Fungaemia

Hail,
And a warning - the following post is rated R for contains Rather Distressing Concepts.

I am sitting in ICU, having just had a discussion with the Upper GI Registrar. For those confused by the terminology, registrar is a term that means anything from decider to dog's-body, depending on the team. The Upper GI Reg is a truly tiny woman, someone who seems too small to lift even a paediatric endoscope, and from the expression on her face she seems more of the dog's-body type. We had a brief and depressing discussion about the fate of Mr Wells - a seventy year old man who had suffered a catastrophic series of events (the surgery for his pancreatic cancer had caused a loss of blood supply to his small intestine which had required the insertion of a central catheter which had then become infected with a fungus which had spread to his blood which meant that his kidneys weren't getting enough blood...).

We had passed the point where medical interventions actually benefit the patient some days ago. Mr Wells was no longer able to speak, and the impetus behind these increasingly futile measures was his brother, a man who lived a thousand miles away and seemed unable to accept how bad things are.

I have seen this before - the enormity of some ideas means they require time to grow, time for the mind to make space for them. Ten feet from me a family is gathered around a twenty year old girl who may die before the weeks is out. They have brought a photograph of her and her husband and baby from a year ago, and the rapidity of the decline (methamphetamines, increasing psychosis and now some truly horrible viral encephalitis from which she will not recover) is something her parents are unable to accept. Three times in the last two days Dr White has met with them, and explained in his careful Cornish accent, how it is quite possible that their daughter will not wake up ever again. He uses unambiguous tierms, like "die" and "stop breathing" and "her heart will stop", and each time the parents nod and look grave and then ask when she will be waking up.

A truly ghastly tale of what we call fungaemia - fungus growing in the blood. I can't remember if I told this story before, but when I was working in the injecting drug field I heard of a couple, both HIV positive, one of whom was on buprenorphine (the tablet for heroin dependency that goes under the tongue). He was diverting the medication to his partner (spitting it out so his partner so his partner could inject it). Unfortunately he had oral thrush, and when his partner injected it, he got oral thrush in his blood.

This meant he got hideously sick, and died three months later in the ICU with multiple organ failure.

Anyway, this is all horribly depressing. I am trying to think of something cheery but staring out at the serried ICU patients does not really evoke thoughts of joy. Directly ahead of me is my 208 kilogramme man, the bed next to him is waiting for our 37 kilogramme man - eyes sunken into his head, a chest that is too bony to listen to, a perpetually confused expression on his face.

Weirdly, this means that on average, our patients are relatively normally proportioned.

Aside from this, I have been trying to load medical text books onto my new Palm Pilot. More on this later, but the geeky amongst you will have heard of Clarke's Third Law: "any sufficiently advanced society is indistinguishable from magic".

The problem with the usual application of Clarke's Law is most people imagine it relates to some time in the future, when we all wear lycra bodysuits and jetpack to work. This is untrue - for me it happened about nineteen forty three, the year that that big computer in Pennsylvania started up. Since then it's been increasingly baffling. Computers and stuff like that I just do not understand. For all I know, instead of logic gates and flip flops inside my Palm Pilot there could be tiny tiny little picosorcerers inside, rummaging through the innards of a nanogoat.

Anyway, off to resuscitate our skeletal man.

Thanks for listening, will reply to comments soonish.
John

The gamma male thing

Hail,

I have discovered something distressing about myself.

I am a gamma male.

You know that short, chubby, bookish gorilla who hangs about on the outskirts of the troop while the silverbacks bellow and crash? The one intently studying the undergrowth when other gorillas say "someone really needs to take charge here"? The gorilla who can see that everyone involved in the conflict, really, does have a point and that what they are saying probably sounds quite sensible to them, and really we all just get along?

That'd be me. Listen to this story.

A few nights ago Mr Addams turned up to the ED. He was a chirpy, courteous ninety year old man with acute kidney failure and blood that would not clot, and what with his pace-maker and his blood results*, someone who had gone from being a very healthy man to a ratehr unwell one in a few days.

And another person who hadn't called an ambulance because he didn't want to bother the doctors. As part of the history I asked him if he had any back pain and he said "occasionally, when I mow the lawn or make my bed".

Anyway - he was unwell, and ED thought ICU needed to see him, and called me. I went down there, the first time I'd been there as ICU rather than ED, and was greeted by several nurses and Dr Klaus.

"Thank God" said one of the nurses. "John, you'll help us out, won't you?"

Dr Klaus, I should point out, has never been anything but courteous and supportive to me, yet I am deeply terrified of her. She is an efficient Teuton with an almost supernatural intellect - she used to do neurology, and sticks needles into people's spinal cords like other people brush their teeth. I suspect if someone ever saws open her skull, her brains will explode out like an airbag. She is held in almost religious respect by the other registrars.

"You won't have any trouble admitting this guy, will you?" she said, and smiled.

I shook my head. "Doubt it." It did seem that he would have done better in ICU than the ED. And the ED was chaotically busy, whereas the ICU was like the Marie Celeste.

I wrote up my note and rang my boss - as policy dictates.

"No" he said. "He doesn't need ICU. Let the medics take him." He said - doubtless correctly - that Mr Addams didn't need dialysis, that everything that was needful to correct his problems could be done by other units, and that he didn't want to create a precedent, whereby today we accept soft referrals from the ED, next week we are overwhelmed. Overall, he gave a number of very good reasons why the old man didn't need to be in the ICU. I listened, nodding and saying "Right" and "Of course" and "Probably shouldn't have bothered you" throughout, and put down the phone.

(See, when someone presents to the hospital with a medical problem, a ferocious tussle immediately erupts between the various treating team as to who gets the patient. Emerge says psych should have them. Psych say they should be looked after by medicine. Medicine tries to handball them on to ICU, or if that fails, surgery. ICU look to bounce them back. It's almost the exact opposite of normal commercial competition - in this market, everyone seeks not to win the customer, to force someone else to take them. To win the patient/customer is to lose, to lose is to win).

"We're not taking him" I said to Dr Klaus. Dr Klaus was not pleased. Her eyes glinted gunmetal blue. "He's got ECG changes because of his potassium. He's got no kidneys. He's a very healthy ninety."

I nodded, my divided loyalties probably evident on my face. "He doesn't need invasive monitoring, or one-on-one nursing."

She rolled her eyes. I don't know if at this stage I was still pretending to agree with the my team's decision or if I'd given it up, but either way, I have never been particularly good at that kind of deceit.

Anyway, I went and told the medical registrar. She was very happy and receptive - because changeover was coming, and although she'd get the handover she was basically agreeing for someone else to do the work and look after the patient. From medicine's point of view it was a loss. From ICU's it was a win. But from ED's point of view it was also a loss, because everyone knew that medicine would delay and delay and keep poor old Mr Addams in the ED looked after by ED nurses rather than medical ward nurses.

And from Mr Addam's point of view it was also a loss because the Pterodactyl Man, a very vocal psychiatric patient I saw five years ago and still remember, was being wheeled in strapped to a barouche as we spoke, screaming in fluent triceratops.

Anyhow. Unfortunately, later that night there was another patient bounced by ICU (Dr Fang being the decider) and the next moring the head of the ED and the head of the ICU had a meeting and clarified things. Everything turned out okay, but still, it is a part of medicine I don't like.

The thing is, if this is internal politics, I am internally politically dyslexic. I have an almost vestigial sense of self-presrvation when it comes to this kind of stuff, and I can't align myself intellectually and emotionally with my team. I am not one of these my country right or wrong people. I reckon we should have taken Mr Addams, just because he would have done better and been more comfortable if we had, and we had space and ED didn't.

I remember when I worked at Shipton, one of the ED doctors there, an obese chain-smoker who drank every night when he was not actually working who , referred patients to the medical team from the ED with the skill of a professional athlete, particularly since he was senior and the medical registrars were often peripubescent. One day the medical reg called in sick in the middle of a shift and they asked Dr Marlboro to fill in for him - to go from ED senior to medical registrar. He was then faced with dealing with several of his own referrals and actually tried to refuse one.

Anyway. One thing I forgot to mention about the whole bird flu thing - the 'bird flu is coming' talk was given by a woman who for much of the time wore one of the protective masks. So I sat there listening to a woman talk about bird flu while wearing what appeared to be a large, bright orange false beak, which wiggled as she talked. Possibly a form of protective colouration.

Luckily, she couldn't see me grinning - as I was behind my own false beak**. I later found out that our immunisation nurse has bought herself a portable generator and has stockpiled masks and canned food, in the style of Survivors. Good to see this being taken seriously.

Anyway, thanks for listening. Back to chew some foliage and stay out of everyone's way.
John

*Potassium of six point nine with ECG changes, creatinine of 360, INR of nine point six. To be fair, the potassium and creatinine had been high for a while, not helped by the ACE inhibitor.

**Sarah was disappointed that she was not measured for a beak, however, I did remind her that lying around the house we have a large number of (unpaid) bills. Bills... like beaks, geddit?

Bird Flu

Hail,
To cope with our dramatic undersupply of patients (I use the plural, but at the moment we have two elderly airways disease patients who are both sitting comfortably), our new consultant has instigated a series of surprise tutorials. He does this by pouncing upon anyone looking idle (or even anyone working) and saying "Why don't you look up a recent evidence based article on the management of hepatorenal syndrome and then come and tell me about it in half an hour?".

The answer "because I don't want to" is not considered adequate.

I was asked to give a talk on the diffuse parenchymal lung diseases. The gist of my talk is as follows:

If you get diffuse parenchymal lung disease, it could be caused by any of two hundred causes - from tuberculosis to budgerigars.

Most of the time no-one knows what is causing yours - the so-called 'cryptogenic" causes.

A lot of time we tend to give you steroids and stuff, no-one really knows if this works or not, but it seems better than doing nothing.

Even if it does work, you won't last long and you'll be increasingly sick for the rest of your (often brief) life.

While this is not exactly true, it's not entirely untrue either. The other talk was on our bird flu plan. Basically, the hospital has a plan for if bird flu jumps species to humans as a highly contagious, highly lethal influenza. The gist of the plan seemed to be that initially we would look at containment and subsequently we would look at maintaining essential services. This would be difficult, our consultant warned us, with as many as six hundred and fifty deaths among hospital staff alone, and an ICU that could handle perhaps four to six of the seriously sick people.

There was no place in the official plan for running screaming into the desert.

However, we are all being fitted for special breathing masks, so that come the plague, we can all move amongst the piles of dead with minimal risk of infection. The woman fitting the mask apparently advises us not to smile too much as this may compromise the seal. Somehow, I don't think this will be a problem - the real issue should be whether the masks still fit over a rictus of horror.

Anyway, off to read up on pulmonary emboli - which I will be talking about in thirty minutes.

Thanks for listening,
John

Cry

Hail,
Very brief note - an overdose is turning up in about twenty minutes to the ED and we have to be there. Another too-quiet day at ICU. Our lithium overdose man has been discharged, (after his thirtieth admission), our airways disease woman is sleeping peacefully and our "pink puffer" - a little old man who breathes through pursed lips and cannot walk across the room without resting, but who is listed as the principal caregiver for his wife - is asleep in a chair.

And Dr Fang is doubtless asleep, tormented by visions of other doctors who earn more and have bigger breasted nurses, and Dr Bill is devouring another pizza with the feckless enthusiasm and manic metabolism of youth. Which leaves me studying and several nurses re-reading the newspaper and talking about the lemon detox diet.

A few things have been happening. A mildly amusing anecdote that illustrates the difference between Emergency Medicine in the US and Emergency Medicine in the rest of the world. Our consultant was saying how when he was a junior medical officer, his boss (an ED doctor) invited an American doctor over for some teaching - someone from Chicago or Detroit or somewhere. This was back in the seventies, by the way. The American doctor talked a bit about EDs (or ERs) in the US, and then it was question time.

First question from one of the British doctors: "We don't have as many guns over here as you do - so how many shootings would you see in the ED in a year?"

US doctor: "Oh, about ten, fifteen in a year"

UK doctor: "Really? I would have thought you'd treat more gunshot wounds than that..."

US doctor: "So sorry, misunderstood you. We treat about five, ten gunshot wounds a night. But every year we see about ten, fifteen people who are shot while they are waiting in the ED waiting room"

Another world. I won't bore anyone with my deeply predictable views on gun ownership, but I vaguely - and I mean vaguely - recall reading that most people who own guns never use them. Following "not used at all" the next most likely use to which a gun is likely to be put is to commit suicide. Following that the next most likely use is homicide (I can't remember if that is only completed or if it includes attempted as well), and after that comes protecting yourself against the home invasion (by some guy who is also almost certainly carrying a gun, and thus further spoiling the averages for the law abiding folk).

But anyway - not something there's any point arguing about. My sympathies to anyone who's had a loss.

Further news: I am beginning to suspect I suck at my job. Not all of it, not every last bit, but important parts. And some of it is doubtless due to lack of practice - it's been a long time since I've had to think about all the causes of long QT syndrome, for example. But some of it, I fear, may be more serious than that.

Without wishing to grab my hanky and rush off, I have realised that there are parts of my job that I am not good at, that I have never been good at, and that I will, in all probability, never really be good at. There are skills are not going to come to me no matter how hard I work, there are areas of emergency in which I will never reach an adequate standard.

See, part of ED is not only knowledge base, it is cognitive style, ways of seeing that affect your thinking and thus your ways of doing. This will all sound waffly, but the way I see things - and thus think things and do things - is Dionysian rather than Apollonian, synthetic rather than analytic, mediaeval rather than enlightenment. Perceiving rather than judging, in that Myers Briggs thing - and in ED you need someone who can make a quick judgement.

This means when a patient comes in the things that stick out to me are impressions rather than facts, inappropriate emotional flatness, say, rather than elevated serum potassium. And I'm not saying this to say "Oh, look how mysterious and ethereal I am, not like these common clods of clay, my fellow registrars", because I envy my fellow registrars their ability to hear ten different serum electrolyte levels and spit them back at the consultant five minutes later. I wish I could do that, deliver those quanta of objective information, but the thing is, I find it really, really difficult.

And it's getting easier, but it's bloody hard work. I still waffle when I should be clear, meander when I should cut to the chase. Because of this - and a number of other proofs - I remain convinced I am not particularly smart and not particularly good at medicine. Speaking with patients, basic concepts in medicine, that kind of stuff I can do, but this high velocity data flow stuff, this crystalline clarity, this unambiguous certainty... not easily.

And yet, for some very difficult to articulate reason, I have chosen a training programme that has as its end point the assumption of a leadership role in exactly the kind of situation at which I suck.

Anyway. Two years ago I would have poured my heart out about this. Instead I am going to go down to the ED, and then go home and sleep... so I can get up early and hopefully read up on some of this stuff before I go in.

Thanks for listening,
John

Dr Fang

Hail,
Vast apologies for not posting/responding until now. I know I feel disappointed when I look at someone's blog and there's nothing there, so sorry about that. But things have been moving rapidly here, and there is much to write.

First, a rather morbid look at how brains work - or some of them, anyway. At the moment I am sitting in the doctor's office in the Alcohol Unit. Outside my window is the driveway to the hospital car-park, and across the driveway the autumn sun is shining on the pomegranate tree. The day is quiet, no birds sing.

When I was young, and went to visit my grandparents (I remember long silences, and the smell of camphor-wood chess pieces in the dim light, white bread and thick clotted cream and strawberry jam and the ticking of a clock), there was one book that I treasured above all others. It was a book of Greek mythology, something I devoured and read again and again and again. It was a dull olive green, quite weighty, and contained numerous pictures and extracts from poems - Laocoon and his sons being taken by the serpents, Daphne being coccooned in bark, Hermes whispering Argus to sleep so he could cut off his head.

Much of the stories were illustrated in a romantic way - romantinc in the old, dangerous sense of the word. Myths of blood and sex and violence, lavishly illustrated in a style perhaps not suitable for young minds.

And illustrated with a particularly vivid illustration was the story of the rape of Persephone, taken by the God of the Underworld to be his bride.

The thing is, even thirty years later, unless I deliberately imagine otherwise, every time I see a pomegranate, tree or fruit, I see some sobbing maiden-goddess on a dark throne beneath the earth, thin and starving, her mouth stained red, and the God of death and wealth standing triumphant at her side.

So - there I was, sitting at my desk, notes open in front of me, and just outside the threshold of hearing was her, weeping, beneath the asphalt.

That's how I reckon brains work. Kids reading this - don't do drugs.

Anyhow.

Work at the ICU progresses. We had what I (and only I) would call industrial action the other day, in that the boss took a day off. For the last few months he has been the only full time consultant. He has been promised cover: an ICU consultant was allegedly coming from India, then another from Canada, then a third from Arizona, but all had cancelled or fallen through - better offers in Queensland, deaths in the family, snakebite (seriously, the guy from Arizona) - , so Dr White was left running the place by himself. The Royal had been talking about sending him someone, but of course, nothing had happened.

So last weekend, after being on for ten days in a row (eight oçlock to five oçlock plus being on twenty four hour call, which more often than not meant pre-dawn call-ins and never being more than fifteen minutes away from the hospital), and several months of six-day weeks, Dr White took the radical step of saying he was taking Sunday off - cover or no cover.

So we had to close the unit, which meant that all the ICU patients were shipped to the Royal, and we virtually closed down, and the Sunday registrar arrived to find an almost empty ward with a few overflow patients who had nothing wrong with them and nurses standing around looking stunned.

Anyway, that was the Great Intensivist Strike of 2007, and the Royal have decided they can spare someone after all, and the new guy (from England) allegedly arrived yesterday. We shall see. Dr White is back, twinkling of eye and bright of tooth, with his vast selection of educational horror stories - "It is a horrible truth of medicine that if a child weighs less than his or her hospital notes, that child will die", that kind of thing - and I feel a lot safer with him there than me and Dr Fang.

Dr Fang is my fellow registrar. It pains me to say it but he is one of the two or three people I went through medical school with whom I suspect I genuinely dislike. He is deeply racist - Aryan girlfriends, anti-Asian comments, didn't speak to my friend Masako for three years, frenziedly barbequing kangaroo while shouting about the football - which may be more explicable in someone of mixed Asian-European parentage, buit is no more easy to deal with. He is contemptuous of anyone who earns less than him and envious of those who earn more - the bulk of the first handover was spent bitching about what the locum registrar got paid. And his other frequently expressed complaint is that there are not enough cute nurses in ICU - or often that the ones who are there are not cute enough, I'm not sure. Either way the average cuteness does not come up to his standards.

Scene: Dr Fang bent over some unresponsive man, trying to get a tube in, speaking to nurse:
"Give him sixty of rocuronium, do a blood gas - but first get me someone with bigger norks".

Having said that, he knows more about this kind of stuff, having been doing it for two years as opposed to two weeks, which is good.

Anyway, much more to write, and comments to answer, hopefully this weekend.

Thanks for listening,
John

Responsible

Just have to share this with someone.

This morning at the Motorist Assessment Clinic I saw four patients, to determine if they were alcohol dependent or not. What we do consists of a questionaire of about a hundred questions, a brief physical exam and some blood tests. It's a procedure loathed by all - the patients find it degrading and intrusive, the doctors find it degrading and boring. Unfortunately it's apparently the best way of determining if someone is alcohol dependent and thus unfit to hold a licence.

People get sent to us after two normal sized drink driving offences in three years or two biggies in five. I used to live in fear of seeing some of my friends in the Motorist Assessment Clinic when they were sent there. Now, of course, I worry about seeing some of my friends in the psychiatric hospital when I am sent there.

My own feeling is the whole process sucks.

It sucked particularly today when I saw Mr Theopolos, a gentleman whose licence had been revoked after he had picked up driving with a breath alcohol of point one six - about three times our legal maximum. He sprawled on the chair, glaring at me, arms folded.

"It's all been shit since last time" he said.

"Uh huh?"

"Since you - " and here he pointed at me "took away my licence."

I had been thirty kilometres away at the time, but never mind. "How's that affected you?"

"Makes it a lot more risky to drive, I can tell you" he said.

"I'd imagine it would" I said.

"And that's why I'm drinking so much more now."

"So you're drinking a lot more now?" I said, pen poised over the 'alcohol dependent' box.

"Shit, yeah" he said.

Tick.

"So how did losing your licence cause you to drink more?"

"Moral self restraint" he said, pronouncing the words carefully as if they were something either he or I would not understand. "Once you took my licence away I didn't really feel the need to exercise any moral self restraint."

I didn't ask if this was the same moral restraint he exercised to get his original conviction back in March 2005.

"I see."

"I didn't have as much responsibility, so I started drinking more. You're all to blame." There was a pause, and he summed up. "Lack of responsibility caused this."

I nodded vigorously, glad we could agree on something.

And the thing is, he did have a point - one of those "the less you have to do, the less you get done" kind of things. Maybe more responsibility would have been better for him than less. But somehow I can't imagine the police picking him up, breathalysing him, and saying "Yep, that's way over. Turn up at this address: from tomorrow you're driving a school bus. And one more conviction and it's airline pilot for you"

Anyhow. More cogent stuff later. Thanks for listening.
John

The Man from Snowy Liver

Hail.

Late night, and my belly is bulging with post-first week rum-and-raisin ice cream. I have just opened my bottle of merlot and started to write. In the next room I hear occasional exclamations of joy from Sarah - she has been searching ebay for rural clothing, and so far has seen a pair of Outback Dessert Boots, and a Genuine Australian Stockman's Hat, "As worn by the Man from Snowy Liver."

Anyway. I have survived the first two days of ICU, my first shifts of hospital medicine in a very long time, and I have learned several remarkable things.

I have learned that there is some part of my, some strange, self-punishing part, that thrills to this. The first shift I woke at six, after staying awake running through stuff in my head almost all the preceding night - blood gases, scans of the brain and the heart. I got up before dawn and looked outside. The moon was full, the sky was still dark, with a few streaks of cloud in the sky. The air was cold, it seems we haven't had much of a summer here, it came late, was weak and is leaving early.

The previous night there had been a lunar eclipse, the moon had been the colour of blood, a portent. Now it was full and pale.

I stood outside on the cold lawn, filled the water-troughs for the chooks and scooped them a few bowls full of grain, and felt a thrill, and electric exultation, a feeling of being alive. Like there was some blanket of fat being removed.

I can't say what it is, exactly, but I have missed this.

Anyhow. I arrived early. One of the best things about ICU is the shifts go eight to eight thirty. This means I am in the car park at seven thirty, which means I always get a parking space. Most people aren't here at this hour, you pick your way past cars belonging to JMOs and cleaners and the pathologically keen.

The ICU is up two flights of stairs. It's a relatively small department - fifteen beds at full funding, but running at a little under that at the moment. It's almost the opposite of ED - it's small numbers of very sick people, rather than the reverse. In bed one is a woman who had a heart attack after her gall bladder surgery and has now gone into type two respiratory failure and is on her way to pneumonia - that sort of thing.

We have several overdoses - which does give me some transient feeling of disquiet - and several people in what is called "acute on chronic" organ failure. These are people who have had, say, very poor kidney function for a number of months, just hovering on the edge of dialysis, and to whom something happened - a bit of diarrhoea, maybe, or a touch of a chest infection - which pushed them over the edge. Now a machine cleans their blood.

If they are lucky, this will be a temporary thing.

It is also a place where remarkable stories are told. The boss, Dr White, a green-eyed and red-headed Irishman in his early fifties, is a vastly learned man. He spent the first fifteen minutes telling me that he must be consulted at any hour of the day or night if I had any concerns about patient health or welfare, and I spent the same amount of time telling him that I would not hesitate to consult him at any hour of the day or night if I had any concerns about patient health or welfare, and after that we seemed to get on fine. He has an inexhaustible supply of stories that he tells with evident glee - stories of surgery gone awry, for example, untimely and tragic deaths, family outings consumed by tragedy, that sort of thing.

"Talking of amphetamine withdrawal" he would say (and we had been) - "a year or so ago we had a big guy in. Not so much tall, but broad, arm'sbreadth across the shoulders, big guy. he'd been brought in by the police after causing an affray with a pickaxe handle or something, and he'd got this cut on his head, and the urine looked like rhabdomyolysis, so we got him. Anyway, the police sat on him for two days, and this guy lay quiet as a mouse. Didn't move or anything.

So they finally hand over to the security guard and head off. Security, of course, is a three foot tall geriatric with a walking frame, looking like Pinocchio's uncle in the cartoon. The cops have been gone two minutes when our guy wakes up, needs a toilet break.

So security takes the guy in to the toilet.

"I can't do it with you watching me" says the prisoner, who is handcuffed to said security guard.

"Sounds reasonable" says security, handcuffs him to the towel rail instead and steps outside.

Ten seconds later the guy erupts from the toilet stall, bradishing the steel towel rail, knocks old Geppeto to the ground and starts running for the doors. Everyone gets out of the way and he disappears down the stairs. By the time the police arrive, he's gone.

So they ask us for a description. They already have a pretty good description of what he looks like, but we tell them - squat, bald, bearded, covered with home-made tattoos.

"What's he wearing?" asked the police officer.

"A hospital gown" said the nurse. "Neck to knee, open at the back. And it didn't really fit him, because of his size, gaped a bit. Nothing underneath. And a handcuff, and a towel rail."

"Can you describe the towel rail?" asked the officer.

"Metal. Long. Like a cylinder" said the nurse. "You know, you hang towels on it."

"Right, right" said the officer. "And he's handcuffed to it." Then he looked up at the nurse. "Which wrist was handcuffed?"

We all had this mental image of the police pulling up a bare-arsed, screaming tattoed man in a hospital gown, charging down the highwayhandcuffed to a towel rail and saying "Wait a minute - this guy's got a towel rail handcuffed to his right hand. Can't be our guy. Sorry sir, our mistake."

Anyway, more tales of this kind of stuff to come. For now* I have admit my man in a wheelchair who claims to be drinking - wait for it - nine litres of wine a day. Ninety standard drinks.

The Man from Snowy Liver, indeed.

Thanks for listening,
John

*Started this entry last night, finished this morning. I am not actualy disorientated to time, person or place.

John

Sugar

You could smell Mr Tossel when you opened the waiting room door. He had that slightly plastic wet paint smell, and if that wasn't enough for you there were the freckles of paint in his hair, paint punctuating his overalls and spattered on his boots. He lumbered into the room like an ox.
"Can we make this quick?" he said. "I've left the dick-brained apprentice in charge."

I'd scanned the file on the way up to the waiting room. "Should be okay," I said. "No big changes?"

"Same old, same old," he said. Mr Tossel had been with the programme for fifteen years. Fifteen years of picking up his dose from the chemist three times a week, three monthly doctor appointments, no heroin since the late nineties.

"Still on one hundred and fifty?" I said. That's a big dose. The pharmacist doles it out into a paper cup as a sticky red syrup, dilutes it with water. Still, methadone rots your teeth (it's not the sugar, it's the decreased salivation, happens with all opiates), and Hep C does too (an autoimmune effect on the same salivary glands), and he was lucky to have the teeth he had.

He nodded.

"No heroin?"

"Not since last time."

"Speed?"

His face curled. "Nope. I can't stand the way it makes you smell. That metallic sweaty smell." He thought. "Plus it turns you into a fucking psycho."

"True enough. How's things otherwise?"

"All the same. All the same as it always has been."

I stopped writing for a moment, looked up at him. "You must get bloody sick of coming in to see us."

He grinned. "You must get sick of seeing me."

"Nope, you're paying my mortgage, mate."

"Things are going good. I've even started to cut down on the sugar."

There's no real place on the methadone assessment form for a dietary history, even though a fair proportion of our clients are clinically malnourished (if you know someone who is taking speed or ice, get them to take multivitamins - mainly B and C). "The sugar?"

"Two kilo bag lasts me... " he paused as if calculating. "Seven days, now."

I nodded. "That's a lot."

"I reckon it is," he said. "Thing is, I can't stop it. I just love the sugary drinks. Even at night. Every night I make myself a milkshake, put it near my bed. I get three litres of milk - meant to be good for the teeth, they say - three litres of milk, twenty five spoons of sugar, fourteen spoons of vanilla essence and two eggs. I mix it all up and drink it at night when I get up."

"You get up often?"

"I'm always up," he said. "Ten times a night I'm up. Pissing and pissing. Like there's no tomorrow."

"You get thirsty?"

"Christ yeah. During the day - five, six litres of that Sunnyup stuff."

Sunnyup is a particularly lurid local brand of soft drink, produced in nine different fluorescent colours and radioactive flavours, currently available without prescription but hopefully soon to become Schedule Nine drugs alongside pharmaceutical heroin and magic mushrooms.

"You tired?"

"Last few years, pretty much all the time," he admitted.

I stared at him. I could almost imagine the sugar in his blood - damaging eyes, kidneys, veins. "Have you ever been tested for diabetes?"

"Came back clear," he said.

"How many years ago?"

"Ten - maybe twelve."

I looked around the room. We don't have a glucometer, or an ophthalmoscope, or much of anything in the rooms. Like a lot of doctors who lack confidence, I try to always get some independent verification, some number I can point to and say, "Look, that proves it" - even though I know the story in this case is more than sufficient. A story without blood test results, for example, is a useful starting point, something that can help people. A list of numbers without a story attached are only useful as academic exercises.

"I think you have diabetes," I said. "I'm not certain. But I'm pretty sure. Go from here to your local doctor's. Actually, I'll ring, make you an appointment. First thing in the morning - without one of those drinks, if you can - go get this blood test."

I hate GP kind of work, sending sick people whose diagnosis you don't know and whose treatment you haven't even started out into the wild world. Part of me thinks "But who will look after them?"

Anyhow, we had a talk about diabetes - he knew a bit about it, his mum and his brother had it - about how it could be controlled, and how if he didn't control it he'd be leaving the dick-brained apprentice in charge of more and more stuff.

"If you want to keep working," I said to him, "go to the doctor Friday."

He nodded.

After he left I turned the air conditioner on - I love the smell of paint and grease and chemicals, anything that suggests hard work and industry, but I know some of my clients are sensitive souls. And all that day and a lot of tonight - despite what that "Keeping Doctors Alive" booklet says - I have been worrying about Mr Tossel, and thinking about what the future holds, and how it may not be that good. And thinking about our role in this, about methadone's role in stuffing up every single endocrine system your body sends out, stacking on the fat, maybe predisposing him to what he has now. Wondering if anyone told him fifteen years ago, wondering why no-one saw this before now.

And also, part of me wondering at it all, turning the paradoxes over in my head. Someone like him, big, strong, calloused hands, skin like armour - his blood sweet like rosewater syrup. Strong enough to work twelve hour days in cramped rooms in the Australian summer - but not liking speed because of the way it made him smell. Someone with shoulders and skills like his having to lie in bed of a morning, leaving things to a skinny, dick-brained apprentice.

Anyhow. Work tomorrow. Shall post replies to comments soon.

Thanks for listening,
John