Lest We Forget

First I must give a huge shout out for my in laws who gave me a fantastic week, in spite of the weather.  Thank you for the break, the opportunity to rest without feeling (too) guilty and for generally looking after me!  I really, really appreciate it.

We drove back home on Sunday, a damp, dreary drive.  By the time we reached the first services on the M4 motorway I was beside myself – pain, nausea, swearing I would never make another car journey.  I was grey – even I could see I looked awful, and whilst a fix of caffeine helped, getting back in the car took an enormous effort.  But then something happened that put things into perspective.

images (1) From out of nowhere, a stream of motorbikes appeared, rider after rider bedecked in red.  Their mixture of T shirts, scarves and even hats over cycle helmets formed a crimson river billowing out behind them.  Many carried flags, wreaths or giant poppies.  We left the M4 for the M25 and another fleet of riders was heading towards us on the opposite carriageway.  This was the “Ride of Respect” and I don’t know how many riders turned out on Sunday on small bikes, Harleys, huge modern Suzukis, trikes, but they paid their respects to our forces in the most poignant way I’ve ever seen.  Why was I complaining?

It’s funny, but the first time I “experienced” nerve pain was as a new student nurse caring for an old soldier.  He had served in WW2 and had a wicked sense of humour.  In other words he had great fun teasing us first years.  “Nurse, please help, I need to get up to have a pee” and then he would roar with laughter when he saw the young nurse’s face as the bed covers were pulled back and realization dawned that he had no lower legs.  He would never say what happened to leave him a double amputee, only that he was the lucky one.  Most of the time he was happy go lucky with a throaty guffaw of a laugh, but every couple of days he would change.  He would rock backwards and forwards, and weep as the pain in his feet became unbearable.  Yes, that’s right, his feet.  My first experience of phantom limb pain.  The worst time for him was during the night when he cried out in agony, but there was little that could be done to help ease it.  We cared for his stumps to the best of our ability, and helped him fit his prosthetic limbs when he could tolerate them, but it is only now that I can truly understand to a very small extent what this uncomplaining old soldier was going through.

At one of my outpatient appointments with my last surgeon, Mr B, I asked why he couldn’t just “snip”the affected nerve and be done with it.  His response was that I knew better than that, as I would still feel pain after – exactly like phantom limb pain.  The actual problem is not in my foot or my leg or even my sciatic nerve, but rather right in the nerve root which then tells my brain that my foot has pain.  In the same way my patient’s brain was being fed false information that made him “feel” sensations in his non existent feet.  The nervous system is ever complex.

Today as we remember our war dead on armistice day, it is so important to remember our war living too – those wounded and in pain, physical and emotional.images (2)

I’m still alive

This evening I heard a young lady of 18 state that she wakes every day in pain, but “the pain lets me know that I’m alive”.  

She has suffered with juvenile arthritis since she was a little girl and has chronic pain in every joint in her body, yet she is taking part in the Children in Need rickshaw challenge.  A team of 6 youngsters, each with their own special story, started their journey yesterday at Land’s End, and will cycle across southern UK to arrive in London next Friday for the live BBC Children in Need event. 

 
What a wise head on such young shoulders!  I will try my hardest to use this philosophy on waking each day.

Support Team Rickshaw at http://www.bbc.co.uk/programmes/articles/vgrPhwRvgf4Gb4XkM0NXXB/the-rickshaw-challenge-2015

Panorama

imageHands up who saw Panorama on Monday night!  I watched it with my father in law by pure chance as I hadn’t noticed what the subject matter was to be.  For those of us living with chronic pain prescription pain killers are a huge part of our daily lives – and not just the opiates dealt with on the TV.  Believe me, some of the non opiates have some equally nasty side effectives and are just as difficult to withdraw from.

I remember well when the new man made drug oxycodone was first licensed for use in palliative care.  It was sold to us as the new wonder drug with fewer side effects and a reduced effect upon liver and kidney function.  However the nickname of Hillbilly heroin was starting to reach us and the alarm bells should have been ringing.  Very quickly the drug was being used for that notoriously difficult diagnosis – you guessed it, chronic pain – and it started to make its way onto the black market to join its cousin, heroin.  These days no American cop show worth it’s salts has a season go by imagewithout several references to “oxy”!

What about Joe Bloggs who visits his GP with sciatica? How will he be treated to help ease his symptoms? Diazepam – Valium- is always a good mainstay for short term use to reduce and relax muscle spasm, but what about pain killers?  The vast array ranges from low level opiates: cocodamol, codydramol, dihydrocodeine and the highly addictive tramadol; non steroidals such as ibuprofen, naproxen and diclofenac sodium; and the drugs found to help nerve pain such as the antidepressant amitryptilline and anticonvulsants such as carbamazepine, gabapentin and the gold standard pregabalin (Lyrica).  This must be prescribed by it’s trade name since various patents and licences have lapsed.  I have never known a drug to contain a list of possible side effects as long as that distributed with pregabalin – the manufacturer lists every body system to cover themselves! So Joe will leave his GP surgery clutching a script with probably suboptimal analgesia – that is not inadequate amounts, but rather not the best combination for Joe.image

So several years later Joe is finding that his long acting opiate (MST or OxyContin) is on the increase, the dreaded pregabalin is causing weight gain amongst other effects and he is taking higher doses of his short acting opiate (sevredol or oxynorm) for breakthrough pain. He is walking through the day in a fog after a sleepless night, with a brain and memory filled with opiate shaped holes, weighing 4stone more and now diagnosed to have chronic pain.  Oh, did I mention that he is also a fully paid up member of club Prozac by now?  Many of us living with chronic pain face depression and the need for “happy” pills.  More of that another time.  Alongside this Joe is attempting to show the DWP that he really can’t jump through the hoops that they would like him to, as he is no longer able to work.  Perhaps you recognise this weary, tired, depressed, overweight person who remains in pain?  To be continued…..image

How am I doing in Hereford?  I am being extremely well looked after – spoilt in fact – and I do feel guilty for not helping out.  We have had the same dismal weather making a damp squid of bonfire week as the rest of the country.  There have been a few bright lights and loud bangs for the dogs to bark at though!  I have managed to walk to the supermarket and met lots of neighbours on the way, including the retired gynaecologist (a Tommy’s man who objected to the pairing with Guy’s!) who made me laugh when he asked in a stage whisper how my bladder is!!  I continue to play with the voltage of the Scs as I need a higher stimulation in the cold, damp weather which is also aggravating the EDS – my shoulder slid out last night.  Does anyone else get paranoid that they will run out of voltage for enough relief?  How positional are other people’s Stims? I have found that if my pain is excruciating down to my foot, that lying flat on the floor increases the level of stimulation – I must speak to the CNS next week to see if I need reprogramming!image

Apologies for the odd posts today – problems with the iPad meaning I have lost the second half of the post twice!!

Pinch, punch, first of the month

I can’t believe it is November and so the countdown to Christmas begins. How true it is that the older we get, the quicker time flies.  Back at the end of the summer holidays, which feels like years ago now, I knew that I was exhausted and needed some time out from home life. A holiday somewhere hot and relaxing would be perfect…….alas not to be, due to a severe lack of funds, inability to sit on a plane or any friends/family owning a beautiful villa in, say, the Caribbean! Then came my call for my Scs trial and you know the rest of the story for the last 6 weeks.

We are now at the end of half term and finally my time for some R & R has arrived in the shape of a week with my in laws in Hereford. No kids, no cooking or picking up dirty clothes that don’t belong to me.  Can’t say the same for the dog as I’ve left one behind to be replaced by two here!  Duncan and I drove up yesterday, which is a challenge in itself as the journey is about 4 hours on a good run.  The last time I came the drive really took its toll and I’m never quite sure how long it will take me to recover.  Obviously we take regular breaks, but the final stretch on A roads is a challenge as my lower back is near explosion by then.  I feel a huge pressure in the lower spine which grows and grows in intensity – I’m not sure if this is worsened by the fusion and titanium, as I have been told that the metal reacts to changes in air pressure.  Sounds good anyway!  The Stim definitely helped to make the journey more tolerable and, when we stopped for lunch and by sitting in a different position I was able to increase the intensity, the feeling of relief absolutely washed through me.  I can’t adequately describe just how emotional it is to be able to induce that at the push of a button.  We arrived in time to see the All Blacks victory over the Wallabies, and for the British men to make history at the gymnastics World Championships.  I really must work on improving my core – those young men have inspired me, at least for this evening anyway!

We woke this morning to the fog that shrouded most of the country, befitting for Halloween weekend and giving me the perfect excuse to stay in and spend a slobby day avoiding the cold and damp.  The house is one half of a listed Georgian property on the outskirts of Hereford city centre and a stone’s throw of the cathedral. Duncan has returned home to rescue mum from the trials of overseeing teenagers and to ensure they are ready and raring to return to school in the morning.  My father in law has “enjoyed” initiation into Strictly and X Factor, ha, ha, ha and we had some fun using 3D glasses to watch the new BBC wildlife documentary.  He plans to get his own back by setting me to work tomorrow to try out my new bionic powers – he reckons mowing the lawn would be a good place to start!!  

I meanwhile will enjoy having the bed to myself and reading for as long as I want to; apparently I need to watch out for builders early tomorrow morning, as they strut their stuff on the scaffolding that currently shrouds the house, whilst renovating next door!

Those little things we don’t mention

This week I should have been back at Tommy’s for an appointment at the Joint Pain and Urology clinic – it was cancelled due to a shortage of doctors.  I’ve touched briefly on one of my pages about additional problems caused by nerve damage in the back, but even for para & tetraplegics with the very worst back injuries, as a society we really don’t like to mention the more personal bodily & sexual functions that can fail as a result.

It stands to reason that when a back is broken and a spinal cord severed, that any part of the body that functions from nerves below this point will no longer work properly.  So equally if nerves are damaged beyond repair, bodily functions become abnormal too.  More of this on a “page”, but when I was seen last Christmas for the first time at St Thomas’, Dr Palmisani was the first consultant who took my comments about my bladder seriously.  So seriously that he set the wheels in motion for a urology referral, to check whether I had the dreaded female stress incontinence or something linked to my back.  I knew it wasn’t S.I. – in my experience many male doctors assume that any woman with children will have a damaged undercarriage from childbirth – “I’ve had 3 C sections” I told him “my undercarriage is intact!”.download  I think that I already knew what the problem was – lack of sensation, going all day with no urge to “pee”, UTIs and then being unable to go.  “It’s your age” friends have said, to which I thought “I’m not that old!”  But earlier this year I was seen at Guy’s by a sympathetic female urologist, who immediately said that my symptoms were classic for the level at which the nerve damage is. She also mentioned that there are 3 professions who develop an ability to hold on for long periods of time – bus drivers, cabbies and nurses – so I was already half way there. The bladder stretches beyond normal capacity because the nerves no longer signal that it is full to the brain.   I believe the non technical term could be “baggy balloon bladder”.images

The tests that I have undergone I will detail on a separate page – not everyone will want to know! – but at least with the indignity of childbirth you walk away with a baby at the end; after this indignity I just walked away with a box of catheters and a lesson in intermittent self catheterisation!!  When I had the scs trial, Dr Palmisani suddenly put it to me that he was thinking of speaking with his urology colleague with a view to using an electrode or two to stimulate my bladder……it all sounds slightly experimental and unfortunately the different specialities weren’t able to link up before the stimulator was implanted, but it could mean that somewhere down the line there may be more surgery, a tweaking of my implant programme and a buzzing bladder!tumblr_n5hn3yEnV41t7pikho1_1280

Final thoughts go to my mate Jean who has had her full implant today………

Sorry to have been away……

It has been over a week since I last posted and during that time our household has been hit by a variety of ailments from migraine to ladies’ problems to chest infections.  The yocomic conungest is into her second week of half term – 2 weeks!  I remember only getting 2 days for one of our half term breaks – the middle started his half term with a trip to Comic Con London – grown people running around dressed as comic book characters! – and I believe that our student is on a project week before reading week next week.  Reading week indeed – the university term only started at the beginning of the month.
The last week has been a bit bumpy for me.  I can safely report that the stimulator doesn’t help certain pains of a female variety, but I already knew that these symptoms exacerbate my back pain and so I spent a couple of miserable days at the end of last week.  It was probably rather ambitious to imagine at the beginning of the week that I would be able to attend governance meetings on consecutive nights – but I did manage the first one.  I won’t lie – it was a struggle.  Sitting for several hours in an upright seat and trying to concentrate and participate was much harder than I had anticipated, but I consoled myself that I was only just over 3 weeks post op.  But I really wasn’t well enough to attend the training with my own governing body the following night – I’m really sorry that I probably picked the wrong session, fellow govs!

As I become more mobile again, I am having to learn how I need to use the stimulator to best help me.  The change in weather is always a problem for most chronic pain sufferers and is also a problem for those with added joint issues like myself.  I know that I have already posted that the level of stimulation has changed since the permanent implant,  and I am probably a bit paranoid about increasing the voltage level.  When you have taken a mixture of strong medication for years, and you have been trained in pain control in a previous life, it is very hard to lose the mentality that says your body becomes tolerant  and therefore requires more and more for the same level of relief.  Of course in the case of opiates this is true to an extent, but please don’t be mistaken for this being the same as addiction – as hospice nurses we struggled every day with the false belief that it is better for someone in pain to resist drugs as they may cause addiction.  In the majority of cases all the time an individual has pain, the correct analgesic will be used by the body like a key in a lock to fit the pain receptors and thus inhibit them.  Finding the correct key for the lock is not always quite so easy…. Of course this does happen to a degree with the stimulation and thus with the low frequency stimulator that I have, the hospital instructs patients not to use it continuously in order to avoid creating a new “norm”.  Does this make sense?

I managed a dog walk at the weekend with Duncan and am happy to report that I was far more comfortable with the stimulation switched on.  My mobility and stamina remains hampered by the pain and stiffness at the fusion site, but it is great to be able to have some control over the leg pain.  I am still playing with levels in order to sufficiently cover my foot – I might just have to make do with a nice, new pair of boots!!  Saturday afternoon provided a perfect opportunity to sit down and recharge my battery in front of the first semi final of the rugby world cup.  Not sure I’ll ever get used to saying I need to charge myself up, and I must stop talking about being “turned on” or “off” as the former has produced some very quizzical looks……..

Time for a photo op – no, not related to that last comment!! – I had let the battery run down to 50% as instructed and the charger had already been powered by the mains.                                                        imageimage

The above pictures show the positioning of the paddle over my stimulator and the charger – the paddle is very reminiscent of the paddles on the defibrillator that used to be on resuscitation trolleys, although it doesn’t deliver such a hefty charge!

The charger is showing:

top row: my stimulator turned off, the volume, my battery at the half full mark

middle row: the imagepaddle making contact with my stimulator,

bottom row: the level of connectivity between the paddle and my stimulator, in this case it is poor with only 2 boxes filled out of 8.

The charger is now showing full connectivity between the paddle and the battery as all 8 boxes are filled in.image  Whilst in theory it is possible to be ambulant whilst the charger is strapped to your back, in practice I would say that the level of connectivity is quite positional and thus use the couple of hours it takes to watch a film, read or watch the rugby!!  It was a great match.

A gaggle of girls has just arrived home after a day out in Brighton, so time to put the pizza in the oven and prepare for a very giggly sleep over.

One day at a time

The big day has finally arrived!  I mentioned weeks ago that a birthday present for 2 teenage girls was a shopping trip to the Westfield, Shepherds Bush and tomorrow is D day.  They are excited….not so sure about Duncan.  The words cold feet spring to mind.  I will make a decision whether I can manage to go with them in the morning – at least there is plenty of disabled car parking and lots of coffee shops.  I think that there may even be shopmobility and the option to borrow a wheelchair if it all becomes too much – and that is just for Duncan!  So the girls have their vouchers and their birthday money, and instructions about what is considered a suitable purchase that mother will allow them to wear.  Oh, to be a teenage girl again…or not.

Meanwhile another one of my group is currently undergoing a scs trial, whilst another has had hers cancelled as she needs another operation.  She is absolutely gutted after struggling with chronic pain for years.  Yes, she has another condition that is causing her pain and obviously requires treatment, but she has a back story that is very similar to mine and so many others – an initial back problem from a bulging disc, several failed  surgeries and the resulting pain which nothing helps.  Drugs, side effects, sleepless nights, the desperation that sets in to find something, anything and it becomes a vicious circle.  By the time we arrived at the inpatient programme, we two had definitely been round this block several times and taken our respective families with us.  But we gelled immediately and understood each other, so this is why I can understand how desperate my friend is now feeling because I’ve been there.

Personally, I’ve felt rough for the last couple of days and I think that I probably have tried to carry on and overdone things.  The overwhelming need to be able to tell everyone that you are feeling great and that yes, it has absolutely all been worth it, is enormous.  On Friday I decided that I needed to show my face at a coffee morning hosted by the head at my daughter’s school.  A downside was that it was from 8.30 am – a dreadful time of day for me.  But I made it and my friend and I duly poured coffee and snacked on mini danish, before the first friendly face popped over to say hello.  This was followed by a couple of other parents, and then I spotted a friend talking to the headmistress, who has been very supportive of the whole family over the last year.  She immediately wanted to know how I am doing, as did my friend whom I haven’t seen since the beginning of term.  I could feel myself becoming clammy and faint, and the ability to speak with any clarity disappeared rapidly as my senses seemed to fail me.

On returning home – still only 9.30am – I had 2 more visitors during the course of the morning.  Whilst it was lovely to see everyone, I just felt like I was on a loop as I tried to describe the effect that the stimulator is having, no it isn’t a cure, hopefully it will help me to be able to function better etc., etc.  Someone else has commented today that I seem to be disappointed in my stim results and I am sorry that I may have given this impression.  It certainly hasn’t given me a magic wand to waft away all the pain, and the relief I experienced during the trial was different to that which I’m feeling now.  I’ve already mentioned that I require a higher level of stimulation voltage on the lithium battery, and that I can understand that I am adjusting to and thus becoming used to the sensations.  I am a bit worried that I will continue to need higher and higher levels of stimulation and will thus “run out” of options as I reach the top dose!  But rationally I know that this is a very long way off and that the changes are due to being more mobile and the stim is not yet scarred in place securely yet.  One reason that we are not allowed to sleep with the stim turned on, is that it is important for the body to have periods of non stimulation, so that it can really appreciate it when it is switched on.  The parasthesia should not become a new base line.

So it is tough explaining the results over and over, when the expectation is so high.  Our expectations on ourselves are the highest though, and we all desperately want this treatment to be the answer to our prayers, so if I can have more better days and nights than not, then I have won the lottery.

Bad day

Back to some more personal musings this afternoon.  I woke up after a pretty good night in pain – the type of deep pain that runs the whole length of my leg and foot and is worsened by the cold.  In this case it is the change in weather temperature, but it can also be down to cold air conditioning.  I have really struggled to get on top of the pain and felt pretty low this morning when I couldn’t get enough relief with my Stim 😪.  A shower and hair wash just about finished me off, with that awful period of time that I described before when I step out and feel physically ill.

So I know I have been horrible today – sorry to those who have been around me.  The engineer is back for a driving lesson, and spreading his horrible cold germs!  Apparently he has told his tutor that his presentation for this term will be about neurostimulators, and he has a Guinea pig to show off.  One team member of the electrical engineering department at UCL has apparently been doing some research work into the speciality.

Thought it was time to show a couple of photos – not massively pretty, but I’m less blue now!imageimageimageThe Stim programmer has to be held directly in contact (above) with the implanted stimulator site (left).  The top 2 inches of the long scar is where the electrode leads are implanted – the scar beneath runs down to the natal cleft and is from my previous 3 surgeries.  It is keloid, over over granulated – a common problem in Ehlers Danlos due to collagen irregularities.

Blast from the Past

I stepped back in time yesterday, when I visited Charing Cross Hospital.  No, I wasn’t the patient for a change but giving moral support in the same way that it has been given to me in bucket loads recently.  The last time that I was there was on my last day of work on the head and neck unit in 1995, OMG 20 years ago!  So much has changed superficially in the reception and the initial public areas with the advent of Costa etc, but as we started to trudge the corridors trying to locate the clinic,  nothing really has altered at all.  CXH

I already had a back problem when I started work on ward 7 North in 1991 and the job interview was the easy part.  Every nurse had to go through Occupational Health and who wants a nurse who has undergone major back surgery recently?  I had to literally jump through hoops to show that I was fit enough, strong enough to manage the rigours of a 32 bedded surgical ward – a very specialist surgical ward for head and neck, maxillary facial and ENT surgery.  It was really intense work and exceptionally busy as we were a regional unit for the type of surgery for head and neck cancer that other surgeons would close the book on.  The team consisted of 5 consultants, 2 Senior registrars(consultants in waiting in those days!), 2 registrars, 2 senior house officers and our nursing team of 2 sisters, 8 staff nurses, and our wonderful auxiliary Mabel & cleaner George.  We worked hard, but then we played hard – as a team.  OK, the consultants only really came out for major events like the Christmas party, but the rest of us socialised regularly.  At times the ENT outpatients was even known to be transformed into a party venue on a Friday night!  We worked long hours, the nurses worked a 7 night shift pattern every 4 weeks, the junior doctors were constantly on call and we dealt with some horrific cases – but we were a great team who respected each other.  Mr Cheesman, the main head and neck surgeon to whom the tricky cases were sent, would not send his major surgical cases to ITU, saying instead that “his” nurses gave the
images (9)best care! A huge compliment.

I do believe that this sort of team work is a thing of the past – the days when the cleaner was as much a team member as the sister, and you could eat your dinner off the kitchen floor.  For then the services started to be put out to tender and standards altered.  My experience as both a patient and a relative at some district general hospitals across the country has been poor and in a couple of cases appalling in recent years.

However my faith has been somewhat restored by St Thomas’ and Guys’ – they may not be quite like my old unit and I may be reminiscing with rose tinted specs.  The pain unit is specialist, but it isn’t just within this unit that there is a difference in the attitude of the staff – the staff generally are patient focused, keen to please, happy and helpful.  I’m afraid that even my old stomping ground didn’t match up yesterday as we were passed from pillar to post.  But my stim was invaluable and I probably kept it switched on for a lot longer than I should have – eventually my back and leg got the better of me, and Duncan had to leave me in the sitting room of the wrong department as I couldn’t manage another step!  Shame that I don’t have real bionic woman powers…..

 

Blue badge

blue badgeYesterday I received an email reminding me that my blue badge is due to expire next month and I need to apply for renewal.  The process was fairly straightforward online, but having gone through so many strands of the benefits system since being “medically pensioned”, is it only me who finds the lack of liaison between departments so frustrating?  The number of times that I have given identical information to slightly different departments, and the amount of time and money that could be saved if there were joined up thinking and communication between them.  I had to upload another photo, which then had to be processed – yet there is already one on file that is on my current blue badge.  I really haven’t changed that much!  I automatically qualified due to my disability, oops no, my personal independence status, but I am pleased to see that the application process is tighter now than it was 3 years ago and that I was asked to send documentation regarding my mobility to the council.  When I applied last time I was surprised that I didn’t have to provide any form of proof, and have been frustrated at a lack of consistency across areas. Not to mention the rise in thefts of blue badges from vehicles and subsequent black market (http://www.disabledmotoring.org/news-and-features/news/post/127-blue-badge-theft-increases). I had better stop there!

This has got me thinking about how much chronic pain robs us of our independence and sense of self.  I still remember so clearly the first time that I put that badge in the car windscreen when mum and I went food shopping 3 years ago.  The last thing that I wanted was a bl..y blue badge for so many reasons, but on that day I felt an overwhelming sense of both shame and sham – I felt guilty that I was using a disabled spot when there were others so much worse off than me, but it was also like admitting defeat.  A loss of independence and actually facing up to needing help.  My dad and godfather always used to joke that they planned to retire to a chateau in France and “what was the point in having a nurse in the family if not to look after us?”.  A nurse with a dodgy back is probably worse than no nurse at all!

My blue badge has become a life saver in so many ways though, as my mobility has deteriorated over the last few years. images (1) The second fusion – the revision and extension – has actually made things harder physically and at times I feel like I’m going to snap in two at my waist.  I wrote on one of my pages about the Ehlers Danlos consultant’s comments regarding fusions, and I really understand where she is coming from now as the strain at the joint above the screws feels under more and more duress.  the stimulator can’t help with this pain.  So to be able to park the car in the centre of town and avoid a long, slow, painful walk back is priceless.  I walk with a stick or a crutch these days – too many falls leaving me too unstable without – but only 2 out of 11 of us used an aid from our pain group.  One of the men, in his 50s, said that he found it infuriating (using rather more colourful language!) that when he parked in a disabled spot he would regularly get disapproving looks, despite his blue badge.  In fact he has been on higher rate Disability Living allowance for several years, but he doesn’t look disabled – you can’t see his pain.

As a hospice nurse, I did become skilled in recognising the tell tale signs of an individual’s pain and our nearest and dearest will learn to recognise those signs in us; but Joe public is easily fooled by a cheery greeting, that very upright posture (from screws and rods, or indeed from the need to stand up to feel the scs!) or a slash of lipstick and blusher.  Sometimes we need to be fooled too.