Fire

Several things going on.

Firstly, bit of a soap opera night a few nights ago. It was almost "Previously on ER". You could do a montage, with that horrible asthma kind of music they used to have, and a series of short clips -

Me talking to a bald man with blood on his hands, with the police waiting outside to question him, and him saying "I can't remember anything" and four business suited detectives standing outside saying "two dead and one in intensive care, looking bad, no-one knows about the children..."

Me talking to a hundred and eighty kilogram man covered in soot, lengths of rag tied in his hair, bright blue eyes staring, while I tried to listen to his chest as he barked, snarled and growled at me, and tried to edge between me and the door.

Me and my fellow registrar talking to a sleepy gentleman in his fifties as we informed him that all our efforts had failed, he would have to have bowel surgery, and agreeing that perhaps it would be better if objects designed for the purpose for which he had used them came with a sortof string on the end, so that if you did lose them, in the heat of passion, you could pull on the string and retrieved them. And thereby avoid the inconvenience and embarrassment of the surgeon having to retrieve them for you.

All in one twenty four hour period, I kid you not. Murder, madness and a real estate agent who'd stuck a foreign object up his bottom.

The whole thirty centimetre gel filled vibrator thing is easy to laugh at (and many of us did), but it does make me grateful that my sexual proclivities are so mundane. From what I can work out, most men on the planet want something like what I want. This meant that in my youth trying to get what I wanted was relatively low risk and high return - so I got sex and love and so on.

But God knows how lonely and unsatisfied I would have been had I only been able to achieve sexual congress with someone who was willing to wear a fish costume, or be no more than four foot tall, or who would pretend to be a bear.

The sooty man was someone who lives more often in mental institutions than out of them, often for years at a time. He lights fires all the time, inside and outside his house, and feels that people are plotting against him. It is true that people are plotting against him - this time it was the landlord, who was sick of him lighting fires inside his house, and called the police.

The more cynical, and to my mind culpably ignorant doctors in the ED occasionally remark that "the voices" never tell the chronically mentally ill to get a job, or wash, or make a contribution to society. I don't know why this man lit fires, but he had done so for twenty years, and there was no medication that really stopped him, and on occasion he had leapt out and attacked a fire officer with a length of steel pipe when they arrived to extinguish the fire.

You can imagine, in this part of Australia, with a drought starting to bite across two thirds of the nation, and the eucalypts sere and dry, how easy it was for this man to be locked up for so long. And he is not a photogenic subject, with his scars and his staring eyes, and his extra forty kilos from olanzapine, and his criminal record of assaulting a fire officer. No-one's going to stand up in Parliament and call this a miscarriage of justice.

A similar story, this one involving an elderly man from around Fang Rock, one of the suburbs further south of here, the edge of our catchment area. Neighbours had become concerned (and that's never a promising start to a paragraph, is it?) that the occupant, an Italian man in his fifties, was acting strangely, so they called the ambulance.

When the ambos arrived at the place, around sunset, they found that the old man had almost flooded the place. Specifically he had made a huge, shallow moat around his house, thirty feet wide in places but only a few centimetres deep. They stood on one side of the moat and shouted and called, but got no answer, so they splashed off across the water to the front door.

"I reckon the old bloke's a bit confused" said one guy. The water was about ten centimeters deep, but the bottom of his trousers was already wet.

And the second ambo glanced towards him and saw over his shoulder the Italian man standing staring at them, stark naked except for a pair of big black Wellington boots, holding one end of an electric cable in each hand, and crying with fear, and trying not to drop them.

Apparently they "talked him down", and it took close on an hour before he would let them out of the water, but that one moment would stay with me for the rest of my career. I don't know how ambos do it.

Other than that, the writing is difficult and slow, but the moods are improving, and I can actually see the light at the end of the tunnel, the time in the near future where I will not spend the majority of my blog entries droning on about my feelings and my mental state, but will actually have something interesting to say.

With that in mind, have a look at this site:

http://www.postsecret.blogspot.com/#

If you've ever had that juvenile "no-one knows what it's like to be me" depression, then this is required reading.

John.

Valproate and goblins

Well, I don't actually know if this is working.

This is how valproate feels to me. The effects start to kick in in the first three or so days and for me they really hit their stride after a few weeks. It's been the required few days, almost a week now, so I can probably say some of what I'm feeling isn't placebo.

And what I'm feeling is calm. There's a kind of relaxation, a kind of shift of focus, a widening of my mental field of vision. When you're depressed - anyway, when I'm depressed - there are certain ideas, certain images, certain suspicions that I can't get out of my head. Where-ever I look, they are there. When I get really depressed, the ideas become facts, the images become more real than the people and things that normally surround me, the suspicions become realisations. This hasn't happened for ten or so years. But that's pretty much when I edge over from depressed mood to actual psychosis.

But on the valproate, I can avert my mind's eye. Things are there, but you can look away. You can imagine, for example, that everyone in a room is seething with contempt for you, that every time the police come into the ED it's for you, but you can recognise that as imagination and imagine it away. It's not an inability to conceive of failure, like in mania, it's more a removal of the well-springs of panic. To a great extent, valproate (for me) gets rid of that diffuse, omnipresent and omniscient fear.

So, the wonder drug. Who wouldn't want to take that?

Well, if things were different, me. I don't like all of the effects. And I don't just mean the fat, sexless, somnolent side effects. I mean I don't know that getting rid of the fear is an unmixed blessing.

See, I am finding it harder to write. Easier to study, easier to work, easier to plan stuff and get stuff done, no panicking, but harder to write. The last few days I haven't been able to write at all, (which I feel has been amply demonstrated: I should have put up a sign on this blog saying "frontal lobes closed for neurochemical renovation. Speed limit fifteen ideas per hour. Neurons closed except to local traffic. Expect delays in literary production, thoughts of actual substance will resume soon.").

I don't know why removing the fear should remove the impetus for writing, but I've got an idea. I have this half-arsed theory floating around that is difficult to articulate, but basically it says there is a close, a very intimate relationship, between art and fear. Creativity and terror spring from the same root.

It's hard to explain. Art is hard. And I don't know that art is the right word there, and I'm aware I'm talking about something a lot of people know a lot more about than I do. But to me art is an attempt to communicate something, and you wouldn't make the effort, you wouldn't try to try to communicate unless at some level you were uncomfortable with being alone.

That's making it sound more spiritual and deep than it actually is. If there is a fear, and I believe a lot of our drives, our desires, our ambitions are just fears looked at from a flattering angle, what is it a fear of?

I can't put this in English. But I wonder how much art would come out of someone who did not fear being alone, who did not fear being irrelevant to others, who did not fear being passed by and forgotten? Once you've transcended all that, who would bother? If I didn't fear, and thus did not need reassurance, and coddling, and admiration, and attention, would I be writing this?

I don't know that a lot of good writing comes out of ennui, or comfort, or satedness.

I don't know. It's just an idea, and now that I look at it in print, it's a less clear one than it seemed before. I blame the neuron goblins. You know those realisations you have while you're driving to work or going off to sleep that amaze you with their profundity, and you write a few brief words down, possibly slewing all over the road as you do so, and then a day later you look at them and they don't make a lot of sense and they don't even make an impression, like blowing on cold coals, and you think "what happened to that great idea I had before?"... well, it's the neuron goblins.

Anyway. One fear I've obviously lost is the fear of putting my name to gibberish. In a few days I will actually be able to post about recent events, including work. And since those recent events have involved pyromania, foreign bodies and attempted murder, there's something to build on here.

John.

Not actually about medications, madness, etc.

Well, sleeplessness isn't a desert without vegetation or inhabitants. It has sex-starved cats.

Specifically the black siamese that my wife says is "too feeble" to go outside to one of the pens during the night, even though it is on heat, or whatever the feline is for "gagging for it". This debilitated animal spends the nocturnal hours feebly knocking crockery onto the floor, weakly bashing up larger and sleepier animals and insipidly exploding onto my pillow in a snarling fit at three AM and honking in my ear about how it needs some good good loving.

So, it's four AM. Up since two. Alarm set for six. Start at seven.

First day back at the ED today. Not the most inspiring of days - I had one of those patients where the more you looked at her the worse she got. I should call this the Gorgon Effect. She started out as someone really thin who had had diarrhoea for a three days - a priority four. Then it turned out she had diabetes and the combination of her diarrhoea and her diabetes had turned her blood to something like Fanta - sweet, acidic and not compatible with good health. By this stage she was rapidly turning into one of the sicker patients in the department. Then we got her bloods back and it was discovered that her kidneys had basically shut down.

I still don't know exactly what caused what - if her kidneys went bad and caused her blood to go wrong or if her diarrhoea kicked her diabetes up a notch or what. With some people you get the impression that their health is suspended by a number of strings, like one of those people who... suspend themselves by a number of strings.

Be easy on me, I'm tired. Anyway, the point of that torturous analogy is that if one string breaks, it puts more strain on the others, so another one breaks, and so on.

This is why when old people come in, with their chronic kidney failure, chronic heart failure, chronic lung disease, etc. come in, things can so rapidly go bad. One system failing drives another over the edge and so on.

A patient also said thank you today. This is gratifying stuff until you realise exactly how little it reflects on your performance. I have received detailed thank you letters from patients whose care I completely bollocksed up, and the hospital I have worked at has had complaints from people we have miraculously pulled back from the brink of almost certain death.

Plus there is the embarrassing and possibly best concealed fact that many of the people to whom my actions meant so much have completely vanished from my memory. I was approached by a woman earlier last year who greeted me like a dear family friend and sighed "George is back in again"

"Oh yes?" I said, trying to conceal the fact I had no idea who she was.

"Same old trouble, I'm afraid" she said.

"That's no good."

"And Burt's driving now" she volunteered.

At this stage I didn't know whether this was good (perhaps Burt had had a stroke and was now recovering?) or bad (because maybe Burt was an alcoholic or someone prone to seizures whos licence I had taken away), so I just raised my eyebrows and nodded.

"And those new tablets really did the trick. Not like the last ones" she smiled.

"That's good" I murmured, unsure whether I had precribed the good ones or the bad.

"Anyway,, just wanted to say hello. And thanks again" she said. "We'll never forget you".

Will write back more once the valproate has cleared stuff up a bit.

Uninspired

Hail,

A few quick words before I go off to discuss stuff with my consultant and probably work.

I am feeling better now. Both valproate and reboxetine have some rapid effect, although you need to be on both for a number of weeks for the full effect to kick in. And I think there is some therapeutic benefit in admitting symptoms and doing something about them. And hopefully the mild nausea and the agitation from the reboxetine will counteract the sluggifying effects of the valproate.

I have seen someone go from a size ten dress to a size twenty in a few months of valproate. It's always seemed to me to be evidence of divine malice that the side effects of the anti-depressants are so depressing. Weight gain, hair loss, sexual malfunction. You take the drugs and your depression lifts... until you look in a mirror.

Seriously, the latest anti-psychotics have a considerably milder weight gain effect, and that's going to be good for my patients, particularly the Hogarth House ones.

Anyway, enough of this. As I said before, depression is a kind of malignant tumour of the self, it's a neuro-chemically induced rage of selfishness, where your sense of self swells and grows until it takes over your entire body. I get depressed and all of a sudden everything has to be about me and my feelings and what will make me happy. It's a damaged ego, not what is ususally meant by egotistical, but there are some similarities. An egosarcoma. That plus it's damn boring. So enough of depression.

Work today. And then home to clean up the house (one last thing - there are certain widely accepted signs of depression: poor sleep, depressed mood, etc. I hereby propose another one - running out of stuff. I got up this morning, used the last clean bowl, had to wash a spoon, had a bowl of cereal which was the remnants of three almost empty packets (Nutrigrain covered Vitabrits with Honey Somethingorothers, anyone?) and in doing so used all but the last three mls of milk.

So today, do shift, clean house, "study" for opiate prescribers exam. Get life back together.

John

Attack of the smiling starfish

Well, no posts for a couple of days because I wanted to spare everyone my whining. In the interim I have been to see Dr Pala, a round-faced, cheery man with a tendency to draw diagrams about everything ("Now, if this line represents your worst feelings, and this curve here the amount of time ..."). The end result of this has been an alteration in anti-depressant (escitalopram to reboxetine) and an alteration in my valproate dose. And review in a week's time, and promise to stay on this for at least two months.

And in the meantime I have been boxing and judoing and going out socially and keeping busy and seeing friends and even saw two movies, all that stuff that I tell my patients can help. And I know it will.

The movies, by the way, were Kingdom of Heaven and the Star Wars one. Kingdom of Heaven was good, but you got this feeling it was a wee bit too epic - all the dialogue was portentous and significant, everything was emotionally charged, there was no mediaeval version of people sitting around doing jack all and someone saying "Hey, did you see the cricket?".

And the Star Wars one was good. One thing I noticed was the Sith Lord names. One character was called Darth Sidious and another called Darth Vader. It seems that Sith Lords are named by geting normal English words and removing the prefix "in": in-sidious, in-vader. Somewhere in the galaxy there are Dark Lords of the Sith called Darth Digestible, Darth Flammable and Darth Teriordecorating.

Oddly enough, I had two drug reps drop by in last few months - one flogging reboxetine and the other hawking escitalopram. They present evidence that their medication is the one you should be using, they burble on about how side effect free it is and how much better it is than the others, I ask a few questions and they leave me some samples and flee. The medical journals are full of advertisements for the products, complete with catchy phrases, slogans and little cartoon creatures. Reboxetine is advertised by a large, green, smiling starfish kind of thing that appears in their advertisements with its arm (?) around the patient, who used to be depressed but is no longer, since he was befriended by a large, green, smiling starfish that no-one else can see.

One of the side effects of valproate is listed as "taste perversion". Gives me a weird mental image of a tongue wearing a rubber corset and stilettoes.

Sigh. Plus hair loss, acne, weight gain, weight loss and mood and behavioural fluctuations (!).

Not looking forward to this. Perhaps I'll move back into denial. That always sounds as if it neighbouring small town, you can imagine this geography - eighty eight kays to Denial, just stay on the main highway, first turn off after you go through Puberty. If you end up in Complete and Total Ignorance, you've gone too far.

Always seemed a much more relaxed kind of place to live than here.

John

Isobar

Now, I logged on to write another in what looked to be a continuing series of malignant tales, this one involving heroin and train-not-spotting, but I don't know that I will.

It is late, and I am tired, and telling these stories is the kind of thing you'd want to be careful about. Mood-wise. I don't know that surrounding yourself with happy things makes you happy, but you'd have to cautious about any propensity for morbidity in someone with any mood disorder. Telling story after story of death and dismemberment, blindness and cancer and collapse... it's a poor prognostic indicator.

Don't know. I'm starting to get that feeling I've done wrong, that vague guilt, that sense of things ruined, things on the turn and gone sour. The canker in the bud, that sort of thing.

You tell these stories, of cancers and amputations and stuff like that, and you wonder if at some level you don't feel that these are your stories, if you're not using these people's suffering as a metaphor for your own. If perhaps these stories swim to the top of the ocean for a reason, if perhaps you are trying to say something about yourself with those stories.

Gore and grue and therapy gone wrong aren't just 'sit around the campfire' stuff. They are told for a reason. They mean something to you for a reason.

If the stories that cultures tell tell you more about the culture than about what actually happened, then the same applies with people.

If my mood is going down, then hopefully this will be something that can be headed off at the pass. I used to sort of wait passively for the mood to go down, I've learnt if you attack it, if you almost mount a military operation against a low mood, it passes more quickly and has less effect.

The military analogy is actually quite apt - choose the ground on which the battle will occur, enlist your allies, ensure your forces are in readiness, move to cut off the enemy's supply lines, take it by surprise.

I get the feeling sometimes of a low pressure system moving in, like something on a weather-map. Isobars entangled like loops of wire, so tight and close they look like something that if it gets around your neck it could strangle you. The air is cold, there's dark moving in from the Southern Ocean, there's the smell of something like rain.

Anyhow. Sleep, and I will feel less morbid in the morning. I'd want to, because it's off to the prisons to see people whose lives are markedly more shit and probably less self-pitying than mine.

Imaging

Back from night shift, and wondering if my being awake at noon really qualifies me as an insomniac.

Read someone's blog the other day, and she had this quote saying "Sleeplessness is a desert without vegetation or inhabitants." Originally by one Jessamyn West. I don't know who Jessamyn West is, but s/he got that thing damn right. Have a look at the blog, too:

http://g_pi_exile.blogspot.com/

Damn fine writing. Has inspired me to maybe actually review these occasionally before posting so I can write coherently.

But not tonight. Tonight is pure brain to keyboard. Times like these I am too tired for any kind of extended thought, so I might just restrict myself to a few short, malign anecdotes.

Friend of mine just came back from a stint in one of the EDs in Queensland. Part time he worked in a family doctor kind of practice, seeing the wealthy healthy, measuring cholesterol and so forth, the rest of the time in the ED. He told the story of a madwoman who came to his practice a few months back.

She said she had a brain tumour, she said. She could feel it, something pressing and thrumming behind her left eye, worst after exercise, changed throughout the day, that kind of thing. She described the classic symptoms of a tumour headache. And a woman in her late forties, not impossible. She asked for a CT scan, to rule it out. Seemed reasonable.

Here is where any doctors would have left off thinking. She needs the CT, do the full neurological examination (fifteen minutes of Simon tapping her with a hammer and engaging in awkward small talk), get her the CT, go on from there.

But not Simon. He keeps chatting, asking about sleep, appetite, tension, where she came from, which doctor she normally sees, that kind of thing. Pretty soon he's convinced she has more going on, something going on in her mind as much as her brain. In fact, she has symptoms of a fairly severe delusional state.

A delusion, by the way, is a fixed, false belief. There is some room to manouvre in this - false is not the same as unverifiable, and there are culturally apppropriate false beliefs, that kind of thing. But generally delusions are demonstrably false beliefs that are inaccessible to argument.

However, mindful of the First Law of Psychiatry (Mental illness does not prevent physical illness) , he arranges the scan and does some research.

By the time she has had the scan he has discovered that woman 'fitting her description' has had twenty eight CTs of her head in the last year - all of which are normal. SHe still knows she has cancer. Fixed false belief - not susceptible to argument, whether that argument comes in carefully chosen words, or the tapping of a hammer below the knee, or the pattern of light and dark on a computer screen.

Anyway, she comes in for the result of the latest CT, and as gently as possible Simon raises the issues of the vast number of normal scans, the lacunae in what she told him, the various identities. He mentions delusional beliefs, the causes, the consequences, the treatments.

No joy there. She stormed out of the room. Out of this story, he thought.

Until four months later, and he's in Emergency, and he's scrolling through the CTs on the screen, looking to see if Smacked in Head by Mate is actually bleeding into the brain, and sees her name. "Jesus Christ" he thinks. "Not again." Another bloody CT head.

And looks up the scan, and she's got cancer.

He rings Dr Sock, the neurologist. Doctor Sock is small, Indian, distant, brilliant and depressed a typical neurologists. It's not a big cancer, she says, but not a nice one, either. Luckily, they caught it early. Something may still be able to be done.

Does Doctor Sock know that this woman is cut snake crazy asks Simon, for a moment deviating from the appropriate mediacl terminology.

Pretty much, says Dr Sock. She's had thirty CT scans in a year. That's a lot of radiation, and it's almost certainly a radiation induced cancer. The likely thing is the scans gave her the cancer.

See? Mental illness kills people.

Anyway, enough malign little snippets. Read an interesting word the other day - femininism. Celebrates frilly feminine things. And I have decided to refer to the current influence of the Christian Right over the teaching of evolution andstem cell research as the Endarkenment.

There should be a word for that thrill of recognition you get when someone defines/explains/makes clear something you have known about for years but have been unable to articulate - something that means "That's what I've been trying to say all these years".

Anyhow, next post may be about crises - ways people do and don't get off drugs.

John

Post traumatic stress disorder disorder

Hail,

Just back from my short course on treatment of drug addiction, more of which tomorrow.

Interesting anecdote the first: They (the detox unit) used to do full psychiatric assessments of people who were going into methadone treatment - a series of screening questions to work out which of the patients might have depression, schizophrenia, anxiety disorders, etc. There's a lot of mental illness in the drug using community, although no-one knows what causes what - does depression cause you to take drugs or does drug-taking cause depression?

Anyway, there were some questions about post traumatic disorder, things like "have you ever been the victim of an assault" "Have you ever been in a motor vehicle accident" "have you ever lost anyone close to you". Almost all of these things have happened to people who are on opiates, they have several centuries worth of misery crammed into a few years.

Well, people kept getting traumatised by the questions designed to test them for post traumatic stress disorder, and eventually someone completely fell apart while reading the questions and ended up having to be sedated and taken away to hospital (which further traumatised other people watching). After that a meeting was held and it was decided that even asking about trauma in our patients was too great a cause of trauma, so they stopped asking. So now when someone says "How many opiate dependent patients have symptoms of post traumatic stress disorder", we have to say no-one knows. Essentially the diagnosis of PTSD vanished. From one point of view, everybody with PTSD was cured.

But (and this is the weird bit) he said it didn't affect much anyway, because treatments for PTSD are "notoriously shit" and they were having pretty much zero success anyway. So going from a hundred people on the unit diagnosed with PTSD to zero didn't really make much of a difference - either to the patients or the doctors. The patients went from getting "notoriously shit" treatment which didn't help, to getting nothing. And as far as the doctors were concerned, the patients were just as sick for just as long whether you treated them for PTSD or not. To a real extent, PTSD ceased to exist in the detox unit.

So what does this mean?

Reminds me of that whole 'the only meaningful definition of a disease is "something that doctors or drug companies have a treatment for."' thing.

My youngest son used to be shy. He blushed and spoke in a small voice in front of strangers, and hid in his room when the next door neighbour (a very tall man with a loud voice and a propensity for practical jokes involving dead animals) came over. Luckily he outgrew this.

But a few years back the drug paroxetine was authorised for the treatment of social anxiety disorder, and what was varyingly a characteristic or a character flaw or a vice became a disease. Previously it had been hardly diagnosed -because there was no treatment. Now he would have social anxiety disorder.

I don't know. Some days I imagine my descendents at some gathering, the family picnic on Titan or something, and my name comes up in passing, the way great uncle Sam's does now - once a decade or so. And one of the more smartarsed amongst them will nod and say "You know, looking back on it, it's quite clear the old bastard had pretty severe CAD* - but nobody even knew about it then."

And my great-great-great grand-intersex will smile and nod and say "It's explain why he was so bloody unpleasant. He could hardly frinkle for a minute without blurding."

"Poor old male" one of my more sentimental progeny will say - this one probably an attempted clone of me from some material found in a hanky when they excavated my room, and thus half composed partially of human cells, partially of cat hair. "Imagine what if must have been like, living like that. Great Grand-robot said he wouldn't get treatment, refused it right up to the end. Not even a minor personalitectomy."

"No wonder all the old people had to be put in those geriatrighettos, on Venus," says my great grand-daughter, a cybernetically enhanced piece of seaweed. "I remember the day the trialobytes came to take him away. It was quite unpleasant. "I'm not going to some prison," the old galah shrieked. "It's not prison," said the trialobyte. "It's quarantine."

Okay. Bed-time.

John

*Catchy acronym disorder, obviously

Chooks

Chook, by the way, is the Australian word for hen.

I got home the other day and the chooks had escaped.

Nothing sinister in that, you say. A few plump hens,wandering around the back yard in the sun, pecking in the garden for earthworms, a sufficiently bucolic and serene image for the most jaded palate. Et in arcadia chooks.

But how did they come to escape? I looked at the chook run and saw that the brick that usually holds the hen-house door closed had been tipped over. No one, no human being, could have done this. The only possible culprits were the cats, specifically "Fluffy", a Persian-Thylacaleo cross who lives in my brother's room. She often played near the chook's house.

So, the cat, despite my express instructions, had let the chooks free. And the horse, allegedly our noble servant, had stood by throughout this act of rebellion and done nothing.

It is clear the farm animals are rising against us.

This actually happened to this patient in Florey about two years back. He had been "breaking" a horse, and in the end it was him who ended up broken. He had got on the horse, been bucked off, landed on his back, got back on, been bucked off, landed on his side, lay there for a few moments, got back on, got bucked off again, landed on his head and neck, and was clambering on again when physically restrained by his sister and brought to the emergency department. He ended up having two fractures of the vertebrae of his back, two cracked ribs, a broken collarbone and a fracture of the spinous process of the fifth vertebrae in his neck.

More on the horrors of horse-riding later. But the thing with this guy is his brother had been in Florey a few months ago having been attacked by a swarm of dogs, and and last year his father had been cleaning the verandah and was sweeping the underside of the roof (!) to get rid of cobwebs, when he dislodged a huge nest of bees which fell onto his head. On holiday in Queensland that summer his sister had been stung by a box jellyfish and bitten by a bat.

I always imagined his family coming to visit him, stumbling across the car-park on their way to the wards, being swooped by vast predatory birds, their ankles lashed by venomous serpents, while lumbering she-bears break from the forest to maul them. For some reason the entire animal kingdom had declared war on them.

Anyway, enought of giggling at the misfortunes of others.

Enough, I say.

A few months back, when I was at my most stressed prior to the exam, I used to go out and stare at the chooks. They would cluster around the handfuls of grain I threw out, and I would
watch them standing in the early morning sunlight, clucking and ruffling and banging their almost brainless heads against the ground. I would see this and my heart would fill - and I know that sounds wanky, but it does, you actually physically feel some emotions rise in you - with emotions I don't know how to describe.

Tenderness, envy, exhaustion, awe, peace.

I don't know if there is a chook tao, but there ought to be.

This will excite contempt, but I think I derived such comfort from the chooks at that time because that was what I wanted to do with my life, something brainless and eternal and simple in the sun.

You know that almost last scene in "Minority Report", where the three psychics are on that island, sitting by the fire, reading big books with a few sheep outside? Phillip K Dick understood stuff you can't put in words, and then he put it in words.

Anyway, chooks are amongst my favourite creatures.

I should point out that these are pampered creatures. They get abundant food, they get to wander around the garden daily, they are protected from all harm. The other day they turned their beaks up at poppyseed bread. I should have got my German grandmother to talk to them. Half an hour of "think of the starving chickens in Ethiopia" and "When I was your age I would have been grateful for a bit of shell-grit and a puddle in the clay, never mind this fresh food and water foolishness", and they would have eaten themselves to death.

John

Plucked from the jaws of danger...

.... then coated with sauce and garnished with a bit of parsley and forced down the throat of even more danger.

Bit of a wild time at Florey. We had a big brawl down at the Drowning Neuron or whatever the local pub is called, and as usual the victims were brought to us. Unfortunately, there were victims from both sides (orcs of Saruman and of Mordor), and the victim's girlfriends and mates from both sides, and so the atmosphere in the waiting room was already pre-ignition, and then when more drunks from a third party turned up it was all on.

It started with glowering and gurning, progressed to muttered obscenities and within half an hour we had called a code yellow (internal emergency) because there was this large crowd of people outside kicking at the doors trying to get in and finish what they had started.

Meanwhile inside the actual ED, Smacked in the Head a Bit (Cubicle 12) had got out of his bed and went over to remonstrate with Punched in the Kidneys (Cubicle 10), and Punched to the Ground and Repeatedly Kicked (Cubicle 8) was trying to get into cubicle 4, taunted by drunken bellows from Glass vs Head, Denies Loss of Consciousness, Appears Intoxicated. Mrs Punched in the Kidneys and Smacked in the Head a Bit, Jr. had already been taken away by the police, and in the background you could hear Smacked in the Head Bigtime was explaining how he didn't want stitches, he wanted to go outside and smack some bastard out, then we'd be able to do stictches.

This reminded me of the only other Code Yellow I had been involved in. For your information, here is Florey's current Code list:

Code Black: Violence - move quickly and quietly away from relevant area.

Code Blue: Cardio-respiratory arrest - move quickly and quietly towards relevant area.

Code Red: Fire or smoke

Code Yellow: Internal Emergency - see below

Code Brown: External Emergency - like a bus roll-over outside, meaning expect hundreds of patients.

Code Green: woman having baby somewhere unexpected, like in the lift. I know an amusing story about this, for later.

There is also my addition to the Code codex: the Code Beige. This is when regulations demand a code be called and certain actions carried out but all those concerned can see the code is crap. Some of the ambulance teams are not empowered to declare someone dead, and so are compelled to commence and continue resuscitation, in the face of overwhelming evidence of its futility, until a death can be certified by doctor. When you see the ambos amble in, one hand idly patting the vast sternum of a man in advanced rigor mortis, the other occasionally squeezing a bag to blow oxygen into his mouth, then you are seeing a Code Beige.

The only other Code Yellow I was involved in was last year, with the Vampire of Morbing Vyle. He was a strongly built young man, well known to the local psychiatric and police services. He did not, as far as I can see, have any of the classic mental illnesses, except on those occasions when he had too much alcohol, too much marijuana or a very little bit of speed. And the time Collingwood lost the Grand Final.

I don't like to say this, but he was a Very Bad Man. He had attacked one of the security guards in the car-park, leaping out with a Halloween mask and a screw-driver, with both suffering considerable injuries in the process. He had stabbed his friend's dog to death, probably raped a psychiatric patient while in a ward, had restraining orders out on him at Shipman and the Royal, set fire to a car with some homeless guy inside and was generally a deeply unpleasant man.

It is depressing that he gets classified on the triage sheet as "Psych", along with the many deeply decent people and normal people who struggle to cope with schizophrenia, anxiety disorders and depression. But anyway.

The Vampire of Morbing Vyle was so called because, and I swear to God that I am not making this up, when he stabbed his friend's dog to death he had drank its blood, and he had had his teeth cosmetically sharpened into little points (which may nor may not have given him his slight lisp) and several of his psychiatric reports from his (brief and unhelpful) psychiatric admissions stated he believed himself to be a vampire and to require human blood for sustenance.

Anyway, TVOMV was in the cubicle, being seen by muggins me about his anger management issues (security guard standing ten feet away outside the cubicle and me smiling and looking calm and concerned and holding my pen in a 'look at me funny and this pen will go in through your lung and pierce your aorta' manner, and he was going to leave, and they called a code somethingorother somewhere else and we all went off.

Then we looked and he was not there. And then the security guard came running out down the corridor saying that the someone had apparently stood on the toilet in the men's cubicle and moved one of the big ceiling tiles across and possibly - just possibly - escaped into the ceiling.

So, the next three hours we were on code yellow. That meant we went around in pairs, got all the movable patients into rooms where we could almost guarantee a hundred kilo lisping vampire in a Slipknot Tee-shirt would not drop down from the ceiling and attack them, and spent every spare minute glancing upward, like religious martyrs in a Renaissance tableau or flying saucer devotees.

I was paired with Annabelle, a tiny, forty kilo nurse with an assertive personality and a high degree of resuscitation skills. She would have been no good in a fight, but if things did go awry, she would be almost certainly be able to help resuscitate me.

Three hours, by the way, was the time required for the police to review the tape which showed the Morbing Vyle Vampire after discharge buying a wagon wheel from the waiting room vending machine and unconcernedly strolling out into the night.

Anyway, half way through this we were all huddled in the fishbowl, listening to the occasional thumping, dragging and whispering noises many of us swore we could hear from the ceiling, and I said "My God, this is what paranoid schizophrenia must be like."

Seriously, that kind of thing leaves you awestruck with admiration for people who can go around with those fears, those nameless noises, that certainty of being watched by malignant forces, and still lead some kind of life.

Schizophrenics of the world, we salute you.

Handover

A very brief post today.

Just finished a run of early morning shifts (start at seven, finish mid afternoon) and I've got that post-clinical fuzz. All wired up and nothing to write about.

Well, there was today's shift.

The morning shift seems like not such a bad shift, but in some weird way it is the most feared.
It is the most feared because of the beast known as the handover.

What happens in emergency (and all other hospital wards) is doctor X is manages a patient for a shift and then s/he hands over the care of the patient to doctor Y, who may later hand over to doctor Z, or Doctor X, or whoever is walking past. Doctor X basically says something like "Cubicle fifteen has a fifty eight year old woman with three days of abdominal pain, mild fever, looks like typical cholecystitis, I've taken bloods, should be back soon, if they're okay she can go."

Theoretically this should be good. But it relies on Doctor X, and on occasion Doctor X doesn't know his arse from his olecranon.

As happened the other night. I turned up, grabbed my coffee and a computer and slumped in front of the terminal. I usually turn up a few minutes early to the dawn shift just in case there's some disaster, but this time there wasn't, so I picked up thirty three year old woman, post-seizure, did a fairly quick workup (post seizure is easy) and fell into my chair for the handover.

The two I got allocated were an old man with a DVT ( a blood clot in deep veins of the leg) and a woman in her forties with "possible meningitis". Everything needful had been done, I was assured, the CT scan was booked for seizure woman, the ultrasound was booked for leg man. Then we're half way through handover and some guy gets hold of the portable ultrasound and checks leg man's pulses in his leg and he doesn't have any.

A brief diversion here: you have arteries and veins. Arteries carry blood from the heart to the body, that's what you feel when you feel your pulse. Veins carry blood back from the body to the heart. A blockage in a vein, like a DVT, is serious, but unless it occurs in a nasty place (like the lung) is not of itself life-or-limb threatening. A blockage in an artery is bad news for whatever is down-stream of the blockage - heart (a heart attack), brain (a stroke), kidney... or leg.

This bloke had a blockage in the big arteries of his leg. That meant that his blood was not getting to his leg. Without blood the affected organ dies, and this was the reason for his cold, immobile, pulseless, blue leg, and the reason that instead of having an injection and a cup of tea and being sent home, he was going to have to be transported to the Royal to get his leg chopped off.

Grim news indeed.

And then the other woman who had "possible meningitis" came back with a white cell count of thirty (i.e.: was incredibly sick) and tried to get out of the bed, wrestling with us while delirious and fecally incontinent, and had to be intubated and so on.

The disturbing thing was this woman's family had bundled her off to bed last night when she was drowsy, incoherent and in considerable pain, and when the infection (whatever it was) was already raging though her. If they'd got her to hospital earlier she would have had less chance of brain damage.

The meninges, by the way, are this wrapper around the brain and spinal column, when they get inflamed you get meningitis. Meningitis can be aseptic (not caused by a virus or a bacteria), viral or bacterial. All of the forms are nasty but baterial is usually the worst and I suspect this was bacterial.

The reason they had bundled her off to bed with bacterial meningitis was "she was always like that". One of those "the slightest cough was pneumonia" people. Histrionic.

I don't know about all this. She would have been fairly unwell. Fever, deeply confused, in considerable distress. Surely someone would have noticed.

Now may be the time to reveal my universal law of human behaviour, which has served me well throughout my life:

If you hear something unbelieveable, and the only reason you can't believe it is you think "nobody could be that stupid", or "nobody could be that cruel", then what you heard is probably true.

There you go. Try it, it works.

Anyway, bedtime.

This friend of mine, arguably the smartest emergency doctor I have ever worked with, likes to have a can of beer or two after night shift. This was night shifts at Shipman, the House of Death. He reckons it's great to sit out on the verandah, singlet and shorts, stubby in hand, at eight in the morning and smile at the drivers going off to work. One guy actually slowed down his car and wound down the window and shouted "Hitting the piss already? Get off your arse and get a job, you useless shit!!" and drove off.

No point me doing it, the only people I'd enrage would be the chooks.

John

Peace

A strange thought came to me last night.

It was about one am and I was watching Mr Cray leave the Emergency Department. He was smiling and looked relaxed and comfortable, and those with him were happy and laughing. A spirit of cameradery, of knowledge of a worhtwhile job done well, seemed to follow him as he proceeded towards the exit. He had come to us tormented by voices, angry, lashing out, paranoid, in crisis, dependent on drugs and alcohol, and modern psychiatry had done its mysterious work and now he was calm, more at peace than he had at any time in the last few months. The psychiatric treatment of mental health patients gets a lot of stick, but occasionally we do do things right.

"Look at that" I said to the intern and the security guard. "Out of the strong comes forth sweetness. A triumph of modern biopsychiatry."

And as the ambos and police wheeled the barouche bearing Mr Cray's bruised, restrained and heavily sedated body down to the lockup ward, from which he would be discharged back onto the streets, he seemed - or did I imagine it - to drool in agreement with me.

"We really can make a difference to people's lives" said the intern.

The security man pressed the icepack to his jaw, grimaced and nodded ruefully.


I have only partial recollecion of my time in the ED on the "other side"- as a patient. It wasn't the best of times. And like most memory what you interpret as an objective linear narrative, as data about what went on, is in reality a melange: distorted scraps, imaginings, images, things that never happened but you thought they did, things that happened but to other people, what you wanted to happen and what you feared would happen. Unmatching fragments of a puzzle that your brain has shoved together and distorted.

We forget decades and remember moments. Do a Google search for Charles Bonnet Syndrome. What we know is not so.

But from looking back and extrapolating from what happens daily to other people, I can work out what it must have been like.

I would have waited a while, with my increasingly concerned workmate trying to keep me calm as I gibbered, in the waiting room amongst fevered children and footballers with twisted ankles and women with abdominal pain.

I would have been seen by someone with, to be fair, minimal psychiatric training, possibly only a few lectures and some work experience in medical school.

That person (a young, caucasian man with dark hair, wearing a lab coat, I can't quite make out his face) would probably have been tired and possibly nervous - he was young and relatively junior and there may not have been consultant support because there were damn few emergency consultants around at the time.

He might have got the short end of the straw. In our ED the new patient's paperwork is put in a box in order of priority: a priority three (say abdominal pain and fever) is placed above a priority five (say rash on fingers for the last eighteen months). The quickest way to unpopularity in the ED is said to be "cherry-picking"*, going through the box and selecting the patient you feel like seeing rather than the one who the triage assessment says needs to be seen next.

Well, if anyone does cherrypick, and it's hard to stamp out, the following pateints are the ones who will miss out and have to wait even longer:

psychiatric assessment
requesting admission for detox/withdrawal/needs accomodation
anal pain
rectal bleed
old person from half-arsed nursing home, demented, had a "turn", no further history available.

As you can see, almost half of those are psych, and all of them could be if it was a truly unfortunate psychiatric patient.

I like psych (oddly enough) and people are only too willing to swap. On occasion (and more at Shipton, only once or twice at Florey) I have been deliberately sought out - "swap you something for a psych?". I have got rid of "scaly rash on scalp", "might have been bitten by insect, not sure", and any number of "generally unwell" for extra chances to see psychiatric patients. "When I started out I palmed off a lot of babies that way. Sick babies frightened me. Then I sortof worked out if I never saw any, they would always frighten me, so I saw lots of them and now they don't.

Anyway. I am going to have to try and psych myself up to attend a tutorial this afternoon, so on with it.

[Note to self: insert insightful, profound or witty closing line here]

John

*Eating someone's lunch isn't good either. Sorry, Danny.

Chest tube / Rape

Well, it was all happening tonight.

Two thirty in the morning on mothers day.

I should point out, by the way, that if I can turn these into something interesting I am going to see if I can hammer them into a book. Then I will be able to retire on the fabulous wealth.

So: random thoughts from today.

I put a chest drain in today. This is a big polypropylene tube which, for reasons I am sure are only dimly understood by the victim, doctors stab into the chest of patients. Basically, if you have fluid (exudate, blood, whatever) in between your lung and the membrace of the lung, we paint you yellow with iodine and inject local anaesthetic into you. Before we do that we have lied to you about how successful the anaesthetics and analgesics will be - if you ever have one done, it's gonad-explodingly painful.

Basically, it goes yellow stuff - local anaesthetic - five centimetre cut parallel to and between your ribs (sortof under your armpit), then I alternately stick my fingers and some tong kind of things in and smurch my way into your chest, like something from Alien. I am a naturally gentle soul, but today I learnt that the best thing to do is really go for it and virtually lean on the forceps so as to drive tehm into the chest. I poured in the lognocaine (the local anaesthetic that you get when you have stitches) but it didn't seem to do much good, and we were pumping in the fentanyl (sortof like morphine) as well.

Once you've burrowed your way into the chest (the layers go yellow-stained skin, subcutaneous fat that looks a little like bubble-wrap, smooth glossy red flat muscle, and then "inside"), you have to get between the ribs (which is a bloody narrow space - feel it), making sure to go over a rib rather than under one (all the important nerves, vessels and arteries run below each rib, but it's not fra from just above one rib to just below the next one).

And then you lean on the forceps with what seems like a fair amount of weight, as the woman shrieks, and drive them through into the empty space where her lung should be.

You break through into the emptiness and there's this hissing, sucking, gurgling sound, and red stained fluid starts gushing out and the hole gurgles and spits and sucks with each of the woman's breaths. Then you get the polypropylene tube and stick it in the hole you've made and sew it up tight. Then she lies there, all zonked out from the pain relief, with this plastic hose sticking out all covered in tape, and slowly the stuff inside her lung starts to drain out and she goes upstairs to get better.

What else. We had a man in his thirties come in today. He had been riding a dirt-bike and had come off. Only doing about twenty kilometres an hour, he reckoned. But the handlebar had driven into his spleen and he was bleeding pretty badly internally, and he just lay there getting paler and paler and paler. Almost the first thing he said when he came in (and almost the last) was that he was a Jehovah's Witness and he didn't want blood, even at the cost of his life.

Anyway, he just got worse and worse and eventually arrived at the Royal with a belly full of blood and a blood pressure of sixty and needed urgent surgery. By this time the fluids (non-blood) we had given him were fairly clearly not working.

I mentioned this to my boss and she said that they might give have to give him blood. I pointed out we had both documented that he would rather die than have a blood transfusion. She said it was very hush hush but sometimes they do it anyway, secretly in surgery. It depends on which surgeon you get.

There you go. Daddy does know best, after all.

Let me point out here that my rage at this is in no way due to any soft spot in my heart for the fanatics who teach this kind of crap. People who teach that blood transfusions will damn you to Hell, even if they are large and organised groups of people who wear suits and so forth, are dangerous people. Exclusive religion is dangerous.

It's also a sign of a poisonous degree of egotism - anyone who believes that God will chose, from amongst the entire human race, to surround himself for all eternity only with Jehovah's Witnesses has a very disturbing different view of the Lord.


Brief rant here:
All fanaticism, and you can lump the young socialists and the young conservatives and the Amway Youth and most patriots in with this, seems to me to have the same brain-deadening, us lot uber alles effect. Any Christian splinter group that originated in the US after about 1800 AD seems particularly prone to this pathology: shit theology plus blind obedience equals ruined lives. I have lived like this, in my previous waving the Bible and shrieking in tongues phase. It's a venomous mix of self-deception, mealy mouthed desperation and lower spinal cord reflexes behind an increasingly brittle smile.

And it's the only way that faiths like that one operate, their principle mode of preying on the lonely, the earnest and the overfed. Epistemological Amway, McGod and Jesus Lite.

(Bile gland off/And here I was a few posts ago worrying about expressing my anger/bile gland on)

I don't know a lot about how God made us, but He made our brains too good for fundamentalism. I have atheist friends who would nod sagely at the last few paragraphs, but from what I can tell they beleive in the potential for unlimited goodness, wisdom and mercy from human beings instead. I don't know how you can do that. To see the poor bastards trudging from house to house, each of them believing that the Creator of all things visible and invisible has chosen them as a vessel is to see a walking refutation of every humanist vision of paradise.

In the end I think I believe in God because the alternative is believing some kind of salvation is available from my fellow human beings.

My God. Evident issues here.

And don't feel especially despised if you're reading this and you're a Jehovah's Witness. You can cut and paste and apply the same tirade to most denominations. Tragically, there is nothing special or unique about any form of fanaticism. All of them are alike in believing themselves unique. I can say that because I've been there. You can say that fundamentalism works for you, but you can't say it's never a cage, because I was there and it was one, and that's what you're building each time you go door to door or hand out Bibles on the street. A cage to put your children in.

But anyway. It may be a stupid, ungainly, ugly religion that sucks IQ points as surely as one of those bowling ball sucking vacuum cleaners sucks bowling balls, but it's their choice. If you want that, no-one has the right to take it from you. We don't sneak ham into the Islamic Student's dinner. I don't know if there's such a term as theological rape, but pumping blood into someone who didn't want it is close.

Well, that's that. Me cast into Hellfire if it turns out God is the small-minded bigot these people preach - not that I'll mind. I'll be down there with the Jews and socialists and the lesbians and the winebibbers.

I am too tired to even mention the murder waiting to happen that we sent home.
Maybe next entry.

But God that was cathartic.

John.

Infidelity II

I've been thinking about this.

One of my colleagues, a nurse, joined us recently at Florey (the good emergency department I currently work at) having moved from Shipman (the evil emergency department I used to work at).

I bumped into her a few weeks afterwards and asked how she reckoned it was going, and said "It's good here - everyone gets on well, there's not much gossip".

She smiled sadly at me, with that expression usually found on saintly daughters of demented parents, and informed me of the following:

The senior doctor on for the day was a lesbian, as was the red-headed RN, the new EN with the glasses and today's outpatient nurse. The pharmacist was gay.
The head of the resus team had just broken up with one of the security guards
The blonde paediatric registrar was shagging the Vietnamese triage nurse
The tall, strongly built Sri Lankan Indian consultant who was taking us for pathology tutorials was bonking the blonde paediatric trained nurse and wanted to leave his arranged marriage but his wife had told him she would take his children off to darkest Sydney and he would never see them again.
The new gangly, morose looking orderly was having it away with the lisping, eminently bonkable Greek radiologist
One of the emergency interns had done an infectious diseases rotation at Glasson Street, the sexually transmitted infections ward at the Royal, and was in the back room getting a coffee when her boyfriend checked in with a panic and a list of names, and a story that she said would have qualified for the British Fantasy Award.
The anaesthetics registrar had been caught applying what I will call genital CPR to one of the surgical registrars in the store-room

and so on. Apparently there are loops, and I am out of them.

I don't know if that counts as a lot of stuff. For a start, it's all hearsay, and as anyone who has ever gone camping in the Deep South in midwinter knows, there can be a hell of a lot of smoke without fire. The other month one of my friends told me his wife of six months was leaving him and taking their child, because she had thought that marrying him would make her love him but it didn't. He cried, and I put my arm around him, and if he'd been a she the nest day the story would probably involve the two of us smeared in chocolate pudding and wearing fish suits.

I don't know what kind of environment infidelity blossoms in. I don't know if it's more common where people are bored or people are under stress, not that the two are mutually exclusive. Emerge seems to have a steadily rotating crop of nubile and virile nurses and doctors, who have to work closely under emotionally trying circumstances. People cry and people get tired and people need comforting, and everyone tries to be supportive, and there is that "we happy few"cameraderie, and plenty of secluded places to duck into. Anyone who reckons sexual attraction is not a risk in medicine is dangerously ignorant. And the other relationships, the openly acknowledged ones, the husbands and wives and partners... shift-work is notoriously difficult. If you look long-term, many doctor's marriages do not survive ten years. Infidelity is easy.

Me, this is something I have historically had trouble with. I am the kind of person who goes weak in the presence of beauty. In my younger days I always had hold of the next relationship before letting go of the last, like a gibbon swinging through trees. From fifteen to over thirty I seemed unable to function without at least one, and ideally two or three, sources of some kind of comfort, sex-on-tap.

I was a horrible teenager, and a worse twenty-somethinger. I'm not such a good person now.

I read somewhere that improvements in health and the other cosmetic sciences mean that the average high-school class contains more concentrated, weapons grade beauty than Michaelangelo or Renoir would have seen in his lifetime.

I know this sort of thing gets to me.

Occasionally I find myself staring. Sometimes I pick myself up spending slightly more time working up the slim, tearful, big-eyed girl with the fever and the headache rather than the fat, aggressive, pug-nosed boy with the fever and the headache. Once in a while I will catch myself staying a bit long over coffee with an earnest, big-eyed brunette, especially when discussing some aspect of the days work which shows me in a favourable light.

I think that as long as I find myself checking up on myself, as long as I regard my own actions
with a jaundiced and deeply skeptical eye, I should be okay. This guy I know is an alcoholic. He didn't drink for fifteen years, one night he went back to it, had three days of incoherence, came home to find his suitcases packed in the hallway. He adopts the alcoholics anonymous approach to alcohol, none of this "alcohol management" stuff, prohibition all the way. Even after ten years alcohol free he considers himself an alcoholic who hasn't had a drink today.

Without wishing to go into inappropriate amounts of detail, I think if you know your weaknesses, if you keep it in your eye, you can live with it. I am not one of the people who can risk that kind of thing. I try not to touch anyone at work. I don't stay in the same room as a single female. I try to look out for my favourites and avoid them.

Not feeling the attraction would be good. But if you can't not feel it (and what I mean by the attraction is not something cerebral, some deep apprecation for their wit and charm and the structure of their personality, it's skin and hair and uniform and the like, some momentary flare) the next best thing is to make sure you are never ever at risk of acting on it.

As for now: I know I would not survive life without my earnest, big-eyed, brunette wife. I know something vital would be gone from each of us without the other. It's not something I can risk.

It sounds like melodrama. But it works if I think of myself as someone who hasn't had his first drink today.

John

Infidelity

Tonight I think I will break the first rule, and talk about fight club. And this won't be brilliant prose, this is bare-bones and exhaustion.

Saturday evening shift in Florey, and it was on. We are in a new department, the new, improved, safer emergency department, but still teh same old, unimproved, dangerous patients. I walked in at three and one of the RNs (Bianca, tiny, blonde, worried looking) came over and said "Look, can you look at this guy, he came in with abdo pain and now he's unresponsive". I went in and there's this mountainous man on a bed looking grey, lying on his back, staring straight up at the ceiling. I go up and ten percent of my brain is listening to the story (came in with abdominal pain, has had some morphine, suddenly ...) and the remaining eighty percent is working out that he's not seeing me when I shake him, he doesn't have a pulse on his wrist or a femoral pulse* or a carotid pulse and I'm not hearing a lot in his chest, and everyone's looking at me and I say "Well, let's call the arrest", and suddenly there's a nurse pushing on his chest.

Embarrasingly the other ten percent is thinking "I haven't had my coffee yet." Sad but true.

Then everything went really slow for a moment. I don't mean one of those "out of body, look, I'm on drugs" slows, but over what seemed the next half an hour three or four extra doctors ambled into the cubicle and checked things out, and the nurses in a leisurely fashion fossicked about for laryngoscope, tourniquet, blood gas. In reality this all happened in less than two minutes.

And we kept resuscitating him, and he got halfway back, mumbling and grasping at things with his good hand, and I handed over and went out to talk to his wife, and then when I got back he was still being resuscitated, and then he went on a transfer to the Royal and five minutes from the door the big artery in his belly finally burst and no power on earth could have saved him.

His wife, huddled in the relatives room, muddling about with cups of tea and long distance phone calls, seemed quite baffled by the whole thing. I went in there early in the resus and told her we didn't know what it was but we had three specialists in there and we were going to send him to the best hospital for this sort of thing, all possible care was being taken, and went out to where they were pummelling his heart and sticking huge needles into his unresponsive frame.

One day I am going to look around the hurly burly of the resuscitation room and see a figure of death, an avatar, an actual incarnation. It'll will take the shape of a doctor or nurse or some orderly that later no-one will recall knowing, someone slight and unassuming, just watching, and when one of us glances up from slithering a greased platic tube into the windpipe of a child or squashing a dead woman's chest and sees that figure we'll know what is going on.

Then I went out to my side of the ward (we are divided into outpatient and inpatient teams, I was outpatient) and discovered practically everyone else was in one of the other two simultaneous resuscitations that were going on (heroin in someone who had been drug free for eight years, found in a hotel car-park) and something else I never actually found out about. The only person left on was the intern who is a well-meaning girl but I think has a bit of tunnel vision - she seems to ration patients to "one patient, one diagnosis, one treatment", so the man who came in with gout who also had a blood clot in his calf and pneumonia and maybe heart failure was getting great treatment for his gout.

Once I fixed that up I got to see the actual patients. Saturdays in the winter seem to go "football and stuff" to "violence and stuff". The football side of it was a sprained wrist, a wrenched knee, three broken ankles and a concussion. Violence was a woman smashed on the head with a tyre iron, a man strangled and kicked, a thin Vietnamese man whos girlfriend had broken his nose with the base of an electric kettle, a man stabbed in the head by "his mates" who had arterial bleeding (that bright red, squirting, fountain kind of bleeding) from his temple and was talking to us while blood "squikked" out the side of his head, and an otherwise sensible man whose experiment involving cooking, alcohol and an samurai sword had gone surprisingly awry. He, too, had arterial bleeding, and when I took the bandage off and poked at the wound a jet of blood shot past my nipple and onto the wall. We ended the night with a Croatian man who had walked to his sisters' house after a high speed car collision, and was wheeled in to see us with a compound fracture of the jaw and at least three other fractures.

Anyway, the buzz is wearing off and I am going to bed. The infidelity of the title is this idea I am working on at the moment, some idea about the serial thrill-seeking beast that is on the backs of most emergency doctors, and the consequences this has in their lives. Read the book ("Intimacy") by Hanif Kureishi. He hasn't got it all right, and it's difficult to like his abyssmally self-centred hero, but it's masterfully written.

John

* the big pulse in your groin. No, your groin.

Iron Man

Hail,
Underemployed at the moment - I think my pale, sweat-beaded face and my hoarse voice croaking out incomprehensible gibberish terrified the patients away. So today I am sitting in my surgery at Hogarth House, surrounded by my superhero posters, and I reckon I might write about Iron Man.

The superhero posters, by the way, are a new innovation. When I got here the room was decorated in Early Mental Asylum Blue, with eye-catching posters advertising genital herpes and domestic violence. After much psyching myself up, I snuck in one morning and put up my own posters. So now as well (and occasionally instead of) "Men, rethink your third drink" and "Oh No, I've got Chlamydia!", it's Daredevil and Ultimate Iron Man.

Daredevil would be close to my favourite. For those unfamiliar with the books, and only aware of the predictably uninspiring movie, Daredevil is a man who was blinded as a child by an industrial accident. Almost in compensation, this accident gave him heightened senses - he can hear heartbeats, smell fear, feel print on paper.

Now what makes him good? For me it's a lot of things. The way Matt Murdock has been written when the writing is at its best is as a complex and deeply flawed man. He is a selfish hero. He is driven by things he doesn't understand and which have some absolute control over some aspect of his life, things with which he will not negotiate. He is a deeply religious man who at some level appears to be punishing himself, and who seems determined to drag others along and down with him. He is given to inappropriate, destructive disclosures. Because of what he's done, the people he loves have suffered horribly.

But you can't help but admire him. Like many driven people, his courage, his ability to put things ahead of his personal safety, is remarkable. Plus you get organised crime, fight scenes and pretty damn funny dialogue.

I think if I had to say one thing about the character that impresses me it would be his vulnerability. If you look at Superman, Superman is an Apollonian superhero. He flies above the people he seeks to save. He is literally invulnerable. His skin cannot be pierced, his closest friends are not even of his species.

But Daredevil is a Dionysian hero. He's embedded in the lives of the people he is trying to save, he is intimately entangled with them, he sometimes knows them better than they know themselves. And this is not the distant overseer's knowledge, the human panopticon's calm weighing and discarding, this is someone struggling with and failing to contain his own internal demons who can almost literally feel the pain of others. And he's vulnerable. Bullets don't bounce off Matt Murdock, they cut right through and damage him. In the end he's not some uberalien floating above us, he's a blind man going up against people with guns, a lone man surrounded by powerful, secretive enemies, enemies who have already killed and crippled those close to him.

This is not coming out right. I was going to write about the Ultimate version of Iron Man, how Mark Millar has changed him from the relatively unheroic prospect of an invulnerably rich man in a super-powered mechanical suit to someone new, someone who needs the control and protection of a suit or armour between himself and the world. But it's hard to get this stuff across.

Anyway. I have better go get my stuff organised. Post again in a few days.

John

Chad amongst the Reptile People

A friend of mine, for the love of what must be a truly remarkable woman, has gone into the desert:

http://ch-ade.blogspot.com/

I don't know that he's enjoying it all that much. It's not like Jesus in the wilderness. No-one taketh him up into an exceeding high mountain, and sheweth him all the kingdoms of the world, and the glory of them; and saith unto him, All these things will I give thee, if thou wilt fall down and worship me.

Instead they taketh him out to an exceeding flat land, and sheweth him obese cowboys and aboriginal alcoholics, and the horror of them, and saith unto him "Here are tiny children balancing upon enraged animals and bookshops without books."

His blog entries have become increasingly un-nerving, and finally, tonight, I received confirmation of my deepest fears:

http://photos1.blogger.com/img/254/5554/640/Alice%20Gymkhana%20roadhouse.jpg

He has been captured by the lizard people of the outback. See their inhuman, grimfaced fanaticism, their casual attire, their hands on hips* insouciance? All too soon we will have the Prime Minister saying that nothing at all can be done, refusing to pull Australian troops out of the lizard people territory, and then these fanatics will shed more innocent blood.

Well, it makes as much sense as a lot of stuff. I think Chad should treasure this photo. Then, in the near future, when the lizard folk over-run an Earth made arid by global warming, you can produce this and say "look! We were friends once!"

Have you noticed how many isolated Australian towns have outsized ... somethings? I am not well travelled, but I've seen three big sheep (two ewes and a monster ram), a big orange, two gargantuan cows, several dinosaurs (advertising what local product I don't know - dinosaur costumes?), a small herd of giant horses (wooden, concrete and fibreglass) and I think I have seen a ten metre yabbie somewhere.

If I haven't seen it, it's a disturbingly clear mental image. Easy ten metres, all plates and pincers, a deady decapod, bristling and clacking.

Hmmm. If I didn't see it, wonder where that image came from. Probably an ancestral memory when I was some worm thing.

Hold on, back in a sec, there's something at the door.

[sound of someone walking off, opening door: a fury of bristling and clacking erupts. Narrator barely manages to stumble back to the keyboard, horribly mauled, to type:

"Aaaaaahaahahahahahahhhhhhhhhhhhhhhhhh" and expire.

END.

John

*Do lizards have hips? A free pancreatoduodenectomy to the first person who answers this correctly and manages to explain how they know this without incriminating themselves.

Okay, Im really tired. I'm sure if I just slowly back away from the keyboard, nobody else need get hurt.

John

Lobotomy Lad and Drawing Pin Girl

Hail,
Thanks for the comments. And in the tepid light of day, and after close on thirty six hours sleep (only interrupted by shuffling to the cupboard for drugs stolen from work - i.e.: half a packet of home brand paracetamol and some out of date phenergan) I suspect that things are not as crap as they seemed to be before.

So, not sick and not depressed.

I tell you what though, none of the credit for this can go to my patients, some of whom have been deeply depressing. A few days ago I had a new nurse at the prison and she mentioned some crime that one of the boys had done, which is the kind of stuff I go out of my way to avoid knowing. And so there's me looking at this guys dodgy wrist and wondering if he might have strained it when he and the other guy (who is no longer with us, having graduated to the Big House) HELD SOME BUGGER DOWN AND TRIED TO SAW HIS HEAD OPEN WITH A HACKSAW.

Apparently this guy owed him money or something. I don't know what they were trying to achieve by cutting his head open, dead men write no checks and I doubt they were going to flip up his up and find a crisp roll of twenties wedged between his cerebral hemispheres. Anyway, that was Lobotomy Lad. He got his wrist strapped and was told to take a few days off metalwork - presumably including hacksawing.

Later that day I saw the next disturbing patient. The precise details of Drawing Pin Girl's history are too horrible to go into, but she spent half her childhood in Furby Ward (the Paediatric Psychiatric ward attached to the Royal) and wears these special glasses now, because there is some part of her sight they were not able to restore.

I have always thought we have names for the class of people who are depressed, paranoid, anxious, etc., but not for the class of people who make them depressed, paranoid or anxious.

Well, that was a few days ago, when I met these two patients, and to a certain extent I'm over the horror now. I have arranged for the other doctor to see Lobotomy Lad (sounds like someone from the old Legion of Superheroes, doesn't it?) and I am referring Drawing Pin Girl to a paediatric psychiatrist. Ideally one who practices on Mars.

Tell you one glorious thing about an anonymous web diary. I can confess all these unsuitable emotions and feel cleansed. I feel like Midas' tailor: I have got up in the night, ran down to the riverside, dug a deep hole and whispered my terrible secret into it:

"Sometimes my patients just freak me out".

Thanks for listening,

John

Blocks and Tackles

Hail,

Irritometer's in the red today. Due to the additive affect of this virus coming in the middle of night shift I have slept all day yesterday, all last night and all day today and I still sound like a crapulous dalek after a gin binge. Everything gets under my skin.

I have tried to use this anger, like they said in that creative writing course years ago. I was going to write a list of "things that shit me", but I have started and deleted this entry eight times today, because each time I write down something about something I loathe I start to feel horribly guilty, so I delete it.

I think at some level I am worried that if I write down what I really feel about some people, then that person's feelings will be hurt. Just to be clear, we are talking about people like Marilyn Manson and George Bush.

This can't be good. I am sure it's not therapeutic. And I am sure that Marilyn Manson, a heavily made-up-and-even-more-heavily-marketed teenage pop idol who dresses as a bikini clad corpse, is not going to be staring at this page with tears rolling down his face saying "I thought John was my friend!".

It's a weird phenomenon. Every time I articulate one of these "critical of someone else"/"possibly impolite"/complaints about my lot/unChristian/unprofessional thoughts I freeze up and can't write. It's ridiculous.

Let's try it now.
So: things and people that I crap me.




Nope. Didn't work. Talk about inhibited.

I saw this book of peotry once called "Blocks and Tackles." Damn fine title, I thought. That's what life is like. That's why self expression can be difficult. You try to say something and the internal censor stamps on its head even before it's formed. More like an internal abortionist than an internal censor.

Hmmm. What do the preceding few paragraphs mean - things crap me that shouldn't normally crap me, the inability to articulate my feelings, disturbed sleep? Well, it almost certainly means that the tide is moving out again.

Bugger.

Don't know if I've used that image before, it's certainly not one I would claim to have originated, but it's a good one. The tide goes out and exposes the stuff we normally keep covered.

Well, we shall see. No night shifts for a few weeks, which is good.

John

The Not So Great Satan

And tonight reporting to you live from Florey Emergency Department.

Tis the night before changeover, and all through the ward,
not a creature is stirring, because we are bored.

Because it is a that increasingly rare phenomenon: the genuine quiet night. And we're all bored.

Well, not actually. My vomiting woman is bored with vomiting, and the mother of the croupy baby is bored with her child being croupy, and the devil child in cubicle three, who seems to have modeled his psychiatric symptoms on a combination of bad horror films and Marilyn Manson videos, is bored with rolling his eyes and muttering, and the charming, white-haired demented elderly man is bored with being charming, white-haired and demented.

I remember a few years back seeing a very pleasant man who had suffered a stroke, and had developed what they call "amorous dementia". He seemed quite lucid in every way, except that he was extremely pleased with everything. I walked into the room to see him and he stared and said "My God, you're a fine looking fellow, aren't you?". I asked him how he was feeling and he said this was the finest hospital in the world, and the nurses were jewels of women, every one. And when they brought him the sandwiches he waxed rhapsodic about them, and said that dignitaries and potentates dining in five star restaurants would envy him these sandwiches.

Now, he was extremely happy, deliriously happy, unreasonably happy and satisfied with his lot, certianly the happiest of men, but the neurologists had no hesitation in declaring him disabled. And he was. He was like a radio only tuned to one station, emotionally colourblind, or cognitively tone-deaf. His own extremely poor prognosis, the evident distress of his closest friends, his rapid deterioration - none of these disturbed his almost beatific joy. If he had been allowed out of the department, he would have been the most vulnerable of men, someone with all the street smarts of a teen girl on ecstasy.

Who would have thought that the capacity to feel disgust, rage and contempt was a vital survival skill?

Anyway, I can probably send croupy boy home now. Next entry may be about PAP syndrome, which is a damn fascinating neurological disorder.

Thanks for listening,
John

Sick

Hail, he croaks.

You know, I've been reading over some of these posts and it''s amazing how you can express yourself clearly and lucidly by typing in at one end and the machine turns it into incomprehensible gibberish at the other and posts it on the net.

Anyhow, don't expect my full eighty IQ points here today because I've got a virus. I was examining a baby and was peering into his mouth with one of those lights and a tongue depressor and the little angel coughed down my throat. So now I have a nose like a tap and eyes like Peter Tosh and I sound like Rod Stewart.

More hideous revelations from my musical canon later on. It's not my fault, my mum played this kind of music to me when I was an impressionable child. I read this study once where you get two groups of pregnant rats and while they are pregnant you feed one group food with garlic in it and the other food with onions in it. You stop before the ratlets are born, and then when the ratlets are old enough to eat solids, you sit them at table in front of a rat smorgasbord, and the rats whose mother ate a lot of garlic while they were in the womb prefer to eat garlic, the rats whose mother ate onions scarf onion.

Similarly, I think "Sympathy for the Devil" is the best song ever written.

Anyway, last night (three PM to about one AM) shift was reasonably run of the mill, except for the man who booked in looking for God. He wasn't actually my patient but the first I knew of him was that he had appeared at the nurses station extremely loud and angry and shouting in heavily accented Italian. I went over to the nurse's station and said "Can I help anyone" and he turned around and was appraently displeased with what he saw, and started advancing towards me. Not running, just a stiff-legged, incredibly tense, extremely angry kind of way, staring and shouting and pointing at me. I'm backing off with my hands in a "don't shoot me, I'm only the piano player" way and security are elsewhere on the premises, and with that spare few percent of my brain I was thinking that if I backed into an obstacle, like a bed or something, and he kept coming, then I was going to have to do something.

I can't bring myself to say hit him, but that's the absolute worst thing that could happen. That's something so horrible, assaulting someone who is not in control of what he does and who has come to you for help, but I tend to imagine the worst and ensure we're covered for that and then go on from there. Every mild twinge in the chest is a massive heart attack until proven otherwise, every headache is a tumour the size of a Moa's egg, and at some level I was thinking if he managed to place a hand on me I was going to have to do something.

I have never been so glad to see the security guards turn up.

What else?

Someone who'd had an endoscopy (where they push a lubricated tube down your gullet to look at your stomach, and maybe fix up an ulcer or snip out a bit of what's ailing you), two days ago and had been having sticky black poo and feeling increasingly crap ever since. So she was bleeding from the gut and she was also on a medication called warfarin, which is rat poison that stops your blood clotting, so she was looking and feeling fairly crap.

Luckily warfarin is one of the drugs whose effects you can reverse, as opposed to, say, aspirin. Anyhow, we had to transfuse her as well and they sent her upstairs.

Plus kid fell over playing soccer, kid dropped big sheet of corrugated iron on leg, man playing football did his leg in, croupy baby, croupy-sounding eleven year old and so on.

Anyway, it's paracetamol and fluids and a nap for me if I want to be fit for judo tonight before night shift.

Told you it wasn't going to be that exciting.

John