Pizza

Hail,
A quiet day here, so reading a few psychiatric papers, and something I read stirred memories of training at Mulberry House. And it's a remarkable day here weather-wise: rain is scraping at the windows, a cold wind from the South is blundering around the door, and outside you can see flung birds tumble across the sky.

Absolutely glorious.

Sarah is in the next room, looking at rustic cottages and remarkable chickens on the internet, and having a soft boiled egg, so all is good at the moment.

I was invited to a talk the other day by the Pfizer rep. Most drug reps are female, and young, and blonde, and impeccably presented, and seem very glad to see me, and they talk to me... well, like a woman who will get paid relatively well if she can make me feel important and smart and valuable in fifteen minutes, and relatively poorly if she can't. I find the whole dynamic rather depressing - sometimes I feel we are living in the Leaden Age of Psychiatry.

The Pfizer rep, I'm glad to say, is very different from those kind of people - she's a brunette. Still, she does give out free samples of something I trial my patients on, so we meet.

Anyway - something she said reminded me of something that happened to one of my friends a while back, something he refers to as the Great Last Minute Pizza Hut Suicide Prevention Dash.

This colleague of mine was working in a large hospital in Sydney, out near the shore. It was a sizeable hospital, a wide patient range, a number of consultants, and she was on call about one night in four. This particular night, at eleven o'clock, the phone rang.

"Doctor Rebecca? It's Emily LeStrange."

My colleague felt her heart sink. Emily LeStrange was a woman with a long history of borderline personality disorder. BPD is, at its worst, a truly crippling disorder, something that slashes away at your ability to hold a job, have friends, maintain a relationship, feel anything. One of the problems people with BPD face is that their condition (and I don't know about this "talking about a condition as if it is separate from the patient" thing here) - their condition can be very difficult for the inexperienced (and even the experienced) treating doctor to handle, let alone treat successfully.

Symptoms and signs of the illness, ways in which a person engages with and protects themselves against the world, elements of the disease - these can be interpreted by those around them as attempts to gain attention, as acts of sabotage or of malice. The patient acts, the doctor reacts, the entire therapeutic relationship spirals down the plughole.

Back to our story.

"How can I help you?" said my colleague.

"I just want you to know that before he discharged me, Dr Nardil put me on a MAOI*," said the voice.

MAOIs (mono-amine oxidase inhibitors) are still probably the strongest anti-depressants out there, but they are rarely prescribed nowadays, because of the large number of drug and food interactions. People on MAOIs have to avoid certain foods (cheese, preserved meats, etc.) and drinks (particularly Chianti), because of the risk of a dangerous reaction called a hypertensive crisis.

Every medical student has this drummed into them. If someone on a MAOI eats bean curd, or herring, or (for some reason) banana peel, they may die. Their blood pressure goes through the roof, "possibly followed by their head" as one of my lecturers said.

"Uh huh," said my friend.

"You haven't asked me where I am," came the voice.

Long pause. After a while Ms LeStrange continued.

"I'm in the line at Mordor Pizza Hut, and I've just ordered a Double Cheese and Prosciutto Explosion!" (actual words)... and I'm going to wash it down with a bottle of Chianti!"

And she shook the bottle near the phone. It made a sloshing, gurgling noise. So did my friend.

"Sorry, incoming call," said my friend, and put her on hold. He rang the Pizza Hut.

"There's a woman waiting in line in your shop," he said to the manager.

"Uh huh," said said manager, sounding all of fourteen.

"You can't give her her pizza - it'll kill her."

"Whatever you say, mate," said the pizza guy.

"I'm serious. I'm a doctor. Her head'll explode!!!"

"Mmm, mmm," said the man-boy. "Do you mind if I put you on speaker-phone?"

In the background my friend could hear the sound of a cash register opening and closing. He imagined a line inching inexorably forward. In desperation he shrieked, "Don't say I didn't warn you!" and hung up - and called the police. A few minutes later they burst in through the doors. There was an altercation and apparently Ms LeStrange was wrestled to the ground, and then into the back of the waiting ambulance, shrieking and trying to stuff a hot slice of pizza into her mouth.

Anyway, the medication Ms LeStrange had been given was what is called an "irreversible" MAOI, which means the side effects (including the whole "pizza/exploding-head" reaction) takes two weeks to wear off. My friend went to the tribunal and was given permission for an extended detention order, and Ms LeStrange went to the locked ward and was given no pizza, no beans and no banana peel.

The whole episode was a disaster, to be honest, and questions were asked, predominantly of Dr Nardil. I don't know what came out of it. But it does spring to mind every now and then when I see a pizza commercial.

Anyway, cats to feed and so forth.

Thanks for listening,
John

*Rhymes with Yowie, a large, mythical Australian anthopoid.