My Heart Op

We don't know the reason for the stroke that I had in 2011.

It could be high blood pressure: my blood pressure is high, but not very high. Blood pressure is responsible for a third of strokes, and may be caused by excess dietary salt. I've been trying to reduce my salt intake, and I'm also taking Ramipril daily. My blood pressure has come down somewhat, but it's hard to get consistently accurate measurements.

It could be a Patent Foramen Ovale (PFO) - a hole in the heart that's supposed to close at birth. In about 25% of people, it doesn't close properly. However, 50% of people who have an early stroke have a PFO. It's possible that a clot forms in the hole, then escapes and lodges in the brain, for example.
PFO closure is a simple, day operation. Imagine pushing a tiny cocktail umbrella through the hole, then opening it up: but it's a more sophisticated bit of kit than that! It can be inserted through a large vein in the leg. It's a very safe operation, and there's some evidence that it really can reduce recurrence of Transient Ischemic Attacks (mini strokes, whose effects last only a very short time).

There are three studies that show a reduction in adverse events in the five years after the operation. None have shown a statistically significant effect, but adverse events turn out to be very rare, so larger studies may be needed. It may be that aggregating the statistics from the three studies would demonstrate a statistically significant result. Anyway, having declined the operation after the first study was published, I've now decided to go ahead with it.

I was very pleased to be given a choice of dates for the operation. I turned down May 1 (the day before the County Council Elections) and May 8th, the annual meeting of Lewes District Council. Instead I've elected to have the operation on May 15th. They only do it on Wednesdays, it seems.

I still have the altered sensation in my left side: often pain, but generally hypersensitivity to cold, heat, pressure, and so on. I think it's probably going to be permanent.

Edited to add: Yesterday (16 April), I got a phone call to say that the 15th May date isn't actually available. I had a choice of 1 May, or to go back on the waiting list. I chose to go for 1 May. Also, my wife and I watched a Holby City staff member (Tara Lo) die on the operating table, which is discouraging, even if entirely irrelevant! The letter that I got from the hospital says that my consultant has performed this procedure 260 times, and not had serious adverse affects. Tara's operation, in contrast, was (a) a high risk procedure, (b) on a brain tumour, and (c) fictional.

Conference Calendar

The agenda for the Liberal Democrats' spring conference has just been published. You can read the announcement on Lib Dem Voice. I maintain a Google Calendar called LDCONF in which I put our conference events, for my own purposes. But, I also make that calendar publicly available.

You can see it below, or at http://s.coop/1c87r or,

you can the events to your Outlook, Apple iCal, or smartphone calendar by downloading the file at http://s.coop/ldconf2012 or,

you can subscribe to the calendar (and get future updates in your calendar) at
http://www.google.com/calendar/feeds/eiloart.com_ov92vs7r372538okh8ibq1uefs%40group.calendar.google.com/public/basic

I've taken a different approach to fringe, which is to add each time slot as a single calendar item, and put details of the events into the calendar item notes. If I find the time, I might split these out, but I'm not sure that won't just make a complete mess of calendar displays!

SIlver Skins for Mountain Lion

A while back, annoyed by the appearance of the Address Book and iCal applications in OSX 10.7 (Lion), and inspired by Giles of Simple and Usable, I created a silver skin for Address Book.

Mountain Lion has improved the Address Book interface, and renamed it "Contacts". It's great that you can now see groups, group members, and contact details in one window; they've done away with the awkward switching between groups. But they've retained the somewhat annoying attempt to look like a real, leather bound, address book.

Similarly, there's a better appearance to the renamed Calendars, but they've retained the silly leather bound look, and torn off paper look.

So, I've created silver skins for both of these. And I've gone one better by creating a proper installer package. You can choose which app to fix using the Customise button, but by default it'll just fix both of them.

The installer should only work on Mountain Lion, and it should refuse to change apps on other versions of OSX. Also, it requires that Contacts.app and Calendar.app are in the usual locations.

update 21 August: fixed link. Sorry!

Should a banker be paid more than a nurse?

I'm listening to BBC Radio 4's Public Philosopher. Today's topic is "Should a banker be paid more than a nurse?"

I think the answer is "no". Banking services, though, are scalable, so individuals can get rich (and throughout, here, I mean filthy rich) providing those services. The next few paragraphs explain.

The BBC programme is an exploration of the moral arguments. The explanations of the high pay for bankers are given as:

1. bankers have more talent, 
2. bankers work harder,
3. society values bankers more,
4. the market values bankers more.

Let's deal with talent and hard work first. Nurses often work extraordinary long hours. Their training requirements are higher, so they have more talent (both professions owe more to training than personality), and their knowledge base is broader. A banker may, perhaps, have a talent for economics than a nurse, but collectively the bankers don't seem to be in control. The nursing profession, on the other hand, doesn't have sudden widespread crashes in performance. Anything that looks like that would probably be a failure of public health professionals, or more likely the press; witness the MMR hoax.

I think it's pretty clear that most people value nurses more than bankers. We'd all rather live in a society with no finance professionals than a society with no health professionals. We don't like it when our bank branch closes, but we protest when our local hospital closes. If society doesn't reflect that preference in individual pay, then that's because some structure in society isn't reflecting the aggregate opinion of its members. That structure would be the market.

But, what is it about the market that gets banker so well paid? Much better paid even than doctors, or NHS bosses. I think it's this:

We all make a living either by creating wealth or by tapping the income or wealth of other individuals - usually through an organisation. But, wealth creation only happens through creating exchangeable physical products, say through agriculture or manufacturing. Neither bankers nor nurses do this. They get paid for providing services, which are not exchangeable.

Service providers get their income from tapping the income or wealth of people who buy their services. There are two ways to get rich doing this: either tap the incomes of lots of other people, or tap the incomes of a smaller number of richer people. But, to get really rich, you need to provide a service that lots of people can use. That is, an impersonal service - one which you can provide many copies of. That service might be a music recording, a piece of writing, a televised performance or a bank account. Of course, you need an army of sales people to funnel the money your way, but those people don't need to be highly talented or well paid. In fact, it helps if they're not well paid.

A nurse, however, doesn't provide a replicable service. She (or he, but usually she) provides a personal service that can't be duplicated. It has no value if you know you're going to get exactly the same service as the person in the next bed. Even if you have the same condition as your neighbour, you may respond differently to treatment, for example. And, even if you did need exactly the same treatment, the nurse can't provide that treatment on a CD, or over the web, to many people simultaneously. Nursing isn't a spectator sport.

 So, this is where the market fails. Any individual will value their nurse more than their banker. But no nurse will be able to get paid for nursing services by more than a few people at a time. OK, a nurse might write a book about nursing, or run a nursing company, but neither of those things are nursing (the first is writing, the second is provision of management services).

In fact, the services that we value most are personal services. And, the people providing those services are never going to get rich, except by providing those services to people who are even richer. Oh, and if you're providing a personal service, and you want a higher income than your average client, then you need to be draining their wealth, or subsidised through taxation, or providing an occasional service that they really value.

There are, of course, elements of the health service, in which people can get rich. They can do it by cherry picking clients (private health provision), but they can't get wealthy in the same way as a banker, or footballer, or pop star. They can do it in management, but they have to be managing a really large organisation, and probably in the private sector. They can do it in manufacturing of drugs or medical equipment - because drugs and medical equipment are replicable and therefore their manufacture is not a personal service. In fact, it's wealth creating, and it's scalable.

I've made a Google calendar for the Liberal Democrats spring conference.

You can subscribe to it at this address: http://www.google.com/calendar/ical/eiloart.com_ov92vs7r372538okh8ibq1uefs%40group.calendar.google.com/public/basic.ics

There's little chance that I'll update anything on the diary now (unless you tweet @ianeiloart with errata), so you're probably just as well to add the events by clicking here: http://s.coop/ldconf2012

My Brain

I woke up on the 17th, a month after my stroke, with new pain in my wrist and knee. Previously the evil had withdrawn from those regions. I was worried that this reversal of progress might indicate a new stroke. My wife drove me to A&E, where I had a new battery of tests. They called my consultant, who ordered another MRI scan, and asked to see me after that. I swear that scanner is getting noisier - still, just the one scan this time.

I went straight up to see the consultant and she had the scan on her system straight away, which was pretty impressive. I know, that shouldn't be impressive these days, but…

A slice of my brain.

Anyway, I took this snap with my phone. It shows a slice through my head, viewed as if from below. It doesn't show the stroke damage - that's lower down than this slice - but I liked this slice because it shows my eyes and optic nerve, so it's quite easy to read. You can also see one ear (I've played with the contrast a bit, and you can't see the other one), and my "wonky nose" as the consultant put it. The black 'holes' near the front of my eyes are actually the lenses, not the pupils.

The good news is that this particular scan can show new stroke damage - that is damage that's occurred in the last ten days. And we didn't see any. So, I'm somewhat reassured that my brain isn't just gradually melting away. And, I've been prescribed some new drugs to help with the pain. They're gabapentin, which is also used to treat epilepsy.

Stroke update

I want to describe the symptoms that I'm feeling, and how they've changed since I had my stroke on 17th October - almost three weeks ago. I've definitely improved in some ways, having recovered much touch sensation, but I'm also feeling more pain and cold.

My stroke (for which I'm still awaiting a definite diagnosis, by the way) was a pure sensory stroke. It hasn't affected my mobility or cognition in any way. That is, apart from a slight lack of confidence when using my left hand. Fortunately, I'm right handed.

Half Michelin man

Currently, I'm feeling the following symptoms pretty much all the time, but all only on the left side. In short, I feel like my left side has been blown up like a balloon, but the sensation is different in different parts.

In my face, I feel like I have a black eye and cauliflower ear, and am a bit numb on the chin. The ear is constantly slightly painful, as if someone had punched me there quite hard a few hours ago. The eye sometimes feels a bit dry, and I use optrex eye drops a few times a week. I don't know if it really is dry, but the eye drops do seem to help.

My neck feels stiff, which is a symptom that has come on in the past few days. Lifting heavy shopping bags hurts my shoulder more than it should. The upper arm feels constantly as if I have a blood pressure monitor inflated on it, but isn't painful. The lower arm including part of my hand (but only the little finger) feels like it's slightly sunburned. When I'm tired, or cold, the pain extends right up my arm, and becomes quite serious. I haven't resorted to pain killers yet, and have no idea if they would work, but this does keep me awake at night somewhat.

My side, over my ribs, feels like it's ballooned up. When I wear a heavy coat, it feels like I'm carrying a few phone directories under my arm. That's the most peculiar of all the sensations, since it feels like my arm should be sticking out almost horizontally. And yet, there's no apparent motion impairment. Between my rib cage and my waist is numb, but I'm please that the chafing sensation at the waist has subsided now.

When I sit down, it feels slightly uncomfortable. It always feels as if someone has left a wooden ruler on my chair, so I always have to check that there's not actually anything there. My thigh also feels constricted, just like the upper arm. Also like the upper arm, it can become painful when cold, but not to the same extent. From the knee down, I feel relatively normal!

Signs of improvement

There have been changes, particularly over the first few days, and I'll try to describe them. On the day of my stroke, I was sitting in an armchair and tried but failed to lift my arm. Looking down, I realised my arm had slipped off the arm of the chair, and was trapped between my side and the chair arm. Within a day or so, I'd recovered enough sensation in my arm that that wasn't possible.

Also, on that first day, I was walking very tentatively because I could not feel the weight on my foot, so I wasn't sure of my balance. In fact, I was walking independently and quite well, but I had to look down to be sure of myself. The next day, though, I was walking normally, and my wife still complains that I walk too fast!

The strangest sensation on that first day came when I need to remove ear-plugs after an MRI scan. MRI scans are very noisy, and the radiographer had inserted ear-plugs for me. After the scan, though, I was left to remove them myself.

I took the right one out first. Then, I raised my left hand, and touched something, but what? It had to be my ear, but neither my hand nor my ear was giving me any clues. It was simply impossible to remove the plug with my left hand. So, I reached around with the right. It was still tricky. Of course, I couldn't see, so I had to grope around to find the plug in what felt like someone else's ear. A week later, when I went for a repeat scan, I had no problem inserting and removing an ear plug with my left hand.

Pain management

I mentioned that I've not been using pain killers. That's partly because the pain isn't severe, and partly because I'm concerned about how pain killers might interact with my other medication - which included aspirin for the first two weeks. The best way to deal with the pain is just to get on with life, and take my mind off it. Staying warm helps, too.

From what I've read, there's a good chance that things will improve, but it could take a few months and may not be a complete recovery. Exercising the affected areas might help - apparently recovery in the arm is more common than in the leg, and that may be because the arm gets more exercise just in daily activity.

Finally, on the Thursday after the stroke, my wife printed out some diagrams of a body, and we compared how a simultaneous light touch on both sides (for example, on both elbows) felt. At each point, I rated the sensation on the left compared with the sensation on the right. At many points, I could only just sense something on the left, and at some points not at all. At other points, I was super-sensitive. We repeated this exercise a week later, and there was a dramatic improvement almost everywhere. However, there are many other types of sensitivity - to heat, to sharp pricks, to cold and so on, and we've not measured any of those.