Monday, February 19, 2007

Gather Yourselves Together

I had a medical student today. The Royal sends them, fifth years doing their eight week psych rotation, spending a few days at the alcohol unit, half a day a week sitting in with our psychiatrist, that kind of thing. I hope it's valuable - I spoke to a pathologist on the phone the other day about a patient and she was quite emphatic.

"Tell your patient he's drinking too much" she advised me, speaking about my fifty-standard-drinks-a-day* man with the end stage liver disease. "Tell him to just be sensible".

Hopefully our guy will learn more than that. And Alex seems keen - a tall, golden-haired fellow, the kind of person they would have called strapping and clean-limbed a century ago, keen for "one of the specialties", not emergency, or psychiatry, and not general practice. And he seems pleasant enough. "Quite cute", Sarah says, which I admit may be in some small way responsible for my initial wariness.

And he is keen. Although he prefers to hold a clipboard when talking to patients, understandable nervousness I suppose, and when he does hold it he holds it like a shield between himself and the patient. And when that is not available he stands with each hand grasping an end of his stethoscope, which he has slung around his neck, one hand just above the bell, another just below the ear-pieces, which gives the impression of a nineteenth century lawyer in a frock-coat asking the accused to repeat a particularly damning piece of testimony.

But he knows the questions, and asks them in the appropriate order, and does the physical examination like it's not the first abdomen he's prodded, and I get to sit in the big chair and watch, which is pleasant enough.

Today Alex saw his first two patients. The first was Mr Gleer. Alex had to lean in close and ask his questions slowly, and Mr Gleer did his best to speak as concisely as possible. He is a well dressed, angular man, polite and deferential, and his voice is like rain on slate, sibilant and soft. He had, or perhaps has, oropharyngeal cancer, and three years ago they cut out the base of his tongue, took out numerous lymph nodes, part of the bone of the jaw, his larynx. A year ago he found it had crawled into his sinuses - they have told him that will be much more extensive surgery. He cannot speak much louder than a whisper.

Fifty years old, smokes a pack and a half a day. "It's like this, doctor" he says. "What's the worse that could happen?"

He is not in treatment for his cigarette problem - interestingly, we have no inpatient treatment for nicotine withdrawal, although we regularly have people booking in for management of their marijuana withdrawal, and about a year back someone rang me and asked if he could book in to detox from his ear antibiotics.

Instead Mr Gleer is in for alcohol withdrawal - alcohol is one of the three big causes of oropharyngeal cancer, along with tobacco and being cursed by a particularly malevolent god. He says he drinks three bottles of spirits a night, but it soon becomes clear that these three bottles of Jacks are diluted with water - it's still a lot, but not enough to kill him.

"I have to hide them, doc" he tells me, his eyes bright, his voice like the curl of the sea on the shore. "Otherwise my wife drinks them." Both only started drinking a few years ago, after the diagnosis. "It was mainly the teeth" he continues. "I had radio and chemo therapy, all my teeth dissolved, I got ulcers everywhere. They said wash out your mouth with a little alcohol. That's where it started."

He is having treatment at what used to be the Oncology Clinic at the Royal. Now it's been remodelled, big letters, Cancer Clinic. "Yeah" he says, "thanks for reminding me".

"How is it going? The cancer?" asks Alex.

"I don't say I'm cured" he says. "I don't say I'm in remission, I don't say cancer, I just say..." and he shrugs.

When he shrugs you can see a deformity, where surgeons lifted up the skin over his chest and throat and took away the flesh beneath. There isn't a word.

Alex performs the physical examination almost in silence, just the soft instructions - breathe deep, clasp your hads together, relax. I sit and watch the deft twitches of Mr Gleer's hands and feet, his reflexes under the tendon hammer.

After that, we chat a bit. He has a brother who is working as a security guard. "He's really a harpsichord teacher. But there isn't a lot of call for keyboard instructors now. So he does security guarding in the night and harpsichord teaching when he can. He's really polite."

And then he goes, walking slowly out, hat on head, seeming much older than his fifty years. Alex and I look at each other, he raises his eyebrows, blows out his cheeks as if he's worked hard.

"Incredible" he says, not holding his clipboard or his stethoscope. "That's incredible."

I don't know what they expect students to get out of this rotation. Like I said, if they get enough to be further ahead than the pathologist I spoke to earlier, that'll be good. But I suspect Alex, even without the cute, will get further.

Thanks for listening,

*About seven bottles of wine a day, every day, or a bottle and a half of spirits.


Blogger Camilla said...

Hey, does this mean you're back at work? :D

Alex and I look at each other, he raises his eyebrows, blows out his cheeks as if he's worked hard.

"Incredible" he says, not holding his clipboard or his stethoscope. "That's incredible."

I sometimes have this reaction after reading your posts. You've really opened my eyes on occasion!


5:25 PM  
Blogger Benedict 16th said...

Sorry to be a nit-picker but

1) A bottle of spirits is about 23-25 standard drinks
700ml x .375 (37.5% alk/vol%) x 0.80 (alcohol density about 0.8 g/mL) = 210 g alcohol
and at 1 std = 10g alcohol
= 21 standard drinks

(the old 750mL bottles, and a whiskey at 40% is still only 24 standard drinks)

2) "Tell him to just be sensible"
Same thing they said to George Best after his liver transplant.

3) Shit - I still don't know the questions, and I certainly don't ask them in the correct order (whatever that is).

4) The lac k of treatment for nicotine dependence, for GPs in Oz, there is a special item that allows access to psychologists funded by medicare for mental health problems, interestingly it specifically excludes tobacco use disorders*
yet includes the quaint diagnosis of neurasthenia


* Dementia, delirium, tobacco use disorder and mental retardation are not regarded as mental disorders for the purposes of the GP Mental Health Care items.

11:28 PM  
Blogger Bronze John said...

Hail Cam',
B ack at work, contemplating quitting Drugs and Alcohol and a week or so off starting ICU. If ICU is good I will probably ease out of the other job. We shall see.


10:16 AM  
Blogger Bronze John said...


The sevenish bottles of wine was meant to be around the three bottles of spirits he said he had, not the one and a half he was acutally having. I hope whatever organ I have in my head instead of a brain is useful in some way.


10:19 AM  

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