Joy to the World

Well, tell you what. I love my job.

So what happened, after the crash course in management of the almost dead patient?

Well, I went in last night and it was good. Not quiet, not slack, but good, busy, a constant stream of patients, no lunch break, always someone to be seen... good.

And I had the English with me, articulate, competent, industrious.

And we had some interesting patients, a tall German backpacker who presented agitated and aggressive in the ED after a day long drinking session who started hallucinating and then turned out to have zero blood alcohol and something else entirely going on.

And we had a woman with small vessel disease (the tiny little arteries in her heart were blocking up) and a man with renal colic and a few croupy babies and someone who tried to stop one of those Bamix mixing things with her finger, and a man with a bleed into his head and a man with arterial blood squirting out of his head... stuff like that. And we fixed the up and we sent them home, or to surgery, or to medicine, for the others to deal with, now that we'd made it safe for them to handle*.

And while I slumbered wheels had been put in motion and ICU had been hauled over the flames and apparently everyone had agreed that yes, it was probably better that intubated, deeply unwell patients were looked after by people who were trained to look after intubated, deeply unwell patients - like, say, the intensive care people. And I was told it wouldn't happen again, and I said no, it won't.

And overnight I had worked out all the same stuff that anonymous posted previously in the comments bit, and then I came home and read someone authoritative sounding telling me what I already thought, which is always gratifying.

And I reckon next time I will be able stabilise someone as much as practicable and then call anaesthetics and ICU down and say "Let me tell you about your new patient", and do that and then leave them to manage her, while I get back to doing what I am able to do and they can't.

And all the nurses were wonderful, and the juniors asked sensible questions and did intelligent , competent things and it seemed everyone was on the same wavelength, everyone in some kind of harmony, everyone a machine for getting them in, fixing them up, moving them on, getting some more in. Until about six thirty in the morning, dawn outside, there were no more of them to get in.

And we had half an hour pretty much free at the end of the night, seven o'clock in the morning, and we all sat around for a few minutes and swapped stories of the last week - and I reckon I had it bad, at least I didn't get a 17 year old, hundred and fifty kilo drunk with about half a kilo of different kinds of drugs in his stomach and turn him into a 17 year old, hundred and fifty kilo drunk with about half a kilo of different kinds of drugs in his lungs. Or spray the walls with aspirated charcoal.

And it was glorious. And the English asked me only those difficult questions which I was able to answer, and we all worked together and grinned at each other like maniacs. And difficult patients with three separate violence alerts in their notes came in and I sent them away, everyone happy. And one of the younger nurses almost flirted with me, saying she'd arrange for me to have three personal nurses to tend to my every possible whim, which might have been even more disturbing of my tenuous equilibrium had she not been gay.

Or maybe possibly less. Sigh.**

"We few, we happy few, we band of brothers."

You know, it sounds weird, but that describes it. Henry V, Act IV, Scene III: "For he today that sheds his blood with me shall be my brother."

By God I love this job. Even when I hate it, even when it exhausts me and confuses me and frightens me and leaves me a few neurons away from panicking. I love it because with the ED, who needs BPAD?

My wife reckons one day they'll invent a new, powerful anti-psychotic and I'll take it and I won't want to be an Emergency doctor any more. I don't think they can do it. This here is powerful stuff.

I came home this morning singing in the empty house. Motown and stuff. "Ain't to proud to beg" in the silent kitchen, "I heard it through the grapevine" in the shower, howling to the startled chooks about my good, if tragically inarticulate friend, Jeremiah the bullfrog. Hollering and hand-jiving across the lawn, scattering cats like ninepins, giving the chickens three days worth of birdseed, because life should be lived abundantly. Chirpe diem.

Anyway.

And gentlemen in England now a-bed
Shall think themselves accursed they were not here,
And hold their manhoods cheap whiles any speaks
That fought with us upon Saint Crispin's day.

Thanks for listening. And thanks for letting me do this job.
John

*probable serum testosterone peak

** probable point of clinical disinhibition.

Breathe

Well, well, well.

What do I say?

What I reckon happens is your brain gets data - spots of light, the disturbance of a hair, a sudden change in temperature - and changes it into something else. What you have inside your head is a machine for turning data into stories. Stories that means something to us, important stories.

The spots of light become eyes staring from branches.
The disturbed hair on the forearm means a spider.
The change in temperature heralds supernatural danger.

That's how we're wired up. We take what's out there in the natural world and make it into something useful to us. We hammer and burn chunks of historical data into personal and communal legends in the same way we hammer and burn chunks of iron ore into surgical tools.

And why all this preamble?

Because I'm trying to write about last night, and at the moment, all I have is data.

Right. Some data.

Last night I was in charge again. This is the new order of things. Me and Pippi and Maad and a few others arrive separately on our allocated nights, ten pm, take handover over the next two hours ("And lastly, cubicle thirty-four is an eighty eight year old woman with three days of cough, sensation of fevers, malaise, who started vomiting today and the nursing home sent her in. Blood pressure was...." and so on) .

So I arrived and it was busy, but I had a good team. Stung by our recruiting failures from the Eastern States, some very bright spark decided to lure people from the UK to work in our ED. They arrived last week, doubtless following the promise of golden beaches and hours frolicking in the waves. Fortunately, shortly after they arrived a local resident was taken by a great white shark*, and anyway, it's bloody cold around here. So they've had nothing to do but work.

So finally the ED is relatively fully staffed, admittedly only in numbers, not in numbers of people at a particular level. The glorious world is come.

So, a good team, a very busy department, and all of the consultants seem to be treating the junior registrars like an endangered species - kind words, offers to stay back and finish off difficult patients, leaving late saying "call me if you have any concerns" - I felt like some kind of Lesser Spotted Goatnuzzler or something.

But come midnight, it's just us. Me and three of the English (oddly enough, at handover they were arrayed in some weird order - from the least knowledgable, who was small and blonde, to the more experienced: each progressively larger and more red-haired - as if that's what clinical medicine does to you in England. Or maybe like the main sequence of stars.).

And so that was the first half of the night.

But by four, things started to wear at the edges, and by five it had fallen to shit.

Prisoner in custody of police, head laceration, otherwise inexplicable photophobia. Photophobia is when you scream when someone looks in your eyes with a torch. You get it in meningitis, whether from disease, head injury or whatever.

Woman who only spoke Romanian, infection that had spread to her kidneys after surgery, blood pressure that wouldn't stay up no matter how much fluid we pumped in.

Forty year old man having a spectacular heart attack whom I never actually saw, treated by remote control and relayed messages.

Vomiting kid after vomiting kid, including the niece of one of the local psychiatrists, and the local psychiatrist had heard of me (in a good, "someone-who-worked-with-me" kind of way, not a "foaming-and-gibbering at the mouth" kind of way) and kept trying to ring through to the ED and ask me to jump his cheerful and vigorously healthy three year old up the queue ahead of the sick people.

Irritable renal transplant patient with his lungs shutting down, his heart failing, and his kidneys already gone, one of those cases where his heart needs less fluid but his kidneys need more and this particular drug will help this organ but knacker the next one and so on - and he was an irritable bastard as well.

And the frightening thing is I was only dimly aware of this all this time, because we were all in the resus room dealing with Mrs Tribulus, who came in and couldn't breathe.

This is where it all fell apart. This is the bit I'm having difficulty coming up with a story about. A lesson, a legend, a moral or something.

Mrs Tribulus had acute pulmonary oedema, APO. This means her heart was no longer capable of pumping her blood around her body, so the fluid was backing up in her lungs, filling them almost to the throat. If diseases truly were demons, as we used to think, this would be some pale, long-limbed thing that came silently into your bedroom at dawn and filled your lungs with foaming saltwater.

It's something deeply frightening for everyone - first and foremost Mrs Tribulus (cold, sweaty, becoming more confused, pale skin mottling) but also for us.

But of course, we're in control. We don't let it show.

Anyway, I did the needful, the basic stuff. Frusemide, to help her pee all the fluid out. GTN, to decrease her heart's need for oxygen. Pressurised air into her lungs. And it took us hours to get a line in her plump, cold, heaving hands, and she was so sweaty the ECG dots kept falling off, and ...

and she wasn't getting any better. She was getting worse. More tired. More slow. Heart-rate up at one fifty, only so long that can keep going. Confused.

But anyway, I knew what to do (even if I am still sometimes too slow in doing it). Call a code - summon anaesthetics, ICU, medicine, X-Ray, get things done. Because this woman needed intubation - the whole paralyse and plastic tube thing.

I'm going to skip the rest. How we called code blue, and no one came, and we called again, and no one came, and then a nurse came and said no-one could come, and I sort of realised in the back of my mind that things were pretty crap out there in the rest of the hospital. And then eventually ICU came, (and he'd done one term of anaesthetics a few years back, and I had done none, so that meant he was in charge), and how eventually anaesthetics turned up, sneering and muttering, and fixed up our deeply dodgy intubation, and fled again, and then ICU had to go, and that left me, with a patient partly sedated and inadequately paralysed, and instructions from ICU to use certain meds and not others, and a woman who kept trying to pull the tube out of her throat, and who wouldn't get her blood pressure up and her heartrate down or her CO2 up, and only using one medication, a sedative, that neither relaxed this woman's muscles or relieved her pain.

Christ knows how she, and we survived. Seven thirty the consultant arrived and all began to slowly become right.

Moral: I don't know. I shouldn't have been left with her, with two of the only three remaining drugs I had ever used in this situation prohibited. I thought I knew what to do, but I wasn't that familiar with the drugs I would have had to have used, and I had been told expressly not to use one of them when I brought it up, and so I was stuck. I am not trained in the management of the intubated patient. I wouldn't leave the anaesthetics reg. to manage a bloody heart attack.

I don't know. That was the worst situation I've ever been in at Florey. What do you do when they say "If you're out of your depth, call" and you've called and people don't come or give advice on how they'd do something (the ICU way or the anaesthetics way) and then leave? We kept calling codes and the anaesthetic guy (who was busy) didn't come. What do you DO?

Okay. Panic off. Start again in one hour. Use last hour to revise use of rocuronium, the medication I reckon would have solved all this. So that if this happens tonight, and if what is supposed to happen does not, I will at least be able to manage things our way.

Thanks for listening,
John

*true

Get with the programme

Very quick note today.

And why is that? I imagine hearing you ask.

It's because tonight and tomorrow I embark on my "stop whining about your life and take your own bloody advice" anti-depressant regimen.

This is a carefully crafted programme of selected exposures to appropriately hedonogenic stimuli. In no particular order, and with much potential for repetition, and with no particular time constraints, these include:

A bottle of Merlot.
Watching the Fourth Test Ashes (the hundred odd year old cricket competition between England and Australia) with my brother.
Watching the new Dr Who video.
Bocconcini.
Green apples.
That lamb shank thing my brother cooks.
A late morning lie-in with my beautiful wife.
Yum Cha.
An umpteenth re-reading of Much Ado About Nothing, Shakespeare's single most enjoyable play.
That Italo Calvino book about Venice.
That other book about Venice.
Watching Minority Report, plus the LOTR films, Singing in the Rain, My Fair Lady and maybe some old Judo with my eldest son.
Ultimates, Daredevil, those creepily good Grant Morrison comics, and League of Extraordinary Gentlemen.
Starting back at the gym.
Starting study but at a reasonable, unpressured pace - that whole knowledge for curiosity things I used to have.

It's weird. I've got this whole "get life back on track" thing at the moment, since I went in and told the consultants that Iskandar had quit and Pippi was going to quit and I had this great new job offer and there were going to be changes either in the amount of work the junior registrars were doing (less) or in the number of junior registrars (losing the last few and ending up with none). And that this wasn't me begging or threatening or imposing any kind of ultimatum, it was just what was going to happen.

I feel weirdly at peace.

Wonder who I've got on with me tomorrow night?

Thanks for listening,

John

A Tale of Two Sickies

Well, a certain theme runs these recent posts. But we shall see.

I have decided to give this a couple more days and see my specialist, or to see him tomorrow if I feel bad enough not to work. And I'm not looking forward to the whole thing. My psychiatrist (and God I wish I could remember what pseudoname I gave him) is very good clinically, but he seems a very decent, comfortable, moral, someone utterly unfamiliar from a personal point of view with the self-loathing that depressed people get, and I find it hard to speak frankly to him about what I am sure are my moral failings.

Good God. I think for the first time I understood there why patients ask drug and alcohol doctors if they have tried drugs, or ever drunk too much, or why psychiatric patients want to know if their doctor has ever been depressed. It's easier saying you can't cope and that you're a failure to someone who isn't perfect.

We were sent to a seminar that covered, amongst other things, the junior "doctor in difficulty" (DID). One anecdote stands out, and uncharacteristically for me this one has an almost happy ending.

Junior doctors get rotated around the wards in ten-week blocks: ten weeks in surgery, ten doing med nights, ten doing paediatrics, etc. Med nights is both the hardest and the most isolated of the rotations, and Shipton at the time was one of the more challenging hospitals to work on, so naturally our story unfolds at Shipton, med nights, late nineties.

Dramatis personae: Andrea and Bethany, best of friends through medical school, inseparable out of it. Half way though the year the respiratory consultants and registrars had their meeting and the subject of intern mental health came up.

Because everyone could see there was a problem. Bethany was turning up late. Her work, initially good, was increasingly sloppy - unfinished drug charts, scanty notes, inadequate handovers. She seemed to lack confidence in her ability to do the job, nursing staff said she was occasionally terse, one of them had caught her crying on the phone. There had been some boyfriend trouble.

Andrea, on the other hand, seemed to be coping with the situation relatively well. Her self confidence had grown, she was calm, confident and concise in her patient care, she looked to be doing well and going far. She was obviously coping with a very stressful situation because although the two girls were never rostered on together, Andrea's day shifts followed Bethany's nights and vice versa, so each one had to clean up the other one's mess. And you can't take sickies on med nights, because it's a week of nights alternating witha week of days and if they can't find anyone, the other person has to do some kind of ubershift to cover you.

But Andrea seemed to be coping well.

And the consultants and the registrars talked about it, and one was delegated to have a chat to Bethany, but it was winter, a very busy time, and just before Dr Sook could say something, word came that one of their interns had taken a potentially fatal overdose and had been admitted to another hospital with major depression.

And of course, it was Andrea who'd overdosed. And if you want to take an overdose, don't take one when you share a room with a good medical intern, because she will come home, find you asleep when you're meant to be driving to work, note your vital signs and put two and two together faster than Deep Blue.

So, what had happened? Why had Andrea looked so happy, seemed so confident? Well, partly because depression is a weakness, and it's one she had felt she had had to conceal, and one she had concealed through much of her life very well, because she was, after all, very very smart. And you are just expected to go from a life where everything has always gone right to a life populated by wide-eyed cripples drowning in dry air.

And Bethany so tired? Because she'd been carrying Andrea, writing her drug charts, checking her patients, rewriting her doses of steroids. She'd done it often through medical school, and now she wasn't going to give up on her friend when she needed her. And she wasn't going to tell anyone she was carrying Andrea, because that's not what friends do, and she certainly wasn't going to tell any of Andrea's assessors that their favourite intern had developed clinical mental illness.

Anyway, they had two sickies that day, the med night was in the Royal getting NAC for paracetamol poisoning and the med day was basically just too tired and upset to do anything. And it all sounds very Readers' Digest, but the thing about some successful people is that by the time you see signs it's often late in the day.

One of the many reasons doctors are so successful at killing ourselves. No tolerance for weakness, no experience of how to cope with our failures and mistakes, deeply self critical, no desire to live as one of the dependent, horribly ill people we see, and access to vast amounts of painless, guaranteed lethal chemicals.

Anyhow, thanks for listening. I am going out to feed the chickens.

Not that gripping today...

Well, what to do, what to do...

A lot been going on.

One thing, there isn't that good a correlation between blog posts and author moods. I tend to be more open in my blog than in my normal life, and I tend to write about (and thus think about) things that upset me, and so the average emotional content of the blogs is certainly more extreme than my normal life.

Having said that, moods have been down for a while, and I don't know that the valproate or the reboxetine are working well enough. Nor is the boxing or the writing or stuff. I wake early, I feel bad, I panic, I've got the whole "intrusive thinking about death" thing... all that. Next step I have to go up to the dose of valproatte that makes me both nauseous and hungry, or the dose of reboxetine that maketh me not as a mighty tower, tall and strong.

Nauseous, fat and impotent. That ought to cheer me up.

Thing is, depression is a complex beast. I've never been fully comfortable saying "depression is a disease like any other disease". That's true in one sense. I tell clinically depressed people that they have a disease, not a character flaw or a moral failing, and that like any disease, there are treatments. And that's true - people who get appropriate psychotherapy and appropriate medications do get better.

But depression is also a response to a situation. I tell people about the differences between, say, reboxetine and street amphetamines, and the most important one is if you feel miserable and you take reboxetine it does you no good at all. It doesnt' make you happy then and there, it only works in a few weeks, and it doesn't really work against misery, grief, sorrow or guilt. It works against the mental illness depression, which resembles some of those, but is different in that the feelings are inappropriate - you feel miserable when you should be happy. You feel horribly, crushingly guilty when you should feel good. You cry and you feel something like sorrow, or you feel nothing at all, when you can't find a need or an explanation for the sorrow.

But there are a couple of things wrong with that last paragraph. The one that worries me is the temptation to try to medicate away something that is not a medical problem, but at least partially a response to a situation. A woman in her thirties comes to me. She says she loves her highly paid, prestigious job, that her husband is a saint, that her life has been remarkably good... but in the last six ro so months, she's started feeling sad. She doesn't sleep, she worries instead. She's started putting on weight, she eats crap food then feels bad about it. She feels guilty, and she's started to avoid seeing her friends. Lately she's begun to wish that maybe there was some way out of all of this.

I could have her out of there in minutes. Does she have the symptoms? Check. Have the symptoms been there for long enough? Check. Are the symptoms not able to be better explained as bereavement, etc. ... well, that's what the crazy person says, isn't it? Check.

Is she depressed? Quite probably.

But is there something else going on? Is her job all that she wanted, all that she was told? What if she's got to where she wanted to go and she's not where she wanted to be? And what if she can't say so, because, for God's sake, she's got the good job, the good husband, the good life, the whole gold star on the colouring in and the elephant stamp on the sheet of sums? What if there is something going on, what if it doesn't mean much to her because it doesn't mean much? What if the part of her that realises she's got a job and a relationship and a life that she should love but doesn't.. what if that's the part of her brain that won't let her sleep? What if it's making her fat because it can't stand him finding her attractive and she wants out? What if the guilt is the unarticulated but obvious response to not feeling and wanting and taking pleasure in what should satisfy you?

Will she get better on the drugs? The evidence suggests she will. And they're good drugs, they've made a lot of people better, they save lives. I've seen it. And with the anti-psychotics and the mood stabilisers I do not have this concern. And I believe that the drugs can treat the pathological side of things, so they can get you well enough to solve your problems, and if that solution includes leaving your A-list spouse and living as a goat on the mountainside, you're more likely to be able to do it medicated and thinking calmly than not. Because depression, while it may be a response to a situation, is not an intrinsically adaptive one. Beaten wives, all that kind of thing.

I don't know. One day someone will come up with a new antidepressant - Stepfordamine. It'll be more powerful than the others, the side effects will be relatively acceptable, and it'll home straight in on those parts of the brain that in happy content people fire more often than the rest of us. Husbands will give it to their wives and they will love them like they did in the beginning. Anyone who reckons something like that wouldn't fly off the shelves, go to the back of the class. Save some seats for those who reckon stepfordamine is not coming in their lifetime.

We shall all be saved.

Sigh. Anyway.

Speaks to self: If you've got to where you wanted to get and you're not where you wanted to be, it's not like you're a fucking cripple. Get up and do something about it. I took today off, I'd done overtime Tuesday and Wednesday and Friday I start nights. That's a start. Tonight I see Sarah. I will write today.

Thanks for listening. Hopefully tonight I can post the truly Sherlockian "Strange Tale of the Depressed Intern", and what was said at the registrars meeting (much more exciting than it sounds) and try and work out what to do for this Friday night, when I may be in charge.

The Night of the Long Stockings

Hail,
Well, back from a weekend shift and a lot going on.

I started at seven in the morning today. I dragged myself out of bed (not entirely hungover, but neurons still crackling from the glorious football) and hunched my way through the rain to the ED. I sortof shuffled past the waiting room (only a few people waiting), grabbed one of those coffees I advise other people to cut down on and sat down next to Dr Longstocking.

"Screen looks good" I said. "How's it been?"

And she burst into tears. And the next half an hour (I wasn't there for all of it) she explained to the senior consultant Dr Van (via sobbing, and gesturing, and wringing of hands around imaginary necks), what overnight had been like.

She'd been on with three others. One was a GP trainee. General practice trainees are good at seeing everyday problems ("This lump on my ear..."), and that's often all they do overnight in the ED. This one didn't do a lot of that, because he was basically disinclined to work. And I can understand him being nervous about his capabilities to do what must have been a very challenging job, but presumably he was less nervous spenidng the money.

One of the others was Wmbesa, a doctor who appears to have evolved on another world where the gravity is much weaker. He moves with almost treacle-like slowness. The first night he was on I remember watching him flow from one cubicle to another like the Blob. In ten hours he sees two ro three patients. He does buggerall.

And lastly she had Dr Rookswen. Dr Rookswen is not like the others - it cannot be said that he does not see patients that he should see. Rather he sees ones that he should not, because he is dangerously, frighteningly, almost "slapstick comedy if it wasn't real life" bad.

No words, no hyperbole, can adequately illustrate this. One example - he's the guy who saw a kid having a seizure and turned out the light to help it relax. So it could choke and convulse in the dark.

No, none of us believed it either.

He is meant to be working under one-on-one supervision. He has been sent down here because he is too fucked (my boss's term) for any other branch of medicine. He keeps trying to escape and see people independently, but normally we can track him down and stop him.

But last night Pippi's there with three imbeciles and more than ten priority twos (really sick people who have to be seen within ten minutes) and a priority one (someone who is dying and has to be seen now) and a waiting room full of people and basically did 90% of it herself.

And first she was seeing them because they were human beings in pain and then she was seeing thembecause they had to be seen and by four in the morning she was seeing them out of fear of them dying (all nobler feelings having fled) and by seven thirty she was seeing them out of whatever spinal reflexes move you around when compassion and fear and conscious thought are gone, but still not far enough gone to let Rookswen moved about unobserved - she sent a nurse to watch over him, much to his chagrin. And nobody died on Pippi's shift, but by God it was a near run thing.

Anyway, this morning Pippi melted, and said she will not be here in a few months if significant changes are not made, and that she does not believe they will be, so she's looking around now for other jobs.

And she is the best doctors we have amongst the juniors.

I don't know. Sometimes I feel my whole profession is imploding.

That sounds stupid, but emergency medicine - I don't know. I believe at some level that we have to do it, that a society or a community or whatever the fuck we are meant to be has some duty to do this. Provide basic medical care for those who cannot provide it themselves.

But in the last few years it's gone horribly awry. The local GPs (that's the family doctors), they all charge now. Twnety five dollars minimum to see a doctor. A lot of people in the greater Mordor-Slytheryn area can't pay that. And I don't give a rats arse whether it's "can't" or "won't", in the end if you're old or you're a baby and you have pneumonia and you don't go get antibiotics, you die.

So the sick, in increasing numbers, come here, where there are decreasing numbers of us to look after them. And it's starting to show - we have more junior doctors, more foreign trained doctors... I worry that we have more questionable doctors. Because we're desperate, and if you're desperate, you'll take anyone.

I don't know. Of the junior registrars I started out with, several have gone. One is definitely still in the training programme, she's that kind of person, emergency medicine material. Another is deeply unhappy, looking to transfer to cardiology or something - and smart enough to. Dr Maad is not really in training. Dr Iskandar has resigned and gone to Queensland and will never return. Pippi has children who want to see her and a husband who almost left last year - she knows there are other positions, places that offer forty thousand dollars a year more for easier work.

And me. I'm part time. I'm not one of the common ED personality types - my boss did a bit of research, got the consultants and seniors to do that Myers Briggs personality test. A disproportionate number of ED doctors are thinkers rather than feelers, extraverts rather than introverts, sensers rather than intuitors, judgers rather than perceivers. When they did the study they published the results on the ED noticeboard. I went and looked it up and my personality type (I think it's INFP) is represented by a smallish proportion of the general population but precisely no other ED doctors.

And I have a wife and children too, and stuff I want to do.

I know it's stupid, but that baby still gets to me. You know, the one that wouldn't breathe, the one I thought was a doll. And I don't know what I'm doing, typing all of this out to a doubtless rapidly diminishing number of readers, maintaining an online record of what is likely to be some kind of breakdown, but I keep thinking about it.

I am a thirty eight year old Australian man, I have more degrees than a thermometer, a father and a doctor and allegedly one of life's winners, and I am ALWAYS at some level afraid.

Is this what it's like for everyone else?

Anyhow. No-one has died yet on "my" shift, no-one has died who wasn't going to die. And no complaints against me personally, and no legal action.

Deep breath, calm down. Truth is, I don't know how much longer I will do this. I feel selfish saying it, but I don't know if I am going to keep doing this. I love doing the job, a few days ago I saw this guy brought in with acute heart failure, pale, labouring, so sweaty we couldn't get an ECG on him... and it all went bloody well. We kept him out of ICU, he ended up being able to talk and eat instead of being intubated or resuscitated... and it felt good and it worked well.

And I love the staff, nurses, doctors, everyone. I love the community, the cameraderie, the sense that we share a common understanding, that despite ER and Chicago Hope and all that we are a closed circle. And I really love seeing patients, and I love it more as I get better at it.

But I don't know. I have to do a year non-ED, that's next year. Maybe it's for the best. Next year will be Hogarth House and Something Else - psych, paeds, drugs-and-alcohol. Nine to five, good pay, easy money. And an option to stay as long as I like.

It's hard now to imagine not doing ED. But I reckon next year it'll be hard to go back.

Thanks for listening, too.

John

The post apocalyptic

Hail,
I will try to make this calmer and cheerier reading than the last meltdown. Been doing a lot of thinking.

First, I'm going to learn to stop worrying and love Dr Zhu. This is not only because I have posted my plan to murder him on the internet, and thus am likely to be amongst the first suspects if his stoat-savaged body were to be found in the dairy section of a large metropolitan supermarket.

It's not because he's not crap, because he is, sadly. But it can't be easy for the poor bugger, being crap. It's stressful being in a new job, it's stressful being crap at your job, it's stressful being in a new job where you're crap and everybody knows you're crap and you know everyone knows you're crap. So, back to doing my job, which is actually to help him get better (while minimising the distress he causes my patients).

So - I might not be able to manage zhu-philia, but I can at least become zhu-tolerant.

What else? Next year's job may be worked out - I have to do a year of non-Emergency stuff. I was thinking paeds or psych but may have glommed a rotation working with drugs and alcohol addiction. Good hours, people who don't die on you, low stress, time to pass the exam or maybe write the novel. The good thing about this is I can have an office affair, because I get to see my wife at meetings.

And I was reading this remarkable article in Harpers the other day about the weirdness at the heart of Christian America, and I had an idea.

Say you wake up one day in a foreign country. Through some Doctorwhovian gift you are able to read the local newspaper and understand the conversation of people in the street. All that you hear is good. The newspapers and the passers by speak glowingly of the courage of their soldiers, the inspired actions of the nation's leader, the fervour and nobility and unquestioned faith of the people. Flags hang from every house, the leader's portrait is on every wall, the young sing patriotic songs.

What can you immediately deduce?

You know you're in some totalitarian hellhole, under the boot of a third-rate thug.

Alternatively, if the newspapers are full of scandal and impropriety, the man on the telly is denouncing the finance minister as a fool and a liar, and every taxi driver regales you with his plan to drag this country back from the abyss into which it must otherwise plunge, then pitch your tent, you've found a paradise.

Well, maybe its the same with George Bush's America - which, from what I can see, is very different to the America many of the people I know live in - George Bush's America and Christianity.

By the way, my football team won this week. I watched it with my brother and a dwindling cask of red. Two hours of shouting, cursing, brawling, drinking, clutching at the sky and hurling myself on the floor in abject prayer... and finally a textbook goal on the siren to get into the finals. My larynx hurts. My knees are bruised. I'm drunk and hoarse and I think I had a some sort of focal seizure back there in the third quarter. But by God it's good.

John


*Favourite Doctor? In some ways the current (ninth) one - dark, damageable, obviously lonely. But then there's Jon Pertwee (the patrician dandy) or Tom Baker (the goggle-eyed one with the voice)... no, it'd be the current one.

I've enjoyed moments in this last series so much I've been embarrassed to tell people. Honestly, there's been goosepimples, tears in eyes, leaping out of chairs, cheering, watching while gnawing back of hand, watching entire episodes standing with your arm holding the tv antenna wire against the curtain rod...

Seriously. Episodes like the original Dalek one, the Blitz one, Father's Day... my friend had them all downloaded free from the Internet before they came out here, and I wouldn't watch them, and I went out and bought them myself. And that line in the Empty Child where the Doctor (in 1940s England) says to the Brits "Don't forget the welfare state!", I turned to my wife and said "See!! He knows!! He knows what's going on!!". Later on I realised that I couldn't actually prove that super-intelligent benevolent extraterrestrials opposed the election of the conservatives, even if we all know it's true. But if that's not suspension of belief, I don't know what is.

John

Imagine a peaceful river...

Hail,
Another long absence, this was meant to be a nightly thing.

And night it is. Eleven oclock, the family in bed, the dishwasher and the numerous cats purring, and me full of that post-breakfast high as everyone else settles in for the night.

Lots been going on.

First off, not for the first time I wish I didn't have to be anonymous in this thing, because I have some quite gloatworthy news. In my idle hours I write stories. A year or so ago I came home from nights and hammered out an eight-hundred word story and sent it off to an internet magazine. They don't pay but the editor seems like a nice guy, we have promised each other a beer if we are ever in the same state, and it is supporting Australian SF/fantasy/horror. Good looking site too.

Anyway, a few months ago I got this call from this guy and he's editing an anthology of the year's best stories and he wants me in it. Me along with this guy called Terry Dowling (one of my all-time favourite authors) and several others. Australian SF is a small pond, but within this small pond there are several biggish names, and they are in this book.

And so am I. First professional looking publication, the first actual book. I've got a copy of it here now. I was so excited I rang a series of three people:

First phone call (ten forty three pm)
Me: Guess what! My God! I can't believe this! Oh my God! I've got the book! I've got it here!"
Him (appropriate glee and praise)

Second call: (ten forty eight pm)
Me: I've got it! The book! I've got it here, I'm holding it! My God!
Her (appropriate noises, goes back to sleep)

Third call: (ten fifty two pm)
Me: God! Guess what I'm holding! Guess what I've got in my hand! Oh my GOD!"
Her (suspicious): ...who is this? why are you calling me?

Well, it was funny at the time.

Anyway, a story in the book, a poem in consideration in a good Australian SF magazine, several stories yet to be rejected... things are looking good. If the poem gets published I may post it here, if I can.

What else. Well, for the first time I was in charge overnight at Florey.

And lo, the sky did not turn red as blood, and an angel of death did not move amongst the scattered people of Fang Rock and South Slytherin, and the Lord did not send plagues of boils and carbuncles and strange fits to discomfit mine patients.

The Lord sent an alcoholic who woke up in the ED and grabbed the nearest bottle and down it, thereby depriving us of about 250 ml of betadine antiseptic wash, and a woman who I sent off to ICU with a provisional diagnosis of Some Weird Shit Happening (deeply strange arterial blood gases, breathing like a bellows, no meaningful history because she was confused and sick and her husband was, sorry, bargain basement stupid), and a series of nervous women with chest pain.

But none of the chest pains turned out to be cardiac, and the Lord did not send me a choking baby, or a septic kid, or a woman in end-stage labour (well, He did, but we diverted her to maternity), and the Lord did not cause any of my psychiatric patients to wax wroth or any of my inpatients to take overdoses. Except of betadine antiseptic wash.

Right. Here goes.

A few days ago, almost a week, a Bad Thing happened.

The following is very bad stuff. The usual warnings apply.

A friend of mine was triage nurse. Triage is the worst nursing job in the hospital. You get to sit behind this big thick glass screen (recently installed) with a security guard (recently installed) behind you, and it's your job to assess people in order of urgency and let them in according to the ED capacity.

Since we are almost always running at full capacity, this means people have to wait. And waiting times can be horrendous - the six hour wait for priority fours a fortnight ago was not even remarkable, the ten hour wait the last night I was senior on at Shipman was more like it. So Pam (brisk, slim, early forties, northern English, remarkably competent) is there and there's a lineup, five people waiting in various stages of irritability because they haven't even got to triage yet and the waiting room has fifty people in it. Here's her writeup:

1744: 44 y/o man with eyepatch, welding, now c/o flashburn. No safety glasses but denies foreign body. P4

1746: 16 y/o, playing football, eversion injury R ankle, able to weight bear. P5

1747: 88 y/o woman, some lower abdominal pain, no nausea/vomiting but anorexic, constipated five days. P3

1750: 22 y/o woman, unprotected intercourse three or four days ago, seeks emergency contraception. P5.

And 1751 was this skinny, dirty, tired looking woman clutching a little bundle over her shoulder, occasionally patting it. She looked up at Pam and said "I think my baby's not breathing".

Things exploded from then. I can't communicate how fast things happened and how slowly they seemed to happen. I was out the back, they called a paediatric code blue, I heard the buzzer and since I was closest to resus I was first doctor out there.

Pam had laid the baby on its back on the resus trolley, started CPR, but it didn't look like a baby. It looked that dull, pale, plastic colour, like a lifelike doll. When you do CPR on a baby it's tiny movements of a single hand or a few fingers. We got high-flow oxygen going, then the consultants arrived, Dr Quinsy, Dr Shingle and Dr Blight, and all of a sudden the room was full.

Paeds reg and paeds consultant turned up and I got out of there, but I kept coming back to see now things were working out. They worked in there for three hours. The kid came in dead and they got him back and he died again and they got him back - tiny heart spasming in useless movements, no blood flow beyond us pressing his tiny chest - and he died again - and by God after three quarters of an hour they got him back. And the tranfer team from the Princess arrived and they took him down the road.

And in the end they couldn't hold him.

And an hour after that Dad's heroin had worn off and he turned up asking why we'd called him.

Why am I telling you this? I don't know. It's none of your business.

Tell you what. This is what I fear. The sick child.

Sometimes I get a clearer image of what is ahead. I have practised medicine for four years. No complaints upheld against me. No legal actions. No-one who died who really wasn't going to die anyway. No dying child who won't breathe.

But this is all coming. I know if you roll a dice enought times you get a six, if you keep spinning the chamber and pulling the trigger, a bullet will find you. Sooner or later, that's going to happen.

Once or twice in my life I've had this thing like they write about in books, things you see before you when you close your eyes, things that come into your head unbidden. That baby boy, the colour and look of plastic.

I feel as a certainty that is coming. I don't know. It won't be that, it may not be a baby. But you stay in this long enough, there's going to be something that you do wrong. You have to cope with that. You have to think of the good you do. But that is the shape of my fears.

But the first few days after that happened I couldn't get that image out of my mind. Christ I wish we could have done more. These aren't sensible thoughts, I know. But I have ideas of this happening on my shift. I don't know. I get this idea of a preventable death, something involving a baby, and then there's just this blank, this scene where I just go, leave, stop all this, get on a bus and go into the desert.

I don't know, he says for the hundredth time. This doesn't make any sense to me, to any conscious part of me.

Rather than write and reveal more I am going off to sleep.

Thanks for listening.

Frustrated

Hail,
As usual, too long between posts. I originally started this as a bit of an experiment, and so that later on when I want to write my book I can refer to this... but it's been slow.

Anyway, whine switch off, on with it.

What has been happening?

Dr Zhu continues merrily on his way, his face unlined by the cares that disturb the equilibrium of many of his peers. He is enjoying the job, he says. It makes him happy. He would like to do more of it, not full time of course, but as an occasional thing, once he is qualified as a radiologist. He likes working with young people and their "funny little problems", it makes him laugh as he wanders along the corridor, shaking his head. It makes him smile, he muses aloud, how "what seems so big to them is really so small".

I'm going to kill him. You heard me. I mean it. I can get away with it, all I have to do is write myself a sick certificate saying I was completely nuts at the time, and I'll be right. And I'm a doctor - none of this "left for dead but managed to crawl to ..." shit. Dead in this case will mean certifiably, irretrievably, beyond shadow of a doubt, dead. Not for resus.

Hahahahaaaa - that was me practising my manic laugh. Convincing?

Wish I could do fonts on this thing. Big flaming gothic letters that bounced up and down.

Anyway, back to my murder plan. I've got it all worked out. Unfortunately, the plan seems to involve a large amount of creamed cheese and more trained weasels than I can get my hands on at the moment, but that's just a supply and demand problem. I'm sure weasels are readily available on the Internet, as are martial arts instructors who are at least willing to attempt to train weasels.

Note to literal minded: I am kidding. I don't really mean it.

Heh heh heh...

I am going to look this up in DSM 4. DSM 4 is the diagnostic and statistical manual of mental illnesses, version four. It describes the commonly accepted features of the commonly accepted mental illnesses. It's quite fun to browse through it and recognise everyone but yourself.

DSM III, I believe, might have had homosexuality as a mental illness. I don't know what DSM II was, I think DSM I was the Malleus Maleficarum.

One thing DSM II might have had was hysteria. As we all know, hysteria is an attack of womanly irrationality brought on by movement of the womb (hence the "hyster-" prefix). It describes the kind of swooning, sobbing, ankle-twisting, petticoat-tripping, ridiculous behaviour that we see women all the time. Strangely absent from DSM II was the male version of this gender-specific insanity. I have decided to remedy the gap in medical knowledge and call male-only madness "testeria".

When a sixteen year old boy with the alcohol tolerance of a hummingbird decides to chug a yardglass of vodka on his birthday, suspect testeria.
When someone will meander about in the trackless desert for hours, encountering strange tribes and hearing the beat of savage drums, rather than stop and read the map book he has on the passenger seat next to him, suspect testeria.
When a man's sexual advances are rejected and he decides that the woman he pursued must be a lesbian ... and then persues her even more avidly because all lesbians are hot (double points if Asian)... suspect testeria.

Anyhow. More later.

Thanks for listening.

John

Nothing to see here...

Hail,
Tried to post some stuff before and it has vanished into the ether. Sorry about that.

Well, lots been going on including a Significant Event which I will talk about later once I've got a few things clear in my mind.

I went to see my boss today about my hours. They are nothing like as bad as people (i.e.: doctors) say they are, they are absolutely nothing like as bad as they were ten, fifteen years ago, but they are starting to grind me down a bit.

Hogarth House is half-time, and half time means nine to five, thirty eight hour fortnights, no problems at all. Nineteen hours a week.

Florey, on the other hand, is meant to be half time. But it's actually slightly more, comes out to about twenty hours a week plus four hours of Tuesday tutes plus two hours a week primary tutes ... that's about forty five hours a week. Plus the truth is no-one ever gets out on time, it's an absolute minimum half hour overtime each shift and usually closer to an hour, so that pushes it closer to almost fifty hours a week, plus (allegedly) study. It's not fifty, but it's not that far off.

And the thing is the shifts...

By the way, I remember reading about a woman who placed an advertisement in the phoe sex section of the newspaper or wherever that said "Hear me moan!". And people who called were treated to a tape recording of her complaining about how her husband never did any work around the house. I found this disarmingly amusing and now the phrase has entered our family lexicon. So, "hear me moan" about my job.

Anyhow... the shifts have been a bit nasty lately. We are desperate, and desperate people do desperate things. One of the desperate things they do is ring you up at short notice to ask if you'll do a shift: "Hi, it's Janey at reception. Pippi's come down with the scruples and Maad's rung in with fulminant proctitis, and the new RMO's been kept back after school. So could you please please pretty please come in tonight?

This is why some people at Shipton used to start drinking when they got home - because you can't work if you're intoxicated.

Anyway, remarkable insight and wit is sparse on the ground at the moment. The moods remain a bit substandard, but I suspect this is not something intrinsic, more a reactive end of winter thing. We shall see.

Thanks for listening.

John

The wonder drug

Hail,
Very brief missive here, a few minutes before I dash off to Florey for the evening shift. It's been cold the last few days, it's raining now, and I reckon teh meds need adjusting.

Well, I hope they do, because I adjusted them myself this morning. We shall see.

I am not entirely sure what's brought this on, if indeed the moods respond to anything internal. I've been trying to work out what to do next year, and whereas in normal people choice is something usually pleasant, I tend to get a bit paralysed by it. That's why I normally like Emergency medicine - when someone's heart-rate drops to thirty, your choices are ultimately pretty simple. Anyway, I've been ringing around the various hospitals and disciplines asking them if they want someone, and generally being agreeable and pleasant, I think at the end of it all I'd promised to work next year in psychiatry, emergency, anaesthetics and paediatrics at four different hospitals scattered throughout the metropolitan area.

Anyway, next year will be psychiatry at Shipton.

I have almost certainly revealed my "contagion" theorey of mental illness beforehand, but if not, here it is. An insight of Pasteur-like proportions:

All mental illness is spread by tiny infectious particles, called crazons.

I developed this theory after my first psychiatry term, when I noticed the depressed people made me depressed, the manic made me feel damn good, the anxious made me anxious and so on. I got so I hid from the avoidant personality types and wanted to smack out the antisocials.

It couldn't last. I eventually realised the paranoiacs were plotting against me, and I had to go to my boss and tell him if I spent any more time with the people with borderline personality disorder I'd kill myself and they'd all be sorry.

Anyway. We shall see. Next post may be about the aliens among us.

John

By the way, we were having a "You reckon that's stupid?" discussion the other day and I reckon I won, with my shamefaced confession that until about three years ago, I believed Tim Curry and Tim Rice were the same, remarkably talented person.

And now for a word from our sponsor...

Hail all,
I will try and find out what the Saudi reg said to the nurse after "The trouble with you Australian women". I think my mind sortof stopped after the first few words of that sentence and refused to process it. I think it was something about knowing their place.

Gloriously slack afternoon in the prisons on Wednesday, with my young, keen and knowledgeable RMO doing all the work (he's still at that stage where peering up someone's blocked nose excites him), while I surf the net for other jobs for next year. This is my other RMO, the normal one.

Plan A, which was to work at Lazarus, has fallen through. They have troubles of their own. And so I am faced with a number of options: a year of paediatrics at Florey, a year of Psych at Shipton, a year of paediatrics at the Princess (the sister hospital to the Royal, but specialising in the more unmanly branches of medicine - women and children). Paeds at Florey would be close. The Princess would be educational. Psych would be easy, so I could study for my exams.

I don't bloody know, I'm sick of thinking about it. Maybe I could go back to my first job, swineherding.

That's actually true. Swineherding, which meant working for a little over two dollars an hour, in the West Australian mid-summer, wearing boots and overalls, in an intensive piggery. Even now the smell of a piggery brings back unpleasant memories - although I suspect for the majority of people the smell of a piggery is not the bracing of odours. I try not to remember the horror that followed when one of the big sows 'escaped' into the sewers, and the "new kid" had to go in and wrestle it out. A large pig with the taste of freedom can easily drag a teenage boy for several hundred feet, even through a sewer. I have never gone waterskiing since.

After that, going door to door selling crackpot religion or circuit breakers was comparatively easy.

Anyway, on the telly recently was one of those "Our Health System In Crisis" stories. Apparently interns are beng rostered onto the cardiac ICU and cardiac stepdown units (i.e.: the wards for during and after your heart attack) in relatively senior positions. This means that people can step out of medical school and start looking after people who've had heart attacks.

I think that the medical establishment, rather than seeing this as a negative, should work with it to extract some good. They should use this as the basis for the next anti-smoking campaign.

Midrange shot: Brad, skinny, confused, awkward-looking, wearing a lab coat, clutching two cardiac paddles.

Voice-over: This is Brad.

Shot: Brad grins uncertainly

Voiceover: Brad is progressing well in reading the ECG

Shot: Brad pointing at significant point on ECG and confidently explaining cardiac pathology to senior. Senior reaches out, turns ECG right side up, allows Brad to continue.

VO: Brad now knows which side of the body the heart is on six times out of ten!

Shot: Brad nods, pauses, nods more certainly.

VO: Brad knows it's important to stay alert through his eighteen hour shifts. So he lives on amphetamine-coated coffee beans and caffeine nasal spray.

Shot: Brad, looking slightly blurry, as if vibrating at an impossibly high frequency.

VO: He's certainly come a long way since medical school, two weeks ago.

Shot: Brad half-naked in a wheelbarrow, genitals covered in shaving cream, during the post-graduation bacchanale, smiling emptily, and clutching a bottle of Jack's.

VO: And that's good, because Brad's on call for the cardiac ward for the next three days straight. He'll be the only thing between your fat-clogged, stuttering heart and oblivion.

Shot: Brad holding buzzing cardiac paddles. One gives off a small spark. Brad twitches visibly.

Text: Stop Smoking Today. For your own safety. Believe us, we know.
This message brought to you by the medical defence fund.

Well, it might work. I've always wanted to have one where we show a ward and there's doctors rushing around trying madly (and unsuccessfully) to save Joe Camel, the Marlboro Man and so on.

Anyway, thanks for listening.

John

Tell them they can kiss my Aspergers

Hail,
Back again, just a quick note. By the way, I'm not sure I come out of this post looking entirely good.

Anyway, tomorrow I go back to the prisons. Normally I look forward to this. But tomorrow, what is normally a joy and a delight will be dust and ashes in my mouth.

Because tomorrow I have Dr Zhu.

Let me explain.

At Hogarth House I have junior doctors under me. I get one every three months or so, they are sent out from Florey or the Royal. They are sent to learn to do community medicine and to learn about dealing with adolescent medicine. First was Doctor Bill, the amiable, well-meaning, sensitive-to-the-point-of-nervous-breakdown from Florey. He went back to palliative care and was replaced by Doctor Rebecca: slim, blonde, enviably bright, and one of those people you feel you can't assess job-wise because personality-wise they are so pleasant to have around.

And now there is Zhu.

I first sensed a grave disturbance in the force around Dr Zhu when I mentioned him to Rebecca, his predecessor.

"I've found out who your replacement is" I said. "It's a Dr Zhu."

She stared. "Not Jacky Zhu?"

I looked down at the email. "Dr J Zhu. Looks like it. Why?"

"Oh my God" she murmured, looking off into the distance. "Jacky Zhu coming here. Oh my God."

"Why?"

Suddenly she snapped back to attention. "What? Oh, no reason. Nothing at all. He's very keen. Very hardworking. Anyway, did we get the blood result on..." and she continued*.

A few days later I was in a resus at Florey, and the entire team (emerge, medicine, surgery, anaesthetics and ICU) were down in the tiny resuscitation room blundering around the body of Unknown Male, Mid Forties, Polysubstance Overdose as he twitched his way into a coma. I was trying to put a line in one of his ropy but highly mobile veins and Doctor Bill (now the Intensive Care RMO) sidled over to help.

"I hear you've got Jacky Zhu coming to Hogarth" he said.

"Yep" I admitted.

He laughed.

"What's so funny?" I asked.

"Nothing" he said, shaking his head. "Nothing at all." Then he laughed again, drawing concerned glances from some of the nurses, and shook his head, and laughed some more, and as they wheeled Unknown Male out, I heard his guffawing echo down the corridor.

A few days later Dr Zhu arrived. Clean. Neat. Clutching a briefcase, wearing a tie. Earnest, enthusiastic, punctual. I showed him around the building.

"This will be your office" I said, showing him the small, sparsely furnished room.

"Ahhh...My own office!" he said.

I must shamefacedly confess that at this point I noticed how much he talked like one of those ghastly "Chinamen" you see in nineteen forties movies. You could close your eyes when he talked and you would be irresistibly compelled to imagine hands sliding into voluminous sleeves, thin Manchu beards and inscrutable utterances. I hate being reminded of that kind of thing, and it's not his fault, it's not logical or sensible or helpful, but the image just juts into my head. I know I would look askance at a black guy eating watermelon and plucking a banjo while toting a bale of cotton (not just because he'd have to have around four arms).

I showed Dr Zhu the tea-room.

"Aaah! A tea-room!" he said. I am not making this up.

"Yes" I admitted. "Here are the coffee cups"

"Aah! Cups for coffee!" And so on.

And so the pattern was set. Initially I thought he had only two emotions; number one was a kind of perplexed delight, grading into delighted perplexity. Number two was perplexed horror, with flashes of horrified perplexity. He showed this one on the second day.

I was telling him about a patient. "At ten thirty we had a fifteen year old girl who presented alone for the emergency contraceptive pill..." I began, but stopped and stared in alarm, because before I could go on he covered his face with his hands, let out a long, sibilant exhalation and rocked back in the chair, shaking his head.

I stared. Had he perhaps misheard me? Had he thought I had said "The cancer has spread to your brain and you have only fifteen minutes to live... hold on, my watch is slow"?

After a full minute he emerged and spoke softly. "So young! How is it possible?"

I opened my mouth to say that it was quite possible that a fifteen year old girl in South Mordor was sexually active. In fact, it was pretty much the local mixed doubles sport.

Then I mentioned the three shallow scars on her forearm, and he asked if I had detained her under the mental health act (i.e.: called up the ambulance and if necessary, the police to take her away to a psychiatric ward against her will). I admitted that I had not performed this basic clinical intervention.

Anyway, it's a difficult thing to delineate. I can't say exactly what is wrong. It might be something that comes good with a bit of practice and a bit of education, it might be nothing. I don't know that I can say it's nothing. But I reckon it might be a while, possibly a considerable while, before I leave Dr Zhu sitting alone in a room in Hogarth with a fifteen year old girl who wants emergency contraception.

John

Oh, and one more thing. After almost a fortnight, he still laughs uncontrollably when someone mentions sexually transmitted diseases. No, I lie, the last few times he managed to get it down to a brief, high pitched giggle, only about a minute in duration. Because, you know, there's nothing as funny as acute chlamydial urethritis. And teenagers really want the doctor giggling as they outline their sexual history.

And this is a thirty seven year old (single) man who has lived in Australia for eight years and the US before that. Not a mujahadiin, a monk or a Martian.

But he's a nice guy, and his knowledge of clinical medicine is certainly adequate, and he is keen, and he dresses well. And I reckon he'll make a top radiologist or anaesthesiologist ... or something. Especially if he starts soon. Like today.

John

* Apparently you don't speak ill of the dud

Three

Hail, apologies for the long absence.

The following post is rated G: for readers accustomed to Gore. Sorry.

Much has gone on, including some nightshift, and I am trying to write this before our tutorial session. We have three hours of weekly tutorials which are interesting, educational and money for jam, but I am struggling against the temptation to stay home and write instead.

What's been going on?

Well, Dr Iskandar, who was there when we saved the Snow Maiden back in April, is resigning. I went in after his last night shift and saw him writing his resignation letter - I believe he only paused to wonder if "shithousedness" was a word. I suspect for Iskandaar "Things had Suddenly become Very Clear", a feeling which means you've worked something important out or you're sliding into psychosis. He will be sorely missed.

So that leaves three - the pleasant, cautious and capable Dr Longstocking, me and Dr Maad.

And I'm not that sure about Maad.

Dr Maad is from Saudi Arabia. One of the nurses worked in Saudi Arabia for ten years, he says it is an unusual place. He did some shifts on what he called the Ward of the Living Dead. He says in Islam, the person is considered alive until the heart stops beating. This means that if someone suffers massive braininjury (due to stroke, motor vehicle accident, etc.) the doctors resuscitate them (get tehir heart pumping and their blood oxygenated, like we do here) and then go and try and explain the situation to the family.

Often this is exceedingly difficult for everyone. In Suadi, especially if the family is very religious, they may not be able to advise the doctro to turn off the machine, because the orthodox religious position is that that is murder, and who can do that?

So you have an entire ward of people who are dead but are kept alive by artificial means. The drugs keep the heart beating for weeks at a time. One of the ways they do this is by shutting down the peripheral circulation (the blood frlow to the skin and fingers and toes, etc.) and increasing the central (to the heart, etc.). Without blood the extremities die. So he would spend hours working on the ward. In the morning he'd come around and removed the body parts that had dropped off (the fingers, toes, and noses), the doctor would check the doses, and that would be that.

Anyway. Dr Maad originally had some problems. He is knowledgeable, efficient, competent, assertive and eloquent, but he did have what one person called issues with the nursing staff. I don't know who started what, but he started one sentence with "The problem with you Australian women..." and things have gone downhill from there. Alienating and entire country and an entire gender in six words - I told you he was efficient. Apparently, and again, this is hearsay, one nurse fetched him a bag of hypotonic saline instead of hypertonic saline, and he growled "Western Dog!" and hurled it across the room.

I don't know if this is true. Registrars are in short supply, they tend not to double us up on shifts, I have hardly worked with him at all. I can imagine it is difficult for all concerned.

Anyway, tutorial calling.

Mr Baluch, by the way, is still alive. He may turn out to be as difficult to shift from the ICU at the Royal as he was from the Florey ED. And I tell you now, if anyone I've met is going to sue, it's him. As soon as he can move his arm independently, he's going to dial for a lawyer. We shall see. Something to look forward to.

Thanks for listening,

John.