Passing out ceremony: an Irish guard faints on St Patrick’s Day Parade, Aldershot 2012. Photo: Getty
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I thought the man had only passed out until he mentioned the severe stomach pain

Sometimes things are not as they first seem, recalls Dr Phil Whitaker about the time when a simple faint turned out to be an aneurysm. 

It was one of those glorious July days. With the sun on the canvas and the combined respiration of several hundred proud parents and grandparents, the atmosphere inside the speech-day marquee was decidedly stuffy. Faces were fanned with programmes; applauding palms were sweaty. As the procession of students collecting certificates and trophies came to an end, an elderly man in the front row slumped against the woman next to him and then keeled over on to the grass.

It took a short time to extricate myself from where I was sitting. Concerned people were huddled around the man when I got to him. For a moment, I thought there might be a full-blown resuscitation drama – he was strikingly grey and unconscious – but a swift check established that he was breathing and had a pulse.

I sent someone to call for an ambulance but within a couple of minutes the elderly man had fully come round. I took a brief history and he denied he had any symptoms suggesting that anything was seriously awry. His colour was pinking up nicely. He started to profess embarrassment at creating such a fuss. It looked like nothing more than a simple faint.

This sort of situation makes you realise how naked you are as a doctor without equipment and technology. I had nothing with which to conduct an examination or tests and the setting was far from conducive. Speech day had now finished; people were beginning to traipse out of the marquee, casting curious glances at our tableau – old man on the ground, doctor crouched in attendance – as they passed. My two children, desperate to get home and start their summer holidays, were making can-we-go-now faces at me. My patient sat up, protesting that he now felt fine. I was on the point of helping him to his feet and wishing him well when I noticed the wetness darkening his trousers.

People are occasionally incontinent when they faint but it is rare. I felt uneasy. I thought back to my first impression of him, how he had looked dead. I told him I thought he should lie back down and wait for the ambulance.

We had a minor battle of wills. His granddaughter was the head girl, he said, and this had been a big day for her; he wanted to rejoin her party. And he had the English distaste for making a scene. He almost persuaded me. When someone told me the ambulance could not negotiate the embankment down to the sports field and asked me if I really thought my patient needed it, my resolve almost faltered again – but by then I’d pushed him for more information and had elicited the grudging admission that, now I came to mention it, there had been a sudden pain in his stomach and his back before he passed out.

My suspicion was confirmed when I phoned the hospital the following day. He was in intensive care, having survived emergency surgery for a ruptured aortic aneurysm. The aorta is the body’s main artery, running from the heart down through the chest and abdomen. Its typical diameter is two centimetres. Genetic factors, high blood pressure and smoking can all weaken the aortic wall, which then distends, forming a dilatation or aneurysm. Eventually, stretched thin enough, the artery wall ruptures.

Death is rapid with a catastrophic breach but with a small minority of patients – as in this case – the initial “leak” is sealed temporarily by a clot. There follows a period during which emergency surgery to graft in an artificial artery may save life, although only half of the patients who make it to hospital survive. Aortic aneurysms predominantly affect men and become increasingly common with age. If they are diagnosed before they leak or burst, surgical repair is much more feasible, with death rates in the order of 3 per cent. Aneurysms are readily detected by a simple and inexpensive ultrasound scan and there is good data linking diameter with risk of rupture. For several years, enterprising companies have been offering scans on a private basis and in 2013 the NHS finished rolling out its own screening programme nationwide. All men are invited for a single scan when they are 65.

With a normal-calibre aorta, the risk is negligible. Aneurysms of greater than 5.5 centimetres in diameter have a high chance of rupture, so surgical repair is usually offered. Those in the “grey zone” are more difficult; the risks of surgery at a diameter of four centimetres are about equal to those of leaving things alone. Repeat surveillance scans are a way of checking for progression.

I kept in touch with the hospital over the next 11 days, at which point sadly my patient died from kidney failure caused by the blood loss he’d sustained. He had, at least, lived long enough to hear his granddaughter deliver her end-of-year speech as head girl, which must have made him proud. I learned later that she was going on to university to study medicine. I found this particularly poignant. By the time she qualifies as a doctor, the NHS screening programme should have helped reduce mortality from ruptured aortic aneurysms but it came too late for her family. The memory of that school speech day and the loss of her grandfather will no doubt stay with her throughout her career.

This article first appeared in the 03 April 2014 issue of the New Statesman, NEW COLD WAR

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Let's turn RBS into a bank for the public interest

A tarnished symbol of global finance could be remade as a network of local banks. 

The Royal Bank of Scotland has now been losing money for nine consecutive years. Today’s announcement of a further £7bn yearly loss at the publicly-owned bank is just the latest evidence that RBS is essentially unsellable. The difference this time is that the Government seems finally to have accepted that fact.

Up until now, the government had been reluctant to intervene in the running of the business, instead insisting that it will be sold back to the private sector when the time is right. But these losses come just a week after the government announced that it is abandoning plans to sell Williams & Glynn – an RBS subsidiary which has over 300 branches and £22bn of customer deposits.

After a series of expensive delays and a lack of buyer interest, the government now plans to retain Williams & Glynn within the RBS group and instead attempt to boost competition in the business lending market by granting smaller "challenger banks" access to RBS’s branch infrastructure. It also plans to provide funding to encourage small businesses to switch their accounts away from RBS.

As a major public asset, RBS should be used to help achieve wider objectives. Improving how the banking sector serves small businesses should be the top priority, and it is good to see the government start to move in this direction. But to make the most of RBS, they should be going much further.

The public stake in RBS gives us a unique opportunity to create new banking institutions that will genuinely put the interests of the UK’s small businesses first. The New Economics Foundation has proposed turning RBS into a network of local banks with a public interest mandate to serve their local area, lend to small businesses and provide universal access to banking services. If the government is serious about rebalancing the economy and meeting the needs of those who feel left behind, this is the path they should take with RBS.

Small and medium sized enterprises are the lifeblood of the UK economy, and they depend on banking services to fund investment and provide a safe place to store money. For centuries a healthy relationship between businesses and banks has been a cornerstone of UK prosperity.

However, in recent decades this relationship has broken down. Small businesses have repeatedly fallen victim to exploitative practice by the big banks, including the the mis-selling of loans and instances of deliberate asset stripping. Affected business owners have not only lost their livelihoods due to the stress of their treatment at the hands of these banks, but have also experienced family break-ups and deteriorating physical and mental health. Others have been made homeless or bankrupt.

Meanwhile, many businesses struggle to get access to the finance they need to grow and expand. Small firms have always had trouble accessing finance, but in recent decades this problem has intensified as the UK banking sector has come to be dominated by a handful of large, universal, shareholder-owned banks.

Without a focus on specific geographical areas or social objectives, these banks choose to lend to the most profitable activities, and lending to local businesses tends to be less profitable than other activities such as mortgage lending and lending to other financial institutions.

The result is that since the mid-1980s the share of lending going to non-financial businesses has been falling rapidly. Today, lending to small and medium sized businesses accounts for just 4 per cent of bank lending.

Of the relatively small amount of business lending that does occur in the UK, most is heavily concentrated in London and surrounding areas. The UK’s homogenous and highly concentrated banking sector is therefore hampering economic development, starving communities of investment and making regional imbalances worse.

The government’s plans to encourage business customers to switch away from RBS to another bank will not do much to solve this problem. With the market dominated by a small number of large shareholder-owned banks who all behave in similar ways (and who have been hit by repeated scandals), businesses do not have any real choice.

If the government were to go further and turn RBS into a network of local banks, it would be a vital first step in regenerating disenfranchised communities, rebalancing the UK’s economy and staving off any economic downturn that may be on the horizon. Evidence shows that geographically limited stakeholder banks direct a much greater proportion of their capital towards lending in the real economy. By only investing in their local area, these banks help create and retain wealth regionally rather than making existing geographic imbalances worce.

Big, deep challenges require big, deep solutions. It’s time for the government to make banking work for small businesses once again.

Laurie Macfarlane is an economist at the New Economics Foundation