Going undercover at the bus shelter

‘Can you get treated for brain cancer in Australia or do you need to come here?” Randy asked earnestly, as his wife, Britney, affectionately adjusted his beanie to cover his scars.

“We’re so lucky to be American,” she piped up, “with the best doctors in the world. Randy would certainly be dead if we lived somewhere else.”

Some background…

Bus-stop-009At 5.06pm, I’d arrived at a deserted suburban bus stop to catch the scheduled 5.07 bus. At 5.08, an overweight middle-aged woman rushed up, panting. Betsy reminded me of a stereotypical loud brash American tourist — but this was in America and I was the tourist.

An excessively long exchange about bus timetables ensued, involving detailed speculation as to whether the bus had come early or was running late. Just as the logorrhoeic discourse was blessedly winding down, Randy and Britney arrived, eager for bus-related news. Betsy was only too happy to oblige.

She was one of those kind-hearted yet strongly opinionated women who have no qualms about asking personal questions and giving unsolicited advice. To be fair, she was equally unfazed about sharing her most intimate details with strangers: financial, health-related and romantic.

To my surprise, Randy’s response to Betsy’s “So, what’s wrong with your head?” was a frank and detailed description of his 13-month journey with cerebral malignancy.

As an undercover doctor, I found this all very intriguing. I’m used to hearing strangers spill their guts, but it is usually within the safe confines of a consultation room, where trust is given freely and confidentiality is assured.

It is an honour and a privilege with which I’m comfortable but I don’t take it lightly.

But Betsy, Randy and Britney did not establish my credentials. I could have been a criminal mastermind, who would use such intimate details for self-serving purposes. Or a writer, who would pounce on their confidences and write about them for self-serving purposes … hang on.

The point is, I could have been anyone — an axe murderer, a doctor, both, neither — and as such, I felt unworthy of their trust.

The conversation turned from the glories of US tertiary healthcare to its personal cost. Randy’s five neurosurgeries, radiotherapy and ongoing chemotherapy at Mt Sinai Hospital had not come cheap. His boss had kept him on unpaid sick leave so that his employer-paid medical insurance could continue, but after 12 months Randy was forced to resign. No insurance company would cover his “pre-existing condition”, leaving Randy uninsured and facing financial ruin.

It made me, once again, realise how lucky we are in Australia.  In recent times there has been outcry over rising out-of-pocket health expenses and the proposed GP co-payment. While these are of legitimate concern to Australian patients and doctors, our system is pretty darn good. A 24-year-old Australian with cerebral malignancy doesn’t have to go into debt to receive quality medical care.

However, my pointing this out to the now-crying couple was not going to help, and for once in my life I didn’t quite know what to say.

Luckily, Betsy did. Having had a two-decade-long battle with Medicare, Medicaid and other social services as a result of her chronic back pain and fibromyalgia, she knew all the tricks of the trade. She told Randy where to go, to whom to speak and to what he was entitled, as well as providing her phone number to call if he needed help. Randy and Britney were really touched, and when the next bus came there were hugs all round.

It was the most meaningful hour I’ve ever spent at a bus stop. I’m glad I missed the bus.

All names have been changed.

First Published in Australian Doctor on 20th  September, 2013

Political Correctness Gone Mad

I suspect that there are very few of you not familiar with the way police officers in New York NYPDCity describe suspects, thanks to endless seasons and repeats of shows such as Law and Order, CSI:NY and NYPD Blue.   A description like this might be broadcast on police radio…

“White male, short blond hair, late teens/early 20s, approximately 6ft, blue jeans, black T-shirt”

According to an article in The Australian (reprinted from The Times), police officers in New York are worried that a new bill being brought city council may mean the above description will have to be changed to:

“Person, approximately 6ft, blue jeans, black T-shirt”

They are concerned because the proposed changes would allow members of the public to launch a lawsuit against the NYPD if they are wrongly apprehended and detained on the basis of race, colour, creed, age, gender, sexual orientation or disability, amongst other things. The police union have launched a campaign featuring an advertisement depicting a blindfolded policemen standing in Times Square.

I was wondering what would happen if similar politically correct measures were brought in for us, as Australian GPs.  The item numbers for Aboriginal and Torres Strait Islander health checks and assessments for those with an intellectual disability would probably be the first to go. The checks which discriminate on age, such as the Health Assessment for those ages 75 and older, and the Healthy Kids Check may well soon follow. Maybe Chronic Disease Management Plans and Mental Health Care Plans could also be deemed discriminatory.

The loss of these Medicare item numbers would not call the sky to fall in – after all, 15 years ago we didn’t have any of these at our disposal and bumbled along OK – but what if such changes affected the way we were able to manage patients? The NYPD are concerned that without being to state and act on the obvious they will be unable to do their job effectively (i.e. catch the baddies).  Imagine trying to diagnose and manage disease if constrained by similar restrictions. We’d have to forget that different racial groups have different propensities to certain diseases. We certainly wouldn’t be able to have a lower threshold for testing for things like HIV and syphilis in men who have sex with men.  Skin colour would play no part in assessing risk of skin cancer.  And everyone gets offered a PAP smear: male or female, young or old – can’t use age or gender to decide who to target.

OK, so this is clearly ridiculous, but my point is, so is not being able to target and apprehend a suspect on the basis of gender.   I shouldn’t be surprised; gender neutrality in language has been a hot issue for years. Perhaps this is the next step? I read that more than half the states in the US have moved to gender-neutral language in all official documentation.  Changing personal pronouns from “he” to “he or she” seems reasonable, despite being a little clunky in places, but changing “penmanship” to “handwriting”, and “freshmen” to “first year students” appears to me to be a little over the top.  When hearing that words like “manhole” have been changed to “utility hole” or “maintenance hole”, however, my eyes roll so far, an observer may wrongly assume I’m an oculogyric crisis. That is, if they are not a police officer from New York. I’m pretty sure identifying someone on the basis of eye position would be in the “considered potentially offensive” list.


First published in Australian Doctor on 2nd August, 2013 On Policital Correctness Gone Mad


Telling a cabbie where to go.

“178 Darley Road*, Randwick, please.” The meter started and the taxi pulled out onto the congested Sydney CBD street.

“What street is that off?” The cabbie’s inquiry was barely audible over the blare of talkback radio.

“I don’t know. I’ve never been there before.”image taxi

“So it’s not your house?”

“You’ve just picked me and my luggage up from a hotel. Do you think it’s likely that I’m a local?”

“It’s possible.”

“That’s true, but no, it’s not my house. I’m not in the habit of paying for a hotel room a few kilometres from where I reside.”

“But you know how to get there, right?”

“No. Isn’t that your job? I tell you where I want to go and you take me there?”

“But you don’t know where you want to go.”

“I know exactly where: 178 Darley Road, Randwick.”

“Well, I don’t know it.”

“Well then, why don’t you use your sat nav?”

“Don’t have one.”

“Your smartphone?”


“Street directory of any kind?”

“Nothing. I use my memory.”

“But you don’t remember Darley Road.”

“There are a lot of streets in Sydney. I can’t know them all.”

“Hence the need for a sat nav or at least a street directory.”

“Most passengers know where they want to go.”

“As do I, 178 Darley …”

He brusquely cut me off. “You know what I mean. Can you ring someone and ask for directions?”

“You want me to ‘phone a friend’ to tell you where to go?”

I wish I’d said something witty about where I thought he could go at this point but I was too busy being incredulous.

“Yes,” he replied, sans irony.

“I don’t think that’s my responsibility.”

“Then I can’t take you there. You’ll have to get out.”

After being unceremoniously dumped on the side of the road, he charged me $6.05 to cover the booking fee, the flag fall and the 50m we’d travelled while arguing. I was speechless — a somewhat uncharted territory for me.

I reckon a GP consultation equivalent would be something like:

“What can I do for you?”

“My throat really hurts. I’d like something to ease the pain.”

“Have you got tonsillitis?”

“I don’t know.”

“Does it feel like tonsillitis?”

“I’ve never had tonsillitis.”

“Did you look in your mouth with a torch?”

“No, I thought that was your job.”

“I haven’t got a torch, an otoscope, or any other light source. I believe it’s the patients’ responsibility to diagnose, or at least examine, themselves. If they don’t know what’s wrong, how am I supposed to treat them?”

“Will you give me something for my throat?”

“Not without examination findings. Perhaps you’d like to ask a friend to take a look.”

“I’ll find another doctor, thanks.”

“That will be $60. You were booked for a standard consultation and I’m entitled to be compensated for my time.”

The first thing I asked the next cabbie was: “Have you got a sat nav?”

“Yes, but I don’t tend to need it.”

I beg to differ, given that halfway through the journey he pulled over, meter running, scrounged around under his seat for his battered street directory and spent a good five minutes looking up the address; and then on arriving at Darley Road slowed to a crawl, reading every house number aloud as we passed: 10, 12, 14 … right up to 178.

I arrived 20 minutes late and $36.05 poorer. So much for my decision to splurge on fast, hassle-free conveyance instead of public transport.

*street number changed to protect privacy.

First published in Australian Doctor on 9th May, 2013.


What it means to be an Australian – Part 2

Last Sunday, on our national day,  I blogged about the staggering costs of US healthcare as I reflected on what it meant to be an Australian.

Here is the story of my own personal encounter with the US health system last year….

Playing it Safe

While in Las Vegas recently, I spent more than $5000 in six hours. Now, before you Bellagio Hotel in Las Vegascastigate me for reckless spending, I rush to tell you that I forked out because I’m not a gambler — I was playing it safe. The hefty bill came from a hospital, not a casino.

En route to visiting my family in Canada, I was enjoying a quiet stopover in not-so-quiet Sin City. I first felt some pain in my right calf while running up the hotel fire-escape stairs (I know, I’m crazy), making me think muscle sprain, but within 24 hours the swelling became quite marked while the pain wasn’t particularly severe.

Given that I’d just endured a long-haul flight sitting in a cramped, cattle-class seat, I decided I couldn’t take the gamble that it wasn’t a DVT. Hoping for an ultrasound, I limped into a walk-in medical clinic, where the consulting doctor thought it highly likely to be a DVT and sent me to the nearest ER.

I grew up on US TV medical dramas, ER being my favourite. The series began in my second year of med school and I soon convinced myself it was a useful and legitimate study resource — a view reinforced when an obscure case in my fifth-year internal medicine viva was identical to the fictional one in a recent episode, allowing me to answer correctly and with confidence.

When I turned up to my first real-life American ER and discovered my treating doctor’s name was Mark Green (the name of my favourite character on the show), I have to admit I felt a frisson of excitement. It didn’t hurt that the real Mark Green MD was attractive, attentive and charming.

Disappointingly, this is where the similarities with the TV show ended. There were no patients miraculously brought back to life from asystole with CPR and a few jolts from a defibrillator, no complex surgical procedures performed by underqualified staff, no doctors and nurses embroiled in interpersonal dramas at patients’ bedsides, and not even a token lovable but disruptive patient with an entertaining form of psychosis. At least, not that I got to see.

It was, well, like an Australian ED, except that everything was bigger: the patients (the average BMI was probably over 30), the chairs, beds, artwork — and the bill.

My ultrasound was equivocal and the D-dimer negative, so an MRI was ordered. It seemed like a bit of overkill but, from what I could gather, MRIs are ordered for practically everything in the US: tension headaches, osteoarthritis, acute back pain, toothache, a broken fingernail.

Okay, perhaps not all of these, all of the time. It did the trick for me though, producing a lovely image of a second-degree soleus muscle tear without a thrombus in sight.

It looked a lot worse than it felt. I kept declining the analgesics the nurse tried to give me, unwittingly reinforcing her perception of the Australian stereotype. “I always thought you Aussie sheilas would be tough. All those snakes you have to kill and jellyfish that bite you. And the sharks.”

She paused, looking proud of herself. “Sheila is Australian for ‘woman’, isn’t it? I learned that on HBO. I just love learning different languages.”

I know the US health system has deep-seated problems, but my brief stint as a patient was a memorable and positive one. The staff were friendly, efficient and professional, and the facilities top notch. The only hurt was the bill. I’m not the first person to lose a fortune in Las Vegas but at least I was insured against the loss!


First published in Australian Doctor on 12th April, 2013 about my trip to the US/ Canada in Feb/March 2013.


Why Halloween and I aren’t so keen on each other

Halloween, 31st October 2012

I’m not opposed to giant pumpkins. I don’t have a problem with people dressing up in costume, as long as I’m not expected to don a witch’s costume to go with my chin (I was once told by a six-year-old patient that my chin is “long and pointy like a witch”, and I’ve had a chin complex ever since).

I just object to being dragged into yet other Americanised opportunity to promote childhood obesity and tooth decay.

Mind you, Halloween doesn’t seem keen on me either. This 31 October, I was travelling to Melbourne, via Sydney, heading for the RACGP to workshop the new vocational training standards. The meeting was a treat but I was tricked en route. I arrived at Sydney airport. My wallet didn’t.

I’d had it at Ballina airport when I paid for parking, but somehow I found myself in Sydney with no ID, cash or credit cards. Thanks to a kind friend who made a mercy dash to the airport with some cash, I made it to Melbourne with at least the means of getting to my accommodation.

Alas, the hotel clerk was not accommodating. Having missed my connecting flight in Sydney, I ended up arriving after midnight, and was in no mood to be told that they couldn’t give me my prepaid room without a credit card imprint and ID.

“I know my credit card details; can’t I just give you the numbers?”

“No. I have no way of verifying who you are.”

“But you take credit card bookings over the phone.”

“Yes, but that’s different.”


“It’s over the phone.”

“Well, how about I go outside and call you on my mobile?”

“We will accept a $500 cash bond in lieu of a card, but we still need ID to give you the room.”

“I don’t have $500 or ID.”

“Then I’m sorry, I can’t help you. My hands are tied.”

I was ready to tie him up myself and steal a room key but sanity prevailed. The duty manager was called, and I eventually got a bed on which to rest my weary head.

I have a new appreciation of some of the many challenges faced by the homeless, dispossessed and utterly disorganised. For me, thankfully, it was just a blip — Halloween deja vu.

This wasn’t the first time I’d spent Halloween trying to prove my identity. In 2010, I landed at Los Angeles airport with a stolen passport, according to US Customs. I was ignominiously thrust into detention with an assortment of would-be immigrants while they “processed my case”, and released seven hours later with a curt “You can go now. Administrative error”.

Again, a missed connecting flight, which meant arriving late in Las Vegas, and an after-midnight hotel fight. They’d given away my prepaid room and claimed the hotel was full. Being Halloween in Vegas, I almost believed them, but wandering the streets at 2am with inebriated, costumed revellers didn’t seem like a good option, so I stood my ground.

They eventually found me a “special” room, which came with a full-mirrored ceiling, an enormous “love tub” set into the carpeted floor, and a bed with various attachments. I tried to convince myself it was a Vegas-style birthing suite that had been properly cleaned after last use, but the stains and lingering odours suggested otherwise. I mightn’t have minded so much if it’d come with a pool table and naked prince.

Next year I’ll try to get back into Halloween’s good books by staying at home and treating any callers to tooth-rotting ‘candy’, with my wallet and passport safely tucked away.


First published in Australian Doctor on 21st November, 2012: On Halloween


Mid-air consulting… Aussie GP style

It’s an early morning flight. You’re tired, grumpy and regretting not grabbing a coffee before boarding. The seatbelt sign is turned off and the mouth of the person sitting next to you is turned on.

She starts yapping away, trying to engage you in small talk. Not wanting to appear rude, you reply, all the while wishing she would just shut up. The situation turns from grim to dire as she moves from the trivial to the personal.

I was en route to present at an international medical humanities conference in the US, and, I have to confess, I was that annoying talker. Why? I noticed a mole I didn’t like on my fellow passenger’s forearm.

Now, I’m certainly not in the habit of giving strangers unsolicited medical advice, but I was sitting there confronted by this highly suspicious naevus, my fingers itching for a dermatoscope, and just couldn’t stay silent. The young American told me that it had been looked at “a couple of years ago” but admitted that he’d noticed recent change. He hadn’t been concerned about it before boarding, but I made darn sure he was before disembarking. I gave him my business card (to demonstrate that I did indeed have a medical degree), and two weeks later received a very grateful email. The lesion turned out to be an invasive melanoma with a Breslow thickness of 1.3mm

On the very next leg of my journey, I again had cause to advertise my profession. Regular readers may recall that the last time I heard “Is there a doctor on board?”, I slid down in my seat and waited for someone else to respond. This time I attempted to redeem myself by volunteering immediately when the call came over the PA system. Two minutes later, faced with an unconscious young woman, my good-deed buzz was replaced by alarm bells chiming “panic”.

According to the nearby passengers, she had been acting “weirdly” before “passing out”. I wondered if this inappropriate behaviour included asking strangers about their moles. She became responsive after some oxygen, but was confused. Later, she started complaining of severe chest, abdominal and back pain. To cut a long story short, the combination of hypoxia, methamphetamine and dehydration had precipitated a sickle cell crisis. The next three hours were not much fun for either of us.

Half an hour in, the drinks trolley came around. Unlike on many of our Australian carriers, a free beverage is offered by this American airline, although the tiny pretzel packets have been banished along with the term “air hostess”. With my patient stable at the time, I requested a tomato juice. The attendant opened a can and half-filled a tiny cup. When I politely requested the remainder of the can as well, he looked at me as if I’d asked for pretzels and called him an air hostess.

“Passengers are only eligible for one free drink,” he pronounced.tomato juice on a plane

“I only want one — a can of tomato juice.”

“But that’s two serves.”

“Hey, I’m saving a life here. Surely that’s worth the extra half can.”

“We are not allowed to give any kind of gratuity to doctors who volunteer their time to assist in an emergency.”

While I appreciate that this situation presents a legal quagmire, the fact is that in the US, this crazy country, I’m expected to tip a waiter in a bar for pouring me a glass of tomato juice, but I can’t even get an extra half-can of unpoured stuff for delivering three hours of after-hours emergency care. I know I’m from Down Under, but it all seems a bit upside down to me.

First published in Australian Doctor on 17th May, 2012 On Unsolicited Advice


Is there a doctor on board?

Qantas plane“Is there a doctor on board?” I used to wish a call like this would go out while I was flying. I had this romantic idea of saving the day, being showered with praise and upgrades, the cabin bursting into spontaneous applause; joining the medical equivalent of the mile-high club.

On a return trip from Canada, my dream was put to the test: LA to Brisbane, 13 hours of economy-class hell, barely a spare seat on the plane and surrounded by more energy reserves than needed to sustain an African village for a year. Yep, morbidly obese Americans — in front, beside and behind me.

The three seated behind me took the cake (actually I suspect they’d taken many a cake in their time). Dad was as loud as he was wide, and his demands and complaints kept the poor flight attendants on their toes.

“I’ve heard this called ‘cattle class’, but I own a big ranch in Texas and, let me tell ya, my cows have more room when they travel than we do here.”

I wanted to point out that most humans were smaller than bovines, and require less room, but I resisted.

“My wife is pregnant and these here cramped conditions are dangerous for the baby. Never flown ‘coach’ before.”

Why did he start doing so now — on a long-haul, trans-Pacific flight with a pregnant wife and, more importantly, me in the next row?

“But now that I’ve been jammed into this damn midget seat, I intend to take up the matter with the airlines — and my lawyer! It shouldn’t be legal!”

Mom’s mouth was mostly occupied with chewing, but in between mouthfuls she let forth a lungful or two. Their four-year-old butterball rhythmically kicked the back of my seat but I didn’t feel I should admonish him — after all, he was exercising!

In the end, I could take no more. I can count the number of times I’ve ever taken a sedative on one hand, but these were desperate times, and a Stillnox allowed me to sleep.

The word ‘doctor’ penetrated my groggy haze.

“She’s got a lotta pain in her belly. We need a doctor — now! It could be the baby! I told you these tiny seats were dangerous!”

Soon enough, the call for medical assistance came over the PA.

“How pregnant?” I wondered. It was impossible to tell from her body habitus — as in the song from Oklahoma, she was “as round above as she was round below”. I had visions of trying to deliver the premmie baby of an obese, litigious American on a crowded plane and half-asleep, I decided discretion would be the better part of valour. I lay in wait, fervently hoping I’d be beaten to the punch.

Luckily, three altruistic medicos swooped in as I watched from my seat. The ophthalmologist and psychiatrist from business class weren’t particularly useful, but the third-year resident from the rear of the plane was marvellous. How he examined her in the space confines I have no idea, but efficiently and professionally he was able to reassure her that her burning epigastric pain was unrelated to her seven-week pregnancy. An antacid was produced from somewhere and the pain settled rapidly.

He was proclaimed a hero and upgraded to business class for the remaining nine hours of the flight. Meanwhile, now wide awake, I was left in the company of my still-whining neighbours, to pay the penance for my inaction.

First published in Australian Doctor 31st March, 2011: On Airline Anguish


Elder Flying Unaccompanied

The queue snaked back from the gate about 100 metres, going nowhere fast.  I sighed as I joined its tail.  I should have stayed in the lounge a little longer, but I’d been silly enough to assume that “Your plane is now boarding” actually meant “Your plane is now boarding”.  It was a large aircraft, but by the look of it the flight was going to be chock-a-block.  At least the trip from Brisbane to Sydney was a short one.

My attention was captured by an unaccompanied elderly male wandering up and down alongside the line, looking bewildered.  Stopping, flummoxed, about two metres from where I was standing, he tried to orient himself.  He looked at the gate number, illuminated in the distance, then looked at his boarding pass, surveyed the line and then looked from side to side as if hoping someone might explain this puzzling situation to him.  He checked again.  Gate, pass, line.  You could see the squeaky old cogs turning but his mind’s wheel was refusing to spin: no mental clarity was forthcoming.  Nothing.  He stood – mute, lost and confused – waiting to be rescued by someone… anyone.

Well, not quite anyone.  A heavily bearded man of Indian subcontinent descent, sporting a garish T-shirt and carrying a well-used backpack was passing by, and upon seeing the confused elder, veered out of his way towards him.  Evangelical zeal lit up the man’s dark, hooded eyes, but before he was able to espouse a single word of whatever fuelled his passion, his target barked, “Leave me alone.  Don’t bother me.  I’ve lost my plane.”

It was the kind of dismissal even a tolerant individual might be provoked to utter if his or her dinner was disturbed by a cold caller with an Indian accent, but coming from the mouth of this, admittedly mildly distressed, gentleman, it came across as plain rude and maybe even a trifle racist.  Quiet titters of disapproval radiated from the line at the outburst.  Most of my fellow line-mates were surreptitiously watching the spectacle, but all feet remained glued to the spots they’d claimed for the past ten minutes or so.

Crowd psychology is a funny beast.  If an individual had chanced upon this poor man who had “lost” his plane (which seemed, by the way, a rather difficult and unlikely belonging to misplace), he or she would more than likely have tried to help, but in a herd, each member surrounded by numerous others, no one seemed eager to step forward, or rather step sideways out of the line, to come to his assistance.

I bucked the trend.  Leaving my bags behind – I was not altruistic enough to risk losing my place – I approached and politely asked the gentleman if I could help.  Grateful, he showed me his boarding pass and explained his dilemma.  I wondered whether I would have been summarily dismissed if my skin had been brown or if I’d been wearing a Muslim headscarf.  Was I being unfairly judgmental by suspecting that the man would have been unfairly judgmental?

But I digress.

“I’m on the flight to Sydney leaving from Gate 22 but there are people in the way,” he said.

I gently explained that we were all lined up for that flight.

“I know that, but I’m flying business class. Where is the other line?”

“I think we’re all boarding this flight together.  Hopefully.  Eventually.  At the moment it appears that no one is boarding at all.”

The man joined me in the line, oblivious of the 10 metres of patiently lined-up passengers waiting behind me.  No one complained about the queue-jumping.

Stepping impatiently from one foot to the other, he stayed mostly silent except for letting forth the occasional complaint about the service.  “There has to be a better way of doing this….  They can’t just keep us standing here like cattle….  They announced that the plane was boarding – why isn’t it boarding?”

If I hadn’t known better, I would have thought that he’d not only never flown before, but had never watched TV or movies containing stories about air travel; I would have assumed that he’d been completely out of touch with how the modern world of transportation operated.  On reflection, “out of touch” is probably exactly what he was.  I had a strange urge to ask him if he knew the price of milk.

I made a couple of attempts at small talk but they were abruptly shut down.  It occurred to me that this may be a man with early dementia – a man who had become confused and frightened when put in an unfamiliar situation.  If so, why did his loved ones let him travel unaccompanied?  Or maybe he was just a cranky old bugger who was having a bad day.  Hard to tell.

After nearly fifteen minutes we had finally shuffled to the front of the queue.  I turned and said, “Goodbye Mr. Howard.  I hope you have a pleasant flight.”

He nodded briskly and replied, “Thank you for your assistance.”

My how the mighty have fallen.  Our former PM having to line up with us plebs!

Now if he’d been seated where I was – near the rear toilets and jammed between the window and a massive smelly wall of flesh which spilled over and under our shared arm rest – Mr. Howard just might have begun to appreciate the joys of air travel for the commoner.

Or perhaps not….