OMG, ICU!

Hail,

No over-arching theme, just globules of news here.

I went down to the ICU the other day, to check things out. The reasons were several - I wanted to meet the consultant, I haven't worked in an ICU before and wanted to have a look around, that kind of thing.

It's a fairly small ICU, a combined ICU/HDU (ICU is intensive care, HDU is high dependency) and at the moment there are only about ten patients in there. The small numbers of patients and the longer duration of their stay means you get to know more about their illness - every half a degree rise in temperature, every five percent fall in a white cell count. On the bad side of it the mortality is about twenty percent - one in five of those admitted to the ICU will die there.

This is very different from the ED - death is actually a rarity. For every fatal heart attack or teen car accident or elderly woman in terminal heart failure we would see maybe nineteen people who either get admitted to the hospital or get sent home. The vast majority of ED work is non-life-threatening stuff.

(Another cutting edge paper, by the way, recently published in the Medical Journal of Australia, suggests that the more overcrowded the ED is, the worse it is for patients - they are more likely to be dead in ten days' time if the ED is overcrowded than if it is not).

So I stood in the ICU and stared about at the ten patients and half my mind was wondering which two out of the ten it would be - the middle aged man in kidney failure, the bloated teen who'd taken an overdose, the diabetic woman with the post surgical infection and pneumonia*. In the background the ventilators hissed and the monitors bleeped and the consulting doctors murmured.

Another thing - again, present in the background but not stated - was the events of O-day, and my few days in the ICU at the Royal. Nothing either of us wanted to bring up, but there. I received a package from the College today and a letter from the Medical Board. The package was something on keeping Emergency Doctors alive - I don't know if it was prompted by the recent death of Dr Green or if it just followed on from it. I looked at it - a big workbook, full of exercises on boundary issues, avoiding burnout, that kind of stuff, and thought that this is exactly the kind of thing Dr Green would not have had time for. Too touchy feely. He'd be too busy working to look at burnout, too busy caring for others to worry about self-care, that kind of thing.

The other was a confirmation letter that I was permitted to practice full time again from the start of this month, subject to regular review, but any further events of this kind within the next two years would prompt a review of my registration.

I don't know how to explain how that made me feel. I can see their point. You can't have impaired doctors practicing - the truth of the matter is we do, as I speak the Board is investigating for the squillionth time the activities of one Dr Medellin, who prescribes vast doses of opiates to high risk patients as a matter of course, eight times the maximum safe doses we prescribe.

For the health workers out there, that's one thousand milligrams of methadone a day, plus a handful of benzos, unsupervised dosing. Write that script without your hand shaking.

And simultaneously Dr Norman, who has again - I stress the word again - been called up before the board because he allegedly prescribed methadone in exchange for sexual favours and domestic chores. Happened in Queensland, struck off or something, came over here.

You know that voice in your head that says "Maybe they're right, maybe I don't know best, maybe I'm fucking up here?". Neither of them have it.

Having said that, I think the problem with letters like that is the temptation they create to conceal your illness from your treating doctor. Every time there are penalties attached to admitting a medical condition that medical condition is concealed. Nurses turn up to the opiate unit and lie about their job. Alcoholics threatened with revocation of their licence and who drink a carton of draught a day tell us it's a glass of red wine after a meal with friends. Junkies pockmarked with holes tell us they're not injecting.

And people in my position are tempted to minimize things like disturbed sleep, recurrent morbid thoughts, that kind of thing.

The thing is, the last few months have cost me over ten thousand dollars, when you add up lost earnings plus hospital fees and so on. And that's just monetarily - when you factor in socially, professionally, personally, I found the whole experience profoundly unpleasant. Unpleasant enough to want to do almost anything to avoid a repeat.

But of course, the problems with concealing your illness is you don't get better. Like anything else. Doctors are only as good as the information they are given, and if you want to get really sick really quickly, presumably you can sit there and lie to your physician till your heart's content - or at least until you start swatting the hallucinations out of the sky.

Anyway. One of the reasons I am allowed back to work at all is this whole "insight" thing - when I am unwell I am almost always aware that I am unwell. I know I was sick and I know I am better now, and I know I will get sick again sooner if I don't take the medications. And I know, like most patients know, that it's a bitch taking the things and that the weight gain, the excessive sleep, the other less unmentionable effects aren't worth the consequences - personal, professional, whatever - of not taking them.

And I know that if I was as certain of what I say as I sound, I wouldn't have to be writing it down.

Anyhow. In truth I cannot wait until I start at the ICU. Monday, eight AM, for a twelve and a half hour shift among the intubated, the septic, the jaundiced and the dying. Can't wait.

Thanks for listening

John

*Possibly her, which is very unfortunate.

Insulted

Hail,
Graphic medical, language and sexual stuff ahead warning.

A rather vexing session at the Drug and Alcohol Service today. I was SMO (senior medical officer) on, which is an administrative term for an enforcer. Basically on these days it is my job to help people negotiate the vast distance between what the patient wants and what we are going to give to him or her.

This is often difficult for all concerned, because on the one hand our clients are in need, in terrible need. I have seen acute opiate withdrawal, mostly in the prisons, and it is a truly horrible condition.

(Heroin withdrawal, by the way, is very unlikely to kill you. You might be one of those truly unlucky people who vomits and inhales your own vomit, which may well kill you, but aside from that it is a period - hours and hours - of aches and shivers and cramps and diarrhoea and misery and wishing you were going to die, but very little chance of death.

Alcohol withdrawal, on the other hand, can kill you. I believe withdrawal from the benzodiazepines (common sleeping tablets) has killed some people, but I'm not sure. Other forms of withdrawal, on the other hand, may actually help save lives).

So, our clients are in need, but we can't and don't give them what they need. Why is this? Well, methadone prescribing in this state is very tightly controlled. You have to turn up physically to get your dose and swallow it in front of the pharmacist. If you manage to get "take-away" doses they are limited. If, God forbid, you lose one of the take away doses - the dog eats it, say - you have to bring in a death certificate from the vet to even get a look in.

Anyhow. Client number one was a woman who presented wanting immediate admission to the ward for a five to ten day detox then an admission to one of the longer term facilities for a minimum of three months. Like everywhere else, there is a waiting list. I explained this to her and there was a lot of sobbing about how I was literally driving her to prostitution and we went through the various options (emergency accomodation, medications to help get her through some of the withdrawal, that kind of thing) and none of this was any help at all and that was that.

Number two was a man who had been caught diverting his dose. Diverting the dose means you don't swallow it, you take it outside and spit it out so you can inject it later on. We don't let people do this because they are more likely to die if they do it than if they don't. He had been caught on video, which was a first because for the last week or so when they went outside his girlfriend had been obscuring the video with her hand, and had had to have a restraining order issued against her by the pharmacist - it was all very complicated.

Anyhow, we told him we would not be prescribing him that particular medication any more, we would instead be prescribing him one that can't* be injected, and we discussed that. There was much shrieking and railing and threats - apparently the entire service is going to be closed down Monday, we will all lose our jobs, that kind of thing - and then he arced up.

We tried to explain things, but to no avail, and as a final paragraph, he explained how he was going to get us shut down. Rather than cause offence, I will translate some of the terms he used into more neutral phrases.

"I'll fucking have this place closed down" he shrieked. "You'll all be out on the street come Monday."

"You are free to appeal against the decision - " began our social worker.

"You don't reckon I can?" he screamed. "Listen boy, I've [engaged in more acts of oral intercourse with prominent political figures] than you ever will. I've [performed acts of the previously described nature] like you wouldn't believe. You'll all be out on the fucking street."

There was the briefest of silences, and I spoke again.

"Look, I can see you're angry. At the moment - "

"Don't fucking talk to me. I've [engaged in more acts of anal sexual intercourse] than you ever will. I've [been the recipient of said acts] from judges and politicians. This place'll be closed down. You'll be [performing acts of receptive intercourse for monetary payment]."

At this point neither the social worker nor myself knew what to say.

"Look -" began James. "All we -"

"I've [performed a truly remarkable act upon a political figure not usually known for that kind of thing]. How much [of this particular act] have you done? You better get to it because I'm going now to [perform said act upon a number of people] and get you all struck off."

He stalked towards the doorway, wheeeled and paused, one hand on the door. "You'll be sorry you tried to [perform yet another sexual act] upon me."

And that was that. I don't honestly know what was going on there, if underneath all that there was some kind of delusional something, if he was disinhibited, something to do with the frontal lobe... or if this was just how he expressed himself.

I'll leave clients three and four for another day. But no wonder voter disenfranchisement is so high. I've felt so disengaged from the political process this last decade or so because I've obviously not been going about it the right way.

Anyway. Will post soon.
John

*well, yes it can, but it's not as good

Futbol

Hail,
The symptoms continue, but rather than whine about myself, I have decided to post a few links to stuff I find interesting.

Here are some modified romance novel covers I found amusing.

Tyrone Brown looks to be getting out soon after only seventeen years in prison. That's the problem with getting tough on drugs - lack of political will.

And here (and possibly only for those of you interested in Australian Rules football) is a partial list of what happens when you get testosterone-fueled young men and subject their behaviour to scrutiny.

This last is a contentious issue, and you can ask three different people and get eight different opinions. Bearing in mind everyone is ignorant until proved guilty yadda yadda (although it's a lot harder to get proved guilty if you've got a five hundred thousand dollar a year lawyer than if you're the aforementioned Tyrone Brown) , it's disturbing to see the sheer frequency of reports of sexual assault and violence against women in this list.

I don't know if professional sports players are more likely than average to commit sexual assaults. On the one hand the club culture supports them. It gives them a feeling of invulnerability that is all too often justified - try searching the list for AFL players actually convicted of sexual assault - and the clubs rewards richly on the playing field what society only ineffectually punishes off it. These are young men selected for their ability to physically and mentally dominate their opponents.

On the other hand, and I don't know if it's true - who knows if those statistics are that far from the average? Perhaps we see a high rate of sexual assault in this population because we are looking for it, because we subject these men to more scrutiny. Who knows? Maybe the only thing more dangerous to a woman than a strong, aggressive, physically dominating young man is a number of them working in a team.

Christ knows. And this without the whole debate as to whether we want good footballers or good people. Do we want players who can kick goals or do we want people who have worked in soup kichens? When it comes to midfielders maybe we pick Ben Cousins (brilliantly skilled elite athlete with alleged links to organised crime) rather than the Dalai Lama (some ball-handling skills but probably vulnerable to physical pressure and hasn't really performed in front of goal) because the purpose of sport is essentially combative. It is a form of war. We watch because we want to see our enemies destroyed, their cities overthrown, their fields sown with salt.

And if it's a war, how do women usally go in wars?

Anyway. Enough misery. Will post again soonish, do comments hopefully tomorrow.

By the way - a quick poll. Toby found the following



image on the net and says it is a dead ringer for me - it is actually Mad King Ludvig II of Bavaria. He actually had to call his wife in and exclaim upon the fact, remarking particularly upon the eyes. I do not believe this to be the case. Few of you will not have seen me in vivo, and even fewer will have seen me in my full-length ermine cloak, but any opinions on this matter would be gladly received.

Thanks for listening,
John

Gather Yourselves Together

I had a medical student today. The Royal sends them, fifth years doing their eight week psych rotation, spending a few days at the alcohol unit, half a day a week sitting in with our psychiatrist, that kind of thing. I hope it's valuable - I spoke to a pathologist on the phone the other day about a patient and she was quite emphatic.

"Tell your patient he's drinking too much" she advised me, speaking about my fifty-standard-drinks-a-day* man with the end stage liver disease. "Tell him to just be sensible".

Hopefully our guy will learn more than that. And Alex seems keen - a tall, golden-haired fellow, the kind of person they would have called strapping and clean-limbed a century ago, keen for "one of the specialties", not emergency, or psychiatry, and not general practice. And he seems pleasant enough. "Quite cute", Sarah says, which I admit may be in some small way responsible for my initial wariness.

And he is keen. Although he prefers to hold a clipboard when talking to patients, understandable nervousness I suppose, and when he does hold it he holds it like a shield between himself and the patient. And when that is not available he stands with each hand grasping an end of his stethoscope, which he has slung around his neck, one hand just above the bell, another just below the ear-pieces, which gives the impression of a nineteenth century lawyer in a frock-coat asking the accused to repeat a particularly damning piece of testimony.

But he knows the questions, and asks them in the appropriate order, and does the physical examination like it's not the first abdomen he's prodded, and I get to sit in the big chair and watch, which is pleasant enough.

Today Alex saw his first two patients. The first was Mr Gleer. Alex had to lean in close and ask his questions slowly, and Mr Gleer did his best to speak as concisely as possible. He is a well dressed, angular man, polite and deferential, and his voice is like rain on slate, sibilant and soft. He had, or perhaps has, oropharyngeal cancer, and three years ago they cut out the base of his tongue, took out numerous lymph nodes, part of the bone of the jaw, his larynx. A year ago he found it had crawled into his sinuses - they have told him that will be much more extensive surgery. He cannot speak much louder than a whisper.

Fifty years old, smokes a pack and a half a day. "It's like this, doctor" he says. "What's the worse that could happen?"

He is not in treatment for his cigarette problem - interestingly, we have no inpatient treatment for nicotine withdrawal, although we regularly have people booking in for management of their marijuana withdrawal, and about a year back someone rang me and asked if he could book in to detox from his ear antibiotics.

Instead Mr Gleer is in for alcohol withdrawal - alcohol is one of the three big causes of oropharyngeal cancer, along with tobacco and being cursed by a particularly malevolent god. He says he drinks three bottles of spirits a night, but it soon becomes clear that these three bottles of Jacks are diluted with water - it's still a lot, but not enough to kill him.

"I have to hide them, doc" he tells me, his eyes bright, his voice like the curl of the sea on the shore. "Otherwise my wife drinks them." Both only started drinking a few years ago, after the diagnosis. "It was mainly the teeth" he continues. "I had radio and chemo therapy, all my teeth dissolved, I got ulcers everywhere. They said wash out your mouth with a little alcohol. That's where it started."

He is having treatment at what used to be the Oncology Clinic at the Royal. Now it's been remodelled, big letters, Cancer Clinic. "Yeah" he says, "thanks for reminding me".

"How is it going? The cancer?" asks Alex.

"I don't say I'm cured" he says. "I don't say I'm in remission, I don't say cancer, I just say..." and he shrugs.

When he shrugs you can see a deformity, where surgeons lifted up the skin over his chest and throat and took away the flesh beneath. There isn't a word.

Alex performs the physical examination almost in silence, just the soft instructions - breathe deep, clasp your hads together, relax. I sit and watch the deft twitches of Mr Gleer's hands and feet, his reflexes under the tendon hammer.

After that, we chat a bit. He has a brother who is working as a security guard. "He's really a harpsichord teacher. But there isn't a lot of call for keyboard instructors now. So he does security guarding in the night and harpsichord teaching when he can. He's really polite."

And then he goes, walking slowly out, hat on head, seeming much older than his fifty years. Alex and I look at each other, he raises his eyebrows, blows out his cheeks as if he's worked hard.

"Incredible" he says, not holding his clipboard or his stethoscope. "That's incredible."

I don't know what they expect students to get out of this rotation. Like I said, if they get enough to be further ahead than the pathologist I spoke to earlier, that'll be good. But I suspect Alex, even without the cute, will get further.

Thanks for listening,
John

*About seven bottles of wine a day, every day, or a bottle and a half of spirits.

Fog

Hail,
I went over Jeremy's today. Jeremy is a friend of mine, someone who's appeared in this blog a number of times before, so heavily disguised I suspect his age, race and sex have changed more frequently than anyone else's. It was Jeremy (at that time tall and red-headed) whom I had detained in the Royal earlier this year, five o'clock in the morning, late autumn, the night of the first real rains. It was Jeremy, who at the time was on five different psychiatric medications and was still deeply, deeply unwell, whom I drove to Clearwater a few months later where he was detained again. It is Jeremy, who when he is well, is arguably the smartest human being I know.

(At Uni he got the science prize for each year he attended, and the Honours prize, and numerous offers from numerous places to do his PhD, and there were three separate boards with his name on scattered around the science wing, and so on. Incandescent bright. Thank God he wasn't in the same year as me).

Anyway, since earlier this year Jeremy has been unwell. There has been a lot behind this. He moved here from the East coast, that's a big stress. He got a new employer. His ex-wife, a brainless and vicious narcissist, married again, which knocked him around a bit, because he's only ever been a one-woman man. A variety of things.

So since early last year he's been unwell. He is on onlanzapine and amisulpiride, which are two antipsychotics, two antidepressants and a mood-stabiliser/anticonvulsant, what he describes as "handfuls of tablets" a day. His psychiatrist is one of the best in the state, and what few guidelines exist for the treatment of the 'difficult' bipolar patient suggest precisely what Dr Bedlam is doing.

And they also suggest maintenance ECT (electro-convulsive therapy, the old electric shock treatment), which is what Jeremy's getting. Currently* three times a fortnight - Mondays and Fridays on one week, Wednesdays on the next. Lately things have been going downhill, so Dr Bedlam has switched things back to twice a week - Mondays and Fridays. This fits in nicely with our study days on Tuesdays.

Tuesdays I do pharmacology and he studies to get into medicine.

Now, some readers may find this difficult to deal with. This is a man who has not really been mentally well for close on a year. In that time he has been hospitalised more than five times and detained twice. He suffers delusions, sees things that aren't there, has fragmented sleep, impaired concentration, inappropriate guilt, frequent thoughts of self-harm. He is certainly not well enough to practice as a doctor in his current state. However, in his defence, when he is well, he's cardiologist or neurosurge material.

Anyhow, I went over there today, a day after his ECT. His father, an amiable and unobtrusive man, was there, pottering around in the background. Jeremy poured me a coffee.

"Do you have it black or white?" he said.

"Black" I said. It's been black since adolescence. With the ECT you have to tell him some things every month.

"How's your cousin?" he asked. "Tell him thanks for the barbeque"

"Good, good". A few visits ago Jeremy had come up to our place for a BBQ, sat and chatted with our friends for a few hours, ate lamb and fresh fruit and drank his allocated one standard drink, went home and had ECT. The next day he came up to visit again, saw the chairs and tables scattered around and asked if we'd had visitors.

"No worries"I said. And we discussed the football, and whether it was worth getting Foxtel, and a few completely normal things like that, and he seemed superficially well. And then he talked about the exam (the medicine one) and the questions they were going to ask.

"They have a section on current events" he said. "I know nothing about current events".

"Relax" I said. I've been doing a lot of de-panicking with Jeremy. He's not used to not knowing stuff. "It's not current events as such"

"Uh huh"

"It's not like the latest half a percent interest rate rise and so on" I went on. "It's more about big themes. They have some texts and you have to read and respond, compare and contrast. It's about how well you can express yourself, argue a point, that kind of thing."

"Big themes" he repeated. He seemed reassured. "The big stuff. Self-expression, constructing an argument...Good....good."

I have been spending a fair part of the last few months reassuring him. He seemed reassured by what I had said. I have to tread carefully with this. If there's something he can't remember and he asks I always tell him, but I try and balance that with putting it in context, stopping him panicking or falling into despair.

I warmed to my task. "Like they won't ask you about - I don't know - they won't ask about who heads the House of Representatives in the US, or the name of the socialist candidate in next year's French elections. They won't ask that. It's more if you're arguing something maybe you'll do better if you can mention some seminal event."

"Excellent" he said. "So just the very basic stuff. Like what?"

"Like the twin towers. September eleventh, that kind of thing."

"Mmmm" he said, and looked at me. "What happened there?"

Smartest guy I know.

See, a year ago I was all for ECT. I say "all for ECT" not in the sense that ECT sessions should be slathered about like shampoo and that every home should have one. But I thought ECT was under-rated and under-utilised, compared to either unmedicated severe prolonged mental illness or to the pharmacological treatments for those severe prolonged mental illnesses.

Deep, prolonged depression is hideous in ways words cannot describe, it is a season in the abyss, a growing old in the dark and the cold, a deep somatic loneliness that holds your heard like a fist. I have almost never been sick, aside from the bipolar, but people who have been have told me they would rather have would rather have almost anything else - dental or renal pain, acute pancreatitis, one of those "just a virus"'s that turns you into the living dead for a month - than depression.

And as stated too many times here - the drugs make you fat and sexless, they give you diabetes and make your hair drop out, they make you sweat and give you pimples and make you nauseous from the moment you wake up until the moment you go to sleep. That's not counting the more unusual side effects, such as the less-kinky-than-it-sounds "taste perversion" (paroxetine and others) or drooling, delirium and death (clozapine).

But ECT. The more I see the less I like. And admittedly this is just one person, and it's one person getting a shitload of ECT, more than once a week for more than six months. And it's someone who's also really depressed - and depression affects your concentration, your memory, your interest in things around you.

But he was smart, confident, clued up and aware. Knew lots about politics (voted conservative, but came from a very rich family), could talk about stuff. All of that seems gone.

I don't know. I don't know what the answer is for him, I don't know what's going to be tried next. But things aren't going that well. The exam's in two months, if he fails he'll fall apart. I'd be feeding him sardines and breaking out the horse tranquilisers, I'd be hospitalising the entire family like I hear some places in India do, I'd be trying bloody anything. Because it's not working.

And if Jeremy was here he'd tell you.

Thanks for listening,
John.

*Don't you dare

The Adventures of Tutter in the Uncanny Valley

Hail,
While waiting (and waiting and waiting) to be cleared to go back to full-time work, I have been thinking desperately about what to do with this blog. It's easier to write when things are going well, but you've got more to write about when things are going badly, and at the moment things are going well... badly. There's the good, for which I am extremely grateful - going down the pub with friends, meeting my best friend from the coast at the airport later today, going to twilight movies with Sarah last night... but there's also the bad. And as stated, I'm as sick of talking about the bipolar stuff at the moment as everyone else is of hearing it.

So - what to write about? What will people will find interesting, what is something that will resonate emotionally or intellectually with them, what is something that they will want to read?

Well, I'm going to write about what I've been reading about. Most recently I've been reading about fear and the Uncanny Valley. Fear because the oldest and strongest emotion of mankind is fear, as HP Lovecraft said.

I'm going to write about fear.
Specifically things that make me frightened that perhaps should not.
Even more specifically, muppets.

Dead set. I don't by any stretch mean a phobia, or a terror, or a fear where I run screaming from the room whenever Tutter


(and isn't that an inherently un-nerving name? Doesn't it evoke "titter", as in to laugh insanely in a padded room, and "tetter", the archaic term for an ulcer, and "totter", to be precariously balanced on the edge of a precipice, on the verge of falling to your death and being dashed to pieces on the rocks below? Plus there's "trotter", the cloven hooves of the Devil Himself?? See? Proof! Proof!!!) -

Ahem.

Not that I run screaming from the room whenever Tutter appears on the television screen. But muppets have always ever so slightly creeped me out, to the extent that I prefer to avert my eyes when they are on the television screen.

I offer no rationale for this. I don't know if it's the unblinking eyes, or the un-naturally high pitched voices, or the un-natural ways in which they move, zipping from one side of the screen to another, or their faces, either inexpressive or too expressive - or the way they move their long ropy arms in that sinister way - but muppets have always struck me as somehow creepy, un-natural, wrong. Unheimlich, as Freud said.

I remember visiting Toby, and we sat in the lounge while his chocolate-advertisement beautiful son watched the Bear in the Big Blue House, and at one stage Tutter went into the walk-in wardrobe and was singing a song, and all of a sudden all the shoes in the cupboard opened their eyes and started singing along. They had big goggly eyes and flappy kind of mouths where the sole comes away from the upper part and they sang and danced about. And, as my niece would say, it weirded me out.

I read up on the whys and wherefores of muppetophobia - there is a community out there, presumably the sworn enemies of the plushies - and the most interesting idea I've read about with has been the idea of the Uncanny Valley.

Basically the Uncanny Valley (and it's only an idea) says that our emotional responses to something non-human change as that non-human something looks more and more human.

Here is the original graph:

An industrial robot, or an egg-whisk, for example, is unlikely to strike anyone as either particularly adorable or particularly repulsive.
A stuffed animal, or a humanoid robot strike people are attractive and interesting in a way that the egg-whisk isn't. The likeable-ness of the object increases as you go from eggwhisk to stuffed animal, like going up a hill.

And things get more and more likeble the more and more lifelike they are... until a certain point. At this point (and different people will have different points at which this happens) the by-now-very-humanlike thing stops being likeable and starts getting creepy.

That's when we get things like those automaton-like shop front dummies, or cinematic zombies, or those remarkably detailed prosthetic limbs. The feelings they excite are not "aww he's cute", but "gaah, he's ghastly". After the hill there's a valley. The creepy looking kid from the "Polar Express" lives smack bang in the middle of the Uncanny Valley.

(There's a whole thing here about how cute things fit in and what makes things cute that I won't get into, the whole big eyes big head baby thing. I remember having a discussion about this with a friend who seemed to have a more highly developed sense of cute than I did, trying to work out what made something cute. We worked out that if you got a normal sized pencil, with a rubber eraser on the end, and sharpened it back to only a few centimetres, that pencil would be cuter than a full sized pencil. Dont' understand cute, never will.)

Theoretically, on the other side of the valley, as something gets more and more humanoid are healthy human beings - and maybe one day, extremely life-like robots - and maybe after that you get idealised human figures (maybe like angels or the Buddha in repose).

Here, by the way, is a damn good book on robots, what the history of the mechanical person is, why they evoke the feelings they do in us. And remarkablew historical detail - mechanical ducks and flute-playing robots of the Restoration period, that kind of thing.

Now I don't know about this Uncanny Valley theory. I can see the evolutionary advantage of it - it maybe stops you breeding with the genetically unfit, or with other, closely related species like Neanderthals, and so on. But I don't know it is necessary, and I don't know that it's proved, or even that it's useful except as an interesting thought, but it is interesting. And I think there is some molecular evidence of Neanderthal-Homo sapiens interbreeding, not that that necessarily implies a lack for revulsion.

And it does explain why Tutter and his polyester-spawned ilk are so damn creepy.

Anyway - have to rest my googly eyes from staring unwinking at the screen, brush the lint from my furry and strangely tubular body and zip off to bed, all the time singing in a weirdly high-pitched voice*.

Thanks for listening. Only two weeks until I can start at the ICU, God willing.
John

*This was much funnier when Toby said it.

Referral

Hail,
Bene sent me the address of a blog to look at - 'tis here. It's a woman writing about her experiences with bipolar - the medications, the highs and lows, the whole thing. A lot more open about some of it than I am now. Give it a look.

If you do want to know about the experience, at the moment you'd be better off asking her than me. I am so bloody sick of it I can't express it, sick of talking about it and hearing about it and writing about it and reading about it and utterly, overwhelmingly, eminently, mightily, vastly, probably transcendently sick of having it.

The last six months or so - depending where I want to draw the line I can say this episode started three months ago, when I was hospitalised the first time, or six months ago, when I started to withdraw at work, eat my lunch in my office, not talking to people, maybe two years ago, just before my unsuccessful attempt at the Primary - the last six months have been abysmal. The highs have been absent, the periods of normality few and chemically sustained, the lows have put me in hospital, in secure psychiatric wards or in the ICU. They've cost me a fair slab of my professional reputation, they've damaged important relationships, they've cost time and money, they've put Sarah through hell and only part of the way back.

And the thing is, they are ongoing. I still don't sleep well without antipsychotics. I still respond to stressors with the same damning pattern of thoughts, the same churning, clunking mechanical progression along panic to self-loathing to suicidality. I still feel the guilt, heavy in my heart like a steel plate upon my chest, feel the loathing of those around me, radiating like cold. I still get periods where I eat crap, huddle in my room, won't see anyone.

This is what I'd expect. And I'm doing all the right things - I've managed not to get any fatter on the olanzapine via aggressive diet and exercise. I've got a good relationship with a good psychiatrist, who recently put me back on weekly visits rather than three-weekly, and most importantly I am taking the medications. And I have, the registrar from the medical board says, commendable insight. That side of it is going well.

Still, I am still sick, and things get to me that shouldn't get to me. I like the image of ruts in a country road, deep scores in the pale red earth, down the gravel road or across the paddock. Unless you have a firm hold of the wheel, when you drive that's the way you're going to keep travelling. I imagine deep indentations in the cerebral cortex, strong neuronal linkages, dendrites intermeshing with dendrites. My mind runs easily down the hollows in the road, only with difficulty breaks out into new ground.

But still. The repetitive thoughts are there, the moods, the cognitive stuff. I am not looking forward to seeing Dr Tesla on Wednesday, because I will have to tell him this stuff, and he will perhaps delay my returning to work, and while I can see his point in this, staying home loafing while my wife works to bring sorely needed money into the house only exacerbates the situation. I depserately want to get back to the hospital and do something. One part of depression that I hate is the way it encourages you focus on yourself, even encourages others to focus on you, as if somehow this behaviour should be rewarded.

Anyhow, these are stupid thoughts. It is late, I have to get up early to drive my niece to work. The gym tomorrow, and maybe some boxing, fix my bicycle, build a compost heap. Do something useful with my life.

Thanks for listening, and I promise to be both more interesting and less whiny next time.
John

Six Gun Gorilla and the End of the World

Hail,
Been thinking about comic-book gorillas* and the end of the world, and trying to make sense of things, and I wonder if anyone here can tell me if this is reasonable. Horrible stuff ahead, and may contain traces of politics.

Years ago, sandwiched in between some old Green Lantern stories and something about the Metal Men, I read a comic-book gorilla story that changed the way I think about the world. It was written in the forties or fifties, and it was, I think, about someone called Congo Bill, who lived in the jungle with, I think, a faithful negro retainer. Congo Bill was a man who, for reasons too complex to get into, could and did change minds with a gorilla. The plots of these stories were remarkably consistent:

Congo Bill hears about crime,
Congo Bill swaps minds with very large (and conveniently nearby) gorilla,
the now-remarkably-intelligent-and-remarkably-large-gorilla swings through trees* to fight crime while the gorilla-minded man raves and gibbers in padded room,
the crime is solved, evil is punished, the mind-swappy thing is reversed and normality ensues.

I immediately loathed and despised Congo Bill. The reason for my deep hatred was that the stories were deeply, almost didactically racist.

The story I read started out with a black man's face, nasal cartilage pierced by a bone the size of a giraffe's femur, peering through the aspidistras. The text box reads "After centuries of darkness, civilisation has finally come to the Dark Continent".

Next panel shows Congo Bill, European explorer/hunter/civiliser three-in-one type, standing around, looking to solve crime.

Then we get the crime, mind-swap, the swinging through trees, etc. etc. I know that gorillas don't swing on vines, but the writers didn't, and didn't care.

And at the end the hilariously garbed African chieftain says words to the effect of "Thank you, Congo Bill, for showing us that our primitive beliefs were only childish superstitions". Or it may have been "our childish superstitions were only primitive beliefs ", can't quite remember. Truly horrifying stuff, nowadays.

Anyway. How does this get to Saving The World?

Well, unless you've been living under a rock, you'll have heard of the most recent IPPC report. There is a download summary for policy makers here. A more succinct summary is that things are bad - admittedly only in the world - and that things will get worse. It would seem that the rate and extent of further deterioration, how much worse things get how quickly, depends partly on what we do now here today.

Important stuff, one might think, if it's true. And with the weight of 2 500 fairly senior climate scientists behind it, each drawing on years of scholarship, stuff that might just possibly be true.

But if you ask some people (ten years old, but still a damn good article) , things aren't actually that bad. Global warming isn't happening. Or if it is, it's a completely natural phenomenon. Or if it isn't, it's probably going to be good for the planet. Or if it isn't, there's nothing we should do about it anyway. And anyway, it probably isn't happening.

You can read these people's comments on the net. Their industry-mandated squealings are published in national newspapers, they get television interviews and column inches and appear in interviews to provide the impression of "balance". These are the people who took the money that the 2 500 climate scientists who wrote the IPCC report rejected, although I think you only get to be called a sell-out if you have something to sell, if you don't shill just for the thrill of it.

Anyway. I could bang on about this stuff, and at home I do. I usually bang on to Sarah for about half an hour as we drive, gesticulating ever more frantically as Sarah smiles and nods, and finishing with blaming untrammeled capitalism. But that's not the point of this.

The point is, you look at the writer of Congo Bill. He was writing in the forties and fifties. No civil rights, no Rosa Parks, no nothin'. He was the product of a deeply racist society. Science and medicine and history and religion all said pretty much the same thing, that there was a hierarchy and that white hetero Anglocelts like me were at the top. You could open encyclopedias and read about the natural superiority of the white man.

I don't know, I don't know the guy, but I think maybe he was doing the best he could with what he had. Like most of us, like pretty much everyone.

But I can believe that about the writer and illustrator of Congo Bill in the forties and fifties, but lately I haven't been able to believe that about the guys who write in the Australian today.

I find it difficult to believe that they can't do any better, that they they never, ever have doubts, that they can't see what is more and more obviously apparent. I don't know that they never hear that still small voice, that flicker of self-doubt, the thing that says "But what if we're wrong?"

I don't know. I once decided that, as a Christian, I was going to try to seek out and understand the people whom I found hardest to forgive. Not understand in some kind of analytical way, but in a "judge not", inside the skin kind of way. Understand what it might be like, say, to only be sexually attracted to twelve year old girls, or to have a that flat, metallic rage against a woman that made it feel perfectly natural to burn her with cigarette butts just because you were bored. Working in the prisons, doing psych, I think in some way all that was part of this.

And for the people in prisons, and the people in the psych wards, I reckon it's worked a bit. I can see people now, where before I could only see pathologies, see someone trying instead of just something broken.

But for the allegedly well adjusted people who week after week grind out this stuff about the sea-levels, the drought, the fires... that's more difficult.

And I can understand that when you've invested a lot of time and energy in something, it's hard to change your mind. And I can understand, maybe, growing up seeing the worst excesses of command economies, how you'd be deeply, almost reflexively averse to anything that challenged the gains made by what you think of as individual liberties and the free market.

But for God's sake, boys. Two and a half thousand scientists. Tens of thousands of species. A planet.

If you can't admit it now, when can you?

Anyway, like Foilwoman says, people don't learn from people arguing about stuff with them - in fact, most people don't learn anyway. I am firing up the bicycle and looking at deep-litter stuff for the chooks (you know what I'm trying to say). But I feel catharted, anyway.

Thanks for listening,
John.

*Writing this my mind went from Six-Gun Gorilla to the other gorillas of Silver Age comics: Gorilla Grodd, Karnak the Living Beast Bomb, Terrifo the Science Ape, Big Julie, a fearsome gangster gorilla with a gun that turns others into apes, and, from what I recall, one called... Tracy.

I don't know why, but some part of me thrills to this kind of thing, to the innocence and enthusiasm of the writers and readers, to the idea of a time when that's what the fiction and the world could be like. The writers cramming as many ideas as possible on a page, the readers devouring everything, both feeling more alive when writing or reading than when they had to close the books, turn out the lights and face the world again.

Shallow John

Hail,
I was going to write something entitled "Six Gun Gorilla and Global Warming" (and I may yet), but in the interim I have just clambered off the scales, and am going to talk about fat.

Last night we went out to a friend's place. It was the first time I had been out to someone's house since the hospitalisation, and the first time I had seen any of Sarah's cat-person friends since any of this blew up, and I was fairly nervous. All that guilt and fear and social withdrawal that I tell my depressed clients to expect "for months" as they gradually recover.

In any event, it went very well - we sat around the table and drank and ate and chatted, and half way though the conversation Samantha (she of the chicken giblets) mentioned how horrified she was by how much weight she had put on. This is someone five foot tall, size six or eight, someone who has probably never weighed more than fifty kilos in her life. She's put on - I don't know, maybe a kilo.

Now, there is a confounding factor here. Sam has Crohn's disease. That means as times she gets flare-ups of ulcers all up and down her gastro-intestinal tract. It's as painful and disabling as it sounds, and if the ulcers in her intestine, say, eat all the way through she can die of overwhelming infection. It also means, or has in her case, multiple episodes of surgery, gallstones, kidney stones, tiredness and ongoing weight loss.

When she was first diagnosed, and she'd lost five kilos in a few weeks, her mother took her to a dietician. He listed the things she must eat to keep weight on. "Everyone's different" he said. "Try what works for you. Cheesecake" she remembers hearing. "Steak. Italian sausages. Corn with lots of butter. Icecream - with topping."

And she stuck to this rigorous diet plan and has remained in relatively good health for the last few years. But now her metabolism has slowed down, and she is concerned about the extra kilo.

Now there are two trains of thought I could board with this. The first is the whole "big" thing - the fact that this is the kind of stuff that has been force-fed into this intelligent and pleasant woman's mind. She senses she takes up more than the absolute minimum amount of space now, and feels that that is wrong. The fact that she has a deeply decent husband, for whom her weight is as unimportant as her blood type and who would love her at any weight between twenty and two hundred kilos, maybe mitigates this somewhat, but that's one man against an entire system of thought. But others have said this better than I do.

So, the other train. Sam was describing how hard it was, now, to lose that extra few hundred grams.

"See" she said, "I hate the food I'm having to eat now. I like seeing my toothprints in the butter when I eat bread. Skim milk tastes like dishwater. Pizza where you can't see the oil isn't pizza at all. Coffee cake, with veins of cinnamon in it."

I don't know. I know that most people will get fatter over time. Most people know that's true, and most people believe it's true of everybody else but themselves. It's a common cognitive distortion - the same thing that lets smokers believe that smoking will give other people lung cancer but not them. I know that's what's happening to me.

And I rage against the whole shallowness of caring about it all. Maybe I can hand-wave a bit of it away, say some of it's the poor self-esteem associated with recent events, some of it's the residual depression, some of it's the very real awareness that the medications I am on make almost everybody fat. But I know it's shallow and stupid and juvenile.

But Sarah in the meantime has lost eight kilos - mostly due to the misery of the last few month sor so, I suspect. And I have a friend coming over from another city in a few days, someone I admire and love and upon whose insights I depend. He's twenty kilos lighter than me, and he assures me that he is over here to drink cider in pubs and swim and talk about greenie lefty stuff - the kind of stuff we love doing together. I know it shouldn't bother me but it does.

But I don't know. I got off the scale today and I'm still ninety three kilos. That's an embarrassing figure, unless it's at the start of one of those personal testimonials in men's magazines that explains "how I blowtorched my belly" or whatever, wherin the writer goes from being a hideous wobbly mass of something to something ripped and shredded and blasted (now that's a healthy way to think about your body) via extreme punishment in mediaeval devices.

For the last few years I have been one of those who seem to be stuck in the 'before' picture, the unredeemed state. Ninety three kilos, BMI thirty one. I have that squat kind of habitus that kind people call 'big boned' - although that doesn't explain why my bones appear to have got a lot bigger in the last twenty years. Less of the Legolas, more of the Gimli. Less Captain America, more... nobody, really.

As an aside, the origin of the word testimonial has to do with the swearer clutching his testicles , as in "I swear by my testicles". Quite appropriate in this case.

Anyhow. The only thing to do (broadly speaking) is eat less, and do more. I bought a bicycle today, having read the short IPCC report in its entirety, and I will be riding to and from the ICU. That plus theoretically three times a week cardio, three times a week gym, eating as little as I can stand, bread with no butter, skim milk that tastes like dishwater, pizza only once a month. And I know there's no point bitching, that in the end if you eat less and do more in smart ways you lose weight - basic physiology. If I hadn't eaten less and done more I'd be ninety eight. I was well over a hundred at medical school.

We shall see. Probably we'll see me in a year, ninety eight again, whining about the good old days of being merely obese. But you never know.

Anyway. No real coda to this one. Speak to you soon,
John

Name

I glimpsed Infinity the other day. And the following contains a little bit of strong language.

Seriously. I was going into Florey to see about the ICU job and he ran past me. I heard his mother call his name - I don't know if it was her with her early onset emphysema, or him with another of his asthma attacks - and as I turned my head I saw his close-cropped head with the protuberant ears scoot out of the doorway.

I remember the first time I saw 'Fin's name. It was on a MR5 sheet, the sheet the doctor's pick up out of the box out the back, and another doctor had it.

"That's not a bad name" I said to Dr Ranuga. "Infinity Storm".

Ranuga, apparently, means something like "Voyager with a Golden Brain". Very 'Forbidden Planet'. Makes John seem a bit blase.

"It is not" agreed Dr Ranuga. He pointed to his name tag, which said, unsurprisingly, Dr Ranuga. "Imagine that. Dr Infinity."

A real superhero name. Envy flared in my breast. Plus he could sign his name with that lying-down eight symbol.

Anyway. Infinity is the brother of Tranquility Storm, whom I have yet to see. I mentioned this to Sarah.

"No relation to Purple Storm, is she?" Sarah said. Sarah's sister went to school with a girl called Crystal Power, and there were also the siblings Candy, Sandy (irritable looking girls) and Dandy (a boy of rather ferocious mien).

"God" I said. I'd forgotten about Purple Storm, a young woman I had met in one of the prisons. The main thing I remember was that tiny, unavoidable pause when speaking to her the first time: "Well, ...Purple...", and wondering if her friends called her Purp'.

Anyway, tonight we went out - first to the pub for red wine and geekery and then somewhere for "sake and stuff". The conversation at the pub began promisingly - we discussed gorilla superheroes, including the fabled "six-gun gorilla", a gorilla raised by a kindly prospector in the Wild West who took it upon himself to revenge the murder by a criminal gang of his foster father, while occasionally robbing stagecoaches and the like. But it quickly morphed into a "weirdest client's names" compilation.

Now, I can't remember who suggested who. We-who-drink-at-the-pub-some-Friday-nights work in disparate fields (the police force, the housing trust, emergency medicine, drugs and alcohol, occasionally psych) but often see the same clients. There is a sort of Grand Tour involved. Much like nineteenth century men and women of wealth would make a leisurely tour of the Continent, reading poetry and visiting spas, our clients make the same Grand Tour - but in this case it's a tour of the prisons, the emergency departments, the addictive substances clinics, the psych wards.

Other than that it's exactly the same, except that it's the twenty first century, not the nineteenth century, our clients are bare-bones skint, not men and women of wealth, and instead of crinoline and iambic pentameter you get Jack Daniels singlets and threats of gruesome physical violence.

Anyway. I can't remember who suggested who, but I opened rather feebly with the twins I grew up with - Flora and Fauna Jones. Luckily they weren't triplets, we might have seen Animal, Vegetable and Mineral.

Daniel reminded us of Number Nine Overcoat and Legalise Marijuana Jackson - I believe that there may be more than one Legalise Marijuanas out there. It's telling that people with conservative beliefs don't tend to name their kids after their beliefs - although obviously there are a number of Chastitys, and although rare, the geriatric ward still holds the occasional Prudence or Temperance.

And there are, of course, the bling names. These strike me as peculiarly sad. Because you get someone coming in with a name like Torana* or Converse** or Hilton*** (one of the latter in juvenile prison), and you fear that those names are as close as they are going to get to owning a new Torana (sixty thousand) or a new pair of Converses or staying at the Hilton. And Torana's dad is on speed and Converse's mum is in and out of Shipton psych. And it's not that you don't hope, it's that you don't fool yourself.

Anyway. We used to have a Doris's Law in Shipton, used when the junior doctors were presenting cases to you. When they started out with the name of the patient (but forgot to tell you the age) and the name was either Doris, Agnes or Pearl you could safely assume the patient would not see ninety again.

Actually, at Shipton you could often assume the patient would not see tomorrow again. I have since seen a two month old Agnes - it may be that some kind of pendulum is swinging again.

Sarah reminded me of Gerald Noname, a man whose rage against his father had assumed almost Freudian proportions, and who had as a result changed his name. He had found it very liberating but confessed he was "always getting funny looks". Sarah suggested he could pronounce it nu- NAM-eh, to rhyme with tsunami, and he seemed quite pleased with that.

I did read of someone whose name was pronounced Shuh-TAYD, sortof to rhyme with Shinead, but which was spelt Shithead. And in the same book, several different spellings of the name Unique (Uneek, Yuniik, etc.) - but none of which were unique.

We winced over Suk Kok and Bang Me and so on. It must be particularly galling to have a name of which you are proud and to travel to a country where is is a source of amusement - a fact I will take into consideration if I ever go to the US.

And a woman did book into Florey a while back called Twig - no surname, nothing. Obviously someone of greater patience than myself. The third time I'd explained that to some tired and uninterested official behind a desk would be twice two often.

I don't know. It's easy to laugh at this kind of stuff. But I wonder if it's not indicative of something. Without wishing to add to anyone's worries this morning (except for those who haven't read or read of the IPCC report), I wonder if it's got something to do with uniformity and fear. Most of the Infinitys and the Converses and the Holden Toranas I see are poor. I wonder if it's not something where the parents think "Well, I don't have much to give them, they aren't going to have as much of a chance as I want, and they need something".

So - they get names of muscle cars and high-status shoes, much like previous generations got called names that meant king or virtuous. Doubtless the thirteenth century, while largely made up of people with "normal" names, had a few pitable little wretches called Grond Strongarm or Throg Great-thews, and the Puritans had their share of Puritys and Chastitys who banged like barn doors.

Plus, Legalise Marijuana Jackson is on the dole. If he was living off his considerable investments, he would not be called Lower the Rate of Capital Gains Tax Jackson. He'd be called Alex or something.

Anyway - enough of this. The cardiovascular system awaits. Or maybe the anatomy of the forearm. I need a coin to flick that says "lose" on either side.

Thanks for listening,
John

Stop Press: Sarah has also reminded me of four daughters, Cashmere, Velvet, Satin and Silk, whom she met on her rural practice. Satin had juvenile diabetes and Cashmere has ear problems. I'd say unusual-but-not-unbeautiful for these.

*Torana (n): Kind of muscle car driven by the poor. Also a gateway, commonly of wood, but sometimes of stone, consisting of two upright pillars carrying one to three transverse lintels. It is often minutely carved with symbolic sculpture, and serves as a monumental approach to a Buddhist temple.

**Converse (n): Kind of shoe, much prized by the poor. Also a proposition in which, after a conclusion from something supposed has been drawn, the order is inverted, making the conclusion the supposition or premises, what was first supposed becoming now the conclusion or inference. Thus, if two sides of a sides of a triangle are equal, the angles opposite the sides are equal; and the converse is true, i.e., if these angles are equal, the two sides are equal.

*** Hilton (n): brand of hotels, much aspired to by the poor. Also an elusive and rarely photographed quadruped.