Tuesday, March 01, 2011
Sunday, October 17, 2010
Boring administrative entry below.
I had the second job interview the other day.
I did the interview to get into GP training. I applied to GP training to specialise in addiction medicine. I want to specialise in Addiction Medicine because I love it, and it's fascinating, and so Sarah doesn't have to work.
On that note, we got the letter from the lawyers today. The lawyers have a website, with a short video clip of a woman talking. The woman says something like "Hi, I'm Lara Laura, Lawyer. For too long, amoral multinational companies have built their vast profits on mutilated, maimed and murdered bodies of innocent people. If you have suffered ..." and so on. It's a bit startling.
We fill in the forms and then we wait. Apparently this is an open and shut legal case, which means it may well be finalised within three years. We shall see.
Anyhow - the interview. It was the second interview, because I didn't get in on the first round - I am unsure why, but not wanting to do the thing they're interviewing you for is quite a disadvantage. I don’t actually want to be a GP – I think this is what they call family medicine over in the US. It may have been that my inability to adequately conceal this was behind my less than stellar performance in the first interview.
Still, it does hurt to fail. You do lie in bed the next few weeks wondering if they have found out what no-one else knew but you always expected – that you’re crap. I am older now, and twenty years ago I would have been swarmed by those thoughts, and dragged under, whereas now they are much fewer, and I am able to see them as not particularly realistic, but they are there.
This time things went better. The questions were about how you would handle a heart attack in a small country GP surgery, how to handle the “he’s got gonorrhoea, they’re both your patients, he doesn’t want to tell her or for you to tell her” and an unusual one that started “tell us about one of your wrong diagnoses and the consequences of that.”
It went reasonably well, and later that day they rang up and offered me the job - the job being ninety km away, doing stuff I’ve forgotten, for a minimum of twenty two hours a week, and a considerable pay cut.
Simultaneously thrilled and un-nerved. It is alarming - I don't know if I have what it takes to be a good GP, I don't know if I don't whether I will know that I do not - if you follow. I don't want to be one of those "crap at medicine and crap at detecting your own crapness" doctors. But if it all works out, in three to five years time, it’s a specialist qualification, and Sarah able to not work at all.
We shall see. More soonish - possibly about one of my patients and night terrors. Thanks for listening,
Unpublished and possibly career-ending letter to a fellow medical practitioner
Dear Dr Zu,
I saw Joanne X today. She was limping and she had many of the clinical signs of sciatica. Imagine my delight when I heard how you had successfully treated her back pain without recourse to drugs of dependence.
I'll have to imagine my delight, too, because that is not what I heard.
She said, and a call to the pharmacist confirmed, that you have prescribed her a bottle of alprazolam. I told her that alprazolam was not compatible with her other medications, because together they could cause dangerous side effects like memory loss.
She asked why I hadn't told her about this.
I told her I had.
This is the same woman you sent to me three years ago because she was addicted to alprazolam. She had nearly been intubated because of an overdose of alprazolam. Her husband and two daughters are addicted to alprazolam. The sojourn in the Barad-dur Women's Prison, the miraculously survived three motor vehicle accident, the three weeks in August sleeping in a station wagon, all are due to alprazolam. I have winched this woman's dose back to nothing over the last three years and three months ago she had what she swore was her last dose of alprazolam.
And then she strains her back and you give her alprazolam.
Sciatica occurs when an inflamed disk presses on a nerve root causing pain. The inflammation is treated with anti-inflammatories, the nerve root pain with analgesics. The only thing alprazolam is "treating" in this case is the very dependency issue that caused ninety nine percent of her problems in the first place.
She also mentioned some concerns about her weight gain. Perhaps you could prescribe her some pastry?
BSc BM BS etc.
Saturday, October 02, 2010
killing people is wrong
Sunday, September 19, 2010
Saturday, September 18, 2010
Friday, January 08, 2010
And herewith a bad thign that happened to Jasper Lucas. Bad language alert.
Jasper is a man whom it is difficult not to like. He is thin, blonde-haired and freckled, with bright blue eyes above a meandering nose. He breeds tree-frogs, and reads thrillers, and once got shot with a rubber bullet in what he said was a demonstration against police violence, in Ireland. Like a number of our other clients, almost nothing of his wild life from twenty years ago remains - bad dreams, bare gums, scars and pharmacology.
I am reluctant to go into detail here, but while his criminal record is scant, his easy familarity with a number of the "hard men from the old crew" suggests there was, at one time, a lot more to Mr Lucas than met the eye. Bad things have happened to him. Jasper's teeth were not removed in the normal fashion, and this has something to do with the six month prison sentence he suffered fifteen years ago. I don't know.
He still picks up his methadone every day from Crippens' Pharmacy. Every two months we discuss reducing his dose, moving him on, getting him away from the pharmacy. Every two months he says he's not ready - reducing his dose causes disturbed sleep, and anxiety, and physical discomfort, and those are things he's of which he's probably had enough.
But he's doing well, and the other day a group of them went to Shylock Services*and treated himself to a graphite pool cue - he plays competitively - and a second hand version of Guitar Hero. His mate drove him home, and he sat in the back seat holding his pool cue and running his fingers up and down the frets of the Guitar Hero game. His mate dropped him off and he went inside to grab a coffee.
While the coffee was boiling he glanced outside. A man in a police uniform ran by across the street, cruched over, wearing a flak jacket.
"That's never good," he thought. "Wonder what that's about?" A few minutes later there was a knock on thedoor. He wandered over, coffee in hand, and opened it to a shotgun. the muzzle was pressed against his face. A mass of armed and armoured men swarmed in, pointing shotguns and screaming.
"Jesus Christ" I said. My own coffee was half-way to my lips. "TRG?"
"It wasn't the fucking girl guides" he said.
He was quite upset. They had hurled him on the ground in "some kind of judo hold" and pointed guns at his head and screamed "where is it? where the fuck is it?" a lot. He had managed to get them to calm down enough to ask for a hint as to what "it" might possibly be.
"The gun!" They shrieked. "Don't fuck about!" and so on.
Note - from here on in, I'm replacing the obscenities with euphemism.
Anyway, it emerged that, unsurprisingly, there was no gun. There had been no gun. There had been Mr Lucas sitting in the back seat of his car, holding his little plastic guitar hero guitar and his pool cue, and miming "Eruption" by Van Halen. This ludicrous story fooled no-one, but the discoverey of the pool cue, the guitar hero game, and the timed and dated receipt on the bed a few metres from the front door and exactly where he said they would be did temporarily set his assailants back. Murmurs (but no apologies, Mr lucas noted) were exchanged, and the horde withdrew. One of them turned as he left and actually said "We'll be back."
"Knock yourself out, you [foolish individuals]" Mr Lucas said, or words to that effect. "I'm getting a Wii next week. If you squint, and you're [dashed silly], it looks like a pair of nunchucks."
Anyway, must heal sick. We shall see what emerges from this.
Thanks for listening,
*I don't know I am comfortable with this name. Shylock was a more complex character than often thought, and the best portrayals bring out this complexity and ambiguity, but the essential facts remain - the vicious Jew. Shylock Services gives you twenty bucks for something worth two hundred, and sells it at one hundred fifty.
Monday, January 04, 2010
Now - I was going to write a bit more on the preceding "sex and medicine" theme, but I don't know that I will. It's probably enough to know that sometimes things catch you off guard, and hit you, and five years later if you look back you are still disquieted by them.
Meantime - the public methadone programme and the whip.
We in the south have a problem. About half of my two hundred patients are on methadone. Methadone, for those who came in late, is heroin unplugged - a slower, safer, acoustic version without that heady mix of outlaw edginess and frontal lobe infarction. It's safer, but it's in no way safe.
Whether or not the programme (and doesn't that sound like something from the Ministry of Clear Thought) saves lives is a matter of debate, but that debate was formed and now flourishes almost entirely outside medicine. From a medical point of view, the numbers are remarkably convincing - you get some one on methadone, they die later*. They get fewer infections. They are less likely to be breaking into your car as you read this.
But they do die. From what I can work out, for my patients, ten "should" die every thousand person-years. I have two hundred people on the programme, maybe two should die a year. Over five years, if they were average opioid dependent people, ten "should" die**. These rates are lower than in a lot of countries, partly because we have little HIV over here.
The rates of death for similar groups who are not opioid dependent is one fifth of that - maybe two in five years, maybe three.
The rates of death on the programme depends on who does it, and how well it is done, but for us it is still too high. We had two deaths last year - car versus tree, and overdose - , two or three in the three years before that - complications of pneumonia, a hanging. One this time last year, when someone stabbed Nicky Walker in the throat with a samurai sword. Maybe we're running at one a year, certainly less than two.
Why? Violence. Overdose. Alcohol. "Pills". The one we are falling down most badly on at the moment is the pills. Specifically, a lot of our patients are on alprazolam, and almost all of our patients who die, or are incarcerated, or are hospitalised are on it.
Alprazolam, as I have said, is like vodka to the frontal lobes. Amnesia, disinhibition, a complete shutting down of the part of the brain that says "uhh, maybe this isn't the best idea". Alprazolam plus methadone means long stays in ICU, constant cognitive impairment, increased chances of respiratory depression and of having six colours of shit kicked out of you.
I've tracked down a few of the dealers. They drive past in their big cars, wearing their fancy suits. Lately, some of the locals have been getting soft, and new guys, blank-faced men from south-east Asia or softly spoken men from the subcontinent have made inroads into their territory. I've got a decent idea of where they operate, who they see. I've even managed to get a few names - Dr Lung. Dr Chandraguptran. Dr Jones.
And I'm taking steps. I'm ringing and writing to them. I'm informing the relevant regulatory bodies. In the end, I might be ringing the medical board on them. One of my patients, a woman who has twice fallen asleep in the waiting room, has seen twelve different doctors in the last few months and been prescribed diazepam, oxazepam, temazepam, alprazolam, clonazepam and nitrazepam. Sedatives are a fair proportion of her caloric intake. She has had multiple overdoses and is only kept alive by being incarcerated.
Dr Jones thought this woman's interests would be best served by one hundred tablets of alprazolam in four days.
Anyway - that's the whip. I am uncomfortable cracking it. But otherwise we have the police in and out of the pharmacy, and the ICU on standby, and the coroner on speed-dial. We have a death rate that is edging closer to that achieved by the Triads and the bikie gangs. We don't have medicine.
I shall keep you informed. Thanks for listening,
*These are all population based studies, which are fine and noble things, but of utterly no use to those whose sons and daughters and family and friends die either "on" methadone or from diverted methadone. A population may have a decreased rate of mortality, but each person who dies remains absolutely dead. in the period during which I did not write, this happened to a relative of mine, a girl - and I chose that word - of twenty six, who died in her sleep over the summer.
These people are seen as side effects, as collateral damage, as the unavoidable consequence of what we do. I don't know to what extent that is true, but if this has happened to you, I and others like me are to a degree responsible, and I am sorry.
** I know the maths isn't like this, but the language is. it's like when I say "giraffes evolved long necks to reach succulent foliage", rather than "mutant giraffes with long necks survived and bred" and so forth.