Nightmares

Weird thoughts here.

Night shift, three in the morning. I'm staring at a row of middle-aged men who are waiting for their second blood tests - the ones that will tell them whether or not they have had heart attacks. And my overdose girl is sleeping it off in the corner cubicle, and the boy who got off the train before it stopped moving is getting his wrist and ankle put in plaster, and Mrs Ouch (not her real name) is having something vital and doubtless therapeutic done to her shoulder.

And for a few blessed moments it's quiet here.

I was talking to one of the other registrars here, and we worked out we had something weird in common. We all have the same nightmares.

Not all the same nightmares, which would alarm me, as if something somewhere was broadcasting horrible visions into everyone's head, like something out of a Lovecraft story, but we all have had, at some time, the same nightmare.

It's one of the ones where something shameful has been discovered. In the dream somehow someone finds out that we are not qualified, that we have lied or cheated or that there has been an administrative mistake of Swiftian proportions or (in one unusual twist) the real "us" died in the womb and we are the next door neighbour's kid roped in as a standin.

We're fakes. We are not who we say we are. It's all been a lie.

Whatever the cause, the consequence is the same. Our falsity has been detected by authority, justice is swift. Everything is taken away. In the dream we lose jobs, family, clothing. One dream-person was deported, another had her nails and hair and teeth forcibly removed. In the most benign form we are set back to primary school, hunching over tiny desks in front of contemptuous six-year-olds.

What's going on? Firstly, I have worked out these conversations are not always a good idea last thing at night for anyone even slightly morbidly inclined.

Second, why are all the doctors all having the same nightmare? I think that's the obvious question here. There's an obvious question, and an obvious answer, but the obvious question is the wrong way around, and the obvious answer is wrong.

The obvious question is "what is it about doctors (I don't know if it's especially emergency medicine, but I've asked a fair few doctors) that makes them so fearful?".
What makes them have these barely suppressed fears that come out at night when your defences are down, terrors you think you've crushed but that silently send their tendrils out when you look away, like a weed growing out from under a rock?

I don't know that it's even a serious question - this is me asking a couple of exhausted people at five in the morning to tell me about their dreams - it's not a randomised double-blind trial. But if it is a question, then the answer might be as follows:

I think the answer is it is the fear of inadequacy, of discovery, of people finding out that they are fakes, that makes these people overcompensate by studying more and more and finding out more and more.

It's not that people who are doctors have these nightmares. It's that people who have these nightmares become doctors. It's those nightmares that make them doctors.

Anyway, work beckons. Four weeks to the exam. Next post - drugs that affect the central nervous system.

John

Neap Tide

Well, things are back to "probably slightly better than normal".

I feel a bit embarrassed about what I wrote, which is normal. Maybe it's even good, I don't know. I know when I started this I believed it would only work as a completely spontaneous thing, every time you have a thought and some time you sit down and bang something out. It's not going to "work" if you go back and edit it.

Lord knows what "work" means.

Anyway. The tide of neurotransmitters that mediates the moods has turned. It's a weird mental image, a clear sea of complex chemicals inside my skull, rising and falling, rhythmically exposing and covering outcroppings of nerves like rocks. And I don't know what the moon is in that analogy, the thing that controls the tides. But whatever it is, the tide has turned, and I am now up and about and back in the ED.

So, last night was fairly low key. I had two of those "maybe it's a heart attack, maybe it's not" cases where the poor bugger has to wait in the ED for eight or ten hours, waiting for the blood tests which will tell him if he's had a heart attack. There was a fair amount of police cases, including one unfortunate girl who stole a car, drove at great speed through the suburbs, crashed said car, fled and was finally arrested by the dogs and subdued with capsicum spray... ordered by her uncle, the police constable. When I went in the atmosphere in the cubicle was fairly tense, and I would imagine it is going to be fairly quiet in that house next Christmas.

That plus a man actually struck over the head with a frying pan whilst robbing a house, like in a cartoon.

And I have to go to court in a few months. I can't remember if I've told you about this, but here goes.

A few months back I saw a woman in the ED, four or five in the morning. Slim, quiet, early twenties. She was south east Asian, had dark hair dyed auburn tied back and she was wearing jeans and a sweatshirt that said "Oxford" or something. She was alone.

She'd been crying, but she wasn't crying now, she had that focussed, clear, "after the storm" look, like people get when some event has passed over them and left them changed.

There is a fair amount I can't say here, even disguised, for about thirty or forty good reasons. But she said that her husband had grabbed her by her throat, choked her almost into unconsciousness, thrown her against the wall. She'd hit her head, but hadn't lost consciousness.

Anyway, the notes indicate that we did the right things. I checked her out for injury, I think we did a soft tissue Xray of the larynx, we kept her for the required time for neurological observations. I documented how she said the police were out looking for her partner, how she assured me that the children were somewhere safe, that she was going to her mother's house at the other end of the city after this.

And I don't know that I documented it, but I gave her the talk. Most domestic violence is chronic, it's almost never a one-off. The longer it goes on the less able you are to leave. It kills people, it cripples people. The usual.

Anyhow, she went off, and that was the end of that, and I went on to the next case, and the one after that and so on.

Then last month I got an email from the police, telling me and about fifty others, mostly police officers, that some guy I hadn't heard of was pleading innocent to some unspecified charge, and they'd keep me informed.

I emailed back saying I thought I was on the wrong mailing list, and they emailed me back explaining that I wasn't.

Somehow, said the police, she and he had ended up in the same place at the same time, three weeks later, and he'd punched her to death. Twenty four years old.

Anyway, this distressed me no small amount. It still does.

It's not what you expect on your wedding day, is it?

I might leave this here. I'll be back soonish with more, probably on an unrelated topic.

John

Back from the Dead

I know the title's melodramatic, but it was a really good song back in the eighties.

And I'm quite depressed.

I checked and I had something like seven of the nine clinical signs of a major depressive episode.

Depressed mood - check. This manifests as alternating irritability (bipolar disorder - the disease the whole family can share!) and what I have to call fear. And not a focal, directed fear either, not something that arises out of some imagined ghastly event in the future, something explicable and limited. Instead it's this generalised, diffuse, protean fear that spread itself like mist across everything, making the chooks getting out of their pen seem a major catastophe, and convincing me that every time the phone rang it was someone wanting me to identify the body.

Feelings of inappropriate guilt. I didn't get these, although everyone else thought I did. I got feelings of appropriate guilt.

Alteration in diet - depression means comfort food, which in my case is carbohydrates and sugar. On normal days it's five veg and three bits of fruit a day and watch the saturated fats and so on. When I'm depressed it's tubs of icecream and kilogrammes of pasta.

Disturbed sleep. It's not me that disturbs my sleep, it's the noise around here. A few nights back it was a kitten breathing, and before that some leaves rubbing together on the tree outside. I lie awake at three am. One day I am going to write a story about the great silent community of the insomniacs, a numberless nation of people lying in the dark, staring at the ceiling or getting up in desparation as the sun rises to play computer games or surf for porn.

Disturbed concentration - I had something to say about this, but it's gone.

Psychomotor retardation - that thing where you walk around with all the energy of an elderly lobster - check.

And so on.

The problem with a lot of this is - well, there's lots of problems. It's humiliating, it's inconvenient, it's mind-meltingly boring.

I have this thing about bipolar and work - I have never made a poor clinical decision because of my illness. I've made a few I can think of because of inexperience and a few due ot tiredness and there's doubtless a lot more that come down to basic bare-bones stupidity, but I've never been able to convince even myself I did anything wrong because of working when I should have gone home. I make sure my immediate superiors know about it, and between me and my wife and my psychiatrist and them that's a hell of a lot of doctor's opinions that I'm fine to work.

But what this means is at the first sign of illness I take time off. I don't take holidays unless I really have to because I want to keep them up my sleeve for sick leave.

Anyhow, I've had two weeks off work, and a fairly crap fortnight it's been.

I think I said at the start of this that it'd be about the bipolar, but I can tell you there's nothing I like less than talking about it. Especially the depression side of it just after it's happened. I find the whole thing deeply humiliating, if the truth be told. It disgusts me, and since it's me who gets it, when I get it I disgust me - the lying around getting fat and useless. The rich white male with all limbs intact whining about his terrible problems. The bottomless pit of insecurity I expect others to tend. The misery that permeates into my bones. I loathe it and I loathe me.

And another thing. I have a theory about this (along with my "for every mental illness there is a corresponding drug that will really fuck you up" theory*). From an evolutionary point of view, depression doesn't have to serve a purpose. It could be a "side-effect" of something that serves a purpose, like some really useful neurotransmitter, or some brain thing I don't understand. It could be something that served a purpose back in the day but is now obsolete, something to get you through the long winter months. It could be any number of things. But I wonder if it hasn't evolved as some kind of psychic parasitism, some mechanism for getting others to do things for you while you lie around on your billowing arse.

Because there is some primitive behavioural thing going on here. Some part of you gets something it needs out of it, there is something in you being rewarded. I tell you what makes the difference with me, what is one determinant of how often I get depressed. As long as I have sympathetic people to whom I can disclose my deepest needs, and who will reassure me I am not a human worm by complimenting me, and who will take up the responsibilities I shuck off, the depression is working for me. And if it's working I'm not going to change.

Well, this is all deeply heretical. It probably won't make sense later on. By "I" I mean something otehr than the fully conscious mind.

I can see why I didn't keep on with psych. I almost did specialise in psychiatry, actuall, but I was put off by aversion therapy. Small joke there.

And I can see that the mood isn't quite up to where it should be yet.

Anyhow, back soon with a bit of normalcy.

John

*Here is the list:

Depression - alcohol
Schizophrenia, schizoaffective, schizoid personality type - marijuana
Bipolar - amphetamines
Anxiety disorders - caffeine, cigarettes, etc.
Whatever mental condition causes you to want to steal your relative's stuff, screw everyone over and make a complete pile of batshit of your life - heroin, cocaine, amphetamines
and so on.

Cricket

Meaningless post today. My brother's thirtieth yesterday, and a couple of us went out the back and played backyard cricket - me, my brother Ryan, my brother's friend Grego and Matthew.

You know how some things make you happy and you can't explain why? Well, times like that, hanging around with Ryan, give me a kind of pure happiness, an ineffable, unadulterated joy. There are two people, maybe four I feel utterly comfortable with in the entire world, and Ryan's one of them. He's someone you feel grateful for knowing.

And playing cricket in the back yard is something it's difficult to make into a task, something where it's hard to set up criteria for yourself to measure your failings and to indicate where you need to improve. For a start we (the players) are all crap. I bowl pace that isn't and spin that doesn't, and my batting technique is built upon a strong foundation of spread-legged flailing. Grego wheezes when he runs in to bowl (smoking), lurches to the side as he releases it (bad knee) and then clutches his lower back where he's ruptured another disc and hobbles off (dodgy ankle). He actually has some ability with the bat, but he doesn't let it interfere with the game. Ryan reckon's he's got got line and length with his bowling, but rarely produces them in the same ball, and last night was bowling a series of perfect offswinging yorkers that were all landing six feet to the left of the batsman.

But Matthew, damn his eyes, can play. He is a modest man who always smiles, one of the most pleasant and adept conversationalists I know, but he bowls long and low and very very fast. In his hands a small rubber ball becomes a deadly weapon. Ryan lasted six balls, Grego five or so, and I faced two bewildering deliveries that hummed between bat and leg before deciding to hook for six, and getting the full velocity of the ball in my scrotum.

Kinetic energy, by the way, is mass (I'd guess a few hundred grams) times the square of velocity (easy over sixty kilometers an hour, dead set). Energy can neither be created nor destroyed, and thusly all the kinetic energy of the cricket ball was transformed into other forms of energy. Initially there was only screaming (kinetic) and falling to the ground (potential becoming kinetic), but later there was a fair amount of sweating (chemical energy), walking to and fro upon the Earth clutching the affected part (metabolic) and calling on the name of the Lord (theological energy).

This much energy expenditure required replenishment, so we sat around drinking cider and talking.

God it was good. It was anxiolyic, anti-depressant, deeply therapeutic, cheap and fun. Patient compliance was high and the few negative side effects were worth it the next day. I am going to write to Medicare. Doctors should be able to prescribe backyard cricket for the anxious patient, and drunken backyard cricket for severe cases. Our psychiatric beds, currently filled with the lonely, the frightened, the friendless and the fat, would be emptied in days.

John

Love gone wrong

Another night shift, another tragic tale of love gone wrong in the southern suburbs.

This time love went fairly seriously wrong, ending up with three guys breaking into some guy's home and beating him half to death with the blunt end of an axe. The police said it was the blunt end, it looked pretty bad to me. Presumably if it'd been the sharp end, they would havebeen able to drive the ambulance less fast.

He came in GCS 8. GCS (Glasgow Coma Scale) is a measure of how bad things are for your brain. If you're reading this, you're probably GCS 15 - the maximum. Your eyes are open, you are able to communicate appropriately and you move your limbs in the desired way. Any deterioration - if something happened and you were unable to open your eyes, or could only move your limbs in response to pain, or you couldn't speak - means a decrease in your GCS, and it means something serious is going on neurologically - in this case, very probably increasing pressure from bleeding inside his skull, which was slowly squashing his brain.

GCS 8 means you are essentially a good way towards a coma, and the danger with that is that you don't "protect your airway" - if your tongue falls back you can choke to death, for example, or you can vomit and then inhale it and die of pizza pneumonitis or whatever they call it. GCS 8 means someone has to intubate - shove a thin plastic hose a foot down his throat and practically into his lungs so we can breath for him.

Anyway, I volunteered to intubate, because I've only done a few before, and it went well, despite the fact I started out with the laryngoscope facing the wrong way, as if I wanted to scoop his brain out rather than save his life. We put in the tube (which is greased and clear and about the thickness of your finger) down his throat and pumped the oxygen in, and then we stuffed another one down his throat behind that one into his stomach, and then a few more tubes (in the wrist, one in the inside of each elbow and one we slid the whole way up his penis so we could drain his bladder) and the team from the Royal came and took him away. Somewhere along the line someone looked in his ears and slid a finger up his bum, so there was no orifice unprobed.

Don't get hit on the head with an axe in our area.

I don't know how he's doing, I haven't been back yet.

A great deal has happened. Moods have been down, which is rather serious and which is something I will talk about later. I don't know about this exam I'm meant to be doing - we'll see. And I may be called as a witness because one of my patients from a few months ago has been murdered, and I've started working at the prisons, and another of my patients has been charged (separate and relatively trivial offence) and so on.

In the end, the "depressive episode" (what's the opposite of evocative?*) was a surprise to nobody but me.

Presumably there is some inverse relationship here - the more things happen, the less time you have to write about them.

Anyhow, sleep. It's weird how sensual your ideas of sleep become on nights - you sit there at six AM, the three or four of you, and you fantasise. You picture your bed in your mind, you imagine the plumpness of the pillows, the soft, enveloping warmth of the blankets, the smooth tautness of the sheet. I don't know if there's a word for it - "linen-porn"? Like food porn and political porn and ... well, porn.

Anyhow, there's obviously another inverse relationship about quality of thought and amount of sleep.

John

*I mean it. It's a crap name. We need something more poetic, more redolent - I could have had a grimmening, a sourmouthing, a joylack. Or maybe some onomatapoeia - "In later years, Sir Nigel began to suffer from what was later diagnosed as severe uuuuuurrrrrhhhhhohtohellwithit.
Watch those levels.

John

Examination Terror

Feeling petrified. Seven weeks to exam. Five in morning.

Have few hours to learn entirety of cardiovascular physiology. Never understood preload and afterload in first place. Was baffled by subject when young, keen and given two semesters to understand it. Now am old and raddled and have few days.

Buddy Guy, one of two most talented blues players alive today, sings " got a cold, cold feeling, seems like ice all around my heart". Australasian College of Emergency Medicine does not describe this condition in pathology or cardiology syllabus. Who Australasian College of Emergency Medicineto argue with Buddy Guy?

Got a cold, cold feeling, seems like ice all around my heart. Doot doo doot doo doo doo.

Still understand nothing of cardiovascular physiology. Does decreasing right atrial pressure during inspiration increase right atrial preload and stroke volume, or decrease them? Or increase one and decrease the other? Or the other way around?

Have lost use of pronouns, definite and indefinite articles, several other core elements of speech.

Have drunk so much coffee can actually hear own heart sounds, feel concentration of cyclic adenosine monophosphate rising, observe phosphorylation of relevant light chain myosine kinases, etc., etc.

Got a cold, cold feeling...

Wife knows more about this than self, even though wife only attended single talk on peripherally related subject in 1983. Talk probably given in foreign language by autistic with speech impediment during acid binge, wife remembers and understands anyway. Wife sits there reading Colleen McCulloch novels, brain bulging softly in the moonlight.

"Abrupt increase in afterload causes moderate increase in inotropy" - is called Anrep Effect or Bowditch Effect?

Why am talking like 1970s Incredible Hulk comic?

Became almost detainably unwell last time had exams. Fear repeat of this. In darkest hours fear failure, humiliation and detention under mental health act imminent.

Note to self - exam will be in Queensland --> look up Qld detention laws, consider pre-emptive appeals process.

Additional note to self - try to avoid episode acute psychosis in Qld - know few words of German, don't want to end up in Baxter Detention Centre.

John