The reasons I won't be coming.

Hail,
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 It's been withdrawn from the market - it was sold as Vioxx.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,
John

*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.