Wednesday, December 28, 2005

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,

*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'".


Blogger Foilwoman said...

I'm glad Declan is ok. Practising hugging with someone you're planning (hoping) to have sex with is not developing your ability to be physically affectionate, btw. It's called "getting it on". Or "being a guy." So practice hugging your brother. Don't ask about the bowel movements, of course, but hug your brother. Hell, hug the pope (our Benny XVI, not the odious pope in Rome). See how it goes.

You mentioned the perseveration that precedes (or is a hallmark of schizophrenia). I have notice a smell to the severely mentally ill, sort of metallic and unwashed. Is that just the smell of the heavy duty psychotropic or anti-psychotic drugs (lithium, clozapine, zyprexa, thorazine, stuff like that) or is it just disease related? I always assumed it was the various medicines, but now wonder (PdeFF doesn't have the smell, an I believe he's on Zyprexa now). Thanks.

2:19 AM  
Blogger Prom said...

Interesting that you have the ability not to see once trained to have the knowledge to not only see but understand. I don't think I could just shut it off.

Still and all, it is good not to treat family and friends even if you do see the approach of something unwelcome.

4:40 AM  
Blogger Benedict 16th said...

When I took my father to the hospital with a ?fracture of the R) shoulder, the thing I remember about the "handover" was the relief I had that I didn't have to take responsibility for any clinical decisions. He has Alzheimer's and was overwhelmed by the experience so he would never have "blamed" me or anything like that... So I wonder why I felt the relief? Is that stress there with every patient we see? Or is it a convenient cop-out so we don't have to take responsibility for our relative.

At another level, I suspect it is no different than being a parent to someone else's kid(s) - where I tend to be much more "hypervigilant" than I would with my own.

Foilest: I'll try the hugs with Declan first, he is less likely to try a Martial Arts manouvre on me*, actually one on my favourite tricks with BJ is to gently rub his thigh when we are out in public... Anyway don't you know the Australian faculty rules?

"At some level you already see the cancer, black and red, nested in his pink lung" - reminded me of the scene in the movie Constantine where the Devil rips out his lung cancer...

* Especially if he is still getting over having a bit of his guts ripped out

Hoddah Hafiz
Benedict XVI

10:20 PM  
Anonymous Camilla said...

Nice chatting to you today, BJ. I forgot to ask on the phone, please will you pass on a hog to Declan for me when he is well enough to accept it? (This is a genuine request and not just me trying to tease you re: the above).

I will be sending good vibes in the meantime *vibe vibe*

And you might be interested to know, it's snowing here again :D

abugo - hmmm. My abugo is playing up today, what with all this cold weather we've been having. I wonder whether the UN will introduce a trade abugo to curtail the excesses of Evil Dictator Abugo?

10:36 PM  
Blogger Bronze John said...

Hail, sorry about the long delay.

I don't know about the metallic smell of the mentally ill - having said that, I have an abyssmal sense of smell. I know some of the antidepressants/antipsychotics can cause a metallic taste in the mouth. The unwashed is definitely true.

I don't know that it's an ability to see as much as not wanting to ask/look/think for fear of what you will see... so stopping yourself before you ask the first question.

Thanks to all for the good vibes.

8:08 PM  

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