Goyder's Line

Year's ago, I used to take the Greyhound bus from Perth to Adelaide and back. My children (staying with my ex wife) were in one vast, flat, dry desert State and I was in another. So once or twice a year for a good many years I would wedge myself into a seat, with a very big book (Dune, Lord of the Rings, Catch 22) and for thirty eight hours either stare out the window or scribble short story ideas in a notebook.

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,

John

Perhelion

Hail,

Horribly sorry about the delay in posting. Lots of stuff to talk about and too tired to talk about any of it.

Coming on up to midnight over here, after three days of on and off rain. The chickens are sleeping, the horse stands in the barn and the cats are in tangles and clumps around the house.

And now is the winter of my discontent made glorious summer by Sarah, who was asleep in bed when I came home, having returned from across the desert. All new coloured hair (apparently) and pale skin and dark lashes and a little smile upon her lips. Sigh.

Well, enough of that. What's been going on? About thirty different things.

I did an internet test to tell whether I am a nerd (someone who is passionate about learning/being smart/academia), a geek (someone who is passionate about some particular area or subject, often an obscure or difficult one) or a dork (someone who has difficulty with common social expectations/interactions)... or none of the above. Chillingly, not only did I get better than ninety percent on the nerd scale, I also scored highly on the dork one. I'm pretty much an antigeek, because I have a terror of new technology and any day now will have mastered the electric phonograph.
Horrors.

I am trying to write another story, since apparently "they" liked the last one, and I am gradually working my way around to starting a novel.

Work goes well. In the ED we have had a run of Bad People. These are those people who for some reason are out of the prison system and are generally not welcome in big parts of the outside world (i.e.: hard to get accomodation because they have armed robbery on their CV, can't move in with friends because they either have none or their friends are headcases, etc...) and end up in the ED.

The following contains adult themes.

Unfortunately, while they have real and often terrible problems, they are not problems that we are particularly good at fixing, so their stay in the ED tends to be rather tension filled for all concerned.

Take yesterday's example. Since I have done a fair amount of psych and some forensic stuff (and have actually been in prison*) people ask me advice about this kind of stuff. Often they arrive with a fax from the mental health or prison people, detailing this person's significant history, and their name on the computer is accompanied by various alerts.

"Thank you for seeing Wolfgang Throatrend" reads the letter. "He is a twenty two year old man currently awaiting sentencing for multiple/aggravated/armed/third degree ..." and then a list of crimes that are too depressing to relate. And the computer informs you that he must be searched before entering the ED, must be accompanied by a security guard at all times and is given to spitting, swearing and armed assault without warning or provocation.

It is difficult to be objective about this. it is tempting to attribute all of this man's physical problems to his character -

"And I woke up with this really bad pain in my chest... what do you reckon caused that, doc?"

"Maybe you being a piece of shit?"

Seriously, I tend to see these people because no other bugger wants to but it is vital we get them seen as soon as possible, treated as quickly as possible, and out of the ED (if possible) prefereably sooner.

But it does get a little bit depressing. Mr Throatrend, last night's least wanted, whose alerts mentioned the breaking of his sister's jaw and a truly ghastly sexual assault on a child, was in there complaining about being depressed and wanting to kill himself, an admission which generated much more hope than dismay. I went in to see him, and did the mental health stuff, and then the psych registrar came in and did the same, and so did the social worker...

and all the while, sitting next to him, holding his hand, is his new girlfriend. A young woman, slim boned, dark hair that hangs around her unlined, open, earnest face. A ring on one slim finger. Five, maybe six months pregnant.

Well, what do you do? From your patient's point of view, this may possibly be seen as a good thing. May stabilise him a bit, someone to listen to him, someone to help him through the bad times, a positive influence. people can change, I am assured.

And I believe people can change, but I also believe most don't. And this man has not got one of the classic mental illnesses - although people with personality disorders are more prone to the classic mental illnesses - he had predominantly the features of a personality disorder. He is another psychopath. Someone who is mentally ill and responds to treatment can understand that things are not as they once believed them to be, we give them chemicals that stop other chemicals being released where they should not be. Someone with a personality disorder cannot be given that chemical insight. He is truly unlikely to change.

Anyway,I feel this is new relationship is not a good thing. It is probably not a good thing for him, because I think he will continue to be the same kind of person he was before. it is not a good thing for the child. It is assuredly not a good thing for her.

Anyway, as we escorted them out, he turned to the psych registrar (a remarkably beautiful young woman who listened, and so someone he wanted to keep talking to) and nodded to his girlfriend and said "Tell her she can do a lot better than me."

I stared up at the ceiling, and the psych reg smiled and said something non-committal, but all I could think of was him using that whole guilt/sympathy/"I'll tell you to leave so you won't/I'll say I'm crap so you cuddle me" stuff that children use.

I don't know. When I was a kid, I loved astronomy. I didn't have the patience to get out there and learn all the stars, but I knew where many of the planets were, and I could recite surface gravities and numbers of satellites at will. And I loved the terminology - Arabic and Greek and Latin, words like incantations: azimuth, perhelion, occultation, lunation. Like many children who had difficulty with common social expectations/interactions, I felt reassured by the empty sky and the orderly movements of the worlds. Much more simple than human beings.

Nowadays, I think may be things weren't like that. "Seek simplicity, then mistrust it". Planets wobble, are perturbed, dark worlds move in unknown paths. And human beings, I think, are less free than I thought they were. There are currents in this girl's genome, things that drag her along like fish-hooks, blind and dumb subconscious evolutionary imperatives that make her hitch herself to a man like this, caress a man who broke his sister's jaw, carry the child of a child molester.

One of the words we use in astronomy is perhelion. The time when a body, a major or minor planet, is closest to the sun. Once perhelion has passed the planet or planetoid begins the long fall away, into the dark. Depending on a very few things - gravity, perturbations of other bodies - it may return only after many years, or it may not return at all.

That was the feeling I got, seeing her walk out of the room. Knowing we might or might not see her again (we see a lot of domestic violence here) but knowing that this probably was as good as it would get. Once the baby's born, or once he starts to get over her, or starts drinking seriously again, or gets off parole and back on the speed, once he gets suspicious, or "loses his temper", the first time he hits her ... it's never going to be any better than this.

This time was her time in the sun. From here it's all into the dark.

Anyway, thanks for listening. Will reply to comments in a day or so.

John

* Four hours, animal rights demonstration, early eighties.

Saint Benjamin's Day

Saturday morning, and not just any Saturday morning. Today is football Grand Final Day.

And not just any football Grand Final Day, but one in which the West Coast Eagles, my brother's team, are playing, and may even win - their first appearance at this level for eleven years.

And not just any Grand Final with West Coast in it, but one where my brother, the sanest human being I know, is here.

My brother runs to a different calender to the rest of us. There are to him three great feast-days throughout the year. And none of this St Eustace's day or the Feast of the Lenticles rubbish. His Saints are a fast bowler, a centreman and a mad wicket-keeper/batsman. The High and Holy days are as follows:

Australia Day - is the first of these. Australia Day is in January. By divine fiat* it is always hot, usually hot and dry, occasionally hot and cloudy. One year we had lightning, one of those summer storms that stalk out across the paddocks on legs of lightning. But usually the sky is a clear, hard blue, the horizon seems a billion miles away, and the leaves of the eucaplypts droop. Australia Days on the west coast smell more like wattle, on the south it's peppergum.

Australia Day is the cricket. If we can, we go. If not, the default celebration is barbecue (steaks thicker than a Bible, oysters, squid, chickens, various crustaceans), drinking and lounging, watching on the tv.

Boxing Day is more of the same, except it's test cricket. Cricket is a game invented for Australian summers - long, slow, the kind of thing you can chat about during the game, or even (heresy) read. Boxing Day is food, alcohol and lounging.

And then Grand Final Day. End of winter, early spring. Another barbecue, planned three days in advance. More of the red wine, less of the cider and beer, consumed for celebration or consolation. Maybe indolently chucking a cricket ball around afterwards. The day's pretty much a write-off for study, or work, which is all pretty good.

Anyway, study and gym tomorrow. Work monday.

Grand Final Day today.


John

*knew a girl who used to drive one of these

Sexual References

Very mild sexual references. In fact, not a lot interesting in this, sorry. But there has been a lot going on. I will write this randomly and hope something comes out of it.

My wife is leaving me, albeit only temporarily, to attend a cat show in another city. She departs, bearing numerous cats in numerous boxes, tomorrow morning at some barely civilised hour. People apparently send all kinds of animals on aeroplanes, last week she saw someone take delivery of a goat - a white, neatly clipped thing that emerged from a large crate wearing a collar, stood patiently while the new owners attached a lead, and then trotted obediently to someone's car.

A few days ago Sarah had to drive down to the airport to pick up some wealthy but inbred feline, the scion of some decadent house, who had paid vast sums and travelled thousands of kilometers to have sex with one of our fine oriental virgins. The entire process strikes me as slightly dodgy. If she starts driving a long limousine and wearing lots of bling, I'll let you know.

She will be away for almost a week. I have told her I will be beating my teeth and gnashing my breasts until she returns.

Anyhow. As part of this "act like you've got a social life" crusade thing, I went down to the city today. I used to have a semi-regular thing going on, where we'd all meet, meander around various bookshops/comic shops/pubs, and read, talk and drink. It's a good idea to buy stuff then go down the pub, because otherwise I come home late, with remarkable purchases ("But Richie Rich rules! And it's a mint condition - mint condition, I tell you - edition of #343, the Garth Ennis one where he fights the Punisher...")

So we're sitting at the pub and the topic gets around to the first moment you worked out you were attracted to the appropriate sex. Not first girlfriend or whatever, but some distant memory from years and years ago, some image or event or recollection, that stayed in your head for some reason, and later on you thought "My God. That/She/He/It was hot..." Maybe before you even knew what hotness was really about.

For Toby it was a Bananarama film clip, a song called Venus. Apparently there was some woman in a tight red jumpsuity kind of costume, burning like a silver flame, all that kind of thing. He remembers her wiggling about on stage, breathing and looking straight at him, and he reckons that things were pretty much determined from then on.

Me, it was an old Batman episode. Fortunately, not the one with the Joker in it, or I'd be erotically fixated on skeletally thin psychotic clowns. It was one with Catwoman in it. I will spare you the details, except to say that the plot involved some giant missile which she intended to use to blow up Gotham City. And at some point, while Batman and Robin battled assorted henchmen and goons, Catwoman (dark hair, dark eyes, catwoman suit) leapt onto said six foot long missile and yowled and gyrated about, seeking to express frustration... or something. Again, the precise details of the plot escape me, but I remember thinking "But I don't even like Batman! or Robin! So why am I watching this so intently?"

Enough sullying of the internet with pornography. Weirdly, considering how I've got rid of a lot of the repressed Biblical stuff, I still find it excruciating to talk about sex to any audience numbering more than one.

So - on to the much more palatable sickness and death. In fact, work has been damn good lately. Dr Longstocking has returned from the exam victorious (or at least partially so, having passed pathology but failed anatomy), Dr Iskandar has emerged from exile after we all thought he'd gone forever, and we are starting to prepare for April's exam.

This means I will be studying again, but it's not going to be like last time. This time I'm not going to give up all socialising, exercising, and relaxing for three to six months and then fall back in horror when my brain turns to mush. This time it's going to be more balanced. So April is physiology, pharmacology and maybe pathology. We shall see.

So, work goes well. We've had a few resuses, including two in which I was pretty much in charge, in which Dr Palsy stood and watched while we worked ... or tried to. It's a difficult thing to do, let go of control, and it's a very difficult thing to do when someone's life is in the balance, but the problem is, if we junior registrars aren't allowed to run things more or less on our own when the consultants are there, then the only time we get to operate solo is at night, when there is bugger all backup. So the best thing to do is to get us working as independently as possible while someone is there to stop us before things go awry.

Anyway, it went okay. I think I have to learn to be, if not less polite, then less circuitous in my speech. I attracted the attention of one of the nurses a few nights ago and apparently said "Excuse me, when you've got a moment, could you start the magnesium running? ... thanks a lot". In a resus this comes across as almost eighteenth century rococo ornate speech. Next will be a request for someone to charge up the defibrillator... delivered in iambic pentameter.

We also had our trauma audit. This is where the team looks at notable cases and works out what was done well and what could have been done better. One case that stuck in my mind, not because of what we did, starts out with a group of guys out drinking (no, really). Stop reading now if you are easily un-nerved. They did the responsible thing and took the bus home. Our guy got to his stop, bumbled out the bus smiling and waving, walked around the front (rather than the back of the bus) and was promptly run over. The bus (and I mean a real bus) drove over his belly. His horrified mates picked him up, slung him in his car (got the keys out his pocket) and took him BACK TO THE PUB, where he sat there for over an hour, looking shaken and bruised but still talking and drinking, when they finally decided that he should go to the hospital. He walked up to triage, complaining of abdominal pain and puilling up his shirt to show where the wheel had gone over him. We raced him around the back, stabilised him and sent him to the Royal where he was treated for four fractured ribs and a broken pelvis.

That, by the way, is positively milkwater compared to my brother's friend. The following is absolutely true, in that my brother hasseen this guy and spoken to him about it. All names have been changed...

So, my brother rang up a mate a few months ago and heard this story. Three late twenties males. Jaques Buffet Point, off the southern coast of western Australia, hundred and twenty kays from the nearest sizeable town. Late summer, just fishing, diving off the jetty and drinking. Drinking copious amounts of alcohol.

Anyway, just on three, Shawn, longneck bottle in hand, reckons "one more time" and runs out and off the jetty, dives in... and doesn't come up. Dave looks out and reckons he sees him lying on the bottom of the sea, with blood in the water. The two remaining blokes dive in, drag Shawn up. He's not breathing, he's got this big cut and dent in his head. They wrangle him up onto the jetty. The two drunks commence CPR. He starts having a seizure, but the CPR works. They get him into the ute, front passenger seat between them. One hundred and twenty kay over dirt roads. They get him to the local GP. Road ambulance to Albany, air ambulance to Perth.

And three months later he is working again. After three - three! - unstable C-spine fractures, with a bloody steel plate in his head and part of his skull wired up. Having survived an open head injury, multiple cervical fractures, anoxic seizures, drunken CPR, being driven from Jacques Buffet to Albany at high speed by said drunkards with his head lolling around like a novelty toy... and the bugger has returned to work.

And here's me taking a sicky because it's my last day at Hogarth tomorrow and what are they going to do - fire me?

Thanks for listening, something more cogent next time.

John

Unprotected social intercourse

Hail,
Just back from some course on sexual assault and desperate to talk about anything, anything, other than the heartbreaking horror of sexual assault.

So.

I am going out today, to see a friend.

This is a very rare event. Normally, weeks, months go by without me going out to see someone. I practically never do it. As a consequence, I suspect, I have very very few friends. It's an embarrassing thing to say, it's got that whole "loser stink" thing attached to it, but it's true.

It didn't use to be like this. When I was in Uni the first time there was this big circle of us. Going around being callow and intoxicated, that kind of thing, strongbow sweet cider and going to see cover bands. The second time I went back, in my thirties, a smaller group, less of the drinking and so on, but still, people you could talk to without it seeming an imposition.

Now there are practically none.

I can blame work for some of this. I have been doing at least part time shift-work for a good few years now, and that can impede things. And we've always tended to live towards the edge of the map, out in the bush with room for the horses and the cats and the relatives, so it's a fair way for a lot of my friends to come or us to go. And a lot of my former friends have babies now, and many of those babies seem to have little interest in politics or science, and to become impatient when we discuss these subjects in their presence. Plus looking after one or two kids means you're tired.

But those things are not reasons as much as excuses. If the truth be told, a lot of it is me.

I find it difficult to maintain friendships. Face to face, difficult. Electronically, slightly easier. Post - not at all.

I have a phone number written on the notice-board in our study. It's from someone I used to know, my best friend for four years in high school. Alastair and I went everywhere together, read the same books, climbed on the same roofs, had crushes on the same girls. Almost a year ago a publisher emailed me, said that Alastair had seen a story of mine in a magazine, wanted to get in contact with me, here was his phone number, I wrote it on the noticeboard.

Still there. Almost a year ago. Haven't rang.

My best friend in my home city, the guy I did all that cider drinking with, best friend for close on ten years ... a brief flurry of emails and phone calls the month or so his wife left him, pretty much nothing since. Not even the faintest echo.

The best friend from the four years of medical school. Similar process.

More recently. A friend of mine from this very city, half an hour's drive away. Luminously intelligent. Consistently wonderful company, can make you laugh so much you have to stop the car or you'll kill someone. The person who introduced me to the Ultimates, Alan Moore, Shawn of the Dead, Firefly, who got me reading comics again. Half an hour away, haven't seen him in over a month, now too scared to.

(and it is 'scared' - seriously. I am looking at the phone now and thinking "for God's sake, just pick the frickin' thing up." I've even writing it. But I'm not doing it)

What is there to be frightened of?

Don't really know that I can analyse it that far. I could say "uncomfortable silences", or "not being welcome" or "not finding anything to talk about", or appearing at an inconvenient time for them. Or not having anything interesting to say, or being boring or out of touch or depressing or whiny or ...

But it's a lot of things, or maybe it's no specific thing, maybe it's an intransitive fear. I've often thought we need the same kind of distinctions in psychiatry as we do in grammar: nominatives, vocatives, accusatives, the transitive and intransitive forms of verbs, that kind of thing. Transitive verbs are like the "chopped" in "He chopped wood", intransitive verbs don't have to refer to an object - like the "ran" in "He ran."

Similarly there should be transitive emotions, emotions that relate to things, and intransitive emotions. Intransitive emotions aren't necessarily about anything you can see in front of you, it seems like they just exist. A state of fearfulness, a state where you fear things because you are afraid, rather than fearing them because they are particularly threatening.

Amazing how much simpler and relaxing emergency medicine is than real life.

What prompted this is me thinking about the sizeable number of people I miss, people I want to see, whose company I enjoy and whose ideas I find interesting, that I have not seen. Anyway, I wrote this down to work it out, and to find out if this is the same for anyone else (my youngest son is shy), and it's pretty much worked out. And I'm visiting someone today.

All I have to do now is pick up the phone.

John

Shotgun

Well, I helped a frightened child today, and that should feel good. Albeit, not an entirely conventional frightend child, and not in an entirely conventional way.

Here's what happened. I turned up to Mauro (accompanied for the first time by Dr Zhu, who improves by small degrees) to heal the sick. It's weird medicine, almost the opposite of emergency medicine - occasional twinges in the belly for the last four years, concerns about miniscule pimples, worries that one ear sticks out more than the other. They do this for reasons of boredom rather than hypochondria - on the outside these kids never ever ever go to doctors.

Anyway, today was the usual round of freezing warts off and gazing at utterly normal looking knees, when the nurse brought in the last guy, Christopher Slocum.

Christopher was suffering some of the symptoms of depression, some of an anxiety disorder, and some psychotic-like symptoms, which had developed since he was transferred from Glasson (the prison for short term incarceration of boys and any incarcerated girls - Mauro is longer term prison for boys). Christopher slept poorly. He woke tired. He was losing weight. He had constant nausea, sweats and palpitations, he feared being in crowds or exposed spaces. He believed people were talking about him, and that strangers were congregating together in a conspiracy to do him harm.

Specifically, he explained, he felt that people wished to do him harm because of the bounty on his head, put there by Amos Clarke, the one hundred and thirty kilo big guy I told you about in June. The five hundred dollar bounty, to "stab him or to cut him up". Because the guy Christopher allegedly shot - the one who was allegedly in the Royal recovering from an alleged large number of shotgun pellets being removed from his alleged chest - the guy Chris shot is Amos's uncle. The big (in Mauro terms) bounty five people had told him about on his first day, and one had already tried to collect.

Five hundred dollars, I suspect, is a lot of money to a fifteen year old in prison.

I felt that a diagnosis of depression and anxiety with paranoid features would be premature in this case, and we agreed that anti-depressants were unlikely to be successful in this case. Chris would have to move.

There is a right way to do this kind of stuff and a wrong way. The conventional way is to tell the staff. This would achieve nothing. They already know, they have put in place the appropriate protocols to protect Christopher, which is basically one on one supervision and exclusion from all group activities. That's going to irk a bit after five years. And no-one here is one hundred percent convinced it will work. Chris certainly isn't.

The other option, the one I took, was to write a letter to the manager, explaining that Chris's health was being compromised by his transfer to Mauro, and advising that he be shipped back to Glasson, the shorter term facility where he was previously being held. This is apparently safer - potential assassins are only in there for a few days at a time, apparently, so by the time they work out who he is and how to do something, they're either back on the streets or back at Mauro.

I wrote a pretty good letter - and after all, a knife wound is an acute medical condition - and the chances are he will get transferred, hopefully soon. It gives management an out, too, they can say that it's that piss-weak doctor's opinion that Chris be returned to sender, rather than admitting they are pretty much unable to guarantee his safety.

Anyway, frightened fifteen year old child helped. I don't know what will happen in the long term, sooner or later something will give. Presumably Chris shot Amos's uncle for some sincere reason, some grevious injury that could not be repayed any other way. It's all so sensible and obvious and necessary and stupid.

Thing is, if Amos gets Chris, he'll just be shifting the bounty onto his own broad shoulders, and he's young enough not to think that matters. So it will go on. It will continue, like it does, until a sufficient number are killed off, a smaller and more amateurish version of what happened in Melbourne, kids playing grownups.

And Amos's family, and Christophers, will continue to send their young sons to the city's finest forensic preperatory schools.

Anyway, thanks for listening.

Next post, religion in the sexual assault class.

John

Smart, Hardworking, Easy to Get On With...Hot

Hail,

Feeling very productive today (unfortunately for me, that's a term we use to refer to a cough more often than a person), so here's something I worked out.

To succeed in this job you need to be two out of three things.

You need to be two out of the following: smart, hardworking or easy to get on with.

See, if you're really smart, but you don't do any work, and you piss people off, sooner or later it all falls apart.
If you're hardworking, but you're stupid and you don't listen to anyone else, you're an impediment and we have to get you out of there before you kill someone or someone kills you.
If you're daft and lazy but you're easy to like, people might like you as a person (up to a point) but they'll get pretty sick of you pretty quick, and it'll be "Get out of my emergency department".

Last month we had a med reg who managed to be neither. He was too lazy to go and see the woman with the possible blood clot in her lung. He was stupid enough to try to send her home with said possible blood clot in her lung, depite her being pregnant, and having only been pregnant twice before and each time having had a blood clot. And he was dismissive of anyone's attempts to prevent this happening. Makes a difficult job un-necessarily more difficult.

Well, last night I told one of my fellow workers this theory, and we both agreed that a special, if temporary, exemption could be made in the case of the certifiably hot. If someone is really mindbogglingly good to look at, that kind of magnetic, head-swivelling way, then for a short period of time they can be anything. But only for a short period of time.

Anyway, must sleep. Thanks for listening,
John

Baby

Half past three in the morning here. Behind me the man with the bright orange crest of hair is trembling in his bed, a side effect of the salbutamol which has treated his asthma. To my left Dr Sock, surgical scrubs and ponytail, is typing in an efficient looking manner - doubtless doing some real work, not writing an internet diary. My two remaining patients are "awaiting bloods", but I strongly suspect their real problem is a night in the emergency department is better than a night at wherever they call home.

And we've had a birth and a death here already.

The first was a code green to resus. Someone pulled up to the emergency entrance in a battered old Commodore and ran into the room, shouting his girlfriend was having a baby.

"She has to go to the birthing unit" said the triage nurse. "It's just around the cor- "

"She's having it now!" hollered the man.

They dragged the woman from the car and loaded her onto a barouche. She was already making that high, keening sound that some women make, a sound I've only ever heard in labour ward. They dragged her into resus, and they put oxygen on her, I started getting a line in, and we called a code green (get the obstetric people and the paediatric resus people down here now), and someone said birthing unit was ready for her.

"We can make it" said Lauren, who was nursing senior. "It's like a hundred metres down the corridor. They've got all the stuff there."

"Okay" said Dr Quinsy. "She's barely dilated. Let's go for it."

And they took the oxygen off, and I undid the tourniquet, and the barouche headed off down the corridor, Dr Quinsy at the "baby end" which was appropriately covered with a sheet. They got about twenty metres away.

"Oh God!" I could hear the woman shriek.

"Don't push! Don't push!' said Dr Quinsy.

"Oh God, I can feel it moving!"

"Moving?" Dr Q lifted the sheet, glanced, and stuck her hands forward. Suddenly there was the sound of a baby crying.

"Jesus" she said. "Right. Reverse, reverse, we're going back to resus!!".

Anyway, by the time they got the trolley backed up there was the obstetric people and the paediatric resus people all ready (for a while it had been like one of those Three Stooges things where people rush in and out of rooms looking for each other), and they cut the cord and everyone cheered, and we ahnded the exhausted and suddenly really sleepy mother a beautiful baby boy.

God, if only more of medicine was like that. Health and happiness and people getting better.

Thanks for listening

Do not enter if nerdity offends

Hail,
I've been asked to do this thing by Foilwoman, so here goes....

7 things I plan to do before I die:
----------------------------------------------
Publish some novels
See if I can fight if I have to
Learn blues harmonica
Go on some weird find-yourself thing into the desert for a month
Stay married to Sarah for the rest of my life
Achieve some kind of basic "okay, we know what to do now" competence in emergency medicine
Live forever (seriously - read "The Spike" by Damien Broderick)


7 things I cannot do:
------------------------------
Sing to anybody's satisfaction except my own
Keep the people I love from all possible harm
"Just deal with" the fact that the forces of evil run the world
Look hot in that angular, dramatic David Bowie kind of way
Dance, except in a "squid on LSD" kind of way
Stick with or remember things that bore me
Read all the books I want to

7 things that attract me to the same (or opposite) sex:
----------------------------------------------------------------------------
Brains
Some characteristic I can't define, maybe best translated as lovingkindness
On most people, pale skin, dark eyes, dark or red hair, glasses, nice bum
On my wife, pretty much anything
The ability to stay, at some level, basically incomprehensible
Not having to run the show, not insisting I run the show
Feminism (a committment to overthrowing the structures that prevent women achieving equality of opportunity, not to be confused with femininism, the belief that the overthrow of those structures is best achieved through wearing frilly clothes with lots of little pink bits on them)

7 things that I say most often:
------------------------------------------

First class
Showtime
Excellent
Perhaps that will give you something to live for
Here is a (insert noun)... that I'm not going to give to you
Who's the best/cutest/smartest/most wonderful wife/niece/cat in the world?
Any of a number of random blues/soul lyrics that I just drop into conversation when I'm distracted, bored or really really tired: "Anyway, we're just waiting for the eight o'clock bloods. Bring it on home to me, yeah, oh yeah, oh yeah, oh yeah. Then he can go home with a letter to his local doctor..."

None of these make any sense except to me.

7 celebrity crushes:
----------------------------
Billie Piper
Christopher Eccleston
Jennifer Love Hewitt
That girl from the Betts and Betts shoes ad when I was a kid
Anya from Buffy, Faith from Buffy, Willow from Buffy...
Susan Storm Richards and the Black Widow
Maggie Cheung

Looking at these, it's surprising how many of them were hyperintelligent extraterrestrials, supernaturally powerful demons, superheroes or otherwise unworldly creatures. Wonder what my wife thinks of that...

7 people I want to do this:
------------------------------------
Camilla
Chade
Sarah
Toby
Any of the anonymi
Susan Storm Richards
The Black Widow

Ta,
John

Animal Heaven

Sunset, still that time of the year where it's cold when the sky is clear. If I look towards where the Indian Ocean should be, I see Venus, Jupiter and the Moon in conjunction, plus a star I used to know the name of. Outside, the silky chickens my wife has bought are murmuring in their pen, they have already laid two eggs, as if eager to demonstrate their co-operativeness. They do not yet know they have landed in animal heaven.

My wife loves animals. When I first met her she rode horses in what's called cross country. Horseriding over here has something of the air of a dalliance of the upper classes, but by God it's tough. She used to travel hundreds of miles, through droughts and flooding rains, to fling her tiny, arthritis-damaged body (she's got some kind of early onset psoriatic thing, takes a small meal of immunomodulating meds every night and morning) onto a vast, semi-feral animal, and then cling like a burr as it galloped around in the bush, trying to hurl her aside. I was given the apparently low-stress job of "watching", and I would crouch, heart in mouth, as she hurtled down a cliff and wrenched the horse over some contraption of jarrah logs and steel.

Back then we used to go to lost of horse shows. That meant rise at five (on the weekend), load up the animals, saddles, bridles, special brushes for brushing manes, special hoof cleaning thingys, all that stuff, and drive out to the mud. It always rained at horse shows, whether in Perth or in Adelaide, in fact, half the droughts in this country could have been stopped by holding a horse-show. Then arrive in some guy's paddock on the side of a mountain, or some blasted heath, or in some fetid marsh, set up all the stuff and watch my wife try to throw her life away.

Sarah tried to explain horse colours to me once. I said if we were going to be in this together, I might as well learn something basic, like the colours. I pointed to a group of horses that looked, to the untrained eye, to be a sort of browny colour.

"So" I said. "Those three horses are brown, right?"

"God, no" she admonished, looking left and right to see if anyone had heard. "They only look brown. Those two are bay, that one's chestnut. Horses that look brown aren't called brown."

"What colour are they called then?"

"Chestnut, roan, liver... pretty much anything. But never brown."

"What colour horse is called brown then?" I asked.

"That one" she said, pointing at a coal-black animal with a vicious grin. Black hooves, black hair, big black heart.

"It looks black." I pointed out.

She looked at me as if I was a child.

"What about that one? The white one?" I pointed at a seventeen hand monster with flashing eyes, busily trampling a small child underfoot.

"No way. It only looks white. It's really grey."

"It's grey? Well, if you call a grey horse that looks white grey, what do you call a grey horse that actually looks grey?"

"Grullo" said Sarah. "Or sometimes blue."

That was pretty much it for me learning about horse colours.

Anyway. Last night. How did it go?

It went relatively well. One remarkable event, perhaps more about that later. But basically a succession of solvable problems, dealt with by myself, Dr Sock (slim, Malaysian, glasses, good at emerge stuff, not one hundred percent good with people), Dr Hassan, (earnest, perspiring, constantly cheerful as long as conversation stays away from world events and current American Presidency), and Dr Pi (intern, saw almost nobody, did exactly what I wanted him to do).

And what did we learn last night?

We learnt that people who don't want to bother the doctor with their chest pain probably should.

We learnt that almost any chronic disease plus depression plus being young plus being male makes things difficult to manage.

We learnt that alcohol is one hell of a drug: an anaesthetic, a calmative, a muscle relaxant, and something that allows you to gaze around the cubicle with a bloody great laceration across your eyelid and a bit of stick stuck in your eyelid stopping you opening your eye and still chat with the nurses.

We learnt that conversion disorder (a non-fatal psychiatric condition) looks a hell of a lot like Guillain Barre Syndrome (a possibly fatal neurological condition). Or maybe we didn't learn that GBS looks a hell of a lot like concersion disorder, and there's been a hideous fuckup. No, I'm sure of that one.

And we at the end of the night I looked back and thought "Penetrating eye injury in drunk. Diabetic ketoacidosis in a man whose blood was turning to treacle. Weird psycho-neuro stuff. Would have terrified the pants off me two years ago."

Anyway, an hour to go.

Thanks for listening,
John

Lies

Hail,
Another post, this one is being written as some sort of distraction therapy. I am senior in emerge tonight, and given the previous nights (33% brilliant, 33% so-so, 33% writing-my-resignation-letter-in-my-head, -while-this-woman-dies-in-front-of-me), anything could happen.

So, I thought I'd distract myself with tales of Shipton, in the Bad Old Days, when it was understaffed, under-resourced, medically backward and a regular contributor to pages one to five of the Daily Sackbut. Usually appearing in sentences along with phrases like "Minister admits..." or "Grieving Family tells of ...".

In fact, let me tell you about two separate occasions where we ended up on page three.

The first was Mrs Murrain.

Mrs Murrain was brought in by ambulance having been found by her husband (at about five in the morning), "difficult to arouse".

'Arousal' in the medical sense does not mean the same as 'arousal' in the normal person's lexicon, when doctors say someone is "difficult to arouse" it means "someone with a persistently decreased conscious state" - more or less unconscious. It suggests some serious problem in the brain. "Highly aroused" means angry or manic, it's a psych term.

When I worked in Aldkodja House (a geriatric psychiatric hospital), one elderly woman was brought in by ambulance with "a persistently decreased conscious state" and with a provisional diagnosis of massive stroke: it turned out she had fallen asleep in front of Passions, and woke up when someone tried to put a needle in her. She was pretty damn aroused by all that, I can tell you.

But Mrs Murrain (mid forties) was not asleep. She was in fact barely breathing - long, drawn-out wheezes, five or six a minute, not enough to keep her going at all. She had a Glasgow Coma Scale of about ten - which means any lower and we would have been looking at intubation. She smelt strongly of alcohol, she had recently been put on valium* for her depression and had been found with an empty bottle of valium and a bottle of sherry beside her, she was on morphine for some reason I can't remember, she has asthma and she had pneumonia. Basically, she had a lot going wrong with her breathing, and there was a chance it wasn't oxygenating her brain properly, and something needed to be done urgently.

And we did it. Big lines in either arm, high flow oxygen, I think we tried a naloxone infusion, chest Xray, bloods, some iv antibiotics...we pretty much did it all. Her husband was hovering nearby, looking frightened. I did my best to comfort him, once she was stable, and then, once there was only him and me and his unconscious wife in the room, I sat him down with his cup of tea, told him we were doing everything that could be done, that the worst had passed, and asked my one remaining question.

"I understand this is a very difficult moment for you" I would have said, "but there is one more thing I have to ask."

He would have nodded. Most people are desparate for something to do to help, and the faith they have in people like us at moments like this is crushing.

"And it's a difficult question, and I wouldn't ask it if I didn't think it would help to make sure we do all we can for your wife. Is it possible, even remotely, from what you know of your wife, that she took all those tablets and that bottle of spirits in an attempt to harm herself?"

He shook his head, and I pretty much let it be. Psych would be speaking to her later on (a few days later on, once everything acute was fixed up) and in the interim she owuld be staying in the hospital. But it looked suspicious, and people with chonic pain are at high risk of suicide, and she did have a nastyish pneumonia, which might
have pushed her over the edge...

Anyway, I handed over to another doctor, (Sarah, actually) and went home.

A week later Dr Shem came over to me. "Have you seen Mrs Murrain's letter?" he said.

"Nope" I said, "... she only got discharged a few days back, didn't she? Anyway, I could do with hearing about one of our successes. Let's have a look."

And he passed me this eight page letter of complaint, probably the single most vicious and bile-ridden missive I've ever seen. It did not mention me personally, it lashed at the medical, nursing, clerical and administrative personnel of the entire hospital. It described her recent bout of pneumonia, during which "events led to [me] becoming unconscious" (presumably the event of her taking all her medications and drinking a bottle of sherry). Suddenly, she wrote, ambulance men had bludgeoned their way into her home, terrifying her dog. They had dragged her from the "weeping arms" (her term) of her husband. She had been left lying in her own excrement while doctors and nurses laughed about her condition - to be honest, I wasn't that much interested in checking her underwear, I was trying to get her breathing. Her husband had been repeatedly harangued about her sanity, she had recieved no treatment at all, and once admitted had been badgered by "so called doctors" who made deeply offensive suggestions about her mental state and recent behaviour.

I remember staring at it, the thought forming in the back of my mind that technically every doctor and nurse and auxillary staff memeber in the ED would have to be called in to explain their behaviour, and wondering what the hell was going on. I had heard of post-surgical psychosis, was this it?

"She did this last time" said Shem. "Knee surgery with Dr Chisel. Tried to have him struck off - but that was only a four page letter. One angry woman."

"Jesus" I said. "Can't please all the people, I suppose."

And the next day it was page three of the Sackbut, and a picture of her standing, arms folded, scowling, out the front of the ED, and a ten second space on channel Ten, and the radio, and so on. More "Shipton, House of Death" stories.

And two weeks later, two weeks, I tell you, a small paragraph on page 67 about how the Ombudsman had investigated it and found we had no case to answer.

That's case one.

Case two was very different. in the back of my mind as I write the idea is forming that I am writing to calm myself down before night shift, and that these events are not the most calming selection. In fact, this last one still frightens me, and it, more than any other single presentation, has changed the way I deal with a common disease.

Nine oclock, Shipton, ED. Changeover had happened fairly recently, so we had new staff on, many oversease trained. I was relatively junior at the time, second/third year out or so, and luckily there were two more experienced doctors on as well.

But none of the experienced doctors knew about Jessica Cesious.

I was standing in cubicle G, talking to Mrs Termagent, an irritable elderly woman who had suddenly become dizzy.

"I think" I said, after listening to her story and having a good look at her, "that you have vestibular neuronitis".

She bridled at the very suggestion. "I do NOT!" she snapped. "I'll thank you to show -"

From several cubicles away I heard a woman's voice, a choked kind of voice. "I...can't... breathe" she said. It was the second time I'd heard her say that in a few minutes. I held up my hand. "I'll be right back" I said, and fled the cubicle.

I tried to follow the sound. Four cubicles away I came upon a room with a terrified looking young woman in a bed, a nebuliser mask on her face, hissing and billowing. She looked pale, and sweaty, and she was shaking. She looked at me again and said "I... can't...breathe." There was no doctor with her.

I walked over to her and put my stethoscope on her back, saying "Don't worry, you're going to be alright." I think maybe because I had done a lot of psych, and I was junior, the thing I was thinking as I walked across the room was that this was someone who was panicking because of her asthma and the ventolin. As I walked my vision widened, there was a terrified looking nurse standing by the side of her, holding a sheaf of notes.

I moved the stethoscope over her broad, pale sweaty back, where we listen for the movement of air in and out of the lungs. Her asthma wasn't that bad, I couldn't even hear a wheeze... Oh my God.

I turned to the nurse, and she said "Asthma. She's saturating 76 percent."

I looked around. There was noone else there. She had no line in her arm, no venous access at all. And she was obese, and sweaty and shut-down, and starting to panic.

"Get Meri" I said, because Meri was the senior doctor on. "Jesus" I said, grabbing a jelco. "Has she had prednisolone?"

The nurse shook her head. I got a line in - which took one valuable minute, but at that time I couldn't - I still can't - deal with very sick people who don't have venous access, because if it all falls to shit, you can't do anything without a line.

She looked no better, she looked worse. We wheeled her into resus, she still looked bad. No seniors had arrived, the nurse was still running from corridor to corridor looking for them. I called a code blue, the first time in my life I had ever called
an arrest code on someone who was still breathing, and asked for some adrenaline to be drawn up while I tried to get a second line in. By this time she was confused, twisting her pale, slippery arm around in my grip, making the difficult and necessary impossible.

And as the rest of the doctors came into the room, she stopped breathing, like her lungs had turned to rock, and hurled herself back onto the bed, suddenly a deep dark blue. There was no pulse. I started cardiac compressions while everyone else started resusciating the dead woman. Probalbly the only time in the last few hours that oxygen was moving in and out of her lungs - that's why her chest had been silent, because she was not actually breathing when I listened to her back and was for one second reassured. And we worked for an hour and a half until the retrieval team from the Royal arrived, and they took her away, with her husband and two toddlers following the ambulance, numb and silent.

And a few days later they turned off the machine, when the scans confirmed massive hypoxic brain damage. And thank the good God that she died, or she'd still be there.

Anyway, that was among the worst things that had happened at Shipton in a year or so. We had completely failed to recognise the very clear signs of a common killer - particularly her oxygen saturation. If any of my readers smoke, they are saturating at 99% - the blood in their arteries is 99% oxygenated. Anyone else should be 100%. Asthmatics who are very unwell reach 95%, those who are about to die may drop to ninety. This woman was seventy six on arrival - by most counts already dead. We had failed to help this woman, our inaction and mismanagement had robbed her of her only (admittedly very very slim) chance of surviving this attack.

But the nurse was new, and was doing a long shift, and had many patients to look after.

And the treating doctor - had he known? Dr Sutekh was not particularly bad, but he was junior, and not familiar with the modern Australian treatment of this common disease. He had only recently arrived in the country, he was still finding his way around - ideally he would have been supervised, but if the senior doctors are supervising, who sees the really sick people? He knew asthmatics require ventolin, but he had not seen a case this advanced. In later conversation, it seemed he had not previously regarded asthma as a killer.

The coroner's inquiry seemed to blame systemic, rather than individual problems.

Anyway, if I know one thing in medicine it is asthma is a killer. Years later, the sound of someone wheezing still at some level frightens me. Asthma and diabetes: in my darker hours I think that for the vast majority of people with even moderately severe forms of these diseases, there are two options for people. You control the disease and you live a long, happy and normal life. Or it controls you and you die in your twenties or thirties.

And when I dragged myself to work the next day (everyone shell-shocked, whispering in corridors, one of the worst events in Shipton's recent history), someone handed me the Daily Sackbut.

"Woman dies to give life to many" read the headline, or something similar. And it turned out that Ms Cesious was an organ donor, and because of her, three people lived who would otherwise have died, and several of the blind could see, the halt could walk, and the weak were again made strong. There was a big picture of the late Ms Cesious's husband, and her two toddlers. And underneath, that bit of the article they extract and print up in bold as sort of a sub-heading, was a quote from him. "The doctors at Shipton were marvellous" he said. "They did everything that could possibly have been done. I'd like to thank them, and I know Jessica would too."

So, that's why I don't read the Sackbut to find out what went on in any widely publicised case. Come to think of it, I don't watch the news at all anymore, haven't since about nineteen ninety. But anyway. Nine thirty approacheth, time to struggle into the shower and get ready for tonight.

Funny, despite all this writing, I don't feel at all relaxed. Wonder why that is? How daft am I?

Thanks for listening,
John

*Satan's jellybabies. Seriously, valium/diazepam/antenex/etc., is a highly addictive drug that has no place in the long term treatment of anything, and very few short term indications at all.

Shipton

Hail all,
and thanks again for the feedback there. And I'm trying to think of something even mildly interesting to say about the last week. I sincerely advise anyone looking for anything written with clarity, humour and insight to read Foilwoman's blog. Stop what you're doing and do it now.

Not that stuff hasn't happened in my life - I quit my Hogarth House job, for instance, and may soon begin work for the Slytherin-Mordor Area Community Council to Help Eradicate Addictive Drugs. But if I wrote about that this'd just be another "My manager sucks" post on the internet... although, by God, this one was pretty sucky.

In the interim I went down to Shipton today, to see my psychiatrist. He is a decent bloke, possibly given to excessive classifications ("as you know, there are four separate grades of mania..."). He comes from India, where psychiatric conditions can become much more severe before they are treated, so he has seen, for example, all four stages (apparently called euphoria, elation, exaltation and ecstasy) of mania. Euphoria is hypomania, a relatively noticable good (or irritable) mood, but still a just a mood. Elation is classical mania, exaltation is severe mania and ecstasy is almost a catatonic state of bliss. His consultant once treated a woman with Grade IV mania (ecstasy), who had been standing in the corner of her room for two weeks, not eating, barely drinking, communing with the Divine, her face a mask of delirious rapture.

"Professor Arjuna worked on her for weeks: ECT (electro-convulsive therapy), lithium... eventually made her better, bought her out of her state. And you know what?" said Dr Pala, "...she never stopped hating him."

He shakes his head and draws another diagram, this time of the midbrain, and proceeds to explain how reboxetine works.

He does this because I have gone to see him and we both agree I am well. I've been pretty well for quite a while now, a few mild to moderate lows, the odd ebullient mood, but really nothing that anyone could point at and say "crazy". But changing jobs is a pretty strong stressor, and I wanted to know if I should increase any of my medications just in case - I am determined not to get sick in the next few months. He asked if I had any symptoms of depression (BPAD, Bipolar Affective Disorder) and we worked out that I had most of the symptoms of the closely related condition MPOD (Manager-induced Pissed Off Disorder), but nothing that could really be attributed to mental illness, so we'd just tweak a dose and review in a fortnight.

While I've been away, two or so years, Shipton psych has had an "upgrade": swipe cards at all the doors, a new security screen, that kind of thing. I saw a documentary on the police forces once, how they've evolved from solitary village bobbies trundling along the beat to a paramilitary force with IR goggles, machine guns, that kind of stuff. It said that the police should be considered the fourth arm of the armed forces - army, navy, airforce, police. Well, you could look at some of these places and you'd think we were the fifth.

Anyway, today is my day off before I work night shift tonight. Not only is it Saturday night in Mordor Slytherin, but it is the Saturday night of the Big Football Game, and Jack Daniels is going cheap down at the local. So, should be good.

Now I must go and drop off my niece at some social function, see you all soon, should be able to write something later today.

Thanks for listening,
John

Syzygy

Sunday morning. Rain prickling on the roof, my wife abed under a blanket of kittens, my brother asleep after his football team won, my niece and her friend reading a lurid book in the bedroom.

It's quiet here.

So. Last issue: I went to the bookshop to get help, like I normally do. I rely on books for a lot of things. They are better than many people; wiser and more discrete. And portable.

Help for what? A biggish hard-to-write-about, harder-to-post thing, actually.

Okay.

There's this friend of mine - actually, that's not the right word. The nurse who was feeling low from a couple of months back. Slim, dark haired, talks a lot, quick witted. I liked working with her when we were both working at Shipton. She was going out with one of the senior doctors there. About six months after I fled to Florey, she came too.

Anyway, new workplace, unfamiliar faces, you tend to talk a bit to the people you know. She and I talked. And that was summer, and summer nights in the ED are slower than winter, and often at five in the morning you're all just sitting together chatting, and there's that cameraderie I was talking about.

And what happened? Well, she had a crap year. She broke up with her boyfriend. Tears in the staffroom, that kind of thing. And then her mother and her had some spectacular crazy Irish Catholic falling out, and then she had a seizure at home, falling and shaking, terrified her kids, and was brought in post-ictal and aggressively disinhibited to her own workplace. It turned out she'd been having seizures in her sleep (had an old head injury from a car crash at seventeen) for about a year. The ex - a fucking doctor, I tell you - hadn't told her until they broke up. Presumably one of those vicious little barbs you throw at people when you leave them - "Oh yeah? Well, you're an epileptic!". Plus the depression (which responded very well to antidepressants, by the way).

And then lastly another seizure, which meant epilepsy, which meant they take your licence off you, plus you have to go on these horrible horrible drugs, like the mood stabilisers that BPAD patients take but often in bigger doses. Make you fat, stupid, slow, affect you at work. Plus single mum, two early teenage daughters...

Two things emerge from the preceding paragraph. How many troubles she had, and how many of them I knew about and tried to do something for. Well, it's my workplace she has the seizures in. I know about the drugs the neurologist has told her fuck-all about, I've been on one of them myself. I haven't been brought into Florey, detained and frothing as a "psych", but it's an image that's always in my head. She's just around the corner, I could sometimes give her a lift to and from work. What are friends for?

This goes on for months.

What do the smarter of us see coming now? The direction, if not the extent, is already mapped out.

So, what happens (or happened about a month ago)? A few days after her licence gets taken off her (by the extremely apologetic Dr Longstocking), she starts work at quarter to five in the morning. I finish at twelve, which actually means one AM. I'd promised to give her a lift a while back, before I thought this far ahead. So, rather than drive home and get up four hours later, I thought could stay over her place (sleep in the car, or on the lounge, all above board) and take her in to work three hours later.

My wife says "sure, no worries". I think to understand her saying that, you have to understand things from her point of view. Now, in this narrative, it seems incredibly trusting, which it was - that's the kind of person that she is. And if I had to point out a place where things all went wrong, where things started to get out of control, it would be sometime before staying the night. But Sarah is like that. Trust.

I'm aware this can be read as building up to some sort of erotic climax here, and it's not going to happen. There are things I'm not going to say here, but the naked truth is it was not four hours of acrobatic, loin-spasming sex.

But it was conversation, and an inescapable physical intimacy in that there's me and her in the same house, alone at night, and both aware of it. You know that moment when you realise that no-one would know if you did something?

We didn't touch. But I don't know. If you roll the dice again, things could have happened. Maybe we could have touched or something. And I reckon in the end what would have stopped it was her, not me: because it was up to me before to stop before now, way back when I started trying to solve all of her problems, and I hadn't. Her the single woman, not me the married man.

Anyway, went home. Slept like the dead.

And since then my head's been like a kaleidoscope. Accusations, alternatives, plans, regrets, imaginings.

I've told my wife pretty much everything. I've told the nurse she can get her own lifts. To be honest, we (the nurse and I) haven't talked for about a week, we're unlikely to talk as much as we used to ever again. Planets move in orbits, we are receding from each other. That's good. I think she's got some guy now, from what she tells me he's married. What do you say?

My wife, I hope and think, is coping. Partly because she cannot imagine doing such a thing herself, she maybe finds it harder to imagine me being unfaithful, which is what I reckon I was, and had been for some time. Partly because the physical act didn't take place. Partly because she can see that said nurse and I are not the kind of people to ever enjoy that kind of communion (and look, there's another biblical word) that Sarah and I have. Partly because she sees I don't talk to or about the nurse much anymore. Sarah has always said she could forgive an episode of casual sex more than she could forgive or deal with an episode of emotional closeness between me and someone else - the way she sees it this is neither.

My wife fears things she need not fear. When she gets upset she worries I will leave her because she has too many cats*. She doesn't understand that living with her is effortless - the only time in my life I have just been myself and had someone love me anyway. I have only ever been in love once in my life. If I'd never met her, it might never have happened at all.

But my head is full. I see this, of course, in biblical terms - sin, punishment, repentence. No less a thing if the sin is only inside your head, if it's in the realm of potential events rather than actual. I don't know, there's some region in your skull where imaginings become plans, where desires grade into intentions. "Things you think would be nice" become "things that (at some level) you try to get".

I don't know.

Confession. I don't know who the fuck it's good for. I don't know that it eases the heart, I don't know that it achieves anything, I don't know it's good for me or Sarah or anyone. It's a first step, but it's only one step. Thing is, I don't want to be the kind of person who is unfaithful, in thought, word or deed. I was for most of my life before her, I don't want to be it any more.

I have to tear things up inside my head, rewrite the program. Do things different.

There's this black anger in me now, anger at what I did and what I could have done, what part of me I thought I'd beaten wanted to have done. I'm back at the gym, I'm hitting the punching bag, if I could hurt myself I would. Weirdly, I have shaved most of the hair on my head off, I look like some prison escapee. I want to get some big painful tattoo, a crucifix all across my back, like Father Lawrence's in Romeo and Juliet. A scar and a display and a reminder.

And simultaneously I'm trying to normalise things, these things that I, much more than Sarah or anyone else, feel have gone awry. Me and Sarah going to a Vietnamese restaurant. Nights at home alone, the two of us. I always buy Sarah flowers, I've started doing that again, even though at some level it fills me with rage because I see myself doing it, pretending to be a good husband when I'm not. That whole idea that if you wear a mask for long enough, your face will grow to fit that shape, and you won't need the mask any more.

I even bought a book** on it (see? the ancients had Delphi, I have the bookshop). Fittingly for a science geek, it describes extra-pair copulations (infidelity, for the rest of us), amongst animals: blue tits and cave bat bugs. Screw-worms, you will be relieved to know, are relatively monogamous, (despite the name), and vixens are actually devoted spouses. Fairy wrens are sluts.

I don't know. The following is another deeply unpalatable truth. There's some part of me that wants to have sex with almost every single reproductive age woman I've ever seen - I can think of only a few exceptions, oddly enough amongst my nearest and dearest friends. Normally it's just background pornography, you see someone, you think "look at her" or whatever and you get a half-second visual fantasy, but then it gets shunted out the way because you need your brain to actually live your life. Then the next one, unbuttoning her shirt or pushing her down onto the bed, then back to parking the car, then the next picofantasy.

Is this what it's like for every other man, too? I mean ninety five percent of the reproductive age women you see, ten or thirty or fifty a day, every year I can remember? Is this normal?

And I reckon part of this is some crap mid-life crisis, too, one of those self-indulgent breakdowns of which I've always been so intolerant. The last few months I been conscious of how unimpressive I look - something I normally don't think about at all. I compare myself to other people, something I haven't done since high school. I stood outside Borders the other day and looked enviously, as we all do, at the people who look better than me. I feel old, short and balding, I feel "not good in bed". My father had an angioplasty the other day, my ex wife has a new boyfriend, my kids beat me in table tennis. All this is as it should be (well, except the first), but maybe it bothers me, at some grunt-stupid "prove you've still got it" level.

Well, the cure for this self-loathing and rage is not some fast car and a blonde. It's not making a fool of myself. I know what I want to do. I have heard of people who have stayed happily married and faithful for decades. I want to be one. I want this to have been as close as it gets.

After all this writing, I don't know that this is postable. I know too many of you too well to be this open to you, and also, it's bloody humiliating - an example of how mindfuckingly stupid one allegedly smart person can be. But if I do post it, remember what I said about the emotional content of these being more extreme than the life - this is a good example.

Anyway. It's stopped raining. The kettle is boiling, I have made raisin toast. I am going to go wake up Sarah.

John

*Fifty. Siamese, balinese, oriental. Various colours and stuff.

** Quote from page two: "...those especially imbued with the myth of monogamy often find themselves beset with guilt, doomed like characters from a Puritan cautionary tale to scrub eternally and without avail at their adultery-stained souls, often believing that their transgression is not only unforgiveable, but unnatural."

I've heard sugar soap works, I'll try that.

Bookshop

Been thinking about bookshops.

I got to go to my favourite bookshop today, maybe my favourite place in the whole town. I don't know what it is about the place that I like. There's the staff, who besides being pleasant and happy to be there seem actually to give a damn about reading and writing. There is the selection - it's practically impossible to go in there and find a book you could hold up and say "Look, this is shite - what were you thinking?". It's a potent form of flattery - the entire environment is set up to tell you that you are an intelligent, cultured person who loves but is selective about his/her reading...and you end up acting like that.

You know, most commmercial intercourse I carry out in some kind of dissociative fugue. When I'm low I don't want to interact with the people behind the counter. I feel nervous when they smile broadly at me, greet me as if I have not seen them for long months. I resent their best wishes and bonhomie. I am not their friend, and at some level I resent the assumption that I am stupid enough to think that someone smiling at me cares if I live or die. I don't want closeness, I don't want to feel at home, I want a bloody sandwich.

But I feel some kind of comfort in that bookshop.

And comfort was what I went there for. To be honest, I went for succour and sanctuary, because all day I had been persecuted by demons. Or maybe these truly terrifying demons.

Specifically the demons of car trouble, misplacing wallets, leaving lunches in the fridge and workplace stress. Plus four of the temptations to mortal sins and a good couple of hundred of the venial.

Anyway, had a brief snippet of a conversation with someone I've always thought said interesting things. I can't quite remember who said what, but I said something about wanting a book that would cheer me up and she suggested a couple of books, and I found one I'd been looking for, and I said "well, better than lithium", and she said "tastes better, too." And I looked at her, and I said "You got that right", and then I probably sortof stared in some daft "I'm thinking" way and I gave her the blog address (with a plea to pass it on to the guy who works there, someone else who makes you comfortable with being interested in books).

Anyway, it would be easy to read too much into this. There isn't an international fraternity of bipolar people: I've known very few. A good friend of mine who may be doing medicine next year. Another medical student a few years back, doing GP now, I believe. Some girl from high-school who went mad and went away, this friend of my sister's who was either bipolar or just unable to stop taking speed... I don't know. I have one close friend with it, a few lapsed aquaintances, and that's it.

But I don't know. I think I imagined that cameraderie (and I know that I may have got things 100% wrong), because I wanted it. It'd be good to just chat, not a full on thing, just a "how was it for you, what worked, what didn't, isn't that guy in the Royal a wanker?". Doesn't matter if I was wrong or right, because I'm not the walk-up-to-someone-and-say "Excuse me, I was just wondering if you had ever been certifiably insane" kind of person. I'm shy at the best of times.

But there was that sudden glancing up, that quick attentiveness, that wanting not to be alone.

Sigh.

Anyway. The more I think of it, the more likely it seems that it's me seeing something that wasn't there. She didn't look mad - she's fairly slim, so I don't reckon she could have the strength of ten men. She wasn't working on some plan for an interstellar drive. I reckon I have to go in there in a few weeks to pick up something - "The Swimmer", I think, a cheery set of tales about the spiritual emptiness of modern folk - and it's going to be just as it was.

Comfortable. Honest. Best bookshop in the city.

Thanks for listening,
John