Welll....

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

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

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

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

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...

... 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

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

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.