Dying for a Drink

Alcoholism isn't pretty. Wernicke's-Korsakoff syndrome is worse. I've just met my fifth patient this year with end stage Korsakoff's dementia, and it's a harrowing illness.

Not so much for the patient; they are goneburgers. Their short term memory is destroyed, so is their ability to learn. They're stuck; memory frozen in the time just before they degenerated into oblivion.

The ugly side of acute alcohol use are widely known, from hangovers to car crashes, both in the young and oldies, too. Most people know that drinking too much stuffs your liver and gives you a red nose. But who really sees it?

The traditional view of alcoholism is that no-one talks about it. The most that's ever said of a fifty-year-old whose drinking patterns are dangerous might be 'Gee, he likes a drink.' It's written off as a part of Aussie culture.

So, next time you think 'Gee, he/she likes a drink.', help a mate out; Ask them the CAGE:

Are you Concerned about your drinking?
Do you ever get Angry or agitated when asked about your drinking?
Do you ever feel Guilty about your drinking habits?
Have you ever had an Eye-opener to get you started the next morning?

If they score more than two, they might need some help or good advice about their drinking patterns. Because there's no point dying for a drink.

Always Open, Never Open

It seems that small towns have a 'never open, always open' way of life. That is, to someone travelling through, if the local shop is open 8am to 5pm, Monday through Friday and that's it. Same with all the other services. But to a local, things never really close. If you're friendly with the shop owner, they might open up for you. It's the benefits, I guess, of being small; you know all your customers and you want to help them out.

For the town doctor, it's a bit different. The surgery is closed on the weekends, but the doctor is always on call. And, of course, the hospital is always open.

You might think that with an official town population of fewer than 500, things would be pretty quiet. But no. The local doctor is extremely busy, and the idea that they're constantly 'on-call' can be exhausting.

As far as community life rolls, the challenge is to be involved 'just enough'. From one point of view, that's being able to have a drink at the local pub without gaining a reputation for such. From another point of view, it's being able to head down to the shop and have everyone say 'G'day', but no-one ask about their test results or medical problems.

Last week, someone in town made a point of mentioning that they'd seen the doctor walking around in shorts and a T-shirt on the weekend, and that it was inappropriate dress. The doc, quite rightly, laughed, and mentioned that he tends to wear that kind of clothing to put across the message; I'm not at work, so don't ask.

Ironically, it's also par for the course to wear stethoscopes to the shops on lunchbreak to give the opposite message; I'm working, so I need to get back to it.

The crux of all this is that when there's one doctor in town, the most important thing they can do is to educate the community to know firstly, when working hours are and how to make appointments and keep them secondly, that it is always okay to contact the doctor in an emergency.

That way, the town doctor not only has some life not chained to the hospital or medical centre and can participate in community life to the full.

Auschwitz and Birkenau

A few months ago I visited Krakow, Poland and the Concentration Camps at Auschwitz and Birkenau. I had arrived in Krakow the night before, and I would be leaving Poland the next evening. This was my day trip;

The sun rose and I felt fucking weird. Just outer-earthly. I haven't really talked to anyone about it since the few days after. But yeah, really odd. dreamlike. but not nightmarish, yeah? I sat on the train and stared into the polish woodlands. My sister had told me that when she was on the train all she could do was imagine jews running for their lives sixty years earlier. I couldn't. I just stared at the trees and the crumbling brick houses and their graffitied swastikas and felt numb. I tried to listen to my iPod, but stopped for because I didn't want to mix my memory and the music up into each other.

I got off the train and started walking. Two chinese-american guys were walking in front of me, and we all recognised each other from Warsaw a few days earlier. They asked directions from a local, who after a funny look or seven pointed them in the right direction, I followed at a distance, wanting to be alone with my thoughts.

Along the walk, a group of five Polish boys, aged 15-ish approach on the opposite side of the street. One of them points at the guys in front of me and shouts out,

"GOOK".

And they all start shouting, "GOOK, GOOK!" as they walk past.

We were less than 500m from the front gates of Auschwitz.

Auschwitz was originally a barracks for the polish army. The Germans took it over pretty early in the war, and started by keeping polish political prisoners there. Then they needed workers and the like, so they brought in Jews. They also used it as a testing facility, where the first Zyklon-B gas pellets were tested. It's actually pretty small, maybe 2 acres, and quite densely packed. Nowhere to run, that's for sure.

I walked under the gate that says (in German) "Work shall set you free." and shuddered. This place was, creepy, haunted, placid, out of time, mindnumbing, frozen and sickly.

I went to see one of the 'barracks' buildings where prisoners were kept. A gentle start to the day, really. There were photos of everything, of course, including how the prisoners slept. Like this >>>>>>>>>>>> and then another row of <<<<<<<<<<<, about eighty people in a row in a thirty metre long room. Four rows deep. Like this; <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
and so on. There were 8 rooms per building and 24 buildings. Numbers hurt my brain.

I went outside in a daze. There were tour groups in gruff german and rolling french at every corner. The people were getting to me. So I went to the Gas Chamber. It was situated about 10m through the fences out one side of the complex. I took a breath and felt sick. The chamber was a converted bunker, with a chimney out the top. It had the only green-lawn grass I'd seen in Poland as a roof. I went inside.

It was the most fearful place I have ever been inside.

Low ceiling, just like a cellar. Dark, cold and empty, save for a wreath and a candle. I stood and cried and cried and cried. I put a stone on the floor just past the hand railing, next to all the others. I went outside.

I pushed through a group of Polish schoolkids, laughing, kicking stones to each other with tears in my eyes. Through the double fences of barbed wire, back into the heart of the camp. I found a deserted part of the camp, visible only by a guard tower, and sat and cried some more. Sorrowful, deep, hurting sobs.

When I stopped, I went to see the rest of Auschwitz. In some of the buildings were examples of torture. Fucked up to the max, the kind of sick stories that kid tell other kids to freak them out. Except there were photos. Photos of the tortures, photos of the apparatus.

And photos of the dead. Every person interned in Auschwitz in the first 3 years of the camp was photographed and their details recorded. My grandfather was there from the 4th-6th years before liberation, so no photo.

The photos are what I remember most. Thousands upon thousands of men (and some women), shaved heads, no glasses, prison stripes. Old men, young men. Wasted faces, gaunt cheekbones and hollow eyes. Some look at the camera confused, others without emotion. Most have no hope and show only fear in their eyes. With perfect, rifle induced posture. I bet the Nazis got a real kick out of those. But one in fifty or so had a look about them, a hope, a strength. Not the manic 'I'll have the last laugh' look, but a firm, stoic, confident look.

They all died. Every single photograph. Dead.

I visited the death wall where they executed people. I saw the 'standing cells' that you had to crawl into through a grill a foot high and was about the size of a pillow, and the opposite level of soft, warm and comfortable. I saw the gallows where a dozen at a go would be hanged in tandem. I saw the 'roll call' area, where every inmate would stand for as long as the commandant required, without moving. Up to thirteen hours.

I read about the Sonderkommando. They were the men charged with travelling to Birkenau and cleaning out the chambers after each gassing and disposing of the bodies. Every six months, all hundred of them would be shot and another hundred trained. This was to destroy the evidence.

It was noon. I was numb. So I took a stone from the yard and left. I held the stone all day. I went and sat outside for a bit, to try and clear my head. Fat freaking chance. I started walking towards Birkenau, about three miles. It was pretty routine for inmates to be sent on the same march, and those lagging to be shot. I took my sweet time, because hey, screw them.

I had also decided to forgo food on this day. Call it symbolic, call it sheer silliness, I wasn't going to be chowing down a chocolate bar in a concentration camp, y'know.

Birkenau is the one in Schindler's List. The one with the 'Gate of Death' and the railway line and the watch tower. I walked straight up the railway line. Through the gate of death. Past the wreaths.

Birkenau is huge. Just massive. Over a kilometre from front the Gate of Death at the front to the forest at back, and nearly a mile wide. And it's all fenced, like deer paddocks. There are single story huts that slept about 600 people, about ten to a box. A box being the size of a king single, made of wood with maybe some hay if you're lucky. Three boxes high. The latrines are as in Schindler's List. You know, when the children hide in the faeces and urine to avoid death.

I strolled around; firstly up to the back of the camp where the shells of the main gas chambers are. The Nazis dynamited them when they were going to lose, to hide the evidence. So, unlike Auschwitz, there's no actual chamber or floor plan, just a brick pit where the 'showers' happened. There's also the Holocaust Memorial in about fifty languages. I felt ashamed that I couldn't read the Hebrew. I walked back down the railway of death and walked down a side road, used to move victims to chambers 3,4 and 5 on the far side of the camp. The road goes right down the middle of the camp, like this.

chambers 1 and 2 at rear of camp. 0000000|| chambers 3,4,&5
][ <-- railway line 000000 Huts 0000000 || ][ 000000 Huts 0000000000000000000|| ][============================|| <-- road ][ ][ gate of death down here.

The sun was setting, and everything was martian red. The temperature plummeted, and I stared at the path. There was dirt and rocks. All red. Like another planet. Like blood. There were long shadows fencing the in and the out. I wasn't in but I as going somewhere worse. I walked along the road. I remembered one of the songs I'd listened to on the train. The song is unsettling anyway; Frou Frou's Psychobabble.

That alien landscape is still burned into my brain. The sick-at-heart feeling, creeping, scrawling at my back.

At the end of the road I turned left and walked towards chambers 3,4 & 5. Behind them is the 'washing' room, where the prisoners were deloused, shaven, robbed of all their possessions, drenched and 'selected' for work or for imprisonment. These were luckier people than most.

Before it reaches the chambers (and ovens), the road passes through two clumps of trees, each about the size of two basketball courts. The sign says... "On some days, the gas chambers were so busy that Jews awaiting death were made to wait in these trees." And there's a photo of maybe a hundred people, all dressed in stock-standard 1930's clothing in the trees. All the women look terrified and empty. All the children are frozen and the men, empty.

This clump of trees occupies my nightmares. I think, deep down, it always has, but now I know what it looks like. The red walk to the trees and the ovens.

I took some time to look at the surrounding chambers and to quietly ponder the sights of the mass, open air graves. I laid a stone on the memorial plaques. That's a Jewish thing to do. It shows you've been and that you remember. I walked past the selection room and the site of the storage room for glasses and shoes and clothing.

It was getting dark. I had a torch, but, let's face it, we both know that getting stuck in a concentration camp after dark, where no one in the world can contact me is pretty much the scariest thing I can think of. So, I made my way back to the memorial, where there was some light, and walked back up the railway line.

Just before I walked back out through the gates of death, I turned and surveyed the barren, desolate fields of death to which I hope I never return. I walked back along the railway lines to the city of Osweincim and waited for my train. I ate a roll.

I caught the train back to Krakow. Just before midnight, I caught a train from Krakow to Venice.

To another world.

Mowers v. Moas

Do you mow?
This is a high yield question in a systems review. Apparently, mowing the lawn is the preferred pass-time in costal Queensland. It also, apparently, has a high rate of medical problems associated with it.

No, I'm not talking about sticking and arm or leg into the path of whirring blades. I'm talking about the folks whose chest pain, breathlessness, nausea, abdominal cramping, leg, arm and back pain all initiate, whilst they are mowing.

And fair enough too, because mowing is hard work. Some farmers spend their whole lives growing and mowing grass. Although, not so much by hand or by push-mower these days. The area around the main Coast hospital is hilly and what with the end of South East Queensland's drought, and weeks of regular rain, the green stuff's trying to turn amazon on Arthur and Martha alike.

There's no sheep here to eat the stuff away, and the other moas are extinct. Far from becoming extinct, Coastal moas appear to be proliferating.

That's why it's a jungle out there.

Perspective

Discharging a patient back to nothing is bad hat. Very bad hat. But apparently, the regional hospital near SQuIRT loves to do just that.

They also have a knack of 'getting people back as outpatients'. This is all well and good when the patient's digs are just around the corner. But when they live 400km West, it's just plain dumb.

The team is trying to discharge the patient because either they reckon the patient'll be better off at home, or they want an empty ward. I really hope it's the former, not just because the treating doc felt that needling the new lump in her chest could wait until 'after Easter'.

There's a little bit of perspective lacking in all this.

The poor old duck is going to be transported, quite rightly, by StateHealth. It's going to cost a couple of thousand dollars in transport, wages and the rest. And at least the same to get her back in a few weeks time. Assuming, of course, that her situation doesn't deteriorate further.

But maybe dear Betty's got things planned with her family for Easter? Easter is, after all, an imporant time for many Qld families, and what'd be worse than hanging out in a hospital for a four-day weekend. For Betty, though, this is unlikely, because she's likely going back to the local 'medium-care facility' - the rural hospital.

So, yeah, I appreciate the idea that staying in hospital sucks. If I was strung up in a hospital over a holiday I'd go stir crazy. It's a genuinely nice idea to have the LOL in NAD further assessed as an outpatient.

But before you ship her out, please have a good, long think about whether that test can be done now, or tomorrow, or maybe after the weekend, just so she doesn't have a twelve hour-round commute. When you weigh up her options, she'll be much better off snuggling down on the ward for the weekend. Sure, she's taking up that bed, but Betty'll probably enjoy being in the same place for a few days.

Frail, dementing octogenerians don't hold up too well when it comes to being transported for more than half a waking day.
Medicine, according to many, is about lists. According to my Med School, it's about first principles. Of course, the answer lies somewhere in the middle; both are essential. Overall, it's about question and answer; it's about the big picture.

First principles make you think; "What's the mechanism for that?" is easily the most popular phrase uttered in first year medicine. That deep knowledgable understanding teaches you to work things out from the bottom, up.

Lists hold the answers; "List the Cardiac causes for acute dyspnoea? Acute Pulmonary Oedema, PE and Tamponade" (Thanks again, On Call) Lists have fast answers and form strong but flexible management plans.

I reckon almost every other health profession is about lists. The practical, no nonsense stuff that leads down a path, somehow. In Pharmacy, it's WWHAAM;

Who's the patient?
What are their symptoms?
How long for?
Actions taken?
Allergies?
other Medication?

For the Ambos, it's DRABCDE;

Danger
Response
Airway
Breathing
Circulation
Disability
Exposure

For Dentists, it's the above/below rules;

Is it above the nose? Yes? Not my problem.
Is it below the jawline? Yes? Not my problem.

And so forth. Rarely, the Med School teaches this well, as in DRABC above. Other times, such as certain aspects of history taking, the school fluffs about. We're effectively made to recite the DRABC mantra until it sticks. Comparatively, though, when it comes the questions for, say, a Cardio history or a systems review history, we're given a few references and told to 'go fetch'.

This all becomes quite frustrating, when one line of teaching isn't as forcefully taught and you consider them to be of similar importance. I do, of course, appreciate the utmost importance of DRABC, but my point here is more that being taught the exact information to elicit on a history is taught in less detail than, say, the biochemical basis of thallassemia major. I'm pretty sure which one is higher yield. Especially considering that said biochemical basis of thallassemia major has a whole chapter in each of Robbins, Harrisons', Davidsons' and Kumar & Clark.

I know my course is all about 'Self Directed Learning', and the strengths and weaknesses of the system. And yeah, getting the questions is the students' prerogative. But as I've mentioned above, the emphasis is skewed. Being direct in taking histories is something that can be taught.

Of course having the basic line of questioning, the automatic thing you do or ask, is great for 'basic operators'. That's not me hating on allied health, that's the acknowledgement of different scopes of practice. The 'best practice' lists and plans are at the top of the knowledge tree; it's the science underneath that makes them work. Penultimate and Final year med students and, to a point, interns, would benefit from having the big picture properly 'hammered home' early in the course, in addition to the finer points of the system.

Some hard and fast lines of questioning, just as a wee bit of ammo, would breed confidence, both from within if not without. And if there's dissonance, then we'll know to ask a guru, to keep everyone safe, and teach ourselves something. But, hell, having a solid system of what to ask when would be a great first step.

After all, we don't need to know how to land in a snow storm, at night, on a helipad, in a jumbo. We just need to have some lists thrashed into us.

DVT [Anaemic...?]




-

Sh1te Towne vs Chickenman

One of the more spontaneous things I did at Uni was to drive a 800km round trip to watch a game of hockey. I was definitely the passenger; the other lads were seasoned road-trippers. On the trip, we played two games. Sh1te towne and Chickenman.

To play Sh1te towne;

  1. When approaching a town, accelerate to the speed limit. The town is automatically a "Sh1te Towne" if the speed limit remains at the maximum throughout.
  2. At the town's "Welcome to xxx" sign, place the vehicle in neutral.
  3. Roll or glide through the town, obeying all road rules.
  4. Should the vehicle's speed a) drop below 10km/h, b) obstruct local traffic, the vehicle must be returned to the appropriate gear, and the town be declared as "Not sh1ite"
  5. If, however, the town's "Farewell from xxx" sign is passed with the vehicle still in neutral, it shall be declared a Sh1te Towne.
  6. Remember, towns may be sh1te in one direction or both. Make sure you check in both directions.

Chickenman is more of a punishment for dilettante passengers;
  1. A passenger 'playing up' or irritating the driver will be asked to exit the vehicle. Whilst it is stationary, of course.
  2. To regain entry to the vehicle, the passenger must walk in front of the vehicle, along the verge, for a distance of fifty metres, whilst; clucking like a chicken, waving their chicken wings, exposing their chicken legs and buttocks to the driver of the vehicle.
  3. In turn, the driver shall honk the horn and flash the lights for the duration of the walk.
  4. Other passengers are also expected to heckle loudly and point out the window at the Chickenman.
  5. The Chickenman shall be granted reentry to the vehicle, which may reenter the flow of traffic.
Stay safe on the roads folks.

Rodeo

Last night, I went to a Rodeo. It was pretty good fun; all the cowboys and local farmers rolling around in their boots and jeans and the like. Of course, one of my more 'city' classmates mentioned the manure, but the atmosphere was thick with more than manure. It was a practice rodeo; no prizes, no judges, no real order of things. It was also primarily a 'kids' rodeo; the average age of the riders was about fifteen. Funnily enough, some of the young bucks even had their wee legion of groupies. For some of the wee cowboys, it was their first ride. They all fared better than the bull that bucked himself dizzy and staggered to the ground. Eyebrows were certainly raised at the announcers warning to "Watch out folks, these fences can move up to a meter!"

The evening also afforded some of the best steak I've had in months. It was, in fact, more delicious than the irony of watching the bovine extravaganza whilst tasting the same. Anyway, some of the local med students had been to this particular rodeo restaurant a few weeks earlier to watch a slightly bigger even that last night's. They even managed to find themselves getting their hands dirty;

It'd been a good night, there had been some good cowboys and a few crazy rides. The usual amount of riders getting smashed up against the fences and no-one had been kicked. One of the more experienced riders was in the shoe, and the gate jumped and away it all went. Bucking and stomping and dust. The guy stayed on for a good six or seven seconds, but the bull was just going bananas. As he lost his grip, the Cowboy fell on his noggin. Some of the people who were watching reckon he got stopmed for his trouble, too.

The Cowboy's out cold. The clowns rush in and the ring fills up faster than a school cafeteria at lunchtime, and the bull gets rushed the hell out of there. Meantime, the bloke's started to convulse, and tremble and the like. He regains consciousness, and his mates try to help him up. He falls down, confused and sloppy.

The students watch on; surely someone out there's a paramedic or ambo or some such. But, nope. One of the final year students, Rocky, heads over and asks if people know what they're doing. They don't. So he suggests the bloke lie down and stay still and get hisself an ambulance. Cowboy's feeling a bit better, and his bravado kicks in. "She'll be right mate, just lemme have a sit out the back for a bit, yeah?" And Cowboy heads with his posse round the back, and they give him a few shots of rum.

Rocky, flabbergasted, comes back and tells the rest of the crew what's goin' on. So one of the girls, Prefontaine, goes out the back to have a chat with the Cowboy. His mates are back ringside, and one of them's about to ride. Prefontaine tells the Cowboy that he just got smashed, and describes the convulsion, and manages to get him to admit that, yeah, he feels like he got hit by a truck. Or kicked by a bull. His bravado and self confidence isn't in the healthiest condition, not surprisingly. He just won't be convinced to catch an ambulance up to the hospital, because he doesn't want to be seen as a sissy. The rodeo's continuing out the front, of course.

Finally, Prefontaine and one of her mates get Cowboy to head to the hospital by offering to drive him up there themselves. And away they go, and half an hour he's in the CT machine.

There's been a stack of publicity about Natasha Richardson and, in Queensland, a recent spate of Courier Mail headlines about folks who refuse medical care, because of the either the percieved cost of care, or because the patient thinks they're fine. Medics who witness these situations need to be assertive and plan for the worst case scenario. And, seriously, if you have a convulsion when you fall off a bull, see a Doc and get a CT.

Septic. [Anaemic...?]

_

Sydney or The Bush

Okay, so I'm not actually based in Sydney. I just liked the title. And, lets face it, the Coast, where I'm based now, isn't the most metropolitan area in Australia.

But, for the next six weeks, I'm out at a wee town called SQuIRT. Yep, Some Queensland Isolated Rural Town. SQuIRT, population <500.

My colleagues are getting shunted to various outposts, inposts and mid-posts across greater Queensland. For some, they've never heard of where they're going. Others have been allocated towns they're most familiar with, either through growing up there or nearby, or because it's a gun holiday spot, or even because their destination is well covered by the mainstream media for 'health issues'. Mostly, though, people haven't had much of a say in where they've been sent.

Actually, I'm pretty sure the choice comes down to Regional, Rural or Remote and the AIHW published a list of several methodologies to define the terms.

Due to SQuIRT's surrounding area and population (about 1,500 all told), I think it qualifies as Remote. However, the proximity of other main centres somewhat lessens the designation on a number of scales, which peg it back variously to 'Outer Regional' or 'Moderately Accessible'. Either way, it's bloody small.

I'd never heard of SQuIRT until it popped up in the MedSchool's email. Not surprising, I guess, given that SQuIRT's not the most populous, not the most acclaimed and certainly not the most marketable joint in Queensland. No worries.

I've got a few plans for my time at SQuIRT; some medicine related, others not so much. Plenty of reading (non-med and med, too), and hopefully some good kms on Rosie, my bike. This is, of course, dependent on the roads being a) suitably metalled and, b) not competing with road-trains for tarmac.

I will say that I'm very much looking forward to living in a small town; meeting new people, seeing what's important in their lives and, well, getting into the routine of rural life in SQuIRT. Oh, and Rural Medicine? I'm definately into that. No worries at all.

SQuIRT