The Demon Dentist of Fang Rock

Hail,
Apparently I am to inherit a new patient, and this is not good. The story goes thus:

Over the last few months, on and off, SMACHEAD has been treating Mr Papadopolis, a cheerful, extroverted market gardener in his thirties with a regrettable morphine habit. He was one of those truly unfortunate people who had had become addicted to opiates after nursing a sick relative - his mother had died after a long battle with mesothelioma and had left a grieving man with a big hole in his life and a plastic bag full of morphine capsules. He had been in for the occasional detox, had fallen on and off the program a few times (i.e.: had used heroin while on the methadone program), but was generally seen as a try-hard, decent enough fellow who was doing his best to get his life back on track after a series of unfortunate mistakes.

Or so they thought....

Because somehow, and this is a small city, and we liase closely with the northern, eastern and western organisations who work with people who use "drugs of dependence", someone found out the truth. Or rather, a truth - the truth that he had turned up earlier to one of the other organisations, and had told them a completely different story.

Mr Papadopolios was in fact, not Mr Papadopolis at all. He was, in fact, completely non-Popadopolan. He was Dr Rynch, a successful dentist-about-town (and no, Virginia, there had been no dying mother either). A few years ago, in an uncharacteristic lapse into honesty, he had described to the northern service a story of five year of heroin use, primarily recreational, to counter what he called "unutterable boredom". A much less heart-breaking story.

Well, once this was discovered, he got a lot less bored, because this confession opened up an entirely new kettle of worms. He wailed. He denied. He gashed his breast and beat his teeth. He begged Dr Durrie (sixties, grey hair, saintly looking) not to report him to the dental board (and presumably to just take the ten thousand dollar fine and the appearance before the medical board). When that didn't work, he threatened her.

"I know where you live" he said to her. And this, sadly, as true, because Dr Durrie is practically the only doctor I know who has her home address in the phone book.

So anyway, he's been handed over to me, and he doesn't know where I live, and I anticipate little trouble from him, because the people who threaten sixty year old women are often not the same people who threaten irritable looking men. And presumably because first thing in the morning, after the traffic jam but before the coffee, I look (and possibly feel) a damn sight more antisocial than he does.

I suspect that antisocial or aggressive patients often tend to end up with male doctors, in the same way that the one woman in a GP practice ends up seeing all the "woman's problems" in town.

Anyway, later on (we have some kind of virus on the computer at home that has disabled the virus protection system - some ghastly electronic immune disease) I will reply to comments and also bang on about the glorious weekend I just had. Also maybe something about giant gorillas.

Thanks for listening,
John

Fit as a fiddle and ready for love

A remarkable article from the journal "Seizure" published last year (yes, I know that shows how rarely I read journals). This normally less than gripping read contains an article by Drs Chuang, Lin, Lui, Chen and Chang, in which they report the case of a 41 year old Taiwanese woman with an unusual kind of epilepsy.

She had what is called 'complex relex epilepsy'. In complex reflex epilepsy certain repetitive or stereotyped actions can bring on seizures, and in this woman's case her seizures were induced "exclusively by the act of brushing her teeth". This would normally be disconcerting enough, but in her case the sezures took an unusual form - "a specific sensation of sexual arousal and orgasm-like euphoria that were followed by a period of impairment of consciousness."

So basically this woman orgasms every time she brushes her teeth. While demonstrating this for the doctors (!) she managed an orgasm after brushing her teeth for 38 seconds, and once after 14 seconds.

Drs Chuang, Lin, Lui, Chen and Chang, demonstrating a remarkable ability to keep their minds on the job, suggest that "tooth-brushing epilepsy, especially with sexual ictal manifestations, may provide insight into the cerebral pathophysiology at the right temporolimbic structure".

I suggest this woman has the brightest smile in Taiwan.

Ayway, back to drugs and alcohol. Thanks for listening,
John

Three degrees below ignition

Hail,
Sunday night here and I have wasted and frittered the weekend - lounging down the pub with my friends, walking somebody's dog, watching an old SF movie with Sarah.

And thinking.

A few days ago I rang Florey and said I was taking a holiday. It was short notice, but not at too inconvenient a time, and it didn't involve night shifts... and it was basically either a brief break now or a longer, perhaps permanent break in about a month or so.

In the last few weeks I've been getting... not quite tired, but something like tired. I go in to see people and I'm not concentrating one hundred percent, and that's partly because I'm not, I don't know, interested. Which is a weird thing to say, but I see patients and I feel somehow disengaged, somehow removed.

I saw some guy the other day, a man beaten badly by his step-children. He was trying to be cheery about it, and everyone was being very low key, but I think normally I would have been a lot more ... I don't know, "present".

But we stabilised him and we did the CT , and we rang up the Royal and told them we had someone who had blood in places in the head where blood should not be, and "significant quantities of air in the retrobulbar space", which meant air from one of his fractured sinuses had got behind his eyeball, and I reassured the patient and his wife, and I spoke to the police, while we sent him up to the Royal before his eyeball bulged out of his skull at us... and all of this I did in some mildly disengaged manner, as if observing events beneath a sheet of glass.

And things have been getting to me which shouldn't get to me. The Aboriginal woman last night, attacked and beaten down at the Mordor Train Station... I felt some of the nurses were smirking at her. And nurses are under a lot of pressure, and she was an intoxicated aboriginal woman, one of a family "well known to the emergency department", and she had been in here many times before and had several alerts next to her name for violence and inappropriate behaviour, but still, she was a woman who had been beaten up, who needed stitches in her head.

And I'm meant to be studying for the exam, and truth be told I have barely opened a book. I try, or rather I try to try, and different things get in the way. I have stories I want to write, friends I want to see, chooks I want to sit out the back and look at.

Unusually for me, this isn't whining, it's realising something. Emergency medicine demands something and of late I have been less prepared to do it.

I don't know. The reasons I stay in the ED are several.

It's the people I work with, the band of brotehrs (and sisters).

It's the helping people.

It's the stories, like I said before, when I was worried that storeis were what I was after, what I took from people, my source of sustenance. As if I was some kind of story-eater: a fabulovore, a sagaphage.

It's the feeling of comfort that nothing can actually fall apart, the reassurance that I have a basic idea of what to do whatever the situation.

A breif seque here: some people reckon it's hard (in an intellectual sense) dealing with really sick people. But it's not. Oddly enough, the sicker people are the simpler a lot of things become.

Karenina's Law (I don't know who first called it that) is the simple observation that there are more ways for things to go wrong than for things to go right. It's the first sentence of Anna Karenina:

Happy families are all alike; every unhappy family is unhappy in its own way.

In mathematical terms it is the second law of thermodynamics, the one that explains why things break down, the law that defines entropy: things fall apart, the centre cannot hold.

dS/dT > 0*, in the punchier, low fat version.

Well, that holds for medicine too - there are far fewer "correct" ways for a heart to beat than there are incorrect ways, there are many more incorrect ways for chromosomes to occupy cellular nuclei than the conventional two copies each of twenty three, and so on. So medicine is hard - you have to know not only how things can go right, but also the very very very many ways things can go wrong.

But emergency medicine is lucky in that at its core is a wonderful simplicity.
All healthy living people are fairly similar, but in the end so are all dying people. The things you need to know about keeping people alive who will otherwise die are almost childishly simple.

Make sure there is some kind of pipe from the air to the lungs.

Make sure the lungs keep filling and squeezing, filling and squeezing.

Make sure the heart keeps beating and, if possible, that there's enough stuff for it to pump. And that stuff should be as much like blood as you can make it, but that's not really that important.

Back to wat I was originally trying to write about: there are lots of reasons to do Emergency, but none of tehm are actually causing me to enjoy it at the moment.

And this isn't depression: I have this very high index of suspicion about my own mental state, I have this horror of making a poor decision due to depression or mania or whatever, but I don't think this is that.

I think it's a little bit of burnout.

Now this may well be a temporary state. Virtually everyone in the training program goes through this, maybe most doctors, certainly a lot of people in other professions. Sarah reckons that it may well be a temporary thing, that a few weeks off from the ED will be good, that I may return full of enthusiasm. And I've got over a month of holidays saved up, and considering my last holiday was the exam, I haven't had one in a while.

Anyway, I rang up and told them I was taking two weeks off. Two weeks (half time, admittedly, but still...).

Two weeks, of which the first week end will be concentrated, unadulterated, intellectual sloth. I shall not think. I will not diagnose, I will not analyse, I will not consider appropriate investigations. I will allow myself some leeway in the matter of imagining, fantasising and speculation, but nothing at all with any purpose, or end, or goal. If someone wants a bandaid put on, they will have to ask Sarah.

I am going to stretch my mental muscles, muscles that have been cramped from sitting too long in one position, and see what I can do.

Anyway, midnight. See you all soon.

Thanks for listening,
John

*Can't type "greater than or equals".

The Great High Holy Day

Five AM in the ED. The title refers to my two weeks (half-weeks, actually) of leave I have decided to take while I decide if I will quit the ED altogether. I have rarely looked forward to holidays as much.

You know, looking back on my recent posts, I am tempted to believe in some kind of literary half-life, where you write something that seems interesting, well-written and insightful and then look at it the next morning and it's turned into some farrago of half-baked thoughts and inarticulate phrases.

Since I am writing my blog rather than looking after my patients, I should explain what they actually have and why I am sitting here rather than doing something about them and their problems.

Cubicle 18 is Ms Marzano, a young woman with acute mania who has been detained under the mental health act. She is sleeping the sleep of the just (in this case the "just been given a lot of medications") and is being transferred to a psychiatric ward. I have barely laid eyes on her - all this was done before I saw her.

Cubicle 15 is Mrs Dubjek, a woman who has Some Weird Shit Going On. Her blood tests are grossly awry, her pain is considerable, her mental state fluctuates, her CT is alarming. Whatever is wrong, it's bad. I don't know what it is. Her GP does not know what it is. The medical registrar does not know what it is. The only guy who has known what it is has been Dr Rookswen, the "weapons grade stupid" medical intern who was previously in the ED. He sent her home a few days ago having diagnosed her with a rib fracture. She is sleeping peacefully.

The next two cubicles are people who have come to hospital saying they want to kill themselves. In the old days this was a passport to admission - it was like saying you had chest pain. But they will be reviewed by the psych team and sent home in the morning. There is a chance that they will kill themselves - people with personality disorders are at heightened risk of either killing themselves or "death by misadventure" - but that risk can actually be increased by hospital admissions. So they will be discharged before breakfast.

Cubicle 33 is a man with constipation, in a bed five paces from the toilet.

Cube 3 is my Aboriginal woman, domestic violence, apparently a distant cousin of one of Australia's top footballers. More on this later.

Cube 8 is an infant with croup, cube 9 has a woman who tripped over a garden gnome and fell into a rose bush, and cube 10 my pale man with the chest pain.

Cube 1 has Mrs Igvatz, who has come in here with her second heart attack. She is only forty one. Eighteen months ago (there are bad genes at work here - her mother dropped dead when Mrs Ivatz was only sixteen, and she is the last survivor of four sisters) she had her first heart attack, a heavy ache in her right shoulder and a catching in the breath. It frightened her deeply, and she has not been the same woman since. She now meets the criteria for a form of agoraphobia, and since the heart attack she leaves her house rarely. Instead, she sits at home - in the last eighteen months she has gained fifteen kilos, and now smokes forty cigarettes a day instead of twenty.

ANd the box has just gone off, and we have fifteen minutes until the zarrival of sixteen yeear old male, found unconscious post assault smells, strongly of alcohol. Which Dr Maad will probably be looking after, but better go anyway.

Thanks for listening

Shoddy Health Care Providers

An extremely brief post here, but did you realise how many of the world's health problems were caused by shoes?

Neither did I. Things your doctor won't tell you....

John

Asymptote

Two o'clock in the morning here, the house is quiet, the chickens are locked away, the dishwasher and my favourite oriental cat is purring, and sleep is elusive.

And as usual, whenever I can't sleep my mind fills with unusual thoughts.

One of the new cats, by the way, miaows like someone rather ineptly imitating a cat. You're sitting at the computer and from the darkened kitchen someone says "miaow". It's rather unsettling.

A moment of scene setting. For the last month or so I've been working at the South Mordor drugs and alcohol unit, seeing people who have some kind of problem with what we call drugs of dependency. That means the thirty nine year old mother on methadone for twenty years, the forklift driver who drinks, the nineteen year old man with the amphetamine psychosis, the twenty three year old woman who smokes heroin.

It's interesting work, and it's learning how to manage something I (and the ED and medicine and the whole of society) don't manage very well at all, and it's something I believe in. And it's interesting stories, told generally by pleasant, articulate people with few pretensions, and it's a glimpse of something that I feel I was perilously close to, something that touched my friends and family but for no apparent reason spared me. That drop of rain that falls just the right side of a hillstop - that kind of thing.

I have been having odd thoughts lately, too, about stories, about how ... fundamental they are, how irreducible they are. Wondering (bear with me) if it makes sense to think of people being constructed of stories, as much as they are made up of atoms. Because it seems to me that when I meet someone and talk to them, while it is true that what you have is two temporary coalescences of atoms squirting air at each other, there are other possibilities.

Sometimes (usually at night, when night shifts are approaching or have just gone) I think we are all made up of stories. Sagas, not cells, memoirs instead of molecules, dramas rather than DNA. If you looked at us under some new kind of microscope there would be immeasurable numbers of tales: miniscule tragedies jostling with comedies, epics entangled with jests, myths forming and reforming as we watched. But unlike the democritan atoms (but like fractals and other objects of one and a bit dimensions), you can't break those stories down to clean, irreducible parts. The more you look, the more story there is. Stories all the way down.

But I digress.

I have been spending the last month or so hearing the stories of patients, and in the last few weeks, one ugly fact has been protruding from the water, upright like a jagged rock. The ugly fact involvement of my profession in so many of these stories. And I don't mean the (relatively common) stories of misprescribed drugs and poorly managed pain and the almost ecclesiastical condescension some doctors display (almost on the level of a deep tendon reflex - someone mentions methadone and the physician's lip curls)... I mean something much worse.

I mean the doctor as a deliberate and significant and knowing player in the drama, not as some disapproving chorus but a character in the tragedy. The doctor in the in the much less savory roles. The doctor as addict, as dealer, as pimp.

The first time I heard this was seeing a patient for a script review. Script reviews are bread and butter addiction medicine. You see someone and see how they are going on their dose of whatever, you help them out with what you can, you occasionally do a urine test, and that's that. It can be full on (some people have a lot going on in their life) but in the low maintenance longer term patients, it's pretty low maintenance medicine.

Anyway, I was speaking to a patient whose main worry was reducing his methadone dose in time for his working holiday (he does "private security work" in the Middle East and South Africa, doesn't seem like a holiday to me) and we were just running through the drug side of it and he mentioned that he occasionally used a bit of morphine "that he got from a friend who's a doctor".

I sortof glanced at him and he at me and we let that go by.

And a few days later I heard about someone else, a psychiatrist, who had apparently been "involved" with a younger patient for whom he prescribed opiates. There had been reports and investigations, but these things are very hard to prove, and the relationship was rumoured to be still going on. More discreetly, of course. And she was still using morphine.

And everyone said how truly terrible and abberant this was, and got on with our work.

Then another guy who went on occasional ("every two, three months max") ketamine binges with his local doctor, and another who was a cray-fisherman, and apparently had quite a good lobster-for-morphine exchange thing going on.

And then Rebecca Glissade, late thirties, upper class Melbournian accent, all silk shirts and pearl necklace, and the only woman I have seen at SMACHEAD who I think will be dead in five year's time.

She was - is, I presume - a psychologist, not a doctor but the wife of a doctor and one of a close circle of friends, all doctors. They had been together all through University (she pronounced the capital U), wonderful friends, dinners at each other's houses in the hills, holidays together in Europe, restaurants in the city. A wonderful, artuculate, exciting, extremely close (and closed) circle.

And they were all on drugs. Well, it was so easy to get. Morphine, ketamine, oxazepam. Medical grade purity, guaranteed supply. None of this haggling in the back streets with some toothless pimp for your third grade product cut with epsom salts, this was clean and pure and exciting and wicked and not at all like that at all. And none of them would ever get caught, because they were so clever, and they didn't have to worry about disease or anything, because weren't they all doctors after all?, and they were so rich, and young, and the way I heard it it was roses, roses all the way.

Well, almost. There was the matter of James. He was in Queensland, in prison, on a remarkable eight hundred and eighty charges of fraud. Presumably still able to dispense medical advice, but no longer a member of the Royal Collage of Physicians. And there was Malcolm - and she didn't say anything more about that, but it had all been a shame, a terrible waste. They drove him to it, you know.

And there was the matter of her, having been kicked off the methadone programe a few months back and only now being reinstated. That matter of the forging the methadone scripts. Her husband - ex husband - now practicing out near Broken Hill somewhere. Took the car, took the money, left the kids. Having to walk half an hour to the nearest bus station to get to see me - Brigadoon, in the hills where she lived in her big house, was known for its public transport routes.

Going into the clinic for a seven day detox, coming out with contacts and someone who could score her some stuff, scoring the same day. Using four hundred dollars of heroin a day, going through the savings at a prodigious rate. The kids (four, six) not knowing, but knowing enough not to knock on the bathroom door when mummy's in there.

And now what? She wasn't holding up on the dose of methadone she was on, she needed an increase. Otherwise she'd be forced to keep on using. It wasn't right that she should be punished, that she should be subjected to this. She wasn't some junky. And her lawyers were trying to talk to his lawyers, try and arrange a reconciliation. Anyway - James, he'd be out of prison soon. His dad had a pretty good lawyer, there were still avenues. He'd be out, and although he couldn't prescribe opiates again, they'd slip up. They wouldn't remember, he'd get under the radar, he'd be back.

He was dux of St Peters, you know that?

Anyway. She left (with her dose gradually increaing over the next few weeks, her deeply unsatisfied), and as she left I noticed that underneath her black woollen slacks was a pair of old running shoes.

Since then I have been struggling to articulate what it is that concerns me so much about this woman. Because there are others in far worse states, others who take more drugs, who live on the streets, who have diseases this woman hasn't even heard of.

And I cn't pin it down. Part of it is the rapidity of the decline, the plunge from the silk shirts to the junkie hiding in the bathroom, walking everywhere because she has no car. Part of it is the sheer number of barriers that have been crossed - a lot of people after ten years on opiates still don't inject, she's well over that. Part of it is the demand we fix her problem in the way she wants and when she wants it.

But I think it's something else. Most people, if something like this had happened... there would be some period of self-analysis. There would be at least some suspicion that what you had done or what you had failed to do had played at least some part in what had happened to you. There would be, if not an acceptance of responisbility, at least a sign that the questions had been asked.

But she's a good way away from that. She is coping via a mixture of denial (her husband will come back, with the car and the cash. James will emerge from incarceration in Queensland with a magnum of morphine under each arm. People will realise she's not a junky like these other disgusting people) and diversion. It's SMACHEADs fault she injected heroin. It's the police who trapped James. It's the medical board who drove Malcolm to do what he did. It's everybody else.

And so, what do you have? You have a woman with great expectations and few resources. You have someone who is injecting heroin from a disreputable source and is defying us to stop her. You have someone in a strnge place who won't even open her eyes. You have someone who, to be honest, does not have the skills to survive in the place that she has brought herself to, the place in which she now lives.

Anyway. Three AM, I have to get on with sleeping. I hope I am wrong about this woman.

Thanks for listening, will reply to comments tomorrow night.

John

Stand up

Hail,
And on the next day....

The next day was largely full of fairly unwell people, but over lunchtime I heard something rather disturbing about a patient who had been seen at Shipton. In this case the fault was not Shipton's. I'll let you work out whose fault it was.

This, too, contains sexual references.

Anyway, what had happened is a man had turned up to the Shipton ED with an erection and a detailed sheet of instructions. This caused the consultant, Dr Prong, some concern, principally because the erection had now been going eight hours and was an unhealthy dusky blue colour.

It emerged that the gentleman concerned had recently begun treatment at one of the new impotence clinics that have arrived in town. He had been having injections of something we call caverject - you inject the stuff into the base of the penis and a few minutes later, Thunderbirds are go. Everyone (presumably) is happy.

By the way, when I was a medical student I managed to accrue not only a pair of Viagra boxer shorts, but a Viagra wall clock and a calculator in a kind of wooden stand - you pressed this button and the calculator slowly rose from the horizontal to the vertical. At Hogarth I managed to get lots of free samples, ostensibly to treat people with anti-depressant induced or anti-psychotic induced erectile dysfunction, which were certainly not abused for alleged recreational purposes by doctors.

Anyway, back to our upstanding citizen. He was actually in considerable discomfort and considerable danger. The condition is called priapism (a painful, prolonged erection) and it is dangerous because it impairs blood flow through the penis. The erection is not caused by sexual excitement and it is not relieved by ejaculation - it's a longer term thing. Erections have been known to last for days - and the longer it lasts, the worse the consequences are, including irretrievable impotence and amputation.

Do not, by the way, inject cocaine into your penis. Priapism may result.

One surgical response to priapism is called a Quackel shunt, and I think another is the El Ghorab procedure. Neither of these names inspires much confidence, one sounds like a dance move and the other like some military atrocity. But by God, they're better than ongoing priapism.

The way the patient told the story he'd basically been sent home with this stuff and told to inject increasing amounts of it until it worked. Dr Prong said he had rarely seen a man so uncomfortable as this man.

Doctor Prong tried everything. The first thing he did was aspiration - sticking a hypodermic needle in and withdrawing 150 mls of blood (about the size of a restaurant glass of wine). The offending organ deflated momentarily but returned to full size within a minute or so.

Dr Prong started injecting the antidote into the base of the penis - 50 micrograms of phenylephrine, then 100 micrograms, then 150 - finally ending up with sticking one of those butterfly things in the penis and giving 500 micrograms every three minutes until things came good - all the time getting ready to send this guy off to the urologists at the Royal for some kind of emergency somethingorother. Maybe some shunting, perhaps a bit of quackling.

Anyway, things eventually came good, but only after what Dr Prong said was heroic amounts of phenylephrine. Dr Prong reassured the man that there was every likelihood that "regional tissue ischaemia had been minimised" (good with penises, less so with people), and the man seemed grateful.

"So" said Dr Prong, a life-long fan of public medicine. "I have to tell the clinic about what treatment we gave, I've written a letter - do you think you'll be going back?"

And the man, who at sixty nine years was still a large and powerfully built figure, clenched and unclenched his fist a few times and looked at Dr Prong and said "Oh, I'm going back there. Just the once."

Anyhow, thanks for listeing. Less visceral posts next time.

John

The Frickin' Finger of Fate

Hail,
Sunday evening, late Spring, the horses stand in the paddock and the chickens roost. We have nine white kittens in the bedroom corridor and a pining mother outside.

And if anyone has ever desired to knit a life-size model of the human gastro-intestinal system, here it is.

Now, I suspect that may be a small proportion of you, so what has happened in the last few days that may be of more general interest?

Well, I worked over the weekend, and we had three very different days. I warn those of an easily offended nature to turn away now. The following contains Adult Themes and Bottoms.

Friday, through the previously mentioned "Emergency Department Law of Association", was bum day at Florey. Three of the first four patients in our end of the ED had what more genteel readers would call fundamental problems, and since the intern managed to grab the one non-rectal patient and "look after" their mildly strained knee for ninety minutes, I looked after all three, one of whom was quite unwell, one very nervous and the other of whom struggled to contain her laughter as I asked her a series of questions about what I felt were deeply unlikely sexual practices.

Four years ago, when I was an even more nervous intern, working in the Emergency Department at Lazarus, I saw a woman who had been involved in a very minor car accident. She had been reversing out of her parking space in a shopping centre and another woman, doing almost exactly the same, had collided with her. She presented to the ED more out of a sense of duty than anything else, and after the obligatory four hour wait, was more than a little tetchy.

I went in and checked her out, and as required, went and presented my findings to the senior doctor - who, I suspect, may have used this opportunity to amuse himself.

"And did you do a full neuro?" he asked.

"Full neuro?" I asked. A full neurological examination, depending on how thorough you want to be, can take anything from fifteen minutes to half a day, and involves checking as many of the functions of the brain, nerves and spinal coloumn as you can think of. "Not a full neuro, no".

"What about the PR?" (Again, a translation - this means a digital rectal examination. It's exactly what it sounds like).

"She reckons neither car was going above five kilometres an hour - " I began.

"So you'd be prepared to stand up in court and say you have definitely excluded cauda equinae? Or transverse myelitis? Or even Guillain Barre Syndrome?"

"well, I didn't think it was that likely - "

"Would you repeat that statement for the benefit of the members of the jury, Dr Bronze?"

And so I went in to explain my new course of action to Mrs Stentor, who was waiting for me with obvious impatience. She was a no-nonsense farmer's wife, and had already got herself out of her gown and back into her clothes.

"Umm, I'm afraid I'm not quite finished yet, Mrs Stentor."

"WHAT?" For the first time, I noticed how remarkably loud her voice was.

"It's just that - "

"LOOK, SONNY JIM. THERE"S NOTHING WRONG WITH ME THAT GETTING OUT OF HERE WON'T FIX. I'M SURE YOU MEAN WELL, BUT I'VE BEEN WAITING HERE IN THIS FREEZING COLD FREAKHOUSE FOR FOUR BLOODY HOURS!!"

"It's just one quick test"

"BOY, I WANT TO GO HOME AND ENJOY WHAT LITTLE TIME I HAVE LEFT WITH MY FAMILY. WHY DON'T YOU JUST RUN ALONG AND LET AN OLD WOMAN LOOK AFTER HERSELF"

"I'm still a bit concerned about your neck."

"WHY? I'M NOT" she hollered. "SEEMS PERFECTLY FINE TO ME!!" And she wobbled her head around like a bobble-head doll, making me bite my knuckles in terror. Something in my appearence must have aroused some sympathy. "SO WHAT DO YOU WANT TO DO?"

And I launched into my rather lengthy spiel. About how damage to the spinal column can be very subtle. About how signs of damage, if detected, can alert us to the possibility of spinal damage early, rather than late... early enough to do something to prevent further damage. About how often the first sign of damage to the spinal column was loss of function of the small muscles around the anus, those of the external anal sphincter. And how any weakening of the muscles could be detected by digital rectal examination, which could... and gradually I realised that her eyes had glazed over.

"DIGITO RECTO WHAT?" she said.

"Examination" I said, and gave her the Readers Digest condensed version. "It's the easiest way to tell if there has been damage to your neck. The best way to tell if there is any damage to your neck is to insert a gloved and lubricated finger into your ... bottom and - "

"MY ARSE?" she screamed. "YOU WANT TO STICK YOUR FINGER UP MY ARSE? - OH MY GOD!!"

"It's just that - " Outside, I could hear murmuring, as if of a small, but increasingly irate crowd, gathering.

"WHAT DO YOU WANT TO DO THAT FOR? MY GOD! WHAT KIND OF PERSON ARE YOU?"

I backed away. The crowd shuffled closer. "Ms Stentor, the only way we can exclude any kind of neck injury is to insert a finger -"

She did not wait to hear more, but gathered up her possessions and stalked towards the door. As she left the room she turned for one more confirmation of what she had heard but found impossible to believe. Her voice fell to a whisper. "You honestly expect me to believe that you can check out my neck by shoving your finger up my bum?"

I nodded. Several other patients seemed to take this as an admission of guilt on my behalf. "Yes, it's called a digital rectal examination. We insert -"

"HA!" she screamed, as if having all her suspicions confirmed. She stalked out of the department, brushing aside the passers by. I stood there, as flummoxed as I have ever been in my life. There was a brief pause, and then the doors opened again, and she leant her head in and fired her parting shot: "HOW LONG'S YOUR FRICKIN' FINGER?"

Well, sorry about that. And to make matters worse, the next post is all about willies.

Thanks for listening,
John

Thalidomide eyes

Hail,
Mondays are medical education day at SMAC-HEAD, so last Monday saw us clustered together in the old drawing room in the organisation's central offices, listening to a talk on drugs in pregnancy.

And it was actually a very good talk - interesting, realistic and on occasion, blow-you-away mindboggling. A few things that stick in my mind:

Paroxetine, a very popular anti-depressant marketed over here as Aropax, may cause cardiac valve abnormalities in the womb. The speaker mentioned this as a "minor abnormality", which is probably true, since 'minor' is the usual medical term for 'something that someone else gets'.

I don't know how close to 'truth' this is - if it's a slight perturbation in the background rate of abnormalities in a minor study, or if it's generally widely known. I didn't know it, but there's a lot i don't know. Medicines/chemicals/etc cause only a small fraction of abnormalities, by the way, something like two thirds are "God knows".

An advertisement for an early anti-depressant, marketed by Roche, featuring a picture of a depressed looking woman, with arrows pointing to her face, demeanour, etc., illustrating various diagnostic features of depression. This was meant to help the concerned physician to better diagnose this subtle and frequently missed condition. Among the warning signs were (and all this without an irony at all), were "poorly applied lipstick" and "wrinkled stockings".

Psychiatry apparently, isn't a branch of medicine, it is a subspecialty of haberdashery.

If you're bipolar and find out you have become pregnant, it's better to be on lithium than valproate. Both cause abnormalities, but the more we learn about lithium the less terrifying it becomes, whereas every other mood stabiliser I know of is truly horrible in utero.

And lastly, a section on thalidomide, originally marketed as a safe and effective anti-nausea medication... and I believe now making a comback in some parts of the world as an anti-leprosy medication, under the name of Thalomid. And we saw shot after shot of phocomelic (literally "seal limbed") babies whose mothers had taken thalidomide.

One of the areas most often affected by 'medicines (and other causative agents) that cause deformity' is the ears. There is some embryological explanation for all this that remains in my head for a picosecond every time I hear it. The interesting thing is how many syndromes cause subtle or gross alterations in the shape of the ears.

And so the most remarkable image that remains in my mind from that talk is of a child's face, a black and white photo, one from the side and one from the front, like prisoner's photographs. The child himself had an expression of mingled defiance and melancholy, someone taken to the doctor against his will. A perfectly normal child, mentally, physically, socially, except for two subtle signs: an underdevelopment of the lobule of the external ear, the archetypal "funny looking ears", and pupils that were permanently of different sizes.

Odd, maybe something to cause him some hassle at school, but nothing truly out of the ordinary. But that kid must have reckoned he was the luckiest kid in America. Because all through his pregnancy his mother had had terrible nausea, and on the advice of her physician had treated it with thalidomide.

Anyway, I should work. Thanks for listening.

John

Signs and Wonders

Hail,

I will skip the usual grovelling about lateness and get right into this.

And I'm just settling in to my new office in the heart of Mordor. SMAC-HEAD's office is nestled amongst several others, all squat, pale brick and barred windows, in the middle of a vast expanse of bitumen, across the road from the railway tracks. It's as if the entire complex has deliberately been made ugly.

There has been some confusion about who is working where when and so the preceding doctor has left some of her personal effects here. As I work stuffed trolls and monkeys loom over me from the bookcase behind me, and pictures of improbably sweet-looking children in eighteenth century dress, with the small stature, big head and pale skin that often goes with paediatric osteomalacia.

I know the secretary has a cheery painting of a bear above her desk. The bear is wearing fisherman's clothes, and clutching a rod in its paws, and is standing in a river smiling broadly towards the viewer. This is meant to reassure us, but I can't help but imagine the viewer's response if they were to see this in real life: a hyper-intelligent tool-using grizzly bear, which has presumably already killed a solitary fisherman and taken his clothes, and now turns its fanged face towards you. How do you stop something like that?

We at SMAC-HEAD are numbers 11 to 13 Mureceptor Drive. Number 7 is Centrelink, to whom you go when you can't get a job. Number 9 is Child and Youth health, the people who take your kids off you, number 15 is the folk who go out to your house when you go mad and take you off to the insane asylum, then there's some kind of gambing recovery place at seventeen.

Up the road, and just around the corner, are the opposition: the TAB (gambling), McDonalds, Smokemart, pokies and yet another Booze Brothers. From there it's only a quick walk to Mr Hydro (hydroponics to grow cannabis), then once that really kicks in there's the gun shop.

Anyway, more on this aspect of the job as it develops. Next post (later today, I hope), why the ears, rather than the eyes, are the windows to the soul.

Thanks for listening

Stay on the scene like a fax machine, huh...

Apologies to James Brown, but the last hour of my job was spend photocopying and so on. Get on up, and so on.

Well, today was spent at the DAC, which either stands for the Dependence Assessment Clinic, or the Desperate Alcoholics Clinic, depending on whom you ask.

DAC is the least loved part of my new job with what I will call the South Mordor Area Council to Help Eradicate Addictive Drugs (SMAC-HEAD) - at least until I can think up a less boring acronym. Around here, the drink driving limit is a blood alcohol of 0.05. One offence means loss of licence, two is loss of licence for a longer period of time plus come to see us, and so on. Soon after that there are lifetime disqualifications, increasing prison terms and so on.

What happens is once you get, say, your second sizeable drunk driving offence you get sent to us to determine if you are dependent on alcohol. The doctor sits you down, asks you thirty or forty standard questions, does a physical exam, takes some blood for blood tests and then two weeks later you get a letter saying whether you are dependent on alcohol or not.

It's weird medicine. Even more than psych, it's "helping" people in ways that they bitterly resent, and asking them to sit idly by while I make some decision that is going to have a significant impact on their life (and on how they see themselves). It's confrontational, and it's also very tightly regulated (I have to ask everyone the same forty questions), there's limited room for rapport or chatting about the footy, and everyone hates doing it.

One thing I find deeply weird at DAC is the sheer amount of lying that goes on. The patient lies to me, and I lie back by nodding and arranging my face as if to say "That seems reasonable", rather than throwing myself on the floor and flailing my arms and legs in the air as I cry with derisive laughter. Then we both mouth our respective untruths about wishing each other well and thanking each other for their time, and then we close the door and smirk about how we sure fooled that guy.

But God, it's difficult to restrain myself. "So all you had was three light beers and a lemon, lime and bitters? and then when they pulled you over you blew five times the legal driving limit? And that's pretty much what's happened the last fifteen times you've been done? including last month where you were done for the illegal use of a traffic cone, and driving a combine harvester without due care inside a church, and your blood alcohol concentration would have killed a Tequila worm? No wonder you seem pissed off."

And that is all true. People who lie about their drinking, I was told, tend to paint unrealistically sober pictures. There are questions in the test that are pretty much designed to identify when people are lying: "have you ever caused embarrassment to yourself or someone else while drinking?", "have you ever had a headache or felt nauseous the morning after drinking?" and so on. While I am sure there are people who have never ever done this, they are not the same people who blow 0.30 on the breathalyser three times in a row.

The weird thing is, I remember in my irresponsible youth drinking much more than I do today, causing embarrassment to myself or someone else while drinking, and having a headache and feeling nauseous the morning after drinking. And to my shame I remember driving home drunk, taking two and a half hours to cover the eighty kilometres of straight, flat highway, a hot December night in country Western Australia, some time in the eighties.

I suppose I could say "who am I to tell these people not to drive drunk?", but I don't reckon there's a problem combining a fallible character with good medicine. I do reckon that's helped me in psychiatry. And I note that it's often the slim, young doctors who tell the middle aged fat men that all they have to do is lose that thirty kilos.

Anyway, off to read everyone else's blog. Thanks to those who've been reading. Hopefully today Sarah can put some links on my blog beside the one she did "so I'd know how".

See you all soon.

Thanks for reading,
John

Snakebite

Seven in the morning, cloudless late spring day, and apparently yesterday we had our first snakebite case of the summer.

We get a lot of them here - Florey sees more snakebites than all of the other hospitals in the city combined. I'm not sure why this is, but I suspect a complex epidemiological association between king brown snakes, barefootedness and alcohol, with a bit of backyard cricket thrown in.

Apparently last night's was some girl who kept a small python ("Robbie Williams" ... I don't know and I didn't ask) which she usually fed on mice. Last night Robbie developed ideas above his station and seized her in his jaws. Presumably the next stage would have been throwing a few loops of snake around her and then slowly devouring her. Instead she went to the ED. We gave her antibiotics and sent her home.

Snakes, by the way, are amazingly beautiful creatures. I saw a red bellied black snake a few years back, swimming through the long grass, head aloft like the prow of some ancient ship. There is something about snakes, something you can see in them, like the way you see a sword within a sheath.

The entire story would have been quite different if she had been one of the area's several licenced taipan handlers. For some reason, some people find the thrill of handling large, often venomous non-taipan snakes insufficient, and graduate up to taipans, which are sizeable, deeply venomous and dislike being handled by human beings. Taipans remain unpredictable throughout their life, even after years of experience, a sort of reptilian gelignite.

My feeling is that the vast majority of the time, the animal does not benefit from any interaction between taipan and man.

I read with alarm, by the way, that alcohol is involved in one out of three "deaths by crocodile" in the Northern Territory - usually involving someone swimming in a crocodile infested pool. This means that two out of three people decide to swim in pools that may possibly contain crocodiles while stone cold sober.

Elf struck

Well....
The sixteen year old girl is alive and well, extubated yesterday, sitting up in bed and discussing mosh pits with the nurses. There is much rejoicing.

And it was long QT syndrome* that kicked her heart into that rhythm, too. So she's probably going to be started on beta-blockers (Sarah says half the performers in the local symphony orchestra are on beta-blockers - they are drugs that stop you feeling the physical symptoms of anxiety: tremour, racing heart, etc., so you can fiddle your fiddle and cell your cello without performance anxiety).

From what I can dimly remember, she may be going off to have something implanted in her heart that will defibrillate when she fibrillates - I don't know if they always do that anymore. Small scar on her chest, a remarkable story to tell her children, and her with apparently most of her neurons intact.

Her extensive family are already booking in for the blood tests to find out which of them carry the same problem in their genes. The possibility of sudden cardiac death in your sleep tends to concentrate the mind wonderfully.

But all has not gone well, in the ED and otherwise, and all up it's been a rather difficult few days. I keep thinking about the girl from last shift in the ED**.

The twelve year old girl who had the stroke, who last I saw was strapped onto a barouche, was sent off to the Royal. When she left us she was unable to move her left arm or leg, her eyes were wide and staring off to the side, as if unwilling or unable to meet her mother's gaze. She had not spoken since her mother found her, nor had she shown any sign she was able to understand what had been said to her.

The prognosis here is exceedingly poor. The problem is the largest of the arteries that supply blood to the brain, the largest artery "downstream" of the carotid, the pulse in your neck. This artery supplies a huge amount of brain. When it is blocked off, areas of your brain darken and die, like fragile creatures downstream of a dammed or diverted river.

These areas of the brain which die create and control movement, including the co-ordination of simple tasks, the direction of the gaze, parts of sight, even things like the amount and extent of sweating - and language.

Language may be lost to different extents and in different patterns - some are unable to understand speech, but can speak, some can only utter single words to communicate an idea. I recall people who could write but not read what they had written.

I have always wondered about the efficacy of teaching sign language to people who had lost their ability to speak post-stroke. obviously, others would have to learn it too, and a number of people who have lost language also have profound difficulties moving, but it may be better than nothing.

And I wonder if profoundly deaf schizophrenic people hear voices? Or do they think strangers flash hostile hand-signs at them?

Eerily, in some people the part of your brain that tells you that "something is wrong with your speech" is damaged along with one of the parts that make speech.

I remember seeing a video in medical school of a woman earnestly trying to explain her situation to a doctor. Her tone, facial expressions and gestures communicated her growing frustration, she even appeared to be repeating some words - but what emerged from her mouth was fluent, well-articulated gibberish: sortof "Water lot calliope that that howitzer, ash one one one thing" and so on.

It became apparent throughout the interview that as far as she could tell, she was speaking completely normally, but everyone around her had suddenly lost their ability to understand her clear and simple English. More frustratinigly, they could understand each other, she could understand them, but no matter how clearly she enunciated and how simple the words she spoke, no-one could understand her.

Anyway, what could be done for our girl? Herein is the problem. If someone has a heart attack, we can go in and remove the obstruction, prop open the artery with a thin tube kind of device called a stent, and restore bloodflow. Alternatively we can give medications to dissolve the clot.

In stroke the situation is less clear cut, partly because of the danger of causing bleeding into the brain. There is a lot of controvery about this, but at the moment the Royal offers emergency administration of "clot-busting" medications to a select group of patients. I don't have the list of criteria in front of me at the moment, but I beleive it includes people previously healthy who have definitely suffered a disabling stroke of a particular type in the last three hours... but who aren't children.

See, there's the problem. We got her in, diagnosed her, scanned her and sent her over to the Royal in a matter of tens of minutes. She arrived there well within time, if she were an adult, for the "clot-busting" medication to be given, and she may have improved significantly once given it.

But she won't get it, because she's a child. And nobody has done trials of this medication in children, because how many twelve year olds have strokes? How much risk is there in trialling a medication like that on the damaged brain of a twelve year old? How much money is there in organising a trial on stroke medicines for the paediatric market? Who wants to be the first to guide the needle up the artery towards the teenage brain?***

So it could help her, or it could kill her. We don't know. I doubt we will.

All deeply distressing, and the kind of thing I have been thinking about too frequently over the last few days.

In times like this, when I lie awake in the early morning, my appetite alters and my mind runs over and over the same sterile rut, there is always the question of incipient depression. I feel it is counterproductive to increase my dose of mood stabilisers - firstly they don't work quickly, they aren't happy tablets, and secondly, this is a grief of a sorts, rather than any mental illness. It is not something that can or should be medicated away.

Anyway, thanks for listening the last few days. I do feel better than I did. Read Champurrado's blog, as I have been over the last few nights. I'd link to it but I don't know how - Sarah did the Foilwoman link to show me how and I didn't understand, so I'm hoping she'll relelnt and do the others soon.

It's impossible to read this and not come away feeling better about life and how it can be lived. I doubt she'd thank me, but VF girl, the one who I feared was going to be horribly damaged... I hope she goes home and her parents and her eat oysters together: "plump, fresh, cold, glistening morsels resting in half shells on cracked ice with lemon, mignonette sauce and maybe some Tabasco". I hope her life is good.

Anyway.

Thanks for listening
John

* one of the rare occasions I have been right about something medical and other people have been wrong. Don't get me wrong - when questions are asked in the ED about lives of the early Roman emporers, the enemies of Spiderman, or British SF of the sixties and seventies, I'm the "go to" man. But causes of VF arrest in teenagers? Not often.

**and increasingly about another job.

***And the other thing is, you don't get to be a neurosurgeon at the Royal by saying "to hell with the risk, who cares what those geriatric milksops say?". Neurosurgery is a very conservative field - can't think of the last neurosurgeon I met with even a tongue piercing.

A call for the issuing of a guidebook to the undiscovered country

As I've said before, I'm not quite sure how I should (or why I do) write this blog. Sometimes it's pretty much straight "what happened today", brain-to-screen stuff that maybe other people will find interesting, or that maybe I can use later - chunks of data for the novel, the television series, the pop-up 3D erotic cookbook... (perhaps not). That kind of thing.

Other times it's thoughts that I carry around in my head for a few hours or a few days, things I try to write in a way that means something, to get some idea out, explain something that at some level has been bothering me and will not let me rest.

This, unfortunately, is about something that's been bothering me, but due to the aforementioned unholy sleep/motivation/concentration trinity, it's not going to be polished prose. It's just going to be data.

Okay. In the last few days, I have seen two particularly upsetting cases, which I will now share with you so that you, too, can be miserable and perhaps make your friends and family, those close to you, miserable too.

(You know, I've never understood all that "a trouble shared is a trouble halved thing". Scarlet fever shared isn't scarlet fever halved, is it? It just means two people with scarlet fever).

Anyhow, case one, Sunday morning, inpatients. Theoretically, our ED is divided into "inpatients" (people who come into the ED and will probably be admitted to the hospital - heart attacks, pneumonia, that kind of thing), and "outpatients" (people who will probably be sent home - dislocated shoulders, the majority of psychiatric cases, etc.).

In reality, half of the inpatients beds are taken up with people who have been admitted to the hospital but are stuck in the ED because there are no beds, so outpatients is full of inpatients plus people who have been sent in by nursing homes, are waiting for pickup, and the waiting room is full of extremely pissed off people - many of whom have problems that would take minutes to fix were we able to have somewhere to treat them.

So Sunday morning ten AM, the box goes off (that's the box we have in the corner that fires up whenever the ambulance are coming on a category one - a big green light flashes, the speaker crackles and pretty much every doctor and nurse in the inpatients end stops what they are doing and listens):

"Florey, we are four or five minutes away with a sixteen - that's one six - year old girl who was in VF arrest. Found by mother who performed CPR, VF when we found her, defibrillated, reverted for about a minute, then another episode lasting over a minute, shocked her, currently sinus tachy, GCS 3, BP holding at 120. No further information at present. With you in four minutes."

VF is ventricular fibrillation. It means the most important part of your heart, the part that does the pumping has gone into spasm. Instead of squeezing rhythymically it quivers uselessly - I have been told that when a heart does this when held in the human hand, it feels like a small bag of worms.

Anyway, when the heart is in VF there is no heartbeat, no bloodflow, and soon, no life. It is "cured" by electrical shock, which is what the men in the back of the ambulance had had to do twice in the ten minutes between this girl's home (where she had been found unresponsive by her mother) and the ED. But by that time, of course, the brain has been without blood for an indeterminate amount of time.

So she came in and there was relatively little for us to do, a quick intubation and some lines in her veins and arteries ... and then she went up to ICU and we started to try to work out what had happened.

Perfectly normal girl. No drugs, no alcohol, no family illnesses. No boyfriend. Not happy, but not unhappy, certainly not the kind of girl anyone ever thought would overdose or anything (and she hadn't, as far as we could tell). A silent father, a staring brother, a mother who wept in the corner of the room. A difficult conversation with the parents, a conversation in which we had no answers, no reassurances, no real ideas - nothing beyond the facts that they had done the right thing, we were doing what could be done, she was stable.

And her in the next room, obese, unmoving, fingernails painted black and a little bit of purple in her hair. "A bit wild", her father had said, "but a good child."

I've said the same about my niece.

I don't know. Out on the floor people were talking - the CT was normal, someone reckoned Wolf-Parkinson-White syndrome, I said maybe long QT, Dr Bedlam suggested some overdose. Sometimes in cases like this all we do is keep people alive and hope they get better. Sometimes they do and sometimes they don't. Sometimes we never know.

I don't know. She isn't dead, but as I speak neither is she alive. She is intubated, paralysed, sedated - it's impossible to know at the moment which of any of her vital functions would return - would she breathe? Would she move? Could she speak? Vital functions, as the name suggests, are those things without which there is no life. Functions essential to the maintenance of the body.

And we don't know about the degree, if any, of what we call hypoxic brain damage. This is the damage sustained by your brain - often the parts of your brain that make up memory, personality, character - as a result of the "downtime", the time your heart is quivering uselessly inside your chest.

There is a second set of vital functions, functions essential to the maintenance of the person. Will she still laugh, and at the same jokes? Will she recognise us? Will she lose memories, abilities, capacities for feeling?

Part of the problem, obviously, is our bicameral understanding of death.

In the old days Death came for you. One moment you were there, one of God's creatures, walking to and from upon the earth, and then you were gone, taken, irrevocably lost to the world of men. Once you're gone, bar miracles, you can't come back.

But that view is inadequate now. There are not just two states, death and life, there are degrees. People are more or less alive, there are degrees of being dead.

Life and death are no longer simply obeservable, they must be deduced, inferred, derived.

Whether someone lying on a bed in front of you is alive or dead may depend upon individual philosophical or theological niceties, or the machinations of the law - which is to say the decisions of lawyers and politicians.

Death has become fragmented - parts of you may be alive, other organs may not. If the situation calls for a corneal transplant, someone can remove the eyes from a person who is legally dead. You can't do that to someone who is alive, although exceptions can be presumably be made for ocular surgeons and military torturers. But you can't remove the eyes from one of those really dead people - or rather, you can, but it's not much good to you. You need one of these heart-beating dead types.

And death is no longer an absolute, it is contingent on simple things - "She is alive as long as we keep the machine going".

So that's death in the twenty first century. Fragmented, contingent, partial, sometimes temporary - but still occuring in 100% of those who survive being born.

Rather than a switch, with only two states, on and off, I sometimes think of two walled cities, separated by a disputed territory. In my mind, one city is always in sunlight, the other in darkness.

A traveller - a man, a woman, a child, a car of teenagers, an aeroplane - leaves the city of light and wends its way towards the city of darkness - (maybe we're dead before we are born, and this is a returning - I don't know). The travellers may cross from one city to the next in the blinking of an eye - instantaneous, irrevocable, uncomplcated. But alternatively, and I suspect increasingly, a lot of people spend time in the hinterlands, the dark forest between the two cities, the undiscovered country from whose bourn no traveller returns. Solitary, unable to communicate with those they have left behind, with no road or track to guide them.

Anyhow. These are, as to be expected, morbid thoughts. And that was Sunday. And then the next day they brought us a twelve year old girl, twelve years old, I tell you, who had had a massive stroke, and we bundled her up and sent her to the Royal.

And to be honest, I'm not sure anyone wants to hear what I have to say about that at the moment.

You know, there is really no unarguable impediment to my getting very drunk at the moment. Sorry about these posts, normal serotonin levels will resume shortly.

More later,

John