Wednesday, December 07, 2005


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 ...


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.



Blogger Benedict 16th said...

Yeah the punitive stuff is what I hated about the Driver Dependence Clinic.

On the other arguement, what about true harm minimisation...
If the druggie wants Heroin, why not supply it, really pure and cheaper than the dealers??

Then the little scrote who ripped off my $300 car stereo last night (car parked on lawn at front of house) wouldn't have caused $10 000 damage to the car, windscreen and electronics and I wouldn't be carless for 6 weeks whilst they get the parts from Japan....

Anyway, seriously, What's wrong with a bit of heroin, I am sure there are quite a few
people in history
who have had some serious habits and haven't gotten in trouble, come to notice, cos they have had an adequate supply. Heroin is quite cheap to make. Oz is like the 4th largest legitimate morphine producer in the world!!! (And it is exported to the US who repackage it and sell it back to us as pills....)

Okay so he might get a little noddy on smack.... so he can't practice dentistry whilst "under the influence"
or say with pupils smaller than 3mm (nah to easy to fake) or some other arbitrary measure of intoxication (liek alcohol and 0.05 g/dL, it used to be 0.13 back in the 60's!).

Heroin, on it's own (so he would have to have regular urines to prove no benzos and any other stuff agreed to in a contract) is pretty harmless. I really do not know the numbers but I think very few heroin deaths were from pure heroin, and those that were were unlikely to be accidental! If I had to have a junkie living next door, I'd rather have a noddy heroin addict that a psychotic, not slept for 14 days, brain fried, mega agressive speed freek...*

Please tell me what is seriously wrong about supervised heroin dosing? (except our esteemed representative and paragon of all that is Australian John Howard wouldn't allow it)

Benedict XVI

PS - if you followed the links...
* at least they wouldn't keep you awake all night coughing......

12:21 AM  
Blogger Bronze John said...

I reckon there is nothing wrong with supervised heroin dosing. It's certainly better than the current system.

Having said that, this guy knew what was going on when he decided to combine heroin and a career in dentistry, so I am finding I have less sympathy for him than for your average heroin user.

10:40 AM  

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