Thursday, January 03, 2008

Architecture

My brother worked in a steel shed. A lot of the time it was loading steel onto trailers for the trucks to take away. They used to get the lengths of steel in - all kinds of steel, long tube and pipe and plate, merchant bar, that kind of thing. He'd pick it up - he used to drive the nine tonne crane, there was a nine tonne crane and a four and a half tonne crane, pick it up off the semis trailers with the magnetic crane and stack it, and next day trucks'd come in from the coast or the shipyards or the mining towns and my brother'd load them up and that'd be that.

On the days when there was no trucks he'd weld - twelve hour days in the pit, steel-caps and thick overalls and cracked welder's mask, forty four degree days.

He is more like our father - technically, his father - than I am. Dad worked in the mines in Kalgoorlie - nickel, copper, silver and gold. It was shift-work, the kind of things where he'd be gone in the early morning, come home to sleep in the afternoons. Mines are warm, but Kalgoorlie was hot, long days under the West Australian sun. The first story I ever sold to anyone was about him and mum in the days before the divorce, each pale-skinned and speaking their heavily accented speech, him the soft tones of the Dubliner, her precise German, him working two or three jobs and her at home with the kids and in the meantime trying and failing to work things out.

Dad worked, and my brother works.

Today I sat in an air-conditioned office and listened to people. In ninety minutes I saw two people and spent some time on the phone. With the two patients I saw I mostly listened, made a few simple decisions, offered the bare minimum of advice. I finished up at four thirty and drove home.

But tonight I am exhausted.

Let me explain.

The first patient is Mr Thames. Mr Thames speaks in a precise estuary accent, and frequently hesitates in his speech, as if seeking exactly the right word with which to express himself. The combination of his manner of speech, his fine, almost thin features, and his presentation (he is close to fifty, the very last of that generation who dresses up to see the doctor) combine to suggest some kind of refinement, almost a gentility in his character. If I am not careful, I find myself drifting along with this impression, treating him in a subtly different way from my other clients, assuming that he lives a life in accordance with these accidents of speech and birth, that he deals with life in the way that the lower classes imagine the upper classes do.

However, if I listen to what he is saying, things fall apart. Mr Thames is one of my most unwell patients. He is barely staying afloat. The waves are rising and he is clinging to things that are slowly sinking beneath him.

There is the issue of the benzodiazepines, the "anxiety" tablets that he takes "to help with sleep". He hasn't slept in three nights now. Doctors refer to the "architecture" of sleep, and it is a surprisingly apt metaphor - Mr Thames takes ten temazepam a night. He takes handfuls of diazepam, some off-white pills he buys from someone he used to work with, packets of over the counter antihistamines, can't go a day without topping up. If normal sleep has architecture, his is derelicted, a ruin, no stone upon another stone.

And the tablets aren't working like they used to, so he's been buying.

The other day he got frightened. He was at some guy's house, out in the southern suburbs - bars on windows, no streetlights, no trees, no jobs, hot and flat, dead lawns and boarded up windows. He was sitting on the edge of the guy's couch, trying to buy some alprazolam, and in the room - "not even in the corner, but in plain view, as far from me as you are" - rats ran unceasingly across the floor. The man himself scratched and picked at his skin as he spoke to Mr Thames, mainly due to the amphetamine psychosis but also because of what he described as "these fucking lice".

A tall man with a beard emerged several times from the kitchen, holding a butcher's knife, to stare at Mr Thames, each time seeming increasingly irritated by his presence, but each time returning to the kitchen to cut up meat.

When he got home he was so frightened by the experience he took all the tablets, fifty tablets in half a day, managed to get half an hour's rest.

I tried to go through the options for Mr Thames. We are forbidden to prescribe alprazolam to people purely as a treatment for alprazolam addiction, although it is possible that something like that may help Mr Thames in the very short term, forestall what may well be his death.

Having said that, whatever amount I prescribed would be inadequate within a month. His consumption is not copious, by our standards, but it is occurring on the background of considerable psychopathology. He drove here today (!), parked his car in the public carpark, asked three or four of the staff if that was okay, if the car was in anyone's way, had he done something wrong, he was very sorry. Anxiety is crippling him.

But everything is overlaid upon everything else. His dependency is overlaid on his mental illness. Behind the mental illness you can see the childhood events that helped make him who he is, details of his childhood, behind that, further back, you can even guess at his genetic makeup. It is quite possible that his GABAa receptor structure is subtly abberant. It is relatively certain that when he was six his father would beat him with a wooden rod for opening his eyes during prayer, and that his mother continues to attribute his illness to demonic possession. Beyond doubt, stretching back behind his parents are his grandparents, their parents, fuckups and freaks back to the Bronze Age.

There's so much going on it seems almost impossible to work out where to start, but in reality the choices are fairly simple. He is not detainable under the mental health act. He has no interest in referral to a psychiatrist, because the good psychiatrists won't prescribe him alprazolam and the bad psychiatrists aren't getting anywhere near him. We are slowly working through -

- I was going to say there we are slowly working through the relationship between his anti-anxiety medications and his anxiety, his sleeplessness and his sleeping pills, but I don't know about that. "Work" in some way implies progress, building something, the construction of something where there was nothing before, and I doubt that this is the case. There is too much damage done, not enough to build with, the foundation too riddled with doubt.

I don't know. I have not been able to express this adequately. Part of the reason I have decided to do psychiatry is that it may give me the tools with which to articulate some of these ideas, ways that I can understand and therefore help.

Anyway. After Mr Thames leaves my room, teary, drenched in sweat, I sink back into my chair. I know it's not the same kind of tired as my brother gets, or my father got - I've had that bone-deep weakness a few times in my life, enough to make me realize I can't do it for a living. But even if it's a less honest kind of tired, it's a significant one. In the mornings some times I punch the punching bag until I cannot raise my hands to my head - this is the same kind of thing, but it's brain rather than biceps brachii. In the same way that exhausted hands can't make a fist, for half an hour after seeing Mr Thames my brain can't articulate a thought.

And that's without the screaming schizophrenic or the heroin-soaked teen mother or the very very bad man with the easy, affable manner.

Anyway. As I write this other people are working. Tonight is tenth wedding anniversary dinner night - I'd better go get ready.

Thanks for listening,
John

7 Comments:

Blogger Benedict 16th said...

So he hasn't discovered Clonazepam (Rivotril, Paxam) yet then? It was the only drug (14-20mg a night) that got my pancreatic cancer patient to be able to sleep at night (with a whisky or two!).

Diazepam seems to have a GABA receptor limit at about 30mg (clinically) and 80mg (from rat studies in all your psych books...*) any more is just greedy and "doesn't work"**
Temazepam - clinically I'd estimate the limit at about 120mg (dunno with Oxazepam), and about 6mg with Alprazolam. (I guess I do a lot of BZD prescribing - maybe I'm fielding for a Butt by the DDU?).
Roofies*** are "the best" but they are hard to get hold of anymore.

Two suggestions for Mr London Estuary - 1) Get him to drink some alcohol - it has an amplifying effect on the BZD
2) Try Olanzapine - it just might work as an augmenting agent - not really any different to his OTC antihistamines

3) only real alternative is ECT

Benny 2¢



* which reminds me I have to give you a copy of this 1950's psych book.... "Psychological Atlas with 400 Illustrations" by The David Catz, actually 1948
** per drug parlance not what those stupid bloody doctors say
*** Flunitrazepam is apparently the ultimate but damn hard to get hold of

12:17 AM  
Blogger Ladyk73 said...

Wow, how does one detox...from that? Haldol?

I was always dead to the world after a day being a substitute teaching in the *very bad* school.

Anyways, my two cents...

Is that this is a beautifully well written post. Thank you

9:47 AM  
Blogger Camilla said...

Happy anniversary! Ten years already? How time flies! May you have many more happy decades to come :D

Camilla

11:16 AM  
Blogger Foilwoman said...

I hope you had a great anniversary. My best to Sarah and the cats.

3:05 PM  
Anonymous Benedict on holidays said...

Oh that reminds me - since I trashed the car - we won't be able to pick the kids up until Sunday.

Cheers
Benedict

9:53 PM  
Blogger CRW said...

Your site is a very interesting read from a medical standpoint. It's nice to see someone in the field with such talent. Thanks for putting it out here for me to stumble upon.
CRW watkinsfarm.blogspot.com

7:24 AM  
Anonymous Milo said...

would you please write again... please...
This is so scary, I have become addicted to your posts and am running out of reading the archives section... All the best to Sara as well.

1:51 AM  

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