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.