A hostile environment or just incompetence?


During the much touted Windrush Affair, which dealt with the inept and outrageous treatment of British Citizens, formerly from Commonwealth Caribbean countries, much was made of government responsibility in the matter. The phrase “hostile environment”, first coined by Liam Byrne, Labour Immigration Minister, repeated by Alan Johnson, Labour Home Secretary and adopted by Theresa May and Amber Rudd, almost certainly arose amongst the civil servants in the Home Office. It was certainly the same policy they had carried out for many years and was in evidence when I married my New Yorker wife in 2000.

It’s nothing they have against immigrants – they’re just hostile to their fellow human beings and to doing a good job.

Having this laid at the door of government was not unfair but having it used for party advantage was risible. The government, of course, claimed it was aimed at “illegal immigration” and I’m sure it was, in their minds but they rarely admit that the people employed to enact government policy are, well, less than perfect. Ordinary human beings from whom all capacity for exercise of common sense and reason has been extracted, squashed or simply banned.

Let’s start at the beginning of my own personally torturous story. My wife to be was supposed to come to UK and settle in, whereupon we would get married and, at some comfortable date in the future, she would take British Citizenship. Luckily it occurred to me that this country I love is far more in love with rules and bureaucracy than with me. Perhaps I’d better find out what those rules were? I logged onto the Home Office web site and had a good read. I was thoroughly confused.  I found their phone number, with some difficulty, and rang it. After one ring my call was intercepted by a good old fashioned answerphone and I listened, attentively, to the brief message: “All our lines are busy now, please call back later”. How, I wondered does an answerphone know that all lines are busy? It doesn’t. This was before any implementation of a managed telephony system. This was an old style answerphone. Fair enough, I thought. They’re busy so they’ve switched on the answerphone, I’ll try again later. Over a period of a week I rang that number at all times of day and night, even 2am on one occasion. The unspoken message was clear, we have no intention of ever answering your call, don’t bother trying and, by the way, there’s absolutely nothing you can do about it.


I returned to reading the web site. It advocated that I should employ the services of an immigration lawyer, if I needed help. I just wanted to know what the rules were, you’d think that would be simple enough, and free. I rooted out telephone details for a couple of said lawyers. I couldn’t understand a word that was said in the first instance. I figured I’d got a wrong number but on the second call I realised the source of my confusion. The lawyer I spoke to, and of whom I only understood around 50%, was completely bemused that I, an obviously articulate, white, English male would need any help bringing my obviously American betrothed to his home country. He did however offer to see me in his office somewhere in Southall if I would speak with his secretary. I tried, when it all became too difficult I decided this was not for me.

I returned to the web site.

From what I could make out, the challenge was that if my future wife came into the country “with the intention” of getting married, she must declare this upon entry. If she did that, she’d be allowed in but would not be allowed to work or make any claim for assistance for a period of two years. If she came in without declaring this and then married, she might be refused residence, ergo be deported. Phew! God knows what happens if you fall in love whilst on holiday and get married and, how on earth does one prove the lack of intent to marry? What if you mused on the matter, idly, over a martini? It felt to me that this way, there were a hundred booby traps one could easily fall into.

If, on the other hand, you marry outside the country, then apply for a visa before entering the country and come in together, all is allowed, no restrictions of any kind. After five years, automatic Indefinite Leave to Remain. So, no contest and, as added encouragement, a wedding in New York City sounded like fun.

Back to website to find out what I would need to support the visa application. Nothing. Zilch. Nada. OK, bright idea, what about the British Embassy in New York, did they have a website? Bingo!  (By the way, they don’t have one anymore)

Not only did they have one, it was welcoming and relatively informative. It even had a phone number. I hardly dared hope but I called anyway. They had voicemail, I was invited to leave a message and though the cynic in me wondered why on Earth I might fall for that ruse, I figured I had to try everything. So I left a message. I left my phone number, apologising for the fact that it was a U.K. number and all but offered them a great excuse for not following through.

Later that evening, in one of my local pubs, my phone rang. A bright, young, well-spoken New Zealand accent greeted me and *thanked me* for leaving my message. Whilst I was reeling from the absurd comparison of attitudes (and walking outside in search of better reception) I spluttered out my gratitude and surprise and explained my situation. The young women took it all in and was wonderfully effusive at how romantic she found all this and how she’d be delighted to help. She promised to have a word with one of the consuls *and have them call me*!!  A vivacious Kiwi working in the service culture of NYC is a world away from my everyday experience – and what was to follow.

Good as her word, she did speak to the Consul and, good as his, he called me. We had a lengthy conversation in which I explained the inordinate difficulties I’d had getting this far, how outrageous the lack of access to the Immigration Dept at the Home Office was and he not only agreed but expressed his own exasperation. By the time we finished, I had a clear and complete list of exactly what documentation I needed to bring. I knew, for example that no bank statements were required. I knew that I was not under any obligation to prove any specific quantities of cash, only that I was in gainful employment. I also knew, because I asked, that I only needed my last divorce certificate, not any previous ones. It makes sense, to get married that last time, you’d need to have proved you weren’t married to anyone else so, only the last divorce cert proves that now.

I was all set. I assembled everything and we made our plans. It was going to be tight because I could only spare a week away from work. It went like this:

Sunday – fly to NYC

Monday – my wife would fly up and join me.

Tuesday – we go together to City Hall to get the licence

Wednesday – Precisely 24 hrs after the licence is granted, we get married at her brother’s house by the local Deputy Sheriff (I kid you not).

Thursday – we arrive bright and early at the British Embassy, we present our papers and get the visa.

Friday – we fly home to England as husband and wife.

Simple, right?

Well, our week was going to turn out to be an interesting one. It had it ups and downs, let’s say.

Ri, for that’s my wife’s name, was living in Lexington, Kentucky. She’d had a hectic couple of weeks. She’d held a yard sale to get rid of possessions, given away most of what she owned to others who would make good use of them. She’d said emotional goodbyes to all her ballet students, who loved her like a sister/mother/mentor. She’d said equally emotional goodbyes to her work colleagues at Planned Parenthood, where she’d been a passionate campaigner and Director of Education, and to her many dear friends. Most of all, she said a tearful goodbye to Zodos, her enormous Maine Coon cat. She was leaving behind her entire life for this incredibly risky but exciting adventure in a land far away.

Her flight was a disaster. Bad weather cancelled flights, rerouted her and separated her from her baggage. She was already on an emotional knife edge, now she risked missing the tight deadlines and losing the few possessions she had left herself with. She was bereft, distraught and beside herself with worry – and totally exhausted. All this I only encountered in the numerous telephone calls at particularly stressful moments or when there was actual news to report. She, of course, was living every moment of it.

Finally, she had a flight and was en route once more, sans baggage. I decided she needed a little something “special” so I spoke to the chauffeur company at the hotel and organised the swankiest limo they had. I met Harry, our driver, a lovely sweet black man who “got it”, exactly. He’d seen his own lookalike in the movie “ Pretty Woman” and knew exactly what was called for. He even opened the sunroof and let me stand up through it as we drove down the streets of NYC, getting in the mood.


We picked Ri up from the airport, Newark I think it was eventually, in precisely the style I wanted for her and she loved every moment as she started, finally, to relax.

The very next day, we hi-tailed it down to City Hall to see what we had to do to get a marriage licence. I’ll spare you. Suffice it to say that government bureaucracy, inefficiency and callous attitudes are universal. They are truly global. The highlight for me was the scrappy piece of paper sellotaped to the glass screen between me and the unkempt teenager on the other side. I hadn’t really taken it in until the mute conscript on the other side recoiled at the sight of the dollar bills I was offering. He tapped the notice in an irritable manner and I read:


My mind ran through a mental recall of other appropriate mechanisms of financial exchange and drew a blank. I shrugged, he wasn’t looking. “How do I pay you?”, I pleaded. It turned out that the only mechanism his employers would allow him to handle, for fear he might pocket the funds, was a Cashier’s Check made out to the City, which I could obtain from a single bank half a mile away. Like I said, I’ll spare you the rest.

So, it’s late Tuesday afternoon and we’ve finally got our Marriage Licence. It took longer than expected and because it has to be a minimum of 24hrs old before we can marry, we had to push the marriage back a couple of hours and reconfirm our Deputy Sheriff. Ri wanted to take the opportunity to show me her home town and, in particular, Central Park; the background to so much of her life, the stage upon which so much of it had played out. Whilst we’re strolling in the beautiful May sunshine, my phone rings. I always hated that. In those days the cost of an international roamed call, even incoming, was enormous and usually turned out to be someone selling you something – no CallerID on international calls. It was the British Embassy Consul that I’d spoken to weeks before from the U.K. I was amazed! He had made a note of when I’d said this was all taking place and had “reviewed his notes”, apparently. He was very pleasant but then he said, “You have brought evidence to show that you can support both of you, haven’t you?,” he asked inquiringly. What had brought this on, I had no idea. “No!” I exclaimed, “no I haven’t. That’s because I asked you specifically if that was necessary and you explicitly told me it was not! We’re here in New York, we’ve just got the marriage licence and we’re getting married tomorrow. What on Earth do you need from me?”

In the most disarmingly matter of fact tone, he said, “Well, we’ll need a letter from your solicitor, attesting to your ability to support yourself and your wife.”

I tried to remain calm, to be polite, not to lose my temper but I have to confess it took every ounce of self-control I possessed and, even then, I’m certain my malcontent was blatantly evident. “Let me get this straight,” I began. “At 5pm in the afternoon, 10pm in the UK, with just one day before I present myself at the Embassy to obtain this visa, you call to tell me that I need a solicitor, that many people would never have need of, who if I have one will be getting ready for bed right about now, to attest, against his professional reputation, that he knows enough about the intricacies of my financial situation such that he can state without hesitation that I can afford my wife. You expect me to have access to his contact details and for both of us to have access to a fax machine and that he can do this at the drop of a hat. Have I got that about right?”  Something like that.

“Well”, he spluttered nervously, “Err, yes.”

“I’ll see what I can do”, was the only response I could muster.


So, I called my lawyer at home and explained the dilemma.  Luckily I did have a lawyer or three with whom I was on good terms.  This one, in particular, is currently serving a hundred year jail sentence, or something, for a massive fraud.  I’m very sorry for him and how he came to be in that position but I don’t think it was anything to do with my visa application!  On the other hand, it does amply demonstrate what a complete and utterly frivolous exercise it was, asking a lawyer to attest to something, this mundane, if £100 million tax frauds could be his penchant.

Anyway, good as his word, when I woke up the following morning, there was the fax of a letter from him, pushed under my hotel-room door.  How many people, let’s say from deepest Africa or Asia, could have achieved that and, if they had, how many consul’s would have treated what it said with the same deference coming from a swanky London address, if it came from Lagos, Nigeria, for example?  The situation is, frankly, laughable but at the time is was a major source of unnecessary stress.

So we got married that day and I only skip over it because it’s not the point of the story, which has already become long enough.  The next day we went down to the British Embassy in New York City, bright and early.  We weren’t the first ones there but we were greeted in a pleasant manner by a shabby little Greek guy who smiled a lot and as he greeted me, crammed a torn-off scrap of paper into my hand and one into Ri’s.  I looked at mine, bemused and saw that it had a number scribbled on it, in pencil.  I am not making this up.

I mused for a moment and then realised, okay, it’s like the deli counter queue in the supermarket.  Someone’s going to call out our number at the appropriate time and that way we all get processed in sequence, makes sense.

So we entered a large room in which 20-30 people were milling around.  We got chatting to some and were finding out, from a variety of nationalities, what their particular adventure was all about, answering questions about what life is like in the UK and stuff like that.  We were all generally having a good-humoured getting-to-know-you session, all resigned to the fact that this could take a while, when our smiley little Greek guy came into the room and tried to make himself heard.  Being so short and obscured by everyone else in the room, this wasn’t as easy as it sounds but by a process of Chinese whispers we all got the message that he wanted us to line up, in front of one of the windows, in the order of our numbers.

Not at all like the Deli-counter queue.

By this time, 20-30 more people had joined our merry throng and the task, it seemed to me, was to find the person with the number immediately prior to mine so that I could dutifully line up behind them…..just as soon as they figured out who they were supposed to line up behind….

“I’m 27, who’s 26?”, someone called out.  “I’m 42, has anyone got 41?”  “What number are you?”  “31”, “17”, “48”…..this was going to take a while.  I have honestly never witnessed such a chaotic scene as the numerous fragments of a conga queue accumulated, each manoevering around the room, trying to join up the broken elements into one coherent snake.  It took about 20 minutes but it kinda kept us amused and certainly brought us together, literally and metaphorically but largely in the shared sense of incredulity.

Finally, we’re in our place in a queue and someone has apparently appeared behind the glass screen.  I looked at the number of people in front of me and quickly calculated that we were going to be standing there for a good couple of hours, or more.  Ri and I took it in turns to sit and rest our feet, before swapping back to maintain our place in the completely unnecessary queue.  Its necessity had become apparent, however, within moments of us completing our exquisite dance when our little Greek friend proceeded down the queue, from the front, collecting his precious torn-off scraps of paper with their numbers, scribbled in pencil.  A prime example of recycling at work?  I guess austerity had begun some ten years earlier in the Consular Service than in the rest of government.  So, now, deprived of our official numbering system, it was essential to retain our place in the queue, you’ll understand.

After what seemed like an interminable wait, with the occasional shuffle up by one meagre place in the queue, we arrived at the glass window.  The Mancunian woman behind the glass, the one with the total charisma bypass, motioned for me to hand the paperwork through the slot at the bottom.  She never once looked up, she never smiled, in fact her facial expression never waivered from its default setting of sour.

She started to rustle through our papers.  She looked at a section of the form, the part dealing with previous marriages, and located my divorce certificate in the pile of documents.  She rustled some more and then, again without looking up she chastised, “Where’s the other divorce certificate?”.  Rattled a little, having spent weeks preparing so carefully and being literally on the brink, I retorted “But the rules specifically said I only need to bring the last one, it specifically said that….”

“Just asking”, she said in a tone that was both flat and simultaneously mocking and implied she’d omitted the phrase, “just kidding”.


Then, “Where are your bank statements?”.  “There are no bank statements, I responded, the rules don’t ask for back statements, if I’d been asked to bring bank statements I would have brought them”  the sense of panic was clearly evident in my voice.  I went on to relate, very briefly, my conversations with the Consul, his omission of any need to provide evidence of means, his call 36 hours earlier telling me I needed the lawyer’s letter to which I pointed…..  “Can’t you just get a printout from an ATM?”, she asked, to the papers in front of her, not to me.  “I’m British, I said, my cards don’t work over here.”.  This may all sound strange in 2018 but in 2000, not every ATM was VISA/MC compliant for UK Debit cards.  Ri piped up, “I’ve got one”.  “I need one for each of you”, came the miserable Mancunian from behind the screen.  “How much does it need to have on it?”, I asked.  “Doesn’t matter”, came back.  At this point I wanted to say well if it doesn’t matter, why in the name of Christ do you need it?  I probably would have said that but I had just remembered that I had been solicited by phone a few weeks previously, by Citibank who were on a drive to open more accounts in the UK.  I had gone along with it and had opened an account with a token £500 for no other reason than they made it sound easy and, get this, that another bank account may always come in handy.  Handy wasn’t the half of it on this day.  I thrust my card into Ri’s hand, told her the PIN and, whilst I held my ground at the window, ushered her downstairs to the street to get us a couple of printouts.  When she appeared, somewhat breathless , some four minutes later she was beaming with success as she waived the two little chits in the air and thrust them under the window to what I can only describe as a disappointed grunt. Yes, it really did feel as if we had undone her plans to scupper our application.

Finally, she was done and without having made eye contact with us for the entire twenty minutes, she threw our papers in a basket with a few notes and other attachments fixed with paper clips and instructed “See the cashier, next window”, before calling “Next!”.

I’d not really figured out the “next window” thing but now I realised, this Consular Official, the Mancunian with the charisma bypass, was apparently not trusted to handle the dosh.  That was above, or below, her paygrade.  We resumed our place behind the same people we had previously stood behind in the first queue but felt somewhat elated that no one, so far, had refused us a visa, nor demanded of us anything we couldn’t produce – at a push.

While we were in this queue I spotted the price list on the wall.  It was one of those boards where you press letters and numbers into position, like they use in café’s and other old-fashioned places.  It had a glass door with a brass frame, as if someone might want to steal the numbers or try to cheat by rearranging the figures to reduce the price of their particular service.  I scanned the list, looking for the appropriate item.  “Spouse Visa £480.00”.  Blimey!  I thought.  It had never even occurred to me to ask.  I scanned up and down the price column, most things were in the range of £10-30, I think something was £45.  Importing wives appeared to be a lucrative little number for the government.  I guess they worked on the premise that there is absolutely no competition.  It’s not like choosing to go somewhere else for your holiday or having someone else certify a document.

I had plenty of cash on me, some sterling, mainly US dollars.  The prices were all quoted in Sterling so I figured I’d use up what I had (given it was a lot more than I expected) and hand the rest over in dollars.  I got to the window, and presented the fellow with some chit or other that the charisma bypass had given me.  He retrieved the my file, and asked me for an amount in dollars.  I handed him about £400 in sterling and asked how many dollars he’d need to make the difference.

He responded, and once again, I am not making this up, “I can’t take pounds”.  Flatly, just like that.  “You mean, Sterling?”, I clarified.  “Right”, he affirmed, “Pounds”.

I was aware that I was being artfully elaborate but I felt the situation demanded it:  I pointedly took two paces backward, and craned my head as I scanned the room, taking in the various paraphernalia that affirmed the nature of the building in which I was standing and I held out my arms in gesture at everything around me.  I returned, two paces forward.  “I am right in thinking that I am in the British Embassy?  This is British Sovereign Territory?  I only left home a few days ago and the currency of The Crown when I left was still Sterling.  Has something happened?”.  Of course I was being blatantly sarcastic and, I felt, with absolute justification.  He wasn’t moved.  “I can’t take pounds,” he said, “what would we do with them?”.  “Put them in the bank?”, I volunteered.  “In a Sterling account in London through a US bank, in the same way that I hold US dollars in New York through a UK bank?” I explained, helpfully I thought.

“Well we can’t take pounds, you’ll have to get dollars.”

I checked, I didn’t have enough.  At least, I thought to myself, they do actually accept cash so, one up on the New York City bureaucracy we’d dealt with just two days previously.  I asked if there was a bank nearby and he confirmed that there was one on the ground floor.  My “friends” in the queue assured me they’d hold my place for me and let me back in when I returned so I headed down in the lifts to the ground floor.  Yep, there was a large branch of one of the domestic US banks and I ventured to the counter.  I handed over my Sterling and asked to change it into dollars.  The woman was cheery and friendly and I wondered what it would take to have her organise a class in customer service for the folks just six floors above her head.  “ID?”, she enquired politely.  “Err..” I fumbled as I realised that my passport was up on the 7th floor along with every other scrap of ID I possessed and I tried to translate that to this pleasant lady.  As if talking to a moron, but ever so politely, she suggested “Driver’s license?”.  Feeling ever so dumb but instantly realising the difference between a traditional US licence, complete with photograph, and my large sheet of paper folded to one sixth of its natural size size, with lots of type and absolutely no photograph, I decided to tough it out.  I held it out proudly.  She took it from me gingerly, it looked pretty fragile even then, it looks positively decrepit now!

She took it to the back of the hall and gathered several colleagues around.  She opened it reverentially and together they poured over it, first one side, then the other, spreading it delicately down on the desk top.  There was a lot of frowning and puzzling and then it was over.  She came back to me, smiling sweetly, handed me back my licence and dished out the cash.  I’m going to credit my English accent and that very touching reverence that Americans seem to have for we Brits, for her failing to uphold her duties to the absolute letter of the law.

I raced back up to the top floor, resumed my reserved place, such nice people in the queue, and waited until it was my turn to hand over the fat, sweaty, wad of cash as Jacko described it in As Good As It Gets.  We were done.  We didn’t know we were done, we were just hanging around for someone to tell us what comes next.

After about an hour, when the last window had closed, out came a consular official and announced that the office was now closing for lunch and we should all go away and be back in one hour’s time, when we’d find out what came next.  What chaos.  So now, we had one hour to find somewhere to eat in downtown New York, eat, and get back, or risk not getting a visa.

So ended phase one.

Frankly, I’m not sure I have the energy for describing phase two and I’m even less sure that you, dear reader, have the appetite for it.  Suffice it to say it involved an interrogation, some game playing and a great deal of smiling and trying to be nice to people to whom I wouldn’t normally give the time of day.

Let’s leave it there.  Let’s not overlook the point of all this though.

The point is that it matters not one jot who’s running the government.  What matters is the leadership, management, training and recruitment down at the coal face and that is under the firm grip of the civil service and their unions.

If you employ muppets and don’t even try to educate them to the level of say, barely employable, put them in the control of frustrated traffic wardens and generally treat them as if you care neither about them or the people they are there to help, then this kind of crap will continue.  I doubt any government minister will ever find the will, determination or a suitable mechanism to impose change on the self-perpetuating life-force that is the civil service.  I don’t believe this is a party political issue any more than it is a national character trait.  I think it’s the way the world chose to travel and not enough people cared sufficiently to steer a different course.  How you could possibly change it now, I really don’t know.  What I do know is that it would feel really good if it looked like anyone was prepared to try.

Meanwhile, let’s acknowledge that those people at the coalface are just ordinary people like you and me who’ve had their charisma exorcised, their humour lobotomised, their empathy ostracised and, frankly, this is just the level of crap we all have to put up with.  Now go outside, away from this “hostile environment”, marvel at the world of nature and let it put a smile back on your face.  😊


No Pain, No Gain?


The most amazing thing to me about the operation to remove a substantial chunk of my right lung, the upper of three lobes to be precise and, thinking about the method of entry to the chest cavity, what has to be cut through before you even get to the lung, was the relative lack of pain – from that day to this.  As I write I fear that I may live to regret so bold a statement when the nerve endings start to repair themselves but just for now it feels like an almost pain free experience.

The same cannot be said for the two chest drains that were of course an essential part of the process.  These remove both air and interstitial fluid that builds up in the thoracic cavity following an operation of this sort.  The fluid is normally carried away by the lymphatic system but given the damage done to it during the operation and the amount of fluids being produced, the lymph needs help for a few days.  Air, of course, whilst it may sound perverse at first but becomes obvious when you think about it, is not something normally found in the thoracic cavity, it’s supposed to be inside the lungs, inside said cavity.  Air inside lung – good.  Air outside lung – bad, lung collapses and you risk death from asphyxiation – something to be avoided if at all possible. It is they that; have been the source not only of the minute to minute aching (that is for the most part entirely bearable and when not is easily made so with a dash of morphine or a tramadol capsule) that; have forced me to lie flat on my back to sleep (something I’ve never mastered in my life and thus have had very little sleep until last night) and that during removal (of the first one) gave me the most excruciating pain imaginable.

I’m sure it must be possible to have worse pain, perhaps I just lack the imagination to understand how any pain could actually get any worse than that pain was, except by continuing for longer.  Is it more painful to have your leg hacked off at the knee with a machete?  How could I ever know without experiencing it and I’m pretty sure that if I were to experience it, the knowledge of what was being done to me, the nature of it as a malign attack rather than a palliative process and the understanding of how long this was going to go on for would ensure that I placed it higher in my list of lifetime’s painful experiences but, the question has to be asked, would the actual amount of pain second by second be any greater?  Would it not just be pain, pure and simple, governed in volume by the number of nerve-endings responding to the stimulus?  I don’t know the answer, maybe there’s a scientist or two who do but I’d say it’s always going to be a somewhat subjective issue.

The fact is that removal of the first chest drain, which took place in the hospital, was excruciatingly painful.  I found the reaction of several of the nursing staff, to my tale of the event, curious indeed.  I got the impression that I was being regarded as some kind of wimp, making a huge fuss over nothing.  Well, let’s be entirely fair here, suppose I was a huge wimp and was making a big fuss over something that most people find so pleasurable that it’s a toss-up between, ooh I don’t know, popping down the pub for a drink with your friends or, nipping next door to your mate, Kevin, and asking him to whip a garden hose out of your chest without anaesthetic.  Yes, let’s suppose that’s the measure of the seriousness of the procedure to the average bloke.  Well, here’s a thing now, pain, as I mentioned before and as we all know by established research, is a subjective issue.  The fact that one person can stand an amputation of a limb whilst biting on a stick of wood, as all good cowboys do, whilst another would actually suffer a heart attack as a result of the pain and die, is what makes it subjective and, being subjective, it is all about the subject, in this case the patient, and not about the practitioner, in this case the medical staff.

So the question first arising here is what should be the relationship between practitioner and subject, between medical staff and patient.  Primum non nocere is a Latin phrase that means “First, do no harm”, it is a fundamental precept of medical ethics known to every medical practitioner everywhere in the world.  That is all that needs to be established about this relationship for my purposes but let’s broaden it a little and say that, of course, one of the primary functions of “medical care” is one of “care”.

That’s a word that has many sub-definitions, meanings and connotations but I think we all understand what it means when used in everyday parlance and particularly in a medical context.  Care is diligence, doing one’s job carefully, omitting nothing, overlooking nothing, considering everything.  Care is also concern and compassion, actively wanting to “do no harm” indeed, wanting very much to take one out of harm.  In this subjective instance, to relieve pain wherever possible, not to cause any additional pain unless it is entirely unavoidable, to consider the individual patient and their perception of pain, to work to alleviate the fear of pain which is, of course, a very large part of the actual experience of pain.  That fear causes physical tension and tension exacerbates pain so if one can bring someone to a relative relaxation there will be less experience of pain, even though the pain stimulus may be exactly the same.  We all know these things, I’m not telling anyone anything they didn’t know before but that, perhaps, is one of my central concerns.

It is these things that we all know so well that often get overlooked, forgotten about, disregarded when the pressures of the day to day, the very familiarity of it, risks bringing with it an unconscious disdain.  Cultural issues also play a part as do generational, age-related ones.  Pain is regarded differently in different cultures and it’s probably true, the more westernised a country becomes the less acceptable certain levels of pain become.  In this country, of course, we also have to measure up to that level of stoicism inferred by the phrase persistently attributed to the British caricature with their “stiff upper lip”.  It’s the same stuff and nonsense that causes even modern day liberal parents to train their children in the “big boys don’t cry” theory that blights most of their lives and is considered in professional circles to be at the root of much violence and spousal abuse…but that’s another subject for another day.  For now the point is that this so called stoicism has worked well for a country that, in times of war, rationing, poverty and deprivation needed to find ways of maintaining morale.  Well, folks, those days are long since over and I hope we no longer judge people as to their “Britishness” on whether or not they can cope with apparently intolerable pain, suffering or deprivation without so much as a whimper or a sniffle and I’d like to think we were, these days, encouraging boys to shed a tear rather than bottle up their emotions like a pressure cooker until they kill someone.

So on the day that I’m told I can have one of my drains removed I am both elated and nervous.  The elation does not need to be explained to anyone who has ever had one or, in my case, two of these buddies tethered to your body.  For the rest consider the, “wherever you go, I go” principle of the attachment with all the discomfort, complication and restriction that places on every movement from planning a trip to the lavatory ten minutes ahead of time to wanting to roll over in bed without ripping a half inch hole in your chest cavity which will inevitably strangle you in the same instant as the rushing inflow of air crushes your lungs.  It’s rather unlikely that such a thing could ever happen but not in one’s imagination it’s not, there it is an ever-present threat.  The opposing nervousness comes, of course, from those self same roots, how on earth can it not be painful to remove a half inch hose from your chest wall after your body has been busily doing all it could to accept it as part of  you and welding tissue to the tube by way of reconstruction.  Thus it is indeed the case that I approached the moment with a not inconsiderable fear, about as considerable it must be said as the bronchoscopy I had endured some three weeks earlier or the subsequent CT-guided biopsy, involving a very long needle through that very same chest wall.  In the first case I was given mild sedation but had to remain awake because my cooperation was required.  In the latter, no sedation for similar reasons but as much local anaesthetic as was called for that turned the process into something that, in my mind never really happened.  A very clever surgeon assured me at each deeper penetration that all he was doing was giving me more anaesthetic and the half of my brain that was shouting “don’t listen to him, you know exactly what he’s doing, he’s assaulting you with a very large sharp steel instrument” was subdued by the other half of the brain that readily accepted the much more pleasurable and acceptable premise that all we were doing was getting ready for a procedure that was not going to happen until I was properly anaesthetised.  Now that surgeon, one Simon Padley to give him his due credit, knew exactly what games he was playing and the benefit to both of us in playing them.  Here’s the thing, he would no more have thought to stick a needle through my chest wall without a local anaesthetic than he would to remove a hose pipe from the very same place without one.

As I later described it, these two prior procedures accurately reflect the usual situation where the fear of the procedure was some ten times worse than the actuality.  In the case of this first chest drain removal the actuality was ten times worse than the previous fear of it and that is how I knew something was not right.  From my own research and deduction, I now believe I have a pretty full picture as to why this was and what caused the very real and excruciating pain that I experienced and which continues in much abated form, just by way of reminder, to this day, five days later.

I have scoured the web and read many professional documents on the subject of chest drains and, in particular, on their removal and what considerations are given to the questions of pain and appropriate anaesthesia.  I have arrived at several conclusions:

  1. There appears to be no single authoritative work on the issue to which practitioners can turn with confidence.
  2. There are conflicting opinions as to the level of potential pain and the steps to be taken to ameliorate it.
  3. There are, incredibly, medical professionals out there who do not believe that anaesthesia is required even for INSERTION of a chest drain – that should make interesting reading for the justice profession when considering what action to take against youths on sink estates shoving penknife blades into each other’s chests on a Saturday night.
  4. Rather than the “national” health service conducting research and publishing established guidelines, each individual hospital is apparently charged with investing our hard-earned taxes many thousands of times over in conducting their own research and formulating their own individual policy to apply in their very own hospital assuming of course that they think to even do so – good god almighty what lunatics are running this enormous NHS asylum?

What comes across loud and clear, as if one needed such research or evidence, is that there is a sufficient body of it out there from around the world – the English speaking westernised world so far as my research was limited – that one cannot deny that there is a very strong likelihood that the patient will experience significant pain when a chest drain is removed and therefore that local anaesthetic should always be applied in addition to intravenous or oral sedatives such as morphine.  Of course, there must be instances where no anaesthetic was used and no pain was experienced by the patient, else there would be no variance of opinion but why on earth would that lead you away from taking the precaution of administering a little lignocaine just to be sure?  Primum non nocere.

Growing up in the fifties and sixties I learned to equate the word “dentistry” with the synonym “extreme agony”.  How did I manage that?  Well I’m sure I’m not the only one but the inevitable result was that as soon as I was responsible for my own decision making, quite early on in my case, one decision was that henceforth I would be visiting dentists over my “dead body” so to speak.  Put more simply, I simply wouldn’t be visiting them ever again.  Thus it was that by my mid-twenties and a decade or more of dental neglect brought about the very pain I had been so strenuously avoiding.  Mercifully a friend recommended their “private” dentist and it was from him I learned that, his words not mine, “Robin, there is no reason for you to ever experience pain from dentistry and so long as you are my patient I give you my guarantee that will remain the case”.  Thirty odd years and two or three dentists later (don’t they retire early, these guys?) not to mention fillings, caps, bridges, root canals and nerve extractions, I have never to this day felt any pain in the dentist’s chair nor needed to take more than one dose of painkillers after the event, when the anaesthetic wore off.  So why the difference?  Simple, it’s a cultural thing but its also a capitalist thing.  These guys are in business, they “get” customer service, they want you coming back to them to help fill that pension fund that enables them to retire early and in relative luxury.  They best do that by making sure you have not the slightest fear of visiting them – and EVERY fear of visiting someone else.  Hey presto, professionally administered, pre-emptive pain relief materialises as if by magic and absolutely no procedure commences until the patient confirms that the anaesthetic has done its job.  There’s a lot to be learned here but, unfortunately, because of the irrational structure of our “beloved” NHS we have to try to achieve this in the absence of a profit motive, which, after all, is just a motivation to give excellent customer service.  If the staff are excluded from that motivation then I’m afraid we lose an essential driving component but, what we lack in the construction of the service we can at least attempt to bolster by way of policy and training.

Gloria and Glena are both very experienced and capable nurses, of that I have no doubt.  I took to Gloria immediately, I felt very safe in her care and from various things we had chatted about I felt we could relate well.  I had never seen Glena before in my life and so when she walked into my room and was briefly introduced to me, I assumed she had been brought in from a general ward somewhere because of her specialist experience in chest drain removal.  She was to officiate with Gloria assisting.  Fair enough, it seemed like a good combination but on reflection it occurs to me that there was little or no discussion over what was about to happen – apart from some guidance on breathing instructions that I would be given again at the time.  All of this conversation, such as there was, took place behind my back, quite literally.  I was laying on my left side looking at my wife whose hand I was holding.  Gloria and Glena were behind me.

Glena’s touch was very gentle, yet very sure and I was comforted immediately.  Given she was a total stranger to me (and yes I do believe that is a major issue in the way we deliver health care in this country, one that can be solved simply and inexpensively with a little thought and conversation) the touch of her hands was my only real way of assessing how safe, comfortable, assured I would feel and it helped me to relax initially.  I hadn’t read up on what was involved, who does on such a relatively minor procedure?  No-one had explained it to me but I had automatically assumed that a local anaesthetic such as lignocaine would be used, it just seemed so obvious.  I don’t recall at exactly what point I asked for this but I believe it was Gloria that advised me that “nurses aren’t allowed to administer anaesthetic”.  I have no idea how accurate a statement this is, whether its a misinterpretation or misconstruction of an actual policy ruling but the question formed instantly in my head was the one I repeated to all those involved later: “How is it possible that it can be ok to allow a nurse to remove a hose pipe from my chest cavity with all the attendant risk that such a procedure implies and yet not allow that same nurse the responsibility to administer appropriate analgesia?”  It beggared my belief then, in agony on my side, as it does now in my very comfortable and painfree home, bathed in warm spring sunshine.  It beggars that belief to the point that I don’t believe it and because I don’t believe that Gloria would lie to me then I must assume that it is some kind of misunderstanding.

I put this point to several of the nursing staff later, during a shift change ward round and I think they misunderstood what I was saying.  I was inferring that I have no problem with the nurses doing the drain removal and thus, given that level of trust, no problem allowing them to administer local anaesthetic.  It appeared that some people thought I was implying that as nurses were not allowed to administer local anaesthetic, they should not be allowed to remove chest drains.  The two interpretations could not be more starkly contrasted and, of course, such a misunderstanding would have reflected very differently on me indeed.

Something else I recall Gloria asking me, when I was trying to make it understood just how much pain and distress I was in at that time, is what gave me clues to my later findings.  She asked me whether it felt like burning.  Well that was it, precisely.  Until she verbalised it I hadn’t considered the nature of the pain, my mind was so full of the pain it left little room for other tasks unless prompted.  As I described it to her then it was like someone had taken a burning hot flat iron and held it to my side, the way one’s skin sticks to a dull black hot metal object like a surprisingly hot chimney flue.  The only thing wrong with that analogy, I clearly remember thinking at the time, is that a flat iron has a very particular shape and the shape of this pain in my mind was square.  It might seem odd but yes it really did have a ‘shape’.  A couple of days later, still trying to mentally bridge the understanding gap of those who made me feel I was making a mountain out of a molehill and my own vivid knowledge of what I experienced, it was this shape memory that prompted me to ask my wife about the substance that had been used to disinfect the surrounding area.  I recall Glena and Gloria discussing preparing a sterile area around the drain, I remember Gloria warning me this would be cold, and it was.  There was almost no interval between the application of this preparation and the beginning of the task of removing the sutures retaining the drain tube and the almost immediate pain I started to feel.  The pain grew and peaked every time Glena sought out a thread or made some other touch to my skin, it was indeed as if this square of my body was on fire and the slightest additional stimulus was a gallon of fuel poured on the flames.  “Was it that yellow stuff?”, I asked my wife, who confirmed it was exactly that, “Betadine” she advised knowledgably, that being the brand name, in the U.S. at least, for a range of povidone-iodine (PVPI) topical antiseptics.  I was already wondering about a reaction to iodine and this confirmation sent me off in that direction.

Sure enough, I discover reams of information about adverse reactions to iodine based preparations, including Betadine, everything from life-threatening allergic reactions to the much more common reaction that I experienced.  My experience was of course exacerbated because of the substantial use of morphine based sedatives since the operation, those sedatives causing an over production of histamine which, as I crudely understand it, creates a set of circumstances which combine into a severe skin reaction.  So severe, in fact, that the following day the skin around my dressing was red raw and had actually blistered.  My wife has been treating it with TCP and Savlon these last few days and it’s starting to clear up, the blistering just bled out last night.  I have no idea what the policy is for testing or checking whether a particular patient is going to react to the use of a given preparation such as Betadine.  With what I do now know I suppose I can assume that where a policy does exist it will be different in each and every hospital across the country which, as I’ve intimated before, appears lunatic to me.  What I know though is that a pause of a few minutes, literally 2-3 minutes, between application of an iodine based preparation and the subsequent procedure would have allowed time to detect the reaction and countered the effect, delaying the procedure until the situation was resolved.  Whilst being a safeguard against my situation, that of course would not protect those who have the more severe allergic reaction so I’m rather surprised that there is no scratch test or similar as a matter of course before application of such substances, given there is no emergency being addressed here.  I guess someone might conclude, perhaps rather presumptively, that if the patient had just gone through major thoracic surgery that the same substance would have been used and that no reaction was noted.  That however is hardly a sound basis from which to presume and does not take into account the other factor referred to in respect of the build up of histamines.

Forewarned is forearmed, as they say, so it will be no surprise to anyone that when it came to removal of the second drain I was fully equipped with all the information I needed by which to direct how things were going to proceed.  I had made an appointment with a thoracic surgeon at my local private hospital for 8am on the Saturday, four days after the first drain was removed.  An hour beforehand I took a 10mg dose of oral morphine as a precautionary general sedation.  I explained the background to this new surgeon and requested that he use an alternative to iodine for the disinfecting process and that he use lignocaine prior to removal.  He clearly noted the residual inflammation and blistering and so to say that he had no hesitation in agreeing my proposals is to understate it, both he and the attending nurse displayed a healthy degree of incredulity that anyone would attempt removal without a local anaesthetic.  I normally have no problem with injections and so the acute sensitivity I felt to this particular lignocaine injection confirmed to me, beyond doubt, just how sensitive this area had become.  That said, the pain was gone in a second and the rest of the procedure was entirely pain free.

I could spend the next six months researching this topic but, frankly, life is too short for me.  For the profession, I really do think this is something that should be looked into seriously and urgently.  The questions I would want to address would be:

  1. Why do we not have national policy guidelines, developed as a result of research conducted by the most eminent professionals available and imposed automatically across the entire NHS?
  2. What training do we need to deliver to medical staff on the methodology of minor surgical procedures? Preparing the patient, allaying fear, making sure where possible that there is a bond of trust before the procedure is started?
  3. How do we best redress cultural obstacles throughout the NHS to effective pain management practice?
  4. What tests or procedures should be adopted to prevent experiences such as mine, within reason and where practicable?

What I went through was hardly life-threatening and what I was being cured of most assuredly was!  It is therefore clear that a relative perspective must be maintained here but to suggest that such minor issues should be ignored given that the patient should “thank their lucky stars” that they are still alive, is not exactly the kind of professional approach I would expect from a civilised and wealthy society such as ours.  Patients heal better and faster when their pain is well managed, it’s a simple fact.  Patients that heal faster are cheaper to treat.  Patients that do not experience pain are easier to manage.  The whole topic is a no-brainer surely, instead of the moronic “no pain, no gain” maxim we need to instil “no pain, we all gain”.