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Friday, September 30, 2016

Haiku on Upset/ Patch/ Really/ Way


Upset apple cart
Gold green army marches on
Come the decider

I know you're upset
The slight hunch of your shoulders
Eyes and mouth downturned

Upset the milk jug
Puddle forming on the floor
Have you seen the cat?


Class structure gardens
Roses versus Veggie Patch
One born out of need

Striped T and eye patch
Accented "Hail me hearties"
And we were pirates

That patch of sunlight
Inexorably moving
Chased by playful cat


An ant with an egg
Scurrying to find shelter
Really determined

Really glorious
Bright sunshine with a cool breeze
Autumn has arrived

Not particular
Yet made up of particles
Really intriguing

Brand new idea
A millionaire in my dreams
All lost by morning


Weighed down by troubles
Overloading your system
No way to live life

You and I, my love
Have come a very long way
Loved every moment

The path can be hard
But if that is the way home
Just have to do it

Thursday, September 29, 2016

Making of a Child Psychiatrist: (46) Working in Medicine (2)

That first year of working as a doctor was momentous. Being a medical student had been enthralling; full of unexpected experiences and new learning, but it was always tainted a little by the hand to mouth existence of living on a grant, even after Jan began bringing in a wage. Earned money arriving in the bank every fortnight was seriously meaningful. I felt different, more confident, and more assured that we had a good future on front of us, whichever way the fates took us. My depression of the previous year disappeared as my sense of competence and meaning in life grew.
While I missed Jan on the two nights a week I was on call, it was also a special experience to be working alongside colleagues who were sharing parallel learning curves. Cases were discussed in great detail, and then filed away somewhere in the personal archives of my brain. As a group our sporting activities fell by the wayside, but our awareness of, and interest in, sport more generally out there in television world burgeoned. Tottenham beat Chelsea 2-1 in the FA Cup. We cheered anyway, and a couple of soccer fanatics explained the game to those of us who had no idea. Celtic became the first British team to reach a European Cup final beating Inter Milan 2-1; always good to beat the Italians I was told. Francis Chichester completed his single-handed voyage around the world in Gypsy Moth 4, and was feted. John Newcombe and Billy Jean King won their respective finals at Wimbledon.
I had continued my friendship with Andrew Stanway, who was in the process of finishing his own degree, but continued as the editor of the King’s College Hospital Gazette. I had an idea for a small article for each issue to reflect the lifestyle in the Medical Officers’ Mess. I only ended up writing about 5 episodes of about 3-400 words apiece, but it was a way of continuing my ongoing need to write, allowing me a small creative endeavour to wind down from the complexity of a days’ work. I imagined the Mess as a foreign planet (which it had been when I first arrived there), and pretended to be a reporter from ‘ResMedOff’, describing events and daily life in allegory. A silly idea really, but some people found the pieces amusing. I have no idea whether they survived. They were of course typed up on an old typewriter, so the only record might be deep in the archives, wherever they are.
Of course, there were other ways of gaining release after the majority of work had been completed for the day. Emerging from my cocoon of listening to classical music and jazz, I was told about some guys called Keith Richard and Mick Jagger who had been jailed for possession of drugs. The Rolling Stones were probably aptly named, and gaining a reputation for being bad boys, but they played pretty good music. The Beatles had only recently released Sergeant Pepper’s Lonely Hearts Club Band, and not only was the music played repeatedly (and sometimes too loudly), but people began to adopt some pretty weird clothes.
And young doctors can be naughty. So over a few weeks, there was talk of something called Marijuana and, being a smoker, I took some notice. One night was planned as a special night in one of the shared quarters for a group to sit in a circle, listening to psychedelic music, and ‘share a joint’. I was curious, and wanted to be part of the group. So I set aside my slight disgust at smoking something soggy that had been passed from lips to lips, and duly took a drag. When another joint came round the circle, I repeated the experience. I wasn’t sure what to expect, and thought it was all a bit disappointing. I did notice several people looking a bit dopey, and swaying to the music a bit more, but I really felt very little. That is until an hour later, when I began to develop the king of all headaches; a real thumper. All I could do was politely excuse myself from the group, though I am not sure anyone noticed. I went to my room, took some aspirin, and tried unsuccessfully to get some sleep. Waking in the morning felt like hell, and the headache was still there; nothing would relieve it until it had run its course after about 24 hours. I struggled through a ward round, and then absented myself as ‘having a migraine’. I went back home to Jan, but nothing I did seemed to help; it just had to take its course.
I guess I was lucky, in a sense. I had no idea what the headache meant, but I have always valued my ability to think and feel, and perhaps have a need to be in control of my own daily life and destiny, so I made a decision then and there never ever take anything like that again. I have kept to that for the rest of my life, and count myself fortunate for having that early adverse experience. I am not necessarily down on people who seem to enjoy drugs. If anything I find myself on the one hand admiring them, but then on the other wondering why they would bother. Some of these attitudes were further developed a bit later when I was doing psychiatry at a drug clinic, but I will explore that in its place in my narrative.
The group process with its music and occasional mayhem concluded at the end of the year with a Friday night Christmas party where the mode of dress was definitely hippy with headbands. Someone had organised a light show with a projector and multicoloured bubbles lowing across a wall. The atmosphere was sweet and heavy, and alcohol flowed freely. We danced gently into the small hours of the morning and then wandered down Denmark Hill to recover at home for the weekend.
Actually for some months we had been taking life a little more carefully. Jan had announced that approaching the grand age of 24 we were going to be parents with an expected delivery date of February. She had enjoyed her pregnancy, mostly feeling well throughout and certainly looking terrific. I know that she was anxious about the process to come, but even more anxious about what would happen to her job, and our newly positive bank account. Luckily, my salary increased with each job. I had begun at £800 per annum, then this was to be increased as a senior house officer in my second year to £1100 a year, as I finished my first medical job and took on a joint Diabetes and Pathology job.
The other major anxiety was accommodation. We were only allowed to rent the hospital flat for one year, so we had increasingly urgent discussions about where to live and how to manage. Our old flat at Camberwell Grove was unavailable, and might not have been appropriate given its position on the second floor.
I had been loosely promised the opportunity of a junior registrar in psychiatry job for October 1968, which would increase my salary to £1400 a year. Lots of ifs and buts, and Jan was very keen to continue her own work at King’s, planning to go back to work as soon as they would take her. The department, luckily, had found out that Jan was a treasure, and offered for her to be half time for as long as she would be able to manage with a baby in a pram.

I am not sure who actually found our first house, but it was a recently refurbished tiny two storey terraced house in East Dulwich. It had a next to nothing front garden, and a pocket-sized back garden covered in new lawn; and there was street parking. It was cute and we loved it. So we went to Lloyd’s bank in Westgate-on-Sea where we had always banked to see whether we could get a loan. These were never easy to gain in those days, with banks falling over themselves to avoid any risk at all. Somehow $5,000 was seen as an enormous amount of money to lend to two 24 year olds with uncertain salaries, even though we were professionals in the making. It felt like we were back in Paris, begging for £10 for petrol to get us back to England on the Vespa. Luckily, Jan’s father (who had occasionally played golf with the bank manager) agreed to be our guarantor. On that basis, we had a home, and the family rallied around to transport our meager furniture. Welcome to 5, Henslowe Road. Welcome to 1968.

Wednesday, September 28, 2016

Making of a Child Psychiatrist: (45) Working in Medicine (1)

At the end of my 6 months I moved into the next challenge – as one of two house physicians to the Professorial Department of Medicine. For many reasons, I am not sure I was ready. Where Casualty had been a steep curve in learning techniques to deal with even the most serious of trauma, yet filled with satisfaction because of the teamwork, Medicine was much more serious. It was an academic unit where registrars and medical staff seemed to be highly competitive, vying to know more than the next person or at least score off them. Days began with lengthy ward rounds where I felt consistently under pressure to perform. Questions would be asked; just simple things like the most recent blood pressure, and if the student who had clerked the patient did not know, everyone would turn to me. I was next one up the chain. I had been on the ward all the previous day and half the night, I had spent considerable time with the patient and had written the last comments in the notes; I should know. The senior registrar, or the consultant leading that round would stare at me ‘dead fish’, and then with a sneer turn and ask the sister in charge (who always seemed to have the answer).
I realised after some weeks that there was a pattern to these formalities, a process based in a reasonably rigid hierarchy and the need to hold your place in the pecking order. I have never been good with rigidity and formality, but tried hard to be ahead of the game. The pressure was intense and constant; I hated it. I seemed to get support and sympathy from the nursing staff, including a couple of charge nurses who would attempt to prime me on what might be expected at tomorrow’s round, or try to mouth the answer during that day’s round.
I did get better at the game, but on occasion would fall down badly. There were regular nights of the week when I was rostered on call. I remember one week in which I clocked up over 140 hours, which included two separate nights where I was on the ward all night, had bacon and eggs with the nursing staff in the ward kitchen and then, unshaven and probably slightly sweaty, endured what felt like an endless ward round in which I was berated for not collecting some apparently crucial results from the biochemistry lab. I began to learn how to ‘use’ medical students. After all, they were just lower in the pecking order, and had much more time to ensure that everything was right as far as ‘their’ patient was concerned. I tried to be decent about it, but still felt like I was ‘using’ them. Stupid really; after all I had been in the same position only months prior and had survived.
On call was painful. Despite the fact that Jan and I lived only minutes down the road from the hospital the rule was that, on call twice a week, I had to be on site and sleep in the resident medical officer quarters. And it was severely frowned on to have a partner sleep in the hospital, even if you were married.
The accommodation was ordinary but fine and regularly cleaned, meals were quite good, and there was always a nightly snack trollied up from the kitchen late in the evening. Strangely, this brought the maximum number of medical staff together in a social gathering. We got to watch television when the day’s work was done. Of course if we were called back to the ward it often meant doing it at a fast rate. It was often an emergency. Then of course, from time to time I was called down to Casualty to review a case, but only if the registrar was busy elsewhere. Being a House Physician on the Professorial Medical Unit did not confer executive decision-making powers, even if I was known for having survived 6 months in Casualty and knew most of the staff. I was still the junior.
One section of the medical ward was given over to the beginnings of a major trend for King’s. One of the consultants Dr. Victor Parsons had a major interest in renal medicine, and was on his way to building a personal empire later relocated to Dulwich Hospital which, with St. Giles, had joined the King’s group in 1967. Peritoneal dialysis was fast becoming a way of assisting patients with acute renal failure. It had been used sporadically in the United States since the 1950s, but there were many complications including mechanical problems like obstruction of flow, leakage, and then more serious issues like peritonitis, perforation of viscera, abdominal haemorrhage, and adhesions. Treatment could be maintained only for a few days and, for it to be successful, all the mechanics had to be right. The idea was that an airtight sterile entry tube into the belly delivered a regular flow of at body temperature hypotonic fluids which covered the outer layers of the omentum and gut. Then there was an airtight exit tube. Effectively the surface of the organs leaked fluid and this was washed away. This leakage had been known about for a long time – the ‘ascites’ (the medical term for ‘dropsy’) connected with serious renal damage. The immediate advantage to patients coming to the unit was the relief of their own ascites which can often be very painful. The second advantage was the washing out of toxins from the blood stream across the gut and omental surface. Over a short time, renal patients would suddenly have a clear mind and be able to think. This in turn would encourage them to avoid ‘giving up’.
Of course, as you can imagine, the technology of the machinery had to be absolutely correct. Absolutely everything had to be done within strict sterile precautions. It was all new and, looking back through all the years, I can feel the tension that existed in the Unit, and fully understand it. Everyone was on trial. From my perspective, I was fascinated by the process, happy to accept the training, and overjoyed when finally I was allowed to replace (or at least assist the registrar replace) tubes if they got clogged in the middle of the night. I did not know that Vic Parsons and the unit were on trial. At that stage you have no idea of the politics and machinations, and the history-making side of what we were doing was never really explained to me. Ultimately it was to be successful, and the whole circus was moved into bigger quarters with extended facilities. Fascinating to have been there, even if I never really felt part of the program; simply a junior doctor who would move on to other things in a matter of months, and would not find out the importance of the whole thing until researching a life story almost 50 years later.
Of course not everyone was suitable for peritoneal dialysis. In addition, the process in the early days had strict time limits to avoid infection and internal abdominal scarring. There was a reticence to repeat the process too often, even if someone was at death’s door. There was one patient who stands out in my mind. He had been a senior physician in Sri Lanka for many years. He had travelled to the UK and King’s as a last resort to stave off renal failure. He had a series of peritoneal dialysis treatments, but it was never enough, and he had been taken off the program. The use of renal transplants, tissue typing, and medications to prevent rejection were still in their infancy. He knew his renal status was terminal, and chose to stay on the ward for his last weeks, often surrounded by family and former colleagues.
He was a charming and urbane man, and had endless stories from his early days in medicine. So whenever I could, often after visitors had left, I would sit with him while he reminisced, often for half an hour or so. I felt an immense sadness that this man’s experience and skill would all be lost as he faded. But it was more than that. I felt an affinity; I was just drawn to him. Perhaps I recognised that one day this might be happening to me; but looking back, that was far too philosophical for my younger self. I had not experienced the coming of death at such close quarters, but I don’t think that was the fascination. I just enjoyed being with him. I have a sense that he taught me some humility. I was deeply saddened coming in one morning to a ward round to be told he had passed away in the night. I did not weep, but I did feel an immense sense of loss.

Some months later, a rather large and very heavy box arrived at our flat from an unknown sender. Jan and I opened it to discover the most exquisite dinner service of hand-painted china. It is robust, and still in use 50 years down the track, not a piece broken through endless cycles in dishwashers. There was a card simply noting thanks from his family for my care, explaining how much my time spent with him had meant. I was, and remain, bemused by this kindness. I somehow felt that I was the one who had gained from the experience. He had been somehow a haven in the midst of the ward turmoil. And I believe it was he who taught me not to fear death, a lifelong and very special gift.

Haiku on Double/ Place/ Struggle/ Left


Not sure why I'm here
Saw this double decker bus
And came for the ride

Double decker bus
Iconic symbol in red
Spirit of London

Cello sits forlorn
Slightly grumpy and twisted
Double base envy


Establishment place
Please place my plaice in my place
Yes, on the placemat

Accept refugees
Stop radicalisation
Make our place humane

We need each other
In that basic loving way
So, my place or yours


The old baritone
Still able to sing in tune
Struggles with high notes

If you can struggle
With time it makes you able
To struggle some more

The struggle for peace
Continues throughout our world
Where we are able


New karate class
Punch left fist stomach level
No! The other left

Leftovers for tea
The most sumptuous salad
Reduced to two leaves

Writing on the wall
Left for the future to read
Humanity is lost