The Doctor and Martha

Hail,

First off - this infrequent updating is driving me nuts - you kno whow you avert your eyes when you drive past the gym where you have your membership, or other stuff you should be doing? Anyway, I have changed my schedule at work around and as part of it I will be updating Fridays and most Tuesdays. If I don't, and thereby sink into illiteracy, I will have only myself to blame.

So, if I still have any readers after this, Fridays and Tuesdays.

Having said that, I read somewhere that blogs tend to have a life-span, that after a while most people no longer find it necessary or rewarding to talk about themselves. I don't know if this is happeneing to me - I know a year or so ago I used to want to opur stuff out, now I am less open about stuff. Part of this comes with diminishing anxiety, growing confidence, and presumably a corresponding diminished need to present yourself to the world in the hope of approval and healing. But as far back as I can rmemeber I have written and wanted to write, and I miss it when I don't do it, so there may be a bit of life in this yet.

So, on with it. And fairly frequent strong language herein.

I saw Enid Charlesworth the other day. Not her full name, but her full name is something like that, something evoking English children's novels in the pre-war years, all stories of ginger pop and mysteries and jolly good times.

Enid herself is nothing like that. She is amongst my favourite patients ever, for reasons I cannot fully articulate. She is in her early forties, slim and bird-like, almost reflexively foul-mouthed (the only woman I know who fitted three obscenities - two adjectives and a noun - into a simple request to her partner for a cup of coffee). No heroin for two years, the occasional shot of speed, smokes like a volcano, the sole carer for her three children under fifteen, one under five.

In our consults she sits and tells me stuff about her life. Her previous job as a stripper ("my grand-dad came. He said it was a really dignified, artistic show"), her previous drug habit ("and I heated the shit up in the spoon and it went yellow and started to smell of vanilla - the fucker'd cut it with custard powder! I went round and smacked his fuck'n head") and her tribulations with her ex-partner ("and he leaves this note sayin' he'd took the kids and gone off to Sydney! I tracked that bastard down, I can tell you. Kicked the door in - one of those pissy plywood ones - kicked him in the nuts with my steelcaps. He's lying there on the ground crying and I'm saying "Don't be such a whining martha, get up and fight, you bastard").

And she's been doing really well from the methadone point of view - or she was until the last few months.

Enid's hit forty five. Methamphetamine years are like cat years, and even though she's hardly using in some way's she's old. She's got emphysema and airways disease - runs out of breath easy. The doctor's got her on steroids. She's lost weight, her skin is warm, the whites of her eyes are always visible - she has clinically evident hyperthyroidism. She burns through food, she can't sleep or relax, her heart races, she trembles and she's chemically anxious.

The thing is, both of these conditions - her airways disease and her hyperthyroidism - both of them weaken her. The diseases and the medications make her fatigued, weaken her bones, make her what we call "emotionally labile". Angry, unsteady, frightened.

And this is a woman who does not see herself as someone who is frightened, or weak. She drives trucks across the Nullabor, the same job that employs her brothers when they are out of prison and killed her father when she was thirteen. She can, she says, "beat any fucking man at any fucking thing". The thinning of her bones, the shortness of her breath, these are the things that frighten her most. "And I can't go around with fucken spindly little bones. How am I meant to change a truck tyre like that?" And she grasped the imaginary wheelbrace in her hand and wrenched it around.

And that's when she started crying. Only for a few moments, but I reached out and touched her on the forearm, and I didn't say all the things I normally say at a time like this.

I don't know. Waiting lists for thyroid surgery are long. There is no surgery for her airways disease. Either way, even with the best possible outcome, things aren't going to get good. She's only forty three. And who'se going to look after her four year old if she gets sick? The 'whining martha'?

I don't know. I got the impression - I don't know why, I can't justify it - I got the impression that there was more going on than just her fear of what was going to happen - justified and terrifying though that may have been. And more even than the emotional effects of her medical conditions - the anxiety from never being able to catch her breath, the low-grade fear from her heart pounding all the time. First time she'd cried, she said, in almost thirty years.

I don't know. There's a time in your life you have to change gears, rebuild things. Mechanical analogies seem apt here - the words that come to mind when Enid talks about her life are toughness and strength and endurance. She is someone with few advantages who has done what she has done because of strength of will and toughness of body... and that is all eroding now, becoming unsteady. Muscle and breath and concentration, bones that might break, a mind that won't keep on the task.

I don't know. There was a girl I knew, when I was growing up in the small country town in Western Australia - I say girl, although she must have been eighteen and I was probably only eight. She was spoken about as beautiful, although when I remember her the only picture that comes to mind is someone in blue jeans, pushing a pram with honey-coloured hair falling over her face. I think she had freckles and green eyes.

The reason this came to mind tonight was when I was young she became sick, ballooned up, eyes disappeared behind slits. There were whispers - there are a lot of whispers in towns like the one I grew up in - about kidney failure. I didn't know what it was. All us kids knew is she used to be skinny and then she was fat and then she had to go up to the city for dialysis - we didn't know what that was, but they hooked you up to a machine - and after about two years she died.


Anyway. Children, most children, like most people, are monsters. There's a certain distance and once someone gets beyond that distance their suffering ceases to be something you feel and instead becomes something you vaguely imagine. But I remember my mum said it was such a pity, because she used to be so pretty, and I wonder if at any time the same thing went on in her head.

The things that defined her - beautiful, popular, a good mother - all that shifting away under your feet.

Anyway. I think I think this because in the ICU you see some of that, usually only for a few days. Quickwitted people becoming slow, strong women becoming weak, loving fathers who can't recognise or respond. Some days you get on your bicycle to ride home and you find yourself thinking that the smartest people I know, my teachers, the most dignified and learned and vigorous, one day they will be none of those things.

Despite the tone of this post, the moods are going okay. Yesterday I had one of my tutorials. I go once a week as a form of aversion therapy - I use the fear of humiliating myself in front of my peers to get me to study. And it's easy to humiliate myself in front of my peers, because there is a class of ten, all male, and all but one (me) are from India.

Why should this terrify me, you ask?

Because they know so much. I am not sure if it is due to the Indian medical training system, or the "I was a consultant physician in India, but they won't recognise my qualifications here so now I am sitting in a tutorial with ignorami like you" phenomenon, but at least three of them know more medicine now than I have ever known in my life. They are amazingly learned.

We were asked to described the clavicle - the collarbone. I am not studying anatomy at the moment, haven't done for five years, I could probably tell you three sentences about the collarbone. It goes from blah to blah, it hurts when you break it, sheep don't have one. The examiner asked Amand to talk about the collarbone.

He spoke about it for five paragraphs.

Seriously - what if joins to, how it bends, what muscles and nerves run through it, structures above and below and behind it, all from a standing start. Admittedly he is preparing for the anatomy exam and I am not, but it's still bloody impressive. At my best I could probably have managed a paragraph.

Anyway. I am so far doing adequately in my study - pharmacology, physiology. I had best get back to it. I will leave you with the following physiology fact: not only is blood thicker than water, it is around about three to four times thicker, depending on conditions like polycythemia and anaemia and rates of blood flow.

Thanks for listening,
John

Two words we don't tell you

Hail,
Have given up on the cardiovascular system for tonight and am now drinking red wine out of my official Drug and Alcohol Services "Count your drinks for good health" cup. We wave these at patients at the Driver Assessment service to try to frighten them into sobriety. It does not work at all. But the cups are nice.

I am in a slightly odd mood today, because today Mr Jarusnich, our drug dependent and often very difficult to manage bodybuilder
(Opening dialogue last visit:
Me: So, how are things?
Him: Well, you lot are still forcing me to take ecstasy and fantasy instead of giving me enough painkillers...

and later on

Me: This private detox facility you're going to...
Him: Yeah, they're much more understanding about the screaming and the violence and the throwing stuff around. They understand that it's not your fault.)

... Mr Jarusnich is no longer with our service. Well, he's not with me, anyway. He was banned for life from the local pharmacist (who has taken a restraining order out on him after Mr Jarusnich again threatened to kill him) and because of that can no longer be seen by us.

And although the visits with him were frequently difficult, and although he was one of our clients whose mental illness, in the broadest sense of the term, made him very, very high risk, I feel I will regret not seeing him. I think we kept him alive, and although meetings were frequently difficult for all concerned, and satisfactory for no-one, each time he moves practitioners or services is like another spin of the chamber, another step closer to the time when he finds some deeply dodgy doctor who will give in to his threats and accusations for long enough to prescribe him something that will kill him.

Anyhow. Yesterday in the ICU I heard two of the words that doctors use to conceal stuff from patients. These are terms you should watch out for if you don't like being spoken about as if you are not there or shouldn't be informed.

The first was while we (the four members of the ICU team and the seventeen members of the surgical team) were gathered at the foot of the bed of Mr Dolor, a middle-aged man with an acute exacerbation of his chronic pain. Mr Dolor was on a number of pain medications - including, oddly, morphine (an opiate) and buprenorphine (an opiate antagonist, something that stops opiates working) - and was having these attacks of what looked and sounded in a lot of ways like very severe pain. The surgeons were suspicious because there was lots of screaming and crying and rolling around but no rapid heart rate, no sweating, normal blood pressure, and only a very mildly abnormal Xray.

Also, and I may be being harsh, surgery is the most materialistic of the disciplines. To some surgeons, if it can't be grasped with a pair of forceps it doesn't exist. This is, of course, why they can work such miracles, but it also means that when presented with patients like Mr Dolor they can become wary.

"I feel the predominant lesion here is supratentorial" said the new surge reg, and there was a bit of snickering around the end of the bed and everyone moved on.

Supratentorial literally means above the tentorium cerebelli, the membranes that separate your cerebrum from the lower parts of your brain. So, when a doctor says your problems is supratentorial s/he means "all in the mind" - and s/he doesn't want you to know that that's what s/he thinks.

The other word, or phrase, is "mitotic lesion". It came up while we were gathered at the end of the bed of Mrs Oat, a cheerful woman who was just getting over her pneumonia. There had been something unusual on her chest X ray, we had ordered a CT scan, and subsequently a biopsy by bronchoscopy (Dr White had stuck a tube down into her lung and sucked up a bit of whatever it was shouldn't have been there) and sent it off to the lab to look at what it was.

Throughout the entire diagnostic process we had become more and more suspicious and Mrs Oat, as her pneumonia resolved, had become more and more cheerful. She smiled and waved at us every time she saw us.

Late one evening we got the pathology report. Small cell cancer, aggressive looking, extensive. Median survival was maybe months, maybe a year. The next day, at the ward rounds, I spoke to her treating doctor.

"Have you seen the path report?" I said, quietly.

He glanced at her and nodded. "Mitotic lesion" he said.

Literally "mitotic lesion" means when your cells are dividing something has gone awry. When doctors use it it means cancer. Specifically, when doctors use it in front of you it means they think or suspect or know you have cancer but they don't want to tell you about it.

Anyway. On that happy note - shall post and do comments soon.

Thanks for listening,
John

Myristolated, palmitoylated and prenylated

Hail,
Discourteously long time no post, my apologies. And this isn't going to be some magnum opus, some big work, it's going to be a selection of trivial insights posted in between pharmacology questions.

First off, today I have been studying, and results so far have been goodish. It's a weird feeling - If I hadn't basically dropped out of the programme for a year or so I would, obviously, be a year or so ahead of where I am now. Others who were behind me are now ahead, which feels odd.

One of those, who last year sat the exam I am studying for now, assures me that "the secret" is memorising the entire textbook and doing hundreds (at least) of practice multiple choice questions. Memorising (the smaller and simpler bits of) the textbook is actually coming along relatively well - although every so often I come up against sentences such as the following:

Proteins may be myristolated, palmitoylated or prenylated (i.e.: attached to geranylgeranyl or farnesyl groups).

This sentence is found on page ten and is accompanied on page eleven by what purports to be an explicatory diagram. The text underneath assures me that what is depicted is myristolation, palmitoylation, and both forms of prenylation (geranylgeranyl and farnesyl). There is also some kind of squiggle with the word - one word - glycosylphosphatidylinositol underneath it.

When I was doing theology, years ago, we were introduced to the term hapax legomenon. A hapax legomenon is a word only used once by an author - James Joyce has a couple. You can use them to argue whether a particular text is by a particular person, for example. The next best thing to a hapax legomenon is a dis legomenon, a word only used twice. As far as I can tell, myristolated is one of Ganong's dis legomenons. He brings it in, mystifies us with it and lets it go.

Anyway. In the interim I have been working at the ICU and at the Drug and Alcohol place. The drug and alcohol side of things goes well, but to be honest, I think I am reaching some kind of limit with it, some kind of plateau. I still believe it's useful and worthwhile work - although perhaps if I believed I wouldn't have just asserted that I did, rebutting an arguement no-one has put forward - but it does wear you down.

And lately there has been more of the coercive stuff - taking driving licences off people, forcing them to go to the chemist to pick up their medications every day "like a junkie" rather than getting them all in one lot, cutting them back on medications - frequently medications that other doctors have prescribed.

This is partly because we have had a few deaths around here lately. As a result, government controls on what we are allowed to do have tightened up. This has taken some of the independence out of the job, I find myself making fewer and fewer decisions and more and more often just referring to the handbook.

Possibly as a consequence I have found fewer and fewer reasons not to be honest about some stuff now. I am up-front brutally honest about methadone, for example. "This is a horrible drug" I say to people. "It can screw up every hormone in your body. It can make you fat and tired and miserable. Your bones might get brittle and your muscles might get weak and your teeth will all fall out unless you take incredibly good care of them. Plus, the laws and regulations and controls mean a lot of the liberties you have now are going to be compromised."

And it is bad. But the way things are for my clients, heroin's worse.

The ICU progresses. The boss is back from his holiday, taller, more cheery, with his mop of red heair looking even more photoshopped onto his head, and we have been very busy - almost at full capacity. To get an Intensive Care Unit bed (as opposed to the Slightly Less Intensive Care Unit bed, often known as HDU or high dependency unit beds) you have to be either intubated (a machine doing the breathing for you) or have failure of two body systems. This means your heart and lungs, or heart and kidneys, or liver and kidneys are needing serious support.

Because of this you get one on one nursing. ICU nurses, by the way, are a remarkable lot. They know vast amounts. Having said that, at Florey being an ICU nurse is a much easier job than being an ED nurse. Almost anything is.

Anyway, we have our full quota of patients and they are horribly unwell. In bed eight the curtains are drawn around Mrs Reynolds, a woman who was hospitalised with an adverse reaction to her herbal medication - dropped dead of a heart attack at fifty one, smoked fifty cigarettes a day for thirty years. She died while getting dressed to go to a school play, she has never been without visitors. Immediate CPR, ambulance only ten minutes away.

Throughout her stay our notes had said "no neurological activity" - she did not speak, she did not move, when you shone a light in her eyes nothing happened. Her heart beat, her lungs moved. Her extended family were gathering - Queensland, Tasmania, Alice Springs. This morning I came in and she had died again in the night.

I don't know. I don't know how I want to be remembered, or even if. I gave this a good deal of thought a few months ago, how to minimise the impact on those I was going to leave behind, making arrangements for being found, that kind of stuff.

But one thing I didn't take into account was this whole partial thing - the way some elements of your life stop, while others pass on.

I don't have the words here for what I am trying to say.

Your heart stops for a number of minutes, maybe ten. The brain darkens, is damaged, parts of it die. The heart, being only a muscle, stupid and tough, is rescuable in a way the brain, and thus the psyche, is not.

You died, back on the floor of your kitchen, getting ready to go out. We are preserving the appearances of life, the beating heart, the sighing lungs, the face in repose, but you are not there. Substance versus accident.

I don't know. Part of it is the preservation of the old idea of death as a state, as a separate kingdom, as something whole and fixed. It is none of those things anymore, it's something that to a certain extent parts of us can be moved in and out of.

Anyway. These are not helpful thoughts to anyone. I have to get on with studying, or I'm going to be completely myristolated come Friday.

Will try to write soon. Thanks anyway,
John

Magnesium, troponin and Power Girl

Hail,
A brief halt to my whingeing to actually talk about work. But be warned - this post touches briefly on the misery of others, but ends up being all about me.

Last Saturday the tide turned.

I remember where I was at the time. I had got there a few minutes early and was printing up the blood results (quick and easy guide to Intensive Care medicine - if anyone looks unwell, give them magnesium. Helps the heart, helps the lungs, helps the brain. In fact, everyone reading this should be doing so chomping on some green leafy vegetables) when we got the first MET call of the day.

"Emergency" said Dr Hu (I am not making this up). Bed-block has become so bad lately that admitted medical, surgical and psychiatric patients are waiting hours and hours in the ED. While the patients are physically in the Emergency Department, they are "legally" being looked after by the medical or surgical teams, and if something goes wrong, it's us who get called.

(Of course, psychiatric patients aren't stuck for hours in the Emergency Department, awaiting beds. That would be wrong. They wait days).

So, Dr Hu and I went downstairs to the ED, to see Mrs Ami, an eighty three year old woman having what looked very much like a heart attack. We ordered the GTN so her heart didn't need as much oxygen, we ordered the fluids to bring the blood pressure back up because the damaged heart and the GTN was dropping it, we ordered morphine, we even ordered some magnesium -

And half way through I started to feel I knew what I was doing. I made suggestions, I gave instructions, I disagreed with my colleagues and a lot of the time we did what I thought should happen (well, at least until cardiology turned up, who actually "owned" the patient). And everything went right - well, for us it went right. For Mrs Ami, who was eventually transferred to the Royal in the back of an ambulance, it wasn't looking that good. But for the first time in a long time I felt relaxed doing medicine.

See, it's been months since I've had that feeling, that faint background calm. Not since starting ICU, not since Clearwater in fact. And on the surface that isn't so surprising - I was pretty sick. I took a fair amount of time off. Prior to that I'd been working in an unrelated field, so that was over a year away from any kind of acute medicine. And I'd forgotten a lot and my professional self-confidence - never the best - had become like some kind of vestigial organ.

Anyway. That self-confidence is still there today. I'm studying too, and it's getting in, and coming back when I need it. Not that I reckon I know it all, but I feel better, less like that drowning mouse in the antidepressant test, more like someone who can actually do some remarkable stuff but who looks like maybe I shouldn't be taken seriously.

That's a real illustration, by the way. And the woman can apparently fly. Look, up in the sky...

Anyhow. I've been spending the whole post going on about myself. I don't know what happened to Mrs Ami. Not good, I suspect. She was eighty three, and had had the pain all night before coming in - she belongs to that vanishing generation, amongst whom are some of my favourite people, who die early after a lifetime of hard work because they "don't want to bother the doctor". The front part of her heart was damaged, I don't know that she would have done so well.

But we shall see. Tonight I do a bit of study and watch old episodes of House with Sarah. Tomorrow or tonight, comments.

Thanks,
John

Why I am not an alternative therapist.

Hail,
First, some news from the world of science.

Have you ever noticed how gravediggers are such jolly, happy people, merrily playing japes upon each other and laughing all the while?

Me neither. But I was reading about the alleged (and this is all very experimental) anti-depressant effects of Mycobacterium vaccae, a common-or-garden soil bacterium. It seems, as far as such things can be determined, to somehow have some anti-depressant effects. It seems to make drowning mice less depressed, anyway, which means it may be a promising therapy for those of us who when depressed feel like a drowning mouse (paws up).

Now, this is obviosly a long way from us opening the psych wards and herding the depressed out into the fields, but I am reluctant to dismiss ideas like this. I have vague ideas about the number of efficacious, cheap, relatively safe therapies we withold in modern medicine, mainly because they can't get through the same set of hoops that, say, the latest product of the multi-squillion dollar pharmaceutical industry can. I have unclear images of the deeply depressed spending time sitting in the sun, psych ward beds like individual rooms, families instead of individuals being treated, therapeutic communities. That kind of thing.

But not the kind of thing you can copyright and run an advertising campaign on, so unless things change, some pendulum swings back, that's the end of that. We are left without alternatives.

I should stress here that I am not talking about alternative therapies in the commonly accepted meaning of the term, crystals and so forth. If by alternative therapties you mean stuff that has been tested and shown not to work, I am not a believer in alternative therapies. No harm to those who are, many fine people, etc. etc. etc., but there is a philosophical chasm between most believers and me that I suspect will never be crossed. The attached philosophical baggage - the whole romanticism versus classicism, the things alternative therapists say about nature, the mind and the self - I can't adopt that.

That's an ugly looking paragraph there, but I suppose what I am trying to say is that you don't have to be tin-foil-hat-wearing crazy to realise that modern medical questions and answers are at the very least distorted and at worst defined by a very sizeable medical/pharmaceutical/economic industry. The industry - and I don't so much believe in conspiracies, I believe in people acting in their own interest, influences the treatments and the illnesses that exist, who gets considered as a patient and what it is acceptable for a doctor to do, and so on - says what questions can be asked as much as what answers will be given.

Having said that, if you tape a magnet onto your belly-button ( I saw this last week, on a woman whose licence I had to take away), it won't make your knee get better any faster. I beleive I know this as much as I know what country I live in, or whether my wife loves me, or a number of other things. And if you sell magnets to people and tell them, or hint to them, or allow them to believe, that they are helpful, you'r not a doctor anymore, you're a charlatan, on the same continuum as those nineteenth century women who pulled muslin from various orifices in seances, or cold-readers who tell grieving widows that they can communicate with the dead.

And don't tell me "They laughed at Galileo, now they're laughing at my new remedy" stuff. They laughed at John Brinkley, too - when he implanted goats glands into men's testicles and told them it cured low libido. And it wasn't because he subverted the dominant hegemony of the pharmacomedical paradigm, or because he allowed the vibrational energies of the glands to cleanse the blocked tissue in a way inaccessible to conventional allopathic medicine, it was because his ideas were crap.

Anyway, my preachy detector just went off. I think I am defensive about this because a sizeable number of alternative therapists over the years have told me how close-minded and docile and unthinking I am purely as soon as they find out what I do for a living. But I have seen a young woman who never used contraception because her chiropractor told her she couldn't have children, and a baby born who would never walk or talk because of the herbs his mother ate while pregnant, and a friend of mine has seen - but I haven't yet - dissection of the carotid artery following chiropractic manipulation - i.e.: a stroke.

Anyway. Enough of this. We need meaning and healing and life, some of us at some times more than others, but trusting people who offer to sell it to us seems dangerous to me. But I better go off and be a slave to the dominant hegemony.

Thanks for listening, and sorry for being such a curmudgeon.
John

Three deaths

Hail,
A few minutes before Jacob Rowe - my pleasant, affable sports journalist with the heroin problem - turns up, and I have time to reflect on the last few days.

I don't know about the ICU job. The thing is, there is this distinction between medicine as in the academic subects (psychiatry, emergency, intensive care, etc.) and medicine as in the various jobs. Psychiatry the academic discipline - I love it and was good at it. Psych as a job - not for me. Emergency - love it, not actually that good at doing it, definitely not that good at learning it.

When it comes to ICU, the whole thing's a bit odd. I would love having more to do with the patients, even though we almost never get to sit down and talk to them face to face and explain things at length, it's more a gathering around the charts and murmuring amongst ourselves. I love the complexity of the physiology - how and why your blood sugar falls in the face of overwhelming organ failure, that kind of thing. I love working with the senior consultant, Dr White.

But Dr White is on holiday - finally - and we have a succession of locums (or is it loca? You know, datum, data, stratum, strata?) filling in for him, and things have gone into a bit of a spiral.

This is perhaps best illustrated by the fact that three of my patients died yesterday. Hear me moan, as they say.

The first one was the man we had resuscitated last night, Mr Ivory. We had been about to leave when the MET call pager went off. This means a medical emergency team call, someone crashing who is not actually in the ED, in this case an elderly man who had suddenly become unresponsive with no recordable blood pressure. We got there and found the elderly man, yellowish and trembling, and pumped him full of fluids and almost miraculously he became an irritable, sarcastic and occasionally aggressive man, trying to pull his oxygen mask off and grabbing at our hands - "back to his old self" his daughter said.

I note that in these resuscitations I tend to take a back seat, let others make decisions. I know this is not how it should be, to be honest it is irresponsible and verges on the dangerous, but still it happens. I feel it is to some extent a confidence thing. Three months ago I was detained, I am still new to this, I am still nowhere near my best. The trust in myself will come slowly if it comes at all.

Anyway - our patient. The back-story was that Mr Ivory had been brought in from his nursing home with lack of energy and what turned out to be some rather ugly blood tests - white cell count of twenty eight, high enough to make the treating team consider leukaemia as well as pneumonia. His fever and his rapid breathing and, to be honest, the neglect of the twenty two year old medical intern - had meant that he had become remarkably dehydrated.

So, we gave him fluids and he got better but we moved him upstairs anyway, and handed over and went home.

The next morning when I come in things look worse.

Mr Ivory's blood pressure has dropped and his kidneys are shutting down. The way your body is wired up kidneys both have an important role in controlling blood pressure and are very easily damaged by changes in blood pressure, which makes them less able to control blood pressure - it all seems rather poorly designed, but there you go.

Back to Mr Ivory. His chest sounds raspy and wet and you can look at him and imagine things going wrong - bacteria breeding in his lungs, malignant cells budding in his bone marrow, heart stuttering and failing, the dark blood moving sluggishly through the kidneys and gut, slowly starving them of oxygen. His blood pressure spirals down, his heart-rate speeds then slows.

By ten o'clock in the morning he is almost unrousable. We put him in a room separated by a thin curtain from our eighteen year old girl with the diabetes and his family gather around his bed. His daughter looks up at me and smiled and said "After all your hard work yesterday". We get another blood test back suggesting heart damage, the nurse tells us his kidneys have essentially shut down. He dies silently, while we are all away.

The second patient to die that day is a woman, Mrs Umber, only sixty years old, whose husband has been with her all day and all night for the last few days. She has airways disease - some days it's almost impossible to find someone in here who doesn't smoke or drink or inject. For the last two or three years she has been largely confined to the house - she can't walk ten metres without resting, climbing even the gentlest slope is impossible, cannot dress herself in the morning. Dr Chang rightly uses this as a "quick and dirty" measure of quality of life and surmises that life for someone who cannot walk out to the letterbox may not be much of a life, may perhaps be something that should not be held onto too tightly.

The question as to who makes the decisons about the intensity and duration of resuscitative efforts is complex, and there is no one solution that will satisfy everyone, or be appropriate for all patients in all situations. Doctors, patients and families are involved. Doctors, families and patients have different understandings of the medications, the illness, the life that is being saved or lost or held in that in-between quantum state.

This is a complex area, one that I have written about before and will again. However, the unpalatable truth is we use questions like these ("Before she came into hospital, what could your wife do for herself? Could she walk down to the shop? To the letterbox? Around the house? Dress herself?") to guide decisions about resuscitation. The vigorously healthy get more treatment than the unwell.

Having said that, of course, you wonder about the quality of life of a woman of letters confined to wheelchair versus a woman of action, and you also wonder how Steven Hawking would have fared had he come into our hospital with pneumonia.

Mrs Grey deteriorates over the course of the afternoon. The decline is masked by the chemicals we pour into her that make her heart beat, and the adjustments we make to the machine that makes her breathe, but over the next few hours the numbers climb higher. Some time that afternoon she passes the point where the machine and the chemicals are doing all the work.

The family gather around. Her pastor is there, there is a prayer which we are invited to join - our consultant says he will, but sends us out. There is hope that she would be stay for the arrival of her friend from Brisbane, her dearest childhood friend, but we will not have that long. Despite the toxins and the tubes, she is slipping away before our eyes. The consultant tries to explain that the machines are only giving the appearence of life, that there is failure of kidney, lung, heart, liver and brain.

Her sister asks me. So there is no hope at all?

No, there is no hope at all, I say.

A few minutes later her heart stops, despite the maximum doses of the medications.
There is soft sobbing, then the nurse turns off the machine.

I leave to go back to my other patients. As I do, a stout, kind-looking woman, her face stricken, rushes in the door and looks around frantically.

Between five and six there is a brief delay, the eye of the cyclone. It's already a pretty bad day. Downstairs emergency is apparently overflowing, fifty people in the waiting room, doctors called back, working double shifts. Soon it's going to spill upstairs. In the interim, the consultant gastroenterologist comes in to see what can be done for Mrs Slate, our woman in bed four who has advanced cirrhosis of the liver, bone marrow suppression and bleeding from the gut.

As we suspected, nothing that we aren't already doing. She is drinking herself to death, and will die within the year. She is not suitable for the transplant list. She is thirty six.

The last death - and by this time we are exhausted, moving listlessly from patient to patient, is Mr Black, a man who yesterday was out in the garden, in remission, his tumour responding well to the radiotherapy. A few hours ago he collapsed, was found by his wife, was brought in to the ED. We take him on because ED is almost at detonation point, and because a busy Emergency Department is not a good place to die, full of the desperate and the detained.

By the time Mr Black comes to us his breathing has almost stopped. His family are gathered around. We murmur about the diagnosis - pulmonary embolus? myocardial infarction? - but he was down too long, he has cancer, nothing can be done.

Three times I go into the room to discuss things with the family, to try to answer unanswerable questions.

Can he hear us?

Is he in pain?

Does he know we are here?

I say that as far as we know he is in no pain, that we are watching him for signs of pain and giving him the strongest pain killers that exist. I say that some people who have been very unwell and recovered - people who weren't sick in this way, because he will not recover - have said that they could hear people around them, could feel the presence of their loved ones.

I don't know if these things are true or not. I think I say all these things because they seem to be as true as but more comforting than the alternatives.

Mr Black takes only a few hours. The room fills - each time I go in there there are more children and nephews and nieces and grandchildren. Several times they watch the halting movements of his chest, the unbearably slow, struggling agonal breathing, and for a few short minutes after his breathing stops his heart can be heard through the stethoscope, beating softly and slowly. His children hold his hand and cry out that they love him.

Finally I listen for a full minute, and look up and tell his wife that I cannot hear a heartbeat.

As soon as I say that I am called out of the room, which is perhaps for the best, because I have tears in my eyes. There is another resuscitation call on the fourth floor, but at that moment Dr Ferentes (smart, hardworking, easy to get on with and at this moment, due to our almost palpable gratitude at seeing him, certifiably hot) arrives and volunteers to go down and do the MET call while I sit down and start the day's death certificates.

Anyway. Don't really know why I wrote all of this down. There's a horrible tendency when I write this kind of stuff for it to end up being about me, about how difficult my job is, about the psychic pressures I put up with all day and, by extension, how noble I must be. I'm not trying to say that at all - or at least I don't think I am, I hope I'm not. I am among the least noble people I know, I crumple under pressure. Having said that, I don't really have any other explanation as to why I write this stuff down.

I don't know. Normally in my life, even my career, months go by without a death. This last ten days there have been five, three in the ICU and two in the addictive substances side of things. It's not that I am the victim here, I am not the one left holding my father's hand telling him I love him, or being too late to see my best friend die, but at some level I am knocked about by this, and in some way talking about it - or writing about it - works some stuff out.

Anyhow. Thanks for listening. I will try to be more cheerful next time.
John

300 and the death of comics.

Hail,
It's always hard deciding on an "absolute worst film in human history". There are so many variables to take into account.

Do we go for a simple, amount-of-pain-per-viewer-per-minute calculation? This would seem to be the more democratic approach, it levels the playing field - a gifted amateur with an 8mm camera can compete in crapitude with a Spielberg or a Scorsese. This gives us "Robot Monster", or "The Rats are Coming, the Werewolves are Here", any number of seventies horror films.

Alternatively we can try to factor in other variables: look at cost, actor or director talent, and original story. By this measure only a film that that could have and should have be good can ever be truly bad - the in effect trying to compare the horror that was with the greatness that could have been? This opens the field to horrors like Independence Day, or nine out of ten SF movies made since the seventies.

Or perhaps an approach intermediate between these two extremes - dividing the cost of the film, for example, by the price of a paediatric dialysis machine to work out how many children's lives could have been saved had they spent the money on something different instead of "Battlefield Earth".

Of course, you have to factor in how many children were actually sent into renal shutdown by watching Battlefield Earth, that does complicate things, buit still, it's worth considering.

Anyway. It's not an easy thing. But by most measures, 300, which I saw two nights ago, is probably a contender.

It is unalloyed, unadulterated, 200 proof, weapons-grade turd. I kid you not, it is laughably, unselfconsciously, uninsightfully bad, less a film than a celluloid enema. CGI eczema. I would rather grate my own pancreas into a salad and eat it on icecream than watch anything like that again.

Honestly. Words do not do justice to this. 300 crosses the boundary - and I have never felt this about a film before - between being merely a crap film and being a truly bad film, a film that adds to the sum of human misery, something that actually stupidifies and lessens its audience.

Why is this so? Maybe it's the storytelling. The story proper opens with a flashback showing the early childhood of the main character, Leonidas, soon to be King of Sparta. For the first few minutes we get to see a lot of young Leonidas, as a shaven-headed youth, being beaten up, chiefly by his father. Kick, punch, strangle, gouge, that kind of thing.

This goes on for a bit, actually quite a bit, then there is a flurry of character development and young Leonidas starts beating other people up - more scenes of kids getting the bezeus smacked out of them. If there is ever some kind of award for most realistic scene of boy-on-boy violence, this would have to be it - preteen Leonidas beats the pixels off some kid in a scene that would have been cut from Deadwood.

Next teen Leonidas gets sent out into the snow and meets a cartoonish (as in cover your mouth or you will laugh out loud) wolf which he kills - an animal with the physique of Wile E Coyote but the hair of Sonic the Hedgehog. A few frames later Leonidas is king, and grown to manhood. End of that flashback.

The emissary from the Persians arrives in Sparta. He is sneering and black and wears jewellery, so we know he is bad. Leonidas (who wears, and I am not making this up, leather Speedos and a scarlet cape) takes time off from beating his own son to throw him into a well. By "him" I mean the ambassador, not the son, although that was doubtless an off-screen "test of Spartan manhood" that we missed. This is only the first of the seven squillion "screw the people and the law, I know people will see that I'm right once I start killing folk" things this loon and his equally one-dimensional wife do. Next ...

Oh God, I'm so tired already. There are simply not enough electrons in the universe to list how crap this film is. Xerxes, previously believed to be the warrior king of the largest empire the world had ever seen, is here revealed to be an eight foot tall, tinsel-wearing wimpering drag queen presiding over a carnival of freaks. Bizarrely, those grouped together as freaks consist of lesbians, amputees, (including, I think, one amputee lesbian), hunchbacks with nine-month gestation hunched backs, people with multiple facial piercings and vast numbers of what look a hell of a lot like Arabs (there is one hunchback who starts out on the Spartan side, but predictably he is rejected and ends up with the freaks, wearing his freak Persian hat).

Arrayed against them are the Spartans, who fight on the side of freedom, presumably the freedom to throw their babies off cliffs and beat their kids with sticks. When they are not doing that they parade around half naked bonding and swearing felaty to each other and sneering at the boy-loving Athenians.

But no, it's not just the storytelling.

It's the look - the whole thing looks like a video game, and that's because it is. There are almost no real actors in it. Every second Spartan warrior is computer generated, and so has that slightly out of focus, fetal alcohol syndrome look they had on Polar Express.

It's the dialogue -
Stricken father - Heart? I have filled my heart with hate.
King - Good.

It's the cartoonish correspondence between physical and moral stature - good people are beautiful, bad people are ugly. Good people are straight, bad people deviate in some way from Millers incredibly limited set of acceptable things to do with your sexual organs.

It's the whole - oh, forget it.

I think at some level the person I am angry at is myself.

See, years ago I read, and loved, superhero comics. There is probably no way to explain this to anyone else, anyone who didn't share the same experience. All I can say is that way of looking at the world, those ideas of superhuman potential and science creating wonders and secret heroism - those ideas sunk deep into my psyche. There is part of me now that was formed by reading about Spiderman and Mr Fantastic and Daredevil and the Silver Surfer, part of me that resonated to them, read about them and their struggles and felt understood.

But anyway. I gave up on superheroes for a while, and when I came back they, and I, were different. Reimaginings of the field by Alan Moore. Big ideas like Grant Morrison. Novels of psychoterror like Bendis' Daredevil. Almost unreadably tender stories like Millar's Ultimates volume 1.

Great stuff. And don't think I'm not grateful. But two years ago I was buying three or four comics a week, now it's one a month, and that's close to being dropped. The racks are full of stuff I just can't maintain an interest in.

I think the reason I am dropping stuff is I keep seeing some of Miller's stuff in comics everywhere. Ugly villains and beautiful heroes. Might meaning right. Simple violent solutions to complex real-world problems.
And it's not just Frank Miller and his imitators, which I honestly believe exemplifies is all that is bad in comics and literature and art, all that is lazy and stupid and self-indulgent and unaware about story-telling, the relentless burrowing down to the lowest common denominator. It's the whole intrinsic limitations of the media, the fact that in the end there are a very few writers who can say anything interesting anymore about human beings with the limits removed, or tell affecting stories about people who behave in ways no sane person would ever behave. It's a feeling of irritation when I get handed something on a platter instead of having to work for it, it's a resentment at being told how to feel and how to think and who is good and evil, or even that such things exist.

I don't know. I don't know that you get "over" an art-form. People don't get "over" books, or music, so I don't know that I have got over superhero comics - although, come to think of it, I got over tv and radio a while back, so it's not impossible. I will probably still continue to buy a few things every so often - maybe Daredevil, definitely the Fortean Times, a few others. Anything by Alan Moore. But maybe you do get over stuff.

Anyway. Don't go to see 300. Read the book instead, and spend the money you would have spent on the money buying tickets for someone you hate to go and see the 300. Or buy your own leather speedos and put on your own show, or maybe grate your own pancreas into a salad. Anything.

Thanks for listening,
John

Cute and insubstantial post

Hail,

I don't normally get involved in the cat side of things. My wife, who is beauteous, breeds cats which are beauteous, and it makes her happy and that's enough for me. She is highly thought of in this field, as she is in others, and strangers write to her from far corners of the globe asking obscure questions about cat genetics, which she answers. I am, and will remain, deeply ignorant of this kind of thing.

But one thing I have discovered is that the cat fancy, as it is called, seems to have more than its fair share of eccentrics. Many of them have interesting sexual pasts, for example - the ex-brothel manager who now breeds Russian blues, or the woman who was imprisoned back in the seventies for taking artistic photographs of street kids. Others have unusual ways of looking at the world - the national circuit judge (and ex-Atlantean princess) who is in constant communion with the fairies, for example, the same woman who took the photos, or Crazy Nigel*.

I listen to these stories and smile because Sarah is happy, and also, when it comes down to it, my friends aren't that orthodox either, thank God. I have only once expressed an opinion, when Sarah said someone from the US had expressed an interest in one of her cats (i.e.: wanted to pay eight hundred dollars) but he was a gay white supremacist. I said we could maybe send him a black , mixed race cat, or alternatively direct him to a supplier who may be more appropriate for his needs.

But today Sarah showed me a remarkable entry on a cat newsgroup (written by people about cats, not actually written by cats) which I have decided to transcribe below.

In the end I decided not to keep the Black Boy from Beauty's litter and so I had him desexed and he went to his new home in WA today....I waited all afternoon for a phone call and none came so I just call the lady to ask if he was ok...When I asked why she didn't call she said she was trying to get her husband and family to ACCEPT him!!!!

She ummed and ahhhed and then said they were going to try to come to terms with him... They were very disappointed that HIS EARS WERE NOT BIGGER...I mean VERY disappointed... So disappointed that she didn't want to call me... Her husband is TRYING to like him!!!!!

I told her to put him on the first plane back to me tomorrow and she again ummed and ahhed and said MAYBE they could learn to love him!!!!!! But she said his coat is lovely... Oh good on her!!! I told her I would call her back as I was very uspet and she said "Oh don't get upset I am sure we will get used to him!!!!!"In the end I had to hang up or I may have said something VERY VERY nasty!!!!

Here is the offending boy with his tiny tiny ears!!!!




Like I said, I don't normally post stuff about cats, but I thought this was too odd to pass up.

Now I am going to go off and respond in a thrilled manner about blogs that make me think. Plus comments, and the genitourinary system.

Thanks for listening,
John

*Crazy Nigel, and I am not making this up, was a significant figure in the Innsmouth underworld back in the eighties. His career started when he (at that time called Fat Nigel, over one fifty kilos) was told to go and put the frighteners on someone who owed his employer money.

"Take this" he said, handing Fat Nigel a gun, "and wave it about. Frighten the bugger."

So Nigel took the gun, the first he had ever seen, went in there, got as far as "Listen up" before the gun accidentally went off and shot the other guy in the foot. There was much shrieking and cursing and Fat Nigel apparently felt terrible, but felt he couldn't flee without giving some explanation. He mumbled his little speech and apologised and fled. It was all a terrible accident, but the money got paid that day and Fat Nigel became Crazy Nigel, who subsequently became prisoner number such and such and then a circuit cat judge.

The organ of Zuckerkandl, and cursing the darkness.

Hail,
And sitting at home having been sent home with some vague virally thing. I have spent half the day lying in bed whining at the cat and lacking the gumption to study, write or even play my stupid computer game*. I've been trying to read - actually, below is a list of the last however many good books I read.

Spook by Mary Roach
Stiff by Mary Roach
The Ice Museum by Johanna Kavenna
Tough Jews by Rich Cohen
Monkeyluv by Robert Sapolsky
Almost Like A Whale by Steve Jones

That's in between the fascinating excursions into the pharmacology of the genitourinary tract.

Anyway, will endeavour to write something interesting and then get on with study - today I am revising the cardiovascular drugs. Some of it is quite interesting - if your blood pressure goes way up out of control, we sometimes give you a drug called nitroprusside. That works, except as a side effect it forms cyanide in your blood. You can get rid of the cyanide by adding another chemical that normally poisons your haemoglobin, but combines with the cyanide to form a third chemical - it's all rather mind-blowing.

Plus I am one of these people who can't remember stuff unless I understand it, so when I read that a certain medication can cause, say, necrosis of the Organ of Zuckerkandl (a real organ, by the way) , I have to forcibly stop myself from wasting hours finding out why. Inflammation of the organ of Zuckerkandl, by the way, in the old days might have been called Zuckerkandlitis. Now it is the much less evocative para-aortic body inflammation or something.

Been thinking about that horrible Salon article, about various aspects of it. In the areas where I work I see a lot of medicated kids. The youngest was a six year old on olanzapine, which is a powerful antipsychotic with very significant side effects. He had been put on the medication by a specialist, a paediatric psychiatrist, and from one point of view I couldn't say it was the wrong thing to do. Both his parents had schizophrenia (they had met in one of the psych wards, a remarkably common occurence), and the child was certainly much quieter, less distressed and more docile on the medication than off it.

But there were a lot of questions. I don't know that anyone has done the long term studies where we see what antipsychotics do to the six-year old brain. I don't know that they've done the studies that show these things reduce the incidence of psychosis, or the risk of suicide, or the duration of hospitalisations. I don't know that anyone's ever looked at exactly how much obesity these kids get, how much cognitive slowing, how much sooner their diabetes comes on because of the medication.

And that's even with staying away from the diagnosis. Now, I'm not even the aglet on the shoelace of the boot of a paediatric psychiatrist, those people know stuff I don't even know I don't know, but it would seem to me that psychiatric illnesses in kids are difficult things to diagnose. Particularly schizophrenia, maybe less so for the mood disorders. It is difficult sometimes to disentangle the symptoms the patient has from the symptoms you suspect they have, for example, and children's ideas can be remarkably malleable - you can always find what you are looking for if you look forcefully enough. And bizarre beliefs? Intrusive thoughts? Auditory hallucinations?

I was going to give some examples here of weird things I thought and believed as a child, but I just realised that the conclusion "and there's nothing wrong with my mental state!" maybe wouldn't hold a lot of water. But my eldest son wanted to grow up to be a dinosaur.

And I know I'm in danger of the whole romanticising of the mentally ill here, but that's not what I'm trying to say. I'm trying to say that as doctors, we often make mistakes, and the giving of anti-psychotics to kids seems to me to be an area where horrible mistakes could easily be made.
In medical school we were taught that illness is a derangement of the normal functions of various organ systems. That's not the only way of looking at it. I've said before that an illness is whatever a drug company can sell a medication for: shyness, chubbyness, not having double D breasts, getting bored easily.

Well, from another point of view, the point of view that killed Rebecca Riley, illness is whatever society reckons doctors should treat.

I don't quite know how to articulate what I am trying to say. The actual receiving of treatment , the rx, changes the thing being treated. If something, some characteristic, is treated by a doctor there is the assumption that that characteristic is pathological, that that characteristic is not normal, that it is not, say, a quirk of your character or a flaw in your personality or one of the normal slings and arrows of not-actually-that-outrageous fortune that we have all been putting up with for millenia.

And if there is some advantage that will accrue to somebody by some characteristic being treated as a medical condition, then they will try to get that characteristic treated as a medical condition.

And doctors will do it, especially if there's money to be made. The Golden Rule kind of thing - whoever has the gold makes the rules.

And this is a controversial view, and one I haven't thought out, and one I am sure will strike several of my fellows as saying something deeply suspect about myself - but you can't have it both ways. You can't maintain the - I don't know, mana? - of being a doctor, you can't see yourself and have yourself seen as someone somehow involved in an intrinsically noble profession, you can't get whatever respect is left in the profession if all you do is make porn stars' breasts bigger, or sedate kids so their parents can spend more time in front of the telly, or whatever.

Medicine is meant to be about healing the sick. It's only medicine if that's what it does. Otherwise it's shilling.

Anyway, enough of this. Out to hang the washing (under the light of the autumn full moon) and get a grip on the anti-arrhythmics - very unfutile drugs we give when your heart is beating incorrectly that can cause your heart to beat incorrectly.

Thanks for listening,
John

*Civilisation II. Owes me months of my life.

Ox-bow

Hail,

Long time no post, and it may possibly be that way for a while.

Don't know. The mood's not one hundred percent. And while that doesn't mean I'll be grabbing my hanky and rushing off into a corner just yet, it does mean that my writing (and reading) may be less frequent than hoped. So sorry about that.

The thing is, some of what I'm feeling is not endogenous depression. I feel tired, for example, but I am working close on a fifty hour week, in two jobs, one of which is new and bloody challenging and the other of which is challenging in a different kind of way. Plus I am studying for the primary exam in September, which is taking up a fair swathe of my spare time.

The study is also a bit anxiogenic - everytime I sit down to study this little voice starts murmuring in my head about how I'm never going to be any good at this. It does go after a while, because studying is calming in a way. But there is the issue of why I am putting myself through this when others, perhaps wiser than myself, have left all that behind them.

Lest anyone be concerned, when I said "a little voice murmuring" I was speaking metaphorically. I remember hearing a cricket commentator once talking about the batting performance of Australia's captain and he said "And Ricky Ponting is on fire! He is literally on fire!".

Anyhow. Luckily the medications I am on at the moment are the less nasty kind. I once came up with this measure called the FI or Futility Index of a medication. The Futility Index is a measure of how much overlap there was between the side effects of a medication and the symptoms of the disease it was meant to treat. Antidepressants (that make you fat and sexless) being prescribed for depression (which makes you fat and sexless) - that kind of thing. The tricyclics have a fairly high FI - both the medication and the condition they are prescribed to treat make it easy to kill yourself, for example.

Anyhow. A link to a truly hideous story on Salon - and a thought-provoking albeit preachy and poorly thought out one on Slate.

More stuff, and hopefully less whiney, in a few days.

Thanks for listening,

John

PS - Ox-bows, by the way, are those left-behind pools of water that are formed when a river gets too slow and meandering to carry all its water to the sea.