Shut-down

Hail,
Just thought I'd mention that a few days ago our branch (the southern administrative division of the Drugs and Alcohol Department) had to be put in lock-down. Lock-down is where we call the police, lock all the doors and put our security people on alert.

This was occasioned by a man whom none of us recognised, who stormed in, bellowed how we had taken his kids away - the Department of Family Health welfare is next door - and said we'd better lock all the doors, because he'd be back with a hammer to kill us all.

He then left, got onto a red bicycle with a carry basket on the front - I am not making this up at all - and pedalled away. His accomplice in this was a toothless woman in a pink jacket with hello kitty on the back.

Anyway, with the manager being away on leave I closed the place down. My experience has been that the patients who are going to hurt you come from two groups - those you don't suspect (little old ladies with delirium) and those you do (angry young men with psychoses). When the covering manager (five foot three) arrived she offered to stand out the front "in case he comes back", but that wasn't well received, so we all sat inside and our clients had to knock on the door and we'd peer at them through a slot and let them in, like a nineteen twenties speak-easy.

We initially did not know who this guy was, but a few hours later we got a phone call from a woman who wanted to speak to us about the assessment of particular, un-named client three months ago. The desk woman said we couldn't give out information like that, the woman said "All we want is an appointment with the same guy who assessed Joe Smith three months ago" and then the male voice in the background began bellowing "Don't tell 'em my bloody name, you stupid bitch!!!" and they hung up.

We sent the police around to Joe Smiths house. Later someone rang Family Health and he'd had all nine of his kids taken off him for various reasons, and when he saw us he'd been smoking two hundred dollars worth of marijuana a day. Unless you are being savagely ripped off, that is a substantial quantity, and I suspect may in some way be connected to both his state of mind and his meathod of dealing with his problems.

Anyway,
all action and litle reflection this post, which will probably be countered by the next one.

Thanks for listening,
John

Now I’ve always been puzzled by the yin and the yang

Hail,
Sitting at home, listening to one of the best five albums ever made - Tom Waits, Orphans, buy it now, listen to "2.19" and cry - and thinking about yesterday.

I was called down to see Mrs Callahan yesterday, and she seemed a little bewildered, a little confused, bright blue eyes wide open as she asked us what was going on. I sat by the bed for as long as I was able and answered truthfully what I could, but what I told her was that I didn’t know, none of us knew, but in a few days we would be able to tell her everything.

Mrs Callahan was not someone I knew well. This was unsurprising, she was eighty one years old, and she hadn’t been to a doctor in seventeen years. Her hair was white and her nose was aquiline and she was one of those upright, erect women, the ones you see wearing gloves in autumn and who dress up to go down the shops. She was evidently well loved – the walls of her cubicle were plastered with crayon drawings by her grand-children saying “get well soon”, and her three daughters sat by the bed throughout.

From what I could trace out, the story went thusly. She had gone to the local butcher’s shop to buy something for her dog, had completed her purchase, and as she turned to leave, turned and collided with a large young man. She had fallen onto her outstretched hand, and the butcher had called an ambulance, despite her protestations, and taken her to Florey, where she was seen by Dr Ravneesh, one of our young, keen, but relatively inexperienced interns.

For those of you who do not work in hospitals, I should elucidate – doctors do not do as they wish, their behaviour is tightly controlled. There are standards, and protocols, and guidelines. The reason for this is economically driven - numbers of emergency trainees grow slowly, numbers of patients sky-rocket, it is an assumption that each year more will be done with less, and that this process will continue indefinitely. A few years back ED was a seasonal discipline, like saltwater fishing or fruit-picking - winter was busy but summer relatively calm. In terms of patient numbers it has been winter now for three years, and worsening.

Because of this, we are rigorously controlled with respect to what we can do. Don’t bother asking your ED doctor what your cholesterol is – we won’t be checking it, go back to your General Practitioner. Your thyroid – not our problem. Anything preventative – you’d be lucky. The American model of Emergency Medicine, the “greet them, treat them and street them”, is so much the dominant paradigm that its primacy, let alone its efficacy, is no longer even challenged.

(Obviously, I am talking rampant anti-Americanism here, and I hate their freedoms. But I feel I should re-iterate – America has the best music in the world. It invented superheroes. It gave us Philip K Dick and Serenity and E Annie Proulx and Scorsese and so much other stuff it beggars belief. Man on the Moon, for God’s sake. But slightly more than half the voting public can be brought to their knees in terror by uttering one of the following three words or phrases: “Socialism”, “Black men”, or “non-Christian”.

Weird, isn’t it, the way some people go on about these threats, almost as if their livelihoods depended on it. Is there such a thing as a phobocracy?)

Anyway. Somehow the intern who saw Mrs Callahan had slipped through the net. She asked her questions, and in fact took a complete history. She performed a detailed physical examination, including listening to her chest. Aware of what she had found, she ordered a set of bloods and, along with the X-ray of the wrist, a chest X-ray.

Which found Mrs Callahans lungs more than half full of fluid.

Now, there are two main possibilities here. Mrs Callahan has a massively enlarged heart, a murmur that can be heard almost without the stethoscope. She may be in severe, possibly end-stage heart failure. The other possibility relates to Mrs Callahan's breast cancer, treated fifteen years ago. She had had surgery, radiotherapy, was given the all clear. But this fluid in the lungs could be a malignant effusion. The cancer may have returned.

Either way, things are bad for Mrs Callahan. She is booked in for an urgent echocardiogram, an ultrasound of her heart, which is the first step in finding out what is wrong and what, if anything, can be done about it. Although she is fit and well, she well be in no shape for cardiac surgery. She is also booked for a bone scan and an MRI of her brain. It may be, says Dr White, that the cancer has spread to her brain. Our role may be to determine, once all is known, if she is suitable for resuscitation.

Anyhow. We don’t know yet, I may know when I return in a few days. Everyone to whom I have spoken seems shocked by the rapidity of it all – Mrs Callahan came to us a healthy and independent woman and now the same woman lies in bed, her heart maybe failing, her bones maybe riddled with cancer. It is hard to avoid thinking of the evil eye here, how looking causes illness, or if not that, then Schoedinger’s writing, things that become true because they are observed.

We shall see.

In other news, the man in bed eleven, Mr Steed, continues to defy medical prognostication and has so far not died. I feel this shows a disregard for common courtesy, a contempt for medical authority and a cavalier disregard for hospital finances. He has been in bed eleven for twenty eight days now, initially in acute hepatorenalcardiopulmonarybrainiosplenic failure, and is now off the ventilator, un-yellow, and sitting up talking (in whispers, and weakly).

This has cost us, Dr Fang assures me, two and a half thousand dollars a day, not as much as the penniless man in the Royal who was in ICU more than seven months at a total cost to the taxpayer of more than half a million dollars, but still, money that could have been spent elsewhere. For example, said Dr Fang, did I realize how much Dr Black must be on?

Anyhow - the problems is, Mr Steed is now in his twenty eighth day of kidney failure. There is less and less hope he will recover kidney function, and he will almost certainly have to go on dialysis. Long term dialysis requires an almost religious commitment, I am told, to three ten hour sessions a week, on a machine that cleans your blood. Mr Steed is a man with a long history of IV drug use, his family suggest he is not a man who faces problems straight on. He may not be able to cope with ten hours three times a week on a machine.

If this is true and he misses a session the levels of potassium in his blood will rise, toxins will begin to poison his system, and after several weeks he will have a heart attack and die, presumably wasting even more money.

We shall see.

Anyway. Thanks for listening, see you soon,

John

Bear naked

Hail,
Harpers for May 2007 mentions a recent Uni of Queensland finding that lesbianism is rife amongst koalas. Apparently, the females studies will rebuff advances by males and moments later be observed in blissful clumps (anyone know the collective known for koalas?), up to five at a time, doing what comes naturally.

As you'd expect, if you type "lesbian koalas" into the search engine, you get a lot of articles hosted on humour sites, most of which have inverted commas around the word "mating", and reassure us that this behaviour is found predominantly in incarcerated koalas, a la prison sex. I haven't been able to read the original article, but several articles refer to "explanations" for this kind of behaviour:

One theory put forward by the researchers is that the females do it to attract males; another is that it is simply hormonal, or that it is a stress reliever.

Presumably no-one thought "because it feels good". That's aside from the startling theory that sex has something to do with hormones.

I have in my posession a vast tome called "Biological Exuberance", a survey of documented same sex relationships in the animal kingdom. Page after page of gay antelopes, masturbating walruses, oral sex among the apes* and the like. It also mentions the difficulties researchers had in accepting what they saw - reactions ranged from disbelief ("to conceive of these magnificent beasts as queers - Oh God!") to repugnance (hence the title of a published paper in the Entomologists' Journal and Record of Variation, 1987: "A Note on the Apparent Lowering of Moral Standards in the Lepidoptera").

Lepidoptera are butterflies and moths, and the horrified author, one WJ Tennent, had discovered the Atlas mountains of Morocco were the San Francisco bath-houses of the butterfly world.

I am desperately hoping the author was taking the piss, but irony is usually absent from scientific papers. Then again, so is horror.

My strong suspicion is that this is sex for pleasure, and happy animals are healthy animals - this is why there is a genetic tendency towards homosexuality. In human beings, I suspect there may have been an additional effect - more male-male or female-female sex, for example, means closer bonding, which is good for the tribe (which has a lot of your genes in it), and good for you, because someone may be more likely to save you from being trampled by a mammoth if he knows that he's also losing a great piece of Pleistocene ass.

And while I don't believe in "one gene = one behaviour", if there was something touted as a gay gene, and a test became available for it, it would prove heart-rending for those who believe homosexuality is utterly wrong but abortion is wronger. If I had those beliefs, I don't know how I'd raise my child.

Having said that, it'd be a fair sight more heart-rending to be the child of those parents.

Anyway. Back to the thrombolytics. The particular one I am studying at the moment was originally derived from Chinese hamster ovaries.

Thanks for listening,
John

*title for a never-published novel, the last in Edgar Rice Burroughs' Tarzan series.

Patient. Centered. Learning.

Hail,

Saw something remarkable today.

I was at a friend's house studying, her son is in third year medicine, and if we sit in the same room I do less surfing the net for claptrap and he does less computer gaming. He was showing me the new video he had been sent.

"Look at this" he said. It showed two cartoon people talking at the screen.

"What is it?"

"It's what used to be our communication tutorial. They stopped doing the tutorials two years ago, now we get these."

I stared at the smiling faces of the cartoon lecturers, talking about confidentiality, punctuality and professionalism.

"This one's called 'how to communicate with patients'" said Andrew.

"Important thing to know. How do you participate?" I asked.

"There's a checklist thing on the internet. Ticking boxes. It's pretty simple."

"Okay. Do you actually see the tutor?"

"I think he's in Melbourne and she's on leave."

"What about the patient? Do you actually get to communicate with a patient?"

"Not really. We're meant to do a video, but everyone just gets their friends or relatives to pretend to be someone and do the video that way. I've got Jules's sister, we're telling her she's got Crohns' disease."

"Jesus" I said.

"It's pretty much the same as last year. Jules did her last year, asked her why she wasn't taking her asthma medication."

"Because she hasn't got asthma?" I hazarded.

"That's maybe it. Hope the whole Crohns thing doesn't come as too much of a shock."

"She should deal with it" I said.

Anyway. That's the golden rule - whoever has the gold makes the rules, and medical and nursing schools are no more immune to this than anyone else, and cartoons are cheaper than consultants - and hopefully Andrew's excellent communication skills with his best friend's sister and his cartoon tutors is able to translate to the real world when he meets sick people.

Thanks for listening,
John

The more ICU, the more I want you

Hail,
And herein a bit about bad doctors and bad luck.

First, the last. There is a man in bed eleven - have I mentioned how everyone who goes to bed eleven dies? Have it tattooed on your chest - not for bed eleven, Florey ICU - about whose case everyone who works in the ICU, every nurse, every doctor, knows. I have spoken to his relatives in Sydney every day, have sat with his sisters and mother, Dr Fang knows what ventilator and dialysis settings he is on at any time, and how much of what is flowing into his veins, Dr Black contacts the hepatologist and the infectious diseases specialists every second day.

This is because he is far and away the sickest person in the hospital, and also because of what happened.

Mr Steed came to us with sepsis - an overwhelming infection that had started in his veins and spread throughout his body. He was a man with a long history of IV drug use who had recently holidayed in Thailand. He had started feeling unwell a few days before takeoff, concealed the fact, deteriorated en route, almost died on the plane home.

When they brought him up to us he was rain-coat yellow and delirious, in multi-organ failure - a massive infection in his lung, growths on his heart valve that frequently broke off and whirled downstream to occlude the blood supply to his brain, kidneys that were shutting down and a liver that has all but ceased to function.

Depending on how you look at it, that was up to five organ systems in crisis - liver, lung, heart, kidney and brain. We put the tube down his throat to help him breathe, pumped him full of chemicals to make his heart pump, hit him with multiple antibiotics and some uber-anti-inflammatory stuff that costs twelve and a half thousand dollars a vial. For the kidneys we did dialysis.

(For the brain and liver, nothing. There are artificial hearts and basically artificial kidneys and machines to help you breathe, but the liver, bat transplantation, and the brain are essentially unreplaceable. Apparently some kind of pig liver thing is on the way).

The lungs were really the only ones we could do a lot about at the moment, so we put in a chest tube - you paint the side of his chest with disinfectant, inject some anaesthetic, make a cut with a scalpel big enough for a couple of fingers and poke a long thin plastic tube into his lung to drain the pus - in the hope of opening up his lungs again.

Unfortunately, we hit his spleen instead. It's just below. The spleen is full of blood, he bled three and a half litres - close on a gallon - in under a minute and had to be rushed off for emergency surgery where they removed his spleen entirely.

Apparently - this all happened when I was away - the responsibility for the error will be shared between Dr Black, who put the tube in, and the ultrasonographer, who marked where it should go. Both are from southern India. Dr Black is about forty, one of the most impressive doctors I have ever met: deeply compassionate, extremely competent, fantastically knowledgeable.

I realised last night that if I was asked how Dr Black looked I would probably say he was good looking, because he is such a good person and is very good at his job. Whereas if asked about the ultrasonographer, I would say she seems like a good person, and was probably good at her job, even though I have only seen her once and have never spoken with her or worked with her - I would say she was nice and competent because because she is very good looking. That's the level my brain works at. Good people seem beautiful, beautiful people must be nice, everything smudged.

Anyway. Since I've mentioned a very good doctor, a bit about a very bad one. I don't know if I've mentioned Johnny Knuckle before. Dr Knuckle is one of the five or so truly bad doctors I have met. He graduated from medical school after nine years of a six year course, starting out two years ahead of me and finishing one behind. When I saw him he was on his third attempt at intern year - still unable to work unsupervised twelve years after starting.

He worked with us at Shipman, in the ED, the last year I was there. One time, during a moderately unbusy session, I was sitting at the desk educating the medical students about football and he asked if he could ask my advice.

"Sure," I said, wary.

"I've got a patient who was eating at an Indian restaurant when his tongue swelled up and he wasn't able to talk..."

"Can he breathe?" I yelped, half-rising from my chair. The most emergent problem in this case is anaphylaxis, a severe allergic reaction where the mouth and tongue swell up and can block the airway.

"Don't worry, I've already given him adrenaline, that's all okay," said Knuckle. Adrenaline is the appropriate treatment for anaphylaxis - he did get that right.

"Okay," I said.

"But I was wondering if he needed a CT head?". This is what we used to call a cat scan, basically an X-ray on steroids.

"What for?"

"To chack if he was having a stroke."

"Does he have any signs or symptoms of a stroke?" I asked.

"No," admitted Knuckle.

"Well," I said, pleased at my own wit, "he may be having a stroke. I may be having a stroke, you may be having a stroke. But until he shows signs or symptoms of a stroke, no CT."

"No CT?"

"No CT."

I finished up and went home. Two days later I went back and the place was in an uproar. One of the seniors grabbed me as I came in. "Did you hear about Knuckle?"

"What now?"

"Some guy collapsed in an Indian restaurant, face like this, arm like this -" and here Dr Porcino imitated the profound one-sided paralysis and facial droop of a man with half his brain's blood supply cut off - "and Knuckle gave him adrenaline and nearly killed him!!!"

Anyway. Sarah reckons I have written this before, or maybe it's just because I've told her so many times before. Praise God, Knuckle was as crap at documenting as he was at other aspects of medicine and had not written "discussed with Dr Bronze" in the notes.

Any medical students reading this, take note. If anyone askes your advice, do not just give it, especially if the person asking your advice has grade IV (malignant) stupidity or end-stage ongoing bafflement or however these things are measured. Go and see the patient. Otherwise it's as legally defensible as other forms of diagnosis by hearsay.

Anyhow. More on this later.

Thanks for listening,
John

The Fighting Has Intensified Along The Road To Peace

Hail,
Been thinking (it being night here, and winter, and only a few hours until I have to get up again anyway) about one of our clients whom we have cut loose. And Sarah's in Tasmania at the Intergalactic Cat Show, so I am allowing myself just a little bit of melancholy.

First things first. The drug and alcohol field is not like other fields of medicine. There are several ways medicine can be divided up - general versus specialties, internal medicine versus surgery, that kind of stuff.

Sometimes the doctors working in a particular field have their own methods of division, usually with their own specialty (good) separated from all the others (crap). Radiologists think doctors can be divided into "radiologists" and "people who have to ask radiologists for advice". Surgeons think in terms of other doctors (who can't actually cure what's wrong with people) and surgeons (who can). Emerge thinks in terms of "emergency doctors" - those who take the patient history, examine the patient, diagnose the illness and treat and usually cure the patient - and "other doctors" who do... all that other stuff. That's when they are not making our patients sick in the first place (GPs) or stopping us curing them (other hospital doctors).

Anyway - apologies to my fellow doctors. This is why I write under a pseudonym.

To me, drugs and alcohol is in the same division as psychiatry - there are the same issues of choice and capacity for judgement, the same problems of social justice, that kind of thing. Like the mentally ill, with whom there is a huge overlap, drug and alcohol clients can be told when and how to take their medication, can be prescribed medications they do not want to take and prevented from taking medications they want to take.

Additionally, they can be told to report to the doctors within twenty four hours to urinate in a pot, they can be prevented from driving, they can be told to do such and such or their medications will be compulsorily increased or decreased.

But there is one way in which drug and alcohol clients are separated from as far as I can tell all other patients. Drug and alcohol patients are the only ones where people can be too sick for doctors to treat them.

This is what happened to Jessica Jones. Jessica Jones is - or was - one of my five most unwell clients, along with the Maddest Man in Mordor Mr Jarusnich (deported to a private drug rehab centre in Queensland), the Amazing Belushi Siblings (back in jail, thank God), and Tina Jackson, the World's Unluckiest Woman*.

Jessica had been avoiding seeing me since I put her on the doctor shopping list. I also capped her dose of methadone at 120mg a day until the last moment of the last hour of the last day of eternity, or until we got three urine drug screens from her without benzodiazepines in them, whichever came first.

I did not do this purely out of malice, but because I believed Jessica was extremely likely to die on the opiate substitution programme. She was on a very substantial dose of methadone. She swallows entire bottles full of sleeping tablets - fifty at a time, doses that would put other people in extended comas. She has been in hospital several times with cellulitis (an infection of the skin from dirty injecting), endocarditis (an infection of a heart valve from dirty injecting) and reactions to tablets she "just picked up". She continues to drink alcohol, she suffers from recurrent chest infections.

Recently, however, two very bad things had happened to Jessica. Her partner, on again, off again, had managed to reduce off the methadone programme. Having conquered his heroin problem, he did as more and more of our clients do and began using crystal methamphetamines.

Amphetamines in very many ways are far worse drugs than opiates. If you don't actually overdose on opiates, they are relatively benign of themselves. Most of the harm my patients suffer from the opiates seems to come from the injecting and from the criminality. Amphetamines have both of those problems plus a few of their own - strokes, bleeds, psychosis. Amphetamine years are like cat years - ten years of speed makes a good twenty year old look like a very bad forty.

Correspondingly, Jessica's partner was one of the first people I thought of when I heard that a man in his thirties had driven his motorbike into a salmon-gum out near Innmouth. He had been four days awake, she said later, trembling, seeing things flicker across your field of vision. Apparently last time anyone at the clinic saw him he had been picking at his skin, saying there were insects beneath his skin**.

Anyhow. He was dead. And that same week she had come into money, a sizeable sum of money, several tens of thousands. When seen by Dr Grizzle had been using twelve hundred dollars worth of heroin a day. Plus methadone, plus whatever else she could find, plus three different kinds of sleepers and bottles full of all that stuff I had sent out the alerts about...

Anyway, to cut a long story short, where she had been very bad now she was worse. I rang Central and said I didn't think we could handle someone like her. Central, which means the senior drug and alcohol doctors, said to transfer her, which I did. And the next day I heard she was being reduced off the programme. Essentially this means they had had a meeting and decided that she had become too sick for our service - not just too high risk for me, too high risk for the National Drug and Alcohol Services, pretty much too high risk for anyone in Australia except some of the more experienced private prescribers.

Basically, we prescribe methadone to people who whom it is safe to prescribe, and she is not one. If we prescribe, said my boss, she will overdose on the methadone and die soon.

If we don't prescribe, however, if we cut off her supply like we are doing, what is called a "forced reduction" where the dose decreases ten milligrams a week or ten milligrams every few days, a long, protracted period of withdrawal, weeks of cramps and aches and sweats and chills and diarrhoea, I suspect she will die even sooner. Because this is not a woman inclined to take things on the chin, to be stoic, to endure. And down any street in parts of Mordor are people keen to relieve her pain. Unless she is physically stopped, locked up or something, she will overdose anyway.

(I should stress that we have offered her a third option, an inpatient detox, but there is no way on God's green earth she will take that up, and even if she did, I have never heard of a forced detox working. The idea itself is window-dressing, the "lipstick on the pig" part of punitive pharmacotherapy).

Don't know what to do. Well, I do, because there is nothing I can do. Basically, I am not allowed to prescribe for her. To be honest, I don't know that I would if I could, I did call my boss about her and I did say she was too much for us to handle... maybe I'm just using the fact that someone else has done the actual cutting off to allow myself to feel I wouldn't have done it.

At night now, something about it seems wrong, although intellectually it is right and in some ways I am less worried (I had almost been rehearsing my coroner's speech).

I feel we should do something, but to be honest I can't think what. Wherever this woman goes, bridges burn.

Anyway. I shouldn't worry. I will try to talk to someone about this, some of my less close medical friends. They are, mostly, sensible, restrained people, whom I suspect may wonder at my continuing to work in this field. They are people who will remind me that you can't make someone give up drugs, that in the end it's someone's right to do whatever they want, even if that is die. They will say, and they will speak truly when they say, that my job isn't to make sure everyone has a happy ending, my job is to make sure I do my defined task within certain very narrowly defined boundaries.

"You can't save people from themselves" my deeply reasonable friends will say, over a bottle of very good wine. I will perhaps protest a little, like people do when they want people to continue to compliment them, and after a glass or so I will allow myself to be convinced. These are difficult patients. There is a high intrinsic mortality and morbidity, the rules are there for a reason. There is only so much one person can do. I'm doing my best.

"You might be right" I'll say.

"You know your problem? You care too much" they'll say.

"Don't be fooled" I'll laugh, but I'll like hearing it, and maybe I'll get tehm to say it again. Afterwards I'll drive home, elecric windows closed against the cold night. If I time it right I get to catch the sacred music programme on the ABC.

Hopefully ths will not precisely coincide with Jessica Jones being brought into Florey ED, that clammy grey-blue, breathing three times a minute, frontal lobes darkening, damage already done.

Anyhow.

Enough about that, about all of this. Things are not that bad. And this is not how I am feeling all the time, it's just what I am writing. I don't know exactly what I'm trying to say here, and I get the feeling I have not succeeded, which is a pity.

Next post maybe about something cheerfuller.

Thanks for listening,
John

* Actual given reasons for the presence of drug metabolites in her urine:
1 (heroin). I was asleep at a party and someone must have injected it into me.
2. (unknown opiates) I tongue-kissed my boyfriend and he's on drugs - I must have sucked it through the pores on his tongue
3. (amphetamines) There must have been some amphetamines in that new diet drink I've been drinking - sustagen or something. The medical records indicate a similar "something I drunk" justification being attempted for the presence of methamphetamine metabolites in her urine around about the time they brought out New Coke.
4. (benzodiazepines) They gave me valium at the hospital when I went there with my sprained ankle - see, here it is written in felt-tip pen, poorly spelled and unsigned, at the bottom of this typed discharge letter from the hospital you work at.

** and for some fucking incredible reason, the person who saw this did not detain him, and three days later he was dead.

The Winter Shunt

Hail,
And that oddly poetic sounding name, evoking perhaps someone standing at a train station, some time in the nineteenth century, watching steam locomotives bullying carriages back and forth, refers not to that but to a particular operation to cure the dangerous condition of priapism, or a painful, long-lasting erection.

There you go. I write to you today from deep in the glomerulus, that rococo structure of tubules and cells in the kidney that turns blood into urine. Doesn’t seem quite as miraculous, for some reason, as the breast, which turns blood into milk, or the brain, which I suppose turns blood into thoughts, but still, it’s impressive. If we didn’t have kidneys, we’d all still be lounging in the primal sea.

Renal (means kidneys) medicine is something I never really got my head around last time, but this time it is seeming to come together a bit better. A lot of it is so simple you think there must be some kind of trick to it. Kidneys are basically a tea-strainer with a long tube behind it, plus a couple of little pump things on the tube, adding a touch of this and subtracting a touch of that. Urine is basically blood with all the stuff we don’t want to throw away becasue we might need them later taken out, and some stuff we reckon we won’t need anymore chucked in.

In their spare time, kidneys make hormones (sounds like someone crocheting football scarves, doesn’t it?), make sure you don't suffer the embarrassment of running out of red blood cells and look after your blood pressure. Proponents of Intelligent Design, by the way, might like to explain to me why when you get high blood pressure one of the first things to go is your kidneys. But once your kidneys are damaged they can’t really control your blood pressure anymore, so that goes up further, which further damages your kidneys… so the only thing that could stop the situation is one of the first things to go. As well designed as a wax fire-truck, or a chocolate teapot.

Penguins, by the way, never get cystitis, what is commonly known as a bladder infection. This is because, being birds, they don’t have bladders (not urinary bladders, anyway). Amazing fact for the day.

By the by, in an effort to lift my spirits I have been reading fiction. Unfortunately – and the reasons behind this are pretty clear to me – I have chosen not-extremely-uplifting books - Primo Levi and Kafka, who, by the way, wrote a lot of crap among the brilliant stuff. Levi's book details the rise of Fascism in Italy – apparently when he was awarded his chemistry degree, it specified below his name that he was “of the Jewish race”.

Being genetically German Jewish, I will now tell two of the very few jokes I know – my German one and my Jewish one. They are even less funny when I tell them. I don’t believe in “national characters”, but one of these is about a political situation and the other could be about a variety of groups of people – it makes more sense as a “doctor” joke, or even a “me” joke.

The first my father (he whose uncle was a rabbi) told me. A television reporter arrives in the Holy Land and is looking around for a story. One of her compatriots suggests that she interview the “the old Jewish guy”: an elderly man who has been coming to pray at the Wailing Wall three times a day for more than fifty years. So she does so.

“So, how long have you been coming here to pray?” she asks.

“Fifty years” he says. “Three times a day for fifty years.”

“That’s amazing piety. And what do you pray for?”

“I pray for the end of hostilities. I pray that one day there will no longer be the sound of gunfire in this land. I pray that the children of Israel and the children of Palestine can come together in peace, love, mutual understanding and respect.”

“That’s truly beautiful. And how do you feel, after fifty years of praying for this?”

“Like I’ve been talking to a fucking wall”

The next joke I read somewhere and told Sarah and she said it was about me. A busload of Germans/doctors/whatevers arrives in heaven. There is a big sign pointing to the left and to the right. To the left the sign says “Heaven”. To the right the sign says “Lectures and examinations and workshops about Heaven.”

So all the Germans/doctors/whatevers go off to the right.

Sad but true. Obviously it’s not about all doctors, it’s about a particular temperament, a particular way of looking at things, an attempt to displace something or cleanse something or hold something at bay by learning, studying, controlling. You see it in medicine, in law, in the more hardcore gyms and in the cleaner homes.

Nietsche – who, let it be said, also said a lot of crap amongst the brilliant stuff - said there are two ways of looking at things – Apollonian and Dionysian. Apollonians – and no-one is one type, it’s more an approach to things – Apollonians have the ripped abs and the tidy desks and the sensible financial strategies, but the Dionysian gives you Buddy Guy and sex in the outdoors. Beauty versus ecstasy.

I think I, like most people, would like to think that I am at heart a Dionysian in an Apollonian world. From what I understand of what Nietsche said, it's not that simple. I think what you sometimes see in doctors is that sometimes the only way to approach some of the stuff that happens in medicine, some of what would otherwise tear deep holes in you, is to channel and subsume the emotional stuff into numbers, lines on a cardiac monitor, protocols.

I don't know. I write instead.

Anyway. Sarah is in Tasmania - hence these odd, meandering thoughts - and I have now to go and feed the multitudes of cats. It's weird the way they come up to the door of the run and squall at you, and when you raise the lantern their eyes glow. You can tell, apparently, two different breeds of white cat by the colour of their tapetum - the membrane at the back of the eye that reflects the light. And then I have to go to bed, because due to the instrasigence of Virgin Airlines, I have to get up at three in the morning and drive five cats to the airport.

Anyhow, thanks for listening,
John

One last thing - about comments. I feel maybe part of the reason I am so crap at replying to them is that if they are complimentary I get embarrassed. I do appreciate well-wishings and so on, but sometimes I don't know what to say - "You're right, I am fantastic" doesn't seem appropriate. I don't want to sound like a galah, but there are other people out there who write more regularly and coherently and interestingly and just overall better than me and live more interesting lives - I would feel more comfortable handballing any positive comments off to them. Go and read their blogs, follow the links on the side.

And I do enjoy getting the comments, I just never know what to say in response.

By the way, I have to update my links but I don't know how.

Thanks for listening,
John

*One of the non-crap things he said: There are some who, from obtuseness or lack of experience, turn away from such phenomena as from "folk-diseases," with contempt of pity born of consciousness of their own "healthy-mindedness." But of course such poor wretches have no idea how corpselike and ghostly their so-called "healthy-mindedness" looks when the glowing life of the Dionysian revelers roars past them

Ephemera

Hail,
ANd the following contains stuff that is, according to Sarah, "really awful". You have been warned.

Firstly, I have recently found two of the best websites in the world. One of them led me to the work of these artists who made these:



What do you say after you've made something that beautiful?

Anyhow. Vaguely philosophical mood tonight, too tired to study the kidneys. I vaguely recall - and I may have said this before - that in old versions of the Old Testament the kidneys were supposed to be the site of the moral sense, the sense that differentiates wrong from right. Hence Psalms 16:7, which I learnt in Old Testament studies was originally "the LORD instructs my kidneys during the night".

Nowadays we are much more advanced than those foolish people - current versions say "the LORD instructs my heart". Still, it's an interesting idea, someone elderly and intellectually atherosclerotic slowly drifting into subclinical renal failure and becoming increasingly amoral.

Explains so much.

I suppose I am in a slightly ambiguous mood today because the last few weeks have been crowded with extremes. ICU and drugs and alcohol, and also Emerge, seem to almost be bipolarogenic. And I'm not complaining - indeed, it can hardly be co-incidence that I've chosen to work in fields where every few days there is a death, every few days a miraculous survival - but I have to be careful that not too much of this rubs off on me. I can't say that death and sickness and grief are to any real extent contagious, I can't claim I share in the suffering of my patients, but these things affect you, get under your radar, under your skin. I'd be a stupid person and a crap doctor if I thought otherwise.

And ICU has been particularly frantic lately. It is winter here, and winter is the dying season, all the wards overcrowded, pneumonia and influenza and infectious exacerbations, this hospital visit a little longer than the last, comiong on more frequently, saying longer, until in the end you come in and you never get out.

The names of bacteria are like the old names of demons, where before we had Shemyaza and Naberius now we have Pneumocystis and Haemophilus and Influenza. The names still have the poetry and the powers are still as strong - Shemyaza is "Infamous Rebellion", Naberius restores lost honours...

- and isn't that something, isn't that a power worthy of a real demon, a true Marquis of Hell, a power something that could tempt even the best of us on days that those sheet-wearing grape-dangling nymphs wouldn't get a look in? -

...Haemophilus is "Lover of Blood", in bed nineteen Mrs Damson breathes shallowly and rapid.

Anyway. I am at a bit of a loose end because of the man in bed eleven - seriously, it's that bed again, almost Lovecraftian, one day I'll look in the pillowslip and find Brown Jenkin or somebody - and his ongoing determination not to die.

The story of Mr Mason is relatively, almost horribly simple. He went out with his wife to visit their daughter, she served him tomato soup. He had had this many times before, always with considerable enjoyment, and he sat down to devour it with relish. Within a few minutes he noted an unpleasant itching sentation "in his throat", and a mild, almost comical swelling of his lips. He pushed the plate away, went into the bathroom, washed his mouth out and took some antihistamines. The problem did not go away, but neither did it seem to get worse, so Mr Mason finished playing with his grandchildren and went home. He felt unwell, a little nausea, and did not eat anything that night.

The next day there was still a mild swelling and a barely perceptible tingling of his throat. "Well, if you don't eat, you'll starve" said his wife, and she made him poached eggs - no tomatoes. He thanked her and said he was certainly hungry. He took a few mouthfuls, lurched back in the chair and fell to the ground.

What happened next is difficult to determine. Mrs Mason - fifty five, a short, strong woman - tried what she remembered of mouth to mouth, but it didn't seem to work. She remembered that his face was all swollen up, lips like balloons, face distorted. Someone called an ambulance, they came priority one, got him inside. They closed the door and he arrested, they were crunching on his chest as they pulled into Florey ED.

The ED got a tube down into his throat and started him breathing. He got the unholy triad of muscle relaxants to paralyse him, sedatives to make him unconscious, analgesics to kill the pain he was feeling. They put a line into his artery, took some blood out, ran it through a machine, got a stream of numbers on a sheet of curling, freshly smelling paper, filed it with the other notes, the amounts and concentrations of adrenaline, the minutes of cardiac compression, the voltages and electrocardiograms.

When he got up to us, intubated and unresponding, Dr Kala showed me the blood gas. "There is a set law governing how quickly the carbon dioxide rises in the arterial blood in the complete absence of ventilation" he said (he really talks like that). "Three to four millimetres per minute. What is the normal partial pressure of arterial carbon dioxide? How long has this man been without oxygen?"

"Twenty four minutes" I said.

"Twenty four minutes" he agreed. "What are the clinical signs that distinguish hypoxic from other forms of encephalopathy?"

I didn't know. He pulled the curtain aside, gestured with one long-fingered hand towards Mr Mason. Mr Mason's hands twitched, his eyebrow raised, the muscles in his cheek convulsed, making it seem like he was about to speak.

"Myoclonic jerks" he said "are a very poor prognostic indicator."

"Is this... permanent?"

"Possibly" said Dr Kala.

"Can we do anything?" I said.

"We must try" he said. "This is very distressing for the family. Clonazepam, valproate..." I began writing in the medication chart.

But nothing has worked. Mr Mason's family - small, internally riven - drift in and out at various times, studiously avoiding each other. Mr Mason's widow - because that is what she is - sits by his bed, holding his hand. He is in constant motion, almost seeming too alive, a man full of vitality, possessed by animal spirits. The corners of his mouth twitch as if at a joke. He smacks his lips as if tasting fine food. His hands clutch at his wife, his eyes open and he looks around the room.

But when you shine a light in his eyes, his pupils do not constrict. If you squeeze the sharp metal handle of a tendon hammer between his fingers, he neither cries out or draws away. The touch of cotton wool on his cornea - the white of his opened eye - does not cause him to blink.

There are requirements that have to be met here. After four days the neurologist will review him - sit down with the CT and the MRI, poke and tap him with his tendon hammer and his pin. While there is hope, even very little hope, thin as those lines of light on the horizon of planets when the day is just ending, while there is hope there we keep his heart going and his blood pressure up and his lungs filling and sighing.

But I don't know. By Sunday, when I work next, things will have moved on. The mathematics say that the most sensible thing to do is to turn off the respirator - almost no-one who survives this wakes without horrible disability. But I don't know how his relatives will go doing that if they have to decide when he is in the bed smiling at them and looking around and grabbing at their hand.

Anyhow. Thanks for listening,
John

Better than Valproate

Hail,
Well, I've found the secret to ending depression and I'm getting it from Amazon.com. Expect remarkable (albeit probably discreet) changes.

John