Thursday, June 22, 2006

Crossing Over

One funeral and two phone calls from the police "just clearing up loose ends" about patients of mine who have died, and I am feeling a bit "in the midst of life, we are in death"-like.

Consequently, today I did something I wouldn't have thought I'd do a year ago. And today I am finishing the bottle a bottle of cab sav that is impressively packaged, highly recommended but leaves a sour taste in my mouth and probably isn't very good. This is, believe me, the appropriate wine for the occasion.

So, prelude.

I saw Mrs Weber the first time two months ago, one of those cold clear days at the end of spring, where the sky is that empty pale blue and the sun gives bright light but no heat. She had previously been Dr Grizzle's patient, and I wasn't really familiar with her case. She was the ten thirty appointment, but ten o'clock hadn't turned up (he had, it turns out, been detained and admitted to Jack Napier House, the high security forensic psychiatry place in Innsmouth, where the three admission criteria are you must be bad, you must be mad, and you must be dangerous to know).

So it was Mrs Weber sitting on her chair, a woman with eyes the colour of the overcast sky and hair a dirty straw colour, wearing some old kind of woolen coat over a pair of stovepipe jeans and a pair of thin-soled sneakers. I called out her name. She looked up, and I could see she was crying.

I closed the door and went out to the waiting room. Occupational health and safety regulations have since made this an offence, in part because the head of psychiatry in South Australia was shot and killed by a patient a few years back, and partly because we need some kind of industry into which we can put all those people who used to work making ships and so on, so now they make laws to stop other people doing stuff.

Anyway, I came out and sortof crouched down in front of her and asked if she was okay, if she wanted to come back and talk some other time or if she wanted we could talk now, but she gathered up her shopping bags full of stuff and came inside, weeping silently.

I think at one stage I must have asked what was wrong, because what I wrote down for that half hour was an almost biblical catalogue of woes. She was homeless. Her children had been taken from her, as had her grandchildren. She had been raped - again, it was so many times now she'd lost count. The one friend she'd trusted had stolen all her stuff. Hassles from her ex, child protection, her children....

And so on and so on. The notes suggest I asked only minimal questions, partly because she was crying so much she couldn't speak, and I wrote "needs social work consult urgently" and then I went into the room down the hallway and got our beautiful, impeccably groomed, so-good-looking-you-don't-want-to-talk-to-her social worker to see her then and there. And as she was lead from my room I noticed that she was crying if anything more than when she came in.

Anyway. I glimpsed her a few times after that, usually in the morning when the practice was at its busiest. She was more a nursing patient than mine, and I had asked a few times about her and received a roll of the eyes in response.

It emerged that although she was on methadone, the big drug issue was her drinking, and she had to come in every morning to be breathalysed to see if she was sober enough to be given her methadone. Most mornings she wasn't, and would have to come back in the afternoon, or miss a dose.

Two months passed, and Sam the nurse bumped into me in the corridor.

"You've got Sarah Weber tomorrow" he said. "I'm really worried about her."

"What's wrong?" I said.

Well, a hell of a lot, it turned out. She'd been admitted to Florey a few months ago - I rang up and got the discharge summary and sat and read it while my coffee went cold.

"Good God in Heaven" I said. "Good God. She's going to die."

And she was. She had been admitted with seizures - potentially fatal seizures caused by trying to give up alcohol "cold turkey". She'd had blood tests done - I thought guiltily of what I hadn't done the morning she sobbed uncontrollably at me - and the blood tests were horrible. Kidneys that were several decades older than she was, a alcoholic heart that was big and thickly muscled and horribly, horribly weak. Liver function tests that showed her liver corroding inside her belly. A CT of the liver that showed it swollen, lumpy, deformed. Blood that wouldn't clot, because her liver had basically given up making the proteins that stop you bleeding to death when you cut yourself.

I did the maths. Ignore the heart for the time being, because clinically she'd never been in heart failure, same with the kidneys. They were going to go, but they weren't the things that would go first. The big risk, the thing that kills practically everyone on methadone with a crap liver who is still drinking alcohol and also taking unknowable amounts of valium - I scanned through our notes, read the name of her GP, covered my eyes - the thing that killed them was one day they just stopped breathing.

Whether it would be her (very infrequent) heroin, or the cask of wine a day, or the handful of diazepam, or her liver just not coping with the load... it wouldn't matter. You drink your cask along with your methadone, the alcohol stops your liver breaking down the methadone - you basically die of a methadone overdose. But after you've finished drinking, your liver, which is used to dealing with all that alcohol, rips through the methadone, so you get underdosed - maybe you treat that with heroin. Or more alcohol, or diazepam. Again, you die. And that's with a functioning liver - Christ.

And Florey had seen her before. She hadn't told Dr Grizzle this - a year back she'd had hepatic encephalopathy, which means her brain was getting poisoned because her liver wasn't working, not clearing the crap out of her blood. Hepatatic encephalopathy was what my pathology text called "an end stage manifestation of liver disease, often immediately preceding a precipitous decline".

Gods. I sat down with Sam.

"What can be done?" I said.

"What hasn't already been done?" he said. "There's a small army of people trying to look after her, and she won't have any of it. Tells them all to fuck off. And she's drinking more now than five years back."

"She won't see another five years" I said. "She might not see this one out."

"Can anything be done, you know, psychiatry wise?"

I shook my head, tio my shame I had already thought of this. "Not crazy enough to detain. Not brain damaged enough to get a guardianship board ruling. Free to make her own decision."

"Are there any medications?"

"None that work when you don't take them." Depressed, homeless alcoholics have notoriously poor compliance with medication regimes. And she'd been tried on altrexone (three days), acamprosate (one)...

Nice military-sounding word, that, regimes.

Anyway. The conversation went around and around, and I read the notes some more, and I looked at the CT report and shook my head, and I went back and had another cup of coffee (if you have alcoholic cirrhosis, by the way, whip into the coffee - preliminary evidence suggests it may actually help), and I couldn't see a way out.

So, got on the phone to my boss, and then we called her in. We sat her down and we explained our reasons and the rules under which we operate, and her choices, and we let her think about the offer of an admission to hospital for alcohol and valium detox, and maybe a changeover to a medication that was safer in people in her situation.

And we explained our concerns about us prescribing a drug that would quite possibly play a part in killing her in the next few years.

And we reminded her how she'd been able to blow zero on the breathalyzer three years ago, and that was a really positive sign.

And then I told her that unless she was able to come in here and blow zero every single morning we were going to have to reduce her off her methadone - removed the medication that stopped her using heroin.

There was silence for a few moments. She knew that what I was threatening would make her suffer for months, long drawn out weeks of cold turkey, never comfortable, never warm, always sick and shaking and afraid. And the only things she would have to take away the pain - alcohol. Valium. Hammer.

What we were threatening would probably kill her sooner. Maybe we could just ignore the stuff from Florey, keep her on the methadone...

Could you repeat that for the benefit of the members of the jury, Dr Bronze?

Anyway. She said she'd think about it, ask one of her non-existent friends. This time she didn't go on her way crying, it was more a pale face, set and shocked, with something of the uncomprehending about it.

I suspect I know what will happe.

She won't take up our offer of detox. You have to want to stop drinking, and she doesn’t.

She won't be able to blow zero for more than a day or two at a time. Again, what else in her life could be stronger than the urge to forget it?

And she won't be any better off without the methadone. She may have less chance of that just stopping breathing, the "sounds more peaceful than it is" death that she was heading towards before I interfered, the death that could claim her any day now.

But I'd choose that over the slow and unutterably horrible death of liver failure, the skin the bright, soft yellow of a child's raincoat, the confusion, the belly swelling and taut, the speckled bruising wherever you have been touched. The end of many alcoholics. Jack may live here, but he dies in hospital.

Anyway. I reckon she'll be off our books in two or three months. The drugs and alcohol version of the transfer TDT - transfer "to die there". The important thing, it appears, is that when she dies, soon (later than if we'd kept with the methadone, I'll admit that), the coroner can look at what happened and check up the list of agencies who were involved in this death and see Drugs and Alcohol's name not there. He or she can see we did the sensible thing.

And the thing is, I may have done the wrong thing by my patient, the one I am sworn to protect, but I did the right thing by my medical career, and by the organization, and by our risk management people. And if you look at things from a utilitarianist point of view, greatest good for the greatest number, there's a shitload of them and only one of her. That's a lot of good I've done... for our organization.

Our organization. May they be beaten with an empty bottle to within an inch of their life, and if not, may the shades of cowardly doctors and callous lawyers squat upon their chests anight like nightmares.

I can, if required, repeat that for the benefit of the members of the jury. And I know there's nothing better that could have been done, that it's a choice between the lesser of two evils, and here I am blubbering like a boy about it, but, whatever. Luther said Credu ut intelligam - I understand because I believe. Drunk and late at night, I can only do one of them at a time. I can understand I did the right thing, but there's not a lot of beleiving.

Anyway. Off to bed. Sorry about the self-pity overdose. As I said, I would feel less bad about this if I had not had the police ring me twice in two days about different patients who died - none of which I actually killed, but still, it is not cheering.

Thanks for listening,



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