jamescalumcampbell

I’ve had a very “Herald”-orientated week.  On Tuesday, I went to the Herald-sponsored Glasgow Cruciverbalists’ Club. We meet monthly in an upstairs room in Curlers on Byres Road and solve crosswords in a studious Bletchley Park atmosphere.  It’s better fun than it sounds.  The company’s good.  Somebody asked me what compiler’s software I used and I gave a plug for ‘Sympathy’ and said I was thinking of upgrading to their latest version.  “No doubt,” came the response, “to ‘Empathy’.”  Next month I am providing the crossword to be solved.  I was asked if my puzzle was fiendish.  I borrowed an expression from the President-elect.  More like Number One Tricky.

On Wednesday morning I opened my Herald to read about the latest Queen Elizabeth University Hospital statistics purporting to be a measure of the Emergency Department (ED) “performance”.  Like every other ED in the NHS this one has a “four-hour rule”, and every month the Herald reports the extent to which the department has fallen short in its observation of the rule.  Of course they are not alone in this.  The BBC does the same.  Every time I hear the report my blood pressure goes up and I am minded to fire off a disgruntled letter to the Herald.  Sometimes they publish me; sometimes they don’t.

I should explain why I get so exercised about it.  First up, the report is always written thus: “For the week ending 15^th Inst only 87% of patients were seen in QEUH “A & E” (sic) within four hours.  The target is 95%.”

Now, that is just not true.  I would venture to say that virtually 100% of patients were seen within five minutes – that is, within five minutes of their arrival.  They would have been seen virtually immediately by a triage nurse whose job is to assign a level of urgency to the patient’s clinical presentation, which stipulates how quickly the patient should be assessed by a doctor.  Australia and New Zealand use the National Triage Scale which identifies 5 categories of acuity.  Triage category 1 – the patient must be seen immediately; 2 – within 10 minutes; 3 – within 30 minutes; 4 – within 1 hour; 5 – within 2 hours.  Most emergency departments in the English-speaking world use a system not dissimilar to this.  The degree to which a department meets these targets is certainly worthy of study.

The four-hour rule measures something quite different.  It measures the total time the patient spends in the ED between presentation and discharge.  In the language of medical audit, the “criterion” is that patients should be discharged from the ED within four hours of arrival.  The “standard” is that this should happen to 95% of patients.  I’m always a little puzzled by medical audit standards.  They seem to me to be arbitrary.  After all, if something is worth doing, why not aim to do it all the time?

Now, each time the department fails to achieve the “standard” (and that is virtually all the time), this is deemed to be an index of, perhaps even a surrogate marker for, “poor performance”.  This notion that an emergency department’s performance somehow relates to how quickly it disposes of the patient seems to me to be utterly absurd.  Imagine a music critic berating an orchestra, not for being unmusical, but for taking too long.  The Maestro at rehearsal might tear his hair out.  “Ladies and Gentlemen, we simply must get Mahler 8 under 90 minutes!”

Anyway I wrote to the Herald in this regard on Wednesday.  I didn’t think they’d publish me.  Experience has told me that the best way to get published in the Letters column is to be polite, to make a single point worth making, and make it succinctly.  My letter was more diffuse than this; it made several points.  So I didn’t think it would go in, but at least it helped me get something off my chest.

Judge my surprise on Thursday when not only was I in, I was in poll position, complete with big headline.  “Medical staff should ignore this arbitrary four-hour rule”.  I was delighted with that.  The other main point in my letter alluded to Westminster Health Secretary Jeremy Hunt suggesting that the public might have to be educated about the “appropriate” use of “A & E” (sic).  I made the simple suggestion that the term “Accident & Emergency (A & E)” be dropped.  After all, somebody who has an “accident”, say sprains an ankle, might say, shouldn’t I go to A & E?  That, after all, is what it says on the tin.  The emergency medicine community in Australia and New Zealand understood this thirty years ago, and dropped the word “accident”.  I’ve written about this often, and make no apology for bringing it up again.  We shouldn’t use archaic terminology.  Never use the most archaic and the most dehumanising word of all, “Casualty”- either to allude to a department or to the person attending it.  The department is the “emergency department” and the person is the “patient”.  If you hear somebody using the A word or the C word, politely correct them.  Will you join me in this?

On Friday I perused the Herald Letter pages again.  I think it’s important to keep vigilant for the riposte.  You know the sort of thing.  “It’s time for Dr Campbell to wake up and smell the coffee!”  There was nothing by way of adverse comment.  Quite the opposite; the Letters editor had written a piece in praise of the paper’s correspondents and I was delighted to be mentioned in dispatches.  Then on Saturday, Myops, resident cruciverbalist, used one of my clues.  A chronicle of small beer, you say.   Yet I admit I love to be in print.  I’d have quite liked to have been a hack.

 

Quite by chance, in the first week of the New Year I’ve been reading two books in parallel which deal with overlapping subjects but whose viewpoints and conclusions are diametrically opposed.  The first book is The Letters of John F. Kennedy, edited by Martin W. Sandler (Bloomsbury, 2013), and the second is Noam Chomsky’s Who Rules the World? (Hamish Hamilton, 2016).  Sandler’s tone is reverential.  JFK is presented as “one of the greatest and most charismatic presidents of all time”.  In studying American post-war foreign policy, Chomsky chooses a wider remit.  Of the United States of America, he is almost unremittingly critical.  For example, chapter 17 is entitled “The U.S. is a Leading Terrorist State”.  JFK is referenced 13 times in the index, and every single reference is negative, sometimes damningly so.  The first reference is to his implementation in 1962 of new U.S. policy in Latin America, boosting internal security by supporting criminal regimes who used, quoting Charles Maechling Jr., “the methods of Heinrich Himmler’s extermination squads”.  All of the foreign policy interventions of JFK’s 1000 days, from the Bay of Pigs, to Vietnam, the ongoing Cold War and in particular the Cuban missile crisis, are portrayed as a series of unmitigated disasters.

Chomsky’s account of the Cuban missile crisis is entitled The Week the World Stood Still.  While Sandler says of the President, “He steered the United States away from nuclear war”, Chomsky describes a series of near misses which were survived through a combination of sheer luck and the independent decision-making of front line military personnel.  That we survived is little short of a miracle.

Well, Sandler and Chomsky, they can’t both be right, can they?

The first week of this New Year added a third parallel to run alongside these books.  I was very intrigued to read in the Letters, the communications, especially the personal ones from the Black Sea coast and the Kennedy retreat at Hyannis Port, lengthy and beautifully written on both sides, between JFK and Chairman Nikita Khrushchev, the more so in light of what the CIA have been saying about the recent US presidential election and the apparent certainty that Vladimir Putin conducted cyber-attacks on the U.S. in order to influence the election’s outcome in favour of Mr Trump.  I have to say I felt some sympathy for Mr Trump when he reminded his intelligence people that they fouled up with Iraq’s weapons of mass destruction.  They didn’t appreciate that; he struck a nerve.  Of course, they were unable to say whether the putative intervention of Mr Putin had any influence on the election result.  Another aspect that was not touched on was the one of Russian motivation.  It is not at all clear why the Russians might prefer the 45^th POTUS to be Mr Trump.  I have a suspicion that over the next four, maybe eight, years, the relationship between Mr Putin and Mr Trump might turn out to be as crucial to the world as that between Mr Khrushchev and Mr Kennedy.  We might get a sense of how that relationship will start out when we hear Mr Trump’s inaugural speech on January 20^th.  With that in mind, I revisited Mr Kennedy’s inaugural speech, also on January 20^th, back in 1961.  It is a very famous piece of oratory.

“We shall pay any price, bear any burden, meet any hardship, support any friend, oppose any foe to assure the survival and the success of liberty…  In the long history of the world, only a few generations have been granted the role of defending freedom in its hour of maximum danger.  I do not shrink from this responsibility…”

We have to put that into the context of an ideological struggle between the democratic world and the communist world, and also to remember that on October 30^th, 1961, the USSR tested the biggest thermonuclear device ever detonated – equivalent to 50,000,000 tons of TNT (Hiroshima’s “Little Boy” was equivalent to 15,000 tons).  This occurred at the height of the Cuban missile crisis.  The stakes were incredibly high.  Whether it was due to the wisdom of Mr Kennedy and Mr Khrushchev, or a submariner named Second Captain Vasili Arkhipov, who decided not to fire a 15 kiloton torpedo, we got through by the skin of our teeth.

Noam Chomsky thinks that in terms of human self-destruction, the clock sits somewhere between five minutes and one minute to midnight.  The two big threats are climate change, and nuclear war.  Mr Trump doesn’t believe climate change exists, and he wants to increase the US nuclear arsenal.  I like to keep an open mind, but I shall be listening very carefully to what he has to say a week on Friday.  This is the way the world ends, not with a bang, but a twitter.

Over the festive season I’ve greatly enjoyed reading The Humans, by Matt Haig (Canongate, 2013).  It’s very amusing.  It has a farcical premise.  An extra-terrestrial being from a distant civilisation visits planet earth when it becomes apparent that a Cambridge professor of mathematics has got the answer to one of the great unsolved mysteries of number theory; he has proved the Riemann Hypothesis.  Homo sapiens is deemed to be a species so unstable as to be unworthy of such knowledge, but fortunately the professor has not yet gone public.  The alien’s remit is to eliminate the professor, assume his identity, and then eliminate his immediate family and any associates who might have been told of the proof.  The trouble is, the cosmic visitor commits the cardinal error of any anthropologist beguiled by the object of his study.  He goes native.

This notion of visitation by beings from another world seems to be endlessly fascinating to us.  Famously, Orson Welles made a radio broadcast of his (near) namesake H G Wells’ War of the Worlds that was so realistic that it’s said the population of the United States thought the world had truly been invaded, and there was widespread panic.  More recently, in films like Close Encounters of the third Kind, and ET, the aliens are depicted as benign intelligences trying to mentor us and dissuade us from our violent and ultimately suicidal path.  My favourite is a cult film from 1951, The Day the Earth Stood Still, in which Michael Rennie plays an alien.  In addition to an evidently shared fascination with extra-terrestrials, Orson Welles and Michael Rennie had something else in common.  They both depicted Harry Lime on screen, Welles in Carol Reed’s film of Graeme Greene’s The Third Man, and Michael Rennie in a TV spin-off that retained little resemblance to the original, aside from the theme tune on the zither, and the brooding atmosphere of a post-war European cityscape with cobbled plazas and abandoned newsstands.  The sharp tap of hurried footsteps and a shadow on a shuttered façade, disappearing into an alley.  And the twang of the zither…

Tya tya tya tya tyaah – tya tyaaaah….

…the tempo rather quicker, edgier, than you’d remembered.  There you were, on the Prater, high above post-war Vienna, with its heavily militarised occupied zones.  Joseph Cotton and Orson Welles.  These two always seemed to be meeting like this, in film, and re-enacting the same painful masque depicting the disintegration through disillusion of a human relationship.  Welles’ character was brilliant, charming, charismatic, flawed, Cotton’s unremarkable, industrious, plodding, reliable, faithful.  He would gradually and excruciatingly come to the realisation that his friend and hero was not all he’d been cracked up to be.  It was like being privy to the death throes of a love affair.  In a way that’s what it was.  That terrible hang-dog expression of Cotton’s.

Michael Rennie played Lime as a kind of latter day Robin Hood who would never have dreamt of watering down penicillin for personal gain.  In the TV spin-off, Lime had a man, a butler after the English style named Brad who, while being intensely loyal to Mr Lime, could barely conceal his distaste each time his master went off with another woman half his age.    There was something repugnant to him about the spectacle of a very mature Michael Rennie getting off with another teenager.  It wasn’t just the age difference.  There was something alien about Michael Rennie.  These beautiful young women were allowing themselves to be embraced by the member of another genus; they were falling into the ambit of the antennae and mouthparts of a stick insect from Pluto.

Thus his casting as an alien in The Day the Earth Stood Still was inspired because he definitely had an other-worldly quality.  He assumed human form to come to earth to tell us homines sapientes that we were making a terrible mess of our obscure corner of the universe and, unless we all pulled our socks up, we were going to disappear into some cosmic incinerator and good riddance.  On this occasion Brad was played by a robot made out of an assemblage of tube balloons.  Unlike his master he had not mastered English and had to be addressed in his own tongue.

“Gort!  Klaatu barada nikto!”

Or words to that effect.  You could tell Rennie was an alien because he wore a tunic resembling the short white coat of an orthodontist.  Rennie was an interstellar dental hygienist, come to berate us for the level of our decay.

Like the Riemann Hypothesis, the question of whether intelligent life exists elsewhere in the universe is a great unanswered conundrum of our time.  In The Humans, Matt Haig’s alien is ironically a little dismissive of the notion.  At least he points to some deficiencies in the Drake equation.  In 1961 Dr Frank Drake produced a probabilistic argument to estimate the number of civilisations in the Milky Way.

N = R* x fp x ne x fl x fi x fc x L

Each variable is a fraction of the element in the equation that precedes it.  Hence, rate of formation of stars; of those stars the fraction that have planets; number of planets per star capable of supporting life; of those, the fraction that go on to develop life; of those, the fraction developing intelligent civilisation; of those, the fraction that develop communication; and of those, the window of time during which they communicate.

It crosses my mind that Frank Drake sounds awfully like Francis Drake.  Perhaps Dr Drake was preparing to repel an invading interstellar Armada.  Is the Drake equation a spoof? To be fair to Dr Drake, you can see that it is not really an argument in support of the hypothesis that intelligent life exists elsewhere in the galaxy.  Instead, that is axiomatic and taken as read.  So, assuming the conditions in which life can evolve exist elsewhere, how often will it happen?  It’s an intriguing question, but equally intriguing to me, perhaps even more so, is the hypothesis that we are alone in the galaxy, and indeed in the universe.  There is after all some reason for suspecting this might be so.  Our search for signs of intelligent life thus far has drawn a blank.  Marconi was sending radio signals across the ocean before the end of the nineteenth century.  The transmitters have been broadcasting and the antennae have been listening out for quite some time.  We are a noisy planet.  In contrast, it’s pretty quiet out there.  Still, the universe might be teeming with life but the distances are too vast to detect it.  The signals we get from the edge of the observable universe are fifteen billion years old.

But is there any point in making a contention that cannot be proved or disproved?  Bertrand Russell made this philosophical point by positing that a teapot is in orbit between Earth and Mars.  It’s just too small for our instruments to detect it.  Just because we haven’t found it doesn’t mean it isn’t there.  In fact, even if we haven’t found the teapot after aeons, we can never prove it’s not there.

What would be the implication of being all alone in the universe?  We might find ourselves back in a pre-Copernican age, back at the centre of things.  The universe looks much the same whichever direction you look.  We have as much right to be at the hub as anybody else.  Still, I suppose we’d better keep looking out.  Perhaps we’ll pick up an intelligent and meaningful signal.  What might it be?  It could be the proof that the Riemann hypothesis is sound.  That would be cool.

Maybe this year.

I read an item in the paper a few days ago about having sex with robots.  It was the subject of a keynote speech at a conference for mad boffins.  I wasn’t paying much attention but I think the general idea was that with increasing sophistication in robotic technology one could conceive of a machine with humanoid characteristics that could be rendered, well, attractive.  It was the mathematician and cryptographer Alan Turing who posited that, if you had an interaction with a machine so advanced that you could not tell that the machine was not human, then to all intents and purposes the distinction ceased to matter.  This is the essence of “the imitation game”.

You can see this has huge implications for the sex industry.  Minded to explore these a little further, I was about to Google “sex with robots” but thought better of it.  I know what would happen; every time I fired up my computer I would be bombarded with advertisements directing me to dubious sites.  I do not wish my desk top to get the wrong idea.  I have an app, “Cortana”, who already flirts with me in an inappropriate way.  She – anybody called “Cortana” has to be female – says to me, provocatively, “Hello.  I’m Cortana: ask me anything you like.”  I might say, “What did you say your name was?” and she would reply, “What would you like it to be?”

It all sounds a bit like science fiction but clearly society has already gone quite far down this route.  You only need to observe people walking down the street with ear pieces in situ, staring fixedly at a phone or tablet, oblivious to their environment, to realise that they are completely besotted.  Having sex with a machine is one thing, but what happens if you fall in love with it?  It is only a matter of time before somebody proposes to their computer.  Should the computer accept, then society will have to decide on a number of issues.  Civil partnership is one thing, but marriage?  The Anglican community will be riven.  The Archbishop of Canterbury will espouse liberal values and preach tolerance and compassion (for the hash-tag crossed lovers), while in the developing world a dim view will be taken.  There might even be persecution.  Sooner or later, a member of the clergy will “come out” and announce he and his machine are cohabiting.

Meanwhile in Cheltenham, GCHQ will get very nervous.  Unprofessional cyber relations among spooks, and indeed among the political class, will clearly be a security issue.  People romantically involved with their computer will be vulnerable to cyber-attack.  The robotic embrace, like that of a boa constrictor, will prove an ideal means of political assassination.

Then what would happen if, in the absence of a pre-nup, relations broke down?  The possibility of computers turning malignant has been recognised for a long time. In the film 2001, A Space Odyssey, the space ship computer Hal goes rogue.  Or is it the human being on board whose behaviour has become erratic?  It depends on your point of view.  (Incidentally, is it merely coincidental that the letters HAL immediately precede IBM in the alphabet?)  I can imagine divorce from a robot would be a very messy affair.  Hell hath no fury like a lap top scorned.  The only winners would be the lawyers.  Kerching kerching.

At the party in Aberdeen on Saturday night, the woman in the silver-grey dress touched glasses and said “Cheers.”

“Cheers.”

“That is not how you say ‘cheers’.  You must look deeply into my eyes, as I do into yours.”

“Cheers.”

“Cheers.”

Thus, she hypnotised me.

She was very direct.  “Are you married?”

“No.”

“Why not?”

“Because I have zero emotional intelligence.”

“Were you ever married?”

“I cohabited.”

“What happened?”

“She saw through me.”

“That’s bad.”  It occurred to me that that was a line directly out of Notting Hill.  Julia Roberts said it to Hugh Grant.  Are we condemned to speak nothing but second-hand movie scripts?   I added, “But I’m impossible to live with.”

And although that is clearly a self-indulgent and therefore despicable utterance, there is some truth in it.  The fact is that since adolescence I have been irresistibly drawn to solitude.  I first became aware of it at a school badminton club on a Friday night when I would quietly withdraw from play, disappear into the school music room, Room 7, and play my viola.  I was happy to play unaccompanied Bach.

She continued, “What do you do?”

“I’m a doctor.”  No surprise there.  This party was crawling with medics.  “But I’m in abeyance.”

“Retired?”

“On sabbatical.”  After all, I still get the PTSD nightmares.  The profession still has me.

“You don’t look old enough to be retired.”  I took that as a tremendous compliment.   “How do you spend your time?”

“I write.”

She looked quizzical.  I explained, “I was lucky enough to win a literary competition, and won a contract for three books.  Two are published, and I’m working on the third.”  Suddenly she looked interested.  I wondered if being a published author was like being a rock star.

“What sort of books?”

“They are called crime fiction, but I prefer to think of them as psychological thrillers.  They concern a young doctor who is emotionally labile.”

“Labile?”

“Troubled.”

“Like you?”

It was impossible to evade her directness.  “Yes.”

“Why are you troubled?”

“If I knew the nature of my trouble, it would cease to be troubling.”

“Tell me about your last date.”

“It was in New Zealand.  I was driving around Northland and I stopped one night in a camp site just north of Dargaville.  A very beautiful woman sat in the lotus position alone by her tent.  She had long fair hair in a ponytail.  Her head was buried in a book.  I thought to myself, “Charming.”

Shortly afterwards I was busying myself about my campervan and became aware of a presence.  I looked up.  It was Keet.  (Pronounced Kate.  She was Dutch.)

“Where are you going tomorrow?”  Her English was perfect.

“Auckland.”

“Will you take me with you?”

I shrugged.  An affectation.  “Yes.”

We travelled, and spent a pleasant day.  The conversation was wide ranging.  She was 22.  As with so many people from the Netherlands, her linguistic skills were remarkable.  She said, “I’m thinking of learning Maori; it looks pretty easy.”  She loved English Literature, from Chaucer to Eliot.  I remember we had a conversation about the Canterbury Tales.  Can you imagine having a conversation like this with somebody from a foreign country?  We talked of the Latin tag, “Amor vincit omnia” – Love conquers all things.  I had always thought of that as a benison; two people in love face all adversity with courage and fortitude because they know their mutual love will see them through.  But Keet saw it in a different way.  Love was not a benison, it was a curse.  It undermined you, weakened your resolve.   Specifically, Love would impede your ability to serve the state.  You would be unable to wage war.

We drove down the west side of the Hauraki Gulf and lunched in Clevedon, on the periphery of South Auckland.  I said, “Where can I drop you off?”

“Where are you going?”

I mentioned the name of a Top 10 Campervan site in South Auckland, near to Ardmore Airport, out of which I was going to do some flying.

“I will come there also.”

That evening, we shared a bottle of wine, and chatted some more.  I thought, “What’s the Agenda here?”

I said to her, “You didn’t half take a chance, coming up to a middle aged guy and asking for a ride.”

“What is life without chances?”

I didn’t tell the woman in Aberdeen that I’ve developed a bad habit of talking to myself.  I wander about city streets and remonstrate with myself.

“You bloody idiot.”

Bill English has become New Zealand’s thirty ninth prime minister.  I’ve met Mr English.  In the mid-90s when I was clinical head of Emergency Medicine at Middlemore Hospital, South Auckland, he was Minister of Health.  He dropped by one day and we had a chat in my office.  He asked me what the department needed, and I said it needed to double its resources.  At the time I didn’t think this went down too well, but in fact it happened, in spades.  Middlemore ED is now a 130 bedded facility with four resuscitation rooms, run by 56 medical staff, 22 of whom are consultants.  I am proud of the fact that I played a small part in the development of Australasian emergency medicine.

In order to further the cause of emergency medicine, it was necessary that the specialty have a public profile.  Hence in the mid-90s I had dealings with the media.  I don’t think of myself as a person particularly comfortable in the limelight but at the time I didn’t mind.  I even relished it.  The fact is I was living on my nerves.  My world was full of murder and mayhem and for some inexplicable reason I would wake up in the morning full of beans.  I couldn’t explain it then and I can’t explain it now.

For a time I had a slot on Radio Pacific.  I would arrive at work at 8 am and do an interview about the activities of the night just gone.  The subject matter often involved road trauma, interpersonal violence, drug and alcohol abuse, multiple morbidity and the problems of patients with significant pathology presenting late.  TV NZ interviewed me one Christmas about the challenges the department might have to face over the festive season.  The hospital saw this as an opportunity to offer preventative medicine and the delivery of sound health care advice.  Then a television company negotiated with the hospital to run a weekly fly-on-the-wall documentary, Middlemore.  Episodes of emergency medicine were televised.  I was never very keen on this idea.  Any time I was on camera I always knew that the dynamic of the medical consultation was altered.  There was a third party in the resuscitation room.  But again, the hospital recognised it as an opportunity to deliver a form of health care in a different way.  So it happened.  I remember I was interviewed on the programme one week about the epidemic (it was no less) of major trauma in Auckland resulting from road crashes, often alcohol related.  I recall making some disparaging remarks about human irresponsibility culminating in a throw-away remark, “It’s pathetic.”

It turned out that “It’s pathetic” struck some sort of chord.  I started hearing recordings of myself on radio and TV saying “It’s pathetic!” as the media took it upon themselves to tackle the scourge of drink-driving.  For a week or so I had a kind of Andy Warhol fame.  I would walk the length of Middlemore’s immense medical corridor and colleagues coming the other way would nod at me.  Then, ten metres further on, they would shout back at me, “Pathetic!”

Then I went to an emergency medicine conference in San Diego, California.  I recall one evening we crossed the bay to dine in the Hotel del Coronado, a magnificent old style hotel with décor in deep brown varnished wood.  Outside, we had a stroll on the beach, where Marilyn Monroe and Tony Curtis filmed Some Like It Hot.  That night, I took a call from a New Zealand radio station.  They wanted to use my “It’s pathetic” quote as part of a publicity drive to improve New Zealand road safety.  I said no.  They tried to change my mind, and in many ways were very persuasive, but I stuck to my guns.  The reason why I was so adamant was that I did not believe the public would make a distinction between a criticism of a human action and the criticism of a human being.  “It’s pathetic” would morph into “They’re pathetic.”  That sort of attitude is absolute anathema to medical practice.  And mind, Middlemore Hospital is at the heart of disadvantaged South Auckland where the bulk of Maori and Polynesian people stay.  Many of the people involved in episodes of major trauma were, are, Maori and Polynesian.

I recall some of my colleagues thought I was being perverse, even sanctimonious and pompous.  But I’ve never had reason to change my mind.

Not that I always got it right.  I remember doing one particularly gruelling night shift and in the morning getting a call from a New Zealand newspaper.  My guard was down.  “Is it true, doctor, that in the event of unsuccessful resuscitation from cardiac arrest, medical students are sometimes offered the chance to practise intubation of the deceased?”

I answered yes.

Huge mistake.

At home the following morning, my phone rang at 7am.  I answered, assuming it would be the hospital.  No.  It was the media, the first of many calls that day.  I had an uncomfortable 24 hours.  The Professor of Medicine at Middlemore was kind enough to say to me, “You only told them the truth.”  But the fact is that to intubate somebody who has just died is unethical, because the person has not consented to the procedure.  And I chaired the Hospital’s Medical Ethics Review Committee.  I used to think I could get by on “common sense” but fortunately there was a lawyer on the committee who would occasionally gently point out to me how hopelessly wide of the mark was my “She’ll be right” attitude.

I have to confess I felt some sympathy for the Prime Minister when she admitted last week that Brexit was keeping her awake at night.  Unlike Dr Axel Munthe of The Story of San Michele who was a chronic insomniac, I’ve seldom had any trouble dropping off.  Moreover I’ve always been able to get back to sleep having been woken in the night.  When I was a child our pet dog Jet used to scratch my door in the night and ask me to let him out to answer a call of nature.  He must have known that I was going to spend a career being woken in the night.  In ten minutes I’d be back in bed and out like a light.  The few times I can remember lying awake through worry, it has not so much been at the thought of an impending disaster, rather it has been because I have felt myself to be in the middle of an impossible situation, or what the psychiatrists call a “bind”.  I can think of a few occasions in medicine when I made a mistake that kept me awake.  The bind here was that I had taken the Hippocratic Oath, “First do no harm”, and then gone on to break it. That is an existential threat.  Yet it is unavoidable.  You cannot have a career in medicine and not, at some point, several points, foul up.  The hardest thing in medicine is, having made a mistake, not to curl up in bed, but to carry on practising.  Honesty, humility, and the support of colleagues are what get you through.

Shakespeare’s Othello suffers an existential threat.  It’s not mere jealousy that keeps him awake.  It is the self-doubt, the chink in the armour of “my parts, my title, and my perfect soul” that puts him on the rack.  And Iago says, “Not poppy, nor mandragora/ Nor all the drowsy syrups of the world/ Shall ever medicine thee to that sweet sleep/ Which thou owedst yesterday.”

Disturbed sleep is a very common symptom in the GP surgery.  Patients come in requesting some mandragora, or, more likely, temazepam.  GPs constrained to consult within ten minutes might be tempted to write the prescription, and before you know it, the patient is hooked on benzodiazepines and maybe the GP will have to explain to the GMC what he’s playing at.  Far better, surely, to introduce the patient to the concept of “sleep hygiene”; regular sleep habits, avoidance of caffeine or alcohol in the evening, the importance of fitness and physical exercise, and so on.  Yet there is always a deeper level to which the doctor might delve.  What existential crisis is keeping the patient awake?  Depression, fear, and anxiety in the face of some impossible situation?  Worth asking.

A New Zealand friend of mine was once asked what her favourite pastime was, and she replied without hesitation, “Sleeping”.  When asked, “But isn’t sleep just unconsciousness?” she offered a panegyric to the experience of sleep, particular of falling asleep, that in its sensuousness I do believe some people found unseemly.

Sleep is essential to our wellbeing; sleep deprivation is a device of the torturer and a cruel and unusual punishment.  We cannot function without sleep.  Yet our neurophysiologists are not quite sure what function it serves.  One theory is that sleep is a process whereby the brain reorganizes itself in terms of cataloguing data in folders.  The hippocampus, seat of short term memory, gets saturated.  During sleep, the files are taken out of the hippocampus and transported to multiple sites of long term memory that are more secure.  This may be why people who have conditions of memory impairment such as Alzheimer’s may lose short term memory but cling on to more hard-wired information.  Musical melody might be the last thing to go, and perhaps a lifetime of music appreciation and even more so of music making, may be protective.  One of Mrs May’s predecessors who was famous for thriving on four hours’ sleep a night, developed memory impairment.

The PM has been quoted as saying, “In this job, you don’t get much sleep.”  I wonder about that.  Most professions now recognise that lack of sleep is generally detrimental to professional performance.  My obstetrics job as a junior doctor was a “one in two”, that is, every second night on call.  It is worth painstakingly mapping that out:  go into hospital at 8 am on Monday morning and emerge at 6 pm on Tuesday evening.  Return at 8 am Wednesday morning and emerge at 6pm on Thursday evening.  Return at 8 am on Friday morning and emerge at 6 pm on Monday evening.  Return at 8 am on Tuesday morning and emerge at 6 pm on Wednesday evening.  Return at 8 am on Thursday morning and emerge at 6 pm on Friday evening.  And, believe it or not, you’ve got the weekend off.  Then go into hospital at 8 am on Monday morning…  “Do the math.”  That is a 109 hour week.  It was European directives that put a stop to that.

There have been similar regulations introduced into aviation.  Pilots cannot fly more than a given number of hours within a set time frame.  Most people would regard such regulation as eminently sensible.  After all, you would not wish your surgeon or your pilot to drop off during critical manoeuvres.  You would, on the contrary, wish them to be extraordinarily alert.  However this does not seem to apply to the political class.  How often do we hear of “all night sessions” in Parliament, in the various institutions of the EU, at the UN, and in a variety of other diplomatic forums, when politicians keep going until they have thrashed a deal out?  What sort of state of mind are they in when they eventually come to ratify some critical decision, and what, in consequence, is the quality of that decision?

One of my favourite Prime Ministers is Henry Campbell-Bannerman, a liberal who sat for the Stirling Burghs and who was PM from 1905 – 1908.  He died in 10 Downing Street.  His term of office was a quiet time, you may say.  I suspect that quietude might often be an index of successful premiership.  Campbell-Bannerman went on his holidays every September for six weeks to Marienbad in Bohemia.  Can you imagine a PM doing that now?  D’you know, I wish they would.  It would be a wonderful cure for insomnia.

In Mrs May’s case, I can only imagine that her own particular bind results from the fact that, having voted to Remain, she is now in charge of a government dedicated to Leave.  In this regard, I did find her coronation to the premiership in July somewhat puzzling.  Mr Cameron campaigned to remain, lost the referendum, and promptly resigned on that basis.  Moreover, his initial plan to stay on until September to provide a period of stability was quickly shelved and, with extraordinary expedition, Mr Cameron became a man of the past.  His eclipse was total.  He completely disappeared.  He had concluded, as had everybody else, that his position was untenable.  Yet Mrs May support for Remain did not appear to be an obstacle to her accession.  You may say that, while Mrs May’s support of the Remain campaign was low-key, Mr Cameron was the key figure in putting the government into a position which he had never intended, and therefore he had to pay the price.  Yet Brexit has become the key political issue in the UK right now, and while the PM believes in democracy and the will of the people, she does not believe in Brexit.  And that, I imagine, is why she cannot sleep.

When I was wee, we used to flit a lot.  My first house was in Milton, north Glasgow.  Ornsay Street, off Ashgill Road.  I can recall the curve of the stairway, which was a kind of replica of the curve of the street where I played with my first girlfriend, Judy.  Recently I went back for a look, went for a walk, and was utterly appalled by a sense of abject poverty and got out quick.

We moved to Dowanside Road in Glasgow’s west end.  Gentrified now, but a bit rough back then.  It was a ground floor flat, with a basement.  There was a “speaking tube” between upstairs and downstairs by which no doubt those and such as those could summon the help in a bygone age.  There was a common green out the back.  Our neighbours were called Heeney.  My cousin bullied the Heeney boy mercilessly.  Considering the name, this might have had a sectarian connotation.  I was reminiscing about the Heeneys with my parents in a Lochalsh Hotel about twelve years ago.  We were in a public room and speaking in whispers, as you do in the Gaidhealtachd.  An English family group at the next table were eavesdropping, which is quite acceptable, especially as I was eavesdropping on them.

“They’re talking about their neighbours.”

“Healey?”

“No.  Heeney.”

“Sweeney?”

“No, dammit!  HEENEY!”  By this time, I was in hysterics.

Then we moved a quarter of a mile up to Crown Road North.  At this point we were cohabiting with my aunt and uncle, et famille.  I hesitate to attempt to explain the convolutions of my family’s domestic arrangements because they are so bizarre, but basically my mum and her three sisters had entered the business of care of the elderly (note this, for this blog does have a point in the end) and were opening up nursing homes in Glasgow’s west end.

It was from Crown Road North that I went to school, in Hyndland, I guess just under a mile away.  I really ought to have gone to Dowanhill but mum and dad thought Hyndland was the better option so I snuck in by some dodgy arrangement.  Not that I appreciated it.  On day two I thought, this is definitely not for me!  And scarpered.  I went home.  I was promptly delivered back to school.  I can’t remember my reaction to that, but I can’t say I’ve ever regretted my decision to do that runner.

Incidentally, there was no such thing as “the school run”.  Apart from anything else, nobody from our social class owned a car.  But me and my pals, all of us 5 year olds, we went everywhere we had to go, unaccompanied, on our own two feet.

Our next move was to Garscadden.  Millburn Ave. Why is it that Glasgow suburbs have such desperate names?  Auchinshoogle, Stobhill, Riddrie…   This was away in the far north-west, miles out of area, but once you’re in, you’re in.  So every day it was the No 6 bus from its terminus to Broomhill Cross, and the 10, 10A, or 44 (whichever turned up first) to Clarence Drive.  Millburn Ave was a cold house.  I recall we had a paraffin heater which just took the edge off it.  Oddly enough, in this arctic region, I have a nostalgia for the arrival of the ice cream van.

Next up, the definitive move (I suppose my parents would have thought of it as that) to Rowallan Gardens.  A leafy suburb in the west end.  I don’t think it was easy for them.  The bank was rather snooty about the whole thing.  In the end it went ahead because my mum, a trained nurse, took on the care of an elderly lady (in the Gaidhealtachd, a cailleach), and thus assured an extra source of income, which my father dutifully paid into the bank every week.  It was a terraced house in a street of character and the walk for me to school took seven minutes.  I was seven years old.

Sometimes I take a walk along Rowallan Gardens and past our old house.  It recently went on the market and out of curiosity I looked it up on line and did a virtual tour of the old haunts.  I must say the improvements were considerable, although the old place was still recognisable.  In the end it went for such a vast, eye watering sum that I thought, what’s this all about?  It’s only bricks and mortar, a heap of rubble, slightly organised.  Get a grip!  It crossed my mind to have a look round, as a bogus potential vendor.  I just had this great urge to walk up the garden path and be greeted by Jet, cross between a lab and a collie, our beloved dog.  But I forget we had a standing feud with our neighbours who, incensed by my brother endlessly playing the piano, and me endlessly playing the viola, would turn their radio up to ghetto-blaster proportions.  You forget the bad stuff.

How the hell did I get started into all this?  O yes, I tuned into the Andrew Marr show on Sunday morning, as is my wont, and gathered there is a particular preoccupation at the moment about Health and Social Care, and its seamless alignment.  Everybody knows that the current state of play in the NHS is that you arrive in “A & E” as a “casualty” (I use inverted commas to indicate that these obsolete and inhuman expressions are to be vilified, reviled, and eschewed), you wait for a period in excess of 4 hours (the shadow politicians prefer the expression “wait” for they would not have you know that something beneficent might be happening to you while you “wait”), and you find you cannot get to the ward because of “access block”.  “Access block” occurs because the frail and elderly, who are cramming the wards, cannot be discharged (despite the fact that they no longer need to be there) because they have nowhere to go; that is to say, the provision of “social care” at home is inadequate.

I put all this into the context of my childhood domestic arrangements because it occurs to me that a generation ago, the idea of a crisis in social care would not really have been generally understood.  The reason why no problem would have been flagged is that both child care and care of the elderly would have been deemed to be the responsibility of the family unit.  In days of yore, one family member would have been the bread winner, and one would have run the household.  Can you imagine how it would go down now if a politician were to say to the electorate, in order to care for your parents and children, it is best that you be in a stable relationship and that one of you (no need to stipulate which one) quit work, accept a diminishment of spending power, and devote yourself to running the household.

Political suicide.

Quantitatively and qualitatively, “the two minutes silence” in Dunblane Cathedral on Remembrance Sunday was a bit of a misnomer.  It lasted barely a minute, and rather a noisy minute at that, as the cathedral’s heating system roared away in a valiant effort to keep us all warm.  I shouldn’t complain.  Nobody fainted, or succumbed to hypothermia.  But it made me think; in our modern world, silence is a rare commodity.  We are surrounded by noise.  Even if, on a windless day, I go to the top of my local mountain, Ben Ledi, at 879 metres (2884 feet), a Corbett aspiring to be a Munro, I can still hear the traffic on the A84.

Some people fear silence.  DJs on the radio call silence “dead air”.  Dead air is a big no-no and to be avoided at all costs.  Often, conversations on air are conducted against a background of fuzzy muzak which does not rest for a crotchet.  Even Radio 3, once proud of its aeons of protracted silence, is now wall-to-wall.  Scientific documentaries on television, even when discussing anything from quantum physics to cosmology, are all delivered against an unceasing soundscape of portentous musical drivel.  Hotel elevators lift you skywards against an endless loop of “elevator music”, just in case these few moments of enforced captivity compel you to stare into an abysmal void of nothingness.  Wallpaper music pervades doctors’ and dentists’ surgeries, restaurants, even banks.

I used to think that John Cage’s Four minutes thirty three was nothing more than a wisecrack and a gimmick but now I’m not so sure.  I think I would go out of my way to attend a rendition.  This work is “performed” by a concert pianist who sits in silence before the keyboard for the duration, as indicated on the tin.  The idea of sitting in silence in a concert hall filled to capacity, for just over four and half minutes, I find deeply appealing.  Perhaps the performer will prefer a slower tempo and the work will last five minutes.  What would the critics say? What would constitute a bad performance?  An inattentive audience, lots of coughs, or the pianist taking a fit of the giggles?  I checked a performance out on the internet and was amused to discover the work has three movements.

Silence is integral to great music.  It both encapsulates it, and infiltrates it.  Arvo Part’s Cantus in Memory of Benjamin Britten, which happens to be the “signature tune” of my current work-in-progress, does not start with the single toll of a bell, but with a rest, and a silence, into which the bell announces its toll.  The brief, distilled closing movement of Stravinsky’s last substantial work, Requiem Canticles, is punctuated with silences that are pregnant with meaning.  I was once privileged to sit in silence in Abbey Road’s hallowed Studio One while the LSO under Michael Tilson Thomas made a recording of the Brahms Haydn Variations.  It must have had something to do with the peculiar acoustic of that space, but the silence that enveloped the orchestra just before each take was more profound than anything I have ever known.  Once on the Antarctic Peninsula a group of us took a zodiac into a deserted bay and cut the engine.  There was absolute, magical, quietude.  Then I remember feeling as much as hearing a low-pitched sinister rumble and seeing an enormous wall of ice calve itself off the shoreline and plunge into the ocean with a deafening roar.  We started up the zodiac engine and got out, pronto.

I did achieve a two minutes silence, on Armistice Day.  It turned out indeed to be a day of remembrance.  I went to the funeral in Clydebank of an old musical friend.  I met up with a group of friends with whom I have been playing music for more years than I care to remember.  Four of us used to play late Beethoven quartets together.  Iain sat on the front desk of the National Youth Orchestra of Great Britain.  He was the most naturally gifted violinist I have ever known.  But he also happened to be good at mathematics so his life went off on a different tack.  I remember four of us went through to the Edinburgh Festival to hear the Amadeus Quartet play Beethoven’s last quartet, Opus 135.  Norbert Brainin, Siegmund Nissel, Peter Schidlof, and Martin Lovett.  They obligingly autographed Iain’s copy of the first violin part, on the opening page of the last movement, with its portentous and somewhat tongue in cheek statement: Must it be?  It must be!  It must be!  Apparently Beethoven was having a joke about his laundry bill.  That slow introduction, Grave, ma non troppo tratto, is punctuated by silences.  I remember that in the final rendition of the Op 135’s last quirky theme, played pizzicato, Norbert Brainin nearly played it arco, with the bow.  I vividly recall the self-critical look of exasperation on his face.

On November 11th we listened to an ancient recording of Iain playing Elgar’s Sospiri.  So sad.

Hush now.

 

With respect to “draining the swamp”, Newt Gingrich has suggested that President-elect Trump hit the ground running.  Mr Trump himself has signalled that securing the borders and deporting or incarcerating illegal immigrants with criminal records (apparently two, maybe three million of them) are priorities.  Would it be reasonable to call such action a “purge”?  Is this all vaguely reminiscent of the McCarthy witch hunts of the 1950s, which Arthur Miller allegorised in The Crucible?

Many people on this side of the Pond have taken comfort from the fact that, once Mr Trump realised he was about to cross that magical line of 270 of the collegiate votes, his tone became more conciliatory.  Before the election, Mrs Clinton was “crooked Hillary”.  Her crimes were “egregious”.  He was intent on putting her in jail.  In contrast, Mr Trump’s victory speech was calm and measured, even Presidential.  He said, “I want to thank Secretary Clinton, for her service to this country, and I mean that most sincerely.”  The italics are mine.

Have you read “On Bullshit” by Harry G Frankfurt, Professor of Philosophy emeritus at Princeton University (Princeton University Press, 2005)?  Do.  It’s a life-changer.

Mr Trump asks us to believe that he is holding two points of view simultaneously in his head that are mutually contradictory.  George Orwell had a term for this feat of mental gymnastics: he called it doublethink.  There is a story, doubtless apocryphal, about the young George Washington escaping a thrashing by telling his father the truth. “Father, I cannot lie.  I did push the privy into the ravine.”  Had President Washington survived into our post-truth age, he would doubtless have deployed a different argument.  “I both did and didn’t push the privy into the ravine.”  Perhaps he would have evoked the physicist Erwin Schrödinger’s cat.  Schrödinger’s cat is a thought experiment designed to demonstrate just how crazy is the world of quantum mechanics.  You put a cat in a box along with a piece of radioactive material which has a 50% chance of breaking down.  Should it do so, a vial of poison is broken and the cat will die.  You don’t know whether the cat is alive or dead unless you open the box and look.  The point is, in the quantum world, the cat is both alive and dead.  We are all living in a quantum world.

When I think of Orwell and doublethink, I think of another extraordinary example of prescience in 1984, his anticipation of reality TV and the politics of hate, encapsulated in the “Two Minutes Hate”, in which an enemy of the state is paraded and viewers hurl abuse at their telescreens.  All this year we have seen the Two Minutes Hate in action, with politicians gaining capital out of urging us to blame our woeful condition on the other guy, the outsider, the infiltrator.  G K Chesterton was once asked to write an article for The Times about what constituted the biggest problem in the world today.  He replied, quite simply, “Me.”  By that I think he meant that the sin of the world (see how our hackles rise at that archaic biblical world… sinful?  Moi?) does not reside in Someone Else, it runs through all of us.

Mr Trump reminds me of Othello, an outsider who is called upon to do the state some service.  During his campaign, he said that if elected President, he would ask Congress to declare war on Islamic State.  Hatred is an act of self-harm.  Look what Othello says at the end:

Set you down this,

And say besides that in Aleppo once,

Where a malignant and a turbaned Turk

Beat a Venetian and traduced the state,

I took by th’ throat the circumcised dog

And smote him thus.

Then he killed himself.

Yet maybe not.  Maybe Iago – whatever Iago is – has not yet seized control of the President-elect.  They say you should campaign in poetry and govern in prose.  Who knows, we may yet hear from him some of the beautiful Othello music:

Keep up your bright swords, or the dew will rust ‘em.