Loose Screws

(This is a continuation of an earlier post called “Critical But Stable”)

Prisoner X, was quite clearly severely brain-damaged by his attempted hanging, and he stayed on our intensive care unit for some weeks. You see he still had the capacity to breath for himself, and to regulate his blood pressure etc. These are functions of the brainstem, the lowest part of the brain, which receives blood from the vertebral arteries and these, which run within the spine itself were not compressed or damaged by the ligature which pinched off his carotid arteries at the front of the neck as he hanged himself. I doubt he considered these anatomical niceties as he plotted and committed his suicide, which was possibly in response to his hopeless and helpless full life term sentence.. Whether he was now in a coma, a vegetative state, or a minimally conscious state, was a moot point as these terms hadn’t been clearly defined at the time, and it was still too early in his clinical progress to tell which anyway.

Two prison officers were tasked with keeping an eye over him 24/7. He was handcuffed to his bed-rails at first whenever they suspected he might make a run for it, but gradually these precautions were dispensed with. My only previous experience of wardens was as a viewer of the TV programme and movie “Porridge”. The true-life counterparts of Messrs McKay and Barrowclough looked rather similarly past their prime, and spent a lot of their time polishing the seats of their pants at a little desk set up outside X’s cubicle.

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Mr Mackay, left.

I started duty on ITU one Sunday morning and wandered in at 8 am to receive handover from my

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Mr Barrowclough, right.

exhausted predecessor. The first staff I met were the two prison officers who were both engrossed in each reading their own copy of the same Sunday tabloid newspaper, called “The News of the World”.

In total innocence, I had a light-bulb moment and said to them

“Ah! That’s why it is called the “News of the Screws*!”

They both eyed me severely as if I was taking the Micky out of them. I truly wasn’t. I had just reached an erroneous conclusion.

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Another memory of X was when I had to accompany his dormant form down to the CT scanner to see if there were any radiological changes in his brain’s grey and white matter which might help us reach a prognosis. The scanner was at the polar opposite end of the hospital from ITU. The two wardens, clinking with chains and keys, a nurse and myself accompanied X as we trundled his bed through many long corridors. He travelled feet first. and I was at the head of the bed watching the monitor and his face.

It was the custom in those days to dress the eyes of unconscious folk with small rectangles of a glass-clear hydrated polymer gel. This stuff kept the eye surface from drying out while allowing inspection of their pupils etc. It also had the unsettling effect of making the patient look like they were wearing rimless spectacles because of the way the ceiling lights reflected unevenly off the curved surfaces. I have always found an emotionless face bedecked with characterless glasses to be rather sinister, like this guy’s:

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Even SpecSavers couldn’t help here

The reader should also note that these events were occurring shortly in the aftermath of that horrifying movie “The Silence Of The Lambs”, which I had seen and which had unsettled me greatly with its imagery.

I couldn’t help my imagination. For the whole of that transit, there and back, I became convinced that Prisoner X was in fact all along faking his coma, and that at any moment he would jump out of his bed and slay us all with his bare hands before making off to the local underworld. The sweat ran down my back and I could only communicate in sparse, panicked one syllable words.

As it turned out, everything went by without any slaughtering at all. The scan got done, and Prisoner X was returned to his cubicle as if nothing had happened. The scan result was inconclusive. We had to keep him going with intensive care until he died of natural causes, or we had a good reason to withdraw treatment.

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Here is my final X anecdote: One evening after several weeks, I was looking after the complex caseload on our 10 bedded ITU when suddenly the Nutty Professor burst through the doors and told me he wanted to do a ward round. His involvement with day-to-day clinical work there was completely unheard of, but I suspected his mania had put the idea into his head. Although I enjoyed his company socially, the prospect of a close clinical encounter with him made my knees begin to knock. Anyway, he press-ganged me towards the first cubicle, where Prisoner X was, and asked me for a brief summary of his case. I started well, middled badly, and was finishing worse (I was nervous you see), when he put his hand on my quivering shoulder, and with a smile said, in his strong northern accent and way:

“Cut to the chase lad! Is he a cabbage, or is he a vegetable?”

It was at that moment that I noticed we were not alone. There behind the door was sat X’s mother, knitting and listening to us.

I am sure everyone reading this can understand my cringing, embarrassed, discomfort at that moment. I said quietly “Professor, this is the young man’s mother…..”

The Prof’ took it all in his stride. His simple response to her was:

I’m sorry for your troubles Ma’am, but the outlook is bleak.

And with that we quickly moved to bed 2.

Prisoner X was eventually extubated and moved to a ward. Within a few weeks, he succumbed to aspiration pneumonia due to his swallowing difficulties and poor cough. May God rest his soul.

 

*The “News of the World” is nicknamed the “News of the Screws”. In English, “screws” can refer to illicit sexual congresses, prison wardens, and also metal fasteners,

 

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The Critic

(This is a true story, but I am not proud of it at all. Thus I will let my dear friend, Frank Konfeshun, tell it like it was).

Once when I was a rascally raffish registrar, everything at work went perfectly swimmingly, for a change. I finished work on a high and it took little persuasion for me to follow my co-workers across the road for some celebratory beers. The conveniently sited pub was called “The Dog And Broken Bottle”. [That is made up, shurely? -Ed]

Professional enmities were quickly dissolved by the process of parley through barley. The consultant head and neck surgeon whom I had upset earlier that day even bought me a pint. I had hovered over his shoulder as he decimated somebody’s face to root out all the cancer within it. It was not a pretty sight. I facetiously remarked that seeing surgery like that made me wonder why more research wasn’t being done into miraculous cures. My timing was poor as he was just at that moment about to perform the most critical and delicate part of the procedure. I can remember his glowering and wilting stare over his surgical face-mask to this day.

He bought me that drink as a mature act of forgiveness, I believe. He was many years my senior, and many thousands of £s richer, having a near monopoly on his surgical specialty locally, and private medical practice was plentiful in that city.

His magnanimous gift left me feeling all warm and fuzzy inside. I checked my watch and saw that I should probably head home. In a virtuously thrifty moment I decided not to spend my frugal cash on a taxi, but I would instead catch the bus. The stop was several hundred yards distant and so I wended my weary way towards it.

Along the route, my eye was caught by a brightly illuminated hoarding above a shopfront which advertised “Southern Fried Chicken”. My coarsely rumbling stomach advised me to explore further. I entered the premises and the delicious aromas I encountered reassured me that I had made a good call. I perused the overhead back-lit menu and ordered the largest meal-deal available.

Within minutes I was gorging on a bucket of greasy bread-crumbed boneless chicken with chips and a fizzy drink. Mmmmmmh, it tasted real good! My hunger abated, but then I became aware of another internal sensation. My stomach, assaulted by all that beer and then more latterly by the fatty poultry-fest decided to table a motion.

The unmistakable sensations of nausea came upon me. I got up and ran out the door. Being a naturally tidy person I sought somewhere to vomit while producing minimal mess. Right there by the exit was a large open-mouthed bin. I stuck my head into it and heaved heartily, with great relief resulting.

At that very moment a rather posh young couple wandered past, arm in arm. They were both immaculately turned out: he in a long black coat, hat and scarf, over a city suit, and she decked out like a minor royal trying to slum it elegantly and with style.

They had obviously just fully witnessed my gastroenterological denouement. The beau turned to his belle and enounced in perfectly posh prose:

“Oh look darling: A Critic!”

And then they strolled on. That anonymous encounter and those wry words have stayed with me for over 25 years. I laughed myself hungry all the way home.

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The “bargain bucket” is dual-purpose, I discovered.

 

Prophecy

Disciple: “I wish to become a teacher of the Truth.”

Master: “Are you prepared to be ridiculed, ignored and starving till you are forty-five?”

Disciple: “I am. But tell me: what will happen after I am forty-five?”

Master: “You will have grown accustomed to it.”

My first experience of prophecy was at the age of seven. Like most of my schoolmates heading home I had to walk down the hill to the bus stop and wait there. The road west afforded a view of almost a mile. The bus home came from that direction.

The sharper-eyed and more observant of us amongst all that rampant cloud of be-blazered, be-capped and  bezerker-ing pre-teens to which we belonged, would espy the oncoming bus home from afar and announce its imminent arrival. We few were proto-prophets in a way, I suggest.

Prophets speak truth to power (and chaos also), but not by mumbo-jumbo or other superstitious means. True Prophets are always very grounded and reasonable, and base their advice upon what they selflessly see going on about them.

False prophets on the other hand tend to be agenda-benders whose untruthfulness readily reveals itself.

 

Irritable ‘Bowl’ Syndrome

Complaint letters are always an occasion of sadness for me as they either indicate a performance failure by my team, or they very rarely sometimes indicate a plaintiff in search of some ££compo. I often deal with complaints because amongst my sparse professional tool set is the ability to see medical blunders from the patients’ point of view. It is still a very difficult role: receiving anyone’s anger and bile always is, but at the end of the episode, it must be addressed without fail.

Sometimes the only relief I get in this grisly business is spotting the unintentionally funny spelling bloopers in the complaint letters. One such came from some poor soul who felt that his irritable bowel syndrome had been mismanaged. (In fact it hadn’t). Here’s a picture and caption about the title to make the point:

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(Bowl, in a ticked off voice, is whinging:) “Oh so I am only good enough for Tiddles now am I? What about the quinoa salad, or truffled souffle?” “Don’t you dare use me to hold your shaving soap again!” [Better stop there: I’m all bowled out]

Surgeons

I have been a doctor since August 1986. My colleagues can broadly be categorised as either physicians or surgeons. This piece is about the latter. Surgeons concern themselves with human anatomical pathology, whereas physicians get busy about human physiological pathology. Anaesthetists concern themselves with all of the above, though in less detail perhaps, while trying to remain kind approachable and calm, to patients and colleagues alike.

I heard a comic comment at a medic’s dinner long ago:

Q. “If the medical profession be likened to a world-renowned symphonic orchestra, then what is the anaesthetist’s role in it?”

A. “They drive the lorry!”

How I laughed! Yes my chosen profession is very worthy and very dull, like a special forces soldier’s life is, between siege breaking and hostage saving episodes, I suppose.

Anaesthetists are involved in 70% of all inpatient treatments. Anaesthetists are the largest group of all hospital doctors by number. We are the invisible elephant in the room…..

[BB, you have an astounding talent for wandering away from the subject, which is SURGEONS! -Ed]

Surgical competence and skills are distributed “normally”, which is statistical speak describing how most surgeons are middle of the road, and a few are very good, and a few are bloody awful. The bell curve is a plot of competence against numbers of surgeons.

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The poor performers, which I am tempted to call the “bell-ends” are only 16% of the total, or 1 in 6. I have worked with a few of these, and remembering them makes me shudder on their patients’ behalf . One such Consultant at a top London teaching hospital had a joke forged in his dishonour.

Q. What do you call Mr X when he is wearing a suit?

A. The defendant, m’lud.

Yes, the judiciary eventually catches up with these charlatans but they do seem to live charmed lives. Anyway, enough of the dark side. I really want to talk about all the few fantastic surgeons.

I want to talk about Alan the orthopod who could fix a fractured hip in 20 minutes, or David who could remove an appendix in 9 minutes flat, or Douglas who could perform a hysterectomy in 25 minutes. All those times were skin-to-skin, ie first incision to last stitch. Not only were they fast but they were providing surgical product of excellent quality. It was a joy to behold them at work, like it is to watch any God-gifted artist at play. Their deftness in parting and mending flesh and bone was a work of art.

Guess what, Alan never made it to Consultant, as his bosses felt threatened by his effortless competence. Douglas remained a permanent locum surgeon, though not by choice. Alone, David survived professionally, though only by playing the game of jumping through hoops, ticking boxes, and licking boots. Even so, he got thoroughly shafted by his highly valued mentor before reaching his well deserved career destiny.

Medicine can be a perverse old game. Talent is not always rewarded as it should be.

 

 

 

Do Not Go Gentle….

This is a famous poem by the Welsh genius Dylan Thomas:

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

And you, my father, there on the sad height,
Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.

Dylan Thomas was an impecunious alcoholic for most of his life. Nevertheless, he had an undeniable genius for poetry and prose and it was for these gifts he is most remembered.

The above poem was written alongside his dying father’s bedside. It is more a maddened grief-filled raving against death than hope-giving advice to the dying. It is tragic heartbreak all condensed into a very small bottle. For such is all heartbreak, ultimately.

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Burns Night

Today, the 25th of January, traditionally is celebrated the life of the Scottish poet Robert “Rabbie” Burns (1759-1796).

(It is also my father’s birthday).

Tonight, all across Scotland, and amongst the Scots diaspora, much haggis, ‘neeps and tatties will be swallowed, and much much whiskey will be swallied in Burns’ honour. I totally approve.

Modern life has become so miserably rule bound and unspontaneous that I relish the prospect of celebrating Rabbie the dead poet genius with full-on Christian anarchist verve.

Before I moved to my final resting place, professionally speaking, I used to live in Scotland amongst the Scots. A finer folk is hard to find. They combine a huge quickness of mind with a vast passion of spirit and transcendentally gifted humour – every one of them that I’ve met anyway. I am obviously joshing when I say they might almost be Irish!

Scots are famous for producing great engineers, both the mechanically minded, the literary talented, and also the socially/politically active. Examples in reverse order:

  1. William Wallace, the original heather-and-bracken-roots freedom fighter.
  2. Rabbie Burns and William McGonagall*.
  3. “Scottie” the chief engineer of the Starship Enterprise*.

Burns gave us “Auld Lang Syne”  among many other poems. It translates roughly to modern English as “old long since”. It is an expression pertaining to shared nostalgia, and as such is very appropriate for use around the ringing in of the new year.

I went to a Burns Night dinner once. I was at a professional conference at the time in my role as educational supervisor for my tiny wee Scottish hospital. It was held at the Highlands Hilton in Coylumbridge. I was suffering one of those bad colds/flu at the time, you know where you can’t stop sneezing or wiping the drips from one’s nose. I spent the entire day before the dinner trying desperately to follow all the highfalutin’ edu-speak being piped at me from all around, while fending off the utterly natural desire to nod away retiring to my room and take to my bed with plenty of scotch nearby.

By suppertime, I was exhausted and delirious. I carried on pretending to be interested in the proceedings, but found myself locked in conversation with a very much more mature psychiatrist from the Hebrides, whom I in my increasingly paranoiac state I presumed was trying to psychoanalyse me before recruiting me as a spy for the obviously invading Martians. The pleasantries and platitudes rallied betwixt us, as if between ambassadors, until the bell was rung, and we all processed to the dinner tables. By this stage I was swaggering and staggering though not because of alcohol. The last thing I remember is tucking into the oatsy ovine offal encased in the poor wee lamb’s own stomach , whilst quaffing some unremarkable whiskey……

The very next thing I remember is waking up the next morning, thankfully fully clothed and on top of my hotel bedclothes. I had a dry dry mouth, a bunged-up nose and a very sore throat, but I felt better than I had the night before. I instinctively praised God for His having provided another day of life ahead of me. Then I quickly topped up with hydrating fluids and found some carbs and fat (ie a bacon sandwich). My next mission objective was to get home ASAP and kiss my wife and children before bedtime.

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When I were a younger doctor, Burns Night at the hospital was traditionally celebrated on November the 5th: Guy Fawkes Night. Back then, youngsters could freely purchase even megaton grade fireworks at their local corner shop. Guess what! Those pre-teen pyromaniacs often suffered from “friendly” fire. Here is one of the less grisly images:

Fortunately, firework injuries are now much less common and severe. Restricting of behaviours by legislation  can be fruitful sometimes, don’t you think?

*More joshing. Sorry, sometimes I can’t help myself!

Orthopods

The surgical speciality of Orthopaedics gains its name from the Greek: It basically means “the straightening out of children”. Back then, these bone, joint, and muscle surgeons were mostly employed dealing with youngsters who had wonky skeletons for whatever reason.

How times are changed. Orthopods nowadays mostly earn their living by replacing the hips and knees of elderly folk. They also fix fractured wrists, ankles, legs, spines, necks, and collar-bones as these conditions arise.

Because orthopods are so fixated on bony matters, they often lose the more subtle and complex nuances of medical practise and thinking. I first witnessed this as a medical student. The orthopaedics registrar was handed an ECG recording from one of his potential victims. Back then an ECG was a long paper strip covered with pink checker work and wavy black line recordings of the patient’s heart voltages. Clearly bemused by this piece of medical evidence arising from beyond his ken, he humorously commented “Well, as ECGs go, that is a lengthy one!”

Another bit of orthopodish wisdom came to me during my attachment to the Nuffield Orthopaedic Centre. The rather raffish, roguish and witty senior registrar with a double barrelled name was telling us how unwise it was to schedule any patient to have surgery on both arms at the same time. We simpletons in the audience prayed he tell us more. His simple and sagacious reply was

“Everybody, to be optimally happy, must be able at all times, to attend to both ends of their enteron”.

Only an Oxford orthopod could furnish an answer like that, I suggest.

Anyway, here’s an amusing animation from America showing a typical interaction between an orthopod and an anaesthetist, who don’t really understand one another. This is so very true to life.

(The patient’s body is at nearly room temperature, her pH or acidity level is incompatible with life, and asystole is the complete absence of heart electric activity. Yes, you’ve guessed, she’s snuffed it. Still she does have a fracture….)

Here is my final piece of nostalgia. On a trauma ward round, the chief orthopod of the day opined that what this particular patient required, in all merciful reality was

“a rigid external prosthesis”.

We students were mystified by this piece of jargon. It was in none of our pocket textbooks. I tugged at the sleeve of this bone-mangling Jedi Master to ask the big obvious question.

“It’s a coffin, dear boy!”, he replied, and then breezed off to the next bed.

The Blarney Stone

In the Summer of 1984, during the medical school holiday, I rode my little motorbike from Oxford to a village in County Waterford where my mother was tending her mother’s cottage while trying to enjoy a holiday of sorts from life in London.

It was great to be with mum, but I was a restless 22 year old, and my holiday didn’t really come alive until some pals from medical school turned up with some wheels. You must realise that this meeting took place in the time before the world had GPS and smartphones. I guess my friends used their memories, a map, and paper and pencil to get to my location.

Noelle and Paul stayed the night, and entertained my mother with their youthful freshness, intelligence and verve. Before bedtime, we walked down the hill to the local alehouse. When our young summery presences entered the bar, it immediately fell silent, which was a bit spooky. We found ourselves surrounded by a large company of mostly old Irishmen in black suits wearing flat caps and drinking Guinness while conversing or playing dominoes. There were no women apart from the barmaid. I began to feel awkward for Noelle, but this was unnecessary as her brightly innocence triumphed over their reactionary instincts. Our novelty surprised them for only a short while I suppose, because we were soon asked what drinks we would like.

We ordered our alcohol though the choice was slim. The chatter and supping restarted. Everything went back to normal. Rural Irish life is very pub-oriented and almost always has been. It would take something as major as a meteor-strike to change that social habit permanently. The bucolic sons of St Paddy work very hard in intemperate weather for long periods each day with little financial reward. A few beers of an evening is surely and thusly well deserved, if not even a bit medicinal. At least that was the opinion of the local doctor who died at a grand old age-from alcoholism it’s rumoured.

After breakfast the next morning, we three headed off on an adventure. We were aiming  first for Blarney Castle just north of the city of Cork which lies in the south-west of Ireland. The castle is a well preserved example of a Norman keep, a style of military architecture typified by a tall narrow building with lots of high windows from which arrows could be launched, and surrounded at best by a high wall and a moat. It was designed to withstand being besieged by enemy forces for a long time whilst the aggressors waged a battle of attrition upon the incumbents. I even like the name “keep”, as it was clearly a place to be “kept”.

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Blarney Castle on a good day.

I forget many of the details of our visit, all except our attaining the top deck. There we joined a queue to kiss the world-famous Blarney Stone which lies underneath the battlement walls.

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To kiss the stone one must lie on one’s back and contort one’s upper torso and head down into an opening. Several people have fallen to their doom while attempting this feat.

My friends and I all performed the ridiculous ritual without any serious misadventures. I can only speak for myself but for ever after, I have exhibited a preternatural talent for public speaking, which my earlier congenital shyness had always precluded.

Noelle and Paul went on to become very successful Consultants in Oncology and Public Health. Both of those specialities require being very gifted with the “gab”, to be done well.

“Blarney” is a nickname for Ireland itself but also for voluminous and overwhelming Celtic bullsh*t.

I leave it to the dear readers to discern how much of this reminiscence is not false news.

K9 Capers

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I used to put pictures like this by the bathroom mirror to encourage the family to look after their teeth. It worked.

Without doubt, the most hair-raising incidents in my anaesthetist’s career have occurred while I have been working with dentists, orthodontists, or their more sophisticated cousins, maxillo-facial surgeons.

The reason for this is simple. Both they and I share the same orifice: I have to provide oxygen and anaesthetic vapours via the mouth, while they have to do their business in the mouth. Conflict of priority is a constant risk, and can lead to some perilous situations.

The rest of this article, and its sequels, is a series of anecdotes from my professional encounters with the K9 crew.

People with mental handicaps are major consumers of dental health services. This is because they often fail to brush their teeth frequently, or grind them in their sleep, or they suffer dental trauma by one means or another in their chaotic daily life. They are also extremely un-amenable to standard medical care because in their simplicity, they see all immediate pain as an ultimately bad thing; they are unable to trade a current sacrifice of discomfort for a future pleasurable gain. In this way, they resemble all very young people of sound mind. At this point the anaesthetist is usually drawn in to render them senseless while the K9 crew does the needful. These patients get assembled into operating lists, and these lists are often insensitively nicknamed the “Mental Dentals”. I have never liked that sobriquet by the way. Everyone of us who reads or writes this article is only one stroke away from a seriously disabling mental handicap that would render us possibly worse than those poor souls who have had to endure theirs from birth or childhood.

One day, a particular anaesthetist was rostered to anaesthetise a whole bunch of disabled young people for various minor dental treatments. The individual was what I term a rugby-doctor, one of many produced by the UK medical training system back in the day. He was a doctor second, but a rugby star first. As a result, his bedside manner was worse than his scrum-side manner. He tended to speak rather coarsely and abruptly as if addressing his team-mates. His empathy and sympathy were rather lacking. As well as having rather rough features and complexion, he also possessed a badly broken nose.

Anyway, he turned up early to the clinic in the suburban house throatily and dully announcing “I AM HERE FOR THE MENTAL-DENTALS”. The young receptionist told him to take a seat in the waiting room while she arranged everything.

After an hour or so, the waiting room was overflowing with patients and carers and the receptionist was in horrendous hysterics: The anaesthetist had not turned up! The dentists were all there waiting and getting pretty ticked off. Phone calls got made. Where the hell was the blooming gas-man eh, eh?

The anaesthetic secretary at the hospital finally found the solution. She described Dr G as about 6 foot 5, built like a brick outhouse, and as ugly and graceless as sin.

The clinic receptionist recognised the description as matching her first visitor that morning. She went out and fetched Dr Turnip-Face around behind the curtain, and the show finally got on the road.

Dr G and the dentists upped their game that morning and finished only slightly late, after all.

My lawyer has advised me to say that I can neither confirm nor deny that I am Dr G.

More K9 stories later.