Cheers

Hail.

I've been thinking about what bothered me about the obese woman who took the tricyclic overdose, and about some stuff I've been reading. I draw your attention to the almost unbearably sad events described in Forensic Science International - do not follow link unless you are up to it.

See, Mrs Werther was brought in by ambulance following a tricyclic overdose, her first in ten years. She has a son at home, a "disturbed child", she also took some of his dexamphetamines. She is estranged from her family, has a husband but "they aren't close", these last two facts from the psych nurse who has collected the collateral history - Mrs Werther remains unconscious.

It doesn't take Einstein to do this maths. She is alone.

But anyway. She is lying there, pale and gelid, with the rubber tube in her lungs*, and will probably remain so for a day or so. And then she'll wake up, still depressed, no family, a difficult child, a husband who so far has not come to visit her.

I think part of what makes me angry about this - before I say this, part of what makes me angry is neurochemical, part of it is the slow seeping away of the tide - part of what makes me angry about this is the whole idea of choice. Behind the disinterest of the nurses and the open contempt of Dr Fang is some idea that this woman doesn't deserve sympathy because she chose to do this, she did it to herself.

Not to be too brusque about it, this idea and this whole way of thinking is bullshit. Excuse me while I have a "Gospel according to me" moment:

Sympathy isn't something you turn on and off like a lightbulb according to how much the other person deserves it. It's a perception thing, like whether you see a bend in the road or not. The other person is a human being, you either see that or you don't. If you don't see it, there is stuff you can do, books you can read and people you can talk to, prayer or doing stuff for the poor or whatever, but everyone knows that anyway. And you don't have to do it, it's your life, and good luck to you either way.

Here endeth the lesson, sorry about that.

Anyway. Mrs Werther. I don't think Mrs Werther "chose" to do what she did, for about seventy different reasons, but one of them is I am less and less convinced of the existence of choice. The idea that we all have free choice, that we weigh up alternatives and choose what to do doesn't seem useful to me. It doesn't explain a hell of a lot.

Take obesity, a subject close to my heart*. I hold these truths to be both widely known and self-evident:

Eating more and exercising less makes you fat.
We (most of my readers) are getting fatter at however many milligrams an hour.
We hate it - God only knows what the diet and fitness industry is worth, but it's up there.

And yet, we "choose" diabetes and shame and the next size up of pants and that much-longed for early heart attack. Who in their right mind would do this? The "choice" theory doesn't explain this.

Here's another set of factoids:
I believe a child's life is worth more than a CD.
I know can save a child's life by sending about a CDs worth of money to Mediciens sans Frontieres.
I got myself the latest Blind Boys of Alabama CD and it's pretty damn fine.

Of course, if I read in the paper that some other guy let a kid die so he could get a CD, I'd presumably be outraged.

I don't know. What I reckon, the way I look at things, is there are programmes running in our heads. These programmes have been put in our heads by evolution plus a bit of how we're raised with maybe a bit of tweaking from us thinking. I don't know a lot about computers, so I'll name these programmes after what they do:

The "eat as much as you find" programme.
The "do as little as you can get away with" programme.
The "trinket collecting" programme.
The "look after your kids" programme, etc.

And, most importantly, the "tell yourself it's all okay" metaprogramme.

The way it works is there's triggers that set these programmes into action. You are surrounded by people who are eating, or you feel anxious, or you're tired, or you're bored, you see the slice of chocolate dalek cake, half a second later it's at the lower oesophageal sphincter. No reasoned weighing up of the factors, no real thought, not a lot you'd normally call "choice", just the evolutionarily sensible outcome of perfectly natural, billion year old desires.

Same thing happens with the CDs. In each case, the programmes ensure that we do what works for us and - and here's the kicker - that however uncomfortable we feel about the bad consequences - the bulging belly, the starving child - we feel not quite bad enough to stop causing it.

Anyway. I will go off and read something uplifting. Work still goes well, I still get that sense of wonder - I put a nasogastric tube in someone the other day, a thin tube about the thickness and colour of an earthworm that is meant to go up the nose and down into the stomach, and it went down into his lungs instead (this happens reasonably often on the first try). I could feel the air moving in and out with every breath he took, and the yellowy-green substance that was meant to ooze out of the tube didn't. So we pulled it out and tried again.

More cheery next time,

John

* a couple of kilos of pericardial fat.

Three

Well,
Mrs Quintain did not do well. I came in and there was another patient in her bed, a white-haired man who kept cracking jokes, and when I checked on the computer there were no bloods, no Xrays from about three days ago. In the end, Dr White said, it was probably the pneumonia. She is gone and there is no record of her passing.

That is what death in the hospital is like - less and event than the absence of an event, less something that is noted and marked than something that ceases. For a brief half-hour there is a space and then another face, another sick person, another respirator patient.

. That is what happened with Burian, my friend who died in the Royal, earlier last year. I woke and there were messages on my phone, I rang and got put through to admissions and they said that the patient was unknown, there was no-one of that name in the hospital.

A hospital now is a machine, like everything is a machine, and like all machines a hospital has structures and practices designed and constantly modified to maximise efficiency. The walls are white and each room is identical and there are no pictures and when someone dies the most efficient thing to do is to move them out and move the next one in.

I don't know. As you can probably tell from the tone of this, I am a bit low at the moment.

Part of this is no doubt situational. A number of things have been going on lately. My patients keep dying, of course. The death rate in the ICU is one in five. I don't know what the death rate is in the Drug and Alcohol field, but it is high in a different way. Three of my drug and alcohol patients have died in the last three months - none from my medical care, and one not even in my medical care, but still, it's something that affects you.

And the last one in particular, a young Asian man, twenty six, whom we'd seen for a few days before Christmas when he tried to get off heroin. It didn't work, buprenorphine gives nothing like that slow opiate buzz, and he only turned up twice, in the dry months before Christmas. He went away, we rang a few times, then we closed the book and we never saw him again until the government pathology service asked us if we knew about the death a week ago.

I didn't, and I found his file, and there was his photo in the front sleeve - strong-jawed, pugnacious, dark eyed, looking straight into the camera and through me. As if he saw something in the distance, something real, something more substantial than mere flesh and blood.

Twenty six. That age it's either violence of some kind - stabbing, suicide, car crash - or it's heroin, and this was heroin.

It's rare, I think, at that age. I'm not sure, but I think most heroin deaths are thirties and forties. Anyhow, the coroner is not sure if she is going to look at this, and I have asked to be informed either way.

So, that hasn't been helping. That plus the deaths in ICU - not so much the matter of the deaths but the manner of them - and the study, and a few other things. We have a new boss at the ICU - a Dr Black, who will be sharing Dr White's load - and that means I had to sit him down and give him my practiced "I have bipolar" speech. I'm getting quite good at it now, have it down to a minute and a half, a carefully constructed monologue on how well supported and managed I am and how dangerous and incompetent I am not, and a carefully prepared clinical question to use to terminate the conversation:

Me: " - as a March hair. Stark, staring bonkers. Now, could you have a look at this blood gas for me?"

And on top of that - and this will seem trivial and whiney - but I am studying the psychoactive drugs this fortnight and the last few days I have been revising the antidepressants, including the tricyclics - the drugs I took when I overdosed - and reading about the management of overdose - and by extension, what would have happened to me.

Plus we had a tricyclic overdose in the ICU a few days ago, a pallid, obese, gelatinous woman, mouth distorted from the endotracheal tube, and all around her the rustlings of contempt, Dr Fang in his two hundred dollar shirt, the slim nurses moving briskly past the room.

It's odd, because I look back on some of that and there is no memeory. I remember sitting in the ED and I remember waking up and nothing in between. Dendritic protuberances were not formed, soemthing didn't happen in the medial temporal lobe, and you get another space, another absence where something should be.

Anyway. This means dragging myself to the gym - seriously, if an antidepressant did what exercise can do, in terms of efficacy and drug interactions and side effects, it'd slaughter every SSRI on the market - and keepng on taking the valproate and stuff and seeing Dr Tesla on Monday.

We shall see.

Anyway. Apologies for this morbid post, and count yourself lucky you weren't here for the much longer one I wrote and deleted, working title "The hopeless hopelessitude of life". Off to Dr Tesla.

Thaks for listening,
John

Iatrogenesis

Hail,
Lots to tell today, and not a huge amount of time before our first bit of disciplinary pharmacotherapy, so on with it.

First off - news from last week. Mrs Bishwakarma is still alive, gradually improving, and I suspect she will do well, from an acute medical point of view. Mr Graves died, surrounded by family. His heart went across the Nullabor, his kidneys and liver to Sydney. His blood type did not match Mrs Bishwakarma's.

Everybody lives, as Doctor Who said. All in all, good lives and good deaths. There are good feelings in ICU - sometimes you win. I thinnk that's part of what makes ICU and ED much easier on some level than the drug and alcohol work.

So - who have we been worrying about this week?

Well, for me, it's Mrs Quintain. Mrs Quintain is a woman who may have been killed by the care and affection and attentions of her doctor.

Here is the story. She went on a camping trip with her husband, daughter and grandchildren to Cape Irukanji, staying in a caravan park, fishing and prawning and doing crossword puzzles. Unfortunately, somewhere along the line she became unwell. Nausea, vomiting, diarrhoea, ongoing loss of weight. When you are sixty three, even a young sixty three, two weeks of that can knock you about a fair bit. When she came to see her doctor she had lost eight kilos* in a fortnight.

Her doctor was obviously concerned and did a remarkably thorough set of blood tests, Xrays and so on. One of the things he tested for - and it's certainly a consideration in a sixty three year old woman who smokes and has chronic loss of appetite, tiredness and nausea - was pancreatic cancer.

Pancreatic cancer is, as I have said several times here, one of the nastiest forms of cancer to get. Almost the only good thing to be said about it is you don't have it very long. Ninety five percent of people who have inoperable pancreatic cancer are dead within five years, most die within the year.

Anyhow. The doctor sent off the plethora of blood tests and did the scans and called Mrs Quintain in to discuss the results.

"You may have cancer" he said. "But I think we've caught it early. It didn't show up on the CTs, but the blood test is positive."

She was terrified, but followed his advice. The next stage was an endoscopic procedure - she would be sedated, a slim black tube with a camera in it would be slid down her throat, perhaps a dye would be squirted in to enable the physician to have a better look, and anything sinister would become clear. She went in for the endoscopy - the full name is an endoscopic retrograde cholangiopancreatography - three weeks ago.

It didn't go well. The tube tore a small hole in the lining of her gut. The bacteria-laden intestinal fluid leaked into what we call the peritoneum, the sac in which your guy and stomach and so forth float. Infection spread like a cloud. By the time she came to us she was barely able to mount a fever, her blood pressure was low, se was slipping in and out of consciousness.

That was three weeks ago. We pumped her full of our remarkably simple chemicals and got her well enough to get back to the surgical recovery ward. She did well for a few days, but then an astute intern noticed her breathing rate, and found that the amount of oxygen in her blood was low. A chest X-ray revealed pneumonia. She was sent back to the ICU.

We "fixed" that, by bludgeoning her with great scoops of weapons-grade antibiotics, and sent her back to the surgical ward. She'd been there sixteen hours when the code was called. At three in the morning they resuscitated her. A scan the next day - her fourth or fifth - showed a massive blood clot in the lung - despite the anti-clotting agents we had put her on.

"Never seen anything like it" Dr White said. "Massive thromboembolism on clexane. Not in twenty years."

So now she lies in the ICU, intubated, unconscious, on infusions of adrenaline and antibiotics. It's not looking good - infection in two places plus a sizeable blood clot, maybe brain damage from the resuscitation, a healing hole in her gut...

About the only thing that isn't wrong with her is pancreatic cancer.

I am not making this up. We have scanned every micrometre of this woman's body. Her pacreas has been visualised from every possible angle, scanned with sound waves and Xrays and magnetty things and whatever else we can come up with. I have more chance of having pancreatic cancer than she does.

Anyhow. The problem with blood tests and scans and everything else is that, like everything else, they can be wrong. Medical literature is alive with sotries of "false negatives" - tests that tell you you havent' got the disease when you have, and "false positives" - tests that say you've got the disease when you haven't. It's the same with every decision making process - trial by jury, speeding tickets, surfing internet dating sites. Pobodys nerfect. And obviously the more tests you order, the more results you get, the more likely it is that you one of them will be false.

So. If things go as they well might, who or what killed Mrs Quintain? Medical language, like the crypic speech of other gang members, is often designed to conceal rather than reveal meaning - Dr White had stood at Mrs Quintain's bed and spoke of the "mitotic lesion" a few days earlier. But there is one medical word that perfectly describes what happened to Mrs Quintain: iatrogenic.

Iatrogenic means caused by doctors. An un-neccesary blood test, poorly interpreted, an inadequate clinical history, a cascade of errors, some preventable, some not. In this case doctors have brought this woman almost to the threshold of death. If life is daylight, and death is night, she is in the twilight, the penumbra, and the light is fading. We have poisoned her, pierced her gut, given her pneumonia, shocked her heart. And we are not finished yet. Soon as she wakes up, we'll be on her again.

Anyhow. It may end up well. ICU does drag people back from the dead, even those we've dragged most of the way there in the first place. We shall see. But whether or not she survives this, I am going to sneak in and amend her adverse drug reactions status - the part where we doctors write what substances a patient is allergic to. Next to aspirin and penicillin and the sulfa drugs, I am going to write "doctors".

Thanks for litening,
John

Next post, by the way, may be about stupidity as a virtue.

*Two and a quarter pounds of jam/weigh about a kilogram.

Roundabouts and Swings

Hail.
I had one of those days that made a good story the other day, something with inherent symmetry today, like a page out of a medical drama.

I came in early and things were tense, Dr Fang loping along the corridors with arterial blood gas results, the ICU consultant and the radioloogy registrar clustered around a CT, a whole air of dangerous instability, lightning about to strike. Amongst the new patients was a tall, clean-shaven man, strong-featured, and his beautiful, well-dressed wife, each in their sixties. Mr and Mrs Grave, the nurse said. Her sitting by the bed, holding his hand, him intubated, the corner of his mouth pulled down.

There was work to be done, and I started doing it, because apparently the retrieval team from the Royal was on its way. I gleaned as much as I could - sixty year old man, atrial fibrillation, warfarin, ceased it for a colonoscopy -

And here I will pause to translate - a man in relatively good health, who had an irregular heartbeat. The smaller, less important chambers at the top of his heart beat irregularly, and because of this he was at risk of getting blood clots in his circulation - if blood is allowed to slow down, it clots - and to prevent this happening, he had been put on an anti-clotting drug. He had, as per medical advice, ceased this drug a few days before his colonoscopy.

Colono- is colon, the lower bowel, and -scopy means to look, and it's pretty much exactly what it sounds like.

- anyhow. Our man had ceased his warfarin in preparation for this procedure, and a few hours ago had collapsed to the ground, unresponsive. He had been brought to us by ambulance, CT showed what was thought to be a massive bleed but turned out to be a malignant stroke, a blockage of one of the larger arteries leading to the brain that is rapidly fatal. We had kept him cold and there was desultory talk from the neurology registrar about craniotomy -

- another pause to translate. Cranoi is cranium, the skull, and -otomy is "hole", and in the simple, delarative language of medicine it is exactly what it sounds like. Craniotomy, the drilling into and cutting out of a largish piece of the skull, may or may not save lives in cases of malignant stroke, but in Mr Grave's case it was not really an option - even the most primal reflexes were gone.

Of four people who have emergency craniotomy, two will die, one will be severely disabled, one will regain independence - if they are caught early, if the stroke has not damaged too much of the brain. When you held Mr Grave's CT up against the light, the dark ischaemia and the bright blood and the distorted swollen architecture of nerves covered more than half the circle of his brain, like a moon eclipsed. When he came in the ED registrar had brushed his eyeball with a cotton wool bud - he did not blink. Everyone like this, in whom emergency craniotomy is performed, dies.

I should also mention that craniotomy may be amongst the earliest of the surgical procedures. There is archaeological evidence of craniotomies performed, with stone tools and stone-age medicines, from which most people subsequently recovered. The Incas apparently did fairly well.

So, once the senior neurosurgeon had clarified what we saw on the CT, the retrieval team was called off and the tenor of the room changed. Nurses, doctors, spoke in murmured tones, began discussing options. Mr Grave's handsome wife sat and held his hand, his cluster of blonde children and grandchildren sat with folded wings and bowed heads, his youngest grandchild sobbed.

Meanwhile I was called down to the ED to see the first of our new patients, a woman with paracetamol OD. When I got there, Dr Ravindran was trying to get blood from a shrieking five year old boy. He spoke in the information-dense way that doctors do when they are very tired, very irritable or very good.

"Thirty eight year old woman, nil previous, ingestion twelve to twenty four grams, minimum forty eight hours ago, nausea, vomiting, abdominal pain, GCS fifteen, nil jaundice, LFTs, BAL, screen and coags not back yet, NAC, bed six." He turned and waved an inflated glove in the child's face upon which he had drawn a smiley face*.

This translated into a very bad story. I went in and sat next to Mrs Bishwakarma. She was tearful, her face sheened with sweat, a vomitus bag under her chin, a thick plastic tube snaking into her bandaged arm from a bag of clear fluids. I asked her what had happened.

It was all very hard, she said. Her husband. He had thrown her out. He said he wanted a divorce. She did not want a divorce. Why did he want a divorce? He had changed. He was not the man she had married, he was not behaving like a good man. She had been thrown out of their house and now there was another woman living there, with her husband. What did he mean by behaving in this way? She did not want a divorce.

Half an hour later we had settled on, if not a story, a series of stories. She had taken one (or two) packets of paracetamol. She had thrown up immediately afterwards (or she had not). It was to treat her pain (which she said may have come after the paracetamol or before it). Her pain was so terrible, doctor. She had not known it would hurt her. She had. She wanted to die, doctor. She wanted to talk to her husband.

I looked at her eyes, that deep, dark brown, and couldn't see jaundice there. Grief and fear and fluctuating realisation that something is lost are not documentable clinical signs.

I called a nurse in and felt Mrs Bishwakarma's abdomen. Striae, maybe someone who'd had children. Pain in the right upper quadrant.

She wanted to go home, to speak to her husband, to ask him what he was doing with this other woman. Could I call him, could you, doctor, and make him come in and talk to her?

I said I would go and check the blood results, and I went out, came back, sat down. There was a baby screaming outside, and the sound of a nebuliser, and the occasional alarm of a monitor.

"The tablets you have taken have damaged your liver," I said.

Silence.

"Am I going to die, doctor?"

"I don't know," I said.

Another silence. Times like this, people hear one word in ten of what is said to them, and nothing of what is said quickly. But two days after the overdose she still had paracetamol in her blood, and her liver was inflamed, her blood losing the ability to clot.

"Can you call my husband?"

I nodded, and said as soon as we got her upstairs, we would try. I went out, rang the ICU, told them we needed the last high dependency bed. I sat staring at the blood results, then on an impulse rang the number she had given when the ambulance brought her in, left a message on the answering machine.

Anyway. We went upstairs and told Dr White, and he had just sat in with the family of Mr Grave and told them of the outcomes, it being not a matter of if, but when, and death probably within the day, and Mr Grave's widow had said that he had not wanted to live disabled, so that if we possibly could could we let him go, and that he had wanted to help people all his life, and was an organ donor, and what should we do about that?

And that brings us up to here. Like I said, there is a symmetry here. Because my suspicion is that Mrs Bishwakarma has suffered such damage that she will need a transplant, and it is my suspicion that Mr Graves will be dead by the end of tomorrow, and that we will have gained something that we have lost.

But it's a long way from being a perfect symmetry, because the mathematics are that Mr Grave's blood type will not be the same as Mrs Bishwakarma's, and the mathematics is that Mr Grave will die, and because of him someone we don't know will live, and that Mrs Bishwakarma will live another two to twelve days and then die.

Anyhow. I should return to my study of respiratory physiology, but I can't tonight. I am going to lounge with my wife and watch Grey's Anatomy (it's only season one and we've already had conjoined twins and a schizophrenic psychic - it's not looking good). I got a story published in an anthology today, held the book in my hand and saw my name on the back and on the first story, and I am feeling celebratory. So it's merlot rather than methaemoglobin tonight.

Fellow students of emergency medicine, do not do as I am doing, study and pass instead.

Thanks for listening,
John
*He'd drawn the face on the inflated glove, not the child. Just had to clarify that.

Grey's Psychopathology

Hail,
I've been messing about for a few days with an idea for a post entitled "robot sex", but instead I'm going to write this one. Robot sex, however, is on its way.

ICU tomorrow. This means today is my last day of weekend, so last night Sarah and I sat up watching "how to be a truly appalling doctor" DVDs: I borrowed a season of House and a season of Grey's Anatomy from the video store.

We ended up designing this drinking game people could play where whenever anyone on the show does something that would get them disciplined, sacked, arrested or struck off the medical register you drink a glass of whatever you're having. This will get you cirrhosis of the liver in six months, or three if you add in every time someone does something that would get someone killed.

Alternatively, if you don't believe in drinking, you can bet beforehand on who will do something fatal/sackable etc. first: Last night's Grey's Anatomy had us asking would it be the beautiful main character (an emotionally unstable lustbucket who would tongue-kiss a gila monster), her room-mate with the secret crush (a dough-like boy-child only ever three minutes away from a complete attack of the vapours), her repellant fratboy pursuer (whom I believe is actually there to try to end lives), or her best friend (emotionally constipated to the point of impaction, and with a clinically evident anti-social personality disorder)?

Anyway. I am hoping to get in to work early tomorrow, because if I do, I can spend half an hour on the computer looking up what happened to my patients from last week.

The frustrating thing about modern medicine, the succession of short term interventions. The ICU, like everywhere else, is set up for high volume, short term, rapid turnover kind of interventions, lots of moving people in and out. Sometimes it reminds me of one of those advertisements where the guy turns up and shouts a lot about how he's gone completely crazty and he's got to get rid of of a lot of stock.

We could have put that on an ad for Shipton ED. Everything or everyone must go.

The reasons for this high turnover stuff are complex, but basically to me it means most of the time the guy I left there on Tuesday night isn't going to be there next Saturday.

So, if I get in early, I can look stuff up. Tomorrow is checking on Mr Sweet (our malignant diabetic from a few days ago), to see if he is still detained, Mr Grave, a man about whom more later, and Mrs Chang, to whom I suspect a truly terrible thing may have happened. And more about her later too.


Thanks for listening,
John

Treacleaemia

Hail,
I know this is becoming a theme, but bowdlerised bad language and grue follow.

Been thinking about doctors crossing boundaries (as opposed to doctors crossing borders, although sometimes one can lead to another).

Part of this came up from following the Kerouac saga (executive summary: George Bush appoints a loony who believes contraception is demeaning to women to run the government department responsible for providing contraception to women but is forced to back down, which presumably means more demeaning for more women in the long term) and part of it from a number of recent things I have seen or heard in the ICU or the Drug and Alcohol Service.

I think I see these things because the two fields I work in have two almost completely opposite ways of looking at things. Emerge and ICU want people to be cured. They deal with medically unstable people, people often so unwell or so unknown that the medical procedures the doctors carry out to diagnose or treat these people are invasive and dangerous and expensive. Additionally, particularly in the ED, space and time and staff and emotional energy are limited resources. Because of this ICU and ED doctors and nurses want rapid, quantifiable progress.

Because of the emphasis on vital signs and quantifiable results, psychiatric or behavioural disturbances don't work well in the ED or ICU. This includes the patient whose behaviour either got him/her in there or is stopping him/her getting out. There is limited patience with, say, the man who has smoked his way into airways disease, or the woman who has drunk herself into liver failure. To the ICU or ED doctor, the worst patients of all are the non-compliant psych patients.

Drug and Alcohol services patients don't think so much in terms of cures. The whole idea of a cure for alcohol dependence, say, is disputed. Truly successful treatment is often measured by lifelong abstinence - although I suspect there is a requirement here that moral flaws require moral punishments. I don't know - it's hard to tease out the correct term for this: are reformed (there's that moral element again) alcoholics* cured? Or are they still sick? Or are they in remission?

Anyway - longer term stuff. Subtle improvements. Non-invasive measurements of progress - urines that probably show up a tenth of the substance use in our client population. Requiring a different set of clinical skills, helping a large number of people, satisfying in a different way.

The thing is, drugs and alcohol don't handle medically sick patients very well**, and ICU don't handle psych/drug and alcohol patients well.

Case in point was Mr Sweet, a man who had been brought in to the ED thirteen times in the last two years near (very near) death, with a total cost to the commuity of over seventy thousand dollars.

Mr Sweet has type one diabetes, the type where things can go spectacularly wrong if you don't take you insulin - blindness, impotence, kidney failure by the early thirties, as I have seen. He had stopped dosing Friday and two Mondays ago was found by his girlfriend (semi-conscious in the traditional pool of his own vomit) and brought in. His blood sugar was seventy - the highest I have seen, the highest reading most of the people to whom I've spoken have heard. A blood sugar of seven is high, this man had treacle in his blood.

He was brought in, dragged back from the brink and once he regained consciousness and the tube was removed, he began abusing staff.

We were all [genitals]. We could all [have sexual intercourse and leave]. The nurse could [perform yet another sexual act] if she reckoned he would stay here. The whole place could [be the passive recipient of an act of sexual intercourse].

After he had reduced one of the nurses to tears I went in and talked to him. He was insiting on leaving against medical advice. It is difficult to do any kind of psych interview with someone who is non-compliant with the interview process, and has recently been pumped full of mind-altering chemicals, but I ended up detaining him, and ringing the psych reg and saying this was the crappest detention I had ever done, but I couldn't be sure if he had a treatable mental illness, but he wasn't taking his antidepressants, hadn't seen a psychiatrist in five years, kept interspersing his obscenities with assertions that he didn't care if he lived or died, and I reckoned that was where the smart money was.

Two weeks later he is still detained, which is comforting.

Anyway, after I had told him about the detention and after I had explained to him that no-one in the hospital could get him out ("Not the nurse, not me, not my boss, not the director of the hospital, no-one before nine o'clock at the earliest when the psych consultant comes around..."), he and my boss had a discussion.

"I don't want to be here" said the sick man.

"We don't want you here either" said my boss, Dr Angle. I winced. "There are sick people, really sick people who need your bed".

"Well, why don't you [go home and have sexual intercourse***] and I'll get out of this [odoriferous latrine/ odoriferous end of digestive tract] and ..."

"Do you have some kind of problem with authority figures?" said my boss, the authority figure, taking a step towards the bed and leaning down. By now I was contemplating what to do if someone took a swing at someone.

"[Most certainly]"

"Why?"

"Because you're a dickhead" sneered the man whose life had recently been saved.

"Well, you're the biggest [intercoursing] dickhead I've ever met in my life!" bellowed Dr Angle, BSc BM BS, visiting consultant intensivist and Fellow of the Royal Australasian College of Anaesthetists.

"Dr Angle, Dr Angle" I squeaked. "PLease come out and have a look at this (completely normal) ECG!"

Anyway. The mentally ill don't only get sick too, they get sick more often and have poorer compliance and have more co-morbidities and so on and so on. And they tend to be poor, so they are more and more a part of public medicine. We are slowly, I hope, learning to deal with it.

Anyway, thanks for listening.
John

*I probably shouldn't be using this term, it's more correctly "alcohol dependent person". In my defence, I will point out that I'm fat, not overweight, and I've been crazy, as much as unwell, and if I ever lose my leg, I want to be called a cripple.

** When I was at Shipton someone died in the psych ward. A code was called and all hell broke out. No-one knew where anything was, no-one knew how to use it, once they got the oxygen on someone tripped over it and yanked it out - it was hideous.

*** Weird term of abuse, isn't it? Sounds much more pleasant than finishing your shift.

Fixed up real soon

Hail,
And morbid humour and bad works herein. Particularly the last few lines. If you are at all unsettled by this, skip this entry.

First off, read FW's blog. Very fine lately. Follow the links therein. And don't forget all this stuff next time you in the US have an election. You gave us Motown, Philip K Dick and superheroes - how about some of that quality in the White House?

Anyway. Another couple of shifts in the ICU survived. Sarah is playing with her new laptop, the cats are fighting over the smoked salmon (a dollar a pack, expires tonight, from the discount bin) and I am desultorily cleaning up the carnage of last weekend's birthday party for Sarah, writing, and studying the anti-arrhythmics.

ICU continues to be enjoyable - I am gradually growing in confidence, and may even survive next weeks' departure of Dr Hu and his replacement by Florey's Best Intern. Dr Hu had hoped for radiology but is being rotated to psych, and may tomorrow have to come and see the patient that today he dumped on psych.

Part of my enjoyment of ICU derives from Dr White's method of teaching, which relies heavily on the recounting of hair-raising stories of hideous mistakes he has seen in his long medical career.

He told us today about a case he saw when he was in Sheffield. A man, early forties, a labourer, came into the hospital with pancreatitis - nausea, vomiting, very very severe pain in the left or central upper part of his belly, and a general feeling of life-is-crapness. The pancreas contains all the enzymes your body uses to digest food, in pancreatitis it basically starts to digest itself instead, the pain is apparently top five.

However, the cause was quickly found (a gallstone blocking a duct) and the surgeon (from the South of the USA) assured him he would be "fixed up real soon".

Truer words were never spoken, said Dr White. The patient was put on opiates for his pain, but the overnight doctor, concerned about developing addiction, cut back on the opiates and supplemented them with anti-inflammatories. Anti-inflammatories are damn fine medications, but if your kidneys are compromised (say, by all the vomiting and so forth that accompanies pancreatitis) they are dangerous. The overnight doctor gave him the equivalent of two ibuprofen, not a remarkable dose, and the patient went into acute kidney failure.

Needless to say, the patient was now in "a spot of bother". He lay there, horribly dry from all the vomiting, and was given medication to stop him getting an ulcer, developing a blood clot, etc. His pain from his pancreatitis continued, however, necessitating huge amounts of something like morphine, and two nights later the night doctor - same guy as a few days back, wracked with guilt - decided to give him an injection of local anaesthetic into the membrane around the spine to finally give him complete pain relief.

This he did. A few hours later the pain started to get worse, not better, and soon after that the patient complained that he couldn't move his legs. The injection into the spine had bled, recounted Dr White, due to all the anti-clotting medication he'd been put on - and his spinal cord had been crushed beneath a vast bruise.

Anyway. There are only so many ways that story can end. The labourer never got out of the wheelchair. Dr White, who was the other assistant anaesthetist in this case, emigrated. I don't know if the doctor is practicing, there really seems no reason to say no, except to point out that some people would find it impossible to go doing that kind of thing after something like that.

Another distressing tale is the man who had a bit of asthma and took one of his wife's anti-inflammatories - actually a period pain medication. He remembers feeling a little odd and then waking in the ICU three days later, having stopped breathing. Given what happened, he did wellish.

Not that non-steroidal anti-inflammatories are bad for you. They are bad for a smallish proportion of people under some circumstances and good for others.

Anyway. Enough grim tales. We also heard today about the new gee whiz ventilators we are getting - if you are ever unfortunate enough to be in the Florey ICU (unlikely), and am lying there looking up at the ventilator (even more unlikely), it is worth noting that the ventilaors (small boxes on stands with screens in the front, fifteen centimetres each way) cost more than thirty five thousand dollars each. They are smaller but slightly noisier than the big ventilators, which are thirty centimetres cubes but cost seventy thousand dollars each.

And apparently a night in the ICU costs $3 000. I marvelled at this when I heard, and suggested to Dr White that one could get a pretty good hotel room for three thousand a night. He said that in a hotel room you wouldn't expect a highly trained professional attending to your needs twenty four hours a day, and then we agreed that for three thousand dollars a night, perhaps you might.
Enough smut. Looking after the patients is getting better now. A lot of this is just practice - telling a story in a certain way - and noticing stuff about how the ward runs, and what is wrong with patients. We spent a lot of time talking about hepatitis today - the discussion of "exactly how much diarrhoea do you give your patients with hepatic encephalopathy" dominated a fair part of lunch. Much mention was made of the Child-Pugh score in assessing chronic hepatitis, wherein each patient gets a calculated score between five and fifteen. A score of less than
six means a one hundred percent chance of living out the year*, a score of over ten means don't put off that fishing trip. This is similar to the New York Heart Association score (where the calculated score ranges from I to V, in increasing degrees of fuckedness).

In my more callow**, intern years I remember hearing my then registrar refer to a patient with liver failure of having a "Cornflake score of four", meaning he was actually about the same colour as a cornflake. Being too tense to appreciate humour, I actually went and looked this up. The only prognostic grading score the intern or night doctor needs is the INC*** (Intern/Night Cover) rating:

INC score 0 - will live indefinitely, probably bury us all.

INC score I - will die sometime.

INC score II - will die this rotation, ie, in the next three months, while me and the other three interns are on duty.

INC score III - will die this week, while I am on.

INC score IV - will die this shift. Wake the registrar.

INC score V - will die this hour, while the reg is asleep and I am trying to untangle these paddle things.

INC scores VI to VIII are reserved for increasingly advanced stages of death that have occurred but have not been detected by the doctor, as in when you are trying to prop the dead guy up in front of the X-ray machine, or, chillingly, trying for over half an hour to get blood from someone who was actually in clinical rigor mortis.

Anyway, too tired to be interesting. Sorry for the gallows stuff. Thanks for listening,

John

* note, of course, that this does not mean you are invulnerable.

** an adjective literally meaning "without feathers". Over ninety percent of my fellow students fell into one or another of these categories.

*** soon to be published in a Journal one of my friends is thinking of editing to which we can submit some of our clinical findings. The working title is AJS, or the Australasian Journal of Shit-We-Made-Up.

Everything bad is good for you.

Hail,

And contrary to the title, this isn't going to be one of those articles you get every Christmas that say chocolate is good for your mood and drinking alcohol is good for the heart. Having said that, if you have cirrhosis from years of alcohol abuse, as I am sure so many of my readers have, drink lots of coffee. It seems to work amazingly well.

Anmyway, random thoughts on some stuff I've been reading about.

It's not the first bit of research to point this out, but another paper has been published looking at the link between lesbian sexual identity and obesity. Basically, women who call themselves lesbians have a higher BMI than women who call themselves heterosexuals. The BMI is one that puts them in the overweight/obese range. And it's not muscularity, stresses this latest paper, it's obesity.

There were a couple of things I found interesting about this - things maybe I wouldn't have found interesting in the same way two years ago when I was working at Hogarth House, seeing the fifteen-year old anorexics. But the main thing that gave me pause was the authors suggesting that part of the cause of the greater rates of obesity in lesbian women may be their healthier body image.

Now, I don't know that what they say is true about the better body image, but I have heard a couple of studies say that. I don't know that lesbian women have a lower rate of eating disorders than straight women (I know women of all orientations have a lower rate of eating disorders than gay men, but everyone has fewer eating disorders than gay men) - my memory is it's a complicated area. And the hostile to-ing and fro-ing of studies in politically charged research areas like this makes the Middle East look like a meditation retreat.

Annyway, the thing that gives me pause is the association between healthy body image and obesity, the link between a (healthy) way of looking at things and an (unhealthy) result. There seems to be a contradiction here - in what sense can the body image be called healthy if it leads to illness?

Obesity kills a hell of a lot of people, and it makes them sick for years before it kills them. If a healthy body image is associated with obesity, it's a serious risk factor. By this reading, happiness and confidence may actually be bad for you, and misery and self-loathing good.

Mothers and fathers, one could argue, if you wish your children to succeed in life and be popular and avoid premature misery and death, raise them to hate their bodies - they'll be anxious and conflicted and maybe cut themselves in their bedrooms, but they'll be less likely to be fat.

And given the high rates of heart disease amongst men, try to make sure your son turns out gay - the low body image and high prevalence of eating disorders may make him slimmer, although I can't be sure about that. Although, if your boy is going going to grow up to be gay tell him the best thing to do is to hide - gay men who disclose their sexuality in the workplace have higher levels of cortisol ("the stress hormone"), which might lead to increased blood pressure, high cholesterol, all that kind of stuff. Plus, the cortisol will make sure any fat he does have will be unsightly abdominal fat, which won't do a lot of good for his eating disorder...

I don't know. In the ICU we don't see life's winners, and we see the morbidly underweight - excluding the cachectic - on rare occasions, the morbidly overweight on a daily basis. But this idea that being happy makes you sick is an ugly idea. I think I find it ugly partly because I have strong opinions about fat, and partly because of my own experience - when I am overweight, as I am now, I feel guilty in the presence of the healthy, silently reproached, as they float lightly around, in some strange way being slim at me.

Anyhow. Weird thoughts. It's intersting, too, interesting about the lesbian side of it - you could argue that like murder, pre-eclampsia and many sexually transmitted diseases, poor body image seems to be a consequence of heterosexuality in women - a series of plagues that, were they visited upon gay men rather than straight women would be clear evidence of God's wrath.

And the link is fairly easy to draw out - at some deep level, every woman who lives under our realm of ideas knows that big is bad, that to take up space is wrong, that being small is the only way to demonstrate that you are not a threat. There is a sin in having substance, and to be seen to be strong is an act of rebellion.

I don't know. I told someone about this and she suggested that maybe it all made sense if you said obesity was an eating disorder of itself - underappreciated, unglamorous, but real. In this reading, obese people are the cockroach of the eating disorder world, anorectics are the polar bears.

I don't know how far you can push that idea. There are some ways in which anorexia is an illness that obesity is not - people with anorexia have fixed ideas about their weight, and the medical term for a fixed, false belief is a delusion*. We overweight people have no such delusions.

Anyhow, enough of this. I have to go off and starve.

Thanks for listening,
John