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Wednesday, November 30, 2016

Non-suicidal self-injury in the over 40s (A free download)

This paper is drawn from ANESSI - our large Australian national epidemiological study of NSSI.
For this study, we looked at all the people in the study who were over age 40 and had in the past, or had recently self-injured. Makes for interesting reading.
The full paper (pdf) is Free to download from OMICS (Sunnyvale) Copy and paste the following doi 

'6:5 DOI: 10.4172/2161-1165.1000266'
in your browser
Martin, G. & Swannell, S., (2016). Non-Suicidal Self-Injury in the over 40s: Results from a Large National Epidemiological Survey. Epidemiology (Sunnyvale) 2016, 6:266. doi: 10.4172/2161-1165.1000266

Self-Harm in Children under 14 (Free Download)

Another free to download paper. In many ways this is a unique sample, even if the study is fairly small and based on an impatient sample - with all the difficulties that case-notes can provide.
Palmer and Martin, 2016. Self-Harm in Children under 14: A Comparison of Inpatients Who Self-Harm with Those Who Do Not. J Child Adolesc Behav 2016, 4: 302. 4:3, (2016)
http://dx.doi.org/10.4172/2375-4494.1000302
http://www.esciencecentral.org/journals/selfharm-in-children-under-14-a-comparison-of-inpatients-who-selfharm-with-those-who-do-not-2375-4494-1000302.php?aid=76279

Friday, October 28, 2016

Haiku on Compose/ Wander/ Repeat/ Paradise

I am now composed
Words dancing to the music
My heart in the song

Decomposition
Political parties smell
Self-interest rules

Compose yourself dear
La Gioconda smile please
We're ready to paint

It is a Monday
What shall we all do today?
Wander round the shops

English football pools
Wolverhampton Wanderers
Just one of the names

Staying on the task
Sometimes very difficult
The mind can wander

You can unsubscribe
As many times as you like
Repeat junk mails come

I repeat myself
Sincerely apologise
Or did I do that?

Repeat after me
So I just said: 'after me'
And got detention

Feathers all over
A rich transvestite costume
Bird of Paradise

In Paradise Road
House signs 'Shangri-la', 'Heaven'
One even said 'Fool's...'

Took me time to learn
Paradise is where you are
May I stay here, love?

Thursday, October 27, 2016

Making of a Child Psychiatrist: (55) Moving towards General Practice (4)

And so I learned about grief. The next few weeks were grindingly horrible for everyone. We each of us lived in our own puddle of sadness, trying to reach out to support each other, but struggling with what felt like a catastrophe.
I had to keep on with my work; after all I had only just begun a few weeks before. I wanted to walk away, but kept going having no idea about the accuracy of diagnoses, the quality of my work, and development of relationships; I just do not recall. I do know I had little energy or enthusiasm, and finished each consultation as soon as I decently could. Word had travelled fast, so there was the occasional condolence from people I barely knew. What do you say in return, but a bleak “Thank you”?
I was numb. But there were also times of extreme anger that an experienced GP did not actively follow up a smoker in her 50s with a chronic productive cough, who came from a family that included a history of cancer in the extended family. I swore to myself I would do better than that. At times I wondered whether I should report the GP, but I did not know how this was done, and just felt too empty of energy to follow through with what became just a repeated internalised threat. Was I angry with the staff at Ramsgate Hospital? How could I be when David and his whole team had tried such heroics? It was not their fault that it was too little too late.
When I was with family, I must have been very preoccupied. Even here I cannot remember much except the subdued tone of family discussions. So, I know there was a funeral, and have been reminded it was at St Saviour’s church where I had been a choirboy, where we had been married, where Jonathan had been christened, where Jan’s sister Wendy had married her Jim on the 24th April 1970, and where we planned to get Roderick christened. A ‘family church’… from which I wanted to run away. To my mind God had played a cruel trick piling life and family events on top of one another, perhaps to see whether we would survive. I have no idea who was at the funeral, but have been told that my Martin grandparents from Sydney were in the UK prior to going on a European holiday, perhaps even originally planned to include Eve and Ted. I assume they were there, as I assume family members from the May side also gathered. But I do not have a visual recollection; I guess I just wanted to close my eyes and run away. Then there was a journey to the crematorium. I do not remember driving there, nor do I remember what happened. I have always been the family photographer, but there are no photographs I know of from these gatherings. In fact, I became almost unable to plan taking photographs for well over a year. I was not aware of this at the time, but was brought to the realisation of it many years later when Rod asked us why there were so few photographs of his early years compared to those of his brother. He was not impressed, even when we explained.
Work was a distraction. I buried myself in the daily routine. Other distractions were attempted. I had formed a strong bond with Nigel, one of the male staff on the Obstetric Ward. As one of only two junior males in a women’s world we tried to back each other up when necessary. During work breaks or down time, we played cards in a common room, and I began to teach him bridge. After work, from time to time we sloped off to a local Casino that had only recently opened up in Ramsgate. Given my history as a medical student, I had ongoing ambivalent feelings about wanting to play poker. On the one hand, it was exciting and I thought I knew how to play. On the other hand, watching the games unfold it was all too rich for me and in the end I kept to my old Med School promise and never did sit down to play. I did play some blackjack and came out sort of equal. I did enjoy playing roulette and did some background reading on systems and odds. I had a couple of spectacular wins, but over time gave it all back. So I decided to not ever do that again as well. But the bright lights, the hubbub and the energy of the place did provide distraction. It did not fix the real problem, it did not make me a good family man, and Jan was to make that clear a couple of times. I gave up. Nigel was to become one of Rod’s Godfathers, although we lost touch very soon after I immersed myself fully in being the local doctor and settling down.
Even at that time, I formed the idea that distraction does not work. Working in the practice there would be moments when I forgot that I had just lost a precious person whose smiling acceptance, support and unfailing love had begun to shape the kind of person I was becoming. But then I would be driving to a home visit and have to pull over, turn the engine off, and just sit (and occasionally blubber). Or there would be a small reminder, a word or an image that would bring back a small flood of memories. And yet, Ted, Eve and Andrea had been in Australia for three years in my late teenage years and after the family got back I was engrossed in medicine and my relationship with Jan to the point that we rarely met up. No difference. In fact I may have been regretting those distances or absences. Like everyone else, you go over and over old images and tapes, searching for something you may have said or done wrong, something regretted. The phrase ‘if only’ can preface many of these micro-conversations with your self. I was grateful that I did not feel guilt about the last few months; I had recognised the problem as soon as I was informed and had done the best we could under the circumstances, even if it did not change the ending.
I know that others were grieving around me. Jan was struggling in her way, and I am sure I did not provide anywhere near enough support for either her internal struggle or her day-to-day management. As has happened too much throughout our marriage I withdrew into myself, and needed to work it out on my own. This is probably best described in modern terminology as ‘conservation-withdrawal’, not really a depression, rather a ‘reculer pour mieux sauter’ (a pulling back so you can jump better next time). But fancy terms don’t help maintain relationships, and I have been ever grateful that my soulmate in life has been prepared to suffer my vagaries.
Gradually, I found myself enjoying little bits of life again. A conversation over an extended family meal that included joyful old family stories might provoke laughter. Watching Jonathan struggling on the garden slide would provoke anxiety, care and an amusing story to be told. Watching Jan with Roderick developing the bonds that still exist today would provoke a rush of love and appreciation. My energy for life returned. Part of this was the need to find a home in Birchington. We came across a spectacular older style stucco house with lead lights and oak flooring and doors – an updated copy of a modernised copy of an Elizabethan design. It had high walls containing a simple garden, and gates apparently rescued reputedly from the old Bank of England in Threadneedle Street in London, with ornate dates (1826) in the design. The house was called ‘Old Gates’ and the address was Coleman’s Stairs – which made the whole thing very cutesy. We thought it beautiful, but the asking price was £14,000, somewhat more than our first home in London. The bank was once again very reticent to lend us money even though we had a deposit and guarantors, and I was in the process of becoming a local GP. Eventually an ultimately bad compromise was reached. The house was on the centre of three blocks, and the two outer blocks would be sold separately for houses to be built. The bank was prepared to lend the £9000 we needed for the house and middle block. So with a flurry of activity, and considerable help from extended family, we moved in.
There was so much to do and in spare time we buried ourselves in practical tasks. The small dining room needed a fresh look, and Dad came up from Bristol to share his wallpaper hanging skills to help turn it into a very smart little room. The kitchen was primitive and elderly, so I decided to clad the walls with pine boards and build a small and comfortable breakfast area with red padded seats complete with storage compartments underneath. In the summer I hired an extendable ladder and a backpack and cleaned up the stucco, spraying on a fresh coat of white paint. Later in the year as autumn emerged, I found some do-it-yourself double glazing that I put in place on the upstairs windows to take the pressure off an elderly boiler driving equally elderly large bore central heating throughout the ground floor.

We were settled, close to the practice and not far from the shopping centre, just up the road from a much loved aunt and uncle of Jan’s, a short drive from Jan’s parents, enjoying our growing family, and in our own home. Given all the changes leading to a more settled existence and the passage of time, we healed.

Wednesday, October 26, 2016

Making of a Child Psychiatrist: (54) Moving towards General Practice (3)

We moved into an upstairs Kingsmead flat, and Jonathan enjoyed having access to his grandparents and a house to roam when his little brother was taking his mother’s attention. He had always been rather an independent little explorer, and on one occasion had gone AWOL from our hospital flat, walking to the local shops on the path next to a main road. Luckily someone recognised him, and he was returned safely. The Kingsmead rear garden was walled and had an expanse of grass, so it was safe to let him run without fear of major injury. We were happy with our extended family, and felt settled and supported.
I began my steep learning curve in general practice, trying to get to know the geography of Birchington and the most economical way to find a particular house, meeting new patients and their families and trying to get a handle on who was related to whom. This was before computers, so we had cryptic little notes in Alan Bowie’s elegant longhand on slim ruled buff cards in packets all sorted in alphabetical order in a wall of little boxes. The clinic staff were welcoming, provided rapid access to notes, and seemed to know which forms needed to be completed for blood specimens. I did not yet have my own prescription pad, but was able to use temporary pads after I had introduced myself to the two pharmacists and their staff in the village. In particular I got to know our three midwives, two district nurses, and a health visitor – everyone keen to tell me about what they did each day, which patients were struggling, and who might need home visits.
Home visits occurred after a morning surgery, and there was always a short list. With luck I could get them completed before heading home for lunch. I found it a strange process knocking on front doors explaining who I was, and then intruding into people’s privacy, sitting in lounge rooms absorbing the atmosphere, meeting other family members keen to meet this young man trying to hide his baby face with an emerging beard. Trying to gain a sense of the history of the current problem and what might be necessary was sometimes easy, but often complex. Patients seemed to be on a plethora of medication, but I decided not to change things too quickly given I was the ‘new boy’, and did not want to be dismissed as a meddler until I felt I was on secure ground. Sometimes I would meet up with one of the nurses in the home, and they were able to both inform my practice and translate so that everyone could understand. Eventually it dawned on me that a home visit was a rich insight into people’s family relationships and manner of living, whether they were wealthy professional people using their holiday or weekend home or those on welfare living on the local caravan site.
Two afternoons a week, I had small antenatal clinics where I had a shared arrangement with the midwives, and was happy to be guided by them until I knew better (which did not happen often). The strange situation was that almost all the babies in the practice were born at home and, while I knew them all through the antenatal clinic, I was only called in if there were signs of impending problems, or if I needed to do some suturing (and even that was surprisingly rare). We did have the possibility of using what was called a ‘Domino Scheme’ arrangement with the hospitals such that if a birth began to look complicated an ambulance was called, the birth occurring in hospital but involving our practice midwife. There was then a rapid 24-48 hour return home as soon as everything had been sorted. Efficient, great for continuity of care, and good for family and community cohesion. I only remember this program being used for two of my patients during all my time in the practice. Of importance, I don’t remember any losses of either maternal or infant lives.
Once a week I was expected to drive to St. Nicholas, a tiny farming village with two main pubs for a population of only about two hundred people drawn from two main family groups – the ‘Beans’ and the ‘Loves’. It took me ages to begin to understand the generations, and a curious part of me was always on the rather fruitless lookout for possible genetic inbreeding.
The ‘clinic’ was a large room at the back of the local church, with wooden chairs and an oversized oak table. The waiting room was the front end of the church replete with pews and, of course, everyone knew everyone and everyone’s business. There was no equipment and no drug cupboard, so I learned after week one to ensure I took everything with me. I think for many weeks I was an object of curiosity, and it seemed to me that many symptoms were trumped up just to get a look at this new doctor person. Farming people are incredibly resourceful, and have their own ways of managing illnesses. I had to be very gentle, very patient, and very respectful. Word travels very fast in the local pub.
One of those cases you never forget was man in his 50s complaining of epigastric pain. When I explored the history he had had it for at least two months, gradually getting worse. It did not seem to be related to food or alcohol, though a sense of fullness seemed to make it worse. He had had no vomiting, but when I questioned him, from time to time there had been some rather tarry black stools over the previous few weeks. I examined him in the chair, but really needed to examine his belly with him flat on his back. I don’t know what the vicar would have thought, and I don’t know whether he or the church council ever found out, but with my patient stretched out on the ancient table with his head on a jumper, I examined his ‘soreness’. He had a solid mass about the size of an orange where his stomach was, and it was tender to touch. He was not jaundiced. I got his wife in, and explained to the two of them how concerned I was. I wrote a brief letter in long hand explaining my findings, and phoned for an ambulance to Margate Hospital. I am not sure he was happy with ‘this new bloke’, even if his wife popped in the next week to tell me what had happened. When the opportunity occurred, I did a home visit, only to find out he was on the back of a tractor somewhere out towards Reculver. He was to survive fairly well and active for almost two years.
I was six weeks into this new life learning how to be a father to my two little boys, attempting to help Jan whenever I could, and the complex steep learning curve of being a local doctor, when I phoned my parents in Bristol to begin to discuss arrangements and a date for Rod’s christening. My father answered the phone and seemed unsure about what he and my mother might be doing. Eventually he came clean and admitted he had been worried about my Mum, who had had a recurrent cough, and had been to her local GP but was not really getting better. He was a little thin on detail, and so I asked if I could speak her. He shouted up the stairs, and there was some discussion, but eventually Mum came down, coughed to clear her throat, and rather quietly answered the phone. I could hear that she was breathless, and that made me curious and anxious. It is unusual for people to get breathless coming downstairs. Bit by bit I dragged the story out. She had had a cough for several months. Yes, there had been phlegm that varied in colour from cream to green. No, it had not changed much despite two courses of antibiotics. I asked if there had been blood in her phlegm. There was a long pause, but when I pressed her she admitted to small amounts over the previous two weeks when she had had a coughing fit. Did she have chest pain? Yes, a nagging dull pain down the left side. Had she had a temperature? No, not really. How long had she been breathless? Possibly over the last couple of months, and it seemed to be slowly getting worse. Had the GP listened to her chest? Yes, the first time, but not since. Had the GP organised an X-ray? No. Did she have another appointment? No. What I knew about my mother was that she had been a smoker of 20 cigarettes a day since forever. I was not just curious now; I was scared.
I asked her to put Dad on the phone. I went over the story, and he added a couple of bits of information. Mum had actually been smoking a bit less recently. She had never been a very physically active person, but really did not want to go anywhere, even in the car. We discussed the local GP, and Dad was obviously furious that so little had been done. I suggested the situation was serious, and demanded he pack up the car and drive to Westgate so that we could get some expert attention for Mum. In the meantime I would phone a consultant physician I knew from student days – Dr. David Lillicrap who had provided the most amazing clinical experience and supervision for me at Ramsgate Hospital in the run up to my finals.
The nearly 4-hour car journey from Long Ashton to Westgate must have been awful for the two of them. My sister Andrea was told they had to stop the car several times for my mother to vomit. She was certainly exhausted when she arrived, and not keen to eat dinner. In contrast she was very keen to hold Jonathan and then her new grandson, which brought smiles and tears. She looked drained, dispirited, and I am sure she knew she was seriously ill. I listened to her chest, and apart from all the crackles I could hear when she breathed, there was an obvious change in tone to percussion about two thirds down her left lung suggesting a pleural effusion. She knew that I knew she was seriously ill, but at that point I simply muttered about some consolidation suggesting a pneumonia. We settled her into bed, and time seemed distorted between then and the urgent appointment David had very kindly arranged for the next day.
David’s news was bad. The Xray had shown a large primary cancer in the left lung with a pleural effusion. In addition there were spots across both lungs suggesting what he called miliary spread (spots everywhere) of metastases (secondaries). He had discussions with a colleague and his team, and they were prepared to try aggressive high dose chemotherapy, but he did not hold much in the way of hope. I explained it all to Dad, and he wanted whatever could be done to be done. David spent a lot of time with Mum explaining the treatment, noting she would have to stay in hospital, and would not be feeling well as a result of the chemicals.
We all lived a nightmare for the next few weeks. Dad spent hours with Mum at the hospital, and was like a shadow for the rest of the time. And, of course, he had the duty to tell Andrea, who needed to take leave from her Teachers Training Course in Totley, Yorkshire, to come down to be with Mum as much as possible. Jan was quietly withdrawn and had to focus on the two boys, but did get to see Mum in hospital. I went to Ramsgate Hospital to sit with Mum as often as possible after evening surgery. She was very unwell from chemotherapy, and distressed that her rich curly brown hair was falling out so quickly. She was amused to have been measured for a wig, and was enjoying wearing different headscarves, but distressed she was stuck in a bed and not getting out into the Spring sunshine. She reported the staff as having been very attentive and kind, although the hospital was old, the paintwork drab, and there was an absence of anything like a view.
I had a time with David Lillicrap about three weeks into treatment, after a set of follow-up Xrays. These were showing very little change in the cancers, though the pleural effusion had receded a bit. He told me that they could not give Mum more treatment than they had given her. They had been as aggressive as they dared, and her body had coped, but there were no other alternatives. He had conferenced her case with several colleagues, but could not hold out any hope.

Mum knew. One evening she said to me: “I’m going to die, aren’t I?” Sitting on the bed, I had to tell her what David had told me, and finished up with having to tell her that she was going to die. She smiled, telling me it was alright, and we wept and held each other. She asked if I had told Dad what I had been told, and then asked me to tell him so that they could discuss it together. I did so; but he had known. He almost lived at the hospital for the next few weeks. Andrea had to return to Totley to start a four-week teaching practice. The day she went, Dad stayed with Mum all day, coming home late in the evening; he looked grey and spent. The following morning we had a phone call to say she had gone. So then Dad had to phone the College Bursar who had to inform Andrea of mum's death, and organise for her to travel back to Westgate. Louie Evelyn Martin died on the 1st June 1970. She was 50.

Thursday, October 20, 2016

Making of a Child Psychiatrist: (53) Moving towards General Practice (2)

My last day of working at King’s was 20th September 1969, and we were due to move into the flat at Margate General in mid October ready for me to begin work.  Our little East Dulwich first family home had to go back on the market to make us a small profit and pay off the bank. The in between was a flurry of activity, sorting furniture and transporting it down to Kent in a van driven by my brother in law Jim, husband to Jan’s older sister Wendy. Luckily the summer seasons at Kingsmead were over, and Jan’s father had begun to convert the hotel into apartments. So there was temporary storage space for our belongings as well as us. I know that Jan’s parents, having always been family oriented people, were utterly delighted we were moving to Kent and would be living and working just up the road. Jan was delighted to be coming home, even though she had been forced to give up her job with all the respect it gave her as a professional. We created upheaval, but nobody seemed to mind. I guess that is the wonderful thing about family life.
We also had some family news. Jan had missed several periods, and was certain she was pregnant, with our new family member due in early April. So everything was new and full of promise. We no longer had a house to call our own, but that could be organised during my time at Margate.
One of four in the block, our ground floor flat was functional, sparsely furnished in a simple utilitarian way, and it had its own small fenced garden and a car park.  Jan did not enjoy it. Perhaps it was not ever to be a part of ‘us’. She was pregnant, and it was too empty and clinical to ‘nest’. Unfortunately there was also a constant smell of curry permeating the entrance hall and our flat. Both Jan and I love a good curry from time to time, but the couple of doctors upstairs were from Pakistan, and so curry seemed to be on the menu every day. Add in Jan’s pregnant state, a hyperawareness of smell, and my absence during working hours, and she preferred to be elsewhere. The problem was that she did not yet drive confidently and independently, so she had to catch the bus into Westgate to be with her parents or with an Auntie Kate, who was to be very supportive over many years.
The entrance to Maternity was a short 100 metres away from the flat. So I was able to get back to the flat for lunch when Jan was there, and was also home early after work, even if it was a bit too convenient for staff in need of a doctor urgently – even when I was not on call.
The Director of Obstetrics was Dr. Jean Burton-Brown (‘Miss Burton-Brown’, as she was known), who came from an august family of eminent surgeons who had served England and the Empire over generations, with a great grandfather in the Bengal Medical Service, a grandfather who was a Brigade Surgeon in the army, and a father who had been a surgeon in the navy. She had qualified somewhat late at the age of 32 and been a doctor during the London Blitz, gaining her membership of the College of Obstetricians and Gynaecologists in 1944.
She had an immense reputation for her gynaecological and obstetric work in Kent where, for over 20 years, she had developed the services against the odds, and overseen the building of the Maternity unit. She was highly esteemed by nursing staff who were certain she would always be there to back them up. But I suspect that when I joined the staff in 1970 (when she was only three years away from retirement), she had had her fill of jumped up young men who knew very little. She had high expectations, could be dictatorial if you did not listen, did not follow protocol or were a bit uppity. She could be scathing, and in the early days I came in for several dressings down when I had not completed a task to her liking or to her standards. I learned rapidly to toe the line. Luckily, given my experiences in Plymouth and at King’s, in the day to day business I was always ready to learn from nursing staff, and not embarrassed to get something checked out. I was also happy to refresh my obstetric knowledge through my ever present Brudenell textbook. Given my past experience of surgery, I don’t know how I would have managed as her Gynaecology house officer. But, Obstetrics is almost always a happy process with positive outcomes, despite occasional human interference. So although there were clinical panics from time to time, the staff were a happy constructive lot, and the 6 months from the work point of view passed very happily.
In retrospect, and although I would not have been conscious of it at the time, I am certain that my psychiatric experiences played a role. Most births are not traumatic in a long term sense, but if things begin to go wrong, the possibility of lifelong trauma is a serious issue. I knew that people survived trauma much better if their anxieties could be soothed. So there were several pregnancies that just did not want to go into full-blown labour, despite hours of waiting and special drips. Sitting, listening to life stories, soothing anxieties and keeping a positive demeanour certainly did no harm, even if you could not measure the good. Sitting with, and listening to, anxious or angry husbands who were demanding action where none was appropriate, seemed to help everyone. It was a form of abreaction without the use of Ether or intravenous injections. I was often threatened with violence because I was somehow seen as responsible for a circumstance. “You’re the doctor; you should be doing something!” But although there had been stories bandied about, violence to person or property did not occur during my time.
I found myself having the most ordinary of conversations while masked and begowned, completing necessary sutures. Similarly on two occasions, I had to complete manual removals of recalcitrant placentas. Here you are doing the most odd procedure, and listening to the most ordinary of discussions about the future plans for a woman and her new family.
I was never to be in charge of a caesarean section, given my youth and inexperience, but I was always happy to assist. In those days it was not a lifestyle choice, it was an emergency procedure to save the lives of both mother and child. They were such joyous occasions, and there was always that sense of having beaten the odds.
Our second child was due to be born in the maternity unit on 6th April. The issue was that if he was born prior to April the 5th, we would recoup a whole year of tax. So what, I hear you say. Never muck about with nature. Just let life take its own course. We discussed it again and again. We certainly could do with the money. The word from several of my midwife friends was that a dose of caster oil would create strong bowel movements, and that this in turn would prompt labour if Jan and the baby were ready. We decided to take the risk on 31st March, and with a mix of excitement and concern Jan swallowed her medicine.
Early the next morning, we both woke to an audible thump, and Jan had a strong urge to go to the toilet. Within minutes, there was a cry of need from the bathroom, and Jan announced she was in labour and frightened she would deliver down the toilet. We moved her step by step back to the bed and gathered her ‘ready’ bag. I raced across the tarmac into Maternity, grabbed a wheelchair, and charged back to the flat. We then raced back up the slight incline, through the doors and down to the delivery suite where our Roderick was born about 20 minutes later – our April Fool son, apparently no worse for his precipitate journey. So the whole labour was about 45 minutes from ‘thump’ to a newborn’s cry. I was so glad I was working in the unit, so glad we had a flat so close, and so grateful to the midwives at 6.15am on April 1st. I wished we had not challenged nature. There is always a cost to such manipulation.
Part of the cost was that Jan had a slight perineal tear, which may have been avoided if the skin had had time to stretch. I phoned Jan’s consultant, an older man usually very amiable. He refused pint blank to drive all the way from Canterbury at that time in the morning just to do a few stitches. Suggesting that I had had loads of experience and should do it myself, he put the phone down. I was appalled, and just could not bring myself to do something that I felt was not quite right. We organised one of the nursing staff with some prior experience and I supervised the process, still seething. Jan was to stay on the unit for the next 10 days, in part because that was the routine, but also because Rod became quite jaundiced after 2-3 days, and his bilirubin levels rose to the kind of levels the paediatrican thought might need transfusion. Luckily I had followed protocol and taken a sample of cord blood. So we were prepared. Jan was advised to give up the attempt to breast feed because there might be a sensitivity to breast milk. She had been so keen, and was deeply saddened and somewhat affronted. Rod stayed in neonatal intensive care for several days under bright lights, on a drip, and wearing eyeshades to protect his eyesight. He was to have food sensitivities throughout childhood.
There was a grand sense of closure to my six months, and Miss Burton-Brown took me aside about a week before I finished up. She actually thanked me and showed a faint smile; I have to say I was immensely grateful for her tutoring. However, she had to have the last word. I was going up to London the following day to do my Diploma in Obstetrics exams. I had been growing (what I thought of as) a very hip young man’s beard since my time in psychiatry (don’t all psychiatrists have beards?) She had told me on several occasions that beards were filthy things, harbouring germs likely to infect pregnant women and their newborns. She had never reached the point of demanding I remove it, but certainly had maintained the battle line. She told me forcibly that if I tried to do my Dip. Obst. with a beard, I would be failed. I asked her if she was serious, and she repeated herself, turned on her heel and stalked off. The following morning I shaved off the beard, but felt quite denuded throughout the journey. I attended the College, wrote the paper, had my oral examination, and that evening returned home feeling I had probably done fairly well. The following morning I began to re-grow my beard.