Restraining patients: two memories

I read this morning that in England “Every 15 minutes, on average, a patient with learning disabilities was restrained in hospital last year.” https://www.bbc.co.uk/news/uk-54848098  Patients were restrained 38 000 times in 2019, an increase of 16 000 from 2017. NHS England has encouraged the reporting of episodes of restraint, so some of the increase may be changed reporting rather than more incidents. We don’t know. Reading this brought back two memories.

One was of an editorial I wrote in the BMJ in 1997 https://www.bmj.com/content/314/7075/164:

Don’t treat shackled patients

And keep trying to understand what the Nuremberg trials taught us

“Last week Britain was shocked by the report of a young man who was shackled to a bed until two hours before he died of stomach cancer. He was shackled because he was a prisoner. Last year doctors and others had to protest about women prisoners being forced to give birth while shackled. Understandably doctors unused to treating prisoners in NHS hospitals are not sure about “the rules.” But they should be. Doctors should simply refuse to treat patients who are shackled, and doctors’ organisations should support them without quibble. This is the state making doctors participate in unethical acts in the way that was described in the BMJ‘s December 7 issue marking the 50th anniversary of the Nuremberg doctors’ trials.”

Very short, very blunt.

Another memory was of Christmas 1976 when I was working as a junior doctor in the Eastern General Hospital in Edinburgh. I’d started work in August and was inexperienced. We had admitted a man who had been a heavy drinker. He may have had a heart condition, I can’t remember. Heavy drinkers are at risk of delirium tremens (the DTs) when admitted to hospital—because they suddenly have no access to alcohol.

The first sign that the man was developing the DTs was when he reported rats running up his bed clothes. I can’t remember how we treated him or, indeed, whether we treated him, but whatever we did it wasn’t effective. He became very disturbed, leaping out of bed, and pulling out his drip, so that blood flowed from his arm.

“We’ll have to jump him,” said the registrar. “Remove your tie.” It’s the command to remove my tie that I remember most vividly from that event.

“Why?”

“Because he might strangle you with it if you don’t.”

I took off my tie, and we pursued the man. We grabbed him and pulled him to the floor. He was raging, but he was old and weak. I was able to hold him down while the registrar injected him with something, I can’t remember what. We held onto him for a while, but he quickly became drowsy. We carried him back to bed.

Did we do the right thing? It’s hard to see what else we could have done once he was raging, but if we’d been smarter we would have stopped him developing the DTs.

I remember the incident as exciting.

The moral from these two memories? You draw it.

A ripping yarn of plotting and loving in revolutionary Russia

I read The Lockhart Plot for two slightly odd reasons; one, my mentor, who is now 91, mentioned it to me; two, I feel some distant contact with one of the central characters, Moura Budberg, because I met Hugh Clegg, an editor of the BMJ before me who was married to Moura’s niece. I imagine that he met her and attended her Russian Orthodox funeral in 1974.

In essence the plot is a dubious and probably inevitably doomed attempt by a group of British, French, America, and Russian adventurers to overthrow the new Bolshevik government in Russia after the revolution. The country was in such chaos that the plot might conceivably have succeeded, in which case today’s world might be very different.

It’s a story that cannot be fully told. All the accounts by governments and participants are incomplete, unreliable, and contradictory. This is, as the author Jonathan Schneer writes, is true of all history, but it’s especially true of this story:

“Despite [the lack of reliable evidence]…the plot has not lacked for American, British, French, and Russian historians. But the many authors who have tried to tell the story, in journal articles, chapters of books, and sections of chapters, all had to pick their way through a maze of opaque papers, reports, and cables, and then through a minefield of intentionally misleading accounts and statements, false trails, and outright lies. They have been more or less credulous, more or less creative, more or less successful. To a greater or lesser extent, every historian faces similar difficulties no matter the project; all written histories are imperfect and incomplete—but the Lockhart Plot is a more difficult subject than most.”

Schneer tries to compensate for the lack of evidence by giving us different versions of events, sharing doubts about the reliability of sources, and being clear what we don’t know. This way of telling the story adds to the complexities of an already bewildering story with dozens of characters with difficult names. (The book would have benefited from a list of the characters.)

The conclusion of the book is stark: “The story of the Lockhart Plot is a story of debasement on all sides then, and of fear, cynicism, opportunism—and futility.”

But it does make for a fascinating, almost unbelievable story. There are two main components to the story—the plot but also the love affair between Lockhart and Moura. If Schneer is to be believed, then Lockhart, although he didn’t deserve it, was the love of Moura’s life. Despite having multiple affairs, including with Maxim Gorky and H G Wells, Moura kept her love for Lockhart and saw him often until his death. After his death she held a service for him in the Russian Orthodox church in London. He, in contrast, abandoned and fell out of love with her as he had done before with two women who loved him intensely.

In a book filled with remarkable characters Moura is the most remarkable—and she was a survivor unlike most of the others. She remains a mystery. Was she a secret agent of Russia, Britain, both, or neither? Nobody is sure, but she moved through life with passion and flamboyance.

Schneer sums up the story thus:

“…the story of the Lockhart Plot is more than an authentic historical thriller. It transcends all the elements of the genre: suspense, treachery, violence, love and desire, larger-than-life personalities, to make a larger point. At a historical moment when literally everything in Russia was in the melting pot, all the protagonists, on both sides, understood what was at stake, but not one understood his own inconsequence.”

A brilliant account of the “locked-in syndrome”

I first read “The Count of Monte Cristo” some 20 years ago, and I remembered two things vividly from the book: the account of being stoned and making love to statues who come to life https://richardswsmith.wordpress.com/2020/10/25/whats-it-like-to-be-stoned-alexandre-dumas-tells-or-reminds-you-in-vivid-prose/ ; and the description of the “locked-in syndrome.”

I learn about the “locked-in syndrome” at medical school, and it seemed just about the worst thing that could happen to you. Here’s a description of the syndrome:

“Locked-in syndrome is a rare neurological disorder characterised by complete paralysis of voluntary muscles, except for those that control the eyes. People with locked-in syndrome are conscious and can think and reason but are unable to speak or move. Vertical eye movements and blinking can be used to communicate.”

It is Monsieur Noirtier, a rabid Jacobin in his day, who now suffers from the syndrome. After the description below we read how Noirtier manages to communicate via his granddaughter to change his will to obstruct his son and help his granddaughter. He can communicate a yes or no by how he moves his eyes, and if he needs words his grandaughter runs through the letters of the alphabet until he indicates the desired letter. She then gets a dictionary and runs her finger down the page until she hits the right word.

Perhaps the most important part of the account for anybody with a family member or friend with the condition and for health professionals is the end:

“…this apparently dead clay, almost returned to dust…was still a man of immense learning, unparalleled perception and a will as powerful as any can be when the soul is trapped in a body that no longer obeys its commands.”

Sight and hearing were the only two senses which, like two sparks, still lit up this human matter, already three-quarters remoulded for the tomb. Moreover, only one of these two senses could reveal to the outside world the inner life which animated this statue, and the look which disclosed that inner life was like one of those distant lights which shine at night, to tell a traveller in the desert that another being watches in the silence and the darkness.

Consequently, in old Noirtier’s black eyes, under their black brows – black, while all the rest of the hair, which he wore long and resting on his shoulders, was white – in his black eyes (as usually happens with any human organ which has been exercised at the expense of the others) were concentrated all the activity, all the skill, all the strength and all the intelligence once distributed around this body and this mind. The gesture of the hand, the sound of the voice and the attitude of the body may indeed have gone, but these powerful eyes made up for all: he commanded with them and thanked with them. He was a corpse with living eyes and, at times, nothing could be more terrifying than this marble face out of which anger burned or joy shone.

Only three people could read the poor man’s language: Villefort [his sone whom he hated and who hated him], Valentine [his granddaughter, who was the one person he loved and who oved him] and the old servant whom we mentioned. But Villefort rarely saw his father (indeed, only when it was unavoidable) and, when he did see him, made no effort to please him by understanding, so all the old man’s happiness derived from his granddaughter: Valentine had succeeded, by devoted effort, love and patience, in understanding all Noirtier’s thoughts in his looks. She replied to this language, incomprehensible to anyone else, with all her voice, all her expression and all her soul, setting up lively dialogues between the girl and this apparently dead clay, almost returned to dust; and which, despite that, was still a man of immense learning, unparalleled perception and a will as powerful as any can be when the soul is trapped in a body that no longer obeys its commands.

American polity has had a near-death experience

American polity has had a near-death experience, said Jeffrey Tulis, professor of government at the University of Texas at Austin, in a discussion I just listened to from the London School of Economics. He made his comment when we didn’t know the result of the US election, but his comment was based on Biden winning. If Trump wins, he said, the American political experiment is over.

The US, he continued, is like a patient with cancer. We don’t know whether our condition is treatable, how long we can survive and how we will die. We are, he concluded, in a very very serious condition.

Whether Trump wins or loses he did extremely well. Despite being impeached, mishandling the Covid-19 pandemic, the economy tanking, international alliances collapsing, and cosying up to dictators with no advantage to the US—any one of which would have sunk any other politician—he will end up with something like 75 million votes, more than any other Republican presidential candidate.

Trump has mastered the “politics of grievance.” He has, for example, made it possible to be openly racist. The US, said Tulis, has always been racist, but hypocrisy meant that it wasn’t acceptable to be openly racist. Now it is.

A striking feature of the 2020 presidential election, said David Smith, senior lecturer in American politics and foreign policy, University of Sydney, is the enormous turnout. Biden, he estimated, will finish with 81 million votes to Trump’s 75 million. Trump can turn out his base like nobody else, but he also turns out the other side.

Trump, he argued, completely dominates American politics. In normal years the president features in about 10% of political news stories—but Trump features in 25%. He also motivates people to get out on the streets because he is such a divisive figure.

Politics in the US is all about Trump and, said Smith, will continue to be about him. He won’t go away and if he loses is the front runner to be the Republican candidate in 2024. There’s a dreadful thought.

Letter to a dying teacher

I’m not sure why, but the other day I remembered this letter I wrote to Nigel Ballantyne, who taught me English when I was 14 and was the teacher who most inspired me. We walked a version of the Pennine Way together when I was 16, something that probably wouldn’t be allowed now. He was dying when I wrote the letter, and his daughter told me she read it to him the night before he died. In retrospect I shouldn’t have left it so late, and I should have visited him rather than simply write to him. But I did just squeak in.

Dear Nigel,

I was sorry to learn this week from my brother Brian (Arthur) that you are seriously ill. I’m writing to wish you well and thank for all that you did for me. I think of you with great fondness.

For me you are forever young. I remember you fresh from university, tall and gangly with your flapping black gown. You inspired in me a love of literature, one of the greatest gifts that I have ever been given. The love has stayed with me and sustained me, and I have an unbroken chain of books stretching back to when you first taught me.

I remember your passion for Dylan Thomas, and how you got us to try and write a story in his style. I got 17/20 (or was it 14, either way it was a good mark–you were a tough marker) and felt elated. I remember as well doing a project in your class on the Romantic poets and becoming immersed in them. I read poetry every day, and it’s hugely important to me in a way that many don’t understand.

Teaching, I’ve come to understand, is one of the most important and most difficult of jobs. I’ve never been trained to teach, but I have done a lot of teaching. For the past six or seven years I’ve been teaching a couple of times a year at the Royal Tropical Institute in Amsterdam, and now that I’ve finished I wrote a blog reflecting on what I have or haven’t achieved.

Richard Smith: What have I achieved in six years of teaching?

If you read the blog, you’ll see that I mention you first among teachers who have inspired me. You’ll see too that I believe strongly in the philosophy that teaching is more a matter of lighting fires than filling buckets, and you certainly lit a fire in me, one that has yet to go out.

I remember too how you ran the cross country team, and how we would cram into your mini and drive off to compete with other schools. The other day I boasted to friends how we squeezed 11 into your mini. I think that I must have been exaggerating, but it was certainly a big number. All that, I imagine, would not now be allowed.

You also came into my mind when I travelled recently on the recently-opened Border railway. I thought back to when we walked together a version of the Pennine Way and travelled from Riccarton Junction to Hawick, where somebody shouted at us for being German (it was the shorts, I think). That was my first time ever in Scotland, a country where I spent seven years and met a wife. I remember too that first day (or was it the second?) when we walked in bitter weather across Kinder Scout, and, although exhausted, set off in the evening to walk miles to a pub, only to find it had been burnt down.

Thank you for all that you did for me and being such an inspiring teacher.

Best wishes

Richard (Smith)

Cannabis and me

I blogged the other day about my father smoking his first joint in his 70s, https://richardswsmith.wordpress.com/2020/10/30/the-night-our-father-in-his-70s-nearly-died-from-his-first-joint/  and writing the blog led me to reflect on my own experiences with dope, at least one of which was very strange.

Recently a friend pointed out something to me I’d never thought before but on reflection is obvious: you are most likely to remember events that felt intense. This is certainly true of my memories of my experiences with cannabis or dope, as I call it.

I had never smoked dope before I went to university in Edinburgh in 1970, and I was painfully conscious that I hadn’t. Somehow I’d lived through the Summer of Love, read the Beat Poets, been to see the Rolling Stones in Hyde Park, revelled in an Implosion at the Roundhouse, and enjoyed concerts by Led Zeppelin, Canned Heat, the Mothers of Invention, Jethro Tull, and many others without ever smoking dope or having sex. I felt an anachronism, an outsider, a loser.

As I reflect on this I realise that I was feeling the peer pressure that all adolescents I feel. I desperately wanted to be one of the people who smoked dope; I was much more interested in belonging to that group than in the effects of the drug.

My chance to smoke dope came not long after I got to Edinburgh. I was invited to some sort of event—was it political or artistic, I can’t remember—in a flat that overlooked Arthur’s Seat. People began to pass around joints. My excitement mounted as a joint came close to me, and eventually it reached me. I was nervous that I might to cough uncontrollably because I’d never smoked tobacco: there was nothing cool about smoking cigarettes—in fact, it was distinctly uncool. As I sucked in my first lungsful of dope I didn’t cough, but I can’t remember any mental effects. I left unsure if I had been stoned, which means I wasn’t.

After that smoking dope became routine, although it never had the least impact on my studying or running. All I remember are the parties where one room (the alcohol room) would be full of people dancing wildly to the Stones while in another room people were stretched out in the gloom listening to the Grateful Dead and passing round joints. I’d move from one room to the other.

My next clear memory came in the summer of 1972 when I was picking tobacco on the Northern shores of Lake Erie in Canada. Six of us lived in a hut on the farm, and soon after we arrived one of the other students spotted what he was sure were cannabis plants growing at the back of the hut. I ran to a garage about a mile away to buy skins (cigarette papers), tobacco, and matches. When I got back, we toasted the cannabis leaves, rolled them into a joint, and lit up. We passed round the joint, but slowly we realised that whatever we were smoking it wasn’t dope. We were disappointed.

The punchline to this story is that a few days later we visited another farm and learnt that the students there had also discovered the “cannabis” plants, but unlike us they were still smoking the leaves and “getting stoned.” We laughed at them, but 40 years later it occurs to me that it could have been us who was wrong.

My most intense experience with dope came a few weeks later when I ran away from the farm with a Quebecois. We stayed in his parents’ house in Montreal, and he gave me a joint to smoke. He disappeared, and I became extremely stoned with the weirdest effects. I became convinced that my penis was disappearing inside me. I held onto it desperately. Eventually my anxiety receded, and I’ve never had the experience again.

I knew that that this was something that happened in islands in the Pacific and that it had a name—koro. Whole villages would pull like a tug of war team to stop a man’s penis from disappearing. Whether I had the experience when stoned because I knew about it or whether my knowledge was irrelevant I don’t know. But looking up the condition now on Wikipedia I discover that koro is now in the Diagnostic and Statistical Manual of Mental Disorders as genital retraction syndrome.

What I experienced was an episode of psychosis.

My next memory of being stoned was in 1973 in Herat, Afghanistan, where Alexander the Great had built a fortress that dominated the city. G and I had crossed the border from Iran the previous day and that very day the King’s brother-in-law had deposed the king, who was away having an eye operation in Rome. Afghanistan turned from a kingdom into a republic, and, as Time, said “in one leap forward Afghanistan was in the 14^th century.” We knew none of this at the time, but in the evening we went to a café and smoked dope. This was pure, strong stuff, and when we left I walked through the streets hallucinating.

The thought today of walking completely stoned through the backstreets of a city in Afghanistan is nothing short of terrifying, but in 1973 I was young.

That’s my last memory. Slowly but surely dope left my life, and I haven’t smoked or eaten any for possibly 20 years. I had joined the club I so badly wanted to join, but now it was boring and I had joined other clubs, including fatherhood.

Last concert before lockdown, of the year, and perhaps of the winter and my life

I had tickets to hear the Brodsky Quartet play all of Beethoven’s last string quartets at the beginning of the year, but the First Lockdown (the Second begins on Thursday, will there be a Third, Fourth, and Fifth? Possibly) cut off the last concert. Yesterday I got to enjoy the concert, and the excitement, joy, gratitude, and apprehensiveness of the audience could be heard and felt in the unusually prolonged applause. We may pine for “normal life” (which was actually an unsustainable, abnormal life), but our lives don’t lack for death and drama, two excellent backcloths for Beethoven’s music.

The quartet began with Beethoven’s very last quartet, the 16^th in F. He wrote the quartet in October 1826 and died in March 1827. He was deaf with his health failing, but you wouldn’t know it from the joyful first movement. It was a galvanising moment when the quartet hit their strings for the first time, and I reflected how you feel the music physically in a live concert in a way you can’t with recorded music no matter how good your sound system.

The second vivace movement is light and fast: I imagined Beethoven on a horse cantering through a forest. The third lento movement is Beethoven dying, “a sweet song of rest,” as Beethoven intended. The final movement is nothing short of crazy: after the grave opening the quartet accelerates to a rasping of the strings that could sit comfortably in a piece of heavy metal rock. Supposedly the opening asks “Must it be?” and the allegro answers “It must be.” Death?

After the first piece the viola player spoke     and started by saying “this is a sight for sore eyes.” The sight was rows of people in masks with every other row entry and an empty seat between each household. I was on my own and had an empty seat either side of me. After he said this the audience applauded. The viola player then told us how Mendelssohn, the composer of the Fugue in E-Flat, Opus 81 no 4, that they were about to play had been central in rediscovering the beauty and importance of the music of Johann Sebastian Bach but had also revered Beethoven. The piece they played used a blueprint by Beethoven and quotes him in the middle section but also was clearly influenced by Bach, creating almost a string quartet that Bach might have written had the form been around in his time. Mendelssohn wrote the piece in the year that Beethoven died, and it was easy to hear the influence of Beethoven–but I could hear Bach as well.

The quartet went straight from Mendelssohn’s fugue to the Grosse Fugue, which Stravinsky  called “this absolutely contemporary piece of music that will be contemporary forever.” I must have heard it 50 times, but I can never get to the bottom of its complexity. It is delightfully and joyfully beyond me.

As I left, I thought “that’s enough to carry me through the pandemic.”

A found poem: the dinner companion from Hell

I sat on this board

I’m into youth promotion

I gave that ballet dancer his big break

I ran the Derby

I was the Telegraph, the Economist

I’m doing trade in India

I’ve done China

I’m brilliant

I’m bored

I can learn more

I do not align myself with my party

My wife’s brilliant

I always go for younger women

I was the executor of Max Rayne’s estate

I live in Buckinghamshire in a National Trust house

I rang up Michael Gove to tell him he should license imams

I’m a chocolatier

Found in Diary of an MP’s Wife by Sasha Swire (and read to me by Chicken)

The night our father in his 70s nearly died from his first joint

Reading the account of being stoned in “The Count of Monte Cristo” https://richardswsmith.wordpress.com/2020/10/25/whats-it-like-to-be-stoned-alexandre-dumas-tells-or-reminds-you-in-vivid-prose reminded me of the evening when my father first smoked dope.

“Come quickly, I think I’ve killed Syd.” My brother phoned and said something like these words to me at about one in the morning after he had given Syd, our father than in his seventies, his first joint.

Syd had come to London from Bath for a policeman’s ball (yes, really). He was staying with Brian, my brother, and had come back from the ball to find my brother smoking a joint filled with cannabis, dope, hash, weed, whatever you might want to call it.

Like many people Syd, who had never smoked dope (as I call it), was fascinated to know its effects. He said this to my brother, who offered him a joint.

Syd was a heavy smoker. He’d been smoking since he was 7-years-old, since 1929. He sucked deeply on the joint, and moments later had some sort of fit and passed out.

My brother felt awful. He thought he’d killed his father. He was reluctant to call a doctor or an ambulance because of the illegality of what they were doing—but also because he didn’t know the best action. He rang and told me the story.

I got out of bed and into our car and drove to Balham, some three miles away. I wasn’t anxious: I thought it unlikely that one lungful of dope would kill Syd. Indeed, I couldn’t stop myself laughing. I imagined the story in the papers: “Policeman, 72, killed by first joint after policeman’s ball.” Not a bad way to go, I thought, almost like the famous “Shot by jealous lover while in bed with his son’s mistress.”

By the time I arrived, Brian was calmer. He’d got Syd to bed. Syd was asleep or possibly unconscious. “Don’t tell him I called you. Pretend that you were passing by.”

It seemed unlikely that I’d be passing by at 1.30 in the morning, but I went through to see Syd.

“Hallo, Syd, it’s me, Richard.”

Syd stirred. “Oh, hallo, what are you doing here?”

“I was passing by. How are you feeling?”

“Beeootiful,” answered Syd, stretching out the word.

At this point the night turned from tragic to comic. “Sleep well,” I said and went back to see Brian.

He was still shaken. Feeling that you’ve killed your father is not a good feeling. But then we began to laugh.

After I left Brian sat beside Syd’s bed and said: “I’m so sorry, dad, I thought I’d killed you.”

He replied: “It wasn’t your fault, I asked for the joint.”

What is a good doctor? An unanswerable question

I’ve been watcing three television programmes about Harold Shipman, a general practitioner who murdered more than 200 of his patients. It took some 20 years for the authotities to recognise what in retrospect should have been obvious–at least in part because most of his victoms were elderly women. As I watched the programmes I thought of a quote about Shipman that we published above an editorial trying to answer the question “What is a good doctor?” https://www.bmj.com/content/325/7366/667 The quote reads:

“I remember the time Shipman gave to my Dad. He would come around at the drop of a hat. He was a marvellous GP apart from the fact that he killed my father.”

I was then led from the editorial to the piece I wrote to accompany the issue devoted to the question “What is a good doctor and how can we make one?” https://www.bmj.com/content/325/7366/0.10

Our readers have sent us on a wild but illuminating goose chase. They asked us to answer two simple questions: “What is a good doctor and how can we make one?” We commissioned the finest brains, searched both “the medical literature” and real literature, and invited our readers to help us—but the end result is that we don’t have a good answer to either question. And we never could. We have been pursuing an illusion.

But how can this be? The profession is thousands of years old. Billions are spent on medical education. Colleges, academies, and councils from every country in every age have deliberated on the questions. “Surely you can tell me whether Dr Shipman down the road is a good doctor or not.” “Well he seemed to be until it emerged that he’d murdered hundreds of his patients.”

It may be possible to identify the world’s best batsman. He (or she) has a very narrow task—to score as many runs as possible; and we have excellent data. But even with such a task there are questions of style, speed of scoring, and courage under pressure. What about the best composer? Might it be Beethoven, Bach, Bartok, Cage, or Ellington? The task is to make beautiful sounds that will stir the listener. Or is it? What about Cage’s piece that is all silence? So it’s not so easy to define a good or the best composer, but what about a good person? What is a good human being? We will have a thousand answers to such a question and never agree, and defining a good doctor, I suggest, lies in degree of difficulty somewhere between defining a good composer and a good human being. In fact, it’s impossible.

But the profession hasn’t been prevented from trying. Britain’s General Medical Council has produced a long list of what is required of a good doctor. Polly Toynbee writes that: “It is in the nature of every profession to set itself an ideal character and attempt to impose it as best it can on new entrants. It is also in the nature of humanity to fail that ideal most of the time” (p 718). The point is perhaps not the list of qualities but the search and the discussion.

If we cannot define a good doctor, then it is unsurprising that we don’t know how to make one. There seems to be some agreement, however, that we are doing poorly at the moment. Medical education may be removing rather than instilling the human qualities that make for a good doctor. We should, say our readers, select the right people and then “stop them from going rotten through overload, cynicism, and neglect during their training and early career (p 676).

But probably we shouldn’t be thinking too much about individuals anyway. We are obsessed with individuals. Good doctors, said George Bernard Shaw almost a century ago, must practise within a good system, free of perverse incentives that push “wildly beyond the ascertained strain which human nature will bear” (Is that your health system? Probably not.