Matters medical including Porphyria, Bill Wyman, and the NHS

Matters medical including Porphyria, Bill Wyman, and the NHS

Grumpy old doctors are renowned for harrumphing over their whisky and soda ‘It’s not like it was in my day.’  In my own case, although I don’t harrumph, and I can’t remember the last time I had a whisky and soda, I live my life as Thoreau would have it, ‘in quiet desperation’, but it is a desperation born not of whatever he felt were the demons that assailed the common man, but of a fear that one day I will need the emergency services of the NHS and find myself treated by underprepared juniors in a system which militates against the sort of continuity of care which was a feature of working in a hospital in, say, the 1970s.

Two articles in the Daily Telegraph of Wednesday November 16^th sparked off this anxiety.  The first pertained to an inquest in Darlington on the death of a 38 year old woman after a caesarean section.  The lady lost two litres of blood during the operation and the gynaecologist asked for an urgent blood transfusion.  Two hours later, the transfusion had still not been given, the patient developed liver and kidney failure, she was not admitted to ICU because of a lack of beds, and nobody thought to link the organ failure with the fact that she was hypoperfused and hadn’t been given the blood.  Her husband stated that ‘the doctors and midwives dealing with his wife... did not communicate properly’, and ‘medical staff gave the impression that no one person was in charge of her care’.  Now, a newspaper article cannot give the entire facts of the case, but unfortunately, after a lifetime of working in the NHS, I’m afraid that it seems an all too credible scenario.  This is particularly true in the case of obstetrics I’m afraid.  Anaesthetists sometimes say that their work is 99% routine and 1% sheer terror, and obstetrics is a little bit like that.  Most medical personnel are reluctant to admit to this, even though they know it is true, but in common with a number of gynaecologists I have a rather low opinion of midwives.  They may be very good at the touchy feely stuff, but apart from the routine management of labour, their medical knowledge is poor.  Gynaecologists/obstetricians likewise lead a very blinkered existence.  They are so entrenched and focussed on a very limited area of medicine that their other clinical skills are rudimentary.  Fortunately, out of say 1000 deliveries, only one or two give them cause for concern.  In the case above, who knows why the gynaecologist didn’t return to the patient’s bedside for two hours?  He might have had a huge operating list to work through.  He might have had to go to clinic.  He might have had to pop in to his local private hospital to pour unction onto the ego of an overpampered late primipara.  It’s best I leave this one because the details were not given, but unfortunately, another case on the same page perhaps raised deeper concerns about the lack of experienced junior doctors available and the lack of basic clinical skills.

The headline read:  ERRORS:  ‘Tonsillitis’ was heart inflammation.  I quote the entire article:  ‘An NHS hospital is retraining nurses after a teenager with suspected tonsillitis died when staff failed to properly monitor her condition.  Melissa Furnival, 18, was taken to Wigan Infirmary after she complained of being unable to speak or eat, Bolton coroner’s court heard.  Over the next seven hours, staff were said to have made a series of mistakes over the way she was monitored.  Miss Furnival, the mother of 15-month-old Rosie-Leigh, lapsed into unconsciousness and died.  Tests showed she died of viral myocarditis – an inflammation of the heart muscle.  Verdict: natural causes’.  Now, for all of you non-medics, viral myocarditis is a rare condition, but its manifestation, namely heart failure, particularly when this severe, is easy to pick up if a proper clinical examination and simple but sensible tests are performed.  I’m not arguing that the nurses may need retraining, but once again the implication that it is the nurses who should be diagnosing and managing the condition is very worrying.  Did the A&E staff only summon an ENT SHO?  Was there nobody senior enough to see this poor young woman who could have said ‘Wait a moment.  This isn’t just tonsillitis.’  I suspect that because our hospitals are so busy and so under-doctored, the patient was only assessed by a triage nurse.  Scary stuff isn’t it?  Among the various problems that the NHS has faced in recent years, the one that without doubt has ruined the training of thousands of doctors is the EU Legislation on Working Hours.  Junior doctors, whose lives have changed immeasurably since I was ‘on the house’, are only too keen to have the extra time off, but it is patient care that suffers, as well as a reduction in the clinical experience that juniors can acquire.  No one is arguing for a return to the 100 hour week that some of us worked, but regrettably, 40 hours or less is not acceptable, both because of the lack of experience that results, and also because of the reduction in continuity of care.  I suspect that some will feel that I have ‘got that off my chest’, but the most far-sighted of junior doctors also agree that this is the case, and rue the fact that they may get sent home at the end of a shift, without the option of attending to watch a difficult operation or a case that is a little out of the ordinary.

Time to move on!  Things medical are on the mind not just because of newspaper headlines, but because we have been to see Alan Bennett’s ‘The Madness of George III’.  Despite my fulminations above, nobody can gainsay the fact that Medicine is somewhat better than it was in 1788, when the play is set.  Alan Bennett loves to have a little go at all sorts of sacred cows, and doctors are a valid target.  Few playwrights have been able to resist the urge to do this, and Shaw is the prime example (The Doctor’s Dilemma).  Alan Bennett first caricatured doctors in his play ‘Habeas Corpus’ as I recall, and he has returned brilliantly to the topic in his recent novella ‘Smut’.  Indeed, now I come to think of it, one could find a very good PhD thesis in the portrayal of doctors on the stage from Shakespeare to Moliere and beyond.

For those who don’t know, after some clever medical detective work in the 1960s, it seems most likely that King George III suffered from a rare inborn error of metabolism called acute intermittent porphyria.  The key features of this condition are sudden and terrifying abdominal pains with constipation, fits, and psychiatric symptoms.  There is a fast pulse and sometimes hypertension.  In the classic form of AIP, large amounts of the precursors of heme appear in the urine and discolour it.  After exposure to ultraviolet light the urine turns blue or purple.  All of these features occur in Alan Bennett’s play.  Most sufferers from this disease only have crises with symptoms if they are given certain drugs.  I can only recall seeing two cases in my professional career, it is remarkably rare.  To cut to the chase in Alan Bennett’s portrayal of the doctors, the first laugh comes when the King’s Physician is sent for.  Sir George Baker, President of the Royal College of Physicians, attends, and says ‘Good God.  With any patient I undertake a physical examination only as a last resort.  It is an intolerable intrusion on a Gentleman’s privacy.  With His Majesty it is unthinkable.’  After the King’s illness is plain, Baker is found to have sold his stocks and shares.  ‘The King’s doctor sells his stock, ergo the King is not expected to recover.’  Next we meet Dr Richard Warren, physician to the Prince of Wales.  The King reminds him that he cannot be the servant of two masters.  Warren says ‘I am a servant of humanity, sir.’  The King responds, ‘Yes, and how much does humanity pay you?’  Finally we meet Sir Lucas Pepys, a physician who is completely fixated on stools and their appearance as a guide to health.  There follows a scene where the three physicians reveal the depth of their ignorance, the general view being that a ‘gouty humour has settled on the brain’.  After bleeding and purges they decide to ‘decoy the humours’ to another part of the body by blistering the King’s back and legs.  The King retorts, ‘And it is His Majesty’s opinion that the physicians’ health would benefit by the application of blisters to their arse.’  But it is no use.  The King is now a victim and not a monarch.  Finally, as most of you know, a clergyman physician who runs a lunatic asylum is called in.  He has no idea what is wrong, but asserts ‘Oh I can cure him.  I’m just not certain what from.’  In porphyria, as indeed we see in the play, recovery is spontaneous but gradual.

So, what was this production like?  David Haig, who played the King, gave a superb performance as King George.  But one cannot forget the magnificent acting of Nigel Hawthorne in the film (and of course on stage in the original casting).  Haig was especially good at portraying the agony of the King, and at recovering his majesty in the closing scenes.  The poetry of the lines where His Majesty remembered the wonders of America was delivered with a slightly frenetic style by Haig, whereas Hawthorne momentarily ‘forgot’ his madness, and delivered them with the beauty that they deserved.  The play transfers to the West End from mid January 2012 until the end of March.

We booked for Bill Wyman a long time ago and had good seats at the Lighthouse.  Unfortunately the sound system was not great.  The speakers were all in a huge bank above the stage and there was a good volume, but little distinction between the instruments, for example when the flautist stepped up to the mike to add to the accompaniment.  Bill has a very low key and deadpan delivery.  He quite clearly enjoys just playing the music he likes, and is able to gather great players around him.  For most of the evening, he just stands there, partly hidden by his tinted glasses, and plays.  There was a good mix of most types of song, jazz, blues, pop.  Georgie Fame played for almost all the numbers, and performed some on his own.  A surprise special guest was Mary Wilson of the Supremes.  Apart from a little avoirdupois she looks fairly remarkable for her age of 67!  Higlight song for me:  a beautiful version of the Everly Brothers’ ‘So sad’ sung by their vocalist and one of the band.

Final entry for the last week or two:

Bakkels Gets on the Case!

A not very imaginative pun on the conductor at the BSO yesterday – Kees Bakkels (Dutch, hence the wordplay).  Wonderful concert.  If you were going to design a wonder concert this would be pretty close to the best.  First half: Beethoven Emperor Concerto played by Louis Lortie.  Second half:  Mahler No. 1.  Not that I am an expert, but Lortie seems to me like a man at the top of his game.  From his CV a hugely experienced professional – has given complete series of Beethoven Concertos, Chopin Etudes, Mozart piano concertos, etc.  He has apparently conducted regularly from the keyboard and it shows.  When he plays with the right hand only his left wanders off into space, drawing shapes through the air in time with the music.  All of these movements were studiously ignored by Kees Bakkels, one of the orchestra’s favourite conductors, who carried on regardless.  Kees now looks just like Liszt’s double in his long frock coat and long straight hair.  My parents gave me the Beethoven when I was very young, an old recording by Jakob Gimpel.  Wonderful.

Finally – because Lindsay’s book club had read ‘We need to talk about Kevin’, we all went to see the film on Tuesday.  Well acted, but incomplete compared with the book, and in all probability an unfilmable book...

Concluding rapidly and without any clever sign offs.  Tomorrow very early we are off to Egypt for a holiday.  Nervous because of the unrest there.  Well, we will see...