Benjamin, teal and anarchy

I have just listened to a podcast with Benjamin Zephaniah interviewed by Krishnan Guru-Murthy.

They talked about anarchy.

Benjamin prefaced his words with, ‘No one is going to agree with this, and I will offend people on the right and left,’ (I paraphrase). He expressed his preference for anarchy.

Not I believe folk running amok, more, a reversion to how we used to be, back before shopping centres, democracy, TV and central heating. A more honourable, refined, age.

Benjamin provided as an example the response to Grenfell Tower – the main statutory body that provided meaningful action was the fire service, the rest was self-organised, coordinated, instigated; people finding flats, clothing, food, support – the community rallied and protected, long before government had rolled-out its red-carpet.

And so, with teal.

This is the belief that allowing people to join together, to collaborate in meaningful activity will create structure; the governance will stem from our love of doing what is right.

When you explain Benjamin’s view of anarchy or teal to people there is always resistance which for some continues indefinitely, for others becomes part of acceptance and understanding.

‘What if, someone didn’t like you and wanted to hit you?’

‘What if, someone didn’t want to work?’

Two examples, the first concerned with the response to lack of police, the second, reflex to lack of management.

Ironically, if I am out an about, and someone decides to hit me, the existence of the police will not stop them from doing so and, also, if someone at work doesn’t want to work, merely be present or play Candy Crush, the existence of management isn’t going to stop them; sure, you can put-up CCTVs, but there is always some out of the way nook – ask any NHS smoker.

Rules and punishment don’t keep people safe, they don’t stop bad things from happening, they merely allow for a structure, a guiding principle, ultimately what happens depends on doing what is right.

I am with Benjamin.

I say get rid of government, hierarchy, structure.

I’m not a pacifist – there is certainly a difference, and anarchy doesn’t mean chaos – look at Buurtzorg; a national company without central control. How refreshing. No board members deciding what is right, just frontline workers perceiving and delivering.

Ultimately, this will never happen.

Evolution has created humanity that is split; the left and the right will always remain at odds.

Just as we need the lovers – ‘Hey, look at that tribe over there, we could work with them to plow this field.’ There will always be, those to the right, ‘Stay away from those strangers, they want to rob what little we have, and, if they come closer, hit them!’

Society is a cocktail of these two extremes, swirling, mixed-up, for ever.

You can hear the podcast here.


Dog (in winter)

This morning

my dog

ran at a man in my garden.


He was checking-out the height

of the conifers



to trim

and even


all the



As far as I could see

he was just

doing his job.


Travelling around


for overgrown


and offering



Yet, he knocked at the back door;

which in itself was odd

as we have a perfectly

good front doorbell.


Perhaps that is how gardeners go.


(The last one we had showed a special interest in my neighbour’s lawn).


He was solid, tall,

wearing an orange jumpsuit.


Perhaps in his late 50’s

greying hair.


my dog skeetered to the door

as she does

when anyone arrives.


And squeezed her way out.


For a moment the guy looked


as anyone would

when 20kg of

unknown black and white hound

are flying at them.


And in that split second,

I thought;

good dog!

before rushing her inside.


Then I thought,

poor man,

this is how he earns his living.


And I didn’t take him up on the offer of tree surgery


I took the tattered orange

calling card.


I now don’t know if he was genuine or

a prowler,

I strongly suspect the former,


who would dress-up in orange,

with matching props

to case a joint?


And this a corollary of our times.


Locked-up behind doors


as fearful as my dog

who displays her anxieties

by barking

and raised hackles.


I am not sure how I express my fears;








And, it is interesting


I had


The passage

Of Youth.





Is not able

To accomplish the feats




I used to spring


Roads, (in Giffnock)

Up stairs




Now I

Move with


So as not to fall over.


That, I’d accepted.



My mental


I had denied.


An aged mind


Worse than the body.



Now I see it

Now I understand.


The past is the past

It is gone


I am left





I am trying to remember


to give my son


in his forthcoming exams.


Once upon a time

in a different world

I had an understanding

of the concept.



It is far away;

So remote

& out of reach

That I can’t do it.


It feels like grasping





It is

as if



in Langside College

was a different



Indeed – he was;

If we take 7 years

as the timespan for renewal;

I am almost


different people from who I was




Who am I now?



If anyone else has been in this situation, I’d love to hear what you did…



This might not be the best title for Boxing Day.

I can’t get away from it however;


The writing will help me move-on.


Last night I watched a programme about Tommy Cooper.



Silly jokes


just like that


He was present through my childhood.


His final day

Summed-up by an appearance on TV

Sunday, 15th April 1985.


I am not sure whether I can remember

The event

Or the news coverage afterwards.



The moment has remained.





Termination of existence.


And this to me is the pain.


I was talking with a colleague, a couple of months ago, about death –

(this a topic central to the lives of physicians),

She said that her preferred exit would be sudden,

Here one moment,

Gone the next.


Just like that.


For me, this is worst form of departure.


Sure, dying, particularly if you are young is never fun,


Especially, if pain or fear are associated.


At least,

When the event is pro-trac-ted, you can sort things out;

Have an opportunity to

Kiss your children one last time,

Say, sorry

To those you have wronged.


Tidy-up any messes.


A famous Samurai Legend describes the

Reason for barracks being so neat

Is that,

If you die on the battle-field,

No one will have to clean-up after you.


An anticipated death allows for this,

Suddenness not.


I think of

John Peel,

Somewhere in Peru,


Harry Dawn,


My dad for that matter,

Although he sensed something wasn’t right,

His departing words,

look after mum.


After the Cooper programme

I watched

The Making of Bohemian Rhapsody


Freddie’s old ma

Describing her joy

At purchasing a copy of the single

At the time of its release.


He went gradually,

He faded away

As is

The lot of most.


The average age of a person

When their parents


In the UK

Is 50

Or so.


I am reading The Haunting of Hill House;

One of the characters,


Lives through the deterioration and death

Of her mother,

Providing the care

That allows for her own opportunities to fade.


This a quid pro quo


The premature loss of loved ones.


When I was 19,

I remember a fellow student

And his sister

Both of whose parent’s had died

too young.


I sometimes think of them;


How do you experience the maturity of your own children,

When your parents are not there to guide you?


Sudden death,

Gradual dissipation,

Neither ideal

During the festivities

Of an economy reckoning with recession;


It doesn’t encourage you to spend

Other than



Or wicker.


In Mo Gawdat’s


Prove for Happy

He expresses his belief

That we, our spirits, souls, essences are eternal,

They have always been

And will always be.


Sure, our bodies

Run-out of steam

Give-up the ghost, as it were,

But the what




Unravelling all of this


Not to end on too sad a note,

Is the reflection

That those who once were

Are still here,


Whether we go in a flash


An ebbing,

Nothing changes.



This might not be the first time I have started a blog with an obscure medical acronym, but there you are, in healthcare they are rife.

NAFLD stands for, non-alcoholic fatty liver disease. You can see why the medics resort to the abbreviation – it’s a bit of a mouthful.

I’ll first explain what this is then give you an account of why I find it interesting, at this time of the year in particular.

NAFLD is a condition where fat is deposited in the liver; big-deal you might say; isn’t that foie gras? Yes, although us humans don’t have to resort to gavage as they do in certain countries; for us it is a combination of too much sugar and fat, lack of exercise and a genetic predisposition. This condition, where excess fat is stored in the liver, is initially benign and probably present is a significant number of people in our over-developed world;

As with all chronic disease, it starts with a little and over time becomes a lot.

With the passage of time, fat accumulates, it starts to change the architecture (a medical transmogrification, borrowed from design, of the word ‘shape’) and subsequently function; the first signs are usually abnormalities of liver function tests, ultimately, in the case of some unfortunate people, cirrhosis, liver failure and yes, death.

So, this is like many other diseases; they start small, get big and occasionally kill you – heart disease, cancer, COPD, whatever.

The thing about NAFLD is its relationship with ALD – yes, you guessed it, ‘alcoholic liver disease’ – the latter being probably as common, yet, carrying with it far more stigma – ALD being considered more a disease of lifestyle, rather than its little brother NAFLD which is more complicated.

It is funny. Particularly now at Christmas when a trip to the supermarket is a game of dodge the alcohol, chocolate and sprouts; our society being so keen to promote the sale of food and drink that in moderation are OK, but excess harmful (try eating too many sprouts!)

If you ask a patient, ‘How much do you drink?’ a perfectly benign question, part of a routine medical assessment, the response if often influenced by anticipation, people often dialling-down on the quantity for fear of judgment; rumours and whispers abound, ‘Did you hear about the Absinthe drinker in bay one?’ kind of thing.

And here, we are getting to the point.

ALD is considered bad, unfashionable, self-induced; it is associated with weakness of will (like the ‘fatties’), insobriety, irresponsibility; NAFLD is more a ‘disease’, like stroke, cancer, arthritis or the common cold – it’s beyond our immediate control.

31439_1CRUK_advert_3x2.jpg(I hate this campaign)

And hence the risk; folk with both ALD and NAFLD actually appear very similar – at least biochemically, when you look at their blood tests, that is; and, because ALD is probably more endemic within the population of people receiving NHS treatment or care, there is often a cognitive bias on the part of the doctors and nurses to assume that anyone with dodgy liver tests is an alcoholic, ‘sure, they say they drink just one brandy at bed-time,’ kind of thing, knowing that this may well be an underestimate.

And, this, I promise is the point; it is the point of the point.

Over the years I have encountered a few poor people labelled as ‘alcoholic’ who are completely abstinent; tea-totallers, who may have never even sipped a Babycham; yet, through a series of whispers and incomplete handover this is what they become;

Other people with an even rarer diseases of the liver – primary biliary cirrhosis, auto-immune hepatitis and haemochromatosis also sometimes find themselves in the ‘alcky’ trap.

This is how medicine operates; it is mostly so complicated, the demands so great that people fall-back on heuristics and labels.

Why have I written this blog? Well, to apologise to those people who might be wrongly assigned a self-induced condition and to explain that much of this doesn’t stem from doctors or nurses being bad, just, the human condition, great pressure, over-reliance on short-cuts and the necessity for workarounds in an over-pressured health service.

Some other conditions that suffer similar cognitive biases:

Lung cancer > smoker

COPD > smoker

Homeless > drug addict

Obesity > over-eater

Dementia > old

Parkinson’s disease > old

Palliative > dying

Asian > family do everything

I’ll stop here before I reveal too many of my own prejudices or inclinations, suffice it to say, we are all humans, just that.

Season’s greetings to you all.


When, did I become a man?



Does that mean?


Was it an age,

Or a stage?

Was there a

Here marks the spot

In time

Or space,

Or, perhaps,

More gradual,

An insidious process of



I never felt it happen,



Then child


And man.


The final common pathway

For us guys

That is –


I imagine

Follow a similar course.


Something I know


When I open my eyes,

When I climb out of bed,


The sun rise

Or set

Or stare into the eyes of my dog,

I am nowhere a man,

Not a mensch,

Not a grown-up, adult, bloke,

Just me,

At some point

In time.

charles burton barber in disgrace.jpg

How do you think it went?


I laid-out all the,

What I felt,

To be most important points of the plan





At least appeared to

Be present.


And, really, how do you think it went?







We didn’t reach a conclusion




I was a little pushy.


Not pushy,



I had a witness,

It’s all kosher.

No chance of recourse.


So, you didn’t reach a conclusion,


Was there a shift?

A move towards an agreement?





How do you think she felt?


It wasn’t personal.

It was what it was.


What does that mean?



She appeared to take it well.




What about the feelings?


Those don’t concern me.


PS Can I today, thank Time. For we are passed the shortest day and summer approaches.

winnifred eaton

One thing at a time.

You can only think or do one thing at a time.

We, humans, are serial processors.

First this then that then that.

A > B > C > D

My computer works in parallel.

First this then that and that then that, that, that, that.

A > B&C > B&C&D&E&F > B&C&D&E&F&G&H&I&J&K&…

It has something to do with RAM – Random Access Memory – not enough and the that’s are limited.

All of us have done the trick of patting our heads and rubbing our tummies – the childhood NASA test; I think the assessment methods are more sophisticated nowadays. This isn’t parallel processing – it is making actions unconscious so you can do more than one thing at a time; you can ride a bike and talk on the phone only when the cycling or the talking are unconscious; you see, we have lots of unconscious RAM, our conscious minds are not so hot.

Sometimes I marvel at individuals’ supposed ability to do more than one thing at a time – read a document and join a conversation. They aren’t really – even women who claim that evolution has allowed for the capacity to watch children, cook mealies, breast-feed and polish the silverware simultaneously. It is really just lots of serial switching backwards and forwards, with some assistance again from the unconscious – the internal Jungian vortex.

And the thing about this serial nature – it is not actually a limitation or a curse, it is our salvation.

I wrote recently about mind wandering – the meandering of our thoughts that is often associated with stress or anxiety…

…She didn’t reply to my email… She is ignoring me… She has never liked me… I am worthless … It is hopeless… There’s no point…

This kind of thing; illogical connecting that leads to frustration, worry and psychological drain.

It is actually possible to worry about something and go about your daily activities, although that again is the switching which uses twice as much energy – physical and psychical.

I am talking and every so often an intrusive thought pops-in to challenge my focus.

The solution, in taking advantage of this serialism is, when you notice that your mind is travelling down an avenue of negativity, pessimism or anxiety, is to find something else to occupy you. Something that provides sufficient cognitive load so as to fill your senses; this could be watching TV, stroking a dog, monitoring your breathing in and out. It doesn’t matter what. Some pray, others exercise.

If our brains were parallel processors how grim… how frightening, the potential to worry not just about one thing, but multiple… I am getting old, no one likes me, I might fall over, have a heart attack, forget my lines, become ill, make a mistake, lose my job, embarrass myself; in parallel we would all soon crash.

So, celebrate the way we are.

And, have faith in the unconscious, for this is where the magic happens; the subterranean world of ideas and imagination – it is where novelty starts, where surprise and intrigue develop. It is bottomlessness, never ending, always capable of more; an infinity.

The next time your head leads you astray; find something else and go for it.

As described, the ideas in this blog have been inspired by my reading ‘Solve for Happy’ by Mo Gawdat.



20/12/18 Happy Birthday Michelle!

‘But, why do I have to go?’

These were the words I overheard recently as I was leaving work.

The scenario was a woman in her, early 40’s, sitting in hospital chair, being pushed from one ward to another. With her were two healthcare assistants.

‘The doctors know all about me, why am I being moved?’

‘You must be getting better now,’ the younger of the two women reassured, ‘How long have you been in?’

‘Three days,’ the patient replied, ‘No one told me, I didn’t know what was happening.’

‘We are always moving patients, to make room for new, you’ll be looked-after by the same doctors, don’t worry,’ the other healthcare assistant explained.

I was witnessing the process of outlying.

This it when a patient is deemed well-enough to slip-down the list who require close monitoring on a medical ward and can be supported somewhere else – often a surgical, orthopaedic or in the case of women, gynaecology ward – those areas in the organisation that are prone to ebbs and flows of patients, some elective, others emergency.

Cancel an operation and voila, capacity is created. This might lead to great distress for the patient who had been waiting for a hernia repair, but at least there is more room to accommodate an emergency.

Such is the game of cat and mouse that is played in every hospital in every town and city in the UK. The numbers of patients moved, and the pace of change is always at its peak in the winter when the numbers of older people with chest infections increases, and with this their length of stay.

It takes you more time (and cheyshek*) to recover from an infection when you are 90 than when you are 30. This is a fact of life.

I have written before about outliers. It has been an obsession of mine over the years. I haven’t yet discovered a system that works consistently well for patients, doctors and nurses.

Evidence suggests that every time a patient is moved between wards, they stay one day longer in hospital, two moves and the time doubles.*

Patients moving from ward A to B is a necessity of 21st Century Healthcare.

Over the past decade things have improved tremendously – thanks to medical and frailty assessment units, a significant proportion of those who used to be admitted for several days are now supported at home.

When I was a house officer in the late 90’s, patients with a swollen leg were routinely admitted and started on intravenous anticoagulants with six-hourly blood monitoring, all with syringes often prepared by poorly trained junior doctors; I can remember scenarios where ‘query DVT’ was classed as an infectious disease (the possibility if not a clot, was infection) and such patients were transferred from Ninewells Hospital to Kings Cross, the then Infectious Diseases Hospital in Dundee.

Now all of this is done as an outpatient. In some areas you don’t go near a hospital bed; your GP gives you a tablet and you have a scan in the radiology department the same or next day.

Efficiency and effectiveness in the NHS have improved dramatically, yet, the numbers of patients continue to increase – some of this because of rising expectations and awareness (of heart attacks, strokes, for example) and often, because our society is ageing, and with age, comes disease.

Added to this, hospital closures and rationalisations of service have increased the pressure; poor planning of nurse, doctor and therapist training has left the UK with a workforce vacuum, we struggle to do more with less.

I won’t go too deeply into the politics, suffice it to say, the reality of ‘outlier’ is the reality of being a hospital patient. I don’t have statistics and it is likely that most patients don’t go through this experience, yet, the shift is so significant for an individual’s experience that the effects are disproportionate.

And, back to the patient.

I walked along the corridor, listening to her worries, eaves-dropping on the reassurances offered by staff and I thought to myself, ‘What a situation.’ (Stramash**?)

I don’t have any alternative solutions.

In pressurised systems, something has to give otherwise there is a pop.

Some hospitals have prioritised the care of outliers – seeing those patients first on ward rounds, not leaving them until last when the doctors are tired, and it is late in the day.

Some will question the wisdom of seeing the ‘well’ outliers over ‘sick’ base ward patients – there is no easy answer; and, frequently for those teams discharging patients from outlying wards, particularly at times of pressure, they are rewarded by receiving additional new outlier patients from other teams.

It becomes a little unfair.

And hard.

I guess the point of this reflection is for us to stop and reconsider the experiences of our patients. Realise how frightening it is to be alone and vulnerable, subject to investigations and treatments you don’t always understand.

We are all in this together,

Collaboration is likely the only solution – that is, patients, staff, relatives, carers, all part of a multidisciplinary team fighting the odds.


*cheyshek = Yiddish for strength/energy/va-va voom

**stramash = Scot’s for ‘mess’

Mind wandering & etc.

Earlier today, I was writing about High Definition TV and my thoughts relating to the potential harm it is doing to our senses.

Within that blog I mentioned nostalgia. (Here is a separate blog specifically on that subject).

The day before I referred to the title of a book of poems by Jack Kerouac – Safe in Heaven, Dead. This is along the same lines.

We can only ever be certain about the past. The present is always ending, and, tomorrow isn’t;

I have been brought back to thinking about these ideas by Mo Gawdat, a remarkable Egyptian business/tech/thinker, in his recent book, Solve for Happy. Mo, an engineer by training takes his analytical mind to the concept of happiness to develop an algorithm for others to use. He has also started the global movement; #Onebillionhappy – his idea to contribute to the happiness of one billion people globally (as of 2018, he has some work to do).

This is getting off the topic.

A few concepts are well established within the world of Mindfulness.

  • Mind Wandering – that is the unscheduled, dis-coordinated ambling of the human mind from topic to top, which is part of the human condition. We all do it.
  • Mind Wandering tends to occur more frequently when people who are anxious or depressed.
  • Mind Wandering is the opposite of Mindfulness, which encourages us to free our thoughts from ideas and emotions and be in the moment.

All this is very clear – if you want to learn more, John Kabat-Zinn’s book, ‘Full Catastrophe Living’ is an excellent resource.

What Mo helped me link in my mind yesterday was the relationship between the states of Mindfulness, Mind Wandering, being and remembering.

Here is roughly what he says:

Think of a happy moment from the past.

Go on… think of one;

Here is mine – last winter standing on the edge of the Ramon Crater with my children.

Remember the scene – the colours, sounds, feelings, associated emotions;

For me it is a rich, anchoring moment that is buried deep inside.

One thing is very likely however – at that moment, I was almost certainly not in a state of Mind Wandering. I was there, experiencing the heat, the smells and sounds.

These states of being which Csikszentmihalyi calls flow are when we are at our best, gaining the most from being alive.

Such states are inconsistent with Mind Wandering – thinking about unpaid bills or what Gloria, Gaynor or Graham think about you, ambling-off into future states of imagining what might be if or if not.

Now, this moment is the experience.

For me this is consistent through my life; those times that I treasure most are those occasions when I have been present – physically, emotionally, spiritually.

Can anyone remember a moment of Mind Wandering?

In essence, this is squandered life.

It adds little.

It isn’t even thinking.

Generative thoughts, the place that creates new ideas mostly happens in the unconscious, usually, when you are busy doing other things – as John Lennon said.

The point of my blog?

Well, probably it is a call for people to read Mo’s book.

Also, to observe those moments when you are so caught-up imagining what might or might not happen that you miss all the heavenly glory (sorry for the excessive quotes – that one was Bruce Lee).

Take a moment, stop worrying.

Be in the now.



Do we live our lives in HD, High Definition, that is?

Last night I had a weird HD moment; sitting with my daughter watching The Gremlins.

I remember seeing this movie in 1985 – I was 12, too young to officially get-in to the 15-classification film (Muriend Cinema (where I saw Superman), Glasgow, now I believe a supermarket). They were less age-obsessed back in those days and let me and my pal inside. As far as I know I have not been harmed by the experience – although, some might disagree.

Anyway, that is not the point.

As we watched the film (ironically, my daughter is also 12 – I was therefore in some way passing-on this contravention; sorry future generations of Kersh.) I was puzzled as to whether it was the original or a remake.

Amazon said it was from 2012 – which indicated not, and, the images looked different, I even convinced myself that the opening scene with the dad in Chinatown was a remake.

It just seemed too real, too modern.

Yes, the initial credits were awry, but still.

Only when I saw Corey Feldman’s name appear did I get it – yes, it was the original; they had HD’d it. The experience from my adolescence had been passed through a digital wonder-machine and pooped-out modern.

It took away some of the mystery.

My daughter didn’t seem that impressed – Gizmo (the name for my pet chameleon a few years later), looked artificial and nowhere near as ‘real’ as something you could buy today.

For me, abstraction adds to the experience; heck, I love B&W – my children won’t go near it.

What brought this into perspective was the 1985 Top of The Pops that we watched afterwards; John Peel had hair; Bon Jovi and the Human League featured. This however was in original definition; the washed-out haziness of thirty years ago.

It felt so much more real, homely, like chicken soup.

I remember the hours I used to experience playing with simple games on my ZX Spectrum; my son now has Red Dead Redemption 2 with its hyper-real graphics, sound-track, changing seasons and intricate detail.

What effect will these two variances have on each of our development?

Is it a form of dependence?

If you are weaned on rich-food, can you ever go back to the joys of plain?

The 21st Century is obsessed with modernising the experience – whether HD, 5K, virtual reality, or the next plans to speed-up the internet;

Haven’t we reached a stage where things are real-enough? The download speed of my computer adequate? Sure dial-up back in the day was frustrating, but now, come-on, can’t we focus our attention on other things?

Perhaps this is me revealing my Luddite tendencies. Nostalgia; longing for the good-old days (and, more on that in my next mindful update…)

When I was a teen, questioning the validity of high-street competition, different makes of cars, coffee or chocolate, my brother stated, ‘You’re a Communist, aren’t you?’

I don’t know.

I am certainly no longer, although sometimes it seems as if enough is enough and our attentions would be better focused on getting back to basics; that is, nature, the environment, consumption, fraternity and so on.

I mentioned last week, a trip to the optician. I am getting my eyes checked today. Will my experience of life improve with a new prescription? Will it detract from my present-day filling-in the blanks? Who can tell? I’ll keep you posted.

corey and gizmo.jpg


It seemed inevitable,

Well, not necessarily, it could have remained a flat-line;

That hasn’t been the case.

Since I started blogging in 2015

More people have been reading.

I still don’t know what is most popular – blogs or poems.

Poems are certainly easier to pen although the blogs are likely better for self-expression.

The numbers of readers have been rising (here is the data if anyone is interested)

2015 – 1,759

2016 – 5,142,

2017 – 11, 048

2018 – 20, 617

(At this rate it will take me until somewhere in 2023 to reach a million people).

Ironically, as the blogs have become more popular, I have become more constrained in how and what I write. I guess the chance of my upsetting someone or taking a wrong-turn has increased.

For the first-time ever this year I was invited to tone it down.

(Here I reflect on Biko’s book… I write what I like – look where that got him.)

I know I could give-up; there would be no great loss. I could resort to the diary or journal, but I have never been very good at that, I always seem to drift away. There is something special about blogs, likely the immediacy of sharing that makes the medium hypnotic. (aka a dopamine thing)

And yet, I don’t open-up fully, there is always more to say, more life that has been lived, more time passed for reflection.

It is interesting that this year, in a sensational media event, a doctor was called-out for the content of their reflection; their openness and honesty with themselves and their supervisor was made public, all, sending a shiver through the profession.

And, what is the point?

I originally started blogging to make some of my ideas concrete.

The relationship between safety, mindfulness, imagination, the unconscious and creativity were early themes.

More recently I seem to have focused on analysis of my life as a doctor – the good, the bad, the challenging. Mostly I feel I ask questions; only occasionally do I arrive at an answer.

I have some dedicated readers who make me feel worthwhile.

In the three years I have been blogging I have only had one, maybe two altercations with readers, and those mostly misunderstandings. (Not counting the time I was blocked!)

Blogging is walking a tightrope.

It’s not the fall that kills you.

Perhaps I am running-out of things to say;

There is an adage; when in doubt, act.

Perhaps I should adopt, when in doubt, shut up.

Sometimes I think of white blood cells and their response to infection; the overwhelming increase of defensive mechanisms aimed at maintaining the status quo.

Mostly it is just self-expression.

Bruce Lee called Jeet Kune Do the art of expressing the human body.

Perhaps blogs are the art of expressing the human spirit.

The spirit encounters ups and downs, rides a roller-coaster, frequently made more vulnerable by changing seasons.

I remember in the 1980s they used to talk about biorhythms. These still exist today although they sit firmly in the realm of pseudo-science.

And yet… our world is in flux, it does follow a pattern, we are travelling in time and space with an uncertain destination.

When will we get where?


It wasn’t inevitable that more people would read the blog,

That attention would grow.

Would I have carried-on as I did back in 2015 if nothing had changed?

An aspect of this is nostalgia.

We like to look back on the surety of a lived-past and remember.

Once I was young, now I am old. Tomorrow who knows?

This is the same logic that prevents me from planning too far ahead.

Yesterday, someone asked me to book a meeting for next November.

I said yes, but I just cannot conceive of such a thing.

They talk of five-year plans, I tend to live in a five-minute window of being. Now and a minute, now and a little bit more. You’d think a lifetime of experience would convince me differently, but not.

Yesterday is a comfort.

Safe in heaven, dead, Said Kerouac.

I get the sentiment!

Why not exist perpetually in a merry moment? Why not maintain a constant now/joy?

I guess it’s not how we are programmed.

If you can balance the threat of tomorrow, weave this in to a context of eternal optimism, you are moving in the right direction.

Let it flow, as they say.




A tent, or tepee is soon to arrive in the hospital.

I’ll explain a little about the why and the wherefores shortly, but, first, I’d like to think about dens.

When growing-up, my cousins lived in a house with a den; in effect where they would sit and watch TV and eat meals; as opposed to the lounge or dining room.

My kids over the years have created various dens; all sorts of fabric constructions – blankets, sheets, jackets and shirts.

There is something magical about a place of your own.

Occasionally, in the morning, I would find a child had spent the night underneath a pile of crumpled-up linen and duvets.

As a youngster I remember my mum making me a wigwam; this, distinct from tepee is that the former is less permanent – designed for getting about. The wigwam was made-up of interlocking poles aligned with neatly machined slots attached to fabric. It would balance precariously on the slope of our back garden.

As an even younger child, pre-school, I used to love crawling under the dining-room table. The smugness, safety, security of being tucked out of the way.

Yes, we are getting a tepee.

Supported by a wonderful organisation called Camerados.

‘Where did you get the name?’ I asked Maff one of the founders; ‘Ah, from Whitman,’ he said…

“Camerado, I give you my hand!
I give you my love more precious than money,
I give you myself before preaching or law;
Will you give me yourself? will you come travel with me?
Shall we stick by each other as long as we live?”

And kind of funny, at least to me, as this takes me to somewhere in the late 90’s drinking Cream Sherry with Nick, reciting Leaves of Grass before heading out on the town.

The joy of oddness.

Is there anything worse than being a circle conformed into a triangle or square?

And, intriguing how this takes me to wholeness;

In the workplace (or any place) you can be your best, give your most, when you are yourself; when you are confident, open and secure, when you are not wasting physical, psychical or other energy on second-guessing or over-analysing. Stigma and prejudice bring us down, they prevent growth and progression; happiness, openness and light lead to creativity.

And, so, the tepee.

It is an installation designed to create a space for wellbeing. A place for people to be themselves, to allow their defences to fall, where patient and staff, carer, therapist or doctor can connect as humans; the project is called human hospitals. An attempt to re-humanise the clinical, to balance the scales of person-centredness.

Anyone care to join me?

If you are interested, you can check out the tepee that was until recently installed in Blackpool Victoria Hospital. (here).

Thank you, Walt, thank you, Walden.

Here to the spirit of now!



Today I learned a sad fact,

I should

Have been aware




It was one of those things I had chosen to forget.


It was about the eyes.


Visit to the optician.


I like the bright,

My son the dark.


‘Ah, that is your age,’

Says the guy.


By the time you are 65

The amount of


Hitting your retina

Is only a


Of your youth.


A diminution,

A fading away,

My palsied vision


Aspect of tomorrow.



In Glasgow, if you say somebody or something is mental it means little more than whatever they are doing or saying doesn’t make sense. It isn’t pejorative.

In the world of health and care where the stigmas of good and bad still at times run rampant, mental can have a different implication. In general, it leads to mental health and wellbeing. All very separate entities from the physical, which seems to stand on firmer ground, particularly outside of psychiatric circles.

I attended a meeting recently. The discussions related to physical and mental health. What was what. Where is the line drawn between psychiatric and physical?

For some this is straightforward – after all, if you open the ICD-11, ‘diseases of the nervous system’ you can find a long-list of all that might befall an individual’s psyche – everything from anxiety and depression to the more obscure such as Capgras and Alien Hand Syndrome.

That to me is all very well.

The problem relates to humans.

You see, we don’t tend to come packaged with one condition. There is always more, and, the older a person, the longer they have to acquire additional disorders – diabetes, asthma, colitis, saropenia; it doesn’t really matter. Humans (most of us at least – I am exluding the odd 100-year old super-human still running marathons) acquire physical health conditions like the barnacles on a ship.

How then do you split a person? For, by the very nature of mental health, there is going to be an overlap, an inter-relation with the physical. Someone who has ‘just’ Schizophrenia will experience the world differently to another who has this condition and psoriasis or cancer.

My suggestion is that we stop talking about physical and mental as if they are separate – just, as I have discussed in previous blogs, there is no physical and social care, just care.

So be it with physical and psychiatric – there is just illness and health (or, disease and wellbeing). Either the body is working, or it isn’t. The component affected shouldn’t influence our conceptions. Yes, we need people who know a lot about a little – specialists and yes, we still need the generalists, but let them get themselves together and review how they approach the world.

As an aside, I am listening to Stephen Fry’s ‘Secrets of the Victorians’ on Audible. In a recent episode, I listened to his descriptions of lunacy and madness in Britain in 1800’s. Much of which seemed to differ little from Barbara Robb’s Sans Everything of the 1960’s, nevertheless, there is good reason for so many rules and regulations specifically focused on mental health – I get that, yet, the world has evolved, our understanding has changed, perhaps it is time for another reform?


A Yiddish aside

At present I am reading ‘The Death of Methuselah and Other Stories’ by Isaac Bashevis Singer; this perhaps is the reason that Yiddish words are buzzing around my consciousness.

I spend most of my time in an English-head, that is, when I am not within medicine; occasionally I slip into Hebrew although not very often.

Yesterday I was out walking with my son and I commented that I was ‘shveetzing’ – this the Yiddish for sweating; it was unusually warm for the 1st of December and I was wearing a too hot coat.’

‘How come you know so many Yiddish words?’ My son asked.

‘I don’t really, I just picked up a few from my parents.’

My mum and dad were both born in Glasgow – their heritage goes back to Poland and Latvia as with many present-day Jews in the UK. Their parents or grandparents would often converse in Yiddish, in the early days, probably the late 1900’s and early 20th century, Yiddish theatre and newspapers were still available in some parts of London and Manchester.

Will Urdu or Hindi become the Yiddish equivalent of people living in the UK today within a generation or two?

Who knows.

Yiddish certainly adds a flavour to one’s experience of life; the words so mellifluous, rich and many-layered.

Here is a selection of ‘f’ words which to me always seem particularly poignant; I can almost hear my dad saying them, perhaps on a Sunday morning pottering around the house.

I can’t attest to the absolute validity of the translations or the language as this is all a transliteration of a young boy overhearing the banter of older folk; nothing written, all spoken and influenced by Glaswegian accents;

Ferkreemtie – someone who looks so miserly and miserable that their face is folded-up on itself

‘That lady at the off-licence always has such a ferkreemtie face’

Fershleptebobbiemeyse – An old grandma’s tale – a story that is convoluted, rambling and over-long

‘I eventually gave-up listening to Norma’s story, it was such a Fershleptebobbiemeyse’

Fareeble – a falling-out, especially between relatives, often in relation to a trivial event e.g. forgetting a birthday

‘I long for the days before our fareeble with aunty Gretchen, when we used to on holiday together’

Farfallen – woebegone, collapsed from lack of inner energy

‘The old man who had lost everything was farfallen.’

Ferd – silly or stupid person

‘Stop being such a ferd!’

Finster – pitch-black

‘It was finster, I couldn’t see a thing’

Fleyshick – meat-containing

‘I can’t touch that, my hands are fleyshick (from eating meat)’

Fleegle – a little chicken wing

‘Dad said you could have the fleegle today.’

Frummer – a very religion (Jewish) person

‘I see some frummers have moved-in across the street!’


Dedicated to mum, dad & papa


Gum and Gods



To my shoe




I walk around

before realising

That the


Is actually




Spat out


Left behind

By somebody.


And now attached to me.


I can’t remember the last time

I experienced this;

Whether fewer people are chewing

Or I am less exposed, I don’t know.


Sometimes you have to place the shirt or

trouser in the freezer

Which usually only

Partially works.


There is also a magic


You can apply;


It is perhaps the invention of this agent

That has negated

The placing

Of the stuff,


When there is a remedy or a quick-fix

The threat diminishes,

The act of doing


And transforms

From a meaningless

to pointless.


Twisting action into futility

Is sometimes

Seen as the role

Of bureaucracies,

This time

It is a collaboration of

Industrial chemists.


Now, imagine

There were equivalent


To similar



The effort to wake and climb from bed on cold winter morning;



The frustration of being unable to express oneself at critical moments;



The realisation that I am old and everyone I love, gone.


You would likely need more than a couple of drops

To have change.


Take this, pill three times a day for a week and

You will no longer

Feel anxious

When arriving at work.


Or more modern;

Apply this plaster

To your right


And before you know it you will be assertive.


All human emotions,



And fears



Would this be

The Arriving?

The Grand Unified Theory –

All things big and small together?



Would it be the end?

More a

Time of Revelation

than happiness.


This would be the wiping-out

Of the Human Condition;

We would either morph

Into Gods

Or become no more relevant

than the gum I stash under the table.


Hypo-perfusion or embolic phenomenon

There is a thing

That happens to some of my patients;


The scenario:


Sitting quietly, often, after a meal, perhaps breakfast or lunch

And suddenly nothing,

Slippage into unresponsiveness.


I don’t say


For, that is altogether different.


These guys,

Always old,

Grey of hair

And thin of skin.

Are able to maintain an upright posture,

Can stay sitting,



No response to stimulus.


You measure the heart rate,

blood pressure



even, blood sugar;

All reassuringly normal.


Bloods, ECG, normal.


Chest X-ray, normal.


CT, normal.


Brain waves will likely have altered,

Although, that is not something we do.


And, we are left,

Old person,

Suspended in nothingness;




That is

Reticular Activating System



Most theories


Cerebral autoregulation,






No one



Modern medicine never works…


Cannula, Glasgow Coma Score;

Sternal rub,


Finger-nail press,

Skin-flap pinch.


Time almost always does the trick;


And staying calm.


I suspect some watch me

And think

‘He’s cold… Detached’


It’s not that, it is the realisation

That there is nothing you can do to make any difference

In these situations,


assurance to

family and friends.


Such an exposition of vulnerability;

You can’t even blame the demon



dodgy drugs,

It is how

The human body expresses deterioration.


Sands shift

And the

Person falls

And there is no more.

jackson pollock fractulose child.jpg



Only really come to prominence

When they cause problems.

When sitting

In the background,


One amongst

a trillion;

Flora within the fauna,

Most of us can ignore their existence.

The shape, colour, size or prettiness

of these




Goes un-noticed.

The wallflowers of miniature.



or if

Things change,

Perhaps a moment

of mutant madness

And benign

Becomes aggressive

Hold on!

This, then, is when the white blood cells are summoned.

‘Hey guys, we have some trouble-makers, down in the gut, go and sort them out!’

Says the spleen or marrow or lymphatics;

A forward force of neutrophils and macrophages

Rush ahead.

If able to neutralise the new guys

all is well

We revert to

Social norms,

Continue as before


If, before

Was fractured.

‘those guys aren’t for giving-in



They are determined to change the landscape’


Send the forces

of our immunity,

to the upstarts!

You try to change




& your considered









Is what goes;

The tradition that has failed us is the tradition that we want.

Nothing else will do.

Better to fail in a failed system than to undertake an experiment with the same outcome.


Get back in line!




I, we, can diminish you.

I appreciate you’re already only a couple of microns,


With my manipulation,



I can make ye smaller;


Progress can’t be halted.


They call me,


I try to build myself up, try my best to reach a point where all things are equal,

inter pares







the final carrier pigeon.

queszalcoatl ann agoryanina saatchi art.jpg

That was an occasion to celebrate.



Safety and confidence

On Friday I attended a teaching session for trainee doctors in Rotherham. It is usually a fun, relaxed event where I, the old guy in the room get to hear case presentations and descriptions of disease, investigation and treatment.

This time the subject was irritable bowel syndrome.

The range is wide, last week it was ECG, next time skin rashes. We medics like to keep our minds agile.


This blog is about two things, separated by 15 and directly touching upon what happened last week.

Here I begin…

It was 2005 or so, I was working in an A&E department in a big hospital. A patient had anaphylaxis. This is otherwise known as severe life-threatening allergy; the kind of response that led to the death of Natasha Ednan-Laperouse in July 2016 in relation to food labelling at Pret a Manger.

Anaphylaxis is rare.

Allergy is common.

Many more people are prone to anaphylaxis than have a reaction – general, people manage to avoid peanuts, kiwi, bee stings or whatever the allergen.

Occasionally a person inhales, swallows or touches something that sends their immune system into a frenzy.

Feelings of terrible anxiety, palpitation, vomiting, flushing, wheezing are followed by crashing blood pressure.

It must be horrible.

On this occasion I had just passed my Advance Life Support course, this is standard training for doctors, nurses and paramedics in resuscitation and initial management of the critically ill. In fact, I passed so well that they offered for me to become an instructor.

Anyway, less of the bragging.

The scenario was a middle-aged woman, in the resuscitation bay, me and consultant.

The consultant called for adrenaline – that is a mainstay of initial management in anaphylaxis and prepared to inject this intravenously.

I didn’t say anything.

Intravenous injection of adrenaline is high risk. It can in itself elevate your blood pressure (what you want when it is very low), it can also cause disturbance to the heart rhythm, heart attack and cardiac arrest (it is used as a treatment for cardiac arrest once the heart has stopped – before this stage it can cause the heart to stop in itself).

From my teaching I understood that adrenaline in such situations should be administered intra-muscularly; such is the strength of the drug that even an injection into the muscle is usually adequate and also has less risk of adverse effects.

The patient had a run of ventricular tachycardia (the stage before cardiac-arrest), they vomited, looked appalling and, survived.

Now, I don’t know whether there was something I was missing; was intravenous the right thing? Should it have been sub-cut?

What did I do wrong?

I saw something happening that I perceived to be wrong and I stood-by.

(IV Adrenaline according to the Resuscitation Council UK can be used in anaphylaxis by people who are experienced specialists.) (Whatever that means).

This feels to me as bad as the Kitty Genovese incident.

It taught me more than I contributed at the time.

Shifting to Friday’s teaching, the presenter, made a mistake. She used the Roman Numeral ‘VI’ and said it was four.

Now, we don’t use Roman Numerals that often these days.

I saw the VI and thought, ‘That’s six.’

I didn’t say anything, hoping someone else would point this out.

No one did.

I was then faced with the situation of remaining silent – perhaps no one else had noticed, or, possibly VI is the numeral for four – and I was wrong; I didn’t want to look stupid – as I said at the start, I am the old guy, the person who should know better.

After a few seconds I couldn’t resist and asked, ‘Isn’t that six?’

Now, it didn’t really matter in the general scheme. Four, six, these are just arbitrary numbers particularly in relation to academic studies or research (sure, four tablets are not the same as six).

Way back when, I remained silent in a far more serious situation – one that could have affected the life of a patient (I am sure at that time, the injection should have been sub-cutaneous), yet, there were maybe things I missed; what was most wrong with my action – or, rather, inaction was my silence.

You don’t have to call someone out for being wrong. There are ways and means. (A nether land between mitigated language, staying silent and knocking egos).

‘What dose are you giving?’

‘Is this always intravenous?’

‘When would you administer sub-cut?’

(I appreciate all this is much more difficult in emergent situations).

Think of my story from yesterday with the patient and the fever.

We can express ourselves in a way that leads to behaviour in another with an outcome of fear, embarrassment and threat or you can interact as one who is seeking the truth.

This relates directly to hierarchy; chief chimpanzee can make inferior troupe member feel very bad, induce a state of depression or exile. We sometimes forget the impact of our words.

In this scenario, because it was informal, and no one was offended, I was able to ask the question.

How silly a species that fears questions…

Embrace questions but know that our egos are snowflakes and, delicacy is the favoured approach before bombast.


Nasty v Nice

What do you do?

Here is the scenario.

Nasty takes someone who is struggling and kicks them out. Vamos.

Nice takes the same individual and tries to find a workaround, a person-centre solution.

Time passes.

Nasty has acquired another protégé, Nice is stuck with the same guy.

You can multiply this by two, five or ten depending on the size of the organisation or the situation.

Nasty after a period of time has done-away with any challenge (unless he has identified threat as being not all bad*). Nice however is knocking around, pin-ball; the collective competence perhaps less but each safer in their situation, and, likely more able to perform.

Nasty over time diminishes. There are the initial successes; think Stalin. Think Franco waving to the crowds. Hitler, Mussolini, Pol Pot, Pinochet, all baddies now roasting in the dark dimensions of the past.

And then there are the good… Where to begin? Roosevelt, Washington, Gandhi, Mandela; Jesus, Muhammad, Abraham; lest we forget Buddha.

I don’t know enough about each individual to analyse too deeply. It is the ripples that have continued, the reflection held-up as a guide to tomorrow;

Peace, dignity, respect, sensitivity, tolerance, intelligence, candour.

You’ve got it.

Where would you rather be?

On the winning side of the tyrant or the losing side of the just?

I remember as a boy watching, I think it was Superman 2. Me worried by the twists and turns of the narrative, my dad relaxed, enjoying the moment, assured in the knowledge that good would always win.

Is the fiction representative of reality?

Will the good guys make it through?

Where will I be?

Most of this reflects values. Essence. Taste; flavour.

Savoury or sweet?

From a historical, moral or value-based perspective, I’d rather go down with the ship; honouring the march of time. I would prefer to be called a liar than be one who portrays the truth when it isn’t so.

I accept this suggests a too-straightforward split. Right or wrong, good/bad, hot&cold. Nothing is like this, in the messiness of life or love or fear.

And yet, and yet.

the khan.jpeg

*Think Genghis Khan and Jebe (The arrow).


I haven’t been in a cockpit since I was 12 years old – then, somewhere over Europe, I was allowed to chat with an El Al pilot and crew. Today, this would be considered an outrageous breech of regulations, and, justifiably so.

I cannot therefore comment on what happens at 45,000 feet. I imagine a calm, controlled, relaxed and ideally up-beat scene. Like anaesthetists, pilots prepare for the worst but mostly enjoy an untrammelled existence.

We are told that humans can only process a relatively small, finite amount of information at once. Nowadays we describe this as bandwidth, an allusion to the limitations of the internet.

I can only do one thing at a time, anything more and my abilities deteriorate – the quality of my performance falls away, things slow-down and the tension mounts.

I have had discussions with colleagues who appear to be able to multi-task, with, the most common suggestion being that this is a gender thing; harking back to evolution – men evolved to hunt, women, care for children, cook, mend or whatever.

My kids seem to be able to watch TV and do their homework; something I couldn’t ever achieve. Perhaps they are evolving.

On the ward round there is a difficult balance or interruption, attention and focus.

I must focus on the patient before me; listen to their story, integrate the symptoms and investigations, work-out a plan of treatment or care. At times this can be difficult. Frequently we are pulled in to heuristics; here is an example:

89-year-old man,



Listen to the story, establish that nothing is broken, there is no sinister cause (clot, heart attack), look for heart murmurs, check mobility, look at blood tests, ECG, X-rays, lying and standing blood pressure and, if all is OK, home.


Indeed, inevitably one day they will replace me with a special falls-assessment robot.

What happens however, is, during conversation with old man, I will be questioned about old woman I saw half an hour before, then, a phone call or a text, WhatsApp, fire alarm, request to speak with family… it goes on; handwriting, abbreviations, acronyms, trying to teach, explain and explore, smile, joke, relax, manage time in order to get to meeting, it is sometimes a whirlwind.

I don’t know if we would allow pilots to work like this.

We could create a hunter model. Allow doctor (me) to focus solely on the task in hand and everything else has to stack-up or get in queue. You could argue that interruptions are a hazard in themselves, yet, is interruption, or the ability of doctor, patient, porter, nurse, pharmacist or therapist to speak-out or express themselves not part of the tapestry of our safety culture?

I have seen colleagues who possess such an air that no one would dare interrupt; mitigated language is the norm, questions are left until later.

I’ve never wanted to be like that, yet, it is so very hard to operate in situations of overstimulation.

In the rainforest (where we likely went before or after the savannah), the rain is both a help and a hindrance; you can’t hear prey or the predators. The pitter-patter cancels-out the in-between and things become still.

If there were ward-round, noise cancelling headphones everything would be OK, although I doubt my patients would be impressed with my appearance.

It is a goldilocks phenomenon. Not too much, not too little; just right. Mostly, it will be wrong, and we will have to get along. That is how it is.

banksy headphones.jpg


I was caught-up in the frenzy that is hospital discharge yesterday.

Here is a fictionalised account of the episode:

Man, 70 years old, has fallen and broken a bone in his leg.

He struggles to walk.

The pot (stookie) is applied and his ability to move around improves.

A night in hospital.

Another night; waiting for equipment, support, the effects of the pain killers.

9am and the day of discharge the ambulance is delayed.

Man, let’s call him, Fermi, remains in bed; the pain controlled, his chestiness, perhaps a little worse, but his desire to get home, the peacefulness of sitting in his living room, clock ticking, slippers and worn carpet, smell of his life.

Observations checked – a routine of the ward.

Temperature 39, heart rate 90, blood pressure 110/70, respirations 20/min, oxygen saturations 90% (all normal for Fermi except the temperature).

I return and check him over.

Fermi is very upset; the nurse has told him he can’t go home.

If only the ambulance had arrived on time…

Let’s see what we can do; all is not lost.

I talk with Fermi, sound his chest, listen to his heart.

He seems OK, perhaps lips a little blue, but he wants home.

I agree reluctantly to let him go; using what we call safety-netting (aka protecting your back… ‘your temperature is high, it could be anything…’ ‘If you go home and you feel worse, you need to seek medical attention’ (and similar platitudes).

Fermi, anxious to leave, agrees.

Moments later, as I have moved away, a phlebotomist has taken-out his tourniquet, preparing to take blood; it’s policy. Temperature of 39 requires investigation; blood cultures.

Thoughts in my head… ‘He’s OK, says he is fine, wants to go home, responsible adult, transport imminent…’

‘No need for blood tests I say. He is OK.’

I think, ‘If he was at home with a temperature of 39 no one would be doing blood cultures, and so on.’

Nurse expresses his concern. Doesn’t seem right. Guidelines…

Nurse, also, possibly thinking to himself, ‘this isn’t right… damn doctors… my patient!’

I don’t listen. I am standoffish, almost rude, or perhaps, rude; hard to tell. A few seconds of disagreement and I move-on.

Frustrated that my plans, are challenged. Annoyed that I had not been able to successfully translate the thoughts in my head into words that would convince others. Feeling threatened. Vulnerable.

What now if something goes wrong.

The volume of data, information, decisions absorbed and translated on ward-rounds, particularly those on assessment units is immense.

Consultants are expected to move from patient to patient, young to old, infection to infarction, issue A to B to C all within a constrained timeframe and support decisions (albeit with the team and the patient) that can be life determining.

It is intense.

Shortly afterwards another nurse informed me that the patient’s oxygen levels were even lower.

We cancelled the discharge.


I reviewed him later and he was thankful for staying-in, as were his family; now attached to oxygen tubing, in receipt of antibiotics, steroids.

I apologised to the nurse and thanked them for their good sense and action to do the right thing, to stand up for their patient.

In the discredited methodology (so says my brother) that is the Myers-Briggs Personality Inventory it is believed that we all have a type, or, typology – this relates to our internal preferences; how we behave when all things are equal, when the sea is calm.

For me this is (I think), generally, good humoured, smiling, relaxed, attentive.

When the pressure is increased to a certain level, we can enter the grip. This is when we can behave in ways that are counter to our usual preferences; the quiet guy shouts, the woman obsessed with detail makes rash and sweeping assessments, the emotional soul becomes a tyrant.

I don’t know whether the grip is or is not a thing (Nigel), nevertheless, it is something yesterday I felt raw in tooth and claw.

I have touched on this before when considering arses.

Yes, I was an arse on this occasion.

The episode did not last long, no one suffered long-term harm and I am almost recovered (this blog part of my expiation).

How do we however manage to reconcile the inevitable pressures encountered by mostly loving, caring, sensitive people who are let-loose in hot-house pressure-cooker hospitals, now and into the winter…

20 breeches in A&E

12 patients on trolleys

Delayed discharges




Ambulances queuing

No beds

How do we support our staff and our patients, how do we ensure that the grip doesn’t become a permanent state, the norm? After all, it does no one any good.

In the grip, otherwise known as extreme stress, humans stop thinking logically, we revert to our primitive norms – more likely to bite than lick, shout than smile. (This is almonds and emotions).

Organisations (that is, hospitals) have a responsibility to care for their staff to allow them escape-valves, the possibility to let loose, to unburden. How often is the response to pressure to add more pressure, to turn-up the voltage?

We forget the fragility of our lives.

When I walk around the ward seeking patients with ‘frailty’ (this a whole clinical syndrome that is a thing* of the moment), I often forget the frailty or the fragility of those providing the care, the system and almost always myself.

dog with stookie.JPG

*Link to the British Geriatric Society who won’t publish any of my blogs 😦

pressure2-1 sage barnes guyr hepner.jpg

Comments/feedback/like/dislikes welcomed!

It’s not just old people, geriatrics, tzokrochen…



Talking over Sadie as she is trolleyed to CT.

Food left untouched.


3am transfer.


drip tissued.




Inadequate anaesthetic.


Waiting for nurse.

Fear of asking for nurse.

Fear of fear of asking for nurse.

Fear of nausea.



Bed-bath, bed wash.

Commode. Grey pulp receptacle.



I can hear what they are saying about her, what about me?


They don’t understand.



Aged. Sterile. Forgotten.



Cracked, dirty doors, dusty windows.

Swollen, infected limb. No one is interested any more.

Not our patient.

Not my problem.

Why would anyone do that?



Neck at an awkward angle.


The shape of the pan has indented on my bottom.




Sharp, blunt, unfocused.




Pseudomembranes and toxic stimuli;

Reek of wound spoiled.


Home today.





Cardiac arrest.

Broken-bone chest compression.


90-year-old woman.


Skin and bone.

Cracked ribs.


Forced into dance macabre.

I must do this harm

As the harm



I tear your skin,



Pale, pink.


Saturations too low.



Icy fingers




Angry relatives echoing.



But, what about?


A constant buzz,

Echoing forever.


The touch

Of nine-volt battery on your tongue.








When you are dead and gone,

We will remember.

Whilst you are here, we will forget.


I am a very senior, experienced, boss.

A guru of gurus.


If only they’d had me at Stalingrad.

If only.

I am the panacea,

The elixir



The words

That drop from my lips are













And sad

And forgotten.

sane dream.jpg

The Mandala has a serpent at the centre – the everlasting pursuit of meaning; chasing its tail it spins round, infinitely, echoing the present. Fixed. The hungry demons express their frustration through red-rage, the onlookers cower, the ma and pa retreat to the shadows. Who can tell where, when or how?


Geriatric bundle

I want to make you old and dependent.

Today, at a meeting* we were discussing some of the not so good things that happen to older people during their transition from person to patient.

Very little has to change existentially for this shift to occur; occasionally the happening will be significant – broken hip, heart attack, cancer; at other times the transition can be more trivial – a trip, confusion or flare of arthritis.

The possibilities are endless.

Infected toe/diarrhoea/constipation/breathlessness/disorientation////you get it…

How though, do you take someone, perfectly fit, independent and well and make them into something else? How do you diminish their essence? Marginalise their autonomy?

The NHS has a tried and tested technique; it is called hospitalisation.

If you like, you can purchase a bundle. This, in safety culture is a compressed list of instructions, tools or equipment; all you need, to do what you have to do.

Here it is:

  • Take away the person’s name; Rod Kersh becomes the old guy in bed 17.
  • Change the individual into a disease; the guy in bed 17 with a fever.
  • Lose Rod’s glasses, dentures and hearing aids.
  • Take away his leg bag and replace with hourly urometer (that should keep him tethered.)
  • Dress Rod in outmoded pyjamas or
  • If 5) is not possible, use hospital pyjamas, or,
  • For extra effect use hospital gown (preferably open at the back).
  • Provide sippy-cup for hydration
  • Remove pants and trousers and replace with adult nappy aka continence aid
  • Wrongly time medicines for Parkinson’s disease / write ‘not available’ next to the Madopar/Selegeline/Ropinorole
  • Ensure the difficult to manipulate nurse call alert is out of reach of Rod as his delirium increases
  • Make noise (ideally at three in the morning)
  • Turn lights on then off;
  • Move beds or wards at four in the morning – this is the perfect witching hour for disorientation.

And, there you have it.

Few are able to resist this process; the shift of day to night, the evaporation of autonomy.

Not quite the mixture required for baking a cake, more, the concatenation of circumstance that is today or tomorrow in the NHS.


*Thank you Adnan for the inspiration!


The sound of the cistern is scary.

The scary cistern;



Are calling me.



The immortal


is listening.


As I breathe

AS I sneak a peak

At the adults

Playing Kalookie.


I remember

Harry Dawn,

Red-cheeked neighbour

Walking, Saturday to shul.


There he died.

His daughter

Now living

In Bermuda.


These are



Of the 70’s.



Brought into focus

By Rami Malek

As Freddie Mercury.



Queen ballads

Waltzing though my



Harry’s wife, Betty,

Exponent of Yoga

Would smoke

One Lambert & Butler after another.*


And their house

The smell

Of the era,

Embrocated with pink stuffiness.



a reticulate mess




*God only knows what they did behind locked doors.










On their phones

Society hasn’t had time to adapt to the phenomenon of

‘on their phones’

This is something I have only ever heard


By the over 30’s.

The older people become, the more this is seen as a

bad thing

Until, perhaps, folk reach their 70’s and if they have their own phones,

The antagonism diminishes.

The middle-agers don’t get it.

They haven’t come to terms with the reality of a phone – what it means,

How it integrates with the lives of younger people.

When I was young, I dreamed of this technology –

Star Trek tricorder kind of thing.

I was never particularly interested in talking,

More the ability to scan, analyse, determine.

Amongst my friends I was one of the first to get a mobile;

It was a Nokia.

Solid, tempered plastic.

They used to call me – or, perhaps it, ‘nomad’ as this was the rationale for the purchase,

at that time, I didn’t have a fixed base (I was a locum sometime in the late 90’s).

I remember, as a teenager on the bus to school imagining podcasts. Then as now, I would sit quietly, then as now, I saw the facility of time in-between; the gaps between doing.

Some translate this into Mindfulness – be with the body; empty the mind of thoughts, good and bad and settle the turbulence that is life.

I always wanted to learn or hear more.

When Podcasts and audio books arrived, and, I could listen through my car or phone, a new world was opened.

No longer repeated drilling hourly new bulletins, now I could escape to the country!

And, phones are mostly no longer games.

Phones are links to connection, communication, learning and development.

That young person on their phone might be connecting with a world beyond your understanding. They might be answering the question that will make all the difference.

If you want to pick on someone, go after the light-entertainment bods.

Information flow is multidimensional. Knowledge and understanding are gained through more media today than ever before.

It is all too easy to knock the youth.

Those Angry Young Men, one day they’ll learn, they will eventually see the light and become more like me – they will die a little inside; the Faustian contract; slowly, gently, you are eroded.

I say, encourage the phones.

I say, get over it.

Would Einstein be on his phone during a moment of down-time in the patent office?




In statistical terms, an outlier is someone or thing that stands-out from the anticipated range of data or results.

Existing beyond the constraints of a normal distribution for the individual can be awkward – for scientists it can be the basis of a career.

Luria, in his 1967 book, The Mind of the Mnemonist, A.R.Luria described the experiences of S, a man who was unable to forget.

Big or small, fast or slow, aberrations fill the world of natural history making museums, films and narratives interesting.

In the more mundane reality of 21st Century hospital care, an outlier is someone who is unwell enough to be in hospital but not adequately sick – (or fortunate) to be treated or cared-for in the ward or department of the relevant specialty. These people by and large, exist as second-class citizens, frequently receiving sub-optimal care, treatment and attention; I will elaborate shortly; first an illustrative example:

Muhammad, 91 is admitted to hospital with shortness of breath. He receives the best assessment, investigation and treatment available to Medicine; blood tests, x-rays, the appropriate antibiotics are prescribed for his pneumonia and he is seen within five hours of arriving in hospital by a specialist. Everything is hunky-dory.

Three days later Muhammad is significantly better – no longer dependent on high-flow oxygen; his nebulisers continue and, antibiotics have been switched from intravenous to tablet.

Three in the morning and the hospital runs-out of beds. There is a crisis. Depending on the system or organisation this be – a red, purple or black alert …too many patients are seeking admission for the numbers of beds. (Think ‘the ship cannae take it captain!’ In Star-Trekian).

The norm is for the majority of these additional patients to be both older and experiencing medical causes of ill health – that is, infection, falls, confusion, clots and non-specific pain (although not in the tummy as the surgeons get that).

The pressure builds, beds are needed, and those patients no longer deemed ‘sick’ are stepped-down to non-medical beds; the precious resources of a respiratory ward are required. Muhammad is transferred from chest ward to elective surgery – these are beds that are kept aside to bring-in patients schedule for cancer or other operations.

Muhammad, in the morning wakes and finds that the people surrounding him are no longer ‘medical’ – but, ‘surgical’ – more often attached to drips, drains and other systems of bodily measurement; the ward-rounds are swifter and the nurses more focused.

Mo (let’s call him that), is now a medical outlier – a medical patient on a surgical ward; an unintentional interloper. Not one of us, the body-language says.

Often, such patients are highlighted in a different colour – ‘Mr M A – medical outlier’ – not gall bladder, appendix or spleen; other. The nurses are familiar with the treatment, but the interaction is somehow different – Mo’s measurements are medical not surgical, his pathway not along lines established by mister, but, doctor.

And Dr A, the enthusiastic consultant, after completing his ward round of base ward patients i.e. medical patients on a medical ward will trudge over to surgery to see the outliers. Those additional to surplus, representatives of a failed system, and perhaps just before lunchtime say hello to Mo; tired, the consultant is perhaps a little less attentive – Mo is his 30th patient of the day, after all. And fin.

Medical patients on outlying surgical or orthopaedic wards experience prolonged lengths of stay, they are exposed to greater risk and have a higher chance of deterioration than those supported on medical wards. 1, 2,3 & 4

The solution?

Different places have created different solutions.

In the NHS, the answer would be funding more physicians – ideally geriatricians like me, for the population of the olders is growing at a faster rate than any other. But, no, this isn’t the planning. We stumble-on, slow iterations taking us from here to there.

My mum was once a medical outlier on a surgical ward. It didn’t work for her.

What do you do if you or your mum, dad, sister or brother find themselves outliers, outsiders, strangers in a strange – strange land?

I guess in part, this blog might help – awareness of the problem is part of the solution; realisation that extra care and attention is needed to avoid a secondary experience; beyond this, find those hospitals that invest in quality improvement and innovation, organisations that heed the warning-signs and seek to do better, differently.

Look for a hospital that is person-centred – one where you, or Mo are seen as people not numbers, statistics or disease-codes. And, if you find yourself in a situation where those providing the treatment or care are less informed, perhaps call them out, ask them why, what, how, who; explore their values and motivations.

And get home as fast as you can.

  1. Alameda, César, and Carmen Suárez. “Clinical outcomes in medical outliers admitted to hospital with heart failure.” European journal of internal medicine 20.8 (2009): 764-767.
  2. Santamaria, John D., et al. “Do outlier inpatients experience more emergency calls in hospital? An observational cohort study.” Med J Aust 200.1 (2014): 45-8.
  3. Serafini, Francesco, et al. “Outlier admissions of medical patients: prognostic implications of outlying patients. The experience of the Hospital of Mestre.” Italian Journal of Medicine 9.3 (2015): 299-302.
  4. Stylianou N, Fackrell R, Vasilakis C Are medical outliers associated with worse patient outcomes? A retrospective study within a regional NHS hospital using routine data BMJ Open 2017;7:e015676. doi: 10.1136/bmjopen-2016-015676

What affected me most today?

It is hard to quantify

the significant moments of my day.


I know Each is the same.


We all live lives of stunning colour,


w/ vivid, experience.


For me,

Here is the list:


The early morning welcome of companion, dog-friend, Maisie.

We walk;

Successful avoidance of barking dogs (Alsatian and Rottweiler).


Doris Kearns Goodwin

In the car; currently Franklyn Roosevelt –

Polio paralysis,

rural health camp

and extra-corporeal, leadership morphosis;


At work, events flowed from tearfulness

to cheery handover

and sadness at realisation;



Everything pushed aside

by smile of an old lady,

first fall

then second

then third;

Everyone home, via the CT scanner.


Lying and standing blood pressure –

Would anyone

Expect anything less?


One woman,



Care and provision



Benefiting little from our technological age;


Within a day,

Or two,

She will be dead.


A light extinguished,

Beyond Apple

or Samsung.


In the middle, a smiling

Beautiful encounter


person in her 90’s. (93).


No longer falling,

But benefiting from attention.


I ask her

And her daughter

To rate me.

On a scale of 1 to 10.


One, I am the worst, 10 the best.



Soon after, I am off,

To another assessment,

An evaluation of what I have done,

What I am doing


What I will do.


The day is broken-up

By phone calls

With funeral directors;


Men and women

Doing their best

To ensure

A dignified (timely)

Next step.


Day ends with

Spaghetti Bolognese.







My children amazed

At my inability to take aim,

To shoot;

Likely a reflection

Of my chances in life overall.


I am better-off

Where I am;

Laloux, Proulx and Kafka, Singer, Goleman and Blake,

Fortresses protecting me;

Mantel, Zweig and Nabokov,

Here I come.



I remember the first time I visited Jerusalem.

We entered via the Jaffa gate, my brother and me.

He had some business related to psychology, I was just tagging-along.

Eged bus, then foot.

The spices more a phenomenon than the last time I went.

Zaatar. Which is hyssop sprinkled on just-cooked bread.

At the time I had no sense of the past or the future, I merely existed within a bubble of Greek and Ethiopian Orthodoxy, Via Dolorosa and the Western Wall. I only visited the Dome of the Rock later.

Cold, yellow stone and smooth cobbles.

Just-slaughtered chickens hanging in the early morning.

Dust and smoke and antiquity.



In the past week I have discussed the term imposter syndrome on three separate occasions; I haven’t actually been the focus of the discussion although I am sure I am equally susceptible to the phenomenon.

Well, it is self-evident what it’s about; imposter – suggesting that someone or something is pretending to be who or what they aren’t and, syndrome, that this is in some way a pathology, i.e. the self-belief in an individual’s lack of credibility is wrong/diseased/erroneous.

You could call it self-doubt.

Everyone, or at least anyone bearable has some level of self-doubt.

Whether they have won a Nobel Prize, finished washing the dishes or changed a nappy, it is inherent in the human condition that we will imagine ourselves to have achieved a goal or arrived at a result through less than consistently transparent or reproducible means.

This leads me to think about relativity.

I have stopped saying it (mostly), although I very often used to say something like, ‘I can’t do maths,’ or ‘I don’t understand numbers,’ with the intended message being that I am not a natural mathematician although when it comes down to it I can count and I can add-up bills and accounts and so on.

It is a relative thing.

I do do empathic, person-centred; that is my forte, I don’t have to try, I don’t find that working in this way is tiring, indeed, it is in many ways self-sustaining – I get such a buzz out of connecting with others this way I could probably keep chugging along indefinitely – like a perpetual motion machine, whereas with numbers (chess is another example), or perhaps when I inhabit an extravert role, my batteries drain and unless there is some place for me to escape (bed/isolation/book) I will crash.

So, I think the imposter things has elements of this although there is more.

I personally hate talking about any successes I have achieved; others don’t seem to have a problem. I suspect this relates in some way to ego – whether big or small.

I was talking with a colleague this week about awards – ‘The year’s finest’ or whatever – awarded to schools, wines, sweets, budget supermarkets and anything else you might care to consider.

How much of this has to do with entering the selection process; having the capacity to enter the race automatically raises your chances of winning; if you are too busy creating the best chocolate cake ever, will you have the time or even energy left over to fill-out application forms that ask for 1000 word descriptors of where you shine and where you don’t.

There you have it… I am the world’s best X, I won the award for most accomplished Y.

I could ride the wave of success, for that year and maintain the momentum as far and as long as possible or I could think more broadly, consider that perhaps this is just a step in the right direction.

Who knows?

Would it help or address self-doubt and collapse into the imposter scenario?

Anyone’s guess.

Is the syndrome harmful? Well, probably if it keeps you awake at night worrying, or sends you into a downward spiral of second-guessing and doubt.

Are awards harmful? Probably not unless you start to believe your own press and the publicity and actually see that you are somehow elevated; evolution doesn’t tend to stand still and what was once the best, the greatest, the most… whatever, is soon superseded, overtaken by youth, innovation or necessity.

I think therefore I am.

I pretend therefore I am, sort of, or, at least I might become.

Once I was.

One day I will be.

Most things are finite and eventually end; others go on forever.


PS featured image is not intentionally representative of my brother.

In the midst of Goya’s black paintings

I fell

In love

With the image of the goat

And the



In a circle

Reminiscent of

The Dybbuk,

The Devil

Casting shadows,




Encasing –



The peasants


Passive in their observation,

Crooked fantasy;

Rosemary’s baby,



Ira Levin



Can’t not think of Woody Allen.


Who is the bovid now?



“Into a soul absolutely free from thoughts and emotion, even the tiger finds no room to insert its fierce claws.”

You can interpret this as you like.

Today, I will take it like this…

You could be perfect; a flower, a petal, a sunrise – everything in its allocated position, like soldiers lined-up for report. Sound-off, one, two. Every dimension, angle, line, is square, every fringe precise. Nothing asunder.

And from this exactness, this geometric simplicity, arises, what?

A standardised pattern of yesterday; the same tomorrow and again, and more so.

It is the imperfection that creates the beauty,

That stimulates growth and novelty.

My curse is my blessing; my impairment my essence.

Though I walk through the placid territories, it is the verisimilitude of turbulence that makes me and makes me over again.

Until I rest and regain my strength and aspire to something better.


Agus dei

A moment in Madrid






Jesuitical monk

Prayer gown\



I stand in the sunshine

And appreciate



As it falls onto my skin


Sparrows are listening


An old man drops

A wrapper


Dyed black hair

Scraped backwards,


In the artificial light



Old handguns,

Worn handles.


Disfigured man – melted skin,

Sits begging on street corner



Where people

Fascinated by phones

Caress blank screens

And the machines


Tethered by flexi-cable to temperamental alarms.


The ambulance sirens

Day and



arrival and departure;


A friendly waiter gestures to our choice


Disbelieving the request.


Wine is drunk by the glass

Then the bottle




The music is a blend

Of gypsy,





I catch the eye


A woman.

She rushes to request money;

I gesture to my empty pockets

And she acknowledges the hollowness of my action.


The siren

Reminds me of the Bourne movies

As Jason

Travels across Europe

Evading police, army and secret service.


Something wintry about the memory

That seems

Appropriate for now.


In every direction

People are talking

Some smiling

Others are nodding in earnest.


I am silent



In a time before

The electronic revolution


The car

The wireless

The electric spark

When speed of horse

Was the fastest you could travel,

Everything was different;

The humdrum




What disconcerted then?


Care home home

When I was in my middle-teens I used to visit my grandfather in his care home. I don’t remember if I used to call it nursing, residential or care, mostly it would be ‘Newark Lodge’ which was the Jewish Old Age home in the South Side of Glasgow.

It was an old sandstone building in the affluent part of Pollokshields with a modern red-brick annexe. My friend Heather lived around the corner.

As a postman, delivering copies of the BMJ, Newsweek and Time to various addresses nearby (the Gorbals too, but that is another memory), I dreamed of one day living there; not a care home, rather, a big Victorian sandstone.

My grandfather lived in his /I will call it care home from now, although in the 90’s the term ‘old age home’ was likely more familiar/ for over ten years, from his return from Israel in the 80’s up until his death during my first year after qualifying as a doctor in 1998.

Most people nowadays don’t live as long in care. I believe latest estimates suggest 5 years for residential and one for nursing. Any longer and the health economists are perturbed.

My grandfather’s room (also, from now-on, I’ll give him is proper name, Papa), was on the third, which was the top floor of the new section. We used to get a lift up and down together, although in those days I was fit enough to run up and down the stairs without effort;

He had a room, a bed, chair and view of Maxwell park.

Papa used to take a daily walk round the grounds, either before or after his visit to the bookies (Ladbrokes on Shields Road).

I remember the expression on my mum’s face if anyone ever referred to the place as Papa’s ‘home’ – she would correct, it is a residential home, not his home, the latter being a reference to the place we lived, where he no longer lived for reasons that I will one day describe.

Most Saturdays my routine would be to either cycle, walk or catch the train and spend a couple of hours with him. We would talk about all sorts, often focusing on latest family gossip or news or titbits from my life – exams, thoughts, ideas.

As I mentioned, Papa died in 1998 – I am not 100 per cent sure of the date, at the time I was working in Magherafelt in Northern Ireland; I had to fly home for his funeral.

It is funny how fragmentary memories, shattered in time return, drip by drop; he used to make me a cup of tea from the kettle in his room and with this I would receive one or two Rich-Tea biscuits from a tin; one of those tubs with a special desiccant in the lid.

Sometimes in the summer, after he would sit in the sun for hour after hour, he would fetch me a glass of juice.

He wouldn’t let me go into the nursing section, the place where the people with what I imagine to be dementia were housed; how ironic.

In the lift I remember old ladies with sickly perfume, thick red lipstick smeared over cracked lips. A smell of urine.

I suppose he had a healthy old age, up until the end.

And, how interesting that so many people are now are housed within homes for the elderly. As described, we call them care homes, with the emphasis being on care. We Care, a common motto for all forms of health and social support.

But, do people care? Is caring not now an overused word? It is like so many aspects of modern life, another shortcut to thinking; the way we rationalise the experiences of older people who can no longer live independently or with support in their own homes.

Warehousing geriatrics.

I am perhaps too caught-up in my current re-reading of Barbara Robb’s Sans Everything – the 1960’s work describing the horrific conditions inside geriatric wards in mental hospitals in the UK. Sure, they were likely the minority, but there is a worrying essence which I believe is still present today in some care environments.

Every decade or so we are shocked to see undercover filming of residential facilities for people with learning disabilities or dementia; at these times we reflect on the darker sides of humanity.

Papa I think was always treated with care, dignity and respect. I think he would have said if not.

And people are sometimes surprised at my extreme reaction to lack of care; to situations where a patient is in distress; is wet, is cold, needing the toilet and around them people are rushing not noticing.

Every time this happens, I am transported back, not physically, but in feeling, to standing beside my Papa and later my mum in their hours of need.

How is it that others don’t see it this way?

I know that the phenomenon of compassion fatigue is real; it is a blemish, or rather, a tarnish on the conditions we force staff to experience as they day in and out struggle to provide care; there it is again, that word, that distillation of the interaction between two people, one more vulnerable or in need of support than the other.

It doesn’t matter your viewpoint.

Whether care, home or hospital.

It is all the frontline of humanity.

It is all people exposed for who and what they are in their moments of vulnerability.

It is the abuse of the system by the avaricious and the impecunious that threatens standards.

The way ahead?

Any thoughts?



I caused a mini flu-scare this week

I didn’t realise the impact of my actions. Well, it wasn’t quite my actions, more my thoughts, followed by a question and the actions of others.

I was called to see a patient; he had a temperature of 38.9, was listless and not his usual self; a little disorientated, he couldn’t pinpoint the cause of his malaise and examining him there was nothing obvious – no symptoms of chestiness, no urinary discomfort; his abdomen was soft, the was no pain; I looked in all the usual places and all I could find was a high temperature and what I call rheumy eyes.

A couple of years ago when there was the last major flu outbreak and the virus was rampaging round the corridors of Mallard Ward, I seemed to have worked-out a fairly reliable diagnostic system – essentially, high temperature and nothing else obvious to find other than rheumy, that is slightly swollen and blood-shot eyes, followed by rapid flu-test and voila; diagnosis.

I thought to myself, ‘Perhaps this is flu…’

I then made the mistake, of thinking out loud;

A swab was obtained from the emergency department, a sample taken, then returned.

The poor nurse who ran from my ward to the emergency room was berated for his lack of gown, face-mask and gloves, ‘How could you come here with that, without taking precautions!’

The sample took a while to process; he came back. We called for the result; ‘Where was the nurse’s face mask? What are you guys playing at?’

I became concerned; had I contributed to the spread of infection? I apologised to the patient, his wife and the nurse; the poor support worker who had just been in to take the m a cup of tea had also been exposed. Where would this end?

I left the room, and returned, checking again on my patient, still without mask.

His wife sat beside the bed, Sudoku opened at the very difficult page, bemused.

The sample was negative.

No flu.

It was funny how people panicked at the consideration of flu. As if you cannot say the ‘F’ word without taking all the precautions.

The thing about medicine is that we are often in the dark, struggling to determine what is the cause of what; we work on the basis of hypotheses, diagnostic sieves and risk stratification, usually starting with the worst possible scenario and working backwards; chest pain > heart attack; only afterwards do we think about indigestion. Most people are content with this approach. Sure, experience tends to make you more confident and able to arrive at the heartburn more quickly, but everyone can be caught-out and over confidence is the inevitable step before a fall.

Before we had near-patient tests the flu thing was shambolic; as with me, merely suggesting the possibility would drive a patient into isolation until the result was returned from an off-site lab; this could take days.

When there is a concept that is readily accessible such as ‘flu’, it sometimes over-rides all other considerations, such as in the case of my patient, the sensible approach… he may have had flu, and if so, he probably had flu before the idea came to me and consequently isolation doesn’t and cannot be instantaneous.

This is not to belittle the importance of the infection; when you write ‘influenza’ on a death certificate it brings things into focus.

How readily we jump down these escape-routes, these shortcuts in thinking many of which bypass the person and all caring, compassionate and rational thought, as if, the notion of a crisis is more attractive than the mundane reality of virus. Ill-defined and unexciting. And these kill too, only not with the same drama.

The next time someone says, ‘query flu,’ I’d suggest we all, like everything else in life, pause for a few moments, gather our thoughts and proceed sensibly.


To send home or not?

This is one of the hardest questions in healthcare.

The scene:

Patient is unwell, falls, vomits, experiences chest or abdominal pain; they either make their way to the GP who send them to the hospital or, as is most common these days, they take themselves to the A&E department or are brought by ambulance.

They arrive; tabula rasa. A constellation of signs and symptoms.

A nurse or doctor struggles to make sense of the information; drawing-in the story, the observations, examination and test results.

From here there are two outcomes – home, either reassured or perhaps take these antibiotics or pain-killers or, refer onwards.

For most emergency departments in the UK this means contacting the medical team either to route someone down the acute admission or if older, frailty route.

Before this stage is reached there are already a multitude of variable – thoughts, concerns and ideas passing-through the mind of the A&E doctors or nurses.

The symptoms are innocuous – are they really innocent?

Have I missed an important question?

Could the patient deteriorate rapidly?

Is hospital the safest place?

Yesterday in the hospital during the morning with my team I saw 22 patients, this is excluding relatives. I must have asked several hundred questions and made just as many decisions.

At what point is your bandwidth too full?

There was a moment when I was leaning against a wall, surrounded by people, when I felt that was probably it.

Bandwidth is an interesting phenomenon.

It compares human ability, particularly cognitive processing to a broadband or computer cable; you reach a certain volume of data and things can go no faster, indeed, because of congestion, the process slows-down, like rush-hour traffic.

When we were evolving on the African savannah, I doubt believe this was an issue – sure we needed to cope with lots of information, but, you would only be hunting one impala, not an entire herd.

So, the decision-making processes are difficult and the more information, the more interruptions and challenges, either the slower you get or the more you are likely to opt for a tried and tested heuristic.

In the case of the emergency department, you could sit and calculate the odds of a pain being a muscle tear or a clot, or you could assume clot, admit the patient and move-on.

Assuming clot and being wrong is never as bad as not and being wrong – in other words, you send person home and they collapse and die.

The balance or the challenge however is when allowing for more processing ability in your part of the system, the pressure is moved downstream to the mostly young doctors who are juggling themselves with multiple demands, assumptions and challenges.

The jam at Watford is relieved but the M25 overwhelmed to continue the motorway analogy.

When I see a patient, my first goal is to determine what is happening; or actually, for me at least, it is to do my best to gather the information, have a rough idea where things are heading, put the patient and often their family at ease and plan the next steps;

Again, here as with A&E the situation is similar – keep-in treat or investigate, or, send home, treat or investigate as an outpatient; not that difficult. Yet, here a second-wave of complexity begins.

By the time a patient has reached me they have passed through another layer; more symptoms have been elicited, more blood results, data and information accumulated. In some respects, this is useful, but equally it thickens the soup and makes any next steps more challenging.

And here I am at an advantage as having spent a proportion of my time working, engaging and talking with the services and care providers who operate outside the hospital system, I have a good understanding of who is safe to be at home, particularly if you are old, frail or vulnerable.

From my years examining complaints and incidents I have insight into the potential harmful aspects of hospitalisation often in older people; I therefore have a relatively high threshold for keeping people in.

This however adds inertia to my creaking cognitive processes; if we do this, and that, and that and Nora can do that and that and this, then… Lots of logic functions that result in avoidance of harm and maintenance of wellbeing.

It is not easy.

It is funny however when people consider the fevered hospital atmosphere where cries of ‘discharge!’ often ring-out on Monday afternoon as the system like the mind of the poor doctor or nurse is sludging-up, a fat-ball of actions and risk mitigation.

It might sound dull, yet, I revert to something I have been discussing for a long-long time.

Let’s put all our energy into supporting the decision-making processes up-front, augment the teams who can determine what is happening and how best to help (sometimes called doctors, nurses, therapists, pharmacists and in particularly special conditions, trusted assessors.)

Hospital admission is easy; you just have to worry or overwhelm the relevant doctor or practitioner with enough red-flag symptoms for their resolve to falter. If we can match this with an acknowledgment of the challenges of the work, we might get somewhere.

When I decide home or stay, the pressure can be significant. Nothing however is achieved by operating at a level of intensity beyond my ability.

I don’t have an answer to this; I think if there was more capacity (up front), perhaps more dignified time to slow-down a little, we might make better decisions that would lead to improved outcomes for patients and staff. (Thanks, four-hour wait).

I was talking with a wonderful young doctor yesterday about the pros and cons of sending people home; my mantra, now I am getting old, being, if you are going to be left in doubt, if you might not sleep that night because of worry, don’t do it.

The more experience I have gained, the more I have avoided these perilous situations which save me and likely my patients risk and grief. It is all to do with how confident you feel standing on the edge.

Perhaps my suggestion is to stand on the very brink, on tippy-toes, yet feel safe with whatever safety-net or harness is available.

Collective decision making (led by someone who is willing to take responsibility) is the ideal way forwards.

Stay or go?

‘Go and come back if you aren’t right or you are worried.’

Safety net.

‘I am human, I sometimes make fail, regard me thus and we will be OK.’





I don’t know how it goes in education; I imagine that social services are similar to health. It has been this way for a very long time and it continues today.

What I am discussing is the role of inspection in the maintenance of quality.

Below is an excerpt from the book ‘Sans Everything’ by Barbara Robb which I described previously.

It was written in 1965:

sans everything.JPG

To me, what this means is that the role of inspectors in public services, in the UK at least are to maintain standards to a certain level. I’ll explain what I mean.

Today as in the 60’s if the inspectors are coming, there is advance notice. For hospitals, clinics, care homes and GP surgeries, the inspector is the CQC – the Care Quality Commission.

The CQC has multiple teams of inspectors who visit care facilities across the country; inspect books, records, talk with staff, patients or care home residents.

This all sounds great. And, to an extent it is.

Yet, as described above, rarely do the inspectors just pop-in. They aren’t patients or staff of the organisations monitored (although they are all patients and staff within the NHS). And, here is the challenge.

Life is never great all the time, and care, although for the vast majority – in the UK at the very least, is very, very good, it sometimes fails.

It is usually the failures that are noticed by those working in the organisations. The staffing short-falls, the inadequate equipment, capacity and so on.

Now, are these issues important?

Yes. Certainly, to the individual staff member or the patient affected, but, on a larger scheme, not necessarily.

There are truly awful things – called never events in healthcare – where error is always inexcusable; an example being a patient receiving 10 times the dose of a medicine – 100 units of insulin instead of 10, which leads to coma or some other harm. That can never be acceptable or justified.

The events that don’t trigger this threshold are however ten or a hundred-times more common and in general don’t lead to permanent harm and are often unsystematic – moving staff from ward to ward, moving patient from ward to ward, not washing hands, illegibility of handwriting, incomplete tasks, delays in medicines, falls in older people during their time in hospital; the list is very long – possibly limitless (cf the 20 or so never events).

It is this latter group that the inspectors cannot address.

They can check that plans and processes are in place to ensure there is adequate learning and improvement, they can even gather evidence that things aren’t quite right, but this data doesn’t often go very far.

‘Would you be a patient on your own ward?’ is an incredibly salient question with high sensitivity. A negative answer suggesting that the care patients receive is less than you would expect, were you in their place.

And, the thing with humans, is that we are heavily influenced by the type of question and who is asking and when.

Most of us want to portray a façade of competence.

‘Would you be?’ ‘Yes, definitely.’

It depends who is asking – a trusted colleague or an inspector who might report their findings to your boss.

Inspection does not engender a feeling of trust; even when you have little trust in the people in your organisation responsible for your welfare, better usually, the devil you know.

So, if inspectors are not there to smooth over the cracks, what is their purpose?

As I have said, a certain aspect is to audit; look through the records, check processes, ensure that plans are in place. What happens if a patient is harmed? What happens if a member of staff is overly stressed? How do you cope with increasing or unanticipated demands?

Most of this is predictable and this I believe is part of the role of the regulator – to ensure that these plans are in place and to then offer assurance to the public (and health ministers) that everything is OK or if not OK, can be improved.

This is the reason for the advance notice; to allow organisations to get themselves in line, to oil the rusty hinges, to get everyone to a showcase standard.

Those places who can’t or won’t do the necessary – organise committees, polish the silver, brief their staff, are likely those which are in such a state of chaos that the inspector needs to intervene. If you can’t get your act together with a month’s notice, you have a problem.

I don’t know if this explains it;

Inspectors are there to give people an aspirational goal, if they are in a position to achieve excellence; if not, they at least give you time to wash, hang-up and air your laundry.

They are not a panacea.

In some respects, this suggests that their role is less than some might anticipate, i.e. to make everything well.

And I believe that to be the case.

We are humans after all.

We have fragile egos that can be challenged.

‘Are you proud of your organisation?’ Is a little like, ‘Are you proud of yourself, of the work you have done, of the efforts of your colleagues?’

Again, it depends who is asking the question and how.

How then to create change?

This is a different question.

If you are lucky and a visionary leadership team of engaged, enlightened, creative executives descend upon your organisation, practice or care home, you are sitting pretty; sit back, join in, and get going.

If like most people, that team, those leaders are ordinary people like everyone else they will not necessarily succeed without great effort, luck and engagement.

As with a quote I posted on social media yesterday, leaders don’t tell you where to go, they ask you to come with them. They are embedded in the trenches, they taste the same bitter or sour or salty water; they understand the hardships the precarious situations people encounter daily.

They aren’t on the mountaintops, they are in the valleys.

Here is a memory of a leader I used to know: (you can also see it here)


My old headmaster Moshe


Moshe Ganz, sweeping the leaves,


ankle-high in flood-water,


Kippah hanging from thinning hair.


Wry smile,

Ginger moustache

and freckles.


On Fridays and other occasions

he would get-out his accordion

and play



I remember his expression – ‘yofi’


punch on the shoulder.


All these,

components of leadership,

brought back to me this evening

listening to

John Williams.


Can’t = won’t

My brother noticed a post-it in my office the other day; here it is, cropped and enlarged:

cant and wont

I learned this aphorism many years ago from one of my friends who had just completed an officer’s training course in the Israeli Army.

Suffice it to say, whatever they do to those not-quite teenagers takes them to the limit; too fast, too far, too little sleep, that kind of thing.

Every military does it;

The philosophy – it isn’t that I cannot hold my breath, cope with the cold, the heat, the pain, it is that I will not. I control my experience. I am the captain of my…

These ideas came to me recently when trying to unravel some complicated processes that affect the way people work. We do this that way, we do that, this way, it is so and it has always been.

Let’s do it like this!

We can’t.

It is the same as saying, don’t.

Or, I won’t entertain that altered perspective, that variation in perception.

We do things this way because we have and once, once, when someone did it differently it didn’t work. Fail once, give-up.

That is a self-defeating mantra.

That is what caught-out the Neanderthal’s.

‘We are starving; let’s try vegetables,’

‘The last time it upset my tummy,’ and, the rest is history.

Tolerance of failure is part of this. Do it this way, encounter an obstacle, turn 34 degrees and try again, and again, don’t take adversity personally.

Keep going;

‘I can’t’

No. You choose not to.

Anything is possible.

My brother when teaching classes in Karate used to tell his pupils: ‘Whether you say you can or you can’t you’re right.’

This, the same philosophy flows through.

We are limited by our imagination.

Just as we create our reality.

Heaven or hell are from within.

Sure, if life is shit, life is shit, but, you don’t have to necessarily perceive it one way or another.

There is always tomorrow, a new beginning.

‘Can you walk?’

‘I will keep trying.’

Accepting defeat is embracing failure.

Fall down seven times, get up eight.

Zen and Stoic philosophy coalesce into a sense of being.

Do, do, do!


My medical record…

I still haven’t accepted the standard of not writing clinic or outpatient letters to patients, or at the very least copying them into the correspondence.

e.g. Dear Mr J,

Thank you for attending my clinic this afternoon. It was a pleasure to meet you and…

Here is an example:

Dear Dr Mulberry

I saw your patient, Mr K in my clinic this morning. He attended with his wife Morag and daughter.

Mr K described a three-week history of non-specific dizziness.

He has a history of asthma, diabetes and hypertension.

You can imagine the rest.

It would end,

Yours sincerely,

Dr Z(ygmunt)


This is all formulaic and a little like the heuristics I have described before. The short-cuts that allow productivity but detract from effectiveness. Don’t think, feel. Or, don’t even feel, just treadmill.

There is a problem.

It is called type 1 and 2 thinking.

It is about modes of cognition.

Mindfulness versus unconsciousness (Consciousnessless?).

Doing what is right and doing what gets you from A to B.

Most of us, when conditions are optimal will opt for doing what is right. Driving at 60mph, eating wholemeal, switching the TV off at the wall. Yet, how often are we here?

The NHS is a good example.

Take, an intensive care unit with 10 beds (sorry to pick on the Intensivists) – an 11th patient arrives in A&E, critically ill, requiring support for airway, heart and kidneys.

You cannot accommodate more. You need to find an ITU bed someplace else.

That’s it. Finite. (Zero sum). There might be difficulty leading up to the transfer, which, in itself can be fraught, but tomorrow things settle-down.

This is not the situation when more is added to more and units and facilities are created to accommodate extra and, as with last winter, even corridors outside A&E departments act as temporary holding bays and the nurses rostered to care for eight are responsible for 16 and the number keeps growing.

You cannot meaningfully do what is right all the time, every time. If you do, nothing will happen; you rely on fast-thinking, shortcuts, diverts and make-dos.


Unconscious performance allows you to get the job done. You cannot be mindful amidst chaos.

Going back to my clinic letter; better to be mindful?

Better to consider that the only way to ensure you have the correct information is to involve the patient and their family in the correspondence, to not act in loco parentis, but in collaboration. Equals.

This is OK when the weather is calm. Take that clinic and double the demand; increase the numbers two, three times and the system starts to break-down.

Mindfulness and person-centred care have been a feature of this blog since its inception.

See here if you don’t believe me 🙂

Doing what is right, in the moment, for people not patients, stripping away the pretence; ripping a page out of the Catcher in the Rye. There is a time and a place for everything; there just is not necessarily the space or the capacity.

What do you do when there is ample time, adequate capacity and still people take the shortcut? That, I do not know.

All I can demonstrate is my sense of the way.

Mindfully engaging with a patient and their family is talking slowly. It is listening. It is sensing and hearing, intuiting what is not said and not considered, it is accommodating the in-between – rate of breathing, level of engagement, scent, movement, pause.

Person-centred is not using widget after widget for different shapes and sizes; it is made-to-measure, you flex and stretch to the dimensions of the challenge.

It is openness.



In the beginning was the word and the Word was God.

You can’t have that form of obfuscation when interacting one on one with humanity.

You have to strip away; cleanse; make do and mend.

Homo sapiens; we think.

We are more than thinkers; we are listeners; tinkerers.

If we listen, we are.



Can you kidnap your mum or dad?

I guess kidnap is not the best word when you are talking about your parents, although, I am sure you get the idea.

Remove without permission.

Take away.

Here is the scenario. It is made-up. A fiction that could easily happen somewhere in the UK, today.

Norma is 95. She was born in Cambuslang. Grew-up in Pretoria. Worked as a seamstress and short-order chef. Has a husband Gareth and two children Tom and Elaine;

Norma has silvery grey hair. She is sprightly with a ready smile.

She has her own teeth.

She also has dementia. Or frailty, or, multi-morbidity – whatever you can imagine in the context of health and social care needs coalescing into complexity.

In June she fell, was admitted to the local hospital and since then has remained an inpatient.

I won’t describe the minutiae; the complications and complexities – delirium, falls, broken hip, sepsis, recovery, dehydration, weight loss; on and on it goes. There are infinite possibilities.

Summer passes; she moves from ward A to B to C. Medicine to Orthopaedics to Rehabilitation; she moves to another part of the system and waits.

And waits.

Delays with social care (Yes, Mrs May, you might have fooled some people, but robbing money from the council is actually taking from healthcare), and, she waits.

Norma’s mobility improves, then deteriorates. The process of hospitalisation alters her sense of self, it modulates the moment, twists and turns the possibilities of being.

Social delays. Transfers of care. Discharge to assess. Delayed transfers of care. Pathway this and protocol that. It is an impersonal affair.

Norma is going nowhere.

Five months later.

Norma’s bungalow is sitting empty. Dust gathers on the kitchen-tops.

It is going on and on forever.

96th birthday comes and goes.

You, The Number one Son have an idea.

Your understanding of the machinations of health and social care, your knowledge of processes, pathways, contracts and obligations, leads you to this point:

‘Let’s kidnap mum.’

‘We can pretend to be taking her out for a cup of coffee and instead hold-on to her for a few hours, maybe even overnight.’

‘We can do it; short-term pain for longer-term…’

The idea…

We hold-on to mum, then, deliver her to A&E.

Bed-pressures being what they are, they will give-up her bed after a few hours; she’ll be squeezed out the system at one end and we can take advantage of the other; they will sort her out with some carers (the power of the four-hour wait), A&E, the assessment unit and, Bob’s your uncle, she’ll be home. The long-wait will be over. Fin.

Sure, there will be issues of safeguarding, council rules and regulations; we can run circles around them so long as we give made-up addresses and utilise a little obfuscation.

The system will eat itself.

A mischievous Samsara.

Let’s go!


Today there was a thing about falls.

Old man. In his nineties, he fell. He fell again after arriving in hospital.

What to do with him?

He wants to go home; we risk and capacity assess. Determine what is right, good or not and let things happen.

We tried to get him home.

I can tell you something; he’ll fall again.

We have done everything we can to help him – looked at his footwear, eyesight, muscle strength, medicines, blood pressure lying and standing, we have talked with his relatives, even sat with him and discussed the past.

He’s lived in the same house for 70 years; or words to that effect – this is something I hear almost every day.

The patterns of my life; the symmetry, organisation and habits have been established over a lifetime well lived. Let me home.

It makes me think of Moses and The Pharaoh – ‘Let my people go!’ Let me get home!

If only it were as straightforward.

‘Here you are,’ taxi, hospital transport or ambulance and, voila, back in your living room. Familiar items of furniture; ornaments and faded photographs.

His arthritis has been present for 20 years and getting worse, he can’t hear, he is intermittently disorientated, drifting back to the 70’s. The good times. Well, except for Thatcher.

The doctor says, ‘medically fit,’ you don’t need to be with us any longer – you are at risk of becoming an object – a delayed transfer of care – otherwise known as bed-blocker. We can whitewash your humanity, transmogrify you into data.

Stalin said that one death is a tragedy, a million a statistic.

We can’t allow this to happen to our old folk. They aren’t just dots on data charts, logarithmic anomalies to be explained by The Man.

And, how do I help him?

My powerlessness is evident. It is concrete.

Subverting the trajectory of his life is as good as… wishful thinking, staring dreamily at cloud formations, imagining a different past.

Together we stand, divided we compartmentalise.

Let us take a risk, let us, chance our arm, another day or two of freedom, out-with the rules of the institution and we will be able to look back and laugh.





Are NHS staff chronically dehydrated?

We are supposed to drink between two and three litres of fluid a day to maintain homeostasis. Some of this is dependent on the size of your body – wee versus big, as well as other complexities such as the health of your kidneys, salt in the diet, function of your heart and so on.

No one is the same and the volume is individualised.

Yet, I am sure most people don’t drink enough.

I remember, when a little boy in the summers of the late 70’s my mum’s exhortations for me to drink otherwise I would dehydrate. I never understood the concept – I thought, surely if I were to become a raisin I’d get some warning. (We call that thirst in healthcare; to me then, as a youngster, it was just a cautionary tale.)

I remember a guy I knew in university who lived with a fear of kidney stones, his mum having suffered with one; he would ensure the adequacy of his hydration was tip-top at all times as he sipped on pints of Coke.

In the 21st century, hydration has become much more of a thing. My children freak-out if they haven’t got a water-bottle to take to school, or if we go on a long walk in the summer – the panic sometimes set-in soon after we leave the house; ‘Dad, can you buy me some water…Volvic will do.’

In hospitals you see staff arriving in the mornings with bottles; I have a friend who carries an extra-large dumb-bell bottle of water with her; it is something like three litres which she sips through the day.

I have a cup of coffee before the ward round, then if able have as much of my home-made juice as possible. No more teas or coffee before home-time.

I remember the good-old-days, before the NHS began its process of reverse-engineering into a singularity, when there was money a go-go and drinks were available; water machines, tea at meetings. Gosh, my kidneys didn’t know how good they had it.

We assiduously measure our patients’ fluid intake and urine output – it is an important process to ensure people don’t become dehydrated in the passivity of hospitalisation.

We rarely measure our own.

And the effects of dehydration? Of not sitting-down for 12 hours?

First you feel tired, then thirsty, light-headed, achy; your thoughts slow, ideas and thinking become inflexible, rigid; sore head, double vision; taken to the extreme, your kidneys stop working, although for that to happen you’d have to be working an extra-long shift.

Why do hospitals not pay more attention to the needs of their staff? Providing adequate rest is a given which doesn’t always happen; how about a water-cooler? Something to drink? A place for mindfulness?

Statistically, more accidents happen later in the day than in the morning, more surgical errors take place, more wrong prescriptions are written and there are a greater number of mis-calculations in pharmacy; we humans, vulnerable diurnals become weary as the day progresses; this fall-off in performance is hastened by dehydration.

How can we ensure our doctors, nurses and therapists who are busy measuring the intake of patients don’t miss-out, don’t fall victim to a voracious system?

I sometimes forget to take my water-bottle, these are the days that I don’t work to full capacity; sure, I could take a drink from the tap in the kitchen, but I never seem to get round to that either; having something on my desk helps.

We need regular water breaks;

‘Ward-round, halt! Time to rehydrate,’ I might suggest.

But no, we tend to keep going, breaks these days are not considered right, there is often so much to do, you have to keep on going.

I pity the nephrons of an on-call doctor in post-tory England.

The pee of nurses and healthcare assistants, more prone to infection than their forbearers.

Drink, drink.

Dromedaries of the NHS unite.

prune painting.jpg

Why I like urine

This subject has occupied me over time – my fascination with urinalysis – that is, the checking of urine for abnormalities; mostly whether bacteria are present (I’ve never found a urine virus, but it must be a thing, no?) Or, whether there are too many ketones, salts and so on.

I carry the picture of medieval monks tasting urine around with me as an image of dedication to the field.

medioevo in bottiglia.jpg

Previously I have written about asymptomatic bacteruria – this is the presence of bacteria in the urine, often of older people, which are just there. Not harming anyone, merely present. All the evidence suggests that so long as there aren’t any symptoms, we shouldn’t do anything. Now, it is more complex than this I admit, but it is a thing and every-day causes confusion for nurses and doctors.

E.coli in urine > treat

Instead it should be

E.coli in urine > symptoms > treat

The image I have is one of Teddy Roosevelt rampaging across Africa in the 20’s shooting everything that moved; Lion! Zebra! Meerkat!


It is subtler, more nuanced than that.

The other aspect of urine is infections being blamed as a universal cause of all ills, again, in older people.

‘they fell’ – urine infection

‘confused’ – urine

‘chest pain’ – urine

‘diarrhoea’ – urine

You see the theme?

It is I suspect a human psychological trope where we like to apportion blame to the first thing we can think of; this reminds me of Brexit.

‘Unemployment’ – Europe (aka Europeans viz, Immigrants)

‘Traffic jam’ – Europe

‘Depressed/anxious’ – Europe

‘Wayward children’ – Europe

We love these heuristics, cognitive shortcuts that allow us to stop thinking and move-on.

So, urine isn’t a heuristic, blaming it for all ills is as simplistic as complaining about bad blood, nasty humours or sinister cerebrospinal fluid.

Now, why do I especially like negative urine?

When I say negative, I mean urine that has been analysed and found to be normal; just the right level of sugar, protein or salt; not too much or too little. Goldilocks pee.

What this allows us – the doctors and nurses trying to work out what is wrong with a person, to park causality; to exclude urine as the culprit.

‘their urine is a clean/dirty as my urine, it can’t be the cause of deterioration /dehydration /immobility’

Without this we are in the dark.

I would estimate that of my patients who are potential urine-misdiagnosis victims, up to half never have a urine sample sent to the lab or analysed; possibly more.

It is great if you find old person, symptoms, pee sample, lab result, directions to the appropriate antibiotics and off you go.

You see the complexity?

Rapid-fire thinking and actions do not lend themselves to this kind of behaviour.

Conversely, in hospital, everyone gets a blood test.

They are (for the most part) easy – arm, tourniquet, needle and voila.

Urine is harder to obtain. It sits deep within a pelvis, hidden in the bladder, down a urethra, surrounded by multiple potentially contaminating bacteria. How to get the pee?

I remember taking my daughter to the hospital when she was a baby; high fever and not sure of the cause. In babies they don’t mess around with hypotheses, they get samples even if it means stabbing the poor tots.

We dunked our little girl’s feel in warm water of the hospital sink and she peed.

We can’t do this with adults.

It is the inverse of taking a horse to water.

‘They are confused, we can’t get a sample,’ well, most ‘confused’* people are continent and can hold on to their water – even if on occasion, like everyone they have accidents and, asking for a sample (perhaps, after a cup of tea) is a way ahead.

If you can’t get a sample, you are faced with the dilemma of whether to accept defeat or try something else; this is often the situation if people are not with-it enough to comply. Do you just treat and hope for the best – contaminating other results with the presence of inappropriate antibiotics or, do you persevere?

This is the black-belt realm of medicine that is not at all straightforward and beyond the remit of this blog, suffice it to say, we have ways and means.

And, when I look on the computer and see that my patient’s urine is free of bugs or dodgy solutes I can be please, although this doesn’t make my job any easier – I am left trying to determine what is wrong and why.

Urine, I love urine, so long as it is not on my clothes and it is mine.


*Whatever ‘confused’ means.

For more on this subject, see here!

What did yesterday teach me?

Well, a few things; probably.

Lesson one:

This first one won’t apply to everyone, although, if like me you are in middle-age clutter, at times overwhelmed by too much, consider daily reduction.

Every day get rid of one thing, item of clothing, utensil, book you no longer need – reduce, reuse and recycle.

This should make us all feel a little happier.

Lesson two:

To relax take six deep breaths.

One or two won’t do, too many and you risk collapse. Six. This is enough to lower your blood pressure, normalise brain waves and release a little endorphin into your system. Straightforward, isn’t it?

Lesson three:

Pulp headlined at Glastonbury in 1995 because the Stone Roses didn’t play, this because John Squire broke his clavicle. I never quite understood the reason at the time. I was there. I think. Crazed.

Lesson four, which isn’t a lesson, more a recap:

If you take the time to check an older person’s hearing aids and clean their specs, they shift from being passive to an active participant in conversation; their self-hood is realised, and you are no longer managing a patient but engaging with a person. They shift from black and white to technicolour.

Lesson five:

Again, not something new but a reiteration.

Delirium is terrifying, both for the person experiencing the acute change in personality and perception as well as those family members who are unable to understand the shift; the helplessness, not knowing and flashes of an uncertain future are scary.

Lesson six:

I came upon this on Thursday, but, it still counts.

We all know that cars are stupid and wasteful. They are the second most expensive object most of us own and for most of the time they sit outside our houses or work unused. At least we sleep in our houses.

A consequence of this extravagance is not only Global Warming but too many cars on the road – and so, we build bigger roads. Can we do more car sharing?

The thought that accompanied this relates to patients and, people in general but particularly those in care settings.

You fall, catch a virus or become ill.

Hospitalisation follows.

Out of the 24 hours you occupy a health, social care or other ‘bed’ you might see a doctor for 10 minutes, a nurse for 20, a therapist for 15 and so it goes; the day moves round, you lie in bed or sit by bedside.

Even if all those numbers doubled, to 90 minutes that is still only six per cent of the time in ‘useful’ activity; 10 per cent if you factor-in sleep.

I attended a meeting on Thursday where Professor David Ekers from York University talked about depression in older people and in particular a phenomenon called ‘subthreshold depression

This is where people are not formally depressed – they don’t meet the diagnostic criteria for the disease, yet, they have some of the symptoms – low mood, lethargy, poor sleep for example.

This isn’t recognised as a disease more a pre-condition, like metabolic syndrome – round tummies, raised blood pressure and higher than normal blood sugar – a precursor or red-flag for heart disease and stroke.

Those with subthreshold depression are at significant risk of developing depression with its associated fallout – shortened lifespan, multimorbidity, institutionalisation and so on.

David’s research was looking at the effects of helping people in this pre-stage to avoid developing formal depression.

The results were significant and positive.

Yet, this isn’t a thing.

This is what had me thinking about cars and patients (you were wondering as to the point of that earlier paragraph, weren’t you?)

Our patients spend most of their time doing nothing. Sitting. Waiting. Passively being patient.

How about we took a little of that time and encouraged both physical and mental health wellbeing either as a meaningful activity or as a programme of change, to enable and empower those people who are caught-up in the system.

This is not for everyone, but, imagine if it improved outcomes just a little. Imagine less depression, more engagement, greater happiness.

Imagine where we would be if we shared our cars too.


What makes us human?

And Lot’s wife, of course, was told not to look back where all those people and their homes had been. But she did look back, and I love her for that, because it was so human.

Slaughterhouse-Five, Kurt Vonnegut

Usually it is the flawed nature of our selves,

Our ability to get it wrong

and, wrong again,

To upset those we love;




Special occasions,


underestimate the significance of

the moment.





Are it.




Bluebottles knocking against



We are





Our primitive yearnings,



encourage movement.


During times of stillness

We wriggle,

When sad

We laugh

When confused


vindobonensis palatinus_1191_f10v.png

Rag and bone


They used to shout.

It was


and son

Who had


across from Qalquilia








And Hebrew,


Into Arabic.




was close to its end;

staggering in the heat.





Heat haze



No one was quite sure how to act.




Little blood pressure thing.

I have been planning to describe this for a while;

I don’t know if it is a proper medical thing, if not, I am willing to give my name to the syndrome*.

Here is the scenario:

Man (or woman)

80 years old (could be younger, or older)


Sees GP

Tells GP ‘I am dizzy’

GP undertakes cursory assessment

‘You look OK to me,’ they think to themselves.

‘Perhaps Meniere’s**’

‘Or, vertigo***/vestibular neuritis****/labyrinthitis*****’

‘Here, take these tablets, they should help.’

‘5mg Prochlorperazine, one three times a day.’

Weeks pass.

Still dizzy.

Back to GP.

‘Here, take these, Betahistine 8mg three times a day.’


Still dizzy, occasional stagger, fall.

Time + fall + osteoporosis = fracture.

Time + Prochlorperazine = Drug-induced Parkinsonism (the symptoms of Parkinson’s disease without the disease), leads to fall ­= further fracture.

‘I think we had better refer you to the ENT department.’

All the time

Medicines are accumulating;

drugs for pain,

for osteoporosis

Even, for Parkinson’s disease when mis-diagnosed.

Feeling worse.

& more time.

Rod (not ENT – instead, he’s an enlightened physician of older people).

Let me measure your blood pressure with you lying down then standing-up.


It drops.

(In health your blood pressure rises when changing position; in disease if it falls, the blood supply to your brain, at times precarious, drops, you feel woozy, light-headed, you fall.)

You cannot diagnose this condition, called, ‘Postural hypotension,’ or, ‘Orthostatic Intolerance,’ without measurement.

The treatment?

Stop the blood pressure tablet you have been taking since you were 50.

That drug kept you going – it likely extended your life by 30 years, helped you to avoid a heart attack, stroke or renal failure, but now, it is just making you topple.

All good things must come to an end.

Let’s de-prescribe.

Bye-bye Ramipril (or, Amlodipine, Doxazosin, Bendromefluthiazide or whatever).

The corollary?

The original doctor didn’t measure the blood pressure; they didn’t think dizzy equals blood pressure; they interpreted it more literally, in that dizzy is a disorder or balance,  semi-circular canals; those things in the ear that are upset when too much beer has been consumed or the sea is overly choppy.

It is a failure of medical school and medicine and perhaps a little laziness – measuring the blood pressure up and down takes a few minutes; if you are a GP flying as fast as you can in a busy surgery, this might not be something that is feasible. The alternative? Mis-diagnosis, and falls.

I don’t want to go deep into the minutiae – it can get a little cryptic. It is just, a simple test that requires not sophisticated technology or machinery, just an old fashioned sphygmomanometer and a few minutes.

Yet, at least once a week I catch a patient who has slipped through the net.

Frustrating isn’t it?

The point of this blog?

Well, if you are a doctor, nurse, pharmacist or person disillusioned by healthcare, and  in particular if you are falling or you meet someone who has fallen, get them to lie down; a couch, settee or bed will do.

I usually ask the person to relax, to think of nice things. Breathe deep.

After five minutes, check the blood pressure. Then get them to stand as quickly as possible – ideally this will make them unsteady, light-headed even; then repeat the blood pressure. If the numbers drop from lying to standing, voila, you have it.

I won’t explain anything more – if this happens, it isn’t an emergency, you might not even have anything wrong with you (i.e. disease might not be present), but, it is a good excuse to see a doctor. You could even say, ‘Dear doctor, I am worried I might have postural hypotension (orthostatic intolerance if they are over 50).’

This might save you a broken leg.

It might keep you independent.

It is not beyond the realms of possibility that it could prolong your life.

Hey – a life prolonging test that doesn’t cost anything? I know… It is not an fMRI or laser-guided brain treatment, it is however effective, reproducible and easy to undertake.

I love it.

It is consistent with my life philosophy – do what is most straightforward. The direct route is usually the most valuable. Don’t flounce. Don’t meander. Get to it.

Less is more; daily decrease – hacking away the unessential.

Bruce Lee was with me as a teenager, he is still looking over my shoulder as I amble into my mid-forties.

weeble 1987.jpg

*The syndrome isn’t the postural hypotension, it is the whole beginning to end calumny of misdiagnosis and inappropriate treatment.

**Ménière’s disease is a long term, progressive condition affecting the balance and hearing parts of the inner ear. Symptoms are acute attacks of vertigo (severe dizziness), fluctuating tinnitus, increasing deafness, and a feeling of pressure in the ear. (From Wikipedia).

***Vertigo is a symptom, rather than a condition itself. It’s the sensation that you, or the environment around you, is moving or spinning. (Wiki)

****Vestibular neruritis is a disorder that affects the nerve of the inner ear called the vestibulocochlear nerve. The disorder may cause a person to experience such symptoms as sudden, severe vertigo (spinning/swaying sensation), dizziness, balance difficulties, nausea, vomiting, and concentration difficulties. (Wiki)

*****Labyrinthitis is an inner ear disorder. The two vestibular nerves in your inner ear send your brain information about your spatial navigation and balance control. When one of these nerves becomes inflamed, it creates a condition known as labyrinthitis. Symptoms include dizziness, nausea, and loss of hearing. (Wiki)

Prochlorperazine tablets belong to a group of medicines called phenothiazine tranquillisers. They may be used to treat: dizziness due to ear diseases (such as Meniere’s syndrome or. labyrinthitis), or due to other causes.

Betahistine, sold under the brand name Serc among others, is an anti-vertigo medication. It is commonly prescribed for balance disorders or to alleviate vertigo symptoms associated with Ménière’s disease. (Wiki)

Drug-induced Parksinsonism is the second-most-common aetiology of Parkinsonism in the elderly after Parkinson’s disease (PD). … In addition to typical antipsychotics, DIP may be caused by gastrointestinal pro-kinetics, calcium channel blockers, atypical antipsychotics, and anti-epileptic drugs (Wiki)

Orthostatic hypotension, also known as postural hypotension, occurs when a person’s blood pressure falls when suddenly standing up from a lying or sitting position. Severe drops in blood pressure can lead to fainting, with a possibility of injury. (Wiki)


Drugs and drug reps

I just received an early-morning WhatsApp from a friend praising the actions of David Hambleton and colleagues in defeating the pharmaceutical industry in court – to allow the use of an inexpensive drug (Avastin) to be used to treat a common condition affecting the vision of thousands of people (Age Related Macular Degeneration)(the wet type) instead of the standard medicines which cost 10 or 20 times the price.

Go David and fellows. And thanks Gareth for sharing.

This brings me to an interesting situation. (Dear readers, please let me know your thoughts.)

In my hospital we have lots of meals sponsored by drug companies.

In particular each Friday there is a teaching session, before which a drug rep sells their wares, in turn they buy lunch – M&S if they are trying to impress, Morrisons if on a tight budget (possibly, dependent on the outcome of High Court actions).

Anyway, I usually arrive for the teaching as the rep is ending their talk. I haven’t sat through a whole one yet. Partially this is intentional – I don’t really want to listen to what they have to say and also I am quite a busy guy and I prioritise – teaching beats reps, for example.

I don’t know the effect of these drug-rep interventions although I imagine there must be some cost-benefit return to the companies otherwise they wouldn’t do it; unfortunately, they aren’t allowed to give away pens and little gadgets any more, so they are wholly dependent on their spiel.

So, I don’t listen and arrive at the end.

Is it OK for me to support them providing lunch for the trainee doctors?

That is question one.

The next is the sign-in.

To account to their budget managers, or, perhaps, area managers, they have to get a sign-in sheet, with the names and grades of the different doctors in attendance.

I don’t usually sign. Last week, a drug rep asked me to sign the form despite my not having eaten the food or listened to the talk – in fact, I had asked her to take her presentation down so the teaching could get started.

I refused.

She did not like that.

Now, it would be silly to look a gift-horse in the mouth, as the saying goes. And, these folk are providing our hard working doctors a free lunch. They even get to learn something (although perhaps sometimes with an associated bias) (I don’t believe the reps are allowed to say anything that isn’t true.)

Equally, she has provided food for my doctors, something neither I nor the hospital can afford (not true, but you have to look at where money is best wasted first) (admitting older people unnecessarily to hospital, for example).

Question two, should I have signed?

In many places they manage to pull-off teaching sessions without the food – people bring packed lunches (like I do) – and, it should be the desire to learn, the excitement of the education that draws people, not a chicken and avocado wrap. Yet, who am I fooling.

I am not getting at drug reps themselves; they like the rest of us are trying to get-by. That they work for multinational pharmaceutical giants (if they are lucky) (or small innovative start-ups if less so) is just a fact. I hold no malice towards them.

This is just advertising – and as much as I would love there to be no advertising anywhere, it is an intrinsic part of 21st Century existence; and, without it the advertisers would be out of jobs too.

I want to be honest and open and do the best for my patients every time I act (which ironically, given the content of this blog, is in stopping medicines predominantly) – the teaching is important, it communicates information, it creates a spirit of learning, education and growth.

The court case I mentioned at the beginning should release 12 million pounds locally to be used in different ways within the NHS; across the country this figure will be in the 100’s of millions.

We should celebrate Davids tackling Goliaths, we need more of them; mostly the system is too complicated to unravel into such a dialogue and, I am sure the pharmas legal team are even now working on a challenge or way around the ruling.

In the meantime, I will go on de-prescribing.

david and goliath santiago siri.jpeg

I love you, no, I don’t, not really.

You get this situation;

People behaving one way

And talking another


Vice versa.

I care


Not really;

In fact,

I’d prefer it if you and your condition



Weren’t sitting before me.

The scene

Would be prettier,

More attractive,

Balanced, symmetrical.

Your if-ness

Just upsets

The calm.

I see it all the time in patients;

Obey the pathway,

Follow the pre-conceived,

planned and circumscribed route

and all are happy.

Express an opinion,


opt out (or in)


the flow (Force) is disturbed (perturbed).

Heaven forbid, the system should have to adapt

Or somehow accommodate your strangeness.

You fall;

We don’t do falls.

Your heart is irregular,

We only do hearts

That beat with regularity;

You are too


Your skin is too sensitive,

Our beds don’t suit your build

Or shape.

This dullard says A, B or C

And this other

nonentity agrees


you are left in limbo.

Suspended in nothingness.

They say that mental and physical health

are like

motor engines;

One diesel,

The other


And ne’er the twain shall meet.

Mix a little of one with another and

Your V8 gives-out.

How this evolutionary fluke

happened, I don’t know.


At some point in the narrative,

Person A,

Just before they dreamed-up fascism

Or hegemony

Or, master-slave,

Considered that there are two healths. (aka before Martin Luther).

Mental and physical.

One is OK – that is physical;

My heart is broken,

My ague,



And, the other,


My spirit is out of sorts,

My sense of self

Has bypassed this world;

My miasma is shrivelled,

My sense of



The immediacy of my preoccupations.

And this, inferior.


Demoted to the realms of





raving in a corner,

Methuselah staring at an irregularity on the wall.


From this sense of inferiority


an under-filled ego,



I drive a Porsche

To demonstrate

That my problems

Are less than yours.

My Tesla might get me from A to B,

But your Mondeo is rubbish.

And so,

The battle is on.

The peaceable,

Fun-loving saprophytes,

The old

And forgotten

And regretful

All check the minutes

Until the end of the day.

I say one thing and do another.

I care.

I do.

I love you,

I don’t.



Thinking, feeling, disunity.

I suspect by the time Artificial Intelligence has reached the Event Horizon and we are no longer able to control the exponential acquisition of learning, innovation or action-potential, there will be a problem.

And, a second suspicion is that society will be split in two.

The thinkers and the feelers.

The logicos and the emotives.

Morlocks and Eloy.

I won’t expand on the place of introverts and extraverts; I always imagined that computers would prefer peace and quiet to bombast.

You see, I’m a bit of a feeler.

Emotions are my lexicon, my language, my code.

Sure, thoughts are there, but they are secondary.

First the feeling then the word. (First was the word and the word was)

The tumult extant in my tummy, then everything else.

I don’t think therefore I am, more, I feel… (don’t think, slap, feeeeel😉 )

And when the robots stand us against the wall and number our actions, our understanding of good and bad (?), or the cost effective and the wasteful, I will be there smiling, grinning, looking for a way-in, a strategy for self-expression.

And that they will not like.

That they see as weakness.

I think of Marvin – yes, the paranoid android.

How delightful to imagine the growth of technology into introspection.

We are talking value systems here.

One cowrie equals two hugs and, no more.

A crocheted rug, equivalent to tears of joy.

Sadness, gladness, fear and anxiety all consonant with materials.

The robots will look-on and wonder. Just before they pounce.

Prior to clearing-out the waste-pipes, scuttling the flues.

I might attempt to disguise my true self; acquire the demeanour of Schwarzenegger, Stallone or Steven Seagal; Stolid. Like dumpling.

Robotic citizens of an inorganic system, moving, pausing, contemplating, considering.

Stop – Start kind of thing.

And then, there is none, and then, there is our quantum self,

Boiled-down to nothing.

And after that who will bring the laughter?


Seagal cool.jpg

Someone I know

He looks

So very like someone I know.


A man.

I don’t really know them

Other than I am aware


Dislike them.


Where do you begin

When considering not quite


But similars?


In the winter I took a photo of a pitta-bread maker in Jaffa

Who looked just like my brother,

from the side.


Same skin tone, tache, pattern of balding,

Lips, eyes, smile.


I didn’t attribute any good or bad to the guy,

He was just busy kneading.


My brother did not seem that impressed by the photo.


A couple of years ago I was on a bus in Barcelona,

There was a man,

a few years younger than me,

with two small children.


Looking at him was like looking in the mirror.

I was unnerved.

Nudging my kids to look across,

They agreed.


I took a photo.


This guy however

Who sits along from me in the meeting,

With same

Nose, neck,

protruding upper teeth;

even his mannerisms are replicas

of the one I won’t mention.


I tried not to let this influence my attitude towards him,

aspired to remain on topic.


It wasn’t easy;

I couldn’t smell him,

Were I close enough, I know he would release the same




As with all meetings,


It drew to a close and I was able to leave.

I am only recounting this experience

As the aftertaste

Of the near-encounter

Is still with me.


Considering the moments,

One an image of someone I love,

Another of myself

And this most recent

Not quite my nemesis,

But, someone I wasn’t expecting.

Is it surprising we don’t see more replicas of one another?


Our ability to recognise faces is an evolutionary asset.

It has helped us get on.


Imagine if we looked alike, the consequences would be comic.

Mostly I remember faces, but forget names.


For some it is the opposite,

Some lucky folk can magically match name and face almost instantaneously.

Not me.


I remember working with a doctor many years ago,

She was able,

within a week, to memorise the names of all the staff on my ward.

Something I hadn’t managed in approaching a decade.


I am sure this worked to her advantage,

Facilitating entry into the team.


My slow, plodding, malapropisms led to a much slower absorption.


It is said that our names are the most beautiful thing we can hear.


I’m not too sure about that; I’ve spent a lifetime disliking Rodney.

I find Copernicus prettier.


Fortunately, the guy who caused me so much upset has a name quite different from the other one; I can’t begin to imagine what the pitta-bread man and the Barcelona chap are called.

Ego is that aspect of our personalities that ensures we have enough confidence to face the challenges of life. Shrink it and we struggle, enlarge it too much and everyone has a hard time.

I don’t think we are designed to look around and see ourselves.

I think of the movie Being John Malkovich – I have written about that before, in relation to probably a bigger bastard than I have been skirting around so far – the former Health Secretary;

It is conceivable that the existence of another mirror-image of ourselves, (beyond an identical twin) potentially halves our ego, three and we are down to thirds and so on. Increasingly diminishing until, like the character played by Michael Douglas in Ant Man who disappears at the end into a quantum ripple.

And now, the secret.

Every time I see this chap – fortunately not something that happens often, I will be returned to this moment, and by association other moments of similarity where real and imagine blur.

I am now, sitting in a café in Sheffield.

Imagine someone, my exact facsimile, carbon copy, comes in, orders a flat white, lemon-drizzle and sits down at my table.

Then, we are joined by a third, a fourth; any more would be silly.

What would we discuss?

Would we have the decency to wait for the other to finish talking before jumping-in with theories? Would there be a mid-air collision of id, ego and super-ego;

What would Freud say?

michael douglas doube.jpg



This is the process of turning into stone.

A similar word, petrifying is, I imagine what happens when the process is speeded-up.

Our bodies are built from stone. The bones that support the frames of our selves are a lattice-work of powerful interconnecting calcium and phosphate bridges. Without these, we’d be, well, jellyfish or squid.

I won’t go into the imaginings of other states of existence, suffice it to say, that the World Cup octopus of a few years ago knew he was on to a good thing.

It isn’t the skeleton or even calcium that I am considering here, it is a different form of immobilisation.

Parkinson’s Disease – named after the English Physician who first described the Shaking Palsy back in 1817 is, a neurodegenerative process which results from a deficiency of Dopamine in the brain.

I won’t go into the details – they are beyond me.

Although the disease is called the shaking palsy – the cardinal feature which I find most challenging is the way facial expression is affected.

In the medical world, with its cunning ability to manipulate language, this is sometimes called, ‘mask facies’ or, in more modern parlance, mask-face. This alludes to the often-expressionless demeanour of people who have the disease.

ali norman finkelstein.jpg

Think of Muhammad Ali back in the 1950’s then the shadowy figure seen at occasional public events before his death;


There are all sorts of descriptors used to subcategorise the symptoms – ‘blink paucity’ for example, is one – this, referring to a reduced frequency of blinking.

I personally have always struggled to support people who have Parkinson’s Disease (I’ll call it PD from now on), I think principally because of the incredible complexity of the disease – for those of you medical students out there, it isn’t just dopamine and muscles; there is a whole lot more – as with the treatment which is constantly evolving, developing.

For me, equally important is how I practice medicine.

Before reading blood pressure, renal function or cognitive screens, I look to a patient’s face; their level of alertness, expression, engagement with the environment, responsiveness and smile all factor-in to my assessment. The texture of their skin, the light reflecting from their eyes; this spreads to hair, dress and body posture, but, it is the face that provides the greatest information – is the person in pain, happy, anxious to leave, are they feeling sick, depressed or placid?

Evolution has taught us to read and understand facial expression beyond language or other forms of expression. From a distance you can usually detect friend or foe. The stranger may be carrying a weapon, but their eyes reveal all.

And so, to PD.

OK, I can’t do it… People who have Parkinson’s Disease.

It is reduced facial expression that I find most difficult.

Often an individual’s eyes can shine through the stillness, but sometimes even they are faded to grey.

Usually, when you can’t read a face, the next action is to talk, ask questions, classify experience.

With those who have Parkinson’s this is sometimes just as difficult; speech and language can be slowed-down, to say, ‘I am in pain, my bottom is sore,’ might take two or three times longer than another; add to this the elements of age, often cognitive and sensory impairment and people frequently don’t get to the end of their sentence before the person asking the question has moved-on.

And, part of this is my frustration at my inadequate patience. My need for a response creates a tension. I want to second-guess, fill-in the blanks, all this, detracting from the person’s experience, from their self.

I don’t know the answer beyond forcing myself to slow down;

To switch from the speedy, intuitive facial expression, reading between the lines interactions that mostly guide me to a slower more meditative encounter; acknowledging that the slowing, the disease, the turning not to stone, but the firming-up of expression is all part of the person. None of these can be separated.

A lesson I must learn.

I will end with a reflection on a man I met recently; he lay still, silent, in bed.

In his youth he’d been a martial artist.

The essence of quick, graceful movements, power, strength and form combined.

And now, lying still, stone-like in bed.

I used to have a photo of Bruce Lee punching a sheet of paper; he used to practice his speed techniques by making the paper move by the compression of air from his punches; not hitting the paper, just wafting it with his fist.

I think of this and I think of this man.

It is hard to imagine the person he was ten or twenty years before.

And yes, I know disease affects different people in an infinite variety of ways, this however seems an unusually cruel and punishing situation for one who very likely honed his body to the limits of fluidity. Now, frozen, still.


I am very old.

‘I am very old, I don’t think I can manage any more.’

That was how it began, as I listened.

He is old. Next birthday will be 97. So far, living alone, supported by occasional carers.

He is thin despite a healthy appetite; ruddy cheeks and soft hands; fingernails thick.

The hair on his head is sparse, eyes watery.

This is what happens when the steam is running-out of you.

In medical terminology he is frail – a word I dislike less every time I hear it. Why do we so love to straight-jacket people into categories and classes? Is it so difficult to get our head around alternative person-centred descriptors?

Massive stroke.

Major haemorrhage

Acute bleed

Chronic anaemia

You get the idea.

Frail and robust.

Young or old.

The more we trip into organisational nomenclature, the further we drift from people.

I won’t say his name; I’ll make one up. It could be anything.

Arnold, Albert, George.

Names aren’t that distinctive any more.

Back when I began medicine, when Victorians were my patients I remember Wilhelmina and Thomasina. Funny corruptions of boy names.

Albert is worrying.

Not at all sure about his immediate future.

Interesting; you get to be nearly one hundred years old and you’re worried about tomorrow.

As we age, time passes more quickly.

Something to do with heart-rate; A gerbil’s timescales are indefinite.

Fleeting concerns about tomorrow; and, before you know it another day has passed.

We rehabilitate, enable, convalesce, manipulate you into managing just a little more.

Our health and social care systems long ago ran out of coppers to pay for your time in care.

Wilhelmina would have had her grandchildren and extended family, Albert is left alone.

You don’t want to tell him, ‘Hard luck. Home you go.’ To be locked behind fob-accessible door in 21st Century isolation. The TV will keep you company. Your Apple Watch will remind you that you have friends. Kiss, kiss. As if.

Is it a relief for something definite to happen? Fall, pneumonia, cancer. A juicy condition for the services to focus their intentions. ‘Here, take this antibiotic, you’ll be right in no time at all,’ aka, delaying tactic, panacea, falsehood.

And still, he sits alone. By his bed. Silky Paisley-Pattern dressing gown adhering to skinny legs. Untouched sippy-cup. Drug rounds, pharmacists, technicians, porters, cleaners, nurses, a whirling hierarchy, a dizzying display of health and care.

And, he’ll wait.

His family will argue the case.

He will move through the system.

Wheeled in a plastic chair to place A or B or C.

Manoeuvred, positioned strategically in location 1 or 2 or 3.

He hopes for the best when his thoughts aren’t crowded by memories.

Born in 1922.

Interwar period.

Coming of age in 40’s.

All of living history rolled into his experience.

The analysis, assessment of the moment. Now, today, tomorrow, I am never really clear.

Where will our humanity lead us?


Superficial analysis of complexity


Keeps everyone happy;


Freewheeling downhill

having forgotten your repair kit.


Focusing excessively on the details,


Too thick a lens up to what is small

Can sometimes

Slow us down,

Keep us back,

Postpone the inevitable.


I prefer to skip,


Over the surface;

Jittery they call me

When things are moving




Oily nonsense.

I can’t actually hear a word anyone else is saying


I am not listening.


The bleh, bleh in my head


drowning-out reason.

It is far better,

More enjoyable perhaps

To jive

Than wait.


The more people

You can get

To join you,

To see the world

through the same



The better.

If we all speak Esperanto

We’re laughing,


Someone pulls out

Google Translate

And our efforts are perceived as null.



Was what they called it in the 1950’s.



It is just

Quick talking,

rapid-fire solutions

to dilemmas.

Obscure responses

to suspenseful activities.

Play the piano,




Before Leeuwenhoek

They thought

That small was as little

As you could go;



He discovered

A world inside the world.

Microscopic protozoa


A battleground;




and openly

Takes more effort;


It is the only


Next step,

The only


Way to move from here to there.


If you go,

I will stay,

If it is me

Then not you.


My number is marked,

Which is better

Than us all falling.


Listen to Spielberg.



Where to begin?

I went to see this movie yesterday with my son, not quite knowing what to expect other than it had scored 95% on Rotten Tomatoes.

I won’t mention the shenanigans at the front desk;

It blew me away.

Afterwards, my son told me that I say that about every film I watch at the Curzon.

I say, no, no. This was special.

It was beautiful. Frightening, painful, articulate.

It seemed to coincide with my recent concerns about left and right, the collapse into inanity that is sweeping over America and Britain, the love affair with extremism, Right-wing chaos; it is a blur.

What can I say?

The music, transportation back to the 70’s, humour, sadness, tension and shock. It make me feel small, safe and terrified.

I don’t really want to say more as I am sure it will sound like schlock.

Go see it.

If you don’t like, I don’t mind, for you will have seen it!

How do I put it aside?

My family gathered last night for another season of Strictly.

I tried.


Most years I don’t even join them in the room;

Last night I balanced on the settee, albeit with my laptop for comfort and half and half sat through contestants spiralling onto the screen amidst glitz and glamour.

Well, the inevitable happened; after ten or fifteen minutes of showbiz, I retreated to reading Stephen King’s latest book, The Outsider. (If anyone has read this, please don’t tell me what happens!)

Have I failed my family? Society?

What the heck is wrong with me?

I know my mum, if she were still here, would have been watching, my dad too. It is hypnotic candyfloss. Yet, I preferred the confines of my Kindle.

An easy out would be to blame genetics, but, as I say, both my parents would likely have been there.

The only explanation is my twisted experience and perception, all of my own making.

No one to blame but myself.



Left and Right; Time for a tax?

I think I have provided an evolutionary explanation for the existence or right and left; Democrat and Republican, Whig and Tory. (here).

I suspect the caveat is that in our modern society these inherited advantages break-down; they can and seemingly do become counter-productive.

I’ll take as an example food and fat.

We evolved to live in small groups, hunter-gathering. We were very successful as a species at cooperative working, ganging together against an unsuspecting impala. I don’t have figures for the kill rate of a leopard or tiger, suffice it to say, humans are far better when calling, whistling or shouting from treetops than the larger more robust big cats. The latter are on the verge of extinction, we are, well… what are we?

(Please don’t call me a self-hating human!)

In that environment of feast or famine, plenitude or nada, our ability to eat lots and rapidly gain fat was an asset, in fact, those with a tendency to fattiness were at a significant advantage when the next famine came around.

Nowadays, with famine only really a man-made event (war, government, environment), it is a rarity. Yet, the food keeps on coming.

We acquire fat, we develop diabetes and so on. You know the story.

What was once adaptive has become a disease process.

Could the same be said of The Right?

An example of this might be Brexit and all the demagoguery surrounding the referendum.

There is no logic to our departing from the EU. It is insane. Yet, when you view the process through a primitive rightist lens, when you see invading Europeans and Syrian refugees, when you look at Germany profiteering from what was described as an imbalanced marketplace, when you provoke concerns about the NHS and education, all pulling on the strings of our primitive fears, you get the Right rising-up, believing that a threat exists when there is none and going to the polls.

We live in a world where far more can be achieved by dialogue than force. Whether good walls make good neighbours is probably for another day; yet, there is clearly so much more to be gained by discussion than stone throwing and cutting ourselves off from our family.

Therefore, my conclusion?

We are not going to get rid of the right and left debate, it is embedded in our genes, our cultural inheritance, it is time however to realise just like a propensity to rapid weight-gain that aspect of our natures needs to be tamed, brought under control.

We have a sugar tax.

How about a Right tax?


South Yorkshire Tribe (care sans frontieres)

A past couple of blogs have been about tribalism and belonging. The link to our primitive ancestry that drives behaviour today.

A few months ago, I was thinking about this, it was not long after I moved to work in Rotherham, when I saw my identity shifting – from the Doncaster hospital tribe to that of another South Yorkshire town. (here).

It was interesting and frustrating at the same time.

Back when I arrived in Doncaster in 2007 I was readily accepted into the ranks of that tribe and donned the garb of rebel with a cause; a man driven to improve the healthcare of people in Doncaster, back at a time when there seemed to be significant inequality.

Time has passed and much has changed since then.

I flashed forward to viewing my old tribe and the behaviours adopted by certain fellows to maintain the substance of my former organisation.

Mostly this is to do with workforce – the United Kingdom’s limited commodity.

There are vacancies for doctors, nurses, therapists and pharmacists across the country; in most instances we aren’t at risk – there is usually a doctor available to you, it is just that because of fluctuations in the market, many are employed not directly by the NHS but through private agencies. Most cost hospitals twice the amount of a regular employee.

Maybe when they started messing around with tuition fees and nursing and medical training ten years ago, if they’d have thought of the economy as a whole we’d be in a different place (universities are also tribal entities).

We aren’t.

We are split into inchoate tribes, milling around like characters in an outdated roleplaying game.

And so, the tribalism.

There is meant to be a thing, whether it is called ‘South Yorkshire Working Together’ or something else, the most recent incarnation is, ‘South Yorkshire Integrated Care System,’ the basis is meant to be collaboration.

Collaboration in my lexicon is working as one, bringing together resources, sharing the pain and opportunity, seeing the success of the individual as the success of the whole.

That isn’t quite how it is working.

Adversity (aka austerity and a Tory government) forces tribes to band together.

I remember many years ago in bible classes learning about levels of allegiance – first to your parents, then your siblings, then cousins, distant family, friends, tribe; everything else is secondary. That is how we have survived as a species.

The pull of this is so strong it overwhelms our logic.

And so, we compete.

Compete for nurses, doctors and so on.

Scare resources don’t go a long way in a finite economy.

And the answer?

I see it as one big collective endeavour. We used to call it the NHS.

It is seeing the entire population of South Yorkshire as one entity – all one and a half million people. All the responsibility of the hospitals tasked with providing care.

There is no Sheffield, Rotherham or Barnsley patient – just SY patient.

Our patients, just like our ambulance services move all over, they pop-up in one emergency department and another organisation’s outpatient clinic the next day.

There are no borders or identifiable boundaries.

We need to stop seeing ourselves as tribes of three different towns and one city and perceive the care, support and treatment of our entire population as the collective responsibility of all.

No poaching.

Fair allocation of resources – that is staff; sharing scanners and waiting times.

If I have my heart attack in Barnsley market I should have as good a chance of survival were I in Sheffield; and the same goes for my skin condition, eye disorder or anxiety state.

Whilst we still have the NHS we shouldn’t waste energy on factionalism.

Come on now, we are grown-ups.

And, this is life and death.


Crisis – response

A little earlier I was writing about humans in a state of crisis – the way this brings-out a certain togetherness, bonding those who might otherwise be stuck apart.

Another aspect of crisis is the effect it can have on the individual, beyond the coming-together. You see, crisis, immediate pressure or threat can affect our decision-making.

Most, given ample time and space can come to a reasoned, rational decision when faced with a challenge. What happens when there is a timer counting-down; think back to Countdown and the Conundrum, or, perhaps, the last seconds of a football or rugby match, the moments before the bell rings to terminate the exam.

We behave differently.

Within the realms of the Myers-Briggs psychological framework, where people are allocated one of 16 different personality types, based upon their source of energy (introvert vs extravert), speed of thinking (fast or slow), values system (fact or feeling) and completion (last-minute or forward planner), a list is populated.

I’m not going to tell you what I am, although some can perhaps guess.

You can look on the internet for all different sites explaining the various personalities and how they interact. You can assess your own personality type. It can be quite fun, and some folk have run with the idea to develop Myers-Briggs Star Wars characters and the like.


None of this specifically relates to crisis, as the theory states that we are who we are when all things are equal. When the pressure isn’t on, when we are safe, relaxed, without deadline or threat.

This is when most of us are at our best.

Flip this, induce a state of crisis with tension, deadlines, demanding managers and customers and personality can change. Some of us can behave in very different ways under pressure.

The theory describes this as being ‘in the grip’ – and, as with all these things, there are books written on the subject.

Despite being an approved Myers-Briggs assessor, I have never fully understood this aspect of the theory as it becomes very complicated with different personality aspects and types interacting with others to produce odd combinations.

I have met some master practitioners and it is eerie how accurate they can be when analysing behaviour.

Here is an example;


Take Wonder Woman – her personality type (based on DC Comic Analysis) is supposedly ENFJ – she is Extravert, gets her energy from being around other people, works iNtuitively – she doesn’t always need all the information to act, and, her acts are based on Feeling; the effect of her actions and the actions on the feelings of others matter to her and, Judging – she gets things done.


This is a description from the DC Personality site:

‘Wonder Woman is outgoing and always supportive. She is caring, friendly and intensely loyal. She is nearly the perfect character with a strong will and a warm heart. Wonder Woman never gives up and has a larger than life presence. She is capable of being what everyone around her truly needs.’

(Sheesh; I have just described my mum!)

All this is very interesting, it is what happens when the pressure is on, when the clock is ticking, and her values are put to the test, when perhaps a trusted ally cheats her or her intuitive quick thinking fails.

This is the grip.

Here is the picture, which is essentially a breakdown of everyday function;

Wonder Woman becomes a person who is very critical and untrusting of others and themselves, their logic fails to the point that what was previously obvious now must be analysed to the nth degree; they become indecisive, deferring action rather than taking the decisive actions with which they are familiar.

She becomes… Spock.


Here is a quote from Naomi L. Quenk’s book*

“I am like Dr. Jekyll and Mr. Hyde,” said an ENFJ, describing his reaction to extreme stress. “My humour becomes inappropriate, meant to shock people. I’ve even been known to throw things while in this frame of mind.” An ESFJ said he becomes “angry, out of control, critical, responding too quickly to others with impatience, cutting a person off when they speak.” “I’m critical rather than seeking harmony, self-protective rather than ‘giving,’” said an ENFJ.

It is interesting, the effects of stress upon people.

I am sure we have all witnessed this; the usually placid fun-loving person becomes harsh and rigid, the quiet soul starts shouting and bawling, or worse, the loud brash individual goes silent.

Pressure and specifically crises can have major effects on how we see the world and behave.

This likely suggests that for all crises can bring us together, they can also tear us apart, forcing people into difficult situations where they can make errors of judgment, where they can struggle to find peace or calm.

I guess the point of this is to recommend that crisis thinking, action or behaviour is probably not good for long-term prosperity no matter how it connects us.

Sometimes you just have to be calm.


* Was That Really Me?: How Everyday Stress Brings Out Our Hidden Personality (9780891061700): Naomi L. Quenk: Books


It is really unpleasant to be the person who says things that are not in accord with the views of the majority.

Last night I watched the We Are British Jews documentary on the iPlayer.*

I’d heard about it from several people.

Most interesting was an exchange from my brother…

‘Can’t believe how naïve the young ‘pacifist’ girl was’

So, I watched waiting for this person, to see what they had to say.

This is the character who in the past had visited the West Bank and was against the Kibbutz celebrating the Israeli Army.

The thing is, I get much of where she is coming-from.

When I was in my early 20s, during the elective as part of my medical degree I found a placement in the Hadassah Medical Centred in Jerusalem. That was back in the days when I thought Paediatrics as a specialty was for me.

A week into the attachment I ran away;

Everything I found about the place was so very well… hate to say it, at least to my young eyes, Americanised, the traditional level of engagement with patients, the doctor nurse deference; it is hard for me now to remember the specifics, suffice it to say, I felt stifled.

I was at the time living in the hospital residence; I ran away from there too, to a hostel in the Old City of Jerusalem, just off the Via Dolorosa. It was a magical place full of travellers and lost souls.

Ultimately, I discovered a baby clinic in the Arab Quarter just down from the Al-Aqsa Mosque, run by a Dutch Paediatrician. She welcomed me to join her for a few weeks shadowing.

Here I saw another side of the healthcare divide; from the shining Chagall Windows in the Hadassah Medical Centre to the cracked and tattered flooring of a dishevelled clinic.

I have been writing lately about the left and right divide; well, here I was on the left.

I have never had a problem with the Israeli army; in my fondest imaginings dreaming what might have been had I become an ‘Eran Morad’ but, the Two-State Solution, Amos Oz, Peace Now, and so on, were all closer to my heart than the ranting of the Right.

I can remember, in fact, I can feel it today, over 20 years later, in a similar context, at a meeting in the Giffnock Synagogue in Glasgow where the Israeli Ambassador was visiting;

The room was filled with a mixture of the locals – Jewish people from across the spectrum, come to hear what Yoav Biran (I think it was) had to say;

When it came my turn to express my thoughts relating to equality, freedom and peace, the scene from last night’s TV transported me. Two, three or four people indignant that one of their own could espouse such corrupting views. Such extremism.

Being shouted-down at a young age isn’t pleasant.

I felt for the woman last night.

When people are young and, I guess, idealistic, it is desirable that they see the world through the eyes of others, perceive the suffering of those in pain and distress. We need the right and the left, we even need those who aggressively suppress any other point of view;

It is just sometimes hard to take.

I guess we need those people who can take a beating and come back for more, who can’t ignore their beliefs or principles.

Bring on the pacifist…


*Gah, on a Friday night, avoy.

the tribe of judag.jpg

12 tribes

Everyone enjoys a crisis (unless you are a patient)

Last night I wrote about Sebastian Junger in conversation with Joe Rogan.

Now, I am not wanting (yet) to promote the blog – I still haven’t worked-out whether I like it or not (cf Hardcore History – which is all good; go listen!). Anyway, this interview was incredibly rich in substance, deep in its analysis of different, essentially, existential questions, most of which followed the publication of Junger’s book ‘Tribe’.

Junger talks about the evolution of humans and the reality that we as a species have evolved for most of our history to live in small intimate groups leading lives that expose us to significant challenge, which in turn bond us together creating a sense of wellbeing.

Or, at least, words to that effect.

When you compare this to modern society, for all that we are tribal in our hearts and souls, we are mostly not bound by threat or challenge. For the greater part, we in the UK, the US and other post-industrial nations, lead lives of benign comfort. Even those at the peripheries can still rely that our fragmenting society will hold them together in times of need (you can always turn-up at the front door of A&E for example).

A consequence of this dissemblance is that our groups are loosely held together, and because of the weakness of these bonds, our tribal structure is tested. Give a man a McDonalds and he’ll eat it; give him a thousand and he’ll develop metabolic syndrome.

Crises however have an effect on society, in their imposition of a real or perceived threat, we are drawn more closely together.

I experienced a mini-crisis this week in the hospital.

Very early in the morning I was alerted to an issue with bed availability. Well, at first it was just a message inferring ‘a problem’ – it subsequently transpired that the hospital had run-out of beds; patients were waiting too long in A&E, to the point that the hospital had moved to a state or red-alert, diverting ambulances to a nearby hospital, for several hours.

This was I am sure the correct thing to do at the time, although as happens not just in the NHS, but any large organisation, people moved into a state of crisis.

I won’t go into the details, although by the end of the day everything had settled down and the system was ticking-over with patients flowing as they should. (Through an albeit damaged system – thanks Jeremy & Theresa).

The thing is, this transient crisis resulted in people coming together. I felt a new closeness to colleagues; when the going gets tough, people collaborate – that is the human response to challenge; it plays to our core; provide existential threat and if we have a tribe, we will cooperate, collaborate, join.

The Blitz and 9/11 are classic examples. Refugees thrown together, expats, military units. Sure, the experience at the time can be horrible, painful, traumatic, but, the closeness to other humans consequent upon these events is unique, precious, it helps shift meaning into life.

And, yes, perhaps a paradox, only when we are most threatened are we most alive.

You can’t generate crises (well, yes, some leadership textbooks say you can, but this is a finite resource). You can however probably seek commonality with others and band together.

People don’t have to suffer or die for us to recognise the common themes that bring us together, that add meaning and substance to life.

Seek out your tribe and enjoy.


Left v Right

At last I’ve got it.

It has been a thing that has challenged me for most of my life. (Or, at least, since the age of reason).

The conundrum that is left and right; I am unsure whether to capitalise; for consistency I won’t.

Why is it that some people see the world from a conservative viewpoint – maintain the status quo, Capitalist, everyone for themselves, primus inter pares approach and others sit on the opposite extreme – share, equality, peace now, etc.

Before proceeding, and, in the interests of full disclosure I’ll reveal that I am to the left of centre; sure, when I was younger I was probably more to the left of the left, now, as I settle towards middle-aged I accept the inevitable.

Some things appear so self-evident.

Tax the rich and create safety-nets for the poor and the disadvantaged; provide free education and healthcare; you know the sort of thing. Tolerate different races, backgrounds, heritages and styles. Live and let live.

Well, these are my reality, obvious to me when I look-out on the world, when I consider how things should be.

I accept, or perhaps more, acknowledge that not everyone thinks the same.

I want to acquire more capital, so I can buy that house and have that car and buy those clothes and drink that wine. Money, money, money.

All people are equal; some more than others.

I had better get to the point before I lose everyone’s interest…

It was this week, listening to the Joe Rogan Podcast – brought to me thanks to my amazing nephew David, specifically the one where he interviews Sebastian Junger. The uber-cool American, former war journalist (and past friend of Tim Hetherington) – see Restrepo if you want to learn more.

They were talking about evolution. Well, that, genetic inheritance strongly influences political persuasion; according to Sebastian, 50 per cent of an individual’s political affiliation is genetically inherited.

If your mum is a Tory, the likelihood of you being one increases, mum and dad, the odds are doubled.

This doesn’t take away experience, nurture and self-determination, it is just a factor, albeit a significant one.

Well then, if your political persuasion is inherited, the degree to which you affiliate with left or right, there must be some evolutionary imperative related to this. Why are we not all on the left of the left?

Imagine a society, or, perhaps a tribe where everyone is a tree-hugging lover of all; they probably wouldn’t last long in the struggle for survival, they would be overcome by others who see the world through greed and gain and expansion.

Equally, if the place is over-run by little fascists, mini Mussolini’s goose-stepping their way to conquest, the community will ultimately freeze, overwhelmed by suspicion, paranoia and self-destructiveness.

Society needs both; the creative and the material, the accountants and the dreamers, the numerate and the metaphorical. This balance allows give and take, within a democratic process it provides breathing-space to flourish, to transform.

When I next see Farage (or May or Johnson) spouting negativistic rhetoric – I can now gain a better perspective; they are half of the moon. I am the other side. I needn’t fear. I will not change, oh, no! But, I will now appreciate the difference, perhaps use this knowledge to my advantage.

And, don’t see me as lily-livered, don’t consider my expansiveness a weakness, for without me, you’d petrify.


[96] A


I’ve written before about our local pond; mostly my observations about ducks and their offspring, oh, and there was the slightly ungainly goose I named Ewan.

There isn’t much to it; a round of tired concrete, a few benches with surrounding cherry and sycamores. Old folk sit, the ice-cream man visits at weekends when the weather is good.

Most recently signs were erected, tastefully done with a leafy background requesting that visitors not feed the birds bread. It explains the harms associated with carbohydrate loading in ducks and geese – obesity, arthritis, difficulty surviving the winter and suggests alternatives – shop-bought bird food, grain, millet. Ducks love millet.

Today I found a woman throwing little scraps of white Hovis to the birds; like children they don’t know that what tastes so good is bad for them, they just get the gluten-hit and paddle-off.

I double-checked the sign, considered whether I should say something, and, walked by. I didn’t smile.

Funnily, the podcast itself was about the birth of the McDonald’s French Fry in the 1990’s – beginning with the original production-line milkshake story in San Bernadino in the 1940’s. You can get it here.

It seems that a guy called Sokolov, after suffering a heart attack in his early forties went on a crusade against saturated fat and ultimately made the food chain, and others across the US switch from saturated beef fat to vegetable oil for chip (fry) preparation; this led to a whole number of unforeseen complications the least of which was the inadvertent generation of combustible clothing and aerosolised formalin.

I didn’t say anything to the woman; I am always troubled when I see someone pointing-out the obvious to another; putting aside the gender issue, which I think is a thing i.e. man asking woman to stop feeding the birds and man vs man or woman vs woman or woman vs man, no, this isn’t a gender politics subject, it is the whole unknown of what the woman is experiencing – where she is at and how she might take it; strange guy with albeit friendly dog lecturing on fowl nutrition at five on a Sunday afternoon.

I have the same issue at work when I see bad behaviour; there is the bad, bad behaviour, perhaps someone saying or doing something that is hurting a patient – I think in this instance we are all happy to step-in and say or do something (the risks of inaction are greater than the theoretical hazards of action); it is the more subtle situations – porter with patient bumping along corridor, catering staff talking too fast for old person to determine the menu, doctor with impenetrable handwriting or accent.

Sure, there is a correct way to do this – not dressing-down in public, taking the person aside afterwards, asking them about their actions, probing, analysing, yet, in a hospital environment that is one big cauldron of business and clinical activity, this is often not possible, and things are forgotten.

I see a connection between the low-fat chip, the bread-eating duck and the too-loud nurse; you can do something, say something, but there is always a risk of causing offence, equally, and particularly as was the case with the chips, you risk unintended consequences – fat-fried potato versus vegetable oil; stodgy versus crisp and fluffy.

It is important not to over-analyse our actions, to achieve a certain level of spontaneity, considering the feelings of others, their stat