Saturday, 31 March 2012

100 years today-Captain Scott.

Captain Scott wrote his last diary entry March 29th 1912,  knowing that his death was imminent despite being only 12 miles form safety. The atrocious weather, falling food supplies and exhaustion and weakness was all against them. His last recored words are painfully poignant.
Just before the walk South.
We took risks, we knew we took them; things have come out against us, and therefore we have no cause for complaint, but bow to the will of Providence, determined still to do our best to the last ... Had we lived, I should have had a tale to tell of the hardihood, endurance, and courage of my companions which would have stirred the heart of every Englishman. These rough notes and our dead bodies must tell the tale, but surely, surely, a great rich country like ours will see that those who are dependent on us are properly provided for.

I've been quite taken with the whole Scott thing since childhood. beginning with Scott of the Antartic, the 1948 film with John Mills in the lead role. I didn't see it when it first came out! More recently I really enjoyed Ranulph Fiennes biography. On a very hot holiday in Crotia I recall reading of Scott's persistence in temperatures of minus 40! It's a brilliant read, and has a wonderful picture of Scott on the cover. This particular photo of Scott is the first one you see at the current exhibition at the Queens Gallery, The heart of the great alone.

I lingered long over that picture. Reflecting on the pathos and courage I struggled to move on. It seems to capture the whole story for me. There was just something about British men of that generation. The  the extraordinary willingness of literally millions of men to join the carnage on the Western front is no less impressive.

'Bowing to the will of providence' may seem antiquated to our sophisticated ears, I'm personally glad that in one way at least, I share something with Scott. Belief in a providential God does not paralyse me, since as Scott goes on to say, 'I'm determined still to do my best'. Or as Cromwell is reputed to have said to his troops, 'trust in God and keep your powder dry.'

Wednesday, 28 March 2012

Spring in Olney

It's a joy to work in Olney, the town of Newton and the Olney hymns.


The back of John Newton's vicarage with the spire of Olney church in the background 
Here's some wisdom from the pen of Newton.

Waiting For Spring

Though cloudy skies, and northern blasts,
Retard the gentle spring awhile;
The sun will conqu'ror prove at last,
And nature wear a vernal smile.

The promise, which from age to age,
Has brought the changing seasons round;
Again shall calm the winter's rage,
 Perfume the air, and paint the ground.

 The virtue of that first command,
I know still does, and will prevail;
That while the earth itself shall stand,
The spring and summer shall not fail.

Such changes are for us decreed;
Believers have their winters too;
But spring shall certainly succeed,
And all their former life renew.

Winter and spring have each their use,
And each, in turn, his people know;
One kills the weeds their hearts produce,
 The other makes their graces grow.

Though like dead trees awhile they seem,
Yet having life within their root,
The welcome spring's reviving beam
Draws forth their blossoms, leaves, and fruit.

Yep God knows what he is doing in the winter of our lives!


Monday, 26 March 2012

It's difficult being a GP....

I've got a feeling that I have said this before-but it really isn't easy being a GP. We try our best not to over-prescribe for 'routine' viral illnesses, even when the patient clearly expects to receive an antibiotic. But every now and then we see a patient who is only mildly unwell who subsequently-and to our genuine surprise- becomes extemeley  ill the next day.

Eczema herpeticum-photo taken from open
access website: www.dermnetnz.org
I reflect on this because of an 8 month old baby I saw this morning. He wasn't especially unwell, but overnight he had developed a dramatic increase in the extent and severity of his truncal eczema, and now he also had some small, whitish macules with a surrounding erythematous ring which looked like the beginnings of chickenpox or perhaps hand foot and mouth.  I recalled a lecture from a study day at Great Ormond Street some years ago about the importance of diagnosing eczema herpeticum. It's  usually  associated with HSV (cold sore) infection,  and is a condition that can accelerate from an apparently mild local skin infection into a severe systemic disease, very quickly. It consequently needs anti-viral therapy sharpish. Interestingly the alternative name for this condition (Kaposi's varicelliform eruption), arose because of it's similarity to chickenpox (varicella).

A couple of weeks ago I saw a young mother who'd had symptoms of laryngitis for about 4 days. She was not especially unwell but by the next day she was in intensive care with an empyema needing emergency surgery to drain a chest abscess!  At the end of a consultation for mild infectious disease, I generally say, "if you worsen (I try to specify in what way I mean-in terms of intensifying of symptoms, or new and unpleasant features, or just a non-specific, 'don't like how things are going') please do get back in touch". I caught myself saying it today, and since  the reality is that in general practice one is nearly always seeing conditions at a very early stage of development, patient's need to know if,  and when, they should report back.

I guess I've learnt from bitter experience that some patients will just accept a worsening situation simply because they have 'seen the doctor and he says I'm not too bad'. Always give simple, specific advice about follow up.



Thursday, 22 March 2012

Silence is golden

Here's another quote from the Lent book by Drake which I am reading in the build up to Easter. It is written in the context of Jesus' encounter with the high priest at the beginning of his 'trial' in John 18.

The high priest then questioned Jesus about his disciples and his teaching. Jesus answered him, "I have spoken openly to the world. I have always taught in the synagogues and in the temple, where all Jews come together. I have said nothing in secret." John 18.19-20.
The most eloquent voice that reaches us to day out of the hall of Caiaphas is the Silence of Jesus. He was silent about His disciplesHe would not expose publicly their broken loyalty, their frailty and ingratitude, in the moment of their great weakness. He would be silent about them when He could not praise. How different is our silence. We are silent when praise is due, eloquent when fault is found. How careless we are of the reputation of others, even out friends! How we need to throw the vail of silence over those things which do not redound to their credit. Criticism offered by us in the spirit of gentleness, may become on the lips of others both untrue and unkind. How sternly we need to school ourselves to kind and generous silence.
And Drake goes on to note that it is not just that we (perhaps sub-consciously) want to lessen others, but that at base we wish to big ourselves up,
We are moved by the secret stirrings of pride, and self regard to show the intimacy of our knowledge, the subtlety of our insight, or the superiority of our conduct. Thus self poisons the speech. Beware of being drawn into the discussion of others. It is seldom free from grave and subtle spiritual sins. Save the criticism for the ears of Jesus. 
And so thoroughly chastised by this powerful and winsome teaching I repent and hope to save more of my opinions 'for the ears of Jesus'.

 

Monday, 19 March 2012

Fabrice Muamba, defibrillators and prayer.

How tragic to hear the news of the young Congolese footballer who collapsed during Bolton Wanderers game against Spurs. Like everyone else I l really hope he'll make it.

I gather he received defibrillator treatment twice on the pitch. I hope he received the treatment early enough because time is of the essence. I spoke to a representative of the Resuscitation Council today who say that if you receive defib treatment within 3 minutes of cardiac arrest, that you have up to a 75% chance of healthy survival. The success rate is dramatically reduced after that time.

I mention this because I was in email correspondence with my gym today. It is a well known national chain and they inform me that none of their gyms have a defibrillator. They tell me that they have had a risk assessment and have been graded as 'low'. I'm a little concerned at this, not least because about 5 years ago at the gym I resuscitated a man who collapsed whilst on a treadmill. He survived and subsequently had an implantable defibrillator fitted. Community resuscitation is rarely successful and especially without a defib machine. So it was a real joy for me to know that he recovered well and it was touching to receive a note of thanks form his grateful wife.

I gather all Marks and Spencer and John Lewis stores have defibs. Surely of all place gyms should have them too. When I was present at the gym at the time the man collapsed,  the young staff were like the proverbial headless chickens and assumed that the man in question had simply fainted. I understand that their training is in simple first aid which would include only a fairly basic understanding of diagnosis and resuscitation training.

And listening to an interview from a concerned representative of the Players Football Association, it was interesting to hear in his last remark that he was praying for Muamba. I couldn't help reflecting how counter-cultural such a statement is (especially on the BBC) when just about everything else in the media is so scornful and cynical of religion in general and Christianity in particular.

Sunday, 18 March 2012

A faithful creator

This morning at Grace our senior minister spoke on suffering as a Christian from 1 Peter 4. Ray mentioned four areas where a Christian's convictions and behaviour may clash with the surrounding culture.

  1. Belief in God a creator-there is much cynicism  about this
  2. Belief in God who will judge us all at the end of time
  3. Belief in the complementary nature of the sexes (there is a distinction in roles within marriage and the church despite both men and women are being equally valued by God. I accept that this point is difficult to explain adequately in a few moments and needs nuancin. The best place to read about this is Tim and Kathy Keller's new book, The meaning of marriage).
  4. Ideas about gender and sexuality. Same sex relationships
At the close of the passage are these words from Peter,
So then, those who suffer according to God's will should commit themselves to their faithful Creator and continue to do good 1 Peter 4.19
I've often thought about these words. Why describe God as a 'faithful' creator? The two words do not seem to naturally belong together.  Could it be that as I survey my life as a Christian, with all its challenges and inexplicable life experiences,  I can trust that the God who created the universe from nothing and disorder, is just as able to make something out of the disorder of my life? In other words as creator, God is creative, and I can put my trust in his faithfulness.

Friday, 16 March 2012

Just do one thing at a time

I've already had a bash about this in a previous post, but now there'e confirmation of the wisdom of just focusing on one thing at a time from the Harvard Business Review blog,
Tell the truth: Do you answer email during conference calls (and sometimes even during calls with one other person)? Do you bring your laptop to meetings and then pretend you're taking notes while you surf the net? Do you eat lunch at your desk? Do you make calls while you're driving, and even send the occasional text, even though you know you shouldn't?
The biggest cost — assuming you don't crash — is to your productivity. In part, that's a simple consequence of splitting your attention, so that you're partially engaged in multiple activities but rarely fully engaged in any one. In part, it's because when you switch away from a primary task to do something else, you're increasing the time it takes to finish that task by an average of 25 per cent.

Read the whole thing here and thanks to the excellent Trevin Wax for the link.

Thursday, 15 March 2012

Some things should remain a mystery

Those who know me best tend not to ask for help with their DIY jobs. I'm not sure why my  brother inherited all the DIY genes from dad, but as a result  I've had a lifetime of uselessness with all things practical.

And not only DIY. Take the photocopier at my office. I've been shown how to do double-sided copying so many times, and yet it remains a dark art. I have to ask for help every time. Thankfully there are willing colleagues at hand to rescue me.

But worse, there is the washing machine. I don't think I've ever recovered from my first week at university when I went to the local laundrette in south London and stood staring at the technology all around me Eventually I plucked up the courage to insert 10 pence in the machine for washing powder, pressed the button, and out came a flood of powder, all over me and the laundrette floor. How was I to know that I was supposed to place a disposable cup at the outlet?  Subsequently some old lady (about the age I am now!!) asked if I needed help. I was so grateful.

Even now I'm a little nervous of the knobs and am unsure about mixing colours, and what temperature is needed. Fortunately Biddy has it mastered.

Ok I should know by now, but at least it means I have the opportunity to experience community! Using a photocopier and washing-machine, for me at least,  involves inviting someone else to help me, nay to interact with me. And that's no bad thing. It's good to be asked for help, and even better to be the provider. Ok there's a limit, and laziness is not to be commended, but the principle is a good one.

And in the really big issues of life, like the  meaning and purpose of my existence, and what awaits me after death, and the reality of heaven and hell, and what I can do with guilt, don't we all need help? We need expertise that we just don't possess. Unlike using the copier and washing machine, no amount of self-help and practice will crack the code of life and eternity. We need a helper. The Apostle Paul speaks of the 'mystery of Christ...which has now been revealed to us'. I don't know how God does it, but somehow through the  mystery of Christ, of who he is and what he has accomplished in his life, death and resurrection, my life has found meaning, my conscience is calm and my future secure. All I 'contribute' is to gladly receive his help.

Wednesday, 14 March 2012

Guidelines are not rules

The practice of medicine is overwhelmed by guidelines.

Today I received a mildly assertive letter from a local hospital consultant who wanted to know why a patient had not been assessed 'according to the guidelines'.  I guess if such a consultant was to spend a day sitting in with me at the surgery I may well have to do a fair amount of explaining-deviating from guidelines as I sometimes do.

For me it all comes down to the practice of medicine as an art. Yes it's important to be aware of guidelines. After all they have generally been prepared by a group of experienced clinicians. But guidelines just do not allow for the unique individuality of each patient and each doctor.  Consider,

1. Each patient is one patient! Guidelines are based upon populations.
2. Each patient has a unique context in terms of, attitude towards medication, motivation to engage in treatment, age and comorbidity, medication which is already being taken etc.
3. Over a long career the doctor becomes attuned to particular drugs and their side effects, and knows what to ask during follow up with reference to side effects. Prescribing unfamiliar drugs, even though they may be recommended in the guidelines,  may not be best in the context of the exclusive relationship existing between one doctor and one patient.
4. A too rigid approach to investigation and treatment of each patient doesn't allow for the clinical instinct of the doctor, the tacit knowledge gained from experience which is hard to explain and even harder to teach.

Learning medicine is a life-long pursuit. It's a shame that just when you feel you're getting the hang of it, retirement looms!

Sunday, 11 March 2012

How to lead a service

Leading Sunday meetings doesn't just happen. It requires thought, imagination and some skill.

The Briefing has a surprisingly good article (Ok ok I find much of the Briefing a bit samey-but this is helpful stuff) on the subject. At Grace we have worked at helping each other to do a better job, something the Briefing would be pleased about!
If you’re going to make a start by improving just one thing about your Sunday meetings, improve your meeting leaders. Give them the training, the time, the resources and the authority to pull it together and make it work. Sundays will work better when someone is devoting real time to thinking it through, preparing it, and making it happen.

Read the rest here. 

Saturday, 10 March 2012

To sleep perchance to ...sleep?

Like much else in life, sleep is something we take for granted until we no longer have it.

As a GP I've become increasingly convinced of the importance of sleep, and of asking patients about their sleep habits. I guess I've had many consultations over the last 30 years where 'early morning wakening' has been flagged up and has often been an indicator of an underlying depression. But it wasn't until I read Counting Sheep:The science and pleasures of sleep and dreams by Paul Martin that I began to appreciate just what impact sleeplessness has. From  events of international significance, such as Chenobyl, the Shuttle disaster and the Exxon-Valdez oil spill, to personal irritability, fatigue and premature death!

Today's Times has a feature, 'Valium pills, Temazepam and melatonin: I've tried them all'. It's mainly a tale of caution about the over prescription of sleeping tablets. There's  also the usual criticism of GP's along the lines of,  GPs don't know enough about....(if I had a fiver for every time I heard that). Thus Professor Young from the Royal College of Psychiatrists,
'many family doctors fail to look more deeply at the physical or mental troubles that cause adults to suffer from insomnia'
I'm  not sure how Professor Young came to that conclusion. I've never had a psychiatrist sit in with me in my surgeries and I do my best to unpack the reasons for insomnia. I freely admit however that the subject is complex and is hardly amenable to the 10 minute appointments that we work to. Good sleep hygiene is a start. The open access web site for patients has quite a helpful article.

Wednesday, 7 March 2012

Echoes of Christ

A strangely compelling speech from  young American journalist Thomas Lake when at his old college.

He sees echoes of Christ's love in the stories he writes for Sports Illustrated.

Tuesday, 6 March 2012

Antibiotics for everyone!

I spend a fair amount of patient contact time assessing patients, especially the young and old, who have infections. The majority are not bacterial infections and are self limiting. Some friends tease me by suggesting that all you need to do as a GP is to practice saying 'it's a virus' and buzzing for the next patient.

It's undoubtedly good medicine to not over-prescribe antibiotics. They are after all a limited resource and there's no guarantee that they will keep pace without emerging infections. But trying to discern the patients who do need antibiotics is challenging. Over prescribing risks population harm, through greater drug resistance. But under-prescribing may lead to serious illness in the individuals seen on a daily basis.

I muse on this because of a recent experience where a fit young mother who presented with tracheitis became very ill the day after I had seen her with an invasive Strep A infection. According to the Health Protection Agency web site,

Who is at risk of invasive group A streptococcal infections?

Invasive GAS infections are most common in the elderly (> 75years of age, approximately 8 cases per 100,000 population) and the very young (The most common risk factor for invasive GAS infection is having a skin lesion (a lesion is an abnormality due to disease or injury) of some kind which provides easier entry of the organism in to the body.  A small proportion of invasive GAS infections start with a respiratory tract infection.
  • Other risk factors include:
  • Injecting Drug Use
  • Alcoholism
  • Immunosuppression
  • Diabetes
  • Malignancy (cancer)
Whilst recent childbirth is a potential predisposing factor for GAS infection, it contributes only about 4% of the total invasive GAS infections

None of those were relevant to my patient. How difficult GP is.

Monday, 5 March 2012

Chelsea managers and Junior British Officers

So Chelsea have now employed eight managers in eight years. Even my maths allows me to calculate that the average 'life-expectancy' of such managers is one year. This contrasts with the average true life expectancy of the junior British officer during the First World War. A mere six weeks.

I'm not too sympathetic towards these unbelievably overpaid managers, but I do have enormous respect for the brave young men who lead our soldiers in the chaos of the trenches in the 1914-1918 war.

A fascinating, humbling and truly riveting read is John Lewis-Stempel's account of the 'short and gallant life of the British Officer in the First World War'.. It's called Six Weeks.  I cannot speak too highly of this book. These young officers were ridiculously young and inexperienced and often were in the trenches within weeks of leaving school. Their leadership was exemplary,
The prime reason for the high casualty rate of (young) officers was that in battle officers lead from the front. In the words of Brigadier Frank Crozier an officer needed three seconds lead over the men, so he could say 'come on' instead of 'go on'.
Perhaps that was Andre Villas Boas' downfall. I gather he had never been a professional footballer. So I guess he always had to say 'go on' instead of 'come on'.

Sunday, 4 March 2012

Amazing Grace

Good old John Newton would have had no idea that his hymn, Amazing Grace, would travel the globe and beu more than any other hymn. To him the words he wrote were deeply embedded in his life.

Tonight at our evening service it was lovely to hear the stories of the three people who were baptised today. All so different in age and circumstance. I'll put the link on the blog when it's up on the church website.

We sang the Chris Tomlin version which I love.



For a more classical and beautiful rendition, take a listen to the Celtic Women.

A light touch

Just pebbles Its great to be back in the Hebrides. Although lots of rain is forecast this week, yesterday was a pleasant surprise. So we...