Sine wave

Hail,
Not that good today. See, I was going to post something very cheery and upbeat about, say, some of our chickens, or the lesser-known ductless glands, and I actually started writing yesterday, but it seems that may have been a case of premature exultation.

Because today, and yesterday, I feel ever so slightly bad. Disturbed sleep, that pressure in the chest, that rage and self-loathing, that panicked feeling.

Now this is not cause for panic. Some of this is situational. Without going into specifics, a few things have gone on in the last few days. Some have been social - a close friend of mine is going out with a nurse who works in the Florey ED. He rang up and asked us to come over a few mornings ago, so we popped over for a chat - it was two in the morning, she was in her night-dress bouncing rocks off my car roof and shrieking in Italian as he scurried from the house, wiping blood from his mouth, worldly possessions in a plastic bag - the usual thing.

Dead set. Two o'clock in the morning. Don't ask why he couldn't drive his car. There is a reason, but you'll have to watch our appearance on Jerry Springer for it.

(The next morning I got up late, by the way. It was my birthday and I was delighted to see four messages on my phone. "How nice" I thought. "Someone remembered". And all four messages were from her, fifteen minutes of bile from her - easy fifteen minutes - of drunken diatribe about him ("a diseased loser"), me ("a psycho loser") and Sarah (too many cats, didn't keep the house clean enough).

And about half way through her ululations there was warning - what others might call a threat - telling me to forget about going back to Florey ED because she was going to tell them all about the overdose and the detention order).

This is why gun control is a good idea.

So, there was that, which was actually rather unpleasant. Then there is going back to work at the Addiction Clinic, whereat I am apparently still topic du jour, on Thursday. I am going back part time, and I will probably spend a lot of time hiding in my office while everyone talks about how guarded, paranoid and isolative I have become.

I wonder if I can bribe someone to come up with a new scandal, or photoshop someone in carnal congress with a frog or something.

Plus I am starting to study for the primary, and I am realising that had I not been knocking back tricyclics like there was no tomorrow, in an effort to make sure there was none, I could have registered for the exam, sat it in March and maybe even passed it. As it is I have to wait until September, by which time I will be so damn sick of physiology, pharmacology and maybe anatomy that I won't. Meanwhile everyone else I know, smarter, younger, less weak, moves further ahead.

Anyway.

I am not yet depressed. A month ago I was depressed. Now, from some ways of looking at things things are actually worse in my life - socially, professionally, etc. - but I don't feel as bad. That's why depression is a mental illness - you don't see things as they are, you see them as you are, and if you are depressed, then you see things in terms of guilt, fear, confusion, hopelessness, etc.

Plus, this kind of stuff happens. Fluctuations. Meanderings. The sine wave. You don't fix everything overnight. You gradually emerge from the penumbra.

And I am fairly determined, and fairly sure, that I will not get that depressed again for a while. I have made significant changes in my life - soon I will be working in the ICU, for example, and some part of me thinks that this low-paid, high-stress, shift-work kind of thing is "real medicine", and I feel better about it. And I've made some painful changes in my life, people I miss a horrible amount, and I'm seeing Dr Tesla frequently, and taking the medications, and doing all the right stuff. And I may well ring and see if I can move the next appontment closer.

Because, to be honest, last time scared the crap out of me. It's still weird being in a part of your life for which you have no plan. And I awoke and found me here, that kind of thing.

Here, by the way,



is a picture of a haggis and her fank of young from improbable.com. I find this kind of stuff amusing.

Anyway. Two days until I start work at the drug and alcohol place, a fortnight or a month until I start ICU. Three days till drinks with the comic book geeks down the pub.

Thanks for listening,
John

Faking it

Hail,
The following contains medical stuff.

Been randomly reading some other people's stuff - a blog called waiter rant, another about a bouncer in some kind of nightclub, and Sarah has suggested I read something called "Girl With A One Track Mind".

And what is the reason behind this sudden switch from physiology textbooks to a diet of customer service, beating folk up and hardcore sex?

Well, these are three blogs that have been made into books. And somewhere along the line that was one of my stated aims. Make Stranger's Fever into a book, or at least collect material, make rough notes that later I could hammer into something saleable.

I'm not one hundred percent sure about that anymore. Part of the reason some of these blogs have been made into books is just the sheer quality of the writing - have a look at this, for example. But part of it seems to be that these (especially the first two) are blogs written by people who have

a) insider knowledge to impart (how not to have your soup adulterated, how not to get beaten up, how to give someone orgasms like a string of firecrackers),

and

b) tales of human suffering (usually theirs).

Now, don't get me wrong, I am not saying that these blogs are whiney, because they are not. But the writers seem to encounter a fair number of stupid, arrogant, downright deceitful people who make the writer's job harder than it has to be, and upon whom the writer must exact whatever small revenge s/he can. If I had to put up with what the writers have to put up with, I'd be angry too.

But my blog, and my life isn't like that.

For a start, there are few "secrets" as to how to get better treatment in the ED or the ICU. But there are secrets which seem like secrets on how to get better treatment, but end up being secrets of how to get treated worse: here are some of the few I can remember:

In the old days you used to be able to get a bed in the ED for a few nights by beating yourself up (literally, not figuratively) and then turning up claiming chest pain. The doctor would do a blood test (called CK) which would show muscle damage (from where you'd beaten yourself up), and admit you for a cardiac workup. Nowadays no-one uses CK anymore, they do either serum troponin I or serum troponin T, which show up pretty much only when heart muscle damage has been caused.

And years ago it used to be simpler to get opiates, too. Diagnoses of choice were either migraine, back pain, sub-arachnoid haemorrhage (evocatively described as a "thunderclap" headache) or kidney stones. You turn up to the hospital displaying the symptoms (it is difficult to display all of them, most people can't vomit on request) and get the treatment.

The first problem is the quality of the opiates we supply, if any.

Migraine is not treated with opiates anymore, you get megadoses of aspirin and some IV fluids in a dark room. Note: when faking symptoms, do not bother "bringing your own vomit", and do not (this happened at the Royal a few years back) attempt to substitute canned chicken soup for vomit.

Non-traumatic back pain is a nightmare for all concerned, but the skilled patient can often get some IV morphine out of the unskilled doctor, for a short period of time, until the skilled doctor hears about what's going on, and kicks the patient out of the ED.

SAH gets opiates, no questions asked, as do kidney stones (again - few people can pee blood on demand, and if you turn up at the ED with a sample of your own blood-adulterated urine in a container that has blood on the outside too, don't expect miracles).

And if you do get some opiates, virtually no ED stocks the good stuff anymore. In the UK heroin is used as an analgesic - it's in my Handbook of Anaesthesia, along with a warning about its potential to cause addiction - although I doubt it is much used in the ED. Which is a pity, because it has some good effects, and if I was dying of cancer, that's what I'd want.

Over here we used to use IV pethidine (Demerol), which has a rapid onset of action (therefore more "rush") and for some people a weird speedlike effect; nowadays no ED in the state prescribes it. You still get old-school heroin users coming in to the ED asking for pethidine, but I think there is literally none in the ED.

So what you're left with is morphine, which, if you're used to heroin, is pretty piss-poor. Heroin crosses over into the brain quickly, and a big part of addiction is the short lag time between use and effect. That's why eating something, (i.e.: morphine tablets), is less rapidly addictive than injecting something (i.e.: those same morphine tablets ground up). So, you end up with morphine.

The second problem is the investigations. To get treated for SAH you have to have something called a lumbar puncture. The procedure is this - you curl up like a comma while someone washes your lower back with antiseptic. A junior doctor comes in, wearing full surgical scrubs and looking nervous. S/he appears to be prepubescent. S/he tells you to relax. A senior doctor, similarly garbed, accompanies him/her and talks him/her through the process.

The junior doctor shows you the equipment s/he will be using and explains what will be going on. The equipment consists of several long long LONG needles, and the explanation seems to require sticking a needle through several layers of protective membranes so that the needle is alongside but not quite into your spinal cord. As the doctor shows you the needles the end trembles.

The doctor also explains any risks associated with the procedure. These are not insignificant - they include paralysis, meningitis and death. S/he also explains the risks associated with not carrying out the procedure - these skip past paralysis and meningitis and go straight to death. S/he asks if s/he has your informed consent.

Assuming s/he does so (and I am saying s/he because behind the mask, protective eyewear, scrub hat and surgical gown your doctor could well be a hermaphrodite) the doctor then injects an inadequate amount of anaesthetic into your back. Then he or she inserts the needle, under the careful guidance of the senior doctor, into what will turn out to be the wrong place. You can actually feel the scrape of the needle against the vertebrae. This happens three or four times.

Eventually the senior doctor takes over and slides it in effortlessly. We get the fluid out, put the bandaid on and tell you to lie there for an hour or so or get up and get the headache from hell.

So, not something you want to have done if you don't have a sub-arachnoid haemorrhage.

Of course, you can always stay for the drugs and then bugger off fifteen minutes before the lumbar puncture. You can do that once. Which brings us to the third and most significant impediment to presenting to the ED seeking opiates.

Everything now is on computer. This causes me personally some small amount of concern - my recent ED and ICU admissions are fairly easily available for perusal by my peers, for example.

(Bear this in mind when planning suicide - most people don't succeed, and living with the consequences can be difficult. I got off incredibly lightly, but still it's cost me a fair amount. I am actually in a worse place now than before the overdose - but I feel considerably better, because I am less depressed. That's why depression is a mental illness)

Anyway: if a doctor or a nurse forms the impression that you are seeking opiates he or she types a warning on the notes (all on computer). The warnings come in several forms - violence, contagious illness, allergies... and drug seeking. And a warning typed in in, say, Sabin General or the Royal is accessible at Florey or Lazarus, and vice versa.

This means you've pretty much got one, maybe two presentations with SAH available to you, and only one renal colic. After that, especially if doctors or nurses note how you soak up thirty mg of morphine like it's buttermilk, or you attempt to leave the hospital with the iv line still in, that's it. The next doctor to see you will read "drug seeker" in your notes, and everything changes.

And it changes in a very bad way. People on opiates get treated like shit by the ED. Their pain gets undertreated. Their illnesses, which are often more severe, are overlooked. The DS warning on the patient notes spreads throught the ED like a poison in water, and everyone hardens against you. It's a bitch, and if it is changing, it's changing slowly or not at all.

Anyway. Not particularly useful secrets. The turkens are calling. More later.

Thanks for listening,
John

Sex, crime, disease and the parathyroid hormones

Hail,
The following contains strong sexual references. And the article that got me thinking about this is here.

I was reading up on some ICU stuff and HIV came up, and I started thinking about some of the HIV positive patients I have seen, and about HIV in general. The young guy in prison, the gay sex worker with the (at that time) unbelieveable sexual history, the bipolar bisexual Spanish sailor from Sabin Psych ward when I was an intern.

So, here are the thoughts.

The way I was taught, and what I still reflexively believe, is that people who are HIV positive have a moral duty to inform all past and then subsequently potential partners. But there is a difference between a moral and a legal duty, and the law is very much involved in this area in some states. There is a crime over here - it varies from state to state, but just after Christmas someone across the border got twenty five years for "maliciously causing a grievous bodily disease".

(I don't know the exact legal situation here with regards to "knowingly exposing" (I'll look it up) but when we detect HIV in one of our clients the pathology lab informs the communicable diseases people, who then contact the client themselves. HIV is what is called a "notifiable disease" over here, along with measles, leprosy and some form of rabies you get from being bitten by a bat.

This informing another person or body violates patient confidentiality, but legally "duty to the public" beats "patient confidentiality". Having said that, it's difficult to tell people this stuff, often embarrasing and distressing and frightening to the patient, and it would be an unusual doctor who didn't feel some sympathy with the patient under these circumstances).

Anyway. I've been thinking about the law, and some of the stuff near the edges, where things get complicated, blur the absolutist dichotomies of good and bad, legal and illegal.

Look at these ideas:

Some practices are low risk, so low risk that there are no records of transmission ever happening. Readers of a sensitive disposition look away now, but giving oral sex to someone* when you are infected - as far as I know unless both participants are seriously unwell, or intentional or unintentional bloodletting occurs, the risk is fairly low. Not zero, but the CDC in the US has no documented cases of people getting HIV from receiving oral sex.

(I do have a patient, by the way, who has schizophrenia, who had sex with someone who was HIV positive, who knew she was HIV positive, and didn't wear a condom. He had what is called concrete thinking - another example of how mental illnesses kill you. Not him, by some stroke of good fortune. I will also point out that from a careful survey of the two people of my aquaintance who have herpes - become a doctor, people tell you stuff - it's not always the Lotharios who get it).

Making something a crime stigmatises it, and stigmatising something means people won't want to be tested and won't want to tell "all past and then subsequently potential partners" of any sinister results, and that means more and more HIV, more and more AIDS. This is a big effect, a well documented effect: Denial is death. It is a simple thing that I feel is impossible for some otherwise intelligent people to understand.

Sex crimes are notorious for having low conviction rates, in part because of the difficulty of distinguishing between (say) what he said and what she said. Juries are not particularly good at determining the truth, the whole truth and nothing but the truth in these murky and emotive waters. Juries sit through months of the defence lawyer listing hundreds of other people that this "so called victim" could have got the disease from, they become increasingly enmeshed in a soap opera made up of shallow caricatures fueled by revenge and hatred, capable only of deceit. The jury ends up increasingly unsure as to who did what when, and you end up seeing rich white lawyers and poor black convicts, if you get a conviction at all.

Disease, especially sexual disease, especially sexual diseases that are still associated with junkies, ethnics and queers, tend to evoke visceral, "yuck" responses. Everybody hates these diseases. Nausea, disgust and revulsion are not strong predictors of what makes a good law. Unfortunately they are strong predictors as to how people vote, and thus what laws we get.

And lastly, and most heartlessly - and these are just ideas, not my policy or my practice - is there a responsibility on behalf of the uninfected partner? These questions will come up in court: Had s/he not heard of HIV/AIDS? Had s/he not heard of condoms? In civil cases in the US there are findings of partial responsibility - the train ran you over, but you leapt on the train track, that kind of thing. To what extent are you responsible?

Anyway. I am not in any way saying that knowingly exposing someone to HIV is not a bad thing, I am not even saying that it should not be a crime. I am just saying that it is an area where laws should be carefully framed, in awareness of the milieu in which they will operate, with the larger public good in mind.

Okay. Back to the role of parathyroid hormone in calcium metabolism. I am giddy, expectation whirls me round. Troilus and Cressida, Act III, Scene II.

Thanks for listening,
John

*so much better a phrase than "performing upon", which always brings to mind people holding up scorecards, or those people in the mall who paint themselves gold and stand there.

Clearer than Clearwater

Hail,
Just a quick note. I am catching up on the comments, starting early January, and enjoying it a lot. Thanks to commenters from the commentee. Have a look at this place, by the way:

Where I should have gone

It's a private psychiatric facility in the US, and it costs $1700 dollars a day. I don't know what anyone's budget here is, but I know that if I wasn't anxious and depressed before I was admitted to this place, I would be once I realised what else I could be spending the money on. Ten days in this place means a trip to bloody Paris: sitting on the banks of the Seine, drinking cheap wine, eating the best food, having decadent sex and reading the second best literature in Europe* - what's going to be a better antidepressant than that?

You'd want to be pretty damn sick to justify spending seventeen hundred dollars a day on yourself, and the sad thing is if you are pretty damn sick they won't take you.

How the other half froths. Anyway, presumably makes Clearwater seem like something out of Das Boot.

And as stated earlier, anyone who wants to improve the "hits from exotic places" by actually moving there, even if only for a short while, is welcome. Medical certificates, if necessary, can be provided - it may be, for example, that you have rickets, and that the best treatment for this is to move to the sundrenched shores of Cuba. Or, the way global warming is going, the sundrenched shores of Greenland.

Or perhaps your attack of measles (I dimly recall hearing this called the most contagious disease, just edging out fear, stupidity and the desire to buy whatever the new version of Pokemon is) requires treatment in isolation - perhaps Tristan da Cunha, in the distant South Atlantic, or the Svalbard Islands, north of Norway. Be creative, so I don't have to.

Anyway. Things to do. Panicking and dismay to avoid, the gym to attend, study and house-cleaning and cat stuff to do. I note, im passim, some vaguely heartening news from the UK about the Catholic Church and homosexual adoption.

I will post something substantial once I have caught up on the comments.

Thanks for listening, and speak soon,
John

*Not all on the banks of the Seine. Well, not all at the same time on the banks of the Seine. Not in daylight.

A new champion

Well, if not, then a new contender.

All fired up with pre-ICU fervour, given that I have only a few weeks to get up to speed on hospital medicine after a year of mainly addiction stuff, I have been trawling the medical news.

And amidst the interesting (discussion of how the most popular anti-depressants increase the risk of hip fractures in the elderly), the truly-horrible-even-though-we-know-this-shit-already (the finding that surgeons with little or no experience performing "off-pump" heart bypasses are more likely to perform this operation on black than on white patients), and the thought-so ("Cynical distrust, depression, and chronic stress... linked with elevated levels of inflammatory markers and thus higher risk of cardiovascular disease"), comes this month's contender for the golden Sherlock.

"Adequate Hospital Nursing Care Improves 30-Day Survival for Acute Medical Patients", which should really confuse all those people who've been backing inadequate nursing care as the secret to survival for the acutely unwell in hospital.

Published by one Dr Laurie Barclay this month in the Journal of Advanced Nursing.

Now you have to feel a certain amount of sympathy for the author, because this paper is clearly meant to function more as part of a polemic rather than as anything telling anyone what they didn't already know. Reading this you get the idea that Dr Barclay is probably sick of sending people up to the ICU and finding them dead a few days later and having those who do the budgeting look simultaneously appalled, confused and shifty when told of this. And now s/he has proof, for those for whom proof is needed, that nurses help keep people alive.

So,this month's winner, but not for the usual reasons.

Anyway, must reply to comments, will post again soon.
Thanks for listening,
John

ICU, psychosis*

Hail,
I have a job!

Well, I had a job anyhow, but now I have a job about which I can feel more joy (and yet more terror) than either full time drug and alcohol work or nine to five, wall to wall, day in day out sexually transmissible diseases stuff. Starting (hopefully) in about a month I will be working at the ICU at Florey, doing that half time and the drug and alcohol stuff half time, and maybe after half a year changing to full time hospital work.

I am getting ahead of myself here.

The situation at the moment is I am not working. This is on the advice - and advice seems much too weak a word - of Dr Tesla. He says I am not to work at all for a fortnight post discharge, and then only to return gradually - first part time addiction stuff, then full time, then maybe only then look at taking on anything new (i.e.: part time addiction stuff, part time hospital work).

And, as stated, while I lay intubated in the ICU (that's intensive care unit) at the Royal, or possibly later, as I watched the spots on the floor crawl around, or gazed at the flocks of multi-coloured budgerigars that had for some reason taken up residence in my room on the general ward, my previously half-arranged job in Florey ED was given to someone else not currently detained under the mental health act.

Typical of the discrimination we sufferers face.

Anyhow, there is a process for mentally ill doctors returning to work, and we are working through it. By the way, if ever given a choice, go for being the crazy doctor rather than the drug dependent doctor. The crazy doctor, if s/he has insight, gets to go back to work with far fewer restrictions than does the drug dependent doctor. The crazy doctor without insight, however, who does not comply with the medication, doesn't have the blood tests done, doesn't attend followup, that's the most dangerous and thus the worst of all. That person gets the medical board as a second skin.

You know, the above was a rather humiliating paragraph to have to write. Been a bitch of a year.
Anyway, I am following the plan, and part of the plan was actually getting a job I enjoyed. So I asked around and half an hour later I sat in Dr Claudius' office (him rotund, bearded, a nest of ginger hair surmounting vigorous blue eyes), and said I'd heard he was looking for workers.

He said the first thing is he wanted to know that I would be able to work, to fulfill my committments. The department was understaffed (Dr Pradesh being pregnant, Dr Constantine being unwell, Dr Vijay having to return to India), and the normal level of support would not be there.

He knew I had had a difficult year - and he expressly did not want to know details - but he wanted to know if I could be counted on to operate with minimal support. By support, he stressed, he did not mean techincal support. There would be technical support, but not a lot of the other.

And there was a pause, while I looked at him, and he looked back at me.

I said it had been my experience, working in Emergency Departments, that they were fairly porous, that news of anything of note that happened in one fairly quickly reached the others - often in a fairly distorted form. I asked if this was the case in the ICUs.

He said it was worse in Intensive Care because there was only five departments in the city, one in each major hospital. Rumour mills, he said.

And superimposed on all this, like a ghost, was the image of me intubated, heart-rate elevated, tubes everywhere.

Well, I said, with rumours it's best to believe half of what you see, and none of what you hear**.

Part of me was amazed at my speaking to a consultant like this. But I was strengthened by having heard the rumour about me and noting how markedly it differed from the facts - they had got several key things wrong, doses and so forth, confounding my story with Dr Greene's and that of the psychiatry consultant who had leapt from the sixth floor of Sabin Public around about the same time.

I had been ill, I said, as he had heard. But for the previous five years I had not been significantly ill. And I said I had never made a bad clinical decision on the basis of my... illness, and that assertion could be confirmed by speaking to any of the consultants in the ED. I had a good support network, a medication regimen with which I was aggressively compliant, and I would be relying on him for technical support only. And I did not anticipate any further episodes of illness.

Okay, he said. And then he said could I start pretty much now, like Wednesday, pretty much full time, and I said that wasn't really possible, what with the medical board and so on, and we moved on.

All in all the interview went well. I feel the ICU has its own problems - I know every other ICU in the state has. Maybe in a month's time I will be writing in saying that this is the single stupidest decision I have made in my life. But considering my record over the last year or so, that's unlikely.

The weird thing is after getting the job I slept better that night, and for the first time in over a year I was able to go to sleep without those morbid, self-lacerating thoughts, those imaginings wherein terrible things happen to those I love, grave-faced police officers coming to tell me the terrible news, or regrets for lives not lived, choices not made. I lay there and worried, of course, thought about how I have to learn and relearn how to read an ECG, an ABG, manage ARF and SSS and half a hundred other things. But that's worry of a different kind, worry about things I can change, things I can fix.

So. Tomorrow I continue my recovery - chookwatching, holidaying, spending time doing nothing, but I will also buy the anaesthesia textbook and start tatooing it on the inside of my eyelids.

More news as it comes to hand. Thanks for listening,
John

*Actual name for what I got. Occurs in two forms, with or without budgerigars.
**Who are we to argue with Marvin Gaye?

This Year's Biggest Turkey...

Hail,
Apologies for the delay, and I will reply to comments tomorrow. A great deal has gone on, and some of this will have to be done in point form.

Right. I am released. This is a good thing, an unalloyedly good thing. I have a fairly aggressive followup programme - I am being seen twice in the coming week, and as I left Clearwater no fewer than three people grasped my hand and told me that if I felt in any way that I needed to, I should contact them, day or night.

It's good to be wanted, even if you are paying two hundred or so dollars a day to be wanted.

And it's good to be back home again, to see Sarah and to stare at the chickens (the slim, skittle-shaped turklets have grown in my absence into full-grown turkeys, deepy strange-looking but also somehow beautiful birds), to smack my punching bag around or look at my books and to lounge in front of the telly or in the bed and read.

All unalloyed good. But I would be lying if I said there wasn't some difficult stuff ahead.

For a start, there is the social side of it. Some of my family and friends know nothing about recent events. Others know only that I have been depressed, they may or may not know about the hospitalisation. A smaller (I presume) group know of the overdose, the detention under the mental health act, the less savoury parts of the admission. A very few people - I doubt there would be five - know the full details of my state of mind on the Saturday that I did what I did.

This complicates things socially - before I go out, for example, I have to work out who knows what, who is likely to ask what, what I feel comportable telling them. And the thing is, there is
the fallout that comes from that, in direct proportion to the closeness of those concerned - the hurt, the anger, the fear.

Most of this I "solve" in the short term by avoiding. So if we've met or spoken or emailed or anything in the last few days, it's been against the considerable force of my own moral cowardice.

The decision on whether or not to avoid is not entirely up to me, of course. I got a phone call the other night from a fellow emergency registrar who had "heard a rumour" about one of the registrars taking tricyclics, and finally worked out who the rumour was about. We are meeting Monday for, in her words, "a cup of coffee. Then a jab and a hook and a cross to the head, and kicking you when you're down".

We don't mess with words, us emergency registrars. Kill you, resuscitate you and kill you again.

The thing is, a lot of this I didn't have plans for. And it is embarrassing how much of this stuff I had basically accepted I would never do again that I have been enjoying. I say my sons today, each now as tall as me (not very tall), each of whom has sworn some solemn oath not to cut their hair for the entirety of the summer holidays while they work in the sun picking apricots and plums. My youngest looks like a Dragonball Z character, my oldest like a strange flowering plant. There is some deep, deep pleasure in this.

But in the interim there is the usual stuff. The cabinet full of medications. The counselly talky stuff, some of which is actually quite useful. The slow, jolting, uneaven repair of the damaged relationships. I suspect I have already lost one friendship over this.

Anyway.

Another unintended flow-on from this whold being unexpectedly alive is I have no real job to go to this season. I don't mean "no job", my current employer (name recently changed to the substances of addiction department (SAD)) would have me full time at a moment's notice. But no hospital job, no emergency type job. I may speak later on about exactly why that is important.

But in the meantime, I will say that Florey looks to be out, the Princess is a very long shot, and the front runners are Lazarus ED and the local Sexually Transmissible Diseases Clinic. Which is good hours and good pay but quite possibly not recommended for the recently suicidally depressed.

Anyway, will post more soon,
John

The trouble with triffles

Sarah tells me I have comments aplenty, all of them heart-warming, one or two a wee bit baffling, but as soon as I can read, I shall reply. She also says read Foilwoman's blog about some journalist in the UK clearing up any confusion as to how low a human being can actually go - go thou to her blog and see for yourself.

And how do things go at Clearwater? Oddly, unsurprisingly enough. The same woman or man as was here last time cries late at night, between two and three, a soft, high sobbing, just on the edge of hearing. A distressing, lonely sound, something "calling after someone that wouldn't come", as MR James said. I don't know who it was last time, or this time, and I don't know why they are still here. I do know that they were most clearly heard the first few nights I was here, the implications of which disturb me.

Still, it's not all misery and woe. There are the meals, which resemble aeroplane food, for the same reason (you don't like it? Go elsewhere), and there are the day courses. I have been attending these in a Caesar's wife kind of way - I must not only try to get better, I must be seen to be trying to get better.

There's a whole crack in the foundation there, something that needs to be explored, the whole "good patient is someone who tries to get better, bad patient is someone who choses to remain unwell" thing that if my mind were more nimble, I'd be onto. But the fact is I am trying, because nobody wants me out of here faster than I do.

With that in mind I attended today's talk on generalised anxiety disorder. These are relatively well attended - Diana, the woman running these, makes up in enthusiasm what she lacks in experience. I am going to sound like a curmudgeon however I say this, but I think there is a certain something you get being, say, forty, that very very few people have when they are, say, twenty. Diana would not be twenty five, and she is not one of the one or two.

Case in point. Today's session on Generalised Anxiety Disorder. GAD is actually a remarkably disabling condition, under-disagnosed and undertreated. Anxiety, panic and phobia (now don't they sound like a modern three fates, three grey-faced sisters in a cave, one spinning the thread, a second measuring, the third cutting*) have an impact on the quality of life that people who don't have them don't understand. But before we got onto GAD and its mysterious ways we had to go around the room and introduce ourselves and say how anxiety made us feel, or how we dealt with it.

"Afterwards, can we play some games?" said the young man in the Bob the Builder tee shirt. I guessed mania. He paused, then said in a rush "It's probably not appropriate, but when I get worried I usually masturbate. I worry a lot."

I uttered a prayer of thanks that he had not told us how it made him feel.

"Adam" said the other young man, the one who has worn sunglasses all day and all night for as long as I have been here. "I mainly get anxious that they're not going to treat my pain right, or that I'm going to get addicted to this morphine." Chronic pain, probably some iatrogenic component, morphine dependence.

"Henrietta" said the school-teacher, slim and businesslike. "Little things get to me, things I can't control. Like messy seventeen year old boys, and how they won't look after themselves. And you've used the subjunctive there when you mean the indicative."

The above is as close as I can come to a direct quote, may GAD strike me dead. And she wasn't even an English teacher.

"Thanks for all this stuff" said the strongly built woman, in a voice that was somehow childlike. She had a key with a label on it pinned to her jumper. I felt that fellow feeling I feel for those you suspect are being courteous because they are lost.

"I mostly worry"" said the new woman "about how I'll get through the day."

I looked at her. She was new, hadn't been here yesterday, I'd seen her being half-shown, half-lead around the place late yesterday afternoon. Something in her gait was odd, not Parkinsonism, not that dazed wandering you get with the benzodiazepines, not the phenothiazine shuffle - more the look you see on people who have been led out of the mouths of disasters - tsunamis, fallen buildings, bushfires.

"I worry about what I'm going to do with myself now" she said.

There was a pause, and Diana, cheery, enthused Diana, said "Okay. And how do you cope?"

"Mostly I cry. I lie on the floor and cry. I use tea-towels, one or two tea-towels, so it's a one or two tea-towel cry. Once in a while a three. I wash them separately, of course."

I had this image of this this tall, dignified looking woman lying on the kitchen floor, curled like a comma on the lino or the tiles, face buried in a teatowel to stop herself screaming.

"And how does that make you feel?" said Diana.

"When it's like that" she said "I want to go away. I don't - I don't want to be here anymore."

"You mean bored?" asked Diana.

As GAD my witness, if I had happened to be carrying an axe at the time it would have all been over. Thankfully one of the manic patients interrupted with something about sex or Africa or the history of the krugerrand or something and we were all able to move on.

I am reading, in my spare time, about osteoporosis, the disease of thinning of bone. As a matter of interest, the parts of the skeleton that osteoporosis affects most are those parts with the highest concentration of trabecular or spongey bone. These are the end bits of your forearms, the hips and the back - which is why little old ladies get dowager humps, break their wrists, and fall and break their hips (or break their hips and fall).

As a matter of interest a mirror image of this condition occurs called osteopetrosis, literally stone bones. This disease is so rare that authorities advise ruling out pyknodysostosis before leaping gaily to the diagnosis of osteopetrosis... and you don't see a lot of pyknodysostosis.

Anyway, people with osteopetrosis suffer from too much rather than too little bone - the bone grows into the marrow space, so the body can't make as many white or red blood cells, the bone grows tight around the nerves (some nerves pass through bone) and traps them, the bone is not able to be recycled and is thus weak and brittle.

Well, I thought it was interesting.

Anyway, off to busywork. Should be getting weekend leave on the ... weekend.

Thanks for listening,
John

* I have to share that one of the web pages I looked up on this sort of things years ago warned me not to triffle with the fates. And I am proud to say that I never have.

One last thing...

I have been surfing the internet and stroking my ego, looking at the map attached to this, and have noted that someone has read this from the Canary Islands, someone else from Iceland, and someone from what looks to be Haiti or the Dominican Republic.

Which is all very gratifying, if true. Where things on the internet are concerned, I am a profound skeptic - for all I know these red dots are generated randomly. But I was talking to a friend about this and mentioned the groundswell of popular acclaim in Sri Lanka and Cuba - two sizeable islands with precisely no readers (of my blog) at all.

And we had a bet about which would come first - a reader from Cuba or one in Sri Lanka. Unfortunately, neither of us thought to bet "neither", neither did we think of putting a time limit on this bet. We both reckoned Greenland would be third, or maybe fourth after Madagascar.

So, can someone, somehow, end this for us? It doesn't have to be a real visitor. Create one of those online virtual avatar things I keep hearing about. Hack and phreak and pirate to your pixillated heart's content. My friend and I, who for all you know could be a thousand thousand monkeys banging on a million typewriters, will be just as happy.

Should be able to read comments soon.

Anyhow, thanks for listening, and thanks too for all these bananas.
John

Night of the Living Debt

Hail,
Have been morosely thinking about how this hospital stay is blowing out our finances, so rather than burden you with that I am trying to write something cheering here.

In my spare time – I seem to have a fair quantity of this, if not a particularly high quality – I have been thinking about writing.

When I get out of here I want to do a bit of writing, and one of the things I like writing is stories for anthologies. Unfortunately the whole patient confidentiality thing stops me from banging on about any success I have had in this area recently, but I am having a few things published under my orthonym lately, which cheers me.

Anyhow, I got a few minutes of internet access a few days ago and looked up some speculative fiction anthologies. I don’t write as much of that stuff as I did previously, and I barely read any, but still there were a few small-press markets out there wanting stories for anthologies: one calling for stories set in New Orleans, or in Maine, another looking for time travel stories, that kind of thing. I should point out that these are almost always “for the love” publications – nobody gets any money, people everyone gives their time and money for the thrill of seeing their name in print, either as an editor or an author. The community of people who write and produce these things is fairly close.

Anyway, a few interested me, more as a challenge than anything else. Someone I know is editing an anthology on Zombies. There is a fairly interesting book on this that I read a few years ago, some good source material. Another, which sounds interesting, requests tales of religious madness. And another wants “piratical” stories – before things fell apart here I was sortof reading "The Floating Brothel"and "Buried Alive", both of which could be used in that way. And a writer’s group to which I belong published a heartfelt plea by a woman looking for stories for her upcoming lesbian sleuth stories, and someone else wanted something set in Maine.

So, three or four stories. But I was thinking – maybe not. The problem with writing for anthologies is that if you don’t sell your purpose-written story to “Tales to Amaze – the year’s best bisexual robot matador tales” you’re stuck with something that may not be that saleable to anyone else. So… what if you tried for a strategy to double or even triple your market?

With that in mind, any plotlines for a short story, set in either Maine or New Orleans, featuring either a lesbian pirate and a zombie preacher, or a lesbian zombie and a preacher who is also a part-time pirate, and ideally running to exactly seven thousand words (the maximum word count of the zombie anthology and the minimum of the lesbian sleuth one) will be gratefully received. Try and have some sleuthing in there, no excessive gore (the Maine story wants PG-15 rating, which might make it difficult for the zombies), and at least one character who goes mad (which would not be surprising, considering the appalling funding in recent years of pirate zombie mental health services).

And ideally something with colour and vision and spectacle, something that would attract the eye of, say, a Spielberg or a Tarantino, someone with money who’s not afraid to spend it. On me, who would also not be afraid to spend it. I will remember the person concerned fondly when the movie deal is announced and see if I can get you a bit-part in the film – “peg legged dominatrix in cardinal’s clothing”, or “crazed prelate with eye-patch”.

Anyhow, fame, if not fortune, awaits - all this slothing around has left me with insufficient funds, something I am thinking about all the time. My writing future is in your hands.

Thanking you,
John

In the early days I wrote, and have failed to sell, a story called "Kung fu vampire sex kittens from Mars". Round about five thosand words. Anyone wants to anthologise this, email me.

John.

Tannenbaum

There are, of course, days when you aren’t going to feel that good. Days like today.

I am sitting in my room at Clearwater. Outside I can see the sunlight-dappled trees, the ivy on the red brick of the next door’s building. Inside there is the drone of a therapist’s voice, talking to the woman whose marriage "won't survive this”. Inside my room is the slow whirr of the laptop, the taste of coffee in my mouth, the hard seat beneath me.

The thoughts in my head, the pressure in my chest.

The thing was, panic attacks, when someone came into the ED with panic attacks, the first thing to rule out was a heart attack. Panic attacks and heart attacks may feel the same: the same pressure behind the breast bone, the same fluttering in the chest, the same sensation of needing to breathe, needing to get air in. Oddly, heart attacks may present with or without the textbook "sensation of impending doom", while panic attacks by definition present with.. panic.

Panic, by the way, is a word with an interesting etymology. The Greek god Pan was a wild god, primal and untameable, older than the more restrained deities who were worshipped at Olympus. He had the hindquarters of a goat and a horned head and leering face, and was apparently fond of terrifying lonely travellers through the woods - hence panic.

Anyway, in the absence of leering deities, and without even a single nymph, I panic by myself. Technically it is not a panic disorder, more a severe "low" with features of agitation, but still, I feel it.

I am trying to calm myself by looking at myself as a patient, seeing myself and my fairly run-of-the-mill symptoms as a psychiatry case. Helps keep things in proportion.

Psychiatry, of course, remains a body of knowledge defined by exclusion.

You note the fear and the breathlessness, rule out PE or APO and any of a dozen other acronyms, and what you might have, eventually, is panic.

You note the slowed movement, the depressed mood, the lack of energy, rule out hypothyroidism, each of the eleventeen separate causes of anaemia, you might end up with depression.

You note the irritability, the racing thoughts, the psychomotor agitation, the patient's barely concealed fury at what is in his or her way, rule out thyroid storm or the possibility that any of many drugs – licit and illicit – have turned against you, and you have mania.

So, you progress by exclusion. The mistake that could and often is made here, by junior ED doctors (and from the contemptuous expression on his face, the ICU registrar the morning I was extubated) is to consider this sequence to be a hierarchy of gravity, from the most grave to the least, rather than a simple diagnostic process. It is not that we exclude the most serious illnesses first, and in the end are left with merely the psychiatric illnesses.

The most disabling of the psychiatric illnesses, what our American readers would call the major league pathologies (schizophrenia, unipolar and bipolar depression, the more prominent of the anxiety and eating disorders)… they hurt. I would much rather that, say, a thyroid disorder was causing my patient (or me) to hear voices and to feel the thoughts of the women next door radiating into her bones than to have that caused by schizophrenia.

Surgery, by the way, has close to 100% chance of curing hyperthyroidism. The psych nurse attending me today has a scar across her throat, ten centimetres long. This suggests almost certainly a partial or total thyroidectomy. Surgery is less successful in the treatment of psychosis, although in untreated psychosis the incision may be similar.

And one last thing, something I am writing down so that I can remember it later and say "This is how depressed people think". A day or so after I arrived at Clearwater I was having lunch in the dining room, and I saw the Christmas tree was still up - a tinsel tree with a few gaudily wrapped packages underneath it. The packages were still there, although by that time I had worked out it was a few days after New Year.

"Why haven't the children opened their presents?" I asked myself.

"The children are dead" I said.

And I had to sit there and reason out that there were no children, that there was no evidence that any children had died, that it was just one of several squillion left-over Christmas decorations around the globe.

So. That is your brain on olanzapine, valproate and inadequate amounts of several key neurotransmitters.

Thanks for listening,
John

Bounced

Hail,
I’ve been thinking for the last few days about how to write this entry, and I still haven’t worked it out. I don’t – believe it or not - like melodrama, and I don’t like causing problems or embarrassment for people.

And I haven’t been sure lately about all this self-disclosure. I’ve felt sometimes in writing this blog like I did in anatomy class as a junior doctor – carving down through the layers of skin and fat and flesh, exposing layer after layer of tissue, in the vague hope of finding some central truth.

I think at some level what I am trying to find out in this blog is the same thing that I was trying to find when I did my anatomy dissection in first year (elderly man, advanced prostate cancer, bony metastases): some answer to “how does all this work?”, “how come this is alive?”

You can ask those questions about the mind as much as the body, and you can dissect away at things, anatomizing them, applying mental as much as physical scalpels, cutting deeper towards some anticipated centre, something that will explain everything.

But it's a fool's errand, in anatomy, and in writing. There isn't an answer, a centre, a core. There's just ... stuff. Stuff that helps you understand in increments, but no single key insight or organ. No "aha".

The thing I remember most about anatomy is how as we dug deeper things became more and more strange, grew more and more alien, less and less like a human being. Faces and hands look like parts of a person, lungs and adrenals look alien. Strange organs, essential and vital but (in the first few months of medical school) yet not understood.

Anyhow. There comes a time when you’re going to learn no more through anatomizing, dissecting and digging deeper, when you have to pan back, take a wide angle view, or maybe even think about something else for a while.

So: in the last fortnight or so I have become unwell. Suffice it to say at the moment I am at Clearwater again, and will be “for weeks”. I am unwell, I have been unwellish for months, and I have recently become double plus unwell. I did not plan to come here, but the decision was made without me. I have been detained – and will be until midnight tonight, after which I revert to “voluntary, as long as you choose to stay, otherwise we detain you again”. So for the next few weeks or so, believe me, I’ll be staying.

I say “have become unwell”, although it is debatable how much of what happened has been intrinsic illness and how much a response to events around me. My psychiatrist – Doctor Tesla again, the vaguely mantis-like Netherlander with the crisp enunciation and the unerring clinical eye – detailed the events of the last year with me:

The death of Burian, the writer, and of Dr Greene, the consultant – both senior, almost father figures, both at the end of paths I wanted to travel.

Cancer in a close friend that I failed to diagnose, the subsequent messy and poorly managed surgery in the hospital to which I took him, at Florey.

Psychotic depression in another, whom I detained in hospital against her will,

My own hospitalization earlier this year, for the first time in years.

There’s more. I stopped work in emergency, and for some reason that feels and felt like a retreat, a cop out, a retreat to safer and less turbulent waters. I started work in an area that I don’t believe in as much, one that doesn’t give you that rush, one that rarely gives you even the semblance of success.

Add to that the fact that I failed (at some level) to look after my niece – she returned briefly to her mother over the summer holidays, and she will be staying this year with a family friend. And along with failing her there is the simple fact that I will miss her.

And all of these events - and several more that I have doubtless forgotten - these caused stresses, strains, hairline fractures in my important relationships. I ended up seeing less of my colleagues and friends, even less of Sarah, hardly anything of my sons, seeing more of people at work. That meant mixing with a different set of colleagues and also getting to know more and more about my patients, hearing more and more about the day to day, eternal, horror of their lives.

Failing to do what a doctor should do, or a father, or an uncle, or a husband should do.

And there’s certainly more than that, some embarrassingly stupid stuff (and yet not the most embarrassing stuff in this entry). There’s the fact that in a few weeks I will be forty, that I have a friend coming over in a few weeks who is lissom and single and debonair and I am on drugs that make me sexless and globose. There is the fact that the close friend’s cancer that I failed to diagnose was testicular cancer, the fact that both of the father figures who died were - there is no sensible way of putting this - sexually alive people, men with a masculine vitality. Some of the crisis was stuff about sex and love as much as death.

And there is more to the story than I am going to speak, more that I could say but am not saying here and will not say here. Those who are inclined to do so can guess the specifics of what other things happened, what precise form the other element of this crisis took - please do me the courtesy of not informing me of your opinions, the whole “Ms Scarlett in the library with the candlesticks” thing.

But anyway – a few months of deepening depression, sloping like a continental shelf, then the drop into the abyss.

And I said I didn't like melodrama. Anyhow – some endpoint was reached a few Saturday afternoons ago, NewYear's Eve eve. I was leaving home, allegedly to stay at my brother’s house for a while to sort some stuff out. Coming on to midsummer, but the sky patchy and unseasonably cold, cold like this Christmas was cold, cold and dry like this year has been cold and dry. Three or four phone calls on the way to and from people close to me that underscored how badly I’d fucked up everything I’d cared about, that seemed to say to me at the time that the roads were closed, no way out, no way back.

And a last meal, a very pleasant meal, at a friend’s place, him and his beautiful wife, new house, satisfying career, two lovely children. And driving home that night thinking “fuck it, if you don’t do it now, you never will”.

Anyway. The next bit happens offstage. When next we see our subject it is in the ICU, after sedation and paralysis, intubation for thirty six hours. Certainly not the only person to spend New Year’s in a coma. Waking up enraged after a couple of days with a sore throat and weird bruises everywhere and tubes in virtually every orifice. And a fairly spectacular forty eight hours of what they call ICU psychosis – hallucinations of imps and sprites, crawling insects everywhere, and hundreds of thousands of budgerigars, overhearing malevolent conversations about me that almost certainly weren’t happening.

A few days later getting wheeled through the ED at the Royal to the waiting ambulance that took me to Clearwater. Realising belatedly it’s probably not a good idea to wash down the packet of “pro-convulsants” with a bottle of Merlot (an anticonvulsant) and expect a full clinical effect.

Having said that, there was apparently a hell of a clinical effect, hence the day and a half intubation, and the prognosis was at times fairly poor. Sarah sat at my bedside for days at a time, those friends who knew wept, family members who don’t believe in God apparently prayed and made strange bargains.

But the Royal, to my everlasting embarrassment, are good at what they do. And I awoke and found me here on the cold hill side. Barely able to talk or walk, still occasionally confused, enraged and embarrassed and stupidly and inconveniently alive. With no real plan on what to do next, where to go, how to get there.

No direction home, as the man said, like a rolling stone.

And here I will be staying “for weeks” Dr Tesla has said.

Well. There is a third act to this, and although it is way past lights out I have to write it. It’s hard to write, especially since some of it is stuff I know but do not yet feel. But here goes:

From what I understand, lots of people attempt suicide every day. Many, many try (many even with considerable knowledge of what to take, how much, etc.). Many attempt, with varying degrees of conviction, some “succeed”. But the weird thing I have seen, even at this early stage, is that by failing where I thought to succeed I have in fact succeeded rather than failed*.

I can see intermittently – and you’re going to have to take my word for it - that suicide would have been a failure, not a success. That there was not “no way out”, there were several. That I was not a disappointment to everyone I loved, but I was instead loved most by those I had most recently disappointed but who loved me anyway.

Other times, of course, I plan how next time I won’t be so fucking inept. Hence the prognosis of “weeks” in Clearwater.

Anyway. According to a friend of mine, suicide is an option, but it is the last option, and you don’t get to the last option until you’ve gone through the fifty billion trillion other options. Life sucks? Try moving to Thule to live as a goat on the mountainside, or becoming a celibate lapdancer in Lemuria, or a lolly-pop man and postal clerk in far-off Cimmeria. Write a book, write a limerick, write in lipstick on a toilet wall. Pick a direction and walk as far as you can go (wear a hat and sunscreen and so forth). Meander or motorbike or monorail. Go and see snow, or the desert, or some place you can see the sea. From what I can understand of what he is saying, you’ll never know if change could have fixed things, but if you stay where you are and die, maybe you’ll have died when you could have changed something, maybe some small something, maybe something vast… and been happy again, felt those feelings return.

I sometimes believe now, even if I do not yet feel, that the feelings will return.

And lastly never, seriously never, trust any decision you make in the grips of a mood disorder. The last week or so have shown me just how fucked up my thinking got – the malicious nurses, the imps that danced across my bed, the things that crawled across the floor towards me but never quite got there.

If you have a mood disorder and you think that life sucks, Occam’s Razor suggests it may just be that instead of life sucking it is an episode of your mood disorder that is distorting your thinking. And don’t rely on yourself to diagnose a mood disorder in yourself, because you’ll suck at it when you do it because you’ll be having an episode of your mood disorder and it will be distorting your thinking.

One thing I feel is important to get out of this is that depressed people don’t see things as they really are. I thought I would not be missed, for example, and that has been shown not to be the case. Depression distorts your ability to collect data, to deal with it, to make a prognosis and a diagnosis. I suspect that Dr Greene, the best emergency doctor I knew, maybe didn’t know that. I know I lost track of it for a while.

Anyway. I can’t say what I am trying to say here in the right way, but that is partly because my frontal lobes are still simmering in the eleven secret herbs and spices that the Royal and Clearwater have put me on. Speaking of which, I have promises to keep, and pills to take before I sleep. And lastly – please send Sarah any messages of support/congratulations/commiserations/etc. you want. I think she needs them.

Thanks for listening,
John.

*These are great drugs.

An Announcement From The Management

Dear Readers,

This is Sarah here (Tournee du Chat Noir). I am posting this to let you all know that BJ is not well at the moment, and is in hospital. It may be some time before he can post again, but he would like to thank everyone for all of their support.

We hope that everybody has had a lovely Christmas and New Year.

Bye for now,

Sarah (TduCN)