Assault on a mynah

Very brief fragment of a conversation I just had with a patient.

"Anyway, I'd better get on with this" I said to the enthusiastic, slim Greek woman - enthusiastic, slim and alarmingly off her face on methamphetamines. She had just been released from Britney-Glasson, Mordor's maximum security women's prison, and had spent the first fifteen minutes of her medical assessment chatting about her cellmates - the blueberry bush murderers (the two sisters who murdered a bisexual Malaysian jockey and hid his remains under a blueberry bush*), the methadone bathtub baptist**, the woman who killed her husband (a deeply unpleasant man even by Mordorian standards) and got sent to prison instead of getting her statue put up in the city square.

"It says here you've got some kind of blood disease" I butted in.

"Oh yeah" she said. "That white blood cell thing. Or red."

"Thalassaemia?" I guessed.

"That's the one."

"Did they say which type?" From memory there are several - different parts of the various hemoglobin proteins are deformed, you can get normal haemoglobin genes from one parent and bad ones from another and so on.

"Don't think so."

Ëver been sick with it? like, needed a blood transfusion or anything?"

"Not a day."

"Probably thalassaemia minor then."

She nodded. "That's the one. That bird one. Thalassemia mynah."

Well, I thought that was funny, squillions of little red blood cells, each with a small passerine passenger inside. A damn fine idea. Like Sarah's recent mention of the great feathered snack of the Aztecs, Pretzlcoatl.

Thanks anyhow,

John

* Seriously, only the names have been changed, not the level of weirdness.

** Full immersion. Actually, full and quite prolonged immersion.

The occultation of Spica

Hail
Selected smidgins of news today, Sarah is back and we are relaxing together.

Later I will be replying to comments today from all you wonderful people. As I said before, thanks for the various and numerous well-wishes, and I will ensure they are passed on to Stewart and family. At time of writing his arm and leg are almost back to normal, they feel heavy but he has normal tone, power, sensation, etc. A full recovery is anticipated.

Another (temporary) weird effect, and one which has yet to be fully explained (to me, at least) is that the post-seizure paralysis paralysed his left side, but also affected his handwriting. His handwriting is normally "copperplate", and after the "stroke" it became diminished: much smaller, and "incomplete". This would not be so surprising, except the paralysis affected the left side, and Stewart is right handed, and thus far that was the only complex function disturbed.

That is, it sounds like, a kind of dyspraxia, a loss of knowledge of how to do things. People with dyspraxia forget, or become very bad at, specific tasks - button ing clothes, hammering nails, etc. Sometimes this can take strange forms - the man who could mime eating, but when shown a dinner setting with a pencil, a toothbrush and a fork, was unable to choose which one to use, the woman who knew how to hammer nails but when asked to demonstrate with the hammer supplied tried to use her fist instead.

People with dysgraphia or agraphia may be able to spell but not write, or write but not read what they have written, or (and this last I have only heard about) develop a burning pain in the forearm always and only when trying to write.

Eddington's law applies also to the brain - it is stranger than we can imagine.

Anyway, what else's going on? Tonight I came home and glanced up at the moon, and saw a small, bright star in the western sky, just on the edge of the Moon. I pointed it out to my niece. "Look," I said, "an occultation."

And it was - the local observatory site says the star Spica was going to be eclipsed by the Moon. We didn't get to see it, apparently the full occultation was only visible further east - but it was still something to disturb your equilibrium. Gazing up and out at something burning bright enough to be seen ten trillion kilometres away, two hundred and sixty years into the past.

I remember as a child imaginging aliens, creatures with intellects vast and cool but probably sympathetic, regarding us through telescopes and wondering at us, knowing that whatever they saw was thousands or millions of years in the past. An alien with a particularly powerful telescope, I imagined, would point his/her/squoz's uberscope at a patch of sky, twiddle a knob and a familiar blue green planet would leap into view - but one inhabited by dinosaurs, or tiny horses with toes, or painted Neanderthals worshipping at a cave-bear altar.

And knowing that there was no way, no way at all, of telling what was happening now. The moon I saw tonight could have ruptured two seconds ago - I would not know, because the light could not reach us, and light was faster than anything. The sun could disappear - we would not know for eight minutes. Spica, the star almost occulted by the moon, could have gone nova, or collapsed into a black hole, or been picked up and put in the pocket of whatever unimaginable things strode about out there in space - and we wouldn't know for another two hundred and sixty years.

By the way - what we see as Spica is actually two blue dwarf stars in a binary - but I feel my geek detector going off, so better stop.

Anyway, various newses. I feel I have settled into things at Southern enough to start making a few changes. I have been cutting back on some people's medications (I remember asking one woman how long it took her to go through a bottle of diazepam: she thought about it, mimed grasping the bottle, unscrewing the lid, and jerking it towards her open mouth, and glugging back some water... and then said "about thirty seconds?") and this is causing a lot of problems.

So far I have been accused of forcing four people to inject themselves with heroin, one to break into houses and beat people up, another to rob service stations and a seventh to perform unspeakable (but unfortunately spoken of) acts on old men for meagre amounts of cash. After the third person in a day accused me of this I looked at her and said, "You know, the amount of heroin use I'm told I'm responsible for around here is bloody amazing. I reckon if the Government ever worked out what I was up to they could send the cops in, shut me down and basically solve the smack problem in the South overnight."

Seriously. I'm propping up the trade around here. I should get a white suit and some bling.

Anyway. Enough of my stamping on the faces of the poor. I will answer more comments tonight and post further in the next few days on either my last ED shift and/or the odd man I met in the alcohol unit. And I might just possibly mention the football...

Thanks for listening,
John

Briefly

Hail,
Sarah is probably coming home today. And her father progresses, if not by leaps and bounds, then by slow, physiotherapist assisted movements, because... (roll of drums) the neurologists have told us it is not a stroke.

(My apologies, by the by, to all who have been misinformed. All I can offer in my defence is the plea that I was misinformed by Sarah, who had in her turn been misinformed by another, and so on. Initially the neurologists had great difficulty seeing the stroke in the brainstem: that was partly because it's a hard area to image, and partly because it wasn't the best quality scan, and maybe a little bit due to the fact that the stroke wasn't there at all).

So what is it? It's Todd's paresis, which is a kind of paralysis or weakness that you get after a seizure. He's never had a seizure before, but they reckon he's decided to start now -and they're just working out what to do about that now. But the main thing is the MRI and the CT scan show no sign of a stroke, and because he's still improving.

Apparently he was able to support his weight standing yesterday.

Well, damn fine news. They say Todd's paresis is "often mistaken for a cerebrovascular event", and I am glad he managed to confuse the neurologists, because they confused me for half a year in medical school, and it's good to get our own back. Very good news.

He gets anti-epileptic medications, but no wheelchair.

I am grinning as I write this.

The big question, of course, is, if Stewart has Todd's paresis, who has Stewart's?

Sorry. Anyway, more information as it comes to hand.

Thanks for listening.
John

Progress

Hail,
And thanks for all the well-wishes, too.

Sarah says it's okay to talk about this here, so here goes.

What happened is her dad (tall, grey-haired, Nordic-eyed, one of the three or four smartest people I know) and mother (dark-haired, walks with a frame, one of the other smartest people I know) were on an aeroplane to England when Stewart lost consciousness and slumped over in his seat. Anne raised the alarm (after first smacking him in the chest in case he was having a heart attack, the famed 'precordial thump' you see on some tv shows).

Said alarm was raised and there was a doctor and two nurses on board and those in charge turned the plane around. Apparently Qantas was wonderful. Unfortunately they were over ninety minutes away from the nearest city, so by the time everything had happened (landed in the dead of night, ambulance waiting, whisked off to that city's version of the Royal, called, surprisingly, the Royal, scanned) he was just outside the three hour time limit for safe maximal therapy*.

At this stage I don't know if he was lucid or not, but he could not move or feel his left side at all. When he woke (possibly that night) he was able to understand and be understood

And over the next few days he has gradually improved. All eight hundred IQ points seem be intact, which is good. He can speak, he can understand and be understood. He can feel strange, slight, odd sensations on his left side, and can now feel when someone is touching him, and discriminate between a single touch and two simultaneous touches. He can make a fist and yesterday he could move his left leg a little.

He can see no reason why he should not recover sufficiently to be able to drive his wife around again. And as far as I can tell, this is not one of the artificial good moods, not that belle indifference that psychiatric patients get but whatever the neurological correlate is. I saw a guy with this once, this doesn't sound like that. He sounds exactly like himself.

Soon they will try to sit him in a chair.

It seems odd to sound so cheerful about this, but there are a number of things that could have got worse, and none of them have. This three thousand miles away medicine is so frustrating.

Stewart is startlingly chirpy about this, I have heard him laughing in the background when I have called. I suppose there are a number of possible reasons for this. He is of the generation and the stock that do not complain when things are bad. I suspect foremost in his mind are thoughts of gratitude that he is still able to communicate, that his mind has not been affected, and that he has not, to his reckoning, been reduced to something that needs caring for. His dignity is intact.

And I suspect that the way he sees it, he is still the principle carer for his crippled wife, and it is therefore unthinkable that he should be unwell and more unthinkable that he should display any sign of being so.

Meanwhile, the family have gathered from the corners of the globe to be with him, filling the house. Sarah is translating from the medical whenever the neurologist descends from on high (although, she says, with some difficulty). If, like law and science, medicine is another language, then neurology is a particularly obscure dialect, High Old Eastern Basque or something, a tongue scattered with bizzare diacritical marks and inverted asterisks, with seventeen genders for furniture alone.

Anyway - when we first heard about it (close to one in the morning, three thousand miles away) all we knew was loss of consciousness and one-sided paralysis. We guessed (wrongly) where the stroke was, and worried he'd never be able to speak again, or would lose the ability to read. For someone like Stewart, that would be a grave loss. And when we found out where the stroke was (the brainstem, the bit where your spinal cord sticks onto your brain) we realised again how horribly bad things could have been.

Blindness. Incontinence. Inability to swallow or to taste. A life-long burning pain over the half of the body on the opposite side of the stroke. At worst, locked in syndrome, awake and aware but only able to blink. Eternal coma or death.

And there's still a sizeable chance that any of those things could manifest, that things could worsen in the next few days, but I think that chance gets less as every day passes.

And he doesn't have pain, or mutism, or intractable, life-long vomiting. He can see, he can swallow, he can speak.

He is talking about playing soccer in the hallways when he gets out. Things could have been so much worse.

Anyway, I am due on at Florey in an hour. I must shave, shower and somehow fill my head with all the stuff that has left it in the last few months. Further information as it comes to hand.

Thanks for listening,
John

* they inject some clot-busting stuff into the affected area, like with the heart after a heart attack. This is a relatively simple decision with the heart, because hearts are simple, but brains are less so. Anyway, after three hours, the risks of injecting the clotbusting stuff outweigh the benefits, so they don't do it.

Interesting news in this weeks New Scientist, too, on very early stage research that may lead to treatments for Alzheimers and for type two diabetes. One of the future posts will be about the Spike.

Struck

There will be minimal posting over the next few days. Midnight the night before last we got a phonecall and Sarah's father has had quite a serious stroke. She has fled home and we are awaiting developments.

More information as it comes to hand.

Thanks, John

Sorry..

But this pretty much says everything you need to know about Australian politics this last decade. Explanations available on request.

John

Maddest man in the whole damn town...

Well.

Well.

Well.

Yes, I am struck speechless. I have just had a meeting with what I firmly believe is the maddest man in Mordor. Mr Jarusnich (last seen here and here), the Latvian bodybuilding loon, a madman of the first water. He of the twenty inch arms

- below, for comparison, is a man with either twenty six inch arms, or something like a baby's head inserted into his upper arm,



the twelve out of ten women, the narcissistic personality disorder, the body dysmorphic disorder and so on.

Anyway, Wednesday was our team meeting. The meeting was originally called our "Pharmacotherapy Meeting", after two weeks we started calling it the "Difficult Clients" meeting, and now it is the "People Who Shit Me" meeting. Each of us (doctor, various nurses, social workers, etc.) bring the bulging files of our most difficult clients and slam them on the desk, and we all try to work out what we can do about them.

And as a result of Mr Jarusnich's file notes, and the reports from his pharmacist, and our copies of the various letters to his local doctor/s from the Comission for Drugs of Dependence, and his recent four star urine drug screen (everything except cocaine in it - cocaine's pretty hard to get over here) we had rang his house and asked if he could come in and see us.

So he did. I can tell you now, our clinical intervention did not meet with success. He limped into the room,wearing his four hundred dollar tracksuit pants and his eight hundred dollar shoes, leaning on his walking stick, courtesy of a minor motor vehicle accident three months ago, and we began our futile dialogue.

How was his pain since he lowered his methadone?

Worse

How was his injecting since he lowered his methadone?

Way up.

Did he want to increase his methadone?

No, he wanted to decrease it.

What did he want?

Oxycontin.

As we had explained, we could not prescribe it. This was because the Government would only allow us to prescribe it for people with cancer -

Wasn't that unfair, the way the government discriminated between people. Did the government know how much pain he was in? Did we? Did the doctors and the lawyers who made these rules? Did the cancer patients?

- and because people, such as Mr Jarusnich, injected it into themselves.

And how else was he expected to cope with his pain?

Well, there was the methadone, a very potent pain relief but with little recreational effect when taken as prescribed ...

And so on and so on around in a circle. There are interesting philosophical dilemmas here, about governmental control over access to pleasure, the apparently quite alienable right of someone to inject whatever they like into their own body, the ideas behind heroin trials and so on, but neither Mr Jarusnich nor I were after a philosophical victory. He was after oxycontin and I was after keeping him alive, me employed and my name off the front pages of the Sackbutt.

After fifteen minutes we'd all had enough. "Okay," I said. "You're injecting yourself with heroin again. Do you see that as a problem?"

"No," he said.

"No worries," I said. "When you do, give us a call. Now, the methadone - it may be that if we give you more methadone, you may feel less desire to inject heroin. Would you be interested in that?"

"No way," he said. "I want to get off the methadone. It's for junkies."

"Right," I said. That is a word that is starting to shit me, possibly because I hear it so often from people who are injecting opiates themselves. "Junkie" seems to be one of those terms like the horizon - everyone knows one but very few people admit to being one, if you follow me. The junkie is always someone that little bit worse off than you are.

"Okay," I said, "One last thing. Amphetamine. Methamphetamine. Heroin, codeine, morphine, oxycodone, buprenorphine. Diazepam, alprazolam, temazepam and oxazepam. Ecstasy, fantasy*... this has got to be costing you..."

He nodded, pleased that we were about to discuss his problems. "Shit, mate. You've got no idea how hard it is."

"Where's the money going to be coming from? Long term?"

He dismissed this. "My father, my uncle, my mum, my grandfather. We've got a farm we can sell."

There was a brief pause.

"It says here," I said "that your father is in hospital today getting his second knee replacement. And your mum's got cancer, and your uncle is in a wheelchair with, you said, some 'fucked up muscle disease'. And your grandfather - hasn't he got Alzheimer's? Are they going to be keen to pay for your heroin?"

The question seemed to irritate him with its thoughtlessness. "Well, they won't want to see me in pain, will they?"

There was another pause while I tried, and failed, to think of any common ground here. Anyway, we went back and forth - actually, that's not true, because back and forth would imply some kind of movement, and this was the ceaseless banging of an irresistible force (my refusal to prescribe him oxycontin to inject himself with) against an immovable object (his desire for anything else). Eventually he got up to leave.

At the door he turned around.

"I've been under a lot of stress," he said. "Serious. My uncle's in a wheelchair, he shits himself all the time. My grand-dad's got Alzheimers, he doesn't know anyone in the family any more, just wanders around the farm. And my mum's in hospital getting chemotherapy every day. It's bloody hard."

The poor bastard, I thought. I've got him wrong. He's doing it hard.

"Yeah, chemotherapy every day, and all her hair is falling out. It's terrible to see." He paused. "Do you have any idea how embarrassing all that is for someone like me, something like that? I can't bring anyone around or anything. My sex life is fucked."

He glared at me. Something in my wide-eyed, voiceless, unbelieving stare must have failed to satisfy him, because he turned aside with a grunt of exasperation and left.

I stared at his broad, twisted back until he shuffled out the door, and then I went inside and sat down and closed the door.

Thanks for listening,
John

*But not a lot of reality

Lowering the moral toner

Erotic dreams - now, that should get the number of hits up.

Erotica - why bring that up, you ask? Because all of yesterday I had to sneak around Central for fear of meeting the eye of one of our fellow doctors, who had made a surprising, out of character and rather disturbing appearance in my dreams the preceding night.

The details of the dream need not concern you here. It had all the usual dreamoid sudden shifts of narrative focus (rapidly moving from the big story to the small), the non sequitur plotting and characters with strong but utterly foreign motivations that dreams often have. There was the usual undercurrent of anxiety. From what I can work out, many dreams for many people are about anxieties, are vaguely disturbing, the kinds of things you can't bring out during the day - this was one of those. The plot, I believed, was something about an object of great value, perhaps an enchanted goblet or something, but also involved a photocopier jamming.

Presumably not an enchanted photocopier.

And towards the middle of it, Dr Dryad (a pale, dark-haired woman, well spoken, clinically very good, a bundle of neuroses wound as tight as the inside of a golf-ball) shoved me up against the wall and had her surprisingly wicked way with me.

Anyway, even in the dream I can remember being surprised. Predictably, even in the dream I was wracked with guilt (even more predictably, the guilt came after the event, and not before or instead of). I woke up feeling uncomfortable, drove into work disquieted, and mounted the steps dreading seeing anyone who could have been witness to my shame. I prepared my morning coffee with the shaking hand and blanched face of the condemned.

And to my horror, there she was - brazenly leaning, almost lounging on her desk, erotic in her cardigan, fully buttoned up blouse and sandals. I averted my eyes, painfully conscious of the tension between us as she blatantly refrained from running her fingers through her hair and insouciantly didn't flutter her eyelids. For her part she did her best to avert suspicion, explaining how last night she'd been been at her nine-year old's birthday party and then cleaning up most of the evening.

"You wouldn't believe ten girls could make such a mess of a kitchen. I was mopping the floor at ten thirty at night" she said, before adding "I've never been so glad to crawl into bed"

God, woman, do you want everyone to know?

The others in the room commisserated, but I imagined a few knowing smirks beneath their murmuring. I swallowed in my suddenly dry throat. The electricity was palpable. Dr Dryad was evidently discomforted by my nearness, she left a few minutes later, making some tranparent excuse about "admitting new patients", doing her best to pretend that nothing had happened between us.

Anyway, by the end of the day, my mind was made up. This madness had to stop now. We'd both succumbed to temptation, in a moment of weakness and considerable emotional stress - no matter how we tried, we hadn't been able to get the photocopier to shrink something from A3 to A4 and print it double sided - we'd done something we shouldn't have. We had to put this behind us and go on with living the lives we were meant to. She had her husband and her two children and I had Sarah.

Sarah. How would I tell her? Still, if the honesty in our relationship meant anything...

"Why are you telling me this?" said Sarah a few hours later.

"I thought it was the kind of thing you should know"

There was another pause.

"Why?"

"Well... I don't know. I wanted to reassure you."

"Well, maybe if you hadn't told me inthe first place about you having erotic dreams about coworkers - "

"Well, I didn't want you to worry that I want to run off with her."

"Well, do you?"

"God, no. She's crazy."

"But you sometimes say I'm crazy"

"But you're good crazy. No, you're not crazy. Not crazy crazy. But even when you are crazy, you're different crazy. She's not you crazy or me crazy, she's crazy crazy - why are you turning off the light? Hello? Hello? -"

Anyway, a damn cold night in the Bronze residence. I've given this a lot of thought and I think I can see how the seeds of lust, unsprayed by the weed-killer of self-control, and lacking the scarecrow of - somethingorother - have yielded this harvest of sorrow. I can see how and to whom the blame should be apportioned.

I can only hope Dr Dryad feels guilty too.

Thanks for listening,
John

The Fallout Zone

You cannot, as you know, harm a dead body. The concept makes no sense, and experiment confirms the impossibility. One of the dead lies before you, preserved, let us say, in formalin, in a cold room.

You stab it, it does not bleed.

You poison it, it does not die.

You dissect along the course of the radial nerve, they do not cry out.

The dead, from this point of view, are to be envied. Sleeping peacefully, free from disease or troubling thoughts, no longer driven here and there by fear and rage and loneliness.

And why bring this up, you ask, meanwhile revising your opinion of the efficacy of the more commonly prescribed psychotropic medications?

Well, in the light of a few cases I've seen of late I've been doing the algebra... and I've worked out something a little odd.

A few of my cases lately have involved death. The "two thousand sexual partners and counting" guy with HIV - somewhat worse. Another HIV positive client, a red-headed woman in her fifties who changed her name to Goddesss (three esses) and whose life story both beggars and buggers description - she died last week. And another recounting to the police of the story of Mrs Cesious.

Anyway, as in all cases of death, the patient is no longer the focus of your caring. The patients, in the sense of the ones who bear or suffer, are the relatives, the partners and the friends. You see them, arrayed in concentric circles, damaged in proportion to their closeness to ground zero.



You see them, sometimes just once, in the case of a road trauma, sometimes week after week, time after time, as a loved one dies by degrees.

Pale from another's loss of blood.

Thin from another person's cancer.

Sleepless and wan from another person's pain.

This is what I have explained with the aid of algebra, the thing I have worked out late at night.

The statement "You cannot harm a dead body" is equivalent to the statement "Pain cannot exist in a dead body". Pain evidently, assuredly, demonstrably exists in a warm, feeling, alive body, but just as demonstrably is absent, vanished, gone from a dead body. Mathematically, it is absurd to say that it merely ceases to be.

Where does it go? Where does that pain, that suffering, that misery go to? That shortness of breath, that loss of appetite, that heaviness in the chest? That pale face, cold belly, shaking hands?

It is my contention that there is an algebraic sum involved. There is a law of conservation of pain, that wounds and disease and damage follow laws as ineluctable as those governing mass, charge and momentum. That disease/damage/pain does not leave the dead but is taken up by those left behind them, and only gradually dispersed.

By this logic, counting back, I have seen one man's heroin overdose kill, so far, three people, and I suspect it will kill a fourth. An eldest son drives a car off the road, kills himself, three years later that same car crash kills his mother. Stretching the idea further - and that's all it is, an idea - a grandfather's untreated depression becomes a father's violent alcoholism and a son's HIV.

Anyway. Tonight I will reply to comments and post something on the social awkwardness of erotic dreams.

Thanks for listening,
John

Works and Days

"So" I said to the thin, blonde man, "how're the finances now?"

"Good, good, holding up good." He had a habit of bobbing his head up and down when he grinned, and he was grinning a lot lately. "Always got cash in my pocket, outta debt, all good."

I stared down at the green assessment sheet, where I had written a series of "good"s, "fine"s, even an "amazing".

"You're not making this very exciting" I said.

He laughed, and his head zipped up and down like a piston. "Nah, well, nothing to complain about, is there? No news is good news. Bought a flat-screen tv the other day."

"Must be tiring, though" I said. I had written how he was working laying slabs and pouring concrete - carrying loads of brick, building foot-paths, six days a week, three Saturdays off in six months.

"I've done worse" he said. "Was worse two years back."

I glanced at the notes. "When you were on heroin?"

"Blood oath" he said, and for a moment was serious. "Tell you what, that was hard yakka. Hardest work I ever done."

"Really?"

He nodded, slowly this time. "I reckon I couldn't go back now. I'm too old. Body wouldn't take it."

I stared at his long, muscular arms, muscles as well defined as a greyhound's.

"What was so hard?" I said.

"Mate" he laughed, and shook his head. "Mate, you have no idea."

And he explained. Heroin, and the crime you committed to get heroin, was a full time job. You had to get out of bed early. You wanted to rob people's places when they weren't home, so that meant getting there eight thirty, nine o'clock in the morning. none of this lying in bed all day shit. Get up early, no matter if it's rain or shine, withdrawal or no freakin' withdrawal - if you don't do it, no-one else is gonna do it for you. Drive half way across the city, Mordor Slough to Slytherin Gulch in rush hour. Then there's getting in - dogs, fences, alarms, shit like that. And tvs - they're heavy. Nearly did my back in one time - no compo."

I nodded.

"And when you're not working your worrying about things, money form this guy to that guy, paying the bills, stretching your credit. Cushy government jobs - no offence, doc - people in cushy government jobs don't know what your average guy goes through trying to make a living. There's no support at all."

He shook his head, his face bitter. "Plus, getting rid of shit - where-ever you go, getting ripped off. You break your back for something, take it down cashies and you get ten, maybe fifteen percent. They're the bloody thieves, mate."

"I've heard that" I said.

"Plus scoring, getting rid of shit - Christ, there's no stability at all! Your partners just aren't reliable. Soon as you get some nice little system set up, some clown gets too greedy and bang - three years in Mauro. Plus overheads - don't talk to me about overheads."

I raised my eyebrows.

"Running the vehicle, somewhere to store the stuff - and petrol! Christ, it's a dollar fifty a litre this morning. You can't run an operation with that kind of overheads. Naah, one day I sat down, added it all up, said to myself "mate, you're not on a winner here. Wise up. Work for someone else."

"So now you're laying slabs" I said. He nodded, took a deep breath, calmed himself with a visible effort.

"Laying slabs" he said. "Steady work. Six days a week, some other guy does the worrying. Simple stuff."

Anyway, I think this scenario speaks for itself. The little men and women struggling against insuperable odds, the husband and wife teams working day and night in the face of official indifference and even hostility, the brave little entrepreneurs upon whose back our economy rests - this is how they are treated.

So much for the lucky country, I reckon.

Thanks for listening,
John

PS - a plethora of stuff to write about, which will be done over the weekend. Plus comments. But I had to write this down before I forgot.

Virgin Bone

Hail all,
And apologies for the protracted absence. Will reply to comments soonish.

What's been happening? Well, the mood is improving, in fact, has improved so much I don't feel the need to bang on for hours about myself and my feelings. From the biochemical point of view, things, I suspect, are on the way up.

To mark this, Sarah and I abandoned our ethics, tore off our priciples and went to not one, but two drug company dinners. The last one of these was a while back, and since I spend the intervening months ranting about the corrupting influence that drug companies have on medicine, I felt the pull of conflicting desires as soon as I walked into the room.

On the good side was a a host of colleagues in a high-ceilinged room, smoked salmon and caviar, nubile waitresses and vivacious sales reps, and fine wines (a light shiraz to accompany the samples of zolpidem sedative tablets, a fuller merlot to complement the fentanyl pain patches).

On the bad side was the guilt (about admiring the high-ceilinged room, indulging myself in the smoked salmon and caviar, glancing at the nubile waitresses and vivacious sales reps, and quaffing the fine wines), and the fear that any of my fellow ragers against the machine would see me here.

But by God, it was worth it. Tuesday's talk was full of woe, in particular the woe experienced by people who suffered from insomnia, and the paradise that awaited them if they popped a zolpidem tablet. I think it was the first time I have listened to an eminent, highly successful physician's presentation in his area of expertise and been utterly unconvinced by what he said.

Because it was mostly crap. Not the parts about this new version of zolpidem helping you sleep - that was obvious (although it was interesting that sixty percent of people reckoned placebos, or sugar pills, worked pretty damn fine, too). It was the succession of slightly dubious graphs, the series of studies that examined how well people slept on this medication but didn't look at what happened when they stopped, and the way he skimmed past any evidence that zolpidem had any potential for abuse or addiction.

This on the same day that I admitted a patient for zolpidem withdrawal (taking ten times the usual amount, getting the shakes when she stopped), and read about a man who developed seizures after ceasing his "forty tablet a day" habit.

Interestingly, he began taking the tablet because of his insomnia due to his "conjugal problems". And how did he get forty tablets a day? From his wife (a pharmacist). Published recently in "The American Journal of Health System Pharmacy", and presumably soon on CSI.

Anyway, enough about Doctor Shill's Travelling Show. The thing is, this man had started out having some kind of medical training, and that must have included critiqueing things like what he was saying. So he must know at some level that he's talking crap, that he's slanting some facts and ignoring others, that he's subtly shifted his stance from helping people to helping Sanofi Aventis Pty Ltd. He must know somewhere that he's sold out.

Doubtless these ethical and austere thoughts comforted me as I slurped at my smoked salmon and shiraz and leered at the waitresses.

And stockholders, after all, are people too.

There was also a brief movie about new software for total knee replacement, so we all watched someone scraping, chiselling and hammering at the bones and gristle in a large man's knee, while we munched contentedly on our steak. The surgeon explained all this using phrases like "drilling into the virgin bone", in a manner suggesting an oil magnate gazing over an untouched snowfield.

The second talk was on fentanyl patches. These are, unsurprisingly, patches with fentanyl in them, and fentanyl is a potent opioid. Again, the potential for "things going wrong" is significant.

A man in an ED in the US attemtped sucide by shoving a large number of them up his bottom.
Two men in Norway died after boiling up the patches and injecting the liquid obtained.

A report in a forensics journal warns against leaving fentanyl patches on dead bodies because the patches "provide a source of fentanyl for drug abusers".

And then a report in an Anaesthesiology journal. This describes a man (previously beleived to be dependent on fentanyl) who arrived in hospital for a "standard urological procedure".

He was intubated, i.e.: given various muscle relaxants, sedatives, pain killers and so forth, and the operation went ahead. Suddenly, at the end of the operation the man sat up, extubated himself i.e.: pulled that tube thing out of his throat that we put in to help you breathe) and asked if he could leave. He was persuaded to lie down and a dressing was applied.

During this time the count was commenced and it was discovered that some of the fentanyl (a 5ml vial) was unaccounted for.

Eventually, during applying the dressing, "the missing, unopened 5 ml vial of fentanyl emerged from the patient’s rectum".

Anyay, sorry about the lower gastro-intestinal tract humour. Normal transmission will commence shortly.

Thanks for listening,
John

Carousel

Well.

Obviously things are not right here. It is a matter of frequency, intensity, duration and content of thoughts - all are bad and getting worserer.

Things are, I will venture to say, bad. As usual, they are worst when I am alone. They are remaining so despite the various prophylactic measures. I am reading, going to the gym, doing stuff, taking tablets.

Still, many many times a day, I wish I was dead.

By the way - I am going to write about this as reassuringly as possible. I am writing more so people can get an idea what it's like to have these thoughts, and also in the hope that by writing this stuff down I can get some decent sleep tonight - but it's not as a plea for emotional support (I don't know that works) and definitely not as a "oh God, look how close I am to suicide" thing. I'm not close to it at all, as I am taking some pains to express here, and long before that happened I, or several of the excellent people around me, would have got me into hospital).

So, morbid thoughts. What I am talking about is "intrusive thoughts", thoughts that come into your head 'against your will' - thoughts that keep coming and saying the same old stuff, like an unwelcome and possibly unbalanced actor who, regardless of the play being performed, enters stage right and launches into a soliloquy.

The same thing, several hundred times a day (only a slight exaggeration - driving or lying in bed at night it's every few seconds sometimes). And against the will - I'm bored with thinking these thoughts, I'm bloody bored with hearing them... and still they come.

It's so futile. If I spent all of my time and effort looking for ways to square the circle, or make pi equal to twenty two on seven, that'd be widely recognised as folly. But this kind of stuff - it's different.

The majority of the morbid thoughts are probably suicidal thoughts, although a fair proportion involve horrible things happening to those close to me - if Sarah is ten minutes late home, I know that the only possible explanations involve trucks carrying nuclear waste and firemen with the jaws of life.

In the general population, I suspect fleeting suicidal thoughts are very common - they may even be universal. Recurrent, intrusive ones are less common. The making of plans I suspect is less common again - when I get that bad I go into hospital, and there's no need to do that yet. True preparation for suicide rare, actual attempts are more so, the completed act rarer still. I am a long way from the bad end of the scale.

And every time the thoughts come I come up with utterly concrete, irrefutable evidence why it maust not be done. My wife, my niece, my children, my family, my patients. That plus the sheer ingratitude it would imply to the Cosmic Whoever, the appalling selfishness of the statement that being rich and white and male and literate and tertiary educated and having all my limbs isn't apparently good enough for me, that the respect and affection of the many fine people around me somehow still isn't sufficient.

So it's not at all likely. Plus I have seen the side effects of suicide, seen the people who were caught in the shockwave, the mothers and the children and the sons who were standing near ground zero, couldn't take cover. I am utterly unable to convince myself for a microsecond that things for those left behind would be okay.

So, all of me knows it's not an option. But still the thoughts go on. This is what I mean by squaring of the circle, your mind coming back and back and back to something, an endless successsion of futile attempts to do something that you know is impossible. My mind - see how I distance myself from this, say "my mind" rather than "I" - keeps coming up with this shit.

All the time at night. Any time I am alone - I've been writing fiction like a mad thing, I am trying to study, anything rather than be alone in my head - and these thoughts come into my head. Any time I am not actively doing something that requires me to think specifically and in detail about something else.

Working in the ED, running a resus, would be down-time after this.

The stupidity and futility of these trains of thought enrage me. Why can't I just say "well, a 'painless for all concerned' death is not an option, we've worked that out. Now, rather than think about it, how about we try actually doing something useful or enjoyable in the next few hours?".

Anyway. I suspect things today crossed that threshold between "Well, could be worse, I could have to take antipsychotics" to "Well, I'm starting to take the antipsychotics so it doesn't get worse".

In psych we call this "insight". Insight is closely related to compliance: "Insight" is when a patient sees things the way we want them to, "compliance" is when they do what we want them to. Insight and compliance are two of the three cardinal virtues of the psychiatirc patient, the third being "private insurance". If you have three of these virtues you are assured of entry into the Kingdom of decent psychiatric treatment, if not, you are cast into the Pugatory of the Open Bed System (sleeping in the parklands) or the Hell of the closed Public wards.

I am assuming I don't have to renegotiate those terms "we" and "they" any time soon.

So. I'll start the quetiapine tonight. As the molecular biologists amongst us know, quetiapine occupies D2 receptors in the brain, where the D stands for dumb, and the 2 refers to how it makes you twice as dumb as you were before. So, before that kicks in, what to say?

Well, firstly - Foilwoman has written something smart and insightful about the Human Condition. This kind of event is too commonplace to actually be news, but what she said resonated with me so much that I have now started (as writers say) pimping for her. Go you and read what she has said. Women, read and nod. Men, read and weep.

What else? My workplace has descended into a soap opera. I turned up at quarter to nine yesterday and by ten past I expected swelling music in the background and credits to start rolling down the screen. I was going to write it up with a cast of characters (we have our beauteous and wronged heroine, we have a devious plotter with a shady boyfriend, a no-nonsense matron with a heart of gold, a large collection of misfits, psychopaths and wayward teens, and a plot involving drug dealing, deceit, desperation and dashing off with the rent unpaid) - but instead I had to see patients and police officers.

The police have been seeing me about those three patients of mine who died - the asthma woman (killed by Shipton), the blood on his hands man (killed by insight and a ten metre fall) and the suicide man (who tried to commit suicide, was saved by Florey, and then died from a completely unrelated event a few days later). In each of these cases I have had a minor role, almost always sandwiched between the thoughts and deeds of those higher up the food chain than myself, but I am still required to explain what we did and what we did not do.

Going over the deaths is bad enough. Any death, particularly a death in which you have been involved, and more so a death wherein your involvement constituted at some level a fundamental failure of your duty to protect someone - these are hard. The woman who had asthma, herein referred to as Mrs Cesious, the one who came in and died a few minutes after I had listened to her chest and for a second been reassured by the silence - that death frightened me and everyone around me. For the next few days Shipman was silent, people standing around whispering to each other, and three months later a kid came in with asthma and we all moved like we had been scalded.

And the man who took the overdose, and was treated, and then died in his sleep, and the man who killed however many he killed and then threw himself to his death - they all hurt. But the thing that gets to me while going over these deaths at this point, two or three or four years on, is the glimpses you see through the curtain of legal and forensic text of the survivors.

One of our suicides asked hospital staff to transfer his son to another hospital - his older brother had hanged himself in Florey five years ago.

In another case, the father of the doomed woman said his daughter had rung the hospital an hour before and said she was leaving her husband - an hour later she was dead. Could this have been more than co-incidence?

Anyway. Once you're gone you are not immediately forgotten. Your absence pains those who loved you. Let's leave this as the text for today.

Thanks for listening,
John

The Madness Map

One of our clients was found murdered today, by the by. Found down by the riverbank, no-one arrested as yet. A mood of mild despondency pervades Central.

Anyway.

One of those originless science facts people quote at you says you are probably sitting no more than six feet from a spider. Proponents of this argument point to the sheer number of the little bastards - hundreds per square metre in normal temperate environment. So, where-ever you are, whatever you are doing, take two paces and there's a spider.

And what brings this to mind?

Well, yesterday I was speaking to a doomed woman. She came in to see me at Southern, her three monthly appointment to see how things were going on the methadone programme.

Our side of things was going well - heroin once, maybe twice in the last year, more out of habit than compulsion, down from four times a day. Got her son back from the welfare, sorted things out with her family. From that point of view things were good.

But elsewhere things were a bit sharp, elsewhere the cracks were beginning to show. Steve - off again, on again partner, in again, out again prisoner - was back inside, and that was both good and bad. Good in that he hit her less. Bad in that her brother hit her more.

There was a pause.

"Your brother" I said. The notes said he was fourteen.

"It's okay" she said. "He's moved out with his girlfriend. I said he couldn't keep bringing his mates around and he went psycho - threw the tv through the window, trashed the house. So I called the cops - he fucked off before they came. Last time it took six of them - and he's ninety five kilos now. He's still under a suspended."

"So he's moved out?"

She nodded. "He did three months in Mauro before. Charged with attempted murder when he was twelve. Stabbed some kid in the chest."

I nodded slowly, in that way you do when you don't want to scream "Oh my God!".

"Just like his fucking father" she said. "But I told them. I'm not putting up with it from Steve and I'm not putting up with it from you. Not with my kid in the house."

"It's good you stood up to it" I said.

"I had to" she said. "Mum's getting out soon, and she needs some place to live. And the thing is, I don't want Joey seeing it. He's only five, but he picks up stuff. And he's big too. Five years old, thirty eight kilos. Can't go to playgroup anymore, got expelled, too violent. All the other kids are terrified of him."

I had this sudden, sharp image of this woman, surrounded by vast, violent men.

Anyway. Soon after that she had to go - and that was the day the first four people who talked to me left my office in tears - and I sat there and tried to remember the exact word from my genetics lectures, fifteen years ago.

Prepotency. That was it. The condition of transmitting "more than your share" of inherited characteristics to your child. Menfolk, if all your children look like your partner, and none look like you, one of the more charitable explanations is that she is prepotent.

Somewhere in that line was a prepotent male, transmitting the genes for violence, large size, maybe the same dark, almost black eyes Joey had (and he was a big kid). And maybe a complementary strand, running through the female line, women who choose men like that.

These are ugly, disquieting thoughts.

Anyhow, I mentioned these to Central's resident psychiatrist the other day, a truly excellent practitioner, and he nodded. He described a child he had seen back in the dark days when he did child psychiatry. The mother had brought the boy to him because he was naughty.

Naughty, in this case, meant torturing animals, smearing faeces on the walls and getting up at night, going into the kitchen, using the gas stove to light a rolled up newspaper and running through the house with it, setting the curtains alight.

"What did you do?" I said.

"What can you do?" said Dr Praecox. "Zonk him out for a few hours every night? Nothing works. And she wouldn't be in it. I think they got some kind of alarm system that went off every time he went into the kitchen."

Anyway - the point I was trying to make is the old one about contours. Look at a contour map.



Every closed curve encloses land at a different height - the innermost, land at 5100 whatevers, the next bold one outward 5000, and so on.

It is my suspicion that a similar map can be drawn for the human population.

Imagine that on this map -



the contour lines do not refer to heights above ground, but rather degrees of madness.

See how every peak is surrounded by an area of ground that is not quite so high. The total area above, say, four hundred metres is smaller than the total area above three hundred metres, and so on.

Well, it's the same with schizophrenia, or bipolar, or antisocial. If pure, classical "DSM IV stamp of approval" schizophrenia, say, is 450 m above sane level, then there is a sizeable group of people around them who fit some, but not all of the criteria. Who, if the peak is depression, have fewer than five of the nine required symptoms - only four. Further down are those who have only three, or have them only some of the time, and so on.

What this means is that there's a sizeable group of people out there with at least one or two signs of mental illness.

Paranoia.

Thoughts of suicide.

Anhedonia.

Compulsive rituals.

That kind of thing.

And of course, life events, especial stressors, psychoactive drugs, these all work like seismic shifts, move us up and down the madness map. It may be that most of the madness map is well above sane level, that there is precious little ground actually at sea/sane level, that I and everyone whom I have detained or injected with psychoactive drugs is actively part of a majority.

Anyway.

I started thinking about this when Dr Praecox said if we were all only six feet away from a spider, then how far were we away from a psychopath? If we mean someone who stabs kids in the chest at twelve, runs though the house with a burning brand at eight, I hope and pray and suspect we are quite far. But from someone who, caught at the wrong moment? Someone who could, given the right pressures, slip a few metres uphill?

I don't know. The antisocial personality disorder runs at about 2% of the population (3% of men, 1% of women). I don't know what proportion of anti-social PDs are the actual psychopaths, and I know they are not evenly distributed, because many (but I doubt most) of them are in prison. I don't know the maths, but say in a crowd of a thousand, would there be one? And a crowd of a thousand - a few hundred feet from side to side, loosely packed, like at the football or a shopping centre? Or at their homes, a family of two to four per house? Clustered in some families, like the woman who saw me in Southern, little glittering mother lodes of madness.

Too many variables. In the end we guessed at a generous ten kilometres. Big distances out here in the south, semi rural in some places.

You're never more than ten kilometres from a psychopath.

Less morbid posts will return soon.

Thanks for listening,
John

Death, Drugs, Darkness and Ducks.

Hail,
In my ongoing quest to blame someone else for my inadequacies I am going to attribute some of my recent crap mood to the State Coroner. And this post contains violence, drug use and un-natural bodily postures.

Today I sat with Florey's solicitor and went through every detail of a case I saw midwinter a few years back. It is referenced here and here - hope the links work.

It concerned a young man with blood on his hands who came in to Florey with no memory of the events of the preceding morning. He remembered the few beers, the sitting around in the kitchen wondering how it all had got so bad. But that's pretty much it. No memory afterwards of anything - no memory at all of the long drive up north, nothing of the breaking into the ex-wife's house, not even a detail of the assault - two dead, two critically injured, including the foreign exchange student - no real memory of anything. Not sure how he'd ended up on his father's doorstep. No real idea about how the blood on his hands and trousers ahd got there.

Anyway. During his nine hours in the ED he had been seen by four doctors, of whom I was the most junior, for varying periods of time, of which mine was the most brief. And despite his father's protestations that his son was not safe to be sent to prison, and his mother's statement that her other son, the older one, had hanged himself in Florey six years ago, he was judged sane enough to be sent sent off to prison.

And from where he threw himself from the sixth floor of the prison two days later.

Anyway. Melancholigenic thoughts, if such things exist. And the coroner will determine the presence or absence of any metaphorical blood on any theoretical hands. Luckily, like all histories, the psychiatric notes are written by the winners, and I am sure that everyone will come out fine.

Well, not the man who died, obviously.

Or the two to four people he killed.

And not the friends and doubly bereaved relatives thereof.

But all of us, the doctors, we're probably going to come out fine*. And surely that's important. If you prick us, do we not bleed? And hence today's meeting with the solicitor.

In the interim, and in an effort to do something besides whine about me and my problems, I've been writing. I've written some ten thousand words of draft blog which I suspect will remain forever 'not to be published', accessible only to some future data miner or e-archaeologist who is writing a thesis on the General Fucked Uppedness of Early Twentyfirst Century Western Society.

One effect of all this writing is that the writing is getting easier, and I'm more pleased with stuff I've written. I'm starting to understand how to plot, and I'm getting characters who have some complexity to them.

I think in the start, my characters were all facets of the kind of person I wanted to be, expressions of my hopes. Then, as I got older, they became more like aspects of the person I feared I truly was, or was in danger of becoming, expressions of my fears. Now they are starting to be just people, which is good.

And writing helps fill up that void I drone on about. The last few nights I've worked out depression is a weed that grows in silence and in dark - it's something that is exacerbated, not remedied, by a few days off work. So, you write, you clean, you go to work (the not-very-challenging work, not the ED), you do stuff. Sooner or later (more like later) you go out in public. Probably not for a while, and then subtly disguised.

I think at this stage I am meant to start taking quetiapine, the antipsychotic for the discerning bipolar patient. It is a medication which I loathe on several levels. I am not alone in this - even my imaginary friends agree with me that it's a bad idea. It is commonly prescribed for murderers and speed freaks. I might try amisulpiride. Then again, I might try taking the advice of my specialist, who suggested quetiapine.

Anyway, an interesting tale from a recent client. He tells me how, back in the bad old days (before he became a mid-level accountant) he had intravenous LSD. Intravenous means injected into the vein, and LSD means any kind of crap people can stick on a blotter of paper and convince some teenager is LSD.

(LSD, as I am sure you know, is usually taken orally. But there is no end to the amount of substances that can be injected. The term "adrenaline junkies" is one that irritates me, and not any less since I heard of a small group of men and women in East Mordor who actually inject intravenous adrenaline.

Bang, into the vein and back up to the heart, where it sends your heart-rate past two hundred, sets your lungs going like bellows and pumps your brain full of terror. They use 5mg at a time, a potentially fatal dose. I have given intravenous adrenaline to a number of people in the past, without even telling them what I was about to do, but the people I injected were a very special group of people. When I injected them, they were all dead).

Anyway, this guy had the IV LSD, and sat back, and watched in growing amazement as the three china ducks on the wall spewed sparkles and smoke from their cloacas and flew along the wall - (a new category of visual hallucinations - alongside the religous, nihilistic, erotic and paranoid we must now place the twee) - and suddenly lost consciousness.

When he woke up he was on his back in another room, in an un-natural posture - he mentioned a heel in his ear, a position one normally only attained by teen gymnasts who really don't want to lose at twister. He had vomited over his own shoulder into his other ear. His face and clothes were soaked with salty water, and he seemed to have - yes, a spoon in his mouth. He had bitten his tongue, dislocated a finger and lost control of his bowels, bladder and brain.

"What happened?" asked the life of the party, removing articles of cutlery from his tonsils.

His benefactors explained. It turned out that shortly after attracting the attention of his peers to the flaming bottomed ducks he had hurled himself at them like Aslan at an erring faun and commenced having a seizure. Luckily, each of the three stoned out acidheads with him had seen this many times before and knew what to do, and each member of the treating team sprung into action like pieces of well-oiled machinery.

One leapt upon him and started punching him in the head. That, he believed, was teh apporporiate therapy for the convulsing patient.

Another adopted a different mode of treatment and fetched warm salty water and started pouring it down the patient's throat from a jug.

And the third grabbed a soup spoon and forced it as far down our narrator's throat as possible. Presumably it was this that smacked the uvula around like a punching bag and brought on the copious vomiting-while-convulsing-and-lying-on-your-back, but then again, the warm salty water or the repeated blows to the head can't be ruled out.

All, I am assured, with honest therapeutic intent.

"You do what you have to to save a life" one of his assailants had said.

"Good God" I said. There was a silence.

"Nearly killed me, I reckon" he said.

"No doubt" I said. I'd seen people brought dead from less.

"Yep, right there and then I decided LSD wasn't the drug for me".

"To hell with LSD" I said. "Those bastards nearly put an end to you. That's as close as most people get to being a victim of homicide."

Anyhow, more later, and replying to comments after this.
Thanks for listening
John

*Well, I will, anyway.

Ischaemia / All about me

Hail,

Not back yet, but should be soon. I would apologise for the long absence, but I suspect everyone is better off without enduring what I would have had to say during this last fortnight or so.

There seems to be a lag period here. My illness - and that's an oddly painful couple of words - shows up in my head first, then at home, things with Sarah, then at work (if I haven't stopped by then,which I almost always have), then last of all my writing. In fact, if I look back and try and correlate things - this post must have been before that crash, this one around about the time of the other - then things seems to get cheerier, more prolific, more superficially manic just before the crash.

It's always dawniest before the dark, you could say.

The implications to be drawn from this are not pleasant. It seems that as I get more depressed and more needy I write more. And that suggests that I write because I am needy, that it's a tool I use to get people to like me. Something that the black, squalling thing inside me does, something engineered by the black hole of self-loathing that depression reveals at my core.

And as is clinically evident, not quite over it yet.

Clinically evident, by the way, is usually medical shorthand for "preceding doctor didn't do his/her job". If you have to review someone in the ED with mysterious abdominal pain and you put your hand on their belly and feel they have a bladder the size of a basketball, you can write 'clinically evident urinary retention' in the notes.

Anyway, the medications do work. They do work, which is still weird to me, because the pills are real, substantial things, with weight and form and texture and taste. Sodium valproate, which I was on through much of the nineties and am now on again, is hygroscopic, meaning it absorbs water from the air. You pop the purple tablet out of the foil, leave it on the sink overnight, and it becomes a blob of pale violet mush. And lithium induces nausea - it is used to poison lamb carcasses, to prevent coyotes eating them.

I always had this mental image of a farmer (or thremmatologist, as they are also known) stuffing lithium into a dead sheep, and a bipolar person coming along and saying "Look, mate, you're too late: she's not depressed, she's dead".

Well, I found that amusing. More amusing than I found vomiting my way though second year. Note for the inexperienced - if you drop your lithium tablet in the sink, (due to the tremor it has given you) do not scoop it out and pop the wet tablet into your mouth. It, and you, will last about fifteen minutes before you retch your duodenum out into the basin.

Anyhow. The thing is, tablets are real. They have a kind of gravity about them, a kind of mana - they are chemicals, with all the power that that idea implies. The same ideas that made plastic and TNT and anaesthetics make tablets of lithium.

In mediaeval terms, tablets have substance, whereas mental illness only has accident. It is, at some level, less real.

The reasons for this are obvious.

We cannot, or we have not yet, dissected out a paranoia from the brain, in the same way that we dissect out a tumour. Skilled surgeons do not, as yet, spend hours over an opened mind. We cannot separate out the true and false ideas in the psyche like we can healthy and diseased tissue in the brain. Pathology jars in medical museums are not filled with preserved manias, bottled hallucinations, delusions of grandeur cut in cross-section and stained to show the areas of abnormal growth of the ego. Nobody gazes down a microscope to see if the cellular microtubules shows signs of psychotic depression.

Things are, as far as that is concerned, much more subtle. Expression of proteins, subtle anatomical changes, serum levels of cholesterols. Unless you are trained in this way of looking, there is nothing hard, tangible, obvious.

Nothing of substance. Mental illness is still all in the mind, you see.

The thing is, from the point of view of the sufferer, this world-view is inverted.
I got a virus a few months ago, took you through every miserable shudder and droplet of sweat in these very pages - I would rather have that again than depression (especially since the virus makes you thin, but depression makes you fat).

I would rather have another episode of hypomania or mania than do almost anything else - new car, holiday, sex - and I would rather do anything else than clean up after said episode.

There is no doubt in my mind as to which is the more real.

I could go further. When I was twenty four - I think - I drank cider and did Tai Chi in the room above the uni pub. I was a passenger in a car driven by what I now realise to have been a seriously drunken friend, a brown Datsun something that rolled the wrong way down a street in Freo and was only saved by some last-minute Dukes of Hazzarding from my friend, who leapt in the window of the moving car and stopped it. I fornicated in a farmer's field with a red-headed girl, lay naked in the sun, was observed by three curious horses. I listened to Texas blues and to music that I would nowadays deny ever hearing.

But none of that stuff is any more real to me than the owl chorus outside my window, or the circuitry under the earth, or the hands that moved behind and stretched the membrane of the sky, or the serpent creature that stood at the centre of it all. None of it was more real than being two thousand metres high and made of glass. I have to consciously search through my memories of that time to find things that seem as real, as significant, as possessed of gravitas as the things that filled my head.

I don't know. The tablets do work. Maybe that proves they are real.

Anyhow. Much to write about once this crap all goes. I know it will. That neurotransmitter tide I raved on about is rising, covering some of the rocks, the things I normally leave covered. I'm back at work, soon I'll be able to go out without cringing.

Thanks for listening, by the way. Next post - I worked out most of the time I say this it turns out to be lies - next post is/might be on the eponymous Yellow Fever, and on techniques for the getting, rather than the avoiding, of disease.

Thanks again,
John