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Hospital consultant 'I'd like to dispel a few myths for people about overcrowding'

It’s a hospital overcrowding problem that has been decanted into the Emergency Department, writes Dr Anthony O’Connor.

I AM A doctor and I work as a consultant in a large hospital in Dublin. I am lucky and proud to work as part of a dedicated and effective team in what I truly believe to be a fine hospital, where 96% of patients last year describe the care they received as good or excellent.

I qualified to work as a doctor in 2004 and since then, apart from a 3 and a half year hiatus while working in the US and the UK, I have spent large parts of my days in various hospitals across Ireland apologising for delays in care, both inpatient and outpatient.

The bottom line is that the system nationwide does not quite have the capacity to deal with the demands placed upon it. This does not make us unique, and I’ll expand on that but as you will know, it tends to generate a lot of comment in Ireland, usually focusing on simple solutions that the latest talking head heard from someone who knows someone who read something once.

So, I would like to try to dispel a few myths for people reading about overcrowding.

1. This is an Emergency Department overcrowding problem

No. It’s a hospital overcrowding problem that has been decanted into the Emergency Department. Patients boarding overnight on trolleys have already been admitted to hospital and are awaiting transfer to beds on other wards.

In general, emergency departments in Ireland are reasonably efficient in and of themselves, and work absolute miracles given the staffing levels they have where they are way short of the required numbers of doctors.

The overcrowding is a broader hospital issue. It would be like checking into a hotel and your room isn’t ready because the last person hadn’t checked out, and they give you a blanket and a seat in the lobby. It wouldn’t be the hotel reception’s fault.

2. We already spend a lot on health so we shouldn’t give “them” more money

This is an adolescent view of the problem. The reality is that the Irish health service has been treating more patients for less money for most of the last decade. Serious healthcare systems all over the world know healthcare costs are spiralling and are making plans to meet that.

The truth is we will need to spend more to stand still, let alone catch up. The overall spend is inevitably going to rise and anyone who thinks it won’t in a population that is booming and ageing is committing a gargantuan act of self-deception.

The cost of drugs is part of it, but so are other interventions such as nutrition, surgery and interventional radiology.

To give one example from my own field, when I started off in gastroenterology 11 years ago people with gut failure tended not to live very long. Nowadays lots of people are living for many years with home parenteral nutrition, which is an amazing, lifegiving intervention but one associated with eye-wateringly expensive costs.

As we strive to provide the best and safest care to patients, expectations have rightly increased too and the tolerance for error or oversight is diminishing.

When I started off as a doctor if someone had a headache they were doing well to get a CT scan and lumbar puncture. Now everyone gets an MRI and a review by a neurologist too.

Liver cancer patients who were previously sent home to die are now more likely to get transplants and cutting edge interventional radiology treatments that prolong their lives greatly.

There are other pitfalls of modern medicine. Ten years ago the CT scanners we used were significantly less powerful and accurate than those in use today. Today’s scanners catch disease earlier but also find a bunch of other abnormalities that previously wouldn’t have been noticed and are usually not significant but have to be taken seriously and followed up.

All western societies are going to have to grasp the nettle of health and care costs in the coming years. This will take an honest and difficult public debate and one from which people of all political persusions will need to dismount from their high horses to take part in.

3. Privatisation is the solution

The private sector has many strengths but has never shown any interest in operating a 24/7 open door emergency system in their own premises, so why are we led to believe by some commentators that they could sort it out in others?

The private sector may well have a role in helping alleviate some pressure on outpatient waiting lists by doing elective, low-acuity work, but it is unlikely that the answer to our acute hospital capacity crisis lies there.

4. If only consultants were available 24/7

They are. In our hospital there are about 25 on call every night, but they will be mostly engaged with the sickest patients, as they should be.

I was in at 10pm on an uncommonly busy New Year’s Eve and encountered our radiologist, anaesthetic, surgical, renal and microbiology consultants in that night as well, dealing with a large number of critically unwell people. Amazingly, my mere presence in the building did not stop the people of south west Dublin becoming ill and coming to the hospital.

A friend and surgical colleague of mine took a mutual shared patient we had seen and discussed earlier that day into theatre at 10pm on Christmas Eve, after a deterioration in his condition. My colleague made it home for 2.30am and after checking Santa had been, was back operating on another emergency case at 10am on Christmas Day.

In case you were wondering I’ve asked him and he didn’t notice any private investigators from Prime Time following him.

If we want more consultants at the front door of the building acting as gatekeepers out of hours then that’s fine, but be advised:

(a) You have to pay them.
(b) You need to cancel all the things they were supposed to be doing the next day in clinics, theatres, endoscopy rooms etc and watch those lists pile up.
(c) They’ll end up admitting very nearly as many people as if not more than some junior doctors.

5. All we need to do is invest in community and primary care

This should be done anyway for its own sake, but its impact on the overcrowding will be modest at best. Most of the patients I admitted last month are on oxygen and fluids, and require intravenous drugs and monitoring. They’re sick. They need to be in hospital because there is no other safe place for them to be cared for.

If we invest in and beef up our primary care services it may reduce the frequency with which they get sick but the inconvenient truth is that the natural history of most chronic diseases of the heart and lungs is that they progress to a point towards the end where very frequent hospital level care is required.

Some politicians likes to think these patients can be cared for in primary care centres but a short walk around a trolley-laden emergency department would be enough to know that the vast majority of the unfortunate people there are most definitely in the right building, just the wrong part of it.

6.  The Angola Myth: sure no politician can sort this out

Well maybe that’s true but we haven’t had a left-wing Minister of Health since the current Labour leader Brendan Howlin led the department from 1992 to 1994 (conflict of interest – I am myself politically left of centre).

The first overnight trolley stay reported in Ireland was in the old Meath Hospital in 1997.

Some of the incumbents like Michael Noonan, Mary Harney, James Reilly and Leo Varadkar would be considered by many observers to be right-wing political figures by Irish standards at least. Correlation doesn’t equal causation, but still….

7.  This only happens in Ireland
8.  It’s not just Ireland

I’m going to take these two myths together. Strictly, the latter is true. This does happen in many other countries and is particularly bad in England and Wales at present.

However the scale and persistence of the problem in Ireland is unmatched. Ultimately what happens overseas is to my mind at least, irrelevant. This is a major problem for the citizens of our republic, who are suffering every night. You wouldn’t not get an engine warning light in your car checked out because your neighbours car was making a funny noise too.

Whether it exists elsewhere is to some extent immaterial, although we should be acutely tuned into efforts to solve the problems overseas to see what can be learned. The same is true of our public health alcohol issues too, by the way.

9. There’s far too much waste in the medical system

This is probably true but this is the system we have chosen as a society. In Ireland we operate an almost US-style medico-legal system with huge payouts. This story has many authors and involves hospitals, insurance companies, the legal profession and the judiciary.

We also run an adversarial system of medical council regulation who have frequently held public show trials for doctors who may or may not be guilty of misconduct or poor standards.

The inevitable and predicted consequence is so-called “defensive medicine” where doctors over-rely on expensive tests and interventions. This is described by some, myself included, as waste but equally is another person’s priceless reassurance.

What is abundantly clear though is that defensive medicine is costly and dangerous and can only be overcome with a better regulatory and legal framework.

Dr Anthony O’Connor is a consultant gastroenterologist in Tallaght Hospital. Cork-born, he trained in Tallaght and St James’s Hospitals in Dublin before doing an advanced fellowship in Boston USA and subsequently as a consultant in Leeds, UK before returning to Tallaght in 2016.

Tweeting TDs: Who excelled on social media in 2017?>

1918 was a year of monumental importance that had plenty in common with 2018 Ireland> 

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198 Comments
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    Mute Jamie Jj Tobin
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    May 19th 2017, 9:01 PM

    Well done to him but even more amazing, Chuck Norris once climbed Mt. Everest in 15 minutes, 14 of which he was building a snowman at the bottom.

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    Mute Tweety McTweeter
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    May 19th 2017, 9:24 PM

    @Jamie Jj Tobin:
    That’s nothing. Kim Jong-un once climbed Everest wearing nothing but a swimsuit, fought off a bear attack at the top and then jogged back down the hill, all before getting 18 holes in one on a local Nepalese golf course

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    Mute Jamie Jj Tobin
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    May 19th 2017, 9:36 PM

    @Tweety McTweeter: Well did you hear the time 10 English blonde women and an Irish biddy called biddy are climbing Mt. Everest. The rope they are on is too heavy, so one of them has to sacrifice themselves. After a moment of silence, the Irish biddy called biddy says she will do it. She makes a long, touching speech about her life and to remember her, and all of the English blondes clap and let go of the rope. True story.

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    Mute Jeni Moriarty
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    May 19th 2017, 10:24 PM

    @Jamie Jj Tobin: bahahaha brilliant

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    Mute Ian Hester
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    May 24th 2017, 9:53 AM

    @Jamie Jj Tobin: Pat is in the game to make money I don’t like his style he was on a trek to one of the poles and just to give his story about it a bit of ‘window dressing’ he went on about the threat from polar bears and willing to use a gun if need be.This is the bear’s habitat so far from being brave -its cowardly to have to resort to that.Leave them in peace is best.We are doing enough damage to them through climate change.They are starving to death so unless they are willing to go without guns get out of their domain.

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    Mute Ian Hester
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    May 24th 2017, 10:02 AM

    @Tweety McTweeter: did u hear the one about the paddy who lit a fire at the ‘bog’ on base camp to keep warm etc -he thawed the Kumbu Ice Fall and it caused an avalanche that killed many of them back a few years ago

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    Mute Stephen Cullen
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    May 19th 2017, 9:00 PM

    Follow your dreams folks, we aren’t here for long.

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    Mute Tony Daly
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    May 19th 2017, 10:53 PM

    @Stephen Cullen: even shorter if you die en route.

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    Mute JoseMacPhisto
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    May 20th 2017, 10:59 AM

    @Stephen Cullen:

    He climbed a mountain. For what?

    Plenty of other ways to fulfil your dreams that have benefit for mankind, and don’t stupidly risk losing your own life.

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    Mute Rehabmeerkat
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    May 20th 2017, 12:36 PM

    @JoseMacPhisto: if your dream is to climb Everest… what’s the other ways of doing it? google street view vr?

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    Mute JoseMacPhisto
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    May 20th 2017, 12:58 PM

    @Rehabmeerkat:

    You’ve missed the point.

    The man is married, runs a family business passed onto him. Roughly 8-10% of people who attempt the summit, die either on the way there, or the way down. There’s only so far fitness, stamina, know-how, and determination will get you when the weather turns, an avalanche occurs, or you contract snow or altitude blindness.

    There’s no benefit for mankind, his wife, or anyone else with this stupid kind of risk. It’s pure ego.

    It might be a dream, but with such a high risk of making his wife a widow, for me personally, it leaves a lot to be desired.

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    Mute Dónaldó
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    May 20th 2017, 2:09 PM

    @JoseMacPhisto: “Anger is never without a reason but seldom with a good one” B. Franklin

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    Mute Rehabmeerkat
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    May 20th 2017, 3:28 PM

    @JoseMacPhisto: your right. he’d be better off spending his Saturday afternoons writing nonsense on message boards. far more fulfilling….

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    Mute Sean
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    May 19th 2017, 9:19 PM

    This site says that an Everest climb costs somewhere in the region of $50K.
    http://www.alanarnette.com/blog/2016/12/18/how-much-does-it-cost-to-climb-mount-everest/
    I just wonder how much money was raised for the charity and how much of a bite this climb took out of it.

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    Mute EBurton
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    May 19th 2017, 9:33 PM

    @Sean: ah begrudgery, where would we be without it. Well researched begrudgery too, even has a link to go with it.

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    Mute Sean
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    May 19th 2017, 9:38 PM

    @EBurton: yeah I’m feeling a bit bad now about saying that. Maybe I’m just too cynical but Irish charities don’t have a great record of late. I’m guessing though that this climb was funded by sponsorship and that all the money goes to charity but it would be nice for that to be made clear.

    Here is the link to the fundraising page for anyone who would like to donate.
    https://www.ifundraise.ie/fundraiser/11362357_everest-4-elevate-2017.html

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    Mute cyrilcrowe
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    May 19th 2017, 9:46 PM

    @Sean: he paid for the climb himself and all raised money goes directly to the charity

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    Mute John Mulligan
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    May 19th 2017, 10:33 PM

    @Sean: all the money raised goes to the charity; he paid for the trip from his own pocket.
    What have you done lately?

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    Mute Sean
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    May 19th 2017, 11:09 PM

    @John Mulligan: ha ha I climbed K2 last week but I didn’t tell anyone. To be fair, I changed my mind after my first impetuous comment. Well done to the chap it’s a fantastic achievement!

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    Mute kevin
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    May 20th 2017, 12:18 AM

    @EBurton: I didn’t want to like your comment but it did make me laugh.

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    Mute Debbie Van Tonder
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    May 20th 2017, 7:27 AM

    @Sean: in all fairness – you have the right to question. The Irish public have been deceived by some scrupulous people e.g. The Console debacle. It is nice to read that there are still some honest people out there where all the money goes to the charity. Your question made it clear.

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    Mute ComicbookGuy
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    May 20th 2017, 12:43 AM

    I climbed the sugarloaf once, on the hike from the Carpark to the base I honestly thought, feck I’m not gonna make it, I’m gonna die, but I soldiered on and got there in the end.

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    Mute Randal McNally
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    May 19th 2017, 9:17 PM

    Might be good for there tourism, but why the hell do people insist on climbing Everest and destroying its environment ?

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    Mute offtheball
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    May 19th 2017, 9:48 PM

    @Randal McNally: I suppose it’s not going to be much of an environment if people can’t visit it to appreciate it?

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    Mute Scundered
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    May 19th 2017, 10:51 PM

    @Randal McNally: errr given the nature of the weather there I think you’ll find man under the control of the mountain, not the other way round. They walk on ice and snow, none of which is permanent and the ice fall always moving.

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    Mute David Stapleton
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    May 19th 2017, 11:08 PM

    @Scundered: you don’t know what you are talking about. There have actually been expeditions mounted that do nothing but bring down the crap left from previous expeditions. Tents, sleeping bags, oxygen tanks, etc.

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    Mute Brian Cunningham
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    May 20th 2017, 1:50 AM

    @David Stapleton: There is literal crap all over the place as well. No flushing jaxes to be had at or beyond base camp, I’m fairly sure.

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    Mute John Owens
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    May 20th 2017, 8:58 AM

    @Randal McNally: destroying… you might be an idiot. Just to be sure, check into your local nut factory and give it six months. Good luck!

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    Mute Jon Mackey
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    May 19th 2017, 9:17 PM

    Fair play to that man!

    #arete!

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    Mute the phantom
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    May 19th 2017, 9:58 PM

    Is climbing Everest really newsworthy anymore?

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    Mute John Mulligan
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    May 19th 2017, 10:34 PM

    @the phantom: it’s as hard now as it ever was.
    An awful lot of putting one foot in front of the other.

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    Mute Scundered
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    May 20th 2017, 8:16 AM

    @the phantom: it’s looked upon as an easy one among serious mountain climbers due to its easier gradient but it’s still the tallest of course. Now if it were K2 that’s a story.

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    Mute Ciarán
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    May 19th 2017, 9:58 PM

    Met Pat Falvey in Killarney years ago, Hes a local hero down there, What a feat for any Man or Woman.

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    Mute Guybrush Threepwood
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    May 19th 2017, 10:33 PM

    Fair dues. Pity he didn’t talk about the charity more in the interview. Or maybe the author chose not to include that part perhaps thinking many people aren’t interested in reading it.

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    Mute JoseMacPhisto
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    May 20th 2017, 10:51 AM

    One of the most selfish acts known to man.

    This guy’s no hero. The mortality rate for people climbing Everest is nearly 1 in 10. Climbing it when you’re alone for the sake of pride is daft, but this chap is married. Presumably has some family back home as well.

    I can accept that some people will put their lives at risk for the betterment of mankind (space exploration, knowledge of the oceans etc). This is an ego-driven vanity trip.

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    Mute Martin Fahy
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    May 19th 2017, 9:35 PM

    Well done and all that, and if someone gas the funds to do it, go for it. I would assume the charity effort was separate to his costs about the climb.
    But big deal about the bodies, he would have been well aware he was going to come

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    Mute Martin Fahy
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    May 19th 2017, 9:36 PM

    @Martin Fahy: across them, and prepared for it, so don’t get the big deal about the bodies

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    Mute Chewey Bacca
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    May 19th 2017, 11:35 PM

    Annapurna is the toughest 8000er of them all with a fatality rate of 38% approx. fascinating reading about those who have climbed all of the 8000er mountains (14 of them)

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    Mute Quentin Moriarty
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    May 19th 2017, 11:30 PM

    Scott Fischer and Rob Hall among the dead up there for over 20 years
    Two of many experienced climbers killed on the mountain.

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    Mute Dermot Foley
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    May 19th 2017, 11:59 PM

    @Quentin Moriarty: and my first cousin John Delaney. Rip.

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    Mute Kevin
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    May 20th 2017, 12:20 AM

    @Sean:
    You raised a valid point. No need to apologise for it. Some folks only too delighted to issue a slap down on such reasonable enquiries.

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    Mute Tony Gordon
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    May 20th 2017, 12:09 AM

    Good stuff, and if you see my sis Liz at base camp this week be sure today high!
    (But she’s not going higher than basecamp)

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    Mute Jonathan Caffrey
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    May 20th 2017, 9:22 AM

    Congrats to John. Amazing man.

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    Mute Ken Burke
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    May 20th 2017, 10:58 AM

    @comicbookguy
    Well done. A great achievement. Glad you stuck with it. Getting out of the carpark is always the hard part.

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    Mute Ian Hester
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    May 24th 2017, 9:44 AM

    It costs 50 grand to bring a body down if its retrievable! So had he that covered for insurance if not not much left for the charity then.Better of expending energy stopping Trump or the ‘frackers’ from destroying west Clare.. the Irish have huge inflated egos ….but can’t stop the massive corruption that’s destroying rural Ireland… Seanie Fitz has escaped on his horseback riding to hell….. Thanks to ineptness of the state and corporate law enforcement and the ongoing unwillingness to tackle white collar crime.There’s nothing to celebrate or be proud about with all our own people ending up on the streets of shame!

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