Archive for July, 2010

The call to discipleship – 2

Barth says things like:
one gives up the previous form of his existence
What do I do with that. It is no longer I who live but Christ who lives in me. How do i ever get to live and love well enough for that.
Bottom line – who do I think I am?
I know/believe that I am created/beloved of god. I know that my call is to follow him, to find my identity and meaning and satisfaction in him.
I suspect that in my heart/belief I do not mean that.
I am in deep pursuit of greatness. Not of career or money or anything so obviously (so it seems) facile.
I mean greatness in the sense Steinbeck meant. When he used the word timshel – thou mayest. As Samuel in East of Eden exhorts Adam to the meaning of greatness.
God placed us in the garden and commanded us to live together and order and work our surroundings. I think I get what this looks like, what our greatness should look like.
But this is where the nuance comes in. I think my pursuit of greatness in the sense I so poorly articulate here is really the right thing to do. I get into bother when I neglect the humility and awe that it takes to give up my previous form of existence as Barth put it.
It is not I who live but christ who lives in me.

Beauty dies young

Ugliest church building ever – North Uist

Perhaps occasionally used as a squash court

The call to discipleship – 1

I date all my books when I start reading partly to mark them as mine and partly to help me remember when I read them the first time round.
I read the call to discipleship back in dec 08, I’d read bonhoeffers cost of discipleship a few months before which makes sense.
Barth writes densely argued sentences, the kind where you need to take careful note of the last comma to know which part of the argument the current section refers to. This always baffles me. I was never good with my use of punctuation. And I do things like start sentences with ‘and’. Liz would he ashamed of me.
I skimmed it too quick. I do that a lot with a lot of books. Read quickly with the intent of getting the book done so I can start a new tantalisingly exiting book that’s calling me from the shelf. I’m too impatient to enjoy being present. I suspect that spills over into life too
Anyhow. Reading it again, slowly, a chapter a day, I begin to get a bit more of the depth of what he says.
in the call of Jesus one is met by the fulfilled promise of god as valid for him or her. In and with the command of Jesus, solid ground is placed under their feet when they are on the point of falling into the abyss. What the command requires if them is simply, but comprehensively, that in practice as well as in theory they should regard it as able to bear him, and stand on it, and no longer leave it.
We do not trust in “an idea of Christ, or a christology, or a christocentric system of thought…” The call to “follow me” is the call to accept and pursue and stand firm on an actuality.

A man without a country

This guy put me onto Vonnegut just after he dies. Vonnegut that is not Jason. I am eternally grateful for that.

The guy who made this give me this book:

So I figured I’d give you a bunch of quotes to chew over:

On Karl Marx

When Marx wrote those words we hadn’t even freed our slaves yet. Who do you imagine was more pleasing in the eyes of God back then, Karl Marx, or the USA?

On career choice

if you really want to hurt your parents and you haven’t the nerve to be gay, the least you can do is go into the arts

On taking Pall Mall to court

i have never chain-smoked anything but unfiltered Pall-malls (since I was 12) and for many years they have promised to kill me. But I am now 82, thanks a lot you dirty rats. The last thing I ever wanted was to be alive when the three most powerful people on the planet would be named Bush, Dick and Colon. [Vonnegut died from a head injury in the end]

On marriage and community

when a couple has an argument nowadays, they may think it’s about money or power or sex or how to raise the kids or whatever. But what they’re really saying to each other, though without realising it is this: “you are not enough people!”

On Jesus

how do humanists feel about jesus? I say of jesus, as all humanists do, “if what he said is good, and so much of it is absolutely beautiful, what does it matter if he was God or not?”

But if Christ hadn’t delivered the sermon on the mount with its message of mercy and pity, I wouldn’t want to be a human being.

Most of the time I think we have more in common with the humanists than almost anyone else but the sermon on the mount falls flat for me without the divinity.

Anyhow, read more Vonnegut, it’ll do you good.

Kiss The Rain

One is immensely proud of oneself

[You have to say the title more as “Keesh Le Rain” to get the joke…]

Better Together

We got married.

It was kind of fun.

Most of you were there. Thanks for coming, we appreciate it.

Once me and Simy had got the bouncy castle sorted I finally had to let go of the reigns and let the party run itself. We’d spent so long organising the damn thing that it was hard to let go of being in control. I have issues with control I think.

But you ask people to do stuff for you and you give them their job and you let them run with it. And they nailed it. Absolutely nailed it. Everyone.

One would think I should have been nervous about getting married. But not a bit of it. I was more worried as to whether it would piss down and we’d arranged for 300 people to stand in a tend in a car park in the rain. I would have felt bad if that had happened.

As for getting married I was cool with that. It seemed like a great idea. And I still think it is so why would I worry? I trusted Wylie would turn up and she did.

I still get all teary thinking about the speeches. I missed my Da. I still do. I always will. I suppose that’s how it works.

Here’s to the Nylies. (Copyright Deb Byrne, all rights reserved)

A holiday at the sea

There may be other things to do in the outer hebrides on honeymoon but between world cup matches I did manage to get through a few books:

– The Idiot – Dostoyevsky – I like Dostoyevsky, I really do but I find all the Russian patronymics a litte bit bewildering to follow. Myshkin is a pretty cool character though, especially in the context of his peers

– Philapelphia here I come – Brian Friel – when I read screenplays I can’t help but picture myself watching a performance somewhere

– The Reason for God – Tim Keller – written with enough sense to realise that reason will only get us so far

– The Four Loves – CS Lewis – so good we got Zoomtard to read it at our wedding. Well a little bit of it anyhow.

– Gilead – Marilynne Robinson – I don’t think I got all the beauty and depths of theology the first time I read this. I read it too quick. This is a book to be savoured. Preferrably with a setting sun and a single malt

– Life Together – Dietrich Bonhoeffer – I think I’ve quoted enough from this for now…

Meditation in a toolshed

The house is coming along just nicely thanks. If GOD’s purpose in creating is to bring order out of chaos then I have been humanity at it’s very best.

These two helpful chaps helped clear the garden a bit back before the wedding

And they turned the garden from this:

Into something more resembling this:

And now it’s time for me and Transfarmer to turn it into something more resembling this:

One of the remaining tasks has been to tackle the workshop (the nice wee blue stone building) and clear out even more of the endless trash that appears to have been deposited there.

This morning it looked like this:

But then the intrepid explorer was sent in with wellies.

Then it looked like this

And then we made some shelves and now it looks like this

One feels very satisfied with this kind of work.

Tourist History

This is more of a plug so that you lovely people will come visit me and wylie in out mansion.

We’ll make you green curry and brownies and feed you with good coffee and have you beaten at scrabble by Martha. It’s great.

Wee phil (Phildemort/Milhaus/Philly-O-Fish) was the first person to make it down and stay in our B&B. This seems only fair seeing as he and the office did some of the work on the house.

We took a day (well more of an afternoon) out in Dublin today and made an appearance at the Chester Beatty Library. Wylie threatened to take me here on our second date and I was like “no way i’m not going on a date with a hot chick to a library” so we went to see the Bodies exhibition instead.

It’s free. I like free stuff like this, I need a good list of free things to do in Dublin if someone wants to make me one.

The current big exhibit is about the imperial Mughal albums which you all know lots about. Think Taj Mahal time.

I liked a few of the paintings:

(first ones a bit subtle)

And this one (with the translation underneath)

This is what they’re perhaps most famous for:

Though I have a copy of the whole book sitting on a shelf upstairs so I don’t know what they’re bragging about…

She must and shall go free

I’ve been married a month, and while Bonhoeffer is here talking about “bearing each others burdens” in the context of Christian fellowship it seemed a pretty damn fine exposition on marriage.
It is first of all, the freedom of the other person that is a burden to the Christian. The other’s freedom collides with his own autonomy, yet he must recognise it. He could get rid of this burden by refusing the other person his freedom, by constraining him and thus doing violence to his personality, by stamping his own image upon him.
But if he let’s God create his image in him, he by this token gives him his freedom and himself bears the burden of this freedom of another creature of God. The freedom of the other person includes all that we mean by a person’s nature, indiviuality and endowment. It also includes his weaknesses and oddities which are such a trial to our patience, everything that produces frictions, conflicts and collisions among us. To bear the burden of the other person means involvement with the created reality of the other, to accept and affirm it, and, in bearing with it, to break through to the point where we take joy in it.

Dietrich Bonhoeffer – Life Together

The man who

I live here now. Which I’m still getting used to. I sit here right now, typing this as I consider that I now live here. I find it odd. Nice odd, but still odd. I keep thinking I’ll have to drive back up the M1 soon.

I start a new job here on Sept 1st but have the privileged position of being a kept man as Transfarmer goes out to work everyday.

So far (in the one week we’ve been home) I’ve spent most of the time cleaning and painting and unpacking. That in itself is a fun and satisfying thing to do.

I have also come up with a list of daily or weekly tasks to do (I’m all about lists). Highlights include:

– Praying with “the wife” each morning

– one blog post a day (tick…)

– exercise occasionally (not s sure about that one)

– try out one new recipe a week

– one dinner a week with friends/family

– at least 60 mins of learning anatomy a day

And so after a whole 30 minutes of reading Gray’s I decided to write instead.

I started at the very start of the book. Which may have been a bad idea. I have forgotten all about basic cell structure. Largely because it’s irrelevant to my everyday practice, but it does fall into the category of “things that someone who teaches anatomy should know”.

So I’m getting reacquainted with desmosomes and the golgi apparatus.

And 30 minutes in I’m overwhelmed by the whole fascinating concept of who we are.

A cell “communicates” with another cell by producing a signalling molecule that another cell “senses” with a specific receptor molecule and something in the other cell changes as a result. This happens often enough and someone paints the Mona Lisa.

This highlights two things

1) how hopeless and inadeaquate language is at expressing such things – in many ways a cell cannot “sense” so much as its own existence in the very way that we cannot hope to sense our own existence without these cells. Cells no more know what it means to “communicate” than the pen on my desk yet without such cells we have no notion what communication is.

2) the inability of scientific reductionism to explain the Mona Lisa. The example of cell signalling above will perhaps explain how I bend an elbow but the painting of the Mona Lisa, or any cultural/creative work is a whole different kettle of fish.

And anyhow why would you keep fish in a kettle?

Telephone and rubber band – further tips…

Following on from this post it appears I was onto something.

You can thank me later Craig & Phil…

Crawling with idiots

Following on from this in the BMJ

People like me are crippling the NHS, sucking money from it like leech. Honestly.

I have abandoned my secure pension and holiday priviledges and study leave to become a mercenary.

For those who don’t know what a locum doctor is, it’s kind of similar to a substitute teacher.

Someone on the regular staff is sick or on a course or not present for any number of reasons so we need someone to cover.

Sometimes this gap in the staffing can be filled by other people in the department. frequently the gap is left unfilled and everyone just has to work harder. (or simply the patients wait longer, it’s not like people were sitting twiddling their fingers…)

If the hole in staffing is big enough then we try to get a locum doctor in.

Lots of different types of doctors make up locums.

1) people already in the same department who are looking some overtime – these folk are probably the best to get as they know how the department runs inside out and they have a certain loyalty or commitment to the job already so they often really make the effort

2) people from different specialties/departments who want to keep their experience broad and earn a bit of extra cash – this can range from GPs wanting a bit of hospital experience to guys who are now into specialty training but who did a bit of emergency medicine at some point and are able to work at a lower level in emergency medicine

3) people on time out in a research or academic job who are looking to keep up their skills and supplement their income – these guys tend to be enthusiastic and motivated (motivated enough to do research for a bit!) – this is the category I currently fall into. I’m also working in my old ED (emergency department) so i feel extra wonderful…

4) locum agency staff – often we know very little about who these guys are. Often the locum agencies don’t know. This can range from highly qualified and motivated individuals to guys who have a medical qualification form somewhere but have never managed to obtain an NHS job. Language skills are highly variable and knowledge of both how the NHS works and how the department works is sometimes sorely lacking.

[GP locums and consultant and long-term locums are a slightly different kettle of fish, I mainly refer to middle-grade and junior-grade doctors]

We are also using an ever increasing number of locum doctors. There are lots of reasons for that. I agree part of the blame falls at the feet of EWTD and MMC but there are simply greater demands and expectations on the services we provide. The change in the visa rules leading to a greater restriction in how non-EU doctors work in the UK has also left us short staffed (roughly half of doctors in the UK trained overseas).

The EU regulations that allow free movement and recognition of medical registration means that regulation of EU doctors is to a certain degree out of the hands of the GMC. The best example being this doctor who has been struck off the UK medical registrar but is allowed to freely practice in Germany.

In our department there are two big gaps in staffing. The looming (come change-over in August) gap is that of juniors. No one, it seems, wants to do emergency medicine in Northern Ireland. The training jobs were massively undersubscribed leading the NI deanery to take a trip to India on a recruitment drive.

The junior staff see a large number of our 78000 patients. Will be interesting to see how many juniors we get.

The other main staffing issue is the middle-grade rota. This consists of people who are further on in their training (registrars) but not yet consultants and staff grade doctors (or speciality doctors as we’re called these days). Staff grades are doctors with experience in their specialty, able to work without supervision but haven’t (for any number of reasons) done consultant training.

I’m pretty convinced that middle-grades in our department see the majority of patients (though I’d love solid numbers to back that up). The business of seeing the patients and getting the waiting room emptied and supervising the juniors largely falls to us. Naturally I think we’re the most important part of the department…

[NB the consultants are hardly ornaments in the department but a lot of their day to day job isn’t seeing patient after patient, nor do i think it should be]

We have funding for 8 middle-grade doctors. We had 5 up until I quit in June and now they have 4. To my knowledge the gap is being made up by locums (a group that I now form a part of!).

If we had a fully and consistently staffed rota I think the place would run pretty well but the problem is we can’t fill the posts. No one wants to do non-training middle-grade jobs. Quite frankly it’s too much work for not enough reward (either career or financial) for most people. ED jobs are really tough. Without doubt the toughest of all the jobs I’ve ever worked.

So we will become increasingly dependent on locums and will pay these staff often up to 4 times what the permanent staff are getting. Despite the fact that some of the locums we are paying for this are of dubious value for money to say the least.

I will get (in my opinion) extremely well paid for the few locum shifts I do this summer, in a place I love to work in. But the more the NHS employs locums like me the less likely it will be able to afford the contented and permanent staff it needs.

Take the money and run

Lots of drugs have two names. one short and catchy and marketable and the other long and difficult to pronounce.
For example Tamiflu/Oseltamivir – the names that caught the head lines in 2009. It took me a few weeks to get fluent with oseltamavir whereas just tamiflu rolled off the tongue (and flew off Roche’s shelves and into government stockpiles). Even the name Tamiflu implies its role – it’s a drug that cures flu right?
Drug companies put millions, sometimes billions into development of a new drug and subsequently they get a patent on it. So for the first 15 years (or so) they have exclusive rights to the chemical and can charge effectively what they want for it.
This explains the huge pressure to prove that new is better. That crappy old paracetamol just isn’t up to the job, we need new drugs, and the new drugs are always better.
I’m glad we put people to sleep with propofol and not ether any more (though why we can’t use ketamine like most of planet earth I don’t know…) that was a definite step forward but I’m pretty sure the difference between omeprazole and esomeprazole is as minimal as the difference in names.
The office does a good rant on the “me too” drugs of stereoisomers.
Once a patent runs out then anyone can make the drug and sell it at a competitve price (therefore often reducing the cost by 10 times) to purchasers. These are called generics. In general (with a very few important exceptions) these are identical to the branded drugs
But for doctors time is precious and they read too many drug ads and meet too many drug reps and they tend to remember the short snappy name and not the long hard to pronounce one. So when they prescribe the drug they write the short snappy name and the pharmacist is obliged to dispense what the doctor has written. Even when the generic form costs  a tenth of the price.
The department of health, in a rare moment of common sense has decided that pharmacists should be able to automatically substitute the cheaper generic drug even when the doctor has prescribed the expensive branded version (remember these are the same chemicals, with the same effects, just with different names).
Reading back over that it kind of seems crazy that we didn’t start doing this years ago.

Like eating glass

I’m sure the patient’s consent was obtained for this video…


Effect of delayed lumbar puncture on the diagnosis of acute bacterial meningitis in adults EMJ 2010:27:433-438

The basic overview for everyone

Meningitis is a bad thing. The bacterial one at least. Around the world it kills kiddies in droves. It’s a big deal. Thanks to vaccines and antibiotics it is not so much of a big deal (as in common) where I live. When it happens it’s a terrifying disease it just doesn’t happen that often. Even more so since the pneumococcal vaccine.

The classic (headache, photophobia, neck stiffness) presentation is no longer considered classic because we see it so rarely that we now only see the really hard cases – the kid with the fever and a sore throat who’s dead by morning. In the third world you’ll see the classic presentation all the time.

The test we do to make the diagnosis is the lumbar puncture – the one they do on House in every episode. And as tests go it’s not bad.

Very rarely, and mainly more than 40 years ago, you would put the needle in to take some fluid and the patients brain would squeeze out of his skull from the pressure change. This is as one would imagine a bad thing.

We are all terrified of this happening to us when we do the test (like most things in medicine we are more scared of doing harm than we are keen to do the right thing) so we often get a scan of the patients brain first to see if there’s anything obvious like blood or an abscess in there that might make the patients brain squirt out.

Rarely does this scan do anything other than make us feel better. It is rarely helpful.

As a result we delay doing the useful test so we can do a less useful one.

Most of the time these days we have enough common sense to start treating the patient before we do any tests. Treating bacterial meningitis quickly is one of the few diseases where treating it early makes a genuine difference.

Now I think these guys conclusions are mainly right but I’m not sure the study they’ve published gives them much evidence to say it.

The more complex critical appraisal bit

They tried to look at people who had meningitis and see how long they waited for a lumbar puncture and why they waited and what impact this had on how they did. But there are lots of problems.

– it’s a chart review – they looked at notes and decided what was wrong with the patient from there. Which can be useful but often you can read the chart whichever way you wish to prove your point. What do you do with missing data? What if someone made a decision on data that wasn’t written down? If you don’t tell how you decided what the chart said then everything that follows is dubious

– the patients they choose to look at are those pulled by discharge coding – so you only get in the study if someone thought you had meningitis and wrote it down. This misses those who had meningitis but no one made the diagnosis and thought they had something else. The famous paper on how to do a chart review is here.

– they excluded people who didn’t get a lumbar puncture – this was 10% of their patients. This is a big problem as there was probably a reason why they didn’t get an LP and so you can’t make statements about all meningitis patients, only the ones who got an LP. Though one would question the validity of a disgnosis of meningitis that doesn’t involve an LP.

– they questioned and reviewed the diagnosis of meningitis – they may well be right that some of the people who got coded as meningitis weren’t meningitis but you can’t do this with a chart review with their methods

– the gold standard seemed to be the British Infection Society guidelines – as with most guidelines these are often evidence light (there’s usually not much evidence in existence). I am aware of no evidence that shows that following the guidelines saves lives even though I agree with the guidelines in most respects.

– they do statistical analysis on symptoms of small numbers of patients from a chart review – this bit is completely pointless – when I think someone has meningitis my aim isn’t to ensure whether I’ve written down whether they vomited before coming in, I ask, but that doesn’t mean I write it down so you can’t find it out retrospectively.

– they try to make firm statements about whether or not a patient should have had a CT based on what was written on the chart when in reality there are lots of reasons, many logistical, why this happens or not.

– they note that none of the patients (they selectively chose) had LP prior to antibiotics even though “antibiotics are immediately started after the LP is performed, or sooner if there is a delay of more than 30 mins”. This is kind of weird as the reason they didn’t get the antibiotics before LP may have been that the docs thought there may have been a >30 min delay (for whatever reason) in which case they were following guidelines.

We do lots of needless CT scans – the most useful point I found was that of the 62 patients (two thirds of all) who got scanned none had anything to worry about on CT.

I agree with these guys that we miss valuable information by sending people for silly scans that take too long to move the patients for and get a report and make a decision(not the scan itself which is seconds). I agree that the 4 hour target has caused problems here [though in recent news we appear to be scrapping it]. I agree that we’re all too scared to do the right thing. Unfortunately this isn’t great proof of that.

Together we’re heavy

CS Lewis had a rule which ran something like this: always read two old books before reading a new one.
When he talked of old he meant early church fathers and the greeks and medieval literature. When I say old I mean CS Lewis, indeed anyone dead.
I like the principle of the thing.
I’m currently making my way through Life Together (with an equally awful cover like the one in the link) by Dietrich Bonhoeffer.
I don’t know if it’s a character of the German language or the weight of their minds or something lost in translation but reading either Bonhoeffer or Barth is a challenging experience.
This is not a Harry Potter book you read in a day. I get through about 10 pages a sitting.
What determines our brotherhood is what the man is by reason of Christ. Our community with one another consists solely of what Christ has done in both of us
In that statement lies a core part of what it means to be church.
It is not merely a group of individuals brought together by time, taste and context. It is a GOD ordained body of people, reconciled to one another in Jesus.
The “reality” we see is a bunch of disjointed people who struggle to agree on the colour of the curtains never mind the church’s mission.
Bonhoeffer reminds us of the real reality (sorry…) that we are new creations in a whole new kind of relationship to each other. This is no mere human relationship but a spiritual one.
We need to remember that the spiritual reality of what GOD has done is so much more real than the “reality” we perceive.

Handshake drugs

Interesting article in the BMJ on the conflict of interest involved in the WHO pandemic recommendations regarding the swine flu pandemic of last year – remember that. I’m surprised we’re here at all to remember it given the hype.
The WHO were the official body that declared the “pandemic” and as a result kick started and guided the way we responded.
Most notably this brought an unheard of (though 10 year old) drug to world wide media attention.
It seems a bad idea that the NGO making the guidelines should be based on the science rather than the money but it seems that there is a lot of doubt as to the transparency of the process that WHO undertook and it is clear that many involved had financial ties to those making the drugs that were later recommended and more importantly stock piled (at big cost/profit) in colossal numbers by governments.
These drugs aren’t like penicillin for pneumonia. Even the most optimistic science doesn’t claim it’s gonna save lives. For a disease that gets better by itself in 99% of people then giving out these drugs in the drinking water will benefit only the people making them.
Interestingly the actual declaration of the pandemic triggered previously negotiated contracts on vaccine manufacture. There has been a suggestion that WHO not only changed the definition of pandemic but also that there was some influence on the actual declaration.
However given the way that drugs are developed it’s hard to form an expert committee to come up with guidelines without having a conflict of interest.
Having said all that, one of these days we’ll get a flu as contagious as swine flu (that spread over the globe) and lethal as bird flu (that had a 40% mortality) and we’ll be properly buggered. I think I’d have a different take on oseltamavir if the disease behaved different.
NB – Mark Crislip has a an interesting retort to the reporting on the reporting by the BMJ here.

Telephone and rubber band

Following on from Zoomtard’s post on the new iPhone I figured I’d share some tips on how to survive a move from Northern Ireland to The Republic.

iPhone 4 has nothing on this.


July 2010