Author: jamescalumcampbell

The barista in Muffin Break named Betty brought me my flat white and, glancing at the battered tome that had fallen apart in three pieces, asked, “What are you reading?”

“Halliday, Resnick, and Walker.  Fundamentals of Physics.  I want to understand Maxwell’s equations.”

She pursed her lips, shook her head, and said, “Don’t.  It’s Mulholland Drive.”

“Excuse me?”

“Mulholland Drive.  The movie.  Watch it.  You’ll see.”

Actually, that never happened.  None of that is true.  I made it up.  It’s fiction.  It might even have been a scene out of Mulholland Drive.  But I think I’ll start peddling the expression as a descriptor for any Grand Enterprise that is futile in a particular and specific way.  It occurred to me when I heard some people on Radio 4 discussing David Lynch’s masterpiece of Hollywood neo-Noir.  Somebody averred they were determined to “get to the bottom of” Mulholland Drive.  I thought, “Oh no, don’t do that!”  That way lies madness.  The thing about Mulholland Drive is that it is a nightmare.  The only thing to do when you find yourself in a nightmare is to wake up.  Naomi Watts plays an aspiring young actress arriving at LAX, full of hope, fresh from Canada.  En route, she falls in with a kindly elderly couple, Irene and her companion.  They say fond farewells at the airport.  Cut to the elderly couple sitting together in the back of a car, grinning grotesquely.  They are in fact, monsters.  That is merely one of many, disjointed vignettes.

It wouldn’t surprise me if you could take an undergraduate course in an American college, UCLA perhaps, in “Mulholland Drive studies”.  Some colleges still offer credits for JFK assassination conspiracy studies.  I think that might turn out to be a trip down Mulholland Drive as well.  The point is that not only will you be wasting your time; you will also be damaging your mental health.  Professors of mathematics are frequently plagued by correspondence from amateur mathematicians who purport they have a proof of Fermat’s last theorem that can be written on the back of a postcard.  The prof, if of a kindly disposition, will send back a brief note of discouragement.  “Let it go.  It’s Mulholland Drive.”

I’ve stopped over in LA many times on my way to New Zealand.  So for me the City of Angels has a transient, transitory quality.  If you fly into LA at night from the east, the illuminated, neon reticulum seems eternal.  All these highways yet, on terra firma and in broad daylight, nothing seems to lead anywhere.  Hollywood itself is an archipelago of ramparted estates as secluded as the ancestral piles of the Scottish aristocracy.  You ascend into the intense privacy of Beverly Hills and feel like an interloper.  I recall sitting on the lowest stanchion of the iconic Hollywood sign (I don’t suppose you could do that now) and sharing the same view as the femme fatale played by Laura Harring who calls herself Rita (or is she Camilla Rhodes?)  The asphalt sprawled to the horizon.  I went back down the sinuous, tortuous mountain road – it might have been Mulholland Drive – back into the smog.  Where is the town centre?  It doesn’t exist.  Rodeo Drive feels suburban; Sunset Boulevard doesn’t go anywhere until you pass Pacific Palisades and reach the ocean.

Every time I’ve stopped in LA something bizarre has happened.  I checked into a hotel in Anaheim to find my room was gone and I was put up on a camp bed in somebody’s office.  Disneyland was across the street so it seemed perverse to be so close and not take a look.  Bad idea.  What does an adult male, travelling alone, want to do in Disneyland?  Take a ride in a teacup?  Buy an ice cream and get change in Disney money?  It was like another scene from the David Lynch film.  At least, back at LAX, the ground staff were affable, despite the crush of heaving humanity going through Security.  Jet lagged and on automatic pilot, I had my belt and shoes off ahead of time.

“Be proactive like this gem’mun!  Take his lead!”

But what of James Clerk Maxwell?  Should I let him go?  I can imagine a mathematician shaking his head at me.  “Somebody at your time of life should let differential equations go and concentrate on the Humanities.”  Actually, in my opinion, professors of mathematics rather tend to overplay the Mulholland Drive card.  I think they think that people mathematically gifted have their brains wired in a special way, and that the rest of us needn’t bother applying.  There was a professor at Glasgow who throughout his entire tenure only took on about two graduate students because he thought everybody else was wasting their time.  At the time, university mathematical texts looked very arcane and abstruse because they were written in a symbolic language that had to be learned before the reader might make any headway.  The idea that a gifted teacher would gauge the level of understanding of his student and then pull the student up from that starting point (Latin e ducere) had not really gained any traction.  I remember horror stories from contemporaries of mine who became freshmen in the science faculty.  The engineering lecturer said, “Take a look at the guy on your left; take a look at the guy on your right.”  (Guy, note, not gal.  A woman in engineering?  The hard hat doesn’t suit you, luv.  If you want to come on site, be a calendar girl on the wall of the Nissen hut.)  “By Christmas, one of you won’t be here!”  The Physics lecturer held up a school text popular in its day – Physics is Fun.  “Let’s get one thing straight.  Physics isn’t fun!”

Dreadful.

I liaised with a femme fatale for a time around the turn of the millennium.  She looked a bit like Laura Harring.  She averted her gaze, looked down at her coffee, and said in a low voice, “Don’t come after me, James.  I’m bad news.”  Naturally, I didn’t pay the slightest attention.  I don’t feel myself now in similarly dangerous territory.  After all, as J. R. Pierce wrote, “To anyone who is motivated by anything beyond the most narrowly practical, it is worthwhile to understand Maxwell’s equations simply for the good of his soul.”

Two equations down, two to go.  Then what?  Quantum mechanics?  Don’t go there. It’s Mulholland Drive.

I don’t think Nigel Farage was much impressed with Mrs May’s showing in Florence.  After all, he just wants out.  No doubt many Brexiteers entertain nostalgic reminiscences of Mrs Thatcher lecturing the EU in rather hectoring tones:  “No, no, no!”  I thought of that this week while I chanced to hear an ancient recording of  Gertrude Lawrence singing The Saga of Jenny, with music by Kurt Weill and phenomenally inventive and funny lyrics by Ira Gershwin, an absurd tale told by a woman who couldn’t make up her mind, outlining the perils of doing the opposite and reaching a decision.

In twenty seven languages she couldn’t say no! 

Apposite.  Yet surely it’s all a side show compared with events on the other side of the planet.  In the rapidly escalating war of words between the President and the Supreme Leader, things have got personal.  Mr Trump has called “Rocket Man” a “maniac”, and Mr Kim has called Mr Trump a “lunatic” and a “dotard”.

“Dotard” was new to me.  I checked it out in Chambers.

Dot’ant (Shak.) a dotard; dot’ard one who dotes: one showing the weakness of old age, or excessive fondness. – adj, dot’ed (Spens.) stupid.

I suppose excessive fondness, otherwise known as love, is a kind of madness.  Yet, in this context, love is definitely not in the air.  Mr Kim, the younger man, seems to be mocking the President for his advanced years, so I suppose he is implying that the President is dementing.  As for the President, he just thinks Mr Kim is crazy.

Accusations of madness are extremely common in public life.  Madness has an extensive lay lexicon.  Nuts, round the bend, off his rocker, not the full shilling, one sandwich short of a picnic…  I used to be rather fond of some expressions I picked up in New Zealand, “out to lunch”, “special”, and “mad as a snake”.  I can’t think what it is about a snake that makes it mad, but there you are.  It’s only relatively recently that it has occurred to me that the random (random – another word) accusatory diagnosis of a mental health issue – often delivered remotely – might be objectionable.  Of course when one person accuses another (usually behind his back) of being mentally deranged, usually there is no serious intent to make a psychiatric diagnosis as it might be formally defined in ICD 10 or any equivalent authoritative reference manual.  An exception to this is that during the 2016 US Presidential election, and subsequently, a number of Mr Trump’s critics indulged in a spot of armchair psychiatry and gave him a psychiatric diagnosis, such as Narcissistic Personality Disorder, sans benefit of a medical consultation which would involve undertaking a psychiatric history and a mental state examination.  Spot diagnoses made by people watching the telly have landed even some eminent medical practitioners in very hot water.

Back in New Zealand, I remember seeing in the emergency department a patient, known to the psychiatric services, who presented with an ongoing mental health problem.  The template of the hospital record had a space for “presenting complaint”, into which I wrote “Psych patient”.  I can’t remember the details of the presentation, but it must have resulted in a referral to a consultant psychiatrist, because the consultant briskly got back in touch to criticise me for my use of the expression “Psych patient” which he considered to be demeaning, crass, and mindless.  Of course at the time I bridled; I might even have called the psychiatrist something like – to borrow an expression of President Trump – “a nut job”.  But – and take note of this – I never ever used the expression “Psych patient” again.  That is because, once I was able to get over the injury to my amour propre, I realised that the consultant psychiatrist was right.

What do we mean when we say of someone, “Oh, he’s off his head”?  Undoubtedly it’s a belittling statement.  Its intention is to discredit the person, to trash his reputation and standing, utterly.  His point of view, his deliberations, and his actions are fatally flawed because they lack any rationality; rather, his world view and his modus operandi are founded on the recognised elements of psychosis – divorce from reality, hallucinatory preoccupation, and paranoia.  It’s a damning indictment.  And that is why it is so often invoked.  It’s a shorthand, quick fire method of demolition.  Somebody says to you, what do you think of so-and-so?  You point a forefinger at your temple, rotate it in a gentle twirling motion, shrug, turn down the corners of your mouth, and raise your eyes to the ceiling.   ‘Nuff said.

This is the way that totalitarian regimes deal with dissident members of their population.  They shut them up in lunatic asylums, because their view of the world is so aberrant that clearly they are, well, daft as a brush.  It takes a great deal of self-belief, determination, and sheer naked courage for a person thus persecuted to hold on to his own sense of reality, and to realise that after all he might be the only sane person left in a country that has itself become a vast lunatic asylum.

To taunt anybody with an accusation of being psychotic is a terrible affront to people who have to endure such an illness.  That is why the trading of insults between Trump and Kim is so dispiriting.  They might be kids in the school playground calling one another “spastic”.  Remember how things used to blow up in the school playground.  The current spat over the 38^th parallel is all the more dangerous because it has become puerile.  Since Hiroshima, writers have conjured various nightmarish scenarios of nuclear Armageddon.  They are familiar to most of us; in Dr Strangelove a rogue general launches an attack; in Failsafe a computer glitch cannot be reversed; in Thunderball a malignant criminal organization hijacks two nuclear warheads and holds the world to ransom.  I can’t think of a work of fiction that mirrors the current crisis.  Two heads of state who are both widely considered to be mad are threatening one another with nuclear attack.  It kind of puts the Brexit negotiations into the shade.

Two or three times a year in the busiest Emergency Department in Australasia, of which I was privileged to be the Clinical Head, we would have an influx of new doctors-in-training.  We would hold an induction and orientation, to spell out “the way we do things round here.”  The amount of information to be disseminated was potentially vast and covered matters clinical, ethical, and administrative, issues relating to Health and Safety and Risk Management, as well as more mundane house-keeping notices pertaining to rostering, meal breaks, and the minutiae of day-to-day life in a big department in a big, and crazily busy hospital.   Over the years I came to realise that too much information would not be absorbed and was counterproductive, that most of it could be put into a reference manual, and that the most important thing to do was to create a template of what the specialty of Emergency Medicine was, a model and an outline which could be enhanced and embellished in due course, but which would function as a mainstay which would keep doctors and nurses and patients safe.  I created and developed The Ten Golden Rules of Emergency Medicine.  Here they are:

1. Remember: Emergency Medicine bites!
2. Be on time.
3. Practise the ritual of courtesy.
4. Believe the history.
5. Expose the injured part.
6. Plan for the worst possible scenario.
7. Keep a good record.
8. If in doubt, ask.
9. If you want to panic, think “ABC”.
10. Ignore any of the above rather than have a nervous breakdown.

If you are at all familiar with medical practice you will note that the ten golden rules are in a specific order, which relates to the medical consultation.  The medical consultation is a holy and sacrosanct thing which must be cherished and protected at all costs.  An emergency physician’s shift is a series of medical consultations.  It seemed to me that the best way of orientating a doctor new to our department was to imagine the doctor coming to work and embarking on the first consultation of the day.  If you adhered to the ten golden rules, you would not be immune from trouble, but you would be less likely to fall foul of it.  My induction talk was an expansion of the rules:

1. Remember you are working in a high risk environment. It pays to be on a high state of alert for the unexpected, the perverse, and the malignant.
2. The handover between shifts is critical. Be there early.  The specialty of emergency medicine is defined by time.  Treatment of the decompensating patient is time-critical.  Be aware of where you are in “the golden hour”.  Every intervention has a “rate limiting step”.  Take that step early.
3. Treat colleagues and patients with kindness and consideration. Introduce yourself, and shake hands.  Many mishaps arise out of poor communication, which starts by getting off on the wrong foot.
4. History taking is by far the most powerful tool in the emergency physician’s armamentarium. You ask, “What happened?” and then you listen without interrupting.  You go into a trance and step into the patient’s shoes.  For a moment, you become the patient.  “I was walking along the road and it was as if a giant crept up behind me and kicked me in the back of the head.  I fell down and was sick.”  You scoff.  “Aye right.  What a drama queen.”  The patient handed you the diagnosis on a plate and you didn’t notice.  This is the phenomenon of “interference”.  Some preconception, some ingrained prejudice, has interfered with the process of history taking.
5. The patient must be undressed and in a hospital gown. Don’t practise “keyhole medicine”.  If you don’t look, you don’t see.
6. Tailor your investigations according to the information gleaned from history and examination. Rule out the sinister end of the spectrum, if you can.
7. Write it up so as to communicate your train of thought to a colleague. Think from first principles and avoid jargon.
8. If you’re not sure, ask a senior colleague. The act of presenting the case itself will help you towards the solution.
9. If your patient starts to decompensate, keep calm and think, “Airway, breathing, circulation…” The great triad of decompensation comprises respiratory embarrassment, shock, and diminished consciousness.  They are reflected in the vital signs – respiratory rate, pulse and blood pressure, temperature, and Glasgow Coma Scale.  The order of actions in cardiopulmonary resuscitation (“ABC”) is known as “the primary survey” and is the same for all emergent patients.
10. With the best will in the world, you will make a mistake. Be honest and candid, learn from it, and don’t beat yourself up.

Medical monsters, people who set out deliberately to harm their patients, are very rare.  Most medical misadventures arise from some mishap within the construct of the medical consultation.  Only this week a family member went to see his doctor and was greeted with a harassed, “You’ve got ten minutes!”  The doctor broke Golden Rule 3.  And a friend involved in a road traffic crash (who happens to be a surgeon – that in itself is a risk factor) had delayed diagnosis of two injuries additional to the main injury which had distracted the doctor.  He hadn’t been adequately undressed and Golden Rule 5 was broken.

Then a hospital not a million miles from where I live got subject to a cyber-attack and – I could hardly believe it – patients were advised to stay away.  Modern medicine has convinced itself that it cannot function without sophisticated IT systems.  The art of the beautiful medical consultation is being lost, and that is why we are in such a mess.

 

With the recent ratcheting up of tensions in the Korean Peninsula I’ve noticed a resurgence in the media of public health advice of the “Duck & Cover” variety, about what to do in the event of a nuclear attack.  I was particularly intrigued to hear that if you find yourself potentially exposed to nuclear radiation, it is a good idea to take a shower and lather yourself with plenty of shampoo, but not, note, conditioner.  Apparently while shampoo dissipates radioactive particles, conditioner binds them and facilitates their contact to human skin.

In this age of evidence-based medicine, I wonder what clinical trials established this fact.  Were the relevant papers peer-reviewed?  Have there been comparative studies comparing different products?  Could it all be “fake news”?  And what about two-in-one shampoo-conditioner combinations?  Perhaps the big toiletries and grooming companies will market products “safe to use even at ground zero”.  As they say in the best medical journals, further research is required.

There is a scene in the movie Bridge of Spies (Tom Hanks and Mark Rylance – terribly good) in which, circa 1960, some young American schoolchildren are being educated about what to do in the event of an attack.  The boys look fascinated and excited, but one girl, who is clearly imaginative and insightful, with tears pouring down her face, is the picture of abject misery and despair.  She knows all this public health advice is a load of tosh.  I remember in the early 1980s the British Medical Association produced a publication, “The Medical Effects of Nuclear War”, which painted such a black picture of the reality of a nuclear holocaust that the then government was rather displeased with the BMA and its negative attitude.  It wasn’t good enough, they said, to wring one’s hands in dismay; one had to come up with a plan.  The BMA’s central point was that in the event of an attack, the number of seriously injured patients would be so vast that no medical response could possibly make any significant overall difference to outcomes.

Sir Michael Fallon, the Defence Secretary, was on the Andrew Marr Show on Sunday morning.  Mr Marr pursued him about the alleged slow response of the British Government and the armed services to Hurricane Irma.  Sir Michael answered robustly.  But I thought, that is not the issue upon which to pursue the Minister of Defence.  The question I would wish to ask Sir Michael is this:  you say the doctrine of nuclear deterrence works for us.  (You’ve heard him say it: Trident works every day for us 24/7, protecting us from the threat of attack.)  Why therefore should it not work for Kim Jong-un?  Should we not, indeed, encourage Mr Kim to perfect his long range thermonuclear capability?  Will that not add to the general deterrent effect and will not the world be a safer place?

Meanwhile life goes on.  I listened to the Last Night of the Proms on Saturday night, first half on Radio 3 and second half on BBC 1.  Highlights of the evening for me were the E flat clarinet riff in John Adams’ Lola Montez Does the Spider Dance, and Nina Stemme’s rendition of Kurt Weill’s Surabaya Johnny.  I’m impressed by the professionalism of the BBC Symphony Orchestra; they didn’t merely run through all the traditional chestnuts, they performed them.  The principal cellist’s solo in Tom Bowling was so affecting that the prommers’ crocodile tears became real.  I knew leader Stephen Bryant would slip in an ad-lib in his hornpipe and he did; it was the James Bond theme from the original Dr No.

Then our English hosts invited the cousins to join the festivities and there were party pieces from Glasgow, Enniskillen, and Swansea.  It was good to hear Gaelic, and Welsh.  I’m intrigued by the fact that, following this, Scotland and Wales took early leave.  Maybe Land of Hope and Glory and all that was just asking too much.  Thus far, and no further.

Conductor Sakari Oramo’s speech was good.  He avoided the cliché of the panegyric to music as a uniting force for good in a troubled world.  He even told a joke.  That Scandinavian humour can seem leaden is part of the joke.  Maestro Oramo told us a couple of years ago that a Finnish introvert looks at his shoes while talking to you; but a Finnish extravert looks at your shoes.  Saturday night’s joke was something along the lines of, “I’m a conductor.”  “So, where’s your bus?”  He told it in a Birmingham accent which I thought was quite a feat.

We moved on to four anthems in quick succession.  The rendition of Elgar’s Pomp and Circumstance March No. 1 was unusually thoughtful partly owing to a very steady tempo.  Then came the setting by Parry, orchestrated by Elgar, of Blake’s mystic poem Jerusalem.  It has become a de facto English National Anthem but what can it possibly mean?  What are these dark satanic mills?  Oxbridge?  Call centres?  BAE systems?  What are my arrows of desire?

Then came the National Anthem itself, and, finally, a kind of international anthem, Robert Burns’ Auld Lang Syne.  This used to be an impromptu a cappella rendition by the prommers but has more recently been orchestrated and performed on stage.  At least the BBC Singers and the BBC Symphony Chorus sing accurately in Scots; they had already performed Finlandia from memory in Finnish so one would expect nothing less.

And that was that.  I always miss the Proms when they stop.  The ensuing Sunday evening has the atmosphere of the close to the second movement of Debussy’s Nocturnes, Fêtes.  A jolly band has just marched through town and, as you hear it receding into the distance, there is a sense of anti-climax and ennui.  As we say in Scotland, back to auld claes and purritch.

 

On Saturday I thought to ignore my birthday, this recurrence having lost its novelty value, but I was saved by the kind cards and solicitations of friends, and ended up in the Whiski Rooms on Edinburgh’s mound with an old buddy from New Zealand, a nurse and midwife on a pilgrimage and on her way to Iona.  This assignation had the ghostly, hallucinatory quality of Kurt Weill’s Alabama Song:

For if we don’t find the next whiskey bar

I tell you we must die, I tell you we must die…

It was an opportunity to grow maudlin and re-evaluate the past.  Thus we compared and contrasted our varied and respective lives.  Spontaneous or ramshackle?  Would we have done it any differently?  My friend spends a lot of her time working with the indigenous peoples of Australia’s Northern Territory.  In stark contrast, she has spent the last six weeks mixing with people in grand villas on the outskirts of Edinburgh, wondering if, in not pursuing the archetypal middle-class nice husband nice job nice home nice family nice schools she has missed out on something.

It is a forlorn pursuit, Robert Frost’s contemplation of the road not taken.  In The Unbearable Lightness of Being, Milan Kundera muses that you can never know if the decisions you take in life are the right ones because there is no opportunity to make the other choice; you only get one shot at it.  It occurred to me that many people experience a kind of Grand Fulcrum of Middle Life, un point d’appui.  You spend, indeed you are encouraged to spend, a large part of your early life planning for the future.  You conjure in your head an ideal of life – ideal vocation, ideal location (location location), spouse, lifestyle, social milieu…  You strive to make it happen.  Maybe you fall short.  It doesn’t all work out the way you’d planned.  Events, dear boy…  Yet you do your best; you do what you can.  You compromise.  You come up with a result, whatever it might be.  You evaluate it.  This is the Grand Fulcrum.  A swing of the pendulum.  Now the future, whatever it may be, appears to have narrowed down.  You cease to conjure the future because the future has become immutable.  Rather, you conjure the past.  What if?  Your memory of all that teenage angst is gone, and all you can remember is the sense of possibility.  You would trade the certainty of what you have achieved, for the mere possibility of youth.  Thus you abandon the quest for a fanciful future and gain consolation from the recollection of a past that has been expunged of its agony.  Or, as Shakespeare put it in Measure for Measure,

Thou hast not youth, nor age,

But as it were an after dinner’s sleep

Dreaming on both.

Sometimes I play a mind-game; scientists call it a “thought experiment”.  I’m given a one-way ticket on the Tardis and William Hartnell (long before he developed gender dysphoria) says testily, “All right, where do you want to be dropped off?”  Do you ever play this game?  You say to yourself, if I had it all to do again, would I do it differently?  Knowing what I know now…  So you ask to be dropped off, on a particular path, a road, a corridor, moments before you reach a bifurcation of ways, so that you may make another choice.

No thanks!  I have a sense that my first shot was my best shot, that it wouldn’t be wisdom that I took back with me, but rather a tempered appreciation of my own limitations.  Who knows, I might even whinge in a pathetic way, “How can I play for a Grand Slam when I’ve been dealt a chicane?”

Anyway, even from a practical point of view, it would be a nightmare, to be an aged man trapped in a pubescent body.  You’d be arrested before midnight.  No.  It’s not an option.  Think of yourself as a snooker player in one of these frames in which the cue ball has become constipated within a cluster of reds, and, amid the stalemate of endless safety play, the players ask the referee to rerack the balls.  But the ref says no!  You got yourself into this mess.  Play yourself out of it.  That actually is a much better mind-game to play – the here-and-now game.  You want to go back?  Okay.  Abracadabra, you’re back.  If you still have passion, if you still have hopes and dreams, consider yourself to be back.  Take yourself along that self-same corridor, if you will.  Make that change, if you dare.  Effect that volte-face.

 

To the Far East on Friday, Edinburgh to be precise, to the Festival to hear the Cincinnati Symphony Orchestra in the Usher Hall.  In the first half of their concert they played American music – Bernstein and Copland.  One felt the music was in the orchestra’s blood. They were magnificent.

The Symphonic Suite from On the Waterfront derives from music Leonard Bernstein composed for Elia Kazan’s 1954 depiction of corruption and exploitation on the wharfs of New Jersey.  The cast was stellar – Marlon Brando, Lee J. Cobb, Karl Malden, Rod Steiger, and Eva Marie Saint.  The film was nominated for twelve academy awards, and won eight.  Bernstein’s symphonic suite remains as powerful as the film, perhaps even more so.

Aaron Copland’s Lincoln Portrait followed, a thirteen minute depiction of the character and words of the sixteenth President, for narrator and orchestra.  The narrator on Friday was Charles Dance.  He had Lincoln’s tall, slim, Presidential bearing.  His mid-west accent was, at least to my ears, faultless.  The timing and balance between speaker and musicians was perfect. Charles Dance avoided histrionics and allowed the language to speak for itself.

The dogmas of the quiet past are inadequate to the stormy present.  The occasion is piled high with difficulty, and we must rise with the occasion.  As our case is new, so we must think anew and act anew. We must disenthrall ourselves, and then we shall save our country. 

When was the last time you heard a president, or any politician for that matter, speak like this?

It struck me that On the Waterfront and Lincoln Portrait share a common theme, of the battle of an individual against a remorselessly corrupt and malevolent system.  Actually, both works are about slavery.  Given the recent events in Charlottesville Virginia, it could hardly have escaped the notice of the capacity audience in the Usher Hall that the topic could not be more relevant to the current “State of the Union”.  This might account for the electric atmosphere in the hall.  In the second half, Brahms’ First Symphony was played with equal passion and commitment.  What an orchestra.

At concerts, it’s usually rewarding to engage your neighbour in conversation.  A glamorous German lady sat on my left.  She took a picture of the orchestra on her mobile, and sent it off somewhere.  At least it was before the music started.  I said, “Are you emailing a friend?”

“My boyfriend.  He will wish to know I am not flirting.”

“Is he very jealous?”

“Yes.  He is French.  He is very much in love with me.”

“And is this sentiment reciprocated?”

She rapidly rotated a wrist, an equivocal Gallic gesture she might have learned from the jealous monsieur.  “Too early to say.”

She sounded just like Marlene Dietrich.  She even looked like her.

Phaw-lling… in loaf again, nevah vaunted too…

Vot am I taw doo…

Kant ‘elp eet.

She was deeply impressed by the Cincinnati Symphony.  “One criticism.  The women.  Ugh!  They are not elegant.”  I had noticed that the gentlemen were in white tie and tails, and that many of the ladies wore black trousers and plain black tops – almost jeans and T-shirts.  It wasn’t the last time I saw ladies in black this weekend.  The Black Ferns beat the Red Roses in the rugby world cup final in Belfast.  I’m a New Zealand citizen, therefore may allow myself a brief period of rejoicing.  I didn’t see the match, but I did see a bit of the Haka which was pretty intimidating.

Then Floyd Mayweather beat Conor McGregor in the boxing ring on the Strip in Las Vegas.  I don’t follow the fight game but I was intrigued to hear that, according to the BBC, the contest earned Mr Mayweather an eye-watering £200,000,000.  Let’s see now.  The fight was stopped in the tenth round.  Does a professional boxing round last three minutes?  That’s two hundred million quid for less than half an hour’s work.  Four hundred million pounds is surely a generous hourly rate.  It equates to £111,111 and eleven pence a second.

It was pouring when I came out of the Usher Hall on Friday night.  I passed a beggar on the pavement on my way back to the car.  He was drookit.  I gave him a pound and said, “This is not a night for being out, mate.”  He agreed.  Not that I helped much.  Mr Mayweather earns a pound in nine millionth’s of a second.  Nice work if you can get it.

 

 

“Quotes of the Day” caught my eye in Thursday’s Herald, this one from Tory MP Sir Nicholas Soames, on the decision to silence the chimes of Big Ben for four years in order to protect the hearing of workers during the refurbishment of the Elizabeth Tower:

“Tell these poor little darlings to put headphones on.”

Well!

He might have said, “It’s health and safety gone mad I tell you!”

I developed an interest in health and safety from a very young age – I think I was about three – when I saw my first corpse.  It was on Byres Road in Glasgow’s west end.  A bloodied man lay supine, inert, across the tram lines.  He was a cyclist whose front wheel had got jammed in the line, and he was struck by a vehicle.  A lady, deeply upset, was screaming for somebody to bring a blanket to cover the body.  Precisely this scenario recurred in Edinburgh earlier this year, at the corner of Princes Street and Lothian Road.  The victim was a medical student.

Shortly after the Byres Road incident, Charlie, a pal of mine, abruptly ceased to come out to play with me.  He had died, I was informed, as a result of having stuck a pencil up his nose.  I was strongly advised never to stick a pencil up my nose.  Indeed I never have.  I suppose he must have breached the cribriform plate and introduced a bacterium with subsequent meningitis and perhaps a cerebral abscess.

At school, the russet front cover of the standard F2 jotter was completely dominated by road safety advice.

DANGER!  DANGER!  DANGER!

And then, a list of dos and don’ts.

At the kerb, halt, look right, look left, look right again…

It occurs to me that Nicholas Soames’s grandfather Sir Winston Churchill must not have had the benefit of an F2 at Harrow.  In 1931 he stepped off the kerb and under a car.  In his own words, he nearly died.  Granted he was in New York and forgot the traffic was coming in the wrong direction but even so, if he had looked right, left, and right again, he would have saved himself a lot of trouble and a considerable period in hospital.  Or, as the F2 sums it up:

Better a moment at the kerb, than a month in hospital!

How true.  Winston’s summing up of the entire episode was characteristic.

“Live dangerously.  All will be well!”

Despite, or perhaps because of the F2’s dire warnings, our cohort was given remarkably unsupervised and unrestricted freedom.  We went out to play all day and in all weathers.  In addition to the road safety advice, we were advised never to accept lifts from strangers.  I was playing on a tricycle on the pavement of Glasgow’s Crown Road North – I was about four – when a mad woman came over, hurled abuse at me, and pitched me off my trike.  I played chases with my cousins around the back lanes of the west end of Glasgow.  I fell down a basement in Crown Road North again, cut my head open, and spent a night in Yorkhill Hospital for Sick Children.  The following week I fell in Kinoull Lane and did the same again.  Our games were largely of our own devising.  We fashioned bows and arrows out of string and bits of cane.  It’s a wonder one of us didn’t lose an eye.  We had a crazy phase of firing air pistols at one another.  We used a Gaelic bible for target practice.  It survives, covered in bullet holes.

When I was in Primary VII I was in a team that took part in a road safety quiz competition under the auspices of the City of Glasgow Police.  One of our teachers, Mr Ross, tutored us on the sorts of questions we might expect to be asked.  We would stay behind after school for a practice session.  Mr Ross would light a cigarette – Players or Capstan or Senior Service – and fire questions at us.  He must have done his job well because we won the competition.  We went on TV.  I remember being grilled in a studio in BBC Scotland on Queen Margaret Drive.  The programme went out live in the early evening.  After that, by way of thank you, I and my fellow team members clubbed together and bought Mr Ross a packet of ten Senior Service.  I got them from the Windsor Café just across the road from the school, where I would occasionally pop in to buy a “tipped single” for threepence.  I was 11.  I didn’t particularly realise it at the time, but I think Mr Ross was touched, perhaps even moved.  It was like something out of The Browning Version.

I saw a great deal of road carnage while working in emergency medicine in New Zealand.  The annual road toll at the time was about 500 fatalities.  In a population of – then – just over three million, that is appalling.  Per capita, it would equate to an annual road toll in the UK of 10,000.  People were rather fatalistic about it.  There seemed to be little awareness that road trauma, trauma of any kind, was a pathological entity that had an epidemiology.  Trauma could be studied in terms of its aetiology, pathogenesis, morphology, and clinical features.  William Haddon, the father of injury prevention in the United States, left us a model whose application might sometimes prevent, and would always attenuate trauma.  This model is the Haddon Matrix.  The Haddon Matrix is a square divided equally into nine smaller squares, like a template for a game of noughts and crosses.  The x axis is a time axis labelled pre-event, event, and post-event.  The y axis is a space axis labelled host, vehicle, and environment.  In each of the nine squares are listed the interventions that might cut down morbidity and mortality.  Take a road crash as an example.  Here are some interventions you might consider:

Pre-event: host – go on an advanced driving course; vehicle – design to withstand impact; environment – enforce appropriate speed limits.

Event: host – wear a seatbelt; vehicle – deploy an airbag; environment – site crash barriers at dangerous bends.

Post-event: host – educate in the principles of first aid; vehicle – equip with an emergency locator beacon; environment – provide a sophisticated advanced trauma life support system.

You might say that is all common sense and indeed it is.  But is sense common?  Only a generation ago there was a political struggle to make it illegal not to wear a seatbelt.  Such legislation was deemed by some to be an infringement of personal liberty.  In motor sport, around the same time, three time F1 world champion Jackie Stewart started campaigning to improve survival rates in race car drivers who at the time would kiss their wives goodbye on the morning of a race and not know if they would return at night.  Sir Jackie looked at drivers, cars, and race tracks.  I don’t know if he was aware that he was utilising the Haddon Matrix.  He was ridiculed and vilified by a substantial constituency of the old guard who thought that if drivers were not prepared to dice with death they should be sent a white feather.  Some people entertain an absurd nostalgia for the good old days, of boys in grey flannel shorts and girls in gingham playing bows and arrows and hop-scotch in the street, of grinning miners with dirty faces and pneumoconiosis lighting up, and of the brylcreem generation driving death traps without seat belts up trunk roads without speed limits.  Next to that, and to return to the Palace of Westminster, I suppose hearing loss due to noise exposure constitutes a less severe insult.  Yet it is an occupational injury.  I find myself deeply suspicious of somebody who cares to make a crass remark about “little darlings”.  Why not shut the bongs down for four years?  Radio Four could have a different outside broadcast every day at 6pm.  I would recommend Glasgow University Tower.

I suspect the reluctance to silence Big Ben runs parallel with the reluctance of the establishment to vacate the Palace of Westminster for its much needed refurbishment.  They can’t bear the idea of moving into a modest municipal building in Cardiff or Liverpool or Belfast or Dundee.  I wonder if they fear, deep down, that without the pageantry, the trappings, and all the pomp and circumstance, they will be left with nothing but a void of vacuous emptiness.

 

I was toying with the idea of upgrading my kitchen and bathroom to bring my bijou cottage into the twenty first century.  But I’m bemused to find I’m reluctant to make any long-term or even medium-term plans.  Best wait to see what happens in south-east Asia later this month.

At time of writing, North Korea’s generals are drawing up plans to test medium range ballistic missiles by sending them across Japanese airspace – directly over Hiroshima apparently – to ditch in the Pacific just a few miles off Guam, the US strategic military base in the Pacific.  If the supreme leader approves the plans, these tests will take place during August.

Conflicting messages are emanating from the White House.  While the US Secretary of Defence is looking for a diplomatic solution to these escalating tensions, the President has promised that any North Korean act of aggression will be met with fire and fury “the likes of which the world has never seen.”  Whether this “good cop, bad cop” double act is accidental or deliberate, the undeniable impression is that the US is running on a very short fuse.  Mr Trump says the US military machine is “locked and loaded”.

“Locked and loaded” is a succinct expression, pregnant with meaning.  It sums up the ethos of nuclear deterrence and the way it works, or is supposed to work.  That the system is “locked” implies that it cannot be subject to further interference.  Thus any potential aggressor must realise that an act of aggression will inevitably unleash fatal consequences as sure as night, in this case, a long wintry nuclear night, follows day.  The scene is set; there is nothing anybody can do about it.  Only two possibilities remain; either the aggressor continues on a suicidal path, or he backs down.  It is salutary to reflect that, over the course of the next two weeks, the doctrine of deterrence is being put to the test.

What can you do?  Keep calm and carry on.  I went to see Dunkirk with a New Zealand pal.  She loved it.  I didn’t.  I emerged, shell-shocked, as if from under a bombardment at Passchendaele.  I think that was the general idea.  Call me a stuffed shirt, but I’m becoming disaffected with cinema.  Don’t get me wrong; I thought Dunkirk was beautifully shot.  That Spitfire gliding over the beaches with its engine shut down was a sight to behold.  And Mark Rylance can do no wrong.  But what a racket.  I was already in a surly mood after the coming attractions’ thirty minutes of high decibel bludgeoning, only to find I was to remain under fire for another couple of hours.  You can frighten the life out of anybody by creeping up behind them and discharging a pistol next to their ear.  Yet even a deafening heartbeat – tinnitus begets tinnitus – was preferable to the bastardization of Nimrod from Elgar’s Enigma Variations that was meant to evoke some ancient mystic Britannic myth.  I don’t like to be manipulated.

I went back to Volume Two of Churchill’s The Second World War, Their Finest Hour, and reread The Deliverance of Dunkirk.  This in turn sent me back to Volume One, The Gathering Storm, which I’m currently rereading.  This volume covers the period November 1918 to May 1940, and is in two parts.  Part 1 deals with the years between the two world wars.  Part 2 covers the period of the phoney war, between its outbreak on September 3^rd 1939, and Hitler’s invasion of the Low Countries in May 1940 leading to the fall of the government and Churchill’s acquisition of the premiership. Theme of the volume – How the English-speaking peoples through their unwisdom carelessness and good nature allowed the wicked to rearm.  Churchill called the Second World War “the unnecessary war” because he thought that at various times throughout the thirties Germany’s expansionist ambitions could have been thwarted by peace loving nations working in concert within the ambit of the League of Nations.  He abhorred Stanley Baldwin’s indifference to foreign affairs, his insouciance, and subsequently Neville Chamberlain’s policy of appeasement.  He thought Hitler could have been stopped, if people had been prepared to stand up to him.

Mr Trump brought Churchill’s bust back into the Oval Office when he attained the office of President.  I have a notion that, in putting down a red line for Kim Jong-un, he considers he is being Churchillian.  There’s that famous Santayana quote, that those who do not study history are condemned to repeat it.  The trouble is that history never really repeats itself.  And North Korea isn’t Nazi Germany.  Whatever Mr Trump does, he had surely better act in concert with Japan, Russia, China, and the European Union.

But what do I know?  I have a horrible feeling if I’d been around in the thirties I would have been an appeaser.  “Is this really necessary, Adolf – may I call you Adolf?  Couldn’t we find some way of avoiding this unpleasantness?  Couldn’t we reach some sort of accommodation?  What exactly is it you want?”

At Berchtesgaden, the Fuhrer would have walked all over me.

 

I was chatting this week to a nurse who works in the Catheter Laboratory at the Royal Infirmary of Edinburgh.  She painted a vivid picture of a 24-7 full-on, highly pressured, highly stressed and overpopulated environment.  When I was a medical student, and indeed a junior doctor, in that august institution, there was no such thing as a Cath Lab.  Now it is the sine qua non of acute cardiology.  In fact, cardiology exemplifies perhaps more than any other specialty the way that medicine has changed out of all recognition over the past 40 years.  In these far off days, there was no interventional medical treatment for patients suffering a heart attack.  Patients were given oxygen and morphine and the pathological process would run its course.  (Interestingly, patients in this situation are no longer given oxygen, unless they are blue, because the evidence suggests it results in further occlusion of narrowed coronary arteries.  In my day, failure to give oxygen would have been regarded as a “fatal error” – potentially fatal to the patient and therefore fatal to the medical student under examination.  Similarly, giving beta blockers to patients in heart failure was another fatal error; now it’s often fatal if you don’t!)

The purpose of the Coronary Care Unit (CCU) was to watch for complications such as a cardiac arrhythmia which might be corrected by a drug chosen from a modest pharmacopoeia.  I used to “cover” CCU on call at night, from an on-call room situated four storeys above the unit.  There was a bed, a phone, an ECG visual display unit by which you could observe the patients’ heart traces, a telly and, bizarrely, a drawer full of porno magazines.  There were large numbers of patients many of who smoked, were overweight, had bad diets and got little exercise.  Consequently many suffered major heart attacks and were left in heart failure, for which the stock drug was the loop diuretic frusemide.

Nowadays, the optimal treatment for acute coronary syndrome (see how the terminology changes) is restoration of the patency of the coronary arteries in a Cath Lab, where the vasculature is imaged and the occlusive lesion identified; a catheter is introduced either via the femoral or radial artery, guided into the coronary vasculature and the site of the lesion, and the vessel is reopened with implantation of a stent.  If this is done quickly, heart muscle does not die.  Time is muscle.  This reversal of a potentially fatal pathological process is little short of miraculous.

It wasn’t all doom and gloom in the 70s and early 80s.  The cardiothoracic surgeons were performing coronary artery bypass grafts (CABGs) – sometimes acutely – and valve replacements.  These procedures were highly invasive and in some patients extremely hazardous.  As medical students we had an option to select a subspecialty of our choice and join a unit for two weeks.  I chose cardiothoracic surgery.  My colleagues thought I was mad because the cardiothoracic surgeons had a reputation for being irascible psychopathic bullies.  In fact they themselves were so gobsmacked that a student should choose to spend time with them that they treated me with great kindness.  The morning ward round, in a remote and seldom visited location in the infirmary, began at 7 am.  I would assist in CABGs or valve ops that would take all morning or all afternoon.  After the split sternum had been wired back together the surgeon would depart and leave me laboriously to close up a ten inch skin incision with multiple interrupted sutures, to the great amusement of the anaesthetists.  “This operation is now in the hands of a medical student.”  The craziest of the cardiac surgeons gave me a lift home one night.  We paused at an Off Licence so he could buy a bottle of gin.  “Hold that.”  When I got dropped off I left the car still holding the gin, with the intention of getting out and then placing it on the seat.  He made a panicked dive to retrieve it.

Nowadays, it is getting more difficult to die of heart disease.  In addition to the stents, you will be offered an array of “secondary prevention” medicines.  If your conduction pathways are damaged you will have a permanent pacemaker implanted.  If you are liable to suffer fatal ventricular fibrillation, you can have an implanted automatic internal defibrillator.  This is why patients who have been through this route often end up dying of an entirely different disease, or of “pump failure”; eventually the heart just gets tired and gives up.

Practising medicine is a little like waging war.  You are liable to find yourself employing the tactics and strategies of the last war.  But you mustn’t do that.  The French Maginot Line was useless against Hitler’s blitzkrieg.  One of the reasons why the NHS is creaking and thus is never out of the news is that all these therapeutic options have become available during a time when so much has remained unchanged.  The model of delivery of care, the human resources, the budget, and the ethos are essentially as they were circa 1977.  That doctors and nurses should in any instance now offer a state-of-the-art service is, to say the least, valiant.  And it’s not just cardiology.  The same level of accelerated scientific progress could be demonstrated in respiratory, gastrointestinal, renal, endocrine, musculoskeletal, reproductive…  And the acceleration is accelerating.

We need to find a way of delivering health care such that doctors and nurses don’t go to work every day feeling as if they are organising an evacuation from Dunkirk.

I was driving home from Edinburgh between 5 and 6 pm one day last week, with one ear on Radio 4’s PM programme. Eddie Mair was interviewing one of the BBC political correspondents, as far as I remember, about Brexit.  The correspondent described the current political situation as “a plunging chasm of uncertainty.”

“Plunging chasm of uncertainty?” queried Eddie, in an amused tone.  At the end of the interview he said, “In your honour, I’ll try to use ‘plunging chasm of uncertainty’ before the end of the programme.”

True to his word, he moved on to an interview with a BBC Washington correspondent, about the bizarre reports currently emanating from the West Wing.  “Would you describe the situation as a plunging chasm of uncertainty?”  The correspondent was probably used to fielding the unexpected from Eddie, and he deftly compared the internal conflicts in the White House to the Montagu-Capulet stand-off in West Side Story between the Jets and the Sharks.

The PM programme doesn’t formally end; it just elides seamlessly into the chimes of Big Ben and the six o’clock news via the weather forecast.  I had to laugh when the weather man described the situation as a plunging chasm of uncertainty.

Come to think of it, it’s rather an extreme simile.  You could certainly plunge into a chasm, but if the chasm itself is plunging, well, that would certainly imply a seismic shift of the tectonic plates.  (It’s as well Eddie Mair isn’t interviewing me.  I can just hear him: “Seismic shift of the tectonic plates?”)  There is no finer interviewer on the BBC.  Look what he did to Boris after the general election and the Queen’s Speech.  Not that he interrupted, badgered, or was argumentative or aggressive in any way.  He merely asked succinct, direct, and well-briefed questions.  I don’t know how far behind Chris Evans he is on the BBC pay scale but I reckon he’s worth every penny.

But to return to these chasms, what are we to make of Mr Trump’s appointment of Anthony Scaramucci, replacing Sean Spicer as White House Communications Director?  Mr Scaramucci seems to share a lexicon with Peter Capaldi’s character Malcom Tucker in The Thick Of It.  Of erstwhile White House Chief of Staff Reince Priebus he is quoted as having said, “Reince is a f****** paranoid schizophrenic, a paranoiac.”  Mr Priebus struck me as rather a mild-mannered man.  I confess I got distracted by his unusual name.  I have a bad habit of seeking anagrams hidden in unusual names.  I actually sent a crossword clue to The Herald:

Pi, uber-sincere mixed-up politician (6,7)

The Herald didn’t use it.  Funny, that.  Anyway, Mr Priebus is gone, to be replaced by a four star general (maybe **** has another connotation in the Rose Garden).  General John Kelly has no political experience.  But then again, maybe the military is what is needed, to bring some discipline to the West Wing.

From this side of the Pond (I think we should re-name the Atlantic Ocean “The Chasm”), American politics look more and more like a reality TV show.  The predominant themes of shows such as Big Brother, The Apprentice, Strictly, I’m a celebrity get me out of here, Dragon’s Den and many more, are Survival & Expulsion.  Expulsion of an individual becomes a weekly ritual announcement following a protracted and excruciating pause, itself perhaps following weeks of incessant bullying and persecution from which the mass audience derives a sadistic pleasure.  In the same way, US politicians are being serially expelled from the West Wing amid the same apparent atmosphere of bullying and persecution.  It would all be very amusing but for the plunging chasm of uncertainty we all inhabit with respect to global warming, international terrorism, the gap between the rich and the poor, and the ever present threat of nuclear war.  Who on the other wide of The Chasm is addressing any of these issues with wisdom and humanity?

Senator John McCain, who, despite the inconvenient encumbrance of a brain tumour, turned out to cast the deciding vote in support of Obamacare.  Hats off to Mr McCain.