I can't tell if Razorback's exposing a physiological or psychological deficit. Obviously, I'll need to ameliorate both to complete the challenge. There's certainly something about the 4km corner; it's the pincher and the popper. A few of the blokes in the Coast Cycle Club reckon the corner had a 35% gradient. Regardless, Razorback's last 1500m doesn't drop below 8%.

Current score (unchanged); Capt. Atopic 0, Razorback 2.

I've previously posted about my dislike of Ibuprofen & Codeine combination products. A few weeks ago met an example of my 'doom and gloom' ministrations, Corey.

Corey is thirty and has an addictive personality type. He's loved and kicked amphetamines, marijuana and benzos. He has been employed fulltime in a mid-level job throughout. He started taking Nurofen Plus(R) two years ago, and just over a year ago first nailed a 24-pack in a day. About January, he stepped up to 96 tablets a day, every day.

It was an eye-opening interview; I've only seen this kind of patient through Pharmacist's eyes. After a few minutes of talking with Corey, I asked a whole raft of questions about how many pharmacies he went to, what his usual 'symptoms' were, why he thought he needed so much and what happened when he was denied supply.

The money was never a factor, he said. It was about 'pain' and 'feeling normal'. He visited over forty pharmacies within a fifty kilometre area. If he got denied, he'd just go aroung the corner, returning to the first pharmacy a few weeks later. Corey said that he was rarely questioned about his use; he got denied or lectured a few times and copped more dirty looks than he'd care to remember. But, he said, without the pain killers he'd be in pain. He felt energised when taking them; during our interview, he expressed a desire to take more.

Corey doesn't have good insight, and I'd be pretty guarded about his prognosis. Why'd he even present to the GP? Five nights as an inpatient with Acute Analgesic Nephropathy and NSAID-induced gastritis.

---

The Australian Prescriber Magazine produced this well-written article article on Drug-induced Kidney Disease.

Most importantly, if you are concerned about your use of NSAIDs or NSAID/opioid combination products, or if you regularly take greater than the maximum recommended dosage, please see your doctor.

The challenge is to ride up The Razorback before 30th December. It's one of the steepest, most brutal hill-climbs on The Coast. Razorback is a 5300m ride at an average of 7.9%. This is the route;The Razorback was my climbing 'trial by fire' several months ago; it scared me off when I unceremoniously popped with a kilometre to go. Admittedly, my technique was awful, gearing atrocious and I was frankly unfit. This week I tried again and despite thousands more kilometres and over a dozen good climbs in the legs, I popped again. At the same corner.

The gauntlet has been laid; Razorback by Dec 30.

I thought I'd blog about the challenge not only to spice things up, but also to keep accountable. I also suspect self-induced suffering could make for interesting reading and some good photos, too. I'll post updates weekly on Wednesdays up until 30th Dec; 40 days left!

Today is exactly two years and one week since I first watched someone die. Actually, I watched two people die within and hour. It was in the cavernous and crowded Emergency Room at Viet Duc University Hospital, Hanoi.

The second man was less than twenty; he was jaundiced, cachexic and was becoming septic. He had metastatic cancer and was a waif. His breathing labored. His family kept vigil as he slowly, steadily slipped away. His eyes darted about the room, fearful, anxious. He looked at the three caucasians in the room and begged his mother and brother to ask us to help. The consultant watchfully guided us to the other side of the room. The man's breathing labored more, then began to slow and ease. His eyes flicked and rolled back and away; an hour later, he died.

Meantime, the first man had been hit by a moto. His trolley rolled into the room's fundus, pushed eerily, airily by a porter unseen. The whole world seemed to stand still. Then the consultant sprang to action, cleared out the myriad of Medical Students and ran the show. I stood next to the column in the centre of the room, out of the way. I couldn't understand any of the rapid, intense Vietnamese orders bouncing off the dirty, sterile walls. The student I'd been helping practice his English was now pressing on the man's chest, sweating in the Hanoi autumn heat. The girls hovered around in their white coats, eager to help. The senior resident again shooed everyone away. I stood there, gaping and dumbfounded as the man's mouth greyed, eyes glazed and froze forever.

The consultant turned to me and said firmly "Chết"; an unblinking stare, a quick shake of the head.

"He is dead."

My classmates and I had been let loose all day; mountain biking, hiking, swimming, the lot. As typical twelve yearolds, we'd ran amuck until well past our bed times. It was my second week at a new school and the entire yeargroup was at an Alpine camp for Orientation.

Being the second 'intermediate' year, there were only a dozen other new boys starting at the school. Mostly we were from other schools around town, except Freddie. Freddie was from Hong Kong and had cried nonstop since the day he'd been dropped off at the school's Boarding House.

The teacher, a man-mountain rugby player and coach known as The Fridge, had his patience slowly burning away with a teary, incommunicative and distressed tweenager. More than once, Freddie had been returned to the Boarding House in the middle of the day as he was so inconcolable.

At the Alpine camp, things hadn't improved much. Freddie had been on a few walks but he was still struggling to come to terms with his new life. Hardly surprising; we were twelve years old.

The first night, Freddie sat, awake and miserable, outside on the fort. The Fridge went and sat with him. They talked about moving and school and that sort of thing. Freddie asked what the white dots in the sky were. The Fridge was genuinely stunned. Freddie had never seen stars before; the light and air pollution meant that for a city-dwelling kid, the stars were a thing of mystery.

Freddie cried. Not from sadness or loss. For mystery and awe. The Fridge went to bed and Freddie sat up until the stars faded with dawn. He didn't cry in class after that night.

__

Earlier this year, my father had his lenses replaced. Not the ones in his glasses, the ones in his eyes. A few weeks later, I was home to visit. On the first night, after a late dinner, as we strolled across the garden he looked up. And kept looking and looking.

Freddie hadn't seen the stars in twelve years of life. Dad wouldn't have seen them properly in the last forty years. He tells me they're sharper and brighter than they used to be.

A few weeks ago, I rode from the Coast to Brisbane with my friend Ice. Ice is a chilled-out guy and certainly can turn the pedals. Like all intrepid bicycle rides, we plotted out route and along the way found a nice place to stop. The 'town' Elimbah, which consists of a servo/fisho/bottle-o and a few caravan trailers. I went inside for chocolate and fluids.

There were two other customers; a kid of about ten and a bogan who passed for twenty. Evidently they knew each other, and when the younger bought a Diet Coke for his mum, the elder harrangued, cajoled and deprecated him for his choice. The faux-hawked bogan bullied him; "You're gonna get Cancer!" he sang, and stated that 'Normal' Coke was better for you. The teenage shop assistants smiled and flirted with the bogan, and the younger left, licking both his wounds and his ice-cream cone.

I paid for my chocolate and hit the road, saddened and more than a little perplexed by the happenings in Elimbah. Ice asked if there was something weird happening in the shop; I retorted that it was a weird area, let's keep movin'.

Cancer is a powerful word. It motivates people, it scares people. It changes how someone looks at the world. Cancer evokes a deep, primal fear of the unknown. Understandably, it's not a word doctors just waft around during a consult, and especially as a med student, you don't say the C-word to patients very often. Timely reassurance is important; there may be few things more comforting than the words; "You don't have cancer." But almost never, especially not as a threat, is the C-word used in a routine consultation.

I'm taken aback by the idea of threatening someone with Cancer because they didn't drink your brand of soft-drink. I know the bogan's was being malicious not dispensing medical advice, and that there's no limit to the kinds of insults people hang on eachother, but I remain surprised that such use of the C-word is a viable term of abuse.

Upon moving to Australia, I lived with a classmate whom I'd known through high-school and uni. In addition to Pharmacy, we both played Hockey, he at much higher levels than I. In fact, Rip was selected a few times in NZ underage squads.

One night after hockey practice, we were talking about a player in the club who, despite having capable basic skills, struck us both as uncoordinated. Rip astutely observed that the guy was 'frantic' on the ball. As sports-watchers will know, a good player seems to have 'time' every possession. This appearance of time, due to their superior skills and composure, may almost reveal their decision-making processes, but their opponents are powerless to act. Think Michael Jordan's clutch plays, Mark Waugh's magnetic slip catching or Dan Carter slicing through a defensive line.

The opposite, of course, occurs too. Not that it's shown on television or other international stages, but there are many, many sportists whom, in addition to poor decision-making, have rubbish skills. When they receive a pass or need to make a tackle, their eyes go big, their heart races and *bang* something happens. Either it's good or abysmal or lucky or sufficient; they've frantically played their part.

After a while, the conversation turned to pharmacy. Several parallels were evident between clinical practice and sport, and the metaphor certainly extends to doctors.

In pharmacy, the composed pharmacist copes well with a store full of people, a line-up of 'scripts, several requests for consults. They remain cool, calm and collected, they prioritise according to time, urgency and staffing factors.

Conversely, the same situation my fluster and frazzle an inexperienced manager. Patients wait too long and customers get shirty; no-one leaves entirely convinced that things are going well.

Confidence in one's skills is imperative; safe in the knowledge that you can handle whatever situation presents itself, from an irate customer, to a very sick patient or even an armed holdup.

Whilst I'm yet to see a completely flustered clinician, I'm sure they exist. Generally, though, docs seem to err on the side of composure, bordering on detachment. This is unsurprising, given the sheer volume of patients most clinicians see; their knowledge and skills are well honed. Moreover, a term or two in acute psychiatry certainly establishes a sort of Zen in most docs.

A good clinician has 'time', even in the most acute situation. They have strong skills, both physical and mental, and can action them systematically and repeatedly under stress. Their goals and approach adjust as the situation warrants, all with the 'big picture' in mind.

Rip, quite rightly, describes good sportspeople as 'clinical'; composed, accurate, consistent, aware. All evident to the keen onlooker, and sensed by teammates and patients alike.

Some summers ago, I was lucky enough to work as a student at an interesting Pharmacy in Sydney. The pharmacy was particularly eye-opening for two reasons; the staff and the trains. It was before I graduated, and proved an important experience, with some vital lessons in staffing and a solid Training Ground. This is the final in the series. You can read the rest of the series here, here and here.

At least one of the shop assistants at the Training Ground was terrible. I mean, dead set dangerous, unsafe. Now, I've got an optimistic attitude to shop assistants; they're the cornerstone of community pharmacy. This saga is not designed to "beat down" on Pharmacy Assistants, quite the opposite. Indeed, the tale serves as a lesson of How Not to be a Pharmacy Assistant. It is, thankfully, the exception to the many fantastic techs I've worked with, and relied on in Pharmacy.

Shelly was in her early thirties, and had been in pharmacy for three years. Shelly thought she knew it all. She was known say so in her piercing, sing-song baby voice. Instead, however, her practice of pharmacy was based on a few principles;

1. Always use the strongest thing you can think of, every time.
2. Skin means steroids.
3. If you give someone no choice, they will buy it.
4. All customers are infinitely more stupid than Shelly.
5. All pharmacists are a waste of space and glorified babysitters. They don't know anything about 'real' pharmacy.

Of course, these prinicples are all horribly flawed. Two incidents really sparked my concern that, in addition to atrocious customer service, complete with snide remarks about customer's clothing or ethnic background, really began to worry me.

In the first instance, a bloke in his sixties came in for some cold and 'flu medication. Pretty run of the mill, however, before Shelly even thought to ask, the man mentioned he'd had a heart attack and a 3 vessel CABG four weeks earlier.

He used the words "Open heart surgery", and mentioned his crackingly high blood pressure. No worries, says Shelly, reaching for some pseudoephedrine-loaded Codral. Alarm bells are ringing. Luckily, the patient saves his own skin by asking to talk to the pharmacist. Shelly mooches off in a huff after her suggestions a shot down in a ball of "Safe and Appropriate Medication" flames.

Not to be perturbed by a lack of knowledge or practical skills, Shelly goes about treating a young skater for a sore ankle. And by sore, I mean visibly broken. The kid hobbles in and perches on one of the shop's stools, whilst Shelly begins to 'help' him. I was actually surprised that Shelly was even serving this kid, considering her previous comments about skateboarders.

Nonetheless, she fetches him some ibuprofen, saying loudly "That is everything you'll need." At this point, I got 'ballsy' and sat next to the guy. Considering his version of the mechanism of injury, marked bony deformity and swelling of his ankle and inability to walk on it, it was likely broken. He needed to see a doctor. I pointed him in the direction of the nearest Bulk-billing doctor and he and his mate rolled off. Meantime, Shelly had got the message - she didn't want to help the little punk anyway - but she came over and tried to tell me off for 'cutting her lunch'.

"You're just the student," she hissed. I reiterated that the kid's ankle was broken. The boss appeared and told her to 'pull her head in', and for the time being, she did. Later that day he had some stern words and provided remedial education about WHAM, and saliently, when to refer to the Pharmacist. I found out that she was sacked a few months after I returned to Uni. I'm sure she's still working in a pharmacy somewhere.