The curse

Yet another warning: the following post is rated F. It contains stuff that may Freak some people out.

Years ago, when I was in a writer's group, I heard that the first rule of writing is "write what you know"*. So, with that in mind, a brief entry about problems associated with menstruation.

Obviously, menstruation is not my forte. But I used to live with a girl who had considerable difficulty during this time. I mean lying in bed screaming and sobbing all day, clutching her lower belly and crying, vomiting for three to five days every month while her boyfriend dabbed at her pale brow. She'd given this a lot of thought, and didn't want to take artificial hormones in any way, shape or form, and pretty much planned to write off ten to fifteen percent of her life between the ages of fifteen and fifty or whatever.

It was, to be honest, a difficult time for all concerned. You want to help but there's about eighty reasons you can't and shouldn't and don't. On occasion her mother would come around and wail with her and make her a hot homeopathic infusion to drink, which the boyfriend would later clean off the wall.

After the third time I did a lot of study in the library.

Anyway - Nadia had it bad, but others have had it worse. Many catamenial (and God, that's a lovely looking word, isn't it?) - many catamenial pathologies are relatively common and well known. The latest issue of the DSM (the famed DSM IV) described premenstrual dysphoric disorder (PMDD) - serious premenstrual distress severe enough to interfere with occupational and social functioning, a full-strength version of the more common premenstrual syndrome (PMS). It stresses that PMDD is a severely distressing and disabling condition that requires treatment.

Anti-depressants, by the way, apparently work on this, and can be taken for only part of the cycle. Obviously, they aren't going to work if you are getting irritable and depressed because your husband's a tool**.

You can't medicate away distress or misery, and there are relationships where either you or he or both only permit the wife's distress or misery to be expressed perimenstrually: when it is insulated and diminished as a symptom of a pathology. That way you can both assume that the woman's sobbing or gorging or throwing things is part of her irrational (and therefore irrelevant "women's troubles"), and get on with business as usual.

Anyway, there are also other, less well known pathologies. I saw a woman the other day with catamenial epilepsy - a thin, blond woman in her thirties who had three or four grand mal seizures every month and was otherwise fit and well. This was a bitch, because the anti-epileptics - there is a huge overlap between the anti-epileptics and the mood stabilizers - are often hardcore drugs, and she was on them for the next decade at least.

And a brief search of the literature reveals other, surprising conditions. Catamenial haemoptysis - coughing blood once a month. The way this works is cells that normally grow only inside the uterus can grow elsewhere - like in the lungs - and every month, you get the bleeding. These cells can also occur elsewhere - I have heard of some growing in the brain. Just like normal menstruation, it can be controlled by the oral contraceptive pill.

What else? Catamenial anaphylaxis. Every month you get itchy red welts, sometimes stomach cramps or diarrhea, maybe low blood pressure or difficulty breathing. Allergies are weird - the entire immune system is something I don't understand, mindrootingly complex - and my first girlfriend, the Uniting Church minister's daughter, was actually allergic to cold. We would go swimming and she would get hives and shortness of breath. She nearly died one time (not that I knew it at the time), I remember us both sitting on a rock out at Bremer Bay, her wheezing in short, sharp breaths and me trying to keep her warm, dimly aware something bad was going on and trying to look down her top.

And the other day I heard about catamenial pneumothorax. Every month, along with the bleeding and the other stuff, a bit of your lung collapses - usually the right. I heard about it occurring in a woman in Japan a few years back, and thought "What are the odds?", and then found out they're quite high. Here are some twin sisters who both get it, and .

What happens in this case is you get endometriosis of the diaphragm, that dome of muscle underneath the lungs that is basically responsible for you being able to take a breath. Blood gets in between the diaphragm and the lung, causing (part of) the lung to collapse every month. The woman gets sharp, severe pain in her chest, worse on breathing in, and maybe shortness of breath - there is no "always" with pneumothoraces, you can have a sizeable one with minimal symptoms and vice versa.

Anyway, I have to write and tend cats and stuff today. Thanks for listening,
John

*The first rule is a load of crap. You write what you think someone will buy, or you write what you have sympathy for, or are angry or sorrowful or lonely or curious about, or you write about whatever is in there that can't be reached by any other method. You write because some things can't be spoken, they can only be told. But if you only write what you know, at the end of it, you haven't done anything, haven't moved forward or grown or whatever.

You have to know what you write about, of course, to stop making a spanner of yourself with basic factual errors. But you don't write what you know.

**Usually a proctoscope

The rush and the captured breath

Hail,
And before we start - a brief update on the progress of some characters from earlier posts.

Firstly - Mr Jarusnich, the heavily muscled and deeply uneasy ex-bodybuilder from Serbia. He had been doing well - reduced his methadone from 120 mg to 100mg, dealing with the pain, gradually adjusting to a life without being huge.
Then a few weeks ago there had been a relatively low-speed car accident, and one of his steroid-weakened ligaments (the medial collateral, the one you feel on the very outside of your knee) had been strained. By the time I saw him he was in agony, walking with a stick, scrabbling anywhere for oxycontin or morphine sulphate or heroin - and very very angry.
I didn't normally mind talking to Mr Jarusnich (six foot three and one hundred thirty kilos, he reminded me), but he was angry enough that day that I sent a few people away and we (the nurse and I) conducted our business with Mr Jarusnich in the large (and multiply doored) waiting room.

And the HIV positive man shooting up the morphine tablets? Out of prison, and "lost to followup": not collecting his dose, not answering his phone. I don't know if he's dead or alive - I got the notes down and he'd done this kind of thing before. I keep looking for his name on the patient list each day, but he hasn't booked in.

And the beautiful girl with the brains of a goat - and I don't know that I mentioned her before. Still angry we won't put her on methadone, still tolerating the milder and less "off your face" buprenorphine we give her.

Methadone, by the way, is basically a milder, less satisfying, but publically more tolerable and overall safer version of heroin - nineteen seventies Aerosmith were methadone, the Rolling Stones were pure smack. Father daughter purity balls - methadone, purdah - smack. Chris Claremont - methadone, Warren Ellis - smack.

Her doctor has her on a tightly controlled dose of diazepam - giving her three weeks on three 5 mg tablets, then a month on two and a half or something like this. In the interim she makes do with the handfuls she gets from her friends. She's been on the buprenorphine for three months, she's gained eight kilos - and I've just increased her dose. I have warned her that in three months she will be huge - but it's better than methadone and it's safer than smack.

And in between I've been thinking about drugs and love, about addiction and adulation, about maybe a new use for an old drug, even a new treatment for a very old sickness. And this idea isn't fully clear even to me, which is why after two days of on-and-off writing I don't know that I've got what I'm trying to say across at all. But here goes.

I've been trying for some time to understand what addiction is. I don't mean neurochemically, I mean what if feels like, what it means to the people who suffer from it, how it is experienced by them.

I think I'm doing this partly out of curiosity and partly out of the understanding that if I have to work for a number of months with something I fundamentally don't understand I am going to become either
a) spleen-spasmingly bored,
b) intellectually disaffected
or
c) cut snake crazy (that's what happened with immunology in second year).

And partly because it - addiction - is closer to a lot of us than we think. I have come to believe that I, you, virtually everybody reading this blog, some of us many times, have experienced full-blown addiction.

FIrst, a disclaimer. I know I have said before that my own experience with "things normally thought of as addictive" is limited.

I have never snorted stuff.

I have never injected anything into my own vein.

I have never smoked.

I had marijuana* twice in university and got headspins, I had pethidine and got disappointingly mundane hallucinations.

I have among my close friends one who has had heroin and one who has had cocaine, and when they describe this stuff to me it is as if they are discussing the year they spent among the Venusians, or their experience of sex with vegetables .

I have always thought there is no common ground between us.

But now I reckon I was wrong.

What does addiction actually feel like? As far as I can work out, when I'm talking to my clients, when you're addicted you think about the substance all the time. Thoughts of it come into your head - thoughts about how to get it, how good it is, how good it would be to have some right now.

And things change in your head - presumably neurons extend dendrites, connections are strengthened, things are learned and hardwired - things change so that other stuff becomes less important. You end up doing stuff, stuff that maybe harms yourself or your friends or your family, just to get a taste of the substance. You persist, as the textbooks say, in the face of overwhelming negative consequences - prison, poverty, a blood clot in the lung. You starve other things in your life - your social life, or your career, and you don't even watch as they die.

And when you try to cut down, it hurts. You do all the stuff - you distract yourself, you take deep breaths, you wait for the feeling to pass. But still you get sick, miserable, "lonely" as one man said. Often when you try to cut down the feeling gets so bad that you believe (probably truly) that the only thing that will ease the pain now is the substance. You end up going back, those late night relapses on the telephone when you are at your weakest, and it fucks you around again.

Some of this is familiar, to some extent, for all of us.

When I was thirteen I saw Jennifer Roume. She had black sloe eyes and black hair like Burmese silk, and skin like milk with honey in it. Her teeth - I can see them now if I close my eyes - were even and white and straight, and her lips were that dark bruised cherry red. And she wore the school uniform (a white button up blouse, navy skirt, white socks, black shoes) like nobody else and her hands and fingers were like - and she was, I'm sure you've worked out by now, impossibly beautiful.

I remmeber how I used to feel when I saw her. I remember the thump in the chest, the dry mouth, the pounding. They say beauty is 'heart stopping', or 'breath taking', and that's what you feel, that's what you experience. I remember how nothing else - my family, my friends - nothing came close (except, unsurprisingly, the writing of abyssmal poetry and sessions of futile gymwork and teen preening) to challenging the hold her picture had on my head.

I remember enduring her evident contempt, seeing her holding hands with Craig whatsisface and feeling everything turn to ice inside me. There's a reason they call it a crush, too. I still believe now that I would rather have acute pancreatitis or cholera or bilateral rib fractures than loneliness or jealousy.

I don't know if I was smart enough at the time to do the math, work out the ineluctable social mechanics of it, as fixed and unchanging as the movements of the stars. There is a reason those fairy stories about the beautiful princess marrying the orc are called fairy stories.

But I can honestly say I thought about her all the time.

And sometimes I wouldn't see her for a few weeks and I would be happier, things would go better, and then she'd turn up again, or she'd smile at me in math class, and bang. The heart kicking inside the ribs, the speechlessness, the rush and the captured breath. Back down to zero again. Sometimes my face would ache from grinning.

Now, I'm about the squillionth person to say love is an addiction. But a few nights ago I tried to put myself back there, back in that thirteen year old's head (and believe me, it's happened a lot of times since then), and I tried to imagine how hard it would have been for me to give up on Julie Roume, to go without.

And I was thinking - what would have helped? There were no patches. There was no teenage boy Roumeaholics Anonymous (but by God, there were enough of us to form one - hopeless adulation for that girl swept through the hetero male population of my school like a plague) where we could stand up and say "My names Bill Bloggs and I've been desperately in love with a girl who laughs at me for five years". I suppose for some of the other boys there was the methadone of other forms of release - my fidelity was as absolute as it was hopeless.

And then the other day I was reading about naltrexone (they call it Revia in the US). Naltrexone is an opiate antagonist, literally something that "struggles against opiates." It stops someone getting the rush from heroin. People on naltrexone can take remarkable amounts of opiates like heroin or morphine and get next to no effect at all (This can be good, like if you give something like naltrexone to a patient who has overdosed on heroin, or if you want to take something that will decrease the reward your body gets from injecting oxycontin. It can be bad, say, if you are the person who had just shot up and then some clown comes and ruins your two hundred dollar high, or if you have a naltrexone implant and you are crossing the street and get run over and they try to give you morphine for pain in hospital.).

You get it as tablets (one a day), an implant (in the skin of the belly, low and near the groin) or a once monthly injection (like a vaccination). It's not actually used that much over here, it works while it's in there but people often don't want it in any more. I have seen two people who have surgically removed their own implants.

So naltrexone - so far, so what. Naltrexone, unlike methadone or buprenorphine doesn't only work in opiate addiction. It has been used - with moderate success - in the treatment of gambling addiction. It seems to have some promise in the treatment of alcohol addiction. People are trialling it for nicotine addiction, pornography addiction (one of the more controversial ones), even the predominantly female "mall addictions" of shopping, eating and petty theft.

Now there are about a billion unchallenged assumptions in this line of thinking, which I don't have time to get to here. I am not at all saying that pornography addiction is an addiction in the same way that heroin is. I'm not even sure on the way we use the concept of addiction, I suspect we label a lot of people as unwell when in fact they've just made different choices to us. I don't think naltrexone should be put in the drinking water at schools - I am not saying there is any evidence at all that it would "work", as far as I know there isn't and it doesn't. And I know I'd rather live in a culture where Shakespeare's hundred and sixteenth sonnet and songs like "All I want is you" or "Desire" were written down instead of medicated away.

But it's an interesting idea. We may deny it, but we medicate rage and sorrow, fear and loneliness and boredom. If it worked, who would not want to fix a broken heart?

Anyway. Pure fantasy. But I did wonder the other night about that chubby, funny-speaking, unbearably lonely boy, me as a thirteen year old. I found myself seeing myself as if from a distance, small and clear down the wrong end of a telescope, and wondering whether naltrexone might have done something for (as well as to) thirteen year old me.

Whether if a tablet a day could have kept me speaking to my friends and family, stopped me trying harder and harder at something where the reason I couldn't succeed was because I had to try too hard, struggle to do what others found effortless - and what were the ethical responses to that?

At thirty nine I feel it would have been a bad idea to give naltrexone to a thirteen year old kid to stop a crush. But we do weirder things, we give other psychoactive drugs to children. And making a decision about someone else's medication, weighing up the side effects for someone remote from you in space and time, the consequences of being treated versus not being treated - that's always easy to do.

But I wonder if I'd asked myself back then, thirteen year old me, hunched and miserable on the bed while everyone else went out. I wonder what I would have thought of a way out, whether I would have wanted it so. Whether I would have preferred the disease or the cure.

Anyway, thanks for listening.

John

* Yes, I know it's not usually thought of as addictive. I put it in to show how boring my drug life has been.

Tell me if this makes any sense....

Apparently, one of our local politicians, one Danna Vale (for the conservative party, startlingly enough) was on the radio and in the papers a while back warning people about the danger Australia faces from abortion and Muslims.

Briefly, and as I follow it, her argument is that white Australia is aborting potential Christian fetuses at such a rate that in fifty years, we may be outbred by Muslims, and Australia could become a Muslim nation.

I am, by descent if not conviction, German-Jewish, with a family tree that, God's truth, contains within two generations a rabbi and a member of the SS. Members of my family have heard this kind of talk before, they've probably mouthed it.

The weird thing is, if Vale's right, I don't understand why she's upset. She should be glad. She should be getting her Government to distribute Korans in the schools and building a mosque on every street. And I should point out, the following makes as much sense as anything Danna Vale has said about the issue.

See, from my understanding, it's pretty damn difficult to get an abortion in Indonesia (I beleive it is only medically indicated if the woman's life is in danger). It's worse in Afghanistan (there is no indication for abortion), and it's not a lot easier in, say, Saudi Arabia. These countries, and others like them, are going to supply a lot of the immigrants that will presumably muslimify this country in the next five decades. People and ideas will flow back and forth, young muslims in Australia will almost certainly look to the mother country for guidance on matters of the spirit.

And when the evil day dawns, when the Muslim horde really has taken over Australia, how easy does Vale reckon it'll be for women to get an abortion?

Yes.

Exactly.

It's going to be a lot harder.

Fewer women, by Vale's logic, will be able to abort.

Fewer innocent children will be murdered.

More laughing, happy, healthy children will be born.

God will be pleased.



Surely Vale must find that something worth fighting for?

Surely, in fact, it's the only thing worth fighting for? Surely it's Danna Vale's Christian duty to sweep Christianity from the Australian map, to join with the Muslim hordes who even now swell our borders, to throw open the floodgates and open the ports and airports, to not rest until every church becomes a mosque, every meat pie a kebab and every drizabone a burqa.

First things first, she should lead some kind of crusade to the detention centres and free the fecund and fertile Islamic men, women and children who are imprisoned there.

Go on, Danna. For the sake of the children. We'll all be right behind you.

Thanks for listening,
John

Alcohol, Jesus, bulldozers and ice.

A lighter post today, after the grimness of last post, and one that even touches on the story of the Christ, this Easter Sunday.

But first: I do not have a drinking problem.

Nope, not even close. Never did. Not even that summer ten years ago back on the coast where I woke up in that girl's garden holding a broken garden gnome, or the times I rode my bicycle home drunk. By the Driver's Clinic guideleines, the closest I ever came to was a category called "Episodic Hazardous", into which a surprising number of men in their early twenties often drift.

But actual alcohol abuse or dependence? Not even close.

Lest you think I have judged myself too lightly - and if I could travel fifteen, twenty years back in time now, the first thing I'd tell myself if don't drink and drive/cycle/ride a horse/even walk. No, I tell a lie: the first thing would be "Here's a phone number. Ask to speak to Sarah Barret and tell her you love her truly and madly and deeply and want to marry her, so perhaps you should arrange to meet. Trust me, it'll cut out a lot of crap." And a list of Grand Final winners for the next twenty years - lest you think I have judged myself too lightly, here is a few fragments from what I remember of my conversation with a man in the Driver's Clinic last week.

Again, notes, in this case liberally sprinkled with exclamation marks and underlinings, were taken.

Mr Parch was a thin man, with a long moustache and an unshaven chin, who wore his thinning hair in ringlets. He sat uncomfortably in the chair and stared out over my head, snapping the answers to the questions almost before I'd finished asking them. He was a UFO - someone disqualified from driving "until further order" - and had been through this process - I riffled through the notes - more than five times in the last ten years. Always unsuccessfully.

I proceeded. The litany - have you ever caused serious embarrassment to yourself or others while drinking? Has anyone ever annoyed you by criticising your drinking? Do you ever drink first thing in the morning? - was probably more familiar to him than to me, and he knew as well as I knew that most of his answers were indicative of alcohol dependence.

When it came to the question about limit setting, he snorted. "You can't answer that" he said.

I nodded. "Why's that?"

"Well, who sets a limit? You just drink what's in front of you, and that's it."

"But how much do you put in front of you?" I asked. I hate doing driver assessment clinic, for about forty different reasons, and one of them is this constant niggling at what is essentially a hostile witness.

He grinned and tilted his head, managing somehow to look both conspiratorial, contemptuous and cocksure at once - and with only the same number of facial features as everyone else. "You wouldn't believe me if I told you."

"I'm fairly new at this" I said. Impress me with how much you drink, mate. Make my job easy.

"One time there was seven of us in a house in Innsmouth Bay. Seven people. Seven days. Me and Riley Rollings and Mark O'Neill and Charley Carpany and Mick O'Neill and Wendy the Witch and Joe Duzanski... guess how much we drank? Seven people. Seven days. Guess?"

No idea.

"Forty two cartons. In a week."

A carton is twenty four cans of beer, at mid-strength that's thirty six standard drinks - three hundred and sixty milligrams of alcohol in a day, a dose that would kill most people... and he was drinking close to that, every day. I start to do the maths, but he's not finished.

"Forty two cartons, twenty one bottles of wine, six bottles of spirits. Seven days. Not a mouthful of food between us."

I give up calculating and start guessing. That's kilograms. More than a kilogram of alcohol a day? fifty six kilograms of alcohol? You could run a Brazilian schoolbus on that.

"Course, Rileys dead now. Rileys dead, and Charley's dead, and they reckoned Mick was dead, and I took Wendy the Witch into the liver clinic, drove her in myself. Psychosis of the liver, had to have a transplant".

I stared. His gaze snapped back to mine. "Hey, here's another one for you, quack. Do you reckon Jesus Christ walked on water?"

I nodded.

"Well, it was all a scam. I saw it on the telly a few nights back."

Well, that proves it, then. "Really?"

"Yeah. See, what most people don't realise is that the water he walked on... it was a lake!"

"Okay". You're saying that the lake of Galilee was acutally a... a lake? But this revelation will surely overthrow the Papacy!

"And the lake at that time, it was frozen. All frozen."

"Interesting". Not as interesting as a lake near sea level in the Middle East freezing solid, but interesting.

"And all the ice, it was at the bottom of the lake, and he knew there was ice on the bottom of the lake, and thta's what he was walking on. The church can't explain that."

"Probably not." Mate, Archimedes can't explain that. Ice floats.

"And the other guy, Peter somethingorother, can't remember his last name, when he jumped out, he didn't know where the ice was, and he sank. So, when they say he walked on the water, he did... but it was frozen water!"

"It's all in the details, I suppose" I said.

He did hhave more theories, theories about women and about how most people don't know how to drive a bulldozer (no arguement from me there), and his overarching one, his Grand Unified Theory that seemed to tie together George Bush, South America, the Cronulla race riots and "the towelheads", but I did not have time to document all of them.

Anyway, I collated the answers, did the physical exam (bulging liver, muscle wasting, fine resting tremour, the beginnings of loss of sensation in the lower limbs) and documented the one point in his favour - his one hundred days of abstinence. Both he and I knew it was unlikely to be sufficient - the Minister requires a minimum three month abstinence, and up until New Year's Day he had been drinking a carton of beer a day, "easy". And I sent him off to my boss, who would almost certainly classify him as UFO for the sixth time.

And after that was a man who'd found God (six months back, no longer dependent) and a man who'd found a good woman (a similar outcome) and a man who needed his licence back so he could keep coaching the state fencing team or something (sorry) and a man who offered me discount oysters (and was no longer dependent anyway).

Anyway, today is allegeldy the first day of study. I shall retire to grapple with my physiology textbook.

Thanks for listening, and for the remarkably kind comments from last post, to which I shall reply soon.

BDC

It's not going good at all, is it?

Hail,

Majorly depressing stuff below - you have been warned, as they say.

Firstly, the young gay guy (bipolar, HIV positive, morphine tablets...) from a few posts back? Well, he presented at a local pharmacist with some stolen scripts (not stolen from me, I might add), and was not served, and left in such a huff that he left about thirty of his stolen scripts there. So now it looks like some of his problems are solved. The accomodation problem, and the "I wish I didn't have to walk so far to get my methadone" problem, and a few others. And his social isolation, "how do I get to meet interesting new people?" problem too.

Well, it's the prison doctor's problem now. And his.

What else has been going on?

Well, I met a young woman the other day who finally convinced me I can't do this long term full time, and that I am not a creature from Jewish mythology.

Kali was there for the ten thirty appointment - I had to go out the front and call her in. I was already pissed off because it was the Thursday before Easter and the last working day, and a lot of the clients were coming in with desperate demands for last minute rule changes and exemptions: "I'm going droving in far north Queensland, I'm leaving tomorrow, so I need eighteen takeaways of methadone - I'm on a hundred and fifty. And I have to change pharmacists because the other guy shits me and I owe him lots of money. Anyway - I want to change over to bupe because this other stuff rots my teeth - and can you write me a letter to see the dentist? And can we make this quick, I'm on home D?".

The problem with the drugs and alcohol job is that everything is circumscribed and bound about by laws, so that even changing pharmacists requires the writing of a minor novel in longhand, and simple clinical decisions have to be run by seventeen different government departments. It's like I imagine the mediaeval papacy must have been, but with less wenching, and less getting drunk.

Anyway, I go out the front and get Kali in. She is one of the younger clients we have here, early twenties, wearing blue jeans, white skivvy. She's wearing makeup, but her face is almost paper pale, and it's pockmarked with the scars of cystic acne. She's nervous, and she speaks in a strange way - some slurring of her speech, some grimacing, the occasional stiff flap of her hands or movement of her shoulders she tries to turn into a shrug. Most of the time her head is tilted at an angle, as if she is listening to something.

She sits down, keeps her bag on her lap, and we start talking.

I start out with the usual questions.
Accomodation? - she's back living with her mum, things are going okay there.
Finances? - bad, but they were always bad.
Any change in relationships, with people important to her? No, she sees mostly her mum, things are going okay there.
No offence meant, but any forensic issues coming up? Nope, never been an issue. Things are going good.

And the drug use. The heroin was going good. No heroin for over a year. No withdrawal since I put her dose up to ninety. No real temptation. Any other injecting? - nothing since - oh, probably three months. Maybe once or twice in the last three months, a little bit of speed, that's all. Going good, she nodded, going good. Her mood, her general health... all going good.

I don't know that I was listening to what she said with one hundred percent of my brain. I was writing, presumably using one bit of my brain to write the appropriate things in my notes. Part of me was listening. Part of me was checking back, running through in my head the last time I'd seen her - I glanced at the notes from last March, things I'd underlined.

?increasing speed use.
Nightmares, fragmented sleep
?Meets criteria for post traumatic stress disorder?
ICU admission, pulmonary valve embolus - ?June 2000.
Check next visit for signs of depression.

And part of my brain must have been putting things together. I glanced up at her. Outside the autumn sun shone on the window, cars went by. There was a pause.

"It's not going good at all, is it?" I said.

And then the poison came out.

She was using a lot of speed. Pretty much whenever she can, every two or three days, injecting fifty, hundred, two hundred dollars at a time. Pawning all her stuff - all her stuff is in Cashie's, the local pawn shop. Trying to get it back, but it's been so long, she can't afford it. Always in debt, debts she can't pay. The dealer - he's someone she's afraid of.

The speed - she doesn't know why she does it. She's trying to stop. There's no methadone for speed, there's nothing. But she can't - without it she can't get out of bed. She can't feel anything.

I think I wanted to ask something, but she kept going.

She'd been feeling like this since - since she was fifteen. Everything was good until the year she turned fifteen. When she was fifteen her best friend moved away and the house down the road was empty for a few weeks, and then this family moved in. There was this kid, he was sixteen. Mum and Dad on methadone, they used to share it with him. She started going with him. She didn't know why.

Pretty soon she was feeling like shit, waking up feeling bad, feeling bad all the time. So she went to the doctor. The doctor said she had anxiety and depression. She started her on medications - oxazepam, fluoxetine. One of those drugs has been essentially removed from the paediatric market after it was found to cause an increased risk of suicide, another is a viciously addictive little pill that should never have been on it.

Started out on one oxazepam a day, went up to two. Tried to cut down, got the cramps, the panic, the vomiting. Pretty soon needed to go up to three. Went to see her doctor - gone. Taken away, some kind of medicare fraud thing. Never saw her again.

She went home, packed up her stuff, said she was leaving him. He hit her in the face, threw her onto the bed. Wouldn't take no for an answer.

A few weeks after that she got taken to Florey. She'd shot up something - still can't remember what it was - and got an infection. Bacteria from her skin got in through the needle site, into the bloodstream, clustered on the pulmonary valve, the big valve in the heart on the artery that channels blood into the lungs. Horribly sick, sepsis, pulmonary embolus, scattered blood clots thoughout her body. The notes I'd had faxed from Florey said DIC - disseminated intravascular coagulation, microscopic blood-clots drifting into kidney, liver, brain.

I imagined a dark constellation of blood clots moving out of the carotid arteries. Swirling downstream, lodging in narrow arterioles, jamming up against the mouth of a blood vessel. Blood stops flowing, areas of the brain darken and die. In front of me Kali tilted her head, grimaced, slurred her speech. Told the same story three different ways three times.

After that, things weren't as clear. Raped her, threw her out - first he wouldn't let her go, then he wouldn't let her stay. Kept all her clothes, even her bras and stuff.

Sometimes she thinks maybe that's why she's so depressed, she hasn't got any nice clothes any more.

Tears roll down her pale, foundation caked face.

I gaze at her, cloud-streaked blue eyes like the earth seen from space, that pockmarked forehead, imagining skin, under that subdermal fat, frontalis muscle, and bone. And the frontal lobes of her twenty two year old brain, pockmarked with scar tissue, islands of dead neurons, pale with ischaemia.

I give her a tissue, but she just holds it in her hand.

Then she moved in with her mum. He - the rapist - was in prison, things were good with her mum and her stepdad, things were okay. But he's out of prison now - I do the math, four, maximum five years, and her with a life sentence, maybe a death sentence - and lately things haven't been going good at all.

She has flashbacks, she wakes up finding herself crying, pissing the bed. Sometimes she wakes up and she can hear him breathing in the bed next to her. One time she felt him move.

It's getting tense at home. Her mum and stepdad, now they fight all the time. She doesn't know how much longer she can stay.

She wishes she could die. Every day, always. She doesn't want to kill herself, she ... she just doesn't want to be anymore. She's not alive.

She looks at me, and I think this is the bit that gets me. She looks at me, as if she is asking for something, and she speaks. "I'm not alive," she says. "I'm twenty two and this is it. This is what life is. There's things I used to like doing and I look inside and they're just gone. If I'm this young, and it's like this, what's the next forty years going to be like? I'm twenty two and I've fucked up everything, what's it going to be like for the next forty years?"

I don't know what to say. She looks at me, and I don't know that I can look back. Her eyes are that intolerable, bright baby blue.

I try to say something about help, about medications, support. Say things can get better, that there is stuff that can be done. She knows all the organisations, the mental health people, the support team, the brain injured support groups. I book her in to see me next available appointment.

And her phone goes off, and she has to go, pick up some kid or something. She gets up and walks out. I don't know if it's the rapist's kid or not.

Then the next part, the embarrassing part. I don't get up.

I sit there. I feel like I want to throw up, I get up and stand near the basin. I check the clinical signs - my heart is racing, I'm breathing deep at over twenty resps a minute. I can feel I am shaking.

I check - the door is closed. For a moment I crouch down on the floor, head in hands, deliberately slow my breathing. Sheen of sweat on my forehead. Get up, wash my face. My eyes are wet, my heart is punching at my sternum, trying to get out. Slow, shallow breaths. Calm down.

I keep thinking that in a minute I will go out and get the next one, the next client, the next patient. The patient, as we are always reminded, is the one with the disease. It's not us. But the truth is it takes me more than a minute. It takes time, and my next patient is surprised and gratified by the alacrity with which I deal with his requests for takeaways, dose changes: sure, not a problem, anything else, no, see you three months time.

In Jewish mythology there is a group of people, the thirty six. They are called the Tzadikim Nistarim, sometimes the Lamed Wufniks. Borges wrote about them, and I imagine my father would have known of them from his uncle, who I am informed was both a learned rabbi and a bad tempered son of a bitch.

The Tzadikim Nistarim are the thirty six truly righteous people upon whose righteousness depends the fate of the earth. Thousands of popular stories take note of them. Their presence is attested to everywhere. The story is that God will not destroy the world as long as there are thirty six of these 'hidden righteous' alive. So at any one time (since we can look around us and see that the world has not been destroyed) there must be thirty six of these virtuous people alive, living and dying as ordinary people, unknowing, unaware, but of infinite cosmological significance.

We know, of course, that this is nothing more than a legend, a folktale or a fairy story to be told around the fire in the dark, and that the bronze age scribes who wrote it down were utterly ignorant of cosmology or of the way the universe was formed and is maintained.

In their ignorance these primitives also speculated that in the first instants of Creation, God made a light: not normal light, but a different order of light, a light so powerful, so penetrating, that He only allowed it to last a brief time, and then took it away, and replaced it with a weaker, merely physical light. Modern, scientific cosmology tells us how little we should value this barbarous folktale.

The Talmud, by the by, tells us that if we could see things lit with that primordial light we could see from one end of the world to the other and from the beginning until the end of time.

But - the hidden righteous.

When I read about this, I remember trying to imagine what would it be to be one of these people. What is it like to be a Tzadikim Nistarim? To be not shut off from the pain of others? To be unwalled? To be open to God and man, compassion incarnate, to actually feel the pain of others?

I read somewhere, but I don't know where, or why, that when the Tzadikim Nistarim die, it takes them a thousand years to get to Paradise - whereas for the rest of us, entry is instantaneous. Some of the Nistarim are so virtuous they never get there at all.

How does this make sense?

The idea, as far as I can make it out, is that a heart which has been wounded by the suffering of people around it, a heart which has been cauterised, or frozen, or scarred, will need to be healed before it can enter Paradise. Because in Paradise all is made new, made whole and unscarred.

Most hearts, yours and mine, presumably take only a few picoseconds. But it takes God (and this is the old Jewish God, the fallible, flawed one who was feared, and was angry and felt regret, not our modern mathematically perfect and thus so much less believeable or loveable entity), it takes God a thousand years to heal the Nistarim heart enough for it to accept Paradise, and for Paradise to accept it.

Well. I tell you what. I feel now is the time to reveal myself: I can declare before the world that I am not a Tzadikim Nistarim. I am not one of the thirty six.

There are ample proofs I (and many others) could furnish for this claim, there are perhaps an infinite number. I believe could throw a random object into a crowd at the footy and bounce it off the head of a man or woman more virtuous than me. I married a person, I regularly work with and drink with and do judo with people who astound me with the weights they carry.

But the real reason I know I could not be a Tzadikim Nistarim is I know I could not endure what they must endure. This woman was only one patient. I only heard her story. I see ten or fifteen like her a day. Half of them probably have similar stories, on any given week I will hear worse.

But what I felt the other day - probably the closest I have come to crying in a good while - that was not something I could do many times again. I could not endure that.

In the end either these things continue to wound you or they cease to. There's a limited number of responses - you either bleed to death or freeze to death. Neither of these outcomes is compatible with a long career in this field, in any form of medicine - or social work, or policing, or anything where you continually deal with the damaged.

I think the secret is you have to come up with some third way, some way of separating things out, some way of dealing with the situation but keeping yourself safe, seeing but not feeling their pain. I've seen people who have done it, who can feel this stuff and carry on, doctors and nurses and writers.

I don't know how they do it, but I think I have to find out, and find out quick. Because I have to be able to do it. I don't even know if it's inherent, or if it's a thing that can be learnt, like a judo throw or a new knitting stitch, but by God if it can be I'd better get on to it quick.

Thanks for listening,
John


*I should point out that if any of your friends, family or workmates should claim to be one of the Tzadikim Nistarim, that is a sure sign that he or she is not one. Pick them up on it, this kind of behaviour should not go unchallenged. The true Tzadikim Nistarim does not say, and may not even know if he or she is one.

I am not the urology surgeon... I am a human being.

Never, and I mean never, take anyone you know and care about, to Shipman Emergency Department. Ever. Ever. At all.

And by the way, hideous image warning. Proceed at own peril.

I had decided to use all this ‘early morning wakening’ time more productively. Rather than worrying about the usual dreary round of car crashes and hideous diseases, I decided to worry about our finances. This is a fruitful ground for the dedicated panic merchant to till, and by the time the sun rose I had decided that the only sensible course was for me to go on the game, Sarah to take her French horn and busk in the mall, and my niece to sell her hair on the internet.

When Sarah got up, I gave her the results of my meticulous and even-handed micro-economic analysis.

“Jesus Christ!” I shrieked. “We earn hundreds of thousands a fucking year! How come we’re on the verge of fucking bankruptcy and are going to be thrown into the street?”

Sarah agreed that she had allowed the situation to become inexcusably dire (we have an agreement – she manages the finances and I do the cat litter. From each according to his ability, to each according to his need), and admitted that aside from the fact that we did not earn hundreds of thousands a year, were not on the verge of bankruptcy and were not about to be thrown into the street, my grasp of the situation was flawless.

“We have to learn to do more with less” I trumpeted, as my wife hunched miserably over her cornflakes. “More and more with less and less. Either that, or someone’s going to have to sacrifice a bit of their precious sitting-on-their-arse spare time and do some work around here.”

At that moment, my phone rang. I grabbed at it.

“Hello, Dr Bronze” came the small, pleading voice at the other end. “It’s Lucretia from the Shipman ED. One of our doctors has called in sick and I was wondering if you could help us out with a shift today?”

Not what you want to hear first thing in the morning, especially a morning you have dedicated to pottering around and maybe seeing a few friends. But I could see Sarah’s big brown eyes peering into mine, into my soul. She had heard every word.

I agreed to the twelve to ten shift. A few hours later I pulled into the carpark, collected my ID card and returned to Shipman.

By the way, I should point out that, although elements of this blog are fictionalized to protect the innocent, every word of the following is as I remember it – and as the night wore on I actually started taking notes to “prove” what had happened. I should also point out that Shipman is a public hospital being run by a private company, a private company celebrated for its ability to produce a profit from situations not previously thought of as money-makers, and that any day now it is apparently going to be bought back by the State and converted into an institution for caring for the sick.

At Shipman you pick up a form (the MR5) from the inbox, check on the form and the whiteboard to see where the patient is, write your initials on the whiteboard next to the patient and go to the cubicle to see them. My first MR5 and the whiteboard, suggested that I would be seeing a 53 year old woman in cubicle M with depression.

I walked down and opened the door to cubicle M. A tall, patrician man with a urinary catheter, sitting on the bed, looked up at me hopefully.

“Are you the urology surgeon?” he asked.

“No. Are you Mrs Dolor?”

“No” he admitted. I backed out, murmuring apologies, closed the door and went back to the nurse’s station.

“Where’s Mrs Dolor?” I said.

“In M” she replied.

“No, that’s an old man with an IDC.”

The nurse glanced up at the whiteboard. “It says she’s in M.”

“I went there myself” I said. “Ten seconds ago. It’s not her.”

“Are you talking about M?” asked another nurse. “I thought it was empty, so I put Mr Faucet in there.”

“Well, move him out again” snapped the head nurse, with a roll of her bright blue eyes. She stalked over to the whiteboard and scrubbed out the information for M. “Problem solved” she said.

“But where’s Mrs Dolor?” I asked.

She stared at me, then at the whiteboard, the one from which a few seconds ago she had erased all mention of Mrs Dolor’s existence. There was a pause. “Don’t know” she admitted eventually. “Is she in N?”

Eventually I traced Mrs Dolor to the waiting room, where she lay curled in the foetal position on a hospital bed. I walked back to the nurse’s station. On the way back I passed cubicle M, which had by now been filled (almost literally) by an obese boy with a twisted ankle.

I gave up on Mrs Dolor and grabbed the next MR5. It directed me to cubicle H, where it assured me I would find Mrs Blear, an 81 year old woman with confusion who had had a fall. I flung aside the curtain.

It was the same elderly man with the same catheter. His face brightened.

“Are you the urology surgeon?”

“Sorry” I murmured, and backed out. As I left the room his voice floated after mine. "I've been waiting five hours!"

Eventually I tracked down Mrs Blear in cubicle Q, behind the linen cupboard. Apparently Q can look quite a lot like H if you write it fast.

An hour later I felt in my pocket for my pen, one of those cheap black hospital issue biros. It wasn’t there. I remembered lending it to the surge reg when I told him about my fairly unlikely (but eventually justified) 59 year old man with appendicitis. I swore. It hadn’t been my pen anyway, I had picked it up from the admin desk when I came in.

I grabbed Dr Valentina, the slim and remarkably fecund emergency registrar (one pregnancy on condoms, one on the pill, one on Implanon). “Where are the pens?”

“Pens?” she said. “Pens? Ah, that can be difficult around here.”

I stared. I promise I am not making this up.

“No, really, come with me.” She went to the stationery cabinet and opened the door. It was empty, except for some old Xray forms and three large boxes of booklets about the Shipman High Fibre Diet.

“Goodness” she said. “There’s always the doctor’s emergency cabinet.”

I followed her to the cabinet, through a door where you swiped your card to a cabinet with a four digit pin number. It proved to contain several packets of textas, some soft black pencils, and about thirty highlighters. No pens.

“This is fucking ridiculous” I said. “Is this some kind of unusual demand around here? A fucking pen?”

There was a pause. “You can share mine” said Dr Valentina, who was not used to such language. “It doesn’t write very well. But you have to promise to give it back.”

I swear, no word of a lie.

A few minutes later (I had acquired a pen when the gynae intern put hers down for a moment) a chest pain came into cubicle D. At Shipman cubicles A to F are high acuity cubicles for urgent conditions – priority twos and so on. I went in to see Mr Wirrapanda, a thirty year old Aboriginal man with ongoing chest pressure and left arm heaviness. I took a brief history while I grabbed the stuff to put a line in his arm. I opened the drawer. There was no tourniquet.

“Tourniquet” I said to the nurse.

“What?”

“I need a tourniquet. To put a line in his arm – he needs anginine and his blood pressures only one oh five – where are they?”. When you put a tourniquet around someone’s arm, the vein stands up. It makes it easier to get IV access, to “put a line in”. For an anxious doctor like me there are only two kinds of sick patients – those who have a line in and those who need a line in. The nurse – the one frazzled woman looking after all six high acuity beds, a job that at Florey occupies three – said there might be one in the blood room. I ran out to the blood room. Nope. The nurse had followed me.

“Try resus” she said.

“Resus???”

“There’s always one in resus”.

I had a sudden nightmare image of someone trying to resuscitate a sick child, reaching for a tourniquet to get a line in to save a life – and finding nothing. At Florey the resus room is sacrosanct, checked twice a shift to ensure that everything is present and accounted for.

In the end I found a tourniquet in cubicle H – thankfully by this time Mr Faucet was asleep, catheter still in situ, still unseen by the urology surgeon. I found the tourniquet and got the line in and actually treated the sick person.

Anyway. The shift went on. I saw a little girl who had fallen off a slide and broken both her wrists, and a wman with a rash, and a girl who had broken up with her girlfriend and taken a large dose of essentially harmless medications. And a woman who was gardening and had got a spike of some plant or something through her thumb – I asked if I could take a photo of her injury, it’s a pity I can’t post these – hold on, I’ll try.

If you're not seeing an image of a thumb with a bit of stick stuck through here, it didn't work.

Hold on:




And some other stuff. And eventually, an hour over time, I crawled home, shaking my head. Because of the nail, the kingdom was lost, all that kind of thing.

And the next day I worked a shift at Florey – another doctor called in sick – and had a glorious, camaraderie building, positive self-belief affirming time. Treated a woman wiht bipolar disorder, hepatic encephalopathy, sepsis... you name it, this woman had it. And it went well, and I even got to teach a medical student something, and I came home tired and everything but happy.

All of which will be taken into account when Sarah and I do actually sit down and work out our finances and what we want to do, whether we could see ourselves doing what we are doing now in five years time.

The primary exam, should I ever decide to submit myself and those who love me to that kind of stuff again, is six short months away. The textbooks, cobwebbed, steeped in dust and in the smell of fear, are only a short walk from here, in a rooom I haven't entered in six months.

We shall see.

Thanks for listening,

John

Takeaways

Cold day at Southern today. As I hurried from the carpark this morning rain spattered on my face, and magpies huddled in the bloodwood trees, their feathers blustered by the gusts of wind. Now as I sit inside, with my hands around a coffee mug and the three picowatt heater on, I can hear the trucks rolling past, the wind in the wires, occasionally someone shouting in the carpark. It's ten o'clock and the police have been here once already today - there was a scuffle at the methadone clinic, and somebody had brought a knife.

I'm already feeling a bit fragile. The valproate is working well, and the reboxetine as well as can be expected for the time it's been given, but it's a projected six to ten weeks for a full return to normality, and yesterday was a bad day, an outlier (more on that later). But I've just had a woman in here who cried for a full twenty minutes, and I am making the next person wait for five while I make some phone calls.

A few minutes later ("...no, that was last month, she's been kicked out again... out of the Murphy Road house... well, there must be somewhere, she can't just sleep in the carpark...- I think only her mother. Both her sons are dead, but the mother's in Clearwater, she's pretty much out of the picture... I don't know. I think he's still inside. She's still got the restraining order out on him, but I don't know if that's against the Murphy Road house or what... right. Look, I've got to go, can you get back to me? Thanks"), I go out to the waiting room and ask Mr Castro to come in.

He's a slim young man, pale, crooked teeth, but articulate and with an unusual precision in his speech that makes you listen. I shake his hand and he sits down.

"Can this be quick?" he says. "I'm on home D, and I need takeaways".

And I notice the plastic anklet with the bulky device, about the size of a box of cigarettes. I shrug. Home D is home detention,it means if he misses the bus back late he goes back inside.

Takeaways, I should explain, are doses of methadone or similar medications given out to clients to take in the privacy of their own home, as opposed to under the eye of the pharmacist. Access to takeaways is tightly controlled, because the more takeaways there are the more deaths there are - people inject their methadone, or sell to others who will inject it, and every year we have deaths in which injection of methadone or buprenorphine plays a part. I should point out that not all overdose deaths can be blamed on takeaways, patients often spit out their buprenorphine tablets or vomit up their methadone liquid so they can inject the product, or sell said product to other who inject themselves.

Hideousness alert....

That's how that guy died a few years back here - the other guy who spat out the tablet had oral thrush, and the guy who injected had HIV so he had a really bad immune system, and he got fungemia - fungus growing in his blood, oral thrush in his blood, and it went everywhere, and he died.

That's heroin chic for you.

End of that kind of hideousness.

At time of writing, none of my clients have died of overdose, because I follow the official line on takeaways. This is why so many irritable narcotic users (often resentful, cold and in opiate withdrawal) line up outside the chemist, and this is why there are often fights, and why people bring knives.

"Quick as we can" I say, "but I don't know you, I'm going to have to ask some basic questions."

He nods. "First off, I'm positive. HIV positive."

I nod. This brings the total number of HIV patients that I have seen in the last four years up to six - and that's with working in the ED, psych and drugs and alcohol, places where the invisible congregrate in larger numbers. AIDS is still a relatively rare thing over here.

"I've got colonic herpes – herpes in the large bowel - and Kaposi’s in the intestine. I get a lot of pain. When I go to the toilet, or vomit, I get blood."

"Who do you see for the HIV?"

He mentions a local doctor, one of the few around here with extensive experience in the area. "Seeing him after I see you."

“Any idea of your last CD4 count?"

"Three hundred" he said. "It was ninety". Three hundred isn't good, but it's a hell of a lot better than ninety. Doing well, considering.

"Okay". I try to work out what to do first in teh fifteen minutes we have remaining.

"How's it going on the methadone?" He's on ninety milligrams, towards the high end of the doses we normally see.

"Not good. I've been waking up - three or four in the morning - cramps, runny nose, goose pimples. I get this thing where I have to go to the toilet, right then. Sometimes it gets so bad I can't get there in time."

"Sounds like ninety's not holding you."

He nodded. "I've been using oxys, couple of them at a time. But if I do that I don't take my methadone, I don't want to OD." He's talking about oxycontin tablets, the big green ones.

"How many?"

"Two, maybe four at a time. Crushed up, injected." He shows me a big, angry puncture-mark on the inside of his elbow - not frankly infected, but not good.

"Okay. So did you want to go up?". I have ten minutes left with this guy and all we've talked about is my problems - what I want to find out, not what he wants to tell me.

He nods. "I've been on more before, in prison, and that was good. But I don't know how it will go with my other medications."

"What other medications?"

"Combivir, novirapine.... aropax and olanzapine."

The first two are antio-retrovirals for AIDS, the second an antidepressant. Olanzapine is an antipsychotic. "What's the olanzapine for?"

"Bipolar disorder. It's like depression, but you get these moods that are like highs as well."

"I've heard of it" I say. "I don't want to pry, but the way you speak... do you think you're depressed now?"

He nods. "I'm seeing my psych Friday. I mostly seem to get the depression."

Christ. What do I do first?

"Who do you see?" I said.

He mentions a mutual acquaintance. "He's pretty good" he says, and I said I had heard that he was.

"I just wish he could get me some more of the highs and less of the lows" he grins, the first time I've seen him smile.

"I think the average bipolar one patient gets something like three lows to every high."

He raises his eyebrows. "Bummer."

"Bummer" I agree. "Does the olanzapine work?"

He nods, and then I glance at the clock out of the corner of my eye and work out we have ten minutes to go and we haven't actually talked about anything he wants to talk about yet - it's been me doing all the asking. I get a quick drug history (no heroin for five years, but morphine or oxycodone tablets when he can - and here he shows me the injection site, a red, angry circular welt on the inside of his forearm - ecstasy 'whenever he can get it', last injected speed a few days ago, last ground up and injected oxycodone tablets about 3 hours ago...), and then he gets through all that and looks me full in the face.

"Show your doctor your arm" I say. "Today".

Uh huh. Anyway, we're moving. I live with my mum and her boyfriend and we're moving out to Arkham Fields, had to sell the house. Miles south of anywhere. There's like, no public transport there at all, two buses a day, seven in the morning and seven at night, and we don't have a car, and I have to walk an hour to get to the bus stop."

Outside the wind shakes rain down from the bloodwood trees.

"Dr Grizzle said she would see about getting me takeaways."

"Right".

There's a brief pause.

"I'll be straight with you." I said. "I'm a fairly junior doctor here, I have to run everything past my boss. And if I go to my boss and say 'I want to give take-home methadone to this guy, he's only been with us a month, he's on a big dose of methadone, he's still injecting lots of stuff, he's HIV positive and he's just got out of prison... they're going to say no."

This is all true - and I hadn't even mentioned the bipolar. Giving this man a few days worth of methadone to take home would not be in accordance with the official protocols. Could you repeat that for the benefit of the members of the jury, Dr Bronze?

The wind gusted again. I thought of this man, this essentially dying man, walking an hour to the bus stop in the wind. CD4 count three hundred, was ninety.

"Could you ask anyway?"

I nod. "I'll definitely ask."

The last few minutes we get something done. We increase his methadone, hoping that will at least slow down the injecting. I increase his methadone by twenty milligrams over the next six days, rather than the official ten milligrams - an action that I suspect is not in accordance with the official protocols. We hook him up with a social worker who can look at transport options for him - although I am sure his GP has already done this. I type up a quick letter about the altered dose of methadone to his GP and his psychiatrist - which I will send, rather than give him tomorrow when I see him myself.

And he stands up and sticks his hand out, and I shake it, and he goes.

Anyway. No subtle moral from this one, not a great message of cheer, either. But we have half-hour blocks to see our patients, thirty brief minutes, and by the time you've written to the GP and done the paperwork it's closer to twenty. And that's fine and dandy for some of them, and for the others we are meant to concentrate on the discrete and the soluble, finding out one thing we can make a little bit better for them this visit, and linking them in to services that can help them further.

But sometimes the whole thing seems some impossibly complex fractal thing that, however hard you look at it, can't be altered in any meaningful way by anything you do.

Some of these problems have a horrible symmetry.

If I increase his methadone, maybe he'll inject his oxys tonight and die.

But if I don't, he'll keep on injecting his oxys and he'll probably die.

Of course, either way, sooner or later he's going to die.

Sigh. Could be later, I suppose.

But maybe we can get him not injecting long enough to get a few "clean" urines out of him. And his GP and his psych can keep everything else fairly stable. And in a few months - two, I think, according to the protocol, he can get takeaways - first off, six per month. That's still twenty four or so days he will have to walk in the bitter weather to the bus stop. But six days a month he can hear the wind at six in the morning and roll over in bed and not have to get up and start walking. Six days a month we might have done something.

Thanks for listening,
John

I have to admit...

... it's getting better. It is, in fact, getting better all the time. More on this later. By the way, not the world's most exciting post today.

But first things first - it hurts me deeply to have to write this.

Specifically, it hurts me deeply because I look to have inflamed the infrapatellar ligament, the ligament between my kneecap and the big bone of my lower leg. It;s been grizzling and groaning for a few months now and yesterday I kicked a football around with people who were younger and fitter than I was. I woke up with a knee like a rockmelon and a tendency to whimper, and try and persuade Sarah to help me get dressed. Now I am hobbling around the place on crutches, with a theatrically large bandage on my knee, and complaining to anyone who'll listen (a very short list). Tomorrow I am writing myself up for an ultrasound.

I should point out that this condition should be distinguished from housemaid's knee (prepatellar bursitis), clergyman's knee (infrapatellar bursitis) or the alarmingly named breast-stroker's knee (named after the swimming stroke, not some previously undiscovered profession). There is also the closely related pes anserine (or "goose's foot") bursitis: maybe it's that.

The pain is worst "medial", i.e.: on the edge of the patella closest to the centre of the body. That could mean either breast-stroker's or goosefoot - or possibly the rarely described goose-stroker's bursitis.

Anyway, what's been going on? I was reading in the BMJ* about two new findings. One, published April first, describes a new disease diagnosis - the previously undescribed "Motivational Deficiency Disorder". This debilitating condition, believed to affect as many as one in five Australians, "is characterised by overwhelming and debilitating apathy." Furthermore, "in severe cases motivational deficiency disorder can be fatal, because the condition reduces the motivation to breathe."

Anyway, it continues on like that, and it's pretty funny. And it's written in jest, but I suspect that there's a lot of truth in it.

Another, more serious article, points out that there is evidence that faking happiness at work can make you seriously ill - elevated heart rates, cardovascular strain, presumably leading to heart attacks and so on. The argument goes that it's not so much dealing with clients/patients/fellow workers who are narcissistic, aggressive or just plain bare-bones stupid - it's having to smile amiably and converse in a measured and reasonable tone that kills you. The authors, apparently, call for a reappraisal of the idea that "the customer is always right".

I reckon this will strike a chord with many of us.

As to all the other stuff that was going on - it really is getting better all the time. And thanks again for the various well-wishings and offering of sacrificial ex-husbands and so on, it fills my heart with joy to see how selflessly some of you will offer up things precious to you.

Anyhow, whether it's the valproate, or the reboxetine, or the collected good will and various enchantments of my supporters, or the fact that after the last post I finally buckled to superstition and wore my lucky Silver Surfer boxer shorts to work... it seems that Insert Name Here has been told to Insert Head Right Up There and bugger off. Things are on the up. First class.

Seriously - the mood is getting back to normal, no morbid thoughts for a day or two.

Sleep patterns probably starting to return to normal - and at least in the early hours of the morning I can plan stuff, rather than panic.

Concentration still a little bit iffy - certainly not up to ED standard yet, but adequate for the drugs and alcohol stuff.

Appetite - several tins of fruit, a few meals of pasta and some gloppy sweet stuff later, probably back to normal Monday.

And that means I can go back to the gym Monday, and back to judo (once the knee calms itself down), and start writing again, and do normal stuff. And write on my blog about other people and their problems, rather than about me and mine. Tomorrow I see if I can brush the cobwebs off the punching bag.

As far as communicating, writing is pretty much all I'll be doing - half the family has come down with laryngitis, and I didn't want to feel left out, so I got myself some of that. For the last two says I've been speaking in whispers - I suspect the original cause was probably from talking too much about myself. But this isn't a bad thing - with most of us sick, it's remarkably quiet here. And I've noticed this kind of thing before, where your body basically says "Look, I asked you before to take it easy, but now I'm telling you" and produces one of those lie-in-bed-for-three-days things that remove you from the field of conflict.

Anyhow, no real inspiration today, just glad things are finally returning to normal. Thanks again,

Thanks for listening,
John

*BMJ - British Medical Journal, one of the "big five" medical journals and one of the few that is consistently interesting.