From Galle to galling - a miscellanea of moan

I had firm intentions of just writing about Sri Lanka, with the odd topic of UK home grown news, but so much has been happening in England that I just hope I can reach Sri Lanka by the end of this blog...

I had firstly meant to lament the lack of dedication to work which benefits other people.  When a syndicate of bus drivers in Corby won the lottery recently, to a man they just failed to turn up to work the next day.  It turns out that this group comprises 20% of all public service drivers in Corby, so the effect on bus routes for the poor workers of this former steel town was substantial.  What a load of mean spirited w..... these men are.

At the risk of being a grumpy old man I might as well get it all off my chest.  The quality of working life within the NHS continues to go down by several degrees a month it seems.  The latest Big Brother episode is the reduction in hours being paid to consultants.  While simultaneously being required to do more and more – especially as regards admin and bureaucracy – the number of sessions devoted to non-clinical care, i.e. catching up with medical correspondence, teaching activity, phoning GPs, is being reduced.  At least you are still expected to do it, but you won’t get paid for it.  Some time back we were warned that use of the internet was to be monitored – and clearly there are sites that are inappropriate – but now if any site is deemed unsuitable, access is blocked.  The other day, in my lunch hour (an oxymoron – most people take only a few minutes for lunch and many just eat some sandwiches in their office while answering e mails or dealing with other admin), I went from our home page (no choice, the merry Poole hospital website comes up first) to the main BBC news page (approved), but when I saw the headline ‘England take late wickets to stage comeback in Sril Lanka’ and followed the link – Bingo – Poole Hospital Big Brother threw me out of Internet Explorer, and when I tried the same thing today my computer froze as well!

Many years ago, consultants were encouraged to meet together at lunchtime, and this meant that not only did we know who our colleagues actually were (nowadays we have no idea), but we did sometimes talk about shared aspects of medical care, a subtle but invaluable education for us all.  These days it’s regarded as elitist to allow consultants separate dining facilities, so we are all in the same canteen.  The only people who regularly dine together and discuss matters both personal and clinical are the pathologists, but even they are being squeezed by big brother managers who maintain that they are taking far too long over lunch.  In our brave new pathological world, post mortem examinations have been farmed out to some post mortem factory in Bournemouth, which is not on the site of either of our major hospitals, so it is impossible to attend an examination of a patient who has been under your care to assess whether you have done what was appropriate.  Many patients die without any exact cause of death being determined!  The reduction in NHS funding has resulted in pressure being brought to bear to reduce referrals to the coroner if one is uncertain of the cause of death.  Death certificates are probably as unreliable now as at any time in the past thirty years.  Bear in mind that the only thing the Coroner is interested in, when reduced to its simplest principle is: ‘Was death due to natural causes?’  As students at University College Hospital (UCH), many years ago, we were encouraged to attend post mortem demonstrations which took place several times a week if there were interesting cases.  As we made our way up the iron stairs to the students’ entrance to the mortuary viewing gallery, an imposing sign lettered in gold on a varnished wood background greeted us, ‘Mors ipsa docet succurrere vitae’, or for those of you whose Latin is a bit rusty, ‘Death itself teaches us to sustain life’.  Great stuff.

In politics, we have had some bizarre and unintended black comedy recently.  The Chancellor, George Osborne, announced his budget the other week.  Pensioners have had some tax breaks – some relaxation of tax banding – which the Chancellor has decided to abandon.  Naturally dubbed ‘the Granny tax’, it hasn’t been great publicity for the Conservatives.  A review of the budget in the papers reminds readers that in the USA there are certain no-go areas for taxation and fiscal interference, known colloquially by analogy with the electric subway services as ‘The Third Rail’ – touch it and you die!  Another somewhat bizarre tax is the imposition of VAT (similar to state sales taxes in the US) on food which is heated before sale.  Food is zero rated, but if a pastie is sold at more than one degree above ambient temperature the tax will be imposed.  Mr Cameron (our prime minister) recalled that he had recently eaten a very good pastie, but on further investigation it appeared that the business he claimed to have bought it from closed down five years ago.  It has always seemed to me bizarre and unfair that when you visit a fast food and beverage shop, e.g. Pret à manger, you are asked if you are eating in or taking away, and if you reply that you are going to eat in, a whacking 20% is added to the bill because it is taxable.  Most people say, ‘Oh, take away’, don’t pay the tax, and then sneak off to the far corners of the store and eat in anyway.  Sadly, now that the UK is in thrall to the European Union, we have little choice about our taxation system which is dictated by Brussels.

Finally, a remarkable event occurred in politics this week.  A By-election in Bradford (West) constituency was won by an independent candidate, George Galloway.  Galloway, who calls himself the ‘Respect’ party, overturned an enormous Labour majority and got himself elected.  At the risk of boring you, I will not dwell on Galloway’s past history, a very crafty speaker and self-promoting figure in politics who has previously been a Labour MP.  He was famously a supporter of Saddam Hussain in Iraq, and has had dubious involvement in certain charities relating to Arabic people.  He has coined the phrase ‘Bradford Spring’ to describe his apotheosis.  He points out that so many people are disaffected, and suspicious of politics, they are searching for someone who will speak for them, and he is the man.  In the newspapers today (4.4.2012) the news is announced of his fourth marriage, to a woman aged 27, 30 years his junior, only 4 months after wife number three gave birth to his second child by her...  There is justified speculation about what it can be that attracts them to him.  Apart from wife number 1 the others all either look Arabic or have Arabic names.

As a political footnote, as you will know, we currently have an uneasy coalition government, with the Liberal Democrats being the power brokers together with the Conservatives.  The Lib Dem leader, a man on a hiding to nothing, is dignified with the title ‘Deputy Prime Minister’.  He is one Nick Clegg.  A letter in the Telegraph recently came from someone who visited his old prep school, and looked at the honour boards.  It was noted that even in prep school, Nicholas Clegg was not the head boy on his own – but jointly.  Poor Clegg, no change for him then.

There is no easy segue into tales of Sri Lanka, except perhaps that as I write this, England are playing in their second test match against Sri Lanka, this time in Colombo.  Last week it was in Galle, and we would definitely have been there except that hotels in the area would only accept bookings for 5 days rather than two or three during the match.  At the time we booked our holiday it was still uncertain that the match would be played in Galle because the Australians had been critical of the pitch during their visit there last year.

The highlight in both literal and metaphorical terms of our visit to Sri Lanka was the High Country, and specifically our ascent of Adam’s Peak, known to Sri Lankans as Sri Pada.

This 2243m high pinnacle is perhaps most sacred to Buddhists, the indentation in the rock at the top being said to be where Buddha placed his foot.  But Christians claim it as the footprint of Adam, and Hindus as the footprint of Siva.  There are conflicting claims for St Thomas and the Queen of Ethiopia.  It was also known to Marco Polo, though he did not visit it.  He was aware that fixed chains had been attached to the rock and were needed to ascend it.  These days, the entire path up the peak is made up of steps.  The first section is a gentle ascent through the gardens which rise up from the ramshackle hamlet of Dalhousie.  There is very little to see as one ascends because the majority of foreign tourists do the climb at night, so the tea plantations on the lower slopes are scarcely noticed and the only sights are the booths of the vendors, lit by oil lamps or fires, or occasionally by electric light.  The total distance of the uphill climb is about 7Km, though the distance is as nothing compared with the ascent.  It’s not too clear how high Dalhousie is – perhaps 800 to 100m.  Thus the total ascent is something up to 1500m of altitude.  The major problem with the steps however is the fact that the pitch of them varies enormously, from as little as two inches to around 15 inches in some cases.  Walking up steps which are a foot high is not easy.  The final 30 to 45 minutes is up steps so steep that there is a metal hand rail placed in the middle, which is essential to use.

Every 20 metres or so there is a fluorescent light illuminating the steps.  Very occasionally the light is not working so one needs to step carefully until the illumination improves.  All the way up there are booths, the occasional beggar, religious pedlars, and resting places where the religious adherents can stop and lie down.  Many of them spend hours here overnight sleeping, and can take up to a day to make the ascent.  We have no idea how long it is going to take us to climb – the guide book estimates 2½ to 3½ hours.

Our guide and chauffeur from Red Dot tours, Ervine, has said that we might take an hour to reach Dalhousie from the Tea Trails Norwood bungalow, and dawn is predicted at around 0630.  The alarm goes off at 0145 hours and we are in the car and on our way just before 2am.  On the road we see a few denizens of the night – a ring tailed civet runs across our path; a porcupine rattles its way into the brush; a pair of wild boar trot briefly alongside before abruptly turning off.  In the dirt car park at the entrance to Dalhousie there are literally hundreds of cars and coaches – all empty.  Where are their occupants?  On the hill somewhere presumably.

As we start, there are a few back packers, but once onto the steps it’s clear that most of the pilgrims are local people, of all levels of ability.  Young husbands cradling babies, grannies with walking sticks, obese mothers.  Some of them are still asleep in the resting areas, huddled shapes swathed in blankets like the famous pictures of the figures on the underground platforms during the blitz in WWII.  We have started walking at about ten to three in the morning.  It’s cool and vendors huddle over open braziers, glancing at us as if they realize that hopes of selling supplies or religious emblems are small.  There is little to report except that we just walk and walk and climb and climb.  We are using our walking poles which are very helpful to reduce the legwork, and will prove even more useful on the way down.  I have rather a heavy backpack with two cameras, binoculars, water, a waterproof, and a fleece.  A German girl with no backpack, who possibly weighs about 50Kg as opposed to my 85Kg, and is wearing leggings that appear to be sprayed on to her lovely legs and gorgeous backside pauses to ask me something.  Sadly all she wants to know is the time.  Having got the answer, she skips lightly up the next flight as if she were walking on air.  Other more seriously clad tourists march on past us, but as we find out later, it is a case of the tortoise and the hare, and we make the top very much at the same time as most of these younger walkers, some of whom are about 40 years younger than I am.  Apart from the Sri Lankan families, there really are only three people who are about our age on the walk.  Two of them are a German couple who do not manage to make it.  One is a somewhat hippyish grey pony-tailed man, who is very slim and fit looking for his age.  He has no trouble.  If you are not comfortably able to do a major hill walk of about 10 miles then I would advise not tackling Adam’s Peak.  Surprisingly we meet as many people coming down – all local pilgrims – as we see going up.  Clearly they have not been bothered to stay to see the dawn.  I ask a slightly plump lady in a sari what time she started the climb.  ‘About 6pm’ she answers.  It’s now about 4.30am, so her journey has taken ten and a half hours so far.

Once one is clear of the gardens and firmly engaged on the climb, we can at times see the lights marking the route winding up to what we assume is the top.  It doesn’t seem too far.  But this is misleading.  What we can see is probably only the next section before the path winds out of view.  After about an hour or so I suggest to Lindsay that we should take it easy.  We don’t want to be at the top and hang around in the cold for an hour or more.  This appearance must be deceptive – the steps just go on and on, and we can’t really spot where the summit is.  I have decided that we should do this army fashion.  We will walk at the pace that we will maintain for the whole ascent.  Every 55 minutes we will stop for around 5 minutes, and then resume.  But now we’ve been going for two hours and it seems that we are nowhere near the top.  After about two hours and twenty minutes I ask one of the booth holders how much further it is.  At least another half an hour he says.  And it is.  It takes us in all two hours and fifty-five minutes to reach the top.  The last twenty to thirty minutes is the section where the steps are so steep that we abandon the poles and use the rails to help pull ourselves up.  Amazingly, as we arrive at the level segment by the temple, we see that there are hundreds of people already arrived.  It’s cool, and you need a fleece, but it’s not too bad.  Perhaps that is because of the cloud cover, it is not a clear night.  There is a faint lightening of the sky in the east through the clouds.  Some rain or mist bearing clouds drift across us and everything is suddenly wet, even though it doesn’t feel as though it has rained.  An angry red flush appears in the sky, and the clouds and the lake below become visible in shades of grey.  After the red horizon, the sun is obviously on its way, but the clouds conceal it, so after about 30 minutes on the top we decide that it isn’t going to become any more attractive so we start down again.  At the start there is a huge throng, mostly making their way slowly down the most severe of the steps.  Eventually we can pass them, and the pace of our descent improves.  I’m surprised that our journey downwards takes around two hours, but two hours it is.  It’s nice to see that landmarks become visible as time passes by, so that we can see where we have been.  The bazaars and booths appear even more tawdry in the grey light of dawn.  The garishness of the kitsch religious items is jarring for westerners.  Finally we find Ervine.  We jolt back along the rough roads past Maskeliya to Norwood bungalows where we arrive at about 0915, in time for a spectacular breakfast on the terrace.  The only activity that I can compare Adam’s Peak with is our ascent of Cathedral Peak in the Drakensberg, which was even tougher – longer distance, and ascent from 1400m to 3000m.  The fact that Adam’s Peak is all steps means that our muscles are challenged in such a way that it is very difficult for us to walk or to climb up or down stairs for about five days afterwards.  Here are some pictures to illustrate the climb:

Adam's Peak from Maskeliya Lake

Pilgrims on the peak waiting for the dawn

First light from Adam's Peak

Descending from the Peak

The start of the steps proper up to Adam's Peak

I would like to add so much more about Sri Lanka, but it would almost certainly bore you.  The spectacular nature of the World Heritage sites at Dambulla and Sigiruya, the picture perfect nature of the high tea country, walking up trails between the tea bushes and through woods of cardamom groves, the heat and sunshine on the south coast and the tranquil charm of the old town of Galle inside its ancient fortifications.  Enough.

A view across the roofs of Galle town

Sunset from Galle fort

Easter Sunday

April 8^th.  Yesterday and today we have been out walking in the middle of Dorset.  Yesterday up around Turnworth and part of Bulbarrow Hill with views over to the Northwest to the Blackmore Vale, and today near Cheselbourne, some way West of that with views across to the East to Bulbarrow, Northwards up around Nettlecombe Tout and down over enormous fields of rape back to the car.  Looking to the Southwest we can see the distant tower of the Hardy monument.  Although the trees are not really in leaf yet there is still some beauty in the woods and the skies – wood anemones and bluebells, pure white hawthorn blossom in the hedges, skylarks and buzzards, the drumming of woodpeckers.  The striking thing about Dorset away from the coast is that one sees almost nobody.  We are very lucky to live in this county.  A quiet evening with the final round of the Masters golf to watch.

Hawthorn blossom and a field of rape, Dorset, Easter Sunday

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...