkened streets, night and thermal imaging in action.

One of the reasons I moved from working in the hospital to supporting those in the community was the sense of futility I experienced on ward rounds. The daily nods to people who were receiving treatment for conditions that were potentially avoidable, the pressures to discharge to make way for more and more, the conveyor belt of sickness and disease. Chipping away at a mountain that is always growing in size.

When you reflect on the whole system, it is apparent that the hospital is positioned on a tiny hillock, the greater body of human need and suffering is on a massif ten times that size and also growing, moving ever upwards, with increasing frailty and dependence.

I hate to end these blogs on a down note and, I appreciate I have been writing for too many pages – most will likely have lost interest by now.

And so, tenacious reader, if I have managed to maintain your interest, I thank you and move towards some solutions.

Sure, let’s stick with home first, after all, unless it is an option it won’t be considered, yet, let home first be the option only if the person wants to go home. If home is a prison, let’s rethink.

And let us work on preventative care, let us focus on those who are most at risk.

It is ironic, in that every patient in the UK who is 65 or more has a frailty score assigned to them (if you don’t believe me, ask your GP) and, from this it is straightforward to establish who is most at risk of hospital admission, deterioration and decline, you can probably establish who is loneliest too.

Proactively working with the frailest of the frail is a start.

Those living in care homes are frequently at the top of this list of dependencies. Ensuring their wellbeing is fundamental. Helping them to avoid falls and unnecessary hospitalisation can keep them well.

Virtual wards are a fantastic idea and I look forward to supporting our first patients, I can’t wait to peak-in on their physiological parameters and intervene before anything bad happens:

‘Mrs Jones, I can see your heart rate has become a little rapid and your temperature has increased, how are you feeling?…. I’ll be round to see you in 20 minutes.’

Fixing the loneliness epidemic is more difficult than rolling-out Covid vaccines, yet as important.

This is in part a re-fashioning of our society (easy, eh?!) with intergenerational work, supporting older people to realise the value they can bring to others, establishing the social capital of 90 years of life, translating that into engagement, especially the young.

Getting-in early to medical, nursing and schools of therapy and social work.

Explaining that much of the current direction of scientific research, pushing-back the boundaries of smaller and smaller units of knowledge and understanding, whilst essential for growth of technology is not necessarily of benefit to people as individuals.

Establishing an holistic assessment of health and disease, enforcing the complexity of the human condition and staying away from simplistic diagnoses ‘urine infection’ or pathways of care ‘home first’.

Let’s invest some of our sophistication into human interaction rather than iPhones, TVs and missile launchers, I am sure we can do it.

Let’s listen to what our patients tell us they want. Let’s give them the time and the space to communicate, let’s overcome the fear often encountered by people sitting on hospital trolleys, anonymous in tattered gowns. Let’s enable the disabilities, facilitate hearing and seeing to work-out what matters to our patients (and yes, what matters to those staff providing the care and support) – this is person-centred care and teams in tooth and claw.

Stripping away the routines, the should and must do, drilling-down to what it is to be human, to capitalise on the essence of who we are.

At peace, be at peace.

Thank you for reading.

Ukraine and Ubuntu

It’s hard for me and I suspect most people to think about more than the situation in Ukraine.

It is such a mess, so unnecessary and pointless.

If you have read any of my blogs, you will know that international affairs are not within my area of expertise, apologies for any inaccuracies or inconsistencies in what I now write.

When I look at Ukraine and the West’s response to the invasion I think immediately of Syria and the ineffectual way in which we, the West allowed the destruction of that country.

The similarities are writ large across the actions of the aggressor, specifically one gawky guy, supported in that instance by Russia and China as he oversaw the devastation of his country and the creation of the biggest refugee crisis in modern times.

The West offered sanctions and strong words.

They offered the opposition weapons as they were over-run and killed.

Russia, or, more accurately, Putin and those who enable his position of power will almost certainly take the same tack as Assad.

Threats, sanctions, reprisals and the leaders still receive their freshly pressed trousers and croissants and quail’s eggs for breakfast, they will enjoy everything that the rich in every country enjoy.

In Pyongyang, the rich have their Cheetos and Dom Perignon whilst the population barter for rice and milk.

And Putin has not achieved his position alone. The sanctions I hear are targeting him and his foreign minister. Shouldn’t we be targeting the entire Russian oligarchy?

As the super-yachts sail into Portsmouth, with drunken oil barons partying on the profits of the people, shouldn’t they be impounded, locked up or at least locked-out?

Putin has threatened the world with nuclear war. No, he didn’t say those words, although suggesting reprisals the likes of which we have never seen is the same thing.

Could he, would he?

What is it that drives these people to behave the way they do?

My daughter was watching Channel 4 news with me the other night; there was a short of Tony Blair shaking hands with Putin – it must have been in the 90’s.

‘How old is he?’ She gasped.

Blair has moved-on, his healthy complexion soaking-up the after-effects of premiership.

What keeps some of these men going and going? Bullying, dominating in their tyranny?

Is Putin a ‘great man’ as the theory goes? One whose actions and destiny shape the lives of millions of others?

I guess if he is great, Trump is great and, great is not so great.

That human tendency to self-interest is at its extreme in these individuals.

We are all the same.

(human, all too human)

We could impose meaningful sanctions on Russia – that would hurt the poor, as always, and without hurting the rich, what will change?

Sure, the poor might see beyond the propaganda they are fed, the news behind the news to see that the shortages of basic commodities are not because of Biden or Zelenskyy, but secondary to the actions of Putin, and move to take him out.

That is crazy, impossible.

It is only if those already in power see they must push Putin out, and are happy to jeopardise their positions, their wealth and dachas might they act. And the self-interest of their potential failure which would see their end and that of their families.

A difficult love-hate triangle.

I can’t see myself being brave enough to take a pot-shot at Putin, knowing that if I miss, it is me that is shot.

These folk have an uncanny habit of dodging the bullet.

And what do I know of any of this?

All I see are flashes of light, the light of missiles and rockets flying across the Ukrainian night.

What do I know at all?

If you have read this and realise I have told you nothing new, offered nothing that is not on the news, apologies.

It feels ironic, in that a fortnight ago, I attended a session with Chis Lubbe Nelson Mandela’s former bodyguard, now working for the NHS.

He talked of Ubuntu.

I am, because we are.

The idea, the ideal is great.

How do we move beyond this into action?

How do we, the billions walking round the streets of our neighbourhoods bring our focus to undo the badness that is out there, how do we join together and make a change that is more than words, more than staring at a TV screen?

Any thoughts?

Confusion Screen

Confused?

You might want to undergo a confusion screen.

This was something I was discussing with Dan, the medical student attached to our practice on Friday as we were driving out and about in Maltby.

‘Que?’

Well, there is this thing that developed, I’d say around about 15 years ago, when people (doctors, nurses) started talking about ‘the confusion screen’ for patients, often those in hospital. (aka I don’t remember this from medical school).

It is a basic assessment undertaken to determine supposedly reversible causes of confusion.

It is often considered a necessity before a mental health nurse or doctor will come anywhere near you, for fear the confusional state might be… delirium.

I have written about delirium in the past – I you want a refresher, please follow this link: Delirium.

If not, you will recall that delirium is a potentially reversible cause of confusion, particularly common amongst older people, although us ‘younger ones’ can be affected too, depending on the cause.

This isn’t a blog about delirium although ‘confusion screen’ is sometimes called ‘delirium screen’ – they are one and the same thing.

And, yes, I’ll outline what this screen actually is in a moment, first I thought I’d explain why I thought it relevant to blog about it.

‘Did she have a confusion screen?’ Asks Dan.

‘I’m not sure… I don’t really like that,’ I reply vaguely.

‘What? The tests?’

‘No, more the concept. I have a problem with screens.’

‘What do you mean?’

‘Well, I feel they are too reductive.’

‘So, we shouldn’t do them?’

‘No, don’t not do them, just see them as a means to an end and not an end in themselves.’*

*(I actually didn’t say the last bit, had Bruce Lee been in the car and had he been able to disentangle my thick-tongued response, that is what he would have said.)

OK.

Confusion screen. What is it?

Essentially, if you find someone who is acutely confused, that is, a person who is normally compos mentis who becomes disorientated, before pursuing a diagnosis of ‘dementia’ the screen is normally undertaken, it is –

Urine culture – infections can cause confusion

Blood tests – checking for infections, underactive thyroid, dehydration, raised calcium and so on (the list is long)

In some circles they still advocate checking for syphilis although that has mostly gone out of fashion. (I appreciate, neurosyphilis is out there, it is just not commonly a cause of confusion in older people these days).

That’s it.

There are more tests to do for someone who is confused (and yes, epistemologically and phenomenologically, the concept of ‘confused’ itself is abstruse.)

And that is really the problem.

I don’t like screens.

There are some screening programmes operational in the UK that I am OK with, for example, screens for breast cancer (mammograms) or bowel cancer (FIT tests) – those, I can cope with as there has been lots of work done to demonstrate evidence of benefit to patients (they have their cancers diagnosed early and live longer, for example), whereas the ‘confusion screen’ doesn’t (as far as I am aware) have any evidence for benefit, it doesn’t save or prolong lives, it often just gets in the way.

I also feel it’s too vague.

In Rotherham, there is a pathway (see here) called, ‘The Vague Symptoms Pathway’ – it is a referral route for GPs when they suspect someone has cancer but don’t know where it might be.

The pathway involves checking lots of blood tests (screening) and then referring for a CT scan of a patient’s chest, abdomen and pelvis, with the notion being, if all that is OK, there can’t be much wrong, or, at least, anything treatable or reversible.

As you can guess, this, like the confusion pathway isn’t something that sits well with me.

It is so vague, non-specific, non-person-centred.

I have never referred a patient via this route, ‘Sorry, I don’t know what is wrong with you, it’s all very vague, I’ll ask someone to do a scan.’

For some that might be satisfying, although for others, when the tests are normal and the doctor explains, ‘Everything is normal,’ this is not much of a balm for the weight loss or pain or sweating or other symptoms they might experience. (The next step is often referral to specialist after specialist). (You are really screwed if you have a functional disorder).

I recall several years ago a patient asking for a ‘whole body scan’ – I explained to them at the time that there wasn’t such a thing.

Folk can purchase MRI scans of their whole body, with the idea that something might be picked-up, this is however contrary to the ways in which disease operates and modern medicine (for all its flaws) functions.

Just because a scan is normal doesn’t mean there is nothing wrong, the results are dependent on the scanners sensitivity, the human reporting the images taken, the stage of the disease.

There are no doubt labs in the world today that seek the holy-grail of cancer that can detect abnormalities at such early stages that you can have treatment before anything bad happens.

Oy, I’m getting off topic.

I don’t think I provided Dan with a good explanation of why I don’t like confusion screens, and, yes, if you are my patient, I will likely do those tests, frequently whether you are confused or not.

I think it is the notion that medicine can be approached simplistically.

Sure, we need to be able to explain what is going-on in a straightforward way to our patients, we do however need to have an understanding of the complexity of what lies beneath (or within?)

You can’t screen for complexity, I guess that is it.

Just as you can’t run a memory test by asking folk the time of day, the year and month and arrive at a number that says, ‘dementia’ – it’s more complicated than that.

I guess the conversation should have run:

‘Did you do a confusion screen?’

‘No.’

‘Why not?’

‘It’s complicated.’

Have a good week

Thanks to Dan for accompanying me on my travels.

*Note, I have altered some of the conversation for bloggerly effect.

Safety netting – to net or not?

If you are prone to falling, it is useful to have a safety net. You know, something behind or underneath you that will stop the harm that might occur otherwise.

Safety nets are used extensively within healthcare.

In medicine, you will find this more commonly in primary rather than secondary care, in that, in the former, a patient is typically at home ‘responsible’ for themselves and the interaction with the GP or community nurse is episodic – a phone call or a visit and then they move-on. Most of the minding or supervision is done by someone else – the person/patient, their family or carers.

For hospital inpatients this I different in that that care is usually continuous during the time that person is in a bed or a clinic, in effect, the responsibility shifts from the person to the nurse, therapist or doctor who is doing the doing.

The most common trope, or at least the one I encounter when reading clinical records is the sign-off, ‘If you have any more pain/nausea/dizziness/palpitations/etc call 111 or 999.’

That is the safety net.

It says, ‘I have seen you and at the time of our meeting, you seemed OK, you might be unwell but not bad enough for additional help or transfer to hospital for emergency care, you might however get worse and if you do, don’t ignore the symptoms, call for help.’

This is sensible advice as a worst case scenario would be a patient who experiences central crushing chest pain thinking, ‘I’ve just seen the doctor, she said it was my indigestion, I’ll take two aspirin and lie down.’ Or, ‘The doctor said the rash looked like a bruise, my headache, difficulty looking at the light and vomiting must be nothing to worry about.’

Sure, some readers will think, ‘Honestly, this isn’t nannyworld, people have some responsibility, they should use their common sense.’

It is however down to the language and communication, the confidence with which the doctor or nurse engages with the patient and how that is heard and understood.

You might be wondering, ‘So what?’

Well, for me, the ‘So what?’ is perhaps the over-use or over-reliance on the safety net.

I’ll explain by means of analogy, think a tightrope walker, winging their way between two high places.

The presence or absence of a safety net changes the narrative.

It changes the spectacle for sure, although likely and more importantly it changes the behaviour of the walker, after all, a fall without a net is the end, with the net is an embarrassing bounce.

I don’t want to suggest the carer in the nursing home who calls 111 when the resident has a further funny-do is an bounce, it does however let the initial assessor – doctor, nurse, paramedic a little off the hook. They are OK to be less confident in their original review and potentially even less thorough, and this might be communicated to the carer.

The walker without the net is surely a more careful walker.

Is the doctor who uses a net a less careful medic?

It is hard to say although certainly when I review clinical records, it seems the more junior and less experienced staff tend to rely more on the net than those who have been around longer.

You might question whether the presence of the safety net is an issue.

Well, you see, and this is particularly a Covid phenomenon, the numbers of clinical encounters between patient and clinician who have never met or spoken to one another has increased, whether this is new staff in a surgery who haven’t had the more traditional face-to-face contact or those visiting services (often nurses and paramedics) who have stepped-in to undertake home-visits in place of the more traditional GP house calls.

When you interact with someone who doesn’t really know you, and who perhaps has less access to details of your medical history, the tendency is towards what we call risk aversion – this is the behaviour where every possibility is considered something bad, every rash is meningitis, every bump a cancer, when, in reality, most rashes are eczema and bumps are just bumps.

Disentangling this is tricky and that is the reason we value those working in the NHS for their skill and discernment.

A referral through a cancer pathway or acute admission to hospital for a rash that has been present for 10 years is not usually in anyone’s best interests, yet it still happens and it is more likely to happen if the person seeing you has not seen you before, or has never seen you at all if the encounter is on the phone.

And, yes, we don’t want gung-ho high-risk folk who skirt around the peripheries of diligence and miss important diagnoses.

We want Goldilocks.

And this is the tension between risk aversion and safety netting.

The risk averse doctor or nurse is more likely to safety net, they are more likely to communicate their uncertainty to the patient and carer which leads to an interaction that is diminished of its value, after all, most patients just want some reassurance and, reassurance is not what is provided in the risk-averse, over safety netted encounter.

The solution?

Well, I suspect a major part of this is shifting back in part (not the whole way) to pre-Covid face-to-face encounters when possible, particularly if the doctor or nurse has never met the patient before (and even more if the patient has cognitive, visual or auditory impairment).

It is also returning to continuity of care.

The same clinician seeing the same patient on more than one occasion.

The creation, development and nurturing of relationships.

Unfortunately with the latter, the continuity has been bedevilled most recently by Covid but more generally by the most towards system-led healthcare with bigger and bigger health centres where staff work shifts and individual relationships are broken-down.

(If you are one of 5,000 patients or one of 50,000 you will know the difference).

If I know that Mary has a tendency to rashes or picking spots or whatever, the next time I see her I will automatically view her through a lens of rash/picking/spots. If she is new to me the encounter will be a tabula rasa. And yes, a new pair of eyes is sometimes required to overcome preconceptions, it is however, particularly in my world of older people who are never quite right a greater risk.

How to end?

To net or not?

A doctor who doesn’t net at all is one who lives precariously, and I would not suggest that this is done away with, I would however recommend a review of the language and how it is used, the way diagnoses or impressions are communicated, the way reassurance is provided and received.

‘It’s nothing to worry about,’ will allow a person to feel better, ‘I’m not sure, I think it is nothing, although it might be something, if it gets any worse, if it starts to grow or bleed or not improve, call me back.’ Less so. And, ‘I am sure you will be fine, if you are worried, call an ambulance.’ Not at all.

The week that was and was not!

I had planned to start this blog with, ‘It’s been an uneventfully eventful week.’ I am not sure what that means. I did it and I didn’t. an opening paradox.

The idea came from the book I started yesterday as preparation for the play I am taking my family to see in Sheffield in a few weeks. Anna Karenina.

I won’t tell you the opening although as books go, it is probably the only one other than A Tale of Two Cities and Moby Dick that I know the beginnings. Oh, and maybe On the Road.

I am sure there are many more famous openings.

If you are interested, see below.

Well, what took place in your week Rod?

I was on leave for the first few days.

It was a topsy turvy, as still recovering from IDLES my daughter tested positive for Covid. This was her second bout, the first following a visit to Bristol last year. It is perhaps something to do with Bristol (the band are from there) or, it could be she is hanging-around the wrong types.

I remember thinking before I decided not to think about it, ‘If I am going to get Covid, this will be the place (the concert),’ and, ‘If I do, it will be worth it.’

Well, after a PCR and more lateral flows I have remained clear.

I’ve still not had it.

At work, virtually everyone I know has.

I am either doing something wrong or right.

Back to the uneventualities.

Yesterday I visited one of my patients at home.

It was very sad.

She is a very old lady.

Not only is she old, she looks it too.

She is very, very thin, something the dietician can’t fix.

She is very, very wrinkled, perhaps because of her thinness and her lifetime of smoking (cigarette packets and spent fags scatter the living room as her vape sticks out the side of her chair).

At first I didn’t find her house despite having visited on multiple occasions. I couldn’t see her window which is usually recognisable by the cage.

Eventually, putting-on my glasses and consulting my computer, I walked-up to the right door. It was slightly open, as it always is when she knows I am coming.

Beside the door was the empty cage.

‘Maybe she’s been cleaning it,’ I thought.

Inside, she was sitting.

No Mickey.

‘Yes, he died, he was quite old,’ she said, ’15.’

‘I am sorry to hear that. Will you get another?’

‘They live to be 15 with me, and, even with wishful thinking I don’t have that long.’

She’s survived Covid too.

It’s a strange world.

I read Søren Sveistrup’s book, ‘The Chestnut Man’ at the start of the week, it is, what I believe is called a Scandi-Noir. Police, murder, darkness. I recommend, although it took me a while to get my head around the different Danish names, none of which were familiar.

And, why mention this? No, reason, just a recommendation. It kept my interest and had an unexpected ending. What more can you ask?

Last week I finished the Da Vinci Code and have now moved-on to Angels and Demons, the prequel.

My life overlaps with biblical readings, the Masons and a love of history and art. I guess it is designed for me.

At the same time I am listening to Daniele Bolelli’s podcast about the Assyrians and King Hezekiah ‘The siege that changed all of history’. (Something I studied in school as a 16 year old).

I am drawn into the past.

The Da Vinci Code talks about ancient symbols, and reading about the Pentagram (which follows the golden ratio) and the Star of David (which has its own perfect geometry), I sent my daughter the drawing instructions.

This followed-on from a discussion earlier in the week about circles.

‘Can I borrow your compass?’

‘Why?’

‘I want to draw some circles, what else?’

‘I sometimes use it to draw triangles,’ she replied with satisfaction.

My research produced the Star of David directions. You can try if you like.

Staying with my daughter, she has finished learning about Christianity in her GCSE course and is moving-on to Judaism.

You could call that one of my special subjects.

Sure, I couldn’t tell you as much as the rabbi, I do know things. (Don’t Telma) 😄.

Last night we watched an episode of Shtisel, the Israeli drama involving the lives of an Ultra-Orthodox family in Jerusalem.

Shira Haas on Filming 'Shtisel' Season 3 - Variety

It quickly became apparent that my perception was not the same as my daughter’s, her having such radically difference reference points, for example, my awareness of the switch between Yiddish and Hebrew, the different clothes, mannerisms and mis-translations.

‘Do Orthodox Jews have those things by their ears?’

‘Peyot, you mean?’

‘Yes.’

‘Well, usually, they are something the Ultra-Orthodox have.’

‘Who are the Chassidim?’

‘Would a Reform Jew have them? What about a Kippah?’

There are 101 more questions about the ways of the Jew, no one has written, The Tao of Judaism. There’s an idea. (There is a blog, however.)

I fear I am going-round in circles.

I’ll end with the government, who are, in a mess.

Well, they are always in a mess, it is just that it looks like it might catch up with them.

I’ve mentioned Covid a couple of times already.

It’s hard to get over the knowledge of the partying and so on that went-on in Number 10.

It is also hard to reconcile what took place with all the evidence of lying and falsehood that the government has peddled over the past decade.

I am not crying for the beloved country, but, almost.

If this is what it takes, then, so be it.

It is hard not to become caught-up in conspiracy theories, disentangling who pulls the threads, who is the puppet and who the master.

If the party’s party is over, hooray.

We will still be left with another group of distorted individuals who perceive the poor as bad, immigrants as the enemy and more and more money the ultimate goal.

Maybe they should spend some time drawing circles?

Da Vinci I understand spent decades trying to square the circle. This means creating a circle that has the same area as a square. Don’t ask me how you would do it. It is certainly a good way to keep people busy.

Happy families are all alike; every unhappy family is unhappy in its own way
It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness
Call me Ishmael
With the coming of Dean Moriarty began the part of my life you could call my life on the road.

A ramble through dodgy phone calls via IDLEs and back again.

I was listening to the Adam Buxton podcast the other day.

He was talking about phones. It was a fairly banal conversation with comedian Darren Harriott.

They discussed ringtones.

Back in the day, you could pay £1.50 for one, more recently the bottom has fallen out of that market as they invented apps that enabled you to sample your own music as your ringtone (that’s what I have) (Edinburgh Man, The Fall) or as is the situation with people, particularly the yooths, there is no ring. There might be a vibrate if you are lucky.

The days of phone conversations are numbered.

I don’t mind chatting on the phone.

I have a serious problem with cold calls, that is, people ringing me out of the blue.

If you want to encounter Rod’s dark-side, cold call him when he is expecting a call from someone else, ‘Pause… May I speak with Mr Rodney…’

The main reason I don’t like being called is that I am usually doing something else. For example, were someone to ring me now, they would interrupt my typing.

Intrusions.

Modern-man is not big on intrusions.

I suspect that is because there are so many intrusions that we can’t avoid such as my work desktop setup, the Netflix ping, the sound of traffic or the flash-up adds on free apps.

Am I being narky?

It’s lack of sleep and tinnitus in my left ear; the free ear plugs helped but I still have, ‘Send Sally to the sandbox, baby’ ear-worming.

Where was I?

Oh, intrusions.

What’s this go to do with Almondemotions? Well, I wanted to first describe the lack of ringtones and bells in my life; I don’t, like many people of my generation use the landline at all (no idea of my home phone number – funnily I can remember my childhood number 638 5356 and Essie’s, 638 7519, but not my own.)

And that is because I prefer texts.

‘Please don’t phone me, text,’ I will tell people.

Or email.

You can ghost, delay, emoji respond.

Have I adapted to text or have texts adapted to me?

Oh, almonds.

Well, you see, just as the phone rarely rings in my house, if you spend time with some old folk, their phone sometimes doesn’t stop.

Depending on their seniority, this could be friends calling, although when they become very old, and their friends have died, it might be the hospital or the social services.

For a big group, the calls are from, ‘…Hi, is that Mr Almond… I understand you are interested in purchasing one of our Covid protection devices?’

‘No, this is Mrs Almond, Mr Almond died last year, I am afraid I am not interested in…’

‘Apologies, if you could spare me a few minutes of your time…’

And so on.

During house calls, I hear this from time to time.

Without being ageist (as demonstrated by my last blog), I find older people are the biggest suckers for telesales/rip-offs.

Many are savvy, they use ‘BT Call-Minder’ – this requires you to ‘Say your name, then press the hash-key’

‘Hello, it’s Rod from Almondemotion, calling about your…’

The person then has the choice to ignore or accept.

Some folk have gone all out and have, ‘This telephone does not accept calls from anonymous numbers,’ which cuts you off without discussion.

I called a patient last week.

After the third call (first the line went dead, the second, I could hear her hanging up) she said, ‘I’m on the phone!’ and ended the call.

It later transpired she was on her mobile to her bank. She’d been scammed out of £1000.

How I hate the scammers.

I have come close to being caught once, it was a horrible, intrusive experience.

Statistically it seems that younger people most fall prey to scams, which surprises me. I suspect the bigger hits are the older folk.

It is a murky world.

‘No cold callers’ doesn’t work anymore. They have your number. And your email. They can spook your bank or insurance phone number.

If a fraudster calls an old lady who trips on the way to the phone, is that assault? If they die what then?

Cybersecurity itself is a scam as none of it comes free; it is a peace of mind assurance.

What can you do?

I suppose the best is not to answer your phone.

Those obsolete land-lines have their days numbered

And mobiles?

Will GDPR protect us?

When I have spoken to the bank after the scammers have pursued me they acknowledge there is nothing they can do, the fact I caught the scammers in the act means they are particularly powerless, if I’d shared some cash the police might have become involved.

It’s sordid.

And here is me worrying about frailty.

One narrative says is that it’s OK to target the old as they are rich, Boomers of whatever.

Most aren’t.

Most are vulnerable.

Physically, psychologically.

They feel pain, they feel happiness.

They are you or me in a few years.

We are not apart.

The last time I was visiting a patient and a scammer called, obvious to me from the ‘…’ I was tempted to grab the phone and attack them back.

I didn’t.

I sat quietly.

Listening to the bots whirr.

Listening to my patient’s vulnerability played-out on the wires.

Let’s get IDLES on the case.

What would they do?

10 Sales Tips for Cold Calling - Badger Maps

I was an ageist arse

It has been a busy week and there is likely more to come, least of all my visit to see IDLES tomorrow.

Tantalizing, eh?

Well, what about my being an arse?

I’ll come-clean.

I fell into the trap.

Arses are people, or perhaps phenomena who have surfaced intermittently through my life, particularly my years as a doctor.

I can’t quite provide a definition, although I imagine readers understand I am talking about more than the bottom, back-side, or, fanny, if you are American.

You can read a previous arse blog here.

This time it was me.

I fell into the trap.

And, perhaps trap is what it is, in that folk for the most coast along, with ups and downs and occasionally something happens, perhaps two roads diverge, and they find themselves going down one, not the less travelled by, the arsehole one.

And voila.

A central part of my role as a community doctor involves visiting patients at home. This week I went to see, let’s call her Dora. She is in early 80’s. I won’t provide further details for reasons of patient confidentiality.

I ran through my usual, establishing how she was feeling, working out what was wrong and what could be done to improve the situation.

Her daughter, who I guess was in her early 50’s was present throughout the visit.

I know some doctors, for reasons known only to them often exclude relatives from their assessment, ‘Please step out of the room while I asses your…’ Kind of thing, I am confident there are readers who have experienced this.

Anyway, I am not one of those, for me, it is, whoever you want in the room, bring them in. (OK, sometimes the relatives are unwelcome, by me or the patient, that is another matter.)

When bottom examinations are involved I will usually ask relatives to leave although as I am more of a talky than touchy doctor, bottoms and such things are not often central to my assessments.

At one point, a phlebotomist arrived to take my patient’s blood. I used this as an opportunity to step into the kitchen with her daughter, to determine if I could gain some additional information.

And, it was there that I saw the oldish laptop attached to a grey clamshell phone.

That was the giveaway.

I thought, ‘Oh, that’s an old laptop and phone,’ I then rationalised that the daughter was perhaps working from her mum’s house. I put the thought to one side and moved-on.

It was towards the end of the assessment when I was planning to leave that I asked the daughter, ‘Do you have an email?’

I quite like to stay in email contact with my patients, it helps them have a place to go to gain support and advice, it is also a means for me to share information with them, for example, pointing people to guidelines or relevant websites. (I appreciate some doctors will read this with horror, ‘Share your email address?? What are you thinking?! Patient empowerment?… No, no, no!)

The daughter gave me her address.

I could see my patient, who as part of her condition has a somewhat expressionless face, glaring at me.

‘I have a computer too.’

It was then I realised.

The old laptop and phone.

My patient explained that she likes to sit in the kitchen surfing the internet.

Of course she has her own email.

I apologised, not explicitly expressing my arse-like feelings, but apologising for my ageism.

And there you go.

I’d somehow assumed, as she was older, and, readers, 80’s isn’t that old in my world, she didn’t use email, was disconnected, and I, in my haste to find a quick-fix disenfranchised her.

In my experience of older people with technology, I have found an increasing number have smartphones. They are still significantly in the minority, perhaps 20 per cent. Even fewer are online and connected.

Many struggle with manual dexterity (arthritis) and others with vision (cataracts, macular degeneration) to used icons or keyboards.

Some are personality ageist (the most common form), ‘I’m too old for that kind of thing.’

It’s a mixed-bag.

Only a tiny number use email (a group have an email address but never use it).

I know this will change, it’s a matter of time.

In 20 years we will look back fondly on the oldies who used to survive without an @hotmail address.

Makes my think of my grandfather and his dilute Dettol baths or his pronunciation of Argos (Argosy).

Dettol Antiseptic Liquid, Pack Size: 500 mL, for Personal, Rs 145 /piece | ID: 15390544973

Things of the past.

And, yes, doctor geriatrician, it’s not your role to make things worse!

Again, I seek your forgiveness.

I’ve learned my lesson.

и почитать! | Reading art, Woman reading, Female art

Did you like this blog? Please share it!

Thank you 🙂

Desperately seeking Sheffield’s spirit

I worry about the buskers.

The singers, dancers, street artists and performers.

Winter is never the best time for outside activities.

Covid led to the shutdown and a move to a cashless society.

I have, like I imagine most readers, given money to buskers from time to time, occasionally people who aren’t doing anything, just holding a cup. I don’t know the correct term, most people know them as beggars although this is tricky, an area filled with history and cultural connotations; there is a big difference between a street-living child in Mumbai and a drug-addicted man on the streets of Sheffield.

Covid has been cruel to many.

Most to those who have died or have lost family and friends or people living with the long-term consequences of the after-disease, those working in service industries and on zero-hour contracts have also been disproportionately affected. Oh, and of course, Tim Cook, Jeff Bezos and friends have been affected, although not in the same way.

I haven’t seen an economic analysis of the pandemic although it is likely to have followed the trends seen in most bad things – the poor get poorer, the rich get richer and the folk in the middle encounter some bumps in the road.

The buskers, the folk who craft cats and dogs out of moistened sand tend to be poor.

People living in poverty in the UK have been killed at a faster rate, have seen their cost of living rise disproportionately and their quality of life diminish more than anyone.

And what about the buskers?

Lockdown then cashlessness means lost opportunity.

I can’t imagine what they have done.

I was in Sheffield City Centre yesterday, dodging the packs of young men on the way to the football, the one busker in town was singing his reggae heart-out on Fargate.

I didn’t stop to ask him whether his takings have fallen-off with people carrying around less spare change, it could be, with the changing times, there is less competition and he is benefiting.

It would be a shame to lose human expression on the streets; it’s bad enough that half the shops have shut or moved to Meadowhall.

Poor old Sheffield.

Lots of students but a shrinking soul.

Who’d have thought a virus could ravage a spirit?

Sheffield Street Art: 9 of the best murals you can see in just 30 minutes - YorkshireLive

Greek letters, a return to Leonardo, The Code, and my face

Most of us will have heard of Pi.

It represents the ratio of a circle’s circumference to its diameter.

If the ratio isn’t 3.14159265359 you don’t have a circle.

You have something else.

An oval perhaps, or a squiggly shape.

Omicron has been the most talked-about Greek letter of recent months.

Last week I discovered Phi.

This like Pi is a Greek letter that also represents a semi-mystical number. This is more obscure and is commonly considered the Golden ratio.

Understanding it is a little trickier – it is a ratio present when for two numbers, their relationship represents the sum of the larger of the two quantities.

I won’t draw the algebra as that would be me pretending I understand it.

It is 1.618033988749.

In case you were wondering.

The Sacrament of the Last Supper by Dali – It’s here too

I read about it this week in Dan Brown’s Da Vinci Code. The book that has, I understand been made into a movie with Tom Hanks.

The book has been on one of my shelves for years. It might have originally belonged to my dad.

I’d avoided it as somehow I’d assumed it wouldn’t be interesting.

So far, and I am only half-way through it is an action thriller, my kind of thing.

It seems that in art, nature, architecture and design this number pops-up as somehow providing an ideal symmetry or form.

In the book (DVC) there is a suggestion that Vitruvian Man, the drawing by Leonardo demonstrated a transliteration of this ratio, as if, we, that is humans, ideally made in God’s form, are a perfect reflection of the perfect.

Vitruvian Man - Wikipedia — Vitruvian man

It would be nice were it true.

In Walter Isaacson’s biography of Leonardo, there is an entire chapter dedicated to the creation of Vitruvian Man (named after the 1^st century Roman architect Vitruvius). And, indeed, Leonardo conducted extensive measurements into the ratios inherent in the human form – distance of chin to forehead, eyes to ears, middle finger to thumb and so on.

A person who is six-feet tall is the height of six of his feet, kind of thing.

Most of us will have worked-out that humans are not necessarily that consistent or symmetrical (although, I have to say, in a rare moment of flattery, my optician told me I was ‘quite symmetrical’ the other week. I don’t think that was a come-on, more an observation.) (I think he needs glasses).

It is interesting nevertheless.

Last night, watching the n’th re-run of the Big Bang Theory, Sheldon was wearing a T-shirt with the Fibonacci spiral. I tried to impress my daughter.

She didn’t believe me.

I had to Google and show her.

Here is the spiral.

Here is Sheldon’s T-shirt.

After reading the Leonardo book (Isaacson’s) I also realised that although you have great artists, people who can see and render the world around them with incredible facility, there are also underlying rules and, you could call them tricks.

The reason I mention this is my own feeling of entire inadequacy when it comes to drawing.

I doodle, it’s something I have always done and for the most they are the geometric shapes I mentioned in a previous blog.

I’d love to draw a face.

When I draw faces they usually don’t look great.

And then, I realised, I was not applying any rules.

This led me to watching Darlene Nguyen’s ‘How to draw a human face’

With the realisation that whilst 1.618033988749 is not necessarily something I can achieve, I can follow the rules, paint by numbers.

Whilst drawing this morning I debated whether to show this picture.

What the heck.

Below are some un-rule based drawings and at the bottom the one I sketched this morning.

Please don’t tell me what you think; just accept my openness!

Here is to numbers and all things Greek and obscure.

Have a good weekend.

Innovation, oranges and the impossibility of happiness (Monday imaginings)

Copy of Leonardo’s Battle of Anghari by Rubens

This has to do with relativism and perspective.

I retain a vivid memory, when I was 13 or 14 looking out of my friend’s bedroom window.

He lived in Magdiel, a run-down neighbourhood on the outskirts of Hod Hasharon, 20 miles or so from Tel Aviv.

The view from his window was that of orange groves. Stretching for miles. A sea of green with bright fruit.

I was surprised when I expressed my admiration of the view to my friend; he wasn’t fussed, this was his norm.

When my children were younger we lived in Crane Moor, a small village between Sheffield and Barnsley – rural South Yorkshire.

Drawing of the uterus of a pregnant cow, 1508 - Leonardo da Vinci — Leonardo, cow uterus

There I remember the view from my son’s window, it was of rolling, undulating, grassy fields. Friesians all named Daisy lived there, they would come up to our wall and gnaw on the shed from time to time. Occasionally a mole would visit.

My son at the time didn’t appreciate what he had; he was only eight or nine.

Yesterday evening I was sitting outside a café in central Bristol with my son who has moved there to study, he was drinking an Americano, me an AeroPress coffee (don’t ask). I remarked on the vitality of the place, the vibrancy, most of which is missing when I look out the window of my Doncaster home. There aren’t any cafes where I live, nor many international students.

This morning I had a moment.

I had been talking with some colleagues about ideas to improve care, to unlock the fastidiousness of the system, to draw-out the obstacles and liberate patients; we were talking inequality, new ways of seeing and doing. It was me at my best.

Later-on, in another meeting as I created one of the geometric patterns that I have been drawing since the start of Covid, I reflected on the tedium of the moment and the inspiration of earlier.

I thought of Leonardo, who stands as surely the greatest innovator in history and also probably the worst completer-finisher – See Saint Jerome, The Virgin and the Child with St Anne, The Adoration of the Magi, The Battle of Anghiari. (He held on to the Mona Lisa for 8 years after it was supposedly finished, adding touches)

‘Wouldn’t it be fine to be a Leonardo,’ I pondered. Not necessarily possessing divine genius, as that can be inconvenient, but having the capacity, the time and the space to let your mind wander to the colour of the sky, the shape of hills, the movement of water, muscles and the eye, the mechanism of the woodpecker’s tongue, the development of the foetus, creation, innovation, perspective and momentum.

Studies of the foetus in the womb by Leonardo da Vinci

Alas, no.

There has to be the mundane.

There has to be the ordinary to make the special, well, special.

And that is the lesson.

We should make the most of the tedium, of the ordinary, as, by its very presence we are granted the opportunity for the special, the unique, novel and fun.

Pain can be good as pain can end and with it the non-pain, the anticipation of the prize is often better than the winning.

Maintaining a steady state of wonder.

That’s what we need.

Where did you come from, where did you go?

Yes, I am starting today’s blog with a quote from the classic country-mix Cotton Eye Joe by Swedish band Rednex, a hit in the mid-90’s.

OK Rod, where are you going with this?

Well, I don’t intend the rabbit hole that is an analysis of the lyrics, more an examination of me. See here.

Who I am, where did I come from?

Let’s leave, where I am going for another day.

A retrospective analysis, if you like.

Along the lines of, Who Do You Think You Are?

Last week my brother, the lead, I guess you might call him, genealogist in the family sent me something he had found on Ancestry.com relating to the birthplace of my grandfather, or, more specifically his brother (we have only had inferential evidence previously), as being Fellin, Viljandimaa, Estonia in 1884. Interestingly, he died in Dunedin, New Zealand in 1966. Us Kershes get around.

Anyway, the point of this blog is not to tell you about my family, more to take you on a short detour into who we are, that it you and me, and where we have come from (hence the title).

Reading Adam Rutherford’s recent book, ‘How to argue with a racist’ he examines the common thread that runs through all of us, given our participation in the human race.

In the book Rutherford cites a fascinating statistic (part of the anti-racist argument that some groups of people are better or different to others) in which, taking an average human generation as 25 years, with each previous generation, the numbers of ancestors you have doubles (I have two parents, they had four between them, their parents eight, and so on), after 500 years (we are talking somewhere around the 1500’s me, or any of us, would have over a million ancestors, and, going back a thousand years, over a trillion (1,000,000,000,000) – this is more than 10x the number of people who have supposedly every existed (estimates are around 100 billion).

As the numbers don’t match, the only explanation is that there has been intermixing of families and ancestors, folk having children with their cousins and so on.

My son, the biologist, tells me this is historically plausible from a genetic perspective as, if you are successful genetically in a certain ecological niche (and you didn’t move very far), that is to a large extent because of your genes and hence, maintaining the consistency of those genes should keep you on an even keel wherever you are, it would also explain why, people living in Norway become tall and fair, fair and fair is fair, or whatever.

You are both more distant and more closely related to your next-door neighbour than you think.

This says more. Note the name of the guy who wrote it. Coincidence, I think not!

Looping back to the original notion, of where did you come from, I am interested in the relevance of knowing that my great-uncle was born in Estonia. (I am already considering whether this might win me an EU passport).

What would I have in common with him that I wouldn’t have with my other great-uncles?

I have no way of knowing how many there were as given I am the product of families who have moved around (my paternal grandfather had an Australian passport, by way of Glasgow in the 1920’s), with little documented evidence before that generation, I question, what is the point?

Does this tell me anything about who I am and where I am heading?

As inter-breeding isn’t something we support nowadays, it is likely any family traits have and are becoming diluted with each passing generation.

I don’t want this to appear as if I am dismissing the past or diminishing its importance – I am like anyone, hoping one day for a time-travel portal to open in the back of my garden.

See 11/22/63.

Beyond these fantasies, what can we do?

Most would say, ‘Stop dreaming, get on with it, wash the dishes, do the shopping!’

OK, I get it.

And still, that song is rattling around my head.

I know it will not and hopefully never rattle in the heads of my children.

For me this is intriguing.

I started this blog in 2015 with a concern that I might drop dead and there would be nothing left behind for my children. It was a love-letter to the future. (They aren’t current readers and, there is so much now written, I can’t imagine they will ever get through it all regardless of when I pop-off).

I still worry about the sudden-death thing, although perhaps less than I used to.

Maybe I should get on with other things, such as sorting the garden and repairing the flaking plaster?

Always busy, we aspire to business.

And then, there are the many books I’ve not read, and I’d like to learn the piano and how to paint and maybe start running again.

Or perhaps, I’ll just walk the dog.

Humans Are All More Closely Related Than We Commonly Think - Scientific American

Should I or he or she or they stay at home or go into care?

This is a question that arises frequently between me and my patients and my patients and their families.

There are two particularly common situations, one, during or just after a significant crisis, maybe a physical or health dip or when a partner (particularly one who has been a carer) dies, and, when a person is very unwell and is likely to deteriorate and die themselves.

Stepping-back and looking at ‘care’ in its broader sense, I refer to the move of a usually older person (there are places for younger people, most of whom have significant learning disabilities) into 24 hour care – a nursing or residential home.

Care homes have been in the headlines particularly in relation to Covid as during the first and second waves of the pandemic they were places that experienced the worst effects of the infection. In some homes half or a quarter of the residents died, in others the percentage was even higher, and this not forgetting the numbers of staff who both died and suffered the acute and long-term effects of the virus.

Covid: Care home deaths 'like losing family', say staff - BBC News

Care homes have been an ongoing hot-topic within government circles, principally I believe because of the utter failure to protect our most vulnerable citizens and subsequently for the chaotic and haphazard way guidance and support has been provided to those homes, most commonly reflected in the ongoing 14 (or is it 10?) day quarantine period required of anyone entering a care home as a new or returning resident. (For example, with the latter if they have spent a night in hospital, they are forced into isolation, even if they have just come-out of quarantine and even if their LFT and PCRs are negative) – I sardonically refer to this as ‘Go direct to jail, do not pass Go, do not collect £200’

Locked in a room, when you are 90 and if you have dementia and significant physical and cognitive impairment is horrible. It is cruel and harmful. It is what our older folk have to do, whilst we, the rest are out and about, living it up.

England lifts COVID curbs as experts warn of danger in surging virus cases | The Times of Israel

Thousands of elderly left in homes 'without letters, visits or calls' in final years | Daily Mail Online

There are, broadly speaking, four types of care home, each with an increasing tariff of cost; residential, residential for people who have symptoms of dementia, nursing and nursing for people who have symptoms of dementia. (There are a few ‘complex behaviour units’ for people who have very severe symptoms of dementia).

The irony of some of this, particularly the dementia focus is that nowadays most people living in care homes have dementia; over the past decade, the bar for entry to care, at least if there is public funding for the placement has been raised and people have to be at such a level of frailty and dependence that they cannot be supported at home.

It is common that people who 10 years ago would have been considered requiring nursing-level care (for example, if they have needs relating to insulin administration, pressure area care, complex medicine regimes) would have been in NHS long-stay facilities (see Ward F:13 or Barbara Robb), people who were a little less dependent would have been in nursing or residential care.

From a personal perspective, my grandfather lived for the last decade of his life in a care home in Glasgow. He was so fit, he used to walk a couple of miles most days from the home to the bookies in Pollockshields to place 20p bets on horses at Ladbrokes. (For the Grand National he would be the runner for residents and staff).

The picture is therefore of people in care who are more and more unwell, frail and unstable, consequently we are supporting more and more people at home, either independently or with additional support.

It is a dependency shift to the left.

In most situations that is great as institutionalisation is not for everyone. Conversely, some people actually want institutionalisation; they want to be looked after, they want people around them, they want company. (My grandfather was of the latter).

My point being that over the years it has been harder to move from home to care home, you have to been sicker, frailer and more dependent than a few years ago.

Yesterday’s sick, frail and dependents are now living at home with carers visiting multiple times a day, this is occasionally called ‘double handed care’ where two carers will visit the person at home to aid ‘transfers’ = getting in and out of bed or on and off the toilet.

And so, you might have read some of my blogs about the work I do in care homes in the past.

Some of them aren’t that bad. Some are good.

For others, moving into care is a fate worse than death.

My paternal grandma I recall was in this group and hated the idea, as far as I know she lived at home until her final hospitalisation.

I’ve perhaps mixed-up all of this too much. Jumbled ideas. Let’s see.

There are different levels of care available in institutions called nursing and residential homes (generically ‘care homes’).
Some people will do anything to avoid living in a care home, others are quite keen.
Some care homes are good, others are bad, this is mostly, IMHO, related to the level of staffing, their training and the extent which they look-after and care for the residents (management is important too).
Some people struggle to live at home because of extreme loneliness and social isolation and thrive in care homes.
Care homes are mostly funded by the NHS or Social Care with many people also contributing themselves – so called, ‘self-funders’, for this latter group, the decision whether to move into care is more dependent on them than a bar set by social and NHS workers.
People living in 24 hour care in 2022 are significantly frailer, older and more dependent than 10 years ago, those people who are less frail and dependent are supported at home.
Being supported at home can be great if that is what you want, particularly if you have family who will keep you company and provide additional care, if you don’t have anyone, being alone with a carer popping-in for 15 minutes once or twice a day, can be a painful way to spend your last years of life.

And, my point?

Well, I won’t revisit old-ground, such as the amount of training and funding (wages) provided to carers working either in homes or delivering home (domiciliary) care, in the UK, like in education and healthcare, if our priorities were right we had higher taxes, proportionately more resource could flow into these areas (and please don’t tell me, ‘but the government has invested £xxx million in,’ that is, we know, bollocks).

We would listen to what people want and gain a better understanding of individual’s needs.

Loneliness is horrible.

Even for a socially awkward and solitary person like me, spending too-long alone makes me crazy.

If people thrive on company, provide them company, not 15 minute carer visits.

Yes, there are charities and societies that aim to address this loneliness, none of them provide the atmosphere of a home.

And that is particularly relevant as when we say, care home, the allusion is to a home; not a house or a building, an organisation or institution.

A home is where you are relaxed, comfortable, where you can shut yourself away or spend time with others, where you can eat alone or with company, where you can wear what you like, say what you like, do what you like (within homely reason!)

Years ago I visited a home in Holland; this was for people living with dementia. The central living-place was the kitchen. There was a log fire, comfortable settees; they had a Labrador. That is a home.

There are probably similar homes in the UK although almost certainly beyond the reach of regular people.

When a home is four walls, a TV that you can’t see or hear, an alarm system that calls a central phone-hub every time a person visits, where you gas is cut-off for fear of your blowing yourself up and where hour upon hour can pass without seeing another person, that is not really home. That is existing.

We are human beings who thrive on being with others, being part of a whole, not locked away in a little box-room.

In my experience, those who value home above everything (as compared to moving into a care home) are those who manage to maintain a home, with family, with routines, with ornaments, soft-furnishings and so on.

We are all different, we are all individuals, we are all constrained by something or other.

Let’s work towards home.

Have I got dementia?

I am not sure whether it is strange that people don’t ask me this more often or perhaps surprising that they do at all.

I have found over the years that there are, and I am speaking very broadly, three groups of people who seem me in relation to dementia, or, perhaps described in its wider context, cognitive impairment, that is, a condition that results in impaired thought processes.

Before going-on, it is important to highlight that thought processes is much more than memory.

Dementia isn’t just forgetfulness.

It is a complex disease (the cause of which is still obscure) that affects most aspects of an individual’s mind (that is seeing, hearing, feeling, thinking, remembering, reflecting, imagining, laughing, crying, forgetting).

Sure, it is forgetting where you parked the car, it is also forgetting where you are driving, that you can drive or how to drive.

I have never been a fan of standardised questionnaires – you know, either Likert, that is, ‘On a scale of 1 to 10, how often do you forget where you leave your car keys, with 1 being never and 10, always?’ (Not sure why the focus on cars).

Or, the other scale, which anyone who has been a patient in a hospital ward will have overheard, ‘When was World War 2?’ (Although, thankfully, people have stopped asking this, moving on to more apposite questions, ‘What year is it? What month are we in?’

My friend Vicki bought me Richard Osman’s ‘The Thursday Murder Club’ for Christmas, it takes place in a retirement village in England. One of the protagonists, as a safety-net to ensure her memory is working keeps a daily diary that is two-weeks behind, in that, she will write a fact, say a car registration number, memorise it, then test herself two weeks later to see if she can remember. (This is a little like the get-out used by the character played by Julianne Moore in Still Alice, I recall that had something to do with butterflies).

The Thursday Murder Club: The Record-Breaking Sunday Times Number One Bestseller (The Thursday Murder Club, 1): Amazon.co.uk: Osman, Richard: 9780241425442: Books

Anyway, sorry for the side-track.

As I said, there are three groups.

The first are those who probably have dementia.

Most often these people will seek help not because they are worried or concerned, but because family members have noticed, tried to pretend everything is OK for 12 months and reached the point they feel, ‘Something must be done.’

This usually entails making an appointment to see me.

The encounter usually runs along the lines of:

Me How are you Gladys?

Patient Oh, fine thank you.

Me How do you feel your memory is?

Patient Not too bad, no better or worse than anyone.

Me Have you found yourself doing anything unusual recently, maybe, forgetting where you live or putting the milk in the cupboard instead of the fridge? (Not the best example, I am usually better on the day)

Patient Oh, no, everything is fine.

Husband Moving awkwardly in chair, trying to make eye contact with me, worrying that I believe what Gladys is telling me, suspecting I know what I am doing, but not sure.

Daughter Usually a little more faith in my techniques, but still worried I will take what Gladys says as the truth.

What I was trying to create, in a manner lacking all skill or finesse, was the demonstration that frequently people who have dementia, particularly if the changes have been ongoing for a year or more, reach a state where they lack insight, they forget that they forget, the fog has become so thick they can’t see where they are going or even that they are lost.

Recently I was sitting with a man who over the years has always refused to seek help for his obviously deteriorating memory. He lives alone. He told me he wondered where his dog had gone, Rover.

Patient “whistle”… Rover, where are you? Oh, he must be upstairs on the bed, that old dog.

Me Does he have a dog? I’ve never seen him with a dog.

It later transpired Rover died 20 years ago.

5 Paintings Of Pets: National Pet Day | Art Gallery Blog

I could write more on the topic of how we reach a diagnosis of dementia or perhaps some of the more subtle or obvious signs and symptoms of dementia, that is not for now; here I will move-on to the other group.

The second group of people are often in their 80’s – they have noticed that their memory is not as good as it used to be, they even experience the odd moment of significant disorientation, forgetting the name of a friend or a place they often visit. Typically, they might know it is 2022, they might know it is January, but the date might elude them.

Little things, small fragments, details of this or that.

They are sometimes concerned that something is wrong, they are aware that there are problems, they realise they are not as sharp as they might have been in the past.

When you do the tests I mentioned above they often don’t score perfectly, but pretty well. Their personality, mood, manner, behaviour is usually just as it has always been, with the element of ageing added-in.

In the Psychiatric textbooks this is sometimes designated as Mild Cognitive Impairment – that is, failings in memory and other cognitive tests that are a little worse than might be expected but not that bad.

The explanation being, everyone’s memory deteriorates with time, I am not as sharp now as I was when I was 20, just as our body’s age, so do our brains and the functions they support.

Wear and tear, a little like aching joints – something we wish we didn’t have but something that shouldn’t get much worse and shouldn’t affect your life on a day to day basis; you can still drive, shop, read, do everything you have always done.

(I know some people will be thinking of the old joke about ‘just a drop of blood’ when we say ‘mild’ and yes, it is probably an example of the medical world diminishing something that is of significant importance to the person, nevertheless, that is the word.)

In reality, the data suggests that most people with Mild Cognitive Impairment (MCI) will remain the same, their memory, mood, personality will not change drastically over time, they will just be a little worse than might be expected on these fronts; approximately 10 per cent of people progress into dementia and, depending on where you live, MCI will mean you are discharged from the memory service or you will receive follow-up.

The third group of patients are what doctors sometimes call the worried well. These are people who are worried that their memory isn’t as good as it might, who are occasionally frustrated by lapses in concentration or focus. These patients often make appointments for themselves, often drive to the surgery and tell you what is wrong, ‘Doctor, I am worried about my memory’ = ‘Doctor, I am worried I have dementia’

These patients in the standard testing often do very well, indeed many have an excellent memory, there is nothing significantly the matter; they might have watched something on TV that has got them thinking or they might have another medical disorder masquerading as memory impairment – underactive thyroid, diabetes, depression, drug side effects can all present with similar symptoms that affect an individual’s thought processes.

It is probably as important to support this last group as any other as the worry that something is wrong can be as bad as having a problem.

It is one of the rare times in my job when I have the pleasure to announce to a patient, ‘You are fine, your memory is perfect, you don’t have dementia!’

I have never asked a patient what it feels like to be told this although I imagine it is nice.

And, there you have it, the three groups, which like all things in medicine are never as clear-cut, which tend to bend and blur into one another with people who have dementia becoming anxious, depressed and who also have an underactive thyroid in the mix.

The upshot?

From my perspective, as I have described, the worry you have dementia can be as bad as having a disease; if you are worried, get checked. If you are worried that your mum or dad has dementia, get them checked, it is better to receive a diagnosis early, if that is going to be the outcome as support, secondary prevention and even drugs called cognitive enhancers can be started to slow progression and maintain wellbeing and independence.

Any questions? Let me know.

The Detective - Custom Vintage Pet Portrait - Purr & Mutt

2022

It has been a slow start to 2022.

A sluggish awakening to the New Year.

Like an Escher print we are shuffling round and round.

Ascending and Descending [M. C. Escher] | Sartle - Rogue Art History

Maybe a little different, as the infection is not killing as many, but worse because so many more people are directly affected, or infected.

It’s a, ‘Who invited him (it) to dinner?’

The guest that over-stayed its welcome.

The Waltzer that doesn’t stop.

I remember my first and last Waltzer. It was in Dundee.

You know those round chairs with a central wheel that spin inside a spinning-thing?

Waltzer Hire | Hire Fairground Rides | Eventstar

It was one of those.

In hindsight I am sure the guy (Carney as per Stephen King) thought he had been short-changed by a group of privileged students. If he had, it was not intentional.

He seemed to spin us too fast, maybe double-time, I don’t know if there is a standard for the spinning; certainly not the tempo anticipated of a waltz.

We felt like we were going to die.

When it eventually ended I remember lying on the grass dazed, shaking, close to tears. The lack of control, the voluntary nature of us stepping onto the device, the noise, the sun, even now, 30 years later it brings-back a nausea.

The Waltz today is Covid.

Spinning.

The news, the TV, the radio, work, everything is inundated with updates, information that is only subtly different to that which went before.

Caught in a horrible snare.

There are endless analogies.

It doesn’t help that it is winter and the days are short and the ground damp and cold.

It doesn’t help that I will be 50 this year and most certainly on a downward trajectory.

Looking back on 2021, this was the year I wrote the fewest blogs and had the lowest readership 12,000 versus my 2018 heyday of 22,000.

I am running-out of steam.

(And yes, I no longer have Freda).

As for the blog, there are the key elements – the older people, those living in care homes, the carers and families living with people who are living with dementia; I feel I have probably veered away from my original aspiration of writing about almonds and emotions – the intersection of fear and creativity, my thought of developing a narrative that would lead to some way to better understand what was happening in health and social care, to find a way-out, a solution to the failings.

I have just now (9/1/22 1030), after some clicking changed the name of the blog from ‘Almondemotion’ which, yes, has always been obscure to, ‘Dr Rod Kersh’s Blog (almondemotion)’ – I should perhaps drop the almonds, let’s see what happens.

I think perhaps after seven years of writing I might have anticipated had a broader readership – I know lots of the topics I cover are only relevant to a few, yet some I am sure are useful to a broader readership if I had some way to connect; not looking for viral status here, we have enough of that; that level of attention is not something I would ever want, just a little bit of acknowledgment;

You can only get so far when writing or thinking inside a box.

It isn’t all sorrow – I am halfway through Walter Isaacson’s biography of Leonardo.

If you haven’t read or listened, please consider.

I’ve always loved art, particularly when given the opportunity to understand the theory and ideas behind the drawings, paintings and sculptures.

Leonardo was far more than a painter, he gained a deep understanding of anatomy, maths, physics, sculpture, theatre, engineering, dentistry and philosophy.

Wikipedia describes him as a polymath.

I don’t think I have ever met a polymath.

Perhaps we (I) need an Renaissance to get us out of this?

Nu, what about the news?

I spend too long with the news. On my phone. On the laptop.

When I have an excess of spare time, I even watch it on the TV, although only Channel 4. That is, if the downtime is between seven to eight during the week.

It is hard to avoid listening to updates on the Radio.

It is a noisy imperative banging at your brain.

I’m not sure why the newsmakers as so very intent in their mission.

Covid is a virus, so is the news.

Now, I am not saying anything about the news being untrue or fake, that is all a point of view.

Today, Boxing Day, in case you haven’t read my blog from earlier, there was a news item about Robert Maudsley, the UK’s Hannibal the Cannibal.

Here is a photo.

It is interesting that all of them are represented by tabloids.

I am not sure whether this is because the ‘broadsheets’ (not so broad anymore) don’t feel this newsworthy, or perhaps they feel this is beneath their readers, ‘Our readers would not be interested in such piffle,’ the editor might say. Who knows?

There are computer algorithms underlying this of far greater complexity that anything I can manage. The electronic processers are our ghosts in the social media machine.

And, where else can I go in my downtime, in the in-between moments?

In the queue, waiting for the pickup or drop-off, for the eggs to boil or. My porridge to cool.

I could play a game; I seem to be pulled-back to the news.

10 years ago, I used to buy the weekend Guardian. It was that and maybe Channel 4 and the radio.

Now it is BBC and Google News.

And, let’s face it, it is all bad news.

It is almost a certainty that all news must be bad and if it isn’t bad, it is not news.

Todays are:

Desmond Tutu has died – bad news
Omicron restrictions – bad news
Boxing Day tragedy – bad
Hannibal the Cannibal – bad
Woman died after… – and so on.
Myanmar violence
Wet Boxing Day
Tired of life?
Janice Long dies
Richard Osman (and his food addiction)

Maybe all of this is obvious and if you have read as far as this, or at least Richard Osman’s dietary peculiarities you might be waiting for a revelation, a special Rod analysis or top tip for avoiding the headlines.

Nowt.

Recently I found ‘UnHerd’ an online magazine. It tends to take an alternative view to the narrow newspaper headlines. And there is Positive News.

There is always the Crossword.

Or walking the dog.

Digeridoo or circular breathing.

Or Netflix.

Boxing day reflection

It is sometimes good to look back.

Not all or too much of the time or you can end-up a little lost in wondering whether the past matters more than the present or the future.

It is all relevant, forget the past, you repeat it, focus too much on the future, you are stuck in worry and uncertainty, the present, well, that’s is mostly OK although even Mindfulness needs some down-time.

I am writing the blog directly into WordPress, which is the engine that drives my blogs. All 800 and more are posted on here, right from the start when my ‘thing’ was patient safety and all through the years exploring my identity, questioning the status quo and rallying against the Overlords. It has been a waltz of person-centredness, care, compassion, creativity and imagination, anxiety and worry, focus and hesitation. A pot pourri. A left over trifle, when the sponge and the jelly have collapsed.

This is a look-back; and, why not? The folk on the telly get away with it.

Another component of this blog which will probably only resonate with fellow bloggers is that I am typing it in ‘blocks‘ – this has been a battle for over a year.

All my previous blogs have been written in ‘classical’ which is essentially me copying and pasting from Word into WordPress. Blocks are odd paragraphs that were introduced by the tech guys, for reasons I have yet to understand and which for me make the whole process of blogging more difficult.

Boxing day down-time (raining outside) seems a good occasion to test-out the blocks; there must be something good about them. (I am not one for reading the instructions, prefering intuition – for blocks you need to read the rules.)

Moving back to the past, rather than do a ‘best of’ – here are some of the blogs that have been read the most over the years (this has nothing to do with my blogging prowess, more the chances of folk typing a searchword into Google.

Folk might not have realised that my number-one, most-read blog is about death (some people won’t be surprised by that), you can read it here. It is strange as a number-one as it is very personal, revealing as much about me as anything I have written.

Death – tradition – Jewishness – family – education – self-consciousness

all contained therein.

Over the years I can only recall one person feeding-back to me about this blog and I have wondered as to what those of have read it have thought. Most, probably, ‘nutcase,’ Others perhaps, ‘life, death, here is someone who has stopped in the moment.’

You can tell me what you think. Thumbs up or down. Let me know.

My number-two most read blog of all time is what you might call a medical classic – not because it is amazing, more as it cuts to the the heart (I think) of modern medicine, what it is to be a patient in 2021. The NHS is an amazing institution – the only organisation I am proud to be a recognised as a member, yet, it has its flaws. One is the objectification of people as patients.

You can read the blog, Medically Fit, here.

Well, what did you think? I have created a whole lot of blogs on this topic, you can find them here.

There is a feedback button for any comments. 👈

It’s funny. I’ve been lecturing medical students at Sheffield University of the past 12 years (mostly on old people – the lectures are usually called ‘Age and Ageing‘ after the title of the British Geriatric Society journal.) In that time I have only had a smattering of feedback, usually with students coming to me when I have finished talking to let me know they appreciated what I said.

Very rarely students have logged-on to this blog.

12 years, almost no feedback.

This blog hasn’t had much feedback either, mostly (I think) because you need to have a WordPress account to leave a message.

When I asked the university for feedback on my lectures they told me the students had feedback fatigue and they were only asked their opinions of really important topics ‘Is Sheffield the best place to study in the UK?’ kind of thing.

Sorry for the cynicism.

My third alltime top blog is called ‘Catheters, old men and dementia‘ which is about what it says. My suspicion is that this is a go-to for young doctors who are faced with old men who have dementia and urinary catheters – a sometimes fraught clinical situation; the catheter is in the bladder because the (usually) old man’s prostate is too large to allow him to pee without a tube, the old man, because of his dementia lacks insight into the tube’s importance; he tries to pull it out. The scenario plays-out at 3am when the young doctor is called to the ward to ‘sort it out’ (aka Google) (top-tip for desperate junior doctors = DO NOT US SCISSORS!) (This is tantamount to ‘crossing the beams’ in Ghostbusters and requires the involvement of a urologist).

Is that enough?

One more?

Long-lie is a subject close to my heart. It describes the scenario of an older person who has fallen at home and becomes stuck on the floor.

Every year in our country older people spend their last days of life in such positions, calling for help, stuck, in pain, slowly dehydrating.

I suppose it is an anti-reflection of the Christmas spirit.

In post-Covid UK it is an old man or woman who, after 12 hours on the floor is discovered by their carer who calls an ambulance (30 minutes to get through to 999), waits 10 hours for the ambulance to arrive, which then spends two hours outside A&E with a futher 14 hours on a stretcher in that department.

It all almonds and emotions after all.

You can clap if you like.

More blocks or back the way things used to be?

Bob Ross, Happy and Unhappy accidents (healthcare and filler-TV)

I was taken aback this week to have met two people who hadn’t heard of Bob Ross. I had assumed everyone knew who he was.

It was in the context of reviewing one of my patients in a care home.

He is a man in his 70’s who has dementia.

I brought-up Bob when explaining to my colleagues the meaning of ‘happy accident’ – I was being flippant although the context was not.

The sequence of events was as follows:

Me – Seeing a patient was prescribed 10mg Amitriptyline (an old-fashioned tricyclic anti-depressant, used in low-doses to control pain, in higher doses to treat depression).

My brain – Oh, one of Rod’s dodgy drugs, harmful to people who have dementia.

Me – ‘Let’s see if we can stop it.’

Me – ‘Why has no one else stopped it?’

My brain – Let’s see.

I looked at my notes which documented 10mg.

I looked at the drug card which documented 50mg.

My brain – Odd, I thought, that’s a funny dose, not low (10mg), not high (100mg).

Me – as above.

We then looked at the discharge letter which documented 100mg.

My patient had been receiving half the dose of a drug which is used to treat depression, albeit a drug which in the context of dementia can cause a significant impairment of cognition (thought processes and thinking).

(We hadn’t reached the happy accident yet.)

Nurse – Oh, he has been receiving that dose for a week.

Me – What do we do? (Asking nurse and my colleague, my usual style of problem solving) (A problem shared is a problem halved, my brother always used to teach me)(It is also the basis of multidisciplinary working, although that I only discovered much later in life).

Me – We could put him back-up to 100mg, which might help with the depression side, although after a week his body will probably have adjusted to 50mg (Amitriptyline like other antidepressants should always be weaned slowly). If we do this however, we will be adding more dodgy-drug.

The patient’s level of dementia was such that we could not discuss this with him, although superficially his mood seemed normal.

Me (again) (consultants often do most of the talking on ward rounds) – We could leave him on 50mg, accepting that he had a less than ideal withdrawal and ask for advice from the mental health team, accepting that 50mg of Amitriptyline is less bad than 100mg. (If you want to learn more Google ‘anticholinergic burden’ and ‘dementia’).

We went for the latter.

By this time the nurse was feeling bad.

This is a phenomenon in healthcare called ‘the second victim’ – it is discussed in relation to incidents where a patient is harmed because of an oversight by a doctor, nurse or other member of staff.

The patient who has experienced the harm is the first victim, the perceived doer of the accident the second, and, you cannot underestimate the degree of pain experienced by the person responsible, most of whom have the daily motivation of getting up in the morning to ‘do good’ (remember Hippocrates, first do no harm).

Feelings of guilt (for the harm), anxiety (for the consequences of the harm and the subsequent investigation), worry, depression and more are common.

It was at this point that I went with the latter proposal and left the dose at 50mg, accepting that overall this was probably the better plan.

This was when I described the ‘happy accident’ and the Bob Ross.

I was trying to lighten the mood and make the nurse feel better (acknowledging that this incident, as with many in health and social care is contingent upon something called ‘James Reason’s Swiss Cheese Model’ an American scientist who defined the mode of causality leading to an accident – usually it is not just one event, but a sequence that leads to error; like that holes in a Swiss Cheese, when these are lined-up that is when things happen).

The Swiss Cheese Model - Sketchplanations

I described Bob as best I could, even Googling some of his photos. (I didn’t think discussing James was relevant at that time).

Nada.

Neither had hear of him or seen him.

There you go.

A funny world.

Accidents will happen is a well-worn English trope. (Also song by Elvis Costello).

There is a school of thought which claims that things do not just ‘happen’, accidents, result because of poor design (aircraft engineers have been demonstrating this for years) – fortunately or, maybe unfortunately, humans and the environment in which care is offered to patients is infinitely more complicated than a Boeing 747 and yes, accidents happen.

We do however continue to learn, to investigate the what and the how – the nurse who copied the dose from the original document to the MAR (medicines administration record) made the first mistake, over the course of a week the night nurse (a different nurse) didn’t look at the medicine box (which said 100mg) and read the MAR which said 50mg. It is very possible there was a different nurse every night – night-nurses are an incredibly limited commodity (made worse by, yes, thank you Brexit), the patient was in the home for clinical reasons beyond his control, it is a vicious cycle of complexity that most of us don’t consider when we get out of bed in the morning (or in the night, for the night-nurse).

Bob Ross.

Hero of mine.

Three days, 15 points and just starting to recover from the British Geriatric Society Autumn Conference

This blog might seem obscure to almost all of my readers except those like me who attended this week’s British Geriatric Society (BGS) Conference, I will explain.

It was, as with most educational events these days online. I sat in my office at home and tuned-in.

Nothing particularly surprising or unusual about that.

The thing for me, and what I want to discuss is how the event made me feel. After all, this website is all about almonds and emotions.

Feelings, education, Geriatrics? You might ask, what is going-on?

This event, and on other occasions when I have attended similar events I have been left feeling low. A little hollow or disappointed, mostly at myself.

I believe this situation stems from an intense period of exposure to some very talented and successful people (aka professors) who, for the most, are portraying and showing-off their ‘best selves’ – this makes the experience not dissimilar to the feelings some of us experience when pulled-into Facebook.

Sure, on FB, some people tell you how awful they are feeling, perhaps at life in general, through the struggles with their own emotional demons, at other times, following the death of a much-loved grandfather, usually accompanied by return snippets of ‘thinking of you’ or appropriate emojis (with some accidental thumbs up – meaning I imagine, ‘I’m with you buddy’ rather than, ‘That’s great’.

It is well established that FB can have a detrimental effect on individual’s sense of self, their perception that everyone else in the world is having a party and you are, well, alone, on your phone. (Appreciate young people when out and about doing things are also often on FB, in a hyper-real metaverse).

And so, the conference.

For the most, this was people showing-off their successes, how many older people they had saved from peril (mostly keeping them out of hospital), how many standard deviations from the mean their intervention had generated and so on.

I even ran a slot – I will post it here for anyone interested.

I am as guilty as the rest, as I was a blowing my own trumpet about some of the stuff I have done.

Looking back, the only conference where I have felt at home have been the ‘Risky Business’ events run out of Great Ormond Street. These tend to present people describing high-risk or perilous moments and experiences, it borrows examples of risk and safety from industries and professions outside medicine or healthcare for shared learning – you can see some of the talks here.

The ones that stand-out for me was the boss of BP talking about Piper-Alpha and the woman who fell from The Screamer at Alton Towers and, of course Martin Bromiley.

Now, I don’t suggest that these conferences should be entirely populated by people describing their experiences of failure, it might help redress what I perceive is an imbalance between a Candide demonstration of perfection with an expose into the difficulties of others, a humanisation of academia if you like – nothing salacious, perhaps some grit.

Reflecting on the conference it was I think, sitting with my dogs by my side, early on Saturday morning, rain battering the windows, a positive experience, not least because of one of the final speakers, Professor Mark Edwards from London who gave a thoroughly person-centred and compassionate talk about FND – Functional Neurological Disorders.

Professor Mark provided a philosophical, psychological and neurological interpretation of this group of conditions, described (I think poorly) in the book ‘It’s All in Your Head’ – Freud called them hysteria, suggesting they are a particularly womanly phenomenon – not true; through to the increasingly frequency of these medically unexplained symptoms described as functional (i.e. the body part – they eye, ear, hand, foot is intact yet it is unable to function – the eye looks like the eye of a seeing person although the functionally blind person cannot see.)

What will I do next time?

Well, it is considered part of ‘Good Medical Practice’ according to the General Medical Council for doctors to maintain their knowledge, to stay up to date with modern trends and developments, this means I will be back, I might seek-out the talks that are prefaced with ‘I tried but I failed,’ or, ‘It was harder than I thought’ rather than ‘101 ways to improve the blood pressure of ageing rats’

Thanks for reading & have a good weekend!

PS the ’15 points’ refers to the 15 Continuous Professional Development (CPD) points awarded by my attendance at the conference – usually 1 point equals and hour of CPD. You need at least 50 a year to be considered keeping up-to-date. From this perspective it was worth it.

Broken hearts, or why telephone consultations are less than 35% effective (homage to Heathcote)

I visited one of my patients at home the other week.

I can’t remember the reason for my visit.

Her daughter, grand-daughter and great-grandson were in the room. The wee one was only a tot – three weeks old.

This was our first face to face meeting in over a year and it took me a while to recap on all that had happened to her in the intervening months – over and above the new addition to her family.

She’d been in hospital, had a heart attack, caught Covid, her arthritis had flared; all that kind of thing.

It was when her daughter said to me, ‘How can my mum still be alive? Her heart is only at 35 per cent.’

It took me a moment to realise that her daughter was referring to what we (doctors and those specialising in the heart) call ‘ejection fraction’. I’ll explain more in a moment.

At first I wondered where the daughter had heard this number, then, reading through the records I could see a number of telephone consultations with follow-up letters between my patient and her cardiologist.

In one of these ‘…heart has an ejection fraction of 35%…’ was mentioned. It was to this they were referring.

It is reasonable to worry when you hear ‘heart’ and ‘35%’ – this means potentially, if you flip the maths that 65% of your heart is somehow not working or broken, surely a bad thing. When your phone’s battery is down to 35% you worry, same too for petrol in the car, particularly if this is as good as it gets, in other words, you fill-up your car and you know you can only fill-up to 35%. That is on a good day.

I provided my patient and her family a short lesson in cardiac physiology (normal ejection fraction, that is the amount of blood your heart can pump-out at the end of each contraction is 65%) – when your heart beats, it doesn’t empty completely, this is normal. When disease occurs and the heart muscle is damaged, as with my patient, the pump doesn’t work as well and the amount of blood squeezed round the body with each heart beat drops, and as in my patient’s case, this was 35%.

35% isn’t great, but in context it’s less bad than thinking you should be at 100%. Many aspects of human physiology work this way – you take a deep breath then blow-out. You think that is 100% lungs filled, then empty – a ‘big puff’ when really there is air that is left behind, a big-puff might only be 70% of your lung volume, a regular breath is even less.

Back to telephone conversations.

This has become a standard means of patient-doctor interaction since the pandemic. It has always been a means of communication, it is merely come into the fore since things changed and ‘face-2-face’ became a political ping-pong that the government used to scapegoat the medics.

In the years before Covid I would have loved the opportunity to chat with my doctor rather than travel to the surgery, sitting in a room with coughing strangers, eyeing-up the others, wondering what their conditions might be (asthma, cancer, depression?), always expecting to be next. At my turn, the surgery would flash up my name on a red screen. Not only was I ‘Doctor’ but also ‘Rodney’ both words I don’t associate with who I am (I am Rod, just Rod.) – I would then wonder what the other patients would think about the doctor seeing a doctor and so on. My worry-mind would flip.

Anyway, the day of phones and now emails for contacting your doctor have improved things, at least, for me.

This is, I guess because I am a reasonable communicator and I can get what I want and, if the doctor says something like ‘ejection fraction’ I will know what they mean.

Doctors can be awful in their use of jargon.

The medical language, is, well, a language. It might have few verbs and conjunctions, it is still a mess of Greek, Latin, dysfunctional acronyms and abbreviations that to the uninitiated (that is, patients) often make no sense.

I used to work with a colleague who would preface half her sentences with ‘obviously’ as in, ‘Obviously the RCA is the cause of his symptoms’ or something like that.

Although doctors are being battered over the head for not enough F2F appointments, in reality, telephone reviews are much harder than seeing a person in the surgery.

Take away, facial expression, eye contact and body-language and it is far more difficult to know or understand what is going-on.

In my experience, most doctors would prefer F2F, it is the pandemic that has had a massively negative effect on the nation’s (world’s) physical and mental health and has led to a huge increase in demand for services (this applies across the board – hospitals, ambulances and so on).

Telephone consultations are efficient in terms of seeing more patients in a specific period of time, they are however of less quality.

There are not enough hours in the day for doctors to see all the patients F2F who they would have seen before the pandemic. Battering GPs over the head for this is just another form of political messing that BJ and his cronies like to employ so as to make private healthcare (his pals) seem more attractive.

The thing is, going back to my patient and the situation in general, if you are going to conduct just telephone reviews, you must acknowledge that you will potentially miss-out lots of information, the likelihood of miscommunication will increase, misunderstandings will be inevitable.

In my opinion, telephones are OK if you know the patient (you have at least met them in the real-world F2F once) and you have a reasonable command of English (You are screwed if English is not your first language and your patient’s English is not good, or if they are head-of-hearing) (add-in dementia or cognitive impairment and it is hopeless). Without this, the situation is fraught.

The same must apply to letter writing. Perhaps doctors should take plain-English courses. I hear there is software that can translate from medical into English. Something to consider.

In the end, my patient felt slightly better that her heart is only slightly broken, not completely kaput, obviously, there is a long-way for us to go before what is said is what is meant and what is heard is what is intended.

I’ll leave you with my favourite Heathcote Williams.

Mokusatsu

Asked what he’d do first if called upon to rule a nation Confucius replied, “I’d correct language.
If language isn’t correct
Then what is said is not what’s meant
And what ought to be done remains undone.
Morals and art deteriorate
And justice goes astray –
And if justice should disappear
Then people will stand about in helpless confusion.
So there must be no arbitrariness in what’s said.
It matters above everything.”

Asked to surrender in World War II
The Japanese used the word ‘mokusatsu’
In their response to an Allied ultimatum.
The Japanese word meant
‘We withhold comment – pending discussion’.
When their reply was sent to Washington
The crucial word was mistranslated:
Its correct meaning being changed for
`We are treating your message with contempt’.

The Americans claimed that their ultimatum had been rebuffed
So they were free to play with their new toys.
Two atomic bombs nicknamed ‘Little Boy’ and ‘Fat Man’
Were then dropped upon Hiroshima and Nagasaki.
A hundred and seventy-five thousand people
Either stood about in helpless confusion
Or were turned into radioactive dust.

Today ‘peace’ is mistranslated
And means a seething stalemate instead of calm;
‘Strength’ is mistranslated
And means paranoid force instead of right-minded confidence;
‘Defence’ is mistranslated
And means the compulsive accumulation of profitable weapons
Rather than the thoughtful exercise of skill;
‘Testing’ is mistranslated
And means the deadly detonation of a nuclear device Instead of a tentative experiment;
A ‘disarmament treaty’ is mistranslated
And means junking obsolete weapons because of economic restraints
Rather than abandoning technological violence;
‘First strike’ is mistranslated
And means last strike;
‘Security’ is mistranslated
And means danger;
‘War’ is mistranslated,
And we are invited to believe
That war means peace.

Heathcote Williams

Anxious Jew

Before I begin, I’d like to preface this with the guidance that I plan to discuss what might be considered by some a contentious subject, and I also would like to caveat this with the explanation that the narrative will be dealing with Jew as group of Jewish people, a generality, in the same way the Covid vaccine offers 95% protection from the virus. It doesn’t. Perhaps in the lab this is what it shows, yet, we all know someone who had been infected after double or even treble jabbing.

I would also like to provide an explanation for the use of ‘Jew’ – me, and others like me, that is, Jewish people can be quite sensitive about the word. This is because of its long history as a means to denigrate and defeat us (as a religious, cultural and ethnic group).

Say ‘Jew’ and some of us immediately are on the defensive. We think Jude. We think 1936 and all the rest.

Most of us prefer Jewish. As in ‘he is a Jewish man’ rather than the objectified ‘Jew’

Anyway, none of this is the focus of today’s blog.

To be honest, I was only planning to write one blog this weekend, yet yesterday’s (which I thought was quite good stuff) didn’t pull-in many readers, so, again, here is something different. (If today’s title has caught your eye, here is yesterday’s)*

My sense of the Anxious Jew, or the Jewish Person who suffers** or experiences anxiety is a little like the caricature that Woody Allen built a career upon. I know many people have a problem with Woody given the situation with him marrying his daughter, I don’t want to go there now, that’s for another day.

Let’s go back to Annie Hall, Manhattan and so on.

It was this narrative that I used to rationalise my own and some of my family’s anxiety.

As we all know, anxiety is essential to survival.

Too little and the lion eats you, too much and you can’t move – you are a (literal) puddle of worry; just right and within the limits of individual control and you can rise to the challenge when called upon and back down when all is safe.

In my explanation to myself I interpret my own history which began somewhere in Eastern Europe.

In talking with my children recently, I discovered that they hadn’t heard of Pogroms.

These were the raids conducted by Cossacks and other yobs upon Jewish villages over the past thousand years in Easter Europe.

The usual scenario would be – child/woman/goat/dog dies, the priest can’t explain what has happened, the villagers are too poor to afford a doctor, they have bad sanitation or not enough food, are too afraid to ask the local prince/lord/duke for anything, they need to blame someone, they hold a Pogrom, rape and kill some Jews and the order returns.

This scenario ran for hundreds of years. Even in nearby York, they managed to corral the local Jewish population into Clifford’s Tower in 1190.

Putting aside what people are saying about the Israeli government in 2021, the Jewish people have had a hard time.

It is of course necessary to interpret the behaviour of the solitary Jewish nation in the light of historical events.

Wondered why Israel was so very quick to support and roll-out a vaccination programme? Why they locked-down long before Boris got off his bike?

And back to anxiety.

I worry that this narrative is too convoluted to make sense.

It is my nerves.

And it is this explanation that helps me accept this state.

The state of my nerves keeps me on my toes, it has kept my ancestors on theirs too. I have been selectively bred, a form of operant evolution has led to me being anxious.

My grandfather was anxious enough to leave Russia when he was 17, my maternal grandparents were anxious enough to leave Poland many years before.

My double-masking and hand washing is all part of an occupational necessity informed by a state of underlying worry.

The worry is good, it kept my ancestors alive.

Daniel, my great-great-great grandfather, early anxious Kersh, would have thought, ‘I don’t like the look of the Poles today, their behaviour is worrying me.’ This would have led to belongings on the cart and move-on to the next Shtetl.

It has prevented any of my relatives from being battle heroes (Yes, this is relevant as I write this on the 14^th of November 2021 – Armistice Sunday in the UK). (Papa Ben was wounded in WW2, during an air-raid – he was a master-craftsman cabinetmaker, a solid non-violent profession; on his grave-stone he is describes as a gentle-man). (He was a worrier too).

It can cause problems in an overclocking of thoughts.

It has ensured I have studied, worked hard and done well in exams.

It has kept me on my toes.

Yes, I am at times, an anxious Jew and yes, the circumstances of my life today are not that anxiety provoking and, that can be a problem.

It has led to a Mindfulness preoccupation.

It has led to fretting.

Yet, it is something to embrace. A means to interpret a strange world.

What’s your foible?

*On the topic of yesterday’s blog – I originally called it ‘Geriatrician tells his followers to get high’ – I later worried that a) telling people to do things isn’t really my way and b) although people read my blog, I don’t think of them as ‘followers’ although social media has removed this term from its original religious sense. I revised the title to ‘asks’.

**Apologies for the comments – I still struggle with the concept of people suffering with a condition that is part of who they are and living with the condition, ‘He lives with anxiety.’ The dementia movement cottoned-on to this early and have shunned ‘suffers’ in favour of ‘lives with dementia’.

Thinking mindful – geriatrician asks his followers to ‘get high’

I haven’t mentioned Mindfulness in a while.

There has been so much mindlessness of late that I haven’t had time to stop and think. This blog predates Trump and had transited through the Tory-decade into the Covid present.

Mindless environmental degradation, political wrangling, and profiteering – that kind of thing.

One of my first blogs discussed Mindfulness and Patient Safety – this is still close to my heart although has been subsumed by recent events, principally the madness affecting the NHS, health and social care, what we are doing to poor people, the disadvantaged, the elderly (sic) and the, well… sick (non-sic).

Mindfulness has returned through a recent reimagining of my dog walk.

I’ll come back to this in a minute.

First, ill mention Benjamin Zephaniah and getting high.

Benjamin, Professor of Professor of Creative Writing at Brunel University, often visits schools to talk about his poetry and experiences, the tough times he encountered growing-up, at times down-and-out in Birmingham.

Something he discusses is getting high.

You have to imagine his avuncular bariton talking to a class of 10-year-olds, ‘Everyone needs to get high. Drugs get you high, crime gets you high, these are not the only way to high. I get high in Kung Fu and poetry, for someone else it is running, football or art, we all need to get high.’

Benjamin didn’t say this, only words to this effect, I have paraphrased from various interviews and his recent autobiography The Life and Rhymes of Benjamin Zephaniah.

My problem, and I think the problem many of us have faced lately is that we don’t get high, or, if we do, we resort to maladaptive behaviours, alcohol, drugs, sugar, over-doing-it at work, that kind of thing.

These are what you might call self-destructive, maladaptive highs. They are non-sustainable highs, and they don’t satisfy any deep or significant sense of meaning.

Getting high is flow. It is total absorption in an activity that is in some way creative or self-enriching.

How do you get high?

Walk in the park?

Getting high is essential, you can’t do it once a year. A fortnight summer break is not a sustainable high for it is finite, too infrequent.

I am not knocking summer holidays, just refocusing.

High, which could be defined as flow, or a state of Mindfulness must become part of your routine to have any meaningful impact on your experience and quality of life.

And this is the dog walking.

Regular readers of this blog will know I have two pups – Stella, our 2-year-old Pointer x Springer (we think) and Blake, seven months old Cocker.

Neither have been very good at walking on the lead.

Stella is actually pretty good when I have her in a ‘Halti’ this is a German head device a little like a bridle, and Blake, well, he only really behaves for his mummy when she has tasty treats.

I’ve been working with Stella.

You might think, hey, Rod, you’ve had Stella for a while, why just now the working?

And yes, I confess, I have taken her on daily walks for the past year, long and short trots across South Yorkshire and she has, for the most, been a good compliant hound – avec Halti.

I have taken her walk after walk, mostly with my head in the clouds – Mindless. Not, completely unaware, rather, occupied either with worries about work or listening to the latest edition of Adam Buxton, Hardcore History or Audible.

My mind has been in a Japanese meta-reality rather than on Wong Lane (street near me).

And yes. I have taken myself in hand.

I have for the past month put the Podcasts to one side (the car) and walked Stella without distractions; just me focusing on her and the walk.

I have used positive reinforcement, ‘Yes, Stella! Good Girl!!’ when she turns her head and walks in step.

Avoidance and an occasional gentle tug when her focus wanders.

I still lose-it. I think about the ambulance waits, old folk being taken to hospital, how our staff will manage. My mind wanders. When my mind meanders – the contra of mindfulness, my dog does too.

I don’t tell her off on these occasions – it’s not her fault that my thoughts are not focused. I return to the moment, make a tongue click and with a brief eye-contact give her a Nutty-Butter Bite.

She now walks fine on what is called in the textbooks a ‘loose lead’.

I have become more focused.

In a 30 minute walk my mind still wanders, but much less than a month ago. Every minute of Mindful focus enriches me, strengthens healthy neural networks and is an investment in the bank of Happy Rod.

Life has improved.

Stella is happy.

I even wake happy.

We all need to get high.

Folk don’t realise I am high walking down the street.

I am my own man, my dog is her own dog and there are unimaginable troubles in life that can be parked for 30 or 40 minutes until I move-on.

How high or low are you?

Thanks to the Copper Pot Coffee-Kitchen-Bar, Division Street, Sheffield – latest blog-site venue.

Pictured, full-English vegan with a little too-salty Halloumi 

It’s worse than it’s ever been. Just kidding… Not.

You might consider doctors, nurses and NHS staff in general to be a bunch of moaners. I don’t remember a time when people were not saying how bad it was and predicting that we were on the brink of collapse.

That’s not really true.

I am old enough to recall the time before the financial crisis in 2008, when New Labour was in its heyday and investment in health and social care was at a high. I can remember a trip down to fancy London hotel to attend a conference which looked at new ways to move forward, to grow, to improve the lot of our patients and staff.

It was the year David Blaine was suspended in a large plastic box beside the Thames. (2003).

It’s not like that now.

Now it is as bad as it has ever been.

I think of Harry Leslie Smith.

You know, the one who wrote Harry’s Last Stand.

His recollection of growing-up before the NHS. The description of his sister who had TB. His family were too poor to pay for medical attention. She died, fading-away, not that they could necessarily have done much back in the day, yet, as I have said before, lots of medicine and healthcare in general is being present, it is the act, the participation in a pantomime of care that results in people somehow improving.

This week one of my patients was having a stroke.

Remember the advert? Arms, face and speech – the first signs of stroke that signal the cost of brain being lost at the expense of time, the necessity to reach a specialist centre as soon as possible in order to deliver cutting-edge clot-busting drugs?

I called 999.

It took 15 minutes for my call to be answered.

15 minutes is equivalent to lots of brain cells deprived of oxygen and dead.

The standard emergency response time for an ambulance in the event of a cardiac arrest is eight minutes. I spent almost double that time on the phone waiting to speak to someone.

When I got through it was a call handler in the South-Coast – our local network was so overloaded that lines were being diverted.

Eventually an ambulance arrived.

I had left the building by then (other patients to see).

It was too late by the time my patient arrived at hospital.

Ambulances routinely wait an hour or two outside of A&E departments to transfer patients – there is no space available except in the back of the vehicle.

And when the patient is moved from the ambulance to the hospital stretcher, they can wait sometimes eight or nine hours until they see a doctor, then, there is the often a 12 hours (frequently more) wait on a stretcher before a bed is available on a ward, and then, there is the wait for a medical doctor to review and another wait until you are seen by a consultant.

The situation is dire.

Hospital beds are filled with patients who cannot go home because they have Covid or have been in contact with someone who has had Covid and they need to quarantine.

Yes, folks, Covid, despite vaccine one, two and three is still a killer.

The care homes who opened their doors during the first-wave of the pandemic (with a consequent decimation of their residents) are now saying no. They will not accept these people who pose a risk to their residents. And, you can’t blame them.

The same care homes are struggling to staff the beds they have given the rates of pay they receive and are able to pay staff (some care homes are making a killing, that is a separate discussion), this week only staff who have been double vaccinated can provide care, which is OK, although it has led to a shift of other workers to Amazon, they are planning the same for NHS staff (and, why not?)

The agencies providing home care, that neglected, damaged part of our economy, workers on minimum-wage, zero-hours contracts who are provided with a minimum of autonomy or training are also not filling posts. Brexit has led to a lack of staff from Europe willing to fill these roles.

Hospital beds are filled with patients who need support to eat or drink or get to the loo, there is no one available to provide this care in the community.

People wait weeks.

A few years ago there was a campaign focusing on the last 1000 days of a person’s life – those who are mostly old and frail, who don’t want to dilly-dally, and who don’t have time to spare away from home, family and friends.

We are burning-through those 1000 hours in the same way we use fossil fuels.

The system is a mess.

Fights break-out between health, social care, primary care, the voluntary sector, mental health and physical health.

It’s a scrap for workforce and resources.

Anyone with any sense is getting-out, taking early retirement and trying to stay fit, hoping they will not require a hip replacement any time soon, or, if they do, are ensuring they have enough money to pay privately.

Operations are cancelled. The tumour that should be removed is provided opportunity to spread when our disconnected system doesn’t facilitate rapid treatment, just like my patient with the stroke, instead of brain cells dying, this is cancer cells metastasising.

Gosh, what a barrage of negativity.

It’s no wonder Generation Z are losing faith.

Don’t worry, says the Health Secretary, we have a new anti-viral drug that will sort-things.

Ever heard of pissing in the wind?

My regular news updates come from Google News and The Guardian.

I sometimes (probably daily) think I will stop opening my news apps as they are so depressing.

If it bleeds it leads, they say.

If it consumes CO2 or leads to the loss of endangered species it leads too, although in a more self-destructive fashion.

I usually focus on the crosswords.

We have been thinking of ways to discourage people from attending A&E over the past couple of weeks – ‘only call 999 if your condition is life-threatening’

‘What else can I do?’

‘Phone 111’

111 after a 40 minute wait tells you to ring 999.

Convoluted circles.

The government has even succeeded in turning people against their own GPs, claiming they are not working hard enough, that they should see more patients, that they should do more and more with less.

The Titanic is sinking and we are adjusting the deckchairs.

‘Hello, it’s the doctor here, just phoning to do your routine health check. How are you?’

‘Fine thanks. Don’t you have sick people to see?’

‘We do, it’s just that the government shuts us down if we don’t make these calls. We are damned if we do, damned if we don’t’

‘Nice talking to you anyway.’

‘Take care, see you next year.’

Einstein would laugh.

Scratching away at the same door and expecting a different result.

Even my seven-month old pup knows better.

Try telling that to NHS England.

‘When will I receive my Covid booster?’ Asks patient Annie, 98, unable to leave her house for the past three years.

‘We are working-our way round,’ Says the doctor.

‘A nurse did it the last time.’

‘I know,’ Says the doctor, ‘There aren’t enough nurses to do it now, the doctors are vaccinating.’

‘I had my flu jab last week,’ She says, ‘Why not the Covid?’

‘You have to wait 15 minutes with the patient after giving the jab, it’s not in and out like with the flu, we don’t have enough staff for this.’

‘I thought you didn’t need that with the Astra Zeneca?’

‘They don’t have any of that available.’

‘I understand,’ Says Annie.

They say that baking a cake is science, it’s not like the alchemy of cooking, where ingredients can be thrown in to a curry or salad and mostly the result is edible.

A perfect storm.

The government, and I guess the media have managed to concoct a mess, it’s almost Remembrance Day.

Never before have so few cocked-up the lives of so many. You might say.

And the answer?

The next steps?

The way ahead?

Back at the start of the pandemic there was an explosion of innovation and creativity in healthcare – we are still reaping the benefits.

Two years ago if I wanted to prescribe my patient antibiotics I had to hand-write a prescription, get a relative to pick it up, take it to the chemist then take the medicine to my patient. Now, thanks to the work of some amazing staff on my team, I can send the prescription electronically and the chemist can deliver.

At the start of the pandemic the system, that is the bureaucrats and apparatchiks didn’t know what to do with themselves. They were mostly hiding behind doors or freaking-out, they lost control for a time and creativity could thrive.

Those folk have now regained position, exerted control and are limiting the very innovations required to undo the mess.

We need to find some way to occupy those souls in order for us (the crazy ones, the creative outside the box thinkers) to get on and problem-solve; stop dragging us to meetings, let us hang out and feed our right-brains.

I should probably stop reading the news.

I have started mindfully walking my dog – that helps, it doesn’t seem enough; anyone have an idea? What are the next steps? What do you do when the system is such a convoluted abnegator that ideas are cancelled-out as soon as they are dreamed.

Let’s pray.

patient details have been changed to protect anonymity.

A confrontation with the awareness of my outdateness.

I don’t even want to talk about the masks.

We were at a cinema in Bristol this evening to celebrate my birthday.

We saw The Harder They Fall.

No, it wasn’t the movie that made me realise how far away I am from where I could or should be, nor the paper cups we were offered (to decant our popcorn so as not to make a noise during the movie) nor even the adverts which seemed different to those up-north, it was the toilets.

They were unisex.

Once upon a time there must have been a boys and a girls room; no doubt, the boys with a few urinals and the girls, probably like it is now.

There were two similar doors each with a rainbow heart.

It only took me a moment to get-it.

There was no one else in the toilet, so I didn’t feel awkward, although, as to why I should feel anything, I don’t know. Perhaps something to do with the sound of strange woman weeing. Or a woman hearing me pee. Nothing bad or good, just different.

I came away thinking to myself that it was an unusual experience – a first for me, and so, there you go.

‘I’m not sure about the toilets,’ I said to my daughter.

‘What do you mean?’

‘Well, I could have heard a woman peeing.’

‘Whaaat?’

‘OK, yes, I could cope with a woman peeing, I just didn’t see the point, what is wrong with boys and girls?’

‘What about non-binary people?’ She replied.

My mind hadn’t even gone there.

The notion that for some either a man or a woman toilet might not be for them.

For my daughter, my proud Generation Z girl, it was automatic, reflexive thinking.

Yes, I am past it.

And a final word on masks, they ask you to wear them in the cinema, they even sort the seating, so you aren’t next to someone you don’t know.

In Sheffield, which, yes, is up north, the segregation was absent when I went to see Dune yesterday.

Every so often I kept thinking, in between the Sand Worms, ‘What if the woman next to me has Covid. I am sitting soooo close for getting-on three hours.

Some had masks, others didn’t. (I did and the woman who might have had Covid did as well).

Really going up north, to Scotland they haven’t ever given-up the masks.

We, south of the border have been led along by the donkeys.

Donkey state.

Donkey situation.

An inclusive cinema.

Such a long way to go.

Zazie Beetz as Mary Fields and Jonathan Majors as Nat Love.

Tell Me Why.

Why?

The principal question of human existence, of moving forwards, of gaining a better understanding of the world.

Tell Me Why (Answers to hundreds of questions boys and girls ask) is a book published originally in 1965 by Arkady Leokum.

The copy I have dates from 1980.

It was a gift from my Uncle Bernard and Aunty Elise.

Both now gone.

Bernard was my father’s brother.

He was tall with thick glasses.

He had diabetes and smoked.

Elise was his partner then wife.

All I remember of her is her shining glasses, permed blonde hair and smile.

The life I have lived with moving around has led to most of what might have been stored in the loft as childhood possessions, gone.

I still have the book.

As a child I didn’t have many books although our house was full of them. They were mostly for the grown-ups.

I would read then re-read my illustrated Old Testament then various editions of Oor Wullie and The Broons.

Interestingly, my daughter who has lots of books, both for young and older, tends to watch then re-watch American dramas and comedy shows. I wonder if there is something in that, the repetition.

Nowadays as an adult I struggle to watch anything twice, especially movies, and, the only book I have re-read recently has been Kafka on the Shore.

None of this is the point, or where I was heading.

A while ago I touched on the concept of the Grand Unified Theory – originally the Einstein ideal that would bring together quantum and classical mechanics (whatever that means), or, rather, a theory of everything.

At different times I feel I am closer to gaining an understanding, at others, I have never been further away.

For whatever reason, Covid times have resulted in lots of this kind of thinking.

Tell me why?

Essentially,

Why do you do that?

Why did you do that?

Why did they?

The aspiration to gain an understanding of the behaviours or actions of others is central.

I see a car overtaking on a narrow road, precarious and dangerous behaviour and although the action is one of those I hate, at least I get-it. He (usually) is in a hurry, he is impatient, he doesn’t see that overtaking doesn’t save time, doesn’t get you anywhere more quickly, wastes fuel, jeopardizes the lives of others, and so on.

Around 20 years ago they changed the name of A&E departments to Emergency Departments. This was an aspiration to influence the understanding within the population at large that accidents don’t happen – emergencies do.

The theory being, if people are more mindful, fewer accidents will happen, and, oh, we are so busy with austerity and all that, only come to us if it’s an emergency.

The message did not get through.

(As successful as ‘guns don’t kill people, people do’)

The aspiration to create a deterministic pathway of care has been a failure.

Tell me why you voted for Brexit/the Tories/Trump.

Tell me why you didn’t have the vaccine.

Tell me why you smoke/drink/over-eat/under-exercise.

It is as if there is a simple explanation.

A Grand Unified Theory.

Tell Me Why the book, allocates a page per question and answer. If only life were as straightforward.

Some people have given-up. They have pulled-down the shutters and stopped trying, others are going on.

Tell me why you ignore the environment.

Tell me why you ignore the suffering of humans and animals.

Tell me why you read the Sun / the Mail / the Mirror.

It is all part of a stereotyped mess.

A Classical Mess.

A balagan.

Go look that up.

Detour into etymology via hell and the NHS.

I have been thinking about scapegoats recently.

Regular readers may have noticed I mentioned them in previous blogs.

I have returned to the topic following the experiences of our reception staff.

For reasons of confidentiality I won’t go into the details, suffice it to say (and I know this is a common experience across the UK) one of our team experienced abuse from a patient who was demanding to see a doctor.

You maybe know the back-story – the Health Secretary and his proclamation that in effect Covid is over, doctors and nurses should get back to work (or in the case of carers, find something else to do).

The narrative that GPs in particular are somehow dawdling, playing golf or reading the Financial Times is using a time-old trope of scapegoating too.

(Although not a GP, I have never played golf (was for one day a very unhappy caddy) or read the FT).

Scapegoating.

It was the technique Hitler used during the Holocaust.

After the First World War, Germany was going to pot; instead of sorting things out, perhaps aspiring to not have a World War 2, he blamed the Jews, sent them to the incinerators and got on with bombing London.

I’ll loop back to this in a moment.

First I thought I would explain the hell reference.

I thought I would investigate the origins of scapegoats.

I knew scapegoat had something to do with ritual sacrifice, and, I had actually thought the ‘scapegoat’ was the goat that got slaughtered to pay for the peoples’ sins.

It transpires, that the scapegoat was the other. The one that got its throat cut and thrown on the altar was the sacrifice – I guess, the sacrificial lamb. The scapegoat was the one left behind – it absorbed all the sins and badness of the killed lamb or baby goat, it was then released into the wilderness, probably fall prey to a hyena or lion (we are talking biblical Canaan here).

What I found particularly interesting was the origin of the word ‘scapegoat’ it seems the word came from the Hebrew translation:

ונתן אהרן על שני השעירם גרלות גורל אחד ליהוה וגורל אחד לעזאזל
And Aaron shall cast lots upon the two goats: one lot for the Lord, and the other lot for Azazel.

Azazel meaning ‘removal’ – the goat would be sent for removal, it would be gotten rid-of; you would cast out your sins or bad deed and the goat would take them away; it would escape with your wrongdoings.

Now, for me, although this is interesting, what was more, was the discovery of the meaning of the word Azazel, as I long-knew that ‘go to Azazel’ or ‘lech le Azazel’ was a Hebrew curse, meaning, in effect, go to hell.

All these years and I didn’t know it had to do with goats.

(Occasionally the curse would be shortened to ‘lech leAza’ which would mean ‘go to Gaza’ – that too is telling.)

Back to our receptionist.

We have a zero-tolerance approach towards abuse of our staff. We see them working with us as a team, requiring the same respect, care and compassion as any other member of the practice.

Their work is our work. When they are asking questions, it is as if the doctor or nurse is asking questions, trying to establish an understanding of what lies beneath the demand, ‘I want to see a doctor.’

And, the NHS and our government.

It’s funny. You can still see rainbow signs in house and shop windows saying either ‘Thank You’ or perhaps, ‘Clap for heroes’ – it isn’t that long ago people were rattling their pans in admiration for NHS (then all essential) staff.

The coin can flip easily.

It didn’t take the Tories long to get over their intransigence. To see a way out for their failures as blaming the carers and the doctors.

Yes, they are scapegoating us.

For all they care we could go to hell, so long as they can keep going.

It’s a bit shit.

Woman vs Land Rover

I have just watched a short video clip of a woman driving a big black land rover over a woman protesting in the street.

It was one of the worst things I’ve seen.

The woman whose face was blurred had long fingernails.

Like a witch.

I don’t remember much else about her although I am sure her accent was from somewhereabouts in London, or so.

I found the scene very upsetting as I have always considered the rule of car versus person sacrosanct, in that on the pavement, people come first and even on the road people come first if they are in the way.

Cars don’t have right of way over other people.

It made me think of Tiananmen Square.

You know, man versus tank.

This was woman versus big ugly car.

I’ve always hated landrovers.

I think, because back in the day, the people who drove them belonged to a certain class – the landed folk, those who would hunt foxes and shoot pheasants. (In earlier times they would shoot peasants too 😄)

Now, anyone can drive a LR, they are, as far as I know, very, very expensive, and the message they convey is more, I earn ££££ rather than my family name is Patrice-Bouquet-Smythe.

I see the drivers of the cars as conveying a message of privilege combined with a thumbing of the nose at concerns of miles to the gallon or the climate crisis. (Tigers in their tank, no doubt).

I’ve never been inside one.

I am sure they might be fun to drive.

This woman seemed to typify all my thoughts and feelings about those who drive these cars, which I admit are a diverse group.

Yet, she, felt it OK to drive her car on top of someone.

The Insulate Britain protestors are trying to get the government to invest in housing to achieve our carbon-neutral goals. They want to start with social housing, to offset the cost of heating that those on low incomes must spend to keep warm.

Their direct action has caused lots of upset. Lots of traffic jams and frustrated Southerners.

Despite all of this, whether I agree or not with the movement (I do) the big, ugly car inching its way forwards on top of two women has left me cold.

I wonder what would have happened had she crushed them to death.

Would someone have acted?

Indulgence – Sunday morning in Waterstone’s Cafe

This is a different blog.

I am sitting in the Waterstones café in Sheffield. Laptop, Flat White and Scone. A drizzly Sunday morning, there aren’t that many people about – students likely still in bed, football supporters not arrived for the match, and, with John Lewis shut, the lure of buying a new rug or cushion gone for many.

I’m OK with this although it is a little dispiriting. All the closed shops.

Fortunately, the pandemic has done wonders for Waterstones.

Over the years I have witnessed the closure of more bookshops that I can remember. Back in the day it seemed I could spend the hours going from Books etc. to Borders to John Smith’s and popping into both the Waterstones’ (in Glasgow City Centre).

Not much else to say although I must head home later and prepare my talk for tomorrow.

I started an education group for the community staff in Rotherham, so far it has just been a mixed-group of nurses and therapists listening to me going-on about old-people related topics; I’ve done delirium, frailty and lying and standing blood pressure. Nothing you couldn’t have gleaned by reading my blogs, this format is me talking for 20 minutes followed by a chat.

Readers, you are welcome to join – link is here as well as at the end. It is 3 to 4 tomorrow (October 18, 2021).

The next session is discussion a topic close to my heart – avoidance of unnecessary hospital admission.

This is the systems I employ to keep older people from the grinder that is a hospital attendance or admission.

I read this morning about patients waiting 11 (eleven) hours outside of A&E departments.

That’s 11 hours in the back of an ambulance before they are even assessed by a doctor or nurse.

The significance of this does not appear to have reached the general public.

11 hours is a long time.

I think of the patients – a typical situation might be an 85-year-old woman who has fallen at home. They fall at mid-day, the carer finds them five hours later and calls an ambulance, the ambulance, because the patient is ‘breathing’ could take up to eight hours to arrive at their home, then 10 hours (or so waiting to get into the hospital) (actually journey to the hospital with or without red lights is a trivial part of the experience).

Older person then is assessed by doctors and nurses, blood tests and x-rays. Maybe six hours later they become a ‘DTA’ = this is NHS management-speak for decision to admit. They then might wait 10 hours to be moved from A&E to a hospital bed.

This is the situation in the NHS today.

It’s falling to pieces, distracted by the bluster of the health secretary calling for more face-to-face appointments with GPs. It’s missing the point. It’s as my former colleague used to quip, ‘moving the deckchairs on the Titanic’

Mix-in to that 30-hour gap-period a level of confusion and disorientation – perhaps Alzheimer’s, diabetes and incontinence and noise and dehydration and the picture is not great.

Back to my talk, which I promise will not have too many Book of Revelation references, this being, for although the system is like a battered rag, the staff working inside it, possessed of an eternal Dunkirk/NHS spirit, keep going, keep providing care to the best of their abilities and within those hours and minutes slowly passing there will likely be paramedics, support workers, nurses and therapists providing distraction, comfort and good cheer.

And the point is that often, when people fall-over (for example) a trip to hospital is the very last thing they need.

Yesterday I was called-out on Twitter and shortly identified by a couple of former colleagues.

It made me feel kind of special.

The essence of my work is doing all I can to ensure my patients are as well – mentally, physically, emotionally as possible and putting-in place systems to support them in the community.

An unnecessary trip to hospital is a very wasteful use of hospital resources. (?environmental impact too).

From yesterday’s conversation, someone mentioned their mum who had fallen and was now in hospital waiting to get home supported by carers.

Unfortunately, there aren’t many carers available. People are waiting, waiting to go home because of another fall-out of Brexit.

I remember my brother saying to me before the referendum, ‘Britain is full’ – as if we had reached peak-population. My brother is a very clever guy, he was also very wrong.

It is a perfect mess or storm.

A bonanza of unforeseen consequences.

Anyway, there is hope. We can do more to keep people well and out of hospital.

Here is a graph representing some of the work I have done in a local care home to reduce 999 calls.

Imagine that was replicated across the UK.

(This is some of what I will discuss tomorrow).

My Flat White has gone cold.

It’s hard for me to concentrate in a café where around me people are talking; I listen-in to fragments of conversation. Tuning in and out to the accents, the Sunday morning interactions of couples and friends.

I need to be in my quite space at home.

Or perhaps get some ear-plus.

And a thermos.

Before I go.

Delighted at the German couple behind me.

Can’t understand a word, just picking-up their feminine staccato.

Teams Link – 18/10/21 3pm to 4pm CLICK HERE

Caveat emptor – learner beware.

It seems to me that every item or episode of learning should come with a disclaimer that what the teacher is saying may be wrong.

This approach could make classroom work difficult yet, it might help prevent some of the follies that have led to gargantuan messes.

In the 1970’s Gil Scott Heron sang in The Revolution Will Not Be Televised,

You will not have to worry about a dove in your bedroom
The tiger in your tank, or the giant in your toilet bowl
The revolution will not go better with Coke

The tiger in your tank comes from an advertising campaign that ran when I was a boy.

Esso ditched tigers a while ago, I suspect in part because oil exploration and usage and environmental preservation are awkward bedfellows.

In the old days people thought cars were great.

We now know about the Climate Crisis and the tigers are dying-out.

My daughter recently moved to a new school.

Her reasons for relocating are complex and if you want details you had better ask her.

I was however delighted when she showed me a letter from the headmistress in which she wrote to all of the students (not cc’ing the parents) (students are young people, not children) about a recent decision reached between the school and the student council to alter the events scheduled for the Day of the Dead.

This event, which, ironically happens on my daughter’s birthday on the second of November is a Latin American festival of remembrance, celebrating the lives of those who have died.

If you look at my last blog I somehow touched on this then – it must have been in the aether.

The students had challenged that their participating in the Day of the Dead – dressing-up like skeletons, so very close to Halloween would potentially be a form of cultural appropriation – where the culture of another group is used indiscreetly, perhaps mockingly (if you watch TV shows and films of the 1970’s this was the heyday of the genre).

The students were concerned that their actions could be construed as insulting and lacking respect, and so, an agreement was reached, where the year group who in their course are studying the culture of Latin and South America who have an understanding of what they are doing will dress-up, in line with cultural appreciation. And the rest of the school for whom it would otherwise would have been a fun day will not. No mocking of the dead. The students were advised if they liked they could write a poem about someone who has died.

My daughter showed me this letter as it touched her heart. This is education that is happy to reflect and admit it is wrong, to change direction, to appreciate the feelings of others, to change direction.

I may not have conveyed this as well as the letter and I don’t think it is right to post it here, suffice it to say, it spoke to me as it spoke to my daughter.

What does this have to do with your usual themes of old people and emotions?

Well, to me, there is a very close connection between the approach taken by my daughter’s headmistress and the students who are spat-out of universities, particularly those studying medicine, nursing or therapy.

These health-science courses are predicated on a theory of education that values evidence-base above all.

Drug X, if given to 1000 people will save 10 lives. It might harm one person but the harm is mild. The benefits are worth the costs. Give drug X.

Drug X could be a treatment, a technique or a practice. It doesn’t matter.

When students are told about drug X they tend to hear the ’10 lives saved’ they don’t hear that 990 people will not receive any benefit.

That’s one thing.

And, in my experience, when you have a grey-haired professor telling you that something (especially if it is their research-topic) is true, you believe it.

Fast-forward ten years and it is discovered that drug X after 10 years is the cause of harm to 200 people. The harm was not recognised at first.

Now, I am not an enemy of this theory, it is called Evidence Based Medicine, or EBM, I am however more a fan of Person (or Individual) Based Medicine. The realisation that no matter what a study or multiple studies show, each human is unique and we all respond differently to medicines.

‘That’s not a usual side-effect of the medicine,’ does not mean, ‘You are inventing the side-effects, keep taking the drug,’ more, most people might not have this experience. You are you, you are unique. Let’s stop and think.

It is the stopping and thinking that seems to be lacking in education.

And, it is why I found my daughter’s head teacher’s letter so refreshing.

Educators acknowledging that what they say isn’t necessarily right.

If the government took this approach, imagine where we would be.

Yet, the government is filled with individuals who have an evangelical belief that they are right.

That doctors and nurses aren’t working hard enough, that the poor are poor from choice, and, that good things come to those who deserve it or who were born lucky.

And so on.

Student beware.

When I was a young doctor we thought that giving intravenous lignocaine during cardiac arrest was a good-thing, that it somehow helped the heart. Ten years later we found that it killed people.

What do I know now that will be turned on its head tomorrow?

I am long and thin by the end of the summer… Who am I?

You know the game.

A cryptic clue and an unexpected answer.

It came to me this evening, when I was discussing my role with colleagues.

I am a hospital trained doctor who works in the community and helps older people, although sometimes young ones too. Who am I?

I am a geriatrician.

Although I hate the name.

It always makes the think of paediatrician.

Like we are infantilising the old.

And yes, I can help young ones too, although not too young. You must be an adult for me.

I have a dual qualification, geriatrics and general medicine.

A mouthful.

How easy it would have been had I opted to become a cardiologist or a surgeon, not that those disciplines would have had me.

As a young doctor I always gravitated towards the older ones, those with wrinkles and grey hair, with a story to tell and a complex presentation.

And now, I am stuck, trying to explain who I am.

These days when I call-up a patient to let them know I will be visiting, I usually say, ‘It’s me, Rod, the hospital doctor, your GP has asked me to visit you.’

Or words to that effect.

‘Rod the community physician,’ doesn’t register.

Am I doomed to remain in this grey zone? Trapped like Bilbo Baggins? Time slowed-down, distorted ill-defined graphics and ominous soundtrack.

In the meeting this evening we touched on branding.

Without a clear definition of who I am and what I do, something I can describe in a neat soundbite I’ll be lost. We were talking elevator pitches. I’d need Canary Wharf.

Don’t feel bad for me.

Patients usually get me as soon as I sit down and explain my objectives, ‘I am here to help.’ That is all they want, that is all anyone wants.

Life is hard and the struggle is long.

I am here to help.

Just like that.

I have a grey beard and stop dodgy medicines.

I am a geriatrician.

I am a helper.

I’m Rod.

The offer of a natural death.

A few weeks ago I wrote an article for the Trust on the topic of resuscitation (below). There are many components to this, not least the sometimes forgotten focus on avoidance of its need, that is, within healthcare the role doctors and nurses can play in avoiding a patient’s deterioration and subsequent death. In the NHS this is viewed as the response to the ‘deteriorating patient’ and a fundamental marker of quality of care in a hospital or other care facility.

There is also the science of resuscitation itself which involves the mechanics of what you do, how and when and the underlying physiology and subsequent treatment and support for those situations when a patient is successfully brought back from death. (In recent years for example, it has been discovered that cooling the brain of a patient who has survived resuscitation can aid recovery.)

I am going to discuss documentation.

I know this sounds dull and anyone who knows me knows that I am not a fan of bureaucracy, yet, in this instance it is important.

Before I start I must explain that the state of death I am talking below is a particular one that is when an individual reaches the end of their natural life. Now, this is a tricky topic as the concept of nature is broad and you could question whether three-score years and ten (70) or 86 or 120 is the length nature expects.

Suffice it to say I am talking about old people.

I say old, rather than my usual older as I mean old in its common term rather than the more nuanced and relativistic older. Old in the UK today means (for me) anything beyond 85.

Now, the situation in the UK today is that if you are old and you are ill (or you might just be very old (I have a patient who is 106)), and something happens and you die in your sleep (most people when asked prefer this mode of death rather than a conscious or painful preceding of the moment of extinction) unless you have a document called a ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) completed by a doctor or a nurse, there is a likelihood attempts will be made at resuscitation.

When I discuss this with relatives or patients I usually describe the most common situation where people die in the UK, that is, a nurse or carer goes in to wake the sleeping old man or woman and finds that they have died at some point in the night or early hours of the morning.

They might be warm, they might be cold.

If there is no prior documentation of a DNACPR, at least for care homes and hospitals in the UK (where most of our population die), the carer or nurse must shout for help, call 999 or another sequence of numbers if in hospital and commence if able, CPR until someone tells them to stop.

In the vast majority of situations this is an awful situation for the nurse or carer as they undertake what they know to be a futile procedure, compressing the chest of a person they know to be dead.

How do you know someone is dead? I have sometimes been asked. Well, most people know.

A short while later, the ambulance crew will arrive.

Sometimes the paramedics will arrive at the care home, or in a hospital the resuscitation team and start or continue chest compressions and the like.

It might go on for some time.

Occasionally the nurse in attendance might advise the paramedics or the doctors, ‘He was 100 years old, he was very unwell,’ with the suggestion that resuscitation should not have been attempted at all.

You see, without the piece of paper, there is the belief that resuscitation must be done.

I have seen it happen too many times to remember; mostly in hospitals when I would lead the cardiac arrest team as a medical registrar.

I would arrive on the scene and within moments realise that the actions of the team were futile, the state of the usually naked body (clothing must be ripped or cut-off to allow the defibrillator pads to stick) was beyond saving and, even if ‘saved’ that is, allowed the Return of Spontaneous Circulation (RoSC) would only result in a short-lived period of ‘life’ before they ultimately died.

I don’t want to be too graphic about the events surrounding resuscitation as my aspiration is not to scare, rather, to explain the system in the UK.

If a patient dies in a care home in the UK (or in their own home) without the presence of a DNACPR, the police are called to what is considered an unexpected death, yes, even if that person is 99 and riddled with cancer.

The body will be taken to the mortuary and the coroner contacted.

If no doctor has seen the person in the past month this might even lead to a post-mortem.

I am stressing these points as when I discuss natural death, in other words, passing away, most people don’t envisage this.

Now, most people living in the UK do not have a DNACPR.

There is a school of thought that everyone should discuss death and their wishes, no matter their state of health or age and, I agree there is merit in this. Death as taboo is unhealthy.

In reality doctors or nurses who complete the forms tend to have these discussions with people who they feel have an increased risk of dying. These being people who have significant health conditions, perhaps disseminated cancer or severe frailty, and, what is key, is the involvement if possible of the person to whom the form applies.

If the person is not capable of such a discussion, if they have had a major stroke or had advanced dementia, the usual procedure is to discuss with a spouse or other next of kin.

And this is probably the point of this blog.

My first request, is, that although the level of detail I have provided here is unnecessary for most, the focus should be on death as natural, as an inevitable progression which will affect everyone and, the portrayal that most people die of natural causes in the UK. When death comes, it is almost always unavoidable, with the process of chest compressions and mouth-to-mouth rescue breaths in the very old a futile intervention, one which robs death of its dignity.

During the early phase of the pandemic there were reports of some doctors signing blanket resuscitation orders for care home residents.

I absolutely do not condone this, mainly because it breaks a fundamental aspect of clinical care and support that is, involving the patient or their next of kin in a process of join decision making.

Something people often ask is whether they need to sign anything. I always explain that there is no need. The DNACPR is an indication of wishes not a legally binding document (as opposed to an Advanced Directive).

TV dramas of Lazarus-like resurrections are very rare and almost unheard-of in this group of patients.

A final note relating to resuscitation is that it can be effective in bringing people back to life where they have experienced what might be called an un-natural death, for example a cardiac arrest following a heart attack, electrocution or drowning.

Chest compressions and mouth-to-mouth can and have saved innumerable lives across the world. I am an advocate of CPR which is a skill every citizen should be trained to perform.

Natural and un-natural are perhaps not the best ways of splitting the discussion although most people will get what I am saying.

The discussion, where the doctor or nurse spends time with a patient or relative is in my experience an act of compassion.

There is no law to say that doctors must complete these forms.

It is much easier to change the topic or put it off for another day.

Neither doctors nor nurses look forward to such conversations although most who do so, proceed because they care, because they value the dignity and sanctity of life.

Looking the other way is easy. Stepping forward and acting not so.

Mortality Matters – Issue 2 – DNACPR: What do you say?

DNACPR: What do you say?

Issue 2 – 24 September 2021

Starting discussions about resuscitation with patients, their relatives or carers can be difficult.

Often clinical staff are reluctant to begin conversations as they feel they might upset patients or their comments might be taken the wrong way.

It is a reality of life in the 21^st century that dying without the presence of a DNACPR introduces difficulties and challenges that many patients and families would prefer to avoid (involvement of futile resuscitation, the police or the coroner).

There are different situations when DNACPR discussions are important, for example when a patient is admitted to hospital, is in a critical condition and is not appropriate for escalation of treatment, or, when discussing with a patient their options for treatment and care.

A difficulty many colleagues encounter is knowing what to say.

I have learned over many years that one size does not fit all and as with everything in healthcare, taking a person-centred approach is paramount. Timing is also critical as is ensuring the environment is right.

Very often, in my role as a geriatrician, discussions about resuscitation take place as part of a broader conversation about a patient’s recent hospitalisation, their current treatment plan and prognosis.

Many of my patients have extreme frailty and do not wish to be readmitted to hospital if and when their condition deteriorates; this is within the realm of advance care planning to support admission avoidance.

I often begin my conversation by finding out what the patient or their family want or feel, reflecting on recent experiences, the good and the bad.

I frequently explain that we are able to provide adequate and effective treatment in the community, keeping patients in their own homes or care homes and avoiding A&E attendance so long as there has been a discussion about a patient’s preferences.

Many patients prefer to remain at home even if that means they might not survive. Most patients when asked would prefer to die at home with a minimum of medical intervention or intrusion.

To support this wish I create an admission avoidance document.

When I complete this document I usually explain to patients, that in order to have confidence that we can avoid admission or readmission, a DNACPR is appropriate (being sure to explain what the acronym DNACPR stands-for!)

Most often I say, ‘A DNACPR is a document which allows a person to die naturally, it does not mean a person can or will not receive active treatment or care, it doesn’t mean you will be ignored or overlooked; it is a document that provides those caring for you assurance that when the time comes you can be left in peace.’

Every time it is different.

I also feel quite strongly about the decision-making process, being careful to ensure that patients and relatives see that the form and its completion is a medical decision, with the responsibility for this being mine, the doctor.

Occasionally families are left to feel that the decision is theirs, something that can lead to feelings of guilt.

At other times when a relative is unsure and wishes to reflect, yet I feel it is more urgent or appropriate for the form to be completed I will say, ‘I think it best for me to complete the form now, you can talk with your siblings. Please remember that the decision is not your responsibility, all I require is your agreement or support. If you feel the document is inappropriate it can be cancelled.’

As I say, no one size fits-all.

Be sensitive.

Take your time.

Most patients and relatives welcome the opportunity to discuss this with another person.

If you feel uncomfortable with these conversations please speak with a more experienced doctor or nurse or a member of the palliative care team.

Rod Kersh

Consultant geriatrician and divisional director for community, therapy and dietetics

Manor Field Surgery Blog 10 Dizziness (three-part series)

As a young doctor and even as an ageing one, patients presenting with symptoms of dizziness are usually the ones that we leave until last, passing, if possible, to the back of the queue, the end of the day.

This is not because we do not like people who are dizzy, rather, it is such a tricky condition and at times difficult to understand. (Doctors being (for the most) human, like to do the easy things first).

I thought I would re-kindle my Manor Field blogs after yesterday’s over-65 flu clinic, during which it was apparent to me that many of our patients use Facebook and follow our surgery page. One lady surprised me with, ‘I’ve seen you on Facebook’ (picture below).

This suggested to me, that using my blog to convey health information might be a good idea. (If you are a Facebook reader and want to check out my blog, there is a link at the end.)

Back to dizziness.

I plan to discuss this in three parts as that is how I break-it down in my head when trying to determine the cause of a patient’s symptoms.

I will start with postural hypotension, as this is the only area of dizziness in which I can claim any degree of expertise. In following weeks, I will discuss the middle-ear (semi-circular canals and all that) then the cerebellum (the part of the brain that controls balance).

There are other causes of dizziness and I will touch on them.

Postural hypotension.

This is something I have discussed in several blogs and on Facebook. You might call it my favourite condition, not because it is something I particularly like, more because it is so often missed or under-diagnosed by other doctors, is potentially so debilitating to those experiencing it and can be treated quite easily.

What is it?

Postural, or as it is sometimes called, Orthostatic hypotension (or Orthostatic Intolerance) relates to the symptoms associated with a fall in blood pressure when a person changes posture, from lying or sitting to standing.

It is mostly experienced as a feeling of unsteadiness or light-headedness; some people feel so topsy-turvy they need to sit or lie down immediately after standing.

For a few, if they can’t immediately lie or sit down, they can fall, for some this coincides with a loss of consciousness – blanking-out.

To explain how this works I need people to join me for a short course in physiology, otherwise known as human plumbing.

So long as we are alive, we have blood sloshing around inside us. Blood is mostly liquid with some other components – red blood cells containing iron which give it it’s colour, white blood cells that fight infection and other innumerable chemicals, hormones, and biological substances.

This means, blood obeys, for the most, the same rules as water.

Blood runs around the body in blood vessels, arteries, and veins, pumping in a circle from the lungs to the heart then out to the body and back again to the heart then lungs.

We call this circulation. First discovered by William Harvey, an English physician in the 1620’s.

Now you have that picture in your mind, imagine water, or blood, whichever your prefer flowing up hill. The steeper the hill, the harder it will be to get the liquid to the top. To get that liquid ‘up’ requires energy, that’s the pump and functioning pipes – arteries or veins. You also need enough fluid.

If you do not have enough fluid, the arteries or veins are not doing what they should or your heart is struggling, the blood does not flow and not enough reaches your head.

If you do not have enough blood reaching your head you feel dizzy. If there is not enough for anything longer than a few seconds you risk losing consciousness.

Hopefully, this has given you an understanding of what might be called in textbooks, the fluid-dynamics of blood.

It is nothing fancy. When I syphon my fish-tank water into a bucket I’m applying the same strategy or, when I sip a drink through a straw.

‘All this is very well, yet, you said it was easy to treat,’ some of you might be thinking.

I need to explain a little more before I talk treatments.

First has to do with the blood vessels, you see, they are not like the plastic tube I use to syphon dirty aquarium water, as they are capable of stretching and contracting, they can change their diameter depending on several factors – they can expand when more blood is required to reach a part of the body, your stomach, for example, after a meal requires more blood than at other times, or the muscles in your legs after you have exercised.

To supply more blood, the heart pumps harder and the blood vessels dilate.

If the heart pumps harder and the blood vessels do not dilate you get high blood pressure, which is a topic for another day, if the blood vessels dilate and the heart does not pump-out more blood, your blood pressure drops and, yes, dizziness.

There is more to this than I have written here and, I am not a physiologist, hopefully it has provided enough explanation to act as a primer in understanding some of what happens when doctors (through tablets) or disease (through effects on blood vessels) or medicines (through all sorts of mechanisms) influence blood pressure.

Do you ever feel light-headed when you stand-up?

When you get out of bed in the morning do you wobble and need to sit down?

That is often all it takes to reach a diagnosis of postural hypotension.

This condition can occur semi-naturally if someone is dehydrated, this is easily remedied with a pint of water. If it happens regularly, and leads to you over-balancing or falling, that is the postural hypotension and is something I can treat.

How do we diagnose this condition?

When people are healthy, the natural response for your blood pressure is to increase a little when you change position. This enables your heart to pump blood to your head.

When you are sitting your heart had less work to do than when you are standing. Standing is more uphill than sitting.

We can measure this easily with blood pressure recordings.

Lying and standing.

It is that simple.

You can read how to check your own measurements here.

If your blood pressure lying is 120/80, it should either stay the same or increase when you change from lying-down to standing. From 120/80 to 130/85, for example. When you lie down again it should drop-back to 120/80 (or so, blood pressure naturally goes up and down through the day and from minute to minute).

(The blood pressure doctors use to diagnose ‘hypertension’ is when people are sitting, again, a different subject).

If your blood pressure drops from lying to standing, say 120/80 to 100/50, you likely have postural hypotension.

It is that simple.

The occasional drop is not usually significant and may be related to a degree of dehydration, it might happen if you have a cold or the flu and are feeling under the weather.

Consistent drops of more than 20 mmHg (millimetres of mercury) over 10 is consistent with the diagnosis. (20 the higher or systolic reading, 10 the lower or diastolic reading) 120/80 = 120, systolic blood pressure (when your heart is contracting), 80, diastolic blood pressure (when your heart is resting in-between beats).

What should you do if you find your blood pressure is dropping and it’s making you feel dizzy?

First, sit down, then, talk to your doctor.

We can help!

The treatment might take a little while – we have first to establish the cause of what is happening, yet we should be able to make you feel much better.

‘I quite like the feeling, why medicalise?’ You might think, and I agree, this is always a question when you are thinking of involving a doctor or other clinician.

The problem with postural hypotension is that it tends to have two peaks, one when people are in their adolescence and growing and are quite fit, they may naturally have a low blood pressure (young folk call this a ‘head rush’); this is something that most people grow-out of.

As we age, our blood pressure tends to increase, this leads to all manner of bad things such as heart, cerebrovascular (brain) and kidney disease and is a major focus of Western Medicine, that is treating hypertension – high blood pressure.

As folk age, or other conditions intercede, such as diabetes, some start to develop postural hypotension which raises other complications.

The most significant, particularly for older people (the definition of older is anyone who is older than you) when the effects of ageing can impair balance, coordination, and reflexes.

All of this can result in one of the biggest risks to the wellbeing of older people – falls.

If a younger person falls (anyone younger than you), they usually recover quickly, they might look daft, but the injury if any tends to be minor.

As people age, the risk of falling increases and with it the risk of severe injury, especially fractures.

In older people we need to do everything we can (that is ‘we’ as a society and ‘we’ as doctors and nurses and others in health and social care) to reduce the risk of falling which is a major contributor to loss of independence and reduction in quality of life.

Older people fall more frequently than younger, when they fall the results can be worse; postural hypotension can result in a significantly increased risk of falling.

That is one of the reasons it is important to investigate and treat.

Other reasons relate to the potential harm of inadequate blood supply, even temporarily over a period of months and years to what we call end-organs, the brain and kidneys in particular. Postural hypotension has been linked to the development of dementia.

I debated whether to include that last sentence as I don’t want to scare anyone, and indeed, the risk is probably small, yet, even small reductions in risk are potentially valuable.

Treatment? Might be as straightforward as stopping a culprit medicine or increasing the salt in your diet, you might even require blood-pressure raising medicine.

Get in touch if you have any questions! r.kersh@nhs.net

If you enjoyed this blog, please give me a smile or a thumbs-up, if you are a patient and like our surgery, you could write a review.

Be well and take care and part two will follow soon.

A Grand Unified Theory of Nowt

Yesterday I wrote about the default mind network (dmn), hallucinogenic drugs and mindfulness, amongst other things.

I am not sure how many readers related to all that, it is, I agree, obscure.

For me it was a revelation, not so much because I enjoying discovering new concepts e.g. dmn, it was part of an overall exposition as to what is going on, reflecting the interconnectedness of things, why what happens, happens.

It helps me gain an insight or understanding into the life I and others lead.

It’s like finishing a chapter on the book, ‘Life a User’s Guide’

This is, incidentally, what kept Einstein going for a greater part of his life – the quest to discover a theory of everything; how the pieces fit-together.

I do not wish to suggest that I understand even one per cent of life although for me, unravelling my own and the behaviour of others is fundamental.

When I come to the end of a day and I am not wiser as to the trajectory of my life or the planet, or even my dog’s existence, I am a little let-down.

And this takes me to the subject for today.

It is the government. Or, how BJ came to be PM and the Tories have remained in power for a decade in the UK.

I know I have discussed this before.

It has been bothering me for ages.

I will not go over all the crap that has happened in the past ten years.

Some things have improved (the things that would have improved regardless of who is in power e.g. the speed of my broadband connection) and lots has got worse, predominantly not for me, but for everyone else, whether they are working or studying at a primary or secondary school, whether they work for the public or private sector, whether they have a bad hip or knee and want to get it fixed.

On a slideometer of life, things have got worse for a lot of people. (Or, the numbers who have benefitted from austerity have been small (Yes, you in your Jaguar), the numbers who have lost have been massive).

2022-jaguar-f-type-convertible-110-1622574621

And yet, we, that is the people appear powerless, or lacking interest or motivation to make a change.

And it’s not just in the UK it is everywhere, although for me, most acutely in our country.

None of it makes sense.

The poor getting poorer and the rich richer.

The phrase, ‘turkeys voting for Christmas’ reverberates in my head like Brownian motes.

I listen to people attacking the Labour Party and wonder what the heck is going on.

I see BJ incompetently flouncing from one crisis or disaster to the next and wonder what is going on.

We really have it all in the UK, or rather, the potential to have it all, yet, we seem to be content to give it away, to allow our talent and resources to dwindle to nothing.

And this is why I found the insight I gained from learning about the dmn so fascinating.

It is what our mind is doing when we are busy making other plans.

It connects my thoughts, and dreams and aspirations with the gremlins of my doubt.

And, to be honest, I find it hard to articulate my feelings about the political climate in the UK.

I find it impossible to imagine what needs to happen for people to insist on change, for our county to sort itself out and work towards a state of fairness and equality.

Covid has led to an unimaginable boom in the private healthcare industry. If you want your hip replaced privately you might have to wait a few weeks because the surgeons are so busy working away for private providers.

Sure, this is not as bad as the year (or two) you will be on an NH

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this:

Please share!

Like this: