Geneva, Thursday 2 April 2020

I woke early today and stood outside with a cup of tea. It was a beautiful crisp morning with a clear sky unblemished by a single jet stream. The birdsong was a full-on symphony. For the third day running, I watched a crow in frenzied pursuit of a red squirrel, chasing up and down the trees in front of our balcony. The former was flapping around hopelessly between the branches unable to get near his prey; the latter was simply far too fast and agile. All would seem to be well in the world.

Yesterday, one great British institution – the BBC – announced that another great British institution – David Hockney – has gone into lockdown at his house in France. At the age of 83, Hockney is still drawing, painting and e-painting. I have never totally fallen for any individual painting of his but I am a huge admirer of the trajectory, output and influence of his lifetime’s work. Particularly admirable is the facility with which he – in his very senior years – has brought all his many and varied styles together in his iPad painting. Here’s one of his garden lockdown scenes e-dashed off in the last few days. Accomplished naïvety!

The Beeb also announced that another monumental British institution has suffered a mortal pandemic blow. Wimbledon! And we had tickets to go with friends of yesteryear. Game, set and match, coronavirus! There is, according to “sources,” little hope for the Open Golf Championship on 16-19 July.

Our putting competition continues despite the spirits being a tad dulled by the incessant stream of disconcerting news. Today, I won again – just – (1 up) taking the running total to 10 games to 4.

“Do you think that one day, if I were no longer around, another man might eventually live in our house?” asks the husband. “It’s possible.” replies the wife. “Do you think that one day, if I were no longer around, another man might eventually cook for two in our kitchen?” he asks. “It’s possible.” she replies. “Do you think that one day, if I were no longer around, another man might eventually share our bedroom?” he asks, slightly anxious. “It’s possible.” she replies. “Do you think that one day, if I were no longer around, another man might eventually use my golf clubs?” he asks really quite perturbed. “Out of the question!” she replies. “He’s left handed!”

Geneva, Wednesday 1 April 2020

Let’s stay with the nurses; not only because nurses are fab but also because I see that all the COVID-19 dedicated hospitals being constructed in the UK as I write are to be named the “Nightingale Hospitals.” And so they should! Florence Nightingale was quite some gal! If ever there was someone who made a difference to the plight of sick people in big numbers, it was her.

Florence Nightingale found herself with fifteen other nurses attached to the British Army fighting the Crimean war in the mid-1850s. She was appalled by the plight of the wounded and sick soldiers. Nothing was done for them. More were dying from preventable infections than from wounds because of the appalling insanitary conditions of the make-shift hospitals. Giving consideration to the wounded and sick of their armies was something governments of the day simply didn’t do. She let her displeasure be known back in London via a letter to the Times which, of course, was not welcome across the board, but hit hard. 

She was probably the first person in health care who recognised the principle: if you want to manage it, measure it. She also pioneered data visualisation. Take a look at this graph she made from data gathered in the Crimea. She presented this and similar graphs to the British parliament as evidence of the impressive impact achievable on seasonal mortality due to infectious disease if basic measures of hospital hygiene were implemented. (She even made dumb-downed versions for the MPs who were unused to looking at graphs.) Her data-based insights paved the way for sanitary reform at home and abroad. She designed better hospitals; every British nurse will have worked on a “Nightingale” ward. She insisted on a formal and universal classification of disease. She was the first woman member of the Royal Statistical Society. Even though she wrote that she had been called to her work by God, she established the first ever secular nursing school at St Thomas’ Hospital in London; a major step in the professionalisation of nursing. She never married and, inevitably, became an icon of Victorian culture.

Less well known – and, arguably, as influential – was a letter written by Miss Nightingale in 1861 to a Swiss gentleman by the name of Henry Dunant. Young Dunant had been on a business trip to Northern Italy in1859 when he came across a village called Castilinagno the church of which was full to overflowing with the wounded from a battle just up the road at Solferino. He did what he could do by calling in as many people as possible to help. He realised that from whichever side of the conflict the wounded came, they were no longer enemies. “Tutti fratelli!” was the call of the day. (We’re all brothers!) Deeply moved by this experience, he hurried back to Switzerland and wrote his visionary “A Memory of Solferino.” It’s difficult to believe now, but the European aristocracy of the time saw war as something noble and generally fun. They hadn’t yet realised the impact on soldiers of increasingly effective firearms. Dunant’s publication in which he gave a vivid and moving description of his experience caused wide spread concern in elevated societies. He made four proposals. The first three were: that the wounded should be spared further attack; that the wounded should be protected by a universally recognised flag (later accepted as a colour reversal of the Swiss flag i.e., a red cross on a white background;) and that a neutral, international commission would take care of the wounded whenever there was a battle. The fourth proposal was that the first three would be agreed upon in a binding treaty between all nations. The commission would become the International Committee of the Red Cross and the treaty would become the First Geneva Convention of 1864. Great stuff!

And so far, so good. But Dunant hadn’t factored in Florence Nightingale. And didn’t she have something to say? She let her displeasure be known again. Three of these four proposals were fine but she got quite exercised over the idea of a neutral body caring for the wounded. Bruised by her own experience, she pointed out that this would simply relieve governments of their responsibility for their own wounded soldiers. She was on it like a bonnet! This is the reason why the medical services of all military forces now carry the red cross (or red crescent in muslim countries.) As a result, not only are the wounded and sick protected from attack but also military health-care personnel and facilities likewise. This change was incorporated into the Geneva Convention. It is difficult to think of anyone who has had more influence on our lives and well-being than our Florrie.  

It must have been 1991. Kabul under heavy bombardment. I was asked if I could spare a minute between operations to speak to a journalist. Well….  perhaps it was important to let the world know what was happening here. I gave him a run down about what we were seeing (just so many wounded people) and what we were doing (barely functioning as a surgical hospital.) I asked him if he would like to speak with one of our nurses. He replied “Why do I need to do that? I’ve spoken to the surgeon!” 

Busy day in lockdown. No putting. Watch this space.

Geneva, Tuesday 31 March 2020

The Thai-Cambodian border, 1988. The International Committee of the Red Cross ran a surgical hospital in one of the sprawling camps that were home to over 500,000 Cambodian refugees. The population that the hospital served included the refugees and anyone coming from inside Cambodia brave enough to navigate their way through the border minefields. (About 15% of our patients were mine-injured.) The hospital ran like clock-work under the all-seeing eye and disciplined but compassionate rule of the Head Nurse. Within twenty four hours there, I realised that she was the star of the show. 

It was an extraordinary experience for a young surgeon! When on duty, it was for all-comers. Anything surgical arrived at the door. There was no specialist referral. Médecins Sans Frontières ran the maternity service next door. Many of their clients came from over the border after two or three days in labour. If the MSF midwife asked us to do a caesarian section – a daily event- there was no need for discussion. There was no possibility of an ultrasound scan. As a result, we would never know if the be-laboured woman was carrying twins until, having delivered one slippery little screamer, I exclaimed to the team “Wait a minute, there’s another one in here!” They never, ever believed me until I held up the evidence. I often wonder how often these days an obstetrician would undertake a caesarian section not knowing it was for twins.  

Given seven years of field surgery, a glass or two of wine and a captive audience, I would happily tell surgical stories until the end of lockdown. But, I’ll stop here. There is a much more important COVID-19 story for repetition long after lockdown. It is the everyday and seemingly mundane story of running a hospital wherever it is. The provision of safe and effective curative medicine and surgery is dependent on a whole team of health-care professionals. They, in turn, are dependent on infrastructure including the equipment, machines, medicines, instruments, sterilisers, cleaners … the list is long. This infrastructure is held together by administrators responsible for recruiting and paying the staff, purchasing and putting in place the infrastructure, ensuring a constant supply of electricity and water, a functioning and dignified mortuary, drains that drain, disposal of medical waste  … another long list. You get the picture? The COVID-19 pandemic has rightly elevated health-care workers to a position in public perception of being necessary for national integrity. This position, up to now, has been the near-exclusive domain of the armed forces. (This does not excuse constant use of terms like “war,” “battle” “frontline” “weapons” and “heroes.”) Let’s be clear though, the fuel of this engine is neither clever medicine nor swashbuckling surgery; it is the care provided by all the professionals concerned and, in particular, nursing care. Whilst health care is impossible without infrastructure, without care, it doesn’t even resemble health care. Go nurses! If during the next days and weeks, I drop other surgical stories into the Lockdown Diary, please bear this in mind.

The putting competition….. Yesterday I won 2 up; today 1 up. The running total is: 9 games to 4 in my favour.  For those who have witnessed my wife’s putting for real on the course, this is most unexpected. But, if we believe the epidemiologists, there’s still a long way to go!

So, a moth goes in to see a dermatologist. “Hello” says the dermatologist. “What can I do for you?” The moth replies “Well, doctor, I’ve been feeling a bit down. I’ve lost my job. I’ve split up with my girlfriend. I’m maybe drinking a bit too much. Life’s a bit of drag, really.” The dermatologist says “I’m sorry to hear about all that. But I’m a dermatologist. I do skins. Maybe you should see a psychiatrist. Why did you come in here?” The moth says “Well, your light was on!”