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...

Letter to America - November 2011

Letter to America – created November 6^th to 9^th, 2011

This post is primarily created for Lindsay’s cousin, Tod, who lives in Lancaster, PA.  Tod is an opera buff, and this Saturday, November 5^th we have been together, ‘in a virtual sort of way’, as Tod observed.  We’ve been to ‘The MET Live’ to see Siegfried, Lindsay and I in Poole, and Tod and Annie in Pennsylvania.

The week in Dorset has not been notable for good weather.  It has been grey and dry or grey and rainy.  On Tuesday evening, Penny Jarvis from the hospital came round to show us her pictures and tell us about her charitable fund raising ascent of Kilimanjaro.  It was impressive, in a practical way, with helpful information about everything from clothing to toilets.  Helpful at least if we ever get around to doing it.  We sponsored Penny as did many other people, but I was left feeling that we hadn’t given her enough, considering the miserable weather she encountered.  Wednesday evening was our usual visit to ‘The Lighthouse’ for the BSO concert.  Remarkable young conductor, Krysztov Urbanski, and a lovely concert, somewhat underattended.  The programme started off with Sibelius Peer Gynt Suite No. 1, and continued with the Dvorak violin concerto (Alina Pogostkina on her 1709 Strad).  The second half was Smetana’s Ma Vlast.  Sometimes I think the inhabitants of Poole only turn out if it’s the principal conductor, Kirill Karabits, or if there’s a piano concerto on the programme.  The hottest feature of the evening was Lindsay’s Keralan vegetable curry, served afterwards.

Our most unusual event this week was our visit to Ronnie Scott’s on Thursday evening, to hear the American chanteuse, Stacey Kent.  This was rather impulsively booked only a few weeks earlier, and given the rotten weather it wasn’t a journey we looked forward to.  We first heard Stacey Kent in slightly strange circumstances.  When we were walking the Lycian Way in Turkey this May, our first hotel was a little lodge called the ‘Olympos Mountain Lodge’, an hour and a half west of Antalya.  The music in the lodge was streamed from the manager’s Apple Mac.  Soon we recognised Pink Martini’s ‘Sympathique’, sung in French.  Shortly after this, another song in French with a rather similar feel, but not Pink Martini.  We aked the owner.  ‘Stacey Kent’, he replied, with a surprised air, as if we should have known.  Soon, back at home, we were the owners of her album ‘Raconte-moi’.  Our journey to London was something of an ordeal.  It took us two hours to get to Kensington, where we parked near the Albert Hall, avoiding the crowds arriving for ‘An evening with Engelbert Humperdinck’ and took a cab into Soho.  A rainy, dark, miserable and traffic crowded night in London.  My team at Royal Bournemouth Hospital had done a fantastic job in getting through my cardiac catheterisation list by 4pm, so we were able to walk into Ronnie Scott’s at about 6.30pm.  We had only managed to get restricted view seats, but arriving so early we were allocated the best possible restricted view seats, and they were fine.  Now I hadn’t been to Ronnie’s for around 25 years, and indeed the atmosphere is still great: intimate, and nobody is that far from the performers.  My memories of past visits are so vivid – because of the quality of the artists.  The last visit was to see the legendary guitarist Joe Pass, and before that I sometimes used to go around Christmas time when George Melly and John Chilton’s Feetwarmers always had a one week slot.  The opening act was the James Pearson trio – all very good, fantastic piano by JP.  When Stacey came on, she was as good as we’d hoped and we also found the band members outstanding.  The pianist was so good, so restrained and elegant.  The drumming was genuine accompaniment and not obtrusive, and the bass was a perfect counterpoint – all notes audible and in harmony.  Then of course, there was Stacey’s husband, Jim Tomlinson on tenor sax.  Wonderful, warm sounds, reminiscent of Stan Getz.  In fact, an article about Stan Getz specifically mentions JT as making music in the Brazilian traditions of the Great Stan.  Musically, the Brazilian numbers, mostly by the famous Antonio Carlos Jobim, were my favourites.  Stacey’s sets, as far as I can recall them and notated them were as follows:

Breakfast on the morning tram

It might as well be spring

They can’t take that away from me

Dreamer (Jobim)

Quiet nights of quiet stars (Jobim)

Mon amour

Sait-on jamais

So nice

-----------------------------

Waters of March (Jobim)

How insensitive (Jobim)

The Ice Hotel

Postcard lovers

Cambaya (the train)

S’wonderful

Samba triste (?or samba sarava)

What a wonderful world

The songs about the Ice Hotel and the Postcard Lovers were co-written by Jim Tomlinson (music) and Kazuo Ishiguro (lyrics).  Kazuo is something of a Stacey Kent fan – he chose one of her songs in his Desert Island Discs, and has been pleased to revert to what is apparently his first love – song writing.  He was in the audience for the set, so we felt doubly privileged – for the remains of the day at least.  We enjoyed a good meal as well.  We could have stayed until the wee small hours and listened to the second set by the James Pearson trio – but I guess not many of the aficionados present came from Dorset, so at about 11pm we set out into drizzly Frith Street and walked down to Shaftesbury Avenue.  No cabs of course.  We were almost at Piccadilly Circus before we were picked up and then had to travel back to the Albert Hall.  By the time we arrived back in Kensington all of Engelbert’s fans had long since gone home to their cocoa and hot water bottles, so there wasn’t exactly a crush.  Good journey home but it was 1.30 am before we were in bed.

We slept in a little on Friday, and prepared ourselves for our other major cultural endurance event to come that weekend – the visit to Poole Lighthouse for the aforementioned Met Live performance of Siegfried on Saturday.

After writing this, I felt it was a little uninspired, and felt that only a determined friend or a serious Stacey Kent fan would bother to read on after the introductory paragraph.  After going to bed, I watched a film about the making of ‘Bridge Over Troubled Water’, the Simon and Garfunkel album.  It was made in honour of his 70^th birthday (October 13^th).  I was so inspired I wanted to get up and write on.  It brought back memories of working in the research lab at Will Rogers Hospital, Saranac Lake, upstate New York, in summer 1970.  I worked with a local lad – David Meyer – who had an 8-track stereo player, and the tapes we played all summer were ‘Bridge’, Chicago, and the Crosby Stills and Nash album.  When I left David gave me a copy of the album on vinyl.  Happy memories.  But, remarkably, some of the best quotes in recent weeks have come from the sports section of the Telegraph, and here is one: ‘Nostalgia is the neurotic inability to be able to deal with the present’.  So – I need to move on, but one day, will we look back and say ‘Do you remember when we heard Stacey Kent at Ronnie Scott’s?’

There are Wagnerophiles everywhere, some more likely than others.  To use Shaw’s description, I should perhaps call them Wagnerites.  I wouldn’t really count myself in that number, though I do admit to going to Tristan and Isolde this year, so perhaps I’m changing.  In the audience at the Lighthouse was one of our oncologists, who I wouldn’t have picked as a Wagnerite, and our recently retired Danish cosmopolitan ‘Renaissance Man’, (well he is an artist) neurophysiologist, Christian Wulff (who I wasn’t surprised to see).  Now Tod was enthusiastic about our trying Siegfried.  He called it more ‘approachable’.  There certainly is a lot more going on, with evil dwarfs, dragons, a magical bird, and the occasional leitmotif for one to hang one’s craving for musical recognition on.  I recall going to Gotterdammerung at Covent Garden, before the days of surtitles, and listening to the three Norns groping around in the semidarkness for what seemed like about 2 hours during the first act, not understanding a word and not particularly enjoying the music.  It took several hours and several acts to get to Siegfried’s Death music – magnificent.  As the two old ladies said, talking about Wagner:

‘Wagner has such wonderful moments, dear.’

‘Yes, and such awful half hours.’

But thanks to the magnificent set, the magnificent sound, the quality of the singers, I found that I really enjoyed Siegfried, and could even go back and do it all again.  Jay Hunter Morris, who sang Siegfried, was terrific, and the behind the scenes filming during the intervals showed him as a refreshingly unaffected opera star, from little ol’ Paris, Texas.  In fact his off stage persona conveyed exactly the right heroic naïveté that his on stage character is meant to have.  His recent job working in a health club presumably gave him the magnificent biceps that one needs when forging a magic sword from little pieces.  It certainly helped to have Rene Fleming doing the interviews, and scarcely gave us time to produce our pseudo-Glyndebourne feast (champagne, salmon en croute, dips etc) that we had planned on for the intervals.  It did feel slightly incongruous eating such a wonderful picnic in the unattractive surrounds of Poole Lighthouse.

On Sunday, we had a rather tedious journey to Taunton, to a luncheon party of Susanna Joy’s.  The lunch was good, but it was four hours of driving.  Sobering moment – driving under the M5, queued all around Taunton, because of the major motorway crash there on Friday, the worst in the UK for twenty years.

So that’s the diary.  Lots of other little happenings.  England play an international football match this week, and there is ‘poppy rage’.  They are not being allowed to wear poppy emblems on their shirts.