Asystole

I am putting this blog on indefinite hold for the time being. Something has come up in my private life which I have, unusually for me, no desire to speak about with anyone.

I wish you all well.

John

Doctor, Strange.

Hail,
Well, a bit going on, and time to write about it, because I have come down with the markedly unmasculine-sounding condition of pre-patellar bursitis, or "housemaid's knee".

And the sad thing is I originally damaged caused this through kicking a football around, and last night aggravated it boxing, but it's not called "he-man's knee", is it?

So. Another rewarding day at work - by eleven seventeen, two people had threatened to sue me and another two had burst into tears in my office. The legal threats come thick and fast, more thick than fast, usually from people who can't afford bus fare and will be getting big lawyers onto me as soon as they get off home detention. Today's patient-doctor interaction contained the following gem, about fifteen minutes into the consultation with the woman whose life I had ruined*.

Her: "And I was perfectly happy before you took my benzos away!!!"

Me: "I'm sorry about that, but one hundred milligrams of methadone a day, plus a fifty-tablet bottle of 5 mg valium every three days is too dangerous. You could overdose and die."

Her: "Overdose and die? I've been doing this twenty years and I'm not dead yet"

Me (with restraint): "Plus the bottle of Jack's "every now and then"... if you die it looks really bad on my resume."

Her: "I'm as healthy as a friggin bull!"

Me: "You have no spleen and only one lung. You've got more surgical steel in you than a bloody cyberman. Two years ago you took two packets of nurofen and codeine on top of your pneumonia and you were almost pronounced dead at Florey..."

Her: "You've ruined my life!!!!"

Me: "I'm sorry that you feel the treatment isn't working for you, but if you want, I can refer you to Central instead. They have really smart doctors there, people there who are experts in treating your kind of problems."

Her: "Pity we don't have any smart doctors like that here, we've only got you."

Me: "Yeah, well, for some reason the smart doctors don't want to come out to Mordor and see my clients."

And so on, with the utterly unterrifying threat of legal action hovering over my head like a pink, fluffy vulture on a bit of elastic. I will be seeing a lawyer about this woman, but that will be when it's a coroner's case, in which case I will be fairly comfortable explaining why I did not take her medical advice when prescribing for her.

Plus Christmas is a difficult time for a number of our clients, thoughts of family, that kind of thing.

Anyhow - as I do when I am edgy, and I've been a bit edgy lately, I've been thinking about science fiction, fantasy, superheroes... particularly the latter. I don't know why the idea fascinates me, I don't read much of the stuff lately, only the good stuff, and like with a lot of things lately I've been becoming more and more interested in the ideas behind the stuff, the history, the implications.

Some of this stuff is fairly basic - the disproportionate amount of superhero ideas (Superman, Batman, Spiderman, the FF) that came out the minds of Jewish immigrants to America, for example. Born to noble parents, set adrift in a tiny vessel, developing superhuman powers as he matured to protect his people from aggressors - somewhere in Superman is Moses.

The access to advanced science and technology - not all of them, of course, but before there were superheroes there were science heroes: people like Thomas Edison, who was the star of "Edison's Conquest of Mars", thirty years before Superman, and Doc Savage, Man of Bronze.

But I was thinking about the disproportionate number of superheroes who have no fathers - and whether there could have been superheroes without the absence of those fathers. The father of Jerry Siegel (the writer who came up with Superman, and thus everyone else) was shot and killed when Siegel was still in junior high. And then you look and see that Superman's parents died with Krypton (but not before saving him), Batman's died literally so that he may be reborn, and Peter Parker/Spiderman's has a mysteriously vanished father and almost immediately deceased surrogate father, Uncle Ben.

For Bruce Banner/the Hulk, there is no death of a father involved in the superhero's genesis, in the event that enabled the character to become a superhero (a creature who often combined the strength of an adult with the appetites and thinking of a child). The closest thing to a father is the hostile General "Thunderbolt" Ross, an extravagantly moustached man who bellows and roars and sends wave after wave of tanks and military men after the misunderstood, enraged, childlike but ultimately invulnerable Hulk.

And you also wonder about those boys, being brought up by more religiously orthodox parents, finding a new religion of technology and individual achievement and wealth and freedom in the new land, the New World, and abandoning the synagogues for the street corners.

The loss of another Father.

And obviously there's more going on than that. There's the whole idea about putting on the mask and thus becoming unseen, almost invisible and thus free. There's the fascinating evolution of the superheroes - and here I'm quoting someone else from a newsgroup I used to visit -

how Superman went from being a rabble-rousing
anarchist figure to a tame Establishment figure
who tells children to eat their vegetables. It's how
the dark and deadly Batman was tamed into a
proper law-enforcement officer who told children
to obey their parents. They went from being
fascinating characters with a whole world of
potential to being perfect, boring people who
hang around all day just so other people can
look up to them.

Anyhow. Fascinating stuff. The book I am about twenty pages into is called "Men of Tomorrow" and the tagline is Geeks, Gangsters and the Birth of the Comic Book. Interesting stuff, particularly the almost painfully accurate and tender way he describes the birth of geeks, an entire subculture and personality type birthed by Amazing Stories, the first science fiction magazine. He describes the time when, for the first time "... a generation of misfits (was) given a choice other than complete withdrawal from the world or indentured servitude to it. They were given another place to go." If you are a geek or an ubergeek, or you know one, parts of this book will make you wince.

And lastly, an obituary, reproduced from the British Medical Journal, 11th of November, 2006:

"Dr Donald Duck.
Donald Duck trained in medicine after a brief foray into civil engineering. After a year as general practice trainee in Skye he moved with his wife to the Medical Missionary College at Ludhiana, where he learnt Urdu and Hindi...."

Bizarre: imagine being wheeled in for that emergency surgery and soneone says "Don't worry, Mrs Smith! Your tumour is being removed by Donald Duck!".

Having said that, I've certainly known a few Dr Goofys.

Anyway, thanks for listening,
John

*Not Sarah, another one.

Wake

Hail,
Some bad stuff ahead warning.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On that curmudgeonly note, thanks for listening
John

Axes and superconductors

Hail,
Just a quick post. I went in to Clearwater today for a checkup (sortof the psych patient version of the 30 000 kilometres checkup), and one of the things I mentioned was Dr Greene, how that had affected people, given us pause to think. And I didn't mention Florey by name or anything, but as soon as I spoke the psychiatrist knew who I was talking about - already informed.

And I had mentioned it to one of the doctors at the drug and alcohol service, and I suspect that they would all know by now. And a friend of mine who was a GP mentioned it the other day.

Anyway, what I was thinking about is the way that news like this spreads quickly and effortlessly, like electricity through copper. In fact, that makes sense, quanta of stuff travelling without resistance, as if the community of doctors, any community, was like a superconductor.

Tehre are, of course, substances like graphite, which only conduct electricity in certain directions. Graphite conducts in a plane - electricity may go sideways and back and forth but not up and down. I suspect, although I do not know, that the medical community is like that.

I don't know that they'd be happy with the comparison, but the community I serve is the same as the medical one in a way. In drug-using circles, almost everyone knows everyone, because everyone has at one time or another bought off, or sold to, or ripped off, or dobbed on, been in priosn with or been to the family court about everyone else. So news - news of deaths, or imprisonments, or bashings - travels fast.

We - the nurses more often than I, and the better nurses more often than the worse - get news like this faster than through the official channels. Someone says Jack Daniels got picked up for stabbing some guy in Innsmouth, and ten days later we get a letter from the Dangerous Drugs Council saying that our authority to prescribe drugs of dependence has been revoked, and a similar authority has been issued to Dr Rachet of the Prison Health Service.

Then a month or so later we hear that Jack Daniels got in a fight at the Drowning Neuron, and a week and a half later than that we get a letter from Prisons saying he's out.

By the way, one of our clients got in a fight down at Grunge Pharmacy the other day, and I felt I had to pass on this remarkable one liner he said. He described how this guy he knew pulled up in a car while he (our client) was waiting in line at the pharmacy, and attacked him with an iron bar and a claw hammer.

"You look to have come out of it alright" I said, wondering.

"Thing is, I happened to be carrying an axe at the time -" he began...

Anyway. Back to it.

Thanks for listening,
John

Superman #75

Hail,

I don't know.

There are a lot of problems with writing about some of this stuff, some of the stories, some of the difficult ones.

There is the problem that writing about something in some way 'claims' it, says "This happened to me, this is how I feel and I am the central figure in this", claiming the suffering of the patient for one's self.

There is the closely related problem that by writing you somehow claim some understanding, some insight, some special knowledge... when in fact, a lot of this stuff takes place beyond event horizons, is stuff you can't really understand at all. I can't know the what or why or how of anyone else's head, I'm barely aware of my own.

And thirdly there is the danger of dulling by repetition, of boring the reader or myself, of writing yet another story of loss and tragedy. Over the years skin thickens, senses blunt, nerve endings die off. What was something awe-inspiring and life-changing becomes wallpaper, background, business as usual.

I know there these problems exist, but still, something happened yesterday, something important, and I am going to write this, because this is important.

When I was in the ED, what seems like an age ago but was less than a year, working with Dr Longstocking and Dr Iskandar and Dr Maad, there was a path ahead of us. We were postulants, commonly called registrars, in a training programme, and that training programme consisted of the learning of certain skills, the understanding of certain pathologies, the obtaining of certain abilities ... and in the end, becoming a consultant.

And when we registrars spoke of a consultant, we all meant Peter Greene.

Dr Greene was at the time and still would be the best emergency doctor I have ever seen. He had been trained overseas, some place where there was a lot of trauma, he had seen more gunshot wounds and bodies extricated from cars and blunt trauma than we would ever see. He had intubated throats bubbling with blood and stabbed needles into baby's bones to get access for life-saving fluids and he had brought people back from "no heartbeat, no respirations, pupils fixed and dilated", so that three months later when they got out of ICU they were waiting in the waiting room with flowers and chocolates for him.

Seriously, the best there could be.

"If I get cut in half by a train" Dr Long-stocking once said, "each half will hop over to Florey and Peter will put me together again."

And I think a lot of us knew we'd never be that good, and maybe we didn't even want to be that good in that way, but you shoot further when you aim higher. There was a path and the obstacles were the exam and the anaesthetics term and the rest of the stuff and at the end was being like Peter Greene.

And he wasn't just clinically good, either. When Dr Iskandar and I were with the Ice Maiden, the woman in her twenties who came in and died twice under our hands, it was Dr Greene who I went to see two days afterwards, and Dr Greene who sent me out of the room feeling damn good, proud and confident and relieved. And it was Dr Greene who talked to us all after the methadone baby died and Dr Greene who went around to people after the guy using the fire extinguisher as a club tried to kill one of our security guards.

Anyway, what do I say now?

Monday my brother rang me up and told me Dr Greene was dead.

Died by his own hand, hanged himself, found by his wife Saturday morning. Forty five years old, the body still at the coroner's.

The best emergency doctor I knew.

There's a lot that I could say here that wouldn't work. There's the stuff about the effect it's had - all last night there were people sobbing on the phone, registrars and nurses ringing each other up, horror and numbness and fury and reminiscing all in four short hours. Stories how he made us laugh or saved our arse, times when we saw people who should have died being brought back from the brink by him.

There's the stuff about risk factors, the stuff about how nobody knew, nobody thought, nobody suspected. Nobody wants to believe.

Over and over you hear undercurrents of incredulity that anything, anything at all, could kill Dr Greene.

Because - and I'm not going to get this across, no matter how I write it - he wasn't like that. Death was not in him, you sortof got the idea death backed off when it saw him. He wasn't thekind of person who could suddenly be dead, he was alive, strong, laughing, tall and handsome and broad-shouldered and everything. Everyone's mentor, everyone's idol. Competent and confident and supremely respected.

I don't know. There were some things that, looking back, chill me now.

The fact that he chose what is in this country the most lethal commonly employed form of suicide. The fact that he was so good because he demanded perfection of himself, and to him part of that perfection was not burdening anybody with your own problems. The fact that because he was so admired and so good he ended up doing less and less time on the ED floor and more and more paper-shuffling, administration, something he hated.

The fact that in his last days he was essentially surrounded by doctors.

The fact that he always listened to us talking about our terrors, but he never spoke about his own.

The fact that before he died he flew overseas, got the recruiting done, made sure everything was set up for the department for the next year, made sure we'd be looked after. Got things right.

I don't know. Like with a lot of these things, I don't know that this should serve a purpose, be an exemplar. Men die earlier, people who don't talk are at risk, perfectionism can kill you... we already know all that stuff.

I just keep thinking about how every talk he gave was grinning, occasionally mordant (he opened a talk on the management of road trauma with a photograph of an ambulance that had rolled over and a caption underneath asking "who do you call now?"), a joke in every paragraph.

Whatever. Please do not mistake this as a cry for sympathy, it is more, even now, an expression of disbelief. Tonight I am going around the ED, see how things are. Quiet, from what I hear, stunned and sorrowful, angry and unbelieving.

As far as I and the rest of the registrars are concerned, this has given me some pause, made me think, made me weigh things up. He was the goal, like I said. I am meant to be going back at the end of January, and I know I am less strong in virtually every way than him. Having said that, I bend before I break, and I suspect he could not. Oaks snap in the wind when grass does not.

If anyone medical is reading this, the thing to take away from this is suicide is not something that only takes the weak and the cowardly. If you've been doing medicine or nursing for more than a year and you haven't seen the weak survive things that kill the strong and the good and the great, you haven't been looking.

Anyhow, I have to get back on the phone.

The title above, by the way, refers to the DC comics issue called "The Death Of Superman". Never read it.

Thanks for listening,
John

TV

Hail,

Writing to displace the pre-party terror I am feeling (the usual no-one will come, no-one will talk, no-one will have a good time stuff) so I thought we could do with some prison stories.
And a strong language alert ahead.

(I wrote some notes on this and they have disappeared into the Void, so some of this may even be less factual than usual. But I had an interesting patient the other day, and I feel like telling people about him).

Mr Connolly speaks, and looks and even dresses a lot like my dad, so much so that I find myself listening to him as if he is my dad, the same affection, the same admiration and respect. This is the psychiatric phenomenon known as positive counter-transference, by the way, and each time after I have seen Mr Connolly I know I have to check my notes to make sure a little more leeway is not being shown to him than other people.

But Daniel Connolly has the same clear hazel eyes, the same soft southern Irish accent, the same broad worker's shoulders. I think they would have come over from Ireland around about the same time, they both spent time in London, each used to ride a motorbike. Where my dad drove a bulldozer, made roads and worked in the mines, this guy smuggled heroin and waved guns at people, but the superficial similarities still remain.

Or maybe not that superficial. My dad was a man with a strong moral code, and one day Daniel Connolly, who at that time was working for some Italians who distributed heroin in Sydney, ("... and they did guns and ran a bit of prostitution and so on... I reckon some people would have called them Mafia") got a phone call.

The caller was Psycho Ed, who apparently had a tattoo on his arm that said "World's Greatest Crinimal": his own work, even the spelling. And to be called "Psycho" in the Sydney underworld at that time you had to stand out from a crowd of markedly unusual characters.

"Jesus, Ed. What are you doing calling? You're not welcome here. You come around here, these guys'll put you in the boot of a car."

This was because the world's greatest crinimal had made several emenies last time he was in Sydney, due to a series of misunderstandings, principally the misunderstanding on Ed's part about "paying for what he owed".

Anyway, Ed wheedled and begged and said he was "hanging like a dog" and eventually Daniel agreed to meet him at a football game and get him some stuff. The transaction took place at a soccer match. "That was my first mistake" said Mr Connolly.

Then Psycho Ed asked if Daniel wanted to see where he lived.

"Nah, better get going and all - "

But Ed wheedled and begged and "maaaate"-ed him and said how it was just around the corner and eventually Mr Connolly went with him. "The second mistake." And they make a shortcut through this block of flats and the next minute Mr Connolly looks around and Psycho Ed's disappeared.

"Where the f-" he begins, and then glances into an open doorway... and sees the world's greatest criminal emerging with a old colour telly.

"Are you fucking mad? It's broad daylight" said Mr Connolly.

"He left his door open" said the WGC.

"That's because he's probably in the house -" began Mr Connolly, and as if on cue, a tiny, red-haired Italian man emerged from the house and began hobbling towards them.

"Jesus Christ, look at the size of him" shouted Mr Connolly. "The poor bugger's on the pension."
"Shut up and help me carry this. It's bloody heavy" said Psycho Ed.

"My arse" said Mr Connolly. "That guy - he probably saved for two years to get that. What the fuck are you doing?"

And the situation deteriorated, and by the time the police came there were three men scuffling on the ground and the telly lying smashed beside them.

"Who owned this?" said the police officer.

"I did" wheezed the Italian man, who had been giving as good as he got. "This minchione broke into my house in broad daylight and this selfless gentleman here tried to stop him."

The police shoved the world's greatest crinimal into their automolibe and shook Mr Connolly's hand. "And you, sir" said the officer to the selfless gentleman, "where do you live?"

And Mr Connolly opened his mouth, and thought of his employers hearing about him doing business with Psycho Ed, and thought about leading the police around to the Italian's house, and his own not inconsiderable involvment therein, and he said "No fixed address."

Two big mistakes were enough for one day.

So he got done for vagrancy. And he was too paranoid ("but it's not paranoia if it's true", he said) to call anyone at all. So no-one would bail him and he ended up spending four months in Long Bay jail for vagrancy. No-one knew where he was. And when he got out he went over to the Italian guy's house and told them a truncated version of the facts and fairly quickly got all his stuff out and came over here.

Anyway. There are a number of other prison stories I have been told (oddly enough, most involving someone with the epithet "Psycho"), and I might post them later on. But I can't help feeling that if my Dad had found himself in the same situation, if there'd suddenly been a swapping of bodies after the heroin sale but before the arrest, with the little Italian man hobbling towards him and the WGC holding the colour TV, he would have acted in exactly the same way.

Anyway, party soon. Thanks for listening,
John.

Junkie***

Hail,
And bad language and a rather boring and preachy post ahead, sorry.

A friend of mine has written something that made me think - go and read it - and I am having great difficulty putting any of what I have thought into words.

You know some stories you want to tell but you can't? Because they are so cliched, and so hoary and so so rubber-stamped, that no matter how you try to tell them, how you twist things around to get a new angle on them, you can't?

I should give up. I should just say nothing. Or I could just give the bare bones of it - sketch an outline, then get on with what I am trying to do, sort out my thoughts on something I deal with every day. I don't know.

Here goes: I had a friend. He was one of the smartest, most talented, funniest people I knew. Without wishing to admit to feelings inappropriate for a teenage boy growing up in south-west Western Australia, he had those Dutch good looks that nowadays you find on yoghurt advertisements - blue eyes, white teeth, broad shoulders, something like the sun. He played violin and was centre-half forward for the football team three years in a row and wasn't a wanker. He was so popular that he got called Stevo when his surname was something like Van Handonknob (seriously, something that would have crucified anyone else).

He left school and went up to uni and I saw him three years later and he was completely drug-fucked.

I suspect this has happened to a lot of people. It had happened pretty bad to him. He attributed his (considerable) problems to taking LSD, (which sortof fitted with what kind of guy he was*). He took the LSD and got the desired hallucinations, which involved talking, bipedal rats, and afterwards sat back to watch the cricket when into the room wandered the rat.

The rat asked him what the score was and when were they going to drop that useless Mark Taylor bastard, and Stevey reacted with alarm, which caused the rat to back out of the room, paws raised conciliatorily. One and a half, maybe two foot tall, said Steve. But later it came back, with friends, sitting in the passenger side of a car as he was driving down Slugge Highway, chatting and waving, and then he got other hallucinations, and he'd spent a few months in the closed wards, and a lot of stuff wasn't the same since.

And it wasn't. He was fat, and acne scarred, and he had a tremor, and there was some slowing, some dulling, something it's hard to put into words. Less, now, like the sun, more a candle on a bright day.

And maybe, of course, I didn't see him on his best day, and maybe he came good again, and maybe, of course, it wasn't the LSD and the amphetamines and the mushrooms, maybe it was coming anyway, some genetic lesion sent down the line, a protein folded the wrong way a million years ago. Lines upon lines and generations upon generations of Van Handonknobs, golden boys progressing to bloated men, going from being the blessed of the earth to some junkie loser you'd get off the bus to avoid - if you noticed him.

But I don't know. Maybe it was the drugs.

See, my own opinion about all this has changed. I used to have pure civil libertarian views - the government shouldn't get involved in what people do to their own body. However, I have since come to believe that the polity abhors a vacuum, and a lot of talk about keeping big government out ends up being shorthand for letting big business in.

And considering what big business has done with "normal" meds, I don't feel inspired to let it run heroin**.

So, if the government gets involved... what then? I can't believe prohibition is working. I can't believe we're getting it right. I can't believe our children deserve the punishment that is being meted out to them - infection and psychosis, crime and punishment, body and soul.

(If we all were judged on our sins, who could stand? Hands up if you haven't ever done unwise things - at a wise or unwise age? Done things for pleasure alone, done things you knew you would be told off for? Gone outside the boundaries of the traffic code, the marital vows, the circumscribing dictats of social niceties?

Now hands down if doing that gave you hepatocellular cancer. QED).

And I'm not saying all transgressions are the same, but I am open to anyone who can explain to me how we've got the whole "nastiness of drug - penalty for using it" thing exactly right. Post a comment below.

So if we can't stamp out IVDU (intravenous drug use), and we can't leave it entirely to big business, where does that leave us?

By me, it leaves us having to look at the government prescription and supply of dangerous drugs. I am not advocating heroin at the school tuckshop. But I am advocating the supply of cheap, safe heroin in safe environments. I am advocating decent quality, long term controlled trials of ecstasy and the like and similar and an appropriate response, depending on what they find out, by our government. I am considering advocating flooding the market with cheap, unadulterated amphetamines so that the people who cut it with God knows what are driven out of business, much in the same way that the people who used to flavour whiskey with rattlesnake heads don't get a lot of shelf-space at the local bottleshop.

And clean, cheap needles everywhere, with special airlocky things where you go into the room, use the needle, and can't get out until you've put the bloody thing in a safe place.

And lest anyone think this is the old-school socialist talking, I am leaving a place for private enterprise. There will always be a market for producers who claim to offer highest purity, aged in the test tube amphetamines, or cocaine made only from coca leaves picked by Andean virgins and processed by wizened monks of ineffable wisdom. Let private enterprise get involved, with the proviso that they like anyone else, the threat of legal action keeps them on the straight and narrow if anything happens to the consumers that the consumers weren't warned about.

And what I am suggesting may not diminish the number of addicts. It may well increase it - I don't know, currently these things are fairly freely available, and there is a certain lure of the forbidden, plus a fairly quick realisation by the novice that drugs don't irrevocable lead to ruin, so I doubt it ... - but I could be wrong. It could increase the number of addicts.

But it will decrease the number of patients awaiting livers on the transplant wards, it will clear a lot of people out of the prisons so we can put the truly nasty ones in there, it will diminish the number of prostitutes offering ten dollar hand-jobs off the Mall after hours and it will at least get the psychiatric/drug problem out into the open where people can look at it.

And most of all it will make the stuff so damn cheap that organised (or incredibly poorly organised, from what I've seen) crime has to go back to rigging the poker machines or the horseracing or whatever.

That's where I am at the moment, but it's a shifting thing. One of the problems with theorising about addictive substances is the dog's breakfast they make of ideas like "choice" and "consent". And then there's the whole "what about the children" side of this. But these issues aren't going to be solved tonight.

I don't know - I truly have no idea - whether any of this would have helped Steven. Like I said, I don't know if he had something waiting to happen, or if what happened was caused by him swallowing blotters soaked in flyspray rather than LSD, or if it was the stuff itself.

Anyway, party tomorrow. The weather forecast is forty two degrees (one hundred and seven in America) and I - the drug and alcohol doctor - have to go organise the drinks.

Thanks for listening,
John

*My own drug history is relatively vanilla. When I was in my late teens/early twenties I drank more than I do now and did the required number of stupid things. I have had marijuana once, which resulted in my going to someone's house and eating a loaf of bread. I have never injected or snorted or smoked and am scared to death of anything that has even the remotest tendency to cause mood alterations or psychosis.

**Any more than they do already, anyway.

*** I read this book. I don't know what planet the guy was writing from. Heroin, he tells us a few too many times for it to be co-incidence, makes you look much younger than you are. My wife points out maybe what he means is it makes many people act younger than they are.

But here's a mental exercise for you. Get one of those diatribes against drug addicts and every time they use the phrase "druggie" or something similar, substitute Samuel Taylor Coleridge, or Judy Garland, or Paul McCartney or the like. Breaks the monotony and leads to some interesting mental images.

John

Heart

Hail,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thanks for listening,

John

Weight

Around about eight my friend Veronica rings me. She almost never does. It’s sunset here, the sky the colour of blusher. I am standing outside near the punching bag, burning old papers in the incinerator.

“Can you talk?” she says.

“What’s wrong?” I can tell there is something in her voice. She is very bad at lying, keeps her secrets close to the skin.

“Where are you?” I say.

“My dad’s house. Family barbecue” she says.

As soon as she says that I know what is wrong. I wait.

“I hate him” she says. “I'm in the kitchen. I had to come in here in case I cry.”

I say nothing. This is something you have to let out, not something you can reach in and extract. After a while I speak.

“What’s going on?”

Her voice is quiet. “He keeps saying things. All through the meal. Everything I eat.” She breathes in, a long breath just this side of crying.
“ ‘Don’t you think that’s enough?’
‘You’ll get fatter’
‘No wonder you look like you do’ ”.

“Jesus”. Veronica is eye-catchingly beautiful. Medical students lust after her and the man who fixed our air conditioning a few months ago spent forty minutes in her office and five in mine. I was terrified of talking to her when I first met her.

“Does he know you get sick?”

“He’s always known.”

Veronica was in hospital a while back. There are very few facilities dedicated to those with eating disorders in this city, but the larger private and public hospitals make an attempt. Her father is on the board of one of the larger banks, a man whose success is measurable, demonstrable, mentioned in the right places. He makes sure his offspring have the best private health insurance, she spent a few months in Clearwater a while back.

“He knows. He knows I go home after these things and I’m sick for days.”

“Look, it’s wrong, he’s wrong…” I begin, but I know as I speak that the words are falling into the void. But I do what I can. “He should be proud of you and what you are.”

“Times like this I want to strangle him. Is that wrong?”

“No. Actually strangling him, they say that’s wrong. But I can write you a sick note, say you weren’t of sound mind...”

She doesn’t smile. I try again. “He’s wrong. You’re a lovely person, you do an important job, you’ve achieved things any father should be proud of …” But as I speak I get the image of him coming into her bedroom every morning, like he used to do all through primary school. Weighing her and graphing her weight on the back of her bedroom door.

Sarah worked with Veronica once, asked me one day if I knew whether Veronica's father had abused her. At the time I said I didn’t know.

“I just want to be sick” she says. “I feel like I have to be sick”.

“Don't. You’re a good friend” I say. “You’re a good friend and people who get to know you like you.”

There aren’t many who get to know her. She has, if truth be told, few female friends - she looks too good, dresses too well, smiles too much at men, as if she defines herself by the approval of male authority figures. Her boss, unaware of this history, says she’s a man-eater, when in fact it is she who desperately wants to be eaten, savoured, accepted.

There is more stuff I say, and more stuff she says, and at the end of the phone call she says she feels better. “Thanks” she says, and hangs up.

And she’s probably driven home by now. And I don't ring her that often, and she sometimes doesn't ring me, and I know if I ring now the phone will ring and ring unanswered.

And there’s something going on here, some complex intertwining of food and sex and rejection that I can’t begin to understand. A significant proportion of her boyfriends have been men of a certain type - policemen and prisoners, men with some relationship to violence or authority, hyper-males. One is doing five years in prison, attempted murder - for a long time she visited him in jail, bought him gifts every weekend.

“Hope I helped” I say to the phne, and I don’t know. For a moment I stand there, one fist holding the phone, one poised in front of the punching bag. I think about violence, smashing the bone and skin of men - jabs, hooks, crosses, uppercuts. Splitting the mouths and swelling the eyes of people I have never seen, their faces crumpling and bleeding in front of me.

But they are not here in front of me, and the damage is already done. It's night-time, time to go in.

I walk out of the shed and the ashes drift across the yard. The sky is dark, a dull blue grey, the colour of sickness.

John

God, party, and cricket.

First off, thanks for the comments. And have a look at that map on the side, and think of the many hours it took me, logging on and pretending to be lots of other people from various other countries, and be impressed.

Anyhow, I am trying to cut down on the tales of incipient madness for today. There is something in psychiatry we call inappropriate self disclosure - the sharing of something that causes a crossing or redrawing of boundaries, the telling of a story that forces the listener into another role, perhaps the role of the therapist. It may be that this is particularly easy on the Internet - you can self-disclose into what seems like the Void, feel catharted... and subsequently find that the Void is full of a lot of people laughing at you.

I started writing this blog partly to explain (although I couldn't have said at the time to whom) my experience of bipolar disorder, particularly a doctor with bipolar. But when I am depressed, "This is how this feels for me" can easily become
"Look how much pain I am in", which is only a few lines away from
"Care for me."

I don't want to do too much of that. And I do appreciate the numerous posts and well-wishings and private emails from the deeply caring and compassionate people I have received - thanks again. But part of getting well again is doing something other than being sick.

Consequently, party at our place this Saturday. The invitation we sent out reads, in part,

"Drink fine wine
Eat delicious food
Stare at ornamental cats and chickens
Play backyard cricket (talent capping applies)

We supply BBQ facilities and cheap, good and plentiful alcohol (the red wine may be good, the white is cheap and plentiful). You supply that fine wine and delicious food we were talking about."

The cricket talent capping is necessary because one of my friends can really bowl - he bowled Steve Waugh out once at a cricket academy thing, and Steve Waugh was the Australian cricket captain - and if Matthew gets the ball in his hand and a glint in his eye we are all going to have to take evasive action.

My brother will be fielding from very very deep mid wicket, near the drinks fridge, and I will be providing tactical and moral support somewhere in the kitchen. The rest of us bowl, bat or field like flowerpot men.

The cats and chickens are as previously described. There is no real purpose to the party except to cheer everyone up and get us to clean up the house - I sortof came up with the idea when thinking about a low-calorie, single dose, side-effect free antidepressant. Come one, come all.

In the interim I have been cleaning the house and thinking about religion. This is something that has been going around in my head ever since, on my first night out of Clearwater, my wife took me to the U2 concert (seriously, tickets bought months ago, nothing was stopping me). Anyway, sometime - and I don't know when, sometime between sixty thousand of us singing "Sunday Bloody Sunday" for people imprisoned without trial, and seeing the Coexist symbol up on the screen when he sung "One" - sometime in there I felt some kind of communion.

As far as religion goes for the last ten years I have been a believer, not a belonger. When Ruth and I broke up there was some kind of understanding - possibly only on my part - that I got the uni, she got the church, and I have not really been back since. When I go to the country to visit my sons and they go to church, I go, and four out of the pastor's last four sermons have been about the damnation awating those who do not believe in the six days of creation.

Due to my previous excesses I am a bit wary of belonging, a bit mistrustful about that feeling of communion. As far as the church goes, I am particularly wary about belonging to something that requires me to believe in things I can't believe in any more. I can't do the whole homophobia/creationism/patriarchy stuff. That stuff that makes most of my friends think of Christianity as a mediaeval grotesquery.

But during the concert - and the echoes are still there, still with me - I got the idea that there was a communion for me. That there were Christians who believed what I believe, who took the same things as central as I take as central. Religion rooted in concern for social justice, voluntary simplicity, a religion with more humility than the high-pitched voices of rage I hear on the radio whenever a towelhead or a queer or - God forbid - a woman gets out from under the thumb.

Anyhow, preachy and a little bit bitchy - not a good note to end on. But, if this makes sense to anybody, do tell.

Better go - I have dishes still to wash, and miles to go before I sleep.

Thanks for listening
John