Touchpaper

Tell you what, I might be taking a few days off at this rate.

Not that I don't have things to do - there's lots I'm going to do. I have plans. Great plans, big plans, complex plans, plans involving keeping multiple things going at once. Things will be whirring like the inside of a clock, or the heart of a photon.

I'm going to get up on the roof and clean the gutters out, then put up the aviary and maybe fix the chook-house, once I've scrubbed the kitchen. Plus judo and the gym and stuff. Hit the punching bag again, bit of Muay Thai.

That, I understand, seems like lots of plans. But it's not that I'm not capable of doing things. I feel supremely capable. I feel strong, I feel remarkably strong. Out of the strength comes forth sweetness,as they say, sweetness and fireworks. And I reckon this place, SMACHEAD and Florey and all - I reckon they need me. How could they function without my frenetic energy, my crucial insights, my white-light drive?

Yep, needing less sleep, feeling remarkably energetic and confident, thinking fast and clean.... I know what this means, or what it may mean in a couple of days.

I feel like there is a fire beneath my skin. Honestly, I close my eyes and I feel it lapping. Sometiems I've got so much energy I almost shake, sometimes words tangle on my tongue.

What it probably means at the moment is upping the valproate (from it's current dose of close to bugger all) and taking a few days off. Very probably this Friday off from the ED. Maybe a few days off sooner rather than later.

Not that there's anything wrong with me, of course. It's everyone else who is slowed down.

Anyway, the purple tablets. See you soon.

John

Freeeeeeeee

I read, with disbelief, that a drug company in the UK has been suspended from some trade organisation for taking doctors lap dancing. I am struggling to get a bloody biro out of the few drug reps I see. In the old days it was Viagra boxer shorts (surprisingly comfortable, I might add) and big purple zyprexa mugs (labelled with the name of a prominent antipsychotic), nowadays it's slim pickings. Prescribing for heroin dependence apparently isn't as sexy as heart attack prevention. And generally our clients aren't big spenders, because if you can afford to be a big spender you don't go on methadone, you stay "on the hammer".

This is true, by the way. At the moment there is a drought, or so I am reliably informed, of good quality heroin, and has been since about October 2003. This means that my clinic is full of earnest people looking to get (and succeeding in getting) their life together. Crime rates drop, families are reunited, and young lives are saved.

But the distressing truth is if a shipment of weapons grade heroin were to arrive on the docks tomorrow, the next day the clinic would be almost bare.

Anyway, this all got me thinking about the paradox at the heart of all of this. The people we see, the people who come into the clinic, are people who have been free for much of their lives. Their lives have proceeded according to their wishes and plans, not those of others. They have kicked against the pricks, that kind of thing, they seem to see boundaries and expectations as things to be transgressed.

And I'm not trying to romanticise this, as if the methadone clinic is populated exclusively by the fey and the other-worldly. It's not. It's populated by people who didn't stay in school, or didn't get a job, or didn't think that your telly should stay in your house, or who thought that tablets didn't have to be only for sick people - that kind of thing. People who did the things that they (and the rest of us) were told not too.

The word libertine can be used to mean either free-spirited or morally bankrupt, depending on your view a fair few of my clients are libertines.

Anyway - fast forward to now. They sit in the clinic until they are told to come in. They are given doses which I decide of a drug that sometimes the courts order them to take. At any time they may be asked to provide a sample of urine for us to analyse. Frequently a nurse (of the appropriate gender) follows them into the toilet to ensure that the urine is their own.

They must turn up to the clinic at the same time (give or take about an hour) seven days a week. They may thus be restricted from travelling more than a few hours away - travel interstate is extremely difficult, overseas is virtually impossible. After months of demonstrating your trustworthyness, with sequential clean urine samples and demonstrations of impeccable behaviour at all times, they may be granted "take-away" doses... but these can be withdrawn if they misbehave or are ten minutes late for an appointment.

Now, I'm not arguing that these draconian restrictions are unnecessary. In the south where I work we have one of the highest rates of deaths from "diversion" of methadone - methadone is a synthetic "poor man's heroin" and it can be surreptitiously spat out of the mouth into a cup and then injected into the veins for a more marked (but shorter acting) effect.

I have clients who grind up tablets and inject them into their arms, who frequently present to the Florey having taken handfuls of "some tablets I found in this guy's house" - people where if we keep them alive for a year, it's a medical miracle. If I gave these people a months supply of methadone I would be dragging bodies out of the toilets all day.

But the thing that struck me the other day is how the people who could not or would not be constrained, who decided that the things that held the rest of us back would not held them back, they are the ones who have to pee in a pot when someone says. It's almost as if there is only a finite amount of liberty in someone's life - that if you use it all up at the beginning, you end up in the methadone clinic. It doesn't have to be the methadone clinic, of course, you could be in fetters, or in the madhouse - anywhere else where you do what they say.

And the flip side of this, I suppose, is the people who spend their lives obeying and then are eventually rewarded with power and prestige and freedom - and then have to find something to do with it.

So there you go. Spend as much of your liberty as you can when you are young, broadening your mind and so forth, but not so much that you use it all up before you die.

Thanks for listening,

John

Our true selves

You know, when I started working almost exclusively at SMACHEAD I thought that I would see "less medicine": that I would see only a fraction of the active medical problems that I was accustomed to seeing at Florey, and that my clinical skills, like unused muscles, would rapidly whither away.

But this has not actually been the case. I spoke last week with a muscular-looking man: stocky, red-headed, swollen calves and forearms like popeye... who was until recently a brickies labourer. He has a mild form of muscular dystrophy. By all accounts he should be in a wheelchair by now, and most people with what he has would be dead before his chidren (both girls, and therefore safe) grow up.

"I don't look like I've got muscular dystrophy, do I?" he grinned, flexing a fist, and I sort-of nodded. Weakness in the muscles closer to the trunk means that forearms and calves are often hypertrophied, excessively large. Like the elevated mood of a bipolar patient, or the absence of wheezing in an asthmatic who is about to die, these are not true signs of health but symptoms of a terrible disease. Once you knew what to look for, he looked sick. But he didn't want to hear that he looked like a sick man.

He smokes twenty cigarettes a day. He's not going to die of a heart attack or lung cancer. We are meant to be handing out cheap nicotine patches to our clients, I haven't pressed him on this.

And another patient. A very unfortunate man with, again, bipolar disorder (seems to be a lot of it about...) who came to us for methadone treatment. His problems are twofold - the way his mania manifests and the way his blood responds to the treatment.

Mania affects different people in different ways. Poor sleep, feelings of limitless energy, disinhibition in various ways, that kind of thing.

I get this weird ego thing - I talk all the time, fast and loose, I exercise lots, and form the conviction that I am sexually irresistable, remarkably artistically talented and full of untapped physical and intellectual potential.

A friend of mine buys expensive but useless stuff. In small amounts none of these are problems, and a mild hypomania is actually a damn fine thing: it's glorious. When you have to deal with the consequences of some of the embarrassingly stupid decisions you've made, then the problem arises.

Anyway - this guy tended to get more of the irritability and impaired judgement side of things, and I suspect this had been partly to blame for the crimes which had put him in prison. Stealing cars, robbing video shops, that kind of thing. Since getting diagnosed in prison and then getting out a few months ago he had been a model citizen - one big purple tablet in the morning, two at night, and for the first time in his life he felt calm.

Until the next GP visit. Blood tests showed that the valproate was affecting his body, causing his bone marrow to stop producing white blood cells. If he didn't stop taking it he would die.

"My arse" he said to the doctor. "I've never felt better."

"This is serious" she said. "You could get very sick. I can't prescribe this any more."

Things deteriorated and she sent him to our service. By this time he had resumed taking his valproate (he had quite a few weeks worth in stock) and felt much better. I tried the same thing.

"If I get sick, I can go to hospital. That's what they're for" he said.

"Mate, they will be able to do piss all for you." I said. "Trust me, I work there. You need white blood cells, you'll die without them. First time you get a cold or something you'll crash. If you get sick, nothing works - no antibiotics, no transfusion. They'll have to put you in intensive care if you get a bloody cold."

He shook his head. "Gotta go sometime."

"If you don't stop taking the valproate" I said, "I reckon you'll be dead within the year."

The preceding was a bit dramatic, but not grossly inaccurate. No white blood cells means essentially no immune response - like AIDS but quicker. He was the kind of man who responded to difficulty with anger, and he was looking pretty angy now.

"There are alternatives" I said. "Lithium, topiramate... look, I'll write them down. Work just as well, better in some cases. As long as you don't get pregnant." And I sent him urgently off to a specialist, because this wasn't one I was going to deal with alone.

Anyway. Apparently Diderot said poverty and disease were the "two great exorcists": they drove out what else inhabited the body and left only the true person, the "true self". We do not see a person's true worth, says Diderot, when they are lying on a bed eating mussels and drinking merlot, we see their true worth when they are weakened, sick or poor.

I don't know about that. Leaving aside the possiblity that you can tell quite a lot about people from looking at what makes them comfortable, from watching what they do with the wealth and health they have, the idea that we see people truly in sickness does not automatically convince me.

The muscular dystrophy guy - the guy living a relatively normal life, until recently hosting bricks, watching the telly and smoking ciggies down the pub. He has a weak form of muscular dystrophy - a protein that is subtly malformed, not enough to be completely useless, but not good enough to be strong.

He is in between the sick and the well, someone who has a foot in both camps. You can close your eyes and imagine the person he would have been had one codon been different, one gene subtly altered - as if he stands before you flanked on the right by a strong and vigorous man who will die in his seventies, on the left by a withered figure in a wheelchair, wearing an oxygen mask, maybe days away from death.

I don't know that the sick man is any more true, that the sick man's life shows any more of what this man was really like than does the well man. It makes just as much sense to say that this man's true nature was as we saw it - checked shirt, packet of White Ox tobacco in the breast pocket, suntanned and grinning - and that it was the unhealthy man who was the illusion.

And the man on valproate. Was he any more himself when unmedicated, when his blood was vigorous and healthy but his mind was full of racing thoughts, plans and ideas and scams that almost seemed too good to be true, holding up a service station, shaking with wild ideas? Or was he "really" the quiet man with the thin blood and the intelligent, calm look?

I don't know. I don't know that I believe in "true selves". A field grows a flower, that kind of thing. There isn't a true self, any more than there is a "true path" that a leaf can take as it falls to earth: things happen to you, you ride them out, you do the best you can. Diderot died at seventy one of emphysema and the beautifully named dropsy - I don't know that he was any more his true self as he breathed his uncomfortable last.

Anyway, this is starting to sound like something that should have a moral at the end of it, and I've never been particularly good at morals. I suppose in the end I'm just grateful: grateful that I can load bricks and make plans, that I can look at but not leap upon dark-haired and dark-eyed girls I see, and that my proteins were twisted just enough, but no further, than necessary.

Thanks for listening,

John

My job is not shit

Hail,
Today I have to tell some woman that she will no longer be able to turn up to the pharmacist with a script and pick up a few days worth of medication like normal people. Instead she will be restricted to daily doses of her medication, taken under the watchful eye of our pharmacist.


And all because of one little forged script for opiates, so the police say.

Anyway. Not looking forward to that. She will probably cry, because she cried last time about something else, and I hate making people cry. If I wanted to make people cry, I wouldn't have been a doctor, i'd have stuck with the door to door selling.

Anyway, this made me think about some of the worst jobs I have had. There was the previous door to door selling, of circuit breakers and religious fundamentalism, which I found less than rewarding.

There was picking lemons in the Riverland, during that run where we had ten days in a row over forty degrees and five over forty five and I got paid two dollars fifty an hour. Lemon trees have long spines on them, and the ladders are fourteen foot long and aluminium, and as you balance on the point of the ladder it frequently pitches forward so you gently slide into the thorns and you impale yourself. Four weeks, less than a thousand dollars, sunburn, two dislocated shoudlers and some kind of ankle fracture.

Plus I ate radioactive meat for money in medical school, whcih was actually quite good. Hear me moan, as they say.

But anyway - inspired by this (and the imprisonment of one of my clients,leaving a gap in my otherwise full schedule), and believing that there is always someone much worse off than you, I searched around for some truly bad jobs. Current possibilities include sensory deprivation research assistant or hermit... both of which have appealed to me on previous occasion.

But the past has much to teach us here. Ever wanted to get close to royalty? Work with animals? Inspire people and have an interest in public speaking?

Anyway, I am too easily amused today. Thanks again for the comments. See you all soon.

John

Previously on BJ...

Hail, good to be back (assuming anyone reads this). Thanks for the posts people sent at this time. I have missed this.

Unfortunately, the things I had hoped would have resolved while I didn't write have not resolved themselves.

The bipolar and depressed friend is still bipolar and depressed, we are treating her with episodes of House, frequent BBQs and judo. Things have, in this case, possibly passed their worst. However, with full-blown BPAD, as she has, a gradual easing of the deep-depression-with-nasty-added-features is not unambiguously good news: after the low comes the high, and in her case that can be spectacular.

Her pharmaceutical company (she calls herself a drug pusher) has responded to the precarious state of her mental health by sending her to five different cities in three different time-zones in the next four weeks.

I wonder if I can detain them...

And Burian (sixties, blue eyed, semi-professional playwright and serial monogamist) is still in the Royal. Things move slowly on the cancer ward, in fact it may be that the only thing moving with any rapidity at all is his malignancy. The palliative team will have ward rounds - if not today, definitely Thursday, if they're not called away. There will be radiotherapy - this week, or perhaps the next. A meeting with the social worker - in the fullness of time.

But we are bringing him oysters and red wine and science fiction stories and talking to him, and if he was less confused and more able I would play the game of chess I promised him five years ago, a promise I never found the time to honour.

There is a lot that can be said about this that I am not able to say. I hesitate to try to turn this into a story, although I am pretty sure that is what he would want. He is in a smallish room - large for the Royal - where he spends a lot of time sleeping.

Part of the - I don't know, irony? horror? rage-at-Godness - of the situation is that he is a very terrestrial man, a man who has valued quiet and trees, and now he is on the seventh floor of a building whose window looks out onto a bank.

He is a man who has valued control and precision and a nurse comes in and tells him when to weigh himself and what he will have for dinner tonight. He is a vigorous man who rode his bicycle in the hills in summer and now he hobbles to the toilet. And he is a man of the flesh, who has had a succession of close relationships with a surprising number of women, and I think that's what he misses the most.

Acting out of what seems like the desire to cheer a friend in need but is probably partly motivated by a desire to shove it up the arse of the Royal, I at one stage suggested bringing a "woman of the night" in for a visit, some busty and revealingly dressed nordic goddess. He declined regretfully. This is not my area of expertise, anyway.

Failing that I am going to try to get him a haircut by a nymph of some kind.

Anyhow, enough anger.

The drugs and alcohol job goes well. I have had only one shift in the Ed in the last three weeks. It was one of those "swept off your feet" shifts full of noise and action, where you blunder out at the end of the night shaking your head.

The thing with the ED is you can't do it at all if you don't do it well. It's not really an environment in which you can flap about. If I go back I would want to hit the ground running, do some actual study before-hand, revise the stuff that if I know if I don't use, I'll forget.

Anyway, this was going to be a brief note. More from drugs and alcohol and so forth soon.

I missed this.

Home visits

Hail,
Very brief note here. I haven't been posting. This is because two close friends of mine have suddenly become very unwell. One is bipolar and deeply depressed, and we are trying to keep her out of hospital. This therapy consists of frequent visits where we watch "House" together and convince her to take the medications. The other is in the Royal with cancer in his bones, and nobody is telling him anything.

Hopefully this will all stabilise soon.

Thanks for listening,
John