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 NHS waiting list.

I popped into Tesco yesterday; there was no pasta on the shelves (no petrol in the pump either).

Brexit is hammering a nail into the coffin of our workforce.

Who will look after me when I am an old man? There will not be enough people in the UK to support me. Maybe the robots.

The nightmare of robots feeding me semolina. Robots wiping my ass.

Our workforce is falling to pieces.

I reliably place my disused plastic in the bin for recycling; it is collected every fortnight. I am 90 per cent certain that it is shipped off to another country to be burned or turned into landfill.

Driving around this summer in my car, I looked at my windscreen and marvelled at the lack of splatted insects, we are running of our tiny creatures to support the biosphere.

People are scrambling to buy tickets to fly to Greece for October half-term. The skies will fill with contrails and more CO2 will accumulate.

Eton anointed multi-millionaires will continue to determine my fate, and yours.

Old lady A will move from hospital ward B to C to D then E before leaving hospital to care home A then B then back to hospital then care home C and eventually she will die.

This is what we are doing to our old folk.

Throughout my blogs I always aspire to find a way-out, a solution, the grand-unifying theory.

Yet, for the moment I can’t find one.

All I can do is dig down; take to the mattresses as if the mob is after me; hunker-down and focus on the little bits of my world that bring me joy.

Yes, my family, my dogs. Even my tortoise as he reflects on the summer just past. The shining conkers laying amongst the falling leaves of autumn. That kind of thing.

Go on, surely it’s not all that bad.

The default mind network, flow and magic mushrooms

Yesterday I gained a better appreciation of life.

It was a fantastic moment.

For the past week I have been reading, ‘Entangled Life: How Fungi Make our Worlds, Change Our Minds and Shape Our Futures,’ by ‘Merlin Sheldrake.’

It’s all about fungi and moulds, their roles in the maintenance of life on earth (as an example, they enabled the move from aquatic life to land-living plants)(and now we have Sequoias.)

The chapter that threw me was about hallucinogenic mushrooms.

Magic mushrooms.

Psilocybin is a chemical that has come to the fore in the field neuropsychiatry over the past decade as it has been discovered to have potentially miraculous effects on the treatment of post-traumatic stress disorder, anxiety and severe depression.

Let’s face it, no one quite understands something as complicated as depression.

The exact biochemical events taking place in an person’s consciousness are beyond current science. (Think Pascal – if the human mind were understandable, humans would not be clever enough to understand it) (or, words to that effect).

For the most, we treat depression first with talking therapy (which can be very effective) and if that fails with medicines, usually SSRI’s such as Prozac.

I’ve just said, no one fully understands the underlying pathophysiology of depression. People have even less idea as to how antidepressants work.

When I joke about my work as a medical Shaman, I am not that far away from the methodologies of pharmaceutical companies who ply their trade.

I won’t go into the role the pharma industry has played in influencing the medicalisation of depression as that is getting off-topic and away from fungi.

You see, there is an idea that taking magic mushrooms, has an effect on something I had not heard-of before yesterday – the Default Mode Network, or DMN.

This is what happens to your brain when you aren’t doing anything.*

When your mind is not occupied writing a blog or holding a conversation.

It is part of the steady-resting state when your mind finds time to wander, when you might lapse into rumination; when you worry about the future, what you’ve just done or might do.

It is your brain ticking-over, like a car engine waiting for the lights to change.

You aren’t going anywhere yet lots is happening; you’re burning petrol.**

Now, had I been a cleverer fellow I might worked this out for myself.

And, you might have realised that when the DMN is functioning it could in certain people result in depression or anxiety.

I worry that I might not have enough time to complete all the work I have planned on Monday prior to the deadline when I will be asked to present the results of the…

Kind of thing.

The worry-wort brain.

It seems that Psilocybin has an effect on this network, disrupting or allowing a re-set, providing insights into the workings of the mind, ‘I might be worrying about the report for Monday, but hey, look at the vast span of time and space, tomorrow or the day after I won’t even be able to remember that worry, so, why worry?’

(I think of Bobby McFerrin ‘Don’t worry, be happy’.)

And for me this is fascinating as it puts meat onto the bones of something I’ve known for ages.

In the practice of Mindfulness Meditation (or Mindfulness Based Stress Reduction – MBSR) the state we call ‘mind-wandering’ is considered a source of much of what is wrong with people and society, it is at the core of why people become stressed, worried and depressed.

The goal of this meditation is to calm the wandering mind, to provide people with the resources to focus, to move away from the thoughts that leads to one thought and another, to bring you back to the moment – your breathing, for example.

With time it has been shown that practitioners of MBSR have significantly reduced levels of depression and anxiety (they also tend to be happier and more creative).

And here is the link.

Meditation as part of MBSR quietens the DMN, in a similar way to taking Psilocybin.

Yes, it is easier to take a brew of magic mushrooms than spend a decade meditating, yet, one strategy is legal the other not.

Also, funnily, something I mentioned a couple of blogs ago, around the state of Flow as described by Mihaly Csikszentmihalyi, this too is a means of manipulating the network, to allow a state of calmness.

Linking-up Flow (which I think I get when blogging or walking the dog or driving the car listening to Audible) with MBSR and the Psilocybin experience is for me a revelation.

How can we adopt this to help people?

Perhaps this understanding can help when I try to support those who are in the doldrums.

Perhaps the drug companies might find a way to make magic mushrooms that can be used therapeutically.

Perhaps we can tame Flow.

I am not advocating that anyone eats magic mushrooms – as of 2021 their consumption in the UK is illegal, also, like all things illegal, there is no way to judge safety or quality.

If you want to know more, find a good mycologist.

*Sentences like this always make me think of John Lennon… ‘Life is what happens when you are busy making other plans.’

**Unless you have an electric car like me #cheesysmile

Shady Towers, Social Care, Nora and Whitey on the Moon.

The government and, in particular the NHS are masters at inventing arbitrary names, often allayed with acronyms to describe obscure pathways and processes. It is what they do best. I imagine a conversation between the regional manager for NHS Y (can’t be NHS ‘X’ as that is, unsurprisingly already a thing) and their child:

Freddy: What do you do when you are on the computer in your office?

Mummy: I organise things.

Freddy: Are you a key worker?

Mummy: Yes, I suppose I am.

Freddy: What do you organise?

Mummy: I find ways to move patients and staff around a diminishing system to maximise output, retention and wellbeing of staff and patient care. I also invent acronyms.

Freddy: Can I watch Disney?

OK, what is this about?

Well, I want to focus on patient experience – in layman’s terms, and depending on your age and state of health, that means you, your mum or dad, brother or sister and what happens to them when they need healthcare in the UK in 2021.

During Covid (or when Covid was at its worst) (There seem to have been several ‘worsts’) the NHS developed a scheme to help support hospitals.

The idea was that when a patient did not need to remain in an acute hospital bed, they were discharged as efficiently and effectively (as quickly) as possible.

The process being:

Clinician (mostly male consultant) saying, ‘Medically Fit’ followed by feverish activity by nurses, junior doctors, therapists, pharmacists, clerks and others to get that person ‘out of the bed’

For the most, ‘out of the bed’ meant straight home, sometimes with their family or an ambulance, occasionally in the back of an Uber.

This, the bureaucrats* called ‘Scheme One’.

The aspiration at the start of Covid was that upwards of 95 (or was is 97?) per cent of patients would follow Scheme One; chest pain > heart attack > ambulance > A&E > angioplasty > Coronary Care > 4 days later, home.

Voila. It is a recipe for simplicity.

It works well so long as the ‘medical model’ holds true and patients do as they should (recover without complication from single-organ events).

When patients deviate from the furrow (the actual meaning of delirium) things can go awry, their time in hospital can be extended unnecessarily – this is called ‘length of stay’ or LoS, with extended LoS being a problem.

Some patients stay weeks, even months in hospital beds because of complex issues relating to the interplay of their health and home situation.

I have a man who has been stuck in bed too long because he has eight cats.

I understand the cats are now with the RSPCA.

I don’t know if my patient knows.

Scheme One is fairly dull.

It is Scheme Two that is more interesting and the one where I spend much of my time.

This is when a person is deemed ‘medically fit’ (to new readers of my blog, please Google ‘almondemotion & medically fit’ for lots on the topic) and they can’t go home – perhaps because their home is uninhabitable – they are hoarders, the roof has fallen-in, the street is too dangerous, there is a sinkhole, that kind of thing, or more often, they are too frail or confused to manage even with the care that could be provided to the Scheme Oners, they pass into Scheme Two.

These folk, by and large are moved from hospital into nursing and residential homes in the locality.

The aim of all of this, the Scheme One and Two is to create more capacity in the acute hospital so they can support the newly sick – something called ‘flow’ (not the kind described by Csikszentmihalyi).

To the casual observer, this might seem OK – person (for them most, people who are old e.g. over 85 years and often have either dementia or delirium) who doesn’t need to be in hospital and can’t go home, have to go somewhere, they are sent down the pathway of Scheme Two. (Before Covid these people remained in hospital and became ‘medical outliers/bed-blockers’ – an equally fraught experience).

This enables people (difficult to ascertain whether they are people or patients, it is probably more reasonable to stick with ‘people’) to be moved into care homes and, this is where the problem starts.

You see, taking person A, let’s call her Nora Newman (made-up name), who has fallen at home, she is frail, 90 years old and struggles to hear and see, she has lots of health problems and takes 20 different tablets every day. She has accidents with her waterworks (she has urinary incontinence) and lots of other things going-on. Her daughter, Angela (also made-up) lives in Southampton, (Nora is in Durham) is trying to find out what is happening.

Nora is placed in a care home ‘Shady Towers (yes, also made-up).

Nora used to live in South Durham, Shady Towers is in the North.

This means that the GP who has been looking after Nora for the past 20 years, who knows her well, inside and out is no longer responsible for her care, it is GP 2 who is the responsible doctor for Shady Towers. This arrangement is through another NHS scheme called EHCH or, Enhancing Health in Care Homes.

Part of the complexity is that Nora’s GP doesn’t switch from GP 1 to 2 automatically – there is a period of limbo when the Shady staff are switching her across and GP 2’s admin are registering her.

Nora is in Scheme 2. GP 1, GP 2, the care home manager, Nora and Angela have no idea what Scheme Two means. There is a letter from the local Clinical Commissioning Group outlining some of this on Nora’s doorstep, yet Angela hasn’t seen that. And no one else has had the explanation of the schemes that I am describing here (GPs have been too busy managing patient demand and the complexities of PCN (Primary Care Networks), Care Home Managers too occupied trying to find staff to care for their residents (the Brexit workforce gap).

Nora falls in the care home. She is sent back to hospital. She is confused, disorientated. Prior to Freedom Day Angela couldn’t visit (Nora doesn’t have dementia, the Willy Wonka Gold Ticket to allow hospital visitors during Covid, she was just confused.)

Do you see where this is heading?

Eventually Nora is well or ‘stable’ enough to either go home or at least not remain in Shady Towers, a process of discussion between a social worker, Nora, Angela, GP 2, Care Home Manager and whoever else might be involved – perhaps a physiotherapist or mental health nurse.

As if this was not tricky enough, the social worker is living in a UK that has been diminished for the past decade by Tory Austerity. They are trying to do more with less. They are trying to do more using iPad’s to communicate with 90 year olds who struggle to see and hear, they have irate family who are still coping with the guilt of moving down-south a decade before. They still have their day job of helping people that existed before Covid and before Scheme Two was thought-up.

It’s a recipe for disaster.

People like Nora tend to be those who suffer the most.

Nora is more likely, as a consequence of all of this to be given the wrong or inappropriate medicines (GP issues), is more likely to fall (environment issues), and is more likely to die (complexity and frailty issues).

I was on a call with a high-up social worker this week, her interpretation of this was that patients should be given a choice, should be empowered, shouldn’t be moved from hospital A to Care Home B unless they are in agreement.

I think she has been in management towers for too long.

The reality is that hospitals are experiencing more pressure than ever before, the numbers of patients waiting over 12 hours on stretchers in A&E is as bad as the late 1990’s, patients (people) are staying longer, unnecessarily in hospital, readmissions are up, survival is down.

It is not a brilliant picture.

The PM announced a rise in NI tax this week. I understand this is to offset some of the damage they have done to the NHS over the past decade. Fantastic. (And yes, Whitey is still on the moon).

The whole, the gap, the deficit or deficiency is in social care, yet, that has not been brought to the table.

I haven’t heard anyone saying we need to double the number of social workers or provide them with more support (many of whom are born and train overseas – the Brexit Gap again).

It is a perfect mess, all concocted by our government and voted into place by us. Not me. Yet, you don’t find many people saying, ‘Yes, I voted for this.’

Self-interest eventually comes-back and bites you.

Just as the gas-guzzlers of California are baking in the fires of planetary change, so too the Middle-Englanders.

I read in the Sheffield Star yesterday that ‘580 people died on the social care waiting list’ in that city alone.

It’s OK if it’s not you.

The irony is that more and more often, it is you. Or, me, telling my patients, sorry, the waiting lists are long, you have to wait, ‘If I send you to A&E you might wait eight hours for an ambulance and then sit outside the department for an hour before lying on another stretcher for ten hours before seeing a doctor’.

I hate to write blogs without a way-out.

Here are my thoughts:

Meaningfully invest in social care – more social workers and assessment officers with better support (no one realises how difficult their job can be).
Meaningfully invest in community care – more people like me and more nurses and therapists (and nursing and therapy and doctor support staff to work with them to increase their effectiveness and efficiency)
Acknowledge there is a problem/crisis in order for innovative local solutions to be considered.
Get rid of QoF (Quality Outcome Framework) – this is the driver of primary care payment that makes GPs spend masses of time sorting-out well people, instead of focusing on those who are unwell and in need of attention
Get rid of Care Home Quarantine and visitor restrictions – it’s inhumane
Get on and give old folk Covid boosters
Meaningfully address the imbalance in staffing and working across regions – people living in City A tend to have access to far more specialists than those living in town B.
Make people pay for social care – no dilly-dallying; if people can afford to pay for nursing and residential homes, they should, the absurdity of inheritance has to stop.
Stop giving things silly, arbitrary names

I appreciate this is not a fix to everything – you can’t fix everything; you can move closer to better, that is all I want.

When I take a step and it is away from better or good or kind, that’s what kills me.

*(is there anyone who know how to spell this word?)

Israel / Sheffield / Palestine & Stone throwing

I was in Sheffield yesterday.

The city centre reminded me of Shawlands in 1984.

Run-down, with as many shops closed and shuttered as were open.

No one has said we are in a recession. The times don’t feel great. You can almost see them, like dominoes, one shop closing after another, taking more and more custom and profit and there you go, another gone.

We were in the city as my son wanted to do something with his child-trust fund, now that he has turned 18 he can get his hands on the money.

Afterwards he was scheduled for a haircut.

All of this might seem irrelevant, and, indeed, it is, I am however setting the scene.

It was around 1130 and I saw in the distance some Palestinian flags. This was accompanied by a group of people standing outside one of the out-of-business shops – I think it might have been a bank, requesting that passers-by take a leaflet and BDS.

BDS is an abbreviation for ban, divest and sanction everything to do with Israel.

A woman offered me a leaflet. I declined.

From reading previous blogs, you might have worked out, a) I have Israeli citizenship, b) I am Jewish and c) I quite like Israel.

You might also have established that a) I tend towards the Left, b) I am a humanist c) I care about people, particularly those who are disadvantaged (be they old, young, disabled or Palestinian).

This becomes a confusing Venn Diagram.

Most people, and in particular those handing out leaflets don’t get the subtleties. They watch the news, are called to arms and want Israel to stop its actions. They call the state Apartheid, which, from my reading, is a complete failure to understand Apartheid, and an insult to everyone, the Israelis, the Palestinians and the Black and Mixed-Race South Africans who were victims of that system.

I will not go into the details and I don’t, and indeed can’t provide you with a formal analysis of Israeli, Palestinian and Middle-Eastern politics. I am not an expert in this area.

Ask me about old people and I am happy to provide an opinion.

You see, what gets me, as a Jewish, Israeli, Scotsman living in South Yorkshire is the underlying and effectively impossible to separate line between the words and actions of these protesters and those who I perceive are openly Anti-Semitic (Yes, I know about Miriam Margolyes…)

You might wonder how I came to this conclusion.

Here is my stance; not necessarily in order, but the best I can do.

Israel is a democracy. (A crazy proportional representation, but a democracy – one of the few in the Middle East)
The citizens of Israel, and define them as you will, although I think most would agree, we are talking Jews, Israeli Arabs (Christians and Muslims), Druze and other groups have voted for the right wing government that has led policy for the past decade (I have no idea of the political position of the current government, I believe it is still over on the right), nevertheless, right or left, the government is the government and more than many countries in the Middle East, is elected through democratic means.
The Palestinians living in the West Bank and Gaza do not get to vote in the Israeli elections
The West Bank, aka the Palestinian Authority has its own elections and its own Prime Minister (Mohammad Shtayyeh).
The Gaza Strip, run by Hamas, is not democratic, rules by tyranny and has as its main goal the destruction of Israel.
There are lots of bad things happening on Planet Earth, 2021.
Some countries have better human rights records than others.
If you look at an organisation’s website like Amnesty International, you will see there are abuses happening across the planet – China, North Korea, Yemen, USA, Syria, Lebanon, Myanmar, Saudi Arabia, Russia, Afghanistan, Libya, Pakistan.
Have you visited a UK immigration detention centre recently?
I support the right of the Palestinian people to have their own independent state, I support their right to free elections and all the other rights I have.
I support the citizens of Israel (Jew, Muslim, Christian, Humanist, Agnostic, Druze, Greek Orthodox, Baha’i) to live without the existential threat of terrorism or other forms of attack.
There is disproportionate reporting on the situation in Gaza and the Palestinian Authority in the news (I can only account for The Guardian, which is where I get my Crosswords).
No one is calling for us to stop buying good from China, USA, Pakistan or Russia.
If indeed people did BDS from Israel, they would cripple the international economy given that Israeli tech – software, hardware, medical and other technical innovation is found across the whole spectrum of gadgetry we and our systems utilise – phones, planes, computers, TVs, vaccines, etc.

I think this list is long enough.

Yesterday’s blog was all about apologies. Sorry.

Sorry if I have mis-represented, not aligned the argument well.

My point is this.

Before you throw stones – literal and metaphorical, look at yourself. Are you free from blame? Are the hands of your national aspirations so pure as to place yourself in a position to roll-out accusations of abuse directed at others?

Before you throw stones, do you have all the facts?

Before you throw stones are you merely taking sides to ease your own conscience?

This might sound like I am saying do nothing.

Accept the status quo and find something else to protest.

Meditate, tend your garden, stop eating animal products.

I am not telling anyone what to do.

I am just suggesting that change, as with all these things comes from within.

This blog will not alter anything and I do hope it will not provoke people to call me out for being a hater of Palestinians, for I am not.

Just think how your actions are construed.

There are 8.8 million people living in Israel.

That is 0.11% of the world population.

Around 20 per cent of children in the UK’s 68 million population are living in poverty.

Consider the involvement of Russia and China in perpetuating the Syrian crisis.

Are you banning Chinese goods?

The Jews, in case you hadn’t noticed, have had a hard time the past two thousand years.

We have had enough boycotts in the past. Enough sanction and banning.

Support the Palestinians, but carry in your sights the actual perpetrators of the inequality and poverty, those with a vested interest in the status quo – specifically, and, for the most, the American Right followed closely by rich people everywhere else.

If you want to listen to a Podcast about all things Israel and Palestine, Darryl Cooper has done a great job; you can listen here.

Sorry

I am sorry I was late.

I am sorry I did not wash the dishes.

I am sorry I did not prepare the report for the meeting.

Sorry I am early.

Sorry I ate the last pomegranate

Sorry for not staying in touch.

Sorry I let the dog out.

Sorry for the letter I sent

Or the email

Or the communication that was taken one way and meant another

Sorry for not washing my hands

For not using the hand gel

For attending the party.

Sorry for forgetting your birthday

and

Sorry for not sending a card

Sorry for the delay in my answering the phone

And, not getting back to you,

You see, I’ve been busy.

Sorry for the mistakes I have made

And will make.

Sorry for the pollution created

By my car

By my meat consumption

and my use of technology

Sorry for not listening

For not hearing

For not paying attention.

Sorry for missing you off the list

For allowing my dog to chew the invoice,

The receipt.

The sock.

Your shoes are destroyed

As is my pullover

Sorry, it was, the pup.

Sorry I have changed my mind

From planning for A, then B then C

And, apologies for my capriciousness.

Sorry I cannot attend the meeting

Or the appointment

I can’t make the deadline

Or the target.

Sorry I led you to believe one thing

When I intended another.

Sorry what I taught you is not right,

Indeed is the opposite of the truth.

Sorry I have prescribed you the penicillin when you are allergic.

Sorry I missed the critical measurement on your blood results.

Sorry for referring you to the cancer specialist too late.

Sorry for sending you to hospital, when home was best.

Sorry for not sending you to hospital, when you should have gone-in.

Sorry for the time the ambulance takes to take or bring you back.

Sorry for the discomfort

The awkwardness of my expression

The momentary lapse in decorum.

Sorry, I thought you were someone else.

Sorry, wrong address.

Wrong, number.

Sorry I didn’t catch you when you were in, I’ll call again later.

Sorry for thinking you were this when you are that.

Sorry for the mis-gender, mis-identity, mis-translation.

Sorry for being me and not the person you had expected.

Sorry for my shape, my form.

Sorry, I should have remembered, I shouldn’t have forgotten.

Sorry I didn’t take more photos

Or video film

Of my mum or dad

Or children when they were young.

Sorry I didn’t savour the moment,

Appreciate what I had.

Sorry for the length of these sorrows.

Sorry for the damage to your book,

To the broken spine,

The dog-ear,

the coffee stain.

Sorry for my heavy-handedness

The tightness of the blood pressure cuff

The scratch of the needle.

Sorry for the preamble.

Sorry for bumping your car,

Sorry for not indicating,

For the wrong flavour or ingredient.

Sorry, I don’t have any money on me at the moment.

Sorry, I’m in a hurry, a rush, can’t stop.

Sorry, sorry, sorry.

I apologise and wish things were different,

Had been different,

Had been otherwise.

But.

That is the way they are.

That is it.

That is the reality.

There is no other, no alternative, no switch.

There is no point in my offering you more apologies.

What is done is done.

The end is the end.

And no go o’er.

Balance

I have been watching a somewhat cooky film on Amazon Prime Video called, The Reality of Truth.

In it, tech millionaire Mike ‘Zappy’ Zapolin and some of his rich pals undertake a journey of psychedelic discovery, first travelling to Costa Rica then to Machu Pichu for some Ayahuasca.

You get the idea, lots of self-realisation, Transcendental Meditation, Deepak Chopra, and that kind of thing.

Anyway, one of the ‘psychonauts’ described a drug-induced experience where he somehow left his body and travelled outside of earth beyond the Milky Way and far out into space to the edge of the Cosmos (does the Cosmos have an edge?) – well, when he looked down, he had the notion that everything is in balance.

Some good here is counterbalanced by bad there, black and white, up and down, Yin and Yang, the old Confucian logic.

And yes, this makes sense.

Now, balance is a funny thing, and it came to me vividly yesterday afternoon just after we had taken our puppy for some off-lead practice at a nearby country park.

Anne, that is, my partner and I were checking out some little climbing frames. The type toddlers can march up and down, first holding your hand, then as they grow with greater confidence all on their own.

Anne had a go.

I looked on.

What I saw and what I thought (to myself) was, ‘Gosh, she is taking ages, she is so slow, so unsteady.’

And yes, I went on after her and fell-off.

What does that teach us?

Well, first, people can be overconfident in their estimation of their abilities and second, as we age our balance, first improves – toddler to little child, then from somewhere in your 20’s it declines.

Pretty much as everything else falls-off.

Sure, you can probably find some 90-year-old gymnasts out there who are able to walk on their hands blindfolded, but, for the majority, staying upright is tricky.

We underestimate how difficult it is not to fall, we presume we are better at balance than we truly are.

And, what happens?

We fall over.

I have lost count of the number of old men and women who had overestimated their abilities when replacing lightbulbs or dusting high-up corners of living rooms, only to topple and break their wrists and hips.

What is the corollary? The lesson?

Well, it is, as you age you can no longer do some of the things you used to.

That doesn’t mean you can’t do anything, just, that certain activities become more difficult than others.

When I was 15, I remember cycling about town without holding the handlebars of my bike – I had a special power that enabled me to glide around corners by shifting my centre of gravity.

I remember trying this a few years ago and it did not go well.

Perhaps I’ve had too many knocks on the head.

And what is the point of this reflection?

Well, my first proposal is that people as they age should realise how bad their balance is or has become and secondly, they should work on it.

You see, balance, like any muscle, skill or talent can be developed.

The neural pathways that maintain posture and balance can be improved with repetition.

Do some Yoga or Tai Chi.

Brush your teeth standing on one leg.

Work on it.

Don’t climb a ladder and discover your weaknesses.

If you read this, you might also like this.

The Twa Dogs (Dugs)

I’ve got a problem.

A couple of months ago I bought two puppies – originally nameless they became Blake (Scrappy) and Percy, then Percy became Wilbur.

They joined the household of Stella, our two-year-old Pointer-Springer Spaniel cross.

So far so good.

Very cute.

Cocker Spaniels.

They’ve both had their tails docked which is something I’ll write about one day & don’t feel in the mood to discuss; I hope that is ok. And, that isn’t really the problem.

You see, we semi-rescued Stella.

We bought her in one of the lockdown windows shortly after my dog Maisie died of cancer.

We don’t know much about Stella’s past although we suspect she might have come from a puppy farm (she was about a year old when we got her), she was, to put it mildly, a little damaged.

For the first two or three weeks after she came home I had to physically drag her out of her crate to let her pee or poo – she was terrified.

She was silent, not uttering a whimper.

She would hide.

Over time and with lots of work she has come into herself.

She still has some issues – she barks at my partner and daughter whenever they approach (very loudly – she eventually found her voice), she can’t be let off the lead outside as she tends to run away and she has strong jaws.

The jaws are the problem.

I’ll explain in a moment.

You might have wondered about the pup’s names.

Well, Blake is named after William the poet and Percy after the other great Romantic. My son Rami studied A-level English and loved the Romantics. I sometimes call Blake ‘Scrappy’ as to me he has more in common with Scooby’s nephew than a brooding late-18^th century poet.

Blake (Scrappy)

I gave Percy to my sister as she had been wanting a dog for ages and when the two siblings became available this seemed a fantastic opportunity. My sister lives in Edinburgh so the boys won’t see much of each other, although we exchange photos.

Wilbur

My sister’s son named Percy, ‘Wilbur’ and so the story goes.

Wilbur lives closer to the seaside than Blake and possibly has the better deal.

Anyone who has had a puppy knows that they like to chew.

They are essentially tail-wagging, peeing and pooing chew machines.

And this is the problem.

You see, I am sure when Stella (named after Stella from A Streetcar Named Desire and Stella Artois from Kensuke’s Kingdom (we like books in our household)) was a pup she didn’t have any toys or chews.

Now the pups’ chews (we have bought lots of chews – plastic bones and stuffed toys are the favourites), Stella has discovered a new world.

Stella – chew bandit

The problem we have is that Stella is an adult dog and her jaws are mighty and powerful and very quickly shred the soft-toys and gobble Nylabones. (Real bones don’t work as they bring out an aggressive streak in her that is otherwise sublimated.)

Before the pups, if I bought Stella a chew she would ignore it. Even a stuffed rat called ‘Rodney’ lay unloved by the side.

She has learned to covet the toys (She has also learned from the pups how to run after and retrieve a ball).

And her carnassials destroy the toys.

Poor Rodney the rat lasted a few hours before his tail and ears were removed, our stoat a matter of minutes.

Stoat just before his denouement

Stella steals toys off Blake, she is only interested in those Blake wants.

It is like two toddlers constantly vying for attention.

Fortunately neither of them are bothered by Yoda our tortoise.

I suspect in time Blake will outgrow the chews or at least the toys, or he will be big enough to grab them back off Stella. Who knows, they might fight; hopefully not – for the moment when Stella robs the Blake-toy, he cowers.

Dogs.

Joy.

They provide a window into the human soul.

The goodbye

To stop or not? (Jerzy Kosinski, Oliver Sacks & other ideas)

This a question that has arisen directly out of the mess of Covid.

Picture a 98-year-old Yorkshire woman.

She is frail, grey haired as you might expect.

She has a warm smile and sharp blue eyes.

In the three years I have known her, I have never seen here anywhere except sitting in the chair beside her bed in the local care home I visit.

She always has a puzzled then warm smile when I walk in the room.

Beyond the scene is the context.

Eight or nine years ago the doctor who was at that time responsible for her care saw her walking into the dining room (she has lived in the home for a long time).

He considered her gait unusual, made some assessments and diagnosed Parkinson’s disease.

This is a condition, most common in older people where there is a deterioration in the level of dopamine in the brain.

If you watch the Robin Williams / Oliver Sacks movie/book Awakenings you will see what dopamine can and cannot do to the brain.

I will not go into details as I am no expert, and this isn’t a story of neurodegeneration.

There is one fundamental however and that relates to this mysterious disease (which it shares with several other neurological or brain affecting conditions), that is, it is tricky to diagnose.

If you have cancer, at least, for the most (although not always (story for another day)) a biopsy concludes the diagnosis – a sliver of liver, a nodule of gland or other tissue combined with advanced biomolecular techniques and it is possible to say with a high degree of confidence, ‘You have melanoma.’

This is not the situation for Parkinson’s disease (dementia which is much more common is equally hard) – consequently patients receive what is called a ‘clinical diagnosis’ – this is when a clever clinician, for the most a doctor or other specialist, performs a number of indirect tests and assessments and arrives at a diagnosis.

A more common example is pneumonia.

You are short of breath, you have a nasty cough, feel awful and your temperature is high. The doctor listens to your chest, hears what is called ‘bronchial breathing’, says you have pneumonia, gives you antibiotics, advises that you will feel terrible for a couple of weeks and to get in touch if you get any worse and exists stage left.

This is the way doctors have functioned for hundreds if not thousands of years.

Since Mr Roentgen, we have been able to check the diagnosis with x-rays, and pneumonia is only present when there are changes on the black and white image – we call this consolidation.

There are other ways to diagnose pneumonia – this is the most common and more accurate than a piece of plastic connected to a person’s ears.

In many instances of the clinical diagnosis, if you arrange an x-ray, the film will be clear. This means, the diagnosis is probably ‘chest infection’ – a moot point perhaps, and you still feel bad, but subtly different in management and prognosis (chest infections are often caused by viruses, the prognosis is mostly much better than pneumonia.)

Here what I am trying to demonstrate is the inaccuracy that accompanies the everyday actions of doctors (when I say doctors, I am talking 21^st century, in other words, I mean clinicians – this is shorthand for nurses, therapists, pharmacists and so on). Y’ken?

Many people assume when a doctor says, ‘You have X’ they indeed have ‘X’ – in some cases this is easy to establish – for example if you have an x-ray machine handy, although there are situations where even what looks like something is not – the x-ray might look like pneumonia, yet the diagnosis might be cancer or some other respiratory condition.

It can be complicated.

Things are not always what they seem.

Let’s get back to my old lady.

Several years ago my former colleague saw her shuffling, diagnosed Parkinson’s disease and started her on treatment.

…. time passes….

I came on the scene and from the first, when I met her and encountered her warm smile, her engaging expression and general affect, I said to myself, ‘This woman doesn’t have Parkinson’s disease.’

(One feature of the condition called hypomimia, or if you like, expressionlessness is very common in Parkinson’s, my patient had what you might call normo-mimia.)

This was around two years ago.

I discussed the situation with her carer and her daughter (my patient who also has dementia was unable to grasp the ins and outs of my plans), and we agreed, ‘She probably doesn’t have Parkinson’s disease,’ and, I started weaning her medicine.

She was taking the tablets five times a day.

I stopped the evening dose.

Nothing happened.

I stopped the mid-morning dose.

Nothing happened.

Then came Covid.

And yes, things fell apart.

I have written before, about this care home in that we did fantastically well to avoid Covid except for one outbreak on one unit which was of course devastating.

My patient dodged the Covid bullet.

Yet, I was pulled away to do other things, I became distracted, the gradual withdrawal of a drug in this woman had not been my sole focus and, as happens more commonly, the carers who tend to keep me right, ‘Dr Rod, what about..?’ were distracted too.

And that brings me to my starting point.

To stop or not?

This was two months ago.

I was reviewing my patient and noticed she was still on the, what I call, ‘dodgy drug’ (this being a medicine that in certain circumstances is great, but if inappropriately prescribed or misused can cause harm) (Google the side-effects of Madopar, a common medicine used in Parkinson’s disease if you want to see what I mean).

And then the question.

I mean, she is 98 after all.

She is doing quite well even with her three times a day dodgy drug.

Let her be? De-prescribe (the 21^st century term for stopping unnecessary drugs, particularly in older people) (we had by then moved beyond de-diagnosis which is a term I believe I invented).

There tends to be a medical aphorism, ‘If it isn’t broken, don’t try to fix it,’ yet, my patient, her medicines, you might have guessed, I am the type of guy to scratch an itch.

We decided to continue our weaning.

She seems brighter.

She has been eating more, sleeping better.

Perhaps coincidence, perhaps not having a toxic drug flooding her brain.

If you are lucky enough to have read the Jerzy Kosinski book, ‘Being There’ (also movie with same name starring Peter Sellers), you see the reality that the protagonist, named Chauncey Gardiner brought to the narrative.

Great gardeners you see are tenderers*, they are meddlers, they notice the solitary diseased or sickening leaf and act, they are sensitive, and so too with the clinicians, they tread cautiously, they check and check again, they corroborate before deciding on action.

Think once, think twice.

*Makes me realise, when tending to a patient, my action, essentially offering tenderness, is the key.

You get what you pay for. (this is not a happy one)

I was not brought-up on this mantra.

I remember as a boy, lost amongst the shiny metal shelves of What Every Woman Wants off of Argyle Street .

There, as with the modern-day thrift stores that have taken-over our post-Tory post-Covid city centres, the bargains were waiting.

Sure, they were not worth the 5p you’d spend, but there was something satisfying with the realisation you could buy an over-sized Duran-Duran T-Shirt for £1.

All of that is a long time ago.

Long ago and someplace else.

We are in pandemic UK.

The economics are those of health and social care.

The cost is that of how long you must wait for an ambulance to take you to A&E.

The other day I admitted an old woman; the records document her heart rate as somewhere between 160 and 200 beats per minute. (For non-medical readers, that is considered fast). She was rushed to the hospital. It took 16 hours before the first doctor assessed her.

Today, if your hip is bad, worn and arthritic, if you are lucky, you might get a replacement joint in two years, probably longer by the time you see your GP and you jump through various hoops of assessment and review.

If you have the money, you can fast-track private.

Most of us are not so fortunate.

When things are bad, when the wait for the doctor or the nurse or social worker is several times longer than ideal, I want to tell people, ‘You get what you vote for,’ this meaning, after so many years of Tory government, with public service asset stripping the modus operandi of those running the country (and don’t start me on the lies and deceptions), what do you expect?

You spend peanuts, you get monkeys, I can remember an old Maltese fellow I used to know saying.

Where else can we go?

You stretch the elastic; you pull it and pull and pull and eventually it snaps.

I know that Alan Paton was talking about something else when he wrote ‘Cry the beloved country’ yet, I can’t help feeling we are amid an equivalent nightmare. Note, I don’t say, ‘Walking towards,’ no, we are in it.

No, not the climate, not the uncollected bins, the zero hours, no, not the Shitty White Men travelling on purpose-built spaceships that fly over the filth and poverty of a world falling apart, all of it together.

The amalgam.

The gum or Gestalt of autophagia, we eat ourselves, without realising that each mouthful leads to our destruction. The temporary nourishment a deception. A nonsense.

Our hospitals hold crisis meetings. They aspire to manipulate pathways and systems to increase efficiency, all of which has the opposite effect of slowing us down, increasing our error rate, trebling dissatisfaction and wearing thin the fabric of the spirit that maintains us.

And the absurdity, the madness, like Douglas Adams’ Brontitall. We have riches.

A person can spend 20 weeks on intensive care receiving the most space-age therapy and support imaginable, yet they return home and the carers who rush to provide their evening meal have little sense of person-centredness. What Matters to Me is squeezed, it is transmogrified into time slots and rota allocation.

And this, a pean to what?

No, I am not ready to stop.

Yes, I am tired.

Everyone working in health or social care today is tired.

They are running on the fumes of the fumes.

The odometer says zero.

And, a trip to WEWW’s without a penny in your pocket doesn’t buy you a thing.

Chaos theory. Calamity in action.

The image that has spoken to me the most in the past few days has been that of an empty refuse skip sailing down a village street in an inundated German village.

Floods in the north of the Europe have caused chaos.

The clip I saw on Twitter carried the comment, ‘It’s like Earth is trying to tell us something.’

Mother Earth.

Let’s call her Gaia, is speaking.

She is screaming.

(OK… Saturn is not a ‘she’)

As in labour. The walls quake with the tremolo of her call.

And here, that is, the UK, we have Covid.

We have a donkey leading asses.

The misdirected guided by the uninformed.

Fashla.

Fadicha.

As they say.

And today, I hold my head in my hands as I estimate the enormity of the threat.

The 24-year-old lying intubated on the intensive care unit

of most hospitals in the country,

The wards starting to seethe.

The fear.

I saw an image of Amy Winehouse today and

Thought,

How lucky, she never knew this blight.

It is all an absurdity of course.

We scrabble,

We try our best to do and undo the chaos.

Nothing is really knowable.

Babyteeth

Have you watched Babyteeth?

2019 Movie,

Available on Netflix now.

It’s a comedy,

Although I don’t remember laughing.

It is the story of Milla a 16-year-old free-spirit who is dying of cancer. She teams-up with Moses a struggling drug user.

Her dad’s a psychiatrist, her mum, a concert pianist, is falling to pieces.

It is set in Australia, somewhere near the sea.

The scenes are acts, making It feel like a play.

The soundtrack which my daughter downloaded yesterday (watched it with her) is brilliant.

Vibrant, life-affirming music.

Rotten Tomatoes gives it a 93% which means my son and my brother who have high movie thresholds would approve.

Please watch.

Then listen.

PS What I’d like to know, given there are so many rubbish films out there, why did no one tell me about this before?

Why this is especially precious to me?

Well, until a couple of months ago my daughter was convinced she still had several babyteeth.

A visit to the dentist dispelled this myth.

We are all growing, ageing, slowing-down and deteriorating.

An ideal film for a geriatrician.

If I told you I’m good, you would probably say I’m boasting & Teamworking

There is a famous Bruce Lee Quote from one of his interviews in the year before he died.

The TV talk-show host asked Bruce, ‘Some people say you are amazing at martial arts, Bruce, just how good are you?’ (Or word to that effect).

Bruce’s legendary response, ‘If I tell you I’m good, probably you will say I’m boasting. But if I tell you I’m not good, you’ll know I’m lying,’ encapsulates some elements of his personality, his confidence, competence and skill.

Yes, Bruce was that good.

Now, I am just a doctor.

In medicine we are advised to be as good as the average.

Indeed, there is a principle enshrined in law that the way to judge as doctor is on the basis of what he peers would have done in a similar situation. It is called the Bolam Principle.

I know most people think and would certainly want their doctor to be better than average, and like the ‘better than average’ (Illusionary superiority) heuristic the average person or doctor thinks or believes they are better than average that whatever they do (diagnose, cook, drive, tooth-brush), the reality is that most of us are average, sitting bang in the centre of the normal distribution.

Where am I going with this and what does it have to do with team-working?

Well, I work in several teams.

Indeed, you could say that teams are the basis of most of the successes of human society – we perhaps say that Steve Jobs was why the iPhone is successful or Elon Musk the Tesla, it is really, the teams that are work with and support them who are outstanding. For the most these guys are just loudmouths and good self-promoters.

I work with some amazing teams.

I don’t know if I am considered the Steve Jobs of nursing homes, certainly not, yet, some of the work I have supported has been outstanding.

I want to take one example.

For the past two years I, as part of my role working at Manor Field Surgery in Maltby, Rotherham, South Yorkshire (details provided for international readers) have been visiting the 70-bed nursing and residential home, Layden Court once a week throughout this time.

Over the first wave of Covid I went video but since then it has all been face-to-face.

As I mentioned above, if you asked me if I or the team were doing a good job, my answer would be, ‘Certainly!’ This, you might call it, is the psychologically healthy way to respond.

Yet, the only way to know how good good is, it through measurement.

We in health and social care are not very good measurers.

We tend to measure when things go wrong – falls, complaints, incidents.

And, for all these are only a fraction of the goings-on, they are the standards by which we are judged.

I haven’t measured the rates of falls in Layden Court since I have been attending although I could probably get hold of this data if I had the time to do so.

I’d like to think fewer people are falling.

Having said this, a reduction in falls (one of the single biggest healthcare associated harms) is important, it is not the end of the story.

You can stop people falling by doping-them up so much they can’t move, or like Singapore or Holland, tying people to beds and chairs would stop falls, yet in the UK we would see that as unecessary restraint and an infringement of human rights (the evidence behind restraint is that it doesn’t work, in that it might prevent falls but the harms are so great the people tend to experience other negative events – dehydration, malnutrition, depression, etc.)

I am getting off topic.

You see, a year or so ago I was interested in the numbers of 999 calls from the home.

I felt, if I could show we were having fewer of these, I could then demonstrate the work I was doing was avoiding people (residents/patients) getting into situations where the nurses/carers had to call for an emergency response.

I tried contacting some colleagues in Yorkshire Ambulance Service (YAS) without success, I even submitted my first and only Freedom of Information request to the organisation. This got me some data but not what I wanted and took so long and so many emails that I gave-up.

It was only six months ago when YAS appointed a team to support avoidance of unnecessary admissions from care homes that I was able to ask for and receive the data.

It came in two forms which I will show you.

The first has demonstrated that one of the teams I work with has provided phenomenal input and support to care homes across Rotherham.

The data indicates, if you live in a care home in two other parts of South Yorkshire which are of an equivalent population, you are significantly more likely to have an ambulance called to you and consequently be taken to hospital, and, given what we know about the experiences of older people in A&E’s anywhere in the world, you are also more likely to be admitted to hospital and receive all the interventions (and potential harms) associated (particularly when medical care is provided to people who do not need to be in hospital but are perceived by certain doctors to require hospitalisation). (Rotherham is the red line).

The second graph below, is, you might call it my personal graph.

It indicates the 999 calls to the care home I have supported since starting there in June 2019 (I have cut this graph so that it is equivalent to the time-line above).

There has been a big drop in calls and the same applies to these individuals as to those living across the town.

Now, the point.

Is Rod really great?

No.

Sure, I believe I am better than average (healthy ego), yet, I am not responsible for this work.

I have played a small part in the overall Rotherham Care Home work and a little bit bigger part in the Maltby Care Home work, yet, no, I am not responsible.

It is the team.

The team are what has made the difference.

The way I have worked with the teams of staff – managers, healthcare assistants, cleaners, nurses, therapists, residents and families.

Collectively we have improved things. (And we will continue to improve!)

Take any of us out of the equation and the results will not be the same, they will likely be worse.

This is part of the reason it is harmful to say he or she or they are great.

It is very often difficult to define who they are.

And so too when things are not so good.

If quality starts to fail, you could call ‘everyone’ out for failing, report the lot to the ombudsman and so on.

This sometimes happens. Often it is the result of miscommunication, misunderstanding and frequently in individual cases grief or guilt.

The system response to tarnish the whole team can however be detrimental to that team and the people they support.

Sure, you can’t let bad things go unreviewed, you can’t let bad practice pass, yet, tarnishing everyone can be ineffective.

How have I arrived here from Bruce Lee in a 1970’s Hong Kong TV studio?

Most of us want the best.

We want to be associated with the best – the best team, country, organisation.

Others don’t really care.

Some see the whole of the moon.

Others Brigadoon.

I’ll leave it there.

Occupational hazard – emotional blunting.

My dog Stella was poorly this week.

She was and she wasn’t.

Poorly has many definitions.

It can mean a cold, it can mean an upset stomach or migraine.

Stella had an anaphylactoid reaction.

I have called it this, rather than the more commonly discussed anaphylaxis..

The subtle difference between the two will mean little to most.

The former, anaphylactoid, tends to be less severe. Sure, when it happens, people can look awful, and my poor dog didn’t look great – see below.

Anaphylactoid is an allergic reaction that most commonly appears as angio-oedema, that is swelling of the face – the lips, eyes and tongue.

For the most, this type of reaction although frightening and very uncomfortable is just that, it tends to settle with anti-histamines and avoiding whatever set you off in the first place.

Some medicines, specifically ace-inhibitors are known culprits.

Only very rarely does the swelling become so severe that the person affected is in trouble, that tends to be when the tongue or throat is so swollen they struggle to breath and, yes, that is a problem.

Before talking about my emotions – this is a blog centred around those things, I’ll touch on anaphylaxis.

This is the big bad brother of allergy.

It is when a person’s body is exposed to a specific allergen (food, pollen, bee sting, for example) that leads to the release of histamine and other horrible chemicals into the blood stream and you have what is called a systemic reaction, in that your whole body is affected, you can’t breathe, your blood pressure drops, without treatment people not infrequently die as a consequence.

(As an aside, it is one of the most satisfying conditions to treat, an injection with adrenaline tends to take someone from near-death to feeling fine in around 20 minutes.)

Anyway, back to my dog.

We had just finished dinner and Anne commented that Stella’s face was swollen.

I looked across and she did appear odd.

‘She’s probably holding something in her mouth,’ I said – since the arrival of pup, she has taken to hoarding all sorts of toys and chews in her mouth so the pup can’t get them.

By the time I caught Stella and had a feel of her mouth I agreed, ‘Yes, it is swollen.’

It was at this point that my emotions went awry.

I self-diagnosed anaphylactoid (she appeared otherwise well), yet my son, whose emotions are fairly normal became anxious. ‘We should call or take her to the vet.’

It was half past seven on Thursday night. I was looking forward to ‘Pet-Hospital Puppy Special’ on the TV.

I said not to worry, she will be fine.

Stella’s face continued to swell. Her eyes became puffy.

‘I think we should take her to the vet,’ repeated my son.

‘She’s fine, it will settle.’

‘You’re a doctor, not a vet!’ exclaimed my son.

‘It’s just an allergy.’

By this time I could tell my son was getting frustrated. When poor Stella, lying by my side on the settee tried to bark only to make a plaintive yelp did I start to become concerned.

‘Maybe dog allergies are different,’ I thought to myself.

By this time I had already Googled ‘Angioedema in dogs’

Stella was struggling to stand and my son had given-up on me, and left to request from his mum that we do something, I rang the on-call vet.

I was getting worried.

Anne appeared moments later with some Benadryl mixed-in with doggie peanut butter.

The on-call vet was 25 minutes away in the car.

We administered the antihistamine and drove to the vet.

By the time we had arrived the swelling had started to settle.

The vet did all the things vets do.

Checked her over, charged us £170 pounds.

She was fine the next day.

What I found interesting?

Well, if I had happened to watch Noel’s Puppy Hospital I am almost 100% certain I would have seen people in states of distress and upset far more profound than mine. There are always tears, weeping, sorrow, often for dogs or animals that are far less unwell than Stella.

Even afterwards reflecting on the situation with Anne, we agreed that we had remained inappropriately calm throughout.

Sure, freaking-out never helped anyone and, back in the day when I used to lead cardiac arrests in the hospital I was usually calm and methodical.

Yet there is something odd or unsettling about my lack of emotional expression.

Sure, I love my dog.

I felt quite worried and upset, particularly at the thought she was becoming very unwell due to my tardiness at seeking help, but more, I think of others, behaving as you might say, like ‘normal human beings’ and I worry about myself.

My son was very upset, that to me was a normal human response.

To me and, probably Anne, we encounter so much stress and distress in our working lives we have to some extent become inured.

We see a problem and look to a rapid fix.

The NHS calls for rapid fixes.

The vet took eight minutes to tell me Stella was fine.

Were Stella a human and I was her doctor I would have conveyed the information in two minutes and moved-on to the next patient.

Sure, in many situations, animals receive better care than humans in the UK.

The NHS is currently, because of post-Covid and Covid pressures, melting.

Demand has never been higher, the waiting lists never longer.

A human wanting to see a doctor and being reviewed withing 30 minutes in the UK is unusual; sure, for anaphylaxis, the NHS tends to still be OK although I am sure it would have taken longer, by the time an ambulance might have arrived at the house; the paramedic may even have administered adrenaline which is not the right treatment of angio-oedema – the two conditions are often miss-diagnosed. (Adrenaline works for angio-oedema, it just makes you feel like you are going to die as the chemical rushes a panic attack through your brain.)

The reflection?

Am I more robot than human?

To what extent has being a doctor detached me from the gamut of human emotion? Is it just me – reserved and introverted, preferring to spill my emotions at 3 in the morning on this blog?

Who knows.

I still feel human.

Mostly.

It’s not all about falling over

My colleague and I had lightbulb moments today.

You can define such an event as when you realise or think about something you had never thought about before.

Ping.

One of those instances that over time becomes part of how you see the world.

OK – it wasn’t the Four-Hour Body or a similar time or work saving device, it was, I guess, potentially more significant.

If you think about it, when our children are young we take them swimming. Mostly because it is fun, splashing in water is great and eventually when adequately skilled you can swim in the sea or ponds, if that is your thing.

Another aspect of swimming is that it can help save you from drowning.

It’s an ability that is seldom if ever utilised (saving yourself from drowning) but an important life-skill nevertheless.

What has this all to do with falling over?

Well, it is the skill of getting up from the floor if you have fallen.

That was how Leon Wormley, exercise specialist and director of Functional Fitness in Rotherham, a company which supports those who have fallen to maintain and regain independence described one of the core elements of his falls-reduction programme.

You don’t really want to learn that you don’t know how to get off the floor at two on a cold November morning.

We have a problem in that only a tiny minority of people who fall or who are at risk of falling attend his classes – Covid in particular has interrupted exercise in general and face-to-face classes in particular (same with cardiac and respiratory rehabilitation – crucial components of wellbeing for people living with heart and lung disease).

Anyway.

Lightbulb.

If you fell, and that is to say, hopefully you won’t (although a third of those over 65 fall each year, and the older you get the more frequently you fall), could you get yourself up again if no one was available to help? If your mobile was in the other room? If you were starkers in the shower?

I’m in my late 40’s and I was down on the floor last week playing with my puppy. I was able to get up relatively easily, although with more struggle than when I was 15. (When I could spring cat-like to my feet).

As we age, as each decade passes, our muscles weaken – some say our strength ebbs by 10 per cent every 10 years.

In Japan even very old people are used to getting down on the tatami for tea.

In the UK the floor is unfamiliar territory except perhaps following a toppling.

Get to know the floor.

If you can’t or won’t or are too worried you will not be able to get up again, check out Leon’s team – link at the end of the blog.

Freda, would you have managed?

Leon’s site – https://www.opexfit.com/blog/what-is-functional-fitness & https://www.functionalfitnesstrx.co.uk/

Mystical motor forest

When I was a boy, enquiring about The Zohar, the mystical book of Kabbalah, I was warned not to venture too far, it was compared to a forest, deep and dark.

You go too far, you will lose your way and never return.

It was risking a step into madness.

Haruki Murakami has a similar theme in some of his novels, the hazards of an odyssey.

I only partially heeded the rabbi’s warnings and leafed through the leather-bound tomes.

None of it ever made sense.

I guess the trees were too closely packed, or, I never found the entrance.

This morning’s blog was about my struggles with cars.

All I want is to get from A to B, from nursing home A to B in relative comfort; I like to listen to podcasts and audiobooks. Satnav is important.

Fin.

I have fallen into a forest of fuel type, ignition, transition, hire-purchase and rental, automatic and manual, Korean, Chinese and Japanese manufacture, colours of the rainbow.

Modern-man tends to chop-down the trees.

That is one way of removing the mystery.

Or the risk.

I’ve never been much of a tree-chopper.

Cars, Communism and Consumerism

I have three months left with my current car.

Some readers may have seen by travelling around in my red Mini.

I have had three Minis over the past ten years.

For the most I have enjoyed these cars although recently when I discovered I had achieved a state of negative equity I decided enough was enough.

When I say negative equity, something I had only though related to houses, I understand the payment scheme I have been using has left me owing more than my car is worth. Or, something along those lines. You see, I was thinking of going for a fourth Mini when the garage revealed to me my financial state.

I was a little annoyed as I am sure when they sold me my current car no one mentioned anything about equity and I only really bought it because my the manual handbrake on my last car gave-way (with child inside on a steep incline) and it was too small to accommodate my son’s bass guitar.

Anyway, less of that.

I am looking for a new car.

And, it’s a minefield.

From what I can tell, you can buy petrol, diesel, electric and two types of hybrid.

There is something called a hydrogen car which I only discovered yesterday although those don’t look like they are going to become mainstream.

And here is my dilemma.

I don’t think diesel is a goer. For all they are good for miles to the gallon, they are apparently the worst for the environment. Noisy too.

The bad-old-days.

So, petrol, electric or one of the two types of hybrid.

You might be wondering about the Communism in the title?

Well, I was I think 15 at the time, at the height of my idealism, when I remember expressing to my big brother that I couldn’t see the point in all the choice in the shops.

‘Why so many types of coffee, biscuit or cereal,’ I asked, and this, somewhere in the late 80’s when there actually not that many types of coffee, biscuit or cereal on the supermarket shelves.

‘Are you some sort of Communist?’ He asked.

I filed-away the question which has left me pondering ever since.

In many respects I can’t be bothered with choice. I seem to be getting worse the older I get.

I know Obama and Einstein are two examples of people who had their thoughts so much on other things that varying selection of shirt or tie was not on their cognitive list.

Recently I have resorted to online ordering jeans and shirts based on the sizes of old designs; saves going to the shops and I know they fit.

I guess this is a little like the Mini situation.

Please don’t think me boring, although I realise that is what I am.

My dad, for his 40-odd working career had Cheddar Cheese sandwiches every day.

He was a man of unwavering taste.

Choice is one of those things that when present I can’t be bothered-with, but taken away becomes a big-thing.

I don’t want to delve too deeply into my psyche here, but take me to a restaurant and I don’t really care what I get.

I know part of this is a neurological process; it is the rule of heuristics. Essentially, in-build cognitive tracks that allow us to act without thinking or without dedicating too much mental energy.

A way to conserve energy.

Bruce Lee would have been pleased.

Getting back to cars.

Petrol, seems the worst as it will help accelerate global warming and costs at the pump (as they say), yet these cars seem to be the least expensive, I could therefore get a better car, albeit at the cost of the planet and my children’s chagrin.

Then there is electric which is the best in terms of poisoning the environment although I know the cost (in a planetary sense) of making a new car, petrol or electric is significant and no matter how ‘clean’ the car companies say they are I know there is havoc being wrought in Africa and South America mining such things at Lithium and other rare-earth metals.

Electric appear to be the most expensive.

In the middle are hybrid.

Until yesterday I thought there was just one hybrid.

It seems there are two kinds – one, the more old-fashioned Prius type which charges the battery as you drive, converting braking and downhill coasting energy into electric that is stored in the battery and used for driving short distances and booting the petrol engine. You can drive for two or three miles on electric before flipping back to petrol.

This doesn’t seem that great and although it makes your petrol car a little more efficient, it is nothing special.

Then there are plug-in hybrids which have batteries that can last for 30 or 40 miles then flip over the petrol; if you are driving petrol your efficiency is less as the battery weighs about 100Kg, meaning overall you are carrying around a dead-weight. These are OK for short trips in and around town.

The jury is out on these although I almost bought one yesterday by accident.

Add-in to the mix all the financial mechanisms with a host of different acronyms, hire purchase, pay as you go, or whatever and I am in a mess.

This is why I became fed-up yesterday and decided, ‘I want a red car.’ This was followed by a call to a local dealership.

The only thing that is certain is I want a red car.

The rest is choice and confusion. Obfuscation and complexity.

I wrote this blog with the idea that it might help me come to a conclusion.

I need to hand-back my car by the end of September.

The clock is ticking.

I doff my cap to the Trabant.

Two worlds

Yes and no.

Two worlds.

Renee Descartes coined the term which has now become associated with his name; Cartesian dualism. The mental and the physical. My mind, my spirit. You and my idea of you.

We have right and left. Or perhaps better written, Left and Right.

We exit in a world of off and on; the digital or binary realm is 1 or 0.

I have written before about my thoughts relating to this split in the way the world is divided, perhaps secondary to gender, perhaps the side of the brain that is dominant.

I don’t know.

What is clear and, this by no means says that it is a 50/50 split, people have tendencies or preferences towards one way or another. The majority probably sit in the middle – that indeed is what might be described the human condition; affable, agreeable, Mahayana.

Yet, it is not these folk who determine the shape of the world – it tends to be those on the extremes; perhaps influenced a little by Outsiders.

I’ll get to some concrete examples.

It came to me on Thursday.

I was attending the board of governors of my daughter’s school. I have been a member for the past year or so, I am therefore still considered a newbie – we only meet once a quarter, so that is approximately four meetings, with two that have been online and didn’t really count as I was on Zoom and others were in the room.

You see, there are those who perceive the world to be OK, or not even OK, but good. And, don’t get me wrong, for many people, especially those living in the West or in the UK, life is. Great.

Some people see Great Britain as not a reference to E, S, W & NI, but, our overall splendour as a nation.

Financially, emotionally, socially, for some, things are as good as you might want.

Money in the bank, contended husband, wife or partner, children doing well, and all this, during a period of Covid that remains unpredictable.

Not quite Candide’s best of the best of all possible worlds, but, pretty OK.

My sense is that if you asked any member of the Conservative Party or some of their more passionate followers whether things are ‘OK’ they would respond in the affirmative*.

And yes, if you look at lots of things, if you try to remain objective, the world I see and others encounter day to day, things are OK. There is water in the taps**, electricity when I turn on the kettle, the chance of my suffering a violent death minimal, I have clothes, shoes, a job. I even have two puppies (until next week).

If you re-wind the clock 50 years, and compare what I have with what my parents had, I would probably measure better on everything except perhaps the close-knit community and circle of family and friends that were the backbone of their existence.

Speaking personally, my health is OK, I can sleep well at night, I don’t have chronic pain, and I’ve an Apple Watch.

At the recent governor meeting we heard about all the fab things that are happening at the school – the level of happiness of the children, the satisfaction of parents, the successes and plans for the future.

Yet, this isn’t the whole picture. And this is my problem. It is a recurrent theme in my life, when I hear great things, whether it is the government spouting about the wonderful nature of our country, my employers telling me about the ace things happening across the hospital and in relation to the care of patients and staff, I keep coming back to a position of, and, which is part of an old song (which may not exist), ‘If it’s all so good, why do I feel so bad?’***

And this I struggle to answer.

You see, if I ask a group of people, ‘Are you happy, contented, warm, safe?’ and 90 per cent respond, ‘Yes, absolutely,’ there is a tendency to say, ‘everything is fine, let’s chill-out and watch some cricket.’

And for many people, perhaps a significant proportion of those 90 per cent, that is how they would feel. The ‘Things are good, why worry?’ approach.

And here is the split.

For, you see, within those respondents, whether they are proportionately representative of the whole or not, there are 10 per cent who are not happy. Who don’t feel contended, safe or warm. Indeed, they might be very sad, dissatisfied, scared and freezing in the cold.

If their lack of safety is 10 times greater than your perception of safety, are they safe? Are you?

And this is the point of this blog.

You see, and this is my sense, we question whether we should accept 90 per cent is OK and move on, or say, ‘We must to do more!’ – You could argue that those 10 per cent, whether they represent 10, 1000 or a million people will never be happy, so why try. Some of them might have the same amount of money, security or warmth as the other 90, 9000 or 9 million, yet their perceptions, their level of satisfaction is different.

‘You can’t please all the people all the time,’ is another song lyric.****

When I talk with my daughter, she like me seems to fall in to this minority group.

She has problems listening to some conversations where gender, race or social position is questioned or not valued appropriately.

She has sensitive antennae that create a situation where she feels that some people are being racist, sexist or hostile to others.

And, even if 99 per cent of folk are fine, she has a problem with that one per cent and feels she can’t rest until something is done.

Life and experience teach us that there are always going to be people who hold different values to us, in fact, much of the time there are always others who hold different viewpoints.

In the meeting I found myself isolated in my belief that cricket is a waste of time. Whether I should have confessed this impression I don’t know.

You can see where my daughter gets some of her ideas.

I agree it must not seem fair.

‘We have worked tirelessly to provide a workplace that offers high quality care/service/education/whatever’ – It can seem like a proverbial kick in the teeth when someone comes along, misses all the great work and focuses on the minima.

Yet, that is how some of us are constructed.

I remember telling a former colleague a few years ago, ‘Don’t worry, I am never happy.’

What I meant was, that even if we reach a point of improvement, innovation or growth where 99.9 per cent is great, I will worry about that 0.1, I will want to examine how we can push back the boundaries, review our systems and process to increase inclusiveness, safety, quality, fun.

You could call me a malcontent or you could consider me a continuous improver.

I prefer the latter.

Now to find a way to get this across without offending.

*Please See Haruki Murakami’s Killing Commandatore for the origins of this.

**Can’t think of this without think of ‘The Tiger Who Came to Tea’

***?Olly Murs/Flo Rida/Moby/Dido/etc

****Abraham Lincoln manipulated into Bob Marley

Four pounds

I am not sure what I felt when I heard my son was being paid just over four pounds an hour.

It came as a surprise.

Equally, I’m not sure what I expected.

Back in the day, when I was his age, I remember working as a summer postman.

Traipsing around shaded Pollokshields streets, delivering mail to outsized sandstone mansions one day, 25 floor high-rises in the Gorbals the next. Me, an always early bird, loved the sorting, then the free trips on Corporation Buses and the dreaming that went with my imagining as to the contents of the letters, the occasional BMJ, Time or Newsweek magazine.

I didn’t have a Walkman. I was left to my own thoughts.

My son, zero-hours, works four hours, sometimes five. ‘No, we don’t need you today,’ is the essence of being young in 21^st Century England.

Yes, we will treat you as a part of the commodity chain.

He doesn’t need to work. I am happy to provide. It is however a good experience for him and he is learning, at least that is what I tell him.

‘Think of it as an internship.’

‘I don’t want to be a waiter,’ he says.

‘I know, you are gaining life-skills and, well… Experience.’

He doesn’t answer.

In his heart I am sure he knows it is a con. A swindle.

There are no tips. Or, whatever gratuities exist, go somewhere else.

I don’t necessarily blame the restaurant owners. They have somehow managed to survive 18 months of pandemic trauma.

Yet, four pounds, or a little over, doesn’t seem very much.

I think of the very rich.

They seem easy to identify.

They appear in cars with V8 engines and convertible roofs.

They are the 1 per cent we hear about; those who have more than everyone else put together.

We don’t actually get to see the very rich. They live in hidden-away places, ferried from VIP lounge to business class. The tax-dodgers don’t need to hide their shame as they are hidden in their entirety.

Four pounds.

I imagine an average mid-class restaurant meal.

Maybe 80 pounds a head. If people are living it up, that might go to £120.

Two hours, £120.

My son gets £8 for that time.

That leaves £112 for everything else. Or, if it is a table of four, he gets £8, the restaurant £472.

The kitchen staff, other overheads, the cost of the food and so on.

Would I be happy to know that the young man or woman running around, smiling, tending to my every need gets paid 7% the price of my meal and, none of the tip. (2% of the table).

It’s a bonkers calculus.

I think what troubles me more is that fact that he seems to be content with the work and the pay.

For the first three shifts, that was 12 hours, he was told they wouldn’t pay him if they didn’t want to take him on.

He doesn’t eat meat.

The payment was rice and mushrooms.

A ‘good gesheft’ as my dad would say.

Again, I told him he is lucky. I am here to provide. It is not as if he has a family of his own to support. My dad, at his age already was working full-time and had a family on the way.

The economics of today.

A strange mixture of happenstance and powerlessness.

If he had been born in a developing country, £4 an hour in 2021 might appear reasonable.

I won’t tell you what I think. You probably already know.

We should be raising taxes and so on.

I hear the New Zealand Government is setting a minimum wage at $20 NZ an hour. That, according to today’s exchange-rate is just over 10 pounds an hour.

The point of this blog? Its purpose?

Like many I have written, I don’t know.

It is an appreciation of inequality.

It is a paean to inequity.

Nothing in life is fair, nothing is equal, everything an imbalance, a turmoil of what is and what should or could be.

My son, he’s ready to head out tonight.

Saturday night, rushing from table to table.

Waiters pad in hand.

Trying not to spill drinks or smash any plates.

Smiling, doing his best to please and support.

And me, what I am?

To what extent has Covid damaged medicine?

I’ll start with a doctor from a while ago.

He worked in Rutherford in New Jersey.

William Carlos Williams.

He is also one of America’s greatest poets.

You see, back in the day, in pastoral times, doctors spent much of their time with patients, that is, seeing, talking, developing relationships. Frequently the doctor would pop round to visit people at home, WCW would treat poorly children, he would support the dying.

The kind of the image many of us hold of a family doctor.

As to when all that changed, it is difficult to say.

The modernisation of medicine, chronic disease management, a focus on primary and secondary prevention (stopping people becoming ill with say, heart disease and preventing progression for those already ill, perhaps after a stroke) changed the way doctors worked – more time was spent checking blood pressures and blood results – monitoring people in-case-of rather than because-of.

Over the past thirty years, our population has become healthier – people have stopped smoking, there has been an emphasis on low-calorie diets, zero sugar drinks and so on. With this, people have been living longer (until a few years ago when the average life expectancy started to fall, in part because of deprivation related to the government’s policy of austerity and asset-stripping social care).

People have survived cancers that only 20 years ago would have killed them, keyhole surgery, biological therapy and our current experience of the Covid vaccine has saved more lives, prevented more disease than at any other time.

All of this is fantastic.

Thank you modern-medicine.

Yet, it is not all roses.

You see, and this is something I have talked about before, for all the science of medicine, the unimaginable complexity of molecular biology, immunology and biochemistry, much of what doctors do, particularly physicians and general practitioners (who make-up the majority of medical doctors) is not scientific, it is engaging, listening, communicating, it is connecting with the human being inside each of us, it has far less to do with technology and much more to do with our inner emotional and psychological needs.

For all we spend time typing on keyboards and mobile phones, engaging with Netflix and Pop-Tarts, all of this change has come-about in the past 100 years; the humans we are, the physiological creatures, influenced by hormones, passions and obsessions, our fear of snakes and the dark, our liking or disliking flavours, our biases, our unconscious minds are all still closely related to that of our hunter-gatherer ancestors of 100,000 years ago.

Take away our iPads and electric toothbrushes and we will cope, strip us of community, of relationships with others and we will wither.

It is this human aspect of medicine that is more important and likely does more good than any number of fancy medicines, investigations and treatments.

I am not dismissing MRI’s and fibreoptics, it is just, if you replaced humans with sophisticated robots, and treated our stomach ulcers and damaged cartilage, we might not have these problems, we would develop others.

When we are unwell, we have a need for assurance and reassurance, for guidance, for someone to listen.

This is what (at least to my mind) gives doctors their value.

This is why I believe it will be many years and hopefully long after I retire that robots will be able to do what I do.

And here is the thing.

You see, during Covid, only the very sickest people managed to see doctors. If they were taken to hospital or their needs passed a vetting process that led to a face-to-face doctor assessment (or, you were my patient in our care home, as I carried-on as before visiting and tending).

We all know that the majority of human communication is non-verbal.

It is not what you say it is how you say it.

Take away visual prompts – body language, pupil dilatation, fashion style or not and what is said is potentially distorted.

The communication is diminished. (SEE here for more!)

During the pandemic most doctor contact was done on the phone. In some instances this was conducted on Zoom or Skype, although for the most it was the phone.

It takes less (on average – some people can talk) time to talk with a person on the phone than see them face-to-face.

Doctor-patient engagement becomes transactional – ‘I did this, it was that,’ ‘OK, take this,’ kind of talk.

Indeed, I had a profound experience last week when after talking with a patient on the phone, she offered to see me in the surgery. I, thinking I was being super-helpful and kind, suggested it would be easier if I popped in to see her at home, after all, she had a bad leg.

It was only after, as I was getting into my car that she came (hobbled) after me, ‘I’d suggested I see you in the surgery as I wanted to talking about X.’ – she had been struggling to support her husband who has dementia and she found it difficult to speak in front of him.

I’d missed this subtlety.

I often miss subtleties; it is however more likely they will pass over my head on phone-calls than face-to-face.

Another example of this communication farrago was last week. Someone had the idea of conducting a face-to-face meeting. Given other commitments, I was unable to get to the desired venue, I therefore phoned-in. the meeting was therefore face-to-face for three-quarters of attendees and a few of us were online.

What happened was that the camera for the most didn’t focus on the people talking, those of us dialling-in were therefore left with disembodied communication over the less than perfect audio of VoIP – Voice over Internet Protocol; this is like the talks you have on WhatsApp. The sound quality is never as good as on the regular phone; odd things are done to the soundwaves that mean, FaceTime is OK because you can see and hear the person talking, but FT without the video is worse than a normal phone call and significantly worse than face to face. The people in the room therefore experienced full-on human communication (at its best, or worst), us on the laptops, were shut-out, maintained at a distance.

Now, what does all of this have to do with the end of medicine?

You see, my thesis is that a significant proportion of medicine is human relationship. Previously I have described it as a form of Shamanism. Just being in the same room as someone, mirroring their body language, maintaining eye-contact is itself therapeutic.

The pandemic and all the gubbins of modern medicine – the blood tests, health screening and so on I mentioned earlier has squeezed the amount of time doctors are available to doctor, to do the caring, that is the hand holding, the empathic engagements.

Over the last month GP contacts, we are told by the BBC, increased by 20 per-cent. There were 100’s of thousands more calls to GPs than before. All of this has squeezed the ability of doctors to support, to do the things that make the difference between us an robots. Relationship development can’t be squeezed, condensed or robotised. Transactions have become just that. Exchanges of information. Less silent sigh and more, ‘You said, we did.’ Which is OK if what you said was, ‘I have X, I want Y,’ but less so if you say, ‘I don’t know what I want, I don’t know what is wrong.’

Covid has pushed us towards transactions, away from relations.

And, just like the baby monkeys, if you take away the organic (even a mock-up mamma), they will fail to thrive, so too with our patients.

Effectiveness will diminish.

Patients will call again, and again, and again.

Three, five-minute consultations all taking people in circles, often, and this is very dependent on your individual GP (worse with the very big surgeries), you will move from doctor A, to nurse B and doctor C. Continuity of care and the associated quality of relationship is weakened and the outcome lesser.

People are forced into holding-states, like planes that circle airstrips unable to land, slowly running-out of fuel until they crash.

I like to provide solutions, ways-out of what at times seems like a mess.

I don’t really have an answer.

I think if the government, that is, NHS England, allowed doctors and nurses to spend more time with people and reduced the paperwork (or click-work) demands that would improve outcomes. It isn’t necessarily investing in more doctors or nurses, it is hacking away the inessential as Bruce Lee would say.

You start with a lump of stone and you end-up with David.

That is better than a rickety construction that blows-down when the weather changes.

Has Covid damaged medicine or is our society to blame?

I don’t know.

There is still hope – lots as there are so many people, nurses, therapists, healthcare assistants, carers, pharmacists and so on, all of whom are able to do the human-bit if on they are allowed time.

We are human, human; that is our skill, our blessing and our curse. Allow our humanity to guide us!

Nakata, Aphasia and Sylvia Plath

I am working my way through Kafka on the Shore.

I’ve read it before, yet, for whatever reason, I seem to have forgotten most of the plot.

Yesterday I was re-introduced to Nakata.

He is the character who was strangely affected by an event in the mountains in Japan during the war. He, alongside 16 other children were knocked unconscious by a certain force. All the others recovered, although it took Nakata much longer to come-too and unlike the others he suffered long-term complications – firstly he developed what might be called a learning disability, losing the ability to use abstract thought, talking about himself in the third-person and, he was able to speak with cats.

It isn’t that unusual to hear about people who have a special connection with dogs and horses – we usually refer to them as whisperers. Yet, cats are somehow different.

Murakami loves cats – they are represented as characters and symbols throughout his writing.

Imagine being able to converse with a cat.

That’s what Nakata can do.

I won’t say more – you’ll have to read the book if you want to find out what happens.

It was this connection that made me think about the way I interact with some of my patients.

Those who have difficulties with communication.

This whole field, or, at least, when it goes wrong is the realm of a group of people called Speech and Language Therapists – SALT or SLT for short.

They tend to be called if a person has experienced a stroke and their language ability has been affected or for another reason a person has difficulty with swallowing.

I usually consider Speech and Language Therapists to be the cleverest of therapists as language is so very complicated.

At university I took a class in Psycholinguistics. I thought I was being clever learning about something so seemingly obscure – the psychology of language. Suffice it to say, I was lost and didn’t do any well.

I remember they talked a lot about something called ‘parsing’ go figure.

Anyway.

Communication is really the sine qua non of being human.

It is what separates us from other animals.

Sure, cats and dogs, primates and parrots can communicate, whales and dolphins can sing across the ocean, yet, the nitty-gritty of language, talking, chatting, enquiring, analysing and so on, blog-writing for instance is a human thing. (Setting aside any ideas by Douglas Adams)

And, with this, is the critical injury to what it is to be human if this ability is damaged or lost.

I remember in incredible book I have somewhere called, ‘The Man Who Lost His Language’ by former Sheffield Speech Therapist Sheila Hale. In it she describes the experiences of her husband, Sir John Hale, the historian, after he had a stroke which damaged his ability to communicate.

I wrote a long time ago about my mum’s experiences with communication. After a stroke she developed what is called expressive dysphasia – this means, the part of her brain controlling her ability to produce certain aspects of language was damaged. She could still speak – she didn’t have aphasia which is complete absence, but more subtly, she would be lost for certain words or at other times confuse names or places.

In her living room we used to have pictures of me and my siblings on the wall with our names printed on the frame to help her navigate during phone conversations.

All this more complicated as even before her stroke she would mix-up our names. (My sister, with three brothers always came off the worst for this).

Even before mum’s stroke and certainly afterwards, she and I were able to communicated by looking at one another; our eyes conveying agreement, happiness, frustration or sorrow.

And back to my patients. People I never know that well.

Admittedly, thanks to my career change a few years ago, with my move out of the hospital, I have developed relationships with patients that are far deeper than anything I achieved in the 20 years prior, now I know whether someone is Mr or Mrs or they prefer their first name, or whether instead of that first name it is a nickname or another.

I have gained an understanding of my patients that is deeper than that of most hospital doctors when they transiently assess and intervene during a critical component of a person’s life.

And yet, if they lose their language, I am usually lost too.

There is one woman in the care home who has lost her ability to speak. This, through Alzheimer’s disease. She has never said my name, although I can usually get her to engage, to smile, that is, unless she is feeling unwell. I have a kind of telepathy with her.

I did briefly consider what would happen if we had a Nakata who could communicate with my patients who have lost their language, or at least their ability to speak.

What would they say?

Sure, it is more complicated than this.

Aphasia, or the ability to communicate is more than a mechanical disorder.

People who have had laryngectomies can still communicate with gesture, sign-language or tapping-out on a keyboard, aphasia is more profound, this is not having the words.

I have never read any accounts of what it is like to have aphasia and then recover – I imagine this has happened; I’ll have to research.

And yet, most people do not recover, particularly when the initial loss is profound.

How are dreams or memories affected by aphasia? What do you remember when the language that describes the past is gone? Do pictures still appear? Do images translate into actions?

I think of Sylvia Plath’s Bell Jar.

Trapped inside.

The world moving, people going about their business, but no transfer of air or sound.

Of course all of this was much worse during Covid as we couldn’t make physical contact; there was no hand-holding. The people who knew my patients best were barred from access.

Imagine being inside that bell jar and the lights turned-out. That is what has happened over the past 18 months.

I thank John’s Campaign for fighting the bureaucracy.

All we can do is our best, use our imagination, our creativity to lift ourselves and others out of the constraints, the restraints.

Here is to the summer.

At least being able to feel the warmth of the sun is a form of communication.

Sensory engagement.

Let’s do that.

Roundabout discovery of a great French composer.

It all began with Murakami.

Haruki, the Japanese novelist.

He of Norwegian Wood, Kafka on the Shore and The Wind-Up Bird Chronicle.

And, What I Talk About When I Talk About Running.

It is somewhere in the Wind-Up Bird that there is mention of the piano music of Poulenc.

On my desk in my home office I have an Alexa. It was last year’s birthday present.

When I am alone, undertaking what used to be called paperwork, now click-work, where I sign results and forms relating to my patients, I like to listen to classical piano. It relaxes me and the absence of words stops my mind from wandering.

I may or may not have heard of Poulenc before.

There was however, something about his name that enticed me.

‘Alexa, play Poulenc.’

As with most digital technology, it is good but not that good.

First it played some ‘Lets Link’ by Who Heem (explicit lyrics) then some Pink before I repeated, ‘Play Francis Poulenc’ (emphasis on the final nasal ‘onc’) and it cottoned-on.

Straight away I was caught.

Drawn-in.

It felt like homecoming.

The answer to nostalgia.

First was Gnossiennes then Gymnopédies.

I have played these specific compositions daily, ever since.

It was only yesterday as we were driving in the car, I thought I’d ask Spotify to do the same.

‘You have to hear some Poulenc,’ (again hamming-up the ‘onc’) I said.

My daughter was sitting in the back practicing her French.

This was when I found Satie.

Gnossiennes by Satie.

‘Satie must be the pianist,’ I said, wishing to sound as if I knew what I was talking about.

Contrary to every other time I have ever played classical music in the car, my kids were entranced.

My son said, ‘Siri, what’s this music?’

It was all very 21^st century.

After we arrived at our destination which was the centre of Sheffield, I followed-up on this uncertainty. What does Gnossiennes mean?

For a start I can’t speak French although learning lots of medical terminology has given me an insight into Latin and Greek. Gnossi… Gnosis. Knowledge. Must be something to do with that.

And here I found the music, the compositions had nothing to do with Poulenc. Érik Satie was the Late 19^th / Early 20^th century composer.

The creator of the romantically discordant notes, like raindrops, caramel sounds, drifting.

And here is the second diversion. For, during my searches, I came upon this definition:

I read the excerpt this morning before walking my dog round our local lake.

All the way I reflected on the music and the definition.

I thought of Alexander Trocchi and his view of the human condition. The tragedy of love.

Move ahead, I’ve had breakfast and I return to the definition. I read the Satie Wikipedia articles.

It appears Gnossiennes is a word Satie made-up. No one knows where it came from. And the definition I have provided above is also made-up, it is part of The Dictionary of Obscure Sorrows written by American artist, John Koenig.

After a time you start to question what you know and what you don’t.

Facts can be convoluted or linear.

They can be jaggedy or zigzag.

They can be true or false.

We base so much of this on our sense of the world.

How confused and lost we are.

How capricious the human tongue.

How slippery reality.

Stop now and have a listen.

There are no words.

Just the music.

I guarantee, if you can’t sleep tonight and you play this tune in your head you’ll be gone in moments.

Better than Temazepam.

Poulenc’s not bad either.

Every time I stand up I fall over.

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 late 1990’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 round the body by means of arteries.

Enough blood and enough pressure and all is well.

If the pressure drops, because you are bleeding profusely, that is a problem and also another blog, we’ll call that one shock.

If the pressure drops the most sensitive organ in the body is the brain.

Drop the pressure for a minute or less and you will feel light-headed, keep it dropped for long enough and you will pass-out, continue that low blood pressure and you will die.

All of this is interesting – what does it have to do with standing up?

Well, think of it this way.

If you have a pressure ‘x’ we measure it oldfashionedly using millimetres of mercury (although the mercury has long since gone, what with it being so very toxic). There are two measures – systolic and diastolic – the big one and the smaller one.

120/70

120 = systolic, when the heart pumps

70 = diastolic, when the heart relaxes and fills with blood

The big number is when your heart is pumping or squeezing blood, that is systolic and the lower number is the time in between when your heart is resting and filling-up with the blood that has just been send round your body, this is the diastolic.

Some people have low or high blood pressures, it tends to be whatever your body gets used to that is important.

In the West, high blood pressure ‘hypertension’ tends to be the problem as this can lead to strokes and all sorts of other problems.

More and more, particularly with older people and increasingly as a result of ‘Long-Covid’ we are seeing that low blood pressure is a phenomenon of concern.

If your blood pressure is OK, there is enough pressure in the system to push the blood from your heart the 50 of so centimetres to your brain (depending on the length of your neck/overall size as well as some other factors).

If the blood pressure is too low, you have the problem I mentioned above.

Now, here is the tricky bit that relates to standing-up.

When you are lying in bed or sitting down, the blood requires less pressure as your brain is not as high-up, when you stand, the pressure needs to increase a little, otherwise you have the light-headedness (gravity also pulls blood down to your legs).

I won’t go into this in more detail as I want to get back to the bit that matters to me.

Suffice it to say, if every time you stand-up you go light-headed or dizzy, it is possible (there are other causes) that you have the condition called postural hypotension (or, as my former colleague always said, ‘orthostatic intolerance’)

I have never been one for intolerance, I therefore prefer the former.

This is an incredibly common phenomenon, linked closely with some conditions such as diabetes and Parkinson’s disease although anyone can get it. It tends to be more common as you age.

It is a major cause of older people falling.

Older people falling is often a bad thing.

Falls in older people can be the difference between life or death, independence or a life in care, further falls and restrictions in mobility. Pain.

For a long time the national guidance has been to check blood pressure with a person lying then standing, especially after a fall and especially for people who are 65 years and older.

You see, this is such a common contributor to falls, if you don’ take this measurement, the diagnosis is often missed.

Recently, I have been delighted as what we refer to as ‘lying and standing blood pressure’ or, for short, L&S BP, has been entering the mainstream.

And here is the thing.

Here is my syndrome.

I haven’t given it an official name, although if you want to call it the ‘Kersh-effect’ I am sure my parents would have been proud.

Here is the example.

An 80 year old man, let’s call him Oliver.

Every time Oliver stands he feels odd, he describes this to his doctor as ‘dizzy’

His doctor tells Oliver he knows exactly what is wrong, ‘You have vertigo Oliver, I’ll send some medicine to the chemist.’

Oliver receives a drug called Betahistine (Serc) a few days later from his chemist (he is too dizzy to walk to the shops, he has to wait for a delivery).

Oliver takes the medicine.

A week later his doctor calls-up. ‘How are you doing Oliver? How is the dizziness?’

‘No better, just as bad.’

‘It will be the dose. Try 16mg three times a day.’

Another week.

‘No better, I feel just as bad, last week I fell twice. Whenever I get up things are awry.’

‘Darn that vertigo,’ Says Dr, ‘Let’s try something stronger.’

Stemetil, otherwise known as Prochlorperazine arrives from the chemist. Oliver is taking Stemetil and Betahistine three times a day.

‘Well, how are things?’ Asks the doctor.

Not wishing to appear ungrateful, Oliver replies, ‘Maybe a little better.’

‘Fantastic. I’ll call you in four weeks. Keep taking the medicine, it must be working.’

Four weeks pass.

Oliver falls twice.

Once he is taken to A&E, he has broken his wrist. A Colle’s.

‘Sorry, to hear about your wrist,’ says the doctor, ‘I guess you aren’t much better?’

‘No, just as bad,’ says Oliver.

‘I think we should refer you to a specialist.’

The referral take 10 weeks.

By now Oliver is falling every couple of days. He is finding it more difficult to cope at home. He has noticed his movements slowing and a shake has appeared (we call this drug-induced Parkinsonism, a side-effect of the Stemetil.)

You’ve probably worked it out by now.

I meet Oliver before he has seen the ENT person (who wants to order an MRI in case he has the rare condition called ‘acoustic neuroma’).

I check Oliver’s L&S BP.

Yes. When he stands his blood pressure drops. This had never been checked. It’s the diagnostic heuristic (where a doctor latches-on to a diagnosis and doesn’t let go).

I stop his blood pressure medicines. I stop the Betahistine (that had been causing him indigestion)(I forgot to tell you, the GP had prescribed medicine for this as well), I stop the Stemetil, his shakes settle. He is still dizzy.

I start Midodrine, a blood-pressure raiser.

A week later he is recovered.

This is my syndrome.

Maybe syndrome isn’t the right word. Perhaps condition.

No matter. It is something I find every couple of months. I don’t think readers would believe how common this is.

For want of checking the blood pressure a whole array of mismanagement begins.

And, even if the disorder is suspected, there is a strange phenomenon where my number-one drug – Midodrine, is not used, instead doctors prescribe either support stockings (not sure if anyone has tried to wear these on a warm day) or another drug called Fludrocortisone, which in my experience doesn’t work very well. They may even throw-in a little Stemetil.

(Until a few years ago Midodrine was not licensed in the UK – it was only specialists (like me) who could prescribe; now it is in the formulary and available. I believe it is this hangover that has stopped widespread use) (It was commonly used around the world, just the UK were slow to adopt).

Anyway.

Apologies if this is over-technical.

It is something that has been bugging me for ages.

Now, suffice it to say. If you are a patient, consult your doctor before stopping or changing any medicines. This blog is me thinking out loud – it is not medical advice for you, for this, you need to speak to someone who understands your health, who knows your past and is privy to relevant investigations.

There is nothing to stop you buying a blood pressure machine and checking.

What matters.

On Wednesday, we ran another one of our Conversations about Covid.

This time it was different, as not only had we changed the name to Conversations beyond Covid, we were also missing Penny, Colin and Sara, my usual conversation friends. Fortunately Carole was there.

We were joined by Siobhan Reilly, Professor of Professor of Applied Dementia Research at Bradford University.

Professor Reilly

Siobhan presented some of her research relating to outcomes for people living with dementia.

I know outcomes sounds a little dry, what it turned out to be was a discussion about her work establishing what matters to people living with dementia.

You might ask why this is important, beyond the confines of ‘nice to do’ well, essentially the research assessed through interviews with individuals and groups of people living with dementia what they find important – what matters to them.

You see, what matters to me, is necessarily going to be different to what matters to you – we are different people, with different interests, pasts, futures and passions. We enjoy different food, flavours and fashions. Take away this uniqueness, this individuality and you leave a person diminished. Dementia is enough of a diminisher; this work serves to undo some of that.

Tony Husband the artist was part of the team, adding his interpretation to the work. His are the pictures I have included here. (If you are reading on your mobile phone, click ‘Load All Images’ to see the photos).

Unsurprisingly, when you read the statements, what is important to people living with dementia is very similar to what is important to everyone else.

Those who exist or at least work outside of health and social care might consider this obvious. Why should dementia, a disease, alter what is important? Yet, the reality can be very different. The mechanisms, systems and regulations of health and social care in the UK and worldwide often serve to remove the person, to turn you, me, your mum or dad into a patient, into a series of diagnostic labels or codes.

(It transpires; the UK is a world leader in this, Person-Centred Care.)

As one example, everything that happens, particularly in healthcare has a code.

This is how the accountants and economists can work-out costs or volumes of work, this helps them build contracts and business plans. It is the sharp end of turning soft into hard.

Every disease, test or condition has a letter and a number.

I do know one doctor who is so versed in some of these codes that he writes them in his notes – you haven’t had pneumonia you have had ‘Pneumonia, ICD 104.3’ (or whatever – I made that one up).

All this is very well, and we live in a world where care is dependent on budgets – not wholly, yet, if you only have enough money for three nurses when you need six, the quality of care those nurses provide will potentially be diminished. At the very least three nurses will struggle to support their patients as they should.

Anyone who has spent much time in hospital will recognise the phenomenon of the invisible patient. This is where doctors are talking about someone’s lump or rash as if they are not in the room, porters chatting or carers discussing last night’s TV whilst bed-bathing an old man, it is easy, if you are not careful to shift from doing with, to, doing to, and, when you do to, the person can vanish.

There seems a universal human switch that at times can be unconsciously activated, when people are not seen as people, where the stresses, nature or demands of a role shifts perceptions. It is a feature of every walk of life across every culture.

Patients, with or without dementia experience pain, they can be upset, afraid, happy or sad. They can worry; they have hopes and preferences. They are just like you or me. Indeed, many of them are you or I.

(I did some research a few years ago on the experiences of people attending A&E with hip fractures; if you have dementia and a hip fracture you are more likely to get paracetamol (or nothing) (rather than morphine) as a form of pain relief than someone without.) (Trust me, if you break your hip, you want the opiate.)

It is likely if you are reading my blog you are amongst the converted.

As to how I can get through to those who see my actions as beyond the pale or outside the realm of what a doctor should or should not consider, I do not know.

Siobhan’s work may help shift the dialogue.

Does a 5% increase in survival matter? Does a reduction in bed-days, length of stay or rate of readmission matter to Sadie? Yes and no.

If you are Sadie, you want to be treated as quickly as possible with a minimum of pain and with the appropriate medicines. You also want to be considered as a human. You want dignity, respect, caring and maybe some humour.

Back to what matters to me.

To be honest, I am sitting in a cold garage in Sheffield. It is Saturday morning. I don’t feel much like revealing too much of me.

There is a spectrum.

What matters a lot and what matters so so.

Ambient noise levels, the temperature, the garage who have decided to charge me for the repair I was told would be free*, the rain, the cold, the builder who has spent too long working on our shower, my dog’s swollen ears that have now recovered, the phone call yesterday that kept cutting-out, the offer of a cup to tea or cake, sharing with me a little of who not what you are, comfort, quietude. The grammatical underlining of Microsoft Word, all these things and more. They are what it is to be human (‘ve chuoole’ (and, so on) as Shulem says). Human all too human as he said. We are fragile. We are vulnerable. We are all alone.

*In the end they did the repair for free; Values. What matters. It runs through everything like Blackpool Rock.

** If you want to join the next Conversation beyond Covid which is on Thursday 27th of May between 10 and 11am on Teams, follow this link. We will have Phil Joddrell from Sheffield University discussing his work related to digital isolation.

Reilly, Siobhan T., et al. “What is important to people with dementia living at home? A set of core outcome items for use in the evaluation of non-pharmacological community-based health and social care interventions.” Age and Ageing 49.4 (2020): 664-671.

Muffled sounds, drum beat and dementia

Last night I watched the 2019 movie, Sound of Metal.

The film explores the experiences of Ruben Stone a heavy metal drummer who develops profound hearing loss.

Riz Ahmed of 4 Lions is Ruben.

A few weeks ago I was involved in one of our ‘Conversations about Covid’ in which audiologists from Manchester and Sheffield discussed some of their work.

You see, hearing matters.

I asked the question which I am sure others were thinking, ‘Of all the senses, I imagine if I had to lose one, I would chose hearing.’

This question was naïve.

It reflected little understanding of what it is to be deaf or what it means to have sensory impairment; it is akin to suggesting which organ you could or could not do without, a form of anatomical one-upmanship, ‘the brain’ ‘the heart’ ‘the kidney’ – I see the imagine neurologists, cardiologists and nephrologists proclaiming their organ to be the most important.

No, I had underestimated hearing.

The movie does a good job.

It emphasises that hearing loss is not just the functional inability to hear sounds, it is more, far deeper. The psychology or an individual’s mental approach to the loss is as important.

And, when you start to look more deeply, you realise that sound is not just conversation or telly, it is ambient noise, birds in the trees, the wind, passing cars. My dog licking her paw behind me, my breath.

Sound is music, it is a connection to others, it is an internal link to the past.

Inside my head are stored the shadows of every sound I have ever heard, every song, every voice; etched-out in faint outline, ready to rise again should there be a need.

I can’t hear my mum’s voice although if she were to speak now I would immediately recognise her, the same with my dad, my grandpa, people I haven’t seen or spoken with in decades.

And so too with music.

That hit from 1977 is embedded somewhere inside of me.

Back in the day when I used to have inpatients and work on a hospital ward, I would play the Beatles. This was the sound of my ward rounds. This is the sound that would echo as I chatted with patients.

Norwegian Wood

Yesterday

Michelle

Penny Lane

All resonating, taking me back and creating an atmosphere.

From the Conversation we discussed research which shows that even mild hearing loss can increase an individual’s risk of dementia by two, significant loss by a factor of five.

Hearing is more than noise or sound.

Hearing is communication.

Opticians are on every street corner, we wear sunglasses for fun; hearing aids have yet to become fashionable.

I am often frustrated when I visit a nursing home and the rooms are filled with 40 watt light bulbs. A false economy. The owners save money on electricity at the cost of residents falling over.

Even those enlightened places that have invested in Phillips day-lighting often miss the importance of hearing.

Hearing aid batteries are flat, they are lost, wax accumulates and no one checks.

The confused old lady does not have dementia, she has lost her glasses and her hearing aids were thrown-out with the laundry.

We don’t respect hearing.

Whenever I think of hearing and music I always consider Beethoven.

He was deaf. He seemed to get on OK.

How little I know.

In Scotland and Wales, all national broadcasts from the government are accompanied by people signing. Not so in England.

This doesn’t surprise me.

In essence, I feel that no one cares.

Or, if they care, they don’t think.

If it is something that can be measured, say, amount a person drinks, the presence or absence of pressure ulcers, falling weight, even satisfaction scores, attention is paid.

Yet, the silent world inside our heads is forgotten. Overlooked.

Every so often a fuss is made when a translator can’t be found to help with a clinical encounter where the patient doesn’t speak English.

How often is a fuss made when the patient can’t hear?

It is a moral offence to label someone as ‘being demented’ unless you have proof they can hear what you are saying.

I saw a patient the other week at his home.

His daughter insisted she be there when I visited.

Upon my arrival I had to wait a few minutes until she cleaned-out his hearing aids.

In the end, he could hear some of what I said.

‘He usually says ‘yes’ when he can’t hear.’

What can we do?

My patients sometimes experience delirium.

There are two kinds – hyperactive and hypoactive.

In the former, people tend to have broken sleep, they can be distressed, agitated, restless; with the latter, passivity reigns.

Passivity and deafness seem to be linked.

Those people who experience the hypoactive form of delirium have a much higher risk of dying.

What does deafness do to your chances of survival?

How do we up-end this situation?

In my medical student lectures I always emphasise the importance of making sure the patient can hear you and if they have hearing aids, to check they are working, the batteries are in place and have power.

We need more.

Part of this is design or technology, to make either trendy hearing aids or ones that work, yet more important, by an order of magnitude is to raise awareness.

Awareness that when someone says ‘yes’ this could be part of their conditioning rather than an agreement, when a person is passive, doesn’t appear to engage or seems to not understand your direction, consider that they may be struggling to hear you.

It is the mantra I have been carrying for years – don’t assume the patient is bad or stupid or lazy, don’t foist your prejudices or pre-judgements upon them, engage in a spirit of openness, without baggage.

Check and check-in.

Sensitivity.

Is their response appropriate?

Imagination.

Use a pen and paper, your phone, a laptop – open Word and write big.

Check the hearing aid batteries.

Look into the patient’s ears – admittedly this requires an otoscope, all GPs have them.

If your accent is too thick, your voice too quiet, ask for someone to translate, English to Yorkshire or whatever.

Take it slowly.

Repeat.

Patience.

Eye contact once you have established the person can see.

You might even have to lower your mask.

Don’t shout, this usually just creates muffles noise that doesn’t convey your message.

Speak to an audiologist.

Watch the movie.

Subtitles are optional.

If you want to join my next Covid Conversation – follow this link at 4pm on Wednesday the 5^th of May via Teams (check you have it downloaded first).

Phone fraud and Mammeloshen*

It was approximately one year ago when the fraudsters first came for me.

I remember sitting in our dining room, just beside my aquarium when the phone rang.

The caller was identified as my bank.

I thought, ‘How odd,’ and, answered.

They said they were the fraud department and had detected some irregularities with my account, they were concerned that someone had obtained my details and was spending.

In hindsight this all sounds fishy although, at the time, I went along with their request to confirm my details.

I remember experiencing a sensation similar to that which a fly must feel as it slips down the throat of a pitcher plant. Suspicion mixed with curiosity.

Suffice it to say, the conversation continued.

I remember my son, sitting on the settee across the room listening-in.

I went as far as confirming how much money I had in my personal account, they even managed to obtain my mother’s maiden name.

When they asked me to move money to another account I decided enough was enough, politely hung up and phoned the bank.

Yes, I had been diddled.

It is funny as, the last time I found myself in a similar situation, that is, doubting the veracity of someone on the other end of the line was 20 years ago when as a junior doctor working at the Northern General in Sheffield I received a call from switchboard.

‘Hello, how can I help?’

‘This is number 10.’

‘Number 10 what?’

‘Downing street.’

I laughed and hung up the phone. My curiosity was sufficiently piqued for me to call directory enquiries and phone up No. 10.

It had been them.

Tony was PM at the time.

Anyway, I managed on this occasion with the bank to get away without parting with all my cash, not that I have much.

I called the bank, they confirmed it had been fraud, I was left feeling exposed and that was that.

After the phone-call, my son informed me that to him it had been obvious I was being hoaxed. ‘Why didn’t you do or say something?’ I asked. I can’t remember his reply.

Then a couple of weeks ago I received another call.

Again it popped-up as my bank.

Again it was the fraud people.

This time I was prepared.

I fumbled with my phone trying to get it on ‘record mode’ – unfortunately, my phone doesn’t allow this. I even tried to switch record on my computer. I wanted to catch them in the act. That didn’t work either.

I again politely hung up and called my bank.

Yes, again, fraud.

This time I was a indignant.

On the first occasion I had felt invaded, compromised, stupid.

This time it was something else.

The bank confirmed that my money was safe, they had been fraudsters and nothing bad had happened.

‘But, can’t you do something?’

By now I was thinking of all the people who would likely have gone along with their deception. As humans we are all gullible although older people sometimes retain an air of respect towards authority. I could see someone, perhaps isolated after a year of Covid, talking with the man, revealing all, losing everything.

The bank advised that because I hadn’t lost anything, there was nothing they could do.

‘Couldn’t you track the call, or get the police to do an analysis? I kept him talking.’

Nothing.

In the end they passed me to a woman in a call centre in Scotland who it appeared had been trained to deal with fraught customers. Skilled in the art of calm, she confirmed there was nothing anyone could do.

Searching the net for a way to report what had happened led me down a warren of internet links and unanswered or automated phone calls.

The anonymous 21^st century had turned-in on itself.

I imagined how people who had lost their money might feel. The mixture of anger, frustration and embarrassment, most of this directed inwardly.

I can’t imagine how we protect people from these predators.

Many people I know don’t answer the phone unless they know who is calling (me included) (leave a message please), others just don’t answer the phone.

These criminals have managed to limit the limited contacts some people already have. I am certain they must have taken advantage of the pandemic.

The bastards.

Last night I watched an episode of Shtisel with Annie.

This is the Israeli drama on Netflix which follows the life of Rabbi Shulem Shtisel, an Ultra-Orthodox Jew living in a Jerusalem neighbourhood.

I especially enjoy the seamless shifts between Yiddish and Hebrew in the dialogue.

Anyway, last night Shulem’s mum died.

They had the shiva which is the seven days mourning where the immediate relatives sit on low chairs or the floor with torn clothing and pray and meet with family and friends.

In this episode a man turned up, black suit, peyot and so on.

He took Shulem aside and showed him a video he had recorded of his mum. In HD his mum, bright and smiling recollected the birth of her son, elements of the story of her long life.

‘I have two hours recording, time I spent with your mum.’

‘How did you manage to spend time with my mum?’ (‘Mamme’ he would say in Yiddish) ‘Can you make me a copy?’

‘For a small donation to cover my expenses. A thousand dollars.’

‘I don’t understand, how did you meet my Mamme?’

‘Well, you see, I travel round all the care homes and spend time with the folk and record.’

It became apparent that this man was a memory thief, his intentions to steal the memories and sell them to bereaved relatives, turning up as the mourning starts. A sinister memory bank.

I won’t tell you what happened next.

It is a neat idea, recording the recollections of old folk.

I’d love to have some video of my mum or dad.

Again however this is confidence tricking, manipulation, playing on uncertainty and emotion.

We are all so very vulnerable.

You walk past houses that are sealed tight with fences and high gates, with infra-red video cameras and the whole security works, yet, what is most vulnerable, us, our egos, is harder to protect, and really, the more you protect your ego, the smaller your horizons and this is another kind of robbery.

The answer?

If anyone calls you, ever, claiming to be from the bank, the insurance or whatever, if they ask you for information they should already have, hang up. You can do it politely. Just hang up. If it is the bank, the supermarket or the council you can find their number online and ring up and check.

The worst that will happen is you are stuck in a long phone-waiting queue.

That is a little win for the thieves, but better than a full frontal expose.

Take care.

*Mammeloshen = Yiddish for ‘mother tongue’

Safe in heaven. Thank you Freda.

I learned this week that Freda has died.

The circumstances were odd, a little like our relationship.

You see, Freda and I had never met.

We came close once, a few years ago when I almost visited her at home, although for reasons I cannot remember, that did not happen.

We had been in weekly contact for the past few years.

She was my oldest friend, she was 80.

I am not sure if you can call someone a friend if you have never met them in person on even spoken with them, such are the gifts of digital communication however, we had weekly contact.

Usually Freda would read one of my blogs, both if I managed one on Saturday and one on Sunday and almost always add a comment. Sometimes a literary allusion, a quote from a poem she knew or a reflection of her lived experience.

And, without missing, she would re-tweet my blog.

From time to time we would exchange some WhatsApp’s, mostly it was tete-a-tete via my blog.

Once, perhaps a year ago Freda had stopped commenting. I made contact, perhaps on WhatsApp or Facebook and she explained she had been under the weather, feeling low. I think she became depressed from time to time.

I most recently contacted Freda as she hadn’t commented on any of my blogs and she hadn’t re-tweeted.

The reply later that day was from her niece who had Freda’s phone, informing me that she had died.

It was an odd finality.

I of course was unable to say goodbye, and I didn’t feel it my place to ask more questions such as, when, how, where.

Anything more, beyond Freda no longer being here, no longer being able to read more of my blogs or engage with me seemed like voyeurism.

And yes, I have felt sorry and sad.

Now I will never meet her.

I remember a couple of years ago when I was having some problems at work with comments that my blogs had provided too negative or bleak a portrayal of older people in hospital, Freda supported me with the phrase that sticks-out of my blog being, ‘Older person certified.’

As I have said, our relationship was unusual, not just because we had never met or even spoken, but because it was so very one-sided.

Freda knew all about me, reading my writing and I, knew very little about her.

She lived I Nottinghamshire and she had worked to support people living with dementia, I knew she didn’t have children – she did sometimes talk about her nieces and nephews, I think she had been a teacher, I also think she might have lived in America or even been American.

You see, never having spoken with her, I didn’t know her accent. I saw her photo on Facebook although on Twitter she was just a shadow image, with the intriguing name ‘@ColleyOf’

Freda’s death took me back to the death of a friend of my mum’s.

I remember driving past her house in Glasgow a few years ago, knowing she was ill, knowing she was probably at home and also would have been delighted to see me, yet, not visiting.

What strange psychological nonsense happens in my mind, with my thoughts, I can’t really tell you.

Not infrequently, I think of people, think of getting in touch, maybe talking or catching up, then something, another, seemingly more influential idea over-rides that decision and nothing.

Whether it is the fear that people will not want to see me, a reluctance to intrude, to disrupt the life of another (here I think of Philip Larkin) or some other notion. I keep my head down.

When I was younger I don’t think I had this problem, I remember being more outgoing, revelling in the company of others, going out of my way to make contact – whether that was strangers on a train or bus, or fellow travellers.

Nowadays I keep to myself.

I spend proportionately more time locked into my head.

Some of this is a fallout of my job.

When I was a junior doctor I began hating the phone as my life when working had been ruled by the sound of a bleep followed by a phone call and the request by someone, often a nurse or other doctor for me to do something, usually help, prescribe a medicine, see a patient, fill a form.

Some of my days, particularly Fridays when I work for the surgery are filled with phone-calls – more since Covid. Conversation after conversation.

I always do my best to engage with whomever I am talking. To be present in the moment, to take a person-centred approach, to talk from the heart, yet, this can be exhausting.

A few years ago I was involved with the local charity B:Friend – I was their first chair. I reflected at the time why I didn’t befriend a local older person like others, there must be many round the corner from where I live who would happily spend time with me. Yet, I never did.

My work, the engagements and care I provide for older people don’t come free. Sure I get paid – very well, but more than that, it is the emotional cost that tends to use me up.

This is no excuse – ‘Sorry I never met you Freda, I was too busy being a doctor,’ Well, there is something in that.

I was busy being a doctor and, well, I am odd.

As I have aged I have become like most people, more fixed in my ways, my introversion has increased, the time I spend alone or with my dog has become greater, the hours I spend reading, listening to audio-books or podcasts has expanded.

Me and my dog and silence.

Silence is sometimes needed to re-charge.

And yet, Freda is gone and I never really said hello.

It might seem odd to some, yet, I have been more affected by Freda’s death than the many many people I have known to have died in the past 18 months, most of whom have been patients or colleagues, some I have known for greater or lesser periods of time.

Freda had in a way filled-in a surrogate mum, at a distance.

Most of this is self-indulgence. Exposing my feelings, why?

And, I can’t help thinking how much digital has to blame.

Yes, were it not for the internet and computers, there would have been no blog (these might have been diaries) and there would have been no connection. Yet, there would have been no digital legacy. No Facebook or Twitter ghost.

And, will I now change?

Will I get off my bottom and connect with the friends I haven’t spoken with in years?

I suspect not.

Whilst not tragedy, this is apathy.

I’m sorry.

Take care Freda, I will remember you.

Hey Mr. Blue Sky

It’s funny. I love the song Mr. Blue Sky, yet, when a couple of years ago I used to play it or any of the songs on the ELO’s Best Of album in my car, there was something about it, not sure whether the pitch, the tone or maybe Jeff Lynne’s voice – that drove my son crazy and he would insist I turn it off.

That is not to say my son doesn’t like blue skies; he is as much a lover of sunshine and cloudlessness as me, yet, there was something about the music.

For the past six months, or so – the chronology of events since 2019 has been hazy, I have used when meeting people either on Zoom or Teams a self-made backdrop of blue skies with white fluffy clouds.

It only became apparent to me this week that they had any significance beyond helping to cheer me up during the recent dark times.

This week I met with some of the team; we were discussing ideas for how we could improve the way care is delivered to our patients.

Before I took my recent holiday (two weeks with close-to-home trips to Lincolnshire and the Peak District) I wrote two ‘papers’ which discussed some ideas of how we might work differently.

I have put ‘papers’ in inverted commas, as it took me ages to come to terms with the use of this word in relation to something I had written. You see, in NHS management, when you write something on a document and particularly if you submit it for use in a meeting, your blurb becomes ‘papers’ – ‘I have submitted a paper to the recent…’ kind of thing.

I always used to regard a ‘paper’ as something published in a journal, for example, ‘He wrote an important paper on the association between smoking and…’

Anyway, I wrote two papers.

One focused on how we might improve the support for people living with frailty in Rotherham, considering strategies to slow decline and optimise health and wellbeing and, the other, on how we might care for those people who are frail who have episodes of ill health (essentially doing all we can to keep people well and keep them out of hospital).

Anyway, it was at this recent meeting that Rachel one of my team referred to the document as being blue sky.

What followed was a sudden linkage with the reality of what I had written, which was in essence ideas sans numbers – cost, time scales, that kind of thing and my background.

What became even funnier was the background I occasionally use of a photo I took in the winter of a cob-web.

It transpired that those seeing me highlighted in this way took my background as a kind of message… Rod’s in a cob-webby place today.

When I think about all of this, when I consider who I am, what I like, what makes me happy, that kind of thing, it is the blue sky space. (‘space’ in an architectural, meta-artistic sense).

And, funnily, this links directly with the purpose of this blog, you see, the almond and emotion, this is the part of the brain, the amygdala, shaped like an almond which is the source of our emotional response to the outside world, also the gateway to creativity.

In situations of chronic stress or abuse, we bed-down, we shrink from the light and seek strategies for coping and survival, we think small, we dodge scrutiny, like prey animals, cowering mice sticking to the shadows.

When we feel safe, we can lounge, we can say silly things, we can risk being misunderstood or misperceived, we can experiment, dally, mess about, allow serendipity to intercede.

This is the blue-sky.

How I love the blue sky.

I am a blue sky guy.

To me the blue skies are where we are alive.

This is living.

This is out of the facemasks, the quarantine, the fear, away from the hypercritical, it is a good place, it is fun, happiness, where you might enjoy a little ELO, if you are not my son.

**Anyone interesed in reading these papers, I am planning to send them out next week.

>>If you have read this blog on FB, Twitter or LinkedIn and you found it enjoyable, entertaining or weird – any will do, I’d love if you shared it. Thanks<<

His left testicle.

I often think back to the school years I spent in Israel.

I wonder if my children will carry their own memories of their lives in the classroom.

If I stretch, beyond the playground memories of M. clearing-up after the flood or the distraught Maths or French teachers who, reaching breaking-point, became overwhelmed by our rowdy mischief. I also remember, I.

Now, I. wasn’t a teacher. He was our teacher’s husband.

My memory is of one afternoon in their living-room at home.

It must have been the last year of our middle-school, which was somewhere around 1989.

We as a class, helped by the teacher and her husband had written a play to mark the end of our time at the school.

The play consisted of a number of scenes involving the story of Israel, with new immigrants arriving at the port in Haifa (I still have the brown-leather flat-cap I borrowed from my dad; it is in my garage in Doncaster), some war/battle scenes, through to a re-enactment of an episode of school life where we as a group of wild-but-nice boys raided a strawberry field, day after day.

Hiding underneath plastic tarpaulins, we gorged.

I can’t remember how many forays there were to the field or whether we did this over more than one season.

The final time we went the farmer was waiting and caught a number of us. I don’t think he hit anyone too hard, more probably shaking by the arm and shouting; I remember he was from Yemen.

The story became legend, with the strawberry fields and the chase frozen into my memory.

Anyway,

In the living room, I. who had a theatrical past – perhaps he had been involved in amateur plays, was supporting the production.

None of this really matters as that wasn’t the memory.

I can tell you they had black and white photos of their relatives on the walls of their house, that and a central coffee table is the extent of the detail I have held onto.

And, oh, I. He was wearing sandals and shorts.

It was probably late-May, when the weather in Israel is starting to become quite warm.

Now, the memory, was of I’s left testicle dangling from his shorts.

Saggy, drooping down his leg.

We, the children, probably 15 years old at the time found this hilarious. No one said anything. How could you?

Yet, I now reflect, I. back in 1988 was somewhere around 45 at the youngest, probably in his early 50’s.

That isn’t much older than I am now.

I can’t imagine a situation where I would sit at home with a room full of school children and allow my testicle to hang-out.

Sure, I have encountered old men who let themselves go, yet, this lack of self-awareness seems odd.

It surely was not intentional – a form of auto-erotic exposure. I can’t believe it.

I remember him and his wife as being a lovely, caring, dedicated couple.

My teacher, R’s smile in particular, warm and proud of our academic accomplishments.

Yet, the testicle.

I wonder how long this will stay with me.

I am sure were a similar situation to arise, say, my own kids experiencing

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