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