Wednesday, March 26, 2008

The reasons I won't be coming.

I feel I should explain why I have not been posting, and why I am not currently posting, and why I may not be posting for some time. Crude language follows.

Basically, Sarah is sick. I am not sure how much detail to go into here, but a brief outline is as follows:

She has a fairly aggressive species of arthritis. I don't know what kind, neither does her rheumatologist, it may be psoriatic that's turned into osteo or it may be something else. Apparently there are over two hundred and fifty different arthritides (this is the actual word - sounds like an archipelago off the coast of Sumatra, doesn't it?), including some that are sexually transmitted and one that can be caught from walruses* - I am not making this up. The whole field is too complex for me, which is why her rheumatologist drives a Bentley and I do not. Whatever kind she has, it is not good.

It is a poly-arthritis, which means it affects multiple joints, and it seems to have focussed with particular malevolence on her hips. She has hips that are amongst the worst her surgeon has seen in anyone her age. She is due for bilateral hip resurfacing surgery (i.e.: is basically getting both hips replaced at the age of thirty eight) in about five weeks. Her right knee is causing problems, her shoulders have not been good, her temporo-mandibular joints (the hinge between jaw and skull) ache, and what she refers to as her "fuck off finger" on her left hand has recently become painful and difficult to move.

There are not two hundred and fifty useful treatments for the arthritides, there are far fewer. One of the fundamentals is the non-steroidal anti-inflammatory drugs - ibuprofen, diclofenac and relatives. These are damn fine drugs if you can take them, but like everything else, they have side effects. The most commonly encountered side effect is bleeding in the stomach and intestine.

I should point out - there are newer anti-inflammatories that are alleged to cause less gastric bleeding. There is one called rofecoxib - it seems to increase the risk of strokes, and Sarah's grandmother died of a stroke at Sarah's age, and Sarah has high blood pressure. It's been withdrawn from the market - it was sold as Vioxx. There is celecoxib (Celebrex) - a similar increased risk of heart attack and stroke appears to exist at the dose Sarah would be taking. There was lumiracoxib (Prexige) a similar drug that showed great promise and for a while seemed to be safe for heart, brain and stomach - unfortunately it caused liver failure, and has been withdrawn over here.

Obviously this whole area is highly complicated, and further experimental work needs to be done, but it's not going to be done on my wife.

Anyway - Sarah was on high doses of anti-inflammatories and also an opiate patch. About three weeks ago I had to rush her into hospital and she had an endoscopy (a metal tube witha camera on in poked down her gullet into her stomach) that showed ulceration and bleeding in the stomach, so that was the end of the anti-inflammatories. It was also pretty much the end of her going to work, too.

That left her with fewer options. She is on opiates and has the usual side effects - nausea and vomiting every morning, lethargy, sweating, what she calls "stupidification". Plus she has ongoing, hour by hour, constant pain, significant pain, pain that wakes her when she rolls over in bed and stops her tying shoelaces or bending down to stroke a cat. She walks with a stick.

What does all this mean? When you add up poor sleep, loss of appetite, loss of concentration, depressed mood, constant morbid thoughts about the future, you end up with a picture indistinguishable from major depression. I don't know if it's depression, in the sense of an episode of mental illness, or if it's grieving, or if it's a perfectly normal fucking reaction to a situation I cannot begin to imagine, but it's bad. There are very few perks to being a doctor, but you can write your own referral letters, and we have got her in to see a psychiatrist (one who does not think this is a prozac deficiency problem) and we shall see how things go with that.

Obviously, the next milestone is the surgery, and next week she starts donating her own blood - they will need about two litres, which I think is a bit under four pints. The first hip replacement is late April, the second a week later, the day after her birthday. Recovery from the surgery will take a considerable amount of time.

What can we do? We have been doing the usual distraction kind of activities - we went to the local wild-life park and saw cheetahs and lion cubs. We were all allowed to stroke the cheetahs and everyone else sortof patted them nervously, but Sarah ruffled and tousled them with both hands and came close to hugging them - they seemed to respond. They are remarkable beasts.

And we've bought chicks - the offspring of some prizewinning chickens of a particularly glorious sort, and Sarah is raising them in a little pen, in a box with straw and a lightglobe for warmth, and we have goats and I am repairing the chicken run, while she sits on a chair and hands me tools and is the brains of the operation.

But beyond that there doesn't seem to be a lot of room to manouvre. Something stupid happened to me the other day - see, here I am talking about me now - when I was at work, and she was at home, and I was thinking about her and what had gone wrong and what could go even wronger. I got symptoms of some kind of panic thing. I've only ever had that once before, and this time was worse, because it went on longer. It wasn't the whole mouth tingling, breathing hard, hands curl up thing, but my heart was kicking in my chest, there was this senstaion of pressure, and as hard as I tried to keep my mind on what my next patient wanted and what my last one needed doing - and these are sick people, people who come to me for help - I couldn't do it.

I could not think, I could not stop my heart beating. I ended up having some sort of emotional meltdown and saying I had a virus and going home. I suspect I fooled nobody.

That's another of the perks of being a doctor - write your own sick certificates. Having said that, if I did I would have to write that I had examined myself, and that always sounds rather odd.

Anyway. This has always been the sort of thing I have preached to others and not practiced myself. When patients come to see me they don't want me taking my own pulse and wondering if their description of their symptoms is raising my blood pressure. Despite my rationalisations, deep in my heart I can't stand that kind of weakness in myself. But when you're impaired, you're impaired, and I don't want to go through life never having made a poor clinical decision due to my bipolar but killing off people left right and centre because I am having some sort of unspecified neuropsychiatric event.

We shall see. At the moment, Sarah is eating (first meal of the day to stay down, nine PM) and is washing down her tablets with ginger beer (a possibly efficacious anti-emetic). I had psych today and drug and alcohol tomorrow, if I go in - I took half of today off because Sarah was in the ED.

Psych is going moderately well. It's not the most optimistic of disciplines, and it is challenging in a way that I suspect orthopaedics or renal is not - although they obviously have their burden too. One of my more "difficult to cure" patients is Mr Hunter, a fifty year old man of roguish mien, a wink and a ready grin, always ready with a jest or a saucy remark, who murdered his wife back in the seventies in New Zealand and hid her in a wheelbarrow on the front lawn, and has been utterly and immovably mad ever since. He tells me that the "Eskimos" rule the world, which explains much, and that the brass poles underneath Singapore, Malaysia and Australia will ensure they are saved when the coming Deluge kills three quarters of the world. He, the Pharaoh, will then rule over us for five thousand years.

Remarkable stuff. I also had an Angel of the Lord amongst my flock, a woman to whom I administer electro-convulsive therapy every Monday morning and another whom I sent home once the voices from the men on the roof with guns got quiet enough so that she could cook and clean the house. I know I am not being objective about this, but we are literally not allowed to keep people in hospital for any length of time. The shorter the duration of stay, the better we are said to be performing, and Beuler Ward is one of the best performing wards in the state. Average length of stay is only a little over nine days, and the target is to get it down to seven days by the end of the year. And we'd have got there already, if it weren't for the frankly uncoopreative attitude of the sick people.

The remarkable performance of our ward in discharging the insane back to the streets and gutters has certainly had an effect upon our patients, and I feel that the architects of this particular "key perfomance indicator" can take some of the credit for the noticeable increase in mental health you can see as you look out the car window as you drive from the centre of the city into deepest Mordor.

I also fear (and this may be merely paranoia, or it may not) that I have made a poor impression amongst my fellow practitioners. At last week's ward round we were told about Ms Deer, a woman of twenty one who had come in with post natal depression. For the last three years she had been in a relationship characterized by marked ongoing verbal, sexual and physical violence, only escaping last week. Her partner - he who had beaten her in front of her three year old, who had broken her nose and fractured her ribs - had forbidden her to attend her uncle's funeral. Her family came to get her and he greeted them as liberators, shrieking and waving a machete. The police came and he was taken away to the Royal and detained.

Unfortunately he escaped from custody and fled the premises, pausing only to ring our patient from a public phone to tell her he knew where she was and was coming for her to kill her. Seconds later, scuttling malevolently across the road, he was struck by a speeding car.

"Oh God - how terrible," said the other registrars and nurses. "The poor man. I hope he's okay."

"Fucking excellent," I said, at exactly the same time. "Is he dead? Damn good thing. One less problem for us."

There was a pause, while everyone looked at me, with a grin frozen awkwardly on my face, eyes wide and both hands giving the thumbs up in best Jackie Chan style.

This is apparently unprofessional behaviour. Their ways are not my ways. I read a quote once - "The physician should look upon the patient as a besieged city and try to rescue (him) with every means that art and science place at (his) command" - and if some of those means include hiring cyborg ninja monkeys to climb in the windows of the Royal and make sure this guy doesn't make my patient sick any more, well, I have some sympathy with this view.

Note to the literal minded - I am not being entirely serious. The hiring of cyborg ninja monkeys to "deal with" a rapist and thug would clearly be both irresponsible and unethical and an inappropriate use of hospital funds, and I could not condone it in any way, shape or form.

Especially when trained Queensland fruit-bats carrying taipans or minature curare-tipped echidnas are so much cheaper and do not require a lengthy period of quarantine.

Anyway, the prince amongst men's not dead, he's in neurosurge in the Royal, on one of the upper floors. If he escapes again we will be told about it and will go into lockdown - I don't know that you can get those wheelchairs that you steer with your chin down the stairs, but we'll be waiting.

I don't know what to do about a lot of this. Before anyone asks, I am aware I am a little depressed, and I am seeing Dr Tesla fairly shortly. I feel my psychiatric and my drug and alcohol patients depend on me, but I don't know that things are going that well there, and I may be pulling the plug temporarily. As I said, I don't want to be one of those doctors who sits there listening to a patient telling their story and thinks "This is really upsetting for me", or interrupts the consultation several times to take my own pulse and blood pressure, but neither am I stupid. I would take more time off if I could, but I feel I may need the holidays later when Sarah is post-surgical.

I think part of this is obviously endogenous, and I suspect part of my almost pathologic social withdrawal at the moment stems from the familiar causes. I am writing this with a degree of temerity - I fear that people will send me emails asking how I am, and I feel unable to answer a lot of those. However, I think I am going to have to get out and about, socialize and exercise and stuff, or risk things getting out of hand.

Anyway. The day after tomorrow I am appearing at the coroner's court - there is no question of blame, but I was one of several people who saw someone who then died in custody, so I have been summonsed - and after that, the weekend.

And then, we shall see what we shall see.

I would like to finish this on a happy note. I went to psych training Wednesday and heard about the library. The psychiatry training organisation has organised a new arrangement with the university library. Basically we can read almost any medical journal electronically and free (this is good). We can borrow books from the entire library - up to fifty at a time, for as long as they are wanted (except short term and closed - this is also good).

And the librarian said, "If you want a book, and we don't have it, just email us and tell us what it is and we'll buy it and courier it around to you to read."

There was a pause. I said, "Any book? On anything?"

She said, "Well, we're not that selective. We do have some very broad limits... but I've never refused a request yet. If it's vaguely academic, or quality fiction, the library generally has a use for them. We're quite well funded in this area."

Something in my gaze must have alarmed her, because she laughed nervously and said, "Of course, we don't want you sitting up all hours surfing Amazon for stuff you might find interesting and asking us to buy it for you. There's only so many books I can imagine one person needing, anyway. Ha ha ha."

"Ha ha ha ha ha," I replied.

At nights, when I can't sleep, I sit up and surf Amazon for stuff I find interesting and I ask Sarah to buy it for me. This changes everything. I left with an armful of books on Anglo Saxon England, and I will be back within the fortnight.

In a few months, when you hear Miskatonic University has closed its doors and gone into receivership, you will know who to blame.

Thaks for listening,

*Brucella somethingorother - this is particularly a risk encountered when drinking contaminated walrus milk. Brucellosis also causes swelling of the testicles. I must shamefacedly admit, in five years in the ED I saw a lot of people with joint pain, and a fair few with swollen testicles, and I never once even asked about contaminated walrus milk or milk products. That's all going to change.

Friday, March 07, 2008

I am ion man...

That'd be lithium ion I am talking about. And the following contains brief vomitty stuff - be worned.

Now, I have a modest proposal. I will start by reassuring people about my lack of competing interests - I used to be on lithium myself, but I am not on it anymore. I was, back in the medical school days, when I was a less well but a better person, for about two years, although my memory of much of this is faulty, and I believe I was for a while in the years before.

I remmeber it, I remember the plastic screw-top bottles I kept it in, I remember the nausea and the shakes, I remember that if I dropped some in the basin when getting it out of the bottle it was unwise to pick up the tablet (slightly moistened) and swallow it anyway. I had to throw it out, and to hell with all the lithium-less and manic children in the poor countries. I had to do that because if I swallowed it wet I vomited it up fifteen minutes later.

That was the main bad point. The vomiting and the weight gain and the always being thirsty. That and the fact it didn't really work as well for me as other medications. I remember seeing telling what I now suspect was a callow ED intern more than ten years ago , and she asked me if I was compliant, if I was taking my lithium, and I said if I took any more I'd fizz when I got in the bath. Like sodium does, but slightly less so. We both thought this was slightly funny, but I still had to see the psychiatrist.

Plus it has a very narrow therapeutic window. Just enough is very close to too much, and too much can be fatal. people on lithium have to keep an eye on their lithium levels, which means blood tests - take a few too many anti-inflammatories for a headache and if you're unlucky you can give yourself confusion, vomiting and death.

Now, with all this going on, who in their right mind would propose putting it in drinking water?

Well, me, for one*.

I propose a couple of cubes of it in every dam, a few salt licks upstream of the major rivers, a tankard in the reservoirs. Mix it in with the other stuff, the fluoride and the chloride and the stuff that makes us scared of Moslems. All lithium all the time, lithium for the people.

What could this possibly achieve? Well, while browsing through old issues of Biological Trace Element Research at three AM (that's a lie, by the way, I was looking in Google scholar for any trials of mood stabilisers in cannabis withdrawal - another interesting area) I came across a paper by Shrestha, KP and Schrauzer, GN, about lithium and murder, burglary, sexual assault, etc. in Texas.

Form what I can work out, they looked at the levels of lithium in the variuous counties in Texas back in the nineties - some counties have virtually none, some have as much as 170 micrograms a litre. They looked at rates of homicide, suicide, arrests for drug possession and drunkenness.

And what did they find? A "statistically significant inverse relationship". More lithium, less murder, suicide, drug arrests. Less lithium, more murder, etc. Lithium is good for your community.

Here is the reference.

Obviously there are alternative explanations. Perhaps the lithiumn-addled law enforement officials in Peaceful Valley are too calm to notice the waves of murders and suicides that are engulfing their suburbs, perhaps beatific judges refuse to convict anyone, perhaps being on lithium motivates you to drive to teh next county to sell your cocaine rather than sell it at home. But I doubt it. It may be that our next big public health project is the here. We've all always known that most of the population is crazy, here's a chance to finally do something about it!

I respectfully offer this idea to political candidates of any persuasion.

Anyway, deliriously tired. Please do not write to me suggesting that this is not the world's best idea. I'm glad I'm having any at the moment.

Thanks for listening,

*I know.

Thursday, March 06, 2008

The Clonazepam Curtain

Today we learnt about the psychiatric interview.

We have our teaching sessions in Mulberry House, the oldest psychiatric hospital in the state. Mulberry House is on several acres of prime land just north of the city, land gazed upon enviously by banks and lawyers' firms. Mulberry trees - smooth, pale bark, pale green leaves that the sun shines through - cluster around the buildings, and a river runs through it. In the old days there were peacocks.

In the old days, of course, there was an art school, and pottery, and dance, and long sessions of therapy - and seclusion in windowless rooms, and camphor induced seizures, and occasionally lobotomy. Nowadays, things are different. More on this later.

What this means for us every Wednesday is four hours of lectures. The first few were on the history of psychiatry, at the moment we're looking at how to interview (nine or ten hours) and then there are the introductions to the common illnesses and the common therapies.

So - today was four hours talking about talking. Dr Lung spoke at length on where to sit when speaking to a patient - never stand above them, don't isolate yourself at one end of the room, never ever sit within arm's length (and here he illustrated this by extending one brawny hand and making a grabbing motion). Chairs themselves should be comfortable, should make the patient feel valued (not those orange plastic ones you get in schools) and not intimidating, but not difficult to get out of quickly and not of a weight likely to be used as a weapon.

And what about doors? Doors that open out are an occupational health and safety hazard - people walking down the corridor can get struck by them if you have to exit in a hurry. However, doors opening in can prevent you exiting in that same hurry. Sliding doors are unreliable - if you're thrown against them you can actually jamb them shut. Ideally, multiple doors into (and out of) every room can be arranged, so that both you and the patient can leave at any time, but obviously this is not always possible.

I don't know what that leaves us with - trapdoors, foundling wheels and firemen's poles were not specifically excluded - but I will be on the lookout for those bead curtains (see above) that seemed to be popular in the seventies, in fims where people lounged in pools and smoked opium and had orgies.

Anyhow. We also discussed silence, how to respond to silence, what the patient's silence can mean, what your silence may mean to the patient. Silence, said Dr Lung, can be used almost as a diagnostic tool, an instrument -

And isn't that a remarkable mental image, silence as a diagnostic tool? Using silence and quiet like we use light and steel and radiation. In the same way that you had to keep photographic plates in a lead-lined safe, or the faintest nebula can be seen on the darkest nights, some ideas can only come out in quiet.

Haing said that, I think others may have a more extreme view of this than I do. Dr Lung spoke of a particularly challenging psychotherapy patient his professor had had in the US a few decades ago. His professor had been seeing this patient for intensive private psychotherapy, and had been sitting with him for five one hour sessions a week for eighteen months, often emerging looking tense and drained, and retiring to his room to write copious (but private) clinical notes. Eventually he emerged from one session jubilant. A major breakthrough, he announced, had been made.

"What happened?" asked young Lung.

"He spoke," said the professor. "For the first time in eighteen months."

I don't know what the patient said. It may have been to enquire who was paying for this.


We discussed (briefly) the idea that having had mental illness makes you a better doctor. My opinion on this is changing. I have previously been of the opinion that it does not - if you look at mental illness purely through the lens of the medical model, when you have a heart attack, you don't go to the bloke who's had five heart attacks, you go to the guy who got into cardiology. By that measure, the same thing should apply to psych.

But I don't know - I am changing my opinion, and weirdly enough, it is not my own experiences on the other side of what I once heard referred to as the Clonazepam Curtain that are changing my mind, but things with Sarah. At the risk of embarrassing her, her pain is considerable, and along with chronic pain comes many of the cardinal signs of depression - disturbed sleep, altered appetite, emotional lability*. It's not something I feel like discussing here, but if there is any good to come out of her suffering - and I would do anything to change this - seeing her like this has made me a better doctor.

Anyway. I have resolved to make this a cheerier blog, and I shall end with two short stories from those "how I made a clown of myself" pages in the medical journals. One concerns a doctor who was at the time the night med reg at Royal North Shore or some prestigious hospital on the East Coast. It was his job to go around in the evening, close the curtains, make sure the patients were okay, and in the morning open them up again (it's true - this actually happened, and to an extent still happens. I will leave this for another blog entry). He went to ward 5C, closed the curtains and turned to Mr Saxon.

"And how are you today, Mr Saxon?"

"Terrible, doctor, terrible. All day long they've been keeping me awake."


"The elephants. With their trumpeting and screaming. Constantly, never stop, never heard such a racket."

It is not recorded if the remainder of the standard psychiatric interview was carried out - is it one or several elephants? Are they talking about you, perhaps in a derogatory way? Do they issue commands? Are these elephants known to you, family, friends, famous elephants? - before our hero performed the standard tired med reg intervention - ten milligrams of haloperidol and two of clonazepam in the thigh.

In the morning he saw Mr Saxon sleeping the sleep of the cortically sedated, smiled and opened the curtains - and stared aghast at the circus that had set up on the grounds outside.

Luckily, due to Mr Saxon's relatively advanced chronic renal failure, it was a long time before he awoke, and by this time the circus had moved on.

Another mentions how he had been called out to see a child, whom I will name Blayde Spleenrenden, who had apparently taken a (small) overdose of carbemazepine, an anti-epileptic medication**, and was acting drowsy. He rushed over to the house. Inside were two women, one pregnant.

"Did you see any kids playing in the street on the way over here?" asked the pregnant one.


"Oh - it's just that Blayde's gone down to Maccas and we haven't seen him."

"I was told he was only four..."

"Yeah, well, his sister had to take him down there to calm him down."

"I thought he was very drowsy."

"Well, he woke up and he started screaming," said the non-pregnant one. "What do you think is wrong?"

"It's pretty hard to diagnose without actually seeing him," said the doctor.

The pregnant woman paused for a second and pointed to a picture on the wall. "Well, there's a photograph, him and his sister in the bath when he was two. Is that any good?"

Anyway. I haven't actually gone on about my mood yet, that can be tomorrow.
Thanks for listening,

*There is actually a term called "emotional incontinence" where you blurt things out uncontrollably in a way that causes considerable embarrassment. Before blogging this was actually a disorder.

** This is why I won't do that job. Ambulance, ambulance, ambulance.