Stranger's Fever

Welll....

2011-03-01T20:20:00.002+10:30

Hail,

First off, I am a git for not posting for so long. Sorry, seriously. It's inconsiderate.

Having said that, things have been going on. I am posting at another blog, imaginatively entitled "a stranger's fever" (astrangersfever.blogspot.com), and if anyone is reading this, I would be glad to see/hear from them there.

I will be putting up links and so forth once I can work out how to do it again.

Either way, thanks for the listening through what, looking back, was a rather remarkable period of my life.

Love,

John

GP

2010-10-17T15:51:00.002+10:30

Hail,

Boring administrative entry below.

I had the second job interview the other day.

I did the interview to get into GP training. I applied to GP training to specialise in addiction medicine. I want to specialise in Addiction Medicine because I love it, and it's fascinating, and so Sarah doesn't have to work.

On that note, we got the letter from the lawyers today. The lawyers have a website, with a short video clip of a woman talking. The woman says something like "Hi, I'm Lara Laura, Lawyer. For too long, amoral multinational companies have built their vast profits on mutilated, maimed and murdered bodies of innocent people. If you have suffered ..." and so on. It's a bit startling.

We fill in the forms and then we wait. Apparently this is an open and shut legal case, which means it may well be finalised within three years. We shall see.

Anyhow - the interview. It was the second interview, because I didn't get in on the first round - I am unsure why, but not wanting to do the thing they're interviewing you for is quite a disadvantage. I don’t actually want to be a GP – I think this is what they call family medicine over in the US. It may have been that my inability to adequately conceal this was behind my less than stellar performance in the first interview.

Still, it does hurt to fail. You do lie in bed the next few weeks wondering if they have found out what no-one else knew but you always expected – that you’re crap. I am older now, and twenty years ago I would have been swarmed by those thoughts, and dragged under, whereas now they are much fewer, and I am able to see them as not particularly realistic, but they are there.

This time things went better. The questions were about how you would handle a heart attack in a small country GP surgery, how to handle the “he’s got gonorrhoea, they’re both your patients, he doesn’t want to tell her or for you to tell her” and an unusual one that started “tell us about one of your wrong diagnoses and the consequences of that.”

It went reasonably well, and later that day they rang up and offered me the job - the job being ninety km away, doing stuff I’ve forgotten, for a minimum of twenty two hours a week, and a considerable pay cut.

Simultaneously thrilled and un-nerved. It is alarming - I don't know if I have what it takes to be a good GP, I don't know if I don't whether I will know that I do not - if you follow. I don't want to be one of those "crap at medicine and crap at detecting your own crapness" doctors. But if it all works out, in three to five years time, it’s a specialist qualification, and Sarah able to not work at all.

We shall see. More soonish - possibly about one of my patients and night terrors. Thanks for listening,

John

Unpublished and possibly career-ending letter to a fellow medical practitioner

2010-10-17T09:48:00.005+10:30

Dear Dr Zu,

I saw Joanne X today. She was limping and she had many of the clinical signs of sciatica. Imagine my delight when I heard how you had successfully treated her back pain without recourse to drugs of dependence.

I'll have to imagine my delight, too, because that is not what I heard.

She said, and a call to the pharmacist confirmed, that you have prescribed her a bottle of alprazolam. I told her that alprazolam was not compatible with her other medications, because together they could cause dangerous side effects like memory loss.

She asked why I hadn't told her about this.

I told her I had.

This is the same woman you sent to me three years ago because she was addicted to alprazolam. She had nearly been intubated because of an overdose of alprazolam. Her husband and two daughters are addicted to alprazolam. The sojourn in the Barad-dur Women's Prison, the miraculously survived three motor vehicle accident, the three weeks in August sleeping in a station wagon, all are due to alprazolam. I have winched this woman's dose back to nothing over the last three years and three months ago she had what she swore was her last dose of alprazolam.

And then she strains her back and you give her alprazolam.

Sciatica occurs when an inflamed disk presses on a nerve root causing pain. The inflammation is treated with anti-inflammatories, the nerve root pain with analgesics. The only thing alprazolam is "treating" in this case is the very dependency issue that caused ninety nine percent of her problems in the first place.

She also mentioned some concerns about her weight gain. Perhaps you could prescribe her some pastry?

Yours,

John Bronze,

BSc BM BS etc.

killing people is wrong

2010-10-02T03:48:00.001+09:30

Hail,

And herein a serious post.

It's three AM. I've been up since two. One of my friends is up, and one of the writers whose recent accomplishments I most admire, and so, I believe, is that guy who wrote that book I really loved back in the eighties, but two of them are in Queensland and one is probably intoxicated, so to all intents and purposes I am alone.

The clock ticks. The cats purr. The cold air of the outside world comes in. The real world.

Today we went to see the orthopod. When I went through, orthopaedic surgeons were reputed to be particularly difficult people to deal with. I doubt that was ever true, every time we have seen one they have listened courteously and compassionately and answered every question that we've had. Today, he ran an hour and something late, for reasons I will now explain.

Two years ago, my wife became a cyborg. She has an aggressive and inadequately explained form of arthritis, along with an actual one in a million auto-immune disease. Because of this, she required surgery on both hips, to resurface the head of the femur (the thigh bone) so it moved freely and smoothly in the socket (the hip bone).

This was huge surgery. Even thinking about what went on at that time it is frightening, so I am putting it off. But it required vast amounts of blood, and pain, and courage on her part.

A few months ago I was reading in the New York Times and I read that the prosthesis (sometimes it's called the "implant") has been recalled by the manufacturer because of an unacceptably high failure rate.

I rang up. The hospital had just heard as well. We got the first available appointment, which was a month away.

In the mean time we read more. We were originally told that the implant could last decades without any trouble at all. The web was full of stories of people who had had this major orthopaedic surgery and gone on to full, astonishingly active lives - people who ran in marathons, climbed mountains, the like. I understand there was a fifth dan Shotokan in there.

It turned out that by "decades" they meant for many people, a very few years, and by "without any trouble at all", they meant something entirely different again. My wife has increasing pain and decreasing mobility. She has pain at rest which she did not have six months ago. The pain, the sleeplessness, the inability to do the things she loves, is seeping through everything. Things are as bad now as they were a year before the surgery.

That may not be all. The steel which covers her femoral head and her acetabulum is high in chromium and cobalt. In a number of cases, the metal ions are released into the surrounding tissue, into muscle, bone and fat. They cause pain and inflammation, in extreme cases they cause symptoms of themselves, they may cause difficulties with further surgery.

As an aside, I have always thought that if I was ever angry enough to want to kill someone, I should tell someone about it. That way, even if the "killing people is wrong" part of my brain didn't kick in, the "you'll get caught because you already confessed and explained exactly what you wanted to do and how you would do it" part would. Be informed, therefore, that if this goes much wronger, if, for example, something were to go wrong with the subsequent surgery, or it were to have been made impossible because of ion deposition from the current prosthetic,I feel like going to America, looking up the names of the people responsible for deciding to keep this on the market after the facts became apparent, and removing them from this earth. Without descending into hubris, I reckon I could get a couple before I went. I am smart and rich and could probably get back into shape enough to drag most people's bodies. And there would be none of this "left for dead but managed to crawl to a nearby farm" bullshit. I have called time of death enough times to know what is required.

Obviously, that's the anger talking. And the fact I have said this means I can't do it, and I haven't even been in a fight for twenty years, and yadda yadda yadda. But this anger is a difficult thing to articulate.

Anyhow. We wait on bloods, and on the ultrasound, and we go back. We see what can be done. It may be something else is going wrong. The orthopod said he could not imagine what it could be, but maybe he was having an unimaginative day. It may heal, somehow.

It may not.

Anyhow, it's nearly four. I must retire. Tomorrow I clean the chook cage, and spread compost on the fruit trees, and we set up another quail house. I will hit and gouge the punching bag, and maybe break my resolution and finish a book. And I write again soon.

Thanks for listening,

BDC

Stress leave

2010-09-19T18:04:00.004+09:30

Hail,

And if that title was an incantation, instead of just an indication, things would be a whole lot better.

But anyway. What goes on?

Well, I potter. I write the Novel. I read - currently medieval history. I feed the birds of the air and the beasts of the field.

I have a list of things I try to do each day - prepare dinner, clean house, feed cats, kick-box. I have a pine post, standing, set in concrete out the back, and I have wrapped it in some of that stuff they use to make camper's bed-rolls, and each day I kick and punch and elbow it into submission.

And presumably, time does its work.

I have had three phone calls from work. The first was from the manager, a "hope you are well" call that went straight to voice-mail. The second was from my boss - not the same as the manager - who said the same, and detailed the several things that were being done as we speak to ensure that when I returned things would be measurably better. The last was from the admin person at work, details to follow.

Plus two nurses invited me and Sarah out to a Greek restaurant, and another has found me on Facebook.

All of this is a bit worrying.

For those who came in late, about two and a half years ago I took an overdose. I have bipolar disorder, and I have some expertise in what and how much to take, and although or perhaps because I was quite unwell at the time, it was a near-run thing. I ended up in the Royal, our largest hospital, unconscious and intubated. There were what I believe to be three days of hallucinations, several weeks of hospitalisations, months of ongoing therapy.

This was at a public hospital, and I work in a fairly small field, and Sarah did have to contact people and tell them I would not be in for work for some time. And it is on the hospital record system - now accessible throughout all the hospitals in the city - and the registrar who wrote it up did me the professional courtesy of including my title in the discharge summary. "Dr Bronze presented having taken an intentional overdose of amitriptyline exceeding... and so on."

Why bring this up?

Because I suspect that this is why I am being treated so well. I think that one of the benefits of having a fairly spectacular psychiatric history is people tend to take what you say seriously when you talk about your mood. I emailed my boss and told him I was taking two weeks minimum off, doctor's recommendation, and it was as if I had sounded a siren, or a code had been called. Not a code blue (someone dying, move towards) or a code black (someone dangerous, move away), but a code sparkly swirly, or a code bronze. Code bronze means "John's looking and sounding a bit odd." The appropriate action seems to be neither move away nor move towards, but "move about in a reassuring manner".

Which is good and bad. I feel a bit guilt-ridden, because I know that this is not how others are treated. I have had friends and family, kith and kin, who have been treated much worse than I have. Who have burned down further and needed more care and received less or none. I feel I am getting treated better than I deserve.

Anyhow. I have things to do. Write novel. Feed birds of air and beasts of field. Kick and punch and elbow defenceless pole.

Thanks for listening,

John

Welll...

2010-09-18T09:14:00.002+09:30

... this is under doctor's orders.

Not exactly orders, but doctor's strong suggestions. The story thus far:

Last post, I think, was January. I had vague intentions of writing more, but to be honest, not a lot more than vague. I was writing a book and running a clinic. I had two hundred thousand words and two hundred patients to look after. I had other issues.

My dad, as I may or may not have related, had been diagnosed with lung cancer - stage four non-small cell. The prognosis was exceedingly grim. My brother was going through an on-again-off-again divorce.

And to show it's not all been grim, there was Deadwood and Breaking Bad DVDs, and Facebook, and nights spent lying on the couch eating chocolate with glorious Sarah.

(Hideous realisation: I have forgotten everyone's noms de strange. All I can remember is my wife and my niece. For everyone else, imagine there has been some kind of alien invasion in where-ever the hell this is set, and the aliens have renamed everyone.)

((The above makes no sense to me whatsoever.))

Anyhow - things went on. Then I got burnout.

That was a difficult thing to say. I looked up the symptoms - yes, it's all medicine 2.0 here - and I reckon I had most of them. The staring at the screen for hours while nothing actually got done. The heavy, cold dragging feeling in the chest on the way to work. The concretised thinking. The tendency to cut to the simplest solution rather than work towards the best one. The endless cunctation*.

"I have a new form of bipolar disorder," I said to Dr Tesla (?). He inclined his head.

"Moderate-cycling, where I am deeply depressed Monday to Friday and perfectly normal the other days. And on holidays."

He suggested a few weeks off. I took five days. I went back and it was crap. I took another few days, where I went to the World Science Fiction Convention, Which Sounds Glamourous And Exotic Until You Realise It's Only In Melbourne.

I came back. It was more crap.

I went to my GP. She said don't go in for a fortnight, minimum, maybe a month. See this person, make an appointment to see so and so, do this.

And so, here I am.

And I have also been looking into narrative therapy, writing down things to deal with them. And so, again, electronically, here I am.

Anyhow - I will write more of this soonish. I think if I can write a swathe of stuff, to help "get better", and subsequently keep this to at least weekly, to "stay better", I will be able not only to live my normal life, and write, and face-book and stuff, but also be able to work again. Be able to look go into my workplace, and pick up a file, and actually do something with it.

Anyway, thanks for listening.

John

*actually a real word. Better spelt than spoken aloud, but useful in staff meetings.

Shotgun

2010-01-08T13:06:00.009+10:30

Hail,
And herewith a bad thign that happened to Jasper Lucas. Bad language alert.

Jasper is a man whom it is difficult not to like. He is thin, blonde-haired and freckled, with bright blue eyes above a meandering nose. He breeds tree-frogs, and reads thrillers, and once got shot with a rubber bullet in what he said was a demonstration against police violence, in Ireland. Like a number of our other clients, almost nothing of his wild life from twenty years ago remains - bad dreams, bare gums, scars and pharmacology.

I am reluctant to go into detail here, but while his criminal record is scant, his easy familarity with a number of the "hard men from the old crew" suggests there was, at one time, a lot more to Mr Lucas than met the eye. Bad things have happened to him. Jasper's teeth were not removed in the normal fashion, and this has something to do with the six month prison sentence he suffered fifteen years ago. I don't know.

He still picks up his methadone every day from Crippens' Pharmacy. Every two months we discuss reducing his dose, moving him on, getting him away from the pharmacy. Every two months he says he's not ready - reducing his dose causes disturbed sleep, and anxiety, and physical discomfort, and those are things he's of which he's probably had enough.

But he's doing well, and the other day a group of them went to Shylock Services*and treated himself to a graphite pool cue - he plays competitively - and a second hand version of Guitar Hero. His mate drove him home, and he sat in the back seat holding his pool cue and running his fingers up and down the frets of the Guitar Hero game. His mate dropped him off and he went inside to grab a coffee.

While the coffee was boiling he glanced outside. A man in a police uniform ran by across the street, cruched over, wearing a flak jacket.

"That's never good," he thought. "Wonder what that's about?" A few minutes later there was a knock on thedoor. He wandered over, coffee in hand, and opened it to a shotgun. the muzzle was pressed against his face. A mass of armed and armoured men swarmed in, pointing shotguns and screaming.

"Jesus Christ" I said. My own coffee was half-way to my lips. "TRG?"

"It wasn't the fucking girl guides" he said.

He was quite upset. They had hurled him on the ground in "some kind of judo hold" and pointed guns at his head and screamed "where is it? where the fuck is it?" a lot. He had managed to get them to calm down enough to ask for a hint as to what "it" might possibly be.

"The gun!" They shrieked. "Don't fuck about!" and so on.

Note - from here on in, I'm replacing the obscenities with euphemism.

Anyway, it emerged that, unsurprisingly, there was no gun. There had been no gun. There had been Mr Lucas sitting in the back seat of his car, holding his little plastic guitar hero guitar and his pool cue, and miming "Eruption" by Van Halen. This ludicrous story fooled no-one, but the discoverey of the pool cue, the guitar hero game, and the timed and dated receipt on the bed a few metres from the front door and exactly where he said they would be did temporarily set his assailants back. Murmurs (but no apologies, Mr lucas noted) were exchanged, and the horde withdrew. One of them turned as he left and actually said "We'll be back."

"Knock yourself out, you [foolish individuals]" Mr Lucas said, or words to that effect. "I'm getting a Wii next week. If you squint, and you're [dashed silly], it looks like a pair of nunchucks."

Anyway, must heal sick. We shall see what emerges from this.
Thanks for listening,
John

*I don't know I am comfortable with this name. Shylock was a more complex character than often thought, and the best portrayals bring out this complexity and ambiguity, but the essential facts remain - the vicious Jew. Shylock Services gives you twenty bucks for something worth two hundred, and sells it at one hundred fifty.

The whip

2010-01-04T09:52:00.003+10:30

Hail,
Now - I was going to write a bit more on the preceding "sex and medicine" theme, but I don't know that I will. It's probably enough to know that sometimes things catch you off guard, and hit you, and five years later if you look back you are still disquieted by them.
Bleeargh.

Meantime - the public methadone programme and the whip.

We in the south have a problem. About half of my two hundred patients are on methadone. Methadone, for those who came in late, is heroin unplugged - a slower, safer, acoustic version without that heady mix of outlaw edginess and frontal lobe infarction. It's safer, but it's in no way safe.

Whether or not the programme (and doesn't that sound like something from the Ministry of Clear Thought) saves lives is a matter of debate, but that debate was formed and now flourishes almost entirely outside medicine. From a medical point of view, the numbers are remarkably convincing - you get some one on methadone, they die later*. They get fewer infections. They are less likely to be breaking into your car as you read this.

But they do die. From what I can work out, for my patients, ten "should" die every thousand person-years. I have two hundred people on the programme, maybe two should die a year. Over five years, if they were average opioid dependent people, ten "should" die**. These rates are lower than in a lot of countries, partly because we have little HIV over here.
The rates of death for similar groups who are not opioid dependent is one fifth of that - maybe two in five years, maybe three.
The rates of death on the programme depends on who does it, and how well it is done, but for us it is still too high. We had two deaths last year - car versus tree, and overdose - , two or three in the three years before that - complications of pneumonia, a hanging. One this time last year, when someone stabbed Nicky Walker in the throat with a samurai sword. Maybe we're running at one a year, certainly less than two.

Why? Violence. Overdose. Alcohol. "Pills". The one we are falling down most badly on at the moment is the pills. Specifically, a lot of our patients are on alprazolam, and almost all of our patients who die, or are incarcerated, or are hospitalised are on it.

Alprazolam, as I have said, is like vodka to the frontal lobes. Amnesia, disinhibition, a complete shutting down of the part of the brain that says "uhh, maybe this isn't the best idea". Alprazolam plus methadone means long stays in ICU, constant cognitive impairment, increased chances of respiratory depression and of having six colours of shit kicked out of you.

I've tracked down a few of the dealers. They drive past in their big cars, wearing their fancy suits. Lately, some of the locals have been getting soft, and new guys, blank-faced men from south-east Asia or softly spoken men from the subcontinent have made inroads into their territory. I've got a decent idea of where they operate, who they see. I've even managed to get a few names - Dr Lung. Dr Chandraguptran. Dr Jones.

And I'm taking steps. I'm ringing and writing to them. I'm informing the relevant regulatory bodies. In the end, I might be ringing the medical board on them. One of my patients, a woman who has twice fallen asleep in the waiting room, has seen twelve different doctors in the last few months and been prescribed diazepam, oxazepam, temazepam, alprazolam, clonazepam and nitrazepam. Sedatives are a fair proportion of her caloric intake. She has had multiple overdoses and is only kept alive by being incarcerated.

Dr Jones thought this woman's interests would be best served by one hundred tablets of alprazolam in four days.

Anyway - that's the whip. I am uncomfortable cracking it. But otherwise we have the police in and out of the pharmacy, and the ICU on standby, and the coroner on speed-dial. We have a death rate that is edging closer to that achieved by the Triads and the bikie gangs. We don't have medicine.

I shall keep you informed. Thanks for listening,
John

*These are all population based studies, which are fine and noble things, but of utterly no use to those whose sons and daughters and family and friends die either "on" methadone or from diverted methadone. A population may have a decreased rate of mortality, but each person who dies remains absolutely dead. in the period during which I did not write, this happened to a relative of mine, a girl - and I chose that word - of twenty six, who died in her sleep over the summer.
These people are seen as side effects, as collateral damage, as the unavoidable consequence of what we do. I don't know to what extent that is true, but if this has happened to you, I and others like me are to a degree responsible, and I am sorry.

** I know the maths isn't like this, but the language is. it's like when I say "giraffes evolved long necks to reach succulent foliage", rather than "mutant giraffes with long necks survived and bred" and so forth.

Your doctor may find you sexually attractive

2009-12-28T07:55:00.002+10:30

Hail,
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,
John.

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.

John

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

Sugar

2009-12-22T08:43:00.002+10:30

Hail,
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,
John

The story so far

2009-12-20T07:38:00.002+10:30

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,
John

The Father Thing

2009-12-16T14:27:00.007+10:30

Hail,

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,
John

Gene and punishment

2009-08-04T13:59:00.004+09:30

Hail, And as soon as I start blogging, something happens at work I am legally not allowed to talk about. Seriously - people are dead, and arrested, and so forth. A body has been found, and someone stabbed, and someone else is in custody. It's all been grim.

In other news, I have had to send one of my patients to Sarah.

The reasons for this are as follows: Erica was one of the patients I inherited when I took over this practice from Doctor No about three years ago. Doctor No was a woman of Asian descent who brought a strong, Confucian work ethic to the practice, but whose attitude towards clients was possibly more influenced by Han Fei Tzu than anyone else. Han Fei Tzu was, as those of us who read a few too many "Master of Kung Fu"comics back in the seventies know, of course, the author of the Han Fei Zi, the Fifty Five Chapters.

This rather dispiriting text explains that the ruler maintains discipline via three attributes: (his) position of power (勢, Shi); certain techniques (術, Shu), and laws (法, Fa), and that this power is maintained over an essentially evil and lawless people only through instantaneous and unflinching application of force.

The "certain techniques" in this case seemed to consist of kicking people off the methadone programme, but I digress.

Erica had come to me with a job, a boyfriend, a decent bank balance and a very occasional "habit" of smoking heroin. Three years later, under my care, she was unemployed, penniless, anxious, openly depressed and deeply in debt. She had been an administrative officer with a local bank - now she was working doing sex toy parties (a difficult thing for a woman who wasn't really comfortable doing that kind of thing). Her parents had found her medication, there had been a disagreement, she had come to the clinic with a black eye that she didn't want to talk about. Every month now for the last six months her address had changed, she was couch-surfing amongst a dwindling number of family and friends.

Things were bad.

And they were, if anything, more frustratingly bad for all concerned because she was one of the few who had deteriorated fairly dramatically under my care.

And there were other things, too. She failed to attend appointments, she forgot or didn't like medications, she was unable to attend counselling, or psychiatrist appointments, or meetings with the housing trust - but she was always early to see me. She was always what the textbooks say "cleanly and appropriately dressed".

A few months back she emailed me, on my work email address, which she'd found. That's not in any way illegal or immoral or anything, it's a free country, but it was somewhat alarming, mainly because it was unusual. And also, it does open up the whole "emailing to each other" can of worms. Not that worms in a can email each other, but if they did, it would be, you know, awkward.

I suspect some of you may already be thinking "get over yourself, mate, it's only a freakin' email", but there are things that can go wrong here.
Anyhow - rather than email back I sloughed the letter to Cerridwen, one of our nurses, and asked her to fix the problem. And then next appointment, which was last Thursday, she told me how she felt. Well, not first off, and not verbally.

First she told me how things were going. Things were uniformly dire. She could not go on like this. She didn't know why she was sabotaging herself, why she made so many bad decisions. There was so much going on, emotionally, so many things. She didn't know what to do.

And she reached into her handbag and pulled out a couple of sheets of paper, covered with hand-written notes. "Here," she said. "This will explain how I feel."And she left.

I didn't open the note, I just sat there for a moment.

Then I called Cerridwen and we went and saw Ernie, our senior nurse, and there was a fifteen minute monversation (I think he managed to get a syllable in every few minutes or so) where I told him how all this, well, stuff was going on.

"Stuff..." said Ernie.

"You know," and I waved my hands ineffectually. "It's all look at my terrible emotional trauma, see how nothing can be done, doesn't it make you need to love me, please rescue me," kind of stuff."

There was a long silence. Cerridwen opened the note.

"I have so much love to give and no-one to give it to," she said.

I looked at her, irritably.

"Can it wait?" I said. "We're working."

"Not me, you clown" she said. "Look."

And she handed over the note.

"The only man I have feelings for is married," I read. After that was three or four lines of text, scribbled out and illegible.

"Checkmate" said Ernie.

Now, this should be the end of the matter. Boundaries have been crossed. There is a set protocol here. I have referred her to the Eastern service, where the two doctors are Dr Hahn, a vastly experienced and maternal woman with a long history in the mental health services (on the side where you lock people up, not the side where you get locked up), and Sarah. I don't know that there are a lot of options at the moment.

But there's more to it than that. There is a way in which things for her have altered. There is an aspect of punishment, of rejection, or abandonment to this.

She has become, in some way it's hard to articulate, a "bad patient".

Someone is sick, and they come to us, and we treat them, as long as she is not too sick, or as long as she is only sick in particular, prescribed ways.
The thing is, you look at borderline personality disorder, you look at it as a disease, and there are certain alterations in the brain. Prefrontal cortical control over the amygdala, the bit of your brain that recognises emotions in others, is weak. The amgdala is hyper-reactive, it over-reacts to certain facial expressions. It interprets both negative and neutral facial expressions as threatening.

This is at least partially under genetic control - to an extent, you are born with the tendency to see frightening or enraging things when other people do not. These "heritable risk factors" create difficulties in normal attachment - the emotional instability means fractured, fluctuating relationships that bafflingly, terrifyingly career out of control, that creates further emotional instability, and so on.

Erica - heavily mascara'd, wearing her best clothes, always on time - is going to experience this as rejection. She will experience this as rejection, I think it is possible to see her point of view with this.

So, she is being rejected.

She is being punished.

Generally, you're punished when you've done something wrong.

Generally, it's wrong when it's not your fault.

The closest I ever came to hearing wisdom in my few brief months in the psych training programme was someone saying that pathological personality structures (borderline personality disorder, antisocial personality disorder, etc.) were not things designed to piss the treating doctor off, they were instead structures that the patient had constructed to protect him or herself from the world. Less spite and malice than psychic scar tissue and reflex movements, ways of getting by.

Anyway. I have a patient waiting. I am out of practice with this - the computer ate my last three posts.

Please be patient.

Thanks for listening,
John

In which I mangel my wurzel.

2009-07-24T10:05:00.003+09:30

Well...
I don't know whether to launch into a great detailed explanation, with sub-paragraphs and appendices, for why I have not been blogging, or just to get on with it. I might just try to get on with it , and append appendices where they need appending.
And I do feel rather guilty about all this, regardless of the reasons, but either way - enough with the writing about not writing and more with the writing.

Sarah, by the by, does relatively well, and is interstate for a cat spectacular. Clinically, she remains in a state of advanced gorgeousness. My niece - I can't remember what pseudonym she picked, I think it was something like Ginger* - is living with us, working at the Royal in the surgical admissions suite. The cats thrive, I am building a cattery for them. It progresses at the rate of a medieval cathedral, except instead of generations of artisans they've got me. She has dumped the cartoon-watching boyfriend with the dangly thing in his nose for a Romanian kickboxer called Vlad.

My patients - there are ups and downs. The Global Economic Where the Hell Did That Come From has affected them, like it has everyone else, but in an unusual way - there is the usual unemployment and under-employment, but added to that is the stimulus, or as we call it, the stimulant package. If you don't have a lot and things are unstable and you suddenly get a lot there is a tendency to spend it on stuff that maybe won't help you a lot.

Anyway - that's a brief intro. Will. Write. Again. Soon.

Thanks for reading, too.
John

*Some kind of edible root - Sweet potato? Mandrake? Mangel-wurzel?

Testing...

2009-07-21T15:45:00.000+09:30

(sound of crickets)...

Both woo and hoo

2008-09-16T13:32:00.004+09:30

Well....

I have rather exciting news, and frustratingly, no real way to tell it. This is the situation.

In my spare time I write. I've been doing it from the pre-teen years, if you count the "Shangar the Black" stories*. It started out as mostly science fiction, fantasy, horror, That Sort Of Thing, but lately it's been more mainstream. It's been mostly short stories, because that's what I grew up on, but there's also been this blog, and several uncompleted novels (one autobiographical, one large-scale SF, one rather meandering attempt at erotica, and one in progress), and a great ream of poems and a few plays.

It's been mostly for my own enjoyment. Other people do weirder things.

Anyway, I applied for one of those hard-to-get-into boot camp things, those intensive "couple of weeks in the wilderness" hot-housing courses where they drop you in the desert with only a thesurus and you have to be able to construct a simile using only what you can find in the natural environment, and start a fire using only an aphorism and a lump of anapestic tetrameter... I applied and the other day they rang me and told me I was in.

This is serious good news for me, serious good news. It's happening this summer. I spent the rest of the night running up and down across the ceiling shrieking in a high-piched voice until Sarah coaxed me down with a glass of expensive (i.e.: more than five dollars a bottle) red wine, and I have not shut up about it since. Six weeks in the north Australian jungle with only other writers for company.

It is a bit terrifying. I haven't written short stories for ages. I don't know any of these people with whom I will be spending sixish weeks. I suspect, as I suspect many people do who succeed in anything, that any success I have had in this area has been due to the combined effects of luck, universal background weirdness and typographical errors in administration - my inadequacies may be found out. I may get writer's block, I may get manic or depressed, I not have anything to say. I may turn out to be allergic to semicolons.

But I am going. Pretty much the only thing that could stop me would be something medical happening to Sarah. I have commenced discussions with my boss, where I said I was going to go, and he said that other people wanted holidays around that time and it may not be easy, and I said that wouldn't be a problem, because I would resign and reapply for my own job when I came back, and given that they've been advertising for someone to do a similar job in a nicer area for two years without any real success, and that they would have a maximum of two months to find a qualified medical practitioner mad enough to want to come to the South but sane enough to work here who would out-interview and out-perform me, I reckoned I'd be right.

All calm and collected, but I've almost never disagreed with a senior doctor before, and it went relatively well.

So - I don't know how I'll blog from there, because of the whole confidentiality thing. The writers camp is called Greystoke, it's over a thousand kilometres away, on the grounds of Mangani University in Opar**. It's summer in the tropics. I have it on good authority that the air will be like treacle, that there will be honey-moths and sugar-cane and mango juice, and that there are people who will leave you alone, and there are rivers full of crocodiles.

We shall see. I had best get on with this. Thanks for listening - to be honest, this was written more out of "I want to tell people" rather than any thought that what I have to write will be interesting to others. Next post should be better.

Thanks for listening, will speak soon,

John

* "Black" in the way that black metal music is black - i.e. anaemically white but wanting to be scary.

** No, it's not. But until I come up with a better idea of getting around this whole confidentiality thing, that's what I'm going to be calling it.

Don't you thrust your crochets onto me

2008-09-15T14:20:00.003+09:30

Hail,

And have finally managed to get back onto my own blog after locking myself out for a considerable period of time. I would explain how this happend, but it's actually too pathetic to relate.

In other news, Sarah returned wide-eyed from the recent Supreme Inter-Galactic Cat Show and told me of a hideous encounter she had had.

She had taken her cats, as is her wont, to be displayed at the cat show, and the cats were positioned aesthetically in their cages. Sarah breeds extremely fine looking animals, all long soft fur and remarkable colours, but their nature remains unrepentently cat, and they frequently fail to co-operate with her. In particular, they do not pose regally on their sumptuous cushions of purple satin, looking impressive and inscrutable. Instead they clean themselves, curl up in a ball or on occasion, produce various luridly coloured gastro-intestinal products and sit there looking perplexed.

We have, by the way, two groups of cats, the outside ones and the inside ones. The outside ones are few, they have been given to us by people who say "otherwise he'll be put down". The inside ones are a few more, they are the product of Sarah's exquisitely worked out breeding programme.

The two tribes are at war. When the screen door is opened, the outside cats and the inside cats press up against it and swear at each other. Each tribe has its great warrior, war-chief, what the old Anglo-Saxons called their battle-wolf. The inside cats tremble at the dread name of Twinkle, while the outside cats groan beneath the iron claw of Fluffy.

Anyhow - the cats are in their cages, and people come up and look at them. Sarah was chatting with a fellow fancier*, when a small, red-faced man tapped managed to attract her attention.

"Excuse me" he said, pointing at one of the cages. "What kind of cat is that?"

"That cat?"

"Yes"

"There isn't one" said Sarah.

She was right. The cage held a single tiger-striped cushion. The cat that was going to be put in there was being examined by someone else.

"Well, what's that? is it a Siamese?" said the man, pointing at the cushion.

"It's a cushion" said Sarah.

"In the cage" said the man.

"It's just a cushion" repeated Sarah.

There was a pause. The smal man nodded impatiently. "What breed?"

Sarah stared. "Breed?"

"Yes, what breed is it?"

"Tontine?" guessed Sarah.

The man nodded again, and walked off. Sarah went off to have a cup of coffee and reconsider her beliefs about the advisability of government by democratic election. She put the cat in the cage, and he imediately squirmed underneath the cushion and went to sleep. A few minutes later the man and his family appeared.

"Look" the man was saying to his wife and children. "See?"

"It's certainly unusual" said the woman. "What kind is it again?"

"A Tontine. A Tontine Kushan" said the man, pronouncing it in some exotic-sounding orientalish way. "They're quite rare."

Sarah could endure no more. She did not want the man going around saying she travelled around the state attending cat shows and exhibiting embroidered bits of manchester. She hobbled to her feet. She placed her face close to the man's and spoke clearly.

"There is no cat in there" she eunciated. "It is a cushion."

The man stared at her, then gazed downward. As far as anyone could see, the cage was empty of all animate life. only the gentle rising and falling of the pillow with each breath of the cat below gave any hint of occupacy. The man gazed for a moment, then looked up at Sarah with a belligerent expression.

"Well, if it's not a cat then, how come I can see it breathing?"

This is actually true. Not a word of a lie.

Anyhow - I will post again soonish. In the interim I leave you with a definition from an archaic on-line dictionary I was reading:

crotcheteer [crotchet (whim) + -eer] one who has a crotchet or who thrusts his crotchets on others

Anyone who is enlightened by that explaation, please forward an interpretation to me.

Thanks for reading,

John

*The correct title for a breeder of cats. Thus the Cat Fancier, the Dog Fancier, etcetera. There was actually a magazine dedicated to those who breed the particular species of bird known as the Boy, but the magazine no longer exists. There is a book.

Totally addicted to yo.

2008-08-24T15:12:00.004+09:30

Hail,
I'm madly writing this in between cat-feeding, furniture-shifting, chook-house-building and novel-writing-avoiding, so this may not be a perfectly balanced post.

Firstly, exercise. What I'm doing is doing interval training in the morning, five or six mornings a week, and gym stuff three times a week. The interval stuff in my case is one of those stepper machines, something we bought for Sarah back when she could use things like that. Basically, interval training means short periods of maximal effort (sprinting) alternating with short periods of lower intensity exercise (jogging or something). The gym stuff is to make sure I don't starve my muscles away, it's compound, mass-building exercises--

Christ, this is boring, isn't it? One problem I have, and one reason I am talking about this here rather than with most people I know face to face, is a lot of the talk that goes on around physical fitness/weight loss/muscle building stuff irritates the living daylights out of me. I find it difficult to read a lot of the stuff about exercise. Some of it - the medicine - the physiology, the anatomy, the right way to do stuff, the less value-laden stuff - I find that very interesting.

But if there was a "fitness magazine world" or something, I wouldn't want to live there. It's an unforgiving place, all blinding white-toothed grins, an almost manic joi de vivre, commandments adn prohibitions and judgements, ideas about the world as hard and flat and unyielding as the washboard abs you see on every page. It's difficult to articulate, but I feel that it's not that far from ginseng extract in the morning and preacher curls and three thousand kilojoules a day to something much less attractive - a horrible tight-lipped puritanism, an almost palpable self-loathing (the front of the magazines say "blast your shoulders! burn your thighs! shred your chest! thrust your genitals into the meatgrinder!"). And all of this on top of a weapons-grade narcissism that you'd worry about if you saw it in a psychiatric ward.

Anyway. I remember reading something once, the writer said it was a proverb. I can't remember if it was meant to be an African proverb or an Indian one or a Chinese one, but you can bet it was one of those places we say things come from when we want people to believe what we say is true and wise and unchallengeable.

The proverb said "Tell me what you boast of and I will tell you what you lack". So maybe I'll stop boasting about how unshallow and not-at-all-narcissistic I am and get on with the fat stuff.

So. The best way for me to exercise is that early morning interval training stuff I wrote about above, because for me that's the most enjoyable way of doing it. From what I understand, interval training gets better results per minute than any other type of exercise. I am a morning person, so it makes sense for me to exercise first thing. And I like the gym, I enjoy the solitude and the feel of the cold steel and the way the weights descend through an arc, the basic, functional look to them, and the gym is close, on my way to work, so that works for me too.

With the diet part, which is basically a fairly mild degree of caloric restriction, what works for me is one of those fundamentalist diets where they set out in fairly clinical detail what you are allowed to eat and what you must not. Again, from what I understand, having something concrete like this works better for most people than those "eat when you feel hungry" ad libitum diets, so that's what I'm trying.

It's an Australian one called the CSIRO diet, you can get the books. Ten cents from the sale of every book goes to buy some decent midfielders for my football team. That or a kilo of lithium for me.

And it is working. The other thing I did was get a checkup, get a decent idea of what my starting point was so I could work out how far I would have to go in what direction to get where I wanted to be - all that stuff others have mentioned. Initially I am looking to lose one or two kilos a week, get the waist:hip ratio down below ninety and knock the early stage blood sugar stuff on the head. And it is working.

Anyway - this is something I am uncomfortable discussing. I feel ridiculously greatful to my friends who have not brought this up when I am with them in the flesh. Eating, sex, prayer - things I like doing and do when I can, but feel deeply uncomfortable discussing. I should call my next entry "let's (not) talk about sex".

As an aside, I just got a blood test back and apparently there is a blood test for"Yo antibodies". Theoretically, this is what your immune system would produce after being exposed to even miniscule amounts of "yo".

Will write again soon. Thanks for listening,
John

I have ---'d on the --- of giants

2008-08-19T11:42:00.009+09:30

Hail,
First of all, thanks a lot for the comments, will attempt to reply later today. People have said stuff I am quite keen to respond to, and as soon as it calms down here, I will. I do find this whole issue an incredibly complex topic - each time I try write about it I get ten paragraphs of unfinished sentences. The topic itself is that horrible mixture of the private and the public.

I remember reading somewhere that the obese are unusual in that their sin is impossible to conceal and impossible to excuse. If you cripple the economies of small African countries you get lauded, if you spend every waking hour downloading hot Flemish porn you can at least lead a normal life, but if you really love pasta, you're marked out in a crowd. Obesity is hard to isolate one thing to talk about - every medical "fact" has social implications, emotional connotations, political connections.

But it's interesting. And six mornings a week I am getting up to struggle and blunder and lunge on one of those stepper machines, and each morning I am eating my low GI breakfasts and each night not having second helpings of anything non-carrotty, and all that. And it's working - incrementally, and it's early days yet, but it is working, and I do feel better.

Additionally, as part of a bargain with Sarah - she's a smart woman, but she has some really weird ideas, like "life should be enjoyable" and that "pleasure is not wrong" - I am cooking exciting stuff for us to eat, and doling it out with pathetic demands for oohs, aahs and fanfare. Anyone with any recipes that were too hard to get into "Really good exotic looking cooking for dummies" can send them hereabouts.

And it has been pointed out to me that measuring weight when you are concerned about adiposity (sounds like one of those mediaeval religio-legal terms, doesn't it? "In 1140, following the publication of his summa gastronomica, Bearneard of Cleauerviuaux was convicted of adiposity") isn't the most accurate way of doing things. So adjustments are going to have to be made, some kind of criteria which take into account body fat and physical measurements and so on. I might get one of those electrical scale things where they measure your body fat by sending an electric current through your feet. The good thing about those kind of scales is if my mood gets too bad, I can just strap a couple of them to my head and turn the voltage up.

Anyhow. We shall see. I was going to write something about boundaries - there have been a couple of patients who have sortof blurred the boundaries lately, patients where I have felt that things have slipped out of my hands, ended up in unknown territory - but I am at Central today, and the police have already been called to drag one of my patients away, and I am unlikely to be able to concentrate on something like that.

Instead, some ephemera. Here is a fragment of recent dialogue between me and one of our new patients:
Me: When you picked up the clean needle pack, there's this bit where you're meant to write down what you inject...
Him (defiant): Yeah?
Me: You wrote the letter "M"...
Him (incredulous at my stupidity): For emphetamines!

Additionally, I have in front of me a printout of blood alcohol results that show a 44 year old man presented to Florey last year with a blood alcohol of... 0.77.
That's not 0.07, that's almost ten times the old drink-driving cut-off. It's .15 g/dl higher than anyone else I've ever heard of. If this reading was not an artefact - the most likely thing I could think of is someone used an alcohol swipe to wipe his skin with and that somehow contaminated things - and if this was the Cirrhosis Olympics, this guy's Martin Phelps or whoever. Theoretically, 0.5 would kill most alcohol naïve people. I am trying to work out how much of this guy's blood you would have to drink to become drunk.

And as another aside, here is a fragment of conversation I had with two of my nurses. If anyone can explain where "first nurse" got her idea from, I will be very grateful. I cannot begin to make the connection.

Me (walking past): Jumpin' jack flash, it's a gas gas gas, do do, do do dooo do do dooo do do do...
Nurse: No, he's a porn star.
Other nurse: Bullshit. Ask John.
Me: What? Who? Why? Why me?
Nurse: Isaac Newton, he's a porn star, isn't he?
Me: Isaac Newton?
Nurse: Sir Isaac Newton. Big porn star. In porn movies.
Me: I've heard of a scientist Isaac Newton...
Nurse: What'd he do?
Me: Gravity. Optics. He was the guy who sat under an apple tree, apple fell on his head. First one to get a ray of white light, shine it on a prism, split it into colours.
Social Worker: Didn't he invent calculus?
Me: I reckon. Him and Leibniz, wasn't it?
Social worker: Horrible man.
Second nurse, triumphant: Nothing to do with pornography then?
First nurse: You're both full of crap. Sir Isaac Newton. He's a really big porn star. He's really famous.
Second nurse: What, so he got knighted for services to pornography?
First nurse: Go look it up. And then come back to me and tell me how right I was.

Anyhow. Sorry so little of substance, but there's been a lot going on.
Speak soon, and thanks for listening,
John

Fatterer

2008-08-05T15:27:00.007+09:30

Hail,
Now, this will be a bit of an unusual post - thanks for reading. Any advice gratefully received. I could do with a bit of help, actually. The post has actually taken twice as long to write as usual, there have been multiple writings and rewritings and it sitill hasn't come out right. BUt at this rate, it never will. So: here goes.

I weigh ninetyish kilos, give or take a kilo or so.

That means on the days when I'm over ninety kilos I'm obese, days when I'm under I'm merely overweight. Some of that, obviously, is muscle and bone and the basic starter pack of internal organs, less of it than previously is hair, but a fair amount of it is fat.

Twenty years ago I was seventy kilos.

Now, I could go on at great length about how I feel about all this. I don't know about how valuable or interesting that would be, I suspect that my feelings about this are very much the same as many of the people I know, and that others have written much more eloquently than me about this. I've written and deleted, rewritten and deleted about how I feel about this, but for the moment, let us take it as read - I want to lose ten, twenty kilos.

So - what to do? Part of the problem is the psych medications - almost all the psych medications make you fat with a few exceptions that either let you go crazy or actually push you further along the way. I can't really change that. If I don't take the valproate I get too high (starting ten different martial arts at once) or too low (becoming a stromatolite), and that doesn't work. Plus I get detained, and the gym at Clearwater is crap.

So - from what I have read it is possible to get some of it back. People have done it. It is possible to lose the twenty kilos, to feel lighter, to have more energy, to be able to do more stuff more easily. That is what I want to do.

You know, by the way, thinking about obesity is an incredibly rich area. Every question, biochemical, sociological, philosophical, when examined diverges into new ones, like a fractal or a hydra's head. There are hundreds of questions here. And by the very act of asking particular questions, or answering them, you place yourself in certain positions along a curve, align yourself with blocs against other blocs - you start out thinking "these pants don't fit any more" or "my joints hurt" and three firing of synapses later you're a cocaine snorting nazi.

Anyway. From what I understand, people who lose significant amounts of fat seem to have certain core characteristics. The cornerstone is diet: they restrict caloric intake - low fat, low carbohydrate, low whatever, just low. There is tweaking - certain foods provide more of a feeling of satiety than others, meal frequency and portion size is important, dairy/calcium appears to make you feel fuller, stacking up on the pasta last thing at night seems to be a death sentence - but overall you lose weight when you eat less stuff.

The rest of the equation is exercise. People who lose sizeable amounts exercise as much as an hour a day every day. From what I understand preservation of muscle mass is nigh on essential, any exercise is good, more exercise is better, high intensity exercise is best of all. As far as I know interval training is the best method of exercise, but the type of exercise is secondary to actually getting out there and doing it.

And above all the diet and exercise, the mechanics of it, is the whole cognitive and behavioural stuff, the real interesting stuff. Obtaining and maintaining motivation and performance in a grossly obesogenic environment, tai-otoshi-ing a biological drive that is as old and smart and strong as the need for sex and the need to breathe. Starting and sticking to stuff that for every single one of your twenty trillion ancestors would have been suicidally stupid.

And it's not as simple as willpower. The more I read the less I believe in the whole "free will/free choice/we are as we make ourselves/we choose our future" thing. When I was a kid my best friend's father would quote "I am the master of my fate, the captain of my soul" at every opportunity. He mustn't have ever gazed into the eyes of a pale-skinned brown eyed girl, or been jealous of a friend, or heard the blues, or drawn closer to a fire on a beach at night, or done any number of things. If your soul is your sense of everything beautiful, then we are not the masters of our soul, it is the master of us.

Anyway. We're not a blank slate when we're born, we're not a photographic negative waiting to be slid into the developing fluid, but the depressing truth is we're probably closer to the latter than the former.

So, what's the point of blogging all this?

I'm going to change what I eat and how much I exercise.

I am going to lose fifteen kilos.

I'm going to do it by midwinter next year.

I'm going to get back to seventy five kg.

I know I am going to do this because I am going to have motivation to burn, and all without spending a shred of willpower after Monday night.

Because Monday I am* writing a cheque to the Australian Liberal Party, our version of the Republicans/Conservatives/Daleks party. It will be a bank cheque, one that can't be dishonored, and it's for a sizeable amount, an amount that it will pain me greatly to pay, several hundred hours of my disposable income.

(For those who came in late, I loathe these people. At the rising of the sun and at its going down I have loathed them. I loathe what they have done and what they have failed to do, I loathe them in the morning and in the evening and I have loathed them at suppertime, I loathe what they think and say and do. I hated them in the beginning, I hate them now, and I shall hate them for ever more, amen. When John Howard, our ex-Prime Minister, dies I will dance on his grave in a red dress. A long red dress.

Something low cut. I was thinking maybe slit up the thigh, clingy, but classy. Nothing slutty).

As I said. It's a sizeable cheque. It's an amount that they would certainly notice, particularly as I have requested only some small public acknowledgement of my generosity, a mention in the Worker's Fiend or whatever fascist rag they bring out, printed on the skins of single mothers and written in refugee blood or whatever they use. It may be, for all I know, that my acknowledgement would come with a mimeographed letter of support from Tony Abbott or Philip Ruddock (he's on the left) or that ghastly little moral homunculus himself.

I am not sending the cheque to them. I am depositing the cheque witha lawyery kind of person, along with formalised instructions that should I fail to present to the offices of a particular place on a particular date and "weigh in" and weigh under seventy seven kilos, then that cheque will be sent off.

Now, obviously, the rest of it is up to me. Diet, exercise, all that kind of thing I will have to work out. But motivation? I've turned it up to eleven.

Additonally, I feel I can count on the support of my friends and colleagues, many of whom hate those bastards too, almost as much as I do.

I can count on the support of Sarah, once she has gotten over her horror.

I can count on the realisation that every excess morsel of food, every stepper-free minute of television can, and will, be used against me to bring forward the return of those grasping phobocrats from the limbo to which we so savagely dispatched them a few months ago.

Anyhow, I will keep you informed. Hopefully the next few months will be a gradual loss of surplus fat. Otherwise I'm going to be looking at that starter pack of internal organs and working out which ones are going to die for the cause.

Thanks for listening,
John

*As in "I am saying I will". At the moment this is one of those imaginary futury things. We shall see. And I don't know that full agreement on the wisdom of this plan is shared by all in the household - I may have several of the leading cats on my side, but the chickens are opposed and Sarah is still wavering.

Capsicum

2008-08-04T12:18:00.006+09:30

Hail,

We have moved. The long, toasty period of migration is essentially over. As we speak Sarah is driving the last horse-float full of cats along the winding dirt road, under the blazing stars, towards our new home in the bush.

At night now you can see the Cross, and from what I remember the Serpent Bearer, where one of the stars is a recurrent nova, and the Pointers. I remember years and years ago, standing on a low wall on the southern shore, showing a girl* how you could use the stars in the Southern Cross and the Pointers (Alpha and Beta Centauri) to find true south. You imagined the Cross and the Pointers were each the haft of a sword, and you followed the imagined blades with your eyes, and where the blades crossed there was south, the base of the earth, the frozen land. The southern coast at night is cold, and soft, and quiet. I remember the sea hissing and curling under us.

And I remember her being impressed at how I could navigate by the stars. And I remember her being less and less impressed when we tried to get back to the car but couldn't, because I could find true south using three hundred-year-old light, but I couldn't find the car park I'd parked the car in half an hour earlier, what with it being dark and all. And I remember us blundering about in the sand-dunes, increasingly cold and tired and sober, in the small hours of the morning, tripping over tussocks of wind-grass and stumbling down the faces of dunes and crunching miles along the mud, while the tide came in and the stars disappeared and it started to drizzle. I rang her a few days later and her mother said she couldn't speak to me because she had one of those old diseases you don't hear about any more - pleurisy, or rinderpest, or maybe the ague, something you got from long hours of neglect and exposure to the elements - and that she would call me back when she felt better.

She must still be sick.

Years later, on a different beach, but same hour of the night, in summer, I first kissed Sarah. And it all worked out very well, and nowadays I have a GPS.

Anyway. We have moved to the new house. The new house is in fact old - couldn't afford a new one, had to get a second hand one - all high ceilings and cellars and polished floorboards. Because it is miles from anywhere it is cheap, when I feel the reverse should be true.

The town is miniscule, a pub and a post office and, bizarrely, a stained glass window shop. Every Friday a hunched little white-haired old man appears like a figure from a fairy story and sells vegetables from a road-side stall. People gather half an hour beforehand to buy them, squeezing the capsicums like a lover's buttocks**. I suspect the old man buys the veges in Woolies and peels the stickers off, but never mind.

And in the new house we have electricity, and light, and heat, and several of the other fundamental forces (we're still waiting on the guy who comes around to install the weak nuclear force - at the moment our bosons are all over the place), and a few short hours ago we got the internet. And tonight I go shopping, and tonight - this very night I say! - we will eat something that will not be rye toast with peanut paste.

Life is so good it almost seems unfair.

I have even found a gym in the nearest town. It's the only gym in the area, and it's a convenient thirty odd kilometres away, but it's near the railway station, so every morning at seven thirty I am there. This means I rise in the darkness, potter about the house, drive my nanocar into town, and deadlift and bench press to my heart's (and other organs') content.

The gym is a country gym. it's full of old steel weights with measurements on them in the Imperial system, and eighties music playing on the radio. I think I saw Dee Schneider on the preacher curls machine this morning. The dumbells are beer-cans filled with sand and shot-gun pellets, the punching bag is a wool-bale slung on a hook, and the "boxing-for-fitness" class is three men in blue singlets going at you with pick-axe handles.

Not really. I shower and then catch the train into work. Everyone on the train at that hour is shell-shocked and silent, and my breath curls and steams in the cold air. There are sheep grazing beside the railway station. I lounge on the seat as the trains clacks and sways and read Ulysses, realising as I do that everything I have ever written is inadequate in ways I can't begin to describe yet. I missed my stop the other day because I was reading.

Anyhow. Sarah proceeds slowly. I have informed her that we are about to enter the fourth and final stage of wound healing. Classically pathology states that wound healing consists of four stages - inflammation, proliferation, maturation and remodelling. Like many pathological processes, several alternative physiological pathways exist, and the one we have chosen goes chocolate, cats, novels and seafood. We are now entering the seafood phase, and I am going to be prescribing therapeutic squid tds prn po. Seriously, she potters about and is lovely.

We have, by the by, a new answering machine message. On it you can hear Sarah's velvet tones enunciating her message, while in the background I imitate a horde of Siamese and oriental cats. And quite well, I might add. For those who do not know, these kinds of cats look fairly similar, but Siamese have points (darker colours on their ears, tail and feet), whereas oriental cats are comparatively pointless.

That may be it for tonight. I am going to bed because Mondays are twelve hour days, and I tend to get suddenly seriously tired, and when that happens I make even less sense than usual. I will go off to be and write more in the next few days.

Thanks for listening,
John

*Belle, the fundamentalist Christian teenage mud-wrestler, without word of a lie. I was young and religious and repressed and male and the testosterone was almost crystallising out in my blood. I learnt many things that night, and the one that stands out in my mind is that a very fast left-handed hane makikomi is not an erotic technique.

**I mean "squeezing the capsicums like they would squeeze a lover's buttocks", not "squeezing the capsicums like a lover's buttocks would squeeze them, were the squeezer so inclined and were the capsicum appropriately positioned". Nor do I mean "squeezing the capsicums which were like (i.e.: in some way resembled) a lover's buttocks".

That's probably enough from me.

John

Medical Defence

2008-07-22T13:36:00.009+09:30

Hail,

And here is an interesting article in a recent student BMJ about conscientious objection among doctors - specifically whether doctors are within their rights to refuse to carry out procedures they find unethical. The author is Charles Williams, a medical student, and he writes passionately and articulately and reasonably - but I feel utterly, utterly wrongly - about a subject he has obviously considered at some length. His whole passage gave me a feeling of deep unease, and I'll try to explain what I felt, and why, and why I am less convinced of the rightness of his position after reading his argument than I was before.

(As an aside, as I understand the current Australian legal position, no-one is compelled to carry out an abortion or to provide contraception. In that it's like any other medical procedure. However, duty of care still exists - if you don't provide contraception, you have to make sure that you patient can get access to it somewhere close and cheap and convenient. Otherwise you're not doing your job, and you're liable, which is as it should be).

Anyway. In summary, as I understand him, Mr Williams writes that an inalienable right to conscientious objection exists, and that, as part of that inalienable right, doctors can refuse to participate in terminations. Rather than being penalised or pilloried, they should be praised. He closes by arguing we need more, rather than fewer doctors with the conviction to defend what they believe is right.

This does not convince me, on a number of levels. Lately I have become suspicious when I hear the term "conscientious objection". It strikes me that it is often used as a cheap debating trick - a sneaky appeal to a dubious higher authority. The term "conscientious" evokes a conscience, and by doing so suggests that some final arbiter has been consulted, that the speaker has visited some higher moral plain and returned with something somehow superior to our petty concerns and prejudices. Once something is named as a matter of conscience, it becomes somehow impolite to question or challenge it. There is just a respectful nod and the conversation moves on.

This is a fairly bizarre argument, once you look at it. From what I can work out, it asks the listener to believe that within each of us (or within the speaker, at any rate) there resides an inerrant moral-o-meter, something that enables the speaker to accurately and precisely determine at a glance the moral rightliness or wronglitude of an action, phrase or belief, something whose pronouncements should be taken on faith. I see no evidence of such an organ.

What I do see is a human tendency to rebadge and relabel things to our own advantage, to lie to ourselves and to others in order to maintain our accustomed levels of comfort. It is more comforting - and this isn't the nicest explanation - to attribute thoughts and words and deeds to our conscience rather than to our prejudices, or our laziness, or lack of imagination, or our desire not to think too hard.

Now, that may sound harsh. It is. But if it were true, it would explain how so many of these acts of conscience people talk about somehow end up replicating the same old patterns, making things worse for the marginalized, kicking not only those who are down, but those whom we knocked down in the first place. It would explain how people who draw their inspiration from the Bible and the Judeo-Christian code of ethics, for example, can be at ease with the whole rich man and eye of the needle thing, be udderly unconcerned when a calf is seethed in the milk of its mother, but will be struck with righteous rage when it comes to homosexuals or women. All of a sudden, when it comes inconveniencing others rather than ourselves, the weak rather than the powerful, God is not mocked.

These are ugly ideas. But otherwise we have to say it's an unfortunate co-incidence that Mr William's ideas, if acted upon, would kill vast numbers of women. It's sheer bad luck that Mr Williams' actions would result in sepsis, in fistulae, in suicide and infanticide. It's a terribly unfortunate but totally unforeseeable thing that the prayer-book is followed by the coat-hanger, and the coat-hanger by the coffin*.

Maybe it's not some mythical conscience, Mr Williams. Maybe it's something else, something women have heard from doctors before, something internalised and unconscious but pretty much there all the time.

In simpler terms, maybe it's not God. Maybe it's you.

Anyway. The history of conscientious objection, of people who followed their own moral code rather than that of society or "normal" medical practice, is no cleaner or dirtier than that of any other field of endeavour. One of us is no wiser nor more stupid than all of us.

Sincere, intelligent, diligent men and women have examined their conscience and then sterilized miscegenating women, or electrocuted homosexuals to cure them, or experimented on Jews. In the end, maybe you will get lucky, maybe you won't. If you are a conscientious objector, maybe you will end up lauded as a good person, as a saver of lives, an advancer of knowledge. Maybe you will end up as a footnote, a grainy photograph, a name in an article about Buchenwald or Sakhalin or Tuskeegee.

Either way, you will have done what you believe to be right. But His eye is on the sparrow, mate.

Anyway, I have said too much and left too much of what I wanted to say unsaid. there is a sense in which I don't have a right of reply here, in which the right of reply belongs to those who have seen the cost of the conscientious objectors piety, who have to bury the bodies they created to appease their conscience. That response has been given by Dr Shashi Sigdel, whose response gives less of the air of deliberation of Mr Williams, but more one of desperation and hope, and has the added benefit of being written by the bedside rather than by someone yet to practice.

But I am preaching to the already saved.

In the end, there are only two choices. The alternative to doing what a doctor should do, to doing your job, to healing the sick, to easing suffering, is to selectively doing your job, healing only the sick whom you choose to heal, easing suffering for those who meet your specific criteria. That may be the path Mr Williams has set out upon, and I wish him well with it, but I cannot agree that medicine needs more like him at all.

Thanks for listening,
John

*If only there had been a robust collection of data about the possible consequences of denying access to abortion, a body of evidence similar to the one that Mr Williams regretfully concedes does not exist about the terrible consequences of allowing abortion. Rather than relying on people's consciences as a guide, we could base this data on, say, scientific evidence, derived from clinical trials and the like. We could call it, I don't know, evidence based medicine.

Stop me when I get too crazy.

Migration

2008-07-20T08:13:00.004+09:30

Hail,
And a very brief note here today, because today is the last day of our house-moving. We (Sarah, myself, the various beasts) are in the old house, the vast majority of our stuff is in the new. The house echoes like a cathedral - a rather grubby cathedral with post-it notes stuck to the walls and scattered science fiction paperbacks in the corners, but a cathedral nonetheless.

Ninety odd percent of our stuff is in boxes. This means breakfast is going to be rye toast with peanut paste. That's not that bad, except that was last night's dinner and yesterday's lunch too, and breakfast was a stale sausage roll from a dilapidated service station, something from which you could have extracted ancient DNA, and before that was rye toast and peanut paste. If I don't get up and get on with it, lunch willl be rye toast with peanut paste, or some stale crackers I was going to give to the chooks, or a packet of cranberry jelly.

There is also the spice rack, but man does not live by garam marsala alone. Once we move I am going to sit down and eat something healthy and fresh. I want a salad with seven or eight essential food groups, including three we haven't discovered yet.

Anyway, the new place. We could only afford second hand - it was built in 1904 - and it has these vast high ceilings and little narrow doors. It actually does evoke something of the cathedral. It is close to friends, and it is cheap, taking into account Sarah's diminished interest in and capacity to work.

Anyway, I must load boxes into the horse-float. Shall reply/post/etc soon. Next post, I promise, will have substance.

Thanks for listening,
John

In the throws of love

2008-07-11T10:30:00.005+09:30

Hail,
And this post has nothing to do with that title, it's just that I love the phrase. Love throws you. And it gives me pleasant images of rolling around on tangled bedsheets with Sarah, very close. She is interstate at the moment, and I am showing signs and symptoms of withdrawal.

Anyway. Herewith a brief conversation with a client I saw the other day. He is a licensed painter-decorator, the kind of person another client once described as “not the sharpest bowling ball in the shed”. I had seen him previously and discussed cognitive and behavioural approaches to opiate dependence and relapse prevention. He seemed very pleased to see me.

And for those who don't know, ice is the local term for crystalline methamphetamine.

Mr Chu: “This’ll be the last time you see me, Doc. I’m doing all that stuff you said. I've changed the crew I hang out with, I've taken the numbers out the phone, I’m going somewhere where there’s no fucking heroin at all.”

Me: "I don’t know you actually have to –“

Mr Chu: “It's sorted. I’m heading south. Way south.”

Me: “Okay.... Tasmania?”

Him: “Better. Antarctica.”

Me: Stunned silence. Long stunned silence.

Him: “They gotta paint, they gotta decorate. They gotta want some people down there.”

Me: “Mate, I don’t know about – “

Him: "Made up my mind. Anyway, I was talking to a mate, he reckons there’s no fucking heroin at all. No smack, no speed, not even mull. He say's it's paradise.”

Me: “Paradise? Didn’t know that… there’s a lot of ice, though.” I grinned.

Mr Chu: "Really?

Me: “Tonnes of it. Saw it on the telly. Ice everywhere in Antarctica. Situation's out of control.”

Him: “You reckon?... That's horrible shit, that is. Fucks you up real bad. You sure?"

Me, slowly: “I'm positive. Ice. Lots of ice in Antarctica. Lying all over the place. Ice.”

Him: "How come?

Me, even more slowly: “I mean ice. Ice ice. Tonnes and tonnes of it. All over the place.”

Mr Chu, visibly devastated: "Oh, that’s bad. That's no good at all. You sure?”

Me: “Mate, swear to God. Antarctica is covered in ice. Has been for years.”

Him: "Well, that’s fucked that up. What do I do now?”

Me, after one of the longest pauses held by someone who has not actually taken Holy Orders: "Well, there's a weekly narcotics anonymous meeting in South Mordor…”

One of those conversations where I start to worry if it’s me that’s mad, not him. And for me, that's not good.

Anyway, I will post more later - probably not for the next few days, as we are moving house, and I, being too mean to pay for removalists, am moving us, our furniture, our two horses, twenty chickens, two goats and several score cats to our new house by myself. In the meantime I refer you to FW's blog, to which I would link if this bloody cookies thing or whatever was working. She is being all insightful and thought-provoky there. Damn fine stuff.

Thanks for listening,
John

Welcome back, Tiger - now piss off.

2008-07-07T07:47:00.003+09:30

Hail,

The following contains sexual references.

And here is a link to one of the better medical essays I have read this year - something called "The Itch" by Atul Gawande. He's a damn fine writer, and this is an intrinsically fascinating subject. If you remain silent after reading the sentence that concludes the tenth paragraph, you're dead.

And by the way - it's about itching. A fair proportion of people get itchy reading about itchiness. I just had to stop typing this - and again - to scratch an itch: I get itchy writing about itching. Itching may be one of the few conditions that can be transmitted over the internet, that you can actually contract from someone electronically. Your ISP is a fomite.

What else has been going on? I broke up a marriage the other day.

Now, this will obviously come as no surprise to those of you who know me personally. Chubby, balding, middle-aged man with history of mental illness and interest in superhero comics - doesn't it just scream "marriage-wrecker"? You can tell by the way I use my walk, that kind of thing. But this actually happened. And the following is transcribed as accurately as I can remember it while preserving patient confidentiality - I have not altered it a whit, not a jot.

Maybe a tittle, a little tittle, but that's all*.

Anyhow, back to the marriage stuff. My last patient yesterday was one of my most likeable - a smiling, pink-faced, soft-featured Italian man who had adapted cheerfully to every impediment life had thrown at him. I smiled when I saw his name on the patient list and went out into the waiting room.

"Mr Barbapapa?"

He leapt up and rolled towards me, and extended a pink hand like a pseudopod. We sat down.

"So, how's things?"

"Brilliant. Abso-freaking-lutely brilliant.**"

"That's good..."

"Never better"

"Good to hear it. Now - "

"Yep, moved out, getting a divorce."

"What??" I yelped.

"Yep, all organised."

I was surprised because all through Mr Barbapapa's notes were references to his domestic situation, and in particular the stress that methadone had placed on his sex life. Methadone supresses testosterone secretion, which causes osteoporosis, loss of muscle mass, occasionally depression - as well as depressed libido and erectile disfunction. Mr Barbapapa had not lost his libido, he desperately missed what methadone had taken from him, but he had been unable to have an erection for three years***. To a man in his late twenties, this was a very significant thing.

I had done what I could. We had tried dropping the dose, but it was a difficult thing. Methadone withdrawal knocks you about, and he had a responsible job, a lot of physical labour. We had done the appropriate blood tests, and I had arranged the endocrinologist referral so we could prescribe him supplementary testosterone. And the last visit I had given him a few samples of sildenafil, which is Viagra.

"Try this" I said. And I'd told him that what was going on was a medication thing, tried to do what I could for his confidence, and sent him away.

And here he was. "Yep, it was that viagra stuff you gave me, really sorted stuff out."

I stared. "How?""

"Well, it was a long time coming. I told you - we'd been pretty much just living in the same house for the last three years. So I came home with the tablets and I showed her."

"What'd she say?"

"She laughed." For a moment his face fell. "Said it was a waste of time. She said 'It's not the tablets, you freakin'clown, it's you - you're an arsehole. I've been rooting the guy from the Seafood Shop'."

I stared. "Jesus."

"Yeah, that place on Main South Road, down near the Cashies."

"God."

"Yeah. Did you see what those thieving bastards charge for hake? There's no way -" He seemed to refocus. "Anyway - really got things out in the open, it did. Cleared the air. I don't think we'd really been communicating before that."

"And now you are."I managed.

"You can say that again. Anyway, moved out. And she doesn't want custody, so I've got Adam, which is pretty much the only thing that matters. He's four this week. And I got a new job - like close on double the pay, week on week off, flying out to the mines. And I met this woman - she's a librarian, bloody gorgeous, smart, really nice blonde piece. And we've been going at it hammer and tongs."

He reached into his wallet to show me a photo - I declined.

"Anyway, I want to start coming down off the 'done. Reckon it's time. It's the best thing that's ever happened to me. And it's all down to you and that blood y viagra. Wonder drug, it is."

"Right" I said.

We finished the interview, and he stood up to go. Before he did he reached out and shook my hand. "Gotta thank you again, doc."

"No worries" I said.

"Yep, this Viagra - really helped me out."

Anyhow, off to heal the sick.
Thanks for listening,
John

*At the moment I am talking to people like this, too - frequent digressions, lots of rapid-fire witticisms which only I find amusing, leaping from idea to idea. And I am finding it difficult to sleep, and I have a fair amount of energy, and, most damningly, I feel Fremantle has a chance this week against Geelong in the football. I am compliant with medications and seeing Dr Tesla soon.

** The technical name for this is tmesis, from the Greek temno, meaning "I cut". Actually, it's more accurately an expletive infixation. Now we can all sleep at night.

*** In his defence, not many people can have an erection for three years.

Pizza

2008-07-01T12:20:00.007+09:30

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.

Sad

2008-06-29T23:01:00.003+09:30

Okay, maybe it won't be about Viagra. The papers I was going to read from have been filed somewhere with the rest of the housemoving stuff and consequently be seen again in this age of the earth.

As an aside - I was at the local Good Samaritans shop looking at the second hand books and I bought myself a shirt, a nice subdued purple one to wear to work, for only two dollars. I was thrilled at this, but when I bought it home Sarah pointed out it was one I myself had donated only a month back.

Anyway - been reading about depression, and thinking about the whys and wherefores of the medications.

A lot of my patients are depressed. This will not surprise a lot of people, but the fact is most people on the methadone programme are not depressed. Some are anxious, some have schizophrenia and the related illnesses, a lot of them have PTSD, but there is a (small) number of opiate injectors who are happier and calmer than most other people I know: people who just really really like the feeling that heroin gives you. They have their problems, of course, but the problems seem to be the normal domestic ones plus a few that revolve around getting and keeping the stuff.

And forget what you've heard about drug users being unmotivated. Most of my patients have levels of motivation that would put anyone in the Fortune 500 to shame. In fact, the parallels don't stop there, but that's a subject for another post.

Anyway - depression. Whenever the topic of depression is brought up, antidepressants get mentioned. Patients either say they are depressed and need antidepressants,

And the more I hear about anti-depressants, the less confident I am about them.

I'm not saying they don't work. I think it's quite likely that they do, I have seen people who are quite profoundly depressed start to get better after taking them. I think they can be a valuable part of the therapy some of the time in some people with some conditions.

But there's a lot going on. See, earlier this year, probably the most important paper on anti-depressants of the last five years came out. The authors used freedom of information laws to get hold of data that is usually inaccessible - data from studies the drug companies perform and then either don't publish or suppress, depending on your level of paranoia. When you look at all the evidence, not just the stuff the manufacturers choose to tell you about, details leap out at you.

Antidepressants do not work any better than placebo for most people - people who are in the initial stages of moderate depression. They work a bit better for severely depressed people. They work better than placebos for people who are very very depressed - but it might even be that that is because placebos don't seem to work on severely depressed people.

Now, for a start, placebos are damn fine medications - they are efficacious and cheap to produce. They are relatively safe, although some quite serious reactions have occured - in one clinicla trial, almost a quarter of the people taking placebos discontinued because they couldn't take the side effects any longer. And I believe there have been cases of dependency. Sooner or later there'll be a string of deaths and the stuff will have to be withdrawn.

Anyway - placebos certainly work well in depression - in most trials, people who get anti-depressants and people who get placebos both tend to improve quite dramatically over a course of therapy. I'm not saying that people don't get better if they are given anti-depressants, I an not saying prescribing them is a bad idea... I am just saying it's clearly a lot more complicated than we thought.

I don't know. Another thing - a lot of things work as well as the antidepressants. Exercise works as well as sertraline/zoloft (he says, typing while the exercise thingy sits unused a few metres away). Plus good exercise gives you back the libido and body that depression and antidepressants took awy. Swimming with dolphins is apparently an efficacious anti-depressant therapy, but few pharmacies stock them. One intervention I found useful for some of my earlier patients was getting a divorce.

And that's the other thing. There are assumptions behind the whole anti-depressant thing that bother me. There seems to be this model in some people's head that says "My patient is depressed - she suffers froma mental illness that distorts her perception, her concentration, her motivation, wrecks her sleep and appettite, profoundly disturbs her emotional state. Depression is caused by abberant concentrations of neurotransmitters in the brain, by chemical errors. We can give medication that will correct these chemical errors. When we do, the depression will resolve, and the person will be happy."

I find it difficult to take this train of thought seriously, let alone believe it. It does not accord with what I see. I could write a book on what is wrong with it, but ofor today, the assumption that the normal state is happy, that most people live lives and believe things that under normal circumstances mean they should be happy - it's like those grotesque, shape-changing half-animal creatures, those ones that scream when you shine a light on them. The ones that had that reign of terror that frightened everyone half to death back in the eighties... what were they called again?

Oh yes, Republicans.

Anyway. Most people's lives, I suspect, are not set up to produce ongoing happiness. Most people. Most good people I know worry about what they have done and what they have failed to do, sins of omission and commission. Most people, I suspect, think of others as being happier and more confident than they are. Most people have more responsibility than power.

I don't know. I don't know that we should even if we could, pathologise or medicate away what I suspect in a fair percent of the depressed people I see are normal emotional states. I don't know that we always do people a service by pathologising sadness, or frustration, or rage. What is are we saying when we say to someone "this is not normal, this is an illness, you are an ill person?" Are sorrow and pain part of wellness and normality? What about ways of coping with this without transforming someone from person to mental illness patient? Where is the borderline between discomfort, distress and disease, and what does it cost us when we cross it?

Anyhow. I do not have answers to these questions. I don't know who has. I don't know if my senior doctors do, or if my patients do - I suspect any answers will be individual, true for one person at one time, not easily transferrable. I don't know who holds the truth here, but the more I read, the less certain I am that it's Pfizer and Glaxo Smith Kline.

Thanks for listening,
John

Unbuckling

2008-06-26T21:44:00.002+09:30

Hail!
I've had to type this opening sentence seven or eight times to get it right. This feels rather odd, this blogging. I think it's because I haven't written here since the late Silurian. I'm going to have to work out how to do this again.

And I think I might have to, because the long interregnum between posts is finally coming to an end. Things are falling into place. I am writing again, and enjoying it. It may be a coincidence, but the winter solstice is past, as is aphelion - the earth beneath our feet is tilting to bring our faces to the sun, and each day we fall closer.

And in the other room Sarah scans the internet and chats about cats and horses. She is younger than she was two months ago (well, parts of her are only a few months old) and she is gradually starting to walk about sans sticks. A few days ago she drove, she can pick a kitten off the floor - although I have stressed that it will probably be years before she can safely dress or undress herself, and that there is no point rushing these things.

So, things are good.

Anyway - I will be able to write fairly soon. There are still a few things to do, a few elements of the Great Work to be completed - in two weeks we move house, further south to a small country town, where we will install chickens and a spa and hang paintings on the wall and grow roses, and Sarah will potter and work only if it entertains her.

And I have much to write about. A few days ago we went to a drug company talk by the people who make Viagra, and before we went they asked us if we wanted anything. Sarah wanted doodads and I told them I wanted research papers (Sarah wanted the Viagra clock, and the Viagra calculator which rises majestically from a supine position at the touch of a finger). I have read the research papers, which are full of sentences like "buckling of the penetration tool" and "a one kilogram weight suspended from the penis...".

Next time, unless prevented, I will write about that.

Off to read blogs,
John

2008-05-16T07:53:00.002+09:30

Hail,
Just a brief update on Sarah for anyone who’s interested.

She is home, which is wonderful, and reading amusing and familiar books. She spends a fair amount of time in bed or resting, but she is mobilizing, with the air of two walking sticks. They are stylish and technical looking with built in shock absorbers and she ordered them off the internet from China. There is a lot she can’t do – she can’t pick up anything she drops, for example, or put on her own clothes – but she is mobilizing a little better every day, taking slightly longer steps, possibly getting a little less pain every day.

The main thing is the surgery is behind her, rather than ahead, and she is getting better rather than worse. It is a long process, and I think she got a little discouraged reading about the experiences of other people who had the surgery who were back at work within three weeks. I have pointed out that the surgeon said that she had one of the most advanced cases of osteo-arthritis he had seen in someone that age, that she had had pain and decreased mobility for decades before-hand, and that the views of people in the net are not a representative sample of the real world.

Anyway, small steps. She is on a tapering dose of opiates. Initially she had ice-packs, now we have moved to the topical application of cats. The main priority is keeping her mood up and making sure she does not fracture – the next six weeks are very fragile, and her bones are very thin. After that we are really hammering the vitamin D, gentle exercise and calcium – which I am suggesting will be a holiday somewhere tropical where she can eat yoghurty stuff from a tall glass and so forth. In the interim today she is going out to look at the chooks.

Obviously, a lot more has been going on - there was the surgery, we are moving house, that kind of stuff. More news later, and a return to writing soon.

John

The reasons I won't be coming.

2008-03-26T20:19:00.003+10:30

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.

I am ion man...

2008-03-07T01:49:00.002+10:30

Hail,
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,
John

*I know.

The Clonazepam Curtain

2008-03-06T20:19:00.004+10:30

Hail,
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.

Anyway.

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."

"They?"

"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.

"No..."

"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,
John

*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.

Identy Disorder

2008-02-28T10:35:00.003+10:30

Before I begin: a brief list, names only minimally disguised, of some of my clients:

Purple Storm Jones
Four
Filth Williams
Quentin Freak (changed own name from Quentin Adams)
Legalise Marijuana Jackson
Thor Bludskullen (brother of Odin Bludskullen)
Odin Bludskullen (brother of Thor)
Yoo Suk

And a Dagger, a Knife, countless Blades, Scars, Edges and a Katana.

I should also point out that Chastity Virginia was nothing of the sort, and Wolf Storm was always being beaten up by his fourteen year old step-daughter.

Anyway - I noticed Mr Glub* as soon as I opened the clinic door. Everyone always does. Amongst a clientele of truly unusual characters, Mr Glub stands out. Any reference, in the north, the south, the east, as far south as Ratbite River and out to the prisons a day's drive from here, to "that really weird looking methadone guy" will be immediately understood as referring to Mr Glub.

He's tall - something over seven feet, although some of that is his hair, which is vertical, and that "safety orange" that roadside workers wear. His eyes are as bulging and as blue as the earth seen from a Lagrange point, his ears almost bend forward. He's skeletally thin, probably about fifty kilos. Precisely none of that is melanin - Mr Glub gets sunburnt by a fridge light. His nose bends so that he can - and occasionally does - touch the tip with the tip of his tongue. He sports a pointed goatee.

Add to that that he has some undefined impairment - maybe genetic, maybe a result of his several overdoses - so that he speaks in a high-pitched sing-song voice, and sways back and forth as he does so - and you've got a truly unusual looking individual.

Thing is, Mr Glub's a very nice man, and I was horrified to see what had happened to him. He was bruised and beaten, with a black eye and scratches and scrapes all over him, and when he got up from the chair he walked with a limp. I ushered him in.

"What happened?" I said.

"Well, Doctor Bronze" he trilled -

- It may help if you read his dialogue to yourself in a thin, reedy, sing-song voice, and sway back and forth as you do so. That's how I'm typing it -

"Well, Doctor Bronze, I was waiting in line at the pharmacy -"

and he told the usual tale of how some car had screamed to a halt, some big guy had leapt out with a pick-ax handle and a look of rage and had fallen upon him and beaten him half to death. This happens to my clients quite a lot. As I have written before, it helps to be prepared**.

"Good Lord - that's terrible. We've got to get you to somewhere safe - I think there may be space - " I scanned the secret list of pharmacists we have on the computer. We keep it secret to slow the rate of holdups - "Jekyll's Allcare at Mordor Park, or Crippen's Family Pharmacy - "

"Oh, don't worry about that" he said, rocking from side to side. "It's all sorted out now. The bloke who did it came over and explained."

"Explained?"

"Yes" sang Mr Glub, all seven feet of him. "Turns out it was all a case of mistaken identity".

Explains it all. Anyway, back to the sick.

Thanks for listening,
John

*Not his real name, obviously, but it's close. Something Nordic, almost Viking. He's got the height and the scarlet hair, but he's too harmless. You could imagine him getting out of a longboat, sauntering up the shore and wondering around to stare at the animals and chat to the villagers.

**Sorry, can't do the link exactly right.

Special needs

2008-02-24T22:59:00.003+10:30

Hail,
Long time no write again, and a lot to write about. I’ve been wanting to write, but tied up by a combination of other stuff going on, embarrassment at returning after so long (work that out) and weirdly, too much going on to blog about.

So, insert the usual groveling (and sincere) apology here and read on.

I have formally given up emergency medicine and started psychiatry training. It’s an unusual move, sortof like switching from amateur shot-put to competitive needle-point, but it has surprised very few people, and already I get the feeling that after a few months of psych I will be more comfortable and competent than I was after a four years of fairly hard-core emergency medicine training.

Having said that, the first few months anywhere are a bit tumultuous, and since the mood is actually quite a bit down – no need to panic, I am a long way from the events of a New Year’s, almost a year and a season ago – I am finding things a bit trying. Partly, this is due to the usual process I go through every time I start at a new workplace, where I inform my immediate clinical supervisor about the bipolar.

There’s a few reasons for this, and I suspect it’s the most responsible thing to do, but it’s not pleasant. However, I’ve done it a number of times and by now I have arrived at a fairly practiced two minute performance piece which gets the necessary information across but and keeps the self-disclosure down to a minimum.

Usually my monologue takes the form of ten seconds of what I have, ninety seconds about how well controlled it is, how I see my psychiatrist regularly, how I am compliant with my medications, how I have never in my or anyone else’s opinion made a poor clinical decision due to my illness and how I do not see my job as part of some therapeutic process for myself, and how I am not going to be charging down the corridor shrieking about the Freemasons.

Choruses of owl-headed people, maybe, Freemasons, no.

Anyhow – three paragraphs of reassurance and then I whip out a folder and say “And while we’re here, Mr Smith’s psychosis is worsening/potassium is eight point eight /arterial blood is coating the floor of cubicle three” (for psych/ICU/ED rotations respectively). This brings the conversation to a close.

The reason I seek to exercise so much control over this conversation is it has gone badly in the past.

One of my consultants in the ICU reassured me that I was not the first bipolar doctor they had worked with - “Not at all” he said. “In fact, I graduated with someone, class of eighty eight, Sydney, very smart chap. Everybody liked him. His wife and kids were devastated, you know, afterwards. Of course, looking back, there were signs…”.

Others tell me the about those they worked with who stole the cancer patient’s morphine, or who missed cancer after cancer as the cognitive impairment set in, or ended up shackled to the bed after a particularly difficult night shift, or had a complete nervous breakdown, ran off with a girl thirty years his junior, never worked again.

The depressing thing is I believe that these people were honestly trying to reassure me.

The same cannot be said, however, of Dr Broil, my obstetrics/gynae supervisor in third year. I don’t know if I’ve told you this before, if so, feel free to compare this version critically with the last one and see what a liar I am. But the way I remember it now, Dr Broil was my supervisor for a good part of third year. Third year was pretty much the year I was diagnosed with bipolar, but long before I got the right dose of medications, and a year I was sick for some time.

Afterwards, although I hadn’t been sick during Dr Broil’s rotation, I was advised to go see her and disclose “the whole illness thing”. I did so, and she stared at me for a moment.

“Well, that’s terrible” she said.

I nodded. There didn’t seem to be any arguing against that – and anyway, she was the consultant and the year supervisor, I was the medical student.

“But wasn’t there any screening process?” she said.

“Sceening?” I said.

“Yes, you know. When you got into medical school. To keep people out. Unsuitable people.”

I stared at her. There had been a screening process – there had been a full-day exam, and an hour-long interview, and an investigation of my academic performance over the last ten or so years. It had been a relatively rigorous process, excluding fifteen people for every one it let through, and I had passed.

“Not to be discriminatory or anything” she said. “But to identify people with special needs, needs the school couldn't be expected to supply”.

Needs for what? I had this sudden, clear image of some kind of "brain repolariser" set in the wall of the school, a socket into which I could plug my head to fix things. Well, that'd be nice...

“I sit on the board of St Crowley’s, my daughter’s private school – and we have to screen for people with special needs, like you. " She gazed at me with her bright blue eyes. "Spastics. And autistics, and dwarves.”

Another crystal clear mental image – I don’t know if this is a useful survival skill or what, the generation of detailed mental images under conditions of emotional stress, it’s not really up there with the fight or flight response, is it? - but this image was of four people, society’s flotsam and jetsam, those who had been rightfully ejected from a society that could not afford to coddle them and their "needs". The first was me. Next to me was a young man with rigid limbs – Dr Broil’s spastic. Beside him was a thin man staring into space – the autistic. At the end of the line was a dwarf.

For some reason we were all wearing jester’s motley. We were sitting on a park bench and drinking out of paper bags.

Anyhow, things went on. I passed third year (just) and fourth year, and I blundered on, keeping just under the radar, twisting and turning this way and that to avoid the screening process, and it’s been seven years and I haven’t killed anyone yet. People have died, but they’ve been people who were going to die when they came in, people who had something wrong with them, or people to whom some unforseeable and unpreventable event has happened.

And I have still not, in my or anyone else’s, opinion made a poor clinical decision due to my illness.

That screening process has some pretty big holes in it, apparently.

Anyway, bedtime. Tomorrow I observe electro-convulsive therapy, which should be… I don’t know.

Thanks for listening,
John

Razor's Edge

2008-01-27T22:17:00.000+10:30

Hail,

I got a letter from a Doctor Davey the other day, from Byron Bay. Byron Bay is a day's drive north of Sydney, just near the Queensland border, on the Pacific coast. That guy you know, took all those drugs, just dropped out of everything - he went to Byron. You can stand in the pure blue water at Tallow Beach and watch the smoke from the sugar-cane burning, on a good day there are humpbacks in the water.

Doctor Davey is the only methadone prescriber for two hundred kilometers – he says the town is full of “surfers and travellers and lost children.” He sounded tense and a little worn down. He was asking what I knew about Anushka Sharapova.

I wasn’t able to tell him much. We hadn’t had her for long, only a couple of months. She’d come down from Darwin, had got out of one bad relationship (ten or twelve thin, clear scars on her abdomen, stabbed with a pearling knife), and fell into another when she got here (James Firlik, one forty of methadone, during one of his increasingly infrequent interregnums between prison sentences). She'd come to see me only once, our organization two or three times. When James was picked up outside the pharmacist and led to the waiting police car, she’d disappeared, “fallen off the programme” and possibly the edge of the earth. When I read about the body of a young woman found at dawn in the parklands late last year, she was the one that I imagined.

But it hadn’t been her, and she'd gone, and there was very little I could tell him about her.

The reasons for this are complex. I had not admitted her to our programme, that had been Dr Grizzle, and before I saw Anushka I glanced at Dr Grizzle's write-up - a complete nutritional history, a few questions about body image, symptoms and signs of hyperthyroidism, a gentle but thorough discussion of licit and illicit amphetamines.

And I looked at the BMI, the starting point for discussions about issues of weight and size, and swore, and I went out into the waiting room and called her in.

Anushka was thin, frighteningly thin, the angular frame and stretched-parchment features you only normally see on an thyrotoxic, an ascetic or a cachectic, someone consumed from within by thyroid hormones or God or cancer. She sat, baggy-jumpered, flared jeans, on the chair opposite me and stared with large, dull eyes, and answered the questions about drug use history in a flat, soft voice, monotones, uncommittal, and the only time any kind of energy came into her voice and her face was when explained how she wanted to help people.

“Kids on drugs,” she said, speaking slowly. “I want to talk to them. Be a counselor or something.”

I had a vague idea, spoke almost on impulse. "Is that something you want to give your life to?" I asked.

She nodded, earnestly.

After she left - I had done pretty much the same as Dr Grizzle had done, asked the same questions, come up against the same thick stone walls - yes, she tried to gain weight, no, she didn't think she was overweight or fat, yes, she knew about bone density and tooth decay and constipation and headaches and death. She didn't want to see anyone else, she didn't think that she was depressed, she was a happy kind of person. And the food was just like for everyone else, there were no forbidden foods, no rituals, she ate pretty much everything, she loved eating and cooking food for other people.

I glanced up when she said the bit about "cooking food for other people", but that in itself is not a symptom of a mental illness, otherwise the backs of ambulances would be full of celebrity chefs. I remembered speaking to a woman with bulimia in Florey - she was hungry every hour of every day, always hungry. In the end I prescribed daily multivitamins along with her methadone and wrote her a short script so that she had to come and see me in a month.

I drove home with this vague disquiet, and strange thoughts breeding in my mind. There was a strong sense that I had done the wrong thing, that bad things were going to happen to Anushka soon, but I had no real idea - then or now - what else I could have done, how I could have made things better.

And most of all, I think I did so little because I had and have a profound sense that I had not understood Anushka Sharapova, that the chances were I had mistaken and misheard and maybe even mis-seen her, and that lack of comprehension was what paralysed me and Dr Grizzle and every other unexceptional doctor she had seen.

See, this is how my thought would go. Anushka was starving, I would think. What did she get out of starving, what did she get out of being starved? To be "successful" in suicide, one of my lecturers once said, one has to want to kill, to want to be killed and to want to be dead. It was rare for all three drives to intersect in the same person, when that happened, the person died. I used to think about that, walking the corridor down to the emergency department, rooms full of people who wanted to be dead or who wanted to be killed, but few who wanted to kill.

Anushka, I thought, wanted to starve, to punish, to deny. It's not far from that to want to kill.

And anyway - that whole "three things" thing - maybe it was just a slogan. You can argue that we are all suicides - Most people who die, die from self-inflicted wounds. We eat too much, we still smoke, we don't wear a condom, we go back to dangerous men. When you graduate from medical school, unless you are exceptional, your idea of medicine doesn’t deal well with this kind of slow, partial suicide, these kind of people, yet they are among our most common presentations. At best we see people who don't look after themselves as frustrating, at best, at worst, as morally compromised, taking up valuable resources that we could otherwise use to save people who really deserved it, really needed our help.

I don't know. Those who punish the body are not new to us. St Maria Maddalena de Pazzi lay naked on thorns. Saint Catherine of Siena drank pus from a cancerous sore. St Margaret of Cortona sought to slice through her nostrils and upper lip - Anushka's body is cut, pierced, starved. It's like those images of the Saints where the heart is visible through the rib-cage, burning and beating and crowned with thorns in an empty cage of bones.

It is of interest that as we fatten and age as a culture we focus more of our vision on the anorexic, the ascetic. S/he is a strange figure, someone who stands at the heart of our culture, someone whom we cannot face yet from whom we cannot look away. Like many of the other mental disorders, it is at least partially defined by income - Anushka and those like her must be cured, Gisele and Saint Catherine must be emulated.

I think realizing that I thought like that was why I felt considerable trepidation* in treating Anushka. I had no feeling at all that I saw "her", instead I knew I was seeing what I thought, superimposed on her, an idea that's stuck in my head. What next - prescribing sanctolytics or sanctoplegics, some prayer uptake inhibitors, a short course of diabolic steroids? When you see your own ideas, your own prejudices, your own beliefs and mystifications instead of the patient, you can't do anything for anyone. You don't see other people, obviously, you see something inside yourself, a category, a symbol, a cliché. You can't cure an eidolon, an idea.

But then what do you do?

I wonder if that was part of what was worrying Doctor Davey. I wonder, in fact, if that is part of what makes us struggle in the psych wards against the dying of these young, superficially placid and obedient women, part of what was behind the confusion, the frustration, the fear and opposition that those around Ss Catherine, St Therese di Lisieux and St Gemma Galgani felt.

Anyway, this hasn't come out right. I will try and write more coherently next time.

Thanks for listening,

John
*Current leader, clumsiest phrase or sentence in a work of fiction.

Sleep

2008-01-22T19:20:00.000+10:30

Hail,
Been thinking about a lot of things, sleep and religion and parrots and Tycho Brahe and so on, and I might try to write this down.

There has been a bit of a hiatus in the blogging, by the way, a combination of a number of things - Sarah, packing up stuff into boxes, doing some writing, the approach of Autumn - but in a week or so I start psychiatry training, and posting should improve from then. Reflecting and thinking and writing is encouraged in psychiatry, although posting your patient's sufferings to the world as entertainment is possibly less so. Unfortunately, until then (early Feb) it's probably going to be pretty slim pickings.

First off - go and have a look at this. Shout it from the rooftops, preach it from the pulpit, print it up and put it on a bloody great tee-shirt. Whoever the author is, s/he shouldn't have typed this blog entry, s/he should have carved it on stone tablets for all eternity, because it is truly bloody glorious. Seriously. Print it out and stick it up somewhere.

But anyway. Sarah's on opiate patches at the moment, and I think we've got the right dose. Things are better than they were before, the pain is better, and there isn't so much of the early morning nausea* and vomiting that she was getting, but she says the patches make her sweat, and they affect her appetite, and, most distressing for her, they cause strange dreams.

Not strange dreams in the exciting way. These strange dreams are not ornate oneiric visions in the Edgar Allen Poe sense of the word, or Jungian strange dreams redolent with symbolism and secret meaning, they are dreams that are strange because they are so... unstrange. They are utterly mundane, confusing and occasionally embarrassing dreams that very closely resemble "real life".

Dreams where she wakes up and brushes her teeth and checks her email and then she really wakes up and has to brush her teeth and check her email again.

Wild voyages through the subconcious where she has a cup of tea, vivid multicoloured phantasies wherein she chats with her mum, delirious surrealist reveries involving paying the electricity bill. A few nights ago she either couldn't sleep and spent the night tossing and turning until just before dawn, or she slept like a log but had a dream where she couldn't sleep and spent the night tossing and turning until just before dawn.

She says it's not that whole spacey "One night the great sage Chuang Tzu dreamed he was a butterfly" stuff, either. It's more "One night the great sage Chuang Tzu dreamed he had returned the DVDS so he drove off without them and then a week later he got a hostile phone call from the DVD people and the great sage Chuang Tzu said 'What the hell's wrong with you people, I gave them back Tuesday' but it turns out he hadn't, it was just a dream" kind of thing.

Anyhow.

Speaking of sleep, an interesting article in the New York Times suggesting that what we call normal sleep - like normal eating or normal childhood - is actually a recent and historically abnormal phenomenon. Pre-Industrially it may have been that we slept in two shifts, each of a few hours - a first sleep and a second sleep. Between these two sleeps was a period of remarkable alertness and productivity, reading or talking or tending the animals at two or three in the morning. Priests could pray, adulterers could meet at windows, slaves could whisper together.

Or that's what the author reckons. If that's true, you could argue that what we today call insomnia is normal, is something that used to pass unremarked. I have no idea if this is true or not, and it's of only theoretical interest to the person who wakes tired and red-eyed, but it's an oddly intriguing idea.

I like the idea of that interregnum, that time away from the heat and the light and the eyes of priests and neighbours, purposive and vigorous instead of lying in the dark and staring at the ceiling. I know there is some intimate connection between light and mood - I know that light can be used to treat some severe forms of depression - the most famous is Seasonal Affective Disorder, or SAD. I also know that several of our guests, when we lived in the hills away from the city, so dark you could see nine of the Pleiades, could not sleep in our house - it was too dark, too quiet.

I suppose another reason that my thoughts are inclining this was is that the "sleep medication" zolpidem (sold over here and in the UK as Stilnox, in the US as Ambien) may be reclassified over here as a schedule 8 drug - subject to the same legal restrictions as morphine and methadone. I don't know about this. Zolpidem certainly doesn't help sleep in the way it is used by most people I know, but the more I find out about sleep and mood and cognition, the more complicated it is and the more questions I have.

I have some of the answers in a book on my desk. I have downloaded all four hundred pages of the ICSD DCM, the International Classification of Sleep Disorders Diagnostic and Coding Manual. This is to sleep what the DSM IV is to madness - or rather, what it is to sanity. It classifies sleep disorders, first into dyssomnias, parasomnias, those with medical, mental and other causes, and finally "proposed" (sleep disorders that are on the waiting list), and then fuirther, into hundreds of separate sleep pathologies. As far as I can see, they are listed in order of intrinsic horribleness.

For example: the dyssomnias include relatively common entities like narcolepsy and obstructive sleep apnoea, and the common-sense (stimulant dependent sleep disorder - if you take a lot of speed you don't sleep). It also contains the more unusual: altitude insomnia and food allergy insomnia.

The parasomnias mention impaired sleep-related penile erections and the alarming but hopefully not fatal "sleep related sinus arrest" - you go to sleep and your heart stops - presumably it starts again.

Amongst the "medical and mental" group are (unsurprisingly) African trypanosomiasis (the original sleeping sickness), but also the disorders of sleep that occur as the architecture of the personality is eroded - the insomnias of the various dementias, the slow derangement of Parkinsons Disease. You read about these conditions with a deep sense of - I don't know what, a yearning to offer some comfort to these people, a wish you could just do something. In fatal familial insomnia the part of the brain that permits sleep is scarred and stutters and fails. The ability to sleep is lost, these people can no more sleep than you or I can clench an amputated hand. The time between the last moment of sleep and eventual death is measured in months.

Anyhow. On that happy note I have to start seeing patients, almost all of whom feel and believe that they cannot sleep, haven't not been tired for decades. This means that parrots (and it's a damn interesting parrot) and religion and Tycho Brahe will have to wait until the next post.

Speak soon. Thanks for listening,
John

*No.

Architecture

2008-01-03T18:58:00.000+10:30

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

Resus.

2008-01-01T09:03:00.000+10:30

Hail,
Long time no write, and thanks for the comments. It's not that I haven't been feeling "writey", or that stuff hasn't happened, it's just that a lot has been going on. And you prioritise things, order things in your head, and usually when I do that now blogging is ranked relatively low.

However, I did read that there was an average, almost a natural, lifespan for blogs of about two years. I don't know if that's true, but it seems likely. I don't think it will be true for this blog, but to be honest I don't know. If it is, by that measure Stranger's Fever would be palliative by now.

I started this blog initially to write. I want to write, I've always written, and one thing I have tried to hammer into my head is the idea that you get better at writing by writing, like you get better at boxing by boxing. There is only so far that watching great fighters or reading books by experts can tell you, in the end you get better at boxing by hitting the bag and then getting in the ring, hitting and being hit, being able to do what works. Writing is exactly the same, but with groin punches and biting allowed, no breaks between rounds and a higher rate of traumatic brain injury.

Anyway, I started Strangers Fever in the hope that I would write down some stuff I could use for my "real" writing, and to that extent I think it has succeeded very well. The frequent writing (I think there's over three hundred thousand words here) has made me a better writer. I've written stuff somewhere in here that I'm quite proud of as it stands, rather than just seeing it as raw materials or rough drafts, and a lot of it will be going into the novel, whenever that happens.

But blogging, particularly pseudonymous blogging is about a lot more than producing better writing. Most people who wirte aren't looking to write a novel, they are doing something else - self expression, that need to shout out into the emptiness, that almost psychotherapeutic process of revelation of your deepest psychic fears - initially to nobody at all, and then to strangers who are, like you, safely pseudonymous.

I don't believe life-long psychotherapy is usually that helpful, and for the same reason I don't believe long-term purely psychotherapeutic blogging is that useful. And there has been an element of that in Strangers Fever, that shrieking into the dark, that "urge to purge" that I don't have any more.

Part of the problem is the therapy or something like it worked. There are worries - Sarah's pain is number one, of course - but these are open worries, things we are handling, not secrets scrunched up inside, misery masquerading as madness, that kind of thing.

Despite everything that is going on, I am so damn happy now. Large scale, randomised, double blind trials have repeatedly shown that Sarah is the best wife in the galaxy. My sons are perfect. My job is going brilliantly - yesterday I saw a man on venlafaxine and methadone, suspected and looked for and diagnosed the dangerous interaction between the two, sent him off to his GP with a referral letter that managed to mention both cytochrome p4503A4 and the triumphant return to power at the Federal level of the Australian Labor Party.

I am reading good books and listening to good music, in February I start part time at the psych ward and the director, to whom I have spoken, has read my CV and is eager to discuss how I got to psychiatry from the study of Holocene pollen fossils.

I have had a story accepted for publication in the top SF/Fantasy/Horror magazine in the country, I am writing my non-"Stranger's Fever" novel at the steady rate of three hundred words a day, my cats are sleek and well-fed.

I am slowly losing weight* and twice a week I go to muay thai classes where I get my bottom spanked by teenaged boys (I should put that as a title for this blog entry - that'd get the numbers up). This may or may not be an improvement on this time last year in judo ("the gentle art") where I was getting thrown on my head by teenaged girls - the boys are good, they hit hard and are hard to hit and everything, but grappling that girl was like trying to pin a greased weasel, and in the end, judo beats most other martial arts.

Anyway, sadly, and possibly boringly, there just isn't that much emotional trauma driving me at the moment.

So - what this means is that I am still going to try to write. If I wasn't as shy** as I am, I'd be contacting some of you and asking if you would mind if we corresponded emailingly, but since that is guaranteed never ever ever going to happen, I would still like to keep up this weird kind of relationship. And I still see interesting patients, read fascinating things, have things I want to say and ask about and so on. But I don't want to say I'll be writing stuff regularly when I'm going to be doing other things instead. I'll still be writing, but I'm going to try and promise and achieve weekly rather than daily.

See, I really enjoyed writing that post. I do love this when I do it.

Let's try Tuesdays. Every Tuesdays I'll post something. See how that goes.

Anyhow. Thanks for listening, and more (seriously) soon.
BDC

*Sadly, if I exercise as hard as I can for as long as I can as often as I can and eat frequent meals that total as little as I can stand, I lose weight. As everyone knows, it's not knowing what to do, it's doing it - I should be on the treatmill now, for example. It's not that interesting.

It actually gets slightly more interesting if you look one level higher at the cognitive and behavioural stuff, the economics (in the sense of "the choices you make") of diet and exercise. Someone suggested that people concerned about body fat try the "Blackmail Diet": in this case, I would write a large cheque, with the proviso that unless I weigh (insert number here) by (insert date here) the money will be mailed off to and organisation I despise (insert the various conservative parties of Australia here. Or preferably here) - with the expressed wish that this gift be publically acknowledged in some form.

I know, as much as I know anything, that I would rather gnaw my own pancreas out and then grate it into a salad than give those bastards a red cent. Seriously, you'd see muscles anatomists didn't know human beings had.

** I am in no way an expert, and am open to other opiniuons, but my current medical opinion is that this is largely wank.

John

And what have you done?

2007-12-19T07:11:00.000+10:30

In other news... first off, go have a look at FW's diary - would do the link to the particular post but am too stupid. Warning, may cause spontaneous cheering. That's pretty damn fine writing.

Secondly, Sarah continues much as she was, but thanks all for the well wishes. She uses a walking stick and I am trying to order her a sword-cane through the internet, but have grave doubts on our ability to get it through customs. In the interim, there are walking sticks tastefully carved in the shaped of women's lingerie-clad legs. If I buy her one of them I'd better hope she doesn't also have a sword-cane.

Anywy - this will be a brief letter because I'm writing it from the coast where we are attending a family Christmas - more of which later. I mentioned a while back a change in careers and here 'tis: I have given up on Emergency and a few weeks ago sat the interview of the psychiatry training programme - in fourish years I am not going to be an emergency doctor, I am going to be a psychiatrist.

In a way I think this is like coming out, admitting what kind of person you are after years of denial trying to be something else... but it's that special kind of coming out where you've had your arms and legs and torso out of the closet for years and only your head halfway in and then you pull your head out and say "Prepare yourself, people, I have an utterly amazing announcement" and everyone says "we know already."

If there is a "type of person" who does psychiatry, rather than emergency medicine, a way of interacting with people and looking at stuff and thinking about things, I am that kind of person*.

It appears, by the way, that I have already been practicing some startlingly efficacious pyschotherapeutic techniques for many years, albeit in my kung fu class. As stated, this simple technique can be used to treat many mental illnesses that otherwise require time-consuming therapy, costly and dangerous pharmaceuticals or green-house-gas unfriendly electroconvulsive therapy. I am looking forward to using this technique to cure drug dependency, and will start tomorrow on my larger straight-out-of-prison patients. Quick slap and they're cured. I'll have to be careful not to knock over the ones standing on one leg holding a rose.

I was thinking about denial the other day and how someone at my (basic) level of medicine treats it and thinks about it, and I've worked out I don't treat it or think about it in the right way at all. Denial is one of the things we assess in the basic mental state exam - it is related to questions like "does the patient have insight?", "does the patient believe they are sick?", etc. On bad days I think of it as a scorecard for how much the patient agrees with the doctor.

Denial is generally seen as bad. When I first started out I think I had the idea that part of your job is stripping away the denial and getting the patient to "face facts", which was obviously the first step to healing and so on, because if you don't believe you have a terrible and frequently fatal disease, why would you take the horrible medications doctors prescribe for you?

Nowadays I think that this is not the case. I was wrong about denial.

The wonderful thing about medicine is it is at its heart so simple. Whatever helps the patient become healthy is good medicine. Whatever distracts you from that is... well, it's a distraction.

And denial, in the short term, in inescapable situations, might be part of good health, often a crucial part.

Basic example - you know those horrible moments when you catch a glimpse of yourself in the mirror unawares, and realise how fat/balding/otherwise scombroid you look, those faintly sickening feelings? Thats the stuff that you deny momentarily emerging from the ocean, a barnacled kraken, dark, streaming with seaweed from the deep, profoundly threatening. That basic level of denial is what keeps us going day to day.

And above that there's the other useful kind of denial, situation-specific rather than background denial - the denial that you are working yourself to an early grave, that your partner has been emotionally unfaithful, or that your job and life and friendships are not what you'd hoped them to be. That denial can be an internal armour, the intrapersonal equivalent of the more commonly encountered interpersonal white lies of "how are you going?" and "that's nice, dear".

Of course, whether going on, keeping a marriage together, using your internal resources to maintain said job and life and friendship at all costs, rather than seeing things for what they are and moving on - that's another thing, of course. In those cases denial can be fatal to happiness. But if you don't have the courage, or imagination or whatever it is best called in that particular situation, denial becomes essential. If I had been diagnosed with some horrible cancer, for example, maybe a couple of days of denial would be a good thing.

Anyway. Here endeth the lesson. I am meant to be packing for Christmas, instead of lying here wide-eyed, open-mouthed and inert, like some kind of enormously elongated anchovy.

Lots of marine imagery this post, maybe it's high tide or something. I wonder if there is a belief that creativity pulses with the tides - writers scribbling ferociously under a (say) full-moon perigee, struggling to produce anything under apogee.

Anyway. Off to pack before Sarah does it all.

Thanks for listening,

John

* *Obviously, it's not a particularly eloquent person.

The Picture

2007-12-17T08:56:00.000+10:30

Hail,
Mid morning here, Sarah has just left for work, (I have evening clinic) and I am worrying. This is how things are going.

Without rehashing the whole timeline, Sarah's got relatively advanced joint disease. It's worst in the hips, worse on the right. She's been to an orthopaedic surgeon and he has recommended surgery. That can only happen in April, and surgery itself may be difficult, because to intubate people for surgery they have to bend their neck about, and she has joint disease in her neck as well.

In the meantime she is in considerable discomfort. I know this via deduction - when the day begins she walks with difficulty, almost stiff, like a poorly animated marionette. She moves more freely once her medication kicks in - the dextropropoxyphene lasts maybe two or three hours, the transdermal buprenorphine all day, but only at low levels. She is sleepy during the day - partly a medication effect, partly because pain affects the quality of sleep, erodes its complex architecture.

Towards the end of the day she may wince, or falter, or stop in the middle of a sentence, once or twice she has momentarily paled, and sat for a while.

Joint pain is bad. It's a combination of two or three different kinds of pain - the sharp pain of a fractured joint - (this is what is going on, the radiologist points to where the bony spurs, the steophytes on Sarah's hips have broken off), the dull pain of constant inflammation, occasionally the horrible burning ache of neuropathic pain. The acetabulum, the cup in which the ball of the hip twists and turns, is supplied with nerves that also supply the lower limb - she gets a dull ache in the muscles of her thigh, pain in her knee. The joint itself is corroded and fragile. Looking back - and reading about this - it may have been that the joint has been mis-shapen and weak from birth.

As I said, I know this via deduction, and weak induction, but I do not know this via her testimony, because she almost never mentions it. The reasons for this are, as far as I can work out, complex.

Sarah is afraid that everyone will think she is whining if she complains at all.

She is afraid of being self-pitying, or of allowing her illness to dominate her life, of becoming an illness wrapped in the skin of a person, someone who is their pathology, rather than a successful and fascinating and wonderful person in her own right, a person who has an illness.

At some level, despite my best efforts (and possibly because of my worst) she remains afraid that I will somehow get irritated by this and leave her for a Russian gymnast.

She remains deathly afraid of becoming one of her own patients, and imagines herself toothless and torpid, her life a flat, featureless plane, surviving on the disability support pension.

All of this combines to make her attitude to pain relief deeply stingy, and her mental attitude a curious mix of determined, unrelenting optimism that very occasionally dissolves into glimpses of terror.

I don't know. I am in awe of her, not for the first or last time in my life. It's odd that at a glance I am a lot stronger than her, I can carry her around the yard whereas she can't unload even small bags of cat-food from the car, but there is no way I have her strength. I can kick hard at head height and bench press a reasonable amount and do CPR on a big man for a long time, but there is no way I could last a day doing what she does.

I think that before cliches became cliches there must have been a time when they were new and young and fresh. The first person who said "All flesh is but grass", or "her eyes were as blue as the sky" or "I will love you til I die" must have felt that thought like lightning, as something pure and limpid and true. Now that experience is lost to us, because there is no way, unless we are particularly skilled, that we can express thoughts like that in that way, with that potent combination of truth and immediacy.

Anyhow. I will love her till I die. I wish I could take the pain for her. Her eyes are as dark as the night.

Enough of this. The thing is, that picture that Sarah keeps in her head of her after the operatrion, her better, her healed, is something we are going to be focussing on. It's not the only thing, we are going up to the zoo later on for one of those behind the scene things where you look at baby cheetahs and so on. I have been trying to buy her surprise presents, trips overseas and cats and so on, which is a difficult thing to do when you have joint accounts, and so far every attempt has run into some kind of organisational portcullis or another. But overall it's just a matter of organising stuff so that she doesn't ave to do as much, so that we spend the maximum amount of time together.

See, from that point of view it's not all bad. Everyone's a winner.

Anyway, time to get my act together for tonight, which is seafood and something, and then a romantic DVD or something. Hopefully a more romantic DVD than my last choice, which was actually a horror movie.

Will post soon,
John

How about seventy two relatively sexually inexperienced people?

2007-12-12T18:20:00.000+10:30

Hail,
Been reading and thinking - and this will alarm some of you - about religious belief and faith and stuff. And just to cause more alarm, this comes after reading something our new Prime Minister wrote about the subject a few years back.

First off, I should point out that I have been thinking about this subject in isolation for a while, and like all people who sit alone and think obsessively about a limited range of topics, I've probably gone a little crazy. Some of this, I suspect, may not make a lot of sense to anyone else, whereas to me it has All Become Perfectly Clear. But anyway, here goes.

I don't talk to my friends about religion. I seem unable to do it with any degree of success, the times I have tried the discussions have either wound down blind alleys which are of little interest to either of us, or turned into mutually distressing arguments, or stalemated into mutual incomprehension. And by sheer weight of numbers, it can't be them who is consistently daft about the whole thing, it's probably me.

I think some of the problem comes down to meanings of words. To my friends, religion means some sort of active believing in the supernatural, whereas when I don't mean that. I don't know that anything supernatural has ever occured to me in my life.

To some of my other friends, being a Christian means hoping and wishing and believing that there is a God watching over you who is going to somehow bend the rules for you - cure your medical problems, for example, when He lets others suffer, or change the lights to green so I can be on time to a meeting that maybe I should have left earlier for. I don't believe in that, either.

Some others suspect it's powered by the Afterlife, the whole promise of seventy two virgins . To be honest, I'm not that good at the whole delayed gratification thing at the best of times, and anyway, the way I was taught, that stuff's all theologically iffy anyway. Plus, and nothing personal to any virgin readers, being a virgin doesn't mean things are going to work out between us, or make us mutually interesting or anything.

You know, there's a great story waiting to be written there. Some guy wakes up in the afterlife and there's the seventy two virgins, and things encomplicate. Something this guy could write about.

Just to confuse my friends, when I'm talking about religion I mean a couple of different things, too. The one I talk about least is the most real, the most important, the core thing. I've written about this in this blog occasionally, I suspect it's deeply boring to anyone who hasn't experienced it, and it's something I have no faith in my ability to put into words.

The meaning of religion I've been thinking about most recently is more a cognitive thing. I have been thinking of it as a sort of mental cookie-cutter, a way of thinking we are all born with - some to a greater or lesser extent, but something we've all got. I call it a cookie cutter because it carves up the otherwaise inchoate and unknowable and mercurial universe into handleable, useful shapes, makes it something we can use. This cookie cutter is something evolution put there because it works, because it's a successful method of dealing with stuff. A "way of thinking about things" - lots of things, not necessarily or even most often supernatural things - that you start seeing in a lot of places once you know where to look.

This actually gets quite interesting once you look at it.

Okay. There are certain things a "way of thinking about things" has to have to get called religious. There have to be a division of the world into the Saved and the Damned. There has to be a belief in prophets, in some sort of Received Wisdom. There has to be a vision of Paradise and therefore of Hell, there has to be a Gospel and an urge to spread it, and following on from that a desire to convert the masses, persecute heretics and especially apostates and so on.

Now, this is all pretty obvious, but the weird thing is where you see it. One of my best friends - and one of the smarter people I know - has read Richard Dawkin's latest book, the God Delusion, which is about pretty much what the title says. In terms of a belief in the supernatural, a hope that God will change the traffic light colours for him or an envisioned rendezvous with the seventy two virgins, Dawkins is a deeply and openly non-religious man.

But in the sense I have just outlined above, he is profoundly religious. He's a True Believer.

This friend of mine says that if atheism is a religion then not playing chess is a hobby. To me, that sounds more like a bumper sticker than a hypothesis, and it doesn't apply to Dawkins. If you don't play chess you... just don't play chess. You don't write a bloody great book on it, appear on television denouncing those who do play chess, equate parents who teach their children the Sicilian Opening with child abusers, and dedicate a large proportion of your time that could otherwise be spent writing excellent books on areas you know a lot about to trying to stop people playing chess, denouncing the unbelievers and prophesying the Hell that will follow if your exhortations fall on the deaf ears of this thankless generation and the paradise that awaits the Elect who throw away their chessboards and be free.

This may sound like rhetorical points, but I believe that there is a deeper truth behind them. Dawkins, for example - and he wrote two or three of the best science books of the last twenty five years - is like the rest of us: a man with a religious cookie cutter in his head, a man given to thinking in religious terms. I remember reading The Selfish Gene - and if you haven't, go now and do so, I'll wait here - and being stunned at how this one man had taken the whole popular understanding of evolutionary theory and rotated it ninety degrees, so you could see how it made sense that way too, what a truly great idea Darwinian evolution was too.

And then, perhaps troubled by what he could see would be done with the idea, on the last page he wrote "We, alone on Earth, can rebel against the tyranny of the selfish replicators".

I read that and thought "Thank God" and then later on, a couple on months later, driving down the hill to the ED, I remember thinking "well, I don't see a lot of evidence of that happening", and a few months later I realised the reasons for that.

I don't see any evidence for that because there isn't any. It's not an evidence-based statement. It's a faith statement, one that arises de novo in your head, a function of your conceptual tools and emotional needs, put there by evolution because believers like Dawkins and me fought harder and fucked faster than our more skeptical neighbours. Dawkins has a faith in human nature or the human capacity to rebel or whatever where other people have a faith in the seventy two virgins.

Another example of religious thought in Dawkins' writing is his moral absolutism. To Dawkins, religion is bad ab initio. No matter what comes out of someone's religious (in the traditional sense of the term) beliefs - feeding the poor, visiting those in prison, that kind of thing - to Dawkins, those beliefs are still crap. None of this "by their fruits shall ye know them" stuff, it's all bad because... it's all bad. Religion is brainwashing. Religion is stupidifying. Religion is child abuse.

Now these are pretty strong terms, and to a certain extent obviously he's chosen them to shock, but the thing that struck me when I heard them was their familiarity. We've all heard this kind of stuff from religious people before.

Examples from my own inglorious past. When I was an atheist, religious believers were morons and butchers. When I became a fundamentalist Christian, pretty much everyone other than the Few - the men and women beside you on the bus, the Catholics, the Jews, the North Melbourne Football Club - all were destined for the Hell they so richly deserved. When I became a (comparatively) radical socialist, advocating separatism for women and justifying the overthrow of the state by any means that didn't actually involve me doing anything more than talking, Capital and those who had it were bathed in the blood of the workers. If I'd been into Amway, I would have thought Omegatrend was Satan's child.

Anyway, I could go on about this and I know I have a tendency to do so, but I'll stop now. This was less somethign I wanted to get out there for public consumption than something I wanted to put into some kind of order in my head, some thoughts I wanted organised. And I'm not trying to defend stuff, I'm not saying "my way is the right way" or "religion makes people better" or even "hey, seventy two virgins. That's seventy two!". I'm just trying to explain something I feel. Thank you for indulging me, and apologies to anyone I've offended - it was inadvertent.

Anyhow. I have much to write about besides this - patients and psychiatry and Sarah and so on - and this weekend I will. And I'm not going to post anything more until I've replied to comments, this weekend.

Thanks for this,
John

Briefly

2007-12-09T09:00:00.000+10:30

Hail all,
A very brief catchup note.

Thanks vast amounts for the well-wishings. Sarah is still not well, hence the fewer posts than usual - I have a lot I want to write about and not a lot of time to do it. She is now on some relatively hard-core pain relief. It is difficult to tell if this is working because tragically, Sarah was born without a whinge gland and physiologically almost cannot complain, whereas my whinge gland is the size of a cantaloupe and pulses rhythmically several times a day.

However, we know that good pain relief means good mobility means good recovery from surgery, so there is a functional reason for her to take her medication, an "excuse", and that seems to be working.

In other news, the Great Socialist Dawn (that's an event that I am referring to, not a person) continues here. Oddly, it seems almost exactly the same as the previous administration - and God, that term suited the previous lot, because they weren't a government because they didn't govern and they sure as Hell weren't a leadership because they didn't lead. Things seem unaltered, whichever way you look at it.

Anyway. With Sarah trying to exercise pre-surgically, I have been doing martial arts stuff (sorry about the "sexy women want to meet you" pop-ups, but it's worth looking at) and have managed to give myself sciatica from muay thai. These are possibly sympathy pains, i.e.: pain that you get so you can say "hey, I need some sympathy!", but still it's a real pain in the gluteofemoral region. In the mornings it's coffee, black with two naproxen and some panadol.

Speaking of drug-popping doctors, if anyone's seen "House", how many people reckon he's Sherlock Holmes? House --> Holmes, Wilson --> Watson, isolated, misanthropist, opiate dependent, impossibly keen diagnostic eye. He even plays a musical instrument. Can't remember if I've mentioned that before.

Anyway, work is going moderately well, and I have much more I want to write about, but now I am on call and must go off and work. I am looking forward to writing tomorrow.

Thanks for listening,
John

E quindi uscimmo a reverder le stelle

2007-11-27T22:50:00.000+10:30

Hail,
Rather than bitch about how I have had too much going on to write stuff, I am going to start. And Sarah has suggested I write about something other than her, so I start this with the above quotation from Dante, via one of the great left-wing leaders of this country, originally of the last line of the Inferno:

And thence we emerged, to see the stars again.

And as an explanation, I will point out that there has been a Federal election here, and our archaoeconservative Prime Minister John Howard is gone.

Not just gone, but electorally savaged.

Not just defeated, but defeated in a time of unparalleled economic prosperity, defeated when according to all he beleived in he should have triumphed, utterly gralloched at the polls to the extent that both he and his smirking deputy have lost their jobs and are currently scanning the relevant columns of the newspapers. Tai-otoshi'd into the grave and then that freshly turned grave danced upon by bearded stocky doctors wearing long red dresses.

And I shouldn't gloat. I know it's wrong, and self-indulgent, and selfish, and I know I shouldn't gloat, but I really really can't stop. Watching election night on Saturday was political dark chocolate, political guarana-if-guarana-actually-did-what-it-said-it-did. No, let's be honest, it's political heroin, ideological opium for your huddled masses, pure pulsing pleasure from the vein into the brain.

I am serious - this election has made a difference to things to me. I am profoundly energised. In the last week or so I have started a compost heap, ordered a rainwater tank, gone back to martial arts training. I eat summer fruit, barbecue lamb with rosemary on the verandah and read summer short stories. I have shed fat and gained muscle, and in the bedroom is joy, as those Anatrim adverts say.

I have been reading Australian poets - Robert Gray* and John Murray and Robert Drewe, I wrap my hands and bob and weave in the dusty boxing shed under the incandescent globe, I kick the bag and the shed rattles. I feel I will wake in the middle of the night, laughing.

See, I could go on for years about Howard and what how deeply things were wrong under him, but there's nothing as boring as someone else's domestic politics. So I'll try to pick one example, and explain things using that. And it's a difficult thing to get across, and it may not really get there.

Here goes. North and west of here the sea stretches pale and flat and shallow. The sea-floor slopes shallow beneath it, irukanji pulse in the warm water, dugongs drift like clouds where campfires burned fifty thousand years ago. Australian's relationship to the sea is deceptively complex, we came across it but it killed many of us, it isolates and threatens and preserves us. Waves of us struggled here, nights beneath the stars, people smugglers and illegal immigrants, First Fleet or Tampa, Botany Bay or Nauru.

How is this a metaphor for what happened to this country under Howard? There are close connections, fearful symmetrys, between our inner and outer environments, our "ideascape" and our "seascape", in the last eleven and a half years. What happened out at sea was what happened in our country, a sortof flattened out version of the hermetic doctrine, as above, so below.

In the last eleven and a half years of this government unknown numbers of shiploads of refugees either sank off our shores or struggled to some far-flung island and... vanished. They drowned or were imprisoned, our armed forces repelled them. They were returned to oppressive dictatorships, they were sent back to be treated how we would not treat a dog here. Shiploads full just... vanished.

And as much as and at the same time as and to the same extent as they vanished in the sea they disappeared without trace from our political environment, our ideascape, as completely and fatally as they would have sunk into our unforgiving, hard oceans.

Seriously, Howard's vision of Australia was one where we didn't talk about that kind of stuff. It was one where we all worked long hours paying off the mortgage, making something of yourself, decency and respect for your traditions, cricket and the Queen. Buckle down and get yourself some, but don't rock the boat because then bang, the job's gone just like that, big business knows best, Big Brother in the evenings and we've never ever had it so good.

As much as the sea covered these men and women and children and forgot them, we covered them and forgot them. We did this because - and this is a reason, not an excuse, because we have no excuse - we did do because under Howard, for all his talk of prouder and stronger, we were scared, scared all the time - scared of Asia. Scared of the future, scared of disease, scared of Islam and - ironically - scared of terror.

And last Saturday we showed we were better than that. Better than he hoped and better than he thought and better than him.

Anyway, this has come out all wrong. I sound like I'm hating a country I've never loved more in my life, and denigrating something of which I am fiercely, passionately proud. Anyway, off to put the final touches on the John Howard pinata and revel in the confusion of mine enemies (Conservative quote of the week: The election just showed they may like you, they may agree with what you are doing, they may respect you even if they don't vote for you).

Mmm. That sound in the background is another sacred cow falling from an ivory tower.

Thaks for listening,
John

*Seriously, listen to this from "A kangaroo":
That hungry face moves on grass the way and artist's pencil retouches and shades

Bastard gets it right, doesn't he? And then look at this, from "A poem of not more than forty lines, on the subject of nature":

I awake to rain blown against this one room, beneath the cliffs of forest, on a slope above the valley that has welled with night.

All evening the rain riddled the lamp's beam, that stood outside as if to brace the shack. What I hear now is only the aftermath, shed thickly by the branches and settling like fishing lines through the sea, many small weights sounding separately on the tin.

What do you say to that? Answer on one side of the page, please.

**Note - there's no friendly informal noun for a person of right wing beliefs, is there? Speculation as to why this is welcomed.

Abnormal service is being resumed...

2007-11-26T11:15:00.000+10:30

Hail,
Thanks to everyone for the well wishes. Vast amounts have gone on. As a precis -

Sarah has had steroid plus anaesthetic injections. They have had an almost miraculous effect. She is now sleeping through the night and is much more mobile mobile again. We are both deliriously happy with this.

She is being shuttled from neurologist to neurosurgeon and back. My own suspicion is that this is a neurosurgical "problem" but not one that is amenable to surgery, if you follow me. The good news is that if it gets worse, we know what to do. The bad is until it does, we don't. Currently it is about the same as last time I wrote.

And a lot of other stuff has happened. Our loathed Prime Minister has been swept away, and in a personal rejection unparalleled since the thirties, looks to have lost his seat in Parliament - i.e.: be personally unemployed. I have given up and decided that emergency medicine isn't something I can do any more, for a variety of reasons, and am considering my options. I have an interview today, my suit is in my car.

And things are so much better now than a month ago that it's hard to explain.

Back soon with writing,
John

A chance to cure

2007-11-11T10:38:00.000+10:30

Hail,
First off, thanks to those people who have checked up over the last few days. It has been a bit frantic, only now settling down, but thanks.

First off, a friend of mine had a lovely looking child, first child, a boy. Wonderful mother, wonderful child - photos here.

Now - update. Sarah has been seeing specialists and getting various bits of news. About a fortnight ago we saw the neurosurgeon, Mr Broca. He feels we should wait on the surgery, as a proportion of these cases settle down spontaneously and also because it doesn't look like the kind of problem that would be easily fixable by surgery. I don't know that this is unambiguously good news.

It's difficult to explain how this felt. All the week lasting up to the consult I had been angry. Not snappy or short-tempered, not angry at anyone, not even angry in a way that I could articulate. I only knew I was angry because I could feel it - that calm, measured way of speaking, that change in posture and muscle tone, getting up every morning to punch and elbow and knee and kick the punching bag, half an hour before breakfast, again when I got home. Anger that was just under the surface of my consciousness, waiting for something to materialise, someone to stand forward so you could hit them. An intransitive anger, like that intransitive, objectless fear anxious people get.

The thing is, when Mr Broca said that Sarah wasn't going to have surgery I started crying. Seriously, in the waiting room, so I had to go outside, and Sarah followed me and comforted me. Her (with the medical problems) comforting me (without them). First time I've cried in public since - I don't know. Decades.

Anyway. No surgery yet. And I don't know if this is good or bad. In the end you go to a surgeon to ask one question - "Is this going to get better with your surgery?" - and at the moment we don't have a perfectly satisfactory diagnosis and we don't have a treatment and the problem has not gone away and Sarah gets occasional paraesthesia (that pins and needles feeling) on her forearm.

Mr Broca has referred us to a neurologist and that's next.

In the interim we went to the orthopod. The way it is told in medical school, orthopaedic surgeons are to medicine what drummers are to pop musicians and this guy was to more normal superfolk. It's a lot of hammer and chisel stuff, and geeks often look down on manual labourers. Ortho is intrinsically simpler than, say, renal medicine or neurosurgery. Most damning of all, orthopods tend to be good looking, as well as rich and good with their hands, and that can't be good.

But our guy was excellent. He was clear, and comprehensible, and sympathetic, and examined Sarah, and used words like "accelerating" and "disabling" and "severe", and the gist of it was Sarah's hip joint is bone on bone, and there are pits and cysts in the socket itself, and there are bony spikes growing where they shouldn't, one of which has fractured, and she has less than a quarter of the normal range of motion that she should have.

Try this - stand legs straight, feet together, holding onto something for support. Keeping your leg straight, lift it sideways - this is hip abduction.

Normal range of motion is about forty five degrees, more in trained people. Sarah has ten. He has signed her up for hip resurfacing.

By the by, I am not an orthopod, but from my reading, if you are looking to have hip replacement surgery, ask your doctor about hip resurfacing surgery. If you're suitable, it's a lot better operation. This guy has professional surfers and footballers who've had the surgery.

Anyway, Sarah has been off work for a week or so. The main thing that is worrying us at the moment is the pain, and tomorrow she goes in for joint injections - uberantiinflammatories and anaesthetics injected into the joints. And after that - and not immediately after that, because Medicare is not what it was - comes the surgery.

Anyway, today she managed to go off to a cat show. It's the last one of the year, so we loaded up the cats and she drove off in the early morning light. I am going to potter around and await her return.

I almost feel my next post should be about something other than my worries - maybe my patient with Gender Identity "Disorder" (not to be confused with the much more frightening Christian Identity Disorder - seriously, don't click on this if you are easily offended. Or if you can read. In fact, don't click at all). But it's all I've been thinking about lately. "He who loves gives hostages to fortune", as they said in "Swamp Thing - the Movie". Apparently Francis Bacon also said it, but I think I heard it first in Swamp Thing.

Thanks for listening,
John

Crime and Punishment

2007-10-31T10:36:00.000+10:30

Hail,
Morning here. I’m doing Sarah’s shift at Central. We have a neurosurge appointment this afternoon, Sarah is at home in bed or sorting through MRIs and CTs. I don't know what the neurosurge will say - the pathology is definitely there, the symptoms are there, it's a question of whether he operates or not. From what we can work out the nerve root is being crushed, the one that runs down to her hand, but as well as that there is narrowing of the spinal canal itself, the bone tunnel through which the spinal cord runs. If he does advise surgery this will be a bigger operation than last time.

On the good side things seem to have stabilized in the last few days, but before that they had ben rather hair-raising: last Friday she lost sensation over most of the back of her hand, and it has not returned.

Since I would rather do almost anything than talk about this, I will write about something utterly unconnected.

Mr Grote is one of the patients about whom I worry pretty much constantly. I see him regularly, I discuss him with his care-worker whenever the occasion permits. I am in constant communication with his parole officer, his GP, his pharmacist. Unknown to Mr Grote, and on days carefully scheduled to ensure the two do not meet, I also see his ex-partner, a pale, thin woman with dirty blonde hair. Mr Grote is legally required to remain at all times five hundred metres or more from this woman, and faces considerable forensic penalties if he does so. He is also barred for life from three pharmacies and we are required to have a security guard present whenever he sees us.

Not that any of that was necessary Tuesday. I leant out into the waiting room and called his name, and Mr Grote looked up at me and smiled. Jamie, the soon-to-be second Mrs Grote, smiled too, one of those smiles like a flash of light, and offered to hold the baby. With evident regret, Mr Grote handed over a tiny someone swaddled in a clean white blanket, and followed me into the office.

He looked good. Put on a bit of weight – some of that was the methadone, but it often means the patient is taking less speed, maybe taking his prescribed dose of antipsychotics – and looking the better for it. His face had cleared up, he was notably calmer, he spoke mostly of his new child, his son. Half way through the interview he found the separation too much, excused himself to the waiting room and returned with his child in his arms.

"It happens, after a while" he said.

"What does?" I said, staring at one of the twenty or so new baby photos on his phone.

"You get over it. The smack. You sortof change. Different things become important. Since I had Blayde* everything's sortof come into place."

"You reckon? That's brilliant." I said, writing down what he had told me - no opiates, no benzos, no amphetamines for five weeks and three days.

"Sure of it" he said, his voice soft. "You know - I wouldn't recognize myself from when I was eighteen."

"Most of us wouldn't" I said. For a moment I remembered that line from "The Go-Between" - The Ram, the Bull and the Lion epitomized imperious manhood; they were what we all thought we had it in us to be; careless, noble, self-sufficient, they ruled their months with sovereign sway.

"No, but - " he stared down at the little bundle. "They change you."

"They do" I said. "You're doing bloody well. Congrats. And that's a beautiful kid."

The appointment stayed with me for most of the day, and it pleased and cheered me, and I told one of the nurses about it, and she seemed pleased and cheered too. And so we were all pleased and cheered, and it was in a pleased and cheered manner two days later I went through the pathology reports.

"Good Lord" I said. "Look at this."

It was Mr Grote's two-monthly urine drug screen, taken just before he saw me. Heroin. Amphetamines. Sleeping tablets. Buprenorphine (occasionally used as an adulterant in heroin, otherwise bought on the street). Six out of the nine illicit drugs we screen for, and two of
the remaining three we pretty much never see.

See, this is something I have to watch as a doctor. I believe anything people tell me. Always have done. That's why I ask for the urine drug screens, and I do the blood tests, and I measure all that stuff. Because I know if we ever have to rely on my keen clinical eye, or my innate sense of distrust, we're all doomed.

Anyway, as a result of this, Mr Grote goes from getting six doses a week unsupervised to having to go to the pharmacist every single day of the month and swallow his dose there. It's the loss of a recently hard-won privilege, and it will cost him time and money. He will, I imagine, be bitterly
disappointed. I feel bad about it.

See, the reason I am thinking about this is two articles I read recently. One was a letter by Tamara Speed**, the Treatments and Policy Manager of the Australian Injecting and Illicit Drug User's League to "Of Substance", the national magazine of alcohol, tobacco and other drugs. In her letter, she touches on a number of crucial issues which we as doctors rarely discuss. She talks about the unequal power dynamic, the frequently punitive response of doctors to client honesty, the range of issues that keep sick people away from their doctors.

Reading her letter was like listening to someone speak in a language in which I had once been fluent. She is sayingthings now that I said ten years ago, things I have not openly disavowed but things I suspect I don't take into account as much as I did.

Another, brief example of what I am talking about. Mr Hartley came to see us the other day. He is on a sizeable dose of methadone, no take-aways. His last urine test showed he was taking benzos, which are sleeping tablets. He frequently misses doses - two, three, four in a row - and when he does, he uses heroin, one hundred dollars at a time injected. When he turned up at the counter to see us he had a breath alcohol of 0.06 several hours after his last drink, and did not feel in any way intoxicated.

Later that day, I reviewed his notes.

Hepatitis C - not interested in treatment at the moment.

Several overdoses in the last few years.

Living from house to house.

I wrote him a letter, told him that I wasn't going to prescribe methadone for him any more, that his last dose would be on such and such a date, and that I had made an appointment for him to come in and discuss starting on buprenorphine treatment - a much safer, but less stonifying drug.

Unequal power dynamics. Punishment for telling the truth. Patriarchal, proscriptive, punitive. All of the above.

And the reason I did this is because of the second article I read that day. It's an overview of the characteristics of people who overdose. Basically, it points out that people who are on methadone are at much higher risk of overdosing and either dying or getting permanent brain damage than people on buprenorphine. People who drink a lot and are on methadone - they are at a huge risk. The homeless, people who attract a lot of police attention, people who inject publicly because they don't have a lounge-room crash out in, who buy large amounts because they don't know when they'll next be able to buy again, people who use large amounts because the don't want to be caught with it - each of tehse increases your odds of your methadone killing you.
People who take pills.
People with other illnesses.
People who are socially isolated, don't have friends, don't have a lot of fellow users.

People like Mr Hartley. I think he is one of the five or six highest risk people I have. They've done studies on this and those studies suggest that if I change him over to buprenorphine his life will be prolonged and his brain preserved.

But studies also show that people who die really fast are people who jump off the programme and then keep using. There are obviously a lot of factors that make people jump off the programme, but I can guess a few of them.

People who don't get treated with respect.

People who get their medications changed on them, without consultation by a doctor, who just get told about it.

People who get punished for being honest, people who get watched all the time, people who have their dose of medications cut if they don't obey.

I don't know. O don't know what would make Mr Hartley happy - to be honest I haven't asked, because his choices are fairly limited. I'm fairly sure what it takes to make the Drugs of Dependence Unit (who give me permission to prescribe opiates) happy, and I know I have to keep doing it, because if I deviate from what makes them happy they tell me pretty damn quick. I don't know what would make the Australian Injecting and Illicit Drug User's League happy, but from reading their fora I tell myself I can see the outline - respect, integrity, freedom.

So what's stopping me? The problem I have is balancing this with death, and overdose, and disease. There are less compassionate doctors than me - although I don't know that Mr Hartley would agree, and Mr Grote might be having his doubts around about now, when he gets his letter - but I don't know that they are any better at what they do. There are more compassionate doctors than me, but I know at least one of them has patients like zombies, has contributed to the vast benzo and opiate problems we have around here, has been called up before the medical board on many many occasions, has people who have died early, people addctied for years when they could have been clear-headed, had a normal life, people who can't get out of bed unless there's a pharmacist at the end of the trip.

I don't know. It's a balancing thing. Two years ago I was a lot softer, now I'm considerably more protocol-driven. The more I find out about this are the more I realise how dangerously ignorant I was and still remian. So I ring up for advice, and I read stuff, and I listen to someone tell me how much he's changed and then I send a letter telling him he's losing the very very few priveledges we've grudgingly given him.

And trying to manage all of that while knowing I am still as easy to fool as Mr Grote found me the other day.

Thanks for listening,
John Bronze

* Half-brother of Exavier and Jett. I am not making this up.

** Replaced the previous Treatments and Policy Manager, Elizabeth Smack, in a bloodless coup earlier this year. Her assistant is Gerald Cone and other members of the Treatment and Policy Team include Joanne Bong, Anh Whizz and David LickACaneToad. Okay, I made those names up. But not Tamara.
Yours,
John Tablet.

Plan B

2007-10-24T19:16:00.000+09:30

Hail.

I had this blogging thing all worked out - the subject of the next few blog entries - the overall structures, the imagery: the "next in series" about the three other terrible deaths that happened in that last horrifying weekend in ICU, then a lighter entry about the truly remarkable happiness of Mr Stonemason and where it came from, and lastly something responding to something I read in the NYT - a career-ending entry on doctors and nakedness, the whole nude/naked/stripped continuum.

And I was going to reply to comments, and go to the pub with my friend, and do some study, and maybe later write a brief entry on the drunken man one of our nurses found in her back yard last New Year's Eve. He had fallen asleep on their child's swing, with his black tee-shirt pulled up over his head. When she woke him, calling cautiously from a distance, there was a moment's horrified stillness, and then he convulsed and jerked about, shrieking that he'd been struck blind. It took her several moments of careful explanation to assure him that this was not so.

And then my manager spoke about when her cleaning lady quit. Said elderly Irish cleaning lady had come over to the house one time and found my manager's cat apparently dead. Horrified, she had picked up the cat and ran the few hundred metres down the road to the veterinary surgeon. She burst in with the stricken animal and the vet performed CPR, including that modified mouth-to-mouth they do in these circumstances, and the cat coughed and came back to life, promptly being sick everywhere.

It was all very dramatic. Everyone was very grateful, and my manager lauded the woman to the skies, but three days later she rang in to quit.

"I just can't go back," she said.

"But why? You can't quit, we need you... anyway, why?"

"It's.... the cat," she said.

"Bobbles? The one you saved? But why? You brought him back from the dead!"

"I know," hissed the woman, in tones of the utmost horror. "I shouldn't have. That cat.... is evil!"

And she wouldn't be convinced, and that was that. Apparently five years later evil Bobbles is still continuing on his undead way, lying satanically out on the patio and chomping on his cat biscuits in what I assume is a decidedly demonic manner.

But these are not the main issues. The main issue, the reason no study and little work has been done and why we have been driving and phoning all around the countryside this last week or so, is Sarah is sick. Here is how it happened.

(I should point out that Sarah has told no-one any of this. She is like one of those feline predators, some desert cat or something, that never shows weakness. Not out of any machismo*, just because she's not someone who expresses her emotions like that. Me, as I've said, if I get a paper cut I call my scattered family around my bedside. Sarah's probably had three out of the top seven causes of pain, and she continues on at half my size under weights that would crush me).

Anyhow, ten years ago Sarah and I were in a car rollover. We were driving off to visit the horses and slowed down to turn right and there was a squeal of brakes (even now I remember thinking "Hmm, that's close") and some guy in a big old Statesman hit us driver's side rear. The minivan rolled two and a half times. I remember looking up and seeing Sarah still strapped into her seat, shaken from side to side as the van jolted, her head shaking back and forth. I was lucky - my seat snapped in half so I was able to lie down through the whole thing, curled up like an apostrophe.

Anyway, the van stopped and I clambered out and extricated Sarah and suddenly the road was full of people trying to help, and they took her inside and let her lay down on the bed and then the ambulance came and took us off to Fremantle Hospital.

She was a bit sore for a while but came good and for a while it like she had got away with just some whiplashy kind of stuff, and several years of exaggerated caution about turning right in a car. All seemed good.

Then a few years later, when she was in final year medical school, she noticed some clumsiness. Just a little at first, dropping things she would normally be able to handle, intermittent at first, but subsequently all day every day. She also noticed a deadening feeling, a loss of sensation over the thumb and forefinger of her right (dominant) hand. After a few weeks she could feel or do nothing.

This was all in the final year of medical school. It's part of the reason she's not a surgeon.

Shortly after that the weakness set in, and then the neuropathic pain. Neuro pain is a whole different kettle of worms to visceral or somatic pain, a deep, aching, drilling pain that doesn't respond to opiates, that nothing will shift and nothing will fix. She kept up with it as long as she could - I was driving, having to do everything for her - and when we finally got in to see the neurologist she was on a hundred milligrams of morphine a day, nauseous all the time, sick and sleepy and feeling as close to stupid as she ever got.

The neurosurge reg got her in to see his boss and he spread the CTs and the MRIs across the desk and we talked about what was going on. The nerve root, the thick, soft branch of nervestuff that comes straight off the spinal cord, threads through the foramina of the vertebrae, becomes the muscles that allow you to feel textures and write and pick things up, was being compressed. One of the disks between the neck-bones had swollen out and was crushing it, stopping sensation, stopping fine and gross movement, causing that horrible constant pain. Additionally, it was bulging inward, pressing on the spinal cord itself.

Mr Brophy suggested a minor response and a fairly major response. The minor response was something called a posterior discectomy - they cut a zipper-shaped scar in the back of your neck and carefully slice off the bit of disk that's bulging inwards, pressing on the cord. The major response was called "anterior fusion". In an anterior fusion they cut your throat open from the front. They slice back and cut out the entire disc between the vertebrae and replace it with a bit of bone they took out of your hip. No disk, no problem. You can't turn your neck at that joint any more because there is no joint - it sortof grows around the bit of hip bone - and that's that.

Sarah opted for the minor operation, about three hours. She woke up groggy and upset and for a few days felt not much better, a change in the nature if not the intensity of the pain, but over the next few days it began to recede and she did well. She never got full sensation back in her right hand, but she didn't have the pain any more and she wasn't crippled and I was deliriously grateful to her expensive-suited and gigantic headed neurosurgeon**.

Anyway. All that was ancient history, until last week when the numbness came back - but on the other side, the left hand. And then, in hindsight, she put things together - the difficulty taking blood the other day, the coffee cup that slipped from her fingers, the clumsiness feeding the kittens.

What we suspect has happened obviously is same disc, different side, and that means relatively emergent surgery. We drove in in the small hours of the morning to the Allnite Pharmacist - the 24 hour pharmacist in the city where we send many of our most violent patients, I got out the car looking around like an amphetamine paranoiac, planning to hospitalise anyone I didn't recognise who got within six feet of us - and we got some prednisolone. I got her into CT at Florey the same day, with maybe an MRI if they reckon she needs it later, neurosurge appointment the following week.

This is not good, for a number of reasons. For a start, our income protection insurance does not come into play for another few months. Second, prior to this we had been arranging an orthopaedic surgeon - Sarah has what Dr White calls a polyarthropathy and needs at least one hip, maybe two resurfaced - and Dr White pointed out that any anaesthetist is going to want to have a very good look at Sarah's rather-the-worse-for-wear spinal cord. When they put you under a general anaesthetic they sortof bend your neck back to fit the breathing tube in and in anything other than the most careful hands things can actually go very very wrong. You need your neck.

Anyway. Back to talking about me now - I have been rather concerned about this. I think it is possible that the more you know the more you can imagine going wrong. I oscillate between trying to reassure Sarah and imagining all manner of increasingly unlikely scenarios. I woke up early this morning, lay there in the pearl halflight, with the magpies outside the windows and the cats padding silently around in the lounge room and watched her breathe, slowly, in and out, dependable.

When I found out about all of this I was enraged, a kind of intransitive anger, an anger without object, all the more frustrating because of that. I wanted to fight, to smash, to hit something so it broke like bone breaks, kill whatever was threatening her and somehow make it all okay. But instead I lay there and listened and watched until it was light and then got up and made us both cups of tea.

Anyway. Speak soon, reply to comments soon too.

Thanks for listening,
John

*Still less out of any marianismo, which is a bloody depressing word.

** He was a remarkable looking man. A truly giant head, almost the same proportions as Charlie Brown, and long, slim, tapering fingers. I don't know if that's what he actually looked like or if that's how everyone to whom I have spoken remembers him, like some fifties pulp alien, here to bring peace and universal enlightenment to all mankind. Either way, it's reassuring, and he's very very good.

One

2007-10-17T19:52:00.000+09:30

Evening here in the ICU, and I am deep bone tired. I’m too tired to go home right now – that time when you know your reflexes are just that tiny bit off, your decision making that teensy bit impaired, that yearning for warm soft bed and warm soft Sarah just a little bit too urgent – so I am sitting in the registrar’s room on the last day of my ICU rotation, drinking a weapons-grade slurry of coffee and writing about today.

Before I do, by the way, have a look at this. It's a documentary called "Guys and Dolls", about some truly unusual people. I haven't seen all of it, but it's startling, distressing, heartrending and frightening all in the same ten minutes. You might need broadband - I don't know how broad, the documentary's pretty long so you might need pretty broad.

It’s hard to put the last few days into words. I sit here and write and ten metres from me there are four people – four of my patients - between life and death, three people who are in the twilight in one way or another. In each case I have been involved in their care from early on, and in each case I feel, or know, things will end, or have ended, badly. In each case I will try and explain what happened. I don’t know if there is a less bad, a least terrible, but I suspect I will end up leaving the worst ‘til last. And tonight I am almost incoherently tired, and when I get that tired my glucostat goes awry, I can't detect overabundance of sugar, so this will probably dissolve into something cloying towards the end.

And I'll do comments tomorrow. I've jsut read them and I feel rather grateful.

Anyhow. I started at eight and got the handover from Dr Fang. He was walking with considerable difficulty – he’s come down with something contagious and as such is unlikely to be returning to work. I took over the patient, waved him on when he tried to finish off “ a few last things” and the CNC rang the consultant to get him to ring around for night-shifters. At eight thirty the pager went off – code blue in resus.

Code blue means someone in cardiopulmonary arrest, and ICU are required to attend. I walked down the stairs – code blues in resus are not the same as code blues at other places in the hospital. At resus code blues you walk in and the patient is surrounded by extremely competent doctors, they have high flow oxygen on, there are lines going in and fluid being squeezed in, you look up to the monitor and see heart rate, blood pressure and oxygenation. In non-resus code blues you run in and there’s one terrified looking agency nurse, no-one knows where anything is and a patient in the early stages of rigor mortis.

On the resus Mr Fell was a large man, well over six foot, easy two hundred pounds, with blue eyes and gingery-blonde hair and pale, soft skin. He had been attending a garage sale, started coughing, complained to his wife that he “didn’t feel too good”, was driven to the hospital, clutched his chest and stopped breathing en route. His frantic wife – and I can’t imagine what this must have been like – drove at un-natural speeds to get him to the hospital, and leant on the horn in the carpark. Ambulance men and a group of medical students dragged him from the car and ran him into resus.

By the time I got there Dr Hu was clearly exhausted, thin arms flexing, tiny hands placed precisely over Mr Fell's large and silent heart. I took over and started shoving. This is one area where physical mass, basic substance, is important. I looked up at the monitor. Blood pressure unrecordable. Heart rate unreadable – the line jittered each time I lurched forward, leant all my weight on that massive sternum. Oxygenation – none.

“Adrenaline,” said Dr Kaspar, a woman who gave up neurosurgery to be an emergency doctor, and one of the two or three most respected doctors in the ED. She spoke in that calm, enunciated way that cut through the alarms and the murmur of instructions and the jostling of the resus table, and she always said the right thing. Someone gave adrenaline.

“Pause,” said Kaspar. I stopped, breathed deep. We all looked up at the monitor, which functions something like an oracle and something like a judge.

Heart-rate thirty.

Twenty one. Five.

“Commencing,” I said and he started lurching again. I looked down and slightly to my left you could see Mr Fell’s eyes, ever-so-slightly open, like some people when they are asleep, watching me as I fought to batter some life into the unyielding, inert mass of him. We shocked him - Dr Kaspar calling "everyone clear", everyone standing back - in real life there is a pause between being able to shock and shocking, everyone looks around to check that no-one is standing close enough, the people closest to the patient edge back - and her pressing the paddles onto his chest and jolting. For that few tenths of a second life - movement, response, energy - enters into him, arms swing, maybe a grimace - and you can see why when electricity was discovered it was called "galvanizing". But as soon as the current stops, he falls back. I climb on top of him again and begin lurching.

After a while Dr Sanjeev takes over and I stand back. Every few minutes we stopped to check, every few minutes, nothing. Underneath the seeming chaos, the insistent ringing of the alarms, the calls back and forth of drug doses and blood pressures and milliamperes there is order, and underneath that a growing quiet, a sense of rising despair. People not directly involved turn to each other and murmur. At least ten minutes down-time in the car. Forty five minutes in resus without oxygen. Asystolic almost all that time. Survival after this is at best a matter of increments - we may save a bit of mobility, he may be able to open his eyes. The undamaged man is long gone.

The door bleeped behind me and Dr Kaspar emerged. She had been talking to the family.

"Pause" she says. Dr Sanjeev steps down, I step up, put my hands on Mr Fell's chest, right hand gripping left, elbows locked. Dr Kaspar gazes at the monitor. Nothing. Everyone gazes at Dr Kaspar.

"How long?" she says.

"Forty eight minutes."

"That's it" she says. "I'm calling it." She peels her gloves off. "Time of death, nine thirteen."

And like that, he is dead. It is as if she speaks death, as if her words slay. There will be no feeding tube for Mr Fell, no blank stare, no aphasia, no nurses turning him every few hours, tubes in and out of orifices.

Dr Kaspar turns and goes out to speak to the widow. I know she hates this bit. But I also know the last time Mrs Fell saw her husband alive he was walking and talking and laughing, the man she married. I hesitate to draw a moral from this kind of event, as if it were something performed with us in mind, played out for some didactic purpose, but if I did it would be that I believe, almost as much as I believe anything, that Dr Kaspar has said the right thing.

Chain of command

2007-10-09T20:54:00.000+09:30

Hail,

A brief insight into how it works our ICU. Sarah drove me in early in the morning. Most days I try to get there by seven o'clock, but today I particularly want to get in early - I have been told DrSanjeev is off sick. Dr Sanjeev, tall, cultured, incandescently bright - he whose name means, impressively, "the one who brings the dead back to life", is my intern. He is an essential part of the whole chain of command thing we've got going in the ICU, from the top (the consultant, Dr Black) down through the registrar (me) to said Dr Sanjeev.

The usual procedure in the ICU is Dr Black decides something needs to be done and tells me and I tell Dr Sanjeev. Dr Sanjeev goes off and does it. Occasionally Dr Sanjeev has a problem or discovers something of note about a patient and he tells me. I tell Dr Black and Dr Black goes off and solves it.

I worked out this morning that without Dr Black we don't know what to do. Without Dr Sanjeev, on the other hand, we don't get anything done.

Without me, I suspect, things go that little bit faster.

Anyway. A post of more substance tomorrow, or later today if Mr Grote doesn't turn up.

Thanks for listening, John

Heart failure

2007-10-06T08:09:00.000+09:30

Hail,
Late morning here, the chickens are restless and the goats are at play outside. And today we are not getting family and friends over, as previously planned, to organise an Amish style chook-yard-building, because my car is having emergency surgery, and this will take care of that troublesome cash excess we've been having. The car died a few metres out from work, and was taken away by a towtruck, and will apparently require the services of the transport team.

Most vexing.

Anyway. Before I get carried away, here is a link to this year's Ig Nobel Prizes. The Ig Nobel prizes reward published scientific papers that... well, follow the link. My favourites this year have been those in Lingusitics (awarded to Juant Manuel Toro, Josep Trobalon and Núria Sebastián-Gallés, of Barcelona University, for showing that rats cannot tell the difference between a person speaking Japanese backwards and a person speaking Dutch backwards), and Biology (Johanna van Bronswijk of Eindhoven University of Technology, Netherlands, for a census of the mites, insects, spiders, pseudoscorpions, crustaceans, bacteria, algae, ferns (!) and fungi with whom we share our beds).

Ask me why I never finished in science.

However. I am back from the coast, which was brilliant. The city I sortof grew up in* has a different smell, all wattles and melaleucas, and you drive over the coastal plain and see the sunset over the sea... it works on you, something in it calls to you. Along the side of the highway there were paperbarks and I wanted to stop the car and step out on the soil and feel the bark between my fingertips.

Anyway. Paperbark pollen is flat and triangle shaped, something like this, pine pollen is hollow and ovoid and ridged like the Hindenberg, chenopod pollen (pollen from those little shrub things that grow on drylands) is shaped like a woven basket. Here you can see some eucalyptus pollen mixed in with some sunflower pollen.

You know, I always had the same trouble with science, and I've got it a bit with medicine too. They show me images and I look at the image, I don't look at what it represents. When I was doing my honours year, looking down a microscope for ten hours a day, fifty days in a row, I would put the droplet of oil, mixed with the fossil pollen, on the slide and stare at it under the microscope. And I wouldn't see pine pollen and eucalypt pollen and poacea pollen, I'd see these pink-stained bulbs and structures, the flamingo-coloured light coming through them, and marvel a how they drifted slowly across the field of view. Same thing when I saw electron micrographs of renal cells in medical school. Never really clicked.

And I'm not trying to show how much more fey and ethereal I was than the common clods with whom I sat, because I envied them their ability to look at, say, an ECG or a chest Xray and seize upon the salient points. But that kind of stuff always came hard to me.

Anyway. Tomorrow is one of my last shifts at the ICU, and the day after back to work. We have four patients in hospital at the moment. Three of them have infections of the heart valve - you have bacteria on your skin that look something like this, when you inject they can get pushed in with the needle into the blood stream. They whirl around, trying to settle wherever they can, often ending up on the heart valve. They grow, and as they do, they damage the valve. Two of my guys are okay, but the other one has bacteria running rampant in his blood and is swollen and weak from heart failure.

And the other one - and I have just heard this today - appears to be an overdose, of a medication I gave her. In another sense, another case of heart failure. She has suffered no ill effects, the medical intern tells me, and was dischraged soon after the event, but this is something that will occupy my thoughts from now until Wednesday, when I see her - and long afterwards.

Thanks for listening, will reply to comments tonight.
John

*Sadly, still a work in progress

I can quit any time I want to...

2007-09-27T19:41:00.000+09:30

Hail,
And a variety of small thoughts today, interspersed with bits of me banging on about my life - no great themes here.

Tomorrow we pack up and leave for the coast, a brief family and friends visit. Tonight Sarah is stuffing cats into boxes and ensuring that all of her cat-show paraphernalia is packed (combs, claw-clippers and cornflour) in her Doctor Who suitcase. I am travelling light (leaving space for books and plunder). I am hiring a car and driving down to the south coast, seeing my sister and my mother and travelling close to the area where I grew up - something I have been wanting to do for more than ten years. It should be wonderful.

And I have tidied up at work as much as possible. I have a co-worker - Dr Suresh, a deeply pleasant man whom I fear may perhaps be a little too courteous for this area of medicine. He is a competent and clever man, one who may end up as a renal specialist or a consultant endocrinologist, and he has access to that vast amount of data they somehow shove into your head in some of the Indian medical schools. However, I suspect he has some difficulty with some of our patients.

Case in point - I received a urine drug screen result from Mr Gouger the other day. This showed that, aside from the prescribed medications, Mr Gouger (squat, bull-necked, seven years for armed robbery) had been using a traditional plant-based herbal remedy (probably about three hundred dollars worth of heroin a day), and had been caught by the pharmacist diverting his anti-heroin medication (spitting it out of his mouth, either to inject it into his own arm or sell it to another person for that purpose). I had written Mr Gouger a letter, via his pharmacist, telling him to come in and see us, and explaining that we would be changing both the type and amount of his medication. He saw Dr Suresh. Dr Suresh documented the following in the case-notes:

"Mr Gouger has indicated that he would prefer not to change to buprenorphine-naloxone and that he feels he would rather stay on 6mg than increase his dose to the suggested 16mg."

A few days later the pharmacist rang and asked me what was going on. I looked in the notes and was momentarily dumbfounded. In a similarly genial vein, Dr Suresh had agreed that the recent request of Mr Grote (tall, thin, eight years for attempted murder and four for assault occasioning grievous bodily harm) for a week's worth of morphine tablets that he could just pick up at the pharmacist would be less irksome than having to turn up every day and swallow the methadone in front of our new pharmacist, and would save both petrol and bother.

Anyhow. I wish Dr Suresh well, and suspect he is destined for great things, but I suspect perhaps not these things.

The other day, as part of my wondrous new post-shift-work life, I went to the gym. First step was a fitness assessment, which is like something out of the Inferno:

Midway upon the journey of my life
I found myself within a small room, nude
For my once-limber body had been lost.

And as I stood upon the trembling scale
A woman, slim and stern, with burning eye
And abs on which a walnut could be crack'd

Assailed me with a caliper and pinch'd
My handles d'amour until I hid
My face...

And so on. Anyway, the striking part of the assessment (besides how many times she used the phrase "...for someone your age") was the readout of body fat percentage and so on. They measure all this by putting electrodes on you and measuring impedance, etc. I learned that not only was my percentage of extracellular fluid below average (the shame!), but there, written down by a machine in scientific looking text was my body weight (ninety five kilos), my lean body weight (seventy one) and my total body fat (twenty four kilos).

Striking mental image, isn't it. It's hard to get the image out of your head that somewhere in me is that seventy kilo man I used to be, embalmed and presumably suffocating under the twenty four kilos (that's close on thirty litres, almost eight American gallons) of fat.

God. It's good to know what you're dealing with and everything, but you can see that this is how those disorders start.

I don't know. I have deeply ambiguous feelings about the whole gym thing. One the one hand I love it - I know my mood is directly correlated to how much physical activity I do - the morer the betterer. And I love being able to hit the punching bag - to be able to go out there and jolt it with a gwa sau combination, or a jab-cross-hook. I love being able to do things.

But the Southern Mental Health division could do a sweep throught the place on a weekday about ten AM and fill the inpatient psych beds for the State in an hour. I think many elite sports-people are a little bit mad, but I have yet to meet a professional bodybuilder who was not all that and then some.

Anyway. I am filling up the time I previously spent studying with reading - currently this, pick it up, it's a hoot. I am able to go into the lounge, wander from book-case to book-case and inhale, picking out handfuls of books, each one potentially too wonderful to be left any longer. Currently we have Borges - Complete Fiction, and A Good Scent from a Strange Mountain. Next is Cold Mountain, and then this and then I'm going to try and hunt down this atlas I saw - I feel very self-conscious talking about this - of hominid evolution, and then I am going to try again to read some of the books I have been unable to finish - 1984 (too terrible) and the Shipping News (just too damn good - I kept reading bits out, or just closing the book and sitting there lost for words).

Somewhere in there maybe my anatomy book, but to be honest, maybe not. To be honest, life beckons.

Anyway. I suspect I am now on the borderline between bibiliophile and bibliomaniac. I do fit some of the criteria for dependence - I have found myself having to have a book first thing in the morning as an eye opener, people have angered me by suggesting I read too much, and so on. Like the secret drinker I have books hidden in various places around the house - the desk, the dinner table, the bench where I stand and eat my breakfast in the morning - anywhere I can sit or stand or lie for any period of time. I have several small books I can carry with me, like hip flasks.

Anyway, off to read. I will leave you with this mediaeval curse against book-stealers - sorry if you've heard it before:

For him that stealeth, or borroweth and returneth not, this book from its owner, let it change into a serpent in his hand & rend him.

Let him be struck with palsy, & all his members blasted.

Let him languish in pain crying aloud for mercy, & let there be no surcease to his agony till he sing in dissolution.

Let bookworms gnaw his entrails in token of the Worm that dieth not, & when at last he goeth to his final punishment, let the flames of Hell consume him forever.

I'm doomed, sad to say, but it's been worth it.

Thanks for listening, post again Tuesday,
John

Pain

2007-09-24T18:32:00.000+09:30

Hail,
And herein a post where I try to work out what I'm going to do about Patrick Mawson.

Patrick Mawson - I suspect I have described him here under another name, but I tend to lose track - Patrick Mawson is a thin, chronically dirty, flaxen-haired man with a thin, vaguely mosquitoid face. He speaks in a low whine, and, if the analogy is to be pursued and the unpleasant truth be told, he has not worked since nineteen ninety two. He was recently returned to us from Central after a period of disciplinary pharmacotherapy, and from Thursday he will be my problem again.

And the problem is complex. First of, to my shame, is the problem of "negative counter-transference" - the phenomenon where the doctor experiences feelings of hatred, fear, etc. towards the patient. I don't know if this is true negative counter-transference - transference involves the unconscious redirection of feelings, and I am quite aware of the dull ache in my heart whenever I see Mr Mawson's name on the patient list, and the way the sun outside the office goes behind a cloud, and no birds sing.

(I just looked this up and it may be that the appropriate term for what I feel is parataxic distortion. I don't know if that is the right term or not, but it such a cool, fifties science fiction term that I am going to use it. I reckon with Mr Mawson I have about eighty dioptres of parataxic distortion - I may need glasses).

But another part of the problem is his pathology. Mr Mawson has back pain (a bulging disk) and chronic gastro-intestial reflux. Although he is careful to distance himself from "the junkies", and dwells on his disgust for them at least twice a visit, his records indicate he was sent to us because he was injecting his medication, which he says he was doing because of the pain. While in prison he was sent to a psychiatrist who suggested "a complex mix of cluster B and C personality disorders with predominant narcissistic, antisocial and dependent traits" (I know the psychiatrist - it's possible she had a bit of parataxic distortion, too).

But now he's out, and we are in the difficult position of managing Mr Mawson. The meetings rarely go well. He comes in wanting treatment for his pain, I am only trained in and authorised to treat his opiate dependency. Dependence on prescribed medications is a difficult area - in a narrow sense of the word I am dependent on ventolin. But doctors are okay with prescribing ventolin and are, almost always, not okay with prescribing some of the most efficacious pain and anxiety relieving medications.

This is because the medications only work really well initially. It's like alcohol - when you have your first drink, a glassful gets you drunk. Later, if you drink regularly, it's two or four or a carton and a half a day. And like alcohol, with the opiates and the benzos you get withdrawal if you stop suddenly, anxiety or pain or sweating or twitching or whatever. Shitting and vomiting ten times a day. Can't sleep. And so after a while you are drinking (or taking pills) just to feel normal.

And the tablets don't last as long as they used to, you have to take more and more. And now the doctors are getting iffy about prescribing for you, doctors who used to be alright, faces change, and you get the runaround, place after place closing up on you, and you're in pain and your guts hurt and your heart's beating a hundred times a minute and can't they see this is making you worse? The worst thing for your pain, the worst thing for your anxiety? Doctors, who are meant to help you?

Obviously, all of this - the cancellations, the last minute changes, the waiting for hours in the doctors surgery only to get nothing, be treated like a junky - it gets you angry. And a receptionist or a nurse says something, you say something back, you're banned.

No-one understands.

If it weren't for other people like you, people in the same situation who can spot you a couple of tablets when you're desperate, you'd go under. And they can't be expected to keep giving you tablets, that's not fair, so you end up buying them, fifty dollars for a grey nurse (100mg morphine), two bucks for a valium (5mg diazepam). So you pay.

And you know, because people tell you, people who've found themselves in the same situation, when things get out of hand, when things get really bad, you can make things go further by injecting. That way it doesn't get chewed up by the liver and you get more. Little needle through the skin, into the blood, straight to the brain.

Things tend to go bad relatively quickly after that. Mr Mawson got hep C, turned bright yellow, and while he was sick six big Asian guys* came in and beat him up and took his stuff, broke three ribs.

But how did it get to this? Injecting your medications? Having to buy stuff off some drug dealer instead of getting a script from a doctor? If the tablets were as bad as they say, how come they were willing to give them to you in the first place? Who's fault is this, anyway?

Anyway. Difficult things to manage. Because the pain is real, and the dependence is real, and Mr Mawson's suffering is palpably, demonstrably real. And doing this is not like other fields of medicine, where the patient comes to me because s/he's sick, and we both sortof agree on what's wrong, what s/he wants fixed, and we come up with a plan and the patient goes away happier. This is pleading, and concealing, and emotional blackmail, and on occasion threats (rarely against me directly, usually of harm the patient will suffer, and the dire consequences, and the guilt that will be on my head).

I don't know. I promised to treat pain, to relieve suffering, to help. And my prescription pad sits in my desk, probably glowing like an object in a video game. I can relieve pain, I can ease suffering, in the short term I can help.

But one of the big problems we have in the city is cleaning up after Dr Hindpaddock, a physician frequently under investigation by the medical board. Dr Hindpaddock (by all accounts a deeply pleasant man, bearded and jolly) is a private specialist, and so free of many of the restrictions the government places upon me. He believes, and I quote, "there is no maximum dose of opiates. There is no maximum dose of benzodiazepines." He has patients on three different opiates and two different benzodiazepines a day, he prescribes daily doses two or three times the dose that starts to get me worried.

I rang up one of his ex-patients a year or so back to change an appointment with her. She was a zombie. Horrible thing to say, but true. Slept all day every day, house all dark all the time, slurred speech, hadn't got out of the house except for a doctor's appointment for fifteen years.

That's what worries me. That plus the undeniable correlation between high doses of methadone, high doses of benzos and high risk of death. We had five deaths here in the south at the start of the year - none from people on the programme caused by anything I'd prescribed, but close too home. Someone who jumped off the programme, overdosed a month later. Someone bingeing on speed, didn't sleep for five days, car into a salmon gum on Stone Highway. Another died of pneumonia, another what I reckon was a bleeding stomach ulcer, another cut his wrists in the bath. People who die early.

Anyway. No real solutions here. Thursday I see Mr Mawson and I will disappoint him again. Another reel, another jig, another round of this danse macabre.

Sorry. And as a PS I wrote a letter to a senator which cheered me up a great deal and probably won't even get me sacked. I will see if I can post a bit of it.

Thanks for listening,
John

*This seems unlikely, if only for reasons of economics - six guys of any size would not be needed to force their will on Mr Mawson.

It's amazing how single white guys never commit any acts of violence in this town. It's all gangs of Aborigines or Asians. No wonder the National Front wants them out.

Lightning strike

2007-09-18T09:40:00.000+09:30

Hail,
Got my results from the college today. They included an analysis of the exam I failed - I passed the viva and got fifty seven percent in the multiple choice. Unfortunately the pass mark was sixty. Each multi choice quesiton is worth one and a half percent - I failed by two out of ninety questions.

Such is life. It was probably two of the endocrine ones. But I passed the hard one.

Anyway, I am writing to you today with covered in a faint, bronze-coloured sheen. Because it's a hot day, I've been out hitting the punching bag, and for the last two days I've been taking rifampicin, which, the advisory sheet says may cause "discolouration of bodily secretions". So currently, I sweat a yellowy-orange colour and, were I to be moved to tears, I would cry a yellowy orange colour.

Bronze John indeed. However, on the good side for the next few days I have probably got additional protection from leprosy.

This is all because of Nyssa Menninton. Nyssa had been brought to the ED by her mother a little over a week ago. Her mother had went around to her house and found her slumped on the floor, unrousable, having lost control of her bladder and bowels. She brought her into the ED. ED found her cold, drowsy, battling an overwhelming infection of some kind*, and with a blood pressure so low it could barely be measured.

However, she was young, and otherwise fit, and she resonded well to initial therapy, fluids and antibiotics, so she didn't go to the ICU, she went upstairs to the medical ward.

It's difficult to reconstruct entirly what went on in the medical ward. Some of it is relatively clear - there was an Xray taken on arrival, it appeared normal, there wasn't another one taken later on. There was a single urine culture and a blood culture - both were clear. She was treated as if she had an occult infection and put on some relatively high grade antibiotics. Much mention was made in the notes of her poor self care, her head lice and her toenails, and her unco-operative attitude. Less mention was made of the fact that no-one ever found out where this infection was coming from and thus what antibiotics were best for it.

One week later she was discharged. The medical entry on the date of discharge reads in part "white cell count twenty one, bicarbonate eleven and falling" and then notes she was discharged. The medical discharge summary, were it to be translated, would have to read "Ms Mennington was found almost dead. She clearly had a life-threatening illness. We don't know what it was. She's still very sick, so we've stopped on of the antibiotics and we're sending her home. A nurse will check up on her in a week."

I am aware of this because regardless of the outcome of this admission, someone is going to be called in to explain this.

Nyssa Mennington went home where she continued to deteriorate. At two in the morning her mother checked her for a rash, it wasn't there. At eight thirty she was cold, blue around the lips, still speaking but seeming confused. Her skin was covered in dark purple stains, irregular around the edges, as if she'd been dabbed with cotton wool. Don't click on this if you are easily upset (if you are, here is a less distressing image of purpura). When the ambulance arrived (less than two days after she left) she was breathing fifty times a minute, body temperature low thirties, blood pressure was again undetectable.

Anyway, we have done everything we could. Pumped her full of fluid and antibiotics. She has bilateral pneumothoraces - her lung has collapsed on both sides. When we Xrayed her her left lung had come away from the inside of her chest and collapsed to less than half of its normal size, and this meant that her heart and aorta were being pulled over to the right side of her chest. I painted the side of her chest with disinfectant, injected an inadequate amount of anaesthetic into her chest (between the ribs on the side) and we poured opiates into her veins while I cut through skin and muscle, felt my way though fat and pleura and pushed my gloved finger into the space where her lung was meant to be. Instead of the rising and falling of the lung there was profound** emptiness, so I asked for the chest tube - the slim, plastic tube we were going to push inside her chest to let the air out.

That's were things got a little weird. Every time she breathed in there was this sucking, farting noise, and bubbles formed, and when she breathed out, fluid came out.

The air coming in was sortof expected. I tried to stop the air getting in - air getting in would push the aorta (the huge artery that carries blood out of the heart to the brain and the rest of the body) and the heart further over to the right, the wrong side of the body. if you pushed the aorta too far it would kink, the heart couldn't pump blood out, there would be sudden, massive heart failure, and Nyssa Mennington would be dead with my hand inside her.

The fluid coming out was another matter. I slid the tube in and she coughed. Some fluid spat out of the hole in her chest. A small amount, maybe a mouthful, of what we call serosanguineous fluid - clear fluid stained with blood.

"Nasty" said one of the ED doctors. "Big infection"

She coughed again. A larger amount, maybe a cupful.

"This often happens" said the ED doctor. "Stictch it up."

She coughed again, and straw-coloured fluid with clots of blood in it hissed out. It squirted over the floor, flooded the bed, spattered my gown. I stared through my facemask.

"Hmm" said Dr Umesh. "I've never seen that much before."

Nyssa went into a coughing fit. With each cough fluid vomited out of the hole I had made. Dr Umesh took over in time to have his facemask spattered with blood. He drew the tube back minimally.

"I wonder what else this could be" he wondered aloud. I ran through the possibilites -

"Ladies and gentlemen of the jury, you have heard how Dr Bronze, by his own admission, inserted the chest tube not into the lung, but into the abdominal cavity of the deceased - "

"So, putting a chest tube into the spleen - that's a common mistake. She may have had slightly unusual anatomy, and I'm sure you took that into account. What are the primary anatomical relations of the spleen, anyhow?"

"I'm terribly sorry, Mrs Mennington. During the procedure, the tube entered - I put the tube - accidentally - into Nyssa's heart."

"Mate, buy me anuzza drink - another drink and I'll tell you about when I used to be a doctor - until I put a chest tube into someone's brain."

She continued to cough, and fluid continued to gout out. I asked for the gelfusin to be turned up - not that it would do any good in the short term, but it looked like I was doing something - and Dr Umesh, radiating calm, continued to withdraw the tube micron by micron until she stopped.

"Hmm" he said. We went and got an Xray, which showed that we had not pierced the heart or the brain, and in fact had put the tube pretty much in the right place. It was slightly ambiguous on the matter of the abdomen - it did not rule out the possibility that I had somehow gone in through the lung, then withough noticing extended my finger ten centimetres and shoved it through a big sheet of muscle into her abdomen. However, considering the chest tube was behaving exactly as if it was in the right place, and the patient seemed better, rather than worse, and her heart was now in the right place, and we were getting air, not peritoneal fluid out of the tube, I began to relax.

"You worry too much" said Dr Umesh "It's no big deal." Dr Umesh had not been there a few months ago when Dr Black accidentally put the chest tube into the spleen.

Anyhow, we took Ms Mennington upstairs. We still don't know what is wrong with her. Currently we are treating the two pneumothoraces as spontaneous, which is unusual in someone of her build, even a smoker. We are treating the low blood pressure, the high fevers, the rash as meningococcal sepsis - hence all possible contacts have been given antibiotics that turn their tears and sweat yellow.

If she had fulminant meningococcaemia - "aemia" means in the blood, "meningococcus" is the name of the organism, "fulminant" comes from the Latin for "struck by lightning" and is similarly grim - if she has fulminant meningococcaemia she has less than a thirty percent chance of survival. And that's without two collapsed lungs.

And I don't know. There is something else going on in this woman. She has had a partial gastrectomy - part of her stomach cut out - because she ws addicted to codeine. Codeine (heroin for beginners) is not sold separately here - the only way you can get it easily here is when it is combined with paracetamol or combined with ibuprofen. This means that once you get addicted to codeine you end up taking vast amounts of these combination tablets - thirty or more a day for months at a time. This means vast amounts of paracetamol (acetominophen), which damages your liver, or ibuprofen, which damages your stomach. Often the damage done by these combination medications causes more pain, which the patient treats with more codeine, and so on.

Anyhow - there is something underlying this. Some psychiatric issue, some substance dependence. She is malnutritioned. She has rotting teeth, mouth ulcers, head lice, she is covered with scabs that look like dermatitis artefacta - a symptom of a psychiatric illness where you pick at yourself. Or maybe formication - often seen with amphetamine abuse, where you pick at the insects you believe are living under your skin.

Her mother swears blind she is not "on drugs", but I have given her my drug and alcohol services number. If she lives through this - which is actually unlikely - I have asked her to call.

Anyway. There is something going on, something profound, something dangerous and deadly that we missed the first time. I hope she lives so that we can find it and fix it.

Thanks for listening,
John

* White cell count sixty two point five. Anything over eleven is high.

** I've tried to think of another word that best explains this and I can't. There is something numinous about this, something that so far exceeds my ability to put it into words that it is stupid to try. There is something about having your hand inside the chest of another living, breathing person, feeling a hollowness where you should feel substance - I don't know how to say it better.

Not cold, not dead.

2007-09-13T19:32:00.000+09:30

Hail,
And back at the ICU, for about another month. I have already spoken to Doctor White and given him my resignation, effective end of this month. The reasons I gave were multiple - nothing to do with the amount of work or the quality of the supervision, everything to do with my own depleted stores of time and energy.

Although, having said that, I have found the entire rotation rather disturbing, on occasions dislocating. Medicine is often counter-intuitive - surgery is cutting people with knives, anaesthesia is gassing them or injecting them with poisons, protecting your child from disease may mean injecting them with dead - or even live - viruses. But ICU, existing as it does in that penumbra between life and death, has more than its share of weirdness.

Take Mrs Blaske. When I walked in this morning the staff were working tirelessly on Mrs Blaske. A nurse covered her with a blanket, another changed the bag of saline that was running into her veins. Dr White shone a light into her eyes, listened to her heart, tested her reflexes with a tendon hammer. What they were doing was fairly urgent, her family would be here within the hour.

So we had less than an hour to get her healthy enough to be dead.

The story goes like this. Mr Blaske had called an ambulance around midday the preceding day. His wife was not breathing. The ambos had instructed him in CPR while racing towards their house, sirens and lights, both sides of the road. They had resuscitated her on the bedroom floor.

When she was found she was "in asystole", a term used to describe the complete absence of heartbeat. Several shocks later, in the ED, a slow, faint heartbeat emerged. She began breathing spontaneously a short time afterwards.

However, a CT scan of the brain showed diffuse anoxic injury. An overdose of benzodiazepines, codeine and alcohol - even an accidental, recreational one like Mrs Blaske had had - causes a diffuse depression in the part of the brain that instructs the heart to beat, the chest to rise and fall. Fewer and fewer synapses fire, the electrical signal becomes weaker and weaker, it is hard to avoid the image of a flickering light dimming, or an echo dying down. Eventually, breathing and heartbeat stop altogether.

Some time after that - there is no way of knowing how long - Mr Blaske woke and started CPR.

Now, Dr White was in the difficult position of explaining the fact of Mrs Blaske's death. It is a difficult, horrible task at the best of times, the most terrible news that anyone can hear, and the most difficult news to give, and in this case it was made harder by the fact that Mrs Blaske was lying on the bed, warm (occasionally blushing), and breathing, and with a strong and vibrant pulse.

Having said that, part of this was due to the chemicals we were running through her veins, and part of it was because different parts of the body die at different rates. Previously it was believed that hair and nails continue to grow after death, we now know that it is common for hearts to beat and lungs to fill and empty. Mrs Blaskes brain was irreparably damaged, and death was coming "not in haste, but irrevocably".

So, in order to be able to say this without a shadow of a doubt, Dr White was required to fulfill the legal requirements of declaring brain death, and in order to do this, Mrs Blaske had to be warmed to thirty seven degrees (ninety eight for those who still use Imperial measurments) - there is a saying I heard in the ED "you can't be cold and dead". Previously doctors were required to ensure that the patient's electrolytes (the chemical in Mrs Blaske's blood) had normalised, and check that the levels of certain drugs had to drop to pre-determined levels.

The reason behind this is to avoid wrongly diagnosing death. Very high levels of opiates or alcohol in the blood can mimic death, as can extreme cold. " Muscle relaxants" - powerful drugs like curare - can be difficult to distinguish from death, and severe glandular problems - I don't know, but I am guessing some profound thyroid abnormalites, anyone who knows feel free to set me right here - there are a lot of things to exclude.

But Mrs Blaske did not blink when we stroke the surface of her cornea (the white of her eye) with a tissue. Her pupils remained vast and dark when Dr White shone a bright light into them. When we reached into her mouth with a smooth tongue depresser - like a popsicle stick - and touuched the base of the back of the throat she did not gag.

"Lastly," said Dr White "we assess vestibulo-ocular reflexes".

One of the nurses handed him a 20 mL syringe - without the needle - full of cold water that had been standing in a slurry of ice and water for the last five minutes. He bent over Mrs Blaske, touched her eyes with the finger and thumb of his left hand and murmured "I'm just going to open your eyes now, dear, and then a bit of cold water". Then he slid the tip of the syringe deep into Mr's Blaske's left ear and pushed the plunger.

He stared into her eyes as he squirted ice-water into her ear. "No response" he said. A nurse wrote it down.

"What's meant to happen?" I said.

"Nystagmus. COWS," he said. Nystagmus is a rapid, twitching motion of the eyeball. "Cold opposite, warm, same. You inject cold water - you get nystagmus towards the opposite side. Warm water - about forty four degrees - you get it towards the same."

"Ahah." I said.

"There's footage of one of the ambos having it done. He volunteered," said Dr White. "Water goes in, eyes start twitching, then explosive nausea and vomiting. Neurological analogue of motion sickness."

Anyhow. Much more to talk about, but I am going off to spend time with Sarah. Her arthritis is actually fairly bad at the moment, hence the shift to nine-to-five. We had an MRI done and her immunologist reacted with horror and she is being sent to an orthopaedic surgeon. I would rather not talk about this now but she may need surgery, and I feel she is too young for that.

Anyhow. On that sombre note, I shall go off and reply to comments.
Thanks for listening.
John

Small Idea

2007-09-09T09:56:00.000+09:30

Hail,
First off - failed one, passed one. All through the preparation I knew I was better at physiology than pharmacology. Phys just seemed to stick in my head, pharm wouldn't. I didn't have to work as hard at phys, it seemed to come relatively easily, whereas pharm I had to hammer in. And the phys exam was relatively straightforward, both the written and the viva, wheras the pharm multi-choice was tricky and the viva bloody hard.

So I was pretty sure that I'd done a lot better in one than the other. And I was right. The noticeboard said passed pharm, failed phys.

Yep, failed the relatively easy one, the I always found relatively sensible, the one where the examiners smiled and nodded and said "don't worry, that was good". Passed the hard one I knew I couldn't understand, where I guessed between two equally unlikely alternatives in the multiple choice section and where the examiners frowned and shook their head or waited, pointedly, for answers that never came.

Anyway. It's over now. If I ever study again, it won't be in the next month. I am taking said month off and reassessing my priorities. And thanks again for the comments.

Now, the following few paragraphs have proved rather difficult to write, and my cringe-o-meter is going off as I do so. But here goes.

One thing I noticed wandering around Melbourne in my post-exam delirium was the mix of ethnicities. Mordor is white-bread white, Melbourne has tv ads in Greek, shop fronts with the day's specials written in Arabic, huge Vietnamese and Cantonese communities - and correspondingly, some of the best food I have ever tasted.

Now, someone explain this to me: why, in situations like this, when you get what my grandmother used to call "mixed race couples" (dead set), it's alway the Caucasian guy and the Asian woman?

Seriously. It got so I was counting, and in two days I saw eleven couples. Eleven European-looking men with Asian-looking women. Exactly no cases of the reverse, no Asian-looking men with women who looked European.

Why is this so?

I have a few theories. They're not really well thought out theories, and they're white male hetero theories, and they're rather difficult to express. But maybe it's something to do with our ideas of the mysterious, feminine East, all passive and hypersexualised, the sloe-eyed and obedient woman scrubbing your back and pattering around the immaculate house on her tiny feet.

Maybe it's something to do with the succession of lenses through which we see: that progression from such and such a physical appearance to such and such an intrinsic ethnicity to such and such a set of sexual, moral and intellectual characteristics. If you have straight, glossy black hair and you don't have an epicanthic fold, you must be an Asian. If you are an Asian, you must be
submissive and hyperfeminised and mysterious and so on. So, if you're a certain type of white male, anyone who looks a certain way is going to have a certain appeal*.

And I'm not in any way suggesting that every European-looking man who goes out with an Asian woman is hoping for a geisha girl - although I think any European-looking man who only went out with Asian looking women might benefit from asking themselves that question. And I am aware that there has to be some kind of process going on the other way - Asian-looking women choosing European looking men. I am just wondering if this European man plus Asian woman thing is seen other places, if it is exclusively Melbourne or exclusively me, or there is any reason for the disparity.

Interesting, by the way, to look at the outcome of European wars in Asia over the last century - and I'm using Asia here to mean anywhere that Westerners think of as Asian, anywhere east of Turkey. We rational, masculine, straightforward folk haven't done that well in the mysterious East. God knows how we managed to be defeated so many times - I don't know how the enemy managed any kind of co-ordinated military strategy with all that talking in mysterious utterances and smiling quietly and stroking the beard - but it happened.

Anyway, it's been very frustrating writing this because I know I haven't had the words. it's like when you write about evolution and you write "gazelles evolved to run faster" when what you really mean starts with "a series of random molecular events..." and finishes with "more gazelles in the population that run faster". I don't want to write that someone with Korean great grandparents who is fourth generation Australian, mono-lingual, has never been north of Queensland and plays centre-half back for the Bidyadanga Emus is "Asian", but it's a shortcut you end up using.

Anyway. Enough on this. I am going out to hit the punching bag and revel in my freedom.

Thanks for listening,
John

Sunday

2007-09-04T10:26:00.000+09:30

Hail,
Later this afternoon I get on the plane to Melbourne. Wednesday, Thursday, Friday is the exam, Saturday home, next blog post Sunday.

See, the way I see it the exam has a number of purposes.

One is to make you study and learn stuff, which I have - although, to be honest, a lot of medicine for me has always been trying to pour ten litres into a two litre bucket. I read about the anti-arryhthmics. Then I read about the antibiotics and push that into my head and that somehow displaces the knowledge about the anti-arrhyhthmics. Then the chapter on the antipsychotics pushes the antibiotics out. It all leaks out of my head faster than I can put it in.

I sometimes reckon if you could see it, like if there were special glasses you could put on, you could track me at the moment by the trail of displaced knowledge. It'd look like little glowing droplets, or maybe whorls and clumps and tangles of gnosis. You'd see piles of it around the table in the spare room where I study, a fair bit soaked into my pillow, some of it on the couch where I lounge to watch Dr Who videos. If I ever read a particularly challenging chapter (probably renal handling of potassium - if they ask that we'll have a very quiet two minutes while I tell them about my mum's banana bread, which she always said was high in potassium) it'll diplace some essential knowledge like the answers to "where do I live?" and "what is my name?".

Luckily I'll be able to reconstruct many aspects of my life by following the trail of displaced knowing, like Theseus in Knossos.

That's an uncomfortable mental image, isn't it? I go into the exam room and get harangued about the aminoglycosides by a vast, bull-headed man. I can't remember the volume of distribution of gentamicin so I stab him with his own horn and flee, winding up the ball of wool as I go. And then drive home with Sarah. As long as I remember to change the sails on the Saab.

Yes, well. Another purpose of exams is to winnow out those who are somehow not suitable, not "the right stuff". I reckon this might be the case with me. The exam is going to be hard for me - sorry this sounds so whiny - because it's exacly the kind of thinking I'm not good at - split second decisions, hard data, definitive answers. I've tried to learn to do it, but my brain is wired up different. Oh well, swings and roundabouts.

And the third is to help people decide if this is what they want to do for the rest of their lives. Again, this may or may not be me.

Anyhow. We shall see. The last few days I have been so disengaged from study I have not looked at a book, operating on the "change will do me good" theory. I've spent the time reading and filling my wish-list on amazon.com. See, I am not just another white Anglo male with no exit strategy. After Sunday, and after a decent (and occasionally indecent*) holiday, I am starting my book.

And thanks for the good wishes. My feeling is I'll win either way. If I fail this - and anyone with any experience tell me if this plan is realistic or not - I want the novel to be started before Christmas and maybe finished before next.

See you Sunday,
John

*Cringe, cringe, sorry for the smut.

PS: Quote I read somewhere: "Asking the current American administration for advice on illegal drugs is like asking 1970s South Africa for advice on race relations." Not that I agree entirely, but it's an interesting analogy.

Two strange things

2007-08-29T14:12:00.000+09:30

Hail,
And as the title suggests....

Strange Event the first:

I was going through the patient notes for one of our patieints and I found an old urine drug screen result from the prisons medical service. I reproduce it below in its entirety:

11/10/04
Forensic Urine Drug Screen Analysis:
Methadone.
Buprenorphine
Benzodiazepine.
Methamphetamine.
Cocaine.

Comment: Mr Smith denied any extraneous drug use, claimed "only taking some medications to help with drug withdrawal that Doctor Bronze gave me".

No wonder there's a drug problem up here, it's all down to me and the medications I dole out - "Yeah, coming down off amphetamines can be hard - here, take the edge off it with some coke."

The thing is, I went to a friend's birthday party the other day and he only got some videos. Where are my priorities?

Strange Event the Second:

I’ve been asking the nurses to ring patients on the morning of their appointments to remind them to come in, and this morning Briony (nurse) rang Steve (methadone client). Steve sounded intoxicated.

"Steve – don’t forget about your appointment today" she said.

"My what?"

"Your appointment"

"Why? With who?"

"Drug and Alcohol Services. You know, you’ve been coming here for years?"

"The fuck? Where’s that?"

"Mordor. Like always."

"Jesus. What's the address again?"

Anyway, she manages to get the information across and at ten thirty Steve turns up. Only it’s not Old Steve (Steve the Old-School Smackfiend, hairy and belligerent) who’s been causing us hassle for thirteen years, it’s another guy. New Steve. Bald and confused. Big methamphetamine problem.

Yes, two people, selected from the area almost at random, are both called Steve, and both have out-of-control injecting drug habits. It seems we’d called the wrong number - transposed a few digits - and thus called the wrong Steve. New Steve said he reckoned his family had dobbed him in to it. No wonder he didn’t know anything about us. Old Steve, who had been described by our nurse as "evidently severely intoxicated" that morning, has yet to appear.

Thanks for listening,
John

Shiny, shiny

2007-08-25T17:12:00.000+09:30

Well, good times have come to me now*.

Seriously. Ten days to go to the exam and I feel pretty damn good. Remarkably relaxed, in fact. Remarkably, remarkably relaxed.
Why is this so?

Not entirely sure. It's not the less sleep, boundless optimism, "my wings are like a shield of steel" kind of stuff. It's more something intellectual. It's almost like I have constructed a win-win situation out of this exam.

See, whatever I do, in a fortnight the exam will be over. I will either have passed or failed. If I pass, well and good.

If I fail, I can quit shift-work.

I can earn more.

If I quit I can get a normal job and see Sarah every evening. I can work less.

I can write. All that stuff I promised myself.

I can read. I can finally go into "the room with the books" and pick one of the one or two thousand books - seriously, two deep in the four big bookcases, another massive bookcase in the hall, an unstable ziggurat of novels and anthologies stacked by the bed, and that many again in cartons in the shed - I can read.

I can travel. I am going to go to Asia, I can wander through Europe, I can see New York. I am going to pick people out from these remarkable spots on the map and visit them.

And the career - which if I don't pass the exam will probably end up being Drugs and Alcohol or GP - it won't be that bad. The patients who terrify most GPs - the unexpected emergency, the "psych" and the "druggie" - those are actually my favourite patients.

And I can go back to the gym. Learn a hobby, fencing or hawking or bee-wrestling or something.

If I pass, of course, that'll be okay, too. And even if I don't, it's not certain. I could always try again in six months, although at the moment the thought of that makes me sick.

Anyway. I don't know. The last few years have been rather event-filled, things are calmer now. Behind every time I decided to study or do shift-work or whatever there was an element of delayed gratification and an element of self-loathing if not self-doubt and an element of fear - I'm not explaining this right - and a lot of those feelings are less strong now.

By the way - have a look at Doonesbury for today (27/8/07). There's a phrase in there and a moment of clarity that will just stop you dead. Greatest living American short story writer.

Thanks for listening,
John

*I went to a friend's part and there was a big screen up playing stuff like this, and now it's stuck in my head. Not my fault.

Paradise

2007-08-20T23:08:00.000+09:30

...but I had to post this.

This was in Harpers this month. It's a poem by a woman called Ina Rousseau, first published in 1954, translated recently by Coetzee, whose copyright I am doubtless infringing.

Somewhere in Eden, after all this time,
does there still stand, abandoned, like
a ruined city, gates sealed with grisly nails,
the luckless garden?

Is sultry day still followed there
by sultry dusk, sultry night,
where on the branches sallow and purple
the fruit hangs rotting?

Is there still, underground,
spreading like lace among the rocks
a network of unexploited lodes,
onyx and gold?

Through the lush greenery
their wash echoing afar
do there still flow the four glassy streams
of which no mortal drinks?

Somewhere in Eden, after all this time,
does there still stand, like a city in ruins,
forsaken, doomed to slow decay,
the failed garden?

Good Lord. Does anyone know why I can't find anything else in English by this woman on the net? Even a fleeting reference to a book printed fifty years ago? Does anyone know of a translation of any of her stuff?

See, times like this I really regret being monolingual.

John

Hiatus

2007-08-18T09:32:00.000+09:30

Hail,
I might have to put this blog on hold until the exam, which is 3rd - 5th of September. Slightly over two weeks. That sound you can hear in the background is my adrenal glands spasming.

Thanks, and see you in a fortnight,
John

And I'll try to put one of those RSS things on it, too. Hope everyone else's three weeks goes well.

Seventeen things I'm going to do after this bloody exam

2007-08-12T20:53:00.000+09:30

1. Watch Black Sheep, a horror movie about killer sheep from New Zealand. Tagline "The Violence of the Lambs".

2. Watch the DVD I have bought of my football team's most recent win, while sitting nude in a bathtub of red, green, purple and white... jewels and things and laughing as I trickle them over my head. Maybe pausing occasionally to read aloud from the article published in the newspaper where one of their quislings trash-talked us and told us to expect a brutal physical assault, and then watching the DVD again, which shows how right he was - except for the whole "who assaults, who is the assaultee" thing.

3. Go back to the gym. I dropped an apple the other day and rather than falling to the ground, it slowly revolved around me.

4. Watch some of those Shakespeare Retold things I've got.

5. Go to Thailand and Vietnam. I don't care if I have to paddle there on an inflatable rubber seahorse, I'm going. As an aside - from what I read, the Vietnamese have defeated (at various times) the Chinese, the French and the Americans. That means three out of the five members of the security council. Plus great martial arts, brilliant food, and a few thousand years of history each. And other great stuff.

6. Go down to Innsmouth and lie in the water until I am as pale and wrinkly as one of those brain-people from a fifties sf magazine cover. Hopefully don't get shot by Terran space-captains as I emerge.

7. Plan next year's trip to maybe the US and Europe and everywhere.

8. Feed the goats - pictures to appear on Sarah's blog soon. Sarah has bought them special goat food - it is labelled "High Performance". Which is good, because up till now they have been really underperforming. All they do is gambol and frisk and eat. I expect big changes.

9. Eat squid on the beach.

10. See friends I love.

11. Re-read the early Superman stories, the ones where he was a lefty who tried to rehabilitate juvenile offenders and tore down slums so that decent housing could be built.

12. Hit the punching bag again.

13. Write. I have three novels and twenty short stories somewhere up in my head to finish and get down on paper.

14. Sit and talk to my father. Reread Night.

15. Publish some stuff. I don't care if it's in a cookbook or a superhero comic. Something.

16. Give most of my books to the prisons. I have well over three thousand books in my house, most unread. If I read a book every week I will have to live to some bizarre age in order to read them all. What I am going to do instead is get rid of most of them and buy and read some new ones. Suggestions welcome.

17. Go back to the town I grew up in, the Goldfields, Kalgoorlie, Coolgardie, Boulder. I have this idea of travelling by a combination of bus and hired car to where I was born, on the Greenstone belt, the oldest rock in the world. When you stretch your hand up the sky is dense and hard and clear, and you can feel the earth as porous as a lung beneath your feet. Old mining towns and deserted farms, standing on the old earth, all honeycombed with empty mineshafts and dry wells.

See, if I went there now, the air would be too hot to breathe and the light too bright to see with. I've been inside, been pale too long. I'd have to travel slowly, to adjust.

Seriously, I don't know about this study thing. From one point of view I can't really lose. If I attempt the exam and fail - as I well might - it will be easier next time, and I have learnt stuff. If I attempt it and pass, no complaints there. Either way...

The thing is, I don't know that anyone is really expecting me to pass - there has been no real training programme at Florey this year, and I have been doing this pretty much alone, with no-one to bounce ideas off, practice vivas with, etc. That sounds like whining, but it isn't anyone's fault, just a statistical fluke - there are nine other registrars and all of them are studying the other half of the exam. Plus, I am studying while working in another relatively brain-draining field, plus there's the events of December and the fact it took me a few months to get over that.

Plus I know all of this "it's okay if I fail" stuff could be seen as saying something about my own lack of emotional investment in the training programme, or my own self-image, etc. but really, I'm just so sick of study I want the entire thing to be over, one way or another.

I got another job offer the other day. They come from all parts of Australia - this one was from Alice Springs. It had the usual shots of rugged gorges and beautiful rivers, but also a few shots of venomous snakes and gigantic crocodilians, interspersed with spectacular xrays. The text deviates somewhat from the standard "Come to the Alice" tourist guide, too - it dwells enticingly on the high incidence of stabbings and spear-wounds, and the chance to encounter rare and difficult-to-find diseases such as leprosy, Norwegian scabies and donovanosis.

Anyway. Not yet. I had a brief drunken discussion with my eldest son the other day and the topic of Intelligent Design came up, and I pointed out that not only are some of the most important tissues in the body the worst at healing (how come your hair grows back but your heart doesn't?) but also that there was an appaling lack of forethought around the whole reproductive area. Pain normally serves to tell you that something is wrong - how does that explain period pain, or childbirth pain? And why haven't I got little ribs around my testicles?

Then I reiterated my belief that the absence of a trunk was a major design flaw. Nothing elephantine, just something slim and nimble that you could use to feed yourself, brush your teeth or hair, that kind of thing.

Shortly after that he left.

Anyway.

Thanks for listening,
John

Coda

2007-08-06T19:25:00.001+09:30

Hail,
A brief post here, in between reading about the barbiturates and coming up with new excuses not to read about the barbiturates. And herein an update on the ICU.

When first we spoke of this there were five patients in the ICU who were horribly unwell. Then there were four, now there are two.

Mr Ayre, as stated, left us. He made a brief return one night when I was not there, but we did the same as we did last time (mask on face, antibiotics) and the same thing happened (he became well enough to return to the ward). Mr Ayre's situtation is that he is now in end-stage airways disease, and in the end stages of respiratory disease the intervals between hospitalisations become increasingly short. He moves from the ICU to the general ward to the ICU, home becoming more and more remote. He may not get home again.

Mrs Burns is almost well enough to go to the ward. She is the large, inoffensive woman who had the colonoscopy. The repirator kept her breathing, the chemicals prevented most of the kidney damage, she had four days without surgery recently. Her husband has not left her side.

Mr Wood died. You could almost feel the anger leave the room. It was three in the morning, Dr Fang was downstairs helping with a resus, he died quietly and quickly. His son had apparently been holding out for a miracle, without wishing to sound horribly twee I feel he got one.

Erica Stone has left "AMA", against medical advice, having stayed in hospital for eight days. She was prevented from leaving with the IV line in situ, and arrangements have been made for her to continue the antibiotics for her heart infection, but she is gone.

And Mr Mettle died. He was - and this may not be politic - the one whom we had tried hardest to save. Every ICU consultant, the infectious diseases people, Professor Veoli from the respiratory unit had been there, seen him, clustered around the bed or held hushed conferences in the corridor. Turning up or down the oxygen, adjusting the pressures of air going in and out, thinking of another antibiotic we hadn't tried yet... everything.

But still, there are laws of hysiology, not as clearcut as the laws of physics but in this case as irrevocable. His lung compliance - a measure of how easily your lung inflates, the more easily the better - was the lowest Dr White has ever seen. His white cell count - the white cells are the cells your body releases to fight infection - was so high* people asked about leukaemia. He'd spent a fortnight on adrenaline and noradrenaline, he was starting to get the profound muscle weakness that people who don't move in the ICU get.

I don't know. It seems stupid. You look around you and you see what we've got - magnetic resonance imaging and monoclonal antibodies and artificial kidneys - and you think how come pneumonia still beats us.

Sorry, I don't know how to put that. But it's not cancer, or some horrible AIDS associated phenomenon. It was pneumonia in a vigorously strong young man, who probably didn't go to the doctor from one decade to the next. And we couldn't stop it, and we couldn't slow it, and we never even found out what it was - blood cultures, lung cultures, everything came up clean.

Anyway. Back to the brainstem.
Thanks for listening,
John

*Seventy two. Our lab says normal is four to eleven point five.

Survivors

2007-07-31T15:30:00.000+09:30

Hail,
The exam draws near, and I am still alternating between sitting it and using my handy-dandy get-out-of-jail-free card. In the last month before the exam you can only withdraw if you have documented medical grounds, which I most certainly have, but I don't particularly want to use that excuse. So, most days I can spare I spend reading and re-reading the textbooks and drinking kilolitres of coffee.

I read somewhere that the LD50 (the dose that will kill 50% of those who consume it) of coffee is about seventy cups in twenty four hours. I will probably be safe.

Anyhow. I will, objectively speaking, probably fail this exam. It's not certain but it's the most sensible extrapolation from how I'm going. Even if I do fail, I suspect I will pass next year. The brutal truth is I am not particularly good at exams, never have been. I don't have that kind of crystalline memory, that ability to make rapid, confident sounding judgements. Even when presented with a multiple choice question I spend most of my time trying to work out how every answer could be right. A lot of my day-to-day medical practice is spent looking stuff up. I've only done really well on one exam in my life, and that was the one that got me in to medical school. The rest of them have been barely survived bludgeonings.

Anyway, enough wallowing, it'll be here in six weeks whether I whine or not. What's been going on at work?

A few depressing things, actually, depressing to the extent that I was thinking about starting my study leave early. Mr Steed died. He was the man with the omni-organ failure - infections in his heart and blood and brain, another in his liver, a machine breathing for him through a tube in his throat while another machine cleaned his blood. He had spent close on three months in the ICU, attended each day by his sisters, his father and his mother. It was a death a long time coming, in fact a long time forestalled.

I had come in early that day and glanced at him - a slim, small form, surrounded by his family. I had only seen him dimly through the glass and curtains of the isolation room, in the last few weeks he had contracted MRSA, a very difficult to treat skin infection caused by farmers, doctors and politicians. Despite that he had seemed to be making a gradual recovery. The nurse told me that few days ago he had been showered and had spoken with his family. A few hours after I glanced at him - while I was on the phone, or getting a coffee - he had died.

All I can tell is it was - I don't know, dislocating. Knowing he had died ten steps away, silent and unmarked by us. And knowing he had died, and we, his doctors, had done nothing, despite knowing there was probably nothing that could have been done.

I went into the room - the family were outside, the nurses were already in there, cleaning the blood and shit from the body, it had not been a good death - and I certified the death. I do this in a kind of ritualised pattern - stethoscope on the chest, a minute's silence, listen to the lungs, another minute, the pen-light in their eyes. If the eyes are wide and dark and the pupils do not shrink away when you shine the light on them, you can under most circumstances declare the death.

And I knew I had a job to do, people to keep alive, but all day I couldn't stop thinking about it. And then I spoke with the man in bed eleven, who had just been de-intubated, and I looked down and saw that he had been born the same month and year as me. And something in the look of him reminded me of me six months back - the same round, slightly confused face, the same smiling and nodding as he agreed he'd do things we both knew he wouldn't do.

And so I spent the rest of the day thinking about that. First intubated patient who's got to me in that kind of way.

Anyway. Enough personal trauma. I am going half-time for a month to study, we will see how that goes. What I was going to try to do was give an idea of how things worked in the ICU by following a group of patients as they happened. Here is what has been happening.

Mr Ayre has already gone to the ward. We came around the next day and he was off the oxygen. He looked pretty bad - speaking in short phrases, a visible heave of the chest between each mouthful of words - but he assured us this was pretty good for him. And he was keen to leave. I wrote up the discharge medications and dutifully gave him my "perhaps smoking isn't for you" talk. I am not good at the scary talk, I tend to frame things in terms of "if there's anything we can do to help...", but the truth is in this case stopping smoking might double or quadruple his expected life span and he'd still be dead within a year.

Mrs Burns does not do well. As you will recall, she had had a colonoscopy which perforated her bowel. Every morning the surgeons come and cluster around the bed, and try to screw up the courage for another operation. Her gastroenterologist - the man who did the damage - has been on the phone every day, sometimes twice. She is in kidney failure, has lung disease - it's all bad.

Mr Mettle - the giant of a man - is, if anything, worse. He is the only person of the five with single organ failure - heart like an ox, fit, clean-living - and every day brings more visitors. There are photos of him and his family and friends almost covering the wall.

Still, he does very badly. His lungs are stiff - the ventilator has to work extra hard to inflate and deflate them, use pressures four or five times higher than normal. Those high pressures are almost certain to further damage his lung, but without them he won't be getting oxygen in. His white blood cell count - white blood cells are the ones your body uses to fight illness - is thirty six. Above eleven is considered abnormal.

Mr Wood remains about the same. He has not spoken or moved or indicated anything much at all, but that is how he often is. If anything he is slightly better, which is good news for his son, possibly less so for Mr Wood - although perhaps not, who can tell? Several of the staff - doctors, nurses - have expressed their disgust at this situation, a man with severe dementia and chronic pain being kept alive by a son he hasn't seen for eighteen years - and the senior doctors have rung him every day to explain the situation to him. I don't know what's going to happen here. We all wait on the son, who should be here "soon, the weekend at the latest".

Interestingly enough, by the way, doctors are empowered to make certain decisions and carry out certain procedures against the will of the patient (and the patient's relatives) - the frightened three year old who needs emergency surgery against the will of the parents, for example. Those patients can be forcibly made a ward of the state. But I don't know - and I could be just ignorant - if such a provision would ever exist in the case of an elderly man who no longer recognises his children. And there's a long way to travel from that case to this.

Erica Stone looks relatively good, and her numbers (blood pressure, heart-rate, oxygenation) look good, but that is because she herself is doing relatively little of the actual work of living. Still, tomorrow or the next day we will withdraw the sedation and see how she goes when she wakes up. Her drug doses - the morphine, the midazolam - are remarkable, and from what I have been able to find out the doses of stuff that would kill most of us are what she takes recreationally.

Anyhow. Two have been saved, three at least still to go. More on this later.

Thanks for listening,
John

Five

2007-07-28T16:03:00.000+09:30

Hail,
I've been going through these posts, shaking my head at some of it, and wondering if I've managed to get things across. Part of what I wanted to do when I started writing was to give some idea of what it's like to do some of this, to work in the ICU, or to work in the ED. And looking back, I think some of the posts have worked, but most of them haven't got that across.

This is only to be expected. People don't pour their experiences directly out onto the page. Something happens, and people see it another way, and they go away and think about it in another way, adding and eliding, then eventually when it comes to writing stuff down they what comes out is another thing altogether*.

But anyhow. I haven't been getting the experience across because a lot of what I write is reflective, whereas the actual process of ICU or ED or Drugs and Alcohol of course is looking forward. In the blog I write "This is what happened", whereas in real life, work is "I'll do this and hope to God it works out".

Okay. I am at the ICU. Today in beds eleven through to fifteen, we have five patients. They are all extremely unwell. They are all receiving maximal or near-maximal care. Statistics say that each of them has about a one in five chance of dying. If you factor in average lengths of stay, morbidity, mortality, it's a fair bet that one in five will die within the fortnight*.

So. Five people. Identies disguised as per usual, named after the Chinese elements, but I will describe these people as it happens, looking forward, rather than looking back.

Bed Eleven is Mr Ayre. Mr Ayre is in end stage airways disease. He wheezes, he pants, he sleeps on home oxygen, almost drowning in thin air. He has a resting tremor, and his pupils are wide, and I suspect it has been years since he was not afraid. No-one visits him. He is thirty four.

He is one of those truly unfortunate people against whom nature has conspired. Smoking kills many many people, but it tends to kill those we are less concerned about saving - the elderly, the unwell, the unattractive (compare anorexia nervosa, or most injectable drugs). To be brought down as far as Mr Ayre has been brought as quickly as he has been is rare - he's one in four thousand, actually.

Mr Ayre has alpha one antitrypsin deficiency. In normal people, the molecule alpha one antitrypsin protects the lungs against protein-dissolving chemicals. Mr Ayre makes an inferior version of this molecule, and thus is dying of emphysema many many times faster than anyone else who smokes cigarettes.

On the positive side, he is down to a pack a day.

Bed Twelve, Mrs Burns. Mrs Burns may be a victim of medicine and the need for certainty. She presented to her doctor a month ago with concerns about her constipation. After some perusuading, her doctor referred her for a colonoscopy, the camera-on-a-metal-tube-up-your-bum thing. It went hideously wrong, as these things do. There was an obstruction (a benign one, it later turns out), they tried to get past, the camera-on-a-tube penetrated the wall of the intestine. There was a massive tear in the gut, although this was not immediately apparent. She went back to the ward where she lay while everything inside leaked out into her abdominal cavity. A few days later she presented to emergency, belly taut and swollen, blood pressure almost undetectable.

The surgical team have so far done four operations to fix this. Normally there is a bit of an "attitude" between surge and ICU, there is the strong sense that they see us (and emerge and psych and...) as muggles, but in this case surge are petrified. Mrs Burns is on hardcore antibiotics, she is intubated, chemicals keep her heart running, and every day or so she is having her belly opened up and "washed out". There is only so many times people can take this.

Bed Thirteen, Mr Mettle. A man of remarkable strength and health, his relatives say. Twenty six, an amateur fisherman and volunteer fireman. Brought in from Ratbite River regional hospital with pneumonia that has progressed to ARDS, acute respiratory distress syndrome. When you X-ray his lungs they are not the open, empty black of healthy lungs, they are white, clouded like mist or veined like white feathers. Still, he is tall and strong, and pictures of him amongst his family (blonde wife, blue-eyed child, him bending down to get through a doorway in their holiday shack, him and his brother kicking a football down at Fang Rock).

ARDS is bad, extremely bad. His white cell count is high - almost thirty - and even on the ventilator his blood remains dark and deoxygenated. His fundamental health and fitness and the evident love of his family weigh in his favour.

Bed Fourteen, Mr Wood. Mr Wood lives in a nursing home. All daily activities are carried out by his carers, he can neither feed nor dress himself. He is ninety one. He has had a stroke, he has had a heart attack, he has had laryngeal cancer and cannot speak. Two days ago he had a sudden attack of pneumonia, was rushed to Florey ED.

In the absence of what is called an "advance directive", doctors and nurses assume that full measures must be taken, and Mr Woods was aggressively resuscitated (I think they broke a rib doing CPR) and sent up here.

Here's the problem. Because Mr Wood is in no shape to speak, being deeply confused and all, and his son is his nest of kin. His son lives in Sydney and has not seen him for eighteen years. He has ordered that all possible measures be taken. If his heart stops beating, we crunch on his chest until it does. If his kidnes shut down, the machine. If he stops breathing, it's the tube down the throat.

Miracles, Mr Wood's son avers, do happen. This is true, but I don't know that keeping Mr Wood alive will be one. But it looks like this is what will happen, at least until someone can come up with a better plan.

Bed Fifteen, Erica Stone. Erica lives on the edge. Hep C, spleen removed following a stabbing in the eighties, steel in her skull following an assault in prison in the late nineties. A few days to a week ago she got a dirty hit - although the details are understandably sketchy. What we do know is that she has multiple organ compromise - bilateral (both sides) pneumonia, swarms of something in her blood, and a heart damaged by at least two previous episodes of the same.

Plus she's somewhat immunosuppressed (amphetamines plus Hep C plus an absent spleen) and has something wrong with her thinking - definitely present but difficult to define - some frontal lobe pathology, some memory thing. That could either be from the previous overdoses or it could be from the endocarditis - you inject heroin into your blood, skin bacteria get in, travel to your heart, start growing, clumps of vegetation break off, whirl downstream, stop the blood supply to the brain...

I should point out, this woman is not one of my drug and alcohol clients. The difference in morbidity and mortality between IV drug users on methadone and IV drug users who are not is huge. Arguing against Mrs Stone's survival is her multiple organ failure, the simultaneous presence of at least three different infectious agents in one small woman. Arguing in her favour is the demonstrated fact that death does not want her.

Anyhow. We are going to try to keep all of them alive. And we're a pretty good team. Very smart people do ICU, and we have a large number of consultants, some truly superlative nurses, an ICU that is getting money and people pumped into it at a dizzying rate. But I suspect the mathematics will apply, and at least one of them will die.

I will keep you informed. That plus the update on a few of my previous patients.

Thanks for listening,
John

*I can't remember a lot of my maths. But from what I recall, if each patient has a one in five chance of dying within the fortnight, then the chance of all five surviving the fortnight is aroundabout a third. The chance of at least one dying is approximately two thirds. The chance of things going horribly awry and all five dying is low - about one in three thousand - but it can obviously happen, and has happened before.

And all this talk of odds and percentages, all these cold equations, sound ghastly, but that's what everyone (doctors, nurses, administrators, health economists) does all the time. We've got numbers on everything.

**And that's assuming that the person concerned is even trying to write down what went on. I remember seeing our Glorious Leader on the TV the other day and trying to work out if what he was saying was what he thought actually went on, or (more likely) what he wanted us to believe went on, or (even more likely than that) what he or she wanted us to think he or she believed at the time was going on, or .... then one of my frontal lobes got caught in my amygdala and I fell over.

Seriously, watching him was like watching a professional card shark. What's the term for that mix of emotions you experience when you seen someone doing a truly terrible thing very adroitly, that melange of "What an evil rodent bastard" and "How the hell has the evil rodent bastard managed to get away with this stuff for so long" and "You know, other evil rodent bastards, trainee evil rodent bastards maybe, could learn from this... they should set up a school"?

The Germans probably have a word for it. If they do I'd like to know.

Proximity Errors

2007-07-25T10:16:00.000+09:30

Hail,
By the way - have a look at this. It's not quite as convenient, and I don't know if it saves any watt hours at all, but it looks so, so much better.

Well, a rather rushed missive today, sitting at my desk in the Drug and Alcohol job thinking about how this job is messing with my mind.

Not in a worrisome way. In fact, from the bipolar point of view, things are going very well. The mood, the sleep, the motivation - all of these are perfectly unremarkable. I worry, but it's about things that should worry me, like my exam. I have times of low energy and poor motivation, but it's generally after a twelve hour shift. I still have the lack of confidence, the fear of talking to any but my closest friends, but that is probably utterly normal considering what has happened. Utterly utterly normal.

See, I've had normal, and I've had that glowing, barely containable rage and glee, that ferocious impatience with everyone and everything, that feeling that gold runs through your veins, and although you really really miss the highs, you really really don't miss picking up after them. Normal will do me just fine for now.

But anyway. This job, and how it messes with my mind.

One of our social workers was talking the other day about one of our clients, a fifteen year old girl, on the edge of amphetamine addiction.

(You know those shots of the earth from space, where part of the earth is in sunlight? It's all clouds and seas, and there's the shadow moving across from east to west? And just between the shadow and the light is that softening, that half-light, that brief penumbra, and you know the people down there are looking up and seeing night come?

That's where this girl is now. It can happen quickly at any age, but for her it's a very rapid thing).

Anyhow, our social worker asked me some stuff about what we could offer her, the role of counselling (maybe) and family therapy (possibly) and antidepressants (useless) , and she said "I don't want her to end up going down the bridge."

"The bridge?" I said

"The bridge down at Rye Street," she said. "It's the underage sex one. Everyone knows."

"Is it?"

"Everyone knows Rye Street," she said, staring at me like I was stupid. "If you want underage sex you go down the bridge. Thursday, Friday, Saturday nights. Ask anyone."

"I didn't know" I said. "That's horrible." There's a bank and a saddlery and a comic shop at Rye Street, I've been there myself. Up in the sunlight it's smiling young couples and the Pony Club and Tales of Wonder, and presumably underneath in the dark it's wheezy old men and a quick fumble of someone in Roxy jeans and a cheap teeshirt.

"You must have known," she said. I shook my head.

Anyway. I've been thinking about that. See, Mary (the social worker, long blonde hair, thick glasses that give her owl-eyes, floral dresses) sees a lot of this. in fact, most of every day for her is seeing kids on drugs, the damaged, the diseased, the disposessed. And she's been doing it for a number of years now, and before that the prisons, and before that a stint in a big paediatric psych unit in Sydney.

It's been a lot of what she sees, and if you see things often enough, for long enough, you think of them as normal.

I've noticed that in me. Because most of the people I see every day have some kind of mental illness, or some recent episode of violence, or blood that swarms with viruses, I end up assuming at some level that that's what's going on with everybody. At some level (and I'm not talking about rationally, I mean those unconscious, edge of your vision, only-there-when-you-look-at-them kind of assumptions) you expect to see pathology everywhere. Everyone is on drugs. Everyone has hepatitis. Everyone has low grade psychosis.

One of my friends went to a seminar on child protection, three days of speaking about the unspeakable, talking with people where you can't keep looking and you can't look away. Lunchtime on the third day he went out to get a yiros and walked passed a playground and there was a father pushing his giggling child on a swing and David said he wanted to kill him.

See? That's not rational thinking. Thats not an un-messed-up mind.

Like I said, I don't know the mechanism, but it's like normal vision, it's like sight. Things that are closer appear bigger, you can end up believing that that is all that exists.

I suppose in that it's like love, in a way.

Anyway. I think all this is why my non-medical friendships are important to me. Most of my (few) friends are non-medical. Socially I only see one other doctor, and that friendship is based more on complementary character traits and political beliefs than a mutual interest in serum potassium levels. It's not that there is anything wrong with doctors as friends - I can think of several people I went through medical school with I'd love to catch up with - it's just that I find my work emotionally and intellectually exhausting after a while, and at the end of the day I'd rather do almost anything else than discuss serum potassium levels.

Plus, like every other group of people who work together who then socialise together there are really only two or three conversations that happen, and those discussions happen over and over again. There's a bit of "who's shagging whom", although I tend to miss out on that, and then most of the rest is either

1. How such and such a simple job was screwed up by someone else ("and the notes say by this time she's only saturating eighty two percent, so he keeps on doing piss all and doesn't tell anyone, an hour later they call the code...")

or

2. How those above us are screwing us over, and the infinite variations thereof.

I suspect similar conversations are happening every Friday night in every single profession. Think of the best job in the world - I don't know, for me it'd be running a well-stocked second hand bookshop somewhere nice - and you can bet whoever has it spends some of his or her time complaining about it - this year's caviar is not as good as it could be, and it's almost impossible to get a decent bit of eye-candy to wave those ostrich-feather fan things over you as you quaff another mouthful of wine with pearls dissolved in it.

Anyway, enough whining from me. Back to the kidney.
Thanks for listening,
John

Very Bad Things

2007-07-18T19:04:00.000+09:30

Well,
I don't know if I'll be able to post this one - it's going to require some fairly heavy anonymisation. And it's deeply, deeply violent - consider yourself warned. But the two stories therein are so indicative of how the whole field of commuity mental health works - or fails to - that it seems wrong to keep them to myself.

I've never been a fan of true crime stories. There is some very good stuff - a book called Tough Jews by Rich Cohen, the Godfather, some of the Sopranos, most of Deadwood - but that's almost despite the subject matter than because of it. I've got a vague interest in gangster movies and such, stories set in the twenties and thirties, Jews and Italians and Irish and Poles sighting the Statue of Liberty, but that's pretty much it. The other kind of true crime story, some muttering thug dressing himself in giblets, bathing in synovial fluid and flushing someone's hair down the toilet, doesn't interest me at all.

Part of this is because my experience with truly violent men - several murderers, an unknown number of rapists - has been that they are not personally interesting people. At best they are mundane, at worst they are spectacularly boring. A violent criminal does not have something glittering and special within him, something dark and mysterious that you can just understand if you look hard enough, some conundrum that can be solved. He - and it's almost always a he - has a lack, an absence, is less than his fellow man.

Honestly. A man on one hundred and twenty of methadone, killed some guy with an axe - boring. My psychopathic ex porn actor rapist - tedious. My articulate and clean-shaven standover man - virtually unendurable in conversation. Seriously, every consult with him I run the risk of dislocating my jaw like those snakes who can swallow an egg.

Part of this is as a result of institutionalisation - much of prison life is deeply deeply boring. You are surrounded by people you can't avoid. You can't go anywhere or do anything, a fair proportion of your fellows are depressed and withdrawn, many of them are on sedatives. In one of the local prisons you get two books every three months*.

But part of it seems to be that violent crime, with a few exceptions, seems to be carried out by people with few other intellectual or personal options.

Somewhere in a psych ward in New Zealand, by the way, is the Six Million Dollar man. I have this on good authority from one of our new psych regs who did a rotation in Orcland about three years back. The Six Million Dollar Man is called so because this is approximately what it costs the Government to keep him safe.

He has a ward to himself in Furby House, New Zealand's largest psychiatric hospital, with two guards on twenty four hour watch. He wanders through this ward, dressed in his orange, fire-proof overalls, which will be his clothing of (no) choice for probably the rest of his life.

This level of care is necessary because of his level of illness. Over the course of the last twenty years he has amputated a fair amount of his body - several fingers, a hand, a foot, his genitals.

He sets himself alight. He has done so on several occasions. He has set other people alight, too, and thrown scalding water on them, and attempted to rig up something with an electric cord from the kettle to electrocute the psychiatric registrar (my friend). His forensic history includes a particularly distressing abduction and slaying.

Nothing can be done with this man. He is resistant to any and all antipsychotics - Julia suggests that this is in part because he shows no signs of psychosis at all. It is difficult to work out what is wrong because she was never able to establish a dialogue about his emotional state at all - "no real data about mood, consistently blunted affect". She used to wonder if he understood what she said when she asked about his feelings. He didn't seem to be happy, but then, he didn't seem to be unhappy either, and he didn't seem to be angry the time he tried to electrocute her with the electric cord from the kettle.

Anyway. There was a move at one stage, years ago, to reunite him with his people, him being Maori and all. They bought him all this stuff, put him in a four wheel drive, drove off to the region he'd come from. His people had heard about this, they were waiting at the border with clubs and rifles. Shots were fired. The Mental Health team van didn't get down past second gear, turned around and sprinted back to Orcland.

The nexus between mental health and crime is a nightmare, like those places on the coast where two oceans mingle. In the simplest analysis, a lot of forensic stuff is about punishment, making things worse for the prisoner, whereas medicine is about helping the patient. It's a complicated, torturous dance sometimes to convince yourself you're doing one when you know you should be doing the other.

And it's under-resourced and unpopular too. A few years back Mordor Mental Health - just down the road from here - had a patient called Jacob. Jacob had what we call "polymorbidity", or several potentially serious conditions at once. The several conditions included paranoid schizophrenia, and being poor, gay and Aboriginal. It is no surprise that Jacob was a frequent client of Mordor Mental Health services.

And his paranoid schizophrenia was particularly resistant to treatment too. His neighbours were plotting against him. They were murderers, raping and murdering all day and burying bodies all night. They wanted to kill him and get his social security payments - the princely sum of three hundred and eighty dollars a fortnight.

The psychiatrist bumped up his olanzapine until it didn't work and then switched him to clozapine, the "gorillacillin" of antipsychotics. Clozapine basically bludgeons bad thoughts out of you, but it takes a fair proportion of the good ones with it, and is one of the few antipsychotics that can actually kill you. After they got him on five hundred a day of clozapine he pretty much stopped complaining, evidently it was working, and eventually MMH was able to close their books on him.

And they never got opened again, because a few months later he turned up dead, one of the only male victims of the Saltwater rapists I mentioned earlier. Truly ghastly men. All day murdering and raping, all night burying people in the back yard.

Anyway. it's been a die of uninterrupted grue today, sorry about that. More cheer tomorrow, or at least less violence.

Thanks for listening (and sorry!)
John

*Me, I'd go with Shakespeare (Complete Works plus Apocrypha) and some kind of "Teach Yourself - " book.

Death certificates and the maiden

2007-07-18T18:16:00.000+09:30

Hail,
Dr Hu's luck changed recently. And it's well deserved, too - he's an excellent RMO, and a pleasant fellow to be near, and a deeply decent human being. Smart, hard-working, easy to get on with, consistently cheerful and kind. It's about time something good happened to him, so I was pleased when four of his patients died last week.

I should explain. For a start, they aren't his patients, in the sense that he was not solely or even primarily responsible for their care. He is the RMO, almost the lowest rung on the ICU ladder, and all the (very) simple decisions are made by me and the (remotely) complicated ones by the consultants.

And it's not like these patients weren't expected to die - a certain proportion of the patients in the ICU are patients around whom much activity occurs - glowing screens, beeping monitors, blood and drugs being pumped in and out of tubes - but for whom not much can actually be done. There is a subset of ICU patients who come into the hospital so unwell that all we can do is forestall death until - and herein is often the problem - until the relatives and perhaps even the patient have had time to accept the diagnosis. All of Dr Hu's patients who died were of this category.

And when they do die it is often Dr Hu's job to do the death certificate, and then every morning someone from Records comes up and collects the death certificate.

Here's where Dr Hu considers himself fortunate. Because he is quiet and unassuming and polite, but he is also a man, and the death certificate babe is - well, she's quite clearly a babe.

I am serious about this. I recently entered that age where you look at nineteen year olds in closefitting skirts and blouses and think about how they must be cold, what with all this weather we've been having, and similar geriatric sentiments, but Dr Hu is young. And the death certificate babe has long glossy black hair and wears calf-high boots and a snug woolen skirt and every time Dr Hu sees her he blushes and smiles so much he could charm the dead.

He's much too shy to start anything. But she seems friendly, and lately he's managed to strike up some sort of a conversation, and she seems to laugh at his jokes and look forward to seeing him. It may be that something is starting to go on.

But time is short. Dr Hu's next rotation is orthopaedic, and nobody (usually) dies on ortho. He won't see her from one month to the next. What he really needs is a run of luck - good for him, perhaps (or perhaps not) less good for the patients - so that he can, in medical terms, "establish a rapport" and "construct a therapeutic alliance". Hopefully before that blonde guy from Palliative Care can, although Dr Hu has heard and hopes he might be gay.

Anyway. I've been helping where I can, giving him my death certificates to sign, and I suspect all fo the doctors and most of the nurses are secretly or not-so-secretly barracking* for him. There's not a lot else we can ethically do - I remain confident that none of our staff would go to the extent of making sure that someone dies on Dr Hu's shift as opposed to another doctor's, although the thought has clearly occurred to some of us. All we can really do is keep our fingers crossed for the young lovers and hope that the current harsh winter continues.

Thanks for listening,
John

*Barracking in Australia means "cheering, supporting, encouraging" - one barracks for a football team. In America this is called rooting. In Australia rooting is engaging in sexual intercourse. As sevral of our sports stars have previously shown, they may need us to barrack for them but the other they are managing quite fine on their own.

Dependent

2007-07-18T13:58:00.000+09:30

Hail,
Lots has been going on. I may have to break this down into smaller posts, or it's going to get out of hand. So - today's post is two wildly different stories from the Drug and Alcohol files.

Today I am at the Drug and Alcohol job. It's raining outside, sheeting down, and in most normal practices that would mean fewer patients. But not my patients. Not rain nor snow nor dark of night will stop them from making their appointment. In fact, almost nothing does except a dimly glimpsed but troubling suggestion that the Great Australian Heroin Drought (2000 - current) may be coming to an end.

Anyway. It's not all heroin.

I have just finished speaking to a small, thin Vietnamese man, someone who is already old at forty. I feel I have done him no good at all. Throughout the consultation he hunched forward, blinking unsteadily at me, wearing a shapeless grey jacket and some tracksuit pants, nodding occasionally in a respectful manner, probably as close as he has got to being sober in the last few months. But I know he is only telling me what he thinks I want to hear.

He has, his doctor tells me, been drinking. And not just drinking, but drinking constantly, all day, every day, for as long as anyone can find out. It's common with my clients for the substance-of-choice to become more potent, cheaper and less safe over time - cigarettes become roll-your-owns, paracetamol plus codeine becomes oxycontin tablets crushed and injected - and Mr Vu is a classic example of this. As a thirteen year old he was sharing a sixpack of beer with friends and now his alcohol consumption is truly prodigious.

I do not say this lightly. I have seen men who drink five litres of wine a day, women who keep an open bottle of beer by the bed so that when they wake in the night they are not troubled by alcohol withdrawal, but Mr Vu is something special.

It is impossible to calculate precisely, but Mr Vu obtains two hundred litre barrels of methylated spirits and consumes them at a rate slightly more than one a week. If this is true it is two hundred litres of pure alcohol, two thousand standard drinks in seven days, almost three hundred glasses of wine a day. He mixes each glassful with lemonade to form a drink known as a white lady, a name that to me evokes drinking gin in the nineteen twenties, Etonians and flappers and pince nez and phonographs, rather than blindness, seizures and imminent and sudden respiratory arrest.

Anyway. Two hundred litres of methanol (it is available both as 95 and 100 percent purity) costs only two hundred dollars, making it remarkably cheap and accessible. I think he is already at least partially blind, but I know that precisely none of what I had to say to him impacted at all on him.

There's not a lot left of Mr Vu. That's what dependence is. There is the facial expressions, the physical form, the reflexes and the flesh, but not a lot else.

And just after that I saw Annabelle Trang. Cheerful, leafing through a magazine in the waiting room, almost glowing with health, who almost bounded in through the open door and told me that since we'd started her on the new medication she hadn't used, two months without, longest period without heroin since the late nineteen eighties, and her and her three kids were going on a holiday to Fang Rock. First ever holiday she'd taken her kids on.

"Used to be" she said "the needle got it all."

Well, it's got Mr Vu, and it's got a lot of people, it's got five of my clients since midsummer, but it doesn’t get all of them.

Thanks for listening, and more tonight.

John

Days of Wonder

2007-07-11T10:00:00.000+09:30

Hail,

I did a very strange thing yesterday morning, one of the stranger things I have ever done. Details are as follows:

Mrs Chambers in bed four is not a well woman. There is fierce competition between her multiple diseases as to which will be the one to finish her off - at times the renal failure holds sway, then her heart failure will surge to the fore, recently her pneumonia has broken free of the pack.

Now she lies sedated, paralysed and intubated. There are multiple tubes and cords coming out of her and the blank faces of the cardiac monitor and dialysis machine stare off into the middle distance, like stangers forced together in a room.

Because of this she has tubes in her veins and tubes in her arteries and tubes in her veins and tubes in her bladder and throat, and today I got called to put another tube in.

"Have you ever done a pulmonary artery catheter?" Dr Black asked.

"I've seen one" I said.

"See one, do one, teach one" said Dr Black. "Set up and I'll be there."

So we painted Mrs Chamber's throat with antiseptic, laid the sterile towels over her face, and I put the tube in.

The procedure goes like this. You feel in the throat for the big pulse, the carotid artery. It's a little to the side of the wind-pipe. A little to the side of that is the internal jugular vein. They feel quite different - arteries go from the heart, they are muscular and have a pulse, veins go to the heart, they are flaccid, more floppy-feeling.

Anyway, you find the vein by sliding a needle into it (after injecting some anaesthetic). You can tell it's in the vein when you poke through and the dark blood flows back up the needle. If you've gone too far to the middle and hit the artery the blood is bright red and pulses - that's bad.

After you've got the needle in the vein, you slide a length of wire through the needle into the vein. Then you pull the needle out (not letting go of the wire, because if it slips into the vein they may need urgent surgery. I say may because they may go into an arrhythmia and die), and slide another needle over it and after that we thread a long, supple plastic tube, about the thickness of a drinking straw, into the vein.

This is where it gets remarkable. The tube has a miniscule device in it which measures things like how much oxygen is in the blood, how acidic it is, what the pressure is and so on.

And you push the tube slowly in through this tiny nick in the throat of this woman and watch the cardiac monitor and watch as the blood pressure around the end of the tube changes.

First, when you're in the vein, the blood pressure is low. It doesn't need to be high, it just has to get back to the heart.

Then, as the tip slides through the vein and into the heart, you can see the pressure around the tip jump, pulsing with every beat of the heart.

Then, as it emerges from the other side (it's gone along the vein, through both chambers of the heart and out into the big artery that goes into the lung) the pressure changes again - still high, but not fluctuating as much.

So you slide the tube in, and look at the monitor and think "Okay, the end of the tube must be in the start of the heart now, because the heartbeat's fluttering about a bit."

Then a few moments later you think "Okay, I've pushed it into the main part of the heart" and then a few seconds later you stop it because you realise it's where it's meant to go, the end of the tube is in this woman's lung.

Then you stitch it in and we can start using it.

There is something to this, something, I don't know, wondrous.

I don't know exactly how to communicate it, something shimmering and bright, something almost numinous. You get a bit of it when you take blood, when the needle punctures the skin and the dark blood jets into the syringe, you get a whole lot of it when your gloved fingers press up against someone's lung and you feel it rise and fall, inspire and expire.

Years ago I saw cardiac surgery, and I still remember the old man's heart, smeared and scabbed with yellow fat, lurching in the chest, until the surgeon poured the cardioplegic solution onto it and it stilled. And then, when she had finished, washing away the fluid and it started again.

I've got it a few times in psych, that same silent clarity of perception, that same "nothing else-ness".

Like I said, I don't know how to describe these things, don't have the words. But I know these experiences are not unique to me or to my job, to medicine. My brother, one of my favourite human beings ever, works as a boilermaker. He comes over smelling of grease and metal and, once, burnt linen.

Sometimes, he says, he heats up the metal until it is glowing, and instead of welding it, he lets it cool. Then he heats it up again, glowing red and orange and then gold, for no other reason than to see how beautiful it is.

Anyway, thanks for listening,

John