Do you see what I see?

Hail,

Chaos over here. I have the parent's in law over from the East Coast sleeping in our bedroom, and the mother of our boarder is over from Brisbane and is sleeping on the lounge, and Sarah and I are sleeping in the spare room, up against the ironing board and amongst the piles of washing. This means that when I get up to go to work in the morning I have to run from room to room, clad only in a towel, while my seventy year old mother in law averts her eyes.

This reminds me of one of the very few times I have had contact with the police, aside from the ED or the occasional random breath testing. It was about ten years ago, and we were over East visiting relatives and staying in Sarah's parent's house. We were engaged.

Anyway, around three in the morning there was this great thump and I woke up, and I heard someone scrabbling out on the front yard, near Sarah's sister's car. I hurled myself from the bed and charged outside, pausing at the door only long enough to grab the first available weapon, a large (extremely flimsy) wicker chair. There were two figures grappling in the moonlight beside Joanne's car, and I bounded towards them, chair held over my head, ready to smite some evildoer hip and thigh.

Then this extremely bright halogen lamp was shone in my eye, and I avertd my eyes, gesturing threateningly with the chair, and when I could see again there was a policeman lying on the ground with a handcuffed man, and the policeman stared at me and said "Go back inside and put some effing clothes on."

It was then I realised I was naked, and standing on my front lawn in front of a few disgruntled prisoners and two other police officers, and that I was attractively lit from beneath. It was then that Sarah, who had followed me outside (but more sensibly clad in a dressing gown) realised that the door had swung shut behind us. And it was shortly after that that we realised that we would have to get Sarah's crippled mother out of bed to open the door and let us in.

If you find yourself in this position (the "someone is stealing my car" position, not the "I am naked in front of strangers, threatening them while blind and outnumbered, and someone is shining a two thousand watt light through my genitals" position), it may be worth while doing a quick calculation about the relative costs and benefits of acting. Joanne's car at the time was worth less than two hundreed and fifty dollars, the radiator was tied on with baling twine and instead of a petrol cap she had a rag.

From what I could work out, it had been a car chase and the fugitives had ran into a lightpole and fled, but had been apprehended by two squad cars.

Anyhow, these posts may be intermittent for the next few days. Thanks to the people who leave comments, by the way, I don't know if it's netiquette to reply individually or what, but I shall try. Thanks again.

John

Darkness

Hail,

Disturbing day today.

Tell you what, though: it's weird sitting down to write this. I get this weird feeling when I finally collapes at the computer to write. Today was get up, drive lodger to train-station, punch and kick and elbow punching bag for half an hour, hurl last night's food at chickens, scarf breakfast, shower, drive other relatives to train station, meet new RMO, see wall-to-wall-patients, in lunch break ring sexually transmissible diseases folk and talk to RMO about early signs of schizophrenia and the legalities of detention under the mental health act, have feedback session with manager, see more patients, scribble madly in notes and fax letters, run out door, drive home, lock up chooks and help feed swirling tribe of cats then collapse in front of computer.

It's weird - is there such a feeling as psychic decelleration?

Lot's to unpack today.

For the prurient amongst us, today I had to tell some horrified girl that
a) she had chlamydia
and
b) it's a notifiable disease, so someone would have to make sure her partners knew.

The chlamydia news was as well received as could be expected, since by no-one gets out of the room* without being told that sexually transmitted diseases do not only affect skanks and lowlifes, that they are largely curable and/or treatable, that it's not "fair" that they got caught, etc. I don't know that many people overtly think these things, but it would be unusual if they did not at least recognise the ideas at a basal level.

On a tangent here, but Casanova's memoirs are, as you'd expect, pumped up with sex, but also intrinsically interesting, not only because of when and where he lived, but because of the kind of person he was. But from a twenty-first century point of view, it's horrifying to hear of his recurring symptoms of what they used to call venereal disease, intersperse with is frantic coupling. He relates with glee how the doctor of one particular town thanked him for brinign the pox to the local area, thereby ensuring that they would be kept employed.

THe medical attitude towards spreading disease seems to have hardened somewhat. Nowadays what happens is before you get any kind of test for STIs we tell the clients about "notifiable diseases" - diseases that, if you get tehm, we have to inform the government. Chlamydia is one, so I had to go through th ething with the girl and ask if she wanted to contact her sexual partners within the last twelve months and or if she wanted us to. If you ask us to, it's anonymous: the health comission sends you some kind of letter saying "We have reason to believe you may have been exposed to nobrot fungus" and things go on from there.

She elected to get us to inform one of her sexual partners, although I don't know how much success the clinic will have at tracing "Alan or Andrew Green, late twenties or thirties, had a tattoo of a shield or something on his chest, I think he was once in the Army".

Dulce et decorum est, I imagine, to bang a drunken fourteen year old without a condom, but if you're reading this, defender of our hearth, get a checkup.

Anyway. Darkness.

It's weird what affects you as a doctor. People can tell you hideous stuff and you still go on. It's not getting inured to horror, it's being able to hear without being paralysed. If I mourned for every cancer, every stroke, every miscarriage and suicide, I'd fall apart. And there'd be no doctor at Hogarth, and maybe someone I'd otherwise help would fall away.

So you have to keep listening and analysing and commenting, even as you listen and hurt and mourn. And usually you just ride it out.

But today some kid said something and I was still thinking about it a few hours later, and I'm thinking about it now, so I guess you can say it got to me.

Briefly, and anonymisedly:

seventeen year old man (?boy? whatever) presents with his "depression". Doctors haven't been able to fix it. "Depression" keeps him awake at night. Depression means he's pretty much pulled out of school, can't keep a job, can't concentrate. Depression was too much for his girlfriend to deal with, she dumped him.

Depression takes the form of constant, low-level auditory hallucinations, ceaseless voices, about the volume of a firm voice, intrusive, abusive, denigrating him and telling him to die. Every conversation, every moment, every single thing. Dieyouuselesscuntyoufuckenmakemesickno-
onefuckencaresifyouliveordieyoucan'tdoshitrightyourfuckenmotherhatesyouyougavehercancer...
every day.

No-one has actually dealt with this before. No-one has asked. Twelve five minute general practice consults pay more than one one hour consult. And he's a withdrawn, mumbling, teary kid with a confronting message on his shirt and he smokes a lot of marijuana.

But there's one thing that seems to bring the volume of the voices down, one thing besides the fifty or so (I kid you not) cones a day he smokes, which he believes treats his illness and I believe causes or at least unmasks it.

He goes into his "quiet place", which is an old buried rainwater tank, part of some storage thing years back, seven metres underground, in the dark. No TV, no radio, turns the light off . Sits in the dark for hours, four, five, six hours. Just staring.

It seems to help.

For some reason, this got me. It's one of those ideas that sticks in your head. That horrible mental image, that poor kid, having something so horrible grinding and thumping and scratching and chattering in his head, something so grim and ghastly that sitting for six hours in the dark and silence seven metres underground is better.

Anyhow, tomorrow is meetings and Saturday I'm going into town, and tonight I'm going to have my two standard drinks of Merlot to wash away the idea of people using drugs to wash away their ideas.

Less grim tomorrow.

John

*Not even the cleaner

Threshold

Exceedingly quick entry here. Moods have been subclinically up, hence I've been rather busy, lots of things to do, little hamster wheel thing spinning really really fast, and hence the pulsatile nature of these entries.

What's been going on? (Besides me discovering that I am not the only bipolar individual in Hogarth House: the other sufferer is the building's airconditioner, which went from mild hypomania, giving us a temperature of 21 degrees, to a melancholic fugue today, while we all sweltered in the mid thirties and the thermostat just lay there, muttering about the futility of it all)

Well, I took my oldest son to Judo, and he seemed impressed. He seems a bit suspicious about the whole "gentle way" thing, as he watched petite girls flinging stocky bearded men onto their heads and strangling them, but I assured him judo was indeed the gentlest way that I knew of to throw someone on their head and then strangle them. I have been promoted, by the by, to the lofty heights of orange belt.

Well, Victor... I've been thinking*.

I used to do a lot of martial arts. I practiced all the time. I was one of those unfortunates who practices blocks and pivots while waiting for my girlfriend in a clothing store, so that she would take me into Myers and leave me standing idly by while she considered what brand of cashmere poncho to wear, and fifteen minutes later would look over to see me twitching, posturing and grimacing in a full length mirror as I battled imaginary thugs. And I turned on lights with front kicks and practiced wrist locks on myself in lectures.

Do you ever think that the main reason the universe prevents travel backward in time is not to prevent paradoxes where you accidentally kill your father, but to prevent floods of people surging back along the timelines to eliminate their earlier, more embarrassing self?

Anyhow, me and my Tourette Fu. Thing is, I did ten, maybe fifteen years of martial arts, minimum two nights of classes a week, training of some kind every day. You'd expect me to be pretty good at it by then, hey?

No hey. I was and remain fairly crap. Not abysmal, not frighteningly poor, just not very good at all. Here is the reason:

Four years tae kwon do - black belt

Two- three years wing chun - junior level, could fight possibly a bit

Three years tai chi / ba gua - can make impressive swirly motions with entire body, can't fight at all, good "I have achieved enlightenment" face, buggered my knees.

Six months judo - basic level competency, glorious yellow belt.

Six months choy lay fut - junior level, couldn't fight at all

Six months boxing - fit, able to punch, got smacked about in a sparring match with a half-way decent boxer,

Some more judo - sortof started again, advanced fairly rapidly to the same level, quit.

So at the end I'm sortof slightly good at a variety of things but competent at none.

Why is this so?

Part of it was moving about a lot, that penniless student thing, part of it was injuries, part of it was that cycle of infatuation and disenchantment that you get, limerance and its sequelae.

Now, that's one thing. If you like, you could call it a wasted opportunity. My hands, feet and various other body parts could be lethal weapons by now.

If I could be bothered being introspective about this I could see disconcerting similarities with me and jobs, me and women, me and friends. But I'm sure people don't turn up for this.

So, wait until I get home and I will post of what made today more than slightly disturbing.

John

* obscure Fantastic Four reference. If you recognised this "one of the top ten lines ever" from the immortal "1, 2, 3, 4" by Grant Morrison, proceed to the cashier and collect your winnings in geekdollars.

Patient Zero

Hail,

Odd occurrence at work today. Seven till four (or five or whatever) shift at Florey and I went in, and I'd only been there a few minutes, wandering down to see "32 year old male, lac hand, neurovascularly intact, refuses pain relief" and I walked passed one of the other cubicles... and the patient inside had a seizure. It was a full-blown tonic clonic seizure, of the turn grey and choke type, and we all rushed in there and essentially started resuscitating her, because along with the alternate tensing and relaxing of her muscles she had a prolonged tightening up of her airways, called a laryngospasm, and getting her to breathe was difficult. We ended up putting a mask over her face and using one of those breathing bags.

I should point out that attending two resuscitations in three days is not normal small-town emergency medicine. Normal small town emergency medicine is "I've got this rash" or "I haven't felt quite right since nineteen eighty eight, none of the other thirty doctors I've seen have been able to work it out, so I decided to come in now at three in the morning to get it sorted out once and for all."

Anyway, after a while I left things in the capable hands of Dr Benedict (tight-lippedly ordering adrenaline) and the junior registrar (running through plausible excuses in her head for letting things get this bad), she got somewhat back on her feet. I moved on.

About an hour later I walked passed cubicle twelve, and the reuscitation bell went again. We all swarmed in there like killer bees before someone pointed out that the patient was NFR. NFR is not some new sporting code, in Florey means not for resuscitation, and it meant that the elderly man in cubicle twelve had essentially come here to die. We all swarmed out again.

And then I saw the man with a small (maybe two centimetre long) laceration to his palm and I took the bandage off and he immediately hurled himself on the floor and started crying and vomiting. I stared. "He doesn't like hospitals!" shrieked his wife, glaring at me in an accusing manner. We eventually got him into a bed and I had to give him diazepam before he'd let me look at the palm of his hand, and when he howled and flung himself headlong onto the floor a nurse came over and asked if I wanted my third resus of the day. It was actually the fourth, but we didn't count the elderly woman who earlier that day pressed the emergency alert button because she didn't have a spoon to stir her tea. Two emergency consultants, three registrars and a trainee cardiologist made sure she got one.

Basically an alarming proportion of the people I walked passed fell to shit. I was like some figure of death in a mediaeval religious play. After the third one I became un-nerved and walked across the road for lunch, expecting birds to fall from trees and the girl at the deli checkout to choke on a particularly large air molecule, as if I had become the epicentre of a new plague, Patient Zero of some grave contagion.

Anyway, the day went on, and no-one died, and later on we went up and saw the snow maiden and she was doing fine...ish. Not quite out of the woods. Not out by a long shot.

We shall see.

"Previously on ER..." - I was going to say "Previously on BJ", but that sounds vaguely autoerotic - I foreshadowed a raucuous, knee-slapping series of anecdotes about dead people. I have since been advised that this may be one of those aquired tastes specific to my profession, and that relating that hilarious jape involving the third year medical student, the false teeth, the over-inflated urinary catheter and the woman with advanced rigor mortis may lead some people to believe we are not as deeply caring as we say we are.

None of that's true, by the way. I've never even heard of anyone joking about or with a dead body. I doubt that anyone with that attitude would even get through the first year of medical school. It is my understanding that eighteen years before I started some second year medical student smuggled a cadaver's hand home and produced it at a party. The next day he was called in and expelled from medical school, which basically meant no medical school in Australia would have him, and it was pretty much game over, go off and try to get into accounting. Someone asked the ethics guy about this at uni and the ethics guy said that if the cadaver's relatives had been alive he (the offending student) would have had to appear before them and explain his actions.

But it's a high pressure job, and doctors are often high achievers who have lead sheltered lives, and when high achievers who have lead sheltered lives are hurled for the first time into wards where death, disease and delirium seem to stride freely, when those neophytes have to work long shifts and do things they've never done before, you learn to cope, and one way to cope is to laugh. We don't laugh at the dead or the dying, but we laugh at each other and we laugh about death.

Laughter is meant to be some kind of primitive tension-release thing, a signal to the tribe that everything is fine, a way of looking at something which if it were looked at sanely and sensibly would overwhelm us with with terror, grief, rage, that kind of thing.

My wife was medical intern one year, and eight days out of medical school was called in to certify her first dead body. It was on the eighth floor of the Royal at about five in the morning and she remembered clambering up seven flights of stairs and being shown into the dimly lit "viewing room" with Mr Masters in it. Not that anyone was coming to view Mr Masters at five in the morning, but the hospital needed the bed.

So Sarah's shown into the room and there's Mr Masters lying soft and cold and impeturbable in his crisp linen sheets. His hands looking slightly waxy, his mouth slack, his pupils dark and wide, as if he had died staring at something deeply deeply desired.

She says she approached him quietly, almost awefully, in the old sense of the word.

Felt the underside of his wrist, checked his pulse. Nothing. Wrote it down.

Rested her steothoscope on his still, bowed chest. Nothing. Wrote it down.

Shone her light into his eyes, looking for any response. No movement. Wrote it down.

And just to be sure, reached out and touched his throat, feeling for the carotid pulse, and Mr Masters lurched in the bed and twitched his hand towards hers and said "Gerr".

When she was able to go back in the room again, it was after reciting to herself several times the details of this well known clinical phenomenon. Dead bodies, certifiably dead bodies, often twitch. They may move, they may blink, or close their mouth. They seem to exhale, and formless things like words emerge.

It's quite common, and although it's frightening, it's certainly not a thing to laugh about.

But that didn't explain Sarah and the nurses spending the next fifteen minutes hunched over coffee or hot chocolate giggling until they wept about it.

John

Emails for Algernon

Hail,

Relatively calm today, after coming home irritable and having an argument with my niece. Getting her to help around the house is like those Archimedean paradoxes - she does three quarters of her job, then three quarters of what's left, and then three quarters of what's left and so on into infinity. I have to leave the room when she mops the floor, she gets the mop and does this insipid, feeble, one-armed gesturing with it that wouldn't disturb a hummingbird, and she manages to sweep and mop around her socks on the floor without moving them.

But I love her. Sigh.

Some malicious bastard sent me an email, an article from the Guardian about how reading too many emails is bad for your IQ. The original article is at

http://www.guardian.co.uk/online/news/0,12597,1465973,00.html

If, like me, you get a lot of emails you may have to get someone to read this one to you. Apparently a day with Outlook Express is equivalent to a good few hours of hydro. But the comparison between email and marijuana is fairly slim, people who smoke a lot of marijuana
become socially withdrawn and rarely see their loved ones, they may binge on unhealthy food, and eventually they develop a fully fledged schizophreniform psychosis where they believe electronic equipment is sending them messages.

As an aside, and some of you may find the following a bit grim, so if you don't want to know the score, look away now.

When I first became unwell I was very unwell indeed, and I was dragged off to hospital in something like a manic psychosis. I had extremely strange, very detailed beliefs that were in no way susceptible to argument. Looking back at what I can remember from that extremely difficult time, I can understand how the treating emergency doctor might have initially thought I had schizophrenia. So he asks me all these questions and finally he looks at me and says seriously "Do you think the television is controlling your life?"

Back then, like now, I watched close to zero telly. There was this long pause where I stared at him, exhausted and unwell and more than a little confused, and said "Mate, I'm the only person I know where the telly isn't controlling my life".

Well, it was funny at the time.

Well, it wasn't, actually, but I laughed about it later.

Well, I'm laughing now, anyhow.

Anyway, feeling in a slightly morbid mood at the moment. Next post will be a compilation of stories from me and my colleagues of hilarious hijinx involving dead people.

John

Coda

And a deeply, deeply weird sequel to the "woman who looked like a snow ghost" story.

Three sequels, actually.

The first is that there was a rumour that "they" found four pharmacy cards on her and a minature ziggurat of ibuprofen packets in her house, over four hundred tablets. I don't know who "they" were or why "they" were in her house, I don't know that this was true at all.

But it would explain how a twenty four year old Asian woman can get a bleeding ulcer the size of your fist in her stomach. And she had been in terrible pain for weeks, and pain makes you not eat, so if you're knocking back anti-inflammatories for weeks on an empty stomach, and treating the growing pain with more pain relief that is causing the growing pain, and then not going into hospital because they're going to find out about the four identities at four different pharmacies ....

I don't know. We, the hospital, are telling this story for a reason. But that doesn't mean it isn't true. And if it's true, that doesn't mean we should have treated her differently, it doesn't let us off any hook. But in the end we're telling the story, and I can't help but feel it's shifting the blame.

The second is that she was pregnant, and the fiance swore they hadn't had sex for six months, and they were going to get married in June, and maybe they still will. He'll never know, unless she tells him. Or unless she's still pregnant. I feel it is inconceivable that a four week pregnancy would survive what her body's been through, but, hey, I've been wrong before.

And the third weird sequel is there is no blame. I went into the ED today and spoke to my boss. He is an Irishman, loud booming voice, big hands, uber-confident, the man you call when your head has been ripped off because he's the one who'll save you. He was ebullient. Surgery were very pleased with what had been done, they said. The coroner (or whoever looks investigates cases of temporary deaths) would investigate, because a twenty four year old had had a cardiac arrest on the Xray table, but we were going to come out "luminous". His words, "luminous". Everything we did had earned praise. Our rapid response. The intravenous access, the swift transfusion of the approporiate fluids, the code green (summoning the appropriate specialists), the clear and complete assessment, our well-co-ordinated and eventually successful response to her cardiac arrest. Her death and our successful and permanent reversal of that event.

And my boss used the words "excellent", and "very good", and "entirely satisfactory". He said I was a very good registrar and would make a very good consultant. He pointed out that her heart started beating again because of my frenzied rhythymic shoving at her breastbone, that her heart pumped the blood I had poured into her, through the line I had put into her vein. And that she was talking and it looked like she would be walking, when a few days earlier her eyes were huge, silent and dark, as unresponsive as space, and her hands were clawing at nothing.

And if I, God forbid, were to have a cardiac arrest at age twenty four, would I rather not have it ten feet away from the resuscitation room, with lines in each arm and my veins pumped full of blood and six doctors and twelve nursing staff within thirty seconds of me?

And it wasn't me, it was the team, the nurses and the doctors and the support staff and the radiographer, from the triage sister who saw her out in the waiting room to the orderlies who wheeled her into the lift -

the tumult and the shouting dies,
the Captains and the Kings depart,

- all that kind of thing, and Dr Iskandar deserves more of the praise than me, and is probably at home flagellating himself. I should ring, but it's midnight.

I might ring. He'd want to know.

By God, that space cadet glow.

And when I went out, bemused, Doctor Benedict, the man who scored higher on his primary and fellowships exams than did anyone else his year, was drinking green tea and reading the rugby and looked casually up to me and said "Good save on Monday. Good work, I hear", and then went back to sneering at the Welsh. And in the ED several people came by and wished me well and said "Good resus".

Well.

Some other time I am going to expound on my theory of emergency departments as centres of optical perversity. They are like cosmic phenomena, places like black holes where the normal laws of perspective alter. I the ED that which seems a disaster is a triumph. You go home thinking you've done really well and three months later you open the paper and you're being named on Today Tonight. You stumble home mired with the blood of innocents and the survivors of your reign of blood write you thank you letters and give you boxes of chocolates. Drug addicts who don't have home-made tattoos, people you know are dead who come back to life, weeping girls who cling to their fiances and can't tell him this one thing.

None of this makes any sense. You remember that paper a year or so back that reckoned we might all be living in some virtual reality simulation? Tomorrow it's lie on the lawn and read superheor comics. It was a soap opera the last few days, but it's going to be a pastoral tomorrow.

John

Marie

Entire blog seems to have vanished: when I open my blog a blank white formless thing stares back at me, rather like the year I spent teaching high school. As far as I know, I am typing this into thin cyberspace.

If you aren't reading this, it means the problem hasn't been fixed yet.

John

How things worked out

Well, slightly calmer this post. Have finished my night shifts, tomorrow off to the prisons. And I am stunned, and happy, and deeply tired, but I am going to write this.

So, what happened next?

Well, I rang up and she was in ICU post surgery, and the ICU registrar said she had ARDS (which is a kind of malignant pneumonia, it means the stuff that she vomited when she was in the resuscitation went into her lungs - it's never good) and very probably hypoxic brain damage.

I rang and a couple of nurses went up there after their shifts and apparently there was someone crying and so on.

And then while I am asleep my wife gets a phone call from the ED secretary (a princess amongst women) who says that the woman we resuscitated has been extubated (they took the tube out of her throat) and she is awake and talking.

Words bloody fail me. This is not the first time this has happened. We resuscitated a woman a few years back who was wheeled through the door in cardorespiratory arrest, and we worked on her for forty minutes until the Royal came and took her away, and the next day she was sitting up in bed writing querulous notes to her husband.

People can be almost divinely resilient.

And for all the bad stats, CPR does work. Learn CPR.

Here endeth the lesson. Last night was considerably calmer, too.

Now I somehow have to get my mind back to normal. I have to clean the house and ring my kids and tomorrow is my judo grading.

Will write soon.

Thanks for reading,
John

Suequelae

Right. First off, I started to allow comments and I've been spammed. I didn't know there were blog spammers. There's this book on parasitism by Mark Ridley where he reckons parasites are basially the reason for the otherwise costly, dangerous and inconvenient practice of sex. We all have sex so our children don't have the same parasites as we do. And it's almost a rule of nature that they will appear in any sufficiently complex system: parasites are a sign of life.

So there really is a blogosphere.

Anyway, one of the nights I'm so glad I'm writing this anonymously.

Last night I was on night shift at Florey. Before I go on I should point out that Florey is one of, if not the, best Emergency Departments in the city. But it's a small city, and we have the same problems as every other emergency department. Numbers of patients on the rise - projected by some to triple in the next twenty years. Number of GPs willing to service them free dropping like a rock. Number of emergency trainees not rising fast enough, if at all.

And so last night at Florey we had Iskandar Hassan (a few years ahead of me and with anaesthetics experience but someone who has yet to pass the primary) and me in charge, along with two diligent and intelligent interns who are only a few months out of graduation, and it all went fine until five o'clock in the morning. By fine I mean the usual heart attacks and croupy babies and some girl with panic attacks and so forth.

And at about five there's a priority two (meaning guidelines say see this patient within ten minutes) and they wheel in this twenty eight year old woman the colour of Dover chalk.

I have never seen anyone that white. The same colour as the bedsheets. Linen skin.

Anyway, she'd walked into the ED and the triage nurse had seen that she was translucent and had a respiratory rate of thirty (that's thirty breaths a minute, if you try this at home you will collapse), and an unrecordable blood pressure and had given her practically the highest priority that can be given to a living creature and got her around to see us.

I saw her and called Iskandar. She said she had pain in her belly and when I felt it it was like a rock, tighter than any muscle can make it, blown up from the inside like a drum. I got a big line in (thank Christ I went for a white, not a pink) both elbows and we started pouring in fluids. I got some blood and we ran it and her haemoblobin was 102, which is not that bad on the face of it but we knew it was because of haemoconcentration - hardly any haemoblobin in hardly any circulating blood volume, fake good news. All her blood was inside her sail-taut belly.

She said her only medical history was endometriosis and Iskandar was on the phone calling gynae reg while we poured the fluid in and did the ECG and drew the bloods and some nurse got blankets and we tried to find out more. And we got gynae and surgery registrars down (registrar means a member of a training programme - gynae [tall, Singaporean, bearded, reassuring], is training to be a gynaecologist, and surg [dark, English, quick-witted, ironic, calming] is training to be a surgeon, and then we got anaesthetics down for good luck and if I could have called a specialist in psychoneuroendocrine dermatology of the left nostril I would have.

Anyway. Every man and his dog is in the cubicle and I decided not to take her to resus. Resus is really no better than one of the high intensity cubicles, everything we have in a high intensity cubcile we have in resus and vice versa, but maybe I'd change that if I ran the tape again. Probably not.

Then there was all this fucking about. Gynae wanted an ultrasound. This woman had had forty milligrams of morphine with no discernable result. Her fiance is weeping in the corridor and I keep trying to get a better picture, because by now not enough blood is getting to this woman's brain to keep her thinking straight. And what blood there is is acid. We pumped her full of O negative.

At this stage our differential diagnoses are:

some bleeding thing to do with her endometriosis
some bleeding gynae thing, either an ectopic pregnancy or some monster cyst
some big gastro-intestinal bleed, probably a perforated ulcer
with the latter moving rapidly up the charts.

Anyhow, this is where I went wrong. Gynae orders the ultrasound. It takes valuable tens of minutes to obtain and perform. It does not give us a definitive diagnosis. Gynae gets on the phone to his boss, who clears the woman for surgery. They decide to wheel her up for surgery, via Xray. She is sent to xray as far as I can tell, attended only by two nurses. She is very unwell. on the xray table she starts having seizures. A code blue is called. We drag her across onto the barouche, no pulse, dubious heartbeart, not breathing. We are compressing her chest as we wheel her into the closest room: resuscitation.

And it all went to shit from there. I took turns doing cardiac compressions, I suspect we broke her ribs. We slid the greased tube down into her bronchus to breathe for her, and pumped her full of blood. Anyhow, we finally got a heartbeat after close on half an hour and they took her up to surgery (there they detected and repaired the bleeding ulcer she had) and thence to intensive care.

And the reason she got an ulcer at twenty eight was because she had had a lot of pain from her endometriosis and had been surviving on anti-inflammatories like ibuprofen for months while not eating. Don't eat anti-inflammatories on an empty stomach. They will kill you.

What have we learnt today, boys and girls?

Here is the gist, finally. I have learnt some good things. I have learnt that I can recognise danger, that I get help when I am out of my depth, that I can perform basic resuscitative measures.
But I have also learnt something unpleasant about myself.

I am not by nature a leader. I don't know if I am by nature the kind of person who is an emergency doctor. I still see other registrars as senior, as infallible, as people who are in control and who understand. The hard fact is emergency trainees at a certain level are better at managing acute surgical or gynaecological emergencies than are surgical or gynaecological trainees at a certain level. I didn't even think to step in, to say "this woman is unstable, to hell with the ultrasound, take her to theatre." That's what I thought, but I didn't even articulate it, because I had called for expert help when I felt out of my depth and that's all anyone can do, isn't it?

No it's not. If we all did that this woman would have died there in the high intensity cubicle while we all fluttered and twittered and sqeaked like Homer's ghosts.

If I had said that she'd still be here. If I had trusted my knowledge, if I had used my training, if I had been capable of seeing myself as actually competent, this would not have happened.

They say the dangerous doctors aren't the ones who don't know stuff. The dangerous ones are the ones who don't know that they don't know stuff. That's true.

But you're also dangerous if you don't know that you DO know. Because knowledge and expertise is inaccessible if you deny it exists. Caution and not taking risks is one thing, but when it becomes paralysis and not taking action, it's culpable.

I have fifty minutes to the start of the next shift. I'm going scrub myself down, get into my fighting clothes and go out into the world. No-one will die on this shift tonight.

John.

There is lots more I could say about this. What her relatives said, what kind of accent she had, what kind of things made her smile even in unimaginable amounts of pain. But I have to go.

If anyone who knew her (and I've anonymised her pretty well) ever reads this, I am deeply sorry for what happened to you.

John

Valuable Learning Experience

Well, a monstrous fuck-up this morning.

Back in medical school we had these things called "valuable learning experiences". A VLE is something extraordinarily painful and maybe seemingly futile that teaches you something, usually on a spinal reflex, "avoid this shit at all costs" kind of level. When you step in a rabbit-trap you get a valuable learning experience.

Something you did + some terrible consequence + time to "reflect and appraise"= VLE.

Well, we in the ED had a VLE today. And what happened wasn't all our fault, and we did a lot of good, and maybe even if we did the thing we did wrong right it wouldn't have changed anything, but the consequences of this may be exceedingly dire.

I am sitting at home so tired I can barely type. I have to sleep. And while I sleep I'm going see if I can change the blueprint in my head, rewire my personality, tear some circuits out and hammer something new and radically different together, change my mind and heart and personality by eleven o'clock tonight, rewite the whole fucking thing.

Tonight, possibly, I will write what went wrong with the blonde woman, and why I found myself performing only partially successful CPR in the Xray room on a woman barely out of her teens.

John Mk I.

Back from a shift I once swore I'd never do again.

Right - background information. Shipman South is a smallish hospital in Morbing Vyle, about twenty minutes north of the hospital I normally work in. It is a privately run hospital, whereas Florey, where I usually work, is public. Florey is arguably the best emergency department in the city - calm, efficient, controlled, friendly, unified. Shipman South was, at one stage, possibly the worst hospital in Australia.

I could give concrete examples of its worstness, of the Very Bad Old Days of Shipman South. But I can't do it yet. One or two of the stories are, I believe, sub judice, and all of the others are within that seven year legal period, pipe-bombs in the post, mines under the soil that can still go off. And things went wrong more than once at Shipman, and in the end those people, the relatives of those for whom things went wrong, don't deserve to have their stories used for entertainment. And some of this stuff is emotional ricin. Sooner or later I'm going to work out a way to tell these things in a way that doesn't hurt anyone (and I don't mean "protects the guilty doctors and nurses"), and things will be out, and then we shall see. But for the time being it is sufficient to say that things were bad at Shipman South ED for a good few years, bad enough so that ambulances would avoid it, during the years I was a very junior medical officer.

But they were short staffed at Shipman the other day, and they rang me, and it's under new management, and I was short on cash, so I did a shift tonight (last night now). And it's a lot better.

What did I see? One heroin withdrawal. One weird pain in the stomach. Gout. A tri-malleolar fracture/dislocation of the ankle (those knobbly bits on the side of your ankles - he'd broken the inside one and the outside one and a bit off the back as well). A woman with a blood pressure of two hundred and twenty over eighty and headache and confusion, the first case of malignant hypertension that I'd ever seen. No psychiatric cases, unfortunately.

The heroin case was a difficult one. We get surprisingly little heroin here. Every man and his dog is on amphetamines. Usually every man and his frothing, paranoid, half-starved dog who thinks Chum Meatybites have got little microchips inside them. But there's just not as much heroin.

Heroin, by the way, was originally marketed as a cough suppressant, by Bayer Pharmaceuticals in the late nineteenth and early twentieth centuries. And a damn fine cough suppressant it was, too. Certainly it became increasingly in demand. I had a man from Viagra in my office the other day and I asked him if Viagra as a brand name was better known than Prozac, and he believes it's up there with Coke and MacDonalds and other mood-altering substances of abuse, that Viagra is unquestionably the most widely known pharmaceutical. I thought he was probably right, but I didn't think of heroin.

Anyway, the thing that shat me about this heroin detox patient was the guy seeing her had allegedly taken a medical history and done a physical exam before he started his treatment, and the history was basically heroin use, heroin withdrawal, no hep C, etc. - only drug related issues. There's this woman lying there vomiting her guts up and no-one asks if she's diabetic, no one asks if she's pregnant (heroin withdrawal plus pregnancy means baby can have seizures in utero and end up brain damaged)... it's as if that one aspect of her medical history was all that was going on.

Anyway, she got metaclopromide (for the vomiting), hyoscine (for the cramping pains), lomotil (for the diarrhoea), fluids (once we got an intravenous line in - I couldn't do it, and when I left anaesthetics was struggling, so next step was ultra-sound guided), and we were tossing up whether to give her dextropropoxyphene (which acts on the same receptors as heroin). She had started buprenorphine but had swallowed some (rendering it useless, you have to let it dissolve under your toungue or your liver just chews it up) and had vomited up the rest.

I don't know. My own experience of illegal drugs has been embarrassingly limited, but I'm going to talk about them as if I am an authority anyway. Heroin seems to me to be the best example of a drug that is bad to a great extent because it is illegal.

Across the Pacific I can hear people logging off, shaking their heads in disgust, murmuring "soft on drugs". There is no possibility of communication here, so I won't try.

But the fact is the bad effects of heroin of itself are as nothing compared to the bad effects of heroin as it comes. If heroin was not illegal, it would be fairly cheap. It would be pure. It would not be sold by psycho killers to vulnerable girls. It would cause constipation and the occasional death (deliberate and accidental) by overdose. Very probably less than alcohol, not even on the same page as tobacco.

But that is not the case. A heroin habit costs from one hundred to five hundred dollars a day. There is a limited number of ways that young men and women can get this money: your old men may dream dreams, and your young men shall see visions, but your young girls will peddle ten dollar head jobs and snatch handbags, and don't think your young men won't.

Anyway, this won't change. Our prime minister was offered the chance a few years ago to give addicts somewhere medically supervised for them to inject, "safe injecting rooms", like the places that have saved young people's lives overseas. He just said no, and although the fight continues, most people will be injecting under the trained eye of the local pusher, pimp or prisoner.

I don't know. In medicine, if we do something, we have to prove it works. We don't give aspirin to people who have had heart attacks because we've got it lying around the department. We give it because people did a vast trial of thousands of people who had had heart attacks, and gave some of them aspirin, and some no aspirin, and the people who didn't get aspirin ended up getting more heart attacks. Proof. But public policy isn't like that.

I'm not young enough any more to rail against how the political system is set up for short term, emotionally gratifying outcomes rather than sensible management. I know we get who we pay for. One of the consultants in my ED came from Vietnam, as a three year old refugee. He is one of the four or five smartest doctors I've met, he works sift work for a quarter the pay he'd be getting a s aplastic surgeon and saves lives on a regular basis. He wouldn't have got out of a detention centre nowadays, because we've got to stop people like that.

And the war on drugs is the same thing. How does anyone think it's going? We're not doing quite that well against cocaine. Heroin seems to be doing okay for itself. Amphetamines are proving a rougher nut to crack than maybe we thought, there seem to be more of them about rather than less. Howabout marijuana? That one wiped out yet? Are our children safe? Or is it still one of Australia's biggest (albeint tax-free and unregulated) industries?

Sigh.

John
Anyway, enough from me.

Reading the News

Random thoughts here. Have decided to emerge from my cave and spent one hour checking up on world events. Here is what I found out:

First, something written by someone who knows how to write: Christopher Hitchins, who writes for a magazine called Vanity Fair, and wrote the following entitled "On not mouring the Pope".

http://slate.msn.com/id/2116443/

I also note that developers in the UK are building "Dicken's World", with an Ebenezer Scrooge ride and ice-skating characters - a pirouetting Pecksniff, a gracefully leaping Micawber. Presumably restaurants serving gruel and entrance into the park is via a narrow, cold chimney. Wonder what they'll do with Fagin?

By the way, Dickens managed to become the greatest novelist of his generation while naming people Honeythunder, Pumblechook, Sweedlepipe and M'Choakumchild.

Soemthing else moderately interesting - some economists in the US have traced the economic trajectory of childs names. Rich (white) people start naming their kids something then poor (black) people pick it up, forcing the rich white people to drop those names and get a new set and so on. So the first few years of Madisons go to Harvard and Yale and the next ten years go to Tennessee and Iowa and the next ten years to Chino and Lewisburg.

Anyway, not that verbose today. See you soon.

John

Aftermath

Right.

Last time I posted (note to self - don't post drunk. Alcohol provoketh the desire but taketh away the performance. And causeth the lisp) I had just found out that this guy I went through medical school with had died in a helicopter crash overseas. Some foreign aid mission thing. He's got a web-page somewhere, like all of these things it gives no real impression of who he was or what he was capable of.

here it is, I think - http://people.mydesk.net.au/~mdavey/

Anyhow. I haven't told anyone at work about this, which may seem wanky, but .. I don't know. I don't want to be seen as the bereaved at work. Public grief is something I don't know that I'm comfortable with. Expressions of public grief (and this is another of the fifty or so reasons why practically no-one I work with knows about the bipolar) aren't - how do I put this into English? - they aren't solitary phenomena.

It's as if when along with saying you are grieving you say a lot of other things. You say "pay attention to me, cut me some slack". You say "I knew this man deeply, I had a special and intimate bond, I am wounded in a way that you canot understand but must respect". You say "I am entitled to these things - extra consideration from my fellows, someone to pat me on the back and ask if I want a cup of coffee, people to understand if I don't pick up as many patients as normal, maybe slip off a few minutes early." I imagine myself doing that and I imagine this cartoon of me all miserable, a coffin with a flag draped over it somewhere in the background, and a caption underneath saying "I'm the real victim here". I am not going to do that.

Anyway. Enough on this. Matt's partner Rachael made some really nice hats, go buy one.

In other news. I am back at the ED, which is great. I came back from the exam just completely exhausted, and even now the thought of study makes me slightly sick, but it is so good to be back.

Day one was fairly low key. I saw a woman who might have had anti-histamine poisoning, along with her other problems, and who while I was talking to her kept reaching out and picking up an imaginary glass of water. And more "punched in the head" men, and some renal colic (they call it male labour, one of the top five causes of pain).

After the exam, by the way, when I was deeply ambiguous about continuing on, I was at judo and some girl dislocated her finger and I had to relocate it. And then a few nights later driving back I saw this over-turned car and police and fireys in attendance and no ambos, so we had to pull over and go and stabilise some guy's neck until the ambos turned up. This guy had been turning a corner around midnight, late model sedan, and kept saying he had been travelling "fifty, sixty max" (kilometres an hour). I kept nodding and checking that he had a pulse below his fairly badly dislocated knee, but the car was upside down with only one front wheel, the bumper was five metres back and separate from the car, still wrapped around the light-post, and five metres further on there was the other wheel.

This friend of mine used to get all these photos of obliterated cars that the ambos brought in (they bring them in to give us an idea of the crash: speed, impact zones, any driver's compartment protrusion, that kind of thing), and he'd put the photos up in the doctor's station with messages undeneath that'd say "For sale - needs some panelbeating" or "One careful owner".

Anyhow. Next post no idea, maybe about the radio sex show we were on.

I have tried to fix the thing here so that I can get comments, don't know if it works. Now if only I could work out a way of telling people this blog exists without trumpeting "yes, it's me, I'm clinically nuts, and here's some confidential medical information about people you may well recognise!"

John

Stranger than Fiction

Well, I had all thse plans on what to write today and everything has come to naught, becuase Matthew Davey is dead.

Matthew Davey, for those inconsiderate live-in-their-own-world shits like me who don't read the paper, was a better man than me. Top researcher, top flight doctor, exceedingly decent man. My dubious memory says he was the first one of us to resuscitate someone, some drunken biker dead on the road, as he drove home in second year.

He died on a helicopter crash, two days ago, nine Australian military officers on some peacekeepy thing in Indonesia. It was in the newspaper today.

I shouldn't write these things while drunk.

But he was a smarter man, a more decent man, than I am. I would say we went through medical school together, but he went higher. One time we dissected a cadaver together, and he explained neurology to me, which was no mean feat, square pegs in round holes, that kind of thing.

I borrowed a Doug Anthony All Stars cassette from him. A book and a guide to some stupid video game and I never gave them back, and now they're in the shed somewhere.

And we sat outside a lab once, everyone inside doing endocrine physiology, and we had this weirdly spontaneous deep talk - where two people with no answers tried to talk about what made marriages work, this weirdly serious discussion between two people, neither of whom knew what worked but who wanted things to work out, wanted to find out what made people love and stay in love.

As if a heart is just a gland.

But we were doing the best we can, you know? We could understand glands and proteins, just not hearts and minds.

Anyway, Matt is dead.

He didn't drink that much, so tonight I drank his wine, damaged my brain. Bottle of Merlot.

As if the heart is just some gland.

I ask you. Dying in a foreign country, on a military helicopter. A moment of terror - although he does not strike me as the terrifiable type - and the helicopter plunges into the sea. Leaves a widow and a gap in the tracks.

There was no need for this to happen at all.

I might write more of this when I'm less intoxicated.

Thanks for listening,

John.

PS - Never really understood endocrine physiology.

The Ultimates

Hail,

A while back I was going to talk about superhero comics, and I reckon why not now.

Okay. When I was a kid I read superhero comics. Them and science fiction made me the man I am today. And the Bible. I read that a lot. I had this programme where you had to read the whole thing three times a year, and I so every January, May and September I'd be reminded what the Lord said to Moses after the death of Sihon, king of the Amorites.

This means that if you need a partner for "Biblical Trivial Pursuit: the only trivia game where the answers are not trivial", I'm not the worst bet.

(The worst bet, by the way, is a two way tie - I knew a girl in Uni who got pissed off with "all the religious freaks trying to turn Easter into some sort of religious thing", presumably instead of the chocolates and so forth. And there was some ten year old kid who got dumped at another Church youth group every Friday, and when he read from the Bible and got to a bit with the name "Jesus Christ" in it he'd roar it out in a pissed-off tone, "Boy, I'm getting my belt" tone: - "For there is one mediator between God and man, the man - Christ!! Jesus!!").

Anyhow - superhero comics, in particular the Ultimates. When I was a kid I read superhero comics like other people breathe. They were the "Tales to Astonish" of their time. Mothers, you want your kids to grow up interested in life, interested in science and the world, at least some cursory sense of right and wrong, sit them down and make them read Spiderman and Iron Man comics. I loved the things.

I loved them because anything could happen in a superhero comic, and you had heroes you could trust and look up to, people who'd do the right thing, and because all the stories interlocked and were self-consistent - (you'd see The Black Panther hurling stuff at the Rhino and there'd be this thought bubble coming out of the Panther's head saying "The Rhino - last I heard Iron Man'd put him away for good!", and then an asterisk and it'd say "Check out issue 271 of the Invincible Iron Man for details, True Believer!") they were a world we could immerse ourselves in that was much more accepting than the outside. And because we were familiar enough with the lives and personalities of these characters for them to be more real to us than many of the relatively confusing people around us. And I also loved the way they talk, and the incredibly hot women. There is some part of my head that considers Susan Storm-Richards, of the Fantastic Four, one of the four or five sexiest woman alive.

And I loved the dialogue:
"Though I be ringed about with enemies, still shall my power prevail!"
"Never, villain -nnnngggghh!!"
and so forth. Read that out aloud - what's not to love? Try it in a meeting when things aren't going your way. Perhaps your power will prevail.

But in the end, the reasons I loved them were the exact same reasons I gave them away*. A uniform diet of the spectacular, the invincible and the amazing can't sustain you as an adult. You get an overdose of wonder, it becomes toxic for the stories themselves. In the Marvel Universe anything could happen, and if anything can happen, and you tell the story for long enough, everything does happen, and most things several times. Like those interminable afternoon soaps. So every conceivable and several inconceivable horror has happened to our hero by issue #271, and you just get over it.

So, cue ten or fifteen years.

Then a few years back I started reading again. Not all of them, because most comics, like most books and most films and pretty much all tv and newspaper, are crap. But there's a few select authors. I started reading Bendis's psychoterror novel Daredevil, I started reading the frighteningly erudite Grant Morrison, the deeply disturbing Warren Ellis, the inhumanly gifted Alan Moore... and I started reading Ultimates.

Ultimates is written by someone who appears to be a hard-drinking lay preacher with no "skin". I can't put this into English, but he is someone whose heart must be only a few millimetres below his skin. He writes people that you love, and I am aware that I am saying that about people called Giant Man and Captain America. But good God, this man can write.

"Ultimates" is a retelling of the story of the Avengers, the original Marvel comics supergroup of the late sixties, but it's the Avengers written as if they were real thinking, feeling people, people you can feel for. One thing I remember reading about writing is the secret to good plotting and dialogue and characterisation is the same - "to make everybody right". That's what Millar does. The man whose industrial "accident" kills eight hundred people, the woman who breaks him, the man who kicks him when he's down and the friend who poisons him, the bipolar wife-beater and the woman who leaves him, the left-wing paranoid psychotic who believes he's a Norse God... in this story they do what they do for good reasons, for comprehensible motives, because they are trying to do their best, decent people trying to make sense of difficult situations.

The thing Millar understands is there are no superheroes. There are flawed, fallible people with
unusual abilities. Being able to do some remarkable things doesn't mean that some other, really mundane things, like taking your medications or listeing to other people or asking for help before things get out of hand, are things you do.

Anyway, Ultimates vol 2 issue three almost made me cry into my dry cider. It won't mean as much to you if you weren't raised on superheroes, but give Ultimates (Vol 1: 1 - 13, especially the first half) or Daredevil (Underboss and Out) a go.

John

*Except for Susan Storm Richards. Snarf snarf.

The Not Terribly Good Club of South Western Australia

Hail,

Well, the good news or the bad news?

Which one's which depends on who you ask, of course. From my point of view, the fact that I failed both of the sections of my primary exam is not that good. Physiology - close, pharmacology - not even.

What can I say? I immediately came up with things that, if not excuses, were at least reasons. it's a bloody hard exam. People came out of the multiple choice section crying, and one or two actually fled the viav section (ten minutes, five topics, your time starts now, tell me about the pharmacodynamics of nitric oxide). Natalia Smerdlov, a Russian-trained registrar who went over with me (movie-star good looks, awesomely competent, prize-winning brain) attempted four sections and failed all of them - probably the only exam she's ever failed in her life. Sarah Lotree passed, but on her fifth attempt. Shizuko sat the Anatomy section and found it so demoralising she pulled out of the rest of them. It was actually bloody hard.

My marks were not helped by my combination of terror and exhaustion in the final viva section where I insisted on answering the opposite question to the one they were asking. They asked about nitric oxide, I told them about nitrous. They asked about beta blockers, I told them about beta stimulators. They wanted effects on the vascular endothelium, I frothed on about the epithelium. And so on.

But anyway. The weird thing is how happy I feel. It sounds wanky, but I learnt a lot by doing the study. I had what they call a "valuable learning experience". I gave it a go. And now I am free.

What does this mean for you, ungentle reader (just joking)? It means regular writing of this blog. It also means I can go to the gym, go back to judo, get back to writing, see my wife and family, ring my son, that kind of stuff. I can live a normal life.

I might call this entry quits. I'm so tired what I say and what I type makes no sense at all to me. I have bought a few good books, so future entries may be on mutants, chemical and biological warfare in ancient Greece or the genetics of religion. Alternatively, it might be a drunken ramble about football and superhero comics.

Anyway, see you soon. Thanks for reading.

John