More Unnatural Medicine 

Following my recent blog post titled ‘Unnatural Medicine’ one correspondent bothered to respond thoughtfully and at considerable length. As you will see from the passage below (excerpted from his comments) he writes insightfully and with strong feeling. I quite understand that intensity; health is both a personal and a universal concern. Further, at the head of its hierarchy and ruling our fate, standing over us, exciting our awe and our resentment, are the doctors.

 …On the other hand we see leaders in western medical practice dismiss Chinese medicine, for example, as quackery and voodoo medicine. Despite clinical trials clearly demonstrating the effectiveness of acupuncture, for example, many Scientists declare that there are no such thing as “meridians” in the human body as their existence has not been clinically demonstrated. The hypothesis is dismissed despite evidence gained from the applied testing that they do. Further, many assert that all forms of Chinese medicine, sometimes including acupuncture, should not be considered “real” medicine. (This includes senior doctors advising government and insurers.) Yet this practice has 4,000 years of accumulated clinical practice, is taught in major teaching hospitals in China and practiced daily by doctors in conjunction with “modern” western practice. Numerous clinical trials of diagnostics, treatments and herbal concoctions have been conducted, which are generally dismissed in the west, often merely because they are not available in English. When they are available, the results are howled down because there is no critical mass of such research available. Yet the Chinese pharmacopeia is yielding impressive results in western labs in the treatment of everything from common infections to malaria and cancer. Why is there such resistance to the science of Chinese medicine?
With the social and economic power of the western pharmaceutical industry we continue to see western medicine practised with an emphasis on the provision of drugs as first recourse in treatment. So pervasive is this that you have written about patients who want the prescription of a drug, any drug, rather than wanting to hear a more complex story of how to achieve health and of some doctors who support this approach. We have a culture of “science” where alternatives can often be dismissed and
where pharmaceuticals are pushed to the frontline of treating almost any and every condition. Incidentally, my father peddled Debendox – among many other drugs- to doctors in the 1960s and ’70s for the treatment of morning sickness and later associated with birth defects. It was given to me as a treatment for travel sickness. Hard science and its practice makes mistakes.
Please forgive my self indulgence in presenting my rant, Howard. I know your musings are often light-hearted and exploratory of deeper things. But I guess my point is this: there is an ideological
spectrum in medical practice, which can be said to range from “natural” to “unnatural”. There is medical practice that works with the “natural” processes of the human, which includes an understanding of diet, exercise, psychology, history, social conditions, the environment, etc all having their effects, good and bad, on human lives. In common parlance “natural” usually refers to seeing patients as people first, human beings subject to and part of nature in never-ending cycle of birth, life, death, repeat (depending on your belief). My experience of your practice puts you in this camp. Do as little harm as possible, be cautious, be curious, respect the person, do not jump to conclusions or easy answers, respect the life process. Sometimes trauma means offering treatment (or not) that may cause damage or harm. A difficult choice.
There is also practice that does not respect the human, does not give value to patient’s experience, knowledge of their body, etc. There is a dominant (moot?) practice of prescribing western pharmaceuticals first and asking questions later in the next 15-minute consultation a week later. This well-documented practice is disease focussed
and knows little of health, except as the “absence” of disease. This “unnatural” practice is characterised by a focus on the disease or condition, of which the “patient” is merely the subject. Treat the disease, not the person.
This spectrum lies at the heart of current debate and power struggles within medicine and in policy regarding human health. It has enormous implications also for all policy that focuses on the human species as somehow separate from “nature”, implicitly subject to different rules, with or without the possibility of divine intervention to protect us from
ourselves.
 
I find myself highly stimulated by my correspondent’s comments. I’m bursting with an accumulation of thoughts and feelings of my own, musings and speculations. I suppose these have gathered and grown within me over a lifetime in medicine. (It has quite literally been a lifetime: born into a household that accommodated my family and my father’s medical practice, I grew up in medicine. I was weaned on milligrams and speculums.)
 
My own feelings about western medicine and doctors are as mixed as anyone else’s. I am old enough to need the services of my doctors quite frequently, while still young enough to be doling out medical services to others. Macbeth cries, ‘Throw physic (medicine) to the dogs. I’ll none of it!’ And in a few cryptic words the Talmud declares: ‘”tuv harofim le’ge’hinnom” – the best of doctors can go to hell.’
Does medicine have an ideology? If an ideology is a system of beliefs or ideals or principles, I believe medicine does have an ideology. In the practice of that ideology I see the best of medicine, and in its abuse, the worst. That worst is the exercise of power for its own sake, a petty parochialism, a readiness to denigrate what it does not understand; and, in budget season, a hypocritical piety.(“No, no, no, Mister Treasurer , you must not cut, peg or regulate our fees – or our patients will suffer.’) The best is seen in your doctor’s service of ‘scientia cum caritas’, knowledge with loving care.
For me it is the ‘scientia’ which is the hard bit. Your good doctor is a scholar: the word means ‘teacher’, ‘master’, ‘wise one.’ That scientific doctor applies himself to the evidence. He suppresses his own human hankerings, his romantic leanings, his wishful thoughts. That doctor brings to his work a rigour, an austerity, a devotion to the pursuit of demonstrable truth. When I am sick I truly need that science; and your good doctor brings that to my bedside.
Let me give you an example. While working in the Emergency Department of Alice Springs Hospital last week I watched while five doctors worked to save a man who had been found at a remote roadside, unconscious and convulsing violently. The man was tall, strongly built, apparently athletically fit. His mountain bike was found lying near him. Unable to tell us how or what or when, his powerful body defied his absent mind as it jumped and threw itself around. I stood, quietly appalled, watching a man fifteen years my junior, disconnected from mind, at the threshold of the void.
The doctors watched him for signs. Acutely attentive to which limb moved, which did not; how his pupils reacted to a pencil beam of light; whether and how strongly he responded to voice (initially he’d stir; later he did not), and to a painful stimulus. Here was a biological organism in a near agonal state. The doctors looked up to study the lines and waves and numerals on the screen. How strong is his heartbeat, how effective his circulation? How much oxygen are his lungs delivering to the circulation and – critically – how high is the blood pressure? The readings were elevated above the norm. I misgave and pointed out the elevation to the Team Leader. ‘That’s good,’ he said. He explained that the damaged brain was much more vulnerable to low blood pressure than high. The outcome, he explained, was worse when pressures were low. ‘The outcome’: two words pregnant with knowledge, with meticulously gathered and tested and scrutinised evidence. Tough minds had obeyed tough rules in the gathering of that evidence; now smart scholars would deploy this in our immediate emergency. I witnessed dry science at the service of hot blood. 
It was imperative to control the seizures and to treat pain. Surely he had pain – he’d had a fall, presumably at speed, his skin was torn from his body, gravel and mud grimed his raw wounds – and he was vomiting forcefully on arrival. He must not be allowed to vomit lest he aspirate and block his lungs.
Next the man’s respirations must be controlled. He’d be paralysed and placed on a respirator. He’d become utterly defenceless. The very doctors who would overcame his defences must become his protectors.
To all these ends, all of them critical, all of the utmost urgency, strong drugs would be used – opiates, benzodiazepines, muscle relaxant drugs, anaesthetic agents, anti-emetics. Doses must be calculated minutely, effects monitored, dosages re-calibrated. The precise numbers of milligrams and micrograms would determine whether this man would live, would walk, would think, would speak, read, laugh or love. ‘Will this man ever get back on his bike?’ All lay in the hands of these scientific doctors.
 But how to calculate dosages? Unable to weigh a stuporose man threshing his own body, the doctors had to guesstimate. Too much opiate would lower blood pressure and endanger the damaged brain. Too much anti-convulsant would do the same. And both classes of chemicals might suppress breathing. The anaesthetic drugs must be adequate to paralyse him (to allow intubation and the use of the respirator), but again these agents can defeat their own purpose.
So the doctors injected morphine, eagle eyes upon oxygen saturation and respiratory rate and blood pressure. They injected metoclopramide to prevent vomiting that morphine so readily triggers. They deployed three different anticonvulsants, in doses nicely titrated, before they were able to control the fitting. Now came the intricate business of intubation, the act of introducing a breathing tube deep into the throat in defiance of every natural reflex and physiological objection; this procedure, a pas de deux of surpassing intensity, saw all present hold their breath in unconscious imitation of the patient, now paralysed, whose breath was held from him by chemical restraint. Now the tube was guided truly, now oxygen supply was resumed, hypoxia reversed. All breathed out.
Our patient would never know how medical science saved him. How doctors had used just enough of every hero molecule, how they had threaded that narrow path between his own injuries and the potential harm of their remedies. How every drug might poison him. And of the race of his life, the literal counting of seconds where every second counted, the quietly hectic passage of time when he arrived as quivering meat and was so soon stable. Safe!
Equally deep was the pool of knowledge that detected the cause of all – no, not head injury, not brain contusion, not spinal cord injury – a heart attack had thrown this athlete, engaged in a mountain bike race in unseasonal heat, into coma and convulsion at the threshhold of death.
So, yes, western medicine has its ideology. Last week I saw that ideology save a human person. Clearly I am in awe of that sort of intellectual discipline which is so far above and beyond my suburban skills.
By way of contrast we who practise by instinct, by intuition, must tread the shallows of organic disease, even as we grope in the deeps of human suffering. You cannot afford to indulge our speculative modes of medicine when your damaged organs call out for science.
In the earliest years of my practice I felt frustrated when patients informed me of the advice they’d received from alternative practitioners. Those healers would declare to my patient her spine was out and they’d put it back; they’d looked in her eyes and found her pancreas was sick and they’d cured her with herbs. Not with drugs, no, never with drugs. Those healers prescribed detox diets for the liver, cheerfully unaware that the liver detoxifies all. They told my patient they knew what was wrong, where I knew I did not, where no doctor could – in any scientific sense – know.
I came in time to respect the achievements of these practitioners. My patients felt better for seeing them, encouraged, confident in their recovery. I wondered how this could be and it came to me that the naturopath gave the patient the gift of an unrushed, attentive hearing. The amplitude of time, the emphasis upon natural healing, the resounding vote of confidence in the forces of the natural body helped the patient materially. I realised how intuitive, how insightful, how respectful was this practitioner. I recognised in the naturopath the healer I wished to be. But there was one difference, ineradicable: I never heard a patient quote the alternative practitioner confess ignorance or impotence. Free of the shackles of constraining science, the practitioner never said three words that I need to use every day. Those three words are: I don’t know.
I am pretty confident I have by now offended some readers. This is always a risk with the trenchant expression of strong opinion, of ideology, if you like. And it is not only western doctors who hold an ideological position. I consider it natural to humans, perhaps universal, to cherish convictions about health and its care. These convictions too encompass values, traditions, emotional needs. Mine are distinctively my own. Every distinct human will differ. Expressing my full thoughts on these subjects might offend seven billion humans.
Nevertheless I propose to write a series of short pieces which might include:
Why some doctors resist and resent alternative medicine;
‘Thou shalt not kiss thy patient’ and other absurdities.
Why I recommended acupuncture for a patient whom doctors could not help.
Why doctors prescribe medicines: Big Pharma, big mamma, bad sicknesses;
My Debendox daughter.
In writing on these matters I expect to relieve myself of strong feeling, long pent. And after all that I will scarcely have responded to my correspondent’s weighty concerns.
 
One final vignette before I let you go. In 1972 I joined a rural practice where I worked happily for almost thirty years. Around that time I met a squat jolly man and his slim jolly wife. The couple had three small daughters and I became their family doctor. They were a devout family, members of a small local congregation of a church which is possibly the most widely respected by the secular majority in this country. They wore their piety tactfully – neither crucifix nor yarmulke nor hijab declared publicly their private faith.
From time to time Mother brought the little girls, slim, elfin presences with smiles that sweetened my day. They’d sit on my knee while I discussed their condition their mum. In time they grew up and left their small home town. One of the three, whom I’ll call Sarah, returned and introduced me to her fiancé, a member of Sarah’s church. The two had decided on a career as ministers to the youth in the service of their church. Soon they would marry and take positions in a distant city interstate.
 
When I saw Sarah next seven years had passed. Her father had died of complications of orthopoedic surgery. Her face shone with grief and pride as she introduced her batch of three small children to me. Slim like Sarah, all with biblical names, they played at our feet as we spoke of their grandfather, that squat jolly man, and of his passing. Sarah and her husband petitioned the church for a posting in Melbourne to be nearer the family.
They settled in an outer suburb on the far side of town and I saw nothing of them for about three years, when Sarah turned up in my waiting room. Delighted and surprised I listened as Sarah told me of the strange and slow development of her second child, a boy. ‘Jeremiah might have autism.’ We talked. I told Sarah I was no expert in that condition. She seemed to know that already. She wasn’t after diagnosis, but counsel and for that it was to her old family doctor she turned.
Years passed. Once again I was delighted one day to discover Sarah in my waiting room. She was the final patient of my morning. By chance I had no more patients to see for the next hour and a half.
‘Hello, Sarah. What brings you here?’
‘Howard, this morning in the shower I found a lump in my left breast.’
‘Does it hurt?’
‘No.’
‘Do you have chills, a fever?’
‘No, it’s not mastitis. I weaned Benjamin a year ago.’
I examined Sarah’s left breast. Her slim body habitus made the lump easy to find. It was a hard lump, a little larger than an almond. I felt the opposite breast: normal. I probed her axillae. There, in the left armpit I felt a second lump, also hard. I tried to hide the dread I felt.
Sally looked up at me, searching my face: ‘Can you feel the lump?’
‘Yes. It’s a worry. Please get dressed and we’ll talk.’
We talked for an hour. We talked of the probable cancer, of its possible spread, of treatments, of specialists – who, where, when? Sarah asked, ‘Do think I’ll be cured, Howard?’ I did not think she would. I said the signs were worrying and I feared the worst. Sarah looked down and rummaged in her handbag for her hanky. She sat quietly, tears rolling down her cheeks. She dabbed her eyes and cried some more. The hanky was a sodden ball in her hand. She blew her nose and said, ‘I’m not frightened for myself. The children… they’re so young.’ Fresh tears followed.
At length it was time to finish. I stood up. On blind instinct, driven I suppose by hard feeling, I said, ‘Sarah, stand up.’
She did so. I stepped forward, took her in my arms and hugged her. She hugged me back, hard. I dropped my arms but she hugged on. And on. At length she released me. She took a deep breath, found a small smile and said, ‘That’s what I crossed Melbourne for, Howard.’
I never saw Sarah again. Her surgeons wrote to me from time to time. Eight years after her doctor took her in his arms and breached medical ethics, Sarah died. 

Should Nurses and Doctors Accept Work in Australia’s Detention Centres?

In 2010 I worked in an Australian detention centre for short time that felt like a long time. The experience was the worst in my fifty years in Medicine. I signed a confidentiality agreement, sewing my own lips in the process. I saw no atrocity, no wrongdoing, other than torture by impersonal and meandering bureaucracy. Yet the suffering was general; it saw inmates, guards, nurses and doctors all resorting to self-harmful acts. I saw honourable people treating the detained with skill and humanity. I saw them constrained by employers and distrusted and insulted by patients, who felt sure that we too were liars. Yet we did some good. People, whether sick in body or in spirit, were treated with kindness and respect.

For six months after I returned to the mainland I was visited by dreams in which I sat on Tribunals without name, determining the fate of nameless individuals doomed by history and by Australian laws. Captive in these dreams, I doled unequal laws to defeated supplicants. I’d awaken and ask myself, did I really do that? But, inescapably, I knew I was implicated.

My island was a paradise of procedural propriety compared to today’s islands of Nauru and Manus. Doctors and nurses have returned from these places with distressing reports. Some have argued that, knowing what is now known, it is in unethical to work in these places; that the system tortures inmates; that participating is to become complicit in torture. More moderately, all clinicians and observers who return seem to agree that incarceration harms the inmate. The first law of medical ethics being, first do no harm, is not an ethical practitioner obliged to refuse to share in that harmdoing?

A new element affecting the work of a detention clinician is the outlawing of reporting wrongs seen in that work. Offenders face the threat of two years gaol. Nice systematic irony: to protect the liberty of Australians we incarcerate boat people; to protect the integrity of the system we incarcerate truthtellers. Interestingly, the flood of job offers to work in Detention that recruiters used to send to remote doctors such as myself has dried up. Someone, somewhere must have decided Australian clinicians are unreliable.

What then must a nurse or a doctor or a psychologist or a psychiatric nurse do? If offered, may we accept this work? Even if we are forbidden to speak of what we see?

I compare the situation to working with patients in places of dangerous epidemic disease. The first such case I read of was the cholera that broke out in eighteenth century Naples, where a young Swedish doctor left his fashionable private practice in Paris to work with the afflicted. He found himself working alongside a young nurse who was both beautiful and a nun. At any moment the disease might take them. The two work steadily on, afflicted by the losses and by the erotic fever that seizes them both. The drama of the two who risk all for strangers has never left me. The doctor, Axel Munthe, wrote of this in his memoir, The Story of San Michele.

We saw just such heroism played out by Australian nurses and doctors who went to Africa recently to save people from Ebola. We saw it, and -as a nation, as individuals – we prayed for our heroes and we applauded them.

Nothing new here: nurses and doctors work with AIDS, with multi-drug-resistant TB, with Lassa Fever. It is natural to the species to measure the need before the personal risk.

The second precedent is an unhappy one; during the twentieth century doctors working under dictatorships accepted orders, accepted payment, enjoyed promotion and protection, and participated in abuses ranging from imprisoning sane dissenters in psychiatric institutions, to ‘eugenic’ murder, to torture. And being bought, they shut up about it. If clinical ethics learned anything from these abuses it was the imperative to speak out.

In the light of history I see the duty of free citizens, clear and uncomplicated. It is to go to the camps, to do such good work as might be done, and to speak out.

Adam the Original

 
Years ago I had the privilege of working in partnership with a Brownlow Medallist. Dr Donald Cordner was the scion of a family as distinguished for Medicine as for football. I learned many things from Donald: it was he who transformed me from a sluggard to a mechanism for perpetual motion. Like my father he personified a thirst for a meaningful life both within and without medicine. 

Donald captained the Melbourne Football Club in its fertile years of recurring premierships. Of the Medal he spoke seldom and little. I remember one datum: the Charles Brownlow Medal is awarded to the player voted by the umpires as the FAIREST and the best. Over the twenty years we worked together that described Donald Cordner: he was the best at everything he put hand or foot to; and he personified honour.

 

Like Donald, Adam Goodes captained his club. Like Donald he saw a role for himself in community service. Like Donald, Adam Goodes is a leader, a man of vision, of substance.

 

In 2003 we saw Adam receiving the first of his two Brownlow Medals. Although he shared the distinction that year with two other champions – one of whom captained the club of my own allegiance – it is the image of Goodes that lingers. More particularly the choice of his companion. Alone among the great young men, Adam brought his mother along, the sole parent who raised him and his siblings. Goodes’ mother contrasted with the other companions, generally blondes, frequently trophy females with cleavage.

Mrs Goodes looked what she is, an Aboriginal matron. Nothing fashionable – read, ‘mutable, evanescent’ – just his Mum, the woman Adam Goodes chose to raise to public honour.

 

When I looked at this man, this original, I saw one who stands for family, for loyalty,  one who knows his roots and is proud. Like his ethnically distinctive medallist forebears, Robert Dipierdimenico and Jim Stynes, Adam is Australia incarnate. He reminds us of our inextinguishably diverse makeup. That diversity, for most Australians, is our glory; for some an intolerable truth. When those persons boo Adam Goodes, they boo their community, they boo themselves.

  

 

Africans in my Lounge Room

Trudy ushered them in, the two-and-two-thirds doctors from Africa. Tall, beautiful and young, each greeted us in perfect Hebrew: ‘Shabbat Shalom’, a peaceful Sabbath. Three smiles of perfect teeth lit our room on a rainy Saturday afternoon.

First and oldest was Tom, thirteen years a doctor, eight months in Australia on a Bridging Visa. Next came Afia, with 18 months’ experience in Ethiopian hospitals and I don’t know how much time in refugee camps. She too holds a Bridging Visa. Last and youngest was Oprah, the vulgar fraction: she has completed four years of medical studies in the Congo. Her birth country is Rwanda. I did not prosecute her with enquiry about her double expatriation. Like the other two, Oprah subsists in Australia at the pleasure of the government. That means the kindness of Mister Morrison.

All three understand fully they can be evicted from this land of asylum at which ever moment Mr Morrison’s kindness might run out. As none of the three came by leaky boat they have the right to work. If they can get work. Trudy brought the three to us to help them find work. I had invited two august medical friends, superbly connected senior people in their fields.

We sat down and talked. Tom outlined his situation. In his early thirties, married, experienced in hospital medicine and a recognized expert in immunisation in third world countries, he is permitted to work here as a doctor only under supervision. At present this distinguished professional works as a medical menial, washing incontinent bodies in a place for the aged. Tom makes no complaints about the red tape, he is grateful to be here, willing to go anywhere – to the outback, to the western suburbs – he just wants to use his training. Can we help him find work? This expert in immunisation – he is just back from Geneva, where he was summoned by the WHO to a conference – with his rich experience of tropical disease would be a gift to a hospital or a tropical medical school or an immunisation project or in policy in any of our tropical zones.

Afia, aged twenty-seven, came to Australia by invitation, to attend the recent world AIDS conference. She applied for asylum with her husband, a chemical engineer who is also looking for work. They too will go anywhere. Afia wants to be a GP. I pictured our large communities of people from the Horn of Africa with Afia as the needed human bridge of cultural understanding to bring these many to safety. I saw the many Aboriginal communities crying out for GP’s.

Oprah has been here for a few weeks. Trudy has given her shelter. Oprah wants to become a nurse. In this country nursing is university course and monumentally expensive. However asylum seekers can pursue TAFE studies at no cost. Oprah managed four years of a medical degree; nursing will not be beyond her grasp. She’d be able to train as a State Enrolled Nurse at TAFE and from that platform gain employment and support herself while studying at Uni. I work with numerous African nurses, highly appreciated in the outback, where the barriers between the African and the whitefella are as nought compared to the gulfs all must cross in indigenous health.

There was little talk of the revolutions, the wars, the massacres; there was scarce mention of refugee camps; there was no complaint, no sense of entitlement, no pity of self, no cries for the families left behind. None of the three had met the others until Trudy brought them together on Saturday and coached them in the Hebrew greeting on our doorstep. Afia, Oprah, Tom, three islands in this distant country, three shimmering humans simply happy to be here, eager to work, to stand up, to make their way.

Theirs is an old, old Australian story. I saw the Reffo, the New Australian, the Boat Person, the Gold Rusher, the survivor of the Shoah, the Balt on the Snowy Scheme, the student from Tiananmen Square. I saw my wife’s mother, a child fleeing Danzig in 1938, I saw my Grandpa arriving here alone, aged thirteen, a stowaway escaping the Ottoman police in Palestine.

There we sat – three young Africans, three old Australian doctors and one good citizen. An atmosphere quietly joyful, of welcome guests meeting grateful hosts, a current flowing back and forth of appreciative respect. A meeting, in short, of human people.

The next morning my wife and I happened to have three guests for brunch. One of the three, an old friend, works with survivors of torture; the second is a classmate from medical school whom I knew is a shy blonde, now President of the World Psychiatric association; the third is her husband, a distinguished gastroenterologist, now practising in Addiction Medicine. Our refugee advocate friend, his face ravaged, spoke of the horrendous week just past in which the Minister of All Prerogatives (Mister Morrison) sold the freeing of 103 detained children in exchange for numberless others, both adults and children. These others are offshore, in another country, beyond the borders of Australian conscience.

My wife and I told our brunch friends of the Africans in our loungeroom. Five Australians, all thoroughly unexceptional in our impulse, in our wish to help, spoke with eager seriousness of people, places, organisations, of contacts, of opportunities and of need. Nothing new, nothing unusual transpired. Five Old Australians, descended from New Australians, animated by memory and self recognition, each saw ‘mon frère, mon semblable’. I read in Sunday’s paper of the endless tides of Libyans escaping likely death, arriving in Italy where the locals, quite overwhelmed, yet see what our Morrisons and Abbotts and Gillards and Shortens will not: they see the human face and they give the arrivals succour.

In the few days since this human weekend I have tried to reach beyond my customary postures of anger and self-righteousness, to grope for understanding of my hard Government, of my soft Opposition, of my fearful fellow citizens in the electorate. I can only surmise that, somehow, at some time, my representatives and my fellow citizens have lost something they used to see – the image of the self in the face of the other.

An afternoon in the loungeroom with guests like mine might change everything.

Into the Danger Kitchen

My great nephews are visiting from Boston, and suddenly there’s danger in the kitchen. It started when the older one was the only one: he must have been about eighteen months of age when his mother took him to an allergist for his atopic eczema. That doctor said: ”He’s at the age where he’ll range and browse and try foods that he could be allergic to. Here’s a prescription for an Epi-pen. Inject him with it if he stops breathing.”

The child’s great-uncle, a veteran family doctor, grunted: “Typical American medicine – over diagnosis, over-eager intervention.” The child’s grandfather, an eminent psychiatrist, harrumphed, ”Bah! Humbug!”

Sometime later the mother – my niece – took that child to a pizza parlour where he took a bite of a sesame bun. He chewed once, he chewed again, he gasped, he scratched frantically at his now reddening skin. Then he stopped scratching – and breathing. His mother called 911 and gave him a shot with the Epi-pen. The ambulance arrived shortly afterwards and found the child breathing.

Back to the over treating over-diagnosing doctor who advised: “There could be multiple allergies.” He tested and found anaphylactic allergies to sesame and also to egg, and to tree nuts. Lesser allergies were found to zucchini and squash, pollens and dust mites. The doctor tested for sensitivities to antibiotics. He said, “Well you can’t kill the boy with zucchini or squash, but you could with a cephalosporin. That’s an antibiotic.”

The parents decided to have another child. The younger brother was born and before he had a chance to meet a sesame seed he was tested too. This little feller had his own anaphylactic allergies – to wheat, and to the gluten in barley, rye and spelt, as well as to egg and kiwi fruit. Pollens and dust mites were allergens of a lesser order.

My niece added three to seventeen-point-five and realised nature had dealt her a tricky hand: what one child could eat safely might kill the other. And verse-vica. She and her chocolate-allergic husband have raised these two diabolically matched and unmatched children to twelve and nine years respectively. They subsists on celery and prayer, in Boston, a good place if you have complicated health: they have lots of typical American doctors there, all over-diagnosing and over-treating and keeping kids alive and well.

Now the kids are visiting us in Melbourne. They stepped into our danger kitchen. Their very-great-aunt asked what they’d like to drink. “Water , please, Aunty.”

My wife poured tap water into two surgically clean tumblers. The boys drank as we stood by, Epi-pen in hand.

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FOBT

Some doctors have too much time on their hands. When you’re feeling quite well they go looking and testing for things you aren’t suffering from. They call that preventive medicine. (I call it preventative medicine.) My wife calls it meddling.

Year ago I advised my wife to have a colonoscopy. I offered to refer her to a bottom surgeon, a lovely bloke, quite exceptional in his trade. She declined.

I persisted: “Look, he’s gentle, kind…”

“I know all that. I’ve known him for longer than you have. I knew him when he was a medical student.”
“Then why not see him as a doctor?”

“No! I had the hots for him back then.”

“So? That’s not a disqualification, is it? Was he your boyfriend?”

“No.”

“Did he know you had the hots for him?”

“No.”

“So, why not see a great surgeon and a nice guy who never knew how you felt?”

“I don’t want someone looking at my bottom whom I felt that way about.”

My wife sacked me as her GP and consulted a stranger who sent her bottom to a second stranger.

What goes around comes around and bites you on the bum.

I reached the age of fifty and saw my own GP for a spot of preventative medicine. She said: “You’re Jewish aren’t you?”

I confessed I was. I had the scar to prove it.

“And you are Ashkenazi. You are in a high risk group for colon cancer. I’ll arrange a colonoscopy.”

I wasn’t keen. My wife had told me about the two-litre laxative drink that preceded the examination.

I bargained and we settled for the faecal occult blood test. She handed me a request slip that read:

Test requested: FOBT

Clinical Notes: 50 y.o. male Ashkenazi Jew.

I pictured myself lugging my specimen back to the lab in a shoebox.

I turns out they aren’t that greedy: two smudges would do.

The instructions and restrictions were detailed and grotesque. Being a doctor I didn’t read the leaflet too closely. Didn’t need to. I knew how to “produce a specimen”.

Next morning I awoke early, took my blood pressure tablets and my 100mg of aspirin and felt the urge for an early morning donation. I fought it off as I applied the Glad Wrap, discovering a happy concordance between the width of the wrap and the diameter of the bowl. (Is that cosmic chance or commercial cabal?)

I emptied my bladder elsewhere. (I don’t know what you are supposed to do if you don’t have a garden. Or if you are female.)  Finally I donated. Then I selected, daubed, closed, sealed, dated.

Then I forgot about the entire project. Three weeks later I got around to Specimen No. 2. I collected this and followed the earlier steps. With a light heart and a sense of virtuous health I delivered my daubs to Specimen Collection. Specimen Collection perused the paperwork, checked the dates. And rejected my specimens. Uncertain whether to be outraged or humiliated I asked why. “Dates too far apart.”

I never knew poo had a use-by date.

Back to the beginning. My specimens were collected in timely relationship and delivered to Specimen Reception. I waited in quiet triumph. Specimen Collection had some questions but wasn’t happy with my truthful and humbly virtuous replies. She asked: Did you eat carrot in the three days preceding each of the dates?

Certainly.

Raw?

Yes.

Did you brush your teeth the evenings prior?

Of course!

I am sorry but the lab cannot accept these specimens. Even a single violation voids the accuracy of the technique. Two violations are quite out of the question.

Look, ma’am – very politely, showing some of those teeth in a sweet smile – I am a doctor. I believe I understand the test. I’ll accept responsibility for any inaccuracy.

Sir, we are dealing here with cancer, with human life. The laboratory cannot compromise.

She handed me a new collection set. I stopped by the supermarket for more Glad Wrap and returned to my squat. Carrotless days and unbrushed evenings dawdled by. My teeth turned brown and my fibre-freed stools tore their way out. I sampled my moon rocks and I collected two specimens, a day apart. And returned to Specimen Collection.

With a lovely smile of her own Specimen Collection thanked me and said, See you next year, Doctor.

Er, thanks. Yes.

Oh, by the way, you aren’t taking aspirin are you?

 

 

On Gradually Losing my Hearing – part II

A trip to the ear doctor is preceded by an examination by the audiologist and by the dimness of conversation with my patients. So quiet and restful are their remarks that I have been able to remove the notice in my consulting room that read:

Patients are kindly requested to speak softly and to leave quietly to avoid disturbing the doctor’s nap during your consultation.

In addition to increasing hardness of hearing, there have been frequent episodes of vertigo over the past 12 months. During these interludes a twist of the head is followed by a swimming sensation; the world moves, sliding ever to my right; images swarm, kaleidoscope-like, chasing each other endlessly, clockwise, around my visual field. It is an intriguing symptom, drunkenness without alcohol. Remarkable cheap, really. People pay good money for bad chemicals to achieve these experiences. It makes my ENT surgeon jealous, resentful, motivated to act.

And when the ENT saw an 11% discrepancy in acuity between the failing right ear and the failed left, he mentioned an MRI. When he heard of my increasing vertigo over the past 12 months, he wrote out a request slip. The request slip might be paraphrased as follows:

1.   The patient is deaf, ie old; this condition will worsen but will, like all things, pass.

2.   The patient is a doctor, ie hypochondriachal. He requires an MRI in order to cure him of his hypochondriachal fears, and as a punishment for having symptoms.

3.   During the procedure, please confine his head in a shoebox, then slide that head into an extremely confined space and assault his damaged ears with mechanical sounds at high volume. During this time, so confine him that he is entirely unable to move. If he has never suffered claustrophobia before this, please assure him that the days of calm inside his head are over.

4.   Do not warn him that during his MRI he can expect to wet himself in sheer terror.

5.   Ensure that the young technician who asks him to disrobe is female, charming and attractive. Tumescence will then fight against incontinence.

As you will appreciate the MRI represents the Himalayas of medicine where peak ethics gaze across at the highpoint of patient autonomy and comfort.

Before the scan you fill out a form in which you declare your body’s absence of internal metallic items. The list is long and the list of patients who can say “no” to all these is a shrinking one. Nowadays it is as difficult to qualify for MRI as for cremation. In my unserenity, I might prefer the latter; at least you don’t have to hang around waiting nervously for the report.

“Please take off all your clothes excepting your underpants.” It is not every day that a 67 year old gentleman receives an invitation of this nature from an attractive young woman. I am happy to oblige. She permits me to retain my kippah (skullcap – “no bobby pins please) and my socks. A gent in his socks is the epitome of the sexless vertebrate.

I might just as well wear a chastity belt. Continue reading