Thursday, September 28, 2006

You don't have to be crazy to work here... actually, you do.

Sarah is sick, one of the more convincing cases of actual laryngitis I have seen, and so things here have been rather rushed over the last few days. Consequently no responses to posts as of yet (sorry) and four or five half-finished entries by me sitting in draft form.

The ideas in these entries have probably passed their use by dates, but if I don't post them now... well admittedly life will probably go on. However, I feel I should make an effort.

So... we had our drug and alcohol doctors meeting today. It's a small affair, and today's was smaller than usual, with only me, Dr Blatherton, Dr Grizzle, Dr Dryad and a medical student. The medical student was small and wide-eyed, and said nothing.

Weirdly, I enjoy the doctor meetings. It's almost the only time I get to see other doctors, and the meetings are the only time (except the dinner table) I can discuss medical stuff. We list it down on the programme as "professional development", and if no-one wants any professional development, the boss talks about his junior cricket team or something.

We use the time to discuss any of our worries or concerns about how we practice, so when I am there everyone gets to sit around and watch as I develop myself professionally, often for the full fifty five minutes.

This is also the forum where I (silently) hone and test my theory that the drug and alcohol service only hires doctors with a recognised Axis I or II psychiatric disorder. Some of this is a matter of public knowledge - Dr Grizzle, who has been introduced to our multiply pierced ferociously competent social worker eight weeks in a row, each introduction eliciting the same pleasantly surprised look and handshake of welcome.

Doctor Girzzle recently wrote words close to the following in a patient's discharge letter: "Unfortunately, while Mr Smith was in the Remand Centre his house was broken into and some of his possessions were stolen. Perhaps now he knows what it feels like to have your house broken into, your intimate possessions rifled through and anything of even trivial value sold for a tenth of its price to feed someone’s life of vice!"

All true, and there can be few who have not thought similar things themselves, but not the kind of thing the renal registrar at the Royal needs to know.

So, Dr Grizzle has what she says is bipolar disorder, but I think is either that or schizoaffective. I have managed to conceal my illness from my colleagues via posting about it on the internet. Dr Dryad is, by her own admission, an old-school neurotic. Sarah married me, not the most ringing endorsement of her mental health. Dr Rueben, our hepatologist, is an electrokleptomaniac, buys hundreds of things per week on eBay. As in hundreds of things.

And Dr Blatherton, the doctor who runs the north? Well, the case is not yet closed, and today he told us something remarkable about how he thinks.

I was talking about some terrible lie I had been told and how I had had to gently remind the woman that Wednesday's sworn testimony flatly contradicted Tuesday's sacred oath on her children's lives, and somewhere along the line I said “Imagine that”.

“I can’t” said Dr Blatherton.

There was a pause. “What do you mean, you can’t?” I said.

“I can’t” he said. “I’ve got no visual imagination.”

This struck me as so extraordinary that I felt I had to pursue the matter. “By none, you mean none?”

“None at all” said Dr Blatherton. “When I close my eyes and try to imagine things, I can’t. I can’t picture stuff in my head. It's all black.”

“Good Lord” I said, impolitely but wonderingly. “So if I say ‘picture a triangle’…”

“I know what one looks like, obviously” said Dr Blatherton. “But I can’t ‘see’ it in any way, unless it's there. I suspect most people are the same, actually.”

“If I want to”, I said slowly, “I can picture a pink triangle superimposed over your face. It’s not as real as your face, not as solid, but it’s a definite, very clear triangle, a little more see-through, and I can say what the angles are, the size, that kind of thing.”

The medical student, quiet, big eyed, nodded in agreement.

“That’s weird” said Dr Blatherton. “Is it any use?”

“Use?” I said.

“Does it, I don’t know, serve any purpose?”

I honestly didn’t know what to say to that. I had a feeling like Wells' men must have had when they beheld the Martian on Horsell Common, or the feeling you got when you first tried to work out how it must feel to be a bat. That time you work out that there is no way of telling whether what you say is blue is the same as what I say is blue, or whether we just have the same name for irreducible distinct phenomena.

Trying to explain the sea to someone who hadn’t seen it.

Anyway. Yours in weirdness,

Tuesday, September 26, 2006

Baby Love

Right - I want anyone reading this entry to read through the following list and tell me which one sounds convincing.

Acute Reiter's Syndrome*
Jumping Frenchman Disorder*
Itchy Red Bump Disease*
Persistent Sexual Arousal Syndrome*
Chronic Ergophobia...

Any joy so far?

Because tomorrow I have to ring in with something very very feasible, because otherwise people will suspect, rightly, that I am lying to get out of work.

Why would I do that?

Well, I got a phone call today. It was from the nurse at the Princess, the Royal's subsidiary hospital, which deals with women and babies and women having babies (and quite frequently, babies having babies).

It turned out that a twenty four year old first time mother had been brought to the Princess in the small hours of the morning to have her child. It was one of those much anticipated but poorly timed events, but the mother had been to all the antenatal classes and had apparently built up quite a rapport with the midwives and staff.

And delivery was apparently quite uncomplicated, albeit painful (mother requiring quite a lot of pethidine), and baby was born healthy and well, and not even that sedated from the narcotics. All was well, all manner of things were well.

Until baby began to show signs of opiate withdrawal – an unconsolable high-pitched cry, yawning and sniffing, increased muscle tone and exaggerated reflexes. And the urinalysis showed methadone metabolites in the urine. And mum, confronted with this, broke down and confessed that for the last two years she had been using a some of her partner’s methadone. A tiny dose, five milligrams a night , just to get through some of the stuff she’d been going through. Well, five milligrams a night to the nurse, and fifteen to the midwife, and forty or so to the doctor.

Anyway. Baby has been put on a miniaturized version of our opiate withdrawal programme, "all other things being equal" will be sent home on Thursday on zero point two five milligrams of morphine syrup a day, which is virtually a homeopathic dose for an adult but who knows how much for a newly born liver and brain. "All other things" are by no means assured of being equal – social work are involved, and they are all the more fervent because they didn’t pick this up themselves.

Anyway. There are a number of interpretations of these events which do not require mum being taken out and killed. She is, apparently, virtually hysterical with remorse. She may be unwell herself, she may have tried to give up and failed, she may have concealed what was going on initially out of ignorance or shame and then from mounting panic. A selection of stones in various weights is available at the counter for all those who have never sinned. Time will tell – I will almost certainly never find out.

But I will find out something tomorrow, because tomorrow I have to get her partner’s notes, and bring him in, and ask him how we could best reconcile his frequently repeated assertions (four to six times a year) that he was taking his medication as prescribed, with his wife’s (and the laboratory’s) descriptions of how he was sharing it with her.

And if she’s been lying for two years, he’s been lying to us. That means back to square one for him, swallowing all his doses before the watchful eye of the pharmacist, and an urgent (as in the next day no matter what) appointment for her at one of our offices to work out what help she needs. Because she may or may not have had an opiate problem before, but she’s certainly got one now. It's something that the whole family shares.

Anyway. With a bit of luck, he won’t be our client – he may be Sarah’s, or even the northern clinic’s. And maybe he’ll be forewarned, come in, make a clean breast of it. Hoping that his co-operation with the court will be taken into account come sentencing. Sigh.

Because God I love telling people we know they've been lying to us, and I know I do such good medicine when I'm angry, and I'm deeply pissed off at my own clinical inadequacies and our regulations and whatever cogs in the machine played a part in that kid getting born with parts of his brain all faulked up**.

So that's why I was thinking about feasible diseases. I know I'm angry, I can feel it, and even though I know it's not all his fault (I feel a considerable amount of it is mine), I know that I don't make good clinical decisions when I am angry. And I am a doctor, and by definition these people are sick, and I don't know that sick people benefit from the doctor suggesting that they take their bullshit stories and rx pr ad libitem***.

So. These itchy red bumps are getting bigger, and there’s that pain, deep and unfeasible... I mean unpleasant, gnawing at the fifth ventricle of my spleen. Could be something contagious. Don’t want to go in and risk infecting the rest of the staff, that wouldn’t be professional behaviour. Not at all.

Only thing to do is scratch something impressive sounding on this script of sick notes I have at my desk and send my apologies to work.

Sigh. If only. Anyway, will write more soon (health permitting).

Thanks for listening,

*Genuine medical conditions. Accept no substitutes.
** A private joke, concerning one of the two or three worst doctors I have ever met, which can only be revealed once I am dead or he is dead or he is struck off the register - probably next week.
***rx is "take thou", or "take". "Ad libitum" is as often as you like. PR refers to how the medicine is taken. It stands for "per rectum", and it means just what it sounds like.

Saturday, September 23, 2006

Yield Point

Warning, upsetting sentence ahead, somewhere near the middle.

I do not speak mathematics.

This is not an uncommon failing. It is an obscure language, in terms of fluent speakers maybe rarer than Farsi or Urdu, and the capacity to learn it seems to be something some people are born with, and most are born without. My wife's father speaks it. My son does, a friend of mine from a few years back was almost supernaturally fluent, a kind of 'Dante of the numbers', showed me a pun once made up entirely of funny looking symbols, read scalar transforms like other people read limericks.

But me? Even when it was drummed into me as a child I spoke it haltingly, and what I gained over the years I lost in weeks. I've always been better with verbs than surds, and I know more about pentameter than primes. The ability to speak mathematics seems to skip generations and reappear in odd, non-Mendelian ways.

For example, my eldest son knows that

The image “” cannot be displayed, because it contains errors.

is true. I tend to take people's word for it.

Which is a pity. Because sometimes I feel a bit of grasp of mathematics, particularly that branch of engineering maths that looks at stresses and strains and how materials fracture, would be useful in describing people's behaviour. Particularly their behaviour near the edge.

Take the case of Samantha and Simon, two of our closest friends.

They were (and still are) more Sarah's friends than mine, she met them through cat-breeding circles. Samantha is tiny, petite, blonde, fascinatingly foul-mouthed on occasion and ferociously protective of her friends.

Simon is intelligent, articulate, one of the most charismatic people I have known, a man impossible to dislike. He is a fascinating conversationalist - he has scars on his back where he was beaten up by Gypsy Jokers, he once bowled out Steve Waugh in a practice match, and the wedding photographs around their show him with his hip-length black hair, from the days when he was the lead singer of a heavy metal band.

They seem like the perfect couple, and you would naturally expect two such perfect people to have a perfect life. They breed oriental cats - long limbed, amazingly graceful things, and the house is full of aquariums, Siamese fighting fish and angelfish, gliding in underwater grottoes.

And it's not that it has been easy - Sam's previous relationship revolved around domestic violence, and she has had multiple episodes of surgery for an unpleasant and life-long illness, and children have always been impossible - but you always got the feeling that they were two people who were somehow blessed, and deservingly so.

Until Samantha's sister came to stay.

Sam's sister Ellen is the youngest of the family, a mere twenty seven. She and her five children (nine to three) turned up one day on Sam and Simon's doorstep and said they had nowhere to live. Their previous accomodation had become unavailable due to a complex legal dispute, wherein Ellen's landlord had said that they had to pay for rent, and Ellen had said they weren't going to. In the interim, could they please stay with Sam?

So they moved in. For the first few weeks it was okay. Catching up on old times, the surprising amount of joy that two childless people got from having a house full of children, doubtless the feeling that they were doing a Good Thing. Simon and Sam's house is small, one bedroom and a spare, and what with Ellen sleeping in the spare room and four of the children in the lounge and Damien (the second oldest, an unusal child) sleeping in a portable bed in Simon and Sam's room, things were cramped.

And it was understandable, what with everything Ellen had been through, that she want a little time to herself, and go off occasionally. They loved looking after the kids. And if sometimes she wanted to have the occasional drink in the afternoon, well, who was to judge her? Just till she gets back on her feet.

Three months have passed.

No end is in sight.

Ellen still sits around drinking rum and coke from a can, easy a six-pack a day. She goes out a lot of nights, her most recent relationship with a sixty eight year old owner of a pub, stays out three or four nights in a row. The five kids are enrolled in the local school (and from that point of view are settled in), but are chafing at the bit at home. For four of them this takes the form of screaming fights, the "he breathed my air - she looked at me" kind of thing.

For Damien, the eight year old, it takes other forms.

He pours varnish on the floor.

He carves obscenities into the old wooden table.

He takes the angelfish out of their aquariums and leaves them on the floor.

A few months ago he drowned some kittens, hid the bodies in the water, which poisoned all Samantha's fish.

Simon, a large man whom I have never seen pushed too far, eyes like thunder, has been growing steadily in anger, and has been restrained only by his wife's saint-like intercession.

Damien has, I suspect, some kind of disorder. Conduct disorder, from what I have seen (and working in the fields I have I have seen some) is an unusual disorder: you will notice that the linked article does not go on to describe a list of successful treatments. There are few, and working with kids with conduct disorder tends to be very hard on all of those concerned. Kids with conduct disorder tend to hurt other people and the hurt comes back to them.

Or, as in this case, it goes elsewhere.

Yesterday, one of the prize-winning cats, a fluid, cinnamon coloured creature with an eight-barreled name and a number of medals and titles, was let out of his enclosure (the vet had asked he be kept caged for a few days), and wandered out onto the road, where he was run over. Sam found him when she went to feed the cats their weekly treats of fresh chicken hearts**.

There was, I imagine, a few seconds of unbelieving silence.

And then apparently Sam attacked. She ran through the house like a fury, or a small lioness tracking a bleeding animal. She found Ellen, drinking, startlingly, rum and coke, under a tree in the back yard, and reading the Da Vinci Code while Damien uprooted the vegetable garden.

With a howl Sam hurtled towards her, her hand scooping into the bucket and coming out full of chicken hearts. She hurled them.

The first handful struck Ellen full in the chest.

"What the fnurgh -?" asked the parasite, the last word being mercifully blotted out by chook ventricles. Sam shrieked something that coloured the air, scooped up two more and let fly with both handfuls.

Damien fled. A scattering of giblets rained down upon his back as he did so.

This went on for a minute or so, the younger woman trying to hide behind the tree, her upturned can of rum and coca cola draining out into the soil, while Sam punctuated every shrieking sentence by splattering her with viscera. Ellen tried to stand her ground, emerging once or twice from behind the boughs to collect some viscera of her own and launch feeble and unsuccessful counterattacks, until at last she ventured too far. Sam leapt towards her like Grendel on a Dane and jammed the entire bucket, upside down on her sister's head. She gave it a good right hook for good measure - felling the woman to the ground, Sam boxes clever for a woman of only fifty kilos - and stormed off into the house, hands bloody, hair awry and eyes bright.

Anyway. It appears some resolution may have been reached. The police came, to find Ellen looking like a first draft of a Frankenstein's monster, and Sam nefariously feeding the kittens tinned cat food. It was apparently like a scene from Macbeth. By this time everyone had calmed down, and Ellen had presumably realised that a frank and open discussion with the forces of the law was not in her best interests, and the police spoke soothingly to them and went away.

And it emerged that alternative accomodation could be found, not far from where the kids went to school, and the first steps have been taken towards the parting of the ways. And there may be some hope that this can be achieved without further violence.

Anyhow. I don't know if a better knowledge of what you could call cognitive materials science, or psychic stress moduli, could have predicted this. Brittle materials like concrete, even if they are strong, do not deal with stress the same way as other materials. Brittle materials like concrete deform under stress until they rupture. Ductile materials like steel stretch slowly until they reach a certain point, the yield strength. After this, if subject to further stress, they become thinner, more strained, perhaps even more brittle, so that even a cursory examination should show that catastrophic mechanical failure is close.

Of course, you don't see this if you are more interested in geriatric publicans, conspiracy theorists and sugary alcopop.

But even if you don't see them, if these warning signs are missed, things will fall apart. Bridges collapse, girders buckle, chicken hearts are thrown across the back yard.

Well, I wish I'd been there to see it. In fact, I have yet to tell this to anyone who does not wish that they were there. But at least we should see Sam and Simon, hopefully alone in their house, soon.

Thanks for listening.

**Don't know, never tried them.

Monday, September 18, 2006

Spring, when young men's thoughts...


Interesting little bit of gossip, which won't count as gossip since none of you know the person concerned, which also means I can speak freely.

A friend of mine from a few years back rang me last night, one of my few friends from the creationist years, and we got to talking about stuff. She teaches "difficult kids" - one on one sessions with the kids who've been expelled from every school in the Swamplands. One more than one occasion I have noted down names, suspecting I will meet them in my later work, whether the prisons, the psych ward, the ED or the drug and alcohol service, and at least once I've been right (a young man arrested and imprisoned for shooting a donkey).

Anyway, after I'd banged on about myself for a few hours, she managed to butt in.

"I've got a problem" she said. "I don't know what to do"

"My God" I said. She doesn't ask me this kind of stuff much, and earlier she'd confessed to having had one of her three times a year glasses of port. "Bad?"

"Not... bad" she said. "More ... I don't know. Confusing."

"What is it?"

"One of the ... someone has a crush on me"

"Okay. What's the problem."

"He's nineteen." Jessica is forty. Slim, intelligent, one of the most moral (in the true sense of the word) people I know.

"My God" I said. "First class."

"No, I don't know what to do. I haven't been able to tell anyone else, not even mum. He's nineteen."

"So you've told nobody?"


"That's your mistake. I'd be telling everybody. I'd be writing in to the advice columns. Dear Cosmo. I am a forty year old woman with a nineteen year old who is desperately in love with me (see attached photos). I don't want any advice, I just want to gloat. Maybe you could get one of those planes that drag messages ..."

"He's serious. He's going to have an SMS bill that's out of this world. His SMS's take five messages to deliver, my phone just sits there going bip, bip, bip all the time. The last one was a minor essay on a dream he had about me, eight hundred characters or something."

"Can he spell? I mean in his texts?"

"Yeah, spells very well."

"That's okay then. Never sleep with someone who can't open their vowels."

"Well, he abbreviates.."

"Abbreviating's acceptable, it's the nature of the medium. But that whole there/their thing..."

"Anyway" she said, somewhat tersely. "What do I do? He's nineteen. He was at my fortieth!"

"Good luck to you. He's obviously got taste. Is he decent? Good looking?"

"He's gorgeous. And smart and funny."

I searched back into my memory for how I used to think. "And he's obviously there for a reason"

"I don't know. And he's crazy about me"

"That's colloquial crazy, not clinical crazy?"

She nodded (presumably). "He's a very mature nineteen year old. In a good way." I dismissed images of an elderly adolescent in pin-striped suit and geriatric stoop.

"And you're a very young forty. In a good way." Jessica got in the top thirty women in the last City to Swamplands fun run, and recently played a rhinoceros in an amateur stage show.

"Well" I said. "Anything else on the market?"

"Just this guy from church. He's born again, and he wants to be close to me, but he doesn't want committment."

"Mmmm. Amazing how God changes some people. So what's the worst that could happen? You make a young man very happy? Is that so wrong?"

"There's a lot to it. There's the whole small town thing." Morbing Vyle, where Jessica lives, is essentially a small town made not very good. The congregation is notoriously close and supportive.

Anyway, we worked out that this was one of those "good" problems, not one of those bad ones, and whatever happened it was a much needed ego boost, and I said with the amount of Good Works she did, anyone who even raised an eyebrow at what she did in her private life should be taken by she-bears (Second Kings 2:23-24).

(As can be seen in this pre-minoxidil parable from bronze age Judea. A group of children mock Elisha the prophet, and God sends two she-bears to kill forty two of them.

There are many interpretations that can be derived from this text, about not mucking with stuff you don't understand, and about treating the aged and the holy with respect... but surely one of the interpretations would have to be "don't muck with the bald guy").

But she reckoned she should go slow. And slow for a forty year old woman might be glacier-speed to a nineteen year old boy.

Maybe not. He's decent. And a very mature nineteen. And she's a very young forty. In good ways.

Anyway, she won't tell anyone, but in an oblique fashion I have, so that should enable her to gloat by proxy. Send her your well-wishes/good advice/cries of envy via this blog.

Thanks for listening,

Saturday, September 16, 2006

All Praise Good King Lud

Towards the end of December, a New Age will begin in the Bronze household.

Where once there was lamentation, there will be laughter.
Where once there was woe, there shall be woo hooing.
Where once there were tears, there will be tremendous testimonies of titillation.

Perhaps not.

But things will be on the up, because this Christmas I am getting a GPS.

GPS, for those three or four people on the net less technologically literate than me, stands for Germanic Parathyroid Salamander... or something like that. To be honest, I don't care and I can't remember. It's a little black box kind of thing that you stick in your car and

Dead set.

Apparently it talks to you and says "In three hundred metres, turn left."
And then in three hundred metres (or thereabouts) you turn left (or a similar direction) and after a few more iterations, voila, you get to where you wanted to go.

Seriously, this thing should pay for itself in petrol, valproate and red wine in about a week. No more ringing up Benendict eighty minutes after I am meant to have arrived, asking him if his house is before or after the limestone quarry. No more frenzied shrieking down the phone to Sarah, where I explain that if I knew where I was I wouldn't be lost. No more of that corrosive feeling of self-loathing where you realise you've driven past the same ramshackle house three times, and now the local amphetamine dealers, never the most stable of men, are having their paranoid suspicions confirmed and are sitting inside cleaning weapons.

Behold, a shining world is come.

Well, almost. There are still a few problems. A machine that tells me how to get from one place to another by telling me when and in what direction to turn is going to run into some problems. I can imagine a monologue, spoken in that oddly modulated, calm voice computer things have:

In three hundred metres turn left onto Lovecraft Street.

In one hundred metres turn left.

Turn left now - left I said.

You have turned right. We will attempt to perfom a U-turn and turn back the way you came. In two hundred metres, turn left.

In one hundred metres turn left.

Turn left now - no, your other left - you have turned right.

Please take the next available right turn. That is the side of the car in which you are sitting.

Turn right in one hundred metres.

Turn right n- Oh my Lord. What is wrong with you? Stone the crows*, I can't stand any more of this crap -

And two white-gloved hands will emerge from the sides of the machine, on the end of robot extensor arms, and grab the steering wheel, having first robo-slapped me into unconsiousness. And depending on how intelligent the machine is, I will either regain consciousness just as I pull into Toby's place, or wake up, bound and gagged, in the remote limestone quarry I spoke of earlier.

Not that a GPS is the be all and end all, anyway. It's always got me how modern technology, while it comes up with some really useful ideas, doesn't seem to apply them in what would seem to be the areas of greatest need. A GPS, for example, that tells you how to find your way around the city is one thing. A GPS that could tell you what to do with your life, or give you step by step instructions on how to break up with someone who was making you miserable ("In one hundred seconds we will dial psychokitten's number. Dialling number now...")... that would be good.

And those things where you press a button on the thing and the other thing makes a noise so you know where it is. Like with the cordless phone, where you press a number on the main thing and the other bits make that chirp noise and you can say "Ah, must have left the handset in the lounge" or "Must have left the handset in the study" or "Of course, now I remember, I left the handset face down in the pile of clothes and crockery hidden behind the door of my niece's bathroom".

PCTT, or "pressy chirpy thing technology" as we in the industry call it, has many promising potential applications. We've all experienced the hours of wasted time searching for a missing sexual partner. Wouldn't things be a lot easier if you could just "press and chirp" to find him/her/it/them? And how about a job that didn't treat you like a low-status bilby? Wouldn't it be simpler if you could just walk down the street, pressing your PCT and waiting for the chirp? And remote controls that had controls so you could make adjustments to other people: "Hmmm, nice, but a little more manliness...". And so on.

Anyway. That's the problem with people who design all this stuff. They don't understand people's real needs in the real world. Anyway, I have to go off to sleep, and from what I can remember the bedroom is first left, right, then left again. If I leave now I should get there by twelve.

Thanks for listening,
*Australian made for Australian conditions

Friday, September 15, 2006

Primum non credere

Well, I might have done a bit of nocere today.

That's the nocere of "Primum non nocere" - the First Commandment of medicine. Primum non nocere translates as "first, do no harm. "

Like the First Commandment in the Pentateuch, in fact like every commandment and law, it is written down and quoted and sometimes even publically sworn with every apperence of solemnity.

And like every commandment it has had to be written down and quoted and even publically sworn because it's the kind of thing that nobody really wants to do. Like all laws, it exists to stop people doing something that otherwise they'd be doing all over the place.

Doctors have to be told not to hurt people for the same reason that drivers have to be told not speed and the accused has to swear to tell the truth and people have to be told to pay taxes and not pluck peaches from the neighbour's tree.

(Makes you think, doesn't it - if laws are just catalogues of the more common and attractive sins, then there should be a sub-profession of "forensic archaeologists". These would be people who go through the laws of exotic cultures and strange, isolated tribes, (such as the Bantu of South Africa, the Yali of Indonesia and the Doctors of the Emergency Department), looking at the laws of that society and working out what looked to have been their big problems.

If some ancient tribe had lots of laws about how important it was to only worship Snarg, Deity of Buttonholes, and how anything else must be punished, then you could say that Snarg wasn't getting enough, and that s/he obviously had reason to feel insecure. And presumably, for a bronze age nomadic desert people, all living in close proximity, the coveting of the neighbour's ass was indeed a problem, as was working out how closely someone could be related to you before having sex with them became a bad idea).

So why do doctors have to swear, or at least have it drummed into their heads, to do no harm? Are we that homicidal?

Not at all. Those harmed by doctors who are overtly homicidal are few, whereas those harmed by doctors who are neutral, or well-meaning, or even deeply compassionate, are rather too many. For every victim of a Crippen there are thousands maimed and damaged by doctors who are, they say, just trying to do their jobs.

Some of these harmful doctors are inept.
Others are, at the time, bone-acheingly tired.
Others are too ashamed to ask for help before things go wrong, and too afraid to ask once things have started to go wrong.
Others are arrogant, or ignorant, or lazy, and sometimes all three.
One in a very small number is actually cruel.

As for me, it seems that if I did harm (and it's not a big lump of harm, and it's not a big stuffup, and it may have been no stuffup at all) it was a combination of ignorant and well meaning.

The setting was one of Florey's lecture theatres, and I was giving a talk to a group of nurses. I have been doing talks to the nurses and the junior doctors for a few weeks now, and the differences are quite marked. Doctors are able to prescribe medications, and so attract the attention of the pharmaceutical companies. You turn up to the doctor's talks and there's a full meal laid on, and ties and watches and pointless free gizmos litter the desks. You turn up to the nurse's talk and there's a big Tupperware container of boiled lollies and instant coffee, BYO cup.

Anyway, I was there to talk on drugs and alcohol. This is a fairly easy topic to talk on, of more intrinsic interest than renal carcinomas or effective use of the Wells enucleating spoon. It's easy to sprinkle your talk with startling facts ("By this time Mr Ague was drinking five to seven litres of wine a day...") and the whole thing offers listeners either that frisson of the forbidden or the chance to feel better about yourself than someone else - and often both in the course of one powerpoint slide.

Anyway, rather than bang on about heroin for hours, I slanted most of the talk towards the addictive drugs that would kill far more of my audience, and their children and their parents.

Tobacco, so far ahead it's not funny.


A segue onto the whole "does marijuana cause something like schizophrenia" thing (answer - nobody's sure, and those who are really sure probably shouldn't be as sure as they are, and if you've got any history of being what doctors call schizoid and the rest of us call weird, don't smoke marijuana. Sad but true.).

And towards the end, some stuff on what works and what doesn't work when giving up smoking, that kind of thing.

And that was the nubbin of it. I told them safe, effective, useful ways to give up the number one cause of early death in their age-group.

Good medicine, obviously. Basic applied epidemiology, bargain basement harm minimisation, patient empowerment (for a predominantly female, "lower income than me" clientele and so forth. One one hour talk, one nurse gives up smoking one year earlier than she otherwise would have, a cell divides evenly, a cancer does not form, or forms but starves. Ten extra years on her life.

An hour well spent, one would think.

Apparently not. An article in the June issue of the Journal of Consumer Research describes an experiment that suggests that providing information about treatments for diseases* like smoking, injecting drug use, obesity and so on may make it less likely that the patient* will seek treament. The idea goes that both smokers and non-smokers (or both injectors and non-injectors, or both fat and popular /employed people) who hear about successful treatments for their diseases subsequently see their diseases as less serious. They are thus less likely to quit, because, hey, it's not so dangerous after all, and if things do get bad they've got a "get out of jail free" card.

This makes no sense, on one level. However, it certainly took the self-satisfied grin off my face when I came home, too, and it does fit in with something I have been coming across every now and then as I read, something to do with how human beings treat risk - studies that cite observations that drivers drive closer to cyclists wearing helmets than to cyclists without helmets, or that taxi drivers will drive faster in taxis with better brakes.

The idea that ties all this together is called "risk homeostasis". This is the idea that people have an inbuilt level of acceptable risk, and that they will keep running at that inbuilt level despite attempts to make things safer. You make things safer, people take more risks. The plutocrat driving the 4WD/SUV with the airbags and the seatbelts will serenely cruise through the red light, the terrified student hunched over the steering wheel of his 1972 Chevrolet Impaler will not.

I don't know about this. It seems a difficult idea to prove. I suspect that some innovations are pretty much definitely lifesaving - child-proof lids on medicines, for example, and non-flammable clothing. I don't believe that people wearing flame-retardant woolen pyjamas are more likely to burn rubbish during a fire ban than, say, people wearing flammable nylon pyjamas.

And is it not possible that the risk homeostasis is true for a certain sub-group of the population, motocross-riding, base-jumping adrenaline quaffers like our newest social worker, but not for dyed in the wool physical cowards like myself? Leading to a weak, or partial risk homeostasis effect?

Anyway. Maybe I could have saved more lives by standing up in front of the smoking nurses and saying "Smoking. It kills most people who do it, it'll probably kill you. You'll try to stop, but you won't be able to, and when you finally do it'll be too late. You'll drown in your own viscid lung secretions, either in front of your pale and terrified relatives or abandoned by them, after months of swelling, suffocating, unmedicable terror. Any questions? Didn't think so."

Not really me. Anyway, will write more soon. Thanks for listening,

*weird seeing these words used like that, isn't it?

Saturday, September 09, 2006


Sorry about the extended delay, the remote computer has not been responding. One day I'm going to go over there with a pickaxe handle and give the bugger something to respond to. In cyberspace, no-one can hear you thump something.

So, what's been happening in the interim?

Firstly, it's been so long since I posted that planets have been delisted. I suppose this means that there are pople know who could remember when there were eight planets, then nine, and now eight again, like those people who were born in Petrograd and grew up in Leningrad and died in St Petersburg, all without moving from their home.

This means next time I get nostalgic and maudlin I can whine on about how "in my day we had a real solar system." I can go on about how there was none of this eight planet crap", and I can stare into my winebottle and mutter about how our generation fought for our nine planets, we did the research, we put our bodies and our brains on the line and did the hard yards, and now those goddam milksop liberal appeasement-junkies are eroding our solar system one goddam plutino at a time.

My niece, by the by, has told my fellow drug and alcohol workers that I drink a bottle of wine a night, straight from the bottle, while staring at the computer. You won't be hearing from her again.

What else from the world of science? A researcher has published something suggesting that beautiful people really are smarter than the rest of us - with special exceptions for blonde women and large-breasted women.

Yes, truth is stranger than fiction, and scientific truth is stranger than science fiction.

Currently, this is an opinion held by some Japanaese guys, and does not have the status of a scientific law, and anyway, Hilton's Law already exists. Although there is room for Jordan's Law, I think.

Hmmm. Maybe the beauty/smart thing only works for women who remain bipedal.

What else? I have been working in the ED (yesterday) and Drug and Alcohol centre otherwise. The ED was yesterday, and it was damn fine, although the things I loved most about it (the cameraderie, the growing clinical confidence, the knowledge) are less dependeable now that I am only there fortnightly. I haven't forgotten as much as I thought, but everything takes me longer.
And I am definitely more state of the Ark than state of the art now, more trailing than cutting edge. I am surrounded by bright young things who have yet to forget what I probably never knew. They are clean-featured, and dynamic, and often beautiful, and must therefore be smart, and they are always confident people - and to be honest, I've always mistrusted supremely confident people - and they are almost always right.

But yesterday, and I have to tell someone this because I've told my niece and I've told my wife and one of my better friends, and they're all sick of hearing about it, yesterday, fear and temerity and hubris-phobia won over youth and brains and beauty.

And I am pleased, and terrified, and enraged, in about equal parts, and will tell you about it. A terror shared is a terror halved, or whatever.

When I got there at seven thirty (after a most enjoyable evening watching Futurama with Algernon, who has yet to send me his blog address) I was put in charge of the "low stress" end of the ED, the one with more patients who are less sick. This is the minor trauma end, the end away from the heart attacks, the exploding aortic aneurysms, the burns and so on, and is considered a bit of a doddle by some of the more interventionist ED doctors.

No worries, I said, and took handover of the hallucinating drunk, the vomiting child with the extremely angry parents, the woman with the bowel obstruction and so on.

The big worry ended up being the two alcohol dependent patients. Alcohol dependence is a diagnosis that requires a careful history taking, such and such a period of demonstrated withdrawal phenomena, exclusion of certain other medical conditions and so on. Or you can just look at the fact that the woman walked in with a blood alcohol of nine times the legal limit and the man had a liver that was, God strike me dead, palpable just above his hip, and you can go straight for alcohol dependence.

Anyway, the alcohol dependent man was being treated for alcohol withdrawal, with benzos and thiamine and the usual treatment. The thing is, he wasn't gettting any better.

I went in and stood next to the security guard, who was trying to read a book on Helen of Troy.

"How's he going?" I said.

"Just like that" said the guard. Äll day".

"Do the medical team know?"

The nurse nodded.

I looked into the cubicle. Inside the darkened room the lanky man with the carbuncle on his face was moving about, carefully stepping over imaginary objects, opening doors that were not there, squeezing around and under bulky and inconveniently placed objects must have struck him as most inconveniently placed.

I gazed at him and for a moment felt that weird, cold feeling you get when you realise things are worse than you've thought.

"That's not withdrawal" I said. "How much has he had?"

"One hundred of diazepam."

"Any better?"

"Not really. We don't want to give him any more because his BP's only ninety over seventy, and he's going to fall over."

"The medical team know that?"

"I rang them, they say they know. They don't want him shackled."

I wondered for a moment about a man with alcoholic liver disease, with about one clotting protein per litre of blood, falling over and smacking his head.

"That's not withdrawal" I said. "If it was withdrawal he'd be getting better. And he's not. It's something else."

I went over to the notes, and had a look, and paged the registrar. This had been done multiple times without success. After three pages I got the intern.

"Hi, I'm Dr Bronze, I'm one of the ED registrars. Sorry to bother you - "

"What do you want?" said the intern.

I paused for a moment, and continued a little more carefully.

"I'm a bit concerned about your patient, Mr Binj in cubicle thriteen. He's acting unusually -"

"He's got alcohol withdrawal. Haven't you read the notes?"

Ï have them open in front of me, and very fine notes they are"I said.

I am one of those people who speaks more slowly, gently and politely as I get angry, and I was already addressing this sprat in tones I usually only resort to for the congenitally retarded.

"So what's your problem?"

Ï was just wondering if it was not possible that something else was going on. You know how unwell these patients can get. He's got an unmedicated INR of 1.4 and platelets of 47 and I was wondering if it's possible he might have given himself a bleed?"

Translation - maybe your patient is bleeding into the brain, and I am trying to save his brain and your arse.

"I tried looking in his ears. He won't co-operate"

That's right, blame the brain-damaged guy.

Änd people like this are at a pretty big risk for pneumonia, and he might benefit from a chest Xray..."

"I told you, he won't be still for the Xray!"

"Mmm. I know it's difficult. We might even have to increase the sedation a bit so that we can fully examine him - that'd stop the risk of him falling over and smacking his head, too."

He dismissed what I said. "Too much risk of respiratory depression".

And how much respiratory depression is he going to have when he bleeds into his brainstem? If you don't do your job, this guy will die, we will end up in front of the coroner, and I am writing down that you are to blame.

"It could be helpful, though, if we could examine him. Also, I was wondering if he maybe had a touch of encephalopathy? That would explain - "

"We've given him thiamine!"

And he's still not better, is he? Perhaps this thirty four year old man is getting brain damage as we speak.

"Mmm. I suppose I was thinking that it's possible that, since he may have missed the odd meal lately, that he might be pretty magnesium deficient. That can affect absorbtion, so I was wondering if you'd mind if I sent off a blood and then maybe gave him a bit more thiamine if he needed it - "

I am asking you permission to do your job for you.

He carefully considered this. "That'd be okay, I suppose."

Änd of course, there's the other forms of encephalopathy, and this guy's liver - hello? hello? Jesus Christ, the little bastard's hung up on me.!"

I ordered the medications, but before we actually got them into him he deteriorated, and the nurses called a code on him, and in the end the high dependency unit team took over, and he was shackled, sedated, and wheeled off to CT.

And the med intern had to explain the situation, and write in the notes just after the three pages of notes about how he had not answered his pages and had refused to see the patient when asked, and managed get through all of this with an attitude of one who had been unfairly victimised, rather than one who had ballsed up his job despite repeated offers of help.

Anyway, there is no epilogue here. God knows what he had, but I'll be looking it up Monday and finding it out. But it's amazing how blase some people can be in the face of oncoming disaster.

Anyway, much to write about next time, weddings and teenage brains and so forth.

Thanks for listening, and for letting me vent my spleen. I feel better already.

Saturday, September 02, 2006

Paradoxical Reaction

In the stricter sense of the word, I have seen one or two paradoxical reactions.

A paradoxical reaction, in medicine, is a reaction that is exactly the opposite of what you expect. Rather than the therapeutic effect, you get the antithesis of what you anticipated when you prescribed the medication.

You give the antibiotic and the tuberculosis gets worse.

The patient takes the prescribed sedative and half an hour later she has to be held down by security guards - "Nembutal Rage".

The patients develops wheezing and rash when you give him the antihistamines.

In a paradoxical reaction you cause exactly what you tried to prevent. It's embarrassing, because it's one of those things that should always be in the back of your mind, but when it happens you often work it out a little bit later than you wanted it to.

There are paradoxical reactions in other fields, too - the people who are only interesting when they are unattainable, the money saving measure that costs you, the exercise routine that leaves you laid up in bed for three weeks with housemaid's knee and lapdancer's back... and so on. You elect someone who says he stands for freedom and he ends up wire-tapping you, that kind of thing.

Anyway. I heard about two paradoxical reactions the other day.

The first was a large-framed, almost chubby man whom I booked into the Alcohol Unit. He had that round-headed, slightly baffled 'Charlie Brown' look that some men in their early forties get, that look they get when they when they first encounter mortality, when they feel the rising arc begin to descend. He had, after several years of abstinence, began drinking again, and I was gently trying to work out what had caused this, and what we could do about it.

(You see, some things you ask, some you don't. The man who had left the room before him, tall, multiply pierced, worm-thin, a drummer in a punk band, had begun lacerating himself at the age of thirty two, only a few years ago. Multiple shallow cuts on the inner arms. I had asked a few questions around that, trying my best to listen to something he was not openly saying, drawing back before I got close, and after a minute or so I had the outline of something, like those carnival tricks where the marksman outlines the girl in bullets, and he asked if we could stop. And we did, and I drew back, and you could see the outline of what it was, what he said he had yet to tell his psychiatrist, and it was something horrible that he did not want to know I knew).

But anyhow, our baffled man. I scanned the nurse's history.

"It says you're separated."

He nodded.

"For better or worse?"

He shrugged. "It's better now. I still see my kids, she's got someone else... it's all pretty amicable."

"Do you reckon" I said "that alcohol had something to do with that?"

"With what?"

"With the marriage breakup"

"Shit, yeah" he said. "We'd still be together if I hadn't changed."

"How'd that work?"

"Well, it was okay while I was on drugs. But I went to the doc's and he told me I was killing myself, so I gave up the goey. Cold turkey. I was getting to the stage where you don't enjoy speed anymore anyway. And it brought a lot of tension to the relationship."

"Made it worse?"

"Lot worse. We had these fights. And then the doc told me to give up drinking, said it was was stuffing up my liver, so I stopped. Didn't drink for eight years, started back at the footy, joined the army reserve. Best years of my life, that way. But things got worse."

"The marriage?"

"Really bad. We had these big fights. I don't know if it was loss of control, or what. I remember one time she said "You're such an arsehole. I liked you better when you were pissed all the time", and I said "Well, I liked you better when I was pissed all the time, too'."

I winced.

"Yeah, well, it sounded smart at the time. Then I went back to the doctor and he told me to give up smoking, and I did, really fixed up my asthma, and that was pretty much the last straw."

I had this momentary image of the local general practitioner, an avuncular family doctor of the portly, white-haired type, smiling contentedly as this man left the surgery, thinking of another human being helped.

And the second one was the ongoing battle with Meredith Furlong, one of my ten "most likely" patients at Southern. That's "most likely to have to explain to the coroner" - a woman whose prodigious consumption of benzos, barbiturates and injectables keeps me staring at the ceiling long into the night. She's the "bottle of fifty sleeping pills in thirty seconds" woman. Plus a hundred mg of methadone a day, lungs like a paper bag, kidneys like sultanas and a more steel in her body than a Cyberman.

Anyway, very bad things have happened to Meredith. In the last three or four years she has experienced more tragedy than I hope anyone reading this experiences in their lifetime. She has been arrested, assaulted and abandoned, her body is a patchwork of scars, three of her former partners are in prison, both of her children are in some sort of protective custody.

She has responded to these crises by consuming any and all drugs she comes across. She recently was taken to hosptial because she went to a friend's place, and while browsing in the bathroom cabinet (as we all do) found a bottle of pills and took them all. This was done with recreational rather than any overt suicidal intent. The drugs in question turned out to be some fairly formidable old-school antipsychotics, and she went into what is called an oculogyric crisis - all the muscles in her back and neck stiffened up and they wheeled her in to the ED balanced on the balls of her feet and the crown of her head.

Anyway, lately things had been calming down for Meredith. It had been six months since she had been admitted to the psych ward or locked up by the police. I had managed to start to get a handle on the amount of benzos she was taking (or at least the amount she was prescribed) and she hadn't injected for months.

But just when things seemed to be going well...

"Four hundred thousand" said her partner. He had come in to see me alone, and now he sat in the surgery with his head in his hands.

"Four hundred thousand dollars?"

"Near as" he said. "From the motorbike accident, five years ago."

"Bloody hell" I said. There was a pause, then I said it again, slower and with more
foreboding. "Bloody hell."

He nodded again. "She's out of control."

And he described what had been going on. Six hundred dollars the first day, no sleep for five days. Then her on the phone, calling dealers she'd been unable to afford to see for months. Then the benzo crash - three days of sleep. Waking up and tripping over the carton of beer in the hallway, and the syringes in the bath.

And this guy was no choirboy himself, but there were shifts of proportion involved here that were alarming him. There is a limit to how quickly and how badly you can fuck yourself up on the disability support pension, and Meredith had been doing, by her count, remarkably well.

Until now.

"Now," he said, "it's all going to go to shit."

I told him there was nothing I could do. She wasn't detainable - being mindrootingly stupid isn't a mental illness. The police, he said, were out of the question. Once she took enough speed to develop a psychosis, he could ring the psych crisis team, but until then... did she have any friends who would be interested in stopping her using drugs, some kind of intervention - never mind.

Well, we thought failure and misfortune had been damaging to Meridith, wait until we say what success and good fortune could do.

Anyway. There's apparently an old Jewish curse that says may you inherit a shipful of gold, and it not be enough to pay for your medical bills. It's deliciously nasty when you look at it, which is what curses are meant to be, I suppose. But I don't know of any curses that say may you inherit a shipful of gold and that be the cause of most of your medical problems.

Thanks for listening,