Survivors

Hail,
The exam draws near, and I am still alternating between sitting it and using my handy-dandy get-out-of-jail-free card. In the last month before the exam you can only withdraw if you have documented medical grounds, which I most certainly have, but I don't particularly want to use that excuse. So, most days I can spare I spend reading and re-reading the textbooks and drinking kilolitres of coffee.

I read somewhere that the LD50 (the dose that will kill 50% of those who consume it) of coffee is about seventy cups in twenty four hours. I will probably be safe.

Anyhow. I will, objectively speaking, probably fail this exam. It's not certain but it's the most sensible extrapolation from how I'm going. Even if I do fail, I suspect I will pass next year. The brutal truth is I am not particularly good at exams, never have been. I don't have that kind of crystalline memory, that ability to make rapid, confident sounding judgements. Even when presented with a multiple choice question I spend most of my time trying to work out how every answer could be right. A lot of my day-to-day medical practice is spent looking stuff up. I've only done really well on one exam in my life, and that was the one that got me in to medical school. The rest of them have been barely survived bludgeonings.

Anyway, enough wallowing, it'll be here in six weeks whether I whine or not. What's been going on at work?

A few depressing things, actually, depressing to the extent that I was thinking about starting my study leave early. Mr Steed died. He was the man with the omni-organ failure - infections in his heart and blood and brain, another in his liver, a machine breathing for him through a tube in his throat while another machine cleaned his blood. He had spent close on three months in the ICU, attended each day by his sisters, his father and his mother. It was a death a long time coming, in fact a long time forestalled.

I had come in early that day and glanced at him - a slim, small form, surrounded by his family. I had only seen him dimly through the glass and curtains of the isolation room, in the last few weeks he had contracted MRSA, a very difficult to treat skin infection caused by farmers, doctors and politicians. Despite that he had seemed to be making a gradual recovery. The nurse told me that few days ago he had been showered and had spoken with his family. A few hours after I glanced at him - while I was on the phone, or getting a coffee - he had died.

All I can tell is it was - I don't know, dislocating. Knowing he had died ten steps away, silent and unmarked by us. And knowing he had died, and we, his doctors, had done nothing, despite knowing there was probably nothing that could have been done.

I went into the room - the family were outside, the nurses were already in there, cleaning the blood and shit from the body, it had not been a good death - and I certified the death. I do this in a kind of ritualised pattern - stethoscope on the chest, a minute's silence, listen to the lungs, another minute, the pen-light in their eyes. If the eyes are wide and dark and the pupils do not shrink away when you shine the light on them, you can under most circumstances declare the death.

And I knew I had a job to do, people to keep alive, but all day I couldn't stop thinking about it. And then I spoke with the man in bed eleven, who had just been de-intubated, and I looked down and saw that he had been born the same month and year as me. And something in the look of him reminded me of me six months back - the same round, slightly confused face, the same smiling and nodding as he agreed he'd do things we both knew he wouldn't do.

And so I spent the rest of the day thinking about that. First intubated patient who's got to me in that kind of way.

Anyway. Enough personal trauma. I am going half-time for a month to study, we will see how that goes. What I was going to try to do was give an idea of how things worked in the ICU by following a group of patients as they happened. Here is what has been happening.

Mr Ayre has already gone to the ward. We came around the next day and he was off the oxygen. He looked pretty bad - speaking in short phrases, a visible heave of the chest between each mouthful of words - but he assured us this was pretty good for him. And he was keen to leave. I wrote up the discharge medications and dutifully gave him my "perhaps smoking isn't for you" talk. I am not good at the scary talk, I tend to frame things in terms of "if there's anything we can do to help...", but the truth is in this case stopping smoking might double or quadruple his expected life span and he'd still be dead within a year.

Mrs Burns does not do well. As you will recall, she had had a colonoscopy which perforated her bowel. Every morning the surgeons come and cluster around the bed, and try to screw up the courage for another operation. Her gastroenterologist - the man who did the damage - has been on the phone every day, sometimes twice. She is in kidney failure, has lung disease - it's all bad.

Mr Mettle - the giant of a man - is, if anything, worse. He is the only person of the five with single organ failure - heart like an ox, fit, clean-living - and every day brings more visitors. There are photos of him and his family and friends almost covering the wall.

Still, he does very badly. His lungs are stiff - the ventilator has to work extra hard to inflate and deflate them, use pressures four or five times higher than normal. Those high pressures are almost certain to further damage his lung, but without them he won't be getting oxygen in. His white blood cell count - white blood cells are the ones your body uses to fight illness - is thirty six. Above eleven is considered abnormal.

Mr Wood remains about the same. He has not spoken or moved or indicated anything much at all, but that is how he often is. If anything he is slightly better, which is good news for his son, possibly less so for Mr Wood - although perhaps not, who can tell? Several of the staff - doctors, nurses - have expressed their disgust at this situation, a man with severe dementia and chronic pain being kept alive by a son he hasn't seen for eighteen years - and the senior doctors have rung him every day to explain the situation to him. I don't know what's going to happen here. We all wait on the son, who should be here "soon, the weekend at the latest".

Interestingly enough, by the way, doctors are empowered to make certain decisions and carry out certain procedures against the will of the patient (and the patient's relatives) - the frightened three year old who needs emergency surgery against the will of the parents, for example. Those patients can be forcibly made a ward of the state. But I don't know - and I could be just ignorant - if such a provision would ever exist in the case of an elderly man who no longer recognises his children. And there's a long way to travel from that case to this.

Erica Stone looks relatively good, and her numbers (blood pressure, heart-rate, oxygenation) look good, but that is because she herself is doing relatively little of the actual work of living. Still, tomorrow or the next day we will withdraw the sedation and see how she goes when she wakes up. Her drug doses - the morphine, the midazolam - are remarkable, and from what I have been able to find out the doses of stuff that would kill most of us are what she takes recreationally.

Anyhow. Two have been saved, three at least still to go. More on this later.

Thanks for listening,
John

Five

Hail,
I've been going through these posts, shaking my head at some of it, and wondering if I've managed to get things across. Part of what I wanted to do when I started writing was to give some idea of what it's like to do some of this, to work in the ICU, or to work in the ED. And looking back, I think some of the posts have worked, but most of them haven't got that across.

This is only to be expected. People don't pour their experiences directly out onto the page. Something happens, and people see it another way, and they go away and think about it in another way, adding and eliding, then eventually when it comes to writing stuff down they what comes out is another thing altogether*.

But anyhow. I haven't been getting the experience across because a lot of what I write is reflective, whereas the actual process of ICU or ED or Drugs and Alcohol of course is looking forward. In the blog I write "This is what happened", whereas in real life, work is "I'll do this and hope to God it works out".

Okay. I am at the ICU. Today in beds eleven through to fifteen, we have five patients. They are all extremely unwell. They are all receiving maximal or near-maximal care. Statistics say that each of them has about a one in five chance of dying. If you factor in average lengths of stay, morbidity, mortality, it's a fair bet that one in five will die within the fortnight*.

So. Five people. Identies disguised as per usual, named after the Chinese elements, but I will describe these people as it happens, looking forward, rather than looking back.

Bed Eleven is Mr Ayre. Mr Ayre is in end stage airways disease. He wheezes, he pants, he sleeps on home oxygen, almost drowning in thin air. He has a resting tremor, and his pupils are wide, and I suspect it has been years since he was not afraid. No-one visits him. He is thirty four.

He is one of those truly unfortunate people against whom nature has conspired. Smoking kills many many people, but it tends to kill those we are less concerned about saving - the elderly, the unwell, the unattractive (compare anorexia nervosa, or most injectable drugs). To be brought down as far as Mr Ayre has been brought as quickly as he has been is rare - he's one in four thousand, actually.

Mr Ayre has alpha one antitrypsin deficiency. In normal people, the molecule alpha one antitrypsin protects the lungs against protein-dissolving chemicals. Mr Ayre makes an inferior version of this molecule, and thus is dying of emphysema many many times faster than anyone else who smokes cigarettes.

On the positive side, he is down to a pack a day.

Bed Twelve, Mrs Burns. Mrs Burns may be a victim of medicine and the need for certainty. She presented to her doctor a month ago with concerns about her constipation. After some perusuading, her doctor referred her for a colonoscopy, the camera-on-a-metal-tube-up-your-bum thing. It went hideously wrong, as these things do. There was an obstruction (a benign one, it later turns out), they tried to get past, the camera-on-a-tube penetrated the wall of the intestine. There was a massive tear in the gut, although this was not immediately apparent. She went back to the ward where she lay while everything inside leaked out into her abdominal cavity. A few days later she presented to emergency, belly taut and swollen, blood pressure almost undetectable.

The surgical team have so far done four operations to fix this. Normally there is a bit of an "attitude" between surge and ICU, there is the strong sense that they see us (and emerge and psych and...) as muggles, but in this case surge are petrified. Mrs Burns is on hardcore antibiotics, she is intubated, chemicals keep her heart running, and every day or so she is having her belly opened up and "washed out". There is only so many times people can take this.

Bed Thirteen, Mr Mettle. A man of remarkable strength and health, his relatives say. Twenty six, an amateur fisherman and volunteer fireman. Brought in from Ratbite River regional hospital with pneumonia that has progressed to ARDS, acute respiratory distress syndrome. When you X-ray his lungs they are not the open, empty black of healthy lungs, they are white, clouded like mist or veined like white feathers. Still, he is tall and strong, and pictures of him amongst his family (blonde wife, blue-eyed child, him bending down to get through a doorway in their holiday shack, him and his brother kicking a football down at Fang Rock).

ARDS is bad, extremely bad. His white cell count is high - almost thirty - and even on the ventilator his blood remains dark and deoxygenated. His fundamental health and fitness and the evident love of his family weigh in his favour.

Bed Fourteen, Mr Wood. Mr Wood lives in a nursing home. All daily activities are carried out by his carers, he can neither feed nor dress himself. He is ninety one. He has had a stroke, he has had a heart attack, he has had laryngeal cancer and cannot speak. Two days ago he had a sudden attack of pneumonia, was rushed to Florey ED.

In the absence of what is called an "advance directive", doctors and nurses assume that full measures must be taken, and Mr Woods was aggressively resuscitated (I think they broke a rib doing CPR) and sent up here.

Here's the problem. Because Mr Wood is in no shape to speak, being deeply confused and all, and his son is his nest of kin. His son lives in Sydney and has not seen him for eighteen years. He has ordered that all possible measures be taken. If his heart stops beating, we crunch on his chest until it does. If his kidnes shut down, the machine. If he stops breathing, it's the tube down the throat.

Miracles, Mr Wood's son avers, do happen. This is true, but I don't know that keeping Mr Wood alive will be one. But it looks like this is what will happen, at least until someone can come up with a better plan.

Bed Fifteen, Erica Stone. Erica lives on the edge. Hep C, spleen removed following a stabbing in the eighties, steel in her skull following an assault in prison in the late nineties. A few days to a week ago she got a dirty hit - although the details are understandably sketchy. What we do know is that she has multiple organ compromise - bilateral (both sides) pneumonia, swarms of something in her blood, and a heart damaged by at least two previous episodes of the same.

Plus she's somewhat immunosuppressed (amphetamines plus Hep C plus an absent spleen) and has something wrong with her thinking - definitely present but difficult to define - some frontal lobe pathology, some memory thing. That could either be from the previous overdoses or it could be from the endocarditis - you inject heroin into your blood, skin bacteria get in, travel to your heart, start growing, clumps of vegetation break off, whirl downstream, stop the blood supply to the brain...

I should point out, this woman is not one of my drug and alcohol clients. The difference in morbidity and mortality between IV drug users on methadone and IV drug users who are not is huge. Arguing against Mrs Stone's survival is her multiple organ failure, the simultaneous presence of at least three different infectious agents in one small woman. Arguing in her favour is the demonstrated fact that death does not want her.

Anyhow. We are going to try to keep all of them alive. And we're a pretty good team. Very smart people do ICU, and we have a large number of consultants, some truly superlative nurses, an ICU that is getting money and people pumped into it at a dizzying rate. But I suspect the mathematics will apply, and at least one of them will die.

I will keep you informed. That plus the update on a few of my previous patients.

Thanks for listening,
John

*I can't remember a lot of my maths. But from what I recall, if each patient has a one in five chance of dying within the fortnight, then the chance of all five surviving the fortnight is aroundabout a third. The chance of at least one dying is approximately two thirds. The chance of things going horribly awry and all five dying is low - about one in three thousand - but it can obviously happen, and has happened before.

And all this talk of odds and percentages, all these cold equations, sound ghastly, but that's what everyone (doctors, nurses, administrators, health economists) does all the time. We've got numbers on everything.

**And that's assuming that the person concerned is even trying to write down what went on. I remember seeing our Glorious Leader on the TV the other day and trying to work out if what he was saying was what he thought actually went on, or (more likely) what he wanted us to believe went on, or (even more likely than that) what he or she wanted us to think he or she believed at the time was going on, or .... then one of my frontal lobes got caught in my amygdala and I fell over.

Seriously, watching him was like watching a professional card shark. What's the term for that mix of emotions you experience when you seen someone doing a truly terrible thing very adroitly, that melange of "What an evil rodent bastard" and "How the hell has the evil rodent bastard managed to get away with this stuff for so long" and "You know, other evil rodent bastards, trainee evil rodent bastards maybe, could learn from this... they should set up a school"?

The Germans probably have a word for it. If they do I'd like to know.

Proximity Errors

Hail,
By the way - have a look at this. It's not quite as convenient, and I don't know if it saves any watt hours at all, but it looks so, so much better.

Well, a rather rushed missive today, sitting at my desk in the Drug and Alcohol job thinking about how this job is messing with my mind.

Not in a worrisome way. In fact, from the bipolar point of view, things are going very well. The mood, the sleep, the motivation - all of these are perfectly unremarkable. I worry, but it's about things that should worry me, like my exam. I have times of low energy and poor motivation, but it's generally after a twelve hour shift. I still have the lack of confidence, the fear of talking to any but my closest friends, but that is probably utterly normal considering what has happened. Utterly utterly normal.

See, I've had normal, and I've had that glowing, barely containable rage and glee, that ferocious impatience with everyone and everything, that feeling that gold runs through your veins, and although you really really miss the highs, you really really don't miss picking up after them. Normal will do me just fine for now.

But anyway. This job, and how it messes with my mind.

One of our social workers was talking the other day about one of our clients, a fifteen year old girl, on the edge of amphetamine addiction.

(You know those shots of the earth from space, where part of the earth is in sunlight? It's all clouds and seas, and there's the shadow moving across from east to west? And just between the shadow and the light is that softening, that half-light, that brief penumbra, and you know the people down there are looking up and seeing night come?

That's where this girl is now. It can happen quickly at any age, but for her it's a very rapid thing).

Anyhow, our social worker asked me some stuff about what we could offer her, the role of counselling (maybe) and family therapy (possibly) and antidepressants (useless) , and she said "I don't want her to end up going down the bridge."

"The bridge?" I said

"The bridge down at Rye Street," she said. "It's the underage sex one. Everyone knows."

"Is it?"

"Everyone knows Rye Street," she said, staring at me like I was stupid. "If you want underage sex you go down the bridge. Thursday, Friday, Saturday nights. Ask anyone."

"I didn't know" I said. "That's horrible." There's a bank and a saddlery and a comic shop at Rye Street, I've been there myself. Up in the sunlight it's smiling young couples and the Pony Club and Tales of Wonder, and presumably underneath in the dark it's wheezy old men and a quick fumble of someone in Roxy jeans and a cheap teeshirt.

"You must have known," she said. I shook my head.

Anyway. I've been thinking about that. See, Mary (the social worker, long blonde hair, thick glasses that give her owl-eyes, floral dresses) sees a lot of this. in fact, most of every day for her is seeing kids on drugs, the damaged, the diseased, the disposessed. And she's been doing it for a number of years now, and before that the prisons, and before that a stint in a big paediatric psych unit in Sydney.

It's been a lot of what she sees, and if you see things often enough, for long enough, you think of them as normal.

I've noticed that in me. Because most of the people I see every day have some kind of mental illness, or some recent episode of violence, or blood that swarms with viruses, I end up assuming at some level that that's what's going on with everybody. At some level (and I'm not talking about rationally, I mean those unconscious, edge of your vision, only-there-when-you-look-at-them kind of assumptions) you expect to see pathology everywhere. Everyone is on drugs. Everyone has hepatitis. Everyone has low grade psychosis.

One of my friends went to a seminar on child protection, three days of speaking about the unspeakable, talking with people where you can't keep looking and you can't look away. Lunchtime on the third day he went out to get a yiros and walked passed a playground and there was a father pushing his giggling child on a swing and David said he wanted to kill him.

See? That's not rational thinking. Thats not an un-messed-up mind.

Like I said, I don't know the mechanism, but it's like normal vision, it's like sight. Things that are closer appear bigger, you can end up believing that that is all that exists.

I suppose in that it's like love, in a way.

Anyway. I think all this is why my non-medical friendships are important to me. Most of my (few) friends are non-medical. Socially I only see one other doctor, and that friendship is based more on complementary character traits and political beliefs than a mutual interest in serum potassium levels. It's not that there is anything wrong with doctors as friends - I can think of several people I went through medical school with I'd love to catch up with - it's just that I find my work emotionally and intellectually exhausting after a while, and at the end of the day I'd rather do almost anything else than discuss serum potassium levels.

Plus, like every other group of people who work together who then socialise together there are really only two or three conversations that happen, and those discussions happen over and over again. There's a bit of "who's shagging whom", although I tend to miss out on that, and then most of the rest is either

1. How such and such a simple job was screwed up by someone else ("and the notes say by this time she's only saturating eighty two percent, so he keeps on doing piss all and doesn't tell anyone, an hour later they call the code...")

or

2. How those above us are screwing us over, and the infinite variations thereof.

I suspect similar conversations are happening every Friday night in every single profession. Think of the best job in the world - I don't know, for me it'd be running a well-stocked second hand bookshop somewhere nice - and you can bet whoever has it spends some of his or her time complaining about it - this year's caviar is not as good as it could be, and it's almost impossible to get a decent bit of eye-candy to wave those ostrich-feather fan things over you as you quaff another mouthful of wine with pearls dissolved in it.

Anyway, enough whining from me. Back to the kidney.
Thanks for listening,
John

Very Bad Things

Well,
I don't know if I'll be able to post this one - it's going to require some fairly heavy anonymisation. And it's deeply, deeply violent - consider yourself warned. But the two stories therein are so indicative of how the whole field of commuity mental health works - or fails to - that it seems wrong to keep them to myself.

I've never been a fan of true crime stories. There is some very good stuff - a book called Tough Jews by Rich Cohen, the Godfather, some of the Sopranos, most of Deadwood - but that's almost despite the subject matter than because of it. I've got a vague interest in gangster movies and such, stories set in the twenties and thirties, Jews and Italians and Irish and Poles sighting the Statue of Liberty, but that's pretty much it. The other kind of true crime story, some muttering thug dressing himself in giblets, bathing in synovial fluid and flushing someone's hair down the toilet, doesn't interest me at all.

Part of this is because my experience with truly violent men - several murderers, an unknown number of rapists - has been that they are not personally interesting people. At best they are mundane, at worst they are spectacularly boring. A violent criminal does not have something glittering and special within him, something dark and mysterious that you can just understand if you look hard enough, some conundrum that can be solved. He - and it's almost always a he - has a lack, an absence, is less than his fellow man.

Honestly. A man on one hundred and twenty of methadone, killed some guy with an axe - boring. My psychopathic ex porn actor rapist - tedious. My articulate and clean-shaven standover man - virtually unendurable in conversation. Seriously, every consult with him I run the risk of dislocating my jaw like those snakes who can swallow an egg.

Part of this is as a result of institutionalisation - much of prison life is deeply deeply boring. You are surrounded by people you can't avoid. You can't go anywhere or do anything, a fair proportion of your fellows are depressed and withdrawn, many of them are on sedatives. In one of the local prisons you get two books every three months*.

But part of it seems to be that violent crime, with a few exceptions, seems to be carried out by people with few other intellectual or personal options.

Somewhere in a psych ward in New Zealand, by the way, is the Six Million Dollar man. I have this on good authority from one of our new psych regs who did a rotation in Orcland about three years back. The Six Million Dollar Man is called so because this is approximately what it costs the Government to keep him safe.

He has a ward to himself in Furby House, New Zealand's largest psychiatric hospital, with two guards on twenty four hour watch. He wanders through this ward, dressed in his orange, fire-proof overalls, which will be his clothing of (no) choice for probably the rest of his life.

This level of care is necessary because of his level of illness. Over the course of the last twenty years he has amputated a fair amount of his body - several fingers, a hand, a foot, his genitals.

He sets himself alight. He has done so on several occasions. He has set other people alight, too, and thrown scalding water on them, and attempted to rig up something with an electric cord from the kettle to electrocute the psychiatric registrar (my friend). His forensic history includes a particularly distressing abduction and slaying.

Nothing can be done with this man. He is resistant to any and all antipsychotics - Julia suggests that this is in part because he shows no signs of psychosis at all. It is difficult to work out what is wrong because she was never able to establish a dialogue about his emotional state at all - "no real data about mood, consistently blunted affect". She used to wonder if he understood what she said when she asked about his feelings. He didn't seem to be happy, but then, he didn't seem to be unhappy either, and he didn't seem to be angry the time he tried to electrocute her with the electric cord from the kettle.

Anyway. There was a move at one stage, years ago, to reunite him with his people, him being Maori and all. They bought him all this stuff, put him in a four wheel drive, drove off to the region he'd come from. His people had heard about this, they were waiting at the border with clubs and rifles. Shots were fired. The Mental Health team van didn't get down past second gear, turned around and sprinted back to Orcland.

The nexus between mental health and crime is a nightmare, like those places on the coast where two oceans mingle. In the simplest analysis, a lot of forensic stuff is about punishment, making things worse for the prisoner, whereas medicine is about helping the patient. It's a complicated, torturous dance sometimes to convince yourself you're doing one when you know you should be doing the other.

And it's under-resourced and unpopular too. A few years back Mordor Mental Health - just down the road from here - had a patient called Jacob. Jacob had what we call "polymorbidity", or several potentially serious conditions at once. The several conditions included paranoid schizophrenia, and being poor, gay and Aboriginal. It is no surprise that Jacob was a frequent client of Mordor Mental Health services.

And his paranoid schizophrenia was particularly resistant to treatment too. His neighbours were plotting against him. They were murderers, raping and murdering all day and burying bodies all night. They wanted to kill him and get his social security payments - the princely sum of three hundred and eighty dollars a fortnight.

The psychiatrist bumped up his olanzapine until it didn't work and then switched him to clozapine, the "gorillacillin" of antipsychotics. Clozapine basically bludgeons bad thoughts out of you, but it takes a fair proportion of the good ones with it, and is one of the few antipsychotics that can actually kill you. After they got him on five hundred a day of clozapine he pretty much stopped complaining, evidently it was working, and eventually MMH was able to close their books on him.

And they never got opened again, because a few months later he turned up dead, one of the only male victims of the Saltwater rapists I mentioned earlier. Truly ghastly men. All day murdering and raping, all night burying people in the back yard.

Anyway. it's been a die of uninterrupted grue today, sorry about that. More cheer tomorrow, or at least less violence.

Thanks for listening (and sorry!)
John

*Me, I'd go with Shakespeare (Complete Works plus Apocrypha) and some kind of "Teach Yourself - " book.

Death certificates and the maiden

Hail,
Dr Hu's luck changed recently. And it's well deserved, too - he's an excellent RMO, and a pleasant fellow to be near, and a deeply decent human being. Smart, hard-working, easy to get on with, consistently cheerful and kind. It's about time something good happened to him, so I was pleased when four of his patients died last week.

I should explain. For a start, they aren't his patients, in the sense that he was not solely or even primarily responsible for their care. He is the RMO, almost the lowest rung on the ICU ladder, and all the (very) simple decisions are made by me and the (remotely) complicated ones by the consultants.

And it's not like these patients weren't expected to die - a certain proportion of the patients in the ICU are patients around whom much activity occurs - glowing screens, beeping monitors, blood and drugs being pumped in and out of tubes - but for whom not much can actually be done. There is a subset of ICU patients who come into the hospital so unwell that all we can do is forestall death until - and herein is often the problem - until the relatives and perhaps even the patient have had time to accept the diagnosis. All of Dr Hu's patients who died were of this category.

And when they do die it is often Dr Hu's job to do the death certificate, and then every morning someone from Records comes up and collects the death certificate.

Here's where Dr Hu considers himself fortunate. Because he is quiet and unassuming and polite, but he is also a man, and the death certificate babe is - well, she's quite clearly a babe.

I am serious about this. I recently entered that age where you look at nineteen year olds in closefitting skirts and blouses and think about how they must be cold, what with all this weather we've been having, and similar geriatric sentiments, but Dr Hu is young. And the death certificate babe has long glossy black hair and wears calf-high boots and a snug woolen skirt and every time Dr Hu sees her he blushes and smiles so much he could charm the dead.

He's much too shy to start anything. But she seems friendly, and lately he's managed to strike up some sort of a conversation, and she seems to laugh at his jokes and look forward to seeing him. It may be that something is starting to go on.

But time is short. Dr Hu's next rotation is orthopaedic, and nobody (usually) dies on ortho. He won't see her from one month to the next. What he really needs is a run of luck - good for him, perhaps (or perhaps not) less good for the patients - so that he can, in medical terms, "establish a rapport" and "construct a therapeutic alliance". Hopefully before that blonde guy from Palliative Care can, although Dr Hu has heard and hopes he might be gay.

Anyway. I've been helping where I can, giving him my death certificates to sign, and I suspect all fo the doctors and most of the nurses are secretly or not-so-secretly barracking* for him. There's not a lot else we can ethically do - I remain confident that none of our staff would go to the extent of making sure that someone dies on Dr Hu's shift as opposed to another doctor's, although the thought has clearly occurred to some of us. All we can really do is keep our fingers crossed for the young lovers and hope that the current harsh winter continues.

Thanks for listening,
John

*Barracking in Australia means "cheering, supporting, encouraging" - one barracks for a football team. In America this is called rooting. In Australia rooting is engaging in sexual intercourse. As sevral of our sports stars have previously shown, they may need us to barrack for them but the other they are managing quite fine on their own.

Dependent

Hail,
Lots has been going on. I may have to break this down into smaller posts, or it's going to get out of hand. So - today's post is two wildly different stories from the Drug and Alcohol files.

Today I am at the Drug and Alcohol job. It's raining outside, sheeting down, and in most normal practices that would mean fewer patients. But not my patients. Not rain nor snow nor dark of night will stop them from making their appointment. In fact, almost nothing does except a dimly glimpsed but troubling suggestion that the Great Australian Heroin Drought (2000 - current) may be coming to an end.

Anyway. It's not all heroin.

I have just finished speaking to a small, thin Vietnamese man, someone who is already old at forty. I feel I have done him no good at all. Throughout the consultation he hunched forward, blinking unsteadily at me, wearing a shapeless grey jacket and some tracksuit pants, nodding occasionally in a respectful manner, probably as close as he has got to being sober in the last few months. But I know he is only telling me what he thinks I want to hear.

He has, his doctor tells me, been drinking. And not just drinking, but drinking constantly, all day, every day, for as long as anyone can find out. It's common with my clients for the substance-of-choice to become more potent, cheaper and less safe over time - cigarettes become roll-your-owns, paracetamol plus codeine becomes oxycontin tablets crushed and injected - and Mr Vu is a classic example of this. As a thirteen year old he was sharing a sixpack of beer with friends and now his alcohol consumption is truly prodigious.

I do not say this lightly. I have seen men who drink five litres of wine a day, women who keep an open bottle of beer by the bed so that when they wake in the night they are not troubled by alcohol withdrawal, but Mr Vu is something special.

It is impossible to calculate precisely, but Mr Vu obtains two hundred litre barrels of methylated spirits and consumes them at a rate slightly more than one a week. If this is true it is two hundred litres of pure alcohol, two thousand standard drinks in seven days, almost three hundred glasses of wine a day. He mixes each glassful with lemonade to form a drink known as a white lady, a name that to me evokes drinking gin in the nineteen twenties, Etonians and flappers and pince nez and phonographs, rather than blindness, seizures and imminent and sudden respiratory arrest.

Anyway. Two hundred litres of methanol (it is available both as 95 and 100 percent purity) costs only two hundred dollars, making it remarkably cheap and accessible. I think he is already at least partially blind, but I know that precisely none of what I had to say to him impacted at all on him.

There's not a lot left of Mr Vu. That's what dependence is. There is the facial expressions, the physical form, the reflexes and the flesh, but not a lot else.

And just after that I saw Annabelle Trang. Cheerful, leafing through a magazine in the waiting room, almost glowing with health, who almost bounded in through the open door and told me that since we'd started her on the new medication she hadn't used, two months without, longest period without heroin since the late nineteen eighties, and her and her three kids were going on a holiday to Fang Rock. First ever holiday she'd taken her kids on.

"Used to be" she said "the needle got it all."

Well, it's got Mr Vu, and it's got a lot of people, it's got five of my clients since midsummer, but it doesn’t get all of them.

Thanks for listening, and more tonight.

John

Days of Wonder

Hail,

I did a very strange thing yesterday morning, one of the stranger things I have ever done. Details are as follows:

Mrs Chambers in bed four is not a well woman. There is fierce competition between her multiple diseases as to which will be the one to finish her off - at times the renal failure holds sway, then her heart failure will surge to the fore, recently her pneumonia has broken free of the pack.

Now she lies sedated, paralysed and intubated. There are multiple tubes and cords coming out of her and the blank faces of the cardiac monitor and dialysis machine stare off into the middle distance, like stangers forced together in a room.

Because of this she has tubes in her veins and tubes in her arteries and tubes in her veins and tubes in her bladder and throat, and today I got called to put another tube in.

"Have you ever done a pulmonary artery catheter?" Dr Black asked.

"I've seen one" I said.

"See one, do one, teach one" said Dr Black. "Set up and I'll be there."

So we painted Mrs Chamber's throat with antiseptic, laid the sterile towels over her face, and I put the tube in.

The procedure goes like this. You feel in the throat for the big pulse, the carotid artery. It's a little to the side of the wind-pipe. A little to the side of that is the internal jugular vein. They feel quite different - arteries go from the heart, they are muscular and have a pulse, veins go to the heart, they are flaccid, more floppy-feeling.

Anyway, you find the vein by sliding a needle into it (after injecting some anaesthetic). You can tell it's in the vein when you poke through and the dark blood flows back up the needle. If you've gone too far to the middle and hit the artery the blood is bright red and pulses - that's bad.

After you've got the needle in the vein, you slide a length of wire through the needle into the vein. Then you pull the needle out (not letting go of the wire, because if it slips into the vein they may need urgent surgery. I say may because they may go into an arrhythmia and die), and slide another needle over it and after that we thread a long, supple plastic tube, about the thickness of a drinking straw, into the vein.

This is where it gets remarkable. The tube has a miniscule device in it which measures things like how much oxygen is in the blood, how acidic it is, what the pressure is and so on.

And you push the tube slowly in through this tiny nick in the throat of this woman and watch the cardiac monitor and watch as the blood pressure around the end of the tube changes.

First, when you're in the vein, the blood pressure is low. It doesn't need to be high, it just has to get back to the heart.

Then, as the tip slides through the vein and into the heart, you can see the pressure around the tip jump, pulsing with every beat of the heart.

Then, as it emerges from the other side (it's gone along the vein, through both chambers of the heart and out into the big artery that goes into the lung) the pressure changes again - still high, but not fluctuating as much.

So you slide the tube in, and look at the monitor and think "Okay, the end of the tube must be in the start of the heart now, because the heartbeat's fluttering about a bit."

Then a few moments later you think "Okay, I've pushed it into the main part of the heart" and then a few seconds later you stop it because you realise it's where it's meant to go, the end of the tube is in this woman's lung.

Then you stitch it in and we can start using it.

There is something to this, something, I don't know, wondrous.

I don't know exactly how to communicate it, something shimmering and bright, something almost numinous. You get a bit of it when you take blood, when the needle punctures the skin and the dark blood jets into the syringe, you get a whole lot of it when your gloved fingers press up against someone's lung and you feel it rise and fall, inspire and expire.

Years ago I saw cardiac surgery, and I still remember the old man's heart, smeared and scabbed with yellow fat, lurching in the chest, until the surgeon poured the cardioplegic solution onto it and it stilled. And then, when she had finished, washing away the fluid and it started again.

I've got it a few times in psych, that same silent clarity of perception, that same "nothing else-ness".

Like I said, I don't know how to describe these things, don't have the words. But I know these experiences are not unique to me or to my job, to medicine. My brother, one of my favourite human beings ever, works as a boilermaker. He comes over smelling of grease and metal and, once, burnt linen.

Sometimes, he says, he heats up the metal until it is glowing, and instead of welding it, he lets it cool. Then he heats it up again, glowing red and orange and then gold, for no other reason than to see how beautiful it is.

Anyway, thanks for listening,

John

Guns and Roses

Hail,

Some stories seem so designed for a certain effect that you begin to wonder if there isn't, if not a Designer, a Writer or at least an Audience. Listen to this and tell me how fiction could have improved on real life.

Guns and Roses came to town recently. Twenty years ago they were one of the biggest bands in the world (as an aside, Slash is no longer a member, and Buckethead has been replaced by Bumblefoot - I am not making this up) - and they still have a sizeable number of fans. Older, maybe a bit slower and shorter of breath, but still as keen. And one of the keenest was Mr Stinson, a forty two year old man with a wife and three daughters who had talked of nothing other than the concert "for about the last three months", his wife said.

Seriously, he had all the stuff. All the albums and a couple of the bootlegs, framed tee-shirt, extra copies of the albums in the original packaging. Mobile phone that played "Welcome to the Jungle", tour jacket from the Use Your Illusion Tour, all the stuff.

Anyway, the big night arrived, and Mr Stinson (Guns and Roses tee-shirt, Guns and Roses bandana) and his wife left early for the entertainment centre and got into their seats early. The show opened with a bang and everyone was rocking on, up and dancing and pumping their fists in the air and half way through the chorus of "Paradise City" Mr Stinson clutched his chest and dropped dead.

An ambulance was called, but the situation was far from ideal, and by the time they started CPR fifteen minutes had passed. He came to us - I think the Royal was on bypass - and by the time ED got to him he had fixed, dilated, pupils and only the weakest, most tremulous heartbeat. Not enough of a blood pressure to get blood to his brain, barely enough to get it to his heart.

Florey responds aggressively to these cases. One thing we do is to cool the patients - drop their temperature down to thirty three degrees (that's 91 degrees F, from the normal 37C, which is around 99). We do this by packing ice packs in the groin and underarms, running cold fluids into their veins, sometimes putting a tube up their nose and into their stomach and running cold water into it, or using a fan and wet blankets. The colder you are, the less oxygen your brain needs, although it's more complicated than that.

Having said that, Mr Stinson was as close to death as it was possible to get. An "out of hospital arrest" is rarely survivable, one where there has been a delay of fifteen minutes between the collapse and the commencement of CPR even more so. When you shone a light in Mr Stimson's eyes nothing happened. I only saw him while he was intubated, and the combination of the deep, wide pupils and the large, earnest face was unsettling. His family clustered around his bed and played Gunners tracks to him through a walkman on his head, but numbers are numbers and there was talk among the doctors as to how long therapy would be prolonged. The projected outcome was extremely poor.

However, this seems not to have been communicated to Mr Stimson, because on the third day his heart began to recover, and on the fourth day he started to wake and on the seventh day they pulled the tube out and he was alive.

One would expect that after something like that there would be considerable neurological damage. There is no sign of this. Mr Stimson can move all his limbs, albeit weakly. He speaks, although his voice is hoarse. He recognizes and responds to family, friends, nurses.

But no-one goes that close and come out unscathed, and Mr Stimson has a considerable gap in his short term memory. In particular, the Gunner's greatest fan remembers getting in the car that afternoon - and nothing.

No Sweet Child of Mine, no Welcome to the Jungle, no Knocking on Heaven's Door, nothing. As far as he was concerned it hadn't happened yet. Apparently he took it quite well.

Anyway. There's irony - a word that also means "like iron", as in "this bridge is irony". Thanks for listening,

John

in London, crawling.

Hail
Late at night, a strong weather alert, and a few kilometres from here down on the coast people are sandbagging against the rising tides. Floods in Queensland, droughts on the peninsula and ice in the mornings here.

And I've been reading about London. For those of you not in the know, there have been two failed car bombings in London in the last week - parked cars packed with explosives and nails, set to go off outside a nightclub. Initial arrests have been made - I vaguely recall reading that Britain has more CCTV cameras per head than anywhere else in the world - and disaster seems to have been averted.

And the thing that surprised me at first was that every one of the suspects I have read about has been a doctor. A neurologist, a resident medical officer, someone who worked in the ED.

Now leaving aside the observation that these men are innocent until proven guilty, and leaving aside the whole trying-to-get-into-their-heads thing - was there some moment, some speaking of a still small voice? Perhaps when packing the nails around the explosives, maybe when weighing up the merits of this versus that nightclub? When was the moment when it all became irrevocable? - there are many things to think about in this.

First off, from my understanding most of "the terrorists" since we started noticing have been relatively wealthy, middle or upper class men. That may not be the case, in fact it may be survivor error, or the fact that only the wealthy, middle or upper class men have the socioeconomic grunt to, say, emigrate, get a pilots licence, hire a car, that sort of thing. But from what I understand a number of the people relatively high up in al Quaeda, for example, are doctors. One's a paediatrician.

What would make "a doctor" do this kind of thing? Is it any different to what makes everyone else who does this do it?

I would imagine - and I don't know - that there are two main things that while present in most terrorists may be particulalrly important in the case of these doctors – loss of status and a tendency towards a certain way of thinking. And I should say that some of the following may offend some people.

There is a profound loss of status involved in being a doctor coming from, say, India to Australia. For a number of reasons being a doctor here is a lower status profession here than being a doctor in India. For a number of other reasons being an Indian doctor is a lower status profession than being a white - British, American, European, Australian – doctor.

Part of this is a perception (by patients, nurses and doctors) of inferior clinical skills, a perception which I believe is generally untrue.

Part of it is a mutually frustrating communication barrier and a consequent presumption of stupidity. I never felt as stupid as when I was overseas.

Part of this is a natural patient xenophobia that is magnified in times of terror. When you are having a heart attack, you are reassured when you see someone who looks and speaks like you, and you are terrified when you see a stranger.

Part of it is Australia’s two hundred year old tradition of racism - which, before you judge us, got us this whole damn continent.

Part of it, ironically, may be a class thing - I did work with a very competent, pleasant man, a top researcher in India, who when he wanted some menial task performed would produce a small bell and ring it. That's the way it was for him at home. If he did that in the Florey ED they wouldn't have found the body.

Part of it, for the English bombers, may even be a dissonance between the idea of England that they were raised with and the England of now.

Anyway, enough guesswork. But when you get a young, educated male, one accustomed to and who has worked towards and is entitled to a certain position, and you exclude him (overwhelmingly it's "him") from that position – I suspect that one by one you are removing the control rods.

The other part of it is linked to what kind of person does medicine. Without wishing to go into detail, many doctors come from wealthy backgrounds. They are more likely than average to be religious. Some may have come to medicine from a desire to help - to fight poverty, disease, injustice. They tend to be "doers" rather than contemplators. A proportion of them are believers.

With that in mind, and if packing nails around explosives primed to go off around a night-club seems utterly alien to you, consider the following thought experiment. Imagine if the situation were reversed.

Imagine, unlikely though it may seem, that in one hundred years the Chinese political/cultural/linguistic/military bloc occupies the space where the Special Relationship does now.

Imagine, moreover, that in Melbourne there are thousands of amputee children, that in Manchester our young men disappear overnight, that in Maine and Michigan our men** curse, cringe and obey, in Mississippi our women uncover themselves for bits of chocolate.

Who is going to buckle under? Submit, keep their head down, do the best for their family and friends, try to keep things going, keep themselves and those they care about alive?

Most people, I suspect. Most of life is that series of miniscule alterations and iterations, stuff that happens rather than the carrying out of vast plans. The thing about insuperable odds is, well, they're insuperable.

There's your vast majority of Iraqi people - like most of the French in the early forties, like a whole lot of examples.

But some of us will not see it like that. Some among are is going to take the other path. Strike back, make a stand for liberty, our children, our land, our people? Drive a car packed with explosives into a Buddhist temple, semtex and nails outside a nightclub in Shanghai, execute the journalists who record our degradation?

Who will those people be, what will be their characteristics? My guess is it will be those who've lost most. Those least accustomed to humiliation. Those with a tendency to do, rather than merely look on. Those with beliefs compatible with sacrifice, ideas about eternity, strong feelings about injustice, maybe even those with a desire to help those less fortunate. Humanitarians - albeit pipe-bomb making ones. A fair few may be doctors.

Anyhow. Back to the study or whatever.
John

*My experience has been that there is minimal difference in clinical skills. Of the three truly bad doctors with whom I have worked, one has been overseas trained - probably around what you'd expect from chance. The other two were Australian born and bred, including the infamous Dr Knuckle. For overseas doctors there is an initial settling in period, but after that and once they become familiar with Australian clinical presentations, things even out.

**Nail this poem to the church door. Worked for Luther.