Electronic Opera: Cara Mia Addio

This beautiful song derives from a video game called Portal 2.

Despite its rude derivation, its delightful melody and harmony delights me, and so here it is, with bilingual lyrics beneath:

(Italian:)

*Turret Introduction*

[Verse 1]
Cara bella, cara mia bella! (Beautiful dear, my darling beauty!)
Mia bambina, oh ciel! (My little girl, oh heaven!)
Che la stima! Che la stima! (How I adore you! How I adore you!)
O cara mia, addio! (Oh my dear, farewell!)

[Verse 2]
La mia bambina cara, (My dear little girl,)
Perche non passi lontana? (Why not go a long way away?)
Si, lontana da Scienza! (Yes, far from Science!)
Cara, cara mia bambina, (Dear, my beloved little girl,)
Ah, mia bella! (Ah, my beautiful one!)

[Verse 3]
Ah, mia cara! Ah, mia cara! (Ah, my dear! Ah, my dear!)
Ah, mia bambina! (Ah, my little girl!)
Oh cara, cara mia! (Oh dear, my dear!)

*Instrumental Break*

[Repeat Verse 3]
Mia cara! Ah, mia cara! (My dear! Ah, my dear!)
Ah, mia bambina! (Ah, my little girl!)
Oh cara, cara mia! (Oh dear, my dear!)!)

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Little Babas Supine Skyward Gazing

I have an early memory, reclaimed and reconstructed possibly, of lying on my back perfectly comfortably wrapped by a blanket in my pram which was parked in the shade of some tree with beautifully abundant foliage fluttering and shimmering away above me like a complex song and dance act in the perpetual act of tuning up for their greatest performance ever.

[Take a breath now -Ed]

 

 

 

My Constant Keeper’s Daughter Fair

Buried deep within my coarse donkey exterior lies a heart that is unashamedly romantic.

I can get moved to tears by a mere recollection, a scent, an idea, a sunset, a voice, or even a re-acquaintance with an old friend. I have learned over the years to tame my tears so that my unintentioned blubbering is not a source of embarrassment to those present.

I first heard about Grace Darling during an episode of Blue Peter way back in the sixties. She was a heroine from Victorian times who rowed a lifeboat, with her father, out upon the tempestuous deepness to rescue the crew of a ship in distress. Forgive me while my eyes tear up…. You can read her full story here.

Many years later I came upon this musical track by one of my favourite bands, The Strawbs.

 

I guess this song is so moving to me because our youngest child, darling Gracie, slipped away from us not long before I first heard this.

Here are the lyrics:

You have been my lighthouse
In every storm
You have given shelter
You have kept me safe and warm
And in my darkest nights
You have shone your brightest lights
You are my saving grace
Darling I love you.
You have been the pilot
Who guides me home
You have been my rock
As on the seven seas I roam
And when I was becalmed
You were the strength in my arms
You are my saving grace
Darling I love you.
And when I found my back
Was torn and broken on the reef
You sailed your tiny boat
Across the dark seas of my disbelief.
You have been the anchor
And I the chain
Straining as we hold ourselves
Together in the rain
I have found you ever there
My constant keeper’s daughter fair
You are my saving grace
Darling I love you.

Dr Deekin

 

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Every time I see these, I think of Dr Deekin.

My first boss of anaesthesia was a tall, bluff, tanned and wrinkly man from South Africa. He was a legend in his own hospital and time. I first met him when I was a casualty officer. We juniors were dealing with a very sick, but fully conscious, young man in the resus’ room and failing miserably. We were all out of our depth and “pandemonium” perfectly describes the scene: we were all running around fruitlessly, and there was much wailing and gnashing of teeth, until….

Dr Deekin breezed silently into the room. He had a naturally commanding presence, and we all fell quiet. He walked up to the terrified patient and gripped him with his powerful unavoidable kindly gaze:

“Don’t worry son, you are among friends”

is all he said. Quite suddenly peace and good sense descended upon the patient and upon us all. Our panic had driven us all to madness. We all rebooted, attained IV access, took the usual blood samples, arranged X-rays etc, as should always normally happen.

At some point Dr Deekin simply breezed away, while we were not looking, with nothing more to add. Perhaps he went home to the dragon-like Mrs Deekin he always referred to in the third person, during his unguarded idle moments of conversation.

********************************************************

A few months later, I found Dr Deekin was my ultimate boss, when I started my career as an anaesthetist. My first introduction to him was by proxy: all the other junior anaesthetists had some story or other to tell about him. I gathered that he was a cowboy, a genius, unruly, rude, crazy, unprincipled, wild, and dangerous, but also a very successful private anaesthetist in the London medical scene.

Eventually I was rostered to work with him. He had some funny ways. For instance, he got the theatre technicians to wheel in some huge ventilator machine for his operating list. It was clearly 50s technology with big knobs and switches. It did the simple job of pumping gas mixtures in and out of the patient’s lungs nonetheless. There was a Rolls-Royce chromed badge affixed to its front and I asked about this. He had found the badge on the ground in some car-park somewhere and had pocketed it, only later to award it to his most trusted machine…..

He also eschewed the use of intravenous cannulae, considering them to be unnecessary new-fangled nonsense. Instead, he injected the thiopentone, morphine, and curare through an orange needle in the patient’s antecubital fossa. After the needle was withdrawn, he popped a blob of cotton wool over the puncture site and secured it with a bicycle clip which he kept on his wrist.

At one point, I decided to make him aware that the patient’s blood pressure was only 70/30. He looked up from his crossword to say that left 69 to play with(!). Because of this low blood pressure, the patient hardly bled at all, and survived his major op with no transfusion necessary. I began to discern some method in his madness.

By the end of this list, over-mystified beyond ordinary everyday mystification, I staggered home from this encounter and slept for what seemed like a week.

Dr Deekin always wheeled his patients anywhere head first. His reasoning was “Only coffins go feet first”. Who can argue with that?

He was wickedly mischievous too. He once took a patient to the recovery room who had just had a tracheostomy fashioned. He told the dopey recovery nurse to keep a close eye on the patient’s airway, ie chin up, head back etc. The poor nurse was found much later still at her station still maintaining the patient’s airway, for no good reason. The patient was wide awake and breathing through his new tracheostomy!

Because of his age and vast experience, he was the head of department. He was also its patron saint. He had an uncanny ability for being in just the right place and at the right time. Whenever any colleague, senior or junior, ran into some unexpected life-threatening situation such as a “can’t intubate, can’t ventilate” scenario, Dr Deekin would appear from nowhere and effortlessly save the day. His Consultant colleagues held him in awe-filled esteem.

I eventually fell foul of him thus: One night I was covering the intensive care unit. I was overwhelmed by the complexity of a case. I called for help, and Dr Deekin’s voice answered. He sounded tired and very sleepy. I was glad of a reply and I nervously and obsequiously used his first name, which sounded like “Vic” to address him before explaining lengthily :

“Hello Vic, it is Dr Burrito here, I need your advice….”. I blathered on for a bit longer before he interrupted me. “Do you want me to come in?” he asked directly in a pained fashion. Oh no, no, no I answered, I just wanted you to be aware. He hung up and presumably returned to his slumber.

The next morning as I was finishing my shift I popped into the anaesthetist’s office. Jenny the secretary was already manning her typewriter. “There’s a letter for you from Dr Deekin”, she cheerily remarked. I opened the hand addressed envelope immediately:

Dear Dr Burrito,

Only friends, family, and people I know well, call me by my first name.

You Sir, are none of the above.

V.

I must admit to being a bit stunned at causing such offence to my greatest hero, role-model, and mentor. I went home saddened. I was close to finishing my time in that department before moving on to pastures new, so I did not have to forbear my discomfort for too long.

I subsequently learnt that Dr Deekin was nursing a terminal disease. This totally explained his uncharacteristic testiness.

We are all of us shaped by the people we meet and the experiences we share, especially in our formative years. A lot of who I am today is down to Dr Deekin.

May Perpetual Light shine upon him, and may he rest in peace, Amen.

 

 

A Bittersweet Outcome

 

This is the sequel to “Arguing The Toss”.

During our transit to the brain-shop, I had time to contemplate our reception. I expected to be roasted for breaking professional etiquette and protocol: I had headed off without express permission from the receiving team. I had form for this, though at a considerable distance in time and space.

Actually my goose did not get cooked, neither then nor later. The Consultant neurosurgeon who was in theatre when we arrived, was considerably older than me, and accepted my unruly arrival like the father of any wayward son could: with patient, though pained, forgiveness. Though summoned late at night to theatre, on account of my actions, not one angry word was made by him to me. We just cooperated in making the best of a mess, and let angerless silence dress the wounds.

His quiet competence and soft swiftness of action flavoured with a pinch of sardonic but kindly humour did impress me greatly. I hope that regular readers will know how much such qualities mean to me, and how much I wish to attain them. He was a GOOD AND GENTLE MAN like my own father. He was also “shit-hot” at healing heads, as we say in medical circles, behind closed doors, over cigars.

*****************************************************

The morning after this event, I was back home resting up, and I rang to ask how the boy was doing. “He’s having his breakfast”, the healthcare assistant told me. “Who are you again?” she asked…. Cripes, the tears welled up geyser-style just then.

*****************************************************

I don’t keep bees, unlike one of my dear colleagues who does. I keep huge bumble bees instead, inside my bonnet. The largest of these has the strange name of “SUBSIDIARITY”.

Uncle Wiki’ to the rescue:

Subsidiarity is a principle of social organization that holds that social and political issues should be dealt with at the most immediate (or local) level that is consistent with their resolution.

ie “Local people know what’s best locally”. The people on the scene of a developing situation should be trusted to know what is needed. Distant though superior authorities should bow to the local’s more acute and accurate knowledge, and do all they can to help them.

Common sense? Surely! Sadly, I see little evidence of subsidiarity being actively promoted as a grounding principle in modern life. Instead, all I see is top down heavy legislation and “guidelines” and “instructions” and a general attitude that the “hicks” (like me et al) need more sticks to cow them.  All of these contain the veiled threat that my failure to comply will interfere in my future ability to earn my crust and support my family.  In my estimation, this is demanding undeserved obedience with menaces. Few things make my blood boil more than receiving these threatening demands on a daily basis in my work email inbox…..

Big powerful hospitals need to understand that little weak hospitals, like mine, are not to be seen as annoying nuisances to be made to jump through hoops, but are in fact their legitimate needful family crying for their aid, like some little child of theirs who has scraped their knee, or suffered much worse. I expect a very high standard from my “betters” in the medical profession: I expect the love of a parent from them, and if I don’t get it, I’ll throw a bloody-blue-fit/tantrum!

****************************************************

Alas, for there is very often an “alas”, a few days later, as he was preparing to be transferred home, the boy collapsed suddenly, and the resus’ team found him with dilated pupils and totally unsaveable.

The Coroner reported that there had been a sudden, massive, and rapid re-bleed within the cranium. Even already being in a neurosurgical centre doesn’t guarantee protection from such a thing. It’s a known risk and complication.

The verdict was “Death from natural causes”: Nobody was at fault.

Yep, nature is cruel alright.

tree-nature-rock-sunlight-leaf-stone-monument-statue-sadness-symbol-autumn-religion-cemetery-christian-tombstone-death-close-up-grave-sculpture-memorial-angel-graveyard-art-temple-graves

“The Regiment”

Like most blokes of my age I grew up with a daunting respect for the Special Air Services (SAS), a previously little known branch of the British Armed Forces.

As a teenager I had witnessed them on live TV storming the besieged Iranian embassy in London in 1980 wherein they killed all the baddies and liberated all the goodies (+/- one or two).

Their precious secrecy added to their cachet. They were apparently based somewhere near Hereford and could deploy to anywhere in the world with only seconds’ notice, for immediate lethal action, as required.

Their sudden publicity led to an awful lot of young men fantasising that they themselves belonged to “the regiment”, and so they boasted their ways onward through life, impressing the less discerning girls they encountered, and so on and so on.

During my much later brief professional encounter with the Royal Army Medical Corps as a locum, I got to meet a lot of military people both patients and staff. I quizzed them out of pure casual curiosity about the SAS. Most knew nothing, and most of the rest knew about as much as I had gleaned already. The remaining few were very cagey and hinted that if they told me, they would have to kill me! The only indication I ever got was that an SAS soldier was about as identifiable in public as a bird-shit on a pillar-box.

I eventually realised that my intellectual pursuit for some truth about the SAS was a vanity project, and I gave it up as such. It was just none of my business, at the very least.

****************************************

A year or two later, I was working in some operating theatre in Oxford one evening. My technician was a remarkable man with perfect manners and English diction. He was of inscrutable age, and obviously from the far east, possibly Hong Kong, Singapore or Nepal. He spoke little but was perfectly competent in every word and deed. I returned his reserve respectfully. We thenceforth danced together through our work like a married couple that has transcended mere chatter and polite conversation. The operating list just breezed by.

In a period of leisure, I asked him if he was ex-military. He nodded affirmatively. In one of my silly moments I then asked him if he was SAS. At this, his face darkened. “That is not a question that should be asked” he replied. I backed off rapidly and I apologised for my intrusive gaucheness. We carried on working together for a few hours more.

A good technician is essential to my professional accomplishment. I thanked him heartily for his help. As we parted company that night, he remarked to me with kindly cheekiness “I thought you were from the Regiment too! I returned home very flattered and very embarrassed and very confused.

 

 

 

 

Arguing The Toss

This is a continuation from an earlier article.

The young boy had clambered out of the car like everyone else had. Sadly, as the door slammed to, his fingers got caught in it and he suffered an excruciatingly agonising crush injury to his fingerpads and nail beds. He fainted in response to the intense pain.

A faint is nothing much really: a brief interruption of the blood supply to the head is easily fixed by lying the patient down, preferably on their left side so that their airway remains patent, and waiting  a minute or so for the blood to start coursing through the brain again. Unfortunately, as he fell, he hit the side of his head on a pointy stone protruding from the grass. He didn’t wake up after a minute or two like he would if he had simply fainted. The family were on a driving tour of the rural area when this took place, and being sensible, mum and dad wasted no time trying to summon an ambulance to the middle of nowhere. They bundled their son into the back seat and drove like fury to my hospital.

He arrived thus unannounced and the trauma team assembled around his trolley. Blunt trauma to the head plus deep coma means urgent CT scan: It’s a no-brainer really, if you will forgive the expression. I intubated him and took him off to the scanner fully monitored and tout suite. It took only a few seconds for that marvellous machine to produce a wondrously detailed picture of the problem: a large extradural haematoma, which was expanding and squashing the brain dangerously. By now, it was an hour since the injury. If this kid was to have any hope of a normal life, he needed to have his skull opened by the fourth hour. The neurosurgeons were an hour and a half away at least.

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The large off-white thing is a blood-blister forming inside the skull. The pure white stuff is the skull. The disordered stuff on the left is the swollen misshapen scalp. The dark sliver is all that remains of the brain’s inner ventricles, its wriggle room. This brain is very tight, and needs urgent decompression!

While I brought him back to the resus’ room and got him onto the ambulance trolley, rigged for transfer, the images were beamed across to the neuro-guys and the phone call got made by our surgeon. The minutes were ticking by and I asked what the delay was.

The neurosurgical registrar at the other end was being obstructive. He wanted this test and that to be done, and for us to cross-match some blood for transfusion. I couldn’t believe my ears. Time really was of the essence, and this buffoon wanted us to waste some more. The red mist obscured my vision and I grabbed the handset off my colleague.

“Listen buster, we will finish this ‘fascinating’* conversation when we meet face to face in just a little while”, I yelled at him, rather sarcastically and rudely, before slamming the phone down and telling my team to “GO, GO, GO!!!!”

“How quick do want to get there, doc?” asked the paramedic behind the wheel. We were all aboard and ready for a 90 minute dash across winding roads to the nearest city.

“Pedal to the metal, please”, was my only reply, delivered stolidly. As I braced for a very uncomfortable journey, late into my shift, my eyes watered up. I blinked them clear and then closed them again to make a brief prayer: my own son was the same age as this kid. I had briefly met his parents and siblings to explain what was going to happen. They stood there, pale and distraught, in the corner of the resus’ room like some white marble sculpture, perfectly portraying tragic, grieving, powerlessness. I was already and inevitably involved emotionally with them, having lost a child. “Drive safely please”, I advised the family, as we were going out the doors. I didn’t want any more innocent blood shed.

Being strapped into a seat, sideways on to the direction of travel, inside a tin can with no view of the outside, hurtling, pitching, and yawing violently, is a perfect recipe for inducing motion sickness. Fortunately my technician and I were sea-legged veterans at this, and we both held it down for the duration. The second paramedic, who was out back with us, stood for most of the journey, holding onto the handrails and swaying with the dancing vehicle. He reminded me of a London bus-conductor, only this bus was on the Paris-Dakar rally route.

My main clinical concern was the amount of pressure inside the boy’s cranium (brain-box). Because it is a rigid container, too much pressure inside, can stop fresh arterial blood from entering the skull cavity to nourish the ever-metabolising grey and white matter that does our thinking and dreaming for us. Because the brain is hollow, the cerebrospinal fluid can get squeezed out and thus accommodate  quite a bit of swelling from elsewhere. When that reserve is used up though, the intracranial pressure ramps up rapidly and the incoming blood flow gets pinched off rapidly too. Once brain perfusion ceases, there are only minutes before the brain cells start to die off permanently, leaving only serious widespread brain damage as the best possible result.

There are a few therapeutic options which can buy time:

  1. Hyperventilation: By significantly lowering the CO2 levels in the blood, the blood vessels throughout the body, but especially within the skull will constrict, and thus provide a bit more space. Blood vessels contribute a large part of any tissue’s volume.
  2. Head-up positioning: Raising the head drains the veins within the skull, also creating space.
  3. Osmotic agents: These act by sucking the water out of cells thus reducing their volume. It is a benign sort of pickling. All tissues shrink as a result.
  4. Raising the blood pressure: There are many drugs which can do this; the blood supply to the brain is artificially brute-forced against the opposing raised intracranial pressure, and thus perfusion is maintained.

The problem with an extradural haematoma, which is usually from a bleeding middle-meningeal artery running through the bit of skull that gets fractured, is that all these worthy interventions only serve to promote further bleeding into the haematoma! The only real solution is rapid opening of the skull to relieve the pressure.

************************************

We crashed the ambulance  trolley through the theatre doors at our destination. The full home-team were there waiting for us, including the head-honcho in charge of heads. We all worked together like the innards of a Rolex to quickly get the boy onto the table and prepared for an urgent burr-hole decompression of his skull. My tech-guy and I were rapidly rendered redundant as our hosts took over all care. As we were both already in scrubs, though shop-soiled, we were allowed to stay to witness their Kung-Fu.

The head was shaved, the scalp was painted with antiseptic, and the drapes were applied in a minute or two. The scalp was incised and retracted at exactly the right place and the white bone of the skull was exposed. A normal drill cuts a cylindrical hole, but a burr cuts a bowl shaped hole because the burr-drill has a spherical tip, about the size of a large marble. The bottom of the bowl eventually breaches the inside of the skull while the shallowly sloping walls of the burr-hole prevent the whole drill plunging through and liquidising the brain underneath.

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Top right is a traditional burr-drill. It can be driven by a powered source or even by a brace-and-bit, as beloved by carpenters.

It was like striking oil: The blood and clots gushed out under pressure, and the pressure within the head was relieved instantly. Though there was much more to be accomplished, the patient was now out of immediate danger. Barry-the-tech’ and I decided to withdraw then to our awaiting taxi. As we carried our voluminous transfer kit back out to the hospital entrance, waving to our distant healthcare cousins along the way, Barry remarked that the two of us must have resembled the “Ghostbusters”.

I had to laugh because this was exactly true: We were both bestrewn with backpacks, ventilator tubing, cables, hoses, assorted kit, etc, and we had both played our part in preventing a ghost from being created. Such is the “paranormal” world all healthcare workers inhabit when they “make a difference”.

[BETTER STOP THERE PLEASE: READERSHIP FATIGUE. – ED]

To be continued…..

  • For “fascinating” substitute some other word beginning with “f”.

 

The Second Pigeon Post

This is a continuation from an earlier post

During my incarceration in the worst hospital accommodation in all of creation, if I ever wanted a bath or shower or needed to use the loo, I had to walk to the distant far end of the corridor through three fire doors, each of which was half glazed with wire-reinforced glass. These allowed a partial view right down to the far end, but blocked vision of the intervening floor.

Shortly after moving in, I discovered I had a neighbour. He was about my age but tall and slim and better groomed. [Who isn’t? – Ed]. Unfortunately for him he had zero communication skills, steel rimmed glasses, and narrow set eyes. Our introduction to each other did not get much further than hello. “It’s good to talk” was an advertisement catchphrase at the time. I love irony like that. I was reminded of him in later years by the penguin in Wallace and Gromit:

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Yes this is a penguin disguised as a chicken, but read on…..

One morning early I emerged sleepily from my room draped in a towel robe plus slippers and carrying my wash things and thus began the long staggering walk to the distant grimy purgatory of ablution, provided by the state. The Spring morning sunshine brightly lit my way.

Suddenly, in the distance I glimpsed my very odd neighbour racing towards me from the far bathrooms. He was wearing only a towel, but his face was full of fury and murderous intent, and he was violently wielding a broom this way and that at some invisible opponent as if he was a practitioner of Kendo on an assassination mission.

My sleepy brain woke up with amazing alacrity and began to do risk-analysis: Strange people do behave strangely, I reasoned. Should I confront him or run for my life? Option two coolly won the vote as I am a bit averse to fighting even at my bravest, and so I looked around for the stairwell of hope and escape, as I was on the second floor. Alas, the maniac and I were now equidistant from my source of retreat.

Crunch-time: I had to face my crazed aggressor and possibly be brained in the process. I steely adopted the best faux martial arts stance that I had ever learned from Bruce Lee et al at the movies, and stood my ground to face imminent death….

It was then that my opponent pulled open the final door between us and I at last understood my fate:

There, on the floor between us, gripped by the crazy stick-wielding nutter’s intense stare, was a supremely terrified pigeon, as equally intent as me on finding its way back to normal life and safety.

The stairwell window to my left was half open. Walter, as I named it, seized the day and made a perfect powered-gliding exit through the proffered space, and was never seen again, by me at least.

My co-combatant and I panted with relief as we faced one another across that morn. He’d had his shower, and I needed my bath. We bowed and nodded to one another like ninjas at ease and then continued with our days without another word.

**********************************************

I know it’s called chicken-wire but it keeps all avian critters from entering open bathroom windows. In my root-cause-analysis of this event, I suggest it’s use be mandatory in city hospitals, if only to prevent internecine bloodshed between its essential workers.

Casualty

Everybody should work in the casualty department of their local hospital, if only for one night. All of life is there, red in tooth and craw.

I was a casualty officer for just six months away back in the day. It was my first job as an SHO after my year as a house-officer/intern. Like an infant I learnt more during this period than at any other time subsequently. Firstly, I gained the superpower of being able to send  patients home whose treatment episode was concluded.  Picture someone with a gashed hand whose gash was now stitched up. Only the most paranoid of doctors would admit such a patient for observation.

On the night of 15th October 1987, when the great gale struck the UK, I was fielding the night duty. There were remarkably few customers that night. As a result, conversation flourished amongst the imprisoned crew. The charge-nurse told me a an awful joke, which has stayed with me ever since:

Q. What is the difference between an oral thermometer and  a rectal one?

I had to confess, I didn’t know the answer. With relish he delivered the punchline:

A. It’s the taste!

An interesting case was when I attended to a man of late middle-age who had been beaten up and robbed upon his own doorstep, as he returned from work one evening. He was thankfully only badly bruised and shaken up. He told me that one of his attackers had lobbed a punch at him, had missed, and his punch had broken the glass panel on his front door. The assailant’s hand had been injured  by this. I wrote all this down, and prescribed a treatment plan for him, and then proceeded to the next patient.

This young fellow, who was accompanied by a bevy of his mates in leather jackets, had a nasty injury to his right fist. Like all such patients, he claimed to have punched a wall, in a state of frustration. His story did not ring true however as his hand was clearly lacerated by some razor sharp mechanism, rather than contused by blunt injury. I sent him off for an x-ray and went to the office to write stuff up.

While there, I noticed a couple of policemen loitering near reception. They were attending to interview the attack victim when he was fit to go. I motioned them over and whispered my suspicions about the possible identity of the perp’ to them. They nodded sagely.

The young man was back from the radiology department and waiting in his cubicle with his chums. The film showed no glass fragments in his mit, so I was all clear to stitch up his wounds. Messrs Plod assembled just outside the cubicle’s curtain, careful not to betray their presence. Given the number of accomplices, backup had been summoned.

As I tied and cut the last suture, I informed him that there were some people who needed to see him, urgently.

The curtains opened and all in all. it was a very ‘fair cop’, as they say in old British gangster movies.

Wordplay: A Fair Cop.