The Reek of Wrongness

Hail,
As the more perceptive amongst you have probably guessed, not feeling one hundred percent lately, moodwise. It's the usual unholy trinity of poor sleep, poor concentration and poor motivation, and my muse is not visiting me. In fact, I rather suspect that she has taken an restraining order of some sorts out on me.

You know, if your muse is an incarnation of what makes you write, I don't think she'd be some dignified Apollonian figure clad in flowing linen. Most writers I know write in response to darker urges: subsumed regrets, occult egotisms, hidden terrors, covert rage. My muse (and I suspect the vast majority of muses) would be some Dionysian figure, twigs in hair and scratches on the skin, her face and mouth stained with some unidentifiable substance, her eyes wild and deep.

Or maybe those eyes would be different - blank and pitiless, maybe endless lines of text scrolling across each iris. I have a friend, the most gifted writer I know, who goes through multiple agonies over single words. He would say he loves words and writing, and he's certainly been granted some remarkable gifts, but I don't know that his muse cares greatly for him.

Anyhow. Enough deep blue. What to do about the moods?

Well, one thing would be to get a better fucking job, that's for sure. I am aware that this seems markedly at odds with what I have written before. But I reckon if you want to forget your worries, pack up your troubles in the old doctor's bag and smile, smile, smile... this is't the place to do it.

I will leave the more ER of today's cases for another, calmer time, probably in the late 2240s. Instead, a very biref synopsis of two of the creepier things I have thought about n the last few days.

Mrs Poe, a large-framed woman, previously a widow, and her new husband, Mr Blancmange, a small and inoffensive sort- and the fact that late at night Mrs Poe made Mr Blancmange dress up in the clothes previously occupied by the late Mr Poe.

Now I don't know why that's wrong, but it is.

But not as wrong, not as fleshcreepy, as one anecdote involving my wife Sarah's ex. Before she met me she went out with a tall, lugubrious man, someone who always seemed despondent - despite what I feel was his great good fortune at even knowing Sarah was alive. Now Brad, as I shall call him, apparently played classical guitar (badly, I am informed), but was impaired in his pursuit of excellence by the fact that he bit his nails. He used to bite his nails down to the quick, and you need those long, delicate nails to pluck the strings.

So he made Sarah grow her nails and then cut them off, and he glued her nails to his fingers, and played the guitar like that.

See, how does fiction compete? Thank God he didn't go bald, he could have made her get a haircut and glued her hair onto his head.

Anyway, off to bed. The ED has not been very pick-me-uppy lately, a lto fo what I will call 'outliers' - the subject of a forthcoming post, once the tide rises again. I will get back to reading, writing and suchlike in the shortest possible time.

Thanks for reading,
John

Read It and Weep

Hail,
Well, it's all been going on here.

And today I heard a story of a real Aussie battler doing it tough, a tale tragic enough to bring a tear to even the most jaded eye. Pull up a chair, grab a handful of hankies, Mississippi blues in the background, and listen on, gentle reader.

I'm just starting at the methadone clinic, meeting patient/clients/whatever, and at ten thirty I stuck my head out into the office and asked Mr Chirp to come on down. Mr Chirp (tall, thin, tattooed, barefoot) raised his head from his hands, turned a tear-stained face towards me, and slowly shuffled into the consulting room.

I offered him a box of tissues and gave him a few minutes to compose himself. We sat in silence until he was able to speak.

"What's been going on?" I said.

And he laid down his heavy load.

It seems he'd been kicked out of his house. The landlord, he said, had "come around makin' trouble for me. Saying I had to get to get out, 'cause I'm a bit behind on the rent - which I am, but four months max.

Anyway, he kept goin' on about it, and I didn't want to talk about it, so I pushed him - pushed him out of my house, defended myself. My right by law. And he falls out the door and down the flight of stairs, and he's lying there squealing about his arm or something, and some fuckin' interferin' prick calls the ambulance."

"Was he okay?" I asked. Mr Chirp continued.

"Anyway, then the police come around. They reckon it's assault... but by me! When it's my fuckin' home that's been invaded! Since he's got no prior, Mr Squeaky fuckin' Clean - they back this bastard him up instead of me! Chuck me out of my own house! A fuckin' restraining order... on my own house!!"

The tone of his voice raised another octave, he gestured at the silent heavens. I shook my head at the injustice of it all.

"Anyway, because of this they're bringin up this bullshit 'endangering life' charge I got hanging over me, because of some four guys that reckon I tried to run over them with me car in April. So I got to get out of the house, and my parole officer's cracked the shits at me and reckons I'll go back inside for this, so I told her to fuck off, and that's her gone."

I raised my eyebrows. "So where are you staying now?"

"That's the really harsh bit. No fuckin' where. I went over to my girlfriend's house, reckoned I could crash there a few days, but all the women she's living with - they're all lezzos, they won't let me near her."

"All lesbians, you say?"

"Yeah. She's staying in some domestic violence shelter thing, because of some hassle we had, but that's all fixed up now. But they won't have a fuckin' bar of it."

"I've heard these places can be rather strict" I agreed. "So what now?"

"Fuck knows. I just don't know anymore. There's this guy, I can probably crash at his place, but he's got convictions, he's a speed dealer... and the fuckin' terms of my parole reckon I can't associate with him.

Anyway, I reckon he's still pissed off about me not paying him for some shit he sold me a while back... and it was shit, too, I was ripped off. You know, it's his fault I got back on the hammer - I never would have even tried heroin if it wasn't for him. So I'm the one who got ripped off and there's him bitching and moaning about his fifteen hundred fuckin' bucks. Him and his bikie mates. I don't give a shit about any of them, I tell you that."

"Mmm" I said.

He made as if to go on, but for a moment was overcome with emotion, and buried his head in his hands again. When he could speak, he looked up, and spoke as much to the sky as to me.

"I don't fuckin' know why I bother, you know? I don't know why. I keep on trying to do the right thing, trying to walk the walk, but everybody's always got to sabotage me. Rip me off, piss me off, push my buttons. Tell you what - when those coppers backed that greedy bastard instead of me, it completely destroyed my faith in the legal system."

He sighed deeply, then continued. "Dead set. I try to do the right thing, but everyone always seems to be pushing me into doing the wrong thing. And then standing back and laughing, when I take the fall. Well, I'm fuckin' sick of it!"

He stared at me, a man of fundamental decency wedgied once too often by the capricious hand of fate.

"Tell you what, it's all changing. A man can only take so fuckin' much. It's a new fuckin' plan today, I can tell you."

"Uh huh?" I asked.

"Too fuckin' right it is. No more Mr Nice Guy. No more takin' the rap for everyone else's crap. From today, the people who caused all this shit are gonna start to suffer. Next fuckin thing - the next fuckin thing that does not go precisely to plan, exactly how I want it - I'm gonna find the fucker."

He sat up, and his eyes gleamed with a new purpose.

"I'm gonna find the bastard responsible... and I'm gonna make him pay. Don't reckon I won't."

He jabbed one long, bony finger in my direction.

"Certain people" he said "are gonna have to start taking responsibility for their own actions."

Suxamethonium doesn't kill people, doctors with suxamethonium kill people

Apparently this has happened upstairs, although details are lacking at the moment.

The patient was elderly, and there may have been some rare genetic thing involved, but I don't know. We don't have all the information as yet. This is hideous news.

Hope things go as well as they can do, under the circumstances.

The accused is one of the smarter doctors I know. Movie-star good looks, dark hair, dark eyes, speaks three languages, top of her class and friendly as well - although terrifying when she turns the full force of her intellect upon you, so you feel like an ant looking up through a magnifying glass and seeing the sun.

So - howabout the topic for today is doctors and getting sued - the fear of the law. Lawyers and legolophobia*.

My intercourse with the law has been very limited. A few times pulled over by the police in my younger days. The four hour stretch in what may have been the East Fremantle lockup years ago. Appearing before the judge to explain why the car I was driving was not registered. Nothing for ten years or more.

(Oddly enough, I have always found the idea of lawyers very sexy. I have no idea what that means, especially since the other career choices I find remarkably erotic are doctors and librarians - and women who work in bookshops. Seriously, I feel that those professions have more than their fair share of remarkably hot looking people.... Maybe it's some thing I have for that repressed looking, restrained, pent up sexuality kind of look. "Geek love is strong love", that kind of thing.

Or maybe it's because I find words and books and brains intrinsically hot.

You know, I have books that themselves are objects of almost erotic desire - the smell of them, the way they fit in your hand, the soft, cream-coloured pages, the gentle, firm curve of the page, the valley between where the words join the spine.

Good God. That should get me arrested next time I go to Borders).

But anyway. Doctors and the fear of the law.

The threat of prosecution or other legal action is meant to be something that haunts doctors, and I do see a lot of the fear in the ED. One of the consultants here, a deeply decent and very competent woman, saw a man (short, stocky, fifties) a few days ago who had left sided abdominal pain. He said it was like his kidney stones, he had had multiple attacks of kidney stones, he had pretty much nothing else wrong with him. He responded to the treatment for kidney stones, as he always had, and went on his way rejoicing.

And two days later the police rang up Dr Lazar and said that her patient had been found dead twelve hours after discharge, and that's a coroner's case, so that's what she's got to look forward to.

What everyone is thinking of is whether this man had a "triple A" or not. This is not the name of some Australian professional wrestler, it's when the big artery from your heart to the rest of your body swells up and then bursts (and you die): an abdominal aortic aneurysm. Once the swelling starts, you need urgent vascular surgery, ambulance to the Royal with lights and sirens, that kind of thing.

Weirdly, if you've been stabbed or are having a heart attack (each of which are usually more survivable than a triple A), we send an emergency doctor in the back of the ambulance with you. If it's a AAA swelling up we don't bother - because if it pops in the back of the ambulance it's all over. Nobody can help you.

Doctors can identify AAAs by feeling for them (put your hands side by side, fingers together, a few centimetres apart, in the midline between your belly button and your breastbone - if you feel something pulsating you're (very likely) admirably slim, or that's a triple A. This guy, unfortunately, was too fat for us to feel anything.

The other way of identifying it is by the symptoms - which closely resemble those of kidney stones. Or you can pick it up by a CT scan. The question everyone is owndering about all this is is whether and how recently this guy had been scanned, and thus who should we scan and how often should we scan them.

Anyway, how does this relate to lawyers?

There is a tension in medicine between good medicine and what we call defensive medicine. Good medicine (in the sense in whihc I'm using it) is what's good for the patient, defensive medicine is what's good for the doctor. Good medicine stops patients getting worse and defensive medicine stops doctors getting sued.

Thing is, you'd think that these whould be the same thing. What's good for the patient should be good for the doctor, we're on the same side, after all. If you make the patients better you shouldn't get sued.

But the thing is there is a difference.

It's most apparent in the case of "investigations": blood tests, Xrays, scans, that kind of thing. In an ideal world, with ideal investigations, all patients would be fully investigated: they would turn up, we would use (insert amazing technology here) to know exactly what's wrong with them, and proceed accordingly. Everyone would be happy.

But in the real world, investigations have costs: they cost money, which would otherwise go on more hospital beds, or vital research, or producing pamphlets and posters telling Australians to look out for anyone suspicious-looking. Investigations cost money. Someone has to pay for these things.

And investigations cause complications. Maybe I take your blood and you get an infection or a blood clot. Maybe the CT scan gives you cancer. And even if they are cheap and safe, often they don't tell us the right thing anyway - usually I don't Xray people who may have broken ribs, because chest Xrays are notoriously crap at seeing broken ribs, and if we can't see the broken ribs it doesn't mean they aren't there. If I reckon they've got broken ribs, I just treat them for it.

Here's another example. Ovarian cancer. This is a truly terrible disease. It kills four Australian women a day.... mostly because by the time anyone knows it's there, it's often too late. The symptoms are terrifyingly vague - abdominal or pelvic pain, vaginal bleeding, bloating, abdominal distension, irregular menses... and by the time anyone knows it's there, the surgery required is substantial, the chemotherapy aggressive, the outlook poor (although a damn lot better than a decade ago).

With that in mind, what kind of doctor would not offer his patients a blood test for tumour marker CA125, a substance that is often elevated in the blood of ovarian cancer patients long before symptoms are noticed, that can be rapidly and reliably detected from a few millilitres of blood?

Well, me, and pretty much anyone I know or know of. Because the investigation in this case is unreliable - it misses cancers that are there, it picks up ones that aren't. And if you do the blood test, and it comes back good, but it turns out you do have cancer - what then? Or what if you get an ominous result on the blood test - then you have to have surgery to find out what's going on, and often it turns out you had the surgery but there was no cancer, the test "was wrong". And gynaecological surgery is not without complications.

So what do you do? At the moment there isn't really a satisfactory method for screening people for ovarian cancer, nothing as good as, say, alphafetoprotein is for screening for Downs Syndrome and spina bifida in utero, or Pap smears** are for cervical cancer. Current practice is looking at some combination of a number of tumour markets, trans-vaginal ultrasound (yep, just what it sounds like) and so on.

Anyway - what does this have to do with good or defensive medicine? What do I do if I'm a general practitioner/family doctor sitting behind my desk and someone comes to me and wants the blood test? It's a huge issue - I have to help them understand what the test can do, what it can't, what it will mean if it comes back "positive", what the surgery can and can't do, what if the surgery goes wrong... it's vast. And it's different for every person. And the patient goes in there asking about cancer and comes out with soundbites like "13.7% chance of a false negative".

And this is all good. This is what I reckon medicine should be about - it should be about helping people make choices, giving them the information in a way they can deal with and to the extent that they can make sense of it.

But with defensive medicine, there's this whole undercurrent, this thing that goes through your mind at the same time, that when you look at it really has bugger all to do with the patient and what's best for them:

Scene: South Mordor Family Practice. Hassled looking man with stethoscope sits gnawing his phalanges behind a desk. Across the desk is a slim, worried looking woman gnawing her own phalanges.


Doctor (internal dialogue): Christ, she's asking for this bullshit test. She's twenty two, no family history, no symptoms at all - what are the odds? I'll recommend against it

... but what if she has got cancer? she's frightened, she's come to me for help... and I've told her not to have the test? I'm dead. Front page of the Sackbutt.

May's well do the test, that guy down the road'll do it if I don't. So we do the test... it'll come back normal, she'll piss off...

...of course, I'm even more screwed then if she has got cancer, because 'I told her everything was alright'. Front page of the Sackbutt, seven oclock news

...Maybe I should get her to come back in six months for a checkup, another test - Hold on, what am I thinking? Giving her two bullshit blood tests instead of one?

And if I do the blood test, and it comes back high - we're all doomed. She has to have surgery. Surgery for something she quite possibly doesn't have. And gynae surgery is bloody nasty. And there was that woman I sent off to the Royal last year, got MRSA, that's done me no end of good, still paying that one off. Didn't that guy Benedict sent in get a blood clot, dropped dead two days after discharge? Surgeon's fault, of course, not Ben's, but he has to deal with the family.

DOctor nods head, tries to look thoughtful, stares down at new paroxetine pen, suddenly has an insight. Diagnoses woman with anxiety disorder, starts her on paroxetine, sends her away. Everyone is happy.

Thanks for listening,
John

All this, by the way, is only relevant to screening - ubertests we do on vast numbers of people who aren't particularly symptomatic or at risk, but in whom we want to catch the disease before it starts. If you have symptoms, if you have any sort of family history, then limitations on screening are't relevant to you, see your doctor now.

* A terror of woodland elves - hahahahahahahhhaahaaaaaa!

**Pap smears, by the way, may be on the way out. There's a vaccine in the works, very promising stuff in a largeish trial, and the entire disease of cervical cancer may be getting a good kicking in the next few years. So, any over-eighteens who have ever had sex and haven't had one in the last two years rush off and get one now, before you miss out forever.

I'm in love with a lawyer

Hail,

and the lucky man is Eric Rothschild of the Philadelphia law firm Pepper Hamilton, who is cross examining the creationist Michael Behe in the "Creation versus Evolution - because maybe we got it wrong back in 1925" trial occuring in the small town of Whatcenturyisthisanyway, Pennsylvania. Read all about it in the New Scientist.

Anyway: another inexcusably long delay, sorry about that. A vast amount has been going on, and I haven't even been on the net for over a week. Lots to talk about. One weird thing. I really miss this when I don't do it. Writing this, and reading everyone else's stuff, is really really enjoyable. So, after this straight off to my tour of the blogs - hope everyone's life is going wellish.

So, what's gone on?

"My" murder trial has been called off, the one involving the woman I saw in the ED after she'd been assaulted by her partner, who three weeks after I saw her was assaulted again... but this time died. The first day of the trial he apparently stood up and changed his plea to guilty. Apparently there was much rejoicing amongst the police.

Truly weird thing is, I feel very relieved by this, but I also feel in some way cheated, as if he (the man who admitted to doing this terrible thing) has in some way ducked out of something, some deserved punishment. Which is daft and odd, because the trial isn't the punishment, and I am fairly dubious about the whole trial by jury thing. I can't defend this feeling of doubt, but somehow I don't feel that a criminal trial is a particularly good method of determining the guilt or innocence of a human being. It may be the best we've got, but I don't know it's that good. In medicine we are lucky, we can run tests and do experiments to see if what we are doing works, in law they don't have that advantage.

So, what's been going on? Yesterday we had to relocate someone's dislocated hip. We see a lot of dislocations, they are all pretty much the same idea - give someone something to calm them down, then grab the affected part and pull and/or twist in the appropriate direction. This works for hips, knees, shoulders, fingers, etc.

In the old days it was pretty much grab and twist, manouvres that look a lot like Chinese wrestling techniques - a combination of guile, distraction and speed. Nowadays there's medications so you allegedly feel nothing and remember less. I saw Dr Rigour (very old school) once stride into a room and introduce herself with her right hand proffered as if for a handshake. When the startled man extended his hand, she grabbed his finger and wrenched it back into place with an audible pop and a short sharp scream (his, not hers).

Fingers are easy, the kind of thing you can do in the middle of a judo training session. Jaws are relatively rare, but everyone always remembers them because the large and otherwise sober-minded emergency medicine textbook we turn to in idle hours states lists among the causes "excessive yawning" and "oral sex". Shoulders are very common, dislocating them hurts like hell. Hips are probably the most physically difficult to reduce - big joints surrounded by lots of muscle.

Anyway, we had to pop someone's hip back in yesterday, a techique that really illustrates the delicacy and precision of modern emergency medicine. We gave her buckets of pain relief and something to make her drowsy, and then I clambered onto the bed, stood spread-eagled and dragged on her thigh like trying to uproot a vegetable, and one other doctor heaved on her hip to keep her on the bed and another leant on her inner thigh to make sure the hip popped back in the same place.

So, that was fifteen minutes of considerable physical effort, eventually successful. I shuffled around the ED for the rest of the day like a gnome, remembering how I used to be strong.

Anyway, nothing that gripping here, but good to be back. Hopefully something of more substance later today - possibly about sexy lawyers and the terror thereof.

Thanks for listening,
John

Plastic people parts

Hail,
Writing this at work. Sorry for the long absence, much has happened, as shall be revealed. By the by, my good friend Toby has had a computer upgrade and is now able to read my blog (a fact that alarms me considerably). He did so and complained that everyone else mentioned in the blog has been disguised with a stylish pseudonym, but that he was saddled with Toby. So from now on, he will be known as Algernon. Think tall, broadshouldered, raffish, strong jaw and soft brown eyes, an ability with language that makes the rest of us seem like Neanderthals.

For Benedict, by the way, dark eyes, glossy black hair, strong build and expressive face. Chad is more the movie star blue eyes, quick wit and frequent grin.

We did another intubation practical, using an armless legless plastic person and several separate plastic parts - including a life-sized pink "jaw with teeth and tongue" set, complete with disturbingly life-like tongue.

We do a lot of practice on plastic people parts, more in medical school than now, and I remember once trying to work out how much of a person you could make if you got all of these parts together, like some disturbed Frankenstein. I tried to limit myself to plastic people parts I had seen in my professional career, and I reckon I got pretty close to a whole, if oddly proportioned, human being.

The plastic jaw from the intubation prac could go under the giant (five times life-size) nose that Ear Nose and Throat used to teach us about nosebleeds, and although there is only one ear (a right, from what I can remember) there was a number of eyes, including one showing catacts and one with a retina you could peel off and look at.

Internal organs were also well represented - I was given a number of plastic hearts (by pharmaceutical representatives selling cholesterol modifying drugs), two sets of
kidneys (reps selling blood pressure meds), a pancreas (insulin) and a large, yellow wobbly block of plastic fat, which was given to me by the woman selling orlistat, the weight loss drug. I was meant to brandish this at potential customers, the whole lunchbox sized lump of it, yellow and veiny, to encourage them to lose weight.

Plastic sexual organs were also in plentiful supply - mainly from my time at Hogarth House, where we prescribed constraceptives, etc. to teenagers. There were plastic male and female "parts" to show how to insert/apply/wear the various devices, and a bunch of things called banana penises, which are life-sized and life-like plastic bananas, except that when you slip the skin off, a similarly life-sized and life-like penis is revealed, standing at a jaunty angle and coloured a cheerful pink.

"Just the thing to slip into the fruitbowl when the vicar comes to tea" said the woman who showed me, and laughed for a full fifteen minutes.

Anyway, I will spare you the horrors of the plastic prostates we were meant to examine and describe, and get back to actually seeing someone.

Thanks for listening,
John

Drug of Choice

Well, I haven't been thinking most of today, I can tell you. Why is this so?

Well, it's because of promethazine. I've only been up a few hours, and it's mid afternoon already.

From what I can work out, a fair proportion of doctors on shifts take something, some drug. Promethazine is pretty harmless, it's one of the old-style antihistamines that works on every chemical receptor in your body. Twenty five milligrams for the day between the nights and the same for the first night after the days and I'm pretty much back into the normal day-night rhythm. And the big thing is it has minimal abuse potential - as far as I can find out. If I take it for more than a few days it doesn't seem to work, and that's something that worries me a bit - decreasing effect for the same dose may mean you have to take more to get the same effect, and that's part of addiction. And I watch for the effects - I beleive I have a kind of benevolent boneless lassitude for a few hours after I wake up, a kind of blurry smiley feeling.

Some doctors and nurses take benzos. Apparently ten or twenty of temazepam works well, gets you off to sleep and is out of your system pretty much by the time you wake up. From what I can work out, that's part of what they would have had me on when I was unwell, years ago, and I will probably be uncomfortable with any of those medications for the rest of my life.

But a lot of doctors and nurses take them. Apparently it's a very pleasant feeling, a calming, relaxing thing, something like being mildly drunk.

Pretty much that's it. Coffee, of course, is the lifeblood of the ED. I remember one night getting that tremor, the same kind of tremor that people get when they are put on salbutamol nebs for their asthma, a fine, continuous shaking of the hands. I noticed that night that the doctor having trembling hands does nothing to reassure the patients. But then, with that preternatural vigilance common to caffeine and amphetamine freaks and paranoiacs, I noticed a lot. Like my heart pounding like a wind-up monkey's drum, and my hands around the stethoscope like I was ready to lassoo someone.

And that's pretty much it, in terms of drugs people use at work. Other drugs is different. With little effort I can call to mind the major recreational drugs and reel off lists of people I know who have taken them - several of them successful, a number of them doctors. Heroin, amphetamines, LSD, the obligatory marijuana, opium, etcetera. Most taken before the persons concerned went on to become doctors, scientists, engineers, one of whom went on to become seriously mentally ill.

Now, pretty much all I know about is one doctor who drinks too much and a few nurses who sound like they do, and several who've still got the pack-a-day habit, the one drug that even in almost homeopathic doses will still kill most of its users early.

But five or so years ago Sarah and I had a party at our house, up in the hills, and afterwards, cleaning up the next morning, we found an empty syringe. Just like in the ads. And I remember sitting there with her afterwards, trying to work out which of our utterly innocuous friends, the people who are now GPs and psych registrars and emergency trainees, all upper midle class men and women who sat through the talks on Hep C and amphetamine psychosis and so on, would be doing such a thing.

Thanks for listening,
John

Why we are doomed

I may start this entry and leave "Gay people, my role in their persecution" for another time.

Anyway, three pm, trying to kick myself back into normal sleep patterns. Don't expect prose. And nights went reasonably well, certainly from a 'number of people who died per hour' point of view, because everyone did really really well.

Since starting at the drugs and alcohol job I have noticed I'm "seeing" a lot more people with drugs and alcohol issues, things I think I could have missed. Sometimes it's not that obvious - the fifty year old woman with her eighth admission this year with airways disease who has small, soft bruises on the inside of her elbow. Of course, her drug "issue" isn't the speed, it's the cigarettes that are killing her, but that's different -they are legal.

But in the case of 'twenty eight year old man, fixing television antenna at five oclock in the morning, then leapt from roof to ground' and completely graunched his ankle, you don't even need to ask. But if you did ask, it was amphetamines, not alcohol. A salient lesson for all those who preach you've just got to believe in yourself, because he did, but physics and biology didn't. Gravity - it's not just a good idea, it's the law. And what the hell is on at five in the morning that's so damn important?

Anyway. I learnt something I didn't know the other day, about Hurricane Katrina. Look at this, gleaned from an email some anti-choice mob (Columbia Christians for Life) has apparently** been distributing:

http://liberalserving.typepad.com/photos/uncategorized/katrinafetus.gif

"The image of the hurricane above with its eye already ashore at 12:32 PM Monday, August 29 looks like a fetus (unborn human baby) facing to the left (west) in the womb, in the early weeks of gestation (approx. 6 weeks). Even the orange color of the image is reminiscent of a commonly used pro-life picture of early prenatal development (see sign with picture of 8-week pre-born human child below). In this picture, and in another picture in today's on-line edition of USA Today*, this hurricane looks like an unborn human child.

Louisiana has 10 child-murder-by-abortion centers - FIVE are in New Orleans
www.ldi.org ('Find an Abortion Clinic [sic]')

Baby-murder state # 1 - California (125 abortion centers) - land of earthquakes, forest fires, and mudslides
Baby-murder state # 2 - New York (78 abortion centers) - 9-11 Ground Zero
Baby-murder state # 3 - Florida (73 abortion centers) - Hurricanes Bonnie, Charley, Frances, Ivan, Jeanne in 2004; and now, Hurricane Katrina in 2005

God's message: REPENT AMERICA !"

I will leave aside the "it's not orange, hurricanes aren't orange you evilly stupid fuck... look at the photographs of actual people looking at the actual sky during the actual storm - are those photos orange? are storms usually frickin' orange on your planet??? With purple around the outside????" for now.

And notice the assumption it's a human fetus (actually, technically it's an embryo)? Looks pretty much like a chicken fetus to me. God's will has suddenly become Very Clear to me, excuse me while I go out and shoot the owner of the local KFC - or should I say "murder by rotisserie" clinic.

But you know, you read this and you wonder how anybody manages to write satire any more. How do you take the piss out of a culture that consistently and reliably beats you to the punch? How can you say anything illustrating the poisons in the heart of Bush's Christian America when they do something like this, revelling in teh stuff you'd normally try and shame someone with? How can you expose contradictions between "decent human behaviour" and "what people like this do", when they already put stuff like this out and willingly put their name to it?

You know, years ago, I had very strong left wing opinions - ideas on the environment, war, taxation, international politics, that kind of thing. I use the term "left wing" with caution, because some people seem to believe this means Gulags and the like. To be honest, I am and was more a small-scale leftie, Gramsci and Chomsky rather than Marx and Lenin, more No Logo and Pip Pip than Das Kapital. More thinking that capitalism is not always the answer than thinking communism is ever the answer. Most of what my right-wing friends think of as leftie is stuff no one really believes in anymore.

To me, and I am aware that nothing is more boring than listening to anyone else witter on about politics, the left wing thing is a philosophical thing. It's more about dissent, it's more about saying things could be better. It's more about saying things could be different, and better.

Years and years ago, I did Italian at high school. My interest in Italian was not fostered by any appreciation of the language or its people, its great achievements in numerous fields of art or science. My interest was entirely due to Ms Bianco, a peroxide blonde in what I remember as a white, mid-riffy teeshirt and jeans, with over-inflated lips, who smiled and pouted to a group of thirty frenzied just-adolescent males, and the three depressed and dispirited girls in the class who actually wanted to learn another language.

Out of a year of Italian I remembered* eight obscenities and one phrase:

'Une altro mondo e possibile'

Another world is possible.

That's what left wing is to me.

Anyway, I retain a lot of the ideas, and I know I will go to my grave having only ever voted one way, but one thing I don't retain is the hope in the perfectable man, the socialist ideal. One biologist said about socialism "Right idea, wrong species", and that's pretty much got it right.

Because you read stuff like that and you think, God, we're not really such a class act, are we? We hear about loving each other and forgiving each other and giving all we have to the poor, and we turn it into ferocious fetuses in the sky. Forty five years ago we got to the moon, now we're disputing whether science should be taught in the science class. Jesus. Again, evolution is not just a good idea, it's the law. What next - we ditch nuclear physics and the sun shines because of intelligent shining?

Anyway, tired and rambling and doubtless boring even myself. Will try and write sensibly tonight.

John
*Probably inaccurately

** or so I hear. It may turn out this is all crap, and that Columbian Christians for Life (or more accuratley, Columbian Christians for a God who Kills Thousands) is a completely innocent and not-crazy group of people. I stress I haven't even seen the original email, and itf this is all wrong, my apologies.

John

The Big Dick Talk

Hail,

Thanks for the comments, will try to reply today if I can post from work, if not, over the weekend.

Things go well. I am working at my new (half-time) job, the replacement for the Hogarth House one. It is primarily dealing with people with drug and alcohol prolems. At the moment I am working at the alcohol disorders unit, which is less than a hundred metres away from the largest Booze Brothers store I have ever seen, almost a warehouse. Within walking distance is Behan's (a very large pub), a pawnshop and a second hand clothes store. All they need to do is throw in one of those shopping trolleys and you've got everything for the discerning alcoholic.

Yesterday at Florey I had a tutorial on "managing the airway", which is basically about intubating people, which was very reassuring. But after that we sat around and pretty rapidly we got into the big dick talk. The big dick talk is a kind of testosteronefest, where doctors sit around and talk about horribly sick people they have seen, stuffups they or others have made and so on... with the most points going to the most spectacular blood or ECG results, the most alarming pathology, the biggest disaster averted. It is a kind of competition with the rules heavily weighted towards the older, more experienced doctors, although those with any experience in the third world can often do well. My contribution was relatively minor - the man who came in with a blood alcohol of point five five, i.e.: eleven times the legal limit, a dose that would kill all but the most exceptional people - and who, when this was mentioned to him, expressed suprise and said "I didn't think it'd be that high, I haven't had a drink today."

And another man with a cholesterol in the high twenties (normal, I believe, is below five) - who had pink, foamy blood, visible globules of fat, and when you took it out of the vein and squirted it in a bottle, a thin white film rose to the top of the sample, like the cream on fresh milk.

My alcohol man was eclipsed by the woman with a BAL of point five eight, who, her treating doctor said, appeared almost perfectly sober. She was so incensed at her doctor's suggestion that she should not drive that she walked out of the department, alert and orientated, half an hour before her blood result was rang through to her unbelieving doctor.

But the haemoglobin conversation was the most remarkabe. Haemoglobin is the protein that carries blood around your body. The normal male has 130 to 180 grams of haemoglobin in every liter of his blood, the average female slightly less. Anaemia means (among other things) low concetrations of haemoglobin - you get tired easily, you feel weak, you may get short of breath. Anaemia is technically anything below the normal range - for an adult male, it's below 130 grams per litre, for a female it's below 115 g/L.

A haemoglobin of ninety may indicate someone is pretty damn unwell. Sixty is catastrophic, I ca't remember seeing any lower than that. Dr Bougie, the intensive care guy could. He remembered seeing a child, a vctim of a genetic disorder rarely seen in this country, with a haemoglobin of twenty eight.

At this stage, the blood is no longer red. It is a pale, transparent pink - you put the needle in and take it out of the vein and squirt this thin, almost clear substance into the bottle. With only this extremely dilute blood (as if your blood had been diulted one part blood to four parts water) the skin is greyish white. When you shine a beam of light into someone's eyes - you see this when you take a photo with a flash - light bounces off the back of the eye, an area packed with blood vesses, giving that red-eyed "I am a demon prince, all must worship me or die" look to those photographs of your child or household pet. This is imaginiatively called the red eye reflex.

When they shone a light into this child's eyes, it bounced back silver.

Anyway, I thought that was remarkable. She did well in the end, too.

Best get back to work...

Thanks for listening,
John

I feel your pain...

Note: Scenes of rather extreme gore ahead - I mean it. Stop reading now if you are at all uncomfortable with this.

And for anyone who missed it last time, go now to Foilwoman's blog and read about someone doing better than anyone merely human would do under the circumstances.

Well....

When I started this blog, I had a number of poorly thought out justifications for doing so: Something to get me writing again. One of those self-analysis things. Scraps for the novel/superhero comic/TV series I was going to write. That diary I got when I was twelve that I never wrote in and felt bad about.

Anyway, tonight's going to be one of those straight from brain to page things, just the data as I remember it, and maybe later it's going to be real writing, or useful self-analysis, or something for the novel.

So what did I see tonight?

Two or three priority ones. Priority one means someone who has to be seen now - in medical terms it usually means someone who has "failed their primary survey". The primary survey consists of basic measurements like heartrate, respiratory rate, blood pressure, temperature and so on. To "fail" any one of these means to be in a state incompatible with life, to be virtually dying before the eyes of the triage nurse.

There is another, perhaps softer or more subtle subset of priority ones, people who due to what has happened to them, the history of their complaint, qualify for immediate attention.

One of this "other" group, one of the "people who should be really badly damaged even though they don't look it" mob, was Mr Ergot. Mr Ergot had been driving a trotter (as in horse, not as in pig's foot) around a racetrack and the horse had "sped up a bit". The next thing he knew he was in an ambulance, and he arrived on our doorstep a few tens of minutes later.

He was alert, breathing neither too fast nor too slow, heartrate a steady sixty to seventy, all pulses regular, his abdomen was appropriately soft, and no long bones were broken. He apologised a few times for being a bother, and only admitted to "a bit of a headache" and "a sore elbow", which, when pressed, he described as "seven out of ten".

The sore elbow was because of a largeish laceration, with dirt from the trotting track deeply embedded in it, but luckily there seemed to be no deformity, nothing suggesting a broken bone or dislocation.

Hideous bit follows.

The headache was because when we undid the bandage and pulled gently on one of his tufts of hair, the entire scalp lifted up and away like the skin of a custard, exposing the smooth, slightly sticky, rounded dome of skull beneath.

The skull, you will be interested to know, is not white. Like all bones, it is the warm pinky-red of living tissue. It is only lightly attached to the skin above it, which is why you can put your hands on your scalp and wiggle it about on your skull, and why I was able to slide one gloved hand in between skin and bone all the way back to his occiput (that bulge at the very back of your head) and almost down to his ears on either side.

Anyway, we poured in the morphine and got a CT scan organised. The scan showed no fracture, but a largeish bleed, a sub- or extra-dural haemorrhage (a pool of blood forming between skull and brain) and we got him down to the Royal pretty damn quick, where the neurosurgeons presumably fixed it.

Now, I don't normally go into this much detail. But there is (possibly) a point to this.

The other patients throughout the night were actually fairly unwell - heart attacks, blood clots in the lung ("Again?" asked the woman), a swelling and possible bleeding of the great artery that emerges from the heart... and finally, towards the end, a changing down of gears, an old woman with some sort of vague decline who had been transferred from a hostel with what might have been confusion, an exacerbation of her normal state of dementia.

She needed blood taken, and I sortof volunteered. A mistake. She had those thin, spiderwebby veins that some of the elderly have, micron-thin things that look like pictures of rivers from satellites, pale purple or blue against a white background. Difficult to put even a very thin line in, and she was on warfarin, so every time the needled punctured her pale skin, she'd wince and a blossom of blue blood would swell where the needle went in, and you'd have to put a bandage on that area or she'd bruise, and start again. Ideally you'd have a nurse to help hold her hand, but my nurse was in with Twenty Eight Year Old Male, Doesn't Realise Street Lamp Poles Have Right Of Way.

So it was me and Mrs Mewl, and every time I touched needle to flesh, Mrs Mewl would shake her head and cry out, a long, high pitched sobbing sound, something that might have been a "No", had it not been documented that she no longer spoke.

Anyway - the point, if there is one. That's the one who upset me more. That's the one I was thinking about tonight when I realised I couldn't sleep.

So, what's going on? The physical pain, the physical damage - that seems to be something I can deal with. Emotional pain, that's another step up and back. Emotional pain to babies, say, that's what I find worst of all. I used to go outside and have a breather after every time I put a needle in a shrieking child, I still don't reckon I could do three in a row without taking some time out. Crying toddlers almost make me cry.

But still, I do this job. I keep going in.

Somedays I wonder - here's the uncomfortable bit - sometimes I wonder who would do this job, what kind of person. I've been thinking this a bit because I've been really enjoying it lately, and I feel that no matter how good the other job gets, no amount of better pay and better hours could really make up for doing without Emerge.

But why is this so? Who does this... or more acutely, what do I get out of it?

I don't think of myself as some kind of adrenaline junky. I'm not. I don't ride a motorbike, I don't leap off mountains attached only by some bit of string, I don't even ride horses or take illicit drugs. My recreational life was once described as "very vanilla". And I hate any kind of emotional uproar in my family.

But maybe there is some connection between say the writing and the ED (and maybe the psychiatry beforehand). Maybe - unpalatable thing here - maybe it's all feeding the same thing.

Maybe what I am is not a 'physical' adrenaline junky, but an emotional one.

I don't know. Too tired, anyway, to write on. Sorry for all the gore. More, hopefully, later.

Thanks for listening
John