Friday, September 14, 2012

"It is only a Black Dog, I am a wolf"


Hail, 
I have not been writing much lately, now I will try to write about why I can't write, and why I actually think it is possible I am going a little bit crazy.  And I have risen late on a Saturday, and am sitting in the sunlight typing, black coffee beside me, imaginary cat sitting at my side, and if that kind of behaviour doesn't engender writing, I don't know what will.  

The above quote is something I made up the other day, it's almost the only writing I have done in a long long time.  I was thinking about what I am doing, and how what I am doing relates to what is going on inside me.  I go to the gym a lot.  I hit and kick the punching bag, fairly hard, fairly fast.  In an hour or so I am due at Brazilian Jiu Jitsu.  

Tomorrow I shoot.  

The next day I go back to work.  Rinse, repeat.

It is like I am preparing for a battle - one in which, I suspect, the ability to hit and punch will not do me any good.  It is like I am trying to make myself into a wolf, not a true wolf, but a wolf of the mind, the wolf of our fairy tales and our horror movies.  The wild one, the beast at the boundaries, the grey thing that kills.

Or is killed.  I am fairly alone here at the edge of the Antarctic Ocean.  Lone wolves die.  

There are a couple of possibilities here.  One is that there is something in me that is expressed through this kind of violence.  I have always had trouble with violence, with any kind of conflict.  I have been doing martial arts on and off for years and part of the reason I am not any good is I tend not to look at what I am hitting - target or training pad or person.  Seriously, I flinch.  

There is something going on there.  It's bizarre. 

The other is that this is about control.  At the moment all I can control is what I eat and what I do, what I spend and when I work.  I have written up a diet and exercise plan on one of the many whiteboards throughout the house.  I check my bank balance once or twice a day.        

My job, in comparison, I am finding very difficult at the moment.  It's hard medicine.  It's a new hospital in a new state with new procedures and protocols.  When someone comes in one of the things we have to be thinking about is disposition, with what seervices they will go home when they go home.  I am trying to work out if Mr Smith should go home with an EACH, EACH-D, HITH or PEP programme, how much of that will be done as an inpatient vs as an outpatient, and whether he needs to have an ACAT assessment or OPI through the ACU or can just get away with HACC.  

And in the meantime, how come he stopped breathing, and how long's that been going on?  

I do jest somewhat.  But one of my patients died the other day - well, didn't die, but was being sent away for an operation that would almost certainly kill her or has stayed here with medical management for her condition that will keep her on a ventilator kind of thing for the rest of her life - and I sent myself home the other day because I (a forty five year old man with three tertiary degrees) was crying in the carpark.  

Anyway.  I will try to write more - about the separation, about where I am and what I am doing here and how I am going to get out, in a few days.  

Thanks for listening, 
John   

Tuesday, April 5, 2011

Sick II

Hail,

And this will be brain to screen, no editing, because yesterday I wrote this and then the machine ate it. Pictures to follow.

Practice-wise, three days ago it got better. I had my monthly review with my senior supervisor, she went through my notes, she used terms like "very good" several times in her review. If there is a suckiness threshold, I occasionally cross it.

What that means is you don't get another serve of cheap white whine from me, where I hunch over the keyboard and complain about how hard it is to see all these sick people - as opposed to, for example, actually being one of the sick people, or a carer for one of the sick people, or a child, or a mother or wife.

I don't know where I heard them, but a proverb, a motto and a curse stick in my mind when it comes to sickness.

The proverb, and I know I mis-remember it, says something to the effect that sickness is a loutish guest, who comes before you are prepared, and stays long after you wish s/he had left, and leaves only at his/her own choosing. And s/he also fills the house with his/her relatives and trashes the house before leaving, although that was not initially mentioned.

The motto was apparently written by Alexander of Tralles in the 6th century - "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." I like that way of thinking - while we're undermining the smoking over here, and pouring boiling oil on the bacteria over there, someone with a trebuchet is flinging boulders of prednisolone.

The curse was told to me by my mother. She was the daughter of an SS captain (actually true, we found out years later), and when she was seventeen she had run away with a long-haired Jewish biker. In small-town rural West Australia in the mid nineteen sixties, this caused quite the stir. Correspondingly, you will understand if I am dubious about the origin of this proverb.
But she told me "the Jews" said "May you inherit a shipful of gold, and it not be enough to pay for your medical bills".

Excluding the BPAD, I have been sick maybe three or four times in my life - the "have to lie in bed, can't do what you have to" kind of sick. I got the flu a few years back. Flu is one of those words, like migraine, that people use for mild, essentially trivial illnesses, doubtless to the rage of those who get the Real Thing. Feeling a bit tight behind the eyes is not a migraine, and having a bit of a sniffle is not the flu. The flu doesn't give you the sneezes and make your nose run, the flu smashes you to floor and stands on your chest, wondering if you're worth killing. I lost eight kilos in two weeks with the flu, and when it finished I couldn't walk across the street to the shops without resting.

And I had asthma, wherein I learned that no bugger in hospital tells you anything, and I had some kind of pseudo-appendicaitis, wherein I learned that the patient means the one who waits. And waits, and waits.

Anyhow - off to my two day training session. It's either on advanced life support or self-care for the trainee doctor - I presume if I start chest compressions when I'm meant to be meditating someone will let me know.

More later, including what I was previously writing about the gods of sickness and misfortune, which... unfortunately... got deleted.

Thanks for listening,
John

Monday, April 4, 2011

Tired

Hail,
And today's post will be brought to you by the cerebellum and the pons, two bits of the brain that keep functioning even when the rest of me is too tired to even think.

The cerebellum is the "little brain" we've all got, that looks like it's been blue-tacked onto the back of the spinal cord. It is involved in motor skills (me typing), attention and cognition (me thinking what to type) and emotional regulation of fear and pleasure (me enjoying typing... but not that much). The pons is another bit of the brain that does the relatively unglamorous things. While your cerebella are composing sonatas and building robots for Mars, the pons sits there and manages facial expressions and bladder control.

Mmm. If thought is neurons talking to each other, I wonder what they say to the pons?

Anyhow. I am deeply tired. Here are some of the reasons why:

I sucked at Emergency Medicine the other day. Nobody died, nobody got sent home while actually on fire or anything, but I dropped three sets of forceps while suturing up an angry Irishman's brow, and I sent someone off to another hospital when there was probably nothing wrong with him that couldn't be fixed on Monday, and I forgot something embarrassing about different kind of artificial heart valves.

Not good.

And I wondered three hours into the shift if I should just give up the job, and if it wasn't for the absolutely gorgeous last presentation (a ten year old girl with a cricket in her ear, everything went perfectly, all went well, her coming in crying and clutching her ear and coming out smiling with an inch-long insect in a specimen jar, all black and glistening and bristly), I would have given it some serious thought.

See, three months ago I was really good at my job. Now I suck. And I know all the stuff, how it will get better, how this is how you learn, how it's better in the long term and all that, but at the moment, every day I go in and I do something important ineptly. Not good at all.

And then the next day was study, all day, dawn 'til dusk, writing my "reflective journal" and reading about antipsychotics and prostate specific antigen tests, and trying to get things together.

And today at the practice was madness - people turning up late, and the front desk not realising they were late, and a woman from Tasmania with eight or nine different medications for which she needed scripts, and for which I had to contact three different regulatory bodies, and a man who actually, as he put his hand on the door-knob to leave, described his recent symptoms of what was very probably a heart attack.

And various things I have to write and write down and write about and write about my feelings of writing about them.

And I am worried, deeply worried, about three of the people I saw today.

Anyhow - I didn't want a meandering moan today, I wanted an haiku.

Failing that, I will sign off and write more on Wednesday.

Thanks for listening,
John

Wednesday, March 30, 2011

Sorrow

Hail,

Tonight I revise the examination of the neurological system.

Today, a word on sorrow. I don't know that doctors are that well equipped for dealing with sorrow. Some of that may be personal. To get into, and to a lesser extent, through medical school, you have to be a certain kind of person.

"Focussed" is a word I hear a lot. You have to keep your eyes on the prize, not let anything distract you, be able to shut out things that are not your goal. Some of those things, unfortunately, you find out you may need later. The problem with the focussed beam, like the search-light emanating from a light-house, is everything that is not being focussed on is left in darkness.

You may lose, for example, an initial sensitivity to emotions, to feelings. Your colleagues', your patients', your own.

The stuff about the colleagues I may talk about later. Doctors do commit suicide at a higher rate than average. I am not sure of the figures, I think it's about forty percent higher than "normal" for men, two or three hundred percent for women - partly because, I think, of the particular demands on female doctors, partly because of the cornucopia of lethal means at their disposal. To succeed as a woman in medicine you have to be capable of acting efficiently, making split-second decisions dispassionately under conditions of extreme stress - this is a Very Good Thing, for example, in the Paediatric Emergency department. It is a Very Bad Thing at other times, when things are going wrong in your marriage, you have no experience with seeking, as opposed to dispensing help, and you have a bag full of section one hundred drugs on the passenger seat of the car.


But that's another post. Getting into and getting through medicine can foster a certain amount of emotional lichenification - thickening and hardening of the skin.

I remember a patient who had come in to the surgical ward for a particular, un-life-threatening problem. I cannot remember all of the details - this would be fifteen years ago now. I will call the man Mr White. He was an anxious man, and life on the surgical ward did not agree with him - he was allergic to something in the blankets, the food was not as he had requested, the air-conditioning meant that his ears were always blocked, he couldn't get comfortable in the beds.

We came around to see him - surgical ward rounds, first thing in the morning, twelve or fourteen unfamiliar faces surging into your room when you're barely awake - and Mr Wong (the surgeon) answered his long-winded questions with short, precise oligosyllables: No. Maybe. Later. We don't know.

When we left the room Mr Wong rolled his eyes. "That man - he is crazy," he said.

The next day Mr White's CT scan came back. We reviewed the films on the screen. Cancer, unexpected, an opportunistic diagnosis. It had already run deep, spread through his flesh like lace.

Mr White was duly informed via the appropriate channels.

We walked on.



The next day we (the surgical team) went on rounds again. We strode into Mr White's room. He sat on his bed. The intern delivered her history. Mr White did not speak or look up.

When we went out the room, Mr Wong was perplexed.
"Now he says nothing!" he said. "Not even answers a question! What kind of a man is he?"
"I think he's depressed," I said (in this, as in many things that year, I was deeply wrong).

Mr Wong looked hard at me, and nodded. "You may be right. Get a psychiatry consult and order a brain scan."

I went back that night and sat with Mr White. He told me about how he used to box in the Navy - Australian Armed Forces champion nineteen sixty two and nineteen sixty four. At his insistence I felt his biceps.

"Strong," he said. "Strong, strong."




The reason I was wrong - and it is embarrassing now to reflect on what I did not see - is depression is not grief. Sorrow, grief, mourning - they are different. They share some similarities with the psychopathologies of what we call depression - like sisters, like seeds from the same soil - but they are different. Sorrow, says Samuel Johnson, is different.

"For sorrow there is no remedy provided by nature. It is often occasioned by accidents irreparable, and dwells on objects that have lost or changed their existence, it requires what it cannot hope, that the laws of the universe should be repealed, that the dead should return, or the past should be recalled."

Avarice can at least in theory be satisfied, he says - the pot or the bath or the lake of gold. For wrath a sea of blood, for lust a forest of concubines. But for sorrow there is no remedy. For sorrow, the thing that would ease the pain you know you cannot have, you can never have again - and this magnifies, rather than diminishes, your need.

The hunger is made the stronger by the knowledge it cannot be satisfied.

Johnson also said, by the way, that "where grief is fresh, any attempt to divert it only irritates."
Listen, he could have said, I could have told myself ten years ago. Sit and listen.

Out of interest, a few weeks ago, I saw a woman with her first heart attack. It felt, she said, like a heaviness in the heart, like what she felt when she found her sister's body. That weight, that mass, that burden.




Anyhow. I don't know if there's a moral here. Well, actually, I do.

We - and I mean my profession here - we deal with grief.

We move among the grieving, people speak to us in sorrow.

We ask people to unburden themselves - and then what?

Pick up the burden again, move on, unacknowledged? We have to be able to see that grief - not always or only to weep with those who weep, but at least to see that they are weeping and not order an ophthalmology consult. If we cannot do this it is a deficiency as deep in its own way as not seeing the subtle shapes of the ECG, or missing the shadow on the lung. I am not in any way saying this because I am good at it. I'm saying this because it is important.

Anyhow. Morbid thoughts. We shall see.

My friend is still in un-nameable hospital, suffering from the illness that dare not speak its name. He has regained the use of his legs but has been detained under the mental health act - I am sure he appreciates the way his physical ability and legal right to walk crossed over, going in different ways, like Cold War hostages exchanged upon a bridge.

Anyway, more non-news as it does (not) emerge.
Thanks for listening,
John

Sunday, March 27, 2011

Melancholy booby.

Hail,
Two mildly melancholy things today, actually three.

First, I am sitting here in the ED, alone, like a gull on a rock, and "the box" has just gone off. "The box" is the means by which the various ambulances communicate with the various hospitals.

About fifty kilometres from here, and in transit to the hospital where I used to work, an ambulance is driving through the night. They have a forty two year old man, who an unspecified length of time ago took ninety tablets of a tricyclic antidepressant, with the intention of dying. He has some alcohol on board. The tablets, say the ambos, have already begun their work. His heart-rate is one hundred and twenty, he is confused, his speech is slurred. He may or may not survive.



Here, by the by, is a link to an article detailing drug and alcohol abuse amongst ambulance drivers in Sydney.

Years ago, it seems, this happened to me. The whole thing. I still get slightly sick when I see the dull, mustard yellow tablets.

The thought, this late at night, strikes me. Radio-waves travel at the speed of light. Time has slowed to a stop for them, they do not grow old, as we who are left grow old. If there was some... sloppiness, some slipping of standards, some near-enough-is-good-enough attitude on behalf of the radio photons, then... then they would travel slightly faster or slower than light. Then they could then travel forward, or maybe backward in time - my grasp of physics is not what it once was. Then that ambulance call, just heard by me could actually have been about me, years ago.

Hmmm. A grim mood, evidently.


A tricyclic. They aren't really composed of thousands upon thousands of impenetrable spheres of blackness. They're just drawn that way.

What has brought this on is, as I have said, one of my best friends is in hospital. There are multiple impediments in the way of me ever telling more than the briefest outline of the story, but something like what I just heard on the radio is involved. I have been in and out of the hospital - ED, ICU, renal, soon psych - for a week or so.

Distressing overall.

What else has contributed to the mood? I got involved, which I normally don't, in a facebook discussion about religion. It was an ever so slight variation on the traditional, utterly, utterly utterly futile discussion, because this time there was a graph that could be produced - somebody's recently done research that seemed to show that religious belief itself may become extinct within a matter of... some years.

The person who posted the link to the graph said that this was certainly what he hoped happened, and a sizeable number of other people liked it, and several said it couldn't come soon enough for their liking, and overall there was much rejoicing. And I, the token quietly religious person among the group, sat and read it and wondered what all of this meant.


ECG leads B and C are given as diagrammatic solutions to the common question "how bad can things get, anyway?"

Things like this, of course, would not normally get to me, or (to be frank) be read by me. But today they did.

And last of all, I found (via one of my favourite writers), a poem by someone called Gabe Moses. I don't know Gabe Moses, but to be honest, Gabe Moses started out ahead of the pack with me because of his/her name, and it just got better from there.

Here is the link.

It's beautifully written, and about damage, and love, and what we are and what we are not. If anyone likes it, or even if they don't, I am going to link to more poetry later. Read it.

Anyway. More, and less melancholy, later on. I have an appointment with Doctor Tesla, my precisely-spoken and vaguely grasshopperian psychiatrist, within the fortnight.

Thanks for listening,

John

Saturday, March 26, 2011

Materia Medica

Hail,
And someone I love is in hospital tonight, and for about a squillion reasons I cannot talk about it, so instead something meaningless and light.

I have a number of medical textbooks. I tended, in med school, to use them as anxiolytics. I would buy a book whenever my fear of failure was particularly acute, and I was fearful all the way through medical school, and I still get twinges of that fear even now. Correspondingly I have a lot of books.

A lot of people say that. I mean it. I will have to live well into my seventh century to read the books I have, or find out some way of mainlining neurobiology and Jonathan Franzen.

Anyhow - among the books is a facsimile of the Merck Manual of 1899. It was brought out in 1999 in celebration of one hundred years of what is actually a really good basic textbook of medicine. Merck, I think, are one of those German companies that were confiscated at the end of World War I, and now make a vast selection of pharmaceuticals with vaguely superheroish names - Januvia, Isentress, Zocor. They also brought out the 1899 Manual.


This, apparently, is Seng (see below). It is from a site called "auto infection". I do not think that word means what they think it means.
In case you haven't guessed, I type words into Google and hit images and this is what I get.

And it's incredible. The first part is a listing of "the entire Materia Medica to-day in general use by the medical profession". It does this because "memory is treacherous - particularly so with those who have so much to do and more to think of." Even "the most thoroughly informed man" may suffer in this way, "particularly so because his mind is overburdened".

What is listed? Not a lot of Januvia. Instead, there is 10% hydro-phosphorous acid (suggested dose - 10 - 60 minims).
Formaldehyde.
Ox gall (inspissated).
Gold cyanide.
Mercury benzoate.
Mustard oil.

Sanguinarine - whatever that was. It is listed as small, white needles, with an acrid, burning taste, and the physician was advised to dissolve it in chloroform before administering it. There was also Scutellaria (which I believe was skull-cap), and something called "Seng", which was defined as "not completely defined".


Seng (inspissated).

Spermine could be purchased as sterilised or as an essence, and there was also "Spirit, Ants, True" - superior to "false spirit ants", "false spirit of ants", or "spirit of false ants", or whatever. "Bitter almond water" was a 0.1% solution of hydrocyanic acid.

But it is part II of the manual that truly alarms the reader. Once the physician has familiarised himself with the extensive range of products supplied by Merck and Co., he* can then apply the most fitting remedy to the diagnosed condition, and await recovery.

For acne, for example, the healing powers of glycerin can be utilised - "both internally and externally". Alternatively, mercury or phosphorus can be used - the manual advises that phosphorus is "safer than arsenic", a recommendation you see all too rarely nowadays. For those who prefer not to use harsh chemical products on their skin, the manual recommends electricity.



This is also Seng - presumably after a rigorous programme of diet and exercise. And I don't think this is entirely natural - look what she's done to her hair...

Albuminuria - a consequence of kidney failure - has almost a page of remedies. The sufferer may be offered warm baths, or caffeine, or cannabis. Alternatively, the cautious physician may recommend belladonna, lead or nitrogycerin - which may actually have some beneficial effect, from what I can work out. Alcoholism is treated with capsicum, arsenic or opium.

Sulphurous acid may be inhaled to relieve a clergyman's sore throat. Cannabis treats asthma, cerebral softening may be remedied with potassium, and several kinds of acid could be used to treat the visible sores of syphilis.

I could go on. I don't know where I heard it, but I think that at some time in the thirties medicine actually began to do more good than harm. Prior to that, all the centuries prior to that, it did no good, and it often did harm. I don't know about that. I don't know about folk medicine - I think that what we think of as the core practices and principles of folk medicine are not necessarily the same practices and principles as the practitioners of the time thought. I don't know that we always refrain from harm now.


Seng - may cause side effects. Consult your dress-maker.


Anyhow. As I said, I am worried about a friend, and I am not able to put much thought into this, so I do apologise if it's not up to standard. More, and more betterer, next time.

Thanks for listening,
John.

*that does seem weird now. I keep wanting to write "he or she", or "s/he". But I don't know that Merck in 1899 was speaking to anyone but him.

Wednesday, March 23, 2011

Presenting complaint - Asianness

Hail,
I saw Fang Hong Sun again today. She seemed quite well, she had only come in for a repeat of her oral contraceptive script. She did not, as far as I could see, have a long tube kind of thing sticking out of her back onto a dialysis machine, or any signs of end stage kidney disease.
Which was good, because last time I saw her I had been a Bad Doctor.

There are two or three types of bad doctors. I don't know how to insert drawings into blog things, so you might have to help here. Get a sheet of paper and draw two lines - one horizontal, one vertical - that cross in the middle. Then across the top of the sheet of paper write "how good you think you are" - anyone on the left things they're pretty crap, anyone on the right of the vertical line reckons they're pretty damn good. Running up the side of the page, write "how do you actually are". The top "half" is people who are good, the bottom half is people who are crap.

By "good" here I mean "good at your job" - Ghandi was a great human being, but you don't necessarily want him taking out your kidneys.


Sortof like this, but instead of X and Y there's "crapness" and "perceived crapness".

So - top right is doctors who are good and know they're good. This is what you want. You might not invite them around for a barbecue, but they are competent and have a reasonable assessment of their own worth. And confidence in abilities that you actually possess is a good thing. You don't want a patient lying there with a collapsed lung the nurse saying "This woman needs chest tube, stat!" and the senior guy in the ED blushing and looking down at his feet and saying "Little old me? I shouldn't..."



How Fang Hong Sun did not look


Because if s/he was good but thought they were crap, that'd be first type of bad doctor - top left hand corner of the graph. The one who is actually reasonably competent, but underestimates his or her own competence, so things don't get done.
The other two types, both bad, need not concern us overly much here. They are the "crap doctor who knows he or she is crap", and worst of all "the crap doctor who thinks s/he is good". I have done a fair bit of work with these doctors, because I did five years of emergency, and when someone is truly shit, they get sent off to emergency, because Emerge is generally desperate, and would give Bullwinkle the Moose a couple of shifts if his stethoscope didn't get tangled in his antlers.

(I did see another, similar table once, drawn in cider on a pub table at medical school by a red-headed man explaining to me about phlegm. Doctors who don't like vomit or poo, doctors who do, doctors who don't like sputum and phlegm - the phlegmophobes, of which I was one - and doctors who do. Maybe there's people who really love every kind of bodily fluid - I don't know and don't want to know them.).
Anyhow. Me, bad doctor. I had seen Fang Hong Sun a fortnight before, and she had a viral illness - she had turned her head to the side and uttered a tiny, kitten-like cough - and she wanted antibiotics. Which weren't going to do her any good at all.



How Fang Hong Sun did not react when I asked if I could take her pulse.

And because I lacked confidence in this field, having been a GP for less than a month - I asked on the senior doctors. I described her symptoms.
"Is she an Asian woman?" he said.
I nodded.
"Give her antibiotics. That's what they want."
"People with viral - ,"
"Asians" he said. "Doxycycline. Can't do her any harm."
"Well, actually - ," I began, and I stopped. He was one of the senior doctors. I'd asked his advice. If I knew what the right thing to do was I should have done it.
But now I did, and I didn't do it. I went back in and prescribed her antibiotics she didn't need. I searched through the medical software, but there didn't seem to be anywhere we could list a patient's presenting complaint as "Asian-ness."
Asians are different, apparently. Subtle, and mysterious, and either inscrutable or just very difficult to scrute. And their viral upper respiratory tract symptoms respond to antibiotics. The next week I spent worrying bout her kidneys shrivelling like sultanas and she spent getting better after (and therefore because of) my treatment. And she came back, and she seemed much better.


What Fang Hong Sun did not do to our surgery after we did this.

We shall see. I must go and revise "the irritable bladder" - which to me sounds like a old English pub. "Meet you down the Bladder for a pint."
Thanks for listening,
John.