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.