Thursday, September 27, 2007

I can quit any time I want to...

And a variety of small thoughts today, interspersed with bits of me banging on about my life - no great themes here.

Tomorrow we pack up and leave for the coast, a brief family and friends visit. Tonight Sarah is stuffing cats into boxes and ensuring that all of her cat-show paraphernalia is packed (combs, claw-clippers and cornflour) in her Doctor Who suitcase. I am travelling light (leaving space for books and plunder). I am hiring a car and driving down to the south coast, seeing my sister and my mother and travelling close to the area where I grew up - something I have been wanting to do for more than ten years. It should be wonderful.

And I have tidied up at work as much as possible. I have a co-worker - Dr Suresh, a deeply pleasant man whom I fear may perhaps be a little too courteous for this area of medicine. He is a competent and clever man, one who may end up as a renal specialist or a consultant endocrinologist, and he has access to that vast amount of data they somehow shove into your head in some of the Indian medical schools. However, I suspect he has some difficulty with some of our patients.

Case in point - I received a urine drug screen result from Mr Gouger the other day. This showed that, aside from the prescribed medications, Mr Gouger (squat, bull-necked, seven years for armed robbery) had been using a traditional plant-based herbal remedy (probably about three hundred dollars worth of heroin a day), and had been caught by the pharmacist diverting his anti-heroin medication (spitting it out of his mouth, either to inject it into his own arm or sell it to another person for that purpose). I had written Mr Gouger a letter, via his pharmacist, telling him to come in and see us, and explaining that we would be changing both the type and amount of his medication. He saw Dr Suresh. Dr Suresh documented the following in the case-notes:

"Mr Gouger has indicated that he would prefer not to change to buprenorphine-naloxone and that he feels he would rather stay on 6mg than increase his dose to the suggested 16mg."

A few days later the pharmacist rang and asked me what was going on. I looked in the notes and was momentarily dumbfounded. In a similarly genial vein, Dr Suresh had agreed that the recent request of Mr Grote (tall, thin, eight years for attempted murder and four for assault occasioning grievous bodily harm) for a week's worth of morphine tablets that he could just pick up at the pharmacist would be less irksome than having to turn up every day and swallow the methadone in front of our new pharmacist, and would save both petrol and bother.

Anyhow. I wish Dr Suresh well, and suspect he is destined for great things, but I suspect perhaps not these things.

The other day, as part of my wondrous new post-shift-work life, I went to the gym. First step was a fitness assessment, which is like something out of the Inferno:

Midway upon the journey of my life
I found myself within a small room, nude
For my once-limber body had been lost.

And as I stood upon the trembling scale
A woman, slim and stern, with burning eye
And abs on which a walnut could be crack'd

Assailed me with a caliper and pinch'd
My handles d'amour until I hid
My face...

And so on. Anyway, the striking part of the assessment (besides how many times she used the phrase "...for someone your age") was the readout of body fat percentage and so on. They measure all this by putting electrodes on you and measuring impedance, etc. I learned that not only was my percentage of extracellular fluid below average (the shame!), but there, written down by a machine in scientific looking text was my body weight (ninety five kilos), my lean body weight (seventy one) and my total body fat (twenty four kilos).

Striking mental image, isn't it. It's hard to get the image out of your head that somewhere in me is that seventy kilo man I used to be, embalmed and presumably suffocating under the twenty four kilos (that's close on thirty litres, almost eight American gallons) of fat.

God. It's good to know what you're dealing with and everything, but you can see that this is how those disorders start.

I don't know. I have deeply ambiguous feelings about the whole gym thing. One the one hand I love it - I know my mood is directly correlated to how much physical activity I do - the morer the betterer. And I love being able to hit the punching bag - to be able to go out there and jolt it with a gwa sau combination, or a jab-cross-hook. I love being able to do things.

But the Southern Mental Health division could do a sweep throught the place on a weekday about ten AM and fill the inpatient psych beds for the State in an hour. I think many elite sports-people are a little bit mad, but I have yet to meet a professional bodybuilder who was not all that and then some.

Anyway. I am filling up the time I previously spent studying with reading - currently this, pick it up, it's a hoot. I am able to go into the lounge, wander from book-case to book-case and inhale, picking out handfuls of books, each one potentially too wonderful to be left any longer. Currently we have Borges - Complete Fiction, and A Good Scent from a Strange Mountain. Next is Cold Mountain, and then this and then I'm going to try and hunt down this atlas I saw - I feel very self-conscious talking about this - of hominid evolution, and then I am going to try again to read some of the books I have been unable to finish - 1984 (too terrible) and the Shipping News (just too damn good - I kept reading bits out, or just closing the book and sitting there lost for words).

Somewhere in there maybe my anatomy book, but to be honest, maybe not. To be honest, life beckons.

Anyway. I suspect I am now on the borderline between bibiliophile and bibliomaniac. I do fit some of the criteria for dependence - I have found myself having to have a book first thing in the morning as an eye opener, people have angered me by suggesting I read too much, and so on. Like the secret drinker I have books hidden in various places around the house - the desk, the dinner table, the bench where I stand and eat my breakfast in the morning - anywhere I can sit or stand or lie for any period of time. I have several small books I can carry with me, like hip flasks.

Anyway, off to read. I will leave you with this mediaeval curse against book-stealers - sorry if you've heard it before:

For him that stealeth, or borroweth and returneth not, this book from its owner, let it change into a serpent in his hand & rend him.

Let him be struck with palsy, & all his members blasted.

Let him languish in pain crying aloud for mercy, & let there be no surcease to his agony till he sing in dissolution.

Let bookworms gnaw his entrails in token of the Worm that dieth not, & when at last he goeth to his final punishment, let the flames of Hell consume him forever.

I'm doomed, sad to say, but it's been worth it.

Thanks for listening, post again Tuesday,

Monday, September 24, 2007


And herein a post where I try to work out what I'm going to do about Patrick Mawson.

Patrick Mawson - I suspect I have described him here under another name, but I tend to lose track - Patrick Mawson is a thin, chronically dirty, flaxen-haired man with a thin, vaguely mosquitoid face. He speaks in a low whine, and, if the analogy is to be pursued and the unpleasant truth be told, he has not worked since nineteen ninety two. He was recently returned to us from Central after a period of disciplinary pharmacotherapy, and from Thursday he will be my problem again.

And the problem is complex. First of, to my shame, is the problem of "negative counter-transference" - the phenomenon where the doctor experiences feelings of hatred, fear, etc. towards the patient. I don't know if this is true negative counter-transference - transference involves the unconscious redirection of feelings, and I am quite aware of the dull ache in my heart whenever I see Mr Mawson's name on the patient list, and the way the sun outside the office goes behind a cloud, and no birds sing.

(I just looked this up and it may be that the appropriate term for what I feel is parataxic distortion. I don't know if that is the right term or not, but it such a cool, fifties science fiction term that I am going to use it. I reckon with Mr Mawson I have about eighty dioptres of parataxic distortion - I may need glasses).

But another part of the problem is his pathology. Mr Mawson has back pain (a bulging disk) and chronic gastro-intestial reflux. Although he is careful to distance himself from "the junkies", and dwells on his disgust for them at least twice a visit, his records indicate he was sent to us because he was injecting his medication, which he says he was doing because of the pain. While in prison he was sent to a psychiatrist who suggested "a complex mix of cluster B and C personality disorders with predominant narcissistic, antisocial and dependent traits" (I know the psychiatrist - it's possible she had a bit of parataxic distortion, too).

But now he's out, and we are in the difficult position of managing Mr Mawson. The meetings rarely go well. He comes in wanting treatment for his pain, I am only trained in and authorised to treat his opiate dependency. Dependence on prescribed medications is a difficult area - in a narrow sense of the word I am dependent on ventolin. But doctors are okay with prescribing ventolin and are, almost always, not okay with prescribing some of the most efficacious pain and anxiety relieving medications.

This is because the medications only work really well initially. It's like alcohol - when you have your first drink, a glassful gets you drunk. Later, if you drink regularly, it's two or four or a carton and a half a day. And like alcohol, with the opiates and the benzos you get withdrawal if you stop suddenly, anxiety or pain or sweating or twitching or whatever. Shitting and vomiting ten times a day. Can't sleep. And so after a while you are drinking (or taking pills) just to feel normal.

And the tablets don't last as long as they used to, you have to take more and more. And now the doctors are getting iffy about prescribing for you, doctors who used to be alright, faces change, and you get the runaround, place after place closing up on you, and you're in pain and your guts hurt and your heart's beating a hundred times a minute and can't they see this is making you worse? The worst thing for your pain, the worst thing for your anxiety? Doctors, who are meant to help you?

Obviously, all of this - the cancellations, the last minute changes, the waiting for hours in the doctors surgery only to get nothing, be treated like a junky - it gets you angry. And a receptionist or a nurse says something, you say something back, you're banned.

No-one understands.

If it weren't for other people like you, people in the same situation who can spot you a couple of tablets when you're desperate, you'd go under. And they can't be expected to keep giving you tablets, that's not fair, so you end up buying them, fifty dollars for a grey nurse (100mg morphine), two bucks for a valium (5mg diazepam). So you pay.

And you know, because people tell you, people who've found themselves in the same situation, when things get out of hand, when things get really bad, you can make things go further by injecting. That way it doesn't get chewed up by the liver and you get more. Little needle through the skin, into the blood, straight to the brain.

Things tend to go bad relatively quickly after that. Mr Mawson got hep C, turned bright yellow, and while he was sick six big Asian guys* came in and beat him up and took his stuff, broke three ribs.

But how did it get to this? Injecting your medications? Having to buy stuff off some drug dealer instead of getting a script from a doctor? If the tablets were as bad as they say, how come they were willing to give them to you in the first place? Who's fault is this, anyway?

Anyway. Difficult things to manage. Because the pain is real, and the dependence is real, and Mr Mawson's suffering is palpably, demonstrably real. And doing this is not like other fields of medicine, where the patient comes to me because s/he's sick, and we both sortof agree on what's wrong, what s/he wants fixed, and we come up with a plan and the patient goes away happier. This is pleading, and concealing, and emotional blackmail, and on occasion threats (rarely against me directly, usually of harm the patient will suffer, and the dire consequences, and the guilt that will be on my head).

I don't know. I promised to treat pain, to relieve suffering, to help. And my prescription pad sits in my desk, probably glowing like an object in a video game. I can relieve pain, I can ease suffering, in the short term I can help.

But one of the big problems we have in the city is cleaning up after Dr Hindpaddock, a physician frequently under investigation by the medical board. Dr Hindpaddock (by all accounts a deeply pleasant man, bearded and jolly) is a private specialist, and so free of many of the restrictions the government places upon me. He believes, and I quote, "there is no maximum dose of opiates. There is no maximum dose of benzodiazepines." He has patients on three different opiates and two different benzodiazepines a day, he prescribes daily doses two or three times the dose that starts to get me worried.

I rang up one of his ex-patients a year or so back to change an appointment with her. She was a zombie. Horrible thing to say, but true. Slept all day every day, house all dark all the time, slurred speech, hadn't got out of the house except for a doctor's appointment for fifteen years.

That's what worries me. That plus the undeniable correlation between high doses of methadone, high doses of benzos and high risk of death. We had five deaths here in the south at the start of the year - none from people on the programme caused by anything I'd prescribed, but close too home. Someone who jumped off the programme, overdosed a month later. Someone bingeing on speed, didn't sleep for five days, car into a salmon gum on Stone Highway. Another died of pneumonia, another what I reckon was a bleeding stomach ulcer, another cut his wrists in the bath. People who die early.

Anyway. No real solutions here. Thursday I see Mr Mawson and I will disappoint him again. Another reel, another jig, another round of this danse macabre.

Sorry. And as a PS I wrote a letter to a senator which cheered me up a great deal and probably won't even get me sacked. I will see if I can post a bit of it.

Thanks for listening,

*This seems unlikely, if only for reasons of economics - six guys of any size would not be needed to force their will on Mr Mawson.

It's amazing how single white guys never commit any acts of violence in this town. It's all gangs of Aborigines or Asians. No wonder the National Front wants them out.

Tuesday, September 18, 2007

Lightning strike

Got my results from the college today. They included an analysis of the exam I failed - I passed the viva and got fifty seven percent in the multiple choice. Unfortunately the pass mark was sixty. Each multi choice quesiton is worth one and a half percent - I failed by two out of ninety questions.

Such is life. It was probably two of the endocrine ones. But I passed the hard one.

Anyway, I am writing to you today with covered in a faint, bronze-coloured sheen. Because it's a hot day, I've been out hitting the punching bag, and for the last two days I've been taking rifampicin, which, the advisory sheet says may cause "discolouration of bodily secretions". So currently, I sweat a yellowy-orange colour and, were I to be moved to tears, I would cry a yellowy orange colour.

Bronze John indeed. However, on the good side for the next few days I have probably got additional protection from leprosy.

This is all because of Nyssa Menninton. Nyssa had been brought to the ED by her mother a little over a week ago. Her mother had went around to her house and found her slumped on the floor, unrousable, having lost control of her bladder and bowels. She brought her into the ED. ED found her cold, drowsy, battling an overwhelming infection of some kind*, and with a blood pressure so low it could barely be measured.

However, she was young, and otherwise fit, and she resonded well to initial therapy, fluids and antibiotics, so she didn't go to the ICU, she went upstairs to the medical ward.

It's difficult to reconstruct entirly what went on in the medical ward. Some of it is relatively clear - there was an Xray taken on arrival, it appeared normal, there wasn't another one taken later on. There was a single urine culture and a blood culture - both were clear. She was treated as if she had an occult infection and put on some relatively high grade antibiotics. Much mention was made in the notes of her poor self care, her head lice and her toenails, and her unco-operative attitude. Less mention was made of the fact that no-one ever found out where this infection was coming from and thus what antibiotics were best for it.

One week later she was discharged. The medical entry on the date of discharge reads in part "white cell count twenty one, bicarbonate eleven and falling" and then notes she was discharged. The medical discharge summary, were it to be translated, would have to read "Ms Mennington was found almost dead. She clearly had a life-threatening illness. We don't know what it was. She's still very sick, so we've stopped on of the antibiotics and we're sending her home. A nurse will check up on her in a week."

I am aware of this because regardless of the outcome of this admission, someone is going to be called in to explain this.

Nyssa Mennington went home where she continued to deteriorate. At two in the morning her mother checked her for a rash, it wasn't there. At eight thirty she was cold, blue around the lips, still speaking but seeming confused. Her skin was covered in dark purple stains, irregular around the edges, as if she'd been dabbed with cotton wool. Don't click on this if you are easily upset (if you are, here is a less distressing image of purpura). When the ambulance arrived (less than two days after she left) she was breathing fifty times a minute, body temperature low thirties, blood pressure was again undetectable.

Anyway, we have done everything we could. Pumped her full of fluid and antibiotics. She has bilateral pneumothoraces - her lung has collapsed on both sides. When we Xrayed her her left lung had come away from the inside of her chest and collapsed to less than half of its normal size, and this meant that her heart and aorta were being pulled over to the right side of her chest. I painted the side of her chest with disinfectant, injected an inadequate amount of anaesthetic into her chest (between the ribs on the side) and we poured opiates into her veins while I cut through skin and muscle, felt my way though fat and pleura and pushed my gloved finger into the space where her lung was meant to be. Instead of the rising and falling of the lung there was profound** emptiness, so I asked for the chest tube - the slim, plastic tube we were going to push inside her chest to let the air out.

That's were things got a little weird. Every time she breathed in there was this sucking, farting noise, and bubbles formed, and when she breathed out, fluid came out.

The air coming in was sortof expected. I tried to stop the air getting in - air getting in would push the aorta (the huge artery that carries blood out of the heart to the brain and the rest of the body) and the heart further over to the right, the wrong side of the body. if you pushed the aorta too far it would kink, the heart couldn't pump blood out, there would be sudden, massive heart failure, and Nyssa Mennington would be dead with my hand inside her.

The fluid coming out was another matter. I slid the tube in and she coughed. Some fluid spat out of the hole in her chest. A small amount, maybe a mouthful, of what we call serosanguineous fluid - clear fluid stained with blood.

"Nasty" said one of the ED doctors. "Big infection"

She coughed again. A larger amount, maybe a cupful.

"This often happens" said the ED doctor. "Stictch it up."

She coughed again, and straw-coloured fluid with clots of blood in it hissed out. It squirted over the floor, flooded the bed, spattered my gown. I stared through my facemask.

"Hmm" said Dr Umesh. "I've never seen that much before."

Nyssa went into a coughing fit. With each cough fluid vomited out of the hole I had made. Dr Umesh took over in time to have his facemask spattered with blood. He drew the tube back minimally.

"I wonder what else this could be" he wondered aloud. I ran through the possibilites -

"Ladies and gentlemen of the jury, you have heard how Dr Bronze, by his own admission, inserted the chest tube not into the lung, but into the abdominal cavity of the deceased - "

"So, putting a chest tube into the spleen - that's a common mistake. She may have had slightly unusual anatomy, and I'm sure you took that into account. What are the primary anatomical relations of the spleen, anyhow?"

"I'm terribly sorry, Mrs Mennington. During the procedure, the tube entered - I put the tube - accidentally - into Nyssa's heart."

"Mate, buy me anuzza drink - another drink and I'll tell you about when I used to be a doctor - until I put a chest tube into someone's brain."

She continued to cough, and fluid continued to gout out. I asked for the gelfusin to be turned up - not that it would do any good in the short term, but it looked like I was doing something - and Dr Umesh, radiating calm, continued to withdraw the tube micron by micron until she stopped.

"Hmm" he said. We went and got an Xray, which showed that we had not pierced the heart or the brain, and in fact had put the tube pretty much in the right place. It was slightly ambiguous on the matter of the abdomen - it did not rule out the possibility that I had somehow gone in through the lung, then withough noticing extended my finger ten centimetres and shoved it through a big sheet of muscle into her abdomen. However, considering the chest tube was behaving exactly as if it was in the right place, and the patient seemed better, rather than worse, and her heart was now in the right place, and we were getting air, not peritoneal fluid out of the tube, I began to relax.

"You worry too much" said Dr Umesh "It's no big deal." Dr Umesh had not been there a few months ago when Dr Black accidentally put the chest tube into the spleen.

Anyhow, we took Ms Mennington upstairs. We still don't know what is wrong with her. Currently we are treating the two pneumothoraces as spontaneous, which is unusual in someone of her build, even a smoker. We are treating the low blood pressure, the high fevers, the rash as meningococcal sepsis - hence all possible contacts have been given antibiotics that turn their tears and sweat yellow.

If she had fulminant meningococcaemia - "aemia" means in the blood, "meningococcus" is the name of the organism, "fulminant" comes from the Latin for "struck by lightning" and is similarly grim - if she has fulminant meningococcaemia she has less than a thirty percent chance of survival. And that's without two collapsed lungs.

And I don't know. There is something else going on in this woman. She has had a partial gastrectomy - part of her stomach cut out - because she ws addicted to codeine. Codeine (heroin for beginners) is not sold separately here - the only way you can get it easily here is when it is combined with paracetamol or combined with ibuprofen. This means that once you get addicted to codeine you end up taking vast amounts of these combination tablets - thirty or more a day for months at a time. This means vast amounts of paracetamol (acetominophen), which damages your liver, or ibuprofen, which damages your stomach. Often the damage done by these combination medications causes more pain, which the patient treats with more codeine, and so on.

Anyhow - there is something underlying this. Some psychiatric issue, some substance dependence. She is malnutritioned. She has rotting teeth, mouth ulcers, head lice, she is covered with scabs that look like dermatitis artefacta - a symptom of a psychiatric illness where you pick at yourself. Or maybe formication - often seen with amphetamine abuse, where you pick at the insects you believe are living under your skin.

Her mother swears blind she is not "on drugs", but I have given her my drug and alcohol services number. If she lives through this - which is actually unlikely - I have asked her to call.

Anyway. There is something going on, something profound, something dangerous and deadly that we missed the first time. I hope she lives so that we can find it and fix it.

Thanks for listening,

* White cell count sixty two point five. Anything over eleven is high.

** I've tried to think of another word that best explains this and I can't. There is something numinous about this, something that so far exceeds my ability to put it into words that it is stupid to try. There is something about having your hand inside the chest of another living, breathing person, feeling a hollowness where you should feel substance - I don't know how to say it better.

Thursday, September 13, 2007

Not cold, not dead.

And back at the ICU, for about another month. I have already spoken to Doctor White and given him my resignation, effective end of this month. The reasons I gave were multiple - nothing to do with the amount of work or the quality of the supervision, everything to do with my own depleted stores of time and energy.

Although, having said that, I have found the entire rotation rather disturbing, on occasions dislocating. Medicine is often counter-intuitive - surgery is cutting people with knives, anaesthesia is gassing them or injecting them with poisons, protecting your child from disease may mean injecting them with dead - or even live - viruses. But ICU, existing as it does in that penumbra between life and death, has more than its share of weirdness.

Take Mrs Blaske. When I walked in this morning the staff were working tirelessly on Mrs Blaske. A nurse covered her with a blanket, another changed the bag of saline that was running into her veins. Dr White shone a light into her eyes, listened to her heart, tested her reflexes with a tendon hammer. What they were doing was fairly urgent, her family would be here within the hour.

So we had less than an hour to get her healthy enough to be dead.

The story goes like this. Mr Blaske had called an ambulance around midday the preceding day. His wife was not breathing. The ambos had instructed him in CPR while racing towards their house, sirens and lights, both sides of the road. They had resuscitated her on the bedroom floor.

When she was found she was "in asystole", a term used to describe the complete absence of heartbeat. Several shocks later, in the ED, a slow, faint heartbeat emerged. She began breathing spontaneously a short time afterwards.

However, a CT scan of the brain showed diffuse anoxic injury. An overdose of benzodiazepines, codeine and alcohol - even an accidental, recreational one like Mrs Blaske had had - causes a diffuse depression in the part of the brain that instructs the heart to beat, the chest to rise and fall. Fewer and fewer synapses fire, the electrical signal becomes weaker and weaker, it is hard to avoid the image of a flickering light dimming, or an echo dying down. Eventually, breathing and heartbeat stop altogether.

Some time after that - there is no way of knowing how long - Mr Blaske woke and started CPR.

Now, Dr White was in the difficult position of explaining the fact of Mrs Blaske's death. It is a difficult, horrible task at the best of times, the most terrible news that anyone can hear, and the most difficult news to give, and in this case it was made harder by the fact that Mrs Blaske was lying on the bed, warm (occasionally blushing), and breathing, and with a strong and vibrant pulse.

Having said that, part of this was due to the chemicals we were running through her veins, and part of it was because different parts of the body die at different rates. Previously it was believed that hair and nails continue to grow after death, we now know that it is common for hearts to beat and lungs to fill and empty. Mrs Blaskes brain was irreparably damaged, and death was coming "not in haste, but irrevocably".

So, in order to be able to say this without a shadow of a doubt, Dr White was required to fulfill the legal requirements of declaring brain death, and in order to do this, Mrs Blaske had to be warmed to thirty seven degrees (ninety eight for those who still use Imperial measurments) - there is a saying I heard in the ED "you can't be cold and dead". Previously doctors were required to ensure that the patient's electrolytes (the chemical in Mrs Blaske's blood) had normalised, and check that the levels of certain drugs had to drop to pre-determined levels.

The reason behind this is to avoid wrongly diagnosing death. Very high levels of opiates or alcohol in the blood can mimic death, as can extreme cold. " Muscle relaxants" - powerful drugs like curare - can be difficult to distinguish from death, and severe glandular problems - I don't know, but I am guessing some profound thyroid abnormalites, anyone who knows feel free to set me right here - there are a lot of things to exclude.

But Mrs Blaske did not blink when we stroke the surface of her cornea (the white of her eye) with a tissue. Her pupils remained vast and dark when Dr White shone a bright light into them. When we reached into her mouth with a smooth tongue depresser - like a popsicle stick - and touuched the base of the back of the throat she did not gag.

"Lastly," said Dr White "we assess vestibulo-ocular reflexes".

One of the nurses handed him a 20 mL syringe - without the needle - full of cold water that had been standing in a slurry of ice and water for the last five minutes. He bent over Mrs Blaske, touched her eyes with the finger and thumb of his left hand and murmured "I'm just going to open your eyes now, dear, and then a bit of cold water". Then he slid the tip of the syringe deep into Mr's Blaske's left ear and pushed the plunger.

He stared into her eyes as he squirted ice-water into her ear. "No response" he said. A nurse wrote it down.

"What's meant to happen?" I said.

"Nystagmus. COWS," he said. Nystagmus is a rapid, twitching motion of the eyeball. "Cold opposite, warm, same. You inject cold water - you get nystagmus towards the opposite side. Warm water - about forty four degrees - you get it towards the same."

"Ahah." I said.

"There's footage of one of the ambos having it done. He volunteered," said Dr White. "Water goes in, eyes start twitching, then explosive nausea and vomiting. Neurological analogue of motion sickness."

Anyhow. Much more to talk about, but I am going off to spend time with Sarah. Her arthritis is actually fairly bad at the moment, hence the shift to nine-to-five. We had an MRI done and her immunologist reacted with horror and she is being sent to an orthopaedic surgeon. I would rather not talk about this now but she may need surgery, and I feel she is too young for that.

Anyhow. On that sombre note, I shall go off and reply to comments.
Thanks for listening.

Sunday, September 09, 2007

Small Idea

First off - failed one, passed one. All through the preparation I knew I was better at physiology than pharmacology. Phys just seemed to stick in my head, pharm wouldn't. I didn't have to work as hard at phys, it seemed to come relatively easily, whereas pharm I had to hammer in. And the phys exam was relatively straightforward, both the written and the viva, wheras the pharm multi-choice was tricky and the viva bloody hard.

So I was pretty sure that I'd done a lot better in one than the other. And I was right. The noticeboard said passed pharm, failed phys.

Yep, failed the relatively easy one, the I always found relatively sensible, the one where the examiners smiled and nodded and said "don't worry, that was good". Passed the hard one I knew I couldn't understand, where I guessed between two equally unlikely alternatives in the multiple choice section and where the examiners frowned and shook their head or waited, pointedly, for answers that never came.

Anyway. It's over now. If I ever study again, it won't be in the next month. I am taking said month off and reassessing my priorities. And thanks again for the comments.

Now, the following few paragraphs have proved rather difficult to write, and my cringe-o-meter is going off as I do so. But here goes.

One thing I noticed wandering around Melbourne in my post-exam delirium was the mix of ethnicities. Mordor is white-bread white, Melbourne has tv ads in Greek, shop fronts with the day's specials written in Arabic, huge Vietnamese and Cantonese communities - and correspondingly, some of the best food I have ever tasted.

Now, someone explain this to me: why, in situations like this, when you get what my grandmother used to call "mixed race couples" (dead set), it's alway the Caucasian guy and the Asian woman?

Seriously. It got so I was counting, and in two days I saw eleven couples. Eleven European-looking men with Asian-looking women. Exactly no cases of the reverse, no Asian-looking men with women who looked European.

Why is this so?

I have a few theories. They're not really well thought out theories, and they're white male hetero theories, and they're rather difficult to express. But maybe it's something to do with our ideas of the mysterious, feminine East, all passive and hypersexualised, the sloe-eyed and obedient woman scrubbing your back and pattering around the immaculate house on her tiny feet.

Maybe it's something to do with the succession of lenses through which we see: that progression from such and such a physical appearance to such and such an intrinsic ethnicity to such and such a set of sexual, moral and intellectual characteristics. If you have straight, glossy black hair and you don't have an epicanthic fold, you must be an Asian. If you are an Asian, you must be
submissive and hyperfeminised and mysterious and so on. So, if you're a certain type of white male, anyone who looks a certain way is going to have a certain appeal*.

And I'm not in any way suggesting that every European-looking man who goes out with an Asian woman is hoping for a geisha girl - although I think any European-looking man who only went out with Asian looking women might benefit from asking themselves that question. And I am aware that there has to be some kind of process going on the other way - Asian-looking women choosing European looking men. I am just wondering if this European man plus Asian woman thing is seen other places, if it is exclusively Melbourne or exclusively me, or there is any reason for the disparity.

Interesting, by the way, to look at the outcome of European wars in Asia over the last century - and I'm using Asia here to mean anywhere that Westerners think of as Asian, anywhere east of Turkey. We rational, masculine, straightforward folk haven't done that well in the mysterious East. God knows how we managed to be defeated so many times - I don't know how the enemy managed any kind of co-ordinated military strategy with all that talking in mysterious utterances and smiling quietly and stroking the beard - but it happened.

Anyway, it's been very frustrating writing this because I know I haven't had the words. it's like when you write about evolution and you write "gazelles evolved to run faster" when what you really mean starts with "a series of random molecular events..." and finishes with "more gazelles in the population that run faster". I don't want to write that someone with Korean great grandparents who is fourth generation Australian, mono-lingual, has never been north of Queensland and plays centre-half back for the Bidyadanga Emus is "Asian", but it's a shortcut you end up using.

Anyway. Enough on this. I am going out to hit the punching bag and revel in my freedom.

Thanks for listening,

Tuesday, September 04, 2007


Later this afternoon I get on the plane to Melbourne. Wednesday, Thursday, Friday is the exam, Saturday home, next blog post Sunday.

See, the way I see it the exam has a number of purposes.

One is to make you study and learn stuff, which I have - although, to be honest, a lot of medicine for me has always been trying to pour ten litres into a two litre bucket. I read about the anti-arryhthmics. Then I read about the antibiotics and push that into my head and that somehow displaces the knowledge about the anti-arrhyhthmics. Then the chapter on the antipsychotics pushes the antibiotics out. It all leaks out of my head faster than I can put it in.

I sometimes reckon if you could see it, like if there were special glasses you could put on, you could track me at the moment by the trail of displaced knowledge. It'd look like little glowing droplets, or maybe whorls and clumps and tangles of gnosis. You'd see piles of it around the table in the spare room where I study, a fair bit soaked into my pillow, some of it on the couch where I lounge to watch Dr Who videos. If I ever read a particularly challenging chapter (probably renal handling of potassium - if they ask that we'll have a very quiet two minutes while I tell them about my mum's banana bread, which she always said was high in potassium) it'll diplace some essential knowledge like the answers to "where do I live?" and "what is my name?".

Luckily I'll be able to reconstruct many aspects of my life by following the trail of displaced knowing, like Theseus in Knossos.

That's an uncomfortable mental image, isn't it? I go into the exam room and get harangued about the aminoglycosides by a vast, bull-headed man. I can't remember the volume of distribution of gentamicin so I stab him with his own horn and flee, winding up the ball of wool as I go. And then drive home with Sarah. As long as I remember to change the sails on the Saab.

Yes, well. Another purpose of exams is to winnow out those who are somehow not suitable, not "the right stuff". I reckon this might be the case with me. The exam is going to be hard for me - sorry this sounds so whiny - because it's exacly the kind of thinking I'm not good at - split second decisions, hard data, definitive answers. I've tried to learn to do it, but my brain is wired up different. Oh well, swings and roundabouts.

And the third is to help people decide if this is what they want to do for the rest of their lives. Again, this may or may not be me.

Anyhow. We shall see. The last few days I have been so disengaged from study I have not looked at a book, operating on the "change will do me good" theory. I've spent the time reading and filling my wish-list on See, I am not just another white Anglo male with no exit strategy. After Sunday, and after a decent (and occasionally indecent*) holiday, I am starting my book.

And thanks for the good wishes. My feeling is I'll win either way. If I fail this - and anyone with any experience tell me if this plan is realistic or not - I want the novel to be started before Christmas and maybe finished before next.

See you Sunday,

*Cringe, cringe, sorry for the smut.

PS: Quote I read somewhere: "Asking the current American administration for advice on illegal drugs is like asking 1970s South Africa for advice on race relations." Not that I agree entirely, but it's an interesting analogy.