Hurricane

Hail,
Early morning at the drugs and alcohol job, and I've just had a date with Destiny.

Destiny is a small, blonde girl, two and a half or so years old. Her mother is on the methadone program, seems to be doing if not well, then better than this time last year. Put on a bit of weight, better dressed, looks healthier. Destiny, too, looks to be in the best of health.

Anyway, mother and child came in this morning for a script review. So me, Destiny, Mrs Tribble and a student nurse from Hong Kong all crowded into my superhero-poster adorned waiting room.

"Ireckonoverallitsbeengoingprettywellactually" says Destiny's mother. She speaks at easily twice the normal human speed, punctuating her sentences with laughs or sighs as appropriate. While I speak she grins and stares wide-eyed at me and twists around in her chair. Behind me Destiny leaps full-bodied onto the box of toys, seeming to suffer no harm.

"Good" I say. "So, no feelings of withdrawal on the dose?"

"Nahgoinggreat!Ilikehowyou'vedoneyourhairdear" (this to the student nurse) "IwishIcouldgetthatshine-"
- intake of breath -
"butyouAsianshavedifferenthairtousIknowthisgirlherdadwasPhilipino-"

Behind me Destiny stops fossicking in the toybox, shrieks "Ball!".

I force myself into the conversation.

"And no sweating, you're not drows-" A tennis ball hits me in the back of the head. I turned around. Destiny grins and waves a plastic sword.

"BadgirlI'vesaidbeforedon'tthrowthingsatthedoctor
howmanytimeshaveItoldyouthat?She'ssoexcitable..."

"It's okay" I say. "Do you want to hold her?"

"She'sveryhealthy" says mum, making a shortlived and half-hearted attempt to grapple with Destiny.
"Theplaygroupwomanreckonsshesneverseenanyonesohealthyasher.
Freespirited.Evenherdadusedtosay..."

I wrote something about pupil size in the notes. The tennis ball bounces off the wall in front of me, I grab it with one hand, shove it in my pocket. Destiny bursts into tears and hurled herself under the examination bed.

"So how long since you've used heroin?"

"YearsIreckon-"

I cut her off.

"First class. Any speed?"

For a moment she looks downcast, distracts herself by handing Destiny a pad of post-it notes and my pen.
"Someguycamearoundlastnighthadabitofgoeyjusthada
tasteontheedgeofaknifefirsttimeinages..."

"Goey" is speed or amphetamines, the most common recreational drug in the Mordor-Slytherin area.

"Injected or eaten?" I ask, then lurch forward, in considerable pain. "Jesus!!" I look down. Destiny has slapped a post-it note onto my groin.

Mum is distraught.
"SosorrydoctorI'vetoldhernottodothatdon't
stickpostitnotesonthedoctor"

Somewhere in my mind the realisation is forming that this - the sticking of post it notes on the doctor - is an ongoing disciplinary issue in the Tribble household.

"It's okay" I lie through clenched teeth. I wipe the tears from my eyes and look at the notes. "Are you on any other medications - oh no you don't"

The tennis ball (presumably retrieved from my pocket during my microsecond lapse into unconsciousness a moment ago) sails across the room, towards Ultimate Iron Man. I extend one hand and snatch it from the air.

Destiny stares wide-eyed at me. There is a brief battle of wills. Without taking my eyes from her I poise my pen over the notes. "Any other medications?"

"Nodoctor".

There is a pause, and then Destiny breaks free and leaps on the toybox again. There is a sizeable plastic battle-ax near the bottom of the box, of a style usually found only in old Conan the barbarian comics. She begins to burrow towards it. I take a very truncated drug history, "Speed? Ecstasy? Magic mushrooms?", thrust a urine sample jar in mum's hand and hustle them out of the room.

And close the door, and lean against it.

Things are a lot better for Destiny Tribble. She's fed, clothed, attends some kind of daycare. Mum is off the heroin and is probably using less amphetamines than before - not "a taste on the edge of the knife, first time in ages", but not two hundred and fifty dollars IV a day, taking all the electrival goods down to Cash Converters. Things are better. And the welfare and the mental health team and the outpatient paediatrics people are well aware of the situation. Shafeera Wati, the paediatric registrar up at Florey, remembers the time she saw Destiny in outpatients and wasn't wearing closed shoes - Destiny lunged at her and tried to bite her foot.

A lot of the girls I saw in Mauro, the youth prisons, they were like this. Healthy, excitable, free-spirited.

Anyway. That's community medicine. Very different to the ED, but a lot of overlap, too. From what I can work out, the ED is for acute crises, the community teams (Drugs and Alcohol, Psych, etc.) seem to be for chronic crises... and for people like Mrs Tribble and Destiny, it's all crisis all the time. Always has been, may always be. We succeed if we can help them ride out the bumps.

Anyway, back to work.

The novel, by the way, is a damn sight harder than I thought. But four thousand words looms closer. We shall see who wins - me or a bloody keyboard and a blank screen.

Thanks for listening,
John

J'adoube

And this will be another in the ongoing series of merlot-induced posts.

But for a good cause - my brother's clean bill of health came by today, and the compulsory red-wine-and-backyard-cricket protocol was applied. And I bowled Declan's friend Grego not once, hit the wickets not once but twice, and got him out once caught behind. And there was much rejoicing.

Anyhow -

Today I saw a man who should be dead.

He was in the methadone clinic, one of the methadone success stories - a tall, sun-tanned, vigorous man with bright blue eyes and clean white teeth and a loud voice. He was, he told me, in better shape now than he had been ever in his life.

"You can get so much stuff once you give up the smack" he said to me. "that boat I got, the thirty footer, me and a couple of mates went out fishing. Bought myself a new colour TV the other day - one of those ninety eight centimetre ones, plasma flatscreen."

"Excellent" I said. Our tv is forty three centimetres, and doesn't seem to be able to pick up the cricket after sundown.

"Watching all the American shows, all the cricket, all the games - you got Foxtel, Doc?"

"Not really" I admitted.

"Want to try and drop those last few milligrams, finish up with all this" he said, referring to his almost miniscule dose of methadone. "This winter me and the missus, we're all going to Thailand for a few weeks. How good is that?"

"Never been" I admitted, possibly a little more tersely than I intended. "Anyway: how long since you've used?"

"July thirty first, 1996. Around nine o'clock at night."

I looked at him. "What happened July 31?" I said.

And he told me. Had his last hit - two hundred dollars worth, back when two hundred dollars got you something worth injecting, not the crap they had nowadays. Big hit, drove home. Big old Holden Commodore. Hit a tree on Sauron Street.

"How fast?" I said.

"Not much. Sixty, eighty at the most. But I wasn't wearing a seatbelt. Pretty bad."

He pulled up his shirt to show a long, jagged scar, from the sternum down around along the ribs on the left hand side, all the way around to almost the middle of his back. Another line down the centre.

"Christ" I said.

"Did eight ribs. Both lungs popped" he said. "Pneumo - pneumo-somethings..."

"Pneumothoraces" I said. "Your lungs collapsed."

"That's the word" he grinned. "Both lungs. Lacerated my liver, crushed my spleen into chunks. Broke my breastbone. Even bruised my heart muscle, they said."

"God". I nodded, put pen to paper.

"And ruptured my aorta."

"Jesus Christ" I said. I had a mental image of the great artery from the heart tearing, blood jetting straight from the heart into the - depends where the tear was, into the sac around the heart, behind the lung, up against the windpipe.

A full tear was almost unsurvivable.

"Are you sure? Tore the aorta?" I said.

"That's what the surgeon said."

"You shouldn't be alive."

"That's what he said too."

I gazed at him, at the picture of health. "What happened?"

"I was out for nine days. I remember the drive, I remember hitting the tree, I remember sitting in the seat while the ambulance men cut me out. Couldn't breathe, felt like I couldn't breathe. Then I got in the ambulance, I remember thinking if I didn't get in the ambulance I'd die, and that's pretty much it. Woke up nine days later."

I nodded. "And the heroin?"

"That's the weird thing." he said. "They put me on the methadone in hospital I reckon, and I been on methadone ever since. But the smack? Never really had a taste for it since."

So that's the ultra-rapid detox from heroin. Not the most popular method.

He was not the first "should have been dead" person I've spoken to. There was one guy in Florey last year, who came in with 'abdominal pain'. I pulled up his shirt. There was an ugly red scar, a scarlet "S" that ran from just below his solar plexus to his groin, plus a few punctuation marks.

"What happened here?" I said.

"Bit of an accident at work," he said.

I nodded.

"Got between a forklift and a wall. Concrete wall. Had to take out ten feet of gut."

"Any problems with that?"

"Don't reckon. Actually, it's good. I can eat pretty much what I like. I don't get fat."

"Okay. What about here?" Another mark like a comma.

"Stabbed in 1988," he said.

A brief silence.

"And here?"

"Stabbed in 1992."

I looked up at him and decided that was probably as extensive a history as I was going to take about his injuries. On the way out of the cubicle I saw his nurse.

"Anything we need for that guy?" she said, indicating Mr Kent's** cubicle with a nod of her head.

"Forget about it," I said. "The bugger can't die."

And then a few years ago, the strangest story. I don't know about this one. I can tell it how I remember it, and it seems unlikely, but from what I remember it seemed unlikely at the time... although the man telling the story had nothing to gain but much to lose by his tale. Anyhow:

Mr Turac was a thick-set Turkish man, hirsute, balding, more softly spoken than his appearance would suggest. He lay with his white gown pulled up, a blanket over his lower regions, while I pressed on his belly.

"There?" I pressed up underneath his ribcage, and he flinched.

"A little" he admitted. "What is it?"

I pulled off my gloves. "Too early to say. Could be gallbladder, but could be liver. We'll have to wait until the bloods come back."

"What do you think?"

"The pain you're describing, the way it comes on... probably gallstones. But you said you had some kind of hepatitis last time you went to Ankara, so we're looking into that. The ultrasound and the bloods will tell us a bit more."

"Will I go home tonight?"

"Possibly. But if there's infection or the pain doesn't go away, you may need surgery."

"No!" He paled, one of the few times I have actually seen that - the colour dropping out of skin. "No surgery."

I paused, but he didn't seem to want to say any more. I spoke. "It's a
frightening idea, I know. But it's very..."

I was about to tell him how safe it was when he told me what had happened to him, thirty years ago, in Ankara.

He was young, barely out of his teens. Fit and strong, the son of a businessman, wanting to go in the military. He wanted to travel. Not a stoic man, a sensitive and cautious one. So, when a friend suggested a business trip to the Sudan, he seized the day.

"One thing" said the friend. "It is wild country. Full of disease and madmen with guns. You must be prepared."

"How so?" asked Mr Turac.

"The malaria. The yellow fever. You have to have injections. There are injections now for rabies - very painful, but you must have them. And you must have your appendix removed."

"Removed? Why?"

"Because we will be many miles from civilisation, on dirt roads, and the vehicles will be driven by bandits or drug addicts***. If your appendix becomes infected, we cannot get you to medical treatment quickly."

And his friend pulled up his shirt to show a clean, almost invisible scar. He had had the surgery himself.

So Mr Turac goes in to have his appendix out. He did have some sense of misgiving - it was, after all, a perfectly servicable organ. It had done him no harm, in fact it had served him well all its life. And as far as anyone could see, it was a perfectly healthy and functional piece of tissue. It could normally look forward to a long and healthy appendiceal life.

But not now. Now Mr Turac was lying on a hspital bed, not unlike this one, in a white gown, prepared (physically, at least) for surgery.

They put the mask over his face. He breathed deep and counted, one, two, three.... and that was it.

Until he woke. it was cold, and silent. The room was light, everything was light. He could see no objects. He looked around.

Was this the hereafter?

He turned his head from side to side. There was a sheet over his face. He reached up one stiff hand and pushed, pulled at the sheet. It slid away. With difficulty he sat up.

Mr Turac turned his head. Two men sat at a chessboard, playing chess. One looked up idly, saw him, screamed, leapt up, scattering pawns and kings, and fled, his fellow fast on his heels. Mr Turac lumbered to his feet.

His throat hurt. His belly hurt, in fact it hurt like fire. There was a scar splashed with iodine, near his hip. His belly had been shaved. He tried to call out but he could barely speak. He lumbered out of the room, clutching the gown behind his buttocks.

And there in the silent corridor he waited, until a nurse came along and asked him was he okay, was he alright, was he lost, and he pointed to the room from which he'd come, and it was, of course, the morgue.

I don't know what to make of this story. This is what I remember him telling me - or what I remember four years later.

Is it possible that, as he said, that something had gone wrong, that he was pronounced dead in surgery, and woke up in the morgue? Is it possible?

I don't know. Possible that he "died" (in the weaker, temporary, modern sense of the word) in surgery? Certainly. Seen it happen.

Possible that, having died, resuscitation attempts were commenced and ceased and he was pronounced dead - and yet still lived? Of course - I have been in the resus room when we (not yet me) have pronounced a death in a man or woman (never a child) whose heart was still beating.

But that he was pronounced dead, treated as dead, irretrieveably dead, not only while heart was still beating but while lungs still moved, while his brain still fucntioned? However slow the heart, however slight the rise and fall of his chest, whatever they saw when they shone the light in his eyes?

I don't know. Even on the eastern coast of Turkey, thirty years ago. I don't know.

But I do feel that Mr Turac believed it. His terror, his pallor, his refusal to contemplate surgery in any event. And he was not a man with a long history of mental illness. He was a man with an otherwise sane and balanced view of the world, a man in a position of responsibility.

Who knows? I don't.

But I suppose we now know they play chess in the hereafter.

Anyway, back to cricket and merlot amongst the living.

Thanks for listening,

John

*That, by the way, is what killed Princess Diana. Or so I am told.

**Sorry

*** Apparently there are no words in Turkish for "I hope you have a great time, send me a postcard"

Pico

Not really that much of an entry today...

I should point out that this blog's brave new look (links that link and so on) is courtesy of Chade, who has apparently taught himself HTML or something similarly impressive. I can't even speak punch-card. I haven't got him to put all the links on yet - more soon.

Unfortunately I've been a bit tepid with the blogging. I think each person has only a finite amount of creative energy, only a certain amount of creative stuff to go around. I've just started my six months off from the ED (I tired, I go home now) and part of the Great Scheme of Things was to spend more time on the writing, particularly my attempt at a novel - so now I have to do it.

Minimum a thousand words a week. Sigh.

Anyway, I will post on this as much as humanly possible.

Tomorrow I will try to find a link to this movie I have found that may well redefine the professional-wrestler-who-becomes-an-octopus genre.

Thanks,
John

Sweet

In the winter of last year I worked in Florey with a nurse called Bianca. She was, and there is no other word for it, sweet.

What do I mean by that?

She laughed a lot. She had a discerning wit and a subtle sense of humour - i.e.: she laughed at all my jokes.

She seemed to genuinely enjoy working with patients - she laughed with those who laughed, mourned with those who mourn. I think I saw her cry once (she was the nurse who was with when we sat with Mrs Rose, the woman everyone loved and in whom we discovered cancer).

And she was a good nurse. Petite, blonde, smiling, she could calm the raging psychopath and convince the child to put the hissing mask over his face, and she helped old ladies onto the commode with as much dignity and courtesy as anyone.

She did get a little bit of hassle from the other staff - she was congenitally unable to swear, and referred to certain parts of the anatomy by euphemism: "a man in cubicle seven with a lump in his thing", "a woman in thirty three with a rash over her parts". But I could sympathise with the whole 'made to look silly by religious upbringing' thing, and emergency medicine can be a weird place for people who are a little shy. We liked working together.

I last saw her at Terry's going away morning tea. Terry was one of the older nurses, been in the ED since the early eighties. Nurses in the ED are either old school or new school, he was definitely amongst the old. Fifty years old, a lay preacher for some benign and respectable Anglican group, prematurely grey (his wife, cancer of the pancreas, five years ago, never quite the same since), putting the word 'doctor' at the end of every sentence unless you stopped him. Slower now than he had been, he had decided to leave before he was pushed.

"I can't keep up" he told me once. "All these new young things, reading ECGs and blood gases and stuff. I'm too old to learn that stuff."

Anyway, Terry leaves (big card, small but much appreciated gift), and a few weeks after that Bianca goes. She waas going to travel, go to the outback, work a bit in the remote hospital, Alice Springs, north Queensland, that kind of stuff. Terry went up to radiology nursing (sitting behind a desk all day, reading fishing magazines) and when they were gone I missed them.

And then today I bumped into Charmaine, one of the new breed. Never had much time for her, to be honest, nor she for me, but today she grabbed me and pulled me into a corner, eyes glinting.

"Guess who I saw at Alucard's?"

"Where?"

"The restaurant. Terry and Bianca. Having a meal together!"

I widened my eyes.

"Staring at each other like two lovebirds. Holding hands!"

"Bloody hell" I said, despite myself. Because Terry while a decent sort, was at best distinguished looking. And Bianca was officially hot, and had fled from both Dr Fauces the aristocratic surgery registrar and Brad, the eye-candy male nurse who was on some kind of tastefully nude calendar when he was in Brisbane.

"And you know where they met? You know where they go every week?"

I shook my head.

"The Coroner's Court. The Coroner's Court. I am not making this up. Every day off. Make a day of it together."

There was a pause. I tried to imagine the scene - both of them, holding hands where the judge won't be able to see them, sitting through the almost unbearably morbid findings:

"The said Court finds that Derek Andrew Leong aged 21 years, late of 100 Sauron Terrace, Mordor, died in the aforementioned hospital on the 21st day of October 2003 as a result of a result of neck compression from hanging, complicated by mixxed Diclofenac and Buproprion toxicity..."

"...was admitted to the Royal on 8/11/03 after her daughter found her nearly drowned in her bath after taking alcohol and mirtazepine. About 3 weeks prior to this she had found the body of her ex-husband after he had shot himself and then later had to identify the body. She has a medical history of..."

Her daughter states 'When she was out of my sight I heard a funny noise, a thudding noise. I ran inside to find her hanging onto the side of the table, in the kitchen. There was blood on the floor. I tried to help her stand but her legs were not working, they could not hold her up..."

"Professor Scourge stated that Dr Fomes failed to perform an adequate physical examination, as he apparently paid no attention to the deceased's abnormal vital signs. These included a raised temperature and a pulse rate of one hundred and fifty..."

And so on. Most people who end up in the coroner's court pass through an Emergency Department.

For a start, I reckon good on them. Thirty years different, beauty and the at-best-distinguished, more power to their right arm. Seeing beneath the surface - I don't get into the gossip much, but I might ask Dr Fauces how things are going the next time I see him.

And I like the thought of them, the demure, beautiful Bianca and the respectable, dignified Terry, sitting holding hands in the coroner's court, listening to tales of unsufferable tragedy, eating lunch together.

But it makes me think how wrong you can get someone, how you can be misled by big blue eyes and flaxen hair, or a steel-grey beard and a soft voice. You can underestimate people in the same way that Dr Fauces did, think they are the sum of their physical characteristics. Forget thatt these people are highly trained nurses, who have chosen to work in what one surgeon a few days ago called "the cauldron".

I don't know. The whole gore thing, can't really explain it to my satisfaction. I don't know if it's this need for emotional stimulation, if it's some kind of cognitive extreme sport, if it's some voyeuristic dependence on things graphic and intimate, a pathological addiction to emotional and medical pornography. I've always been a bit suspicious of why people do medicine.

But I suppose it needn't be bad. If people like that have it, have that dependency, then it can't be all bad.

No real conclusion here, but...

I miss those two. I might even pop down to the coroner's court one time to see if they're there. And I'm glad we had Terry and Bianca, and I'm sad we lost them, but I suspect the bond has not been totally severed. I think that the coroner's court is them keeping in contact.

Thanks for listening, and sorry about the last post...

John

Big

Hail,

I apologise in advance for this post.

Just before lunchtime at SMACHEAD, and a gap in the patient roster. My twelve oclock patient hasn't turned up, and I've just seen one of the more alarming people I've seen at SMACHEAD.

I called Mr Jarusnich in from the crowed waiting room, where he sat surrounded by empty seats. Even by SMACHEAD standards he caught the eye. Tall, balding, hugely muscled, tattos on his arms and hands and throat and face, flags and shields and intricate banners, in what looked like the Cyrillic alphabet. He wore a long-sleeved shirt and trousers in the thirty nine degree weather, and when I called his name he rose from his chair and waddled into the surgery.

When I see clients for the first time I try to spend some time just chatting. He was keen to chat, unusually so, in fact, and I spent twenty minutes or so listening to his views on women, his health, the situation in Serbia, the medical profession, and issues relevant to bodybuilding.

Then I escorted him out, wished him well, and got on the phone to the psychiatrist.

Body Dysmorphic Disorder is something I'd read about, but hadn't really seen. Like a lot of mental illnesses, the people who almost fit into the classification vastly outnumber the people who do - I've met many more schizoid personalities than people with schizophrenia, I've seen plenty more people who skirt around the edges of clinical depression than people who are clinically depressed. And I've seen a fair few males with unusual ideas about themselves and their appearence, but I've never met anyone in as deep trouble as Mr Jarusnich.

Simply put, he has made his body into a fortress, and while it protects him from his (largely imaginary) enemies, it also cuts him off from any communication with anyone who could save him.

First, the fortress. The buzz-cut hair. The legs like towers, the thick walls of muscle, the pectorals like bulwarks, the arms like cannons, the incomprehensible heraldry and slogans - expressing sentiments popular in the Serbo-Croatian conflict of a decade ago, slogans, he said, that would get him killed were he to return to Serbia.

And the isolation. He is perhaps the most isolated man I have seen. He lives at home with his parents, but it is a relationship described by his (ex)-psychiatrist as one of 'hostile dependency' - when Mr Jarusnich spoke to me today, it was with some difficulty, because his father had kicked him in the jaw and broke it.

He has no friends. There was a close circle of friends at the gym which he previously attended, but he cannot see them any more. In fact he has spent the last three months "hiding" in his house lest they should see him - for reasons which we shall get to in a moment.

And women? A fine figure of a man such as himself, a figure of literally Herculean proportions? Is there nobody?

This is where the poison came out. Why would a woman want him? he asked. Look at him. Look at those arms - he's got nineteen inch upper arms*. What woman wants a man with nineteen inch upper arms?

I shrugged, in that "go on" kind of way.

Exactly, he continued. They all want the men with the twenty inch upper arms. Big men, real men, men they can be seen with. What woman in her right mind wants a man with little arms like this?

He hates his arms, they are so weak. If he could he'd cut them off. He can't bear anyone seeing him like this.

Like this? I said.

The shrunken chest. The skinny legs. The polio arms. His voice, as he describes his flaws, becomes almost venomous with loathing, and he scratches at his massively muscled forearm, as if to claw it away. No woman would want to be near this.

No women? I said.

No normal women he said. The girls who hang around the gym - the twelve out of ten girls. The real women, women you can be proud of, women who you won't be ashamed to be with.

I don't remember if I was able to say anything to that, but he continued on, gaining speed.

"And I deserve a twelve out of ten woman" he continued. "I've done the work, I've put in the hard yards. But I'm fucked now. It's all come apart, it's all breaking down. All the gear I took, the heavy weights - it's screwed me up. My back's fucked. My knees are rooted. I'm having to lose weight - my knees are gone, my back's gone, three discs - I'm one hundred and twenty kilos - only one hundred and twenty kilos - and I have to lose weight! I'm having to strip down sixteen kilos over the next eight weeks, get down to a hundred. But I want to do it the right way, get really vascular, really ripped, really freaky."

"How are your kidneys?" I said, envisaging a man who had lived on protein for the last ten years cutting back on water and going into acute renal failure.

He waved his hand dismissively. "I've done it before, no worries. But I'm having to go to another gym, which is hard - its expensive, and it's down near Mordor, good hour and a half drive. But I gotta go because what if someone I know sees me like this?"

I shook my head. He continued. "Thing is, it's everyone. All the guys from the gym a few years back. Fucked knees, fucked back. Cancer, heart attacks. Testicular cancer. Some guys, nuts like raisins. Me, I'm on vitamins, supplements: vitamin A 3 000 units a day..." and he counted off a list of eight tablets on his broad, meaty fingers.

The conversation - less a conversation than a lancing of a boil - went on like this for close on half an hour. The constant fluctuating: the lacerating of himself for his weakness, the resolving to train harder, stronger, longer, the detailing of how his efforts to get stronger had made him weak, the increasingly extreme compensations which furthered the cycle...

This is a man who all day twists and turns and peers and preens in front of a broken mirror.

Anyway, I spoke to the psych reg at Florey. He said that there was therapy that worked in people with this kind of disorder, cognitive behavioural therapy or CBT. He didn't know about CBT in people with co-morbid body dysmorphic disorder (once called Adonis syndrome, or male anorexia) and drug dependence, but he told me where to start looking. And I've got a list of suggestions for the next time I see him, phone numbers and counselling appointments and psychiatrists who speicalise in this sort of thing... and I suspect I know exactly how likely it is that he will be interested.

Maybe I could tell him that CBT is actually some kind of illegal supplement, and the psychiatrist is a supplier.

Sigh. When I was working in psych, I discovered a new psychiatric disorder. Designed to nestle somewhere between Major Depressive Disorder and Multiple Personality Disorder, the newly minted Multiple Disorder Disorder classification would cover all those people who had symptoms of more than five other mental illnesses.

People who were depressed, anxious, schizoid, manipulative, dependent, passive-aggressive... all those words I used to throw around with such confidence, calm in my knowledge that they referred to other sick people, not healthy folks like us.

People whose Global Assessment of Function (aka GAF, the psychiatric measure of how well they were able to function in their daily life, coarsely referred to amongst medical students as the Global Asessment of Fuckedness) meant that they would not be amongst life's "doers", only amongst the "done to".

Well, this guy fitted the criteria.

Okay...

Major disgusting alert follows. I mean it. If you are delicate of stomach, or posessed of even the most rudimentary spinal reflexes, look away now.

And as if the Little Big Man was not weird enough, guess who is on the list for next week? The Vampire of Morbing Vyle**. He is being seen here for issues relating to unsafe injecting practices. This man, without a word of a lie, is here because he injects himself with other people's blood. I am not making this up. And it's not as if it is carefully cross-matched blood either, it's anyone who he can find who will consent to this. He came to us in crisis because the alleged donor had reneged on the agreement to regularly provide him with "sustenance", and he was undergoing withdrawal.

Christ knows what I can do about this, except refrain from eating garlic before I see him. Probably needs referral to haematologist specialising in folkloric creatures.

That probably comes a third on the roster of disturbing bodily fluid things I have seen in the last four years. As stated earlier, look away now...

It does not quite measure up to the woman with both psychiatric and respiratory complaints who kept all her phlegm in labelled jars, preserved in vinegar ("Does it look normal?" she asked me, as I stood in her otherwise normal looking house, pictures of border collies and paintings from the kids on the walls. "I mean, the look of it?" "I don't know" I said. "I've never seen phlegm in vinegar before.").

And neither does it come close to the extremely devout man, who took his Old Testament injunction against the spilling of seed upon the ground*** very seriously, and kept it, again labelled, in an orderly series of jam jars stored about the house.

Sorry for that. A trouble shared is a trouble doubled, or whatever it is they say.
My apologies for this probably unpostable post.

John

*In circumference, I should point out.

** Last seen way back in May 2005, true believer! Look, continuity, just like a seventies superhero comic.

Having said that, I don't know if it's the same vampire. Maybe it's a different one. Maybe this is just the beginning of a whole coterie of vampires who will be booking in to see me throughout my professional life. This place is starting to look like Transylvania.

*** Genesis 38, I believe. Apparently Dorothy Parker had a canary she called Onan, and when asked why, replied that he spilt his seed upon the ground.

This won't hurt for long

Hail,

A wee bit morbid, the following post. As they say in the football, if you don't want to know the score, look away now.

It was quiet in the ED this morning (which is just as well, since I didn't know I was on until they woke me at eight AM, and I am doing this on literally three hours sleep and last night's bottle of Merlot). Sarah and I stayed up until five this morning watching House. Good drama, good person, bad doctor.

Anyway, the overnight staff had seen a man with a paracetamol overdose, and sent him off to the Royal just as I arrived, in what I once heard referred to as a "transfer TDT".

People can be transferred to the Royal for various kinds of surgery, for an MRI, for assessment by a neurosurgeon or an endocrinologist or one of the several kinds of ologists that they have and we don't.

Or patients can be transferred 'TDT', which means "to die there". He was one of them. Rather distressing.

Anyway, the paracetamol overdose (I believe you call it acetominophen over there) reminded me of one night a few years ago in Shipton, when I lied to a grieving family in the presence of a dying man.

It was two years ago, in the early spring after a wet winter, and during those last few months at Shipton, when it was as bad as anyone thought it was possible to get.

It was a busy night, and it was made more difficult by the preponderance of junior doctors we had. We had Dr* Sutekh (hardworking, but neither smart nor easy to get on with), Dr Zygon (easy to get on with, but daft as a brush and treacle-slow), and Dr Miaow, (smart, hardworking, easy to get on with, hot... in fact so smart she transferred to a large private hospital as soon as she worked out what was going on. She left Shipton for Saint Dymphna's after two weeks - a private hospital in the centre of town, catering exclusively for the wealthy healthy).

So I was trying to keep the body count down in my side of the ED, when Mr Grieve was brought in by ambulance.

His family told an unusual story. He had been unwell, they said, for a few days, more unwell than usual (what with his rheurmatism, and his drinking, and his depression and so on), and he'd seemed to be off his food. Then he'd come down the stairs from his bedroom and in front of their eyes, collapsed on the kitchen floor. So they'd called the ambulance.

I looked at his bruised and discoloured side, and the shadow on the chest Xray of early pneumonia.

"And when was it that he collapsed?" I asked.

"Tuesday" they chorused.

"So he's been lying on the kitchen floor for... three days?"

"I put a blanket over him" said his wife.

I stared. There was a pause, which the wife ( quite uncrazy to look at), stared back at me. After a minute she spoke.

"He does this kind of stuff all the time. Never happy unless he's the centre of attention."

"Well, he doesn't look that happy now" I said. "He's been lying on one side for three days - his skin is starting to break down. Plus, I think he's got pneumonia. Anyway..." and I described the various tests we'd do, the xrays and blood cultures and recordings of his heart, and we moved on.

Half an hour later I got a chance to speak to Mr Grieve alone. He was not well, and we spoke only briefly. He had little to add to the story - he remembered having a fair amount to drink that night, he'd been very depressed. He hadn't felt any chest pain or shortness of breath, he hadn't taken the wrong doses of his medications - was all this fuss really necessary? Couldn't he just go home?

I smiled and shook my head in that way people do when they know better than you do, and said we'd wait to see what they had to say. And then I went off and tried to sort out 28 Year old Woman With Cramping Pain In Abdomen.

An hour later - things had been busy - I logged onto the computer to find the blood test results.

"Oh my God."

"What's wrong?"

"The man in cubicle seven," I said. "He's dying."

I'd tested for levels of paracetamol in the blood, just in case. His levels were monstrous, over a thousand micromolar three days after dosing. Much too late for NAC, the only antidote, to have anything more than a theoretical effect. I'd done liver function tests, they were bad. His liver was already starting to necrose, to break down.

Jesus. He needed a transplant. We could send him to the Royal, put him on the transplant list... but his liver had only a few more days of function left, he needed a transplant in the next week. The Royal didn't have spare donor livers lying around, a few ice-cream containers in the fridge. There wasn't going to be one.

He was going to die.

Christ.

I sat for a few minutes, trying to rearrange the words in my mouth to make them seem less horrible. In the end I walked into his cubicle. It was silent, the light down low, the garrulous, chattering family outside having a collective cigarette.

"Mr Grieve," I said. "Can you hear me?"

His conscious state, as I remember it, was fluctuating - awake one moment, asleep or confused the next.

He opened his eyes, looked at me.

"I've got your blood tests back." I said. "They are bad."

For a moment he looked away, then looked back. Eyes wide.

"Sir, a few nights ago. Wednesday. The night you collapsed. Did you take your medication?"

He nodded. Like a lot of chronic pain patients (looking back now, the risk factors were there in abundance - male, forties or fifties, chronic pain, dysfunctional family, previous alcohol abuse, depression - he was on an unusual amount of medications. Antidepressants. Anti-inflammatories. Anticonvulsants for nerve pain, morphine and codeine and panadeine forte.

"Sir, is it possible that, for some reason, you may have taken a larger amount of panadeine forte than usual?"

A pause, then a nod.

There was a long pause. Somewhere in the fishbowl the box crackled, an ambulance on its way. I didn't have long. Neither did he.

"Sir, I have to ask this. People, people who are unwell, people who've suffered with depression...when you did this, when you took the panadeine forte, was it possible you were you trying to end your life?"

Nod.

I continued. "The blood tests, Mr Grieve. They're very bad. The panadeine forte you took - it seems it has damaged your liver. Badly. It seems your liver is failing, shutting down. Basically, you need a transplant... very very soon... or you will die."

There was a silence. His eyes were bright with tears.

He managed one word. "How -?" and fell back on the pillow.

I remembered the rest of the blood tests. Deranged liver function, white cell count up, probable pneumonia... he was lucky to be speaking at all.

"How long?"

He nodded.

"A few days, maybe. Maybe as much as a week. Not two weeks."

There was another silence. He seemed to sink into the mattress, head settle back down into the pillow, as if his body were already breaking down, returning to the earth.

Outside I could hear voices raised in conversation, someone on a mobile phone. The family returning. I thought of his wife leaving him lying on the floor for three days. The centre of attention. I looked at Mr Grieve. He face was turned against the wall.

"Sir - when your family comes in, do you want me to tell them about the blood tests? About the liver?"

He stared straight ahead, shrugged. I waited. After a while he nodded. A woman's voice asked a question outside, a nurse answered - said doctor wouldn't be long.

"Sir. People who take too much of their medication. They do it for a number of reasons. Sometimes they make mistakes - take some tablets, forget they took them, take them again, and so on. It happens all the time."

He nodded.

"If you want, that is what I can say. Is that what you want me to tell your family?"

He looked at me, and I noticed the colour of his eyes for the first time, a remarkable deep blue, the colour of the sky at the very zenith where the atmosphere is thinnest, that soft, dark blue that barely masks the emptiness and blackness of space behind it. He nodded.

And the door opened and in they came.

There was a lot more after that. I left them together, went out and checked the amubulance - some man thrown from a horse, and something Dr Miaow could do in her sleep - and went back inside.

Mr Grieve was lying, eyes closed, face against the wall. Apparently asleep.

I explained, in low tones. Chronic pain, depression, multiple medications, understandable confusion, very common. Confusion leading to re-dosing with his medications, more confusion - a rapid cycle. And the Royal, they were the best at this kind of thing, they had all the transplant doctors, the best facilities in the state. Althought I did have to emphasise that the likelihood was very very small, and that the most likely outcome was that Mr Grieve was going to become weaker, more confused, and die. Within a few days, maybe a week. Not as long as two weeks.

The family nodded, asked questions in hushed tones. His wife sat beside him, wiped her eyes, clasped his hand. I asked if anyone had any questions.

"I should have seen this," she said. "I should have told somebody."

"Told them what?"

"A few days ago. Monday night. When he took the overdose."

Her son said "Mum, it's not your fault," but she shook her head. "Monday night. I was down watching tv and I kept hearing the tap running. Upstairs, in the ensuite. Just running for a few seconds, then off. Then a minute later, on, then off. Same thing, over and over."

For the first time that night I felt cold.

"Like he always did, when he took his tablets. But it just went on and on and on..." she said nothing.

"You weren't to know," I said. "Nobody's to blame. This is just one of those terrible things. Look, I'll go arrange an ambulance. Back in a minute."

And I went out, and got on with stuff, and popped my head in occasionally, and the ambulance came and took him to the Royal, "transferred TDT." And his family, silent, weeping, attentive, followed in their wake.

Anyway. Every since then, every so often, when I hear a tap run, I think of him. The man standing alone in his room, handful after handful of panadeine forte, and his wife downstairs listening, hearing but not understanding. He got to the Royal, and I rang the transplant registrar at the Royal a few weeks later, and it wasn't a name he'd heard, and his file at the Royal is now marked closed.

Anyway. There are a few more transplant stories, the accidental suicides, the feast days of the transplant unit... but I feel the need for a bit of quiet now, myself.

And thanks to everyone for their support over the last few weeks. Means a lot.

Thanks for listening,
John

*Note: for reasons which will be clear to no-one but myself, I have decided that as most of the Florey doctors generally have archaic medical terms for names, most of the Shipton ones are going to have names of Doctor Who monsters. The parallels between my two or so years in the Shipton Emergency Department and a low budget, rubber-suited-monster TV show should be pretty obvious.

The Second Broken Heart

Or I could just post from another computer....

Hail,
Another day in the high thirties. Waking at eleven, scrambled eggs for breakfast, lying around reading books with Sarah. Today my niece gets back from visiting her mum, and we are making the most of the silence.

A few days ago I told the first in a diptych of stories of broken hearts. The first was the big man, the machinist in the fifty degree heat, and my blundering interactions with the cardiologist. He ended up staying with us, by the way, and left with a set of detailed instructions about what to do the next time he gets chest pain, and how much sooner to do it.

Now - the second broken heart.

And this is one of the more adult things I have ever posted here. Even anonymised as much as it is it's horrible on a number of levels. Don't read on if you are not the kind of person able to read horrible things, or if this is not what you want to read today.

Mr Calvary was a man in his late fifties, steel-grey hair, bulbous nose and bright blue eyes, who came in as a priority two with chest pain. As soon as I walked in to treat his chest pain I felt that something about him was oddly familiar. It was a relatively quiet night (like frutipicking or whaling, emergency medicine is a seasonal occupation, and summer is the silent season), and when he arrived he was the only conscious man in the high acuity cubicles.

I took the bloods and gave the appropriate medication while I asked him about his pain. He was presenting with resolved atypical chest pain, chest pain that had gone away by itself and was unlikely to be caused by his heart, but still required investigation so it was a less frenetic affair than that of Mr Grande a few hours later. Still, the nurse gave him an aspirin to drink and put oxygen tubes up his nose and an ECG and I took the first of his eight hour blood tests.

All done as quietly and respectfully as possible, because Mr Calvary was crying.

This is not an uncommon thing. Chest pain is terrifying, one of the three or four intrinsically terrifying symptoms (along with "I can't breathe", "I can't move", and "I can't stop bleeding"), and hospitals are terrifying places. And men who are terrified will sometimes cry before speaking. Not some uncontrolled sobbing, not even an alteration in vocal tone or facial expression, just bright eyes filling with tears that slowly trickle down their faces.

I tend to say little at these times. I say a very few things, which vary with the patient and the prognosis:

Much pain in the chest is not the heart
or
You did the right thing coming to hospital
or
Heart attacks are not like they were in the fifties, they are very treatable, survivable events, my own father had one two years ago and now he's up on the roof clearing out the gutters
or
We're sending you to the Royal, they're the experts at this kind of stuff, they can do whatever has to be done
or
Is there anyone you want us to call?


And then a brief time in silence. At times like this there is the danger of talking for your own comfort. Times like this the more you say the less people hear.

After a few moments he spoke.

"I gave up smoking a few years back. Did I say that?"

"You did. Excellent. Damn hard thing to do, isn't it?"

He nodded. Then spoke again. "I forgot to say, my dad, he had a bit of a funny heart-beat a while back. That can't have caused this, can it?"

I shook my head. "Doubt it. But it's good to know. We'll look into it."

He'd told me that, too. There was a pause while I busied myself taking blood. There was something he wanted to say, something that had to come out.

"I've been under a bit of stress," he said, finally. "My son, Jacob."

I waited.

"He came in here. I think you might have seen him. He did... he did a terrible thing." There was a pause. "But he wasn't himself when he did it."

I remembered him now. A few months ago. This man's face, as pale and lined as now, in the background of a small crowd. Standing with all the others outside the cubicle while I sat inside, speaking to his son. Mr Calvary, pale, shocked, standing with the six or eight men in the dark suits. Detective sergeants, detective inspectors.

And I remembered speaking to his son. A thick-set young man with an open, honest face, late twenties, early thirties, tightly curled black hair, wideset blue eyes. Talking to us, the psych nurse and me, speaking soft and low. Sounding open and honest and like he was trying to explain things to us and be as helpful as he could.

Dried blood on his hands.

I remember him telling us about what had happened - telling us how he had had a few drinks, nothing special, three or four beers, had gone for a drive. Didn't remember going over to where his ex-wife was living, the other end of the city. Certainly didn't remember anything after that.

And the next thing he remembered was standing on his father's doorstep, six o'clock in the morning, ringing the doorbell. Saying he'd done something... unspeakable.

I remember as we spoke I could hear more and more detectives turning up outside. Soft voices, low murmuring. Myself and the psych nurse running through the alternatives - dissociative fugue? unmedicated mania? schizoid delusional state?

And then, when we left the cubicle, at the edge of that group of people, his father -steel-grey hair, bulbous nose, uncomprehending look. Documenting everything a thousand times.

Going home. Not sleeping all that well.

And the next day the newspaper reports - was it two dead, the young woman and her father? Beaten to death, some kind of wrench or hammer? And the mother and the student lodger, critical condition in Mordor?

"I remember," I said. "I saw him." His father nodded.

And the newpaper article a few days later. Hanged himself in prison. I took a one and a half hour break that day when I heard, sat in the courtyard, stared at the ghost gums and the candlebarks.

"I thought you did," he said.

He looked at me. "I suppose you heard what happened?" He started to cry.

I nodded, put a hand on his shoulder.

"We've been under a fair amount of stress. On the heart."

I nodded.

"He wasn't himself," said Mr Calvary, and he started crying again. "He wasn't himself."

"I know," I said.

"He wouldn't have done it if he'd been himself. He was a good boy," said Mr Calvary. "A good boy."

"I think he was," I said.

"He couldn't stand to be without her, you know."

"I don't think he could."

The crying stopped. I stood there a little bit longer, kept my eye on the ECG.

Anyway, we talked a little more, and his chest pain settled down, and when I left that night he was asleep. And the blood tests came back negative - the lab resassured us that his heart was not damaged.

Of course it wasn't. It was only broken.

Anyway. That was only the fourth patient of mine who has suicided. The only one who has suicided within a few days of being seen by me. And this isn't about who was to blame - we all knew he was at very high risk, somehow he managed to get past the safeguards. More on that later.

And maybe not. I don't know that this is postable. I don't know that this man's pain - and by this man, I mean the father, not the son, the one who was left to carry the weight, not the one who broke beneath it - I don't know that I can tell people this. I don't know if there is anything that he would want me to say.

I don't know. There is a question here that I am dancing around. Using people's suffering as entertainment.

See, when I first started this, it was for a number of reasons. I was trying to get my head around soome stuff, I was trying to keep a record so I would not forget, there was the raw material for the book, the tv show, the whatever. Career stuff - should I stay or should I go now, that kind of stuff.

But I don't know. The whole posting thing - I've been a bit ambiguous about it recently. I feel there may be unpalatable truths about what I post that I am unwilling to face.

Some of this stuff is about me. When it's about me, that's okay - at the worst it's some kind of exhibitionism, some kind of borderline behaviour. Maybe you grow out of cutting and overdosing and stuff into writing. The writer as the narcissist with boundary issues and a need for constant approval - an axis two disorder, a personality problem.

But at the worst, that's self-indulgent. Its when it's this trafficking in other people's pain... that's different. And I know that it's pretty thoroughly anonymised, and most of the patients are a palimpsest of two or three or four people I've seen. Sadly, Mr Calvary was not the first father of a murderer I had seen, and he is a deliberately artificial construct - the face of one, the medical history of another, the sins of the son of a third.

I don't know. There is this implicit assumption in medicine that information is freely distributable as long as it is anonymised - if you turn up in the ED with an interesting tumour, you can bet that someone will be making a powerpoint presentation about it the next week, and if you're really lucky you'll be a paper in the Annals of something. People are meant to ask, but I know that often they don't: my morbidly obese man from a few months back was still lying in the Royal with a tube shoved down his throat when I did my registrar presentation on "A forty year old man with sepsis".

Is it an act of violence to take someone's story? Can someone own what is said about "them", no matter how obliquely, how altered or obscured? I try to make sure that I alter every detail of every 'patient' I talk about - if you read about a slim Asian woman in her forties with gallstones, it was probably a zaftig Caucasian woman in her twenties who actually had the gallstones, and the Asian woman had something pancreatic, and so on. The conversations, the people, the cases are real, but it's not always the same patient and the same pathology.

Anyhow. It still bothers me. But I don't know that I'm moral enough a person for it to stop me writing.

Thanks for listening,
John

Gap lesion

Hail,
I haven't been (and won't be) posting for a little bit - we are in the midst of getting a new computer and so forth. Will post more regularly - or less infrequently - as soon as possible.

Thanks,

John

The Five People You Meet In Mordor

Hail,

Briefish missive, hopefully more in the next few days.

Saw a kid today at SMACHEAD and he looked somehow familiar. So on the way home I stopped off at Florey (I had to do a bit of paperwork) and checked up his name on the records.

Yep, seen by me four years ago. Today a strapping lad of nineteen, with hair like Absolom and consuming much more than his recommended daily allowance of amphetamines.

But back then he was fifteen, and a much less substantial figure, and reminded me of one of the few times I have laughed when someone has told me their troubles.

He was brought in to the ED by his mother (one of those chilling examples of genetic prepotence: same red hair, same jutting chin, same 'they say I'm paranoid' outlook), having being the victim of an assault.

It was, on the face of it, a most distressing case. Young Heath had been waiting at the traffic lights on his bicycle outside the local pub, about five in the afternoon. Suddenly the doors of the Devil's Armpit flew open and a very large and angry man, whom Heath had never seen, flew out and for no reason vigorously attacked him.

A brief melee followed, during which Heath sustained a blood nose and a ringing eardrum, and at the end of which the man disappeared - fleeing the scene on the child's bicycle.

"Good Lord. Beat you up and stole your bike?" I said, peering up his nose with the auroscope*. "How terrible."

Heath nodded, and his mothers lips became even more pursed.

"Have you gone to the police?"

Mum nodded.

"Good" I said. "The guy who attacked you - did he say anything?"

"Hardly anything."

I switched orifices and peered into his ear. "What did he say?"

There was the briefest of pauses, and then the wronged child spoke up. "He said "That's my bloody bike"."

"Aah." There was a longish pause, during which Mum refused to meet my gaze. I stood back, stared at his eyes. "Right, keep your head still and follow my finger with your eyes. That's a bit of bad luck. How long had you had it? Your bike, I mean?"

"Only a couple of hours" he said, in injured tones.

"Birthday present?"

"I just found it that morning."

"Aah. Found it?"

"Yeah, abandoned..."

"Bit of good luck" I said. "Where was it?"

"Just lying in some guy's front yard. Abandoned."

There was another pause, during which I may or may not have murmured, "No further questions, your honour." Mum studied the wall, the kid looked back at me with that wide eyed (well, one wide eye, one swollen closed one) expression kids use when they want you to believe something that would tax the credulity of a cartoon animal.

"Okay, most of this is superficial bumps and bruising. You'll be a bit stiff for the next couple of days, but you should be okay."

"What about the police report?" asked his mum. "They'll need to see the notes."

"I'll document everything," I said. "Everything relevant, anyway. If the police want it, they can subpoena it. They take these kind of assaults quite seriously," I said. "Leave no stone unturned, that kind of thing. I'm sure justice will be done." Heath began to look concerned. I patted him on the shoulder.

"Don't worry," I said to him as they left. "Truth will out."

The whole "for no reason, some guy" thing reminded me of what we worked out once were the Five People You Meet In Mordor. I should point out here and now that a disproportionate number of people I meet in my work who have problems dealing with other people, or indeed problems dealing with reality, who have unreasonable expectations and non-negotiable demands, who have much to say but little to offer... many of these people are my fellow doctors.

But not all of them are, and having just spent the morning with the Demon Dentist of Fang Rock, here are my five people you will meet again and again and again at Mordor... or any sizeable Emergency Department.

Person One is, as stated, the innocent young male assault victim. As the story goes, he is engaged in some harmless or even praiseworthy pursuit: attending the opening of an art gallery, say, or helping out at an Inner Slytherin soup kitchen. Suddenly, "for no reason, some guy" leaps on him and assaults him, and he limps or flees or is carried in to see us.

It is notable that none of the assaulters, and none of the assaultees who in any way contributed to whatever violence ensued ever present to Florey.

Occasionally, of course, it's not "some guy", it's "a bunch of 'black guys'". The police have got to find this group of Aboriginals and stop them. They are giving their fellows a bad name.

So, Number One is the "Young Man Minding His Own Business When Suddenly..."

Number Two is the "Man or Woman Impervious To Reason". I saw an example of this within the last week. The teenager, hobbling out of the doors of the ED on crutches, mobile phone in one hand and cigarette in her mouth, speaking to persons unknown "Yeah, and they say it's some kind of blood clot or something...".

I.e.: Something you have now, that could conceivably kill you now, that is caused by smoking, that you are telling someone about... while smoking.

And I know stopping smoking is hard, but for Gods sake - maybe an hour or two while we wait to see if you need an embolectomy**.

There are also the "Woman Who Doesn't Understand Where Babies Come From" presenting for her eighth emergency contraception pill in three months, the "Man Who Doesn't Understand Why He Shouldn't Drive Home To Get Pyjamas On The Same Day As His Big Heart Attack" and "The Man Who Says He Will Kill Himself If He Doesn't Get Help Soon, But Not Friday Because That's Pay Day, And He's Getting A Carton. Maybe Sunday".

All this giving up smoking stuff reminds me of one of the very first patients I saw, and still one of the more unorthodox medical presentations and responses I have ever seen. We were set out to sit in on GPs ofices in the first month of medical school. Only the very best GPs volunteered for this presumably unrewarding duty, and some of the best GPs had ... unusual ways of doing things.

I was in Dr Cantharides office in an old practice in the Hills, looking and learning when a sixty year old couple brought their father/father-in-law in.

"We want you to tell Dad to give up smoking," they quivered self-righteously.

"How old is he?" said Dr Cantharides.

The old man opened his mouth but his son-in-law spoke. "Eighty-four."

"And how much does he smoke?"

"Three cigarettes a day. Every day."

I glanced over at the wizened old figure, big blue eyes downcast, and felt a flash of sympathy. Poor old bastard, it was probably his only pleasure. I looked up at Dr Cantharides.

"Mr Seymour," he said. "Eighty-four years old."

The old man nodded.

"Fought in the war, then?"

"Infantry," grinned the toothless man. "Then mechanic on the tanks for a while, up in Darwin."

"What'd you do after the war?"

"Mostly worked on the railroads. Out on the Nullarbor."

I had this brief, vivid mental image of this man, fixing tanks in the tropical heat, facing machine guns in the jungle, hammering railway spikes in the desert. Building a country and making it safe.

There was a long pause. Doctor Cantharides spoke. "Any weight loss, worsening cough, chest pain?"

"Fit as a mallee bull," said the man.

Dr Cantharides sighed, opened his mouth, closed it, turned to the children, then turned back.

"Well, sir," he said. "I have, as I am sure you are aware, a medical duty to perform here. Nicotine is an evil drug, responsible for many young lives tragically cut short, and many otherwise healthy and productive men being condemned to a life of invalidism. I feel it is my medical duty to warn you that if you keep smoking like this, you'll drastically shorten your life, and risk no longer being able to work. You may even have to accept some kind of pension."

He paused for effect, leaned forward and pointed directly at the old man's chest. "If you keep on like this, you won't see one hundred and fifty."

There was a pause while I bit my lip.

"I don't think this is a laughing matter," said the son.

"I bloody do," said Dr Cantharides. "The guy fought in the jungle, for God's sake. In fact, Mr Seymour, have this." He reached into his drawer and pulled out a cigar. "It's Cuban. Got a light.. hold on," and he started to hoke around in his drawer "I had an old lighter around here somewhere..."

Anyway, the conversation became considerably brisker after that, and in the end Dr Cantharides suggested that they may have more luck with, as he put it, "some other doctor. Somewhere else. Not here. Goodbye"

Thanks for listening,

John

*Source of the worst doctor joke ever:
Nurse, fetch me my auroscope!
But Doctor, I don't even know what star sign you are!

** Admittedly, pretty extreme. But it was apparently on 'House' last year, so it must be true.

Better than love...

Saw a very strange thing today.

I was taling to Mr Wormwood, a gaunt, long-haired man recently discharged from prison. He was remarkably tall and thin, a tangle of acute angles, hunched uncomfortably in his too-small chair, with home-made tattoos on his hands and face, and a home detention bracelet around his ankle. He was here for fortnightly "script review", which means we check how he's going on the buprenorphine (a medication for drug dependence), see how he's handling the cravings, see how everything else is going... "having a friendly chat" as my boss said.

Or we would be if the bugger would tell us.

"So, how's it going on the bupe?" I said.

"Alright"

"Are you getting any cravings?"

"Nope."

"How's the sleep? Any sleep disturbances?"

"Nope"

"Some people who use bupe finds it makes them sweat. Any trouble with the sweating? Course, it's been pretty hot the last few days..."

"Nope."

"And the stress levels? Adjusting to stuff on the outside?"

"Yep."

"Mood alright?"

"'salright."

I noticed I was starting to speak in shorter sentences too, as if language was an ability we were both gradually losing. In a few minutes we'd be huddled on our chairs like not-so-great apes, grunting at each other and chewing on sticks.

I stared at him for a moment, and he stared at the floor. Outside an ambulance keened by, the summer sun shone, a bird muttered threats in a tree. I'd asked everything on the list and he'd answered it and we'd got all the right answers and we'd got pretty much nowhere. I decided to try something different.

"You mind if I ask you a personal question?"

He looked up at me.

"The home detention thing, the whole 'three times a week' urine tests. You've been drug-free for ... three months now."

"Yep".

I paused, wondering how to frame the question, then deciding to be honest about what I was asking.

"Do you miss it?"

And his face lit up. The hard angles around his mouth and eyes softened, he grinned, a great, slow, gap toothed grin. He leant back in his chair, as if reminiscing, then leant forward.

"Like nothing else" he said. His voice was soft and low, almost conspiratorial. "Like nothing fuckin' else. Especially days like this, paydays. We used to go out first thing, score some gear... get a couple of grey nurses*, maybe a great white**... we'd be off our fuckin' faces by lunchtime. Go round to me mate's house, he'd have a carton of Victoria Bitter... Jesus."

He paused for a moment, savouring the idea, and gazed off over my shoulder with such intensity I almost turned around to look at what I could not see, had never seen. From whaere I sat, the tightness in his neck and shoulders had dissolved, his pupils were large and dark.

Honestly, that sounds unbelievable, but.... It's a look I've only ever seen on someone cradling a child.

"Right" I said, slowly. The switch was flicked, the light inside him went out. "I might bring your next appointment closer."

And I suggested an increase in the dose, which he grudgingly agreed to consider, and after a few more pleasantries he was on his way. To call in next fortnight, and the fortnight after that, and every single appointment we make, and answer all our questions, and piss in a pot for us... until the bracelet comes off in about three hundred days time, and he can get back to what he was really doing before we interrupted him, back to his real life.

Thanks,
John

* a tablet of morphine sulphate 100mg

** don't know what this was, neither did he. Some bloody big white tablet, apparently.

Who would have thought....

From something I saw on Chade's site....

Your results:
You are Spider-Man

Spider-Man 100% The Flash 70% Green Lantern 70% Catwoman 55% Superman 45% Supergirl 40% Robin 40% Hulk 35% Iron Man 30% Wonder Woman 10% Batman 0%

You are intelligent, witty, a bit geeky and have great power and responsibility.

Click here to take the Superhero Personality Quiz


Plus a random thought inspired by said quiz: as we all know Peter Parker was bitten by a radioactive spider and became Spiderman, with the proportionate strength, speed, etc. of a spider.

Now, there is actually a Marvel comic book villain called the Radioactive Man: what would happen if he bit a spider?

Be still, my beating heart... actually, don't.

A brief intermission at SMACHEAD, and something that happened a few days ago in the ED.

This was the third day of the run of hot days. Summer this year has come late, with Christmas day cricket being played under overcast skies and the grass still green by the side of the road, but it seems to be making up for lost time.

So, three days of temperatures around forty degrees - one hundred and four in the US. Children with sunburn, old ladies with headaches, my bicyclist who almost cycled himself to death, and two broken hearts.

The first was Mr Grande, a huge man, easily one fifty kilos. Broad-shouldered, big-bellied, loud voice. He worked in a machine shop, lifting and working with huge machines, temperatures in the low fifties .

That's over one hundred and twenty degrees, working. Thank Christ I don't have to work like that for a living.

He'd been forced into the ED by his wife, and when pressed confessed to the odd episode of chest pain in the last few days. Just a dull ache, centre of his chest, going down both arms. Came on when he got breathless, made him feel like he was going to vomit. Seemed to get worse when he did something, like lifting that big manifold the other day. Fair made his heart race.

By this time Mr Grande had the undivided attention of three nurses and two doctors, especially when his ECG came out almost unreadable - it was a pattern called left bundle branch block. LBBB of itself can mean a number of things - a problem with the big valve between the heart and the aorta, abnormal growth of part of the heart (maybe in response to some other problem), an abnormality of the heart muscle itself - or a recent heart attack.

I got on the phone to the cardiologist. Florey doesn't have a 24 hour cardiologist -most of them work at the Royal. We have this complicated protocol where if a certain kind of heart attack patient comes in (and we didn't know this was one, but it was starting to look pretty much like it) we contact the on-call cardiologist and get them sent up to the Royal for 'stenting' - insertion of a thin tube into the blocked artery, solving the problem.

In the interim I left Mr Grande in the care of our medical registrar, Dr Anya, who used to be one of our top emergency registrars before she worked out how much better hours almost any other job had.

"You'll like Dr Anya. And she's very very good." I said to the nervous man. "In fact" and here I leant forward and lowered my voice, "you're in luck, because she's as clever as she is beautiful." He grinned, and I turned to walk out the door, and then paused. "Unfortunately for you, so am I - no, just joking, just joking. Nurse, maybe turn up the anginine a little more, Mr Grande looks distressed..."

I had not actually done this before (called the cardiologist for a transfer) and I was surprisingly nervous. Part of my brain was watching cubicle three, where Mr Grande stared bemusedly at the nurses flurrying around him, setting up infusions of mysterious liquids into each arm and popping tablets into his mouth - part of my brain was trying to stop the other parts panicking, and part was remembering my previous, not entirely happy, dealings with cardiologists.

There is a hierarchy in medicine, in a way the entire set-up resembles the renaissance Papacy (with consultants as cardinals and interns as penniless parish priests), and somewhere at the very very top are the interventional cardiologists. The men (overwhelmingly) who, when your heart starts to die because a blood vessel is blocked by fat or scarred by inflammation, will insert a thin wire in through the big vessel in your groin and save your life.

To a man* they are terrifying. An interventional cardiologist is good, and he knows it, and often, in medical school, he makes sure you know it too. From the cardiology viewpoint, a stethoscope is a telephone line to God... and when the cardiologist calls, God better pick up. At Mordor, where I did my medical training, Professor Maul was wont to pick the most nervous student out of the group and reduce them to tears of humiliation... without thinking or effort, the way someone else unlocks their car or peels an orange.

So I rang, to get the $300 000 a year man out of bed, just on midnight.

"Dr Mishka speaking" said Dr Mishka, sounding just like a normal man who had been fast asleep in his bed.

"Sorry to bother you, Dr Misha" I said. "My name is John Bronze and I'm calling from Florey with a 48 year old man with a history of chest pain and first presentation LBBB."

"It's Mishka" said the great man. "How stable is he?"

"Better stay away from the surname" I thought. "No haemodynamic compromise, Dr Mischa" Aaargh!!

"Mishka" said Dr Mishka gently. "And you've given aspirin, anginine, heparin...?"

Calm down. "It's running now, Dr Mothra". Jesus!!! I tried to grab hold of my tongue and pull it out of my mouth.

There was a faint sigh, but the gentle voice continued. "Well, that's okay then. Now, you may have rung the wrong number, because I'm not actually on call tonight - it's Professor Maul's night. But you're doing all the right things - write him up for some verapamil and give Maul a ring. Tell him you've discussed it with me. That's Hanif Mishka."

Anyway, it was funny at the time.

The second broken heart of the night was less so. I will post the tale of Mr Calvary later today... before lunch if my Cambodian prioson release doesn't make it in here.

Thanks for listening,
John

*With one exception, Dr Beatrice Corde, the single most universally admired doctor I have ever met. And the most terrifying. Ailing heart muscle does not die when Dr Corde treats it... it doesn't dare. One man told me his cholesterol count had dropped by ten under Dr Corde "probably out of terror", and another told me he had decided to give up smoking when she marched into his cubicle, grabbed his "secret stash" of cigarettes and hurled them out the fifth floor window.

John

Brand New Day

Hail,
And after a string of days in the low forties (don't know what that is in the non-metric parts of the world, but I think it's over one hundred), this morning the hot spell was broken. We awoke (late) to gusts of rain and a soft breeze coming in from the sea, and six new born baby chicks running around the back yard. Everything old is new again. The cats are affecting nonchalance, but everything that was dry yesterday is now soaked or slippery or speckled with rainwater, and today even the fish were hiding from the deluge.

If this was a musical I'd be swinging around a lamp-post and dancing.

Anyway. New Year's Day.

I had Christmas Day off from the ED this year, which means I pretty much volunteered to work New Year's Eve. And all went well.

I seem to be really enjoying work in the ED lately, so much so that I am starting to regret the six months off I will be taking. The whole "disaffection/dissociation/going through the motions" thing seems to have vanished, which suggests that it was a kind of cumulative exhaustion, a minor case of burnout rather than any deep-brain realisation that I should not do this job. However, I am really enjoying a lot of stuff, I've got a surprising amount of energy at the moment, so I am being a wee bit cautious.

But I will give the six months off a go, see how it works writing-wise and health-wise and marriage-wise, and we shall see.

So how did New Year's Day go?

Busily. I started just before three oclock in the afternoon, and fairly soon I'd seen a drunk punched in the head, a twenty eight year old man who had managed to bicycle and sunbake his way into acute kidney failure, a rodeo clown with a head injury, a confused Irish man with a kidney infection, a five year old child who had had some of the irritant fluid from a glowstick squirted into his eyes (and was a lot braver than I would have been), and a man who, I suspect, (shot of someone riffling through the Reader's Digest, cue stirring music), taught us all a valuable lesson about medicine.

Lawrence was a seventeen year old boy who was our only resus of the day. He arrived by private car (one of those times where someone drives up to the door of the ED shrieking "He's not breathing") and was pretty much dragged into resus, where I was nominally in charge. Initial history from his hysterical sister was that he had coughed, suddenly complained of terrible chest pain and collapsed, unable to breathe. No history of asthma, no trauma, no drugs, nothing.

He was a thin young man, wide eyed, unable to speak, high-flow oxygen and salbutamol hissing into the mask, barely any air moving in and out of his lungs), and as the juniors got the lines in we (me, the consultant, ICU, anaesthetics, med reg) felt for his Adam's apple, probed at his chest with our stethoscopes and conferred in quick, quiet exchanges.

"Exclude pneumo" someone said, and everyone agreed. A tension pneumothorax is one of the five or so common, potentially fatal causes of chest pain and shortness of breath. It happens when air gets in between the lung and the inside of the chest, through some kind of tear or rupture. Air gets in and can't get out, the lung peels itself away from the membrane on the inside of the chest, and the lung starts to shrivel and collapse in on itself.

It's mindbogglingly painful. It can cause great difficulty breathing. And if it's not fixed very soon, it causes the heart to shift over to the wrong side of the chest and the big artery from the heart to the rest of the body (the aorta) to "kink". Once the aorta kinks, you get catastrophic loss of blood flow to the whole of the body, and pretty much immediate death.

It's one of the few things that can kill a healthy young adult in seconds. It can happen spontaneously (or after coughing), especially to thin young men.

And it is something that every single doctor who works in the ED thinks about, something that they run through their head, thinking "Would I recognise it? Would I remember what to do? Would I be too afraid to do it?"

Because what you have to do is grab the biggest needle you can find and stab it into the chest, two rib-spaces down from the collarbone, above the nipple, into the lung. Air rushes out, problem solved.

Anyway, that's what we were all thinking. And that's what we were looking for.

I listened. I could hear a faint wheeze, (he had minimal air entry), and I reckoned the left side of his chest was quieter than the right.

ICU listened, he reckoned there was definitely less air entry on the right, not the left.

Anaesthetics said that the patient's chest movements looked unequal - as if one lung wasn't expanding. Probably the left.

Med Reg reckoned the patient's neck veins looked big - another fool-proof sign.

And I was poised there with a fourteen guage needle - the largest needle in the hospital - sheathed in my hand, (so as not to further alarm the young man with the oxygen mask who couldn't breathe), waiting for the Adam's apple to kink off to the side or his blood pressure to drop or him to go into arrest in front of me.

Anyway, by this time (which seemed like treacle-slow decades, but was in reality a very few minutes), the Xray came back.

No pneumothorax. We all stood about and stared at where it wasn't.

We re-Xrayed.

Still no pneumothorax.

And meanwhile, the young man started to get better from the salbutamol and oxygen we'd given him (everyone who could possibly have anything like asthma gets treated by me as if they have asthma, a remnant from that woman last year who died at Shipton). And more of the story began to emerge - how he'd had chest tightness and wheeze for a while, how he got out of breath really easily nowadays, how things had got a lot worse since he started smoking. And his sister suddenly said "My asthma's like that."

Well, a "valuable learning experience", as they say. Not the VLE where you have to go to the coroner, and in fact, one where my "God know's what's happening, give him a milligram of everything" approach paid off.

But I had been standing over him, needle poised, ready to plunge it into his chest - which, by the way, would have given him a pneumothorax.

I think the weird thing is how the four younger doctors there (me, ICU, med reg, anaesthetics) all "saw" something that this guy did not have. Had it not been for Dr Scurvy, the ED consultant, who reminded us that the kids blood pressure was good, his trachea was mid-line, he was not actually deteriorating before our eyes - I don't know. Maybe one of us would have jumped the gun, got in there before the Xray, been the quick thinking doctor with the big needle, caused the thing we were meant to be treating.

And the First Rule of Medicine:

When all else fails, take a competent history (admittedly, virtually impossible for a few minutes there). In the last resort, do a decent examination.

Anyway, off to see a prisoner on methadone, and responding to comments today, come Hell or high water.

Thanks for listening,
John