Sunday, December 17, 2006


Some bad stuff ahead warning.

I went to Dr Greene's informal wake the other night. It was a bit odd, like most gatherings of doctors are a bit odd, because a lot of doctors are, you know, slightly odd, and even in groups and diluted by a smattering of normal people, the intrinsic doctory oddness remains.

And there are different kinds of odd. I have been at social gatherings of psychiatrists, drug and alcohol doctors and emergency doctors and they are all odd in different ways.

The drug and alcohol doctors gatherings are traditionally held in large houses in the hills, around a swimming pool that has its own tides or in the four acre loungeroom with the mezzanine floor. Extremely fine wines (so they tell me) are selected from wine racks that look like the armamentariums of third world dictators and quaffed, while the rest of the party lounge outside near the pool smoking marijuana and talking about Europe.

I don't go to a lot of these, but I feel I must share a fragment of conversation I overheard last time -

Proud mother: "And this is our youngest, Mungo"

Stoned social worker: "Mango? Mango? That's a very unusual name, isn't it?"

- I overheard this three years ago and still smile whenever I think of it.

Anyhow. Meetings of psychiatrists are actually quite fun, but I detect, or imagine I detect, an undercurrent of tension, a wariness that if one has a little too much to drink or gets even slightly disinhibited, one's colleagues will be able to diagnose one as having some Axis I or II disorder.

And meetings of emergency doctors are strange in another way completely. Like everyone else, ED doctors use after-work parties to air their frustrations, discuss the things that piss them off about the system in which they work, the incompetence of those above and below them and the way (other people's) sloth and venery are rewarded over (the speaker's) dedication to duty and comically archaic insistence on trying to do what they are actually paid to be doing.

But if the structure and tone of the conversations are the same, the subject matter is wildly different. One of our senior registrars was staring into a bottle of beer and speaking about the difficulty of getting the administrative support his role required.

"So this guy comes in, run over by a truck, shattered femurs, non-viable legs, and you know how much time it took to get a vascular guy? Two fricking hours, and then it's some half-arsed trainee - "

And everyone's nodding about how crap vascular is, and I'm looking wide-eyed behind my glass of red, trying not to stare, because some guy's been over by a truck, the big bones in both thighs are broken beyond repair, he's going to have to have both his legs cut off, one of the most important events in this man's life... and that kind of stuff does get to you.

And it's weird that we're talking about it in the same tone you'd use to say "and the server's down for the third time this week", but I know it's also essential.

See, what the senior reg was demonstrating was the emotional resilience that you get, that "dealing with trauma" thing that either makes you a better doctor or a bad one, but without which you can't practice at all. And there's good ways and bad ways of having it, good filters and bad filters, but no filter, no way of coping means no doctor.

I think it's almost as if you need different filters for different kinds of trauma - I know I deal every day with patients and their stories that would enrage or disgust other doctors, for example.

See, I don't know about Doctor Greene. A couple of people were talking about it, asked me what I reckoned about how it could have been prevented, what was going on in his head, and I said it was unknowable. There are risk factors and predictors and and so on, but in the end some people in some situations live and others in the same situation die by their own hand.

But I heard how last year there was a case of cot death, a baby brought in by hysterical parents, and how they worked an hour on what was almost certainly a foregone conclusion, a lost cause. And how afterwards Dr Greene carried the child to the parents, both of them cold and pale and silent and barely breathing in the waiting room, as much like the dead as the living can be, and explained to them what had happened, how everything that could have been done was done, how it was in no way their fault.

And I don't know. He never talked to anyone about it. From what I hear the marriage was not good - he'd had something going with one of the emergency nurses a while back, a deeply decent and much loved woman - like I said, if he'd told more people, if he'd been able to be a little less strong maybe he would have lasted longer.

But I don't know. Event horizons. We make stories to try to make sense of stuff, to "know" things, and some of that stuff is unknowable. But you think of him carrying that dead child in his arms and you do get the feeling that people in his position need some kind of earthing wire, some kind of lightning rod, some way to get rid of the charge.

And lastly, an aside. Another of the cases the senior registrar had seen was a vertebral artery dissection. This means one of the arteries that supplies the brain-stem and the cerebellum - the only truly essential parts of your brain, the parts that tells your heart to beat and your lungs to breathe, as opposed to the "higher" parts of the brain that merely organise the quirks of your personality and are actually relatively disposable - this artery gets a blood clot or a bruise in the vessel wall and blocks off blood supply to the area "downstream".

It is at worst a devastating condition. Ten percent of these relatively young patients die, dying of strokes at the age of forty. And while it is difficult to make yourself entirely safe from this condition (it can be brought on by ceiling painting, or nose-blowing, and it tends to happen more often to women than men), one thing you can do is not let a chiropractor knob about with your neck. As this bloke - the bloke the senior registrar had seen - had done a day or so before he developed the terrible headache in the back of his head and the weird feeling on his face. Two days before he died.

Serious. There was a series of advertisements on the back of buses in Mordor a few years back, telling people how chiropractors were trained for longer (untrue) and were more qualified than doctors (also untrue). I confess, it irritated me. It probably irritated me most because at the time, second year medicine, we were getting certain things drilled into us - do no harm. Do nothing without informed consent. Suspect your sources. The therapies you use must have demonstrated benefit over other, cheaper, older therapies.

And I suppose I thought if you want to compare yourselves to doctors, maybe you could try acting under the same constraints. Try being, say, legally liable for what you do, or critiqueing everything you hear or read, or making sure that the patient understands that this thing you are doing could, say, kill him or her. Try having to demonstrate that what you do works better than a lucky rabbit's foot.

Anyway. From what Ken says the chiropractor is being charged, which is something. It's a terrible thing all around, but if (unlikely) it stops someone doing that particular kind of neck manipulation or someone else going to get it, good on them.

On that curmudgeonly note, thanks for listening


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