Wednesday, May 31, 2006

The Coming Ice Age

Only just back at work, don't expect crystal clean text today.

When I was a child, amongst my favourite books was an old A4 sized hardcover by one Zdenek Burian, on animals of the past. Burian probably illustrated more than five hundred books on palaeontology and evolution, and even now his illustrations - of long-necked saurians, birds out of nightmares and unsettling animal-men - I find unexpectedly moving.

When Burian wrote, the great story of life on earth was simpler. Prehistory progressed, as it seemed history had, via an orderly and inexorable successsion of ages. As in our past we had seen the Age of Stone superseded by the Age of Bronze, and that by the Age of Iron, in Burian's books we saw the Age of Fishes yield to the Age of Reptiles, and that to the Age of Mammals, and finally Man.

There was a mythic quality to these cycles of dominion and overthrow. In each case, the story would be the same. A vast and ancient Empire - the Empire of the Placoderms, the Neanderthals, the Assyrians - would hear rumours of fantastic and terrible beings appearing on the fringes of the Empire. At first these would be dismissed as travellers tales. But with horrible suddenness the strangers would arrive, all would fall into chaos and the old order would be destroyed - making way for the Teleosts, the Cro-magnon Men, the Babylonians.

A powerful, secure-seeming structure to hang a story on, and one which fits more easily in our heads than a lot of others.

And today I heard another young man talking about how everyone's all fucked up on the ice.

Ice, for those of you who don't know, is the crystal form of methamphetamine. Local terminologies vary (as does purity, price, everything), but the basic progression (an amphetamine evolutionary series) could go speed or meth to ice. Anything I say for amphetamines here I say for speed and essentailly the same amount for meth and tenfold for ice.

Ice and its various relatives - and since most of the stuff is not made by qualified analytical chemists, approximations must be made so that when I say "ice" I should be understood as saying "the hodpodge of half-baked industrial chemicals sold by scabby australopithecines with gleaming eyes to teenaged psychotics-in-training as ice" - ice is probably the fastest growing injectable drug franchise in Australia.

Seriously, the young man across from me was saying, it's everywhere. Can't cross the street without someone offering it to you. Down the pub, at the local footy game, when he dropped his kid off to school.

Ice is a very in thing. Ice is not only the new speed (and for the coming generation speed is the new heroin), for a growing number of people it's the new alcohol as well. Go out on the weekend, have a taste. Cheaper than a carton of Carlton Draught, gets you higher and doesn't leave you with a hangover.

But the reason for the young man's concern - and mine - is that ice, even more than the conventional forms of amphetamines, does really bad things to you. It's hard to compare drugs - and any time you do, tobacco ends up so far ahead, so much further along any axis of evil you care to use - it's hard to compare drugs, but by almost all measures it is my unprofessional opinion that amphetamines are worse than heroin.

First, heroin calms people down. They can be pretty bloody uncalm when they haven't got what they need, but somone withdrawing from H does not come into the ED and start swinging the fire extinguisher around by the hose and trash the place, after vigorously masturbating in the corner. No, that'd be that skinny guy on amphetamines last year.

Second, there is a limit to how much heroin you can take. Even if you have a tolerance like Keith's*, you don't get much more than six times a day. But the amphetamines - whatever you've got. Amphetamines you run until you run out.

Third, heroin depends on the vagaries of agriculture and the international situation. This means that there is a good chance that at some time, like now, the supply will become so damn crap that people will consider giving it up entirely. This is not likely to be the case for the amphetamines.

Lastly, and most nastily, you get most people, give them a heroin habit for ten or twenty years, at the end of that time they are pretty much the same person. Generally the same person a lot poorer, and more beaten about, somewhat the worse for wear for having to deal with some deeply nasty people who make their living selling the stuff, and almost always carrying some virological penalty from years of injecting - and a comparable psychological burden from the years of shame and hiding - but the same person. If they have managed to avoid a catastrophic overdose with the resultant frontal lobe damage, and Hep C, and HIV, and have managed to come unscathed through whatever it is they had to do to pay for what they used - then they are relatively okay.

But two years - hell, half a year - on amphetamines, a lot of people change. Ongoing heavy injecting amphetamine use, for even a few months - it changes people's brains in horrible ways.

Speed psychosis. Meth paranoia. Ice hallucinations. Those eyes that look everywhere, that hunching over, that horrible, low-grade, picric-acid "what the fuck you looking at?" state that's only ever one low syllable or sideways glance away from bone-breaking violence. Everyone who comes into the ED stabbed in a drug deal gone wrong - amphetamines. The woman's daughter the other day, the armed robber, held up eight service stations in two weeks - amphetamines. In close on a year I never ever saw a kid in Mauro or Stewart (the juvenile prisons) who hadn't been on amphetamines in the week they'd been arrested. This is the twelve year old rapists, the softly spoken murderers, the sweet teenaged girls who stabbed people. Amphetamines.

Anyway, awareness of this problem is growing. There was a horrific special on Four Corners the other month, the week Burian died - it was on the TV in the next room, wouldn't have known about it otherwise - explaining precisely how bad things were going to get how soon. The local yellow press have been mentioning it in their seven o'clock specials, a few columns in the White Australian, our national right wing rag... things are happening. The other day a doctor from Darwin rang me for advice about a fifteen year old Aboriginal boy on ice.

And I was thinking the other day about all the letters in the Sackbutt. Concerned businessmen, leadess of the chambers of commerce. Owners of car yards and television shops, restaurants and pubs. The exhaustive urine drug tests you have to go through to get a job at DT Breweries, the $50 000 of personal funds donated by one car salesman to a programme to keep kids off drugs, the demands pretty much everywhere for tougher penalties, longer sentences, bigger jails.

All of the pillars of society writing in. And I was thinking that I could discern barely concealed fear. As if we had heard traveller's tales, rumours, as if we had heard that fantastic and terrible beings were appearing on the fringes of our Empire

And I thought about what we have to offer, our society, the society built around the busnessmen whose advertisements and interviews and letters form so much of the Sackbutt, and who in the end pay my wages. I thought about the car, the house, the fine food, the pornshops and the bottleshops and the bookshops. The things our society offers those who forestall pleasure, delay gratification, pay the time and effort and money, do the right thing. Our rush, our drug, our high.

And I ran that through in my head against what ice can do. That neurochemically targetted supernova, that order of magnitude bigger and better and brighter thing, more than speeding in your Porsche at 300 kmh down an open highway, more than getting mindmeltingly good oral sex from an eastern European porn star at 300 kmh in a Porsche while downing fresh oysters by the gallon, washed down with ten thousand dollar Merlot.

Ice is easily made. The products cannot be anything but readily available. The knowledge is out there. And ice is only the current form - mutations, subtle variations are already appearing. The list of potential compounds is vast - while politicians thunder against what I could call "ice I", and announce laws that would impose heavy penalties for possession of any detectable amount of the dreaded substance, the more alert workers in the area are hearing about fucked up kids on something called "Ice V", and somewhere in a lab someone has just made "Ice IX".

We will never catch up. We never were close, but we're getting further and further behind - it is a brave person who speculates on the future of surveillance, but Benjamin Franklin said that the people who give up freedom for security deserve neither, and this stuff is being made in our neighbourhoods - so that's where we'll have to have the police with the ultrasensitive microphones and the infra-red cameras.

And someday soon there'll be something cheap and easily made that you can take just by touching it to your lips and it'll be better than anything you could ever work for, even if you worked all your life.

What then?

The unimaginable. How will our society, built on and by and largely for people who will accept delayed gratification of a certain, admittedly very nice level (show me those oysters again...) - how will that society compete with the offer of pleasure literally unimaginable, pleasure that compared to which everything else for ever after is tepid, pleasure that can be had for only a few dollars?

What then?

I feel sometimes we are like the Neandertals were, staring across the rift as another and yet another tribe of those skinny, unhealthy looking new people came along. Pale and ugly looking, but full of incomprehensible ideas - fantastic and terrible beings appearing on the fringes of our land, and feeling for the first time the vulnerability of our empire we thought would stand a thousand years.

Thanks for listening,


*Keith Richards. Will go to his grave having been the best white guitarist in the world. I don't know about a lot of the pharmaceutical stuff, but there are few non-synthetic pleasures that will ever rival being drunk and hearing those whispering drums at the start of Sympathy for the Devil.

Monday, May 29, 2006

Green Monkey Fever, II

Well, thank God that's over. I am back - paler, thinner, listlesser and with even more of a tendency to feel sorry for myself than usual - but back.

Hmmm - pale skin, gaunt, depressed looking.... irritable middle-aged doctors can't be Goths, can they?

And I do think you sort some stuff out in times like this. At least some part of your brain must be working while your body so demonstrably is not. I am sorting stuff out about work, and writing, and all that. More on that as it eventuates.

Bloody hell. Walked to the shop to get my lunch today, wouldn't be a kilometre, walked really slowly but even so had to stop under a tree for a rest. All I need now is a bloody cloth cap.

Thanks for listening,


Thursday, May 25, 2006

Probably not Green Monkey Fever

A real disease, by the way, and a nasty one.

No real post today, and possibly none for a few more days. I have been in bed with a virus, which means twice or thrice daily showers, drinking vast amounts of fluids and getting ninety percent of my nuritional needs from anti-inflammatories, paracetamol and orphenadrine.

I now know what people must have thought of me when I sent them home from the ED saying "Most of these things go for two or three days". It's been six days of this crap. Please somebody tell me I have never used the term "only a virus". Marburg and Ebola and HIV are only viruses.

I think this may be that thing Danny had that I was so spectacularly unhelpful with.

On the bright side, I have probably lost weight and I have managed to realise how much I am looking forward to going back to the ED.

That's used up my thirty minutes of energy for the day, so back to bed.

Thanks for listening,

Thursday, May 18, 2006

For no reason at all...

... here is a photo of one of my earliest teenage crushes.

See? Thirteen and lusting after a woman with a flock of birds painted on her face. No wonder for a number of years eternal celibacy stared me in the (fortunately birdless) face.



Well, I found that amusing.

Now where was I?

Ah yes. Standing in an underground room, with a Japanese girl, desecrating a corpse.

I have decided to invent a new word or phrase. Adextrosinisterism. Chiral blindness. Amanugnosia. I don't know what the exact word is, but I can come out now and confess before the world that I've got it. I have great difficulty in telling my right hand from... the other one.

You suspect I jest. I do not. When I was a child I was okay - I had a wart on my right knee. It healed, but then I was able to rely on some kind of bump thing on my wrist. But eventually that too went away, and it took with it my last real hope of finding my way around the world.

I (almost) can't tell left from right. It started in primary school, where I confused b, d, p and q, R and 5, and 7, T and Y - but never 0 (zero) and o (oh). I wrote the numeral two backward until at least the age of fifteen (I found my old tape of "Ziggy Stardust and the Spiders From Mars" in the garage the other day - side one, side five). And I couldn't tie my shoelaces until an embarrassingly late age, and still tie them in this weird macrame way.

And I still have to wiggle my hand in a writing way to tell which direction is left, and I am still almost legendarily bad at navigating. I get lost five or six times a year, ending up in unknown valleys, or exotic harbours where surly men load crates bearing unitelligible writing onto boats bound for foreign places, or isolated hamlets in lost valleys, places where the locals eye me warily and everyone wears unusual ethnic clothing with big hats.

I don't mean lost trying to drive to Sydney. I mean when going to the local shop it takes me a lot longer than other people because I miss turns, go via unusual suburbs, lose the car in the carpark and then can't find my way home.

I think this is due to a lot of things. Part of it is I don't tend to pay attention to stuff. I go into screensaver when permitted, and can work up Adult Male With Head Injuries, Appears Intoxicated in alpha wave sleep.

Part of it is finding it really difficult to stay interested in boring stuff, and how to get home when you've got the wrong side of town, have only three litres of petrol and don't remember there being an amphetamine kitchen on that street before before is only really really important, it's not interesting.

And some of it is something more - there are times, at least once a month, where I will fail to recognise familiar places, and be for a moment utterly disorientated (which means literally "unable to find east"). The French have a phrase for it - jamais vu, which is the counterpart of deja vu. Deja vu is "I've been here before" in what should be unfamiliar surroundings, jamais vu is "I've never seen this before", in surroundings that should by rights be familiar.

Both of these occur in epilepsy, by the way.

But part of it is left and right. Never understood it, never got it, never grokked it, never will. When patients describe pain that I suspect may be appendicitis, I surruptitiously superimpose my body on theirs (as in I imagine it, I don't leap in the bed and start spooning), line everything up, press on my body precisely where they are pressing when they show where the pain is on them , wiggle my left hand as if writing something, and if it's on the same side as my writing hand, it's left sided pain. And unlikely to be appendicitis.

And yes, I am an emergency doctor. And no, no-one's ever died as a result of me getting this wrong, because I don't, I just take longer - and I've always found oter people's bodies easier to navigate than mine. And no, I have no plans to go into surgery.

But the desecration. Me and Masako down in the freezing basement, the smell of formalin, the thick surgical gowns that gradually became sticky and stiff with un-named fluids. Me and her and an elderly man who had given his body to science. Whittling - preserved flesh is a strange texture, slightly springy but unyielding for the connective tissue, greasy and brittle for the fat, and colours that suggest but do not evoke life - greys and tans and faint russets, pale yellows and diluted browns. More of autumn, life with death in it, while the bright red blood and golden yellow fat of living people are summer.

Masako and I were dissecting Mr E, whom, it became apparent, had died of advanced pancreatic cancer. He was thin when we got him, and after we'd scraped back the meagre curtain of abdominal fat he was almost skeletally thin - a ribbon of abdominal muscles, pectoral and shoulder muscles clearly outlined, looking like some discomforting parody of a bodybuilder, an aged superman.

Surface anatomy was easy. But it was when we reached the viscera - thankfully after the face and hands had been dissected, and I was able to concentrate less on the person and more on what we were meant to be learning about - by the second day of visceral anatomy Masako was starting to lose patience.

"The left lobe of the liver" she repeated.

"That's it there."

"That can't be it there. That's the right."

"How can that be the left lobe?" I said. "Then what's that over there?"

"The right lobe, perhaps?"

"How can that be the right lobe?"

"I sortof thought on account of it being on the right hand side."

"Then what about his pancreas? Why has he got it way over there?" I stared at his jumbled abdomen, with the organs we'd recoved and put back like a jigsaw puzzle. "Do you reckon he's some kind of freak?"

"No, not him" said Masako. "When I go home I'm getting a tattoo. It's going to have pictures of all of my internal organs on it where they are, so if you ever operate on me..."

This went on for another day or so, but eventually my brain put together the facts that I was standing in a room with an irritable Japanese girl who was holding a very sharp scalpel. And the morgue was a long way away from the rest of the hospital, certainly too far for anyone to hear me scream. And it was already full of dead bodies. One more would't be noticed, especially since they were in short supply ...

So I did it. Carved a little "L" on the pectoralis major muscle, just under the left nipple. It worked fine. As the dissection continued I was more at ease - that big heart-looking thing was on the left, the red-brown livery thing with the consistency of cold rubber was on the right. It all worked out in the end. But that first signpost was the crucial thing.

I like to imagine he wouldn't have minded. His face suggested a decent, if deeply tired, fellow.

Anyway. Haven't looked at anatomy for years, and am unlikely to, unless I manage to whip up the enthusiasm for the exam again. Which I will, once the moods and the chaos and the rest of everything settle up. It may be some time.

Thanks for listening,

Wednesday, May 17, 2006

Our Ancestors

Been thinking about heirlooms, and epistasis, and echoes, and other things that come to you out of the past.

And the following contains extremely bad things, as bad as I have ever written. I cannot sufficiently emphasise this. If you don't wish to be upset, turn away now.

I had a medical student today. A pleasant young woman, an American, from Idaho, educated and literate. She actually seemed to know what methadone was, and what a methadone clinic was for, she was even familiar with Canada's recent courageous trial of free alcohol for alcoholics - and the benefits that seem to be flowing from it.

But she obviously hadn't worked in a methadone clinic before, and I sat and talked with her for a while before suggesting I'd see the first two or so, she could see if she felt comfortable seeing the next one (while I sat in) and we'd go from there.

And so it went. The first client, Mr Phuoc, was wonderfully underwhelming. No problems with his dose. No real temptation to use, hadn't done for four years. None of his friends used now, and apparently heroin was still crap. No other medical issues. Home life stable, girlfriend in Uni. Works part time as a capsicum picker; "picks capsicums when they are round and red" (as Dr Grizzle had written), studying, urines clear for the last four years. Didn't want to change his dose. Nothing else to report.

In and out in twenty minutes.

"My God," she said. "He's doing so well."

"Buprenorphine works," I said.

And the next one - a woman with us for seventeen years (not the record holder, but close), who swept into the unit in a flowing scarlet cape and pressed into my hand her card, which advertised her knick-knack shop.

"Thriving business," she said. "Two stores now, had to hire another girl. Be running the chamber of commerce soon."

When I asked about temptation she seemed genuinely surprised. No heroin for seventeen years, no real idea where to get it now, if she ever tried. She had grandchildren now.

"You've got to fill it up with something," she said. "You can't just go from something like that to nothing. You've got to have something to fill the gap."

And the next one - one of my favourite clients, an elderly woman who astounds me with how she has endured her recent extremely difficult times. We commiserated on the difficulties of dealing with the prison service, and how they wouldn't let her see her daughter, and I said that at least they had downgraded her daughter's charges to being an accessory rather than armed robbery, and she said that had been good. And the medical student handled it rather well, I thought.

"You or me to do the next one?" I said.

"Probably you," she said. "I'll do the one after that."

I looked at the notes. "Mr Stryker," I said. "Should be another good one."

And it was, but it wasn't easy.

Mr Stryker was large-framed, bearded, big Nordic nose and bright blue eyes, a boilermaker-welder with calluses on his palms and scars across his forearms. He sat in the chair across from me, oil-stained jeans and flannelette shirt, with that smell of metal on him, looking like a Norse God exiled to earth.

We discussed the pros and cons of his dose - the seventy milligrams was holding him, less sleepy than when he'd been on one fifty, but it had been hard dropping from one fifty to seventy in two months (I nodded, wide eyed at this) and he was trying to take it slow from now on.

Not that he'd ever touch the smack again - it'd been five years, he didn't know anyone who used now, all moved on, in prison, or up north, or dead - but the main problem with dropping his dose was the moods.

"The moods?"

"Depression," he said. One of the two or three strongest men I've seen in the clinic, and we get some biggies. A calmer strength than that possessed by Mr Wylde, who a few months ago spent his first Christmas out of prison in eighteen years. A deeper and much less brittle strength than Mr Jarusnich, our bodybuilder.

I nodded.

And he described it. He was never happy, he said. Could never remember being happy, didn't know that he had ever been happy. He had seen it - seen the way people gather around the barbecue and laugh, seen that look of contentment on his wife's face when she sat with the cat on her lap and read, seen other people happy - but he himself had never felt it, thought maybe he wouldn't recognise it.

"I don't laugh," he said. "Things go wrong, someone hassles me at work or something breaks, I get angry. And I worry when things might go wrong. But when things go right - nothing. I just find something else to worry about.

My wife - she's the exact opposite. We'll wake up and she'll be like "It's going to be a great day today", and I'm "It's going to be shit." She says "Let's take the car, go down to the valley, see some wineries", and first thing I think is "What if the car breaks down?". All the time.

"I see it," he said, "and I know I'm doing it, but I can't stop it."

We mentioned antidepressants - five years on the highest dose of venlafaxine - and cognitive approaches, and he waved one hand. Done them.

"You tell yourself the good thoughts, but the bad ones keep coming."

"This cognitive behavioural therapy," I said, "you can learn to recognize the bad thoughts, work out if they're true or not."

"I know they aren't true," he said. "But some part of my brain keeps on making them. Sometimes," he said, "I wish there was just some bit of your brain you could cut out. The bit that's not working, just zap it."

"Maybe," I said.

"What I want to know," he said, "is where does it come from?"

"Depression?" I said.

"I mean, way back. Was there one guy, one caveman or something? And something really bad happened, and it just got passed on, down the line?"

"I don't know," I said. "Some people reckon - look, maybe there's about twenty genes, affect the way you think, can make you sad or happy. If someone gets too many of the happy genes, maybe they're too careless, too optimistic, go off and get themselves killed by a sabretooth. If they get just the right balance , a few of the happy ones, a few of the ones where you sit around the campfire eating and sleeping, the cautious ones - they're good, especially in winter, I suppose. But maybe you got mostly the cautious, careful, underestimate yourself genes." I shrugged. "That's a guess. Nobody really knows."

And it may well be crap. But "Explain the evolutionary origin of the common neurotransmitter abnormalities to an intelligent man who left school at fifteen, you have thirty seconds, your time starts now"... feel free to give it a go.

He nodded. "Because my daughter's got it," he said. "She's eight, beautiful little kid. Love her to death. And they reckon you can't tell if kids have deprssion - I can tell. This look she gets on her face - my dad had it, I've got it, she's got it. Goes off by herself sometimes, won't talk, won't even play with her friends. Sleeps a lot when she can. Same as my dad, same as me. I watch her some times, it's like..."

His voice trailed off. I didn't know what to say, but I think he knew there was nothing I could say. You do what you can, you can do a lot, but the child is not a blank slate. Before you tell them you love them, and that they are beautiful, some things are written in the blood and bone.

So, Mr Stryker went on his way, and I looked at the medical student and she at me and we shrugged. He was better than he had been.

Anyway. Something I've been delaying talking about. Look away now.

And the next patient was Rosemary Hawthorne. I picked up the notes and for some reason said, "Maybe I'll take this one."

The medical student nodded.

And I called Rosemary in, and she came and sat down, and it all started.

Not going good, she said. A lot of worries. The trial, some pretty heavy charges. And trouble with Ray, he was out of prison and there was trouble there. And mother's day, and nothing from the kids, not a word, and her thirty seventh birthday, you know, like that Lucy Jordan woman, and nothing then either. Soon her daughter's sixteenth, and she hadn't heard from her in three years.

And not sleeping, and not eating, and couldn't concentrate. Nothing worth eating for, if you understood what she was saying. A disappointment to her kids.

A few days weeks ago she'd knocked the kettle over, hot coffee on her belly, a scar just on top of her caesar scar. And it hurt, and that was good, because she deserved that. She deserved pain.

Lying at night next to him, his house down near the train station, thinking about going and lying down on the tracks. She should be dead. It'd be the right thing.

Wanted to pay somebody from around here, she'd wrap herself up in a blanket and let them beat her, crack her back with a pick ax handle, beat her to death if they wanted to. And there were people who would do it for a few hundred bucks, and she mentioned two or three of my clients, and she was right about two of them.

See, here, a year ago, I would have been looking at depression. Enough of the symptoms without even asking. Almost too easy, exam question classic.

"Tell me about the guilt," I said.

And she did. A year ago, when Ray was in prison. He had to bear some of the responsibility for this, leaving her with the child. His only child. And the other three - her three - gone, welfare had taken two a few years back, then the girl, the thirteen year old, she'd hung around a while but it got too much, upped and gone one night.

And there's her, nobody with her, and the kid screaming and crying all bloody night. All night. All night.

What do you do? How do you cope with that? There was nobody around to help her, just her and the kid, eighteen months old then.

She says she doesn't understand the person she became that night. How she hit him. How she took him out of the cot three or four times, beat him almost senseless, put him back. He'd soiled his nappy, she changed him once, and he cried again, so she took the half a golf club she'd been using and beat him again. Metal end sharp. All along his back. Didn't break anything, but kids bones are soft, they say. Bruises, big welts, bleeding everywhere.

She doesn’t even remember how the police got there. But they took her down to the station and fingerprinted her, and everything before they'd even take her to a hospital.

And she sat up, and her voice, which had been soft and low, came back. Since then, just getting by. Stayed off the smack, doing reasonable. But then Ray got out of prison, and now he was taking her money, all her money, mobility allowance, disability allowance, everything all on speed.

She'd been with him, he wouldn't elt her go. She hadn't been home in three weeks, can't go home. Dishes piled up everywhere, phone cut off. And now she'd been missing counselling appointments, not seeing her son (she was allowed two supervised hours a fortnight, Ray was only allowed one), making excuses.

Things closing down, letting go of things.

There was a day in the near future, wouldn't say when, after that she wouldn't be here. She'd make sure of that. Before the trial.

Anyway. I detained her, which I don't like doing, and wrote a two page letter to Florey, and rang them up and got the good psych nurse to see her. Where I was meant to suggest a diagnosis I mentioned major depressive episode (although the DSM IV clearly mentions only inappropriate guilt) in a woman with prominent Axis II traits.

I mentioned borderline (shallow scars on teh inner wrist) and post-traumatic stress disorder (I described her childhood of sexual and physical abuse "in and out of foster homes", the same foster homes to which all four of her children had now gone) and alerted Florey to what looked to be some prominent antisocial personality disorder traits, which are rare in women.

And the psych nurse sat outside with her and the ambulance came and took her away.

And I gave the medical student coffee and a box of tissues, and said we could talk about this now or next week, and she said next week, she had to get to her lecture. And I'm going to ring her consultant and mention the whole vicarious traumatisation thing to her.

What now? Some things you can write when you can't talk about them. You look back on the clinical practice side of it and you can say that you handled it reasonably well, that you didn't say or show anything when she told you about the child, and you can resolve to look up all that vicarious traumatisation stuff yourself.

But this is why we can't have favourites. Because if we treat people we like well, we'll be able to treat people like her badly. Because when you see her you see the golf club whipping through the air and the curled and screaming child.

And in all that we never mentioned methadone, I didn't write her script, and I have no idea how that side of it is going. So once she comes out of Florey, as damaged and damaging as when she went in, she'll have to make an appointment and we'll have to look at that side of things.

There was something I was going to say here, about heirlooms, and epistasis, and echoes, things passed down from the past, but I reckon it's all redundant now. The child is father to the man, they say, and mother to the daughter, and you can see the same dark genes, the same hideous events, passed along all down the line, dead hand to dead hand.

Thanks for listening, and sorry about that.


Perversions of the Heart

Eight years ago I desecrated a corpse.

And that's pretty difficult to follow up on as an opening line, so avoid disappointment and log off now.

Moods been slightly low lately, as is possibly evident from the recent posts, although there are others doing better under far more trying circumstances (if ever FW runs for something over there, she's got my vote). So expect in the near future endless posts where I whine to my many friends about how alone I am and go on about how no-one understands me - sentiments which will typically be embedded in rambling, barely coherent posts of several thousand words.

Alternatively, my crazy "take more of the tablets before you get sick" strategy just might work.

Anyway - as part of this "get Sarah and me to spend more quality time together" thing, we've been retiring earlier to bed and chatting/reading/etc. You will see there are no picture links on the "etc.".

I've been reading a fascinating book about handedness, from which emerges the following:

Firstly, little known medical fact: most people have their hearts sortof on the left hand side of their chest (see, it was a real medical school!).

But not everyone. Every so often - and I met a man with this in medical school -the heart can be on the right, a condition known as dextrocardia. The man I saw in medical school was a globular but otherwise remarkably normal looking Asian, with the resigned air of someone who was examined by fifty or so medical students every single time he came into hospital - which was frequently.

Thing is, I don't know what kind of dextrocardia he had.

He could have had dextrocardia with situs solitus - which means his heart was on the wrong side but everything else was normal. The vast majority of us - all but one in ten thousand - are situs solitus.

Or along with his dextrocardia he could have had situs inversus - where the position of not only the heart, but of every other visceral organ is reversed. Liver on the left instead of the right, pancreas and spleen on the right and so on. Quite odd.

There is also a bag full of leftover conditions called situs ambiguous - things half-way in between. For example, one where everything in the chest is the right way around but everything in the abdomen is the wrong way around and so on.

(There are more ways for things to go wrong than things to go right - Karenina's Rule).

Deeply weird as all this situs stuff is, it is nothing compared to the even rarer conditions called left and right isomerism, which I think fall into that "situs ambiguous" bag. People with these conditions are as symmetrical on the inside as they are on the outside - their left side, for example, may be an exact mirror image of their right.

It is as if instead of a left and right side of the body they have a left and a reflection of the left, or a right and a reflection of the right.

For example - the unfortunate with right isomerism has all the organs that are normally found in the right side of the body - but may be lacking some on the left. The heart is present, but is more central or even right sided and is deformed - seeming to be made of two right sides stuck together. There is a right lung on the right and a mirror image right lung on the left (with three lobes, instead of the usual two on the normal left lung). The spleen, normally present on the left, may be missing entirely. The liver is in the middle, and so on.

And left isomerism is maybe even weirder. The (often seriously deformed) heart is made of two left sides. Both lungs have two lobes, like left lungs. There is no gall bladder, and there are multiple spleens - up to six. And so on.

Now, that has nothing to do with anything, but I reckon it's deeply deeply strange. And it's filled up my posting time, which means corpse desecretion will have to wait until next time - and I might be able to use my opening line again.

Perverted, by the way, means somethign like turned aside from the normal path. Thought it sounded good, and may get an entirely new class of readers here.

Thanks for listening,

Sunday, May 14, 2006

The best doctor in this spiral arm of the galaxy

Bloody hell. Go now and read this.

What can you say?

I know years ago, I had this plan, pretty much worked out, to go work in Namibia. Sere deserts and sand dunes, drought and starvation and the child slave trade and Lutherans.

It was years ago, before medicine, when I was going to be a teacher. I was going to finish everything off, get the qualifications (a biology degree with emphasis in ecology and a teaching qualification) and fly over to Namibia and Do Good. Later the plan changed to preaching, but the idea was the same. I was reading a lot of mysticism then, Meister Eckhardt and the Chuang Tzu, and I was going to give everything, give up everything, empty out like a shell, until there was only the light of God left inside me.

Well, if you look at it honestly, this man did it, and seems to have been able to be less of a prat about it than I would have been, too.


Thanks for listening,


Saturday, May 13, 2006


Rewrote part of the borderline post, btw. Hopefully able to articulate what I'm trying to say.

Very brief post, following on from the previous psych related ones. I have just been alerted that the antidepressant paroxetine (sold over here as Aropax, in the US and UK as Paxil, used as a treatment for major depressive, premenstrual dysphoric seasonal affective and panic disorders)appears to be linked to increased suicidality in young adults.

This is the first antidepressant about which this has been said - it's an unusually courageous doctor who prescribes any of the new anti-depressants for children, now for at least one medication the same could hold for young adults.

The times, they could be a changing. If this keeps up things may well deteriorate to the point where psychological, cognitive and lifestyle (rather than merely pharmacological) treatments for a lot of these problems may have to be considered. It could be the end of five minute "take these tablets and sod off" consults. Capitalist medicine will have to work out if they want to pay for the effects of depression or pay for safe treatments and even pay to look at the causes.

If that happens, of course, it will mean the terrorists have already won.

End thinly disguised rant. If you're on paroxetine, don't panic (especially not if you have been taking paroxetine to treat your panic disorder), but pop around in the next so many days to see your doctor - earlier if you feel unwell, etc. It is a very small effect, an increase in suicide attempts from "hardly any" to "only a smidgin", but presumably it's a good thing to check up on.

Thanks for listening,


Right. Sara much recovered, and transporting cats hither and yon in preparation for tomorrow's catshow.

The other night, out to dinner for Sara's birthday, I sat next to Natalia. She's someone we both used to work with - the "movie-star good looks" ex-emergency registrar, someone who gave up the lure of low pay, frequent abuse and crap hours for... pretty much anything, really. To be honest, not really the public medicine type. A much smarter doctor than me, a vastly better renal physician or neurologist, but maybe not such a stayer in drugs and alcohol, or psych, or emerge.

Anyway, after fleeing Emerge at Florey she did a bit of medical registraring, thought about GP, and is currently doing some emergency shifts - but at Lakeview, one of the biggest private hospitals in the city.

"You should come to Lakeview, it's very, very different", she tells me.

And it is.

Firstly there is the pay, which is approximately twice per hour what she (and I) used to get working at Florey.

Obviously there's the backup - twenty four hour CT, MRI, angioplasty.

Another "plus" from her point of view is there is no psych cover. Lakeview simply does not provide a psychiatric service, and all psychiatric patients are halted at triage and referred down the road to teh Royal.

The proximity of the Royal means there are neurosurgeons around the corner, that kind of thing.

Plus it means that anything really bad - multi-traumas, burns, industrial accidents - go directly there. Do not pass into Lakeview, do not pay eight hundred dollars (or whatever).

Anyway, while attempting to lure me there (seriously, anyone who has a need to be needed should consider being an emergency registrar. I remember a few years back taking Sara into Cabot Public Hospital, the big teaching hospital near where we used to live, with what looked to be a weapons-grade migraine. As the smiling consultant plunged what looked to be a cavalry lance into my wife's wrist, he tried to get me to quit Florey and work there. He raved about the great working hours - nimbly evading mentioning why he was there at three in the morning - and asked for my email address so he could send me out some paperwork) - and all this while my pale and sweating wife sobbed on the bed.

Now where was I ... oh yes, while attempting to lure me to work at Lakeview, Natalia told me about the wonderful medicine I'd be doing there.

"It's cancer," she said. "Cancer, cancer, cancer."

"Great," I said.

"It is hard," she admitted. "I don't know why. It's really exciting medicine, and nice people, and most people are healthy, much better off than at Florey. But I don't know. It's hard."

She paused. "You wouldn't believe the things I've seen. I saw..." and she told me.

Three months back. Twenty nine year old man with lung cancer. School-teacher. Never smoked a cigarette in his life, healthy. Came in with some aching joints, a wrist that ached. A series of investigations, a cascade of not-quite right results, each blood test leading to another, each time another doctor brought in, worried conferences in the corridor.

Diagnosed, eventually, given maybe to Christmas. When Natalia saw the family this time (they were coming in for the chemo, after the cancers had spread to his brain, given him delirium) they were clustered around him, bright eyes shining, happy.

"Professor Jamieson said we'd have till Christmas," said one young woman, "but now he's said we may get to next Easter."

And a few weeks after that, a thirty two year old woman, some kind of lawyer. Advanced ovarian. Very poor prognosis. A lot of ovarian cancer is fairly extensive by the time it's discovered - the symptoms are subtle, the signs easily missed, often brushed aside by a woman who has a lot on her mind, who doesn't have time to get sick. Thirty two, no family history, never pregnant (which increases your risk, apparently), but never really suspected a thing. Natalia was the one who told her.

And last week, an Asian woman, wealthy, slim, pretty, with metastatic melanoma of the lower intestine - they didn't know if it was the primary or the secondary, but by that time there was little point looking, spread to the liver and lung, dead by Christmas. Not Easter, Christmas.

Another trajectory interrupted, a bright object in its upward arc, struck down before apogee.

And the next day, another.

There is something about cancer, something in it that means it retains its ability to horrify when other things no longer do. Even in the molecular biology lectures we had, there seemed something wrong about it, something unclean. It was a disease of health, of growth and vigour and fecundity, something almost too healthy.

It has something of the flushed red face of the fevered child, the sparkling conversation of the tertiary syphilitic, the long awaited weight gain in the old man who has not eaten for so long - but it's not appetite, it's heart failure. Things that should bode well that are the signs of something terminal. Growth, abuindance, vigour - these things should mean well, but they do not.

Having cancer seemed different to having, say, pneumonia, or kidney failure. Sometimes the cancer seemed the living thing and us the weak, as if, in the end, it was us who failed the cancer. It grows and consumes and waxes, it is us who cannot keep up. Us who sleep and starve while it busily gorges itself. It outgrows us.

I remember hearing - and I don't know that it's true - that cancer is a necessary consequence of life. If cells are to continue to live, they must divide, and if they divide long enough, they will make mistakes. There will be a miscalculation, and a certain number of those mistakes will lead to cancer.

Some fine thread of DNA will be drawn into the wrong cell at mitosis, the genetic material will be unequally distributed. One daughter nucleus will end up with the wrong instructions. Will know how to live but will quite literally not know how to die.

If this is true (and I don't know now, five years later, if it was a memory or an imagining or a dream), by the time you are sixty, or seventy, or eighty, you may have enough microcancers within you (bone, skin, fat, nerve) to make another body.

Tiny islands of malignancy that never managed to expand beyond a pinhead size, cells that learnt the trick of doubling and doubling and doubling their numbers, swelled rapidly... but never managed to work out how to divert blood their way to feed themselves.

They remain as buds of malignancy in bone and marrow and gut. They are buds that do not blossom. Unfulfilled promises, impotent, whispered threats.

I think that was what was knocking Natalia around. FIrst, it was cancer: cancer, cancer, cancer.

But also it was the kind of person she saw die. These people, she was saying, the people who were getting sick and getting chemo and dying... they were like us.

"Good people," she said. "Hard working people." She didn't say the next bit, but I could see her holding the words behind her dark red lips. People who were doing something, working, studying, making successes of themselves. Doing the right thing, doing all the right things. Well-spoken lawyers, slim schoolteachers with devoted fiances, bank managers and their families.

People like us.

That wasn't the case at Florey or psych or drugs and alcohol - or not so obviously.

It's easy to imagine the people at Florey are not like us. They are grotesquely fat, or poor, or tattooed, or smoke cigarettes that they roll with one hand. They come in, drunk and beaten after a fight at three in the morning, when all decent folk are abed, and they go back to teh men who beat them. They curse, and spit, and say "f" instead of "th".

In drugs and alcohol they have done things that we would not imagine ourselves doing - injecting into the veins beneath the tongue, twenty five dollar head jobs (half a cap of heroin), in and out of prison.

And in psych - well, psych is predicated on the existence of a fundamental difference between the healthy and the well. There is a reason early psychiatrists used to call themselves alienists.

But not at Lakeview, not with all the cancer. At Lakeview the careless observer, presented with a mingled crowd of doctors and patients (naked, say, but allowed to speak) might not even be able to tell them apart. There was an unsettling intimacy about what Natalia saw that you don't see as easily at Florey.

At Lakeview Natalia was seeing people like us getting sick. People doing all the right stuff and yet not being protected. Ending up the subject of whispered conferences in corridors, the treatments that don't work, the chemo and the radiation and the spread to the brain. Dying.

We are all standing huddled together, Natalia was saying, and someone is shooting bullets into the crowd.

Anyway. The conversation moved on. She wasn't going to do this for long, not really. There was other stuff. GP, renal - maybe something involving research. Something that gave her time and money, space to be with her family. Do the stuff important to her. Because, and she did actually say this, you never know. You have to do this stuff while you can. Because you never know.

Anyway, off for a father-son bonding thing, down the pub, drinking and watching the football. Shall write again soon.

Thanks for listening,


Midnight, and Sarah, overtired and not one hundred percent well, is asleep in the next room under a geological stratum of blankets. I have fed cats, washed dishes with ninja-like stealth and and devoured any and all leftovers.

So - the promised writing on borderline personality disorder - or BPD, as it is known to its very few friends.

I've been thinking about some of my patients, and trying to understand what's going on with them, what happens to the eighteen year old on heroin to turn them into the forty year old on the methadone programme.

How they change, how things gradually shift inside their heads, settle, calm down - or don't.

I've been trying to work out what's going on in their heads, and what's gone on in mine, and try to understand a bit more of both.

This DSM IV I keep talking about, the Diagnostic and Statistical Manual of Mental Illnesses. It's one of the two or three books that has basically changed medicine. It's fundamental to psychiatry, and I know of nothing comparable that exists for, say, emergency medicine, or renal. Nobody would think to publish a psychiatry paper, or run a trial, or even write up a patient without referring to the criteria in the DSM IV. Medical students and psych interns learn it by rote, and consult our good book as frequently and as diligently as any other priest or friar or exorcist.

But there are problems with... if not the DSM IV, then the DSM IV how it is used, psychiatry 'as she is spoke' by the (usually) junior (probably) undertrained (generally) overworked med reg or emerge intern or psych RMO. These are the people who have the greatest amount of contact with the unwell patient.

(If you suddenly realise what is going on, and the pivotal part the crab people of Venus have in recent events at the highest level, these are the doctors who will be seeing you, signing the forms for the security guards to restrain you and sticking the needle of haloperidol into one anterior thigh and the clonazepam into the other).

One of my problems with the use of the DSM IV as far as I can see, is that it is a book of definitions: the definition of schiozophrenia is this, the definition of autistic disorder is this.

This necessarily involves a series of inclusions or exclusions, binary decisions. Someone either 'suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her', or they do not.

There is no room in the DSM IV for "well, sometimes, kinda, maybe". You're either in or you're out. Fulfill the criteria or don't. Sick or healthy.

(Again, the parallels with the Pentateuch are eerie. A house afflicted with mildew either has or has not been cleansed, a clay pot into which a snake has fallen is not clean, but is unclean, and must be shattered).

See, the problem is, that kind of stuff, the basic medical school stuff, is practically useless in the methadone clinic. At the clinic you get to see that whole slow change a lot of them go through, the alteration over twenty years that you can see. The gradual unravelling of a tightly wound spring, the scouring smooth of a rock in a river, that kind of thing. Fixed diagnostic criteria are of limited use.

I think what I'm trying to say is I know people are more complicated than that, and I've had to change some of my ideas. I've realised that either my understanding of psychiatry is actually pretty close to nothing... or I've realised I've been using a lot of the stuff I was taught in medical school in a stupid and lazy way.

Anyway. Examples.

In DSM IV borderline and bipolar are two completely different diseases.

Bipolar is an Axis I disease - thought of by non-psychiatrists as the real mental illnesses. It responds gratifyingly to medications. It makes people spectacularly unwell - psychosis frequenly appears at either end of the spectrum, as I know well.

Bipolar is up there with heavyweights like schizophrenia and major depressive disorder. It has kudos, mana, a bit of cred. There is a glamour attached to it.

Borderline, on the other hand, is an Axis II disease, lumped in in the DSM IV with the psychopaths, the drama queens (histrionic personality disorder), the weirdoes (schizotypal) and so on (and, for some unexplained reason, mental retardation and autism). These are the disorders seen as milder, less obviously disabling than the full-blown psychoses.

There is an air of therapist helplessness about the axis II disorders - an aura of nihilism, a feeling of things that can't be fixed. Medications, at least until recently, were seen as useless. Psychological therapies involved much effort for little success, and were associated with high levels of doctor burnout.

Psych patients in the ED, if they are lucky, are seen either real psych cases (axis I) or as manipulative and malevolent trespassers (axis II). Real patients get admitted, fake ones get sent back home. Distressingly, both classes kill themselves at unacceptably high rates, but no system is perfect.

If psych patients in the ED are unlucky, they're all lumped together as psych and ranked slightly below the anal pains and the vomit-crusted alcoholics in terms of anticipated doctor satisfaction, and they wait in the waiting room for hours and hours and hours, while the crab people from Venus whispter in their ears.

Anyway, I've worked out lately that my earlier way of looking at things was crap. I've been returning more to the biopsychosocial model we learnt in first year. This sees mental (and other) illnesses as the product of biological, psychological and social factors or stressors.

The diseases wax and wane with the advancing and retreating of those stressors. They change over time, they change with what's going on in your life, how you think, what else is going on in your body.

This means, for a start, that constellations of symptoms which may simplistically be explained away as a disorder (major depressive disorder, brief psychotic episode) can be looked at as products of what's going on in your mind and your life, as much as your biochemistry. That if you're not eating and not sleeping and you've made a noose in the garage, then maybe there's a reson why.

Lately what I'm thinking is happening is that certain personalities, under certain pressures, produce certain mental illnesses.

People with anxious temperaments may develop anxiety disorders.

People who were always a bit odd - rigid, guarded, a bit stand-offish - may develop the schizotypal illnesses.

And borderline - the personality disorder that a lot of my patients have been saddled with? What do they get, what do they tend to grade into?

Here, paraphrased, is what DSM IV says.

People with borderline personality disorder, which usually manifests in early adulthood, have intense, unstable relationships, often marked by self-sabotage.

They may alternately idealise or completely devalue the same person.

They have extreme, often startlingly rapid mood swings.

They make frantic efforts to avoid real or imagined abandonment... sometimes to the extent of self harm.

They may damage themselves or put themselves at risk of harm (this can range from inappropriate spending through promiscuous sex to bingeing on crystal meth).

They have an unstable "sense of self" - they may morph from a helpless cripple in need of rescue to an avenging angel setting right past wrongs in a few minutes.

They feel, all the time, empty.

Now that's not me. I don't have the intense, unstable relationships. I don't cut myself. I avoid putting myself at risk of harm - I wear a seatbelt at the dinner table and am a coward from a long and successful line of cowards*.

But when things are bad, this stuff comes out.

I have a paralysing fear of abandonment, a disabling terror that I can't really explain in a way that will get the intensity of feeling across. When I 'am abandoned', when a relationship breaks up, there is always that part of me that will do anything, anything, to show how I can't do without the person who is leaving me. Lacerate myself so they have to bind my wounds, show them how their leaving makes me feel. I do it with words, instead of razor blades, so in that sense I don't 'act' on it, but it's there.

I have, at times, that rapidly fluctuating sense of self. There is some anxiety, some unsteadyness and formlessness inside me that has only recently stabilised.

The thing about the emptiness - that explains a lot about what I do. The noise and light of the ED, the emotional turmoil of psych and drugs and alcohol. Even at home at night, I fill the silence and the dark with writing.

I am not saying I have borderline personality disorder. I don't, and in this fact the DSM IV reassures me. I do not fit inside the circle it draws around the various types of unwell. But like a lot of people I have a personality that becomes disordered under pressure, that for a moment or a month may fall inside the criteria. For me, it's borderline. For others I know, it's anxious, or antisocial, or dependent.

The DSM IV separates clean from unclean, sinners from sinless, but all have sinned, all have fallen short of the Glory of God.

Romans 3:23. Always found that passage very easy to believe.

Personality's a complex thing, a dynamic, almost creative thing, something that changes over time. People move from disorder to order, health to wellness, as time and tide change them.

You see some twenty year old kid, on speed and smack, and they're living out of the Good Salvos and in and out of prison.

And then the next client is thirty years older and has a housing trust house and three grandchildren.

You see someone cutting herself up and starting to steal things from shops, then six months later, when her husband is back in prison, she's doing okay. Not wonderful, but okay.

Anyway, there was a point to this when I started typing, but this one's been a hard one to articulate, and I don't reckon I've got it through at all. And anyway - one AM and Sara, who suffers from "Won't Tell Anyone She's Sick Until She's Quite Unwell Disorder", needs her brow felt.

Will try to be less wordy next post.

Thanks for listening,


*On the losing side of every war we've been in for the last hundred years. Beaten by the Bolsheviks in Russian, the Russians in Latvia, the English in Ireland, the Allies in Germany (twice)... If I had any patriotism I'd go overseas and enroll in an enemy army.

Thursday, May 11, 2006

When Good Doctors Go Bad

Hail: Very brief post here, while the recently fed cats and dishwasher purr in the kitchen.

Every so often I scan throught the medical journals. It's a lot less often than it should be but lately my priorities have become warped to include a life with my family and friends, and so I let the journals lie and carry on through the guilt.

Now, I don't know if I've mentioned this before, but medical journals are weird places. Due to this whole "evidence based madicine" thing, where to believe something that hasn't been proved to be true marks you down as a dangerous simpleton, there's a lot of crap research out there, "proving" stuff that everybody already knows.

Sexually Transmissible Diseases More Common in Sexually Promiscuous Populations.

Disabling Stroke Often Associated with Depression in Elderly, New Study Shows.

Physician Expertise Improves Outcome of Carotid Artery Stenting (i.e.: If someone's going to make a hole in your groin and use some long wire to shove a little steel tube thing into the big artery that goes straight to your brain, while you're in a very deep coma, it goes better if they know what they're doing).

and my recent favourite:

At-Risk Drinking Linked to Higher Mortality Rate in Older Men (i.e.: doing something risky, like drinking enough to make you get sick or die, means there's more of a risk that something bad's probably gonna happen - like you'll get sick or die. Risky things are... well, risky.).

But they are the minority. There are a lot of articles about stuff I barely understand now - stuff referring to techniques and equipment in fields I never really understood and have little to do with a pulic health service operating in the poorest part of a small, isolated city.

And a lot of the articles are astounding. There is a simple surgical procedure that can help your child get over bedwetting - and it's a lot less alarming than you'd think. It's called a tonsillectomy. Yes, kids who get their tonsils out stop betwetting earlier - maybe something to do with improved sleep, circadian rhythms, that kind of thing.

And if you've got a patent foramen ovale (and if not, they are probably available on ebay), it could be behind your headaches. Apparently people who have a hole in the heart, (a hole in the wall between the left and right sides of the heart), and you get it closed, it can stop migraines. Having said that, I'd guess most bad headaches aren't migraines and most people with migraines probably won't benefit from heart surgery, but it's still "gee whiz" interesting.

And tucked among these are the truly alarming ones. Black people (in the US) respond less well to hepatitis C treatment - presumably for genetic reasons, although I haven't read the paper, and these studies have to be damn well designed to remove any confounding factors. The alarming part of that is hepatitis C is very common amongst people who inject drugs, and those people are likely to be poor, and in the US being poor means you run a higher than otherwise risk of also being black. So the people who most need the therapy are the people who are likely to respond least well.

Also on the fear front: Cognitive Impairment in Older Physicians May Be Widespread. There is an interesting article about this to which I shall try to link.

If it didn't work, the fascinating part is how the authors compare the response of colleagues to the cognitively impaired (otherwise known as demented or dementing) doctor to the response to the mentally ill or drug dependent doctor. The model with the mentally ill or drug dependent doctor is as follows:

People recognize the problem
People confront the physician
The physician acknowledges that there is a problem.
The physician seeks treatment through various sorts of programs
The physician is successfully treated (in many circumstances)
The physician is certified to return to work with some kind of ongoing monitoring.

Obviously, there's a lot that can go wrong at either step, which accounts for a lot of the terrifyingly drug dependent and/or evidently mentally ill doctors I have worked with, but at least it's a model. There isn't a formal model for telling someone, often a very senior colleague, that s/he's not able to do it anymore. And the last half of the equation, the whole treatment/improvement/return thing... in a lot of causes of dementia, the treatment is minimally effective and the prognosis remains unspeakably poor.


And for the last article, something remarkable published in JAMA. White, middle aged, British people smoke more, are more overweight and spend less on their health than equivalent Americans. So why are they so much healthier?

Obviously, we know it's not the tattered remnants of the welfare state, that'd be both subversive and ridiculous. Must be something to do with watching cricket.

Anyway, interesting stuff.


Sunday, May 07, 2006

The football

The following must be read in a variety of tones, and should probably only be read by expatriates.

(Restrained, almost diffident tone):
Several hours ago, two groups of young men struck, kicked and punched a small inflated bladder around on the grass. At the end of the allotted time, it was apparent that the group of young men of whom I have previously spoken quite highly had done this with marginally superior dexterity, fortitude or aplomb, and had to all intents and purposes, "won".

What does this mean?

(Trumpeting tone): It means that for the next few months I am one of the chosen!

(Exultant, monamaniacal tone): I am of divine blood, the lineage of kings, I am an emissary from a higher race! A man who walks while others much cringe! Others, those who in their folly supported the team of wealth, power and priveledge, must do obesiance as I am carried past! For we are the true men, and others of our city are but boys!

(Exultant, monamaniacal English country preacher tone): Yea (and verily). And it came to pass that we did see the West Coast in their pride, waxing* in their arrogance.

And we didst see the men and women of their tribe drinking chardonnay, while the people of Fremantle drank beer or cheap wine like decent people who have to work for a living because their father didn't leave them stock portfolios and investment properties.

And we didst suffer indignities at their hands, with their tales of multiple premierships and sequential Brownlow Medallists and their treasure-rooms groaning with goblets which they in their wickedness had accrued.

And we didst read in the so-called newspapers how we were daily mocked, and we didst see how our mighty warrior Jeff Farmer had been banished for being fleet of foot and admittedly fleeter of temper, and had accidentally and possibly even reflexively given fleeting contact to some thug, helpfully attempting to brush an insect from the villain's ugly face with his fist, last week during the Great Tasmanian Game Robbery. And how he had been given a week's suspension on the eve of the Big Game.

And we didst see in the course of the game, the very game of which I speak, how great Sandilands, our two hundred and eleven centimetre tall camel-human hybrid ruckman, had been viciously struck in the head, fifty metres behind play and out of sight of the umpires, and how he had received a broken jaw, and would be out for six weeks. Plus the pain and the associated emotional trauma and stuff.

And we cried out in our misery, because Longmuir (backup ruckman) was unable to play because of a sore knee sustained a week ago, and while it was not immediately apparent how this could be attributed to the villainy of the West Coast, investigations are proceeding, and will proceed until we can blame that on the bastards too.

But we did not turn aside. We did not falter.

We slew.

We pillaged.

We smote. Yes, on the replay, especially in the second quarter, you can definitely see a bit of smoting going on.

And we triumphed.

Fremantle 12.16 (88)
West Coast 12.11 (83)

(Hoarse voice):
Bloody hell. I am having intravenous strepsils and getting two artificial knees put in tomorrow. I think in that last ten minutes when the lead changed twice, before we goaled in the last forty seconds... I think I got actual angina. There's a writeup that will interest only the expatriates here that gives some hint of the feelings this whole thing generates.

Anyway. That's pretty much it.

Responses to comments and some posts of actual substance to resume possibly tonight.

Thanks for listening


*full leg, probably

Saturday, May 06, 2006

The Haunted

Still trying to put the borderline post into English. In the interim, the haunted.

I saw a woman yesterday who is one of our more successful clients. No heroin for ten years - hasn't known any users for five. She has been clean for not only the last six years (the Years of Famine) but also the four years before that (the Years of Plenty - when people talk about it it sounds like that bit from the Book of Daniel*), before the heroin supply in Australia all dried up, back when you could get stuff that "kids of today wouldn't believe". She is one of our truly stable clients - mother, grandmother, works at the school tuckshop, somebody's confidant and advisor and best friend.

Anyway, for the last five or so years she's been on stream C. She picks up her buprenorphine Mondays, Wednesdays and Fridays, before work, and has takeaways the other days. I looked at her dose.

"Point eight milligrams" I said. "So you're one of our big time users."

She laughed. Twelve years ago it was heroin six times a day, six years ago it was a hundred and fifty milligrams of methadone. Now it's two of the smallest tablets of the mildest under her tongue, an almost homeopathic dose.

"Ever feel like reducing off?" I ask. "Forget about us entirely?"

She shook her head, suddenly utterly serious. "Never" she said. "If it works, don't fix it."

Anyway, we chatted about kids and the hassle they were, and I wrote her script, and she went out and the next guy didn't turn up.

And this got me thinking.

I think some of these people are haunted.

What do I mean by haunted? One meaning is the most obvious. I see clients every day who are fleeing from themselves, people haunted by what they were. She was certainly one. I got the feeling with this woman, and she was a lovely woman, that she could see in every reflective surface, every window pane and mirror, every spoon, the gaunt and ragged junkie she used to be.

One part of helping people like her, I feel, is getting her to accept some of the credit for what she has done. It's surprising (until you think about it) how few of my clients give themselves credit for what they have done. For a lot of them the consultations are all about what a shit parent they've been, how smack has ruined everything, how they've fucked everything up. You have to almost grab them - metaphorically speaking - and say "Jesus Christ woman, you beat smack! You've done one of the hardest things someone can do! Whether you did it for your kids or yourself or whatever, you beat heroin! I want you to get up tomorrow morning and stand naked in front of the mirror and scream fifty times "I am a frickin legend!"

Perhaps not. But you want to send her home with more than she came in with, with more than just the sensation of a temporary rest before resuming her eternal flight.

But I think for some of these people there is another way of being haunted. I'm not sure I can explain this well. I think that instead of the traditional haunting, being haunted something there that should not be, some of the people I see have the reverse.

I think as much as by any spectral presence, you can be haunted by an absence.

I think there are people who sit in the chair across from me who have some kind of absence, a chasm where we have a bridge, a hole within the heart.

When I started doing theology, years ago, the confession and absolution was one of the most powerful parts of the liturgy, and it is something that even now retains the power to move me, long after I found myself unable to mouth the Creed.

From the way I saw it (and I am aware that this departs somewhat from the orthodox understanding) the pastor did not and could not forgive sins. But he could and did tell us that we were forgiven. Implicit in how I saw an eternal God then was the idea that then we must have always been forgiven, that we were always forgiven, that the thing that stopped us and held us back was not how good or bad we were, but how long and how hard we struggled against the forgiveness. As for "good" and "evil", good or bad behaviour, it was forgiveness that made us good, rather than goodness that earnt us forgiveness.

That's clumsy and couched in language that many of my readers will find repellant, but that's where some of my clients seem to have a problem. They cannot forgive themselves. They cannot be whole, the have something lacking, something missing. As real an absence as a deletion on a chromosome, or a leaflet on the heart valve that did not form, a bone that never grew, they lack something necessary for a full and real life.

And they can't get better until they get it. And some of them never will.

Anyhow, that was the feeling I got with our successful grandmother. She wasn't ready to give up the buprenorphine, maybe never would be. Even though on a biochemical level it was doing close to nothing for her, on an emotional level she still needed it. It was a surety, a lifeline, some kind of way that she could avoid taking the next step.

Because while she's on the bup she can see herself as a bad person who's getting treatment. If she wasn't on the bup she'd have choose: to be either a bad person who wasn't getting treatment - and she knew she was better than that - or, more terrifyingly, a good person. And she wasn't ready for that.

Anyhow. In the end, medicine is about what works. If her meds work for her, no problems. It certainly makes a nice change seeing her in between the man drinking five litres of wine a day (every day: each week he goes shopping and loads seven five litre casks of wine into his trolley: Monday, Tuesday, Wednesday...) and the woman injecting amphetamines into the veins beneath her tongue.

Anyway, off for Sara's birthday - oysters and fine friends, one of whom has been "let out" for this very occasion, as long as she goes back and has more ECT tomorrow.

Thanks for listening,

*Not the Daniel who is getting married, to whom loud huzzahs must be directed. Damn good night/celebratory announcement/weird cocktail thing last night.

PS: Geoffrey Chaucer has a blog - and it's damn fine.

Also, it's been a big week in football over here, full of controvery, treachery and intrigue, and as we speak we are playing the arch enemy, the West Coast Eagles. Depending on the result, I may or may not be held responsible for the content of the next post.


Friday, May 05, 2006

Premature Diagnostic... problems.

Sexual references henceforth.

Been a bit frantic here lately, Sarah is across the Nullabor and I and the niece (who in this blog wants to go under the name of Ginger, I kid you not), have been slaves of the cats.

However, I have been reading, in my spare time between talking to heroin addicts and giving presentations on urine testing, about borderline personality disorder (BPD). Borderline and bipolar disorder, and where one relates to the other, and so on.

Bipolar, by the way, is BPAD, or bipolar affective disorder. Seasonal affective disorder, where you get deeply depressed at certain times of the year, is appropriately known as SAD. I think the DSM III used to have a class of major affective disorders (bipolar, unipolar, etc.) that rejoiced in the acronym MAD.

If you are an amateur when it comes to psychiatry (and I definitely am) the DSM IV is a dangerous book. You can, if you are not careful, end up using it as a ”spotters guide to the mental illnesses”. You see someone and you check if they have five of the following symptoms from this list, if the symptoms have been there for more than the minimum required time and so on … and pretty soon you can announce “Aha. This person has Insert Disorder Here. Take these tablets. My work is done.”

I don't know if Premature Diagnostic Ejaculation is a recognised psychiatric disorder, but it should be. You see it happen all the time with interns in the ED. The hassled junior doctor goes into the room, gets straight into it, squicks out a diagnosis after a few minutes and leaves, satisfied, probably wrong and utterly unaware that this has not been a mutually satisfying experience.

Obviously that’s a simplification, and completely unlike most people’s experience of presenting to a doctor with mental distress, but it’s not entirely untrue. Medicine is an applied science, it works via quantities and measurable things, and it works best if it is given discrete, anatomized subjects to deal with. This person fits the diagnostic criteria of such and such, the evidence suggests we treat that with so and so, move on. It’s easy, especially when the clinician is pushed for time, or has to get the patient out of there quickly, or never really feel comfortable with psych patients, to slip into flowcharts, protocols, either-or judgements.

I should point out that even doctors know that every person is an individual, and thus every brain and mind and mental illness is an individual. But technology isn’t about what is true, it’s about what works. Every cow is an individual, too, but the meat processor still works. And so do mood stabilizers, and anti-psychotics, and (to a lesser extent) anti-depressants.

But I can't helpo feeing that that is a problem with the use of the DSM IV. It's meant to be a tool so that when doctor A says "this guy has schizophrenia", then Dr B knows what she's talking about. But the truth is that there is no rigid, crystalline barrier between normal and abnormal, healthy and unwell, and that most people move back and forth and in and out of the diagnostic criteria with little regard for the intellectual convenience of the junior doctor.

Anyway, seeking to keep these brief and relatively more frequent. Next post is actually about borderline personality disorder, and how it affects someone close to you.

Thanks for listening,

Tuesday, May 02, 2006


Interesting idea the other day.

Sara and I were sitting outside on the verandah listening for the silence of the countryside. I say listening for, rather than listening to, because there wasn't much of it. From behind us, in the largest cattery, several of the queens were emitting honks and squawks that presumably translated as "hey, big boy" in Oriental catspeak.

Have a look, by the way, at these - oriental cat/Riverland sultana crossbreeds.

And several of our teenaged roosters were crowing in the back yard, hollering lustfully.

The entire air was charged with unrequited lust. Suddenly I had an idea.

"Why don't we get those together -" I said to Sara.

She finished the sentence "and breed griffins!"

We worked out this would work perfectly. We have white shaggy ckickens (the silkies) and white shaggy cats (the Balinese), and together we could make a kind of bantam griffin, with the head of a chicken and the hindquarters of a cat.

They wouldn't be particularly fierce, of course, since it's difficult to be pecked to death by a silkie, or fly far, or eat much, and they would sell like hotcakes. We could both retire immediately, mythological animal barons and billionaires.

Unfortunately, as someone subsequently pointed out, it wouldn't be long until the novelty wore off and then there'd be the usual dumping of unwanted chittens in the bush - leading to an exploding population of feral griffins and the downfall of Western civilisation, which would be bad. And come to think of it, Eastern civilisation wouldn't do that well either.

Anyway. It was funny at the time. Next time more substantial stuff.

The war, on drugs.

And this one carries a warning that I don't think I've ever used before. The following contains descriptions of bodily fluids that some people may find distressing.

Specifically, it concerns my trip to the drug court, and what I learnt therein.

All of SMACHEAD's workers have to attend the drug court at least once. This is, to be honest, political busywork, but SMACHEAD demands so much less busywork than Hogarth House did, that I went along with a glad face (and a fellow worker about whom I feel a grave disturbance in the force - but more later). In the end it was remarkably educational.

The actual court side of it was a bit of a let-down. The judge (a small-statured Asian man in his fifties) seemed to be in a bit of a hurry, muttering verdicts and decisions without taking his eyes from his cheat sheet, and ducking out into the corridor at the slightest opportunity.

I mentioned this to one of the court people (the Deputy Assisstant Undersherriff or something) and she (a big-lipped girl with glasses and tousled hair) spoke out of the side of her mouth to me.

"It's so he can eat some more protein powders. And at lunchtime he goes down the [insert name of local gym] and works out, seven days a week. So Friday and Saturday nights he can dance in [insert name of local gay bar] wearing only a pair of hot pink bicycle shorts."

All rise for the judge indeed.

Apparently this is all true - although one witness puts the bike pants as more of a mauve. Mordor is a small town.

Anyway, the morning was mainly a steady stream of people pleading guilty or not guilty to a variety of things - one lawyer opposed bail being granted to the defendent on the grounds that he had previously skipped bail in all five mainland states of Australia and both Territories... needing only Tasmania to complete the set. Another had completed - and here the judge was forced to refer to his notes "precisely zero out of his allocated three thousand eight hundred and forty three hours of community service".

"Now that's what you look for in an employee" I said to my coworker. "Consistency. Reliability. You don't want to be sitting around at the start of the day wondering whether he'll turn up or not."

The remainder of the day was spent enjoying a few cups of coffee and chatting with one of the sheriff's aides about urine testing. The drug court's approach to urine testing is fundamentally different to ours. Under drug court rules, the client faces strong penalties if they consume any drugs or alcohol. Under our rules, the client gets penalised is s/he doesn't have some kind of drug in his or her urine - if they have no heroin, for example, maybe they don't need us. If they don't have the buprenorphine we prescribe them, then maybe they're selling it and penalties may be applied.

What this means is that clients are under considerable pressure to produce "clean urines" for the drug court. There is thus a thriving black market in clean urine - and presumably local versions of comapanies like this. Urine is snuck into where-ever the testing occurs, sometimes left hidden in the urinal or passed to the patient in a clandestine fashion. People smuggle it into the testing area in balloons, which have been inserted into orifices not normally designed for those purposes, and produce it on demand. Our man in the drug court even described a device consisting of a bulb affixed to a thin, tranparent polyurethane tube, taped distcreetly to the appropriate area and activated by squeezing of the gluteus muscles.

Over time the drug court comes up with better surveilleance protocls and the clients come up with better scams.

It's a war out there.

Anyway, keeping these short. Will be back soon.