I loved and hated the trips. On the bad side I always used to worry about coming out at the other end twisted and small like an eighteenth century Chinese woman's foot, with the imprint of the ashtray permanently embossed on my temple. But on one level they were good - an opportunity to do a fair amount of thinking, and sort some stuff out, including how come I, like my father, was travelling across the desert to visit my two children, twenty years after he had done so, when those twenty years had been spent ensuring and assuring that I was not the kind of man my father was. And then there was the chance of seeing the Nullarbor and the rest of the continent: Meckering, Southern Cross, Moorine Rock, Widgimooltha, Balladonia Roadhouse, Nundroo Roadhouse, Kyancutta, Iron Knob, Crystal Brook (no brook), Snowtown (no snow), Adelaide. Six weeks of fruitpicking later, goodbye to the kids, back in the bus, Adelaide, Snowtown... you get the idea.
Anyway, one of the things we passed through was Goyder's Line. Goyder was a scientist who understood something important about Australian ecosystems and farming; correspondingly he was hated and reviled thoughout his life. He travelled around South Australia by horse in the eighteen sixties, mapping the local vegetation. Goyder's Line is where things change from those slender, multi-trunked eucalyptus trees called mallee (in the South) to small saltbushes in the North, that trap water in their leaves and grow even where the soil is white with salt. Goyder's Line marks pretty much exactly the northern limits of the "ten inches of rainfall a year" line, which is the line separating places you can farm and places you can't.
South of Goyder's Line is stability, safety, a fair day's pay for a fair day's work. North of the line is chaos, danger, giving everything and getting nothing. On a good year the crop is adequate, maybe even good. But sooner or later, usually sooner, it's pouring water into the sand.
Why this diversion into nineteenth century land mapping? Because Goyder understood something about chaos, about chaotic, unpredictable systems, and it's chaotic systems we deal with in the ED.
Case in point.
Mrs Careen is a sixty eight year old woman with a long history of airways disease. Because of her airways disease she has to take a drug called prednisolone. Prednisolone is a good drug, a powerful drug with a multiplicity of effects, but Mrs Careen (bright blue icechip eyes, accent somewhere between Kyancutta and County Cork) has to take a lot of it, and will never be able to stop taking it, and she's been taking it for a long time.
The prednisolone does open the airways in a way that only drugs of this class can do, but it also thins her skin, and makes her bones weak, and coarsens her face, and plays havoc with her blood sugar, and weakens her muscles and tendons. And so it went that a week ago Mrs Careen (sixty eight, widow, living alone) leant forward to pick up a teapot and felt a sharp, hot pain behind her ankle.
(As we speak we are leaving the coast and moving north, up from the fertile hills and plains and through the eucalypts).
She hobbled to the local doctor and yes, she had partially torn her Achilles tendon. Her ankle was bandaged and she went home with a walking frame. Two days later, buying her Lotto ticket, she tripped with her awkward ankle and fell, striking her head, "only a bump".
I should point out that Mrs Careen is also on warfarin, a potent medication that stops the blood clotting (cows that eat mouldy clover may bleed to death from insignificant cuts, because the mould on the clover makes something like warfarin). She has to be on warfarin because if she doesn't, she'll get another blood clot in the lung like the one that nearly killed her in nineteen ninety five.
So, living alone, a dodgy leg, lungs like the inside of a paper bag. A drug that makes each little bump on the head a potentially life-threatening event. Another drug that means she heals slowly.
(Getting towards the line now).
So, sensibly, she does away with the walking frame. After all, it's probably that that caused her to fall, is it not? And Sunday morning, reading about the cricket, reached for the phone - bang.
Huge, searing pain in the foot. Pitches forward, cracks head on bedside counter. Blood everywhere. Crawls to phone, doesn't want to bother ambulance people, calls her daughter in South Mordor, who comes around, shrieks and calls the ambulance people. She is brought to the ED, stiched, her head is scanned (she is only bleeding on the outside of her head, not the inside), her even-more-torn Achilles' tendon is supported with plaster of Paris.
(Well and truly into the desert now).
And then, our long, frank and ultimately fruitless discussion. How if she went home with one leg in a plaster and fell heavily, it could be all over - she could die, or worse. How we were offering a hospital admission until she could get things organised, send people in to move some furniture, help her shower, cook and clean. Did I say offering? I meant "strongly suggesting", "my medical advice", as close as possible to putting on my police hat and telling her to come into hospital for two days.
And then ordering the taxi to take her home.
You can't blame her. The poor woman has spent three months out of the last eight in a hospital bed. And you can't stop her - sound in mind if not in body. And you can't do anything but admire the whole absurd Irish never-say-dieness of the thing, as she hobbles and lurches towards the taxi, then go back inside to document how she wasn't bleeding in the brain when she left here.
Times like this, I have to sit down and deliberately run certain sentences through miy head, the intellectual equivalent of Hail Mary's and Our Fathers.
Hospitals are to help people.
Informed choice includes the freedom to choose the option I wouldn't choose.
Helping people means helping them do what they want, as long as they aren't crazy or actively killing themselves.
Letting them do what they want means living their life the way they want to.
If I beleive anything, I believe these things are gospel, they cannot be disputed. Even if you are sending a woman home to where she runs a significant risk of dying, sending her into the desert north of Goyder's Line, the line where science and reason and basic clinical honesty says chances of survival are slim.
Anyway, "such is life", as another Irishman living in Australia said.
Tomorrow I have off, and will be mastering the neurobiology of the synapse, writing my tale of adultery, high-end physics, murder and parallel universes, and also doing some kung fu.
Thanks for listening,