46. Not well at all at Joyce Green Hospital !

Key phrases/words: Critical versus serious condition, Joint Casualty and Compassionate Centre, incapacitating illness or injury, critical condition, grave condition, extended visiting passes, late passes, the gate porter at Joyce Green Hospital.

No. 46

Hearing doctors and nurses - or occasionally a hospital spokesperson - describing the status of a patient on the bad-to-very-bad scale in relation to their progress is not something that we are likely ever stop hearing periodically, is it ?

But have you wondered about the terms and phrases that are used in these pronouncements. A number of things have crossed my mind recently. For example, what do the phrases “critical but stable” and “in a serious condition” really mean and how much uniformity is there in their use and finally where did they originate from ?

It seems highly likely that some of these descriptions arose from within the Armed Forces in an attempt to categorise wounded servicemen and women who were being despatched to hospitals or transferred to other centres during and after the two major World Wars.

Indeed an institution referred to as the Joint Casualty and Compassionate Centre now uses the following definitions:

“Having an incapacitating illness or injury” applies to an individual whose illness or injury requires hospitalisation but who does not warrant classification as either seriously ill or very seriously ill but whose illness or injury renders them physically or mentally unable to communicate with friends or relatives.

“Seriously ill”. This term applies to an individual whose illness or injury is of such severity that there is definitely cause for immediate concern but without there being any imminent danger to the life of the person concerned.

Finally the term “very seriously ill” is applied to an individual whose illness or injury is of such severity that his or her life is imminently endangered.

But what about some of the terms that are sometimes used within civilian health services to relatives or in public announcements when these can’t be avoided ?

As most readers will appreciate these words and phrases arise from an attempt to give the listeners a bite-sized description of the patient’s condition without breaking any confidences and without the necessity of having to describe what is actually happening in the clinical situation. Thus shorthand comes into play here and the patient's condition comes to be described as critical, serious, etc.

Being “in a critical condition” or being in a grave condition” usually means that there is a strong possibility of the patient dying within the next 24 hours even with the use of continuous intensive intervention and/or life support, whereas being “in a serious condition” seems to be used to indicate a reduced risk of death within the following 24 hours albeit that the patient still requires active intervention and close observation.

“Critical but stable” and “in a serious but stable condition” aim to be slightly more descriptive and therefore reassuring to either family members or to the media.

Interestingly, from accounts of the work of nurses who preceded many of us, it seems that it was quite normal for hospitals to keep up-to-date lists of “dangerously ill”, “seriously ill” and “critically ill” patients and also for relatives to be issued with “extended visiting passes” authorising gate-porters to allow them into hospitals outside of the otherwise very restricted visiting periods. In fact hospital personnel addressing the media can sometimes still be heard saying that “s/he is now off the critical list”.

Another type of paper “pass” that hospital gate-porters had to check in bygone days were “late passes” issued to resident nurses to allow them back into the hospital (usually "no later than 10.30 p.m.") when they had received permission from Matron or her deputy to go out for the evening !

This must have meant that the gate porters at Joyce Green Hospital were given lists of very ill patients - and of temporarily absent nurses too - and that they must have been required to check-in individuals against his lists until that moment in time when those activities disappeared from gate porters' job descriptions ?

45. Pay-As-You-Eat at Joyce Green Hospital

Key words/phrases: National Health Service, hospital dining rooms & waitresses, West Hill Hospital & Livingstone Hospital Dartford, the “pay as you eat” system, split-shifts, hospital cafeteria,

No. 45

If you were employed AND resident at Joyce Green Hospital prior to 1967- 68 the accommodation that you were given and the meals that you received were, like the National Health Service itself, “free at the point of receipt”.

Historically, charges for board and lodging within the British NHS had always been deducted at source, i.e. taken directly from the employee’s wages and so all resident members of staff - no matter what profession or trade the individual belonged to - simply enjoyed (if that’s the correct word !) the accommodation that they were given and the meals that they were served, “free” at the moment of use or consumption.

I say “served” in relation to their meals because some people reading this will be able to remember when meals were served to them in hospital dining rooms. I can certainly remember being ‘served’ meals by uniformed waitresses in the main dining rooms of both the West Hill Hospital and the Livingstone Hospital in Dartford although not at Joyce Green. In addition and by tradition ward sisters and medical staff had long had their meals served to them by waitresses in separate dining rooms.

However somewhere between 1967-68, a Government edict descended from on high dictating that this deductions-at-source approach to reimbursing the NHS for “meals taken” was going to be scrapped and a “pay as you eat” system introduced into all hospitals. This was done in an attempt to make staff accountable for exactly what they ate rather than deducting a one-price-for-all figure ffrom the salaries of all staff of the same grade and was aimed of course at reducing each hospital's catering budget.

Thus on the appointed day special, separate dining rooms for Ward Sisters and Medical staff were abolished and “Waitress Service” dining rooms arose in their place for those members of staff of any type or grade who wished to pay a small add-on charge for having an individual meal served to them.

Most people however continued to eat their meals in Joyce Green’s main dining room, but - and here was the rub - every item of food that they ate or beverage that they drank after Day 1 was individually priced and had to be paid for at a newly installed cashier’s till in the cafeteria immediately prior to it’s consumption, as in self-service cafeterias in the public domain.

For most employees, but particularly for resident staff, this was completely different to anything that many of us had been used to. Some of you reading this will be able to remember the shock of seeing the cost of the items on their lunch tray mounting up on the till roll ? “Meat x 1 portion = 1/-, portion of potatoes = 2d, portion of carrots = 2d, glass of orange squash = 2d, portion of treacle sponge and custard = 6d” and so on, right down to the halfpenny charged for a pat of butter for one’s slice of toast or slice of bread !

Not only were most staff totally unused to monitoring the cost of the dining room food that they were about to consume but many long-standing members of staff were also institutionalised to the extent that they were not used to handling money on a daily basis. In fact there were some older members of nursing staff “in post” to whom life and the ‘service’ that they rendered was something akin to living within a closed religious order, that is to say, they only left the hospital on rare occasions.

I can certainly remember dedicated ward sisters who seemed to spend most of their lives within the confines of the hospital and who frequently worked split-shifts on their wards (i.e. a morning and an evening shift in the same day) as a feature of their ‘calling’, who struggled to come to terms with the introduction of this new pay-as-you-go system because they were completely unused to budgeting and handling money.

Thus paying their bus or train fare in order to go and visit their family whilst taking a “day off” didn’t create a problem - because they were used to budgeting for this type of special, regular or occasional event – but having to calculate what the food that they had selected on their cafeteria tray was going to cost them and marshalling the necessary coins with which to pay for their meal was much more difficult for them in this brave new world, at least at the outset.

For us as students handling money and paying for food at the hospital cafeteria check-out wasn’t the problem. No our problem was that we didn’t earn very much and yet suddenly found ourselves having to control our appetites and our spending instead of eating to our heart’s content in the hospital dining room, as we had been used to doing up until then.

But here’s a question that I haven’t been able to answer yet. Prior to the arrival of the pay-as-you-eat system how did hospital authorities get back the cost of meals eaten in hospital dining rooms by non-resident staff ? Was a small sum of money routinely deducted from their wage packets as a contribution towards the costs of their meals whilst they were on-duty or were their meals a gift from the bosom of the NHS ? Maybe you can remember ?

44. Horlicks, Ovaltine or Milo ?

Key words/phrases: The evening drinks ritual, James & William Horlicks, Ovomaltine, Ovaltine, Dr Georg & Dr Albert Wander, Milo, New South Wales, Darent Valley Hospital Dartford, Dartford Salt Marshes

No. 44

The question “Horlicks, Ovaltine or Milo ?” was routinely heard at around 8.00 p.m. on most of wards at Joyce Green Hospital wasn’t it ? It was the opening question posed to bed-bound patients by the person or persons doing ‘the evening drinks’ round once the nurses had “taken the report” from the day staff.

Usually it was the Nursing Auxiliary on the night shift or the student or pupil nurse who was on duty who coordinated this labour of love but if the ward was particularly busy and the nursing staff were working flat-out to get the evening medicine round completed and plus those in bed comfortable for the night, this ritual was often awarded to a couple of recovering patients who knew the ropes.

But who ever served the ‘evening drinks’ this time-honoured ritual was an important part of evening ward life wasn’t it ? The process of being offered and then consuming a warm drink and the simultaneous giving and receiving of yet more encouraging words probably assumed even more importance than when the same ritual was performed at home. But how did Horlicks, Ovaltine or Milo achieve such a high profile on the ward beverage-menu ?

Yes of course there were usually other hot drinks on offer from the same trolley, such as tea, cocoa, hot milk etc but somewhere along the line someone must have decided that these three products should feature fairly prominently on the list of soothing drinks ? Or was it that English citizens we were already used to consuming these at home and so therefore their appearance elsewhere was taken for granted ?

Horlicks was created in 1837 by two English brothers James and William Horlicks who had immigrated to the USA. James was a pharmacist and he and his brother joined forces to manufacture this malted milk drink as an artificial infant food. It soon came to be appreciated by a wider and older audience - perhaps being served to invalids and the sick next – and then in 1906 James returned to oversee the opening of a new Horlicks factory in Slough. Commercial advertising history books certainly record the fact that the Horlicks Company first used the “night starvation” theory in 1931 in order to promote their product.

Ovaltine was originally called Ovomaltine (from ova, the Latin word for egg linked to the name of the other major ingredient, malt). It was created by a father and son team, Dr Georg and Dr Albert Wander and was first exported to England in 1909 but it was a misspelling hiccup during the UK trademark registration process that led to it coming to be called Ovaltine in the British Isles.

The last of these three drinks to appear on the scene was Milo, a milk beverage containing chocolate and malt. It was created in New South Wales, Australia in 1934 and is named after Milo of Croton, the Greek hero who was endowed with exceptional strength.

Do you remember the layer of congealed Milo and hot milk skin that seemed to form on the surface of the liquid when hot milk was added to those gritty, powdery granules ?

The perfect technique for producing a ‘perfect cup’ of one or other of these drinks was something that some practitioners had and others didn’t, nevertheless the soothing, calming potion was usually accepted with good grace by the ‘poorly’ person waiting to get off to sleep.

Authoritative opinion always was - and still seems to be - divided about whether the benefits of warm, milky evening drinks are physiological or merely psychological, nonetheless the received wisdom that drinks of this nature really do help to promote calmness, relaxation and sleepiness still seems to be given out regularly.

Perhaps milk drinks are still a feature of the evening routine on the wards of the Darent Valley Hospital in Dartford? In any case I’m sure that the nurses there still do everything in their power to help those in their care to prepare to sleep each evening but it seems to me that only those people who worked at Joyce Green Hospital can recall what it was like serving Horlicks, Ovaltine or Milo to patients who sheltered in their warm wards on cold wintery nights and protected from the winds blowing from across the River Thames or from across the Dartford Salt Marshes.

43. Today we have naming of parts ...

Key words/phrases: Henry Reed (poet), Cane Hill Hospital, Kings College Hospital, C. Dickens, J. Keats, W. Hogarth, M. Faraday, E. Jenner, H. Ellis, J. Donne, T. Guy & J. Harvard, Fred Still, Christine Brown, Annie Zunz, Maurice Mitman, Pemphigus Vegetans, Emergency Medical Service Hospitals.

No. 43

“Yesterday we had daily cleaning. And tomorrow morning we shall have -What to do after firing. But today, we have naming of parts …”

In these lines the English war poet Henry Reed (1914-1986) puts the following words (and others) into the mouth of a soldier who is in Basic Training School. The young man concerned is supposed to be paying attention to a talk on the features of his rifle but his mind is obviously wandering because later, as he surveys the gardens outside of the window nearest to him, we read:

“ …backwards and forwards the early bees are assaulting and fumbling the flowers: They call it easing the Spring.”

Even if the Spring isn’t hovering outside a window somewhere near where you are sitting at present, Reed’s poem really does seem to capture a sense of the arrival of Spring.

But what also interested me in the poem was the fact that while most of the parts of the rifles being referred to in the lesson existed, certain other components were missing. Nonetheless all the pieces had their own particular names and the intention of the instructor was that the “squaddies” should learn them.

The tradition and benefit of “naming” things then led me on to thinking about the naming of hospital wards although I appreciate that 99% of the wards at Joyce Green weren’t named. In general though - where names ARE used to identify hospital wards - the names assigned to them are frequently dedications to famous people, aren’t they ?

Wards at the now-long disappeared Cane Hill Psychiatric Hospital in Coulsdon, Surrey - for example - were named after a selection of writers, poets and artists (e.g. Dickens, Keats and Hogarth), scientists and ‘medical men’ too (e.g. Faraday, Jenner and Ellis, the psychologist), plus other notables with catchment-area connections such as Donne, Guy and Harvard.

King’s College Hospital in S.E. London, which to this day still provides some top quality health care, has some interesting ward names too. “Fred Still” ward” for example is named after one of its previous paediatricians (before they were even referred to by this term), “Christine Brown” ward is named after one of its nursing directors, “Lion” ward, their 10 bedded paediatric neurology ward - opened in 1996 - was named after the now famous cartoon film and “Annie Zunz” ward is named after the wife of a German merchant and benefactor.

Interestingly - and just before we move on - did you realise that by tradition the senior Sisters on each ward at KCH used to assume their ward name when they were on-duty ? So for example a Sister would announce herself on the telephone as: “Sister Fred Still” or “Sister Christine Brown” or “Sister Lion” or “Sister Annie Zunz” despite the fact that her surname was obviously different. Was this done as an aid to clarity or did this stem from the time when nursing was a vocation and women who were "called" were required to put their personal identities to one side as they served God ?

The next question I asked myself to myself was this: Were any of the wards at Joyce Green named after notable individuals, as opposed to being numbered chronologically ?

Maybe your memory is better than mine but I can only recall one name plaque at the entrance to a ward - and this one could be seen at the entrance of Ward 11a, which was also called “Maurice Mitman” (ward).

So who was Maurice Mitman ? Perhaps the very same MRCP who co-authored a paper with Dr S.E. Dore MD, FRCP in 1929 on Pemphigus Vegetans which appeared in the British Journal of Dermatology (Volume 41 Issue 11 Page 408) ? In any case he was certainly a physician at Joyce Green Hospital between 1938-1950.

This surname has either Ashkenazic Jewish origins (Mitelman) or a middle - high German derivation (Mittman) which gives us a clue perhaps to his family background ?

In 1938, when Joyce Green was re-classified from being an infectious diseases hospital to a general hospital (as part of the Emergency Medical Service Hospital arrangements) and expanded from 986 to 1,900 beds Dr Mitman was appointed as Medical Superintendent.

This was a position he held until 1948, when Joyce Green became a National Health Service hospital although he it seems carried on working as a physician within the hospital, maintaining a special interest in the care of patients with “fevers”, until his retirement.

Thus we can assume that he was fairly highly thought of, having been asked to lend his name to a ward ?

But as to any other wards being ‘named’ I have so far drawn a blank. So what about it readers, do you remember any other ward having a name or even being awarded a temporary or
an unofficial nickname ?

42. Happy Birthday Flo

Key words/phrases: Florence Nightingale, Westminster Abbey, Crimean War, Nightingale Foundation scholar, Bournemouth University School of Nursing, Nightingale’s religious convictions, Church of England, Unitarianism, Joseph Priestley scientist, Leeds, Pennsylvania USA, Sister Mary Clare Moore, Lutheran deaconesses of Kaiserwerth Germany, Fort Pitt near Chatham & Rochester, Army Medical School.

No. 42

Florence Nightingale, the great social reformer and pioneer nurse was born on 12 May 1820, something that is remembered with a memorial service that is held in Westminster Abbey each year.

This year the commemoration service is to be held at 6.15pm on Wednesday 9 May 2007 when “the procession and passing of the lamp” ceremony will take place once again.

The lamp - a replica of the type that Nightingale carried during her work with wounded soldiers during the Crimean War - is taken from the Nurses' Chapel in the Abbey and is carried by a Florence Nightingale Foundation scholar. It is handed from one nurse to another and finally to the Dean of the Abbey who places it on the High Altar. This signifies the passing of knowledge from one nurse to another.

Each year the lamp is escorted up the aisle by a procession of student nurses and this year it is going to be escorted by representatives from the School of Nursing of Bournemouth University.

This annual ceremony reflects Florence’s religious convictions and her commitment to caring for the sick. However one thing that I had never thought about in any great detail until recently was : What exactly were the religious underpinnings to her 60 years of service ?

The religious influences that she was exposed to were varied; in fact hers was both a politically and theologically incorrect background.

A politically correct Victorian would have embraced the monarchy, the British Empire and the class structure and the associated theological correctness would have meant supporting the tenets of the Church of England and the Thirty-Nine Articles of faith.

In fact Florence’s roots lay in Unitarianism. This was a new development in Florence’s time and was something that grew out of the activities of Joseph Priestley, an influential scientist, who rejected Christianity’s supernatural claims of Christ’s Divinity and the his Atonement for human sin in favour of a religion based on reason.

Priestley (who was born near Leeds and who died in Pennsylvania, USA) believed that each of us should work for social and religious reform, being guided by God’s Spirit. Many Victorians agreed with Priestley’s ideas and Nightingale was one of the many who accepted this viewpoint and who began to work out this philosophy in their lives.

Later on Florence developed these ideas into a kind of theology of her own in a book entitled: "Suggestions for Thought". In this she declared that the solution to ill-health lay in obeying God’s laws and in working in harmony with God for the betterment of mankind. Thus her ideas were based upon a “deeds not creeds” approach that those of the Unitarian’s persuasion believed would reform mankind.

However she also examined some of the many other religious traditions of her time and it could never be argued that she was exclusively Unitarian.

Florence’s mother Fanny was raised as a Unitarian but later decided that there were social advantages to be had from “being Church of England” and so she had the Nightingale sisters tutored in the tenets of the Anglican faith. The Nightingale family perhaps also felt obliged to associate with the Church of England when some property that her father inherited brought with it certain parochial duties.

Florence however couldn’t accept the Anglican Church’s endorsement of class distinctions and she rejected their overall theology.

Her father supervised and took the major responsibility for his daughters’ education which included classical and modern languages, history and philosophy and when she was 20, at Florence’s insistence, he also arranged for her to be tutored in mathematics.

All of these, plus other influences, inculcated Florence with a strong sense of public duty, an independence of thought, a fierce intellectual honesty and a radical and unconventional religious mysticism which went on to underpin her endeavours. Sadly though her background also left her with an unforgiving attitude towards her own faults and to those of others.

A further religious influence upon her was her friendship with the Sister Mary Clare Moore, the founding superior of the Irish Roman Catholic Sisters of Mercy in Bermondsey, London. In addition we also know that she was profoundly impressed by the practices and commitment of the Lutheran deaconesses that she observed in their hospital in Kaiserwerth, Germany in 1846.

She had what she regarded as four calls from God between 1837- 1861, the first being when she was 16 yrs old, and she recorded many of her prayers and conversations with God in her writings.

As a result of this call from God Florence felt driven into social action and service to those in need. Her spiritual vision and her professional identity were seamlessly combined. As she once put it: "My work is my must".

Finally, did Florence Nightingale ever have anything to do with Joyce Green Hospital or its predecessors ? The short answer is no.

As far as we know the nearest that she got to providing a service in this area was at Fort Pitt, built between 1805-1819 on the high ground of the boundary between Chatham and Rochester. It became a hospital for invalid soldiers in 1828 and an asylum was added in 1849. Miss Nightingale started the first Army Medical School there in 1860 but the hospital was closed in the 1920s and the site converted into a girl’s school.

41. Life actually

Key words/phrases: "Love Actually", Hugh Grant, Nurse Tutors, Miss Bingham, Mrs Parry, Mr Walker, Channel 4 TV, "The Human Footprint", Producer : Nick Watts,

No. 41

Like the Hugh Grant romantic comedy film “Love Actually” with all its sub-plots, real life or “life actually” is just as rich if you think about it, isn’t it ?

For instance, think again for a minute about of the composition of the human body. Perhaps you’ll have been amused in the past by some of the many amazing figures relating to human anatomy and physiology? If you trained as a nurse within the Dartford School may be you can even remember your jaw dropping floorwards occasionally at some of the facts and figures that tumbled out of the mouths of nurse tutors such as Miss Bingham, Mrs Parry and Mr Walker during A & P sessions ?

Do you recall for instance that there are 200 bones in the adult body (discounting the three bones in each inner ear), that the adult intestines are on average 25ft in length, that a grown-up’s skin covers a surface area of 20 square feet (so is blanket size, in fact) and finally, that the human eye muscles are kept the busiest in the body averaging 100,000 movements per a day ?

But leaving A & P to one side, did you see that recent Channel 4 television programme (April 26 2007) entitled “The Human Footprint” ? No ... you didn’t ?! Well neither did I although I certainly enjoyed reading a review of it later.

According to Nick Watts who gathered the statistics together and produced the programme we clock-up some amazing personal records as human beings during our lives.

Did you know that on average the number of apples eaten by each UK resident during his/her lifetime is likely to have been 5,272 and the number of carrots: 10, 800 ? Or that on average each British citizen will have owned 4.8 televisions and 8 cars ? Mr and Mrs Average will also, or so it seems, have taken 59 foreign holidays and spent £286, 311 on taxes.

In the TV programme Nick Watts tried to help viewers to visual some of the enormous quantities of consumables that we chomp our way through by showing a “Hansel and Gretel” house built of the 10,000 bars of chocolate that each of us eat in a lifetime and he even lined up 15,000 pints of milk on someone's doorstep !

The point he was making and the point that I want to flag up again today is how unavoidably repetitious our behaviour can be and what creatures of habit we apparently are.

Each of us will - again on average - have walked, he said, 15, 464 miles, taken 7,163 baths or showers and drunk 74, 802 cups of tea during our 78.5 years of life.

This set me thinking about repetitious acts that each of us may have performed during the working parts of our lives and in particular of course about the number of times we might have repeated certain actions during any time that we may have spent at Joyce Green Hospital.

How many naso-gastric tubes do you think that you passed on patients in surgical and medical wards there ? How many intramuscular injections did you give during your working life there ? How many cups of tea did you drink in its ward kitchens and how many miles do you think that you might have walked to your meal-breaks or whilst collecting or ‘dropping something off’ in one department or another ?

If you worked in one of the hospital kitchens or the hospital dining rooms - how many meals will you have produced or served, or if you were a radiographer there how many times did you say: “I want you to hold your breath now while I count three” ?

In his TV programme Watts suggested that in each of our lifetimes we will have cried (or bathed our eyes naturally) with 121 pints of tear drops, made 117 friends …. Oh and talked a lot too, because according to him a woman utters between 6,400 - 8, 000 words per day and a man on average produces between 2,000 - 4, 000.

So .... sometime today think about the number of times that you have did the same thing at Joyce Green, said the same thing, walked the same path or made the same movement. Can you remember someone who: “Always said … ” or “always seemed to ….” ? Was there someone whose punctuality or clockwork regularity at Joyce Green you appreciated or found reassuring ?


If we really are such creatures of habit I suppose that many of us reading this will have lots of memories about having done “this or that” for the umpteenth time, or even for the last time perhaps ?