Heart

Hail,

And just back from another possibly-a-little-too-much-a-little-too-soon session at the Alcohol Service.

There are a number of problems that arise from being a simultaneously a doctor and a patient in any kind of field, in particular any kind of specialty or subspecialty of mental illness. Admittedly, the degree of overlap is not great - I am an outpatient in the private system with the relatively high-status disease of bipolar affective disorder, they are (largely) inpatients in the public system with the contemptible diagnosis of drug- or alcohol-dependence. I think if the distance were less, if I couldn't put that degree of distance between us, I would be finding things even more difficult than I am.

But as it is I have to keep reminding myself of the distance, because otherwise we are going to be two helpless, hopeless people in a room, sobbing brokenly at each other. Somebody has to know how to make the diagnosis, what the medications can and can't do, how to winkle out the history and what to look for on the exam. All the compassion and empathy in the world is not going to help anyone if I give them aspirin instead of paracetamol and they bleed to death.

The other problem with medicine is that it is of necessity concerned with the morbid and the diseased. Pain and suffering are what it is all about, and if all you do is medicine, pain and suffering become your diet, and it changes you. I have noticed differences between me and my non-medical friends - I lend them books or send them articles only to have them returned to me, the recipient pale and shaking, with whispers that what I cheerily sent or lent was "the most revolting, painful, morbid book I have ever read".

"I thought you liked vampire stuff", I say. ""Vampires, burial and death"? What's morbid about that?"

"You mean apart from all the stuff about vampires? and burial? and death?" my friend shrieks. "Corpse-robbing? people buried alive? Page after page of putrefaction? You're right, aside from that it's a hoot"

I had a similar problem with a book called "Mutants", which I read after my attempt at the primary. I bought it because it was popular science, genetics, that kind of stuff. But - and here's the bit where nobody warned me - it was about... mutants.

Anyway. The problem with spending year after year in the presence of human suffering is you have to deal with it in some way. Either you as a doctor change fields, or you lose yourself in something else, or it begins to affect you less.

Everyone remembers the first time they had to tell someone they'd had a heart attack, everyone remembers the first resus they did that worked and the first that didn't, everyone remembers their first dead body. But not everyone remembers the twentieth, or the two hundredth.

And I may be particularly vulnerable at the moment. I think the events of the last few months, the descent into illness, the hospitalization, the slow and gradual and some-days-I-don't-think-it's-happening-at-all recovery... those events have changed me. As you would expect. Plus the medication, plus the galling fact that I became unwell at work, that people at work know why I was away so long (I know they know because absolutely no-one is asking), plus the demonstrable fact that I am mentally slower, more cautious with my diagnoses, more tentative and less certain than I was - all of these things have knocked me about a bit. Changed me in various ways.

One thing I have noticed is that I am somehow more sensitive to the pain in other people's stories. To put it another way, things upset me that wouldn't maybe have upset me three months ago. It's not like I am left sobbing in the corner after every consult, but the first patient I saw after a month off had had three suicides in his family in the last year.

If I go back to the ED, this'll be why.

Not that we don't see them there. Someone I saw today was living in the parklands, drinking himself to death, said it was eight years since his wife left him. I felt his pulse and he had an irregular heartbeat, a staggering, uneven thing. It was probably caused by his drinking (either the heart muscle gets big and weak, or you get a heart attack from your drinking and your diabetes, or maybe even the pneumonia you get from sleeping in the parklands) and he needed medications. I wasn't sure which ones (we needed to wait on the blood test results) but I knew even if it was just aspirin, he wasn't going to take it.

Doctors are often uncertain about how closely their patients comply with their medication schedules. With homeless people who have drug problems, there is none of this confusion. Unless the substances can be ground up and injected for recreational intent, they don't take them.

So I stood there listening to this man's heart stuttering and staggering, probably already swollen and paper-bag thin inside his chest, and thought that one aspirin a day would probably hold off the inevitable stroke, and knowing he wouldn't take it, and imagining him semi-paralysed in a nursing home for years, no alcohol, and knowing no-one would come to visit him.

And I thought about when I asked him about depression, suicidality, that kind of thing, of how he said he occasionally got fleeting thoughts of "is it really worth it", but reckoned he'd never been depressed, never thought of suicide, never really understood it.

And I remember standing there wondering what it was, what strength, that this man had that I did not.

Anyway. Morbid thoughts tonight. I might go off and watch the latest in my diet of movies and books that make me feel good.

Thanks for listening,

John