Night Shift Australia Day

Just finished two nights and I can't sleep yet.

Nights were good. I'm too tired to write straight, so here is a brief precis of what we had Friday and Saturday nights.

10: 02 - Pool cue versus head. This was a twenty four year old man who was minding his own business when for no reason, some guy smacked him in the head with a pool cue. He needed six stitches and because you can't get local anaesthetic into the ear (there's no stretchy skin over the ear, like there isn't over the nose or the heel) we had to do a nerve block. This is not an arcane kung fu technique, it involves injecting the local anaesethetic somewhere "upstream" from the actual area you want to anaesthetise and numbing the whole area. If you want to anaesthetise the ear, you inject at four places, sortof in front and behind, above and below, slowly, with a small needle, and the pain goes away for five to ten minutes - long enough to stitch things together. You can inject in a certain place in the hand and knock out sensation to a finger, you can inject in a wrist and knock out half the hand, etc.

Anyway, six very fiddly stitches and a tetanus shot and he went out to fight another day.

I didn't ask about the guy. It's always some guy who attacks people for no reason, usually young drunken men who are amiably minding their own business when this loon attacks them. If the police could just stop this one guy, then assaults in the southern suburbs would drop by ninety percent.

11:12 - Girl, stepped in barbeque.
This was horrible. Burns really really hurt. I got a line in and we poured in the morphine, and she was still crying half an hour later. This is almost the only time I have a problem with some nursing practice. Some of the older nurses - and some of the doctors, too - seem to have a problem with handing out the morphine. Not the newer ones, and the training now is to give as much pain relief as can be given safely, and give it quickly. With burns it's actually getting the dressing on and the cool water that seems to help as much as the opiates anyway. But the opiates are important, because the pain is excruciating.

I think some staff worry about creating heroin addicts. Heroin addiction is a big problem, but you don't end up smacking out grannies and robbing servos because we gave you morphine when you stood barefoot on hot coals. Pain is an emergency.

Anyway, all significant burns go up the road to the Royal, and that's where this girl went when the ambulance came.

00:22 Stuck my head in a cubicle to tell a thirty eight year old man (smokes thirty a day, one hundred and forty kilos) that his second blood test has come back, it's not a heart attack this time, go to his local doctor within the next day or so to organise further tests, start on an aspirin a day.

It is a weird feeling telling people my age that they are at risk of heart attacks. The youngest MI (myocardial infarction, exact same thing) I have ever seen was a twenty one year old man who dropped dead in the car park in the shopping centre across the road a few years back. We got his heart going, but not for long - I still remember the jolt, the green line that showed a few brave, normal looking beats, then the useless fluttering of his shocked and dying heart.

He had every risk factor available - Samoan, big, smoked three packs a day at twenty one, uncontrolled diabetes, drank, didn't have a living relative over forty. But Jesus, twenty one. We worked until the retrieval team from the Royal came, and then they called the death. I remember pulling off my gloves and going to answer a phone call from a relative. It was his sister and she was asking if he'd be home by six thirty because otherwise she had to pick up the kids.

Anyway, I'm getting morbid and I'm falling asleep at the keyboard here. More in the next few days.

John

Muscle

I've been reading a book called Little Big Men by Alan Klein. It's about bodybuilders, studying them as if they were a tribe, with their own separate language, social customs, hierarchy, that kind of thing. It's interesting, in a weird way (although I haven't got up to the bit where the naked bodybuilder leaps out of the cake at the gay party, and I'm beginning to doubt it's in there).

A few things he says I don't know that I believe. He seems to be very big on the idea that masculinity, "how to be a man", is something entirely socially constructed, something a culture or society makes up from scratch, with nothing inbuilt. He seems to think that absolutely everything about what it is to be a man comes from nurture, rather than nature. I don't believe that. It's all a complex mix of genes and environment, and I don't think blank slate fundamentalism is going to be what leads us into the next century.

He talks about some of the dominant ideas in the gym, and some of the contradictions. By "the gym" he means the serious, bodybuilder end of things. He points out how you get overly masculine behaviour, almost hypermasculinity.

You notice this in a few ways. For a start, there's sex. There's always a small group of guys who come in around five and bang on about their weekend sexual exploits: what she looked like, how many times, how much she wanted it, how they won't call her back. I don't know that they'd talk so much or so loud if they were each pushing a shopping trolley in the toiletries section of Woolworths. And everything bad or weak is "gay" or "faggoty": fag pecs, gay shoulder press technique, fagotty little weights on the bench.

In between these comments they stare at large pictures of oiled, almost naked young men.

And I'm not saying that all these men are actually latent homosexuals or anything like that. It's just that maybe there is some relationship between their focus on the male body and the rest of their behaviour, that if I wanted to reassure people, including myself, that I wasn't gay maybe I'd talk like that.

Besides sex, there's utility. Men are meant to be about doing useful things, doing stuff, functionality. The same small group of guys there always seems to be stripping down a VS Commodore or building a new room on the house: doing what men do, things concerned with function rather than appearance.

But bodybuilding is all about appearance. The only group of people who spend a comparable amount of time worrying about their appearance is supermodels. Even the most extreme metrosexual or American psycho doesn't spend half of what these people do on tanning lotion. And bodybuilding itself isn't about anyone's ability ot do something - not about how much you can lift or anything - it's about looks. It's Miss America minus the talent section, only swimsuits.

Reading something like this is not flattering. It makes you feel defensive about going to the gym. It paints a picture of people in the gym as egocentric loners. I don't feel I'm an egocentric loner. Some of those losers who train at the gym might be, but I don't know, I don't talk to them much.

Anyway, I was trying to work out what the gym was for me, and the closest analogy I could come up with sounds really stupid. A monastery.

Seriously. It has that effect, it's calming. I think the gym is almost the only place where I feel in control of what is going on in my life. You pull the bar down, the weights on the other end go up, you feel the strain in the latissimus, the big sheet of muscle that covers your back. You curl your arm, the short head of the biceps brachii engages, the weight moves through a certain arc. There's a precision that's almost mathematical, a graded dose-response curve, as true as a chemical equation. Do this, this happens.

For me, I go in there, it's like a monastery. High ceilings, functional objects, an absence of conversation that is like a vow of silence, a series of prescribed and regimented "works" to mortify and chastise the flesh. A cycle of behaviours - chest, back, shoulders - that is like matins, vespers, tierce. And a mirror - as a kid I read somewhere about Buddhist monks using a mirror as an aide to meditation.

Anyway, that's a gratifying image, but it's one I can only sustain for a few moments, until it strikes me as absurd. Monks don't wear lycra, or flex, or shout encouragement at each other during communion - "Come on, big man!! One more wafer!! Now rosaries - two -three - feel the burn!! Work that tonsure!!". Monks rarely turn to performance enhancing drugs.

I don't know. I think there is a connection between the gym and religious life, even if it's a warped kind of religion, an anti-gnosticism: an elevation of the flesh over the spirit, a God who lives in the strong rather than died for the weak.

I'm getting theology in here. I shouldn't write these after night shifts.

Anyway. There was a blind girl who used to go to one of the gyms I went to, close on fifteen years ago. She would trot in and lift her five kilo weights and often stand next to the big benches, where the big men came to lift their big weights in a big manner. She would stand there and they (singlets saying "Gold's" or "Olympic", baseball caps on backwards, buff) would shout at each other. "Get it up!! Drive it in, big boy!! Go hard!! I want to feel it!!"

I wonder if she wondered what was going on. Or maybe she worked some of it out fifteen years ealier than I did.

Bronze John

Violence

Okay, we'll leave the sex and drugs for future entries and go straight to violence. In a way, emergency is all about violence. Someone in one cubicle is being stabbed with little needles, someone else is having precise doses of poisons infused into their vein, another is being told she cannot leave the hospital and must take the medication that makes her fat and slow.

I think sometimes that the most important characteristic a doctor or nurse must have is some kind of internal distance, some gap between the surface of their skin and their soul, something that enables them to do what they do (with scalpels and needles and questions and detention forms) and go on regardless. I sometimes think that distance is the only thing that has enabled me to survive. My patients express their pain, and I make the appropriate responses, and think that I feel the appropriate things, but it is all images projected onto a screeen - vivid and colourful and dramatic, but in no way affecting what lies beneath.

Anyway, violence. Most people I know who work in Emergency have been hit. I can think without effort of nurses who have been punched, security guards spat at, doctors kicked. Most nurses have been punched, kicked in the chest, spat on, arms twisted, hair pulled, scratched, threatened with bodily fluids in one way or another. A year or so back in Perth a psychiatric nurse was beaten almost to death. Before Christmas a man threatened to shoot me in the back of the head - "and I've got a gun, I know you, never see it coming, bang, all your fucking brains" - and then he punched a wall and broke his fist and it was me who had to check out his fractured metacarpal.

And the year before a blonde man, slim, with green eyes, told me he would dedicate the rest of his life to hunting down and killing me and my family. This in front of six police officers. The rest of his threats were a bit woozy as the intra-muscular clonazepam took effect, but even so, it happened.

And in first year I had to leap on a tall, lean man who smacked the senior consultant in the back of the head, and me and the security guard pinned him down. Any bragging rights I may have gained from this episode vanished when I saw a leg protruding from the melee and slapped on a pretty nasty leg-lock, nearly crippling the security guard.
What do you do about this?

It's difficult to even talk about. There are few acceptable male responses to violence - in fact, I can only think of one: more violence. Since that is impossible for about thirty or forty excellent reasons, what does that leave you with? Hospitals offer counselling, but I am not entirely sure counselling works. I think it sometimes makes things worse. The police came around once and asked me if I wanted to press charges, but the perosn who had threatened to kill me was distracted by clouds of invisible psychic sexual organs* and who knows what any of us would do under those circumstances.

Me, I go home and talk to my brother and then I smack the punching bag.

Note the gratifying masculine nature of those responses. I am a real man after all.

Sigh.

I don't know what the answer is. Violence remains a part of the job, and it shouldn't be. The offical stance is that it is unacceptable, but the same offical bodies that issue our mission statments about safe and secure workplaces also close the psychiatric wards, gut community mental health funding and let waiting times extend into the distance.

Maybe part of it's in the training. Nurses and doctors - and it's the nurses who get hit most often - get trained in how to manage chronic renal failure when maybe they should be trained in how to manage a right hook. A few less session on nebulisers and nephrotoxicity and a few more on nunchaku.

Not entirely serious there. But I am running a self defence course for some of the staff I work with: de-escalating, psychology, basic physical stuff - so that hopefully we can minimise the damage for everyone.

Bronze John

* I am not making this up - in fact, I have met three patients with similar beliefs in the last five years. The belief that one is being in some way persecuted by invisible penises/penii is almost common enough to qualify as a syndrome. I'll be damned if I want it named after me, though.

Needlestick

Back amongst the living.

Last time I mentioned needlesticks. I've had three, including the current one. I don't know if this is worse or better than average, I suspect it's worse. Most people I know have had one, most consultants have had several.

The first one was in medical school, final year. I was on the general medical team, with a small Asian man who liked listening to Amy Grant and a hatchet-faced red-headed woman who voted to send Asian refugees back where they came from and whose husband was going to reward her with ten thousand dollars worth of plastic surgery for finishing medical school (both of these are true - Amy Grant - I swear it).

Anyway, I had to take blood from an eighty eight year old English woman. She was normally very placid, but she had developed a urinary tract infection and was "confused". I use inverted commas because while we believed that her urinary tract symptoms on top of her pre-existing dementia had caused an acute-on-chronic decline in her mental state, she appeared quite confident in her facts.

"I'm having a baby" she informed me.

"How lovely" I said, readying the needle.

"Everyone will be very surprised" she whispered conspiratorially. "They'll cause such a fuss".

Well, it's good to have a fuss made of you, occasionally" I said. I had slid the tourniquet around her pale, narrow arm and now the cephalic vein was standing out, fat as a baby's finger.

"Oh, no. This won't be good at all. Mother will be terribly upset."

I nodded. "Now, I'm taking the blood now, Mrs Adams."

Holding the twenty guage jelco in one hand and tenting her skin with the other, I advanced the needle until it just about touched the skin. I always used to ask a question when I took blood, as a distraction from the pain. I fixed my eye on the soft, bulging vein and slid the needle forward. I think my peripheral vision picked up a blur of movement, maybe not. "Why will your mother be - "

And I screamed as the Mrs Adams whipped out a left hook and smacked me in the side of the face. Her engagement ring scraped along my cheekbone and one of her long-nailed fingers stabbed into my ear canal, drawing blood.

"Jesus - ah, shit!" I howled. I had jerked my head sideways and now the jelco was dangling point first from the webbing between my thumb and forefinger. "Shit!!"

"What are you doing to me?" she shrieked. "Nurse! Help me! He's hurting me terribly! Oh God, save me!!!" Concerned staff came running down the corridor, including the hachet faced intern and the small Asian man, while I stumbled into the washroom and washed my hands.

The next time I don't want to write about. Someone left a dirty needle in a pile of paper waste, I was cleaning up and the needle went into my thumb. I never found out who did it or from whom it came - everyone denied everything. Six months of worry, no bad result.

The last time (I hope) was a few weeks ago, trying to get a jelco into a patient who had had a seizure in a corridor. He was a large man, with a numerous tattos depicting the apparently vigorous and fulfilling sexual and social life of decaying reanimated corpses. He was considerably stronger than I was, and there were only three nurses, and it's a damn sight harder to hold someone still than it is to thrash about. In the middle of it all I got the needle in the end of my finger.

Anyway, I had to go off to the Royal to get seen by the Infectious Diseases Registrar, which was humiliating, and we had a long discussion about the risks, benefits and side effects of the anti-HIV therapy, and the incidence of HIV in the community, and took the appropriate action, and am still waiting and seeing.

I don't know if this should shit me more than it does. It is an occupational health and safety thing, obviously. If someone is having a seizure and you have to stop them - if you're a doctor with the right equipment and skills and so on, not someone at home. If it's someone having a seizure and you don't know anything about them because someone just shouted out and you came running around the corner and found him on the floor, you have to do something. Maybe it's meningitis or hypoglycaemia or something.

But there's the risk, and you can't talk about the risk without coming across as some kind of wanker. So, next time. Violence.

Day One

... and just finished nightshift. Right – what’s this going to be about and why am I writing it?

It’s probably going to be about my job. I work most of the time as an emergency doctor in a small metropolitan hospital, on a small city, on the Australian coast. Names and locations have been changed to protect the nocent. I’ve also just started working part time in an outreach kind of practice, providing primary care to twelve-to-twenty-five year olds, which means kids in prison, kids on the streets, gay and lesbian kids, that kind of stuff. Occasionally I do some psychiatry rosters. With a bit of luck I am going to Indonesia for some Tsunami relief work.

It’s going to be about my writing. I used to write much more than I do now, I got some stories published in small magazines. I write science fiction and fantasy and horror stories. I want to write those two or three pages Tales of Wonder and Tales of Unease I used to read as a kid, stories of aliens among us and us among the aliens. I want to write that sort of thing again, because I really miss writing, and step one is to get writing again. Hopefully writing an almost-daily journal does that.

It’s going to be about Australia, where I live, and the kind of places I find interesting. I grew up in South Western Australia, which to me means salt lakes and eucalypts, barley and wildflowers, red clay and salinity, isolation and poverty.

It’s going to be about ideas I find interesting – evolutionary biology, neuropsychology, ancient history, superheroes, religion, kung fu, transhumanism.

And it’s probably going to be about mental illness. I have bipolar disorder - probably Bipolar One, as far as I can work out. It's well controlled, and it doesn't interfere with my work, but it hasn't always been like that.

As to why, there is stuff in all of this I have to talk about. I will try to be as honest as I can, and sometimes you don’t realise something is true until you say it, so I’ll try to speak as honestly as I can.
Anyhow - the caffeine is wearing off. Next entry - asylums or needlesticks.

Stranger’s fever, by the way, is an old name for Yellow Fever. So is Bronze John – if you’re from the US, you get all this and toilet humour too.