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.



Anonymous Camilla said...

Sometimes I just don't know what to say to the stories you tell. I don't mean that in a bad way, it's just that they leave me lost for words. And lost for actions too. What can anyone do in the face of such misery?

12:58 AM  
Anonymous sickgirl said...

Wow, that just left me breathless. Excellent writing as usual. I can always visualize whenever I read your entries.

By the way, my husband finally starts methadone this coming Friday so I am thrilled to bits! Also the jl server has been down these past few days so no one has been able to access any of the journals found there.

Peace, love and happiness...


4:16 AM  
Blogger Benedict 16th said...

Damn I wish I could write as well as you...
Like one of my specials who previously (before I started there) had run around the surgery with a toy gun (the
staff didn't know at the time that it was a toy)...
The one time I have ever sacked a patient, I had real counter transference issues, and I still believe
he was so solidly antisocial that there was no regret, pure calculations...

I hope your god appreciates what you do....


11:38 PM  

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