I well remember the words of one Pharmacist I worked with during my pre-reg. She was a mother of two kids under five, and when it came to kids, mums and the like, she knew her stuff. She was also a wee bit into the natural medicine, but not in a complete hippy way, more in the educated, professional, informed opinion way. Anyway, we were talking about medications for kiddies and pregnant mums and she said;

A few weeks ago, I found myself explaining how homeopathy works to a med school colleague. Here's how it went;

So, in homeopathy, there's two principal theories; Firstly, that like cures like, and secondly, that a little does a lot. For example, to stop vomiting, there's a herb called Nux vomica which is in most of the anti-vomiting homeopathic preparations. Nux vomica is derived from the Strychnine plant, which in typical doses acts as a laxative, a poison (that makes you vomit), and well, it kills you. But, in these preparations it's diluted; invoking both priniples of homeopathy.

The ingredients are typically listed on the pack with a strength along the lines of "Each 2mL contains 2microL of each: Higgildus pillgedum 6X, Randomus plantium 5C". The C and the X mean that the ingredient is diulted by 100- or 1000-times, respectively. On top of the initial mircoL/mL dilution.

So, roughly from these numbers, we've mixed all these herbs together, then taken about a gram of the mix and thrown it into the middle of an olympic size swimming pool. Then, we fill the swimming pool with water and alcohol, and stir. Next, we take a sample the size of a shot glass and tell the customer to spray about 0.5mL in their mouth.

Now, I'm not one hundred percent sure of the properties of this stuff, but a quick and fanciful calculation using Avagadros' number would show that there's almost no chance of any molecules (other than water or alcohol) being in that spray. Call me crazy.

Recently my mum, a teacher, related to me a story whereby one of the pupils in her primary school, was receiveing 'homeopathic' injections for ADHD. This worries me most of all. Surely the negative psychological connotations of a needle in the arm, (or bum, or whatever,) far outweigh and possible placebo effects. Who knows what's being injected into the poor kid; not him, that's for sure. What of the risks of an infection due to poor sterile technique and skin puncture and pain? Or the pain? It's so highly dubious it's not funny.

I've had an interesting run with Methadone patients recently; I've been threatened, abused and generally spat at by 'Regulars'. Don't get me wrong, I'm a strong advocate for the Methadone/Suboxone programme. On top of the typical attempted manipulation and deceit, I've just had some slightly more confronting stuff than usual; the kind of nonsense that tests your patience.

Firstly, though, here's my two cents. Methadone's an essential harm-minimisation tool, which I firmly believe makes a difference. It's seriously important in rehabilitation and addiction medicine that these patients have an avenue for supervised dosing. I appreciate it's pretty good of the owners out there to cop the associated theft, admin hassle and associated stresses, because many people wouldn't give some of these characters a second look. In my first year on the job, I saw at least one person get completely clean. For me, that was enough to justify the programme; if I owned a pharmacy, I would take Methadone/Suboxone patients.

So, a few weeks ago, the regular shows up. He's pretty calm, as per usual. In fact, the area the pharmacy's in has a distinctly relaxed, holiday feel to the place. He was wearing clothing with an extremely offensive message emblazoned across the chest, arms and back. I suggested that he would be unwelcome the next time he wore the shirt, and gave him his dose. He complained quite bitterly, in most colourful language, that we were discriminating against him (highly ironic, considering the shirt's message). He did, however, apologise to my boss the next day.

Of course, few incidents end with anything even close to an apology. Today, for example, I took a call from another client. Not a nice guy. He used to collect his dose up until last week, when he was banned from the Pharmacy, for reasons I'm unaware of. He phoned to ask if he could get his dose. He wasn't pleased to hear the answer, and swore blue murder down the phone. Here's hoping he doesn't try to come in later today.

These events have reminded me of an incident that happened a few years ago; a regular patient was getting miffed. I think he'd missed a few doses, and as there are restrictions on how many you can miss, his dose was declined. Just to aid in negotiations, he grabs the receipt spike , jumps up on the counter and lunges at the shopgirl. She's fine. He wasn't dosed that day.

And, just to cap it all off, there was a drugs-but-no-cash armed robbery about 800m up the road last week...

When I was offered a place in medicine, my boss predicted that my style of pharmacy would change markedly. He predicted that I'd move a lot more toward self-management of many conditions, that I would maintain patients on OTC medication, and that due to an enhanced knowledge, I could throw caution into the wind...

Half of the prediction was true; my pharmacy style changed markedly. Far from taking risks, however, my style, as such, has become more conservative. How did this happen?

At pharmacy school, we are indeed taught to refer conditions which fit the following; a) conditions which require obvious treatment by a doctor, b) anything we can't diagnose and c) symptoms that may have variable causes, one of which may be dangerous. Thus, sticking to these rules hard and fast in your early practice will make you a safe pharmacist.

Once you hit the workplace, though, things change it up a little. Safety, of course, is paramount. But the patient in front of you wants an answer and a solution. Now. Your experience adds up, and you know what's probably wrong and even how to treat it. Oftentimes, the patient might not understand the gravity of the situation. This is pharmacy's greatest challenge; often you're telling someone that they're seriously sick, but that you can't tell them what's wrong. If the patient has some odd symptoms, you might choose to treat them if you're convinced that all is safe and well.

Medicine teaches an entirely different kettle of fish. We have drilled into us that safety is in the understanding. According to Dr Murtagh, we adopt five principles; a) what's likely, b) what's deadly, c) what's often missed, d) the seven masquerades and e) what is the patient trying to tell me? As students we are taught to always consider the worst case scenario.

Consequently, that's exactly what I do at work. A good example unfolded last weekend; a middle-aged patient presented onchyolysed fingernails. She hadn't seen them for two months thanks to her french tips. Usually, I'd be thinking fungal infection, but two days earlier, I'd read up on thyroid exams. It seemed like it could be a case of Plummer's nails. Plus, she was in the demographic for hyperthyroid. So, I suggested that perhaps she'd want to see a doctor... just to check it out.

Ironically, my boss' prediction was in fact the opposite; my style is now much more careful, and markedly less maverick. Far from throwing caution into the wind, I'm hearing whispers of warning through the breeze.

Presently, my year group is in the process of selecting rotations for our final two (clinical) years. This has resulted in a heap of complaints and uncertainty and general bitchiness in the direction of the administration. This surprises me very little, as the general consensus from the students is that the admin couldn't organise a shag in a brothel. So, the crux of this post is to discuss some of the options for years three and four, and what I'm gonna do.

Option 1: Large Metropolitan Hospital (LMH)
This is the hospital I've been at so far. It's big, super specialised, and the 'promotions officer' from the Uni said that it's for those students who appreciate 'Self-directed learning', and may or may not be looking for research opportunities. The Paeds hospital is attached next door, and, well, every speciality is covered. General reports are that the students do lots of watching and not much doing; there's a lot of competition for the little things. Still, I can live in my current house, and still work all the same jobs; I'm well set up. I guess my concern here is that LMH I'd get lost in the buzz, and not get the chance to do anything in the first place!

Option 2: Conglomeration of several Medium sized urban hospitals
I'm somewhat familiar with these hospitals; the group I'd look at more seriously than the others are variously 10, 20 and 50 kms from my current house, all against the flow of traffic, but still within the city limits. Just. They have variously different reputations for patient care and relatively unremarkable teaching records. Summarily, they are all close enough that work etc., wouldn't have to change, but there appears to be quite a bit of changeable travel involved, particularly for certain specialities.

Option 3: Regional Hospital, Coastal location
This hospital is just over 100km away from my current house, and would involve a relocation. No dramas, though, because it's 100km closer to one of my existing jobs, where I can get more hours next year if I want 'em. Obviously, 100km isn't too far to head into the city every now and then. Plus, it's by the beach. The location itself has a population of several hundred thousand, and is rapidly growing. The clinical school is only a couple of years old, and I think because of the size of the school, it's quite close knit.

Option 4: Rural Hospital, semi-coastal.
There are two choices in this category; both towns are around 50k people, with all the kinds of services you'd expect. The clinical schools there have pretty excellent reputations; their by-line involves teaching not "medical students", but "doctors in training", and they have high practical involvement from an early stage. The Uni also reports that Rural students get better marks. The drawback? Well, the schools are 350 and 650 kilometers away, and that obviously requires a relocation and finding a new job. But, rent is free for the whole year! And they're nearly on the coast; just a short bike-ride...

Option 5: Regional Hospitals, inland.
This town also has a population into the several hundred thousands; and the Rural School is based there. It is, in fact, the best established non-metropolitan school, and has a very good reputation for teaching. It's also over 150km inland, and for my mind, not quite within striking distance of the City. Rent is free here too, and I'd need a new job. This school will be very popoular with the large number of students from this area, and hence oversubscribed.

What about my priorities? My requirements are such; I want a well rounded, semi-didactic, hands on education. I need to earn to learn, so work is essential - free rent would certainly take some of the heat out of this. I don't want to get stir-crazy; so ample opportunites for leisure and headspace in the few hours off each week will be relished; for example swimming, walking, maybe even team sports.

When I began Med, I envisaged spending all my time at LMH, but after two years there, I'm read for a change. So, given that I'm prepared to step outside my comfort zone, what next?

The regional, inland hospital holds no appeal. I like the beach, and I'm not that keen to choose a school I don't really want that will be oversubscribed. So that's out.

The urban conglomerate is a safe choice; no moving, a bit of travelling same job. What of the teaching? It seems like a slightly diluted version of LMH. I'll make it my safety option, I think.

The regional hospital on the coast is the most promising; work's already laid on, and the school's new yet promising reputation make it a good choice. The beaches and local national parks are fantastic, and rent is at least $30/wk cheaper than the City. I could head back for social events as required; I know the drive pretty damn well.

The rural schools also hold some appeal. The teaching reputation is widely touted, and colleagues in previous years speak very highly of the experience. Free rent is a big hit too, and would ease the pressure of finding a job so quickly. The tyrrany of distance will be the main challenge; I'd barely see my friends at the metropolitan schools.

After some firm thinking and discussion with Batman and other friends, here's my list:

1. The Coast
2. Rural
3. Conglomerate

Now all I have to do is wait for the results...

Firstly, like movies, everyone knows a little bit about medicine. We are exposed to it every day. There are blockbuster movies, like (urgh) Titanic. Hence, there are also blockbuster illnesses such as Cancer and Cardiovascular disease each account for a third of mortality in the developed world. In addition to this, the factors comprising any disease (movie), are infinitely complex, and can be studied down to the most minute of aspects. For example, a possible topic for a thesis may involve a tiny fragment of a receptor on an obscure cell. Much in the same way that one might know the birth place and date of the chief sound engineer on the movie My Best Friend's Wedding.

Some people enjoy specific genres. Some do horror, some do action, others art-house, documentaries or even cartoons. Think trauma, emergency, tropical medicine, research and pediatrics. Every now and then, actors try something from another genre, even playing minor roles. De Niro did The Godfather, De Niro also did Shark Tale. Hence, actors/doctors find the what they like and they're good at. Sometimes a doctor may switch into admin or policy making, in the same way that Tom Hanks did My Big Fat Greek Wedding, or as Zac Braff did for Garden State.

The endless journals and magazines about Medicine detail advances in research, information, trends and reviews of current practice, just as Who, Ok! and Hello! Magazines let us know which actor's doing what and with whom. It may be professional, or it may be discussing the finer points of interaction (perhaps like a new drug's mode of action?). All this information is testament to the constantly changing face of the industry. In fact, some experts focus on just one area; they voraciously digest every scene in one movie or of one actor, memerise the finer points of their work and timing, in much the same way we have sub-specialists in medicine. Just as for the illness, often the ones who know the most about a movie are the ones that have watched over and over again. Chronic illness must be like knowing every line to a movie; you can predict where it's going, the finer points of this or that screen angle.

I guess the challenge to someone acting in a movie for the first time is to watch, learn and absorb the experience. I'm looking forward to clinical rotations.

Recently I was asked if I would work as a palliative care physician. The question reminded me of the first teaching I received on the topic, way back in pharmacy school.

The lecture remains the most frank and honest presentation about any aspect of medicine I have witnessed. It was raw.

It was timetabled as a double, a rare occurrence in pharmacy. My colleagues and I were expecting a pretty challenging lecture. Pharmacists aren't taught to cope with death in the same outright manner that Med Students are. The consultant giving the lecture was in his late fifties. He was softly spoken and emanated a warmth that reached the back row. After introducing himself, the doctor (let's call him Dr Weatherbury) apologises in advance that the lecture may be interrupted; he places his phone on the lectern.

Dr Weatherbury goes on to explain that today his father, who was in his eighties and had cancer was being admitted to a palliative care facility. He was doing some of the organisation, and hence his phone may ring throughout the lecture.

He then outlined his plan for the lecture; a brief introduction to palliative care and the theory behind it, then a refinement of the general theory to his concept of palliative care, finally followed by several of his own experiences and question time.

I will, very briefly, recount a hackneyed version of Dr Weatherbury's concept of palliative care.

He emphasised that palliative care was an acceptance. It allowed for spiritual and emotional resolutions, and for the patient to make the most of their remaining life. To foster inner peace and to reduce pain.

Within the context of pharmacy, the analgesia aspect of palliative care was briefly discussed. Dr Weatherbury also emphaised the importance of tailoring and establishing the patient's end of life goals. He made a strong point about not 'digging up' long-lost relatives just because you were aware of their existence.

As he was summarising the theories of palliation, his phone rang and he dashed out. We sat. Ten, twelve minutes passed. No one changed seats. No one left.

When he returned, he was apologetic.

Dr Weatherbury began to recount his first palliative patient; an elderly man with End Stage Renal Failure. Dr Weatherbury would pop in each day, 'just to balance the meds'. When the patient eventually said,

"Harry, you can come around here without changing my pills, y'know."

Dr Weatherbury attended every day until the man died.

Among the other stories he recounted was that of a twenty-six year old woman with breast cancer. The was so weak she could barely stand. She had been at the hospice for several months and was depressed and initially despondent. Dr Weatherbury admitted having a hard time talking with the patient. She wanted no sympathy. As with most of his patients, she requested Dr Weatherbury assist her sucide. As always, he refused and opened a discussion with her. Eventually, they talked about what she wanted to do before she died.

She wanted to feel the grass between her toes as she walked on the lawn.

A simple enough request, but one that required strength and some good weather. Otago is known for its harsh, cold spring. She and Dr Weatherbury worked to improve her state of mind, and she became stronger and more resolute. She would achieve this. One day, the weather cracked, and the cold, blue, southern sky bathed the lawn in sun.

The young woman was wheeled to the edge of the lawn, and a nurse took off her woollen socks. Dr Weatherbury helped her up, carefully, slowly. She tottered. She put out her foot and righted herself. She took a few steps.

She looked to the grass. She looked to the sky, and smiled. And cried. The nurse and Dr Weatherbury cried too. He spoke of the reward, the pleasure in a simple act, we all take for granted.

Dr Weatherbury's lecture is etched in my mind. Here was a man whose own father was heading down a path he'd seen so often, yet his compassion was so emphatic and complete. Not through storytelling, but through pure empathy. He brought students to tears.

Case 3: It's 9.55pm on a Sunday. The next closest hospital is twenty minutes away. In walks the last patients of the night; a couple.

He is stressed and sweaty, and talking very, very quickly. But he's fine.

She sits down. She is pale, sweaty, agitated, feeling a bit faint, short of breath and pregnant. Thirty three weeks pregnant. She's not fine.

About fifteen minutes earlier, they had been at dinner, having a wonderful time on a romantic getaway. It's all turned to custard pretty quickly. Before they left on holiday, she'd had a cold, and her doc had prescribed some antibiotics. She had taken the first dose with dinner. About fifteen minutes earlier. Within a minute or two of ingestion the lady (let's call her Sharon) had to bolt to the toilet with diarrhoea. Her initial complaint had been cramping abdo pain; the respiratory signs followed soon after.

I called the ambulance on the spot; this wasn't a case I was going to take lightly. The Ambos arrived within about eight minutes. In that time I dosed Sharon with some salbutamol and tried to extract as much of a history as possible.

When the ambos arrived, we arranged for a dose of antihistamine and they whisked her off to hospital.

The next day, Sharon's husband kindly returned to pay for the medication. I wasn't at work, but apparently Sharon had gone massively downhill on the way to hospital. Fortunately, the ambos managed the situation well and got her there in time. Both Mum and foetus were doing well.

Summary: For all of the cases in this series, diagnosis was based on several observations, including:

Timing - Anaphylaxis happens within 30 minutes of exposure. It's a fast reaction. Other allergies typically take a bit longer to manifest.

Presentation - the patients had several or all of the following signs:

• The hallmarks are a combination of urticaria, erythema, pruritus, or angioedema. Laryngeal oedema, bronchospasm, cough, sneeze, wheeze and nasal secretions are also likely.
• Patients may complain of a generalized warmth, tingling of lips and tongue, a lump in the throat, tightness in the chest or a feeling of impending doom.
• Gastro symptoms are quite common; diarrhoea, vomiting and particularly cramping abdominal pain.

Causes - Anaphylaxis can be caused by a number of allergens; nuts, fish, eggs, bee & wasp stings and some antibiotics are the usual suspects.

Management - As in the cases above, the patient is best taken to hospital for care, especially for an initial attack. Dial 000 or 911 without delay! Adrenaline is the cornerstone of treatment; this should be given by a trained practitioner where available. Other treatments used in conjunction with adrenaline include bronchodilators, steroids and antihistamines. Some patients whom have known anaphylaxis may be supplied with an Epi-Pen; this should be used as soon as anaphylaxis is suspected, and an ambulance called.

Conclusion (in three sentences) -

1. Anaphylaxis is a life-threatening, multi-system allergic reaction.
2. Patients will present within 30 minutes of exposure with respiratory and/or gastro signs.
3. As soon as anaphylaxis is suspected call an ambulance and use an Epi-Pen, if you've got one.

For more information, have a look at Wiki's guff, or talk to a doctor or pharmacist in person.

Disclaimer: This website is provided for entertainment purposes. Anaphylaxis is a complex medical situation and this post has provided a brief overview only. If you think you have anaphylaxis right now, call an ambulance immediately.

This week I've been on holiday; avoiding study and relaxing at an Ocean paradise....

But, I managed to find some more markets;

with windmills,

On Monday I'll be back at Uni and fully wired

These two patients could not have been more different in their attitudes to what was happening to them. Each presented with several hallmark signs of Anaphylaxis. Hopefully they had the same outcome. For one of them, I'll never know.

Case One: Olivia was a twelve year old kid, in her last year of primary school. She'd been away for the weekend with a group of friends (and two mothers), and they'd been camping near the pharmacy I was working at. It's early in the afternoon, and I'm dealing with an lady who has some mild intellectual impairment who has fallen over. I've just seen off an ambulance. They were going to deal with the blood dripping from her head and her altered mental state. She'd actually fallen over twice. The second time was down her front steps, on the way to the 24hr medical centre about the first fall. Hmph. Anyway, in bustles one of the parents with Olivia.

Olivia is very pink in the cheeks. She's sweating profusely, and I can see hives across her neck and upper chest. I quickly ask how long she's been like this, and it's been about ten minutes. She's never had anything like this before. Olivia doesn't have no known allergies, but she's sure as eggs allergic to something. She's deteriorating before my eyes. I get her some ventolin. Olivia says to the helper that she's really scared. For the second time in half an hour, I call the ambulance. I tell them that there's a case of suspected anaphylaxis. The ambos rock up inside four minutes, and whisk her off to the local hospital. The pharmacy gets a call the next day; Olivia's okay. Neither she nor her docs can pinpoint the allergen.

Case Two: It's 6pm on a Sunday and the pharmacy is packed. Like, thirty people and twenty 'scripts packed. The automatic doors whir again and I look up. A kid about 18 swaggers in. He's only wearing white boardies and a cap. Everyone stops what they're doing and just stares at this kid. He is red as a beetroot from the umbilicus to his eyeballs. One of the ladies waiting gasps in horror.

"How long have you had that?", I ask from about 20m away, as I put down the script in hand.
"Oh, about five minutes, I just need some cream for it."
"Have you been coughing since that came up?"
"Yeah, a bit. My hayfever's a bit shit."
"Mate, you're having an allergic reaction, you've gotta go to hospital now."
"Nah, just gizzus a cream."

Then he starts coughing. His girlfriend has run in behind him, and she's worried. Rightly so.

"Listen to the man!" She says.
"Nah, it's just a rash. What about those" cough, cough "antihistamine tablets."
"There's nothing I can sell you that'll help, but I'll call an ambulance for you. What's you name?"
"None of ya business!"

A septagenerian waiting patiently touches his arm and says;
"Sonny, you look in a bad way. If he pharmacist says you're in trouble you need to listen to him."

"I'm fine, aye." cough "I just want some cream..."
"Look chief, if you don't get to hospital in the next fifteen minutes, you're gonna die. You're coughing because your throat's closing up. I'm not kidding here."
"Aw, F*** ya then." And he walks out.

The girlfriend has decided to listen. She asks, quickly, how long I reckon he's got. I impress the importance of getting the guy to hosptial now. She looks worried, and runs out, shouting "Jaaaames....." She takes his keys and gets in the driver's side.

They drive off. I really hope they went straight to the hospital.

Next on Tales of Anaphylaxis: Part III: How to spot it and The Worst Case Scenario