Thunder

Something weird that happened to me and Declan (much improved, by the by), while we were waiting for the surgeon a few days ago. All of these events (the conversation, what I saw, the weather) actually happened, but the whole shape of things didn't really become apparent until... well, just then.

And this is going to be a rather weird post, which I will send off with considerable trepidation.

Right.

A few days ago I spoke to a man about the end of the world.

Declan and I were standing outside the Florey Emergency Department. He was wearing a hospital gown over a pair of boardshorts, and I was wearing a hospital badge and stethoscope. It was hot, thirty seven degrees that day, and Declan was having a cigarette, prior to possibly having an appendectomy.

A thin man came up to us. The man was many other things (Aboriginal, elderly, courteous, suspicious, earnest), but it was his thinness that was most remarkable. He seemed a flannel shirt, an Essendon Football Club beanie, a pair of stovepipe jeans, hung upon a wire.

"Hey, mate" he said to Declan. "Got a light?"

Declan obliged. The thin man took a half-cigarette from his breast pocket and bent forward to light it. He sucked deeply, holding the cigarette filter outward, glowing tip concealed in his palm.

"Will you pray for my mother?" he asked.

Declan's eyebrows shot up. "Your mother?"

"She's a spirit woman. There's a lot of bad shit going down. Lot of bad shit. They laughed."

"Laughed?"

The thin man jerked his head towards me. "The doctors, her sons and daughters. I'm her son, but I'm not like those sons. No flesh of mine, no flesh of hers. Christmas Day, that's when she had her turn."

Declan nodded, slowly.

"They was all sitting down, sitting around her. All in a circle. We was meant to be watching the cricket. Someone gave her vodka and orange - they knew she had the sugar diabetes. The doctor said no vodka and orange, but they went gave her vodka and orange. That's what set her off. Fell down, can't walk, side of her face all twisted up. Can't talk now."

There was a pause. I thought about bleeding in the brain.

"You got to watch out for these bastards. These bastards" he said, jerking his head dismissively at me, and I glanced down at the hospital badge and the stethoscope. I know them all. I know this place, what it's like."

"Been in there, hundreds of times." He indicated over Declan's head to the nearest building, the psychiatric ward. "That place, emergency, all that shit. Been locked up, lots of times. Had to go in there few weeks back to hide. My brother -" and here he gathered me in with his glance, three of us huddled together on the hot day "few weeks back, my brother, he broke in, stole my bones."

I looked at his eyes, dark, almost teary, terribly earnest.

"Took all of my bones out my body" he continued, "sucked them. To get to the salt inside them. Every last one. Came in, in the night."

"Ah" said Declan.

The thin man spoke slowly. "Broke my mum's heart. I reckon that put her part way to her having her turn." He leant forward, came closer.

"But she's not gone yet. We'll know when she goes. She's a spirit woman, spirit woman. Big power, definitely." He glanced around, nodded, as if reassuring a wavering crowd, and went on. "Before she goes - the thunder. Hotter, hotter, night of thunder. All the night. And then..."

"Then?" I asked.

"Nothing" he said. "No nothing. No trees, no sun, no big fuckin' hospital. All gone in dark. Nothin', never again. Spirit woman. Big power. You pray for her?"

We assured him that we would, and he shook our hands, each in turn, and I saw the veins on the back of his hand, big, ropy, good to stick a needle in. If I ever had to. Declan and I shuffled back into the hospital, back to the bright light and the air conditioning. I glanced behind me as the sliding doors opened. The thin man was gone.

And I forgot.

Until just then. I drove out of the ED today, and just outside the gates was a flannelette shirt, lying on the road, the same pattern and colour he had worn, the same pattern and colour every unemployed man around here wears.

It was in the gutter by the side of the road, and as I glanced in my rear-view mirror, a gust of wind must have caught it, and an arm flapped emptily at me, and the shirt inched along the road. I think the Essendon hat was there, too.

I could have stopped and looked, but it was hot. Forty one degrees, and the humidity was rising, and I wanted to get home before the storms forecast for tonight. So I drove on, forgot about it, got on with things, did the things on my list, did what I was going to do, like any other day.

Until tonight, tonight when I heard the thunder.

****************


Well, like I said. Weird. Don't know that I managed to get that across. But anyhow, a less peculiar post next time, and comments.

Thanks for listening,
John

Christmas Day

Well, something went very right today.

I got up feeling reasonably substandard, my body already rejoicing at the prospect of shiftwork.

It is, of course, a few days after Christmas (and a few days before the Nestorian celebration of the same event), and today a virgin was with child in the Florey Emergency Department.

Well, not precisely. The virgin-with-child did not exist. She was a palimpsest, a mirage, a superposition of two very separate creatures. The result of seeing the same object from two different points of view.

Standing in the doorway of the cubicle, the father (Eastern European, skin the colour of strong tea, broad shoulders in a black jacket, white hair in an almost tonsure), saw the virgin daughter.

Stadnign off at a ninety degree angle, the ultrasonographer, and the girl (skinny, big eyed, sweating and pale), and the nurses and me saw the woman with child. Eight weeks and one day old, curled like a comma in her womb.

Balancing all this was not going to be easy.

The girl, Bahini (I feel a certain discomfort saying 'girl', because this was someone who could vote and drive a car and had only that year been her college's media studies apprentice of the year, but that was how she struck me at first), the girl was there with her father and her sister and her almost incapacitating nausea.

She came in crying, sweaty and vomiting, and unfortunately she came in at seven in the morning, which is close to handover at Florey ED, and Drs Bubo, Canker, Noma and Ileus had had enough overnight, what with the Incredible Shrieking Woman and the Medical Registrar, one Dr Horatio, BM, BS, CFU (Bachelor of Medicine, Bachelor of Surgery, Completely Fucking Useless). So Dr Bubo got a line in and took one of every kind of blood test and got some fluids in and started anti-emetics, and all possibly without emerging from alpha-wave sleep.

Dr Bubo, by the way, is going to be a damn good doctor. Smiling, congenitally courteous, smart. Good for Florey.

Anyway: the whole thing was a complex ballet. Her whispered entreaty the moment her father stepped out of the room, the fact that he didn't know yet, the suggestion that the shock would literally kill him. Me saying it was against the law for us to tell him anything she didn't want him to know, the reassurance that this happened all the time (and things like this do), the carefully choreographed switching between conversations as he and the sister wandered in and out of the cubicle.

The whole thing was like an allegory. While he was in the room we discussed nausea and vomiting in general - how its cause was often obscure, the physical examination, the ultrasound, the few blood tests serving more to rule out any sinister cause of her five days of vomiting than to establish any definitive cause.

When he stepped out of the room (lured away by the sister on some pretext, much of the conversation between the two was in Arabic), it was all folate and dating ultrasounds and looking after yourself and "how do you feel about all this, anyway?". And did you know morning sickness killed Charlotte Bronte?

Of course, Charlotte Bronte wasn't treated in the Florey ED.

A lot came out. Mum and Dad didn't know. Sister knew, and the boyfriend, but he wasn't being that good about it. He had said he would be, but he wasn't. And she wasn't sure about all of this, about the baby and everything. Not that she'd ever have an abortion or anything, but this wasn't what she had planned. She was apprentice of the year at her college, she told me three times, apprentice of the year only two months ago. And now this. Twenty one, pregnant, single, alone.

And her doctor - very old style. The family doctor, an old man. Hadn't even laid a hand on her belly, just looked at her over his glasses and said "huh" when she said she was pregnant. Didn't know when she should get an ultrasound or anything, she looked it all up on the internet. She didn't really have a doctor. And she hadn't even heard from her boyfriend for a week. Eight days, actually.

And it was quiet that morning, bright clear day outside, and I had time to sit and talk, and I told her how bad my wife's morning sickness had been (across the Nullarbor by car, stopping every fifteen minutes) and how she'd got over it, and we talked about small meals often, ginger, sips of water, coming into hospital sooner rather than later.

All lies, of course - it was my girlfriend at the time, not my wife, and the trip was by bus, not car, and several other little things, changing the details to protect the innocent, making stuff up to fill in the gaps as I go along, rearranging it to form a more dramatic or aesthetic picture in my head, so that even when I set out to tell the whole, unvarnished, truth something else emerges ... something like now.

Enough of Heart of Darkness. Damn fine book, by the way.

Anyway. We got her better and we got her out of there, a referral letter to Dr Minge* at the Women's Health Unit and a little, post-card sized printout of "the tadpole" as she called it, five centimetres from head to tail, heart already beating.

And everything was managed to everyone's satisfaction, no lies were actually told (although some of the truth was left unsaid), and the virgin soon to be great with child and her father left happily.

Presumably at some time in the near future to have a serious sit-down talk.

See, every time I think about quitting (and I was thinking about it pretty damn hard for a good while then), something like that happens. Something you can feel good about. Something that lets me utilise those special skills I have - listening, looking, lying.

Sigh.

Anyway. I think Emergency has got its hooks in me. I don't know if it's because I am drawn to distress and spectacle, like some blundering insect circling a flame, but in the end it doesn't matter. Even if you do it for that special weird thrill you get, that momentary release when you help someone... even as you see that feeling and extinguish it, it's good. For a moment forgetting who you are, forgetting the debt that's owed, smiling because you made someone smile.

Getting a bit too weird here. The study of moths, by the by, is called mothing, and people who moth are called mothers.

Anyhow, I might take a break, a sixmonth or a year off, I might never even finish the programme, I might never even go back. But days like those - they do the heart good. Days like these, I love them, and I love the job.

Thanks for listening,

John

*this is actually her real name. There was also an Elvis Semen (or Seman, or Seamen, I'm not sure) who worked in Obstetrics at the university where I learnt medicine.

Medical Imaging

My brother got sick today... or so I hear.

What happened was I was at work at my other job, the drugs and alcohol one. I haven't had a lot of enthusiasm for that lately, but that's probably because I haven't been on fire with the fire of the Lord for either job, 'emerge' or SMACHEAD. This is probably due to too much worrying over my career path and too many days off.

Anyway, I was in my new office, putting up my poster of Ultimate Iron Man and running through my lines for my first patient (a bilateral amputee described by his previous doctor as 'the most evil and manipulative son of a bitch this side of Canberra'), when I got a phone call from my brother Declan.

Declan sounded in considerable discomfort. This alarmed me because he is probably one of the toughest human beings I know. He works as a welder, and every so often when we are out playing cricket (bowling low and fast), or reading books together (currently me "Heart of Darkness", him something about Jewish gangsters in New York), he winces. After a while I manage to winkle out of him what is wrong, and it turns out he's got some blister the size of a lobster on his inner forearm arm where "some clown dropped a lump of solder on me", or a spike of metal the size of a crucifixion nail in his thumb, or a clearly fractured toe.

I, on the other hand, am a sensitive man, in touch with my own body and emotions and
making sure everyone else is too. If I nick my thumb opening a can of tuna I call my scattered family to gather around my bedside and hear my last words.

Anyway, Declan is in some discomfort, and of course, an ambulance is out of the question (being as they are, for sick people) and he wouldn't normally call but he doesn't reckon he should drive in. What with the stabbing, unbearable pain in the left part of his belly and the sweating and the vomiting and so on.

I fled SMACHEAD on compassionate grounds and drove him to hospital, dropped him off at the ED door (we arrived just after the shrieking man whose overheated car radiator had burst something and sprayed scalding water onto his two bare feet, and just before the heart attack) and got him around the back.

Doctor's relatives, by the way, are not seen faster than normal people. Emergency doctor's relatives are on occasion seen faster, if the doctor concerned can see them him/herself or if said doctor can ring someone, get them on the phone and manage to convince someone to let their relative jump the queue. I have seen a nurse's nephew, a best friend of a radiologist and someone's twin sister ahead of time, but that's pretty much it. It was one of the few remaining perks of a job which theoretically should place you in a position of great power, nowadays all I can do is snaffle out of date medical supplies for my wife's cats and occasionally grab some drug company food.

Anyway, inside Florey and then the next fifteen minutes explaining to the ED reg, the radiologist and the surgical registrar that although this man was my own flesh and blood I had taken only a brief history, had not examined him, and had no real idea what was wrong with him.

This is a deliberate policy of mine, and one which I have adopted only after considerable thought. I don't, unless its an emergency, treat patients and friends.

The reasons I give for this are usually as follows. First, to treat someone, you have to 'take a history'. You have to ask them stuff, and if they want you to be their doctor they have to tell you the answer. I am a relatively shy man, and my brother shares this characteristic to a considerable degree. There's a puritan, prudish streak that all of my mother's children have.

This means I figure Declan has pretty much told me everything about, say, his bowel motions that he wants me to know. But it's less than his doctor needs to know.

Similarly, the physical examination. The following looks almost unbelievably melancholy in isolation, but here it is: My brother and I don't touch much. He's not a hugger. Australian men raised in the bush rarely hug - that paradoxical-seeming response to the emptiness of the outback where the more space there is around you, the more space you put between you.

I'd like to be a hugger, by the way. I practice with Sarah every day.

And after the history and the physical examination, there's the diagnosis. Each time (three times I can remember) that I have diagnosed a family member or friend something has gone wrong, even if I've done everything "right". My niece, who had a viral chest infection and didn't warrant antibiotics and didn't get them, went off for a weekend and got pneumonia. My friends' son (and first year medical student) who had the same chest infection managed to spike a temperature of forty one night and developed actual delirium - but told me a few weeks later. And my brother's friend who was stung by some nameless insect and got hives turned out to be violently allergic to the antihistamines I gave him (I am not making this up) and had to drive himself to hospital.

But these are all superficial, secondary arguments, for public consumption. I was thinking about this as I stood outside the xray room today, clutching a copy of Heart of Darkness and not being able to read*.

As far as I can work out the main reaon for my unease when presented with my family and friends as patients has to do with seeing, and not wanting to see.

How do I explain this?

I look at my family and my patients very differently. That is common knowledge, but what is possibly not so widely appreciated is when you look at things differently you see... different things.

When I greet family and friends, I gaze into their eyes, I talk and listen, I open a bottle of wine. When you greet patients you gaze at the veins on the back of the hand and the inside of the elbow, I interrogate (courteously, gently, often circuitously, but unavoidably), I open a sterile needle or a bottle of anginine.

And most important of all, if you look at family and friends as if they are patients, you run the terrible risk of seeing in them the same thing you see in patients. And that's not something I want to see.

This is going to sound trite and obvious any way I put it, but here goes: We are all always forever alone, of course, and our nearest and dearest are utterly obscured, less visible to we who love them than is the centre of the earth.

So of course, we construct images of each other.

And what I am trying to say here is the images doctors build of patients are fundamentally different to the images I build of family and friends.

Family and friends are colourful, intricately detailed, moving pictures, probably taller and stronger and more beautiful than they would be in any imaginary "real life".

Patients have some of that but also have an overview, a transparent sheet of something laid over them: something sketched, colourless, a diagram of intersecting lines and shaded probabilities:

Mr Anderson smokes fifty a day.
He's got this cough.
Hasn't gained weight, in fact he's started to lose some.
But he's not worried about that, it's this pain in the side of his chest.

At some level you already see the cancer, black and red, nested in his pink lung.

See, that's the kind of thing I don't want to see when I look at my family and friends. I don't want to see more than I do, I like the picture I have. I don't want to see the future, I don't want to see consequences. I don't want to look at my grandfather playing chess and see the Parkinsonian clumsiness, I don't want to listen to my nephew talk about his "stress" and hear the soft rhythms of perseveration, the footfall of incipient schizophrenia.

And that doesn't mean I don't encourage them all to see their own doctor regularly, or that if it came down to it, "me or nobody", that I would not act.

But things you see you can't unsee.

Like a vampire, once the doctor is invited across the threshold, the sanctuary is breached, the damage is done: Prognosis, palliative, surgical intervention, five-year-survival rate... I could not mouth these words with friends and family.

Anyway. Declan. Appendicitis, all good now. Treated by responsible, skilled, objective doctors, who were doubtless able to tell him to cut back on the cigarettes and maybe think about a bit of exercise too.

And when he gets back on his feet, steak and beer and backyard cricket, King Kong and the comic shop. Take several times a day until symptoms resolve. Doctor's orders.

Thanks for Listening,
John


*There are already in existence several of Bronze's Laws of Medicine, including about half a dozen of psychiatry, three of internal medicine and any number relating to emergency. Some of them are almost good enough to be real laws, and I reckon my naming of SLOPs syndrome ("Sweet Little Old Person", earlier described) will one day make it into some textbook. But today I came up with a law and an addendum to it:

Law: "Don't go into hospital without something uplifting, engrossing and distracting to read while waiting for the surgeon"

Addendum: "Make sure it's not 'Heart of Darkness'".

The misery dog and the dolphins

Hail,
Don't know if I've mentioned this before, but ...

Florey used to have a dog on the staff.

He (at that time) worked on the palliative ward, ward 1E at Florey, the ward where the dying happens. Just down the corridor from cancer, across the hall from paediatrics, set apart by itself in a small, secluded area.

1E looked different, felt different. You could walk down the corridor, passing from one (relatively large) room to the other. The way I remember it, nothing was white, everything was soft pastel or rich and dark. There were carpets and rugs on the floor, paintings on the walls. Wooden bowls of potpourri, music, rosemary and camomile.

The usual definition of paliiative is negative, a medical practice defined by what it does not do: "relieving or soothing the symptoms of a disease or disorder without effecting a cure". An absence rather than a presence. Medicine goes so far, via surgical steel, precisely calibrated doses of poisons, Xrays and scans that look through you, until it can do no more... and then everything becomes palliative. Palliate is what we do when we can't cure. In a way not part of reductionist "real medicine", a refuge for those who don't have what it takes to cut and cure.

But there is another definition, one that seems to me to accord better with the observation that the palliative wards are full of colour and scent and peace, and ours (emergency, medicine, surgery) are empty and white. In this usage palliative is "moderating pain or sorrow by making it easier to bear": the primary function of medicine. The highest, not the lowest, the principal, not some secondary or tertiary discipline. Before we are anything as doctors we should become specialists in palliative care.

But I digress. Jackson the palliative dog.

As part of the palliative care's approach to the dying, they applied for and were granted permission to have a dog - the only dog on hospital premises (in a similar fashion, the only ward in Shipton that still contains a smoking room, at least until a few years back, was the psychiatric ward). Jackson was a medium sized beagle-brillo pad cross, affectionate to the point of clinical mania, and soon became
the most loved, and the most therapeutic staff members of staff.

Anyway, said dog was loved by all, and comforted a countless number of people in their dying days, and all was well.

For the first six months. And then someone noticed Jackson was off his food. A nurse weighed him and it seemed he had lost weight. He began to slink rather than lollop, to lie by his waterbowl rather than climb onto laps, and eventually people thought they'd better tell Prof Kraepelin, because Jackson was nominally his dog, and if they were going to send him off to the vet, bloods and a CT scan, Dr Kraepelin ought to know.

Prof Kraepelin, by the way, was the reason I went through medical school wanting to be a psychiatrist. He was white-haired, softly spoken, learned... and if it doesn't seem too odd a phrase, he gave the impression of wisdom. He had developed the anorexia nervosa unit where most of us had our first experience with psychiatry, and was a champion of the new approach and research that had bought the mortality rate down from twenty percent in the late sixties to the current "unacceptably high" three percent.

Professor Kraepelin listened to the story with grave face (I still remember the lecture theatre whjere he told us this. The silence, the serried rows of attentive faces, the low, carefully modulated voice), and gave his diagnosis.

Is it not possible, he said, tha Jackson is depressed? Or rather, is it possible that, having seen so many of the people he so demonstrably loves die within a few months, that he is grieving?

Anyway, the upshot of this is the palliative dog became something of a hereditary office, like the King of England, or the Phantom. They get dogs in for three to six month stretches, usually from the pound, and then someone takes them home. Some are affectionate, some relatively withdrawn, some dignified, some shy... but all of them as important and therapeutic as the man who cleans the floors and the woman who runs the pharmacy.

Anyway, here endeth the lesson. But I should point out that recent research indicates that dolphins are a successful treatment for depression*. I have brought this to the attention of the head of the ED, but as yet they are not stocked by our pharmacy.

Thanks for listening,
John

The beautiful junkie

In the mood for random, partially connected thoughts today, so here goes. Hopefully I can reply to posts once I get to work.

I have noticed something going on here, and I don't know if it is true, or if it is an illusion, one of those tricks of the light your brain plays on you. I suspect strongly that it is.

But what I seem to notice is this.

A surprising proportion of the young women who come to see me are classically beautiful.

Now, this isn't going to be me getting into some horribly confessorial minefield of "my inappropriate feelings for patients", because that's another entry, and probably not a very scandalous one. And I say "beautiful", rather than "attractive", or "pleasant" or "sexy", or "engaging conversationalists" - I mean people who are often none of those last few things, but who have that high cheekboned, symmetrically featured, fine chiseled look that gets on the cover of Vogue.

The thing that makes Miss China and Miss Jamaica and Miss Sweden look more like each other than they do like their countrywomen.

The thing that distorts the way a person is seen the way a vast planet distorts space, the thing that when someone has it, makes their most insipid jokes funny, their meanest insights profound, their otherwise viciously self-indulgent behaviour at worst quirky... even if they've got all the brains and personality of a Bratz doll.

(I should point out that there is no shortage of unattractive intravenous drug users. And I am in no way suggesting that injecting amphetamines or heroin make you beautiful, because it does precisely the opposite. A lot of people fall on and off our programme, and each time they come back on they get another photographic ID, and the photos all get stuck in the front of the folder. And you can see someone age ten years in five, or five in two).

But today I saw three remarkably Voguelike* young women in a row - high cheekbones, slim, fine-features accentuated by make-up, dressed in fashionable clothes - and I wondered if I was starting to see a pattern. If there was something about beauty (in that narrow sense) that makes you susceptible to drugs?

This would seem deeply counter-intuitive. As everyone knows, beauty makes life easier for you. Babies stare longer at classically beautiful faces than at those who won't get in Vogue. Classically beautiful children do better at school than do ugly ones - almost as if aspiring parents would be better off getting a nose job and breast implants for their kids than after school coaching.

I vaguely recall that beautiful people earn more, get better sex and get it sooner, are less likely to be convicted of a crime... given a choice between smart, strong, rich and beautiful, I reckon a fair few people would want to be beautiful.

But if there is a relationship between beauty and heroin (and I am in no way saying there is, I'm just looking at the idea), maybe it's got something to do with that.

Maybe it's got something to do with never experiencing the denial of happiness.

Maybe it's got something to do with always being able to walk through walls, never really having anything that was inaccessible to you

And maybe it's got something to do with always being wanted, always being looked at, always getting that intoxicating, almost narcotic "I'm important and wonderful and wise" thing played across the screen in some subconscious theatre in your head.

Your pupils widen when you see something beautiful, almost as if your eyes want to accept the beautiful person, drink them in, soak yourself in them. But in the slow euphoria of heroin, the pupils are tiny, shut right down, almost blind - as if nothing outside the self really matters at all.

Anyway, not a fully worked out idea yet, and probably no real objective phenomenon exists - it's much more likely that, like everyone else, I am noticing the beautiful and ignoring the merely wise or brave or good.

I don't know. Insert answer here, anyone.

Thanks for listening,
John

*Vogueons? Resistance is, after all, useless.

The 1992 West Coast Eagles versus... a Dalek!

Probably only three out of those eight words make any sense at all to most of you.

Hail, anyway. A post of minimal substance here, but hopefully something more substantial coming soon.

The title comes from the events of last night, specifically the discussion around the table at three in the morning over the remains of our barbecue. We had gathered to celebrate - for was not December 17th both the feast day of St Olympias and the national day of Bahrain?* - and obviously some festivities were in order.

We started with backyard cricket, (on three hours sleep and two glasses of cheap red wine) and then animated conversation. It was conversation which started out semi-sensible (whether professional sportspeople should be punished for 'unseemly' behaviour), edged into the slightly surreal (how successful would a national cricket team be, if it were composed of moral paragons and ethical giants: i.e.: one where the opening batsmen were the Dalai Lama and Nelson Mandela and the blistering fast bowling was supplied by Dietrich Bonhoeffer), and then descended into lunacy (one of those drunken "who would win" competitions involving my brother's favourite Australian Rules football team and a cyborg psychopath with a sucker for a hand, from a British science fiction show).

And I feel pretty damn fine about the whole night. I can't write about it as well as some of you, and I certainly can't write about it as well as I could if I hadn't had to go to work still somewhat fragile, but the next morning everyone was smiling. Pale, pasty, some walking slightly off the vertical, but smiling.

And today I think I met the most troubled woman in Slytherin, about whom more later.

Tomorrow's post will either be "being quite remarkably beautiful and how it fucks your life up" (about heroin), or "the wall" (the latest in the bad doctor myth cycle).

Thanks for listening,
John

*True.

Why we don't care about you

Hail,
Horrible little story I heard a few weeks back that just popped into my mind.

Seems a few years back a patient came in to Florey ED. She didn't look that sick. She had had a little niggling pain in her back for a few weeks, a kind of "slept funny" pain, and hadn't got around to seeing the doctor about it, and then that morning had noticed some blood in her urine. So, just to get things checked out she turned up to the ED, a glorious, quiet spring morning, and was being seen by bright, bubbly Dr Lues, who ordered the appropriate blood tests and CT scan.

"I'm ever so glad to be here, you know" said Mrs Rose. "Florey has treated me very well."

"That's good to hear" said Dr Lues. "Why do you say that?"

"I had such a lovely time the last time. I came in quite unwell, and the doctor who saw me sat down and listened, and he did and xray and found out what was wrong, and all the other doctors said he'd saved my life. He was such a darling. If he was here now, I'd love to speak to him."

"Of course. What was his name?"

And Dr Scurvy was soon tracked down and a very pleasant reunion took place, with many heartwarming expressions of mutual regard. It turned out that Mrs Rose and Dr Lues had come from the same part of England. Both shared a similar regard for Dr Scurvy, and an interest in keeping birds, and conversation sparkled between them over the next hour in such a way that they went from being complete strangers to what would have appeared to a passer by as close friends.

And all went well until the intern poked her head in the cubicle and said the CT scan had come back. Dr Lues said "Be right back" and trotted to the screen to look at it, and found the huge cancer on Mrs Rose's kidney - which turned out to be aggressive, malignant, and which killed her within the year.

Everyone, except possibly the stoic and courteous Mrs Rose, took this reasonably poorly. Dr Lues didnt see many people for the rest of the shift, and actually took the next day off. Dr Scurvy, who was older, attended the funeral, something that some of the old-school doctors seem to do more than the rest of us. Mrs Rose's daughters spoke highly of him, and also asked for their regards to be passed on to the absent Dr Lues. They said that Florey had treated their mother very well.

Anyway, said Dr Lues, who was telling me the story, there's a moral in that, and it's pretty plain to see.

And what would you say it was? I said.

You can't care, said Dr Lues. You can't go through that every day, ten times a day. You notice something - I don't aask anymore. About personal things. I don't ask if they keep birds, or what their daughters do, or what town they come from. I don't want to know. Because if I want to do my job right, I have to treat the patients as patients. I can't care.

So. I don't know. I have considerable difficulty with Dr Lues' conclusion. I don't know that what she says is true, and I doubt that it is true for all patients all the time. i don't know that I can yet ring up my friends and relatives in other parts of Australia when they go into hospital, and say "Well, I hope your doctor doesn't care at all"

Thanks for listening,
John

Platybelodon't you love me anymore...

Hail,
Five AM, the interregnum between the drunks and the cardiac patients, and I've been thinking about this whole taking a break from the training programme thing.

The way it stands is changeover happens in less than two months, and I pretty much have to decide what to do for the next six months.

My main options are another term of emergency half-time, a term of intensive care half-time, or going full time drugs and alcohol.

The ICU term would be educational and doubtless deeply praisworthy, but to be honest whenever I think about it I get this surge of tiredness. The same kind of thing I get when I think about studying for the exam again.

Going full-time drugs and alcohol is a lot better hours - regular hours, with maybe even a day off a week. That's the option where I would presumably be either studying for the exam (unlikely) or really taking my writing seriously. Writing the novel, the tv series, the comic book, the short stories.

I don't know. See, writing it down like that, it seems the only sensible thing to do is leave the ED, even if only temporarily.

By the way, I know that they'll take me back any time I want. I know this because Dr Pippi has quit and Dr Anya has quit and that's two of thier better registrars - one because her husband has left and the other because otherwise he will leave. So I don't have to worry about coming back.

And at least once a week I get a flyer saying "Why not become an emergency registrar in Queensland/Tasmania/New Zealand/Cairns etc." These advertisements feature images of doctors shoving tubes into various orifices on plastic looking patients, shots of beaches/tropical jungle/rainforest/whatever and photographs of the most photogenic nurses of either sex. The message implicit in this is that you will spend your time lounging on the beach with some microbikini-wearing babe, but the truth, I know, is that while the bikini-wearing babe lounges on the white sands with the jungle in the background, I will be grappling some hundred and thirty kilogram psychotic who reckons he doesn't need stitches.

So why haven't I quit yet? Why haven't I just picked up the phone and given them the six week's warning?

part of it is, of course, the obvious reasons. I work with really good people. It's helping people. It's interesting. It stops me forgetting my basic medical skills.

But I reckon that there is a less palatable reason as well.

I reckon part of it is ego.

A few days ago I was seeing a patient at SMACHEAD and he mentioned that he had some kind of knee problem.

"I've got to see a doctor about that" he said. "Not you, a real doctor. No offense meant."

"Real doctor?"

"I mean, not just a methadone doctor. Like in the Emergency Department"

"Well, if you turn up there Thursday night I'll see you. That's where I work. When I'm being a real doctor."

Fairly juvenile on my part, but still.... I wonder if there isn't some of that I'll miss. Some of the mana, some of the self esteem.

And then I wonder at how revoltingly shallow that is, and why after all these years I need that kind of prop.

As far as I can tell I despise that kind of thing in others, that whole "hot damn, I'm a physician" thing. Theoretically I find that kind of "I'm defined by my job" stuff pitiable. So it makes me wonder when i find it in myself.

How come I've still got this ongoing requirement, this chronic dependency on the praise of others. Am I ever going to be able to shake it off?

I think some of this dependency comes from certain unpalatable facts. Being hospitalised several times throughout my medical degree didn't help things. Being surrounded by people who are better than me at things like interpretation of CTs or the reference ranges for certain blood tests - while that's good for my training, it's not that good for that squalling thing inside me that screams until it is fed.

How come there is this need?

I feel things are getting better, they are certainly a lot better than they were four years ago. The fact that I have not been hospitalised in that time pretty much demonstrates that. But the fact that I have to tell people that probably demonstrates that it's not all good yet.

If it's a self esteem thing, if it's a lack and a fear and a hole where something should be, where is it coming from? Is everybody like this?

I remember thinking one time that no amount of external validation can compensate for a lack of internal validation. I reckon it's fairly clear that a lot of people are like that, that the degrees and the cars and the jobs and the spouses serve primarily to demonstrate one's personal success to some group of onlookers - agroup of onlookers that includes one's self, one's parents, old school teachers and people who didn't want to go out with you.

The weird thing is, when you look at this, that misery and low self esteem and insecurity seem to be not so much impediments as requirements for success. It's almost as if there is some kind of "evolutionary pressure" driving us to be miserable and needy.

Think of two tribes of cave-people, the Happies and the Needies. The Happies have no requirement for external validation - they all beleive in themselves, they all accept themselves for what they are, they don't measure their worth based on the opinions of others.

Just across the valley are the Needies. They are a population of psychological cripples. They loathe themselves. They are lonely, uncertain, yearning, there is a black hole within them that devours attention and love, a beast that cannot be filled, something that grows strong as it is fed, and weakens you as it grows strong.

Who's going to "win": the Happies or the Needies? Or put it another way, who's going to create the works of art, discover the new elements, make songs and make wars? Who's going to need something to believe in and make cathedrals and crusades, who's going to have a requirement to be better than their neighbours and make archers and armies? Who's going to have a need to be loved and make poetry )and progeny)?

See, happiness and contentment are evolutionary suicide. What happened to Platybelodon and other majestic beasts of the past? Is it possible that rather than a meteorite, that it was positive self belief that killed off the dinosaurs?

Well, I don't know about that, but it is entirely possible it will be emergency registrar mediated neglect that kills off the drunken man in cubicle 18 if I don't get off my bum and see him.

Thanks for listening,
John

Crie de cour (and liver, and various other organs)

Well, I'm going to be scanning the newspapers tomorrow hoping not to see my face. Listen to this ongoing concatenation of fuckups.

At around about two in the morning the police notice some guy blundering shirtless down the road. They pull him over, breathalyse him and discover him to be spectacularly, almost incoherently drunk. Blood alcohol was 0.39, which is pretty damn high for a skinny little guy.

From what I can work out they arrested him and dumped him at the ED.

He was not pleased about this turn of events (although to be honest, the scars and the slogans and images tattooed on his body suggested he was the type of man who was frequently and violently displeased). In fact, when the nurse went in to assess him he threatened to punch her.

The nurse went and got Dr Jihad (not his real name, but apparently his brother's), who inflamed the situation by trying to take blood from someone who didn't like needles, blood tests, hospitals, doctors, Arabs, "stuck up ****s", or men with moustaches.

At this time it became apparent that the ED security guards were not in the building, since they had been called away to another displeased person elsewhere. By this time the man was parading around the room with fists raised threatening mass fatalities. Dr Jihad went and sought the advice of the senior registrar - i.e.; me.

Things then worsened. I managed to calm the guy down (there should be some kind of international scale of drunkenness, and when someone weighing thirty kilos less than me and standing six inches shorter threatens to take "all of y'on", it's not a goood sign), when the one security guard that could be spared from dealing with 'kickboxing bikie with the head injury' arrived - which enraged our guy more.

He was eventually escorted outside to have a cigarette while I worked out what to do with him.

He didn't want to be here.

He couldn't be detained. He did not have a "treatable mental illness", and did not require the services of a consultant psychiatrist.

He could not be kept in the hospital under 'duty of care', because our security guards were under express instruction that it was illegal for them to prevent anyone leaving the hospital unless they were detained.

He could not leave, because he was stumbling around the room and was clearly intoxicated to the point where he could not look after himself. If he leaves the hospital and gets run over, it's our fault: we have a duty of care.

By this time he was shouting at a fifty eight year old woman with kidney stones in the aiting room and asking her "what she was fucken staring at".

I asked him if he had any friends or family who would come and pick him up from the ED at four in the morning. He suggested that this was unlikely.

I rang the police and they said that they had no further plans for him. I asked if he was still in police custody, and they said no, and I asked why they thought he needed to be brought to a hospital and lie in a six hundred dollar a night bed that was intended for the use of sick people. The police said he was too drunk for the cells.

I pointed out that they had driven past this man's house on the way to get here, since he lived five hundred metres down the road.

By this time I was beginning to be aware of the other sick people in the ED who needed my attention, and who needed protection from a hostile, drunken, partially clothed man.

I went outside where he was standing with the security guard and raging about being locked up and told him that my medical advice was that he stay in hospital until he was sober.

I said we were willing to order a cab and that we would pay for it to drive him home - I admitted that a taxi in this area could take several hours at this time of night.
I also said that there was no way me or the security guard could stop him if he wanted to walk home, which would be straight down the road, first left then probably only one or two houses along on the right.

I told him I was going to call the taxi, went and got a coffee and then checked two minutes later to find he had, indeed, left the hospital against medical advice.

I feel this was bad medicine.

The whole thing was a lose-lose situation. I think it is very likely that he got home without getting run over. But a few years ago in Queensland there was some guy who presented to the ED as clearly agitated, left a few minutes later and subsequently that day commited suicide. The judge found the hospital responsible.

See, if that guy died on the way home, I'm responsible. If I had detained him, I would have been responsible for the "bad detention", which is obviously a much lesser burden - although it does involve getting called up in front of the boss and told about what you've done wrong.

But I don't like detaining people at the best of times, and detaining him means the psychiatrist has to come and see the man when he's sober, and it's a big thing to do to someone, and this guy didn't have a treatable mental illness, because being drunk and stupid and aggro and unable to hold your drink aren't treatable mental illnesses.

Anyway, not that exciting today, just pissed off. Hopefully back sson with more (and able to reply to comments tonight).

Thanks for listening,
John

I'm just a girl...

And a quiet moment while I let what I have just seen sort itself out. I feel it will be a good few months until the image of Mr Lee-Curtis (tall, middle-aged, distinguished, bespectacled, wearing a school-girl V neck sweater and a pleated skirt, giggling and occasionally coquettishly remarking "I'm just a girl...") fades from my mind.

Which brings me to "Gay people - my part in their persecution".

In the last few years I have gradually come up with a theory which links fundamentalist Christianity, homosexuality and kinky teenage sex. And a word of warning - I find it very difficult to talk about sex. I can't even "hold hands and tell", let alone "kiss and tell" or anything more lurid. But the following does contain - gasp - sexual references.

Right. Background.

When I was fifteen I was born again.

I remember the events with almost luminous clarity. The prayer meetings in the lounge rooms. The preaching and the listening. The spontaneous hour-long prayer. The immersion - and there is no other word for it - the immersion in the Bible, drowning in the Bible, the text of the Bible seeping into your flesh, every line, every word essential for salvation. The long sessions of prayer. The baptism at sunset in the Indian Ocean, coming out of the water speaking in tongues.

I have tried to explain what it felt like. I don't know that I can. There is not really any "like".

But that was what happened. And all this at a time when my emotions, most of which were primarily to do with sex, were in a fair amount of turmoil. As you can imagine, I rapidly developed a case of advanced fulminant weird-headedness.

See, what happens when you become a fundamentalist, or a member of a cult, is you have to accept a whole lot of stuff as Gospel. It apparently is not sufficient to believe, say, that Christ died for you sins, that God is in the poor and the weak and the worthless, that you are forgiven.

That stuff is important, of course, but you also have to accept this whole lot of other stuff about the age of sedimentary rocks, ape-men riding dinosaurs and where God wants you to put your penis.

(Have you noticed, by the way, how few of Jesus's geology lectures or His pronouncements on consensual anal sex made it into the Bible? Instead it's cluttered up with Him banging on about love and not judging people).

Anyway, part of my fundie package was homophobia. Overt, confidently expressed, bellowed from the street corners, sanctioned and approved of by the Creator of the Universe. Three to five years of 'God hates fags'.

This does things to your brain.

And it's not something that just stops, either. It's not like a fever seizes you, shakes your body and then breaks. Recovery from fundamentalism (and I am deliberately using the same terms as you would for any other injury) takes time.

And it's hard. The penumbra, when you're saved just enough to know you're slipping into damnation, when you retain just enough faith to fear but not enough to hope... that's the worst part.

The half-saved/half-damned period as you emerge from fundamentalism is worse than the deep shadow.

In the centre you have no doubts, no fears, because you have been told you are saved, and who can doubt the word of God?

Once you're out of it you can look back and laugh (or grin mirthlessly) and say "Was I really actually that fucked up?"

But the slow crawl through the twilight - that's the hard bit.

But (back on topic) I did get out. And I reckon I can make a case for homophobia-induced brain damage.

For a start, I don't have gaydar. None at all. This causes no end of amusement to my friends, a lot of "surely even you knew ...?". The leather-studded Obstetrics/Gynaecology lecturer who one of the students complained kept banging on about feminism instead of teaching us about the history of obstetrics and gynaecology. The remarkably clean shaven intensivist with his succession of muscular Asian friends. The politically earnest spin bowler for one of our State cricket teams. Richard Simmons, for example: didn't have a clue.

Why? I reckon it's the homophobia. I think maybe when you grow up in rural South-Western Australia, what was and remains a deeply homophobic environment, in a place and time where none of my friends really knew what "poofters" did, and then you go through this period of white-hot religious conviction... maybe the sensors get burnt out.

Second piece of evidence for FAB (Fundamentalist Associated Braindeath) is the series of sizeable group of people whose friendship I aggressively pursued in Uni, solely because they were gay. My refusal to learn why this was not a comfortable experience for anyone concerned. And my fixed false belief that the principle interests of gay, lesbian, bisexual, etc. people were gay politics, gay writing, gay film. There was some echo of this behaviour as recently as a week ago.

I am sure this must have been very tiresome.

Seriously, my skin is prickling with embarrassment as I write some of this.

So, what's the prognosis? Can I ever rejoin normal society, or will I have to retire to some kind of institution?

I've been trying. I sortof have this leftie ideal (virtually the last thing I haven't sold out on) about helping the marginalised, and I reckon underneath the determination to work with same-sex-attracted people, to do something for them, is a gnawing guilt at the feelings which I suspect are still in there somewhere, the guilt at what I once believed and said about them.

And the thing is, there have been some signs of slow, halting recovery. I have friends now - Mark, Lisa, Cynthia, Morrigan - who are gay, and these are genuine, deeply normal friendships.

The reason for this, unsurprisingly, is that we became friends before I found out that each was gay.

I don't know. Maybe it's like a pendulum. Two to five years of homophobia. Ten to fifteen years of compensatory guilt, an anxious, driven urge to somehow make recompense to some amorphous mass of people who you use to make yourself feel less bad.

And then finally, some approximation of equilibrium.

Although I still cringe every time I think of what went on. Anyone reading this who knew me then, sorry.

Lastly, as promised, kinky sex. With admirable economy, fundamentalism didn't only screw up my opinion of other's sex lives. It screwed up my own sexual ... something. . I don't know, sexual development is the wrong word, makes me sound like I grew tentacles or something. But something went seriously awry.

I remember talking to my friend Algernon (in extremely veiled terms) about how me and my first girlfriend, the Methodist minister's daughter, would accompany her dad as he travelled from the nearest large (3 000 people) town to our (300 people) town, to preach every second Sunday. And as he exhorted folk to reach out to their neighbours in a spirit of true love, we would feverishly fornicate in any location we could find**. And then fall to our knees and pray for forgiveness. Twice, maybe three times per sermon, more if there was a baptism or a funeral.

So, sex and guilt, sex and damnation, sex and hellfire, in rapid, probably bipolarogenic succession. We bonked and wept, shagged and prayed, fornicated and ran to read the appropriate passages of the bible. And our distress, our guilt, our misery and sense of damnation was real. Our anguish was no less sincere because it was followed inexorably (and in those days, pretty much inexhaustibly) by further sin.

Sortof "Get thee behind me, Satan, and try it that way".

The slow disentangling of sex and guilt took vast amounts of time and energy which I am sure could have been spent better.

Anyway. I was going to write about how sex is a lot more than the cartoon that fundamentalism says it is, that it's something rich and strange that we are only starting to understand*, but I'd sound all gushy. Enough writing about all this. I have to start my novel today.

Thanks for listening,
John

*Believe it or not:
Author Meizner, I.
Title Sonographic observation of in utero fetal "masturbation".
Source Journal of Ultrasound in Medicine. 6(2):111, 1987 Feb.

** There were, however, compensations. And if anyone ever mentions this blog entry to me in any way, I am going to die of embarrassment.

Why waste your money on surgeons...

Hail,
A moment of calm in between drug dependent patients.

The following contains, now I come to think of it, scenes of what must have been remarkable bloodshed, and is furthermore of now particular literary merit. Don't read on if you are easily stressed.

A few days back I saw someone with a naltrexone implant, a hard plastic lump underneath his skin, a few centimetres southwest of his navel. These things are experimental and of dubious utility, and it hadn't worked on our guy, who was just using heroin over the top of it.

He wanted to know if I could remove it.

I prodded around. "Mate," I said, "I've never even seen one. I'd want to have an idea what I'd be looking for, first. I'll get you an ultrasound, then we can send you to surgical outpatients, have it out in no time."

"Don't have to worry about that" he reassured me. "It's simple as. Tell you what, my wife - the vet took hers out."

"The vet?" I said. "As in animal vet?"

"Wasn't a problem" he said. "And my mate's, I cut it out myself. Went good. He bled a bit, lost a fair amount of blood. Actually had to go off to hospital, get a transfusion... but nah, it went good. It's no worries. Can't you do it now?".

I declined, and eventually, with considerable murmuring, I got him to take the ultrasound form off to the radiologists. I doubt he'll be back. He'll probably stop off at the local handyman store for a Stanley knife.

And for no apparent reason, at the end of this entry (*) is further evidence that Coke is bad for you, and in fact, the more you love Coke, the worse it is.

Hold on - upgrade that warning. Don't read the following unless you have had a complete squeamectomy. I warned you.

People have, several times throughout history, operated on themselves. This is why mental illness kills people.

I dimly recall a truly ghastly story about a bladder stone, some guy stuck on a lighthouse who decided to take matters into his own hands and removed his own bladder stone via an orifice that usually only goes the other way. People have done basic ortho surgery on themselves numerous times. And a woman in Brazil a few years back apparently performed her own caesarean and survived, while her husband was off at the pub drinking.

I was going to write one of the "Leaving the sinking Shipton" stories, but that may have to wait until tomorrow.

Thanks,
John

* From the journal "Archives of Sexual Behaviour", August this year....

Pentaethylene-terephthalate (PET) bottles: a new device for autoerotic strangulation of the penis causing serious injury.

"Strangulation of the penis by application of constricting devices may present a challenge for the treating physician. Depending on the type of constricting material, special equipment is essential for successful removal of the foreign bodies. We report a new form of constricting device, the neck of a Coca Cola bottle made of Pentaethylene-terephthalate (PET). Particular difficulties were encountered upon removal. Technical details of this case are described. Prior literature on the treatment of penile strangulation is discussed...."

The Kong and I

Hail,

Meandering post with no real point here. Normal posts will resume shortly.

King Kong is coming, the apparently-quite-similar-to-the-original Peter Jackson movie, and I have been looking forward to it more, perhaps, than is wise.

Why is this so?

At the core, it's a deeply silly movie. Giant apes, dinosaurs, forgotten islands shrouded in eternal mists. And the black men caper and the women scream while the white men sort things out, and, inevitably, triumph. It has, from that point of view, not much not to recommend it.

And yet...

It may well be that the original King Kong was not a great film, but merely a fairly commercially successful one. I'm not sure what makes a great film, but I reckon if you mean something to a lot of people, over a fair amount of time, that's one kind of great, and by those criteria, Kong was a great film. But nobody, not even in the sanctum sanctorum of some mysterious and secret nerdic society, mentions King Kong in the same breath as... I don't know, Schindler's List, or Some Like It Hot.

Again: and yet...

It doesn't make much sense. Even when you take into account that it's a film that's 'about more than its about', if you follow me, a film about race and sex and libido.

Kong the brutish black man taken from the jungle, exhibited as an entertainment, breaking free then being crushed by the forces of order.

Kong as the Depression.

Kong as the wilderness.

Kong as individual creative energy in the face of the machine age.

And if those symbolic meanings were too complex for all of the ten year old boys who saw teh original film again and again and again, I'm sure some other aspect of it all resonated with them. The idea of something dark and animal and untamed awakening inside them, something that sought to transgress in ways that they were sure were un-natural, impossible, wrong, something that was more comfortable fighting dinosaurs than watching a blonde haired girl with her new boyfriend - I'm sure that made a spooky amount of sense to a ten year old boy.

Kong, like Dracula, like Heathcliffe, like Mr Darcy, like Superman, is always more than what he is.

Anyway. But why am I looking forward to it so much?

I used to believe in wisdom. You know, something that people had, in the same way they had "tallness" or "size" or "baldness". Some people had wisdom and you could go to those people when you needed wisdom and those people would tell you something, reach into their inexhaustible inner stores of wisenessitude and pull something out and give it to you. And if you their wisdom didn't make you wise, at least you got good advice.

I don't know about that anymore. I've been struck by how much of what we say is "wise advice" is stuff that we want to hear. Some answers, some ideas, some images, speak to you at certain times, because there's this inner need. Other times, it just bounces off you.

Anyway, lately, certain images have been bobbing to the surface. One of them is Kong, staring through the bushes, virtually obscured. I don't know what it means, or why it is looming out of the dark at me, but I think it must mean something.

There's another image, which has been distracting me as well. This image actually comes to mind more frequently and strikes me with greater urgency. It's an image from an old comic I bought a few weeks back, when I was at the comic store looking for comics with giant apes, and robots with glowing brains in transparent skull-cases, and cats in super-costumes.

The first time I saw the picture was in an old comic about the Purple Claw, an occult-fighting super-hero of no remarkable merit. Anyway, he goes about battling the forces of evil, as is his wont, and at some stage he turns up in some kind of cave. This is, as far as I can tell, the Vault of Heroes, where the other superheroes of his world live.

And there is a bit of exposition and a plan of action is decided upon, and the heroes rise into the air. There they are: Catman. Jet-girl. The Green Lama, the Green Mask, the Eagle. Rising into the air, suspended aloft by the spectral powers of the Green Lama, poised for action, ready to descend where and when danger calls.

And they're still waiting. AC Comics didn't do well. It folded back in the forties. Its superheroes followed its air aces, its masked cowboys, its scantily clad women of the jungle into oblivion. And literal oblivion here - the word root is the same as that of oubliette, it means "to be forgotten".

Who remembers them now, Catman and Jetgirl, the Flame and Miss Victory? Not-particularly-good examples of a not-particularly-important genre, characters who flourished when the climate was right, but who went the way of most of the Miocene apes, most of the equids, most of the cartilaginous fishes - survived by a remnant population.

Anyway. This image has been floating to the surface more than I feel is necessaary. As if it's trying to tell me something. I don't know why or what. Something in the whole thing strikes me as almost inexpressibly melancholy.

Anyway. In a brief foray into actual news, I am looking at stopping work in the ED for a year to concentrate on my writing. More news as it comes to hand.

Blood

Hail,
And a quiet moment, having just taken blood from the Demon Dentist of Fang Rock. And he wasn't manipulative, charming and deceptive like everyone says. He's just a decent, ordinary guy who's really trying hard to get his life back on track. And it's really unfair that he keeps on getting persecuted and misunderstood. Seriously, everyone from the Dental Board to the Drugs of Dependence Council seems to have it in for ...

waitaminute...

But seriously, I reckon other doctors/dentists/pharmacists/vets are the hardest patients. I was thinking about this a few days ago and it made me realise how much we as doctors rely upon the unequal dynamic of the medical consultation.

See, most times doctors see patients there is a grossly unequal balance of power. Theoretically, the doctor knows everything, the patient knows practically nothing. The patient is sick, the doctor is presumably healthy. The doctor is familiar with the territory of sickness and disease, the patient is not.

Now if this was ever completely true, which I doubt, it is no longer - but neither is it ever completely false. For a lot of people, the workings and "failures to work"-ings of their body are a mystery, clothed in impenetrable flesh, and the doctor , to their mind, has the ability to know things about them that they themselves do not. The patient, who may be supremely competent in his or her field of expertise, a person who makes vitally important decisions that affect the lives of thousands, is suddenly reduced to saying "so, aggressive metastatic dispersal - that's not good?"

And doctors depend on that unequal balance of power. We're not meant to, but it's there, and it makes things easier, and so, like everything that makes things easier, turn your back and it becomes a necessity.

Like the way people depend on escalators and those golf cart things, and pretty soon they end up using them more and more and getting fat and then they are helpless without them.

All a rather pompous way of saying that the Demon Dentist is not the easiest of my clients. He has made it his business to know what I know - drug pharmacokinetics, the relevant legislation, success rates of various detoxification regimes. If he was just a sick person trying to get better this would be one hundred percent great - we could work together, two heads better than one, that kind of thing. But the problem in this case is we have two different, only partially overlapping motivations.

I want him to stop using heroin, and he wants to stop being caught using heroin.

He is appears solely motivated by a fear of detection and punishment. He seems honestly surprised by how "punitive" the Dental Board is being about this. I have to repeatedly restrain myself from grabbing him by the (fashionably cut) shirt and hollering "They have suspended your licence because YOU ARE INJECTING HEROIN INTO YOURSELF!!! What the hell did you expect them to do?".

Seriously, if dental school is anything like medical school, the whole course can be seen as however many years of "how not to get struck off/get sued/kill someone." And I'm sure injecting heroin got a mention there somewhere.

I wonder what he would think if he came to see me and I was staring at him, pin-point pupils, and whispering about how beautiful everything was.

This whole thing leads into the question of how comfortable I am with detecting and punishing people. It's not what I got into medicine for, even though when you look at it, the fields of medicine I have spent most of my time in are the fields where you most commonly impose your will on others: psychiatry, emergency and drugs and alcohol. if I'm not injecting someone with drugs the court says they have to take, or stuffing a plastic tube into their lungs despite their express wish for this not to occur, or having them carted off to an insane asylum yet a-bloody-gain, I'm telling them they can't drive or work or whatever because they are junkies.

Anyway, blood - what I was originally going to write about. I took blood from a patient today, as I often do. And while I did it (thin, smooth, mathematically straight needle, sharp and bright as insight, sliding into that fat conjunction of the cephalic and accessory cephalic veins) I was meditating - and that's probably the best word I can come up with - on how profoundly peaceful the taking of blood is.

Honestly. There's this one moment, this region of stillness, this absence of tumult, when the needle is in the vein and the dark, rich blood jets out, and even the most anxious patient or frenetic doctor realises that there is no response other than silence. In the ED it is often the eye of the storm. At the risk of sounding cloying, there is something sacred about the taking of the blood.

When it goes right, of course. I am sure that it's not like that from the other end. I've had it done and it hurts. And I've done it badly - had to have multiple attempts, probed and missed and probed again, in the inside of the elbow or the back of the hand or the side of the wrist (avoid this if you can, it can hurt like hell if the doctor goes too deep).

The last time I didn't try was a woman who had only one palpable vein on her entire body, and that was a single, pulsing thing in the hollow at the base of her throat, where your collarbones feel like they meet - one vein deep in the jugular notch. And she was cancer thin, and the hollow was sunk deep, and she was confused and frightened, and I thought of the seventy or one hundred things that could easily go horribly wrong, and I called my boss.

When I began I was abyssmal at venepuncture. I still am some days, but they are rare. There are several types of difficult. One type is the extremely overweight - I have got blood from a two hundred and ten kilo man who was slightly more than five foot tall. Another distressing possibility is the sick child. Another is the very old - if they take steroids, for example, for airways disease, they usually have paper thin skin that tears when you apply adhesive tape, or fragile veins that rupture at the gentlest tough. And when they are on blood thinning medications, even the gentlest touch of the finest needle raises great blue black berries of blood swelling beneath the skin.

I have even had a woman pray for me, standing behind me, arms outstretched and eyes closed, calling on Christ Jesus not to abandon me in my hour of need while I tried to get blood from her nineteen year old daughter, who had hands like hot cross buns and all the brains of a labrador. I tried once, the daft girl jerked her hand away, and then as I tried again the woman began swaying and singing Hallelujahs. I could feel my face prickling in embarrassment. Conversations gradually stopped, a small group of medical students watching a chest drain being inserted turned to watch me, and just as I got the line in, dark blood oozing up the barrel of the jelco, the woman began clapping her hands and speaking in tongues.

I think as I withdrew the blood I could feel every single eye in the ED upon me, even the guy in cubicle two in a coma.

They reckon Australia is relatively free of religious and sectarian violence - well, we came close that day.

Anyway, thanks for listening.

John

The wages of sin are ... pretty damn good, actually

You know, I feel so damn good, so damn fine, so very very happy... that a less sspicious man than myself would become a little bit concerned.

There is of course, a good reason for this. I have just had the first four days of my ED free holiday.

And how did they go, I imagine I hear you ask?

Pretty bloody fine.

Thursday I descended on the Bookshop like a wolf on the fold, and glutted myself with books. I have ordered "Spook", the sequel to the truly remarkable "Stiff" by Mary Roach - you know those books where it says on the back "You'll laugh, you'll cry, you'll stay up all night..."?

Well, Stiff will do it. Read all about fat man's dandruff as a traditional medication, Russian head transplant experiments and some allegedly cannibalistic dumpling makers. One of the funniest/saddest/most horrible books I have ever read.

What else? A collection of Chinese supernatural stories, a collection of short stories by "some miserable bastard" (suggested by my ex as particularly suitable for me a number of years ago), a book on the history of morphine and laudanum as patent medications, something on the travels of a Franciscan monk in Asia, a book of Tim Winton's stories ... I think if someone had't pulled me off the discounted books section I would have burst something. I almost needed a shopping trolley.

A glorious orgy of literary excess.

Thursday night we went out with old workmates and drank.

Friday I pottered about the house and then went out and drank.

Saturday morning I went to a geekfest and glutted myself on superhero comics from the fifties and sixties, where square-jawed men in wrestler costumes battled giant apes with ray guns. I have found lately that covers with pictures of giant gorillas or creatures with huge brains and see-through skulls are usually markers of fine literature. The Shipping News was a damn fine book, but who's to say it would not have been improved by Quoyle battling a giant gorilla?

In truly top flight literature, of course, the heroes are assisted in their fight against the giant ray-gun wielding gorilla by animals wearing costumes as well - who have names like Astrodog and Galactic Cat.

Saturday evening we went out and drank too.

Sunday night I did not go out ad drink, but that's because all Sunday day we went out and drank, and by that time I was all dranked out. And over four nights I would have had maybe two bottles of wine, but still, I was and am pretty damn relaxed.

And Sunday we were doing a winery tour with a friend of ours (her cousin has recently arrived from England, so we decided to show him the kind of country that his lot had sent our lot to as a punishment. So it was mile after mile of open, sunlit country, leafy vineyards, rolling hills, the sky a clear and open blue and the magpies warbling in the gum trees, and Sarah and I doing a lot of lolling, eating oysters and some kind of pate thing and drinking merlot, sated with the sunshine of the day, and then going home and reading Borges in bed.

Anyway. Tomorrow is back to work, but only for a few days, and then I have a few more days off. I sspect, although I cannot prove it, that Sarah is trying to show me how good life could be if I didn't do shift work. And I am sorely tempted.

Get thee in front of me, Satan.

Thanks for listening,
John

More full frontal nerdity

Hail,

Another glorious spring day in South Western Australia. The sun is shining, the sea breeze is in, the lorikeets are rustling in the lilly pilly tree, and the methadone clients are sunk in torpor upon the lawn.

And I've been thinking about medical journals.

Not about reading them - God, no. To be honest, I very rarely do. There are too many of them, for a start, and I don't have the oomph to read them, and there's so many other things'd rather read, and truth be told I don't understand most of them... but the main thing is most of them are mindrootingly boring.

I remember when I first got into medical school. I decided to go down to the library to read up on "medical stuff". It took me half an hour just to decide how to look at the papers - did I want to proceed via organs (Heart? Brain? Blood?)? By pathologies (Cancer? Stroke? Hypertension?) Or perhaps countries (The Scandinavian Journal of Anaesthetics?). In the end I just gave up and settled on "stuff that looked interesting".

The ones I remember were some forensic medical journal, and an article on the history of werewolfism. The forensic medical journal included the unfortuanate case of a man found guilty for indecent exposure because he walked back and forth on his balcony stark naked - while fast asleep. He was apparently found guilty because he knew he was prone to sleep walking but didn't wear pyjamas.

And there was also a case of an elderly farmer found battered to death, alone in his paddock in the early hours of the morning, surrounded by nothing except the tracks of his sheep. The culprit was eventually found to be... (and here you had to turn the page...) his prize ram, a beast the size of a Pleistocene mammoth who a month earlier had assaulted a postman and now had turned upon his master.

John Donne wrote a poem about this, which does not actually mention murderous sheep, but you get the idea.

Anyway, medical journals - deliberately, almost exultantly boring. Why does the New England Journal of Medicine not have a single bloody cartoon? Why can't we read an ongoing serial in the pages of Annals of Internal Medicine? Why are there no letters to the editor in the Scandinavian Journal of Tourette's Disease, no recipes for scones in Diabetes, no celebrity gossip in the Indian Journal of Sexually Transmitted Infections, no centrefolds in Emerging Infectious Diseases?

Come to thik of it, why are the titles and articles tehmselves written so badly? Which smart guy (and I will take any odds on a bet it was a guy) decided that when teh most powerful intellectual apparatus in human history spoke, it should speak in the past tense and the passive voice, not so much first or third person, but non-person.

Look at this - the title and first few lines of a recent paper published in the Journal of Pineal Research, by Rocchitta G., Migheli R., Mura MP., Esposito G., Marchetti B., Desole MS., Miele E. and Serra PA.

"Role of endogenous melatonin in the oxidative homeostasis of the extracellular striatal compartment: a microdialysis study in PC12 cells in vitro and in the striatum of freely moving rats."

A capillary apparatus for in vitro microdialysis was used to investigate melatonin and ascorbic acid effects on dopamine (DA) autoxidation or nitric oxide (NO)-mediated oxidation in suspended PC12 cells. Following high K+ (KCl 75 mm) infusion, secreted DA underwent a partial autoxidation or peroxynitrite-mediated oxidation when the potential peroxynitrite generator 3-morpholinosydnonimine (SIN-1, 1.0 mm) was co-infused with KCl....

Verbal oatmeal, isn't it? The frustrating thing is, science itself, the findings, the intellectual battles, the bravely "thinking where no one has thunk before"... that can be very exciting stuff. But the writing seems designed to conceal, rather than reveal.

Would it kill anyone to allow the use of the first person and the active voice? "We did" rather than "this was done"? Permit, if even for a moment, the idea that science was done by (gasp) people?

Look at Who magazine. Even its writers and editors know it's about crap. Nothing in the magazine matters at all. But people buy it. Because it's interestingly written. So why don't science and medical journals go that way?

"Tom slams Nicole: endogenous melatonin has no role in the oxidative homeostasis of the extracellular striatal compartment - and there's nothing you can do to change my mind!"

There was one paper back in the seventies, mentioned in "Biological Exuberance: Animal Homosexuality and Natural Diversity", which was titled something like "A decline in moral standards amonst the Lepidotera.". The Leidoptera, you will be reassured to know, are the butterflies and moths, and apparently some of them are gay.

Anyway. I should actually do what I'm paid for. See you all soon.

Thanks for listening,
John

*Not the good ones. Science, Nature, NEJM, things like that are all good.