Monday, December 28, 2009

Your doctor may find you sexually attractive

The following contains strong language and adult themes.

One of the reasons my blog anonymous is subjects like the above. I am reticent about even posting this post. But the blog is a forum for me to get my thoughts together, and it's raw material, and it's quite deeply anonymised, so here goes.

Forst, two images. One, it's early in the shift, just after midday. I'm working in Florey, the IP4 - the sheet of paper we pick up with the patient's details, all their data, the clinical presentation - says twenty nine year old woman, skin reaction. It's quiet, but it'll get busy later on, and I'm trying to get through this. I knock on the side of the cubicle walk in, there's a woman sitting on the bed, one leg folded under her. I remember chestnut hair and an aquamarine top. I open my mough to introduce myself, but as soon as she sees me she speaks.
"It's here, it's probably nothing but I thought I should - ,"
And as she speaks she drags the aquamarine teeshirt over her head. She is naked underneath.

The second time was when I was in Shipton. I had a patient in X12, one of the overflow rooms. Shipton was not build to be an ED*, and there are long corridors with rooms branching off them, opening to something that may have been a patient lounge back in the seventies when people lounged. So I was trudging down a corridor to see Male, 77, Blocked Feeling in Ear, and I as I walked passed room J the door was open a few centimetres, and there was a woman, maybe late teens, maybe early thirties, bending over to pick up her clothes, holding the hospital gown to her breasts, but still, from the side, I saw the curve of one breast.

Both of these events were more than five years ago. In each case you continue on - you don't break stride, you trudge on down the corridor or you introduce yourself and say you'll have a look in a minute, but when did it start and so on. In each case there was that moment, that kick that startles you with its unexpectedness, that sudden full feeling behind the breastbone, that adrenaline alertness. One of the patients I had no need to talk to, and I didn't, the other was fairly straightforward, one of the consults which, if I was writing about anything else, I would call in-and-out.

But each of these cases troubles me, I think for a number of reasons. There is no room for this. There is absolutely no room for any of this in medicine. And just writing what I have written makes me scurry to supply reassurances and explanations - nothing happened, I didn't treat anyone differently, I said nothing, did nothing that couldn't have been examined in detail by the medical board without concern.

But still -... I can understand something like that catching you mentally off guard, smacking you before you've got your hands up. I can understand that the part of me that I usually don't allow free to grope and grunt and glut myself is still there, is probably still the vaster part of me. I can understand that part of me revels in an unequal power dynamic that tell myself I find repugnant.

But still, I am troubled. People have to be safe in the Emergency Department. Women have to be safe. The triage system assesses heart-rate, blood pressure, pain. It does not mention dark eyes and smooth skin.

Anyway - two brief beats of desire. There have been other cases, both for me and others, which in some sense went further. I will post about them next post.

Below is a brief diversion into how the brain side of swearyness works.

Thanks for listening,

Steven Pinker, a linguist and overall smart guy, writes about swearing and what it says about the human mind. He breaks terms for sexual intercourse into two groups - the transitive and the intransitive. Broadly and simplistically speaking, he points out that when we use the intransitive term, "John and Mary verbed" (made love, had sex, whatever), it is polite, it is gender-symmetrical (we can say "Mary made love to John" as easily as we say "John made love to Mary"), and it's non-violent.

But when we use the transitive terms, it's less polite. I fucked her**, I screwed her, I banged her. The metaphors are more likely to be violent - when we cluster bomb villages, the inhabitants are not made love to. And they are virtually always used by men about women rather than the reverse. In this way of speaking, to fuck is simultaneously to have sex with and to exploit, to damage.

These are not new observations, but Pinker points out that these patterns in language are indicative of patterns in the brain, of patterns in how cells fire, the neuroanatomical correlates of thoughts. We speak that way because we think that way.


*We say ED, you say ER.
**First noted by the linguist Quang Fuc Dong.

Tuesday, December 22, 2009


And in my idle hours, I see patients. I saw one today who had the worst diet I have seen this year. Innsmouth, where my clinic is, is in the worst part of the south, the south is the depressed part of the city, the city overall isn't doing well and the state seems to be settling comfortably into its handbasket. Correspondingly, it's not a lot of fresh chard and snow peas out here. It's chiko rolls and Coke.

But in an area where I have seen one case of scurvy, countless cases of insert-vitamin-here deficiency, and which will one day give the world the first death by fried chicken embolus, Barnaby Trudge stands out.

He stands out in a number of ways, actually. He presented with a cockatiel on one shoulder today. His tattoos were described by Dr No as "pugnacious", they look like his skin could get him into fights that his fists couldn't get him out of. He speaks softly and slowy, and it it is almost impossible to believe his documented gang history and significant prison time.

Today, however, he and the bird were here about his weight.
"I've put on a bit," he admitted. He sat in ballooning pants, with a white tee-shirt draped over his belly.
"How much do you reckon?"
"I'm not sure" he said.
We weighed him. He was up to one hundred and twenty kilos - that's well over two hundred fifty pounds. He is not much taller than I am.
"I might have to do some walking," he said.
"That's part of it," I said. "What do you eat?"
"It's not that good," he said.
We wrote it down. This is what we wrote.

One five hundred gram pack of cornflakes - about ten bowls.
Two heaped tablespoons of sugar on each bowl. It's normally three teaspoons per tablespoon.
Two coffees. Two heaped teaspoons of sugar in each.
Two litres of fizzy drink - each, for what I work out, with twenty four teaspoons of sugar.
Cordial - consumes a half litre a day (concentrate - he does add water). This comes out to another forty teaspoons.

I sat and stared.

''It's no good" he said. "Doctors can't work out why I'm so fat."

I looked at him. "Actually,"I said, "they can. I could be wrong, but it looks like you're eating about three quarters of a kilo of sugar a day."

"I do like it,"he said.

In one way, the solution is simple. He may well do astoundingly well with sugar substitutes. The thing is, it's more complicated than that. Long term opiates (whether for pain or to stabilise opiate dependence) alter the hedonic response to sugars - they affect how much pleasure you get out of them. People on opiates commonly crave high sugar and sometimes high fat foods. People on naloxone - an anti-opiate, it's narcan - eat less of these foods. It has something to do with pleasure, something to do with reward, it's not intimately connected to normal signals of satiety or hunger. It's not a big part of most people's eating, it's not everybody all the time, and from my understanding, it's hard to disentangle mood, energy expenditure, response to cues and all teh other squillion things that go into this kind of research.

And that's without even looking at the politics.

Anyway - Mr Trudge is off to the shops to change his diet and the dietician (almost certainly a slim young woman with meticulous self-control) to amaze her. The good thing about his diet is it is so easily fixed.

The rest of us, not so much.

Thanks for listening,

Sunday, December 20, 2009

The story so far

Now, slightly more coherently.

The way this worked out is my Dad, who had had one motor vehicle accident in his late teens and then got lucky for about fifty years, drove through a red light. It was low speed, no-one was particularly badly hurt, but the ambulance came and he was taken to hospital.

(I live in Australia, ambulance costs $25 a year, hospitals plus cheaper medical and dental costs cost around about one and a half percent of your income a year via tax. You tend not to notice this in the same way that you notice, say, the almost one hundred thousand dollar bill this would actually cost. You guys in America should look into this.)

Anyway - they went to hospital, over my father's protestations, and Dad admitted he had some chest pain. They took Xrays and found a mass.

I hesitated over that word. It is almost too evocative - you can imagine it suspended in the delicate tracery of the lung, dragging you down. You become weak, each breath hurts, your muscles fail... mass.

As a lapsed Catholic it may have, to him, some other associations.

Anyhow - the chest pain led to a number of consultations. The general pattern of those consultations has been the cutting off of hope. It may not be cancer - it is. It may not have spread throughout the lung - it has. It may be suitable for surgery - it is not. It may not have spread elsewhere - it has.

It is stage four large cell lung cancer. Chemotherapy is rather harsh, it delays but does not deny death. It is platinum based molecule, which I suppose is rather impressive. It is initially successful but resistance to it swiftly develops. There are other treatments - treatments as well as rather than instead of - but the most promising of those (the tyrosine kinase inhibitors) don't work that well, and work better on certain subsets of people. They are most efficacious on young, Asian women who have never smoked. Even with the eye of faith, I cannot see my father in this way.

A brief aside: if anyone writes to me and suggests a combination of homeopathy and a gluten free diet can fix this, I will hunt them down and kill them with my own hands. I mean it - I have money, I have a valid passport, I can write my own medical certificates explaining how I was completely insane at the time. Test this at your peril.

Anyhow - today he is coming around to potter about the garden. I will let you know how that works out.

Thanks for listening,

Wednesday, December 16, 2009

The Father Thing

I might skip the whole excuses and assurances thing and get on with this.

I have sortof decided to restart this because there is something going on that I feel I should document. I am not a particularly good documenter, but I did manage to write three hundred thousand words of this back in the day, so the track record isn't that bad. It's something that will be difficult, and I have given more than half a thought to turning off comments and just writing this into the dark, but either way, I am going to give this a go.

My father is dying.

More details will emerge, but the way it has worked out is he had lung cancer, advanced lung cancer, too far gone for surgery, only minimally responsive to chemo. The relevant equations indicate that most people with what he's got die in eight months, of which we have had one. One in five is alive at the end of a year - that will be Christmas next year. Almost none survive longer.

Anyway - more on this soon. I am reticent about posting about this ongoing because it is not a request for sympathy, it is not a seeking of communion, I am not asking people to comfort me. But he grew up in a small town in Ireland, he rode a motorbike, he had to stay one time with people who could, but would not, speak English, and so for three years he only heard Gaelic. I don't know much else about him.

I don't know whatI want writing about him to achieve. I don't know what I should be thinking. I know that the mood is precarious at the moment, I have to keep an eye on that.

But a month ago we were talking about how to train the grapevines that have sprouted green, soft tendrils that curl around the trellices in the cattery. They are merlot, they make loose bunches of large, soft grapes, a rich purple sheened with a dusty colour. They row in cold soils, in clay, in full sunlight. They fruit in the second, maybe the third year. He has planted them but will not taste the fruit.

Anyhow. With this, it is the process, not the product, that is important. This is not a mathematical equation with a specific answer. It is about putting down roots and groping towards the sun so that come wintertime, we can survive.

Thanks for listening,