Today I was asked if the pharmacy sold thermometers that measured "In the old way. Not that centigrade nonsense", by an old 'bush nurse'. She was about 60 and had a most twanging ocker accent.

My wavering faith in community medicine was restored when two blokes, of a similar ilk to the 'bush nurse', had a shop-floor discussion about a new diabetes medication. They both knew how their current meds worked and how the new one differed. I joined the conversation late, but these jokers were on the money with most of their comments. It was a rewarding chat to have.

This morning I listened to my first Dr. Anonymous show on blogtalkradio. I'd been meaning to listen for a while, and I really wanted to listen live. Luckily, class was pretty light today, so I headed to the library with some notes and hunkered down until 11am rolled around. Today was actually Dr A's 1st anniversary show (Mazel Tof!), and the chat was packed. It was great to see so many familiar names; I really enjoyed it!

Unfortunately, about an hour in I managed to unwittingly max out my puny uni download quota, so I missed the last half hour. Meantime, I cracked into some Renal notes. For the first time in about two months I actually felt the need to write something down. This is a truly rare event for me for several reasons;

One; I don't take notes in lectures or tutes.
Two; I read notes on my computer (I don't write them, either.)
Three; If I write anything, it'll be an A4 with about ten words in pretty felt-tip pen, because
Four; my handwriting is frankly abhorrent. I've had pharmacists who couldn't read my handover notes. Seriously.

So, I get a few pages into writing and I discover, living in my book, some insects. A couple of bugs have actually nestled in an made themselves at home, right there in my notebook.

I skipped the page and got back to Rapidly Progressive Glomerulonephritis.

You can probably guess from my name that I've got a few allergies. In fact, aside from eczema, I still enjoy the two popular childhood atopic afflictions of asthma and allergic rhinitis. Whilst these illnesses can be a pain in the neck (or lung, or nose, or wherever), they pale in comparison to the big mama of atopy; Anaphylaxis.

This post is the first in a series of three about Anaphylaxis. The series will detail four case studies and summarise some some things to watch out for. First up is a case study - about me.

It was the end of my third year of Pharm school. I was taking a brief stop-over at home between returning from Uni and embarking on a summer of work in pharmacies overseas. I'd had a minor surgery a few days earlier - a day procedure. So, before I left, my family had decided to take me out to a nice restaurant for dinner. After that, the plan was for my brother and I to hit up one of the pubs. Of course, I would be the driver. Over dinner, I felt immensely uncomfortable. I had a fever and was sweating a bit too much for a balmy summer evening. The wound site was red, painful, hot and still swollen. Yup, I was showing all the signs of infection. After surviving dinner, I requested one of the cars so I could quickly pop into the hospital and get some antibiotics. I'd meet my bro at the pub.

At the hospital, things were pretty quiet, especially for a Friday night. That being said, it was still light outside and I'm talking here about one of the busiest emergency departments in the southern hemisphere. I was seen in about 90 minutes. The final year medical student took a history and gave me a full examination. I'm NKDA. I was pretty impressed at the time, she came across as most professional. She said that she's conferred with her colleague and, Yes, you do have an infection, and we'll prescribe you some of these. Take these two now and here's a 'script and off you go.

Sweet, I thought, I'm off to the pub. I was looking forward to farewelling the crew for the summer and jetting off. I phoned Captain Underpants, my best friend, and confiremd the locale and drove off. On the way, my hayfever really started to play up. My home town's pretty notorious for pollen and the like, and since I'd been there only a few days, I thought it was that. Next thing, though, my throat feels dry. I'm clearing it and blowing my nose and wiping my eyes. I'm pissed off at the traffic, which is minimal. About five minutes after leaving the hospital, I'm at the pub. Captain Underpants comes out to meet me, and he's in a most jovial mood - he doesn't want to wait for the loo, so he's going to piss behind the dentist's surgery across the street. I wander across with him, because I think he's gonna get hit by traffic. He doesn't. I complain about my hayfever.

Then it clicks. I'm having an allergic reaction. I'm in deep. It feels like the world is about to end.

I (pointlessly) ask Captain Underpants if he's sober enough to drive. He ain't. So, I jump into my car and speed to the hospital. At about 25km over the speed limit the whole way. My vision is blurry. Through two red lights (left turns, luckily). I drive up into the hospital. My tongue feels huge in my mouth. I can't close my lips because my gums feel like Bubba from Forrest Gump. My mind is in overdrive. I'm stressing out. I consider the possibility of the car getting towed, and I don't care. I park opposite the ambulance bay in the staff car parks at about a 20 degree angle to everyone else. I dash through the same doors I'd sauntered through an hour earlier. Things have begun to get dizzy. I shove the 'script from my pocket on the triage desk and say; Anaphylaxis! Then, I collapse.

About forty minutes later I wake up and, boy, do I feel awful. I go to scratch my throat, but it turns out I'm strapped to the bed. Both arms have lines in, and I'm wearing oxygen. My brain is charging. The medical student comes over to me, profusely apologising, I tell her it's no-one's fault. My shirt is unbuttoned and I am fully wired for monitoring. I can see hives all over my chest. I get drowsy and nod off - no mean feat when full of adrenaline.

A bit later I wake up; it's about 11.30pm. The nurse comes over and gives me some water. The strapping had been undone and I'm feeling much, much better. I still feel tight across the chest a bit, but hey, I can breathe! She gets me the phone, and I call home. My parents are shocked and a bit cranky - Dad asks if it happened at the pub and whether it could have been avoided. I tell them I'll be in until the morning, so come and get me then. The med student comes back to check on me a few more times; by 2am, I'm asleep.

Most readers will appreciate that the ER is not an easy place to sleep. At 6.30am everything 's buzzing, and frankly, I feel like a million bucks. I'm all full of steroids, and sedating antihistamines which have ceased to sedate me. Dad shows up at seven thirty, and he's really relaxed. Nothing's a problem, no worries, are you okay? Do you need to change your flight? Just prior, I'd been given the word that I could head home, prednisone in hand.

In the car, Dad says that when he walked in one of the nurses had pulled him aside. She told him what had happened and how they'd treated me. He also tells me that the nurse had said, "Your son is very lucky he's well trained. Anyone else in that situation at a pub would probably be dead."

Anaphylaxis is scary as hell, can come from nowhere, and can kill you in minutes.

Next time; Stories of Anaphylaxis: Part II: Two adolescent cases from pharmacy.

Australia has an addiction problem. I'm not talking about alcohol, amphetamines or sports (although they are important issues). I noticed the addiction as a pre-reg, but in the last two months it has once again reared its head. In Pathology, the tutor talked about this same problem, as did my PBL tutor a few months ago.

I'm talking about 'over the counter' (OTC) analgesics. In particular, those that contain codeine. I see it in every pharmacy. I read about it in the news. I've even seen the results on the wards. But there's no move to stop it. No prevention. Frankly, no-one seems to give a crap.

OTC analgesics are the cornerstone of self-medication. Paracetamol and ibuprofen are easily the two most used analgesic +/- antiinflammatory medications sold in Australia. For many patients, however, the analgesia obtained from these drugs is inadequate. To mollify this, many combination products are sold. They are called "Plus" or "Extra", and any product with this moniker contains codeine.

So, why am I so anti-codeine, you ask?

Firstly, codeine is an opioid. Whilst it is not as potent or fast-acting, it maintains all the addictive properties of the big H. Heroin, morphine and codeine have extremely similar molecular structures, and hence maintain many similar properties.

My second point on this matter, I will approach from a more historical context; In 1980s New Zealand there was a heroin shortage. Industrious and creative as Kiwis are, they decided to refine their injectable opioids from another source. This source needed to be readily available and easily convertible to heroin/morphine. Combination OTC analgesics had the codeine, and 'Homebake' was invented. Codeine extraction is a major issue in OTC analgesic abuse; just last year the pharmacy dept. at a major Brisbane teaching hospital mailed information leaflets to every pharmacy within 50km about the practice and how to watch for it. Certain brands are preferred; patients get shirty if you try and give them generics that may take longer to extract.

Whilst I was researching this post (and doing some study for the week), I typed "Nurofen(R)" and "plus" into Google. Google's default suggestions included Nurofen Plus(R) addiction, straight off the bat. My third point here is that these drugs are extremely addictive. Some forum posts report consumption of six to 12-fold overdoes every day.

Finally, codeine is not a very good drug in the first place. I suspect that it doesn't work very well at all. Several studies have shown codeine to provide no added benefit for migraine, and only a minimal therapeutic benefit vs paracetamol post-operatively. Don't get me wrong, I appreciate that sometimes codeine might be needed, but I'm pretty sure that I'm not seeing 100+ post-op patients a shift.

I mentioned the lack of prevention earlier. In fact, there's active promotion of these products for their "extra" strength. The two dominant products in Oz are Nurofen Plus(R) and Panafen Plus (R) . Both have highly public advertising campaigns; one evokes an Entrapment-esque jewel thief bending everywhichway thanks to her Nurofen Plus(R). I appreciate that advertising isn't always about reality, but I'm pretty sure that Reckitt Benckiser and their marketing team aren't going to take the time to mention that their jewel thief should perhaps consider taking the tablets with some food, or asking if she's pregnant. Reckitt couldn't care less; they just want you to go and buy some. Besides, it says on the box not to take too much or use it too frequently. As far as they're concerned, you don't even have to take any; once you've paid for the drugs, what happens is your problem now.

Unfortunately, I get the feeling that most pharmacists don't ask nearly enough questions about this. What I think happens is that the pharmacist satisfies themselves that the patient won't drop dead before finishing the box, and if the patient looks healthy and doesn't appear pregnant, it's an easy sale, an eight-dollar no-brainer. If you're an owner, more so. Remember, packets under 48 tablets don't get recorded, so hey, if they kill themselves it's hard to trace.

Gastric ulcers are one main serious event related to chronic NSAID abuse. That's if you keep chowing 'em down without gastro-protection. You might even tolerate the dyspepsia and reflux, if you're really stoic. By the time you get maleena or even a GI perforation, your pain ain't going anywhere. This is how people die quickly from NSAID abuse.

Dying slowly from NSAID abuse appears much more common. This is called Analgesic Nephrotoxicity. This is when your kidneys, through hypoperfusion and repeated chemical insult, decide to pack up and die. To get nephrotoxicity we're talking about 2-3kg of ibuprofen, or equivalent, over a period of years. For those of you playing at home, that's about 10000 tablets, or around 420 packets of 24. Earlier I mentioned a six-times daily overdose; chances are that young chap will have no kidneys within the next two years. Slowly, his renal function will falter and fail. He may get a big scare when his urine turns blood-red, but it's not common in this disease. Chances are, he'll show up at the ED with metabolic acidosis and all the other signs of renal failure. His kidneys might even look like these ones...


Each time I work up the coast, a girl who's not older than I am comes in for her box of Nurofen Plus(R). She's in each morning before eleven, and frequently returns in the evening for another box. "This one's for my boyfriend", she'll tell the shop assistant. Sometimes she just bites the bullet and buys a 72-pack. She provides a different name each time, and I honestly forget her name. I have refused sale several times. I have regularly refused to sell her even a 24-pack - especially the days when she looks green. I almost never work two shifts in a row. I'm certain she goes to other pharmacies during the week. If I tell her not to come back, I consider this morally abandoning the patient. She refuses to see a doctor. The last time I saw her, she was looking healthy but in a particularly bolshie mood. Comparatively, I was feeling a bit flabbergasted at the world. It made for an interesting counsel. This is exactly how it went;

Pt: "I want some Nurofen Plus(R). Just the twenty-four."
Me: "You take these regularly, don't you?"
Pt: "Yeah; I've had them before. I get migraines. I just need a box."
Me: "Okay, you take them with food?"
Pt: (Hands me $10 note) "Yeah, they don't give me any trouble."
Me: (slowly keying the register) "You know that if you keep taking these at more than the recommended dose that you're gonna die? Your kidneys will pack up and just not work."
Pt: "Hmph. I get pain."
Me: (handing over change) "Yep. I know. You should definitely see your doctor about it."
Pt: (walks off)
Me: "Hope I see you next time."

I meant it, too. I hope she miraculously overcomes her NSAID/Codeine addiction and escapes the horrendous morbidity associated with it. I hope I don't see her up at the hospital on death's door. I hope she asks for help.

So, what can we do about all this? Some commentators have suggested requiring a 'script for all codeine products; I think that's a good idea. Except that it will add hours onto the already choked public health system. Others have suggested up-scheduling all codeine-containing preparations to 'pharmacist prescribed' medications. I think this option will ease but not fully ameliorate the problem. I think that advertising OTC opioid-containing products needs to be made illegal. Public education needs to be increased, and the drug companies held accountable for what the say and do.

I've managed to talk about relatively simple cases above; overdoses in uncomplicated patients. The next step is to consider the heavily medicated patient who just has an ache. Patients perched precariously on the precipice of renal failure, with only a few viable nephrons; "I've just go a bit of a headache, love." You don't want her to suffer, do you?

My suggestions are three-fold; Doctors need to counsel their patients about appropriate pain management. They should urge their patients not to take combination products, and to establish clear and comprehensive pain-management plans which include appropriate follow-up. Patients should question why they need certain ingredients. Do you think the risks outweigh the benefits? Can this pain be treated without medicines, using a cold-pack or having a glass of water? Pharmacists should question, question, question. Have some balls and refuse the sale if it doesn't feel right. Do not recommend larger packs; instruct your staff to offer only the lowest size. Do not up-sell codeine as a stronger alternative.

I never want to hear one of my assistants say either:

"Yes, we have plain ibuprofen, but this Panafen Plus(R) has got the extra codeine in it. That's good for backpain/toothache/headaches/opioid addiction."

or:

"Oh, yes we do the twelve pack Nurofen Plus(R), but you can get 48 or seventy-two if you'd like."

Seriously. Give a crap. Don't feed the addiction.

Overseas experience is fast becoming a standard part of the comprehensive medical education.

These experiences, as such, can be part of an Elective, or more recently, as a Clinical Rotation. The difference between the two is important; an Elective often has more of an unstated objective. It's less well defined, and is frequently approached from one of two points. Either, the student chooses an elective purely so they can travel, with medicine as the excuse, or the student has an area of interest that their elective hospital specializes in. The student may or may not be job seeking for the future. I should point out that the Elective rotation may also be taken domestically - it's not compulsory travel. Far from it, actually, as students cover all their own costs, including accommodation.

Comparatively, the clinical rotation primarily educates the student. It emphasises typical cases, encompassing diagnosis and management of patients in a systematic and best practice context using evidence based medicine. Simply put, a clinical rotation is all about how to do what you're gonna do. At my Uni, almost all students do all their clinical rotations at local metropolitan or affiliated rural/remote hospitals within the state. I'm pretty sure it's like that across Australia; I'm willing to appreciate that it may not be quite the same in the US.

There presently seems to be a bit of a kerfuffle regarding 'international student' clinical rotations in New York. The NY Times had a write up on it. Summarily, there appears to be four points of contention; firstly, that students from a non-American university are taking training places in NY hospitals from American Med students. Secondly, that the non-American university in question is 'sub-standard' (at least one medico quoted in the article insinuates that all overseas Med Schools are substandard), thirdly, that the non-American university is merely a 'backdoor route' for students that couldn't make it into US schools, and fourthly, that the arrangement is completely money driven and there are numerous inside connections.

In the last two days, UQ has announced that a new international Clinical Rotation will be available in 2009. The Dean of the School sent an email to all 1200+ students proudly announcing the new partnership with the Ochsner Health System group in New Orleans, USA. Oschner's website says that it is "One of the largest, non-university based physician training centers in the U.S.", and was established by Dr A Oschner, who first discovered the link between Tobacco and Lung Cancer.

According to the announcement, students will be able to do up to four of their seven clinical rotations, as well as their Elective, in the Big Easy. In fact, 'we definitely will be able to offer Core Clinical Rotations in medicine, surgery and mental health (Year 3), and medical and surgical specialities and paediatrics (Year 4)'. The SoM already has well established programmes in Brunei, but the school hopes that the new programme will help UQ "become recognised as Australia's leading School, and 'Australia's global medical school", and it sounds pretty exciting, really.

In the context of the NY Times article above, this new development unleashes a number of debates.

UQ have quite a few international students, mostly Canadians and Americans. According to the SoM website, there's up to 100 in a year, or 25%. These students get hammered financially and hence generate a stack of revenue for the school. Yesterday, I discussed the new programme with two of my mates who are from the States; they are thrilled. The idea that they can spend most of their clinical rotations 'back home' for the final two years of their degrees is immensely appealing. They were planning on hunkering down under for a further two years, but being so much closer to home will be an opportunity too good to pass up.

This makes good sense for these guys; they're planning on practicing in the US when they finish. I'd be surprised if there's a genuine problem with this, given that there's a shortage of physicians in the US (just like here in Oz), and given the fellows in question will be sitting USMLE Step 1 along the way, they should be just as qualified as their US-based colleagues. Interestingly, there's no way of ensuring or the UQ students on the New Orleans rotation have sat and/or passed USMLE. This would theoretically place the students completing their clinical rotations in the US at a disadvantage to their American peers, and this could impact their future employment, especially if they're made to look like idiots. I haven't yet mentioned the need to provide adequate and relevant assessment from 10,000km away. This in itself provides many challenges. I believe that students whom will benefit most should be selected, with USMLE Step 1 a minimum. Moreover, some financial incentives should be offered, and certainly some accommodation made available, in order to make this a fully equitable opportunity to the class.

I reckon that the number of international students at UQ is about right. For my mind, this, combined with the Australian doctor shortage, is something that should be considered. I also feel that in practice it's a moot point; it would be unrealistic to train international students on the premise that they will only work in Australia. I don't really think that's the aim anyway, but it does add another dimension to the discussion.

The question is; What makes a good medical school? Where one university is berated in the media for creating opportunities for its' students, another claims itself to be a world leader. Certainly, international experience is increasingly a fundamental aspect of Medical education. This experience should not come at the expense of well rounded, current, relevant training. Nor should it come at the expense of a University's reputation for producing graduates of the highest standard. UQ does not want to gain a reputation as a 'lecture and turf' institution, but it also wants to make available a broad range of clinical experiences. What makes the pre-clinical programme at an institution 'world class'? I certainly don't think it is as simple as a specific entry criteria.

For UQ to conquer what Robbie Williams could not, they must do so carefully. The school must maintain its reputation. They can only do this by equipping its graduates with all the skills required to practice medicine at the highest level. They must implement rigorous assessment to ensure that only competent students graduate.

Blurberry - urban fruit

Jack III - flowering colour

Batman and I recently went to a small town market day. The markets are run twice weekly and they have a distinctly country feel; everyone is 'chilled out' and things move just slowly enough feel relaxing. Soon after showing up, we turned down a particular row of stalls in a relatively small corner of the place. The smells were overpowering. Lavender, Sandalwood, Rosehip and Orange peel. My allergies went to town. Hastily, we continued on; rainbow and tie-dye hallucinations flicked past. I caught sight of some signs "Have your palm read", "Mystic Medusa heals" , "Essential oils for pure relaxation", "Pure oils for essential relaxation", "Keep colds at bay". And the scariest of all;

There was practically one ailment for each letter of the alphabet. I thought to myself "Who pays money for this $hit". The answer to this question is complex, because essentially everyone does. In fact, when it comes to Complementary Medicine, I've sold plenty and dispensed a bunch on prescription too.

Unfortunately, a large amount of Complementary Medicine is nonsense. Some of it is kosher. Big Pharma's corporate involvement has really validated alot of claims, especially as far as consumers are concerned. Obviously, the corporates on-board with all this too; almost everyone has heard of vitamin ranges Blackmores, Nature's Own and Swisse. I'm sure they're extremely profitable enterprises. There's big advertising too; think TV, magazines, radio, the lot. It's big business. It might even be mainstream.

Take Vitamins. Loosely speaking, Vitamins and essential minerals are an important part of your diet. If you don't get the right about in your diet, you need to get them somewhere. If you can't absorb a certain Vitamin, then you need to get it into your system another way. There are studies and Cochrane Reviews. The pathology is well understood. This is one end of a broad spectrum. That's why the government fortifies your bread with Folate. It's not a conspiracy - it's public health! Next time you're full of doubt, take some time to read about Wernicke-Korsakoff disease or B-12 deficiency. I'm not saying that Vitamins are the only answer. Or even the main answer. I'm saying that Vitamins have a place in prevention and treatment in appropriate patients.

At the markets, I didn't see treatments that had been subjected to a Cochrane Review. Instead, I witnessed (and smelled) Healing Potions of the worst kind. This is the other end of the spectrum. Remedies that I could make in my back yard, even if I hadn't been to pharmacy school. I wouldn't need to purchase any ingredients; I'd just tear up tiny pieces of newspaper, stir them into a gallon drum of water and sell them as a cure for writers cramp. I would call it;

This is the level of science behind the nonsense peddled at the markets. And, in all seriousness, it's the same science as most of the stuff sold in supermarkets and 'over the counter' in pharmacies. If it really helps with disease, it'll have evidence. Find some. What I'm getting at here is that if your only source for the health benefits of a product is the internet, a neighbour, your mum or your uncle's dog, then for your own sake, ask someone with some balanced, certified knowledge. Remember that complementary medicines can interact with your existing medication, and even stop them from working. That's not a health benefit; that's harmful.

As you can see from the earlier quote, I took particular objection to the advertising methods on show at the markets. For me, this is one of the biggest problems in the whole debate. Only two countries in the world have Conventional Prescription Medicines legally advertised to the general population; New Zealand and the USA. In New Zealand, the difference between Prescription and Complementary medicine is clear; it is illegal for medicines to make unproven therapeutic claims. Prescription medication must only be advertised for approved illnesses. That's why you can't use antibiotics for hypertension. Thus, no evidence means no therapeutic claims. Complementary medicine can only be sold under the proprietary name, such as "St. John's Wort", and only suggestions as to the medicine's uses are permitted. By comparison, here in Australia, John Doe picks up a bottle of, say, Blackmore's Proseren (containing Saw Palmetto), that claims it "has been shown to relieve the symptoms of medically diagnosed benign prostatic hypertrophy". The line is blurred. So blurred, in fact, that John Doe may even be believe the quote above, irrespective of any evidence whatsoever.

Recently on the ABC's Gruen Transfer, a panel show about television advertising, one of the guest panelists commented along the idea that in the advertising industry, you can choose one of two paths. Either the consumer essentially uneducated and you're trying to suck them in, or the consumer is educated and you're convincing them to make an educated choice. The panelist nobly chose the latter. I say that for most it's the former. Especially in health. Considering the broad base of knowledge required and the speed at which new knowledge is attained, truly educated consumers are few and far between. In case you're wondering, I'm certain that the lady selling the Sandalwood Healing Potions is neither an informed consumer, nor an informed seller. Maybe she takes Blackmore's Proseren.

As we know, people take complementary medicines to feel better. The placebo effect is a wonderful thing. It has well documented health benefits and, by gum, it made a big difference to some chronic complaints in the time before conventional medicine. Today, it's much the same. Multivitamins for wellness technically live up to their therapeutic claims. They might actually make you feel better for taking them. But they won't help with your cancer, myocardial infarct or diabetes.

My true opinion on all this was deveopled about five years ago, after a conversation with a medical student. We came to a shared conclusion;


Treatment of many conditions need a wholistic approach. It's called the Biopsychosocial model of Medicine, of which I'm a firm advocate. Adjuvant therapy that doesn't interact may be worth discussing with your doctor or pharmacist. There are always options. Get the opinion of a number of health professionals, and give credit where credit is due. Be wary of anecdotal 'benefits'. Don't unwittingly throw away your money. Don't just listen to a naturopath. Don't just listen to a doctor.

I didn't buy any Healing Potions at the Markets. I bought some Old English Liquorice. Batman bought some sandals. We came home feeling very relaxed. That country market atmosphere was so relaxing you could almost bottle it. Almost.

Batman's canine sidekick, Robin, is pretty special. She had some Atopic Issues of her own when she was young, and has a few sensory deficits as a result. Batman sometimes gets worried about her unique dog.

On Tuesday, I noticed a story pop up on my feed about dogs having the potential for empathy. Far simpler than having Rover snuggle up when you're feeling a wee bit down. Instead, the correlation is yawning. Interested, I tracked back to the paper it referenced (which is actually yet to be published), here.

Keen to try this idea out, Batman and I sat next to Robin and yawned profusely. Within twenty seconds Robin yawned back. I'm still sitting here yawning. Batman is dancing around the house, singing.

Robin has curled up and gone to sleep with her rope.

It's Tuesday morning and Wonderwoman and I have been following the Surgeon around like terriers for days. We knew that Wednesday is surgery day; all day. All we have to find out is which OR and when to meet him. But, for him to tell us, we must be ever-present, bad smells.

The rest of the crew has already seen (and scrubbed in) on a whole day of surgery the previous week. I am keen to catch up. So keen.

We are to attend a lecture at the University. In Vietnamese. The Surgeon is a senior lecturer, and he gives us a tour of the facilities before the lecture. After, we will taxi back to the hospital and head home (or to the bar, whatever). It's 11am.

During the tour of the grounds progresses, the Surgeon quietly says to me; "You will come to OR tonight? I am on call at 7. You will help." I nod enthusiastically.

At 6.45pm, I walk my friends to the Irish Pub, then head on to the Hospital. I can hear music on the PA in the street. The Ha Noi nightlife is pumping. Motorcycles are everywhere. Cellphones are ringing nonstop. The smell of dinner is thick in the air. I rock up to the surgical building. It's a good 300m from the ED; inside it's very, very quiet.

I change into scrubs. I tie the thick cotton surgical boots over my thongs. I put on my mask I've just bought for 12000 dong at the corner Pharmacy. As usual, all my valuables are around my neck , underneath. I tentatively walk to the OR door, and the young nurse just inside the door smiles with her eyes and offers me a seat; there is no scrubbing in or out for observers.

I quietly watch, along with half a dozen other Medical Students. All of them nod to me, then elbow past to see. At the end of each operation, the students move quickly to another theater.

I step just outside and wait for the Surgeon's next surgery to begin. He walks off somewhere. The nurse offer me some Pho. It's amazing; the tastiest I've had. We sit on the floor and they practice their english. They're quite good. It's 9pm.

A mouse runs across the corridor, and all the nurses shriek. I jump up. They shriek more at my reaction. They ask if I need new underwear. I tell them that I am surprised my pet followed me to the hospital. They laugh. They pour me more Pho.

Another surgeon arrives. He is big and burly, and the first person I've met here who's taller than me. "Palez vous Francais?", he asks. "Non, je suis desolee. English." "Hmph." He calls the anesthetist, and gets him to explain that he will be repairing a broken humerus. Would I like to watch? Yes, please.

The anesthetist apologises for how bad his English is. It's excellent. We talkvas he places a brachial plexus block. When he is finished, he puts his gown under the patients head and walks away. As is usual in Vietnam, the patient is still wide awake.

We talk about many things, including poverty, capitalism, wages, neuromuscular-junction blocking drugs, families. He tells me where to find good surgeries during the day. We talk quietly as the surgery begins. Five minutes in, the theater is full of students again. Each one inspects the radiograph - a clean break.

We all watch the orthopedic work; the surgeon puts in two plates, and screws them tight. I watch as the nurse squirts water at the smoking drill-tip. I am thankful that I wear glasses when the blood splatters on the surgeons face mask. No one else has glasses on.

When the fracture has been reduced and fixated, the vascular team set about repairing the vessels. This is too slow and boring for the students. They head off. The burly surgeon stays to watch. He says to me, "You are here from start to finish. Very dedicated." I nod. We watch. It's 10:30pm.

Ten minutes later, the burly surgeon turns to leave. When he reaches the door, the young nurse says something to him. He turns to me and asks "I have elbow now. A young man. Scrub in." I smile and nod. "Thank you."

It's nearly midnight. The gown is hot. Gloves that I wear usually without issue have become dark with sweat. My cap is wet. My forehead glistens. It's at least 30 degrees in the OR. A nurse giggles and wipes my brow without being asked to. The surgery has been going for ten minutes.

"How did the patient do this?" I ask.
"Moto."

I am standing at the patients head, near the monitor. The kid is sixteen. I look into his eyes. He looks back and smiles. The surgeon repositions the surgical site. "Hold it here. One hand only." He gives me the forearm. I hold it turned to the kid's chest, out of the way. I can feel his pulse.

The burly surgeon gives me the suction. "You know how to use?" Yes. (I think so). The nurse fits the wire pins into the drill bit. Bzzzzzzzzz. Water. "Suction!" Suction. Bzzzzzzzz. Water. Suction. Bzzzzzzzz. Water. Suction. Three pins in.

"Now we close. Can you stitch?"
"No"
"Okay, you cut. 10 millimeters."

He begins to suture. "Cutty." I cut. One, two, three, "Too short!", four, five "Good!", six, seven, eight "Too long!", nine... fourteen stitches. There is nodding all around. The surgeon steps away.

"We are finished." It's well past one in the morning. "You have stayed long. Go home now. Celebrate." The nurses are dressing the wound. The medical students wait at the OR door to plaster.

I walk back through the streets, sweaty and exhausted. The night has eaten the city. It is silent. My senses scream at me. The sound of the drill. The smell of burning bone. The taste of my sweat. The feel of the cold steel scissors.

And the patient's eyes. His smiling eyes.

"What aspect of Scleroderma causes the most mortality in an elderly population?"

"I was watching A Current Affair last night and the showed this kid with some sort of CNS tumour. It was quite moving. Anyway, I wanted to ask, firstly, did you see the show, and secondly, your thoughts on leukemia in the elderly."

Tonight Batman and I went to watch The Dark Knight (it was her second time) and I was utterly enthralled. Heath Ledger is captivating, to say the least.

The Batman series, to me, presents an interesting picture of psychotic illness. Obviously, both The Joker and Two-Face are off their collective rockers - that's kind of the point - but Batman, too, ain't all under control. I s'pose that's one of the recurrent themes in several super-hero films/comics/ and the like. It's all about staying in control of what you've got.

Inherently, as Peter Parker points out, "with great power comes great responsibility".

I'd suggest that The Dark Knight and his other super- heroes and villains are just a wee bit closer to the edge than most of us. They're struggling (+/- failing) to repress anger or fear or other primeval emotion. They must control it, sometimes through an 'outlet'.

In the context of everyday life; the whole 'keeping it under control' is what some people keep as gospel. The fear 'losing control' might even be what drives some Med students. The need to stay on top of it all, the fear of failing. Or killing someone. Everyone need to feel in control of something.

That's the absurdity of the Joker. He controls everything and nothing and doesn't care.

With or without opioids, benzos, papparazi, sedating antihistamines and the lip-smacking extra-pyramidal side effects; I'm strongly willing to consider that 'method acting' for this role was the end of Ledger. The Joker was one psychotic man.

Squares into Circles

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Circles into Squares