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Friday, March 31, 2017

Making of a Child Psychiatrist: (67) The General Practitioner (12); A bit more Child Psychiatry +

I would never say that general practice was onerous. Most of the time it was delightful to have responsibility for the care of my own ‘flock’. Much of it was very ordinary to my growing experience, even if frightening to some patients. It was a privilege to be able to relieve the anxieties with confidence.
Of course, Birchington was the kind of place where people had lived all their lives, or where they had retired from a lifetime of work in London 25 years ago and were now prone to the ravages of time and age. So, people had terminal cancers, or serious cerebrovascular accidents, or heart attacks, or their bodies just succumbed to old age. Part of the job was to be realistic, to work closely with our district nurses to ensure that our patients were as comfortable as possible in their last weeks and days. There was no place for hiding the truth, and often my patients were relieved to have the story explained to them in terms they could understand where they had been confused by others not so comfortable to discuss the issues. I guess I had learned powerful lessons from my Sri Lankan doctor friend’s dying during my second job at King’s, but also from being with my mother during her last weeks and days.
So much of what I did was to sit and ‘be with’ someone during the last stages, particularly when they had few relatives and supports but refused to be sent to a hospital or home. One of these was Elizabeth who came from a small family scattered across Southern England, had lost her parents during the blitz in London, but had been part of that generation of stoics who ‘soldiered on’. Elizabeth had secondaries from an ovarian cancer treated years before, and our local oncologist felt their service had reached the end of the line. Despite her chronic pain and discomfort, she did her weekly shopping, cooked for herself, and looked after herself as best she could, adamant she would not accept care. She had worked at the War Office and had a fund of stories about intrigues that had likely never been told and likely never would be. Given my own forces’ connections, I found it easy to listen, and she had the knack of making us both laugh long and loud.
In those days, diamorphine (heroin) was simply part of the doctor’s bag, and I had carried the same five ampoules around in the back of my car for at least two years. From time to time, Elizabeth would be in such pain that the nurses would resort to asking me to help; which I did on a couple of occasions. Such a useful analgesic with few side effects from a standard dose; you could see the relaxation of facial muscles as the pain disappeared and euphoria set in. And the stories got funnier. One of us stayed with Elizabeth for the hour or so after each injection. Nothing adverse ever happened, but the injection seemed to allow her to cope for the next couple of weeks on her oral medications. Elizabeth eventually died in her sleep one night some weeks later, as she had wanted.
I never felt the need to pop into the chemist and replenish my small supply, and was only ever to use one more ampoule of my five - with a patient in her mid eighties, dying from cardiac failure in her own home shared with a younger sister, also just in her eighties. It was in response to a heart-wrenching request from the sister, deeply saddened by watching her sister’s struggle: “Is there nothing you can do to ease her distress, doctor?” My patient died at home 48 hours later, and the sister came to the surgery a couple of days later to express her gratitude for ‘being so kind’.
I guess relieving pain is a major role in a doctor’s life. And relieving pain from psychological and interpersonal causes rather than physical was ultimately to become a major part of my life’s direction. And it began in a seemingly innocuous way.
Ken Fraser had overseen my work with a small number of children and families for about six months at the Canterbury clinic, when he did me the honour of asking if it would be possible for me to do another half-day session. The proposal was that I would visit Lanthorne House once a week, and provide some medical backup by phone if necessary when Ken was not available. Having again discussed it with Jan, and then with John, I agreed. I was excited and daunted, not sure what I would find or how I would manage.
With some trepidation I found my way to Broadstairs, and wandered into the ground floor of a three-storey building, asking for directions to the unit. “Upstairs”, they said, “Lift at the end of the corridor”. No enquiries or checking of identity. So I walked the length of the corridor sensing the atmosphere (echoing, dingy and empty with cries and whimpering off, and the smell of ancient dust and old faeces, barely concealed by disinfectant), and caught the lift to the top floor. Why would you organise an inpatient unit for young people with psychiatric problems on the top floor? Pragmatic reasons, I guess.

I asked for the charge nurse, and was shown into a cramped office where there was one of many case conferences going on between the many nurses, two psychologists, and an activity therapist. I was briefly introduced to the group, and invited to find a seat on the outer circle, where I listened for the next hour or so to the challenges of managing 25 inpatients of varying ages and with a myriad of problems. Fascinating. The charge nurse was clearly in charge, and stood no nonsense. At the end of the meeting, she asked me what I thought I might be able to contribute? Not aggressively, you understand, but clearly marking out her territory and ‘ownership’ of the ward, the staff and the patients. I stuttered a bit, and then took a one down position saying that I had had some minimal training in adult psychiatry and some therapies but had only recently started at the Canterbury clinic working with children and families. I was happy to do whatever I could to assist her in managing what were quite obviously a diverse and tough group of clinical problems; albeit I was only going to be available face to face one half day a week. I must have hit the right note, because she visibly relaxed and asked me to write up some medications for two of the youngsters who were being discharged and needed a supply before they were able to see their own doctor. Writing up medication was the classic role of the doctor, and safe ground, so I was happy to do that! Would I like to see round the unit? More safe ground, and I was happy to do that! She asked one of her junior nurses to escort me round and explain the daily routine. So, for the rest of the day I was introduced to a range of young people, two sets of visiting parents and several therapists who were not at that point deep in therapy. I asked about what types of therapy were available, whether groups were being run, whether excursions were possible within the budget, how many people were on night duty, and how emergencies were dealt with? By this I meant how an individual medical emergency might be handled at night, and was told that on occasion staff from the two lower floors could be called in to assist. After afternoon tea, I was trundled back to the charge nurse who asked if I had any questions? Skating on rather thin ice I asked how she might like to use me? Clearly all the cases were in the overall charge of Dr. Fraser, and she would have to discuss with him what I may be capable of doing. I said that would be fine, and that I looked forward to attending next week, and hoped I might be of use. My first three hour ‘session’ had been completed.

Thursday, March 30, 2017

Haiku on Crash/ Cut/ Confuse/ Target/ Desire


Storms and a king tide
Will the island wash away
Under crashing waves

A crash and grab raid
Car driven through glass front doors
All on camera

Totally tone deaf
Years at back of orchestra
Crashing the cymbals


Having cut herself
She then wrote 'Love' on her arms
And it seemed to help

Cut, cute, cuticle
Have similar roots


Heated and confused
No male in sight anywhere
Clownfish changes sex

So you confuse me
You look so attainable
Yet I keep failing

Ball and three cups trick
Confuses people I know
But never a cat


Arrow through the head
Targeted intervention
Recurrent headaches

Cupid's messenger
Eyes darting round the ballroom
Seeking his target

Ever the victim
Found the target on his back
And redesigned it


Do not desire fame
She's a demanding mistress
Always wanting more

Desire for riches
Makes people blind to the world
Our natural wealth

Desire found wanting
Fantasies lost in the need
Urgency gentled

Making of a Child Psychiatrist: (66) The General Practitioner (11); A bit more Child Psychiatry +

While Ken Munro Fraser was senior in experience, I was to find out he was flexible and open to new ideas. He allowed discussion, and I decided to keep quiet and listen. I had done enough damage with my ‘foot in mouth disease’. Or perhaps not! Over the next few weeks there followed a general airing of ideas about assessment and choosing appropriate therapies for any given child and family. Ultimately, even though I was only there once a week to join in the subsequent clinic discussion, I found out there was a decision about a changed process, with cases allocated within limits on a roster to any of the professionals. The idea was that the ‘case manager’ would gain the best understanding of the case that they could, and then bring that to a team meeting where the next steps in the assessment could be organised, and appropriate therapy planned. It sped the assessment process up, and took pressure off the social workers who often had to ‘hold’ a case until a psychiatrist or psychologist was free to complete their assessment. Of course Ken retained overall control over the decisions, given he was the Director and therefore would have to face the music if anything went wrong.
The reports I heard were that the process was quicker, with professionals able to begin some intervention during or after a first or second interview session, without having to wait for the main team meeting, so patient families felt they were getting some ideas and strategies almost from the beginning. Of course additions or changes could be made if the meeting consensus suggested something. From a personal perspective, it meant I could see cases for whom I had some ‘ownership’ and responsibility for diagnosis, process of assessment, therapy and reporting back to the team meetings. Luckily I was having some supervision each week from Ken to ensure I was looking at my own reactions to families and children, but also learning new skills. He was always suggesting some reading to help this, and would sometimes provide me with an article copied his secretary. So my one session a week, would often entail me spending another couple of hours a week in the evenings. Far from onerous, I found the process exhilarating.
Not that my work in the practice had lost any of its lustre, and there always seemed to be something new happening. We had a social work student approach John Hayden to seek a placement in the practice. Her expectations were that she might get to sit in on clinics, but also spend time around the practice with midwives, our district nurse, and even my visits to St. Nicholas at Wade. She was pleasant, enthusiastic, and careful not to intrude if patients were unhappy for her to be present. Jean had an assignment to complete prior to finishing, and we discussed ideas in the tearoom and while driving.
Two of my clinic patients at St. Nicholas were middle aged men who had each spent many years working as miners at Chislet (until it closed down in 1969) and then Betteshanger coal mines. Jean thought it would be a really interesting experience to go down a mine, facing some of the trials that miners put up with every day. These days, I suspect, all sorts of bureaucratic blocks focused on occupational health and safety might have been placed in our path. But when Jean approached her mentor to gain permission to shape part of her general practice report around the experience of miners, she thought it was a creative idea. When Jean approached the hierarchy at Betteshanger, they welcomed the idea of having real life health professionals gaining experience of working conditions.
And so, with only minimal discussion at home and in the practice, foregoing my three piece suit for some older somewhat daggy clothing one Wednesday afternoon I found myself descending into the depths in a wooden cage dressed in miner’s dungarees, borrowed boots, a helmet and a slightly flimsy facemask. Jean was very excited and kept the miners talking about their experiences. I was less enthusiastic, if not increasingly anxious. I am not sure what I had expected; perhaps a mini-presentation from a miner or supervisor, a visit to the wooden cage, and then a tour of the onsite museum followed by a cup of tea. No such luck!
I realised they were actually going to take us down the 1600 feet or so in the cage (which was noisy and appeared rickety to my untutored eye). I felt unable to say no. I was not being gallant for Jean’s sake; she was thrilled by the whole event and did not need that a mere male to support her. I just felt a bit embarrassed to wimp out, so I gritted my teeth and smiled while Jean went enthusiastically through her lengthy list of questions about mining.
After a shaky, rattling descent that felt longer than it actually was, we landed and the cage door was opened to the dim lighting of a cavern. We were met by the driver of a primitive underground electric train with open seating on narrow gauge rails. I have no idea how far we travelled, but the rounded ceiling seemed to get lower, and the walls closed in. Jean kept up her tirade of excited questions. How did the air stay fresh so far down? (Everything had begun to taste of coal of course, despite the facemasks). Were they still using the pit ponies about which she had heard? Not any more. Had there been any serious accidents? Not for many years. At the end of the line, we were told that to view the coal face we would have to crawl along a passage under what looked like wooden trestles maybe four feet high. Jean had already accepted the challenge and I had little choice but to follow. Lights were strung on the trestles, but the view either side was limited. The track was not really wide enough to turn around even if I had no-one behind me; the forty yards of crawling felt like an eternity. We arrived at a more open area and could see the open face, with miners drilling holes into rock. I tightened my facemask, and wished I had earplugs. The holes would eventually hold an explosive charge, the idea being that the whole face of coal would crumble down ready for transit. There was what felt like interminable discussion of the intricacies of explosive charges. These were men who knew what they were doing, given their lives depended on not making mistakes. There was pride in what they did, and trust and strong bonding between them. You smiled, and asked rather obvious questions; the miners smiled back and give rather obvious answers. I was struck by their acceptance of this dark reality of their work lives, and the tolerance for extreme working conditions. In contrast I felt a hint of shame in my own rapidly building need to return to the surface. I wasn’t sure I could get out quick enough to maintain the shreds of my dignity, and the return journey seemed endless.

I suspect there was endless discussion and a series of stories and jokes between mates in the pub about these two odd professionals needing to explore their work lives. Later I was to meet the two miners who lived in St. Nicholas, and was pleased that they (being blokes) were happy to come to the doctor to discuss often quite intimate problems. Separately, they both asked (with twinkling eyes) if I had enjoyed my visit to the mine, and whether I had recovered from being at the coalface. Obviously the story had got around.

Monday, March 27, 2017

Haiku on Wall/ Fire/ Island/ Pool


When people build walls
They must remember the gates
Ingress and egress

In this interlude
It doth befall that I, Snout
Am to present 'Wall'

We live behind walls
Does it protect us from them
Or all them from us?


Fire in the belly
From the roaring flames of youth
To age's flicker

Nice piece of charcoal
Once a branch that went through fire
Now draws on cousins

Doubt that stars are fire
Doubt thou that the sun doth move
Never doubt I love


Bribie Island home
The 'Sunburnt Country' island
Lies off our coastline

An old John Donne quote
'No man is an island', eh?
Sometimes feels like it

Mother duck with her ducklings
A chain of islands


Your eyes are like pools
Such immeasurable depths

Pooling resources
They came up with four dollars
Enough for coffee

Final game of pool
Needed to pocket to win
His right hand shaking