Thursday, April 06, 2006


Cold day at Southern today. As I hurried from the carpark this morning rain spattered on my face, and magpies huddled in the bloodwood trees, their feathers blustered by the gusts of wind. Now as I sit inside, with my hands around a coffee mug and the three picowatt heater on, I can hear the trucks rolling past, the wind in the wires, occasionally someone shouting in the carpark. It's ten o'clock and the police have been here once already today - there was a scuffle at the methadone clinic, and somebody had brought a knife.

I'm already feeling a bit fragile. The valproate is working well, and the reboxetine as well as can be expected for the time it's been given, but it's a projected six to ten weeks for a full return to normality, and yesterday was a bad day, an outlier (more on that later). But I've just had a woman in here who cried for a full twenty minutes, and I am making the next person wait for five while I make some phone calls.

A few minutes later (", that was last month, she's been kicked out again... out of the Murphy Road house... well, there must be somewhere, she can't just sleep in the carpark...- I think only her mother. Both her sons are dead, but the mother's in Clearwater, she's pretty much out of the picture... I don't know. I think he's still inside. She's still got the restraining order out on him, but I don't know if that's against the Murphy Road house or what... right. Look, I've got to go, can you get back to me? Thanks"), I go out to the waiting room and ask Mr Castro to come in.

He's a slim young man, pale, crooked teeth, but articulate and with an unusual precision in his speech that makes you listen. I shake his hand and he sits down.

"Can this be quick?" he says. "I'm on home D, and I need takeaways".

And I notice the plastic anklet with the bulky device, about the size of a box of cigarettes. I shrug. Home D is home detention,it means if he misses the bus back late he goes back inside.

Takeaways, I should explain, are doses of methadone or similar medications given out to clients to take in the privacy of their own home, as opposed to under the eye of the pharmacist. Access to takeaways is tightly controlled, because the more takeaways there are the more deaths there are - people inject their methadone, or sell to others who will inject it, and every year we have deaths in which injection of methadone or buprenorphine plays a part. I should point out that not all overdose deaths can be blamed on takeaways, patients often spit out their buprenorphine tablets or vomit up their methadone liquid so they can inject the product, or sell said product to other who inject themselves.

Hideousness alert....

That's how that guy died a few years back here - the other guy who spat out the tablet had oral thrush, and the guy who injected had HIV so he had a really bad immune system, and he got fungemia - fungus growing in his blood, oral thrush in his blood, and it went everywhere, and he died.

That's heroin chic for you.

End of that kind of hideousness.

At time of writing, none of my clients have died of overdose, because I follow the official line on takeaways. This is why so many irritable narcotic users (often resentful, cold and in opiate withdrawal) line up outside the chemist, and this is why there are often fights, and why people bring knives.

"Quick as we can" I say, "but I don't know you, I'm going to have to ask some basic questions."

He nods. "First off, I'm positive. HIV positive."

I nod. This brings the total number of HIV patients that I have seen in the last four years up to six - and that's with working in the ED, psych and drugs and alcohol, places where the invisible congregrate in larger numbers. AIDS is still a relatively rare thing over here.

"I've got colonic herpes – herpes in the large bowel - and Kaposi’s in the intestine. I get a lot of pain. When I go to the toilet, or vomit, I get blood."

"Who do you see for the HIV?"

He mentions a local doctor, one of the few around here with extensive experience in the area. "Seeing him after I see you."

“Any idea of your last CD4 count?"

"Three hundred" he said. "It was ninety". Three hundred isn't good, but it's a hell of a lot better than ninety. Doing well, considering.

"Okay". I try to work out what to do first in teh fifteen minutes we have remaining.

"How's it going on the methadone?" He's on ninety milligrams, towards the high end of the doses we normally see.

"Not good. I've been waking up - three or four in the morning - cramps, runny nose, goose pimples. I get this thing where I have to go to the toilet, right then. Sometimes it gets so bad I can't get there in time."

"Sounds like ninety's not holding you."

He nodded. "I've been using oxys, couple of them at a time. But if I do that I don't take my methadone, I don't want to OD." He's talking about oxycontin tablets, the big green ones.

"How many?"

"Two, maybe four at a time. Crushed up, injected." He shows me a big, angry puncture-mark on the inside of his elbow - not frankly infected, but not good.

"Okay. So did you want to go up?". I have ten minutes left with this guy and all we've talked about is my problems - what I want to find out, not what he wants to tell me.

He nods. "I've been on more before, in prison, and that was good. But I don't know how it will go with my other medications."

"What other medications?"

"Combivir, novirapine.... aropax and olanzapine."

The first two are antio-retrovirals for AIDS, the second an antidepressant. Olanzapine is an antipsychotic. "What's the olanzapine for?"

"Bipolar disorder. It's like depression, but you get these moods that are like highs as well."

"I've heard of it" I say. "I don't want to pry, but the way you speak... do you think you're depressed now?"

He nods. "I'm seeing my psych Friday. I mostly seem to get the depression."

Christ. What do I do first?

"Who do you see?" I said.

He mentions a mutual acquaintance. "He's pretty good" he says, and I said I had heard that he was.

"I just wish he could get me some more of the highs and less of the lows" he grins, the first time I've seen him smile.

"I think the average bipolar one patient gets something like three lows to every high."

He raises his eyebrows. "Bummer."

"Bummer" I agree. "Does the olanzapine work?"

He nods, and then I glance at the clock out of the corner of my eye and work out we have ten minutes to go and we haven't actually talked about anything he wants to talk about yet - it's been me doing all the asking. I get a quick drug history (no heroin for five years, but morphine or oxycodone tablets when he can - and here he shows me the injection site, a red, angry circular welt on the inside of his forearm - ecstasy 'whenever he can get it', last injected speed a few days ago, last ground up and injected oxycodone tablets about 3 hours ago...), and then he gets through all that and looks me full in the face.

"Show your doctor your arm" I say. "Today".

Uh huh. Anyway, we're moving. I live with my mum and her boyfriend and we're moving out to Arkham Fields, had to sell the house. Miles south of anywhere. There's like, no public transport there at all, two buses a day, seven in the morning and seven at night, and we don't have a car, and I have to walk an hour to get to the bus stop."

Outside the wind shakes rain down from the bloodwood trees.

"Dr Grizzle said she would see about getting me takeaways."


There's a brief pause.

"I'll be straight with you." I said. "I'm a fairly junior doctor here, I have to run everything past my boss. And if I go to my boss and say 'I want to give take-home methadone to this guy, he's only been with us a month, he's on a big dose of methadone, he's still injecting lots of stuff, he's HIV positive and he's just got out of prison... they're going to say no."

This is all true - and I hadn't even mentioned the bipolar. Giving this man a few days worth of methadone to take home would not be in accordance with the official protocols. Could you repeat that for the benefit of the members of the jury, Dr Bronze?

The wind gusted again. I thought of this man, this essentially dying man, walking an hour to the bus stop in the wind. CD4 count three hundred, was ninety.

"Could you ask anyway?"

I nod. "I'll definitely ask."

The last few minutes we get something done. We increase his methadone, hoping that will at least slow down the injecting. I increase his methadone by twenty milligrams over the next six days, rather than the official ten milligrams - an action that I suspect is not in accordance with the official protocols. We hook him up with a social worker who can look at transport options for him - although I am sure his GP has already done this. I type up a quick letter about the altered dose of methadone to his GP and his psychiatrist - which I will send, rather than give him tomorrow when I see him myself.

And he stands up and sticks his hand out, and I shake it, and he goes.

Anyway. No subtle moral from this one, not a great message of cheer, either. But we have half-hour blocks to see our patients, thirty brief minutes, and by the time you've written to the GP and done the paperwork it's closer to twenty. And that's fine and dandy for some of them, and for the others we are meant to concentrate on the discrete and the soluble, finding out one thing we can make a little bit better for them this visit, and linking them in to services that can help them further.

But sometimes the whole thing seems some impossibly complex fractal thing that, however hard you look at it, can't be altered in any meaningful way by anything you do.

Some of these problems have a horrible symmetry.

If I increase his methadone, maybe he'll inject his oxys tonight and die.

But if I don't, he'll keep on injecting his oxys and he'll probably die.

Of course, either way, sooner or later he's going to die.

Sigh. Could be later, I suppose.

But maybe we can get him not injecting long enough to get a few "clean" urines out of him. And his GP and his psych can keep everything else fairly stable. And in a few months - two, I think, according to the protocol, he can get takeaways - first off, six per month. That's still twenty four or so days he will have to walk in the bitter weather to the bus stop. But six days a month he can hear the wind at six in the morning and roll over in bed and not have to get up and start walking. Six days a month we might have done something.

Thanks for listening,


Blogger Benedict 16th said...

Cool story, but you are mean not giving him any takeaways - I can just hear the DDU asking you what could he possibly need takeaways for....
Anyway I thought for BipolarII it was 37:1 lows to highs.....????

We should catch up and slaughter a bottle and send FoilWoman some dirty* emails!


* y'know like full used nappies and things - what did you think I mean?

9:46 PM  
Blogger Foilwoman said...

Benny: BJ, to my feeble recollection, has never sent me an email, much less a raunchy one. I'd remember that. And it's been a while since you've sent one. Although the "perfect day" email did make me chuckle. And as for dirty nappies, the GaahGirl is not even 18 months old. I have all the dirty diapers I can handle.

Oh, and Dr. John: I just checked out the Adelaide weather report (I do assume, here, that you live somewhere in the vicinity of Benny and Chad) and your forecast is a high of 66 (or 19, depending on the temperature scale you are using) and a low of 55 (or 15). That's just not that cold. I sympathize with the lousy bus schedule for your addicted-bipolar-HIV positive patient, but with a lightweight coat, he should be just fine. (You Aussies think you're so tough: 19 or 15 just isn't that cold.)

1:31 PM  
Blogger Chade said...

Foil: Waht you have to understand about Adelaide is that our summers average temperature is 100F, so that when the cold comes it's a sharp drop. Just last week we were having beautiful days around 80-88F before the weather just plummeted to the 60's. It's a big jump for us. Couple that with the winds which come right off Antartica straight into out beloved city, which is designed is rather falt and designed in a grid format (it's almost impossible to get loset here) that creates a rather successful wind tunnel effect which in turn gets some very nice reverse currents coming off of the hills that border us. It can create quite a bitter cool season.
Then again, we are big girl's blouses when it comes to the cold. Why oh why can't it remain spring forever?

1:57 PM  
Blogger Prom said...

Oh good grief, after 88 degrees I'd kill for it to go to 60.

John, thanks for the comment in your comment box. My friend got her diagnosis. She has advanced adencarcinoma and I guess they are assuming it is of lung origin. However, her right lung is stage 4 (I thought they staged the whole disease not organ by organ but maybe they are using a different staging system then the one I read about) and stage 3A/B for the left lung. She has a clear mammogram and bone scan although note below*

The recommended treatment is a 3 drug cocktail: Carboplatin (DNA replication blocker - fairly standard platinum therapy agent), taxol (I assume this means that they have tested the cells and found them to be hormone sensitive) and bevacizumab (an angiogenisis blocker). I'm assuming that this is mostly for prolonging her life and possible palative effects since everything I read suggests that you can't irradicate metastatic adenocarcinoma.

Docs haven't mentioned surgery at this point and I'm assuming they think it wouldn't help much and would only make her more miserable.

They had done a talc treatment into the pleural cavity of her right lung to prevent more pleural infusion and lung collapse and that seems to be working so far.

* the note from above is a finding in the bone scan of necrotic tissue in her hip from lack of a proper blood supply. The docs didn't tell my friends whether this was cancer related. Is it likely to be related somehow to the demands for blood by the cancer or from poor oxygenation from the diseased lungs or not related at all? I wonder how the bevacizumab will interact with a vascularization problem if one already exists.

This is a 50ish woman who smoked and who was up till now apparently healthy. She's active and feeling pretty good at the moment.

8:17 PM  

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