Monthly Archives: December 2013


In October many French country people were busy gathering various types of fungi to dry, bottle or use in their cooking.gathering of edible fungi will resume in the Spring and I shall look forward to gathering Girolles or Chanterelles one of my favourites.

As they have been something I have come across in French life as well as in my studies of Traditional Chinese Medicine (TCM) I have decided to publish my thoughts and research on this topic.

When I arrived in France back in October the grass in front of the house was covered with an imageabundance of different mushrooms and low and behold I was thrilled to find a cluster of Cèpes (Boletus edulis) outside the back door. They are considered a prize find, an ingredient in various foods. B. edulis is an edible mushroom held in high regard in many cuisines, and is commonly prepared and eaten in soups, pasta, or risotto. As they are so valued anyone owning woodland where cépes are abundance there are signs forbidding people to pick them and French Law would support the proprietor in prosecuting someone found picking mushrooms on their land.

Interdit picking cepes
The French are very secretive about where their mushrooms are located and are even reluctant to tell their close family and there is only one French friend who will allow me to go collecting mushrooms with her.

Cèpes have a distinctive appearance and can be usually recognised easily. However, some mushrooms can be confused with similar poisonous species and if unsure when picking them in France they can be taken to the local Pharmacist who is trained to identify Mushrooms which are edible. The mushroom is low in fat and digestible carbohydrates, and high in protein, vitamins, minerals and dietary fibre.

imageMany years ago I remember when I was working as a junior paediatrician several children were admitted following eating ‘magic mushrooms’ which grew on the local hillside in Wales.
‘Magic mushrooms’ is a slang word for psilocybe semilanceata or ‘liberty cap’ mushrooms (the most common type of ‘magic mushroom’ in the UK) and contain the psychedelic drugs psilocybin and psilocin. These mushroom, when eaten produce hallucinations and sometimes, can cause disorientation, fatigue,vomiting and can give abdominal pains or diarrhoea. There are records of their use in different parts of the World by many ancient civilisations. When these children were admitted together there was absolute chaos on the ward as they effected the children in different ways. Fortunately, no child had any long term effect.
They are Illegal to use

If you want to know more about the effects of these and also to draw attention an FRANKexcellent website regarding any drug abuse:-

While medicinal mushrooms have been used in China and Japan for more than 3,000 years to boost immunity and fight diseases such as cancer, only in the last decade has their power begun to be recognized in the West. In more scientific terms, a number of compounds in fungi have been found to stimulate the function of the immune system, inhibit tumor growth and boost intestinal flora. Particularly, mushroom substances called terpenoids help kill bacteria and viruses and exert anti-inflammatory effects, while complex chain-like sugars called polysaccharides have been shown to exert antitumor and immuno-stimulating properties. – The Natural Foods Merchandiser, March 2005
Mushroom stallI managed to buy some white Chanterelles ( Cantharellus subalbidus)
from the market carefully gathered by an expert and I carefully prepared them and fried them in crème fraiche, seasoned with garlic and parsley imageas instructed by my expert (stall holders in the market love to advise you how to cook their produce) and served with chicken escalope.
Our ancestors would certainly have eaten them and they would have been gathered by peasants throughout history, with these and truffles, peasant food wasn’t too bad, although of course such food is seasonal with chanterelles being found mainly in the spring and autumn or in imagethe rainy seasons. Traditionally mushrooms particularly chanterelles have been assumed to be aphrodisiacs, with the 11th century Normans in Britain feeding them to grooms at their wedding feasts. The minerals they contain along with the amino acids and vitamins, probably make them good for the libido, especially for men with erectile dysfunctions.
Chanterelles have an affinity with certain trees and particularly birch, beech, oak, and pine in descending order, as they seem to like birch trees best, but they also seem to quite like larch and sweet chestnut trees too. They grow in soil which is damp, but not swampy or marshy ground.
If you go picking them, make sure that you wash them thoroughly and clean the gills. This is best done with a soft toothbrush.
They are great added to soups and stews and go well with eggs, but can be used to accompany any meat dish. Treat them as you would any other mushroom as far as cooking goes. Personally I love them and am always happy when I find them either in woods or in the market as I did this Autumn and the man proceeded to give me a lesson on how mushrooms grow and how important the climatic conditions have to be – the temperature, air pressure, amount of rain and sun and the consistency of the soil and the site where they grow . The spore starts to grow about a metre below ground and a fine filament a couple of millimetres thick grows upwards to the surface and if the conditions are right will form a fungi.image
Like other mushrooms they contain vitamins A and D as well as some of the B-complex ones. They contain all the essential amino acids and glutamic acid is believed to boost the immune system and may help fight cancer, infections and rheumatoid arthritis. There is evidence that it inhibits blood clotting, which is valuable in the fight against heart disease. As for minerals, they contain potassium which regulates blood pressure and the contractions of the heart muscle; copper, manganese, magnesium, calcium, zinc and selenium which is good for the mood and the brain

Oyster Mushrooms
I wanted to include this mushroom which you will see on the shelves of your local Oyster mushroomsupermarket and has particularly good cholesterol lowering properties.
Pleurotus ostreatus, the oyster mushroom, is a common edible mushroom. It was first cultivated in Germany as a subsistence measure during World War I and is now grown commercially around the world for food. The oyster mushroom may be considered a medicinal mushroom, since it contains statins such as lovastatin which work to reduce cholesterol.
Pleurotus Ostreatus) is a fleshy, gilled mushroom growing in shelf-like fashion on wood that is a good food and promising medicinal. Protein quality is nearly equal to animal derived protein. Low fat content is mostly of the good unsaturated kind. Also contained are carbohydrates, fiber, vitamins B1, B2, plus minerals, especially iron and an antioxident. This mushroom shows activity against cancer and high cholesterol. It has shown activity in the following areas: antitumor, immune response, anti-inflammatory, antiviral and antibiotic.

Shiitake Mushrooms 香菇 xiāng gu
The Shiitake (Lentinula edodes) is an edible mushroom native to East Asia, which is cultivated and consumed in many Asian countries.
Shiitake Fresh and dried shiitake have many uses in the cuisines of East Asia. It is thought that have been used in cooking since pre-historic times in China,Japan and Korea. In Japan, they are served in miso soup, used as the basis for a kind of vegetarian broth, and also as an ingredient in many steamed and simmered dishes.
More information can be found on:-
A 1980 study found that a virus in shiitake mushrooms could produce interferon, effective in treating cancer but also to boost the immune system. When I was studying Chinese herbs (TCM) during the Swine flu epidemic and on the weekend I attended the tutor was very keen to advise us to make a soup to protect us from catching the flu. The tutors claimed that in China that as it was so difficult to vaccinate such large numbers of people instead shops were urged to stock large quantities of the ingredients especially thee Shiitake mushrooms so that every household could make the soup. I will share this recipe with you should you need it in the coming months.
At that time I duly got home and made the soup and emailed to my student children.. No- one caught the flu!

Recipe For Chicken and Mushroom Soup – ideal on coming back from work, after exertion especially to boost the immune system

4 Chicken thighs
2 Onions
12 Garlic Cloves
4 inches Ginger
2 Red Chillies
12 Shitake Mushrooms
5 Stock cubes
2 litres water
Dried Goji Berries soaked in cold water (optional)

Chop onions,garlic and ginger and fry lightly in oil until soft
Fry chicken thighs until golden brown
Chop chillies and mushrooms and add to above
Add water and stock cubes bring to the boil and simmer for 1-1.5hrs.
Before serving add the Goji berries.

WarningWhilst I have written about several types of fungi, which can add a lovely flavour to our food and at the same time have remarkable health benefits please beware of their potential poisonous properties and never pick them unless you are absolutely certain of what they are.

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Posted by on December 29, 2013 in Training and Advice


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” Le plateau des fruits de mer” can be essential to a French Christmas and New Year as it is to balmy summer days by the sea. The fact that it may well be served in a grotesque imageceramic boat is neither here nor there. Christmas Eve often means the gathering of several generations of a family sitting round a table covered in white linen, or even white paper, upon which are displayed the elevated trays of the freshest seafood of many types of shellfish preferably with lobster and crab and most certainly with a generous number of oysters. They tackle this feast with an arrangement of eating instruments and consider it a harmonious, pleasurable shared experience. This may be repeated during the Summer months but imageChristmas is a time when fishmongers are selling custom made platters in abundance.
At the very least everyone will be buying oysters by the box or at least a dozen from supermarkets stacked with boxes of oysters transported from the coasts of Brittany or imageNormandy. Alternately corners of the streets or outside small greengrocers there are small pop up stalls selling oysters which are graded by size numero zero (the largest) to numero 5 (smallest for garnish) and most people buying numero 3 or 4 but families buying boxes or 2 dozen. They are enjoyed as a starter for the Christmas meal with a glass of Champagne.

My personal introduction to oysters was when I was in my late teens when I was hiking through Northern France with a group of English and French students. We had met in the West coast of Ireland the year before in an International camp and it was evident at that time that the French boys were skilled at collecting shellfish and knew how to serve them. When we met them in France we camped in the grounds of various farms and were introduced to the delicacies of local delicious French soft cheeses,Crêpes aswell as cider and Calvados. The imagelast visit was to the home of Alain who was about to join the French Navy for his National service. He happily took us out in his boat and after a coastal trip then moored in a small cove and told us wanted to give us a surprise. The next thing this swarthy French young man dived off the boat armed with a knife. He soon returned with a bag of oysters he had harvested deftly from the rock something he had being doing for several years. He then prepared them by prising open their shell and demonstrating swallowing them whole . Under the circumstances I found no difficulty in acquiring the taste instantly. I have to say at that time I was not aware they are considered to have Aphrodisiac properties!
Like so many foods, oysters are an acquired taste. The thought of eating them raw remains deeply repellent to some, though if you enjoy other seafood there should be little difficulty in getting to grips with them. While Jonathan Swift once remarked that “he was a bold man that first ate an oyster”, the slithery beauty of a fresh oyster is a unique taste most definitely worth acquiring! Many discover a lifelong enthusiasm and will choose oysters in preference to any other item on a restaurant menu. I include myself in that category.
Hence, since 1989 when I have been frequently visiting France I have very rarely missed having oysters for Christmas and with a glass of Champagne.
When I drink a glass of champagne I always think of miners trapped underground, when I worked in a Welsh Mining valley I was told on good account that on occasions when miners were trapped a tube was introduced into the cavity where they were stranded and champagne was delivered as those above ground believed it was good nourishment. Interestingly, in April 2007, the Journal of Agricultural and Food Chemistry published the results of a recent joint study by the University of Reading and University of Cagliari that showed moderate consumptions of Champagne may help the brain cope with the trauma of stroke, Alzheimer’s disease, and Parkinson’s disease.

Oysters do have health benefits. Don’t worry if you chip some of the shell when preparing the oysters as the shell is a Chinese Herb known Mu Li is also named Concha Ostreae, 牡蛎Concha Ostreae) and is used to treat menopausal symptoms and “calms the spirit”, treating anxiety.
The oysters themselves as well as being rich in protein, they are also low in fat and in calories. They contain significant amounts of zinc, calcium, iron, iodine, copper, magnesium and selenium. Legendary properties have also been attributed: it is believed by some that oysters are the Viagra of the sea. A team of American and Italian researchers analyzed bivalves and found they were rich in amino acids that trigger increased levels of sex hormones. Their high zinc content aids the production of testosterone.
Oysters themselves can and do change gender several times during their lives!



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Posted by on December 24, 2013 in Anecdotes...little stories


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I thought it might be interesting to give a account of a patient’s experience of the health service in France.

Peter is a good friend and like many British people he has chosen to retire in France after having fascinating jobs throughout the World decide that they just want  a peaceful, calm place to spend the rest of their life. Nevertheless, having been busy all their lives they can’t resist getting involved in organising concerts, ambitious needlework/patchwork projects,making jams and preserves,organising barbecues, painting, sculpture,  and  house renovation  not forgetting  writing, fishing, keeping chickens and horses, exploring the surrounding countryside on foot or bicycle and landscaping the land they own.
When friends in the UK say “but what do you find to do all day ?” It is difficult to know where to start. Peter had lived in London and had done various projects in the UK but was finding the incessant aeroplane traffic noise, worked in the City but retired and living under the major flight path was becoming increasingly tedious. He was no longer enjoying the buzz of London and decided to retire to France to build a house. He was initially unsure whether he would ever see the results of his dreams as his blood pressure and cholesterol had been very high despite medication and  he knew he was at a high risk of having a cardiovascular event, either a heart attack or stroke. He was overweight and his diet was poor, the only saving grace was that he had given up smoking many years ago.
After 6 months of living outside a quiet village in the Dronne valley in the Dordogne, known as the land of Primitive Man, the house that had been a dream was beginning to materialise but even better news was that his blood pressure was now within normal limits to the point that he stopped all medication, his cholesterol had fallen from 11mmol/l to < 4mmol/l and he only needed to be on very low dose statin. He had lost weight and was enjoying feeling fit enough to do labouring in the way of moving tons of gravel, felling trees and digging foundations for extensions, running water to fountains etc, etc.


When the men ranging in age from early 60’s to late 80’s get together they spend their time discussing tractors, chainsaws, trailers, where the best builders merchant is and the appropriate French word for useful tools or how nails and screws are sized in France. All this is important as they embark and support each other on another project. Interestingly one of the men described how he had had lunch with apache men on a girder in New York – amazing …….

However, on this occasion the subject turned to medical issues and Peter brought up the fact that he had acquired a hernia whilst lopping some branches off a tree which was obscuring a good view down the river when he was sitting on his newly constructed jetty. It wasn’t long before the men in turn laid claim to the fact that they all had a hernia of some sort of other and proceeded to share how and where they had had it repaired recalling their symptoms concerns and described their experiences in graphic terms. That is the trouble if you are a doctor people don’t hold back in giving their detailed descriptions of their medical conditions as they somehow feel you need to have the full description.
Bernard who had bilateral hernias but was in his late 80’s had been treated for leukaemia and various cancers in the past and is always entertaining as he graphically describes his near death experiences in various corners of the world ranging from being before a firing squad, a noose around his neck or being dumped in the back of beyond and having to find a way out all graphically recalled. He was embarking on building a Chinese bridge over a small lake he had created, was fighting for supremacy with his large Sussex cockerel who had dared to attempt to assault his hen (his wife)and was still playing a round of golf twice most weeks thought he would avoid surgery and had persuaded his French GP to prescribe him a truss! I haven’t prescribed one of those for years since I looked after ex-miners who had such bad chest conditions that they were unable to be even considered for surgery.
Roger,who had had open heart surgery previously had been enthusiastically trying to make a perfect lawn of his one and a half acre garden and had acquired his hernia, was wary of French medicine was opting to return to the UK to attend the London Hernia Clinic. The others present had had theirs repaired in various hospitals throughout the World and were recalling their experiences.

What is a hernia?
A hernia (or ‘rupture’) occurs where there is a weakness in the wall of the tummy (abdomen). As a result, some of the contents within the abdomen can then push through (bulge) under the skin. Normally, the front of the abdomen has several layers comprising skin, then fat, then muscles, which all keep the guts (intestines) and internal tissues in place. If, for any reason, there is a weak point in the muscles, then part of the intestines can push through. You can then feel a soft lump or swelling under the skin.


What are the types of hernia?
Different types of hernia can occur. The most common types are listed here:

Support groups
The British Hernia Centre
87 Watford Way Hendon Central London NW4 4RS Tel:…
Inguinal hernia
This is the most common type of hernia. Males are more likely to have inguinal hernias, as they have a small tunnel in the tissues of their groins which occurred when they were developing as a baby. This tunnel allowed the testicles (testes) to come down from the tummy (abdomen) into the scrotum. Tissue from the intestines can also pass into this tunnel, forming an inguinal hernia.

There are two main types: indirect hernias, which are usually congenital and common in boys, and direct hernias, which are more common in adult men. They can occur in both sides of the body.
With the wealth of advise Peter had been given he decided to phone his French GP next morning.” Could you come down this afternoon about 3pm”, the receptionist said. “That’s fine,” said Peter but then muttered that he would probably have to wait about 40minutes as he spends so much time with each patient.

Having then decided to have the hernia attended to in France and Peter proceeded with the necessary arrangements.
Infact, the GP is a Greek doctor married to an English doctor who had been working in Coventry and they had come to France in 2005 as they had been disillusioned with General Practise in the UK. They had asked me to join them but for many reasons including my attachment to the patients at the Avenue although tempted I had declined to take up the offer.
Peter duly went for his appointment and indeed was seen late. I made no comment. Following the consultation the receptionist had made an appointment to see the surgeon the following week and gave him a letter to take with him. He was then asked to pay 23€ for the consultation at the same time the receptionist put the Carte Vitale in the machine. His contribution was 1€ whilst the rest was reimbursed.

What is a Carte Vitale?
The Carte Vitale is the health insurance card of the national health care system in France. It was introduced in 1998 to allow a direct settlement with the medical arm of the social insurance system.
The card itself is not a means of payment, but a means of easier reimbursement. You should normally expect to receive reimbursement directly into your bank account within a week and the amount reimbursed depends on personal factors but everyone pays a small amount. All residents in France are legally required to have a health insurance as a top up to your public health entitlement, whether through public and/or private coverage. The public health entitlement (and other social security benefits) depends on a number of factors, including nationality, residency status, work status and contribution to the system.
Everyone aged 16+ years of age is required to have one. Children under 16 years are included on the card of their parent or guardian.

Where there are excess medical charges (called dépassements) over the official tariffs you may be able to get reimbursement from your voluntary insurer. If not, the costs fall to you.

imageVitale card is a microprocessor-based or so-called “smart” about the size of a credit card. The updated version launched last year is more refined with photo and signature included. It does not contain any medical information but all the administrative elements needed to support your care:

imageyour identity and your rights-holders under 16 years of age;
your registration number;
the health insurance plan you are affiliated;
the health insurance fund to which you are attached;
your rights to any universal health coverage complementary (CMUC);
your rights to any exemption from co-payments if you get under a long-term illness (ALD), maternity, accidents at work, etc..
The Carte Vitale is strictly confidential. Except for the owner, it cannot be read by the Health Insurance Fund or the health professional seen, unless they are equipped with a business card which allows reading the card. It includes specific rights such as exemption from from certain payments.
You do not have to submit your Carte Vitale during a medical examination conducted as part of a loan application eg mortgage.

You can access the information contained on your Carte Vitale using ATMs installed in the reception points (excluding information on your rights to exemption). These ATMs also allow you to edit the certificates (eg certificate or certificate of daily duties allowances), and update your Carte Vitale.

I volunteered to take Peter to the hospital appointment partly to translate some medical terms but also because I was curious to experience how it all worked. We set off on the 21km trek by car as there is no public transport except taxi. It was reasonably easy to park with no charge. When we arrived we were directed to the outpatients.
It is a public Hospital known as The Centre Hospitalier de Périgueux, public health facility was opened on its present site in 1953. It has 580 beds and has an A&E, a 38bed Maternity unit and 115bed Psychiatric unit. It serves a population of 410,000 and stipulates the following user rights
The user is at the heart of the concerns of the public hospital. It must accommodate all patients without discrimination of any kind. The user rights are specified in the “Charter of the hospitalized person” (circular dated 2 March 2006), which must be brought to the attention of each person hospitalized. This charter is available in seven languages ​​(English, German, Spanish, Italian, Chinese, Portuguese and Arabic).

  • The right to access and quality of care
  • The right to be informed and to participate in decisions
  • Access to health information (medical record)
  • The legal protection of privacy
  • The management of pain in hospital

More details on the website
It has an extremely low incidence of hospital infection and it is a statutory right of the patient to have pain controlled adequately to the extent that a patient post operatively or undergoing a procedure will be asked at frequent intervals to grade their pain from 1-10.
When we entered the hospital we were struck by the quietness of the hospital and the stark cleanliness of the corridors and the rooms bearing in mind it had been built since 1953 and various additions in the past decade. All staff were uniformed including the admin staff who wore white pyjamas, also nurses wore white pyjamas with coloured bands to indicate their status and the doctors wore white coats. They were softly spoken but professional and helpful. We waited in a waiting area and everybody respected the quietness. The doctor wearing a white coat passed by with a patient acknowledging our presence and apologised for keeping us a few minutes waiting. He then showed us into a stark room with only a desk, several chairs and a telephone. He read the letter and then asked to see Peter in another room for examination. They both reappeared and he agreed it was a hernia and needed surgery. He then took out his diary and asked when would be a convenient date, Peter got out his diary and between  themselves they arranged a mutually convenient date. He then explained clearly exactly what he was going to do in a mixture of French and English, showing Peter the type of gauze had he would use and suggested that as he was taking a blood thinning drug that he should stay in overnight and he would also see the anaesthetist. He then dictated a letter to his GP and the anaesthetist. He also answered Peter’s questions patiently. He then sked Peter to write a cheque  for 42€ slipped it under the phone with the other cheques and at the same time handed a form to reclaim this charge from Peters health insurance.
A week later we returned to see the anaesthetist.  Firstly we had to take a number in the main reception area and when called go to the allocated admin staff (a bit like the system at  Perceval  House, Ealing ) who then took the Carte Vitale which demonstrates you a resident in France and entitlement for a percentage of medical costs by the state , the remainder of the cost is met by the insurance company and these documents have to be verified before the patient can make arrangements for hospital admission. also it was necessary to produce a photo ID ( passport or ID card)
Following this the proceeded to the area where the anaesthetist was consulting. The receptionist looked oddly at me to come forward calling me Peter. However, it turned out that most of the patients were antenatal and her expression was indicating that not only had I had an unusual female name but perhaps I looked a little old to be pregnant.
The patient established we saw the anaesthetist who quizzed Peter about his past medical history and current medication,examined him and the asked him to go into the next room to have blood taken and an ECG tracing by the nurse.
imageThe nurse then issued Peter with 2 bottles of Betadine to be applied over the whole body including the hair on the evening prior to surgery and the morning of the surgery, no food or drinks from the night before and to arrive at the hospital at 7am.

We were then told to return to reception to make the appointment to see the anaesthetist and receive paperwork and instructions of what to do prior to admission. The receptionist then arranged the overnight stay and if he wanted a single room that would be 4o€ extra to be paid after the stay.

On the day of the surgery we set off at 6.15am by car in pitch black down country lanes and only the occasional lorry or car to the hospital. As we entered the town the only activity was bakeries selling bread and the bar tabac selling coffee and newspaper and cigarettes. When we arrived at the hospital we trailed down endless corridors into the silent stillness of the hospital to be welcomed by 2 nurses ( one of which turned out to be from the next village)who showed Peter to his room. He was asked to robe in a gown and the a careful inventory was taken of his belongings including watch, mobile phone including the make (although of antique value only) whether there was a charger,rings, money- notes and coins and items of clothing. He was then asked to show ID ( passport, DVLA or ID card ) He was then challenged as to whether he had washed with Betadine evening and morning ( after admitting he had used deodorant under his arms he was sent to the bathroom to apply Betadine under the arms). He was quizzed as to when he had last eaten, whether he wore glasses and how many pairs he had with him, did he have false teeth, similarly if he had a hearing aid and as he some dropping of the mouth from an old nerve problem whether he could manage normal food. Also asked if he wanted to use the TV and then was shown how the mechanism of the bed operated. This was all documented .
I was asked to leave to learn the room, whilst the nurse attended to him. He reported  that they had asked him if he had urinated that morning and then proceeded to shave him from the level of the umbilicus to the the mid thighs and everywhere in between! He was then given a tablet to relax him as he began to doze and adorned with mop cap a porter soon appeared to take Peter to theatre and I made a hasty retreat.
He told me subsequently that when he arrived in the theatre where he was then asked to transfer to the operating couch and wheeled into theatre and didn’t remember anything until he woke in his bed feeling parched. Eventually the surgeon did his round at about 6pm checked his wound and gave him permission to have a light supper – three course as the usual in France and all in sealed containers.

The view from the window was merely other hospital buildings but he was entertained by the starlings gathering on the communication wires constantly jostling for position until an unbeknown signal gave rise to a sudden departure in a large black cloud.(mobile phones are useful to capture these moments!)
He was able to phone me to say all was well so far and he was in no pain (there is a hospital policy,as stated in their brochure to aim to keep patients pain-free). He had a poor night but he found the nurses attentive and reassuring. The next morning breakfast arrived a few biscuits with butter and jam and a bowl of an apology for tea!! He was then told he could wash in the ensuite bathroom and dress but again with an offer of help. Throughout this experience he felt nothing was too much trouble for the nurses and they were thoughtful and reassuring. He was someone who had experienced previous hospital admissions and had been fearful on this occasion, which is normal as people get older and are aware that there can be complications, which friends are only too glad to share!
He rested during the morning and after the three course lunch soup, celeriac and paupiette de veau followed by a yogurt all in sealed packaging.  The surgeon arrived to discharge him after further inspection and advise regarding driving and completing the hand written records and  a prescription and instructions for the nurse to remove the clips after 10 days.
I arrived to collect him and the nurse passed over the papers and he was told to collect the prescription for dressings and painkillers from the pharmacy and then phone the nurse to visit him at home to attend the wound. Then we went to the hospital administration to make the final settlement including paying for the overnight stay in a single room which would have been 37€ but as all the rooms for It is of note that nurses have a practise run from their own surgery premises and can ask patients to attend but usually they visit the home post operatively.

On arriving home he rang the nurse’s home to arrange the visit. He had previously seen nurse Leblanc for home nursing and asked to speak to her and she replied it was her speaking but strangely did not know his house and sounded different… All was revealed when it turned out Nurse Leblanc who he spoke to was the daughter-in-law and Nurse Leblanc  had divorced and remarried. The male nurse had been dismissed as he had made fraudulent claims all because he wanted a  fast car and a bigger house!  Sounded like something out of a soap opera…..

The nurse called at the house every other morning with both nurses alternating.  They left their instruments in a well used tin case at the house and sterilised them by wiping with Betadine and did not use gloves. Nevertheless, the wound healed beautifully and each visit the nurse advised gentle mobilisation. Unbeknown to them he had driven the tractor around the garden!

Card readerAt the end of each dressing each nurse recorded the visit by putting the Carte Vitale into a card reader and a cheque was made out for 30€ most of which is reimbursed.

The wound healed very well and after 6 weeks he was seen by the surgeon for review. He was satisfied that the operation was satisfactory and he was discharged.

Overall, this was an extremely satisfactory experience and an insight into French medical care.

More insights into how the Hospital is organised can be found on the link below

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Posted by on December 22, 2013 in Training and Advice


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Pain is inevitable suffering is optional

Pain is inevitable

Pain can be defined as a highly unpleasant physical sensation caused by illness or injury but can also be defined as mental suffering or distress.

Pain accounts for a substantial number of reasons for patient consulting with a doctor We know that 27% of patients attend with a musculoskeletal problem most of whom will describe an element of pain. There are also those who will complain of pain associated with their chest, abdomen or head of another part of the body. It can be localised or more generalised and can be referred from a site where the cause of pain originates. It is estimated that > 10 million people have persistent pain.

The following video attempts to give an understanding of pain

I have always been interested and puzzled about the concept and the complexities of persistent or chronic pain and how it manifests itself in people of all ages. It is one of the reasons why I took up acupuncture and studied Traditional Chinese Medicine(TCM) in an attempt to treat pain with something other than tablets, capsules or applications as well as develop a deeper understanding of pain and how it can be treated.

Pain words

Pain can be described using many adjectives such as shooting, burning, stinging, stabbing, throbbing and pricking but these all not only describe the unpleasant sensation but have association with a frightening experience. Hence, with pain there is usually a feeling of fear or emotion of some kind. I attended two lectures a few years ago; one was from an eminent American psychiatrist talking about the neurophysiology of depression and how depression could present with pain such as back pain, chronic abdominal pain or headaches and how these pains could be treated with antidepressants medication. The second lecture was from a Swedish neurophysiologist who impressed us by drawing intricate nerve pathways to demonstrate how acupuncture worked bug also by treating pain this could treat depression.

Many years ago it seemed appropriate that when I carried out intricate procedures on very premature babies that because I assumed that it must be painful, it was remarked by nursing staff that when I made the effort to talk reassuringly and stroke them the procedure went more smoothly but analgesia was never routinely given.

Premature baby
It was not until 2010 that research showed that premature babies do perceive pain and are now given analgesia routinely when procedures are performed. Infact premature babies are sensitised to pain by intensive care treatments they receive after birth, a study in 2010 suggested. Tests showed that pre-term infants that have spent at least 40 days in hospital feel pain more acutely than healthy newborns. From this study it was suggested that better pain relief should be given to premature babies under intensive care to prevent them becoming pain-sensitive. Brain activity comparing full-term babies and premature babies was seen when both sets of babies were gently touched on the heel and showed no difference, suggesting that the sensitisation of pre-term babies is specific to pain. This is important, since the sense of touch is triggered by being held or cuddled. It implies that premature babies can benefit from a mother’s touch as much as normal infants.

I remember a child coming to surgery with his mother in floods of tears and when I asked ‘What’s the matter?” He said” A lion bit my ear!” Clearly he felt the sensation of pain but expressed a terrifying fear of how it had occurred. Pain from an acute ear infection is probably for many children their first experience of severe pain and not only do they need pain relief but they need comfort and reassurance.

My personal experience of severe pain was when I was admitted with renal colic as a medical student and realising it was ‘for real’ not one of those pains that all medical students have as they study every speciality. I remember being petrified wondering, imagining what it was and although it was thoughtful to put me in a sideward I felt abandoned and desperate wondering if anyone realised how much pain I was suffering. I was given intramuscular pain relief, which gave me florid hallucinations of Monty Python feet descending on me and those around me changing in form in seconds. I was violently vomiting and terrified and this lasted several days. Then a very gentle doctor sat by my bed explained exactly what was happening and how the stone was working its way out of my system and if not it would be removed surgically next morning. He also listened to the effects I described( this drug has subsequently been taken out of use) changed the medication and then said in a gentle kind manner that if I felt distressed he was prepared to come and see me anytime. The pain instantly became more tolerable and I was able to cope much better feeling less fearful and knew it was happening. Much to the consultants chagrin, as he had come especially early to perform the surgery, about 10 minute before surgery I passed the stone! I never saw the kind doctor again but he taught me what was meant by bedside manner and what being a doctor was really all about – having the knowledge but combined with the gift of being able to allay fear by giving the time when it is needed.

Several cases of severe pain puzzled me for years and interestingly all were in severely mentally ill patients.
The first case was a gentleman who walked into A&E looking pale, cold and clammy holding his fist against his chest but not complaining of any pain despite being asked several times. A routine ECG was performed, at that time performed on all patients >50 yrs and this showed a massive hear attack across the anterior part of his heart.

The second case was of a gentleman again walking into A&E vomiting copious amounts of brown fluid clutching his distended, rigid abdomen but showing no history of pain and on palpating his abdomen no complaints of pain but X-ray corfirmed an obstruction with perforation and emergency surgery revealed widespread peritonitis.

The third case was that of a gentleman who had had a severe mental breakdown whilst working in the City as an analyst and had been treated for skin cancer and was attending a follow up appointment and it was found that he had spinal bone metastases. The day prior to being seen he had walked 7 miles on a country ramble, sadly a week later of widespread metastatic cancer.

The final case I would like to mention was that of a lady who I had been seeing in surgery regularly and knew she had a diagnosis of severe dissociative disorder,which had been the result of years of abuse in her childhood and early teens. Dissociative disorder is a condition whereby your sense of reality and who you are, which depends on your feelings, thoughts, sensations, perceptions and memories becomes ‘disconnected’ from each other, and doesn’t register in your conscious mind. Your sense of identity, your memories, and the way you see yourself and the world around you will change. This is what happens when you dissociate. It’s as if your mind is not in your body; as if you are looking at yourself from a distance; like looking at a stranger. She had been developing swelling of her joints which looked as if they should be painful but she denied severe pain and the distribution of the joint problem was typical of rheumatoid arthritis. I performed the relevant blood tests which came back extremely high supportive of the diagnosis of rheumatoid arthritis . After consultation with the rheumatologist she was seen and given high doses of intramuscular steroids. She then had to have surgery to her cervical spine as she was at serious risk of becoming paralysed from the neck down due to extensive disease in this area. She has been on many powerful drugs for rheumatoid arthritis but is now taking regular injections of an immunosuppressant treatment called adalimumab (Humira) which is a Tumour necrosis factor-alpha inhibitors (TNF-alpha inhibitors) – the human body produces tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is an inflammatory substance. TNF-alpha inhibitors are used for the reduction of pain, morning stiffness and swollen or tender joints. These drugs are only used in exceptional cases of Rheumatoid Arthritis.

Pain can be helpful in diagnosing a problem. Without pain, you might seriously harm yourself without knowing it, or you might not realize you have a medical problem that needs treatment as in the case of those mentally ill patients. I realise many people are brought up not to make a fuss about pain but it is important that the symptoms of pain are shared with your doctor and necessary investigations are done, as treating an underlying cause can often cure the pain. However, sometimes pain goes on for weeks, months or even years. This is called chronic pain and it has been found that a pain cycle evolves as shown below:-

Pain cycle

Sometimes chronic pain is due to an ongoing cause but sometimes the cause is unknown and usually there is a psychological element to a greater or lesser extent. The pain may occur because the brain can’t make enough endorphins. These are chemicals that shut down pain signals. Or, pain signals continue after an injury has healed. In some cases, increased pain sensitivity makes even minor injuries very painful.


The British Pain Society is the largest multidisciplinary professional organisation in the field of pain within the UK.

Our membership comprises doctors, nurses, physiotherapists, scientists, psychologists, occupational therapists and other healthcare professionals actively engaged in the diagnosis and treatment of pain and in pain research for the benefit of patients.
It has published several publications which can be easily downloaded

  • Managing pain effectively using ‘Over the Counter’ (OTC) Medicines (2010)
  • Understanding and Managing Pain (2010)
  • Help the Aged – Pain in Older People: Reflections and Experiences from an older person’s persepctive (2008)
  • Opioids for persistent pain: information for patients (2010)
  • Managing Cancer Pain – information for patients (2010)

It is very important to communicate how your pain effects you describing it carefully , what you do to ease it and what makes it worse and how intense it is using a scale as below:-

Pain scale

It is useful to keep a diary either using a calendar or using an App
This helps to communicate progress that is being made and how it is affecting daily life.

Pain can be classified into several categories:-

Nociceptive Pain:

Nociceptive pain is believed to be caused by the ongoing activation of pain receptors in either the surface or deep tissues of the body. There are two types: “somatic” pain and ” visceral” pain.
“Somatic” pain is caused by injury to skin, muscles, bone, joint, and connective tissues. Deep somatic pain is usually described as dull or aching, and localized in one area. Somatic pain from injury to the skin or the tissues just below it often is sharper and may have a burning or pricking quality.

Somatic pain often involves inflammation of injured tissue. Although inflammation is a normal response of the body to injury, and is essential for healing, inflammation that does not disappear with time can result in a chronically painful disease. The joint pain caused by rheumatoid arthritis may be considered an example of this type of somatic nociceptive pain.

“Visceral” pain refers to pain that originates from ongoing injury to the internal organs or the tissues that support them. When the injured tissue is a hollow structure, like the intestine or the gall bladder, the pain often is poorly localized and cramping. When the injured structure is not a hollow organ, the pain may be pressure-like, deep, and stabbing.

Neuropathic Pain:

Neuropathic pain is believed to be caused by changes in the nervous system that sustain pain even after an injury heals. In most cases, the injury that starts the pain involves the peripheral nerves or the central nervous system itself. It can be associated with trauma or with many different types of diseases, such as diabetes. There are many neuropathic pain syndromes, such as diabetic neuropathy, trigeminal neuralgia, postherpetic neuralgia (“shingles”), post-stroke pain, and complex regional pain syndromes (also called reflex sympathetic dystrophy or “RSD” and causalgia). Some patients who get neuropathic pain describe it as bizarre, unfamiliar pain, which may be burning or like electricity. The pain may be associated with sensitivity of the skin.

An interesting account of the mystery of chronic neuropathic pain

click on link below:-

Mystery of chronic pain

Psychogenic Pain:
Most patients with chronic pain have some degree of psychological disturbance. Patients may be anxious or depressed, or have trouble coping. Psychological distress may not only be a consequence of the pain, but may also contribute to the pain itself. “Psychogenic” pain is a simple label for all kinds of pain that can be best explained by psychological problems.

This close relationship between pain and psychological distress means that all patients with chronic pain should have an assessment of these psychological factors, and psychological treatments should be considered an important aspect of pain therapy. In some cases, psychological problems appear to be a main cause of the pain. This does not mean that the person is not actually experiencing the pain. Rather, the patient is truly suffering but the main cause somehow relates to the emotions, or to learning, or to some other psychological process. Although doctors sometimes encounter patients who pretend to be in pain (some can be called malingerers), this appears to be a rare occurrence. Most patients with pain that appears to be determined primarily by psychological processes are hurting just like those who have pain associated with a clear injury to the body.

Sometimes, psychogenic pain occurs in the absence of any identifiable disease in the body. More often, there is a physical problem but the psychological cause for the pain is believed to be the major cause for the pain.

Another website which gives interesting insights into pain is:-
It also has a series of podcasts which talk about various aspects of pain the edition talks about exploring the possibility of controlling pain through techniques that focus on the brain and the mind using mindfulness a topic I wrote about in a previous blog.



Because chronic pain is so complex, there are often multiple treatment goals. These goals may include more comfort (being “pain-free” is often not possible when pain has become chronic), better physical functioning, improved coping and less distress, getting back to work, helping the family cope, and other positive outcomes. To accomplish these goals, chronic pain often is best managed using what is called a “multimodality” approach.

The patient’s response to therapies may be influenced by age, gender, race or ethnicity, cultural beliefs, or any of a variety of physical, emotional, social, family, occupational, and spiritual circumstances. Treatments for pain must be tailored to the individual, based on each person’s unique condition.

A multimodality approach to chronic pain includes a combination of therapies selected from eight broad categories:

  • drug therapies
  • psychological therapies
  • rehabilitative therapies
  • anesthesiological therapies
  • neurostimulatory therapies
  • surgical therapies
  • lifestyle changes
  • complementary and alternative medicine therapies

In many cases, a multimodality strategy requires the involvement of several types of health care professionals -the interdisciplinary team.

Effective pain management is therefore collaborative in nature, involving good communication among the patient, family, and the practitioners involved in the care. A sense of partnership in trying to find the best therapeutic approach promotes the most creative, and ultimately the most effective, approaches. Patient-practitioner partnership can maximize the patient’s involvement and sense of control in the healing process. Patients must feel empowered to seek the best care and to act in a way that uses their own resources in the service of health. If an interdisciplinary team of practitioners is involved in developing a multimodality approach, the members must communicate freely to ensure the appropriate targeting of therapy. Family communication helps promote positive patterns within the family and may reduce the stress caused by prolonged pain and impaired function.

Integrative pain managementFrom this perspective, Integrative Pain Therapy is a natural extension of state-of-the-art conventional pain management.

Integrative Pain Therapy

The term, “integrative pain therapy,” can be used to describe a broad therapeutic approach to the management of chronic pain, which attempts to combine the best of traditional treatments for pain and disability with the best of the therapies widely considered complementary or alternative. It is part of a larger effort to develop an “integrative medicine approach” to many clinical problems.

This integrative medicine approach links traditional, so-called allopathic, medical treatments with varied complementary and alternative treatments. It is a comprehensive system of medicine, which emphasizes wellness and the healing of the whole person (physical, psychological, social, and spiritual), above and beyond the treatment of any specific symptom or disease (Bell, 2002). It involves the use of all safe and effective therapeutic approaches that can potentially facilitate healing, while empowering the patient to participate in the process of healing. Integrative medicine acknowledges the complexity of health and illness by identifying multiple causes of disease and multiple interventions based on the physical, biochemical, psychological, social and spiritual aspects of health and disease. It recognizes that multiple outcomes may be positive for the individual, and that these outcomes may vary from one person to the next (Rosomoff, 1999).

The goals of an integrative pain therapy approach may include:

  • reducing or eliminating pain
  • using medicines that are appropriate, provide sustained benefits, have tolerable side effects, and support the functional goals of the patient
  • reducing distress and enhancing comfort, peace of mind and quality of life
  • improving the understanding of the role of emotions, behavior and attitudes in pain
  • improving the ability to function physically and perform activities of daily living
  • improving the ability to function in social and family roles
  • supporting the patient’s ability to return to work and function on the job
  • educating patients in ways to maintain rehabilitation gains and avoid re-injury
  • empowering patients to actively participate in pain control strategies
  • promoting awareness and understanding of the factors that contribute to physical and emotional distress related to pain
  • developing the skills and knowledge needed to increase the patient’s sense of control over pain

Integrative pain therapy draws from a broad spectrum of therapeutic approaches. It recognizes the value of multiple approaches to pain management (a multimodality approach) and acknowledges the individualized nature of good medical care. The goal is to employ the safest and most effective therapies to provide maximum benefit.

Foundations of Health

In developing an integrative approach to pain therapy, the starting point is a broad view of health and well being. The foundations of health include at least four elements:

    • stress management
    • proper diet and nutrition</li
    • regular exercise
    • psychosocial support

There are literally thousands of studies confirming the importance of each of these foundations. Careful attention to each can have profound effects on health and illness. The work of Dean Ornish (Ornish, 1999), for example, demonstrated that interventions targeted to these areas can not only halt, but actually reverse, coronary artery disease.
Stress Management.
All people experience stress and some degree of stress may be needed to generate excitement, engage fully in tasks, and perform well. However, too much stress, or poor coping with stress, can undermine health and well being.There are many tools available to help reduce the debilitating effects of acute and chronic stress. The most important approach is to recognize triggers and behavior patterns, and to utilize emotional and spiritual approaches to reverse stress’s negative effects. These approaches can be learned in a variety of ways, such as psychotherapy, education, and training in mind-body techniques. Sometimes, herbal, nutritional or pharmacologic therapies are needed to assist in coping with persistent stress.

Proper Diet and Nutrition

Although science has a great deal more to learn about the role of nutrition in health and disease, it is certain that poor nutrition can contribute to a range of problems. Poor nutrition is common in many developing countries, and there is clear evidence that people living in developed countries, such as the United States, may not obtain enough of the essential nutrients needed for maintaining health (Fairfield & Fletcher, 2002). Because the diet may not be a complete source of all the nutrients needed for optimum health, the use of supplements may be necessary, either to help prevent disease or to aid in treatment.


Proper exercise maintains fitness and is very helpful in reducing stress. Intense aerobic exercise is not necessary to achieve these benefits. Brisk walking may be sufficient for many people. Modest, regular exercise, particularly when combined with stretching and relaxation, or approaches such as yoga and tai chi, provides another essential element for optimum health.

Psychosocial Support

There is a huge body of research that demonstrates the importance of psychological and social factors in health and disease. Emotions, thoughts, connections to others, the response of others to our behaviors-all these factors contribute. Dealing with these types of issues and problems is an essential part of pain management.
Although integrative pain therapy as an approach to the management of chronic pain is in its infancy, several recommendations are possible.

Based on current research the integration of psychological approaches (such as behavioral and relaxation therapies) with conventional medical treatment is strongly recommended for the successful treatment of chronic pain conditions. Some mind/body strategies, like biofeedback, hypnosis, and imagery, are already considered to be mainstream treatments by pain specialists. Others, such as meditation, Qigong, and yoga have extensive historical use and need more study to determine their exact role in an integrative program. The potential benefit of all these approaches is the ability to learn to regulate anxiety, improve coping, and possibly reduce pain.

Research also supports physical activity and exercise as a part of most treatment programs for chronic pain. For example, active back exercises can be effective in reducing pain intensity, pain frequency and disability, as well as in helping to prevent recurrences of back pain. Activity can be supported by conventional physical therapy and exercise approaches, or by a wide range of movement therapies.

There is strong support for a treatment strategy that combines therapies that address the physical, psychological and social aspects of chronic pain. Based on a slowly growing experience, the integration of complementary/alternative approaches with standard treatments may offer the best chance of addressing these broad concerns. All patients should be educated about the range of options and the goals of treatment.

The interdisciplinary approach to chronic pain may involve not only traditional health care providers, including physicians, nurses, psychologists, and physical therapists, but integrative providers comfortable with the widest array of healing modalities, whether conventional or complementary, as well as specialists in specific complementary approaches.

In Ealing we are fortunate that we have an excellent Community Musculoskeletal service which offers standard treatments alongside Complementary therapy.
Shortly,The Ealing improving access to psychological therapies (IAPT) service offers support for common mental health problems such as depression, anxiety and panic for people living in Ealing.
It can provide self-help treatments, cognitive behaviour therapy (CBT), counselling and sign-posting to other servces. For more information view
It will be offering Mindfulness therapy with a special reference to Chronic Pain in the New Year.
Referral information
Ask your GP for more information, or call 020 3313 5660 or email

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Posted by on December 20, 2013 in Training and Advice


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FEVERISH illness in children. – when to seek further advice.

I shall always remember a cold, foggy autumn Sunday evening as a GP > 30 years ago. I was sitting by the fire, reading a good book listening to my favourite album at the time ‘Black Magic Woman’ and the phone rang as I was on call. It was a young, first time father who was a senior executive for Sony and he wanted advice as to what to give his 3 month old baby for a cough. He wondered if Benylin would be alright. No,he did not want me to come out on such a dreadful evening to their home which was in an out of the way village and not easy to find. The majority of the patients lived within 2 mile radius of the practise and I knew most of them well but this was a new family who lived the furthest distance away from the practise. The baby was sleeping well but had not been feeding so well but he shrugged that off as probably being due to the cough.
I thought to myself, ” Did I really want to leave my warm, cosy cottage or leave the book when it was just getting to the crux of the plot and after all he wasn’t demanding that I ventured out .”
However, that gut feeling told me something was not right and I needed to set eyes on this baby and it must be sooner rather than later.
It was a grim, pea-soup of an evening and I drove cautiously to the visit, following the father’s instructions to the letter and somehow managed to find the house with very little problem. The mother greeted me at the door wearing a face-mask and the father and extended family all came to the door similarly clad. I was then shown to the nursery through a house which was something out of ‘House Beautiful’ no clutter, everything perfect, decor impeccable, carpets like walking on soft foam and a bijoux nursery. As I approached the cot I viewed the baby, ashen in colour, shallow rapid breathing and barely rousable. The family looked at me expectantly in silence. How could I tell this family that their baby was life-threatill as they seemed so unaware? I spoke firmly and gently telling them of my findings. The father’s reaction was simply, “Can we go privately?”

At that time in Wales that was not an option and even getting an ambulance to take them to the local hospital was not quick and easy.

Shortly we came to a compromise that I would take the baby and mother in my Ford Popular to the nearest hospital nearly 20 miles away followed by the father in his Mercedes.
We arrived at the Hospital having prewarned them of the arrival and the baby was admitted with a diagnosis of bronchiolitis with heart failure. when I had worked as a junior paediatric doctor I had worked under the watchful eye of Sister Williams, who was always a force to be reckoned with despite being not much bigger than most of the paediatric patients.  I greeted her like a lost friend and she immediately took charge and when the parents saw our relationship it was clear that they were instantly reassured their precious child would be in good hands under the NHS.
The baby thankfully made a full recovery but what remains indelible in my mind are several aspects of this case:-

  • my momentary hesitation to visit,
  • the parents not wanting to appear over anxious,
  • these caring parents who were unable to understand the severity of their baby’s illness
  • there anxiety about their local hospital.

These factors still apply today but a combination such as this could have result in a tradegy.

A retrospective study recently carried out looked at children admitted to hospital with serious respiratory tract infections. The parents of these children were sent questionnaires after the admission and, from their replies, the authors identified factors which may have delayed earlier medical intervention and one of the reasons included ‘Problems assessing the severity of the illness’ and my other observations aswell as:-

    • The belief that their child would not be prescribed antibiotics or would be prescribed antibiotics too readily
    • The belief that their concerns would not be taken seriously
    • Feeling powerless to challenge clinical authority.

Organisational factors:

    • Perceived problems accessing healthcare services
    • Inadequate primary care triage
    • Barriers to accessing timely consultations
    • Past experience of problems accessing healthcare, leading to failure to consult
    • Perceived poor quality clinical encounter
    • Inadequate assessment and communication

It is for this reason I felt it was important to write this blog.

If you have any concerns about your child’s medical condition bring the child to the surgery and if the child is < 5years or an older child which has significant concerns they will be seen as soon as possible. If it is Out of Hours call 111 in order that your child can be seen as soon as possible at the nearest Urgent Care Centre (UCC).

  • Red flagThe following symptoms should always be treated as serious:
      • a high-pitched, weak or continuous cry
      • a lack of responsiveness, reduction in activity or increased floppiness
      • in babies, a bulging fontanelle (the soft spot on a baby’s head)
      • neck stiffness (in a child)
      • not drinking for more than eight hours (taking solid food is not as important)
      • a temperature of over 38°C for a baby less than three months old, or over 39°C for a baby aged three to six months old
      • a high temperature, but cold feet and hands
      • a high temperature coupled with quietness and listlessness
        fits, convulsions or seizures
      • turning blue, very pale, mottled or ashen
      • difficulty breathing, fast breathing, grunting while breathing, or if your child is working hard to breathe, for example, sucking their stomach in under their ribs
      • your baby or child is unusually drowsy, hard to wake up or doesn’t seem to know you
      • your child is unable to stay awake even when you wake them
      • a spotty, purple-red rash anywhere on the body (this could be a sign of meningitis)
      • repeated vomiting or bile-stained (green) vomiting

    It can be difficult to know when to call an ambulance or go to phone 111 seek a doctors advise as to where you should go. This is very important at a time when A&E departments are being replaced by Urgent Care Centres and you may need to be directed to a specialist centre.

      • AmbulanceCall an ambulance for your child if they:
        • stop breathing
        • are struggling for breath (you may notice a sucking in under the ribcage)
        • are unconscious or seem unaware of what’s going on
        • won’t wake up
        • have a fit for the first time, even if they seem to recover

        imageCall 111 and a doctor will advice you where to take your child if they have any of the following:-

          • have a fever and are persistently lethargic despite taking paracetamol or ibuprofen
          • are having difficulty breathing (breathing fast or panting, or very wheezy)
          • have severe abdominal pain
          • have a cut that won’t stop bleeding or is gaping open
          • have a leg or arm injury that means they can’t use the limb
          • have swallowed a poison or tablets

        Above all, trust your instincts. You know better than anyone what your child is usually like, so you’ll know what’s different or worrying.

        When I worked as a junior paediatrician for a rather old fashioned consultant paediatrician I can hear his words echo, ” Remember , mam is always right”, and if I see any child that is always my first thought, until with the mother of father we have looked at the child together and reached the same conclusion of what the problem is and how best to manage it.

        Child with fever
        Fever, or pyrexia, is when the body temperature rises above normal. The average normal body temperature taken in the mouth is 37°C but anywhere between 36.5°C and 37.2°C is deemed as normal. When temperatures are measured in the axilla they can be 0.2°C to 0.3°C lower than this. Aural (tympanic) thermometers may measure the temperature as higher.

        Fever is one of the most common reasons for a child to be taken to see a doctor and is the second most common reason for a child to be admitted to hospital.

        The cause of the fever can sometimes be hard to elicit and this can be a worry for healthcare professionals. It is usually due to a viral infection that is self-limiting but it can also be a sign of serious bacterial infection, including meningitis. Early diagnosis of serious infections in general practice is difficult as incidence is low, the child may present early in the disease process and diagnostic tools are more or less limited to history and examination.

        When a child presents with a fever it is important for the health care professional to take an adequate history and for the parent or guardian to provide accurate information

        History should include asking:

      • How long has the fever been present?
      • Has the parent/carer been measuring temperature and, if so, by what method?
      • Is there a rash? If so, is it blanching or non-blanching?
      • Meningitis
      • Are there any respiratory symptoms – eg, cough, runny nose, wheeze?
      • Has the child been clutching at their ears?
      • Has there been excessive or abnormal crying?
      • Are there any new lumps or swellings?
      • Are there any limb or joint problems?
      • Is there any history of vomiting or diarrhoea? Is the vomiting bile-stained or is there any blood in the stool?
      • Has there been any recent travel abroad?
      • Has there been any contact with other people who have infective diseases?
      • Is the child feeding normally (fluids and solids as appropriate)?
      • What is the urine output? Have nappies been dry?
      • How is the child handling? Normal self/drowsy/clingy and so forth?
      • Have there been any convulsions or rigors?
      • Is there any significant past medical history/regular medication/allergy?
      • Other points to consider from the history:
      • Level of parental anxiety and instinct (they know their child best).
      • Social and family circumstances.
      • Other illnesses affecting the child or other family members. Has there been a previous serious illness or death due to febrile illness in the family?
      • Has the child been seen before in the same illness episode?

    Examination of the child
    Identify any immediately life-threatening signs on examination
    Rate of breathing:-
    Infants 60 breaths per minute at age 0-5 months
    >50 breaths per minute at age 6-12 months
    >40 breaths per minute at age older than 12 monthsLook for nasal flaring/grunting/chest indrawing.Measure the heart rate.
    More than 160 beats per minute in a child less than 12 months old
    More than 150 beats per minute in a child 12-24 months old
    More than 140 beats per minute in a child 2-4 years oldAssess the level of hydration:
    do the eyes and skin look normal? Is the mouth moist? What is the capillary refill time? Are the extremities warm or cool? Is the child feeding normally? Is the urine output reduced?
    Examine for other features:
    Rash: if there is a rash, is it blanching or non-blanching?

  • Capillary refill return
    The capillary nail refill test is a quick test done on the nail beds. It is used to monitor dehydration and the amount of blood flow to tissue.
    Pressure is applied to the nail bed until it turns white. This indicates that the blood has been forced from the tissue. It is called blanching. Once the tissue has blanched, pressure is removed.
    Normal result:If there is good blood flow to the nail bed, a pink color should return in less than 2 seconds after pressure is removed.

Assessment of the child using the National Institute for Health and Care Excellence traffic light system
NICE recommends that a traffic light system should be used to predict the risk of serious illness when the symptoms and signs have been elicited from the history and examination. Allowance should be made for individual disabilities when assessing learning-disabled children.
The following table summarises this system.
If the child has any of the symptoms or signs in the amber column, they are at intermediate risk of serious illness.
If they have any of the symptoms or signs in the red column they are at high risk of serious illness.
Children with symptoms or signs in the green column and none in the red or amber column are at low risk of serious illness.
Management of fever should be guided by the level of risk.Traffic light

Children with any red features not considered to have an immediate life-threatening illness should be seen within two hours by a healthcare professional.
Children with any amber features should be seen by a healthcare professional but the assessment of urgency of the appointment is left to the clinical judgement of the assessor.
Children with only green features can be managed at home with advice for parents and carers, including advice on when to seek further help.
Management by the non-paediatric practitioner
This includes professionals working in primary care and also those working in general accident and emergency departments.

Assessment using the traffic light system should be performed.
Children with any red features should be referred for urgent assessment by a paediatrician.
Children with any amber features in whom a specific diagnosis has not been made, should either be referred to urgent paediatric care or the carers of the child should be given a ‘safety net’, either detailing exactly when to seek further help (ie specific warning symptoms or signs) or arranging a further follow-up assessment.
Children with only green features can be managed at home with advice for parents and carers, including advice on when to seek further help.

Oral antibiotics should not be prescribed if there in no identifiable source of the fever.

Management of specific diseases:

If there is no obvious source of infection, urine should be tested in children presenting with fever.
If meningococcal disease is suspected, antibiotics should be given at the earliest opportunity.
Related blog posts
There’s no such thing as a touch of ‘flu!

Advice to parents or carers for home care of the child

Antipyretic(fever) treatment:

    • tepid sponging is not recommended.
    • Do not underdress or over-wrap children.
      Give alternating paracetamol or ibuprofen for discomfort or distress but not for the sole reason of reducing the temperature. If the child does not respond to one agent and the child’s distress persists or recurs before the next dose is due then give the child paracetamol alternating with ibuprofen at 4hourly intervals.
    • Give regular fluids: breast milk if the child is breast-fed.
    • Monitor for signs of dehydration: sunken fontanelle or eyes, dry mouth, absence of tears, poor appearance.
    • Monitor for appearance of rash: assess to ascertain if a rash is non-blanching.
    • Get up in the night to monitor the child.
    • Keep the child away from school or nursery while they have a fever and notify them.

When to seek further help: if the child has a fit, develops a non-blanching rash, appears less well, the parent or carer is worried, the fever lasts >5 days, the parent or carer is distressed or feels they cannot look after the child.

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Posted by on December 15, 2013 in Training and Advice


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The first day in the life of a Centenarian

As I am writing my 100th blog  on the  December 1st 2013 I am with  a lady celebrating her 100th birth.

image1913 was the year when stainless steel was invented, potato crisps arrived and on 2 April – Suffragette Emmeline Pankhurst was imagesentenced to three years of penal servitude.

Arsenal football team moved to Highbury.

imageKing George V reigned on the throne.

“When Irish eyes are smiling” and Danny Boy were the most favourite songs.

Miss. Williams was a deputy Headteacher at a girls’ Grammar school in Cardiff untill 1970 and although would have like to have studied Medicine she decided to study a shorter course as her father was unwell as she wanted to work as soon as possible. She was an intelligent, keen student and read Biology at Cardiff and subsequently followed a teachers training course.
She was a teacher at the same school and had to set up the Biology department from scratch finding the equipment and devising a curriculum. Despite her short stature she claims she never had discipline problems with her pupils. Her department became an important nurturing ground for future doctors and this was evident on her birthday when cards appeared from former pupils
She had been brought up in Tenby,Pembrokeshire and was a keen pupil from infancy.
She recalled how as a 5 year old her GP performed an adenoidectomy on the kitchen table. She described how when the doctor arrived she remembers coming downstairs in her pyjamas and dressing gown, climbing up onto the table as instructed. She remembers a mask was given to her with presumably an anaesthetic and then felt herself drift into a sleep as if floating on a sea of blue. As she came around she observed the doctor tidying his instruments and as she opened her eyes she said, “Sorry am I awake too soon?” She made a nun eventful recovery.

Several years later she clearly recalls how the family were in the garden watching Amelia Mary Earhart flying over on one of her solo flights. Amelia Earhart was the first woman to fly solo across the Atlantic Ocean and setting many aviation records and disappeared in July 1937 and never found.
Following this event her father developed a severe gastric haemorrhage and the doctor was called. He advised sucking ice on a daily basis for 2 weeks as a way of stopping the bleeding. Her father then went on to have major surgery but was confined to a ‘bath chair’ ( wheelchair) for several years as the incision was slow to heal. He eventually went back to light work but was advised to stay on a light diet of milk, butter, mashed potato and chicken with occasional pork loin and calves foot jelly and large quantities of antacids.
The family moved to Cardiff she claims ‘to have better medical treatment.’ On one occasion her father was taken to hospital with abdominal pain from the a hernia in the old surgical scar and the junior doctor suggested surgery, which she questioned (an unusual reaction in those days). As a young woman she insisted on seeing the consultant who discussed the problem and agreed with her and surgery Ewan’s not performed and her father recovered. She has never stopped questioning the medical profession since that occasion and when I arrived she had plenty of questions and views to air about the present NHS as she has done on every occasion I have seen her. Her father lived until he was 86 years and despite her mother having breast cancer treated with a radical mastectomy lived until she was 76yrs. She has had severe osteoporosis and broken many bones including her right wrist on several occasions. She was one of the first patients to have a Bisphosphonate infusion and other new drugs for osteoporosis and is well known to the Rheumatology department at University Hospital of Wales and always ready to try new treatment as long as it is all the evidence is explained in full detail. She has remained reasonably mobile and proudly claimed that more recently she has been climbing the stairs on occasions instead of using the stairlift!
When we arrived on the Eve of her birthday she had prepared Afternoon tea with ham sandwiches and lemon drizzle cake and was busy doing the Telegraph crossword. The sitting room of her flat was full of cards including a card from the Queen and the Welsh Secretary of State and flowers many from old pupils. She was animated and very excited about her impending party. After supper which she instructed me how to prepare and serve followed later that evening and then insisting on viewing the 10 o’clock news to catch up on the latest International events.
Next morning she was up early as carers called to wash and dress her and there was incessant chat about local gossip and discussions about what she was going to wear and was her new jacket going to coordinate with her dress and shoes. She then sat at her desk to read her emails and send replies appropriately. Fortunately the Warden of the sheltered housing has been able to give her lessons when she bought her laptop a few years ago.

It wasn’t long before the door bell rang and continued to ring at frequent intervals in between the phone ringing  with good wishes from people of all ages. As I was felt weary from the constant flow of well wishers she seemed to get more animated.

She gave me instructions of what to prepare for lunch and then after this received more visitors. Later the hairdresser arrived to style her hair and another carer called in to dress her for the party that she had insisted must be in the evening.
She was driven to a Country Club on the outskirts of Cardiff and joined by about 30 guests. Surveying the scene, she positively glowed throughout the meal, which she had carefully chosen and clearly enjoyed her choice with a glass of red wine. Finally, after a speech from her niece’s husband we raised our glasses of champagne to wish her ‘Happy Birthday’ and then she walked with her 3 wheeled walking aid (she affectionately calls ‘My Merc’) to cut the cake and then gave a short speech to thank those who came and as she said to recommend reaching 100 years of age as it is ‘rather fun’!


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imageI clearly remember one day in Summer 1980 after morning surgery discussing with my GP partner at the time an article he had read in the New England Journal of Medicine. It was a discrete article postulating that a rare cancer called Kaposi Sarcoma was more common amongst sexually active homosexuals. The reason we were discussing this was because a patient, who was homosexual had returned from the USA and had heard a rumour that there was an increased risk of his developing cancer. My partner was was wondering if he should share what he read with the patient or not. We decided that as the article was so small on balance it was probably not appropriate. In 1994 it was found to be caused by a virus and confirmed as an AIDS-defining illness.

HIV/AIDS was formally identified in the 1981.
I came to London in 1982 and I was working as an Examining Medical Physician which involved home visits to disabled people to assess for Attendance Allowance and Mobility Allowance (benefits which preceded Disability Living Allowance). One day I visited a man in Chiswick and after waiting at the door for a while whilst he struggled to get to the door he greeted by saying “I hope you are not going to be like the last doctor and take flight without completing the examination”
He then told me the tale of how an elderly doctor had visited and began the examination assuming the man had Parkinson’s Disease. The man interjected by telling the doctor that actually he was suffering from AIDS and the doctor promptly got up from his chair and hastily left the house. That was how people reacted at that time and believe or not 30 years some people still react in this way!
However, I shall always be grateful to this man as he gave me my first tutorial on this condition and the dreadful side effects of the anti-viral treatment at that time,as it was a
‘new’ disease the majority of doctors had very limited knowledge. He knew that his life would soon be coming to an end.

It is comparatively recently that as doctors we have felt confident to suggest blood testing in the surgery. One such patient we carried out the test and it came back positive and it was necessary to break the news to him. Although, devastated he told us how much better it was to be given the news by the doctors he had known for some years rather than by an unfamiliar doctor and sent Dr Livingstone and myself some flowers. However. sadly this delightful young man died suddenly before we had chance to thank him. Again a reminder of this devastating disease and the stigma that still remains.

Many of the facts and details can be obtained on the following website

but I feel it is important to outline these by reprinting them in this blog to inform and in respect to those patients I have met over the years and particularly those who have been my main source of education.
HIV stands for the Human Immunodeficiency Virus. It is a virus which attacks the body’s immune system — the body’s defence against diseases.
Highlights of facts about HIV in the UK:

  • Over 90% of people with HIV were infected through sexual contact
  • You can now get tested for HIV using a saliva sample
  • HIV is not passed on through spitting, biting or sharing utensils
  • Only 1% of babies born to HIV positive mothers have HIV
  • You can get the results of an HIV test in just 15-20 minutes
  • There is no vaccine and no cure for HIV

How common is HIV?

At the end of 2011, there were an estimated 96,000 people in the UK living with HIV. The majority were infected through sex (40,100 gay and bisexual men and 51,500 heterosexuals).
Around 1 in 4 people with HIV (currently approximately 25,000) do not know they are infected.
Around 1 in every 650 people in the UK has HIV but the two groups with highest rates of HIV are gay and bisexual men and African men and women, where the rates are 1 in 20 and 1 in 25 respectively.
The World Health Organization estimates that around 34 million people in the world are living with HIV.
The virus is particularly widespread in sub-Saharan African countries, such as South Africa, Zimbabwe and Mozambique.

How is HIV spread?

HIV cannot be transmitted

HIV is found in the body fluids of an infected person, which includes semen, vaginal and anal fluids, blood and breast milk. It is a fragile virus and does not live very long outside the body.

HIV cannot be transmitted through sweat or urine.

The most common way of getting HIV in the UK is by anal or vaginal sex without a condom. According to statistics from the Health Protection Agency, 95% of those diagnosed with HIV in the UK in 2011 acquired HIV as a result of sexual contact.

Other ways of getting HIV include:

  • using a contaminated needle, syringe or other injecting equipment
  • tranmission from mother to baby during pregnancy, birth or breastfeeding
  • through oral sex or sharing sex toys (although the risk is significantly lower than for anal and vaginal sex) sweat or urine.
  • The most common way of getting HIV in the UK is by anal or vaginal sex without a condom. According to statistics from the Health Protection Agency, 95% of those diagnosed with HIV in the UK in 2011 acquired HIV as a result of sexual contact.

The main ways the virus enters the bloodstream are:
by injecting into the bloodstream (with a contaminated needle or injecting equipment)

  • through the thin lining on or inside the anus and genitals
  • through the thin lining of the mouth and eyes
  • via cuts and sores in the skin

HIV is NOT passed on through:


  • kissing
  • spitting
  • being bitten
  • contact with unbroken, healthy skin
  • being sneezed on
  • sharing baths, towels or cutlery
  • using the same toilets and swimming pools
  • mouth-to-mouth resuscitation
  • contact with animals or insects such as mosquitoes

There are now more people than ever living with HIV in the UK — around 100,000 — with a quarter of those people are unaware they have the virus.

Where to get tested?
There are various places to go for an HIV blood test, such as:
sexual health clinics, also called genitourinary medicine (GUM) clinics
clinics run by charities such as the Terrence Higgins Trust
some GP surgeries
some contraception and young people’s clinics
local drugs agencies
at an antenatal clinic, if you are pregnant
a private clinic, where you will have to pay

Home testing kits are also available, which allow you to take a saliva sample or blood spot and send them off to a laboratory for testing. These are available online and from some pharmacies, but you will generally have to pay for them.

From early 2014, it will also be possible to buy self-testing kits that will allow you to test yourself and find out the results immediately. It is important to check that any test you buy has a CE quality assurance mark and is licensed for sale in the UK, as poor quality HIV self-tests are currently available from overseas.
It is your choice where you would be most comfortable having the test.
Your nearest location can be found on the NHS choices website

Symptoms of HIV

Most people who are infected with HIV experience a short, flu-like illness that occurs two to six weeks after infection. After this, HIV often causes no symptoms for several years.
The flu-like illness that often occurs a few weeks after HIV infection is also known as seroconversion illness. It’s estimated that up to 80% of people who are infected with HIV experience this illness.
The most common symptoms are:
fever (raised temperature)
sore throat
body rash
Other symptoms can include:
joint pain
muscle pain
swollen glands (nodes)
The symptoms, which can last up to four weeks, are a sign that your immune system is putting up a fight against the virus.

These symptoms can all be caused by conditions other than HIV, and do not mean you have the virus.
However, if you have several of these symptoms, and you think you have been at risk of HIV infection, you should get an HIV test.
After the initial symptoms disappear, HIV will often not cause any further symptoms for many years. During this time, known as asymptomatic HIV infection, the virus continues to spread and damage your immune system. This process can take about 10 years, during which you will feel and appear well.
It is important to remember that not everyone with HIV experiences early symptoms, so you should still take an HIV test if you have put yourself as risk, even if you experience no symptoms.

We should ALL Be aware of the following FIVE facts in 2013
1 People living with HIV have a normal life span if diagnosed and treated in time

2 There is no job which someone can’t do specifically because they have HIV

3 Treatment can mean that people living with HIV are no longer infectious

4 Men and women living with HIV can become parents of an HIV free baby

5 BUT people living with HIV still face stigma and discrimination


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