Author: jamescalumcampbell

Last Thursday evening I had the privilege of addressing the Friends of Aberfoyle & Buchlyvie Medical Practice and I talked about some personal experiences of off-duty or “opportunistic” medicine.  Three of these experiences involved bystander cardiopulmonary resuscitation or Basic CPR, which was serendipitous as this patient group is very involved in community “heart start” and “heart smart” initiatives.  I wanted to express the idea that knowledge of CPR and skill in its delivery is a gateway to every other type of First Response.  So with your indulgence, I reproduce here this segment of my talk.

Does bystander CPR work?

In 1988 I attended the 2^nd International Conference on Emergency Medicine, held that year in Brisbane, Queensland, Australia.  I know the fair city of Brisbane quite well because I worked there for a GP locum service in 1985.  The 1988 conference was very good.  It culminated with a lively debate entitled, “Does bystander CPR work?”  This was before the days of community automatic external defibrillators like the one in the phone box at Arnprior, and many people believed that to invest in CPR training and to create the necessary infrastructure would not be cost-effective.  I had some sympathy with that view because in 1985 while driving to a GP surgery in Brisbane’s northern suburbs I encountered a major road crash and attempted unsuccessfully to resuscitate a young woman.  I can remember her quite clearly, and I still remember her name.  I was upset.  But if I was partly upset at my own inability I shouldn’t have been.  This girl had suffered what is known as “blunt trauma arrest”, and the outlook for that condition remains dismal.

I don’t remember the conclusion reached by the 1988 Brisbane debate, but I do remember what happened after the conference had adjourned.  I stepped out into the Queensland sunshine and went for a walk over the Brisbane River to the Cultural Arts Centre, via the Victoria Bridge.  On the bridge, a man walking in front of me collapsed with a cardiac arrest.  I commenced basic CPR with cardiac compressions and was immediately joined by a nurse from the conference who provided mouth-to-mouth respirations.  An ambulance came – I don’t know how it was summoned because mobile phones then were a rarity and looked like bricks of the sort John Wayne used on Omaha Beach.  But the paramedics arrived quickly, successfully defibrillated the patient, and transported him to hospital.

I don’t know what the final outcome was in that case, but I can tell you what it was the next time I carried out bystander CPR.  Flash forward to Auckland New Zealand a few years later.  In Auckland – actually about this time of year – they hold a huge road-run called “Round the Bays”.  It starts on the wharf in downtown Auckland and proceeds east for about 9k round the Waitemata Harbour to end in the suburb of St Heliers.  I took part many times.  On the occasion in question the field was about 80,000 runners.  After about 3k something in my left calf went “twang”.  I debated whether to run through the pain, slow to a walk, or just stop.  The decision was made for me when the runner in front of me collapsed.  I stopped.

He was non-breathing, pulseless, and unconscious.  I commenced CPR.  I was joined again by a nurse who undertook mouth-to-mouth respirations.  With 80,000 people on the road, the paramedics understandably took a long time to reach us.  We continued basic CPR for some 30 – 45 minutes.  During this time a large number of doctors and nurses running by asked, “Need any help, James?” to which I replied, “Not unless you’ve got a defibrillator.”

When the paramedics finally arrived the defibrillator duly shocked the gentleman back into normal heart rhythm.  He woke up, but because of the hypoxic insult to his brain – lack of oxygen – he was what we call “combative”.  I gave him a little intravenous sedation and accompanied him in the ambulance to the emergency department of Auckland Hospital.  He was admitted to the Department of Critical Care Medicine and walked out of hospital a week later, as we say, “neurologically intact”.  He was entirely well.

So if you are asking me, I think bystander CPR works.

Yet this issue doesn’t go away.  In the British Journal of General Practice of January 2010 a GP wrote an article questioning the cost-effectiveness of CPR training.  I wrote a letter in defence of CPR training which the journal published in February 2010.  In the letter, I pointed out that the benefits of CPR training extend far beyond the particular scenario of a cardiac arrest.  If you can respond effectively to a cardiac arrest, you carry with you the conceptual armamentarium to respond to any medical emergency.  If you undertake a course of First Aid – an undertaking which I strongly recommend – you will, or you should, be taught basic CPR.  Allow me to put on my pedagogic hat for a moment and share with you this one visual aid which I would suggest, if you have an interest in being a first responder, you memorise and hold in your head, heart, and gut.

Here it is:

 

The Emergency:

Breathlessness, Shock, Coma

The Response:

Patient safe?  Am I safe?  Extrication?

Primary Survey:

Airway, Breathing, Circulation, Disability, Exposure & Environment

Vital Signs:

Respiratory rate, Oxygen saturations, Pulse/Blood Pressure, GCS, Temperature

 

Professors of Medicine are wont to put up masses of data and say, “I apologise for this busy slide.”  So I’ve kept it simple.  This is all of emergency medicine on the back of a postcard.  This is what an emergency physician does every single time he – or she – approaches a patient.  The doctor works through this mantra.  On first laying eyes on the patient, the doctor asks, “Is this patient fundamentally well, or fundamentally ill?”  A very sick patient will have at least one of these, the triad of decompensation.  Breathlessness, shock, coma.  Breathlessness: some people call it respiratory embarrassment, but I’ve never seen a breathless person look embarrassed.  Shock – shock isn’t what the daily papers think it is; shock is circulatory collapse, characterised by low blood pressure.  Coma – unconsciousness.

So you see your patient is very ill and you rush to help.  But don’t rush headlong.  Have a care for the situation in which both you and the patient find yourselves.  You may need to move the goal posts.  People fall ill in awkward places.  You may need to shift the furniture.  You may need to move the patient.  Is there a science of extrication?  We will pass over this huge subject this evening.

Next comes your initial assessment of your patient, known as the Primary Survey.  First Aid is as easy as ABC.  Airway – breathing – circulation.  Fix them in that order.  Make sure the airway is open and make sure, if you can, that oxygen gets to the lungs, and that way the circulation has something to transport.

Disability stands for “neurological disability”.  I always think it’s a bit of a lame mnemonic.  “Diminished consciousness” would be better.  You ask, how diminished?  Well, we can quantify it, using the GCS or Glasgow Coma Scale.  Yes, worldwide, Glasgow is home of the coma.

Notice also the way that the vital signs, pulse, blood pressure, temperature, respiratory rate and GCS marry up with the triad of decompensation and our response to it.  To the vital signs we may add oxygen saturations if we have a pulse oximeter, an ingenious device the size of a memory stick which, when attached to a fingertip, or an ear lobe, will tell us the percentage of haemoglobin, the blood’s oxygen- carrying molecule, that is saturated with oxygen.

I say this slide encapsulates all of emergency medicine.  In a sense it informs every medical consultation.  I’m fond of stating that “all medicine is acute”.  By that I mean that every time a doctor goes to the waiting room to summon the next patient he is looking at the patient as he steps forward and, albeit unconsciously, he is going through this mantra.  We doctors sometimes, rather self-servingly, say we have a mysterious “sixth sense” for detecting a patient who is very sick.  But there’s nothing mysterious about it.  It’s a skill that can be taught and can be learned, and it is encapsulated in this mantra.

 

 

 

 

 

 

 

 

In Middlemore Emergency Department in the 1990s we introduced lightning packs.  Their first use was in extreme emergencies, when we wished to rush a patient from ambulance to resuscitation room, and to medical or surgical intervention, with absolutely no delay.  The pack was an envelope containing a form in triplicate to serve as a handwritten clinical record, an array of x-ray and laboratory investigation request forms, principally biochemistry and haematology, an accompanying array of specimen bottles, and a hospital identification wrist-band.  The pack, the wrist band and all the other articles were tagged with a “sticky label” which shared the same unique hospital patient identification number.  Thus an unknown unnamed patient could be identified by his or her unique number and the task of recording patient demographics could be deferred.

We thought we would only use lightning packs occasionally but they were seen to be immediately useful in a variety of situations.  For example it was clear that they would be invaluable if a major incident unfolded and the department received a sudden influx of a large number of patients.  They became an integral part of the hospital’s Disaster Plan.  Initially we held 150 packs in readiness.  We had a low threshold for using a pack in an isolated situation because it was essential that all clinical and clerical staff be familiar with the packs and how to use them.

Then the digital world, the world of the internet and email and information technology erupted, and it became clear that the process of becoming more electronic while going paper-light would be inexorable.  But the lightning packs became all the more important to us.  The systems at the front desk kept crashing.  The front desk would revert to paper, pen and ink, but if we were in a hurry we would just use a lightning pack.  We increased the number of packs held in readiness so that if the lights went out we had a system that could identify and track a 24 hour patient load.  The system was low-tech and that was its power.  It could not be sabotaged.

I thought of lightning packs in May last year when NHS Scotland was targeted by hackers who disrupted IT systems and demanded ransom in Bitcoin.  The attack was named “WannaCry”.  Another attack, “BitPaymer”, was launched in August.  It came in the form of a piece of spam email.  On both occasions patient appointments and procedures were cancelled.  As a result, much money was spent shoring up cyber defences, and more cyber security specialists were recruited.

Now I read in the Sunday Herald that the UK’s National Cyber Security Centre (NCSC) are warning of the possibility of future state-sponsored offensive operations.

Computing power is now very important in clinical medicine.  You can’t run a CT or an MRI scanner without computing power.  That is why it is vital that these systems be quarantined from any potentially malignant outside influence.  But aside from that, there are sound reasons why a Health Service of all things should be particularly robust in the face of a cyber-attack.  In order to function, doctors and nurses might find computers, at least when they work, a convenience, but fundamentally, they are not really needed.  In terms of the trafficking of information they don’t serve any function that can’t be fulfilled by paper and pencil and a telephone.  The beauty of the diagnostic medical consultation is that it relies mostly on the knowledge, skill, wisdom and kindness of the attending physician.  I can’t think of a reason on earth why any general practice or hospital department should cease to function simply because the computers have crashed.  All it takes is for the clinicians to put their heads together and come up with a low-tech plan and a modus operandi for working under such conditions.  Make up some lightning packs and stay open for business.

Meanwhile today’s (Monday) Herald front page is dominated by two headlines:

Protect workforce from the rise of robots, warn unions.

And:

NHS staff taking early retirement doubles in eight years.

Scottish Health Secretary Shona Robison is under huge pressure just now.  NHS Tayside (Ms Robison’s constituency) has come under fire over its use of charity cash to cover general running costs.  This includes the financing of an IT project.

South of the border, I see that Jeremy Hunt is warning the big Social Media empires that if they don’t do something to sort the content on their respective platforms that is damaging the mental health of young people, he will step in and do it for them.

Most people will take a nuanced approach towards the digital world and say that there is nothing intrinsically good or bad about it; it all depends how you use it.  I suppose I must agree with that; why else would I write this document on Word and then post it on my blog?  Yet sometimes I wonder.  I’m beginning to think there is something inherently malevolent about this Brave New World in which we find ourselves.  Clearly we are not in control of it.  Like the Sorcerer’s Apprentice, we are floundering.  It seems to me that IT is a bit like alcohol.  It might be safe and even beneficial in small doses.  (Actually the medical profession is now even questioning that.)  But take too much of it and it will destroy you.  Remember Tiger Tanaka’s remark to Mr Bond in You Only Live Twice concerning saké, that the man drinks the first flask, the second flask drinks the first, then the saké drinks the man.  That truth must be recognised cross-culturally because it is almost exactly replicated in a proverb in Scottish Gaelic which roughly translated says, “One drink: the better of it; two drinks: not the better of it; three drinks: the worst of it!”

So it is with the lap top and the tablet and the desk top.  Remember, you always have the option of switching the contraption off.  I was never so happy in medicine as on the days when the computers crashed.  Suddenly I was no longer under the baleful cyclops eye of the computer screen, and I found I could communicate with my patient without the intrusion of a malevolent third party.  So Log Off! You can have the satisfaction of knowing that the cyber moguls of the great multinational conglomerates won’t like it.

I’m beginning to think the Luddites were right.

 

What is it about Prague and the nasty habit of falling out of a window?  It was the Defenestration of Prague that started the Thirty Years War.  Then in 1948 Jan Masaryk the Czechoslovakian Foreign Minister was found dead in a courtyard beneath a window.  You can read about it in Marcia Davenport’s Memoir Too Strong for Fantasy.  Fell or was pushed?  Hold that thought.

I was in the dressing room of my local gym in Stirling the other day eavesdropping on a lively conversation between two local worthies.  The topic, I think, was football.  If I’m a little uncertain, it’s because the Scottish urban central belt patois was so idiomatic, so rough and so fast, that for all I knew they might have been speaking Serbo-Croat.  And mind, I’m a Glasgow boy.  Yet I kid you not, I didn’t understand a word.  As I left the dressing room one of them paused to address me.  He only said something like, “Cheers mate. See you next time.”  But I realise he had courteously altered his register in order to communicate with me.  I fell to wondering how universal was this ability to alter one’s register to the occasion, and whether such alteration is to be applauded.

Is it an affectation to “walk with kings – nor lose the common touch”?  Should we be the same to all men and women?  I dare say most people adjust their mode of speech to suit the occasion.  When I was young a regional accent was a social disadvantage.  If you wanted to get ahead certainly in any professional field, you needed to acquire some sort of approximation of BBC Received Pronunciation.  That is not to say that, even then, you could not use your natural accent to advantage.  A doctor, for example, with a cultured Scottish accent, might yet sound extremely erudite and authoritative.  But the accent is on “cultured”.  If the accent was Glasgow, and working class Glasgow, say from Partick or the Gorbals, people, including people from Partick and the Gorbals, would cringe.

This is why parents sent their children to elocution classes.  Elocution classes taught you to “talk proper”.  Do they exist now?  I have no idea.  These parents were doing their best to give their children a social advantage.  I guess the ultimate expression of this was seen in Gaels from the Highlands who migrated to Glasgow and made a point of not talking Gaelic at home in case their children picked it up.  Gaelic was low class.  It would hinder their off-springs’ progress.  The irony of course is that now, middle-class parents in Glasgow clamour to get their children into Gaelic medium schools because the advantages of a bilingual upbringing is now recognised, and these schools perform extremely well across the board in the academic league tables.

Nowadays, a regional accent can no longer be considered an impediment.  Much of this has to do with the rise of popular culture.  The Beatles spoke Liverpuddlian unapologetically and, crucially, the Americans could understand them.  Around the same time, Sean Connery gave James Bond a Scottish accent.  Ian Fleming was initially sceptical about the choice of Connery for the role, but he was reassured when an American woman told him Connery had “it”.  Nowadays, if you hear a Scottish actor like James McAvoy expounding on Graeme Norton’s couch you almost have the sense he is hamming his Scottishness up because it’s such an asset.

It’s really because of these powerful icons of entertainment that the upper classes have felt the need to modify their fruity accents.  It’s most obvious in the Etonians’ use of the glottal stop.  Not entirely convincing to a man from Glasgow, home of the glo’’al stop.  Sometimes when I hear a member of the establishment saying something which I suspect might be fatuous, I subject the suspect statement to what I call “the stairheid patois” test.  I translate the statement into Glaswegian, repeat it, and see if it stands up.  You can use any urban working-class accent to effect this test – Liverpool, Newcastle, east-end London.  In fact I think Peter Cook and Dudley Moore invented this test in the Pete and Dud sketches when two geezers discussed High Art over their beer.  Peter Cook was so dead pan that he would make Dudley Moore corpse with laughter.  I was thinking of them the other day when my hugely entertaining barber and I had our usual barrack room lawyer conversation (scissors flashing in front of my eyes) and solved the problems of the world.

“Novichok onna doorknob?  Talk aboot Smersh!  Wurld’s gaun bananas!  And as for the Donald!”  He produced a noise approximating a thermonuclear explosion.  “Story’s endi’, pal.”

I thought it safer to change the subject.  “Any holidays lined up?”

“Well, ah thought of Prague, but the missus didnae fancy it so that’s oot the windae.”

 

In these troubled times in which we live, and mindful of George Santayana’s famous remark that those who do not learn from history are doomed to repeat it, this week I read two books which seem to reverberate into our own dislocated world, and cast light upon our own multi-faceted predicaments.  The books were Churchill’s Legacy: Two speeches to save the world by Alan Watson (Bloomsbury 2016) and The Shortest History of Germany by James Hawes (Old Street Publishing Ltd, 2017).

In the latter half of 1945, Churchill, having lost the General Election after VE day but before the capitulation of Japan on September 2^nd that marked the end of the Second World War, became His Majesty’s Leader of the Opposition.  For a man who basked in the limelight and who loved to be at the centre of things, it must have seemed a terrible climb-down.  One moment he was deciding the future of the world first with Stalin and Roosevelt, then with Stalin and Truman, the next moment he was out of office, powerless, unable to influence affairs other than by writing newspaper articles and asking questions in the House.  No wonder he was visited by his Black Dog.

Then he got an opportunity.  On October 3^rd, the president of Westminster College in Fulton Missouri invited him to give the annual John Findlay Green lecture to the college.  Crucially, the letter was endorsed by a handwritten appendix from the 33^rd President of the United States:

This is a wonderful school in my home state.  Hope you can do it.  I’ll introduce you.  Best regards, Harry S Truman.                 

On 5^th March 1946 Churchill gave a speech at Fulton that was to become almost as famous as the great orations of 1940.  It was entitled The Sinews of Peace.  Perhaps its most famous line is:

From Stettin in the Baltic to Trieste in the Adriatic, an iron curtain has descended across the Continent.

Churchill was alerting the world to the threat of a totalitarian regime’s expansionist ambitions towards the west.  Initially (how true this is of many of Churchill’s speeches) the response was negative.  Stalin, Uncle Joe, was a popular guy.  In 1945 at Yalta, an ailing President Roosevelt had accommodated him to the extent of excluding Churchill from some of their negotiations, and he acceded to many of Stalin’s territorial demands.  Now in 1946, the last thing the American people wanted to hear about was the prospect and possibility of further war.  Truman probably recognised this when he distanced himself from Churchill’s message and denied that he had had prior knowledge of its content. Yet he was sympathetic to the idea that the US needed to prop up a bankrupt and exhausted Europe in order to counter the Soviet threat.

From these deliberations arose the Truman Doctrine – a resolve financially to support Greece and Turkey against the threat of a Communist takeover, and the Marshall Plan – an injection of capital into Europe to kick-start its ailing economies.

Churchill gave another speech of great significance in 1946, in Zurich.  It was entitled Europe Arise.  Here are the crucial sentences:

I am now going to say something that will astonish you.  The first step in the re-creation of the European family must be a partnership between France and Germany…  There can be no revival of Europe without a spiritually great France and a spiritually great Germany. .. If we are to form the United States of Europe or whatever name or form it may take, we must begin now. 

When the first volume of Churchill’s six volume history of the Second World War was published in 1948, its first page declared: Moral of the Work: in war: resolution.  In defeat: defiance.  In victory: magnanimity.  In peace: goodwill.  But De Gaulle was appalled at the notion of a regenerated Germany.  He wanted to replicate the 1918 Armistice reparations arrangements and permanently disable Germany.  The idea of a swift reconciliation between France and Germany must have seemed very strange.  Yet it was this very idea that was to make possible the creation of the European Coal and Steel Community that was the precursor of the European Union.

People have used the Zurich speech to argue that today, in the context of Brexit, Churchill would have been a Remainer.  Yet the close of the Zurich speech would suggest otherwise:

Our constant aim must be to build and fortify the strength of the United Nations Organisation.  Under and within that world concept, we must re-create the European family in a regional structure called, it may be, the United States of Europe…  In all this urgent work, France and Germany must take the lead together.  Great Britain, the British Commonwealth of Nations, mighty America, and I trust Soviet Russia – for then indeed all would be well – must be the friends and sponsors of the new Europe and must champion its right to live and shine.  Therefore I say to you: let Europe rise!          

Churchill’s view of the post-war world, as expressed in The Sinews of Peace and Europe Arise, reverberates right down to our own time when the UK is revaluating its relationship with the US, Europe, and Russia.  Churchill wanted to construct and bolster multinational institutions that would preserve the peace.  In his second premiership, by which time the USSR had become a nuclear power, he recognised the threat of all-out nuclear war and he devoted what mental and physical energies he had left to find a way to avert world annihilation.  He tried to convene a “Summit” – he coined the term – of World War II’s “Big Three” – Britain, America, and the Soviet Union.  But he did not succeed, and this is perhaps the chief reason why he remarked that he had achieved a lot in his life, in the end to achieve nothing.

James Hawes’ Shortest History of Germany shares this dark outlook.  The West is in full retreat.  The Anglo-Saxon powers, great and small, withdraw into fantasies of lost greatness.  In 2016 Joschka Fischer, Germany’s Foreign Minister from 1998 – 2005 said, “The Western World as virtually everyone alive today has known it will almost certainly perish before our eyes.”  Yet, like Churchill, Hawes is not at heart pessimistic.  He sees Germany as “our last hope”, provided – and this echoes Churchill’s Zurich speech – she remains at the very heart of the west.

Things do feel extraordinarily precarious in the world right now.  I have the sense that some minor ruction in an obscure corner of the world, something apparently insignificant, could set off a train of events that could easily spiral out of control.  Bismarck predicted the First World War.  He said it would be sparked off by a minor event, or, as he put it:

Some damn stupid thing in the Balkans.

 

The centenary of the founding of the Royal Air Force on April 1^st has brought much to my mind.  I was in the RAF Volunteer reserve when I was in the University Air Squadron in Glasgow as a teenager.  That my father had been a pilot in the RAF was no doubt influential in my going down that route.  My father had very humble origins in the seaside town of Saltcoats in Ayrshire. (I see that Ayrshire continues to supply the RAF.  The current top man, Air Chief Marshal Sir Stephen Hillier KCB CBE DFC ADC MA RAF, Chief of the Air Staff, went to Kilmarnock Academy.  Kilmarnock Academy’s list of alumni is rather formidable and includes two Nobel Laureates.)

My dad was in the work force from age 8.  He was smart, dux of Kyleshill Primary, and went on to Ardrossan Academy, but he wasn’t comfortable with the posh boys and he left when he was 14 and went to work down the coast in ICI Ardeer.  He got a break when he was chosen to go to the Duke of York’s camp down south (I still have his signed photo of the young man who became George VI) and he got a taste of the wider world.  He joined the City of Glasgow Police, and then war broke out.

The Clydebank Blitz occurred in 1941 and my father volunteered for the RAF.  I know the devastation of Clydebank made a great impression on him and now I have no doubt it contributed towards his decision to volunteer.  He went to London thence by troopship to Canada to train as a pilot.  On board, he attended Sunday worship, when the congregation sang “For those in peril on the seas” with great fervour.

On the other side of the Pond they boarded a train and travelled west for days to places with exotic names like Medicine Hat.  He was subjected to the rigours of RAF training of which I have some personal knowledge.  He didn’t take to the bullying culture.  He actually said to his instructor, “Don’t talk to me like that.  You won’t get the best out of me.”  I greatly honour my father for that because I know what it would have meant for a young man from Ayrshire to say that to a person of authority.  Things got better for him after that and he won his wings and flew with Coastal Command out of Prince Edward Island, tracking the submarine traffic out in the North Atlantic.  I have pictures of him in Canada, lying on the beach surrounded by beautiful women with big hair.

Then he crossed the Atlantic.  Dorval – Gander Newfoundland – Greenland (Bluey West One) – Reykjavik – Prestwick (I have all his log books).  When he got into Prestwick he said to the Commanding Officer, “My mother lives 10 miles up the road and I haven’t seen her for three years; may I visit her?”  The CO said no.  But he went anyway, bearing exotic gifts that rationing had rendered unobtainable.  So I suppose technically he was a deserter.  But he never got into trouble.  In Saltcoats his youngest brother (I spoke to him on the phone on Saturday) answered the door and didn’t recognise the man in uniform and got a hell of a fright.

Then he was posted to the south of England for a time and thence to West Africa where he seemed to spend a lot of his time flying VIPs around.  I remember the year my father died I happened to be going on holiday to Madeira.  He said to me, “I know it well.”  I said, “I didn’t know you’d been there.”  “I haven’t, but I’ve flown over it a lot.”  He flew out of exotic locations like Casablanca.  On VE day he was in Accra. His chums said, “Give us a show, James!” and he duly did a few swoops over the aerodrome.  His last flight before he came home was from Ikeja to Accra, on September 9^th, 1945.

I wouldn’t pretend for a moment that my experience in the RAF VR was remotely as taxing as my father’s experience, but I do believe I got something of its flavour.  You get a sense of it in the film The Battle of Britain.  One of my University Air Squadron instructors flew a Spitfire in the making of that film.  If you’ve seen it, do you remember the rather feckless pilot who tries to land with his undercarriage up and is warned off by a groundsman flying a flare?  The pilots witnessing this at dispersal pass derisory remarks under their breath but lapse into silence when the pilot walks by them.  Then his intimidating Squadron Leader (played by Robert Shaw) takes him up on a training sortie and basically frightens the life out of him.  (But in the long run he doesn’t manage to save his life.)  That scene reminds me that standard procedure in the Air Squadron was that if you “cocked up” you could expect to receive a “bollocking”.  I suppose the rationale was that aeroplanes can be very unforgiving.  Take-offs, as they say, are optional, but landings are compulsory.  So the stakes are high; in the war, considerably higher.

My father never bought that argument and neither did I.  You learn by your mistakes.  Teaching by intimidation in any discipline – it’s the same in Medicine – is useless.  In order to master any art or craft, you must be relaxed.  When I took up flying again in New Zealand I couldn’t get over the fact that my instructor was full of good humour and completely laid back.  He said, “You can fly!”  He didn’t berate; he encouraged.  Over the years I flew the length and breadth of New Zealand and when my father visited it was a privilege to have him sit beside me, to take off and say to him, “You have control.”  He flew 1700 hours during the war so I shouldn’t have been surprised to find myself saying, “You can fly!”  He said, “It’s like riding a bike.”

Actually I’m not sure that it is.  If you don’t fly, you lose “currency”.  And that, too, is true of any art or craft.  Even riding a bike isn’t like riding a bike.

 

 

I find myself this week reiterating a favourite remark of my father’s which he frequently passed on perusing the morning newspaper:

We are not well led.

There is something very puzzling to me about the events that took place in Salisbury on March 4^th, and the rapid response of Her Majesty’s Government.  Bear in mind that the environs of a park bench in the centre of the town are a crime scene, at which the attempted murder of two individuals has taken place.  We should expect due process.  First, the scene needs to be sealed, to allow the police to gather and collate evidence.  It may be that the trail of evidence leads the police to a suspect, or suspects, in the crime.  If the evidence is believed sufficient that there is a case to be answered, it is laid before the Crown Prosecution, and the suspect, or suspects, are charged and placed under arrest.  There is however, at this point, a presumption of innocence until proven otherwise.  The case is tried in a court of law.  It is vital that any evidence gathered be presented and made available to the defence, otherwise, as we have seen recently in various cases of alleged rape, the case will collapse.

Due process takes time.  The Law is generally in no hurry.  It might be said that justice delayed is justice denied, to which the lawyers might reasonably reply, “Do you want it done now, or do you want it done right?”

I think that was essentially the point Mr Corbyn was making last week when he was severely criticised for being unpatriotic.  His critics even used the “A” word.  He was appeasing Mr Putin.  The Foreign Secretary went out of his way to liken Russia’s imminent hosting of the World Cup with Nazi Germany’s hosting of the Olympic Games in 1936, an attempt by a corrupt regime to gain legitimacy and prestige on the world stage.  Considering the terrible price Russia paid standing up to the Nazis, this was certainly a provocative remark.  I think it was Baroness Shami Chakrabarti who said that invoking the spectre of the Fuhrer seldom enhances any current political debate.  There have been calls to boycott the World Cup.  Following the arrest of 90 English football fans in Amsterdam on Thursday for alleged loutish behaviour, I can’t help wondering whether Mr Putin might be perfectly happy not to host that particular fan base.  Football has a problem over which the FA and FIFA are in denial.  Frankly I’m glad Scotland’s not going to Russia.  Even so, I’m not a fan of sporting boycotts.  I suppose the English-speaking world might have boycotted the Berlin Olympics, but wasn’t Jesse Owens’ performance on track and field a better response to any claims of racial superiority?  And we would not have witnessed one of the most perfect races ever run, that of Jack Lovelock in the 1500 metres.  Harold Abrahams, who was Jewish, provided the commentary on that race for the BBC.

According to to-day’s Telegraph, President Trump is poised to expel more than twenty Russian diplomats from the United States.  This show of solidarity may encourage Mrs May, but the Telegraph also reports that Trump’s appointment of “uncompromising” Mr Bolton and “tub-thumping” Mr Pompeo, described as being “stuck in a neo-conservative time warp”, stokes fears of a UK-US split.  A neo-conservative time warp was brought into sharp relief at the weekend with the mass rallies in the US (and elsewhere) of young people demonstrating against the US gun laws, or lack of them.  I was pondering the US’ slavish devotion to the Second Amendment on Sunday morning, appropriately enough, seated in the rear pew of Dunblane Cathedral.  The NRA’s latest suggestion to counter the wave of mass shootings in US schools and colleges is to arm the teachers.  When you think of the great strain our teachers are already under, that must be one of the most fantastically stupid suggestions ever to be put forward, even in the USA.  Put a teacher into a disadvantaged school in a disadvantaged area full of disadvantage children and he will struggle to maintain discipline.  Now overburden him with reams of bureaucracy, useless initiatives, “strategic plans” with endless tick boxes and impossible goals.  Stress him to the max.  And now, give him a gun.

We are not well led.

Did you see the terrific spat between the two ladies reviewing the papers on the Andrew Marr Show on Sunday morning?  One was making the point that Cambridge Analytica might have influenced the Brexit referendum result and the other was saying there was no evidence to this effect.  You might suppose that a debate involves listening to an argument and then, unless the argument persuades you, replying with a counterargument.  No no no.  What you do is talk over the argument so that the argument cannot be heard.  I switched off and instead tuned into Paddy O’Connell’s Broadcasting House on Radio 4.  Mr O’Connell is unfailingly polite.  The BBC had received complaints that Welsh schoolchildren had been interviewed about their views on Brexit (they all turned out to be Remainers) and the substance of the complaint was that their views were “childish” and not challenged.  In response, Broadcasting House “aimed low” and interviewed toddlers about Brexit.  Hilarious.

Next week I think I’ll tune back into Broadcasting House.

Seat 31A in Premium Economy Class, Singapore Airlines’ Airbus A380 – I can recommend it.  Enter the aircraft, turn right and it’s the first window seat on the port side.  There’s plenty of leg room, and the position behind a bulwark even affords a little extra.  I booked the seat both ways on my New Zealand trip.  Premium Economy is a nice compromise between the purgatory of riding down the back, and the exorbitant opulence of the suites, accessed by turning left as you enter from the air bridge.  It’s not just the expense of the suites that puts me off.  I’d feel a bit of a prat, like being borne along in a sedan chair, or driving a red Ferrari.  Incidentally, have you noticed the resemblance between a diagram of the seating on an aircraft, and the stowage arrangements for human cargo on a slave vessel?  Such are the rigours of latter-day travel.  I used to travel business class when I was on business and wanted to turn up fresh usually for a college meeting.  I’ve been bumped up to First Class a surprising number of times, thanks to rendering medical treatment to passengers taken ill.  When I left New Zealand after 13 years I came back to the UK First Class because I wanted to offload the millions of air points I’d accrued.

Back to 31A – I chose a window seat because I never tire of the view from aloft, and I specifically wanted to savour the experience of landfall on NZ’s North Island’s west coast.  As it turned out, I gave my seat up so that an elderly American couple separated by the aisle could sit together.  Sometimes you do something simply because you are importuned.  I was rewarded by the company of a charming young woman from Kashmir, en route to Christchurch to study for a Masters in something like “Big Data”.

On the way home a month later I resumed my seat without even checking the number.  A woman across the aisle did what I’d done on the way out and swapped seats to allow a young couple with their baby to sit together.  She sat down on 31B and whispered to me, “I think I’ve done us both a favour.”  Oddly enough, crying babies do not disturb me, even although I’m very noise sensitive.  I think the reason is that when I did Obstetrics, and Paediatrics, and Neonatology, as a junior doctor, my worst nightmare was to be faced with a non-breathing, floppy, grey, flat neonate, and the most joyous sound in the world is the lusty cry of a pink baby.  I once took an Aerolineas Argentinas flight back to Auckland from Buenos Aires seated beside a screaming infant who was inconsolable for virtually the whole trip.  His mother was profoundly apologetic but I reassured her it was fine.  All I needed to do was put on my headphones and listen to another tango from the fiddle and the squeezebox.  The only thing that seriously discomfited me on that trip was the realisation as we crossed the International Date Line that I’d miscalculated my dates and that on arrival in Auckland at 7 am I would need to head straight for the hospital and go to work.

Talking of noise intolerance, I went with a friend to see The Post in Auckland at The Lido on Dominion Road – Meryl Streep and Tom Hanks, rather good, a “speaking truth to power” movie which no doubt resonates in the current US political climate.  My companion sat on my left but after about twenty minutes she moved to my right in order to distance herself from the incessant blethering of a couple on her left.  I gave it another ten minutes and then leaned across and said, politely but firmly, “Excuse me, would you mind not speaking during the movie?  Thank you very much.”  Unlike a gentleman who recently made a similar remonstration in an English pub, I did not in consequence suffer life-changing injuries from a machete.  My friend said, “James, I’ve seen a new side to you.”  Well, I don’t know about that.

But to return to seat 31A, while looking down upon the endless vista of Australia’s hot red centre, I was rewarded with a remarkable view of Uluru, and the Olgas.  What an extraordinary apparition in the middle of nowhere is Ayers Rock, and no wonder the aboriginal people regard it as a holy place.  I scaled the rock several times (and once ran up in 44 degrees – mad dingoes and Scotsmen…) in the days when it was not considered sacrilegious so to do.  The view of the Olgas from atop is rewarding.  In some ways the Olgas, and the Valley of the Winds, are even more atmospheric than Uluru.  Standing at the base of the Olgas and looking upwards it isn’t hard to imagine one is standing on Mars looking up at Olympus Mons.  I’ve twice driven to Uluru by car from Alice Springs, a 450 kilometre road through the outback.  I found myself driving at 100 mph – no speed limit in the Northern Territory, at least then – and thanks to the unchanging vista having little sense of speed.  The second time I made the journey my fan belt broke about 30 kilometres from the settlement at Uluru and the engine began to overheat.  I pulled over and let the engine cool down, then started up and drove a few kilometres, pulled over, restarted, drove a bit, pulled over… and thus limped to my destination.  I got nervous as dusk fell as I was not insured to drive at night because of the danger of hitting an animal.  During this entire incident I never saw another car nor another human soul. If it had happened 100 kilometres to the north-east I might have been in a spot of bother.  On the return trip – problem fixed – and about 30 kilometres outside Alice, we encountered a vehicle full of aboriginal people that had left the road and overturned.  Nobody was injured.  I gave a bushman in a grass skirt a ride into Alice to get help.  My companion, a young lady from New York, was a bit nervous about that.  The bushman reminded me so much of people I’d worked with in the highlands of PNG.  In Alice, the white man walks along the asphalt roads but the aboriginal man walks along the bed of the Todd River, dry.  In New Zealand, I believe the Maori and the Pakeha knock along pretty well together and this is entirely due to the effort that went into, and continues to go into, the 1840 Treaty of Waitangi.  But in Australia, the white man is on tarmac and the black fella is down on the riverbed.

There is a rock face, a ridge about 600 feet high, above Alice Springs and I once scaled it of an early evening and sat down to admire the view.  I became aware that I had been joined by a kangaroo.  It had never even crossed my mind to consider whether venturing out into the bush at dusk was foolhardy.  At any rate the kangaroo was perfectly sociable.  We didn’t box.

Back in 31A, it was poignant to farewell the beautiful and deserted beaches on Australia’s north shore and to head out across the ocean to south East Asia.   It was about here that I once treated a man in Business Class on the same Auckland – Singapore trip, who had lapsed into unconsciousness.  I remember I was watching Tom Cruise and Demi Moore in A Few Good Men – good movie – when the call came – “Is there a doctor on board?”  Opportunistic medicine is incredibly rewarding.  You are privileged to enter somebody’s life in a unique way. The clue to this patient’s condition lay in his hand luggage.  He carried a generous supply of insulin.  I rummaged in the Qantas medical bag – rather well supplied – and was able to measure this gentleman’s blood sugar.  When I pricked his finger he said, “Whas mah nah?”  He had a serum glucose of 1 mm/L – low.  I decided he had enough of an airway to tolerate oral fluids and ordered an orange juice.  The cabin crew was gone for a very long time and returned with a cocktail, exquisitely prepared, with a twist of orange skewered on the edge of the cocktail glass.

The gentleman recovered rapidly.  Meantime the Captain asked me, “Should we land in Darwin?”  Well, I’ve never been to Darwin.  It was tempting.  But I assured him we could go on to Singapore.  No wonder I got bumped up!  I ordered the patient some dinner.  He said, “Have I been making an ass of myself?”  I spent the rest of the flight – this all happened pre 9/11 – on the flight deck.  There is no more beautiful view than that from the flight deck, at dusk, coming in to land at Changi.

This time round at Changi I had a few hours to kill but fortunately found a very comfortable lounge, as I had also done at Auckland, and whiled away the time.  Still, it’s daunting to reboard and be faced with the announcement, “The flight time is 13 hours and 45 minutes.”  I ignored offers of food and drink and fitfully went to sleep.  Later, I think over India, I watched the movie Three Billboards outside Ebbing Missouri.  Very blue collar.  Very coarse.  Yet very good.  I remember Woody Harrelson’s letter to his stupid subordinate, and the extraordinary and rather touching conversation between the tough protagonist lady and her midget “date”.

Somewhere between the Aral Sea and the Caspian the aircraft seems to go into suspended animation.  Then as we made the interminable journey across the Russian Federation I thought of the latest diplomatic spat that has sprung up, over an incident in Salisbury, between Britain and Russia.  We passed to the south of Moscow and then crossed to Poland and thence to Germany and France, these lands upon which have taken place the greatest conflicts ever known to mankind.  As day began to break we flew parallel with the beaches of Dunkirk.

Landing at dawn, I had five hours to kill in Heathrow’s Terminal 5.  I have to say the Lounge was a disappointment.  It didn’t even have a loo and charged £20 for a shower.  I ask you.  I’m back in the land of carping and bickering and already I’m carping and bickering.  I got a Financial Times and got up to speed with all the parochial preoccupations, then did the crossword.  Eventually I got on a BA flight to Glasgow.

I always watch the safety videos.  Sooner or later, I’m bound to get on to a flight where something goes wrong.  The current BA safety video is quite attention-grabbing because it features various high profile British actors and there is an element of spoof.  It’s typically British, full of irony.  I imagine the Chinese will find it completely incomprehensible.  Gordon Ramsay told me that if I had to leave the aircraft in a hurry I must leave everything, “And I mean, everything!”  I had a coffee (bizarre cup requiring a tutorial on how to imbibe) and a delicious M & S sandwich, all paid for by the beep of a credit card – money is so passé.  After the tranquillity of the A380 it was a bumpy ride and we landed in Glasgow in a cross wind.  Tricky things to finesse, these crosswinds.  Yet it was safe, for which much thanks.  Now I have to grapple with Glasgow humour, and it is then that I know I am home.

What will this journey be like in another decade?  Perhaps on the fourth runway at Heathrow the captain will say, “Our flight time to Auckland today is 25 minutes.  Our cabin crew will be serving lunch.  Transient loss of consciousness in the ionosphere is perfectly normal… We apologise for a fifteen second delay…”  I think I’d rather take the flying boat with Imperial Airways, flying at 6,000 feet and dropping into the ancient capitals of the world to dine and sleep.

Now I close my eyes, and easily conjure an image of Ninety Mile Beach.  So beautiful.  When I was there, I wanted to walk down Sauchiehall Street in the sleet.  Now I am here, I want to slosh down Te Paki stream in the heat.  Such is the perversity of human nature.

 

 

One day last week I attended the 8 am medical handover in the Emergency Department of Middlemore Hospital, South Auckland, where I worked from 1986 until 1997.  I was privileged to be the department’s Clinical Head from 1994 until 3 years later when I moved on to the University of Auckland, and Auckland Hospital.  I’m flying back to the UK on Tuesday but before I leave I’m going back into the MMH ED 8 am handover.  I’m very proud of what the department has achieved.

The story of the birth of the specialty of emergency medicine in Australasia is extraordinary.  When I first came here in 1986 Middlemore’s “Accident & Emergency” (sic) was indistinguishable from any large urban “A & E” in the UK.  The medical staffing largely comprised junior doctors, mostly two years out of Medical School, with very little supervision.  Doctors sought advice on patient management from in-patient specialties, and from experienced nurses.  Adverse events and poor outcomes were commonplace.  Most Australasian “A & Es” had a medical director who for one reason or another had drifted into the role from another specialty.  In the mid-1980s a group of such directors who were well aware of the parlous state of the front door of the hospital got together to see if improvements could be made.  Their centre of gravity initially was across the Tasman in Melbourne Victoria, but allegiances were soon made with colleagues in the other Australian centres, and in New Zealand.  They formed a society, but they realised early on that if they were going to make any real difference they would have to aim high.  They formed the Australasian College for Emergency Medicine in 1984.

The birth of the college was not easy.  In particular, the struggle to gain specialist recognition was protracted, and the acknowledgement from the ancient Royal Colleges that emergency medicine was a specialty in its own right was hard won.

The founding fathers of the college were tough, and astute.  The first college president was a Scotsman, the second from Melbourne.  Both had a surgical background, both were charismatic, and both were completely devoted to the idea that expertise in emergency medicine should reside with emergency medicine specialists.  The college needed to set up a specialist training programme, an academic base, and a research programme.  It became evident that a lot of medical students and junior doctors were interested in training in this new specialty, and it says a lot for them that they were prepared to invest in a career whose future was not assured.

I could write at length about the political struggles involved in acquiring increased resources for emergency medicine, and the gradual evolution and expansion of the discipline.  But perhaps some statistics relating to Middlemore Emergency Department will suffice:

160 beds with oxygen and suction

Six resuscitation rooms

A 22 bed 24 hour short stay unit

105,000 patients per annum (including 23% paediatrics)

24 consultants

18 registrars

14 junior doctors

6 further senior doctors or college fellows

6.5 clinical nurse specialists

12 charge nurses

120 staff nurses.

Nothing like this, so far as I am aware, exists in the UK.  Middlemore Hospital is “front-loaded”.  The emergency department is the hub of the hospital’s acute care.  Compared with the model of care of 1986, when I first arrived here, this is an entirely different way of working.

Of course it would be wrong to suggest that everything is rosy in New Zealand emergency medicine.  Just like any hospital in the UK, the hospital is bursting at the seams.  There is a huge pressure on the system, the public has an apparently limitless appetite for the service on offer, there is access block, hospital discharge delays, and a crisis in social care.  In many ways, New Zealand emergency medicine is a victim of its own success.  The more you can do, the more people ask of you.  The safer your department is, the greater will be the pressure on you to hold on to patents who have nowhere to go.  Sometimes Middlemore ED can resemble an intensive care unit.

Still, sitting listening quietly at the back of the handover, I was tremendously impressed by the work the doctors and nurses were doing, the comprehensive work-up, the appropriate investigations and interventions, the succinctness of the presentations.

Every generation has its challenges.  We were trying to establish a specialty and demonstrate its credentials, while simultaneously seeing large numbers of patients and managing risk.  The challenge now it seems to me is to study the work-load and try to work out precisely what emergency medicine’s role is and how the specialty can deliver, without its practitioners burning out within a decade.  You need to identify the challenges of the day and then devote yourself to rising to them and taking the specialty to a new level.  That is actually what is inspirational about practising emergency medicine.

But I think it’s a young person’s game.  And you can only play it for so long.  Then you must find a way to diversify.  In terms of the current structures of the medical hierarchy, I was the first Clinical Head of MMH ED.  My dear friend and successor still works there but relinquished the directorship to another ex-colleague who in turn has handed the role on so that she can act as the Chief Medical Director of Middlemore Hospital.  A generation ago, that an emergency physician (a “casualty doc” they might have said) should fulfil this role would have been unthinkable.

So, four Clinical Heads.  We’re all going to be there tomorrow.  I’m hoping to get a selfie.

 

 

 

I said to my hostess in Auckland, “I’m going to vanish into the far north for a few days and write a story for the BBC short story competition.”  She nodded understandingly.  “You need to aloof yourself.”

“Aloof myself!  Aloof qua verb!  Can I use that?”  She said yes.  I don’t think she meant I was behaving like Mr Darcy, before he was humbled by Miss Elizabeth Bennet; merely that writing is, after all, a solitary pursuit.  So off I went.

Mind, it comes at a cost.  I spent a night in a town whose main street might have been a Hollywood set for a Western.  Once I’d written a thousand words I took myself off to the movies.  They were showing The Shape of Water.  Strange, but good.  In the USA of the Cold War a bizarre creature, half fish, half man, is captured in the Amazon and brought to a government installation for nefarious scientific investigation, and general abuse by a sadistic gaoler armed with a baton that delivers electric shocks.  The creature – “the asset” – is befriended by one of the institution’s cleaning ladies who happens to be mute.  Well, it’s not the first time a gal has fallen for a guy in a wet suit.  When she realises that her fish-man is due for the autopsy table she resolves to break him out.  While he is on the run (can a fish run?), he slips into a movie theatre and, sitting in the stalls entirely alone, tries to make sense of the film on the screen.

The really strange thing was, I was the only person in the movie theatre.  I sat alone in the deserted stalls looking at a fish-man sitting alone in the deserted stalls…  Like being in a hall of mirrors really.  It was at this point that I resolved that I should no longer be aloof.  Back in Auckland on Sunday morning I went to St Luke’s Remuera.  As part of Lent, the minister preached on the extraordinary episode, which appears in all four gospels, of Jesus getting mad, making a whip, overturning the stalls of the racketeers in the temple, driving them all out with their hens and chickens, and generally wrecking the joint.  He must have known that wasn’t going to go down well.  Maybe he wanted to make quite sure he was going to fulfil his destiny.

The Auckland to which I have returned feels to me a little bit like the temple in Jerusalem.  I suppose it is inevitable; it has just become a little more like the rest of the western world.  It has become expensive.  The house prices are absurd.  Dining out can be a costly business if you are not careful.  Do I really want to pay $36 for a piece of snapper?  What is happening is that the gap between rich and poor is widening, and the wider the gap is, the less inclined people from both ends of the spectrum are inclined to smile, and the more miserable everybody becomes.  This disparity, just as in the UK, is reflected by the immense strain put upon the Health Service, of which I mean to write more next week.  I venture to say that the Health Service in New Zealand, however, is far more robust than the NHS.

But I still think New Zealand is a friendly, open, welcoming, and amazing place.  I think if I were to make a scene in the Auckland Sky Tower after the fashion of Our Lord I might be arrested but I wouldn’t be summarily bumped off.  The long-suffering police would probably decide I had a mental health issue and take me to hospital where my ex-colleagues would aver they always knew I’d lost the plot, and section me.  Instead, I’ve returned to the glorious far north where New Zealand still offers the sense of being a nation at the frontier.  Here, the Maori are not much impressed by glitz and consumerism and big price tags.  They recognise them as false gods.  They would take the side of the fish-man against his upwardly mobile oppressor who fulfils an ambition and buys a brand new Cadillac.

Meanwhile the annual BBC short story prize is up for grabs.  Excuse me while I aloof myself.

 

 

Each time I come to New Zealand I make a pilgrimage to the top of North Island, to Cape Reinga, the place from whence the Maori spirits depart.  When I first came here, the last 20 kilometres of road after Waitiki Landing were unsealed, and the roller-coaster dirt track heavily rutted; you completed the journey leaving a cloud of dust in your wake.  Now the tour buses whisk the Japanese tourists up the super highway and deposit them in the overflow carpark by the toilet facilities a short walk from the lighthouse which looks out over the sun-kissed surf, where the waters of the Tasman and the Pacific meet.  I come here, but more important to me is the journey to Te Paki stream and Ninety Mile Beach.  You hang a left at Te Paki Station about four kilometres north of Waitiki Landing, and take the dirt track across pleasant pasture land down to the enormous sand dunes.

When I first discovered this place more than 30 years ago, it was deserted.  Nowadays it has become a tourist trap because of the craze of sand-boarding down the dunes.  I can’t begrudge the local economy this bonanza, nor that the tour buses should head down the stream to drive up to the Cape via the beach.  I can still kick off my shoes and slosh down the stream to the ocean.  Once past the dunes, by and large, I have the place to myself.  Like climbing a mountain, this is a pilgrimage of transfiguration.  Your cares, whatever they may be, fall away, and you see the world through fresh eyes.  Then, just as you would have to come back down a mountain, you must duly make your way back up Te Paki stream and head inland.

This time, as I walked towards the ocean, unaccountably, I found myself thinking about happiness.  L’s daughter L said, “I’m so happy”, and, an ocean and a continent away, L’s exact contemporary M, daughter of G and J, said, “I’m so happy.”  G being an expat Scot cautioned her, “Don’t say that!”  It’s a fey, Celtic superstition – don’t tempt fate.  Dick Hannay’s young wife Mary felt as much in The Three Hostages when she looked at their most pleasant haven, Fosse Manor in Oxfordshire, and shivered.  Aidos.

But should we be fearful of happiness?  The Pursuit of Happiness is writ into the US Constitution, as an inalienable right, along with Life and Liberty.  Not only that, but that it should be so is held to be a truth self-evident.  When I was at school my mother would often say to me, “I don’t care what you do, so long as you are happy.”  I didn’t pay the slightest attention.  I now realise that she meant this with all her heart and soul.  She was completely indifferent to academic achievement, status, wealth, power, “getting ahead”.

Yet she was a lone voice.  I can’t think the school was much interested in my personal happiness.  It was more concerned that I turn up on time, homework done, pay attention, and conform.  I suppose the school peddled a sort of esprit de corps.  I went to a state school in the west end of Glasgow.  I realise now its structure was modelled on that of an English public school, albeit with a tartan gloss, whose raison d’etre, the nurture of Empire, had become obsolete.  There was a House system.  There were four houses – Bruce, Wallace, Scott, and Burns.  I was in Burns House.  I was glad to be on the side of the pen rather than the sword.  There were prizes for academic and for sporting achievement.  You were applauded for being First – at History or English or Maths or the 100 metres or the high jump.  Captain of the First Fifteen.  Well done.  There were no prizes for being happy.

It’s easy to state that it is more important to be happy than to be wealthy, and yet the attack on happiness can seem quite convincing.  Some profound philosophers have spoken out against the pursuit of happiness and considered that happiness is a by-product of something else.  You devote yourself to some kind of higher calling and perhaps along the way you will discover that you are happy.  You will be surprised by happiness much as C. S. Lewis was Surprised by Joy.  But if you make happiness your goal, it will just evaporate.  Somebody once compared happiness to a body of water held by a riddle being pulled through the sea.  So long as the riddle is submerged and moving it holds the water; but stop, and bring the riddle to the surface, and you find that it is empty.

I have a notion that this is nothing more than a piece of propaganda, manufactured by people who would wish you to take on board the values of their “House System”, whatever they might be.  As the last line of the Desiderata states, “Strive to be happy.”  This raises the question of what happiness is.  Perhaps it is easier to say what it is not.  It is not pleasure, nor gratification, nor ecstasy, though it may contain all of these at one time or another.  It isn’t even the absence of pain or anxiety.  Rather it seems to me to be a sense that the decisions we take in our lives, our “pursuits”, our “striving”, contain within them a sense that what we are about is fundamentally right for ourselves, that what we choose to do is not an act of violence against our own nature, but rather a profoundly natural fulfilment of that which we are called upon to do.  Whatsoever things are right, and just, and true, and of good report…  If you are deeply involved in your own calling, then you may by some mysterious grace know the deep peace of happiness.

At Ninety Mile Beach, I resolved to continue to read and write.  At the other end of this vast shoreline, at Waipapakauri and at Lake Gnatu, this stayed with me, the devotion to Letters.  It’s what I do.

Go placidly amid the noise and haste.