Monday, June 19, 2006

A day of marked crapness

Dropped in on Florey today. Florey, for those who can remember, is the ED where I am allegedly doing my Emergency training. Hadn't really set foot in there for months, but I stopped in there on the way home, went in there, had a wonder around. No real reason.

Or none that I could have explained without embarrassment.

See, the work at SMACHEAD (I did come up with a better acronym, and you reckon I can remember it?) was never going to be full time. It was a stopgap, a way to get some decent nine to five hours, learn some skills, some better (almost twice as good) money, that kind of stuff.

But I don't know that it was something I could see myself doing long term.

The reasons for this were several.

Firstly, I am too lazy and stupid not to be in a training programme. I forget the old stuff and I can't be arsed learning the new stuff. I don't keep up with new developments in medicine anything like as much as I should - although today I started screening my male methadone clients for testosterone deficiency, because methadone, along with making you fat, miserable, weak, toothless and apathetic, makes you sexless. Methadone is a truly crap drug - unfortunately it's the least crap one we have that we are allowed to prescribe that does what it does.

Seriously, I'm forgetting stuff at an alarming rate (is it one kidney, two livers, or the other way around?). The half-life of un-used knowledge in my head seems to be about three days. Sarah can remember all of her one hundred and forty client's names, most of their doses and a fair few of their addresses - she says that if you write something down three times it basically sticks in your memory.

I suspect sometimes that the reason she and I had no children is because we have different numbers of chromosomes. There is something like a species gap between us, in some of the stuff she can do with her brain.

Second, I am a bit frustrated with the drugs and alcohol job. It sounds juvenile, but with the D&A job a lot of the time you are not looking for success, you are checking for failure. You ask how long since the patient slipped up and used heroin, you check the urines to check who's lying to you, you do the physical exam to see if the drinking has screwed up the nerves in their legs so they maybe shouldn't drive. Success - and the vast majority of patients are successes - success seems to be defined by an absence of failure.

Maybe what doctors find so unsatisfying is that it's not that nobody is healed, maybe it's that they heal themselves over time rather than you healing them, and that's much less satisfying to the medical ego than sticking a tube in someone's chest and getting them to breathe again. In the D&A job we don't save anybody - and maybe you do't become a doctor unless you've got that messiah requirement.

Anyhow. Some of this off-pissedness is doubtless temporary - I am still oddly shaken up by that Mr Gouger, whose funeral is today. He seems to have just vanished from our care, no-one speaks of him. The whole thing seems - I don't know. Unfinished, undone. Like there was still something we could do, but we are not.

Plus he was the closest I have come to missing a diagnosis of suicidality - I saw him, a number of months later (about two, I believe) he was dead. All of my other psych patients who have died (see below) there has usually been a period of months intervening, and I have always referred them, either voluntarily or involuntarily, to a psychiatrist. And psych is meant to be what I'm good at.

Although I did speak once to a psych RMO, a young blonde Englishwoman who was woking her way around Australia and showed me her photos of skindiving on the Great Barrier Reef and clambering through rainforests - she had had a worse time. The very first patient, the first patient she sent home froma psych ward killed himself three hours later. Never worked in psych again.

Christ this is morbid. But wait, there's more...

Yesterday I got the most humiliating phone call of the last several years. The police rang me up asking me about a psychiatric patient of mine who had died in 2002. They geve a name and all I could remember was that the guy hadn't used his real name (which was a collection of eastern european consonants), but had called himself "Tim" or something. The date of birth suggested a man in his early forties - which didn't narrow it down.

Anyway, this patient had been seen by me in 2002, detained, sent home or somewhere else, and died soon afterwards.

"Was this the guy who threw himself off the sixth floor of the remand centre the next day?" I said.

"No""said the constable.

"Sorry, sorry. The one who hanged himself in Mauro?"

"No" said the police officer. A tone of wonderment had crept into his voice.

"Terribly sorry. The one who got sent home and then jumped off the Slythering Bridge?"

There was a pause while the constable noted down my name and resolved never ever to see me.

"No doctor, this is the one who died at Shipman because he lay down to sleep- "

"Without his mask, asphyxiated in his sleep. Right, right, sorry. How can I help you?"

Well, howabout I fax you a list of my family and friends and you agree never to see them?

Plus yesterday one of our more troublesome (i.e.: brains of a spoon) clients had to take her three year old child into Florey because he had gotten into her stash of diazepam and oxazepam and eaten some, and was so drowsy he was not breathing. And he's a good kid, and she's a decent woman, but seriously too stupid to have her own children.

Apparently the contempt - from doctors, nurses, ambos - was radiating around the place when they brought her in. The junky mum who'd poisoned her kid. But Child Protection are already involved, so this should pretty much finalise things. So that's the only thing keeping her on the straightish and narrowish gone - but hopefully he's safer.

And I had to tell this other guy yesterday if he didn't stop doctor-shopping for valium I was going to have to cut his methadone, because people on methadone who take handfuls of valium and have Hep C and cirrhosis and drink die at a remarkable rate, and in the words of my boss, "if he was going to kill himself, we didn't want it on our CV".

And I hate, hate, hate cutting down on people's methadone as a punsihment. Thank Christ they're not diabetics - "Well, mate, you knew the rules and you broke them - no insulin for you for a few day"."

So - yesterday I drifted in to Florey. It was a busyish afternoon, it's winter, and Dr Van was on, one of the two or three best doctors I've worked with, used to tutor us in the exam prep, the exam where I missed out by under five percent on passing. And I asked him how Florey was going, and how the exam prep for the other registrars was going, and if is was a bad winter (looking that way), and everyone - doctors, nurses, admin staff - said hello, and I asked about doing one shift a fortnight, just getting back into practice. Looking forward to next January, when I can go back to the hospital at least half time.

Anyway, someone waiting outside to lie to me, and hear me lie to him. Better get to it.

Thanks for listening,


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