'Who the f**k is cutting my f**king T-shirt? That cost a thousand pounds. I am going to sue you, you b.a.s.t.a.r.d.'

The nurse apologised and explained why she had cut itso that I could examine his chest easilyand said we had spares he could have afterwards. He thanked her by spitting in her face and accusing her of being a lady of loose morals. For A&E doctors at this stage, it can be very difficult. Is the patient acting this way because this is their normal behaviour pattern or are they acting in that way due to pain, fright, lack of oxygen and/or brain damage? And if you treat them against their will, are you doing it in their best interest because they are not in a rational state or are you a.s.saulting them? These are all judgment calls, with no right or wrong answers, which makes A&E doctors' and nurses' jobs interesting but frequently difficult.

All his observations were so far normal, and he had no obvious head injury of note. I therefore decided that he was acting in this manner because he wasn't the most pleasant of people. He started to swear about the neck brace and collar again.

'Look mate. We are cutting off your T-shirt because we want to examine your chest and I do not think the T-shirt cost a grand even if it is a real Ralph Lauren one. As for your neck brace, we will take it off as soon as we have X-rayed your neck.'

He didn't seem satisfied.

'F**k the lot of you. I am out of here.'

He ripped the collar off, put the nurses at risk by pulling out his cannula and somehow stormed as far as the end of the resuscitation room, where he was nicked for stealing cars and dangerous driving. This was quite a feat with a broken leg, but it is amazing what the power of the mind and the thought of being nicked (oh, and a temporary plaster cast) will do. After he realised his fate, he accepted treatment and was in theatre later that night to have his leg fixed properly.

How to be seen quickly

Ever gone to A&E and been frustrated at having to wait 3 hours and 59 minutes to be seen and sorted out? Over the years, I have observed various methods of how to get seen quickly. Some of these methods are very inappropriate and have been used by some quite naughty patients to speed up their care at the expense of more needy patients. Please remember that by lying about symptoms, you are putting your and other people's health at risk. Don't do it please.

1. Have a genuine emergency. Best is probably your heart stopping. The ambulance will call us to tell you are coming in and you will be seen straight away. During the day, you may even see a consultant, unless they are doing something that management have deemed more urgent, such as responding to a complaint letter, filling in a compensation form or going to a meeting with a silly t.i.tle such as 'Introducing a Patient Centred Care Flow Pathway: Interim Discussions'. 1. Have a genuine emergency. Best is probably your heart stopping. The ambulance will call us to tell you are coming in and you will be seen straight away. During the day, you may even see a consultant, unless they are doing something that management have deemed more urgent, such as responding to a complaint letter, filling in a compensation form or going to a meeting with a silly t.i.tle such as 'Introducing a Patient Centred Care Flow Pathway: Interim Discussions'. 2. Similarly, have a serious trauma and you will have a team of doctors waiting to see you on arrival. 2. Similarly, have a serious trauma and you will have a team of doctors waiting to see you on arrival.3. Be a child and cry a lot. If that doesn't work, cry loudly, then start to scream.4. If you are pregnant, say you think you are having your baby. This scares A&E staff s.h.i.tless and we get you a swift transfer to the maternity unit. 5. Say you have chest pain as soon as you book in with reception. Clutch your chest and say you feel sick and the pain is going down your left arm. This guarantees going to the front of the queue. Only do this if it is true. About a year ago, I had a bloke who said all this to the receptionist. I was called away from the patient I was seeing and went to see him. The pain had gone (it had never been there) and he had injured his foot playing rugby. He admitted to making it up, as he had a date that night and didn't want to be stuck in A&E. 5. Say you have chest pain as soon as you book in with reception. Clutch your chest and say you feel sick and the pain is going down your left arm. This guarantees going to the front of the queue. Only do this if it is true. About a year ago, I had a bloke who said all this to the receptionist. I was called away from the patient I was seeing and went to see him. The pain had gone (it had never been there) and he had injured his foot playing rugby. He admitted to making it up, as he had a date that night and didn't want to be stuck in A&E. 6. If you have a minor injury, make it a really simple one such as a broken wrist that emergency nurse pract.i.tioners can treat. You don't want to have to wait to have to see a doctor. 6. If you have a minor injury, make it a really simple one such as a broken wrist that emergency nurse pract.i.tioners can treat. You don't want to have to wait to have to see a doctor. 7. Have a condition that an A&E doctor can treat and doesn't have to get specialists to see you. It is bad enough having to wait to see us, but if you have two waits then that is doubly bad. You may even get admitted to a ward unnecessarily, just so that you don't breach the government's 4-hour target. 7. Have a condition that an A&E doctor can treat and doesn't have to get specialists to see you. It is bad enough having to wait to see us, but if you have two waits then that is doubly bad. You may even get admitted to a ward unnecessarily, just so that you don't breach the government's 4-hour target. 8. Be a doctor or nurse at the hospital where you go. Or be a friend or relative of theirs and take them with you to A&E. 8. Be a doctor or nurse at the hospital where you go. Or be a friend or relative of theirs and take them with you to A&E.9. If you are a policeman, fireman or ambulance man, come in wearing your uniform so that the triage nurse knows you are 999. There are some very minor perks to serving the public. 10. Come in with police. It is not that we want to see you that quickly, but we know that the police are needed back on the streets and they don't want to be here. 10. Come in with police. It is not that we want to see you that quickly, but we know that the police are needed back on the streets and they don't want to be here. 11. Please note that calling an ambulance will not speed up how quickly you get seen. 11. Please note that calling an ambulance will not speed up how quickly you get seen.12. ...Neither will saying 'NHS Direct told me to come straight away.'13. ...Neither will saying, 'My father is a big contributor to the local area and paid for your new scanner, you know. I want to be seen now.' 14. The best one I have found, which never fails to work, is simple. Be a politician or an important hospital manager. Not only will you be seen straight away, but you will be seen by a consultant. As well as being seen straight away, you will get immediate access to any form of investigation and if you need to see a specialist, then this will happen immediately. No wonder the politicians and managers don't really know what is happening in emergency care. 14. The best one I have found, which never fails to work, is simple. Be a politician or an important hospital manager. Not only will you be seen straight away, but you will be seen by a consultant. As well as being seen straight away, you will get immediate access to any form of investigation and if you need to see a specialist, then this will happen immediately. No wonder the politicians and managers don't really know what is happening in emergency care.Please note that this is only my prejudiced opinion and sarcastic sense of humour and not really NHS policy.

The dangers of cannabis

It was 4 p.m. on a Thursday. I picked up the next card out of the boxa 19-year-old with personal problems, who was accompanied by his mother. No. No. No! Not another attempted suicide. It drives me mad. With people who have suicidal ideation, my sole job is to check they are medically OK and then determine if they are very suicidal and need to see the psychiatrist today or if it can wait for a GP review in a few days' time. I looked around to see if anyone would notice if I put the card back and picked up something less soul-destroying. No luck.

'What are you seeing next?' asked my consultant.

'Nineteen-year-old. Personal problem.'

'Easy,' he said. 'Just determine if they need to see a psychiatrist today or their GP in a few days time'.

'Thanks for the advice,' I said sarcastically.

'It's a bit boring, though. I'm about to see a bloke with something where it shouldn't be,' he retorted and laughed in a quite inappropriate way.

I had no idea what he was on but I smiled and answered something about how I thought psychiatry patients got a raw deal and how I was quite interested in them. It was one of those comments that you couldn't tell if you meant it sarcastically or not.

I went to the private interview room nicknamed WD40 (it is called the 'Want to Die' room and the hinges need some oil, hence the name). There I saw this very posh-looking mother and her son, who also looked very posh, except that he had an eyebrow ring, dreadlocks and was playing with a packet of Rizlas. (He was a true Trustafarianattempting to be a hippie, but with Daddy's trust fund to support him.) 'So what's the matter?' I asked.

'What are those?' He pointed at a smoke detector. 'Turn them off; I don't want people to know what is going on.'

'They are smoke detectors. Don't worry. What's the matter?'

'Who are you?' he asked without making eye contact.

'I'm a doctor.' I turned to his mother. 'Did you bring him here?' I asked.

'Yar. I just don't know what is going on. He is not himself. He is normally so polite and nice. All he does is scream and say they are after him. I do not know who they they are.' are.'

'There is a battle of good and evil and they need me dead,' he interjected. 'She doesn't understand.'

The conversation continued in a similar vein and it became quite obvious that this was a not a case of suicidal ideation, but an acute psychotic paranoia episode. Not only would he need a psychiatrist to review him, but he would probably need to be admitted to a psychiatric hospital.

As I continued my questioning, it transpired that he had recently been using cannabis. It had started a year ago at his boarding school. He was destined for four As at A-leveland probably a place at Oxbridge that our cla.s.s system had predetermined for himbut he started to smoke dope and lost interest in most things except weed. He pa.s.sed his A levels but only just. He and his parents had planned for him to go on a gap year travelling to find himself and the true meaning to life, or study pottery at St Martin's College of Art or something like that. He never found himself. All he found was a harder dealer. Over the last few weeks he had been buying skunkstronger cannabis than what he was used to. That was when the paranoia started. He slowly changed from a fast-food ordering, ambivalent and stoned teenager into a psychotically paranoid man.

As it was within working hours, it wasn't a fight to get a psychiatrist. Psychosis is the interesting part of psychiatry. Most of their work in A&E is now personality disorders and attempted suicides/cries for help/attention-seeking behaviour. This was good old proper psychosis, but with a new causevery strong cannabis.

I cannot be 100 percentsure that this lad was psychotic because of the cannabis. However, there is a correlation between cannabis use and psychosis and schizophrenia. Whether it is a cause or a correlation, no-one can be sure, but both are on the rise in society and so I reckon that cannabis is at least a causative factor.

So, despite the evidence of this, the government confused the law and people thought that cannabis had been decriminalised. What folly. People like this lad were not scared of the consequences of taking this very strong hallucinogenic drug and so built up an addiction. So what's my solution? I think the answer is legalising the drug. These two facts are not contradictory. Let me explain.

Cannabis use is widespread in teenagers and the young adult population40 percentof people under 20 have taken it. When I was a teenager, the cannabis on the street was relatively mild but now the dealers are selling stronger and stronger stuff.

There are two options. One is keep it illegal and punish people more severely for using it. However, that is never going to workyou can't arrest 40 percentof the population. Prohibition doesn't work. Anyway, in some cases the police don't actively encourage it, but do turn a blind eye. For example, during the last World Cup the foreign police didn't seem to mind our football fans smoking it, as it calmed them down and stopped them beating the s.h.i.t out of the opposing supporters. Medically it is, I believe, much safer to go on a one-night bender getting stoned rather than a drinking binge. I would also feel much safer walking past a group of stoned teenagers than a group of drunken ones.

The alternative is to legalise it. Then you do two things. You can control the quality and power of the drugthe weaker stuff still has the same instant relaxing effect people use it for, but is probably less likely to cause the longer term decline in function and psychosis. You then create very high sentences for dealing with other stronger forms of cannabis.

Users then have a standardised and controlled drug, which is cheaper than the dealers can sell it for and also much safer. Market forces reduce the number of dealers; fewer people go to them and so fewer people are introduced to more dangerous drugs. The cannabis can be taxed and the money spent on treating those that are addicted to drugs, while the rest of the population can make a judgment call about whether they take the drug, knowing the risks and benefits (as we all do when drinking alcohol).

Unfortunately, the government's half-way house is the worst of both worlds and is a ridiculous compromise. It has encouraged the rise of dealers selling very strong and dangerous cannabis. Please reverse this decision, and go back to the drawing board. Get a Royal Commission on how to deal with cannabis and generally tackle drugs in societybut please get some A&E doctors' advice because we deal with it and its consequences every day.

For fit's sake

There are two explanations for the events of last night. First, the organiser of the event was a complete idiot or, second, he was just sick and twisted. I hope the latter, but rather think it's the former. Imagine you were in charge of an Alcoholics Anonymous summer party. Would you take them drinking? No! Or a vegetarian community group, would you take them to a slaughter house? No! Or a nudist group, would you take them clothes shopping? No...but why not? Because it would probably upset them and make them ill.

So why on earth did a local epileptic support group on a summer weekend away organise a disco with strobe lighting? You couldn't make it up. It was epilepsy city in my A&E. Two fitters, one pseudo fitterhe made it up 'cos he was feeling left out. (You can tell if a fitter is making it up by dropping their arm on their face: if it hits the face, they are not making it up but if they move the arm so that it doesn't hit them, then they are making it up.) Two people also attended A&E because they thought they might have a fit, one carer came with chest pain and one with stress. Luckily, it wasn't too busy an evening otherwise, so I saw the funny side.

The best bit came when a druggie was in and saw these two people fitting, and when they woke up, asked where they got their E from as they were really moving with the beat!

The state of some nursing homes

Today I had a 78-year-old confused and scared lady come in from a residential home. The ambulance form said she came in because she was short of breath. The home didn't send anyone with her and there was no accompanying letter. I phoned the home and there had been a change of shift since she had been admitted. No-one really knew what had happened or why she was sent in. I then asked for some details about her past medical history. No-one seemed to know much about that either.

This is a problem that is becoming far too frequent. It is a sad indictment of how we care for our elderly population, where homes are often run for profit and not necessarily to provide as good a service as possible. As always, when there is a problem, it gets dumped on A&E and the ambulance service. I couldn't find any new problems with her and ended up sending her back home with no change in her medications.

Why aren't GPs called out more often for these types of problems? They know their patients and know what is normal for them. Why can't homes give us a clue to the problem and send a letter or carer? Why does this happen so often? Why isn't there a word in the English language to describe me gripping my fingers and making angry facial expressions, which I could use to describe my frustrations?

The best year for the NHS?

I read with interest that Patricia Hewitt, Secretary of State for Health, claimed that 2006 was the best year ever for the NHS. I really think she has lost her last marble. Yes, money has been poured in to the NHS, but in such a bad way that it has antagonised the NHS workers. For those of us who love the concept of the NHS, it has been one of the most miserable of years, not the best ever.

In 2006 we have seen plans for haphazard reorganisation lead to hospital closures without alternative options being in place. We have seen various trusts go virtually bankrupt and having to call in ridiculously expensive management consultants. There has been a loss of nursing and vital ancillary staff jobs and some trusts have seen posts for doctors frozen to save money. Meanwhile, the benefits of being an NHS hospital doctor have been eroded (e.g. by plans to reduce study budgets).

Some private finance companies are making a fortune from poorly negotiated PFI (private finance initiative) contracts and Private Treatment Centres are milking in the profits from guaranteed payments for operations that may or may not happen. The waste drives hospital doctors mad. Meanwhile, in GP land, despite their pay increases, doctors are feeling less and less motivated and more disillusioned with a centrally directed NHS and erosion of their autonomy.

However, it is not just me who believes that 2006 has been a disaster for the NHS. As the BMA (British Medical a.s.sociation) council chair James Johnson said, 'Health workers and patients are paying the price for ill-thought-out government policies such as PFI and for poor NHS management that has led to job cuts and clinic closures...' (for more information see http://www.bma.org.uk/ap.nsf/Content/pr141206).

Fortunately, it is not just doctors and nurses who realise that the fundamentals of the NHS are being eroded. The campaign to keep the NHS public has seen phenomenal growth this year and the number of pet.i.tions and demonstrations about ill-planned closures has increased dramatically.

What is really amazing is that it is not just me that disagrees with the NHS reform plans as they are at present. At a hospital close to my heart, there was Hazel Blears, the chairman of the Labour Party, campaigning against the effects of her party's policiesin this case the closure of the maternity unit in Salford. Reading on the BBC website, I also learned that in April John Reid (a senior Labour politician) campaigned against closures at his local hospital (for further information see http://news.bbc.co.uk/1/hi/uk_politics/6213445.stm).

But, Mrs Blears and co.stop being so hypocritical and NIMBYish. If you don't support these hospital closure programmes you have only got yourselves to blame. It is the effect of sofa-style government without proper scrutiny that leads to the effects of the unintended consequences. So, Blears and co., since you obviously agree with me that that these NHS reforms (which are needed) have been very badly organised and damaged the NHS, then surely you must resign from your positions and campaign for a properly run NHS. If you did this, then I would imagine that Nye Bevan might be turning that bit less in his grave.

Hoping that the ground will swallow you up

It is an easy mistake to make. You are seeing lots of patients, all of whom are new to you, and sometimes you make an a.s.sumption about a patient and the person with them. When this is wrong, it can be very embarra.s.sing. Some of the a.s.sumptions I have made, have made me want the earth to swallow me up: Me Me: '...And you are his mother.' Patient's relative Patient's relative: 'Wife. Not mother'. Me Me: 'Ah, yes. Oops'. To a patient and relative holding hands To a patient and relative holding hands: 'And you are her partner?'. Relative: Relative: 'No. Brother.' 'No. Brother.' To a male relative who was there with his unconscious partner in a blond wig To a male relative who was there with his unconscious partner in a blond wig: 'So what happened to her tonight?' The friend replies The friend replies: 'He has been drinking. He is pre-op, darling. Pre-op. "She" is still a he. Read the name on the card. Stephen is hardly a female name is it?'.

The list goes on and on. However, I also find that some people automatically go out of their way to tell me their significance to each other.

To an elderly lady accompanying her friend To an elderly lady accompanying her friend: 'And you are her friend?' 'No, we are lesbian partners. We have been together now 45 years. We first met when I was only 25 and then we bought our first house together in Stockton-on-Tees. Her family never approved, but mine didn't really understand what lesbians were so just accepted that we were friends. But we are not. We are, but first and foremost we are a couple. A lesbian couple. And don't get embarra.s.sed, it is beautiful.' 'No, we are lesbian partners. We have been together now 45 years. We first met when I was only 25 and then we bought our first house together in Stockton-on-Tees. Her family never approved, but mine didn't really understand what lesbians were so just accepted that we were friends. But we are not. We are, but first and foremost we are a couple. A lesbian couple. And don't get embarra.s.sed, it is beautiful.'

I wasn't embarra.s.sed. I was just a little bored with the life story and felt as if I was on the set of Little Britain Little Britain.

One of the things I tried after a spate of faux pas was to not ask what the relationship of the friend/relative is. After one experience I will not make that mistake again. There I was, asking this lady of 65 all about her abdominal problems and her regularity down below, etc., and then I said, 'I need to examine your abdomen. Would you like it if your friend was here or would you prefer me to ask him to leave?' As I said this, I looked at the slightly dishevelled man who had been standing inside the curtains throughout the whole of our consultation and who had even said 'h.e.l.lo' as I walked in.

'I don't really mind. But he is nothing to do with me. I thought he was with you.'

'Oh', I replied as I could hear nurses looking for the elderly patient who had been brought in for new onset confusion and had gone missing...behind my curtains.

As my experience has grown, I have decided that the easiest way is either to flatter every relative (e.g. say to a mum with her child, 'And are you her big sister?') or just put my hand out to a relative and say, 'And you are...?' and wait for them to reply. I just wish they taught us simple tactics like that at medical school so I wouldn't have had to be so embarra.s.sed over the last few years.

Two similar patients, but two different outcomes

You may think that wherever and whenever you go to A&E, you will get a similar standard of treatment. This is far from the truth. As well as medical expertise, it is the process of how emergency patients are cared for that really affects their outcome. I was at a recent training day when two cases were discussed that really showed this to be true.

The first was a 65-year-old man with severe pneumonia. The junior A&E doctor saw him after a wait of a couple of hours. After various tests, she had noticed how unwell he was and discussed it with her senior A&E colleague. The senior doctor advised that this patient needed a central line, and should then be transferred to ICU. Despite this, protocol in his hospital dictated that the patient be referred to the medical team first and they would have to arrange ICU admission. The senior A&E doctor couldn't sort the patient out as there was a very long wait of minors patients to see.

The man was admitted to the medical admissions unit after 3 hours and 49 minutes in A&E. After another 90-minute wait, he then saw one of the medical doctors. At this point the patient was deteriorating rapidly. His breathing was getting worse and his blood pressure was falling. The junior medical doctor, who was only in his second year of training (as a GP not an emergency physician), did not have the same grasp of the urgency of the problem as did the senior A&E doctor. They didn't see the problem of spending a long time asking detailed questions about past medical history instead of getting on and treating the life-threatening condition.

After another hour, the medical registrar came to review. He soon realised that the patient was very sick and needed this central line. However, he didn't feel confident in putting one in as it wasn't part of his routine workhe was training to be a rheumatologist and had just had a year out to do research. He asked the anaesthetist to do it for him.

After another 30-minute wait the anaesthetist came and put in the central line and treatment was started, as well as closer monitoring of his vital signs. At the same time the medical doctor referred him to ICU. The ICU doctor came down and accepted him immediately to ICU. However, they had not been prewarned to expect this patient, so spent 2 hours discharging another patient from the ICU to the ward to create a free bed. Finally, some considerable time after first coming into A&E, the patient went to ICU, where proper treatment started. However, by this time his kidneys had stopped working and he needed dialysis until he was well again. His breathing had got even worse and he had to be intubated. After a two-week stay in ICU, he died from multi-organ failure induced by the chest infection.

In this case, no individual did anything wrong, but the system was at fault, in not allowing the patient to get speedy ICU treatment. As a whole, the care was not perfect and possibly contributed to his death. As a government statistic it was great he was seen and admitted within 4 hours of arrival in A&E. There are no stars for the quality of his care.

The second case was very similar and happened at a hospital 50 miles away from the first one (and it wasn't a centralised teaching hospital, but a bog-standard district generalthe type the government don't seem to like). The difference was that they had better processes in place and had invested money in emergency nurse pract.i.tioners (ENPs).

A sick man, 68, was brought in with a very nasty chest infection. The A&E senior specialist doctor in this hospital was not busy seeing minor patients, as that was the ENP's job, and so was free to see the patient with her junior colleague. She realised immediately how sick he was.

Also, in this hospital there are very close links between ICU and A&E, which were not there in the first hospital. When the A&E doctor called, the ICU doctor took down all the information and got the unit ready to accept the patient. The unit didn't insist that the patient be seen by a medical doctor (who, remember, may not have a specialisation in acute/ emergency care) but just wanted the name of the medical consultant on that day so that when the patient left ICU they had a set of doctors they could liaise with.

The A&E doctor (who is experienced in putting in central lines) inserted one into this patient while they were in the safe environment of the resuscitation room. She taught her junior doctor how to do it and so he also got training while at work. She started fluids and antibiotics. She also set up the equipment needed to monitor this man's blood pressure beat-to-beat, so they could tell exactly how he was doing. A catheter was inserted and the urine output monitored. Very soon the patient improved. After 4 hours and 30 minutes, the patient made his way up to ICU with the proper treatment well under way. He did very well and was discharged back to the ward after five days. He was home after 12 days.

While all that was happening, the ENPs were seeing the minor patients and the medical doctors were looking after their sick patients on the ward without having to be bothered by the acutely sick patient, who was being well-managed by the A&E doctor. In this case, the patient did very well but since he was in A&E for more than 4 hours the case was probably not regarded as a success in terms of targets, but was placed in the exceptions to the 4-hour rule category. There are no stars for quality of care.

Unfortunately, the process of care that the first patient got is far more common. If the money was put into acute care and the processes of delivery of care were changed, so that they were all like the second example, it would cost a bit at the beginning, but in the end would save a fortune.

One of the main reasons that these situations are so common is that the doctors working in A&E are often not experienced enough and have not had the right training to decide if the patient needs to go to ICU with the result that they are referred to the medical team. The senior doctors, who are capable of making those decisions, are often too busy trying to stop more minor cases breaching their 4-hour rule. This is a crazy situation. We should work closely with the medical doctors and make it a rule that the sickest patients should be seen by the most senior people straight awayA&E physicians or acute physicians, whoever is available at the time (it doesn't matter, as long as we are all working together).

As an aside, to get improved health care, we don't necessarily need centralised care and we certainly don't need your local district general hospital to close. There is nothing high tech about the treatment the second patient received; it was just more efficiently delivered and thus that patient had a better outcome. As my gran used to say, 'A st.i.tch in time saves nine'; she could teach our managers a thing or two, I reckon.

An amusing patient

I couldn't swap my job for any other. Sometimes I just love being at workespecially so when you can have pleasant and amusing patients. Today I had one such patient.

Six-foot-five, built like a brick s.h.i.thouse and tattoos aplenty. When he came in he was all smiles and jokes. He had an infection at the end of his finger. He had been to his GP, who had given him antibiotics, but they hadn't worked. The pus needed to come out.

'I am afraid that I will have to make a small incision and get the pus out.'

He started to laugh, 'I am the biggest wimp in the world. Please no! I can't stand needles; I'd rather lose my finger,' he pleaded.

I told him that he very well might lose his finger and again offered him the option of an 'incision and drainage' of the abscess. He pondered, thought about a life with a nose full of bogies and opted to be brave.

I had just started to inject a tiny bit of local anaesthetic into the finger when the screaming started. Oh my G.o.d! I had never heard anything like it. But he was so embarra.s.sed and apologetic and so nice about it, I didn't mind. I got the emergency supply of gas and air.

For simple procedures like this, gas and air (laughing gas) is hardly needed. But he needed it and boy did it work. What the gas does is to provide a small level of anaesthetic with a large amount of hysteria. You can still feel the pain, but it is no longer upsetting. You can also get the giggles. If the patient gets the giggles, then the drug is working. As long as they stay still, you can perform your operation to your heart's content. But as we all know, the giggles can become infectious. Unfortunately, once they get the giggles, then so may you. That's when the fun/difficulties start.

But you need to start the ball rolling. I started with my favourite joke for wimpish men who are having a procedure done on their arm.

I started, 'Did you hear about the patient who went to the doctor with pains in his arm? "Do you want the good news or the bad news?" the doctor inquired.