# 009 ... Pepper and Salt

"Out here nothin' changes, not in a hurry anyway
You feel the endlessness with the comin' of the light o' day
We're talkin' about a chosen place
You wouldn't sell it in a marketplace, well
Well just a minute now"

Goanna : Solid Rock (Spirit of Place) 1982

There was a sense of endlessness in this place. Two years blurred and were punctuated only with chaotic emotion, anecdotes and meeting primal needs.

There were hard, black times and a few bright positive times. Mostly indeterminate in the milieu of life not infrequently punctuated by the basest struggles to survive.

"Feel goods" were hard to come by.

No one said thank you .. unless perhaps they did but we were too numb to notice. No one paid a compliment except when we generated a mutually supportive social intercourse. Many were ready to criticise purely to ensure that the pecking order was maintained. Some of us hovered between heaven and hell, in more ways than one.

One of my high points was at a time where I was covering for all the medical patients in the hospital. I was called to the ward to examine a patient who had been admitted for management of a painful, inflamed wrist joint. This was presumed to be gout and was treated as such. This patient, despite treatment, was experiencing increased pain and beginning to feel unwell. The medical registrar was off duty so was unavailable for advice. I made a decision to perform an aspirate of this patient's wrist joint (to take a small sample of joint fluid for analysis) and on pure speculation, started the patient on an antibiotic. The following day the medical registrar took me aside and thanked me. She told me that the specialist had instructed her not to perform the joint aspirate the previous day but was concerned that the initial diagnosis of gout was not correct despite blood testing being supportive of gout. As it eventuated, the patient had a septic arthritis and the joint aspirate confirmed the diagnosis. I had commenced the correct treatment, although without a confident reason for doing so, and had acted in a way that bypassed any potential conflict between "god" and "godling-in-training". That day I learned that registrars do as they are told because their career progression is "on the line". That day I also learned that one can feel good making the correct diagnosis, treating the problem correctly and producing a good outcome for a patient.

I was not always right. Mostly I too did what I was told to do by my superiors without harm to the patient, but sometimes I made decisions that did in fact have an adverse outcome, either for my own emotional wellbeing or worse, to the detriment of the patient.


In the early hours of one morning (my night on-call) the nurses on the ward called me to seek advice on a problem with an intravenous line that had ceased to work properly. This intravenous line was a "central venous line" where the end of the plastic tubing placed inside the patient's vein was threaded along the length of the vein and into the major vein near the heart. Various reasons determine the need for such an intravenous line, needless to say, this patient had a good medical reason to have this line. Well, at 03:00am (or thereabouts) that line was discovered to be blocked and despite gentle irrigation could not be unblocked. I made the decision to remove the line and wait on its replacement in the morning. I had never inserted a central line, I was not going to start unsupervised in the middle of the night. The following day the specialist ranted and raved about the removal of that patient's central line. Worse was the fact that the patient was a "private" patient of the specialist.

A few days previously another patient had been admitted to the hospital's intensive care unit from a complication of a central venous line. I was not going to be responsible for creating a similar occurrence in a patient under my care. My mistake was not calling the specialist in the middle of the night. Perhaps if I did there would have been a cascade of other undesirable consequences ... I will never know. What I do know was that given the information I had at the time I made the right decision, it was a shame that "god" did not agree. That day I learned that with all good intentions and without adverse outcome for the patient, one still can suffer unexpected but unpleasant consequences from decisions one makes as a young doctor. I never worked directly under that particular specialist, although I was occasionally responsible for the care of his patients. At times, that specialist was the most arrogant, rude and obnoxious specialist one could have met, and certainly the most unpleasant I have ever met. It was a necessary evil that his medical skills made him a part of the medical team in the hospital and to be honest, he was to be trusted to be a very thorough physician - just lacked the necessary social skills.

I also remember the time that I was the lone senior doctor ("senior" as in "second year postgraduate") of the night. A gentleman who had just retired from one of the services (I can't remember if he was a policeman, fireman or in the armed services) had come in late in the evening with a very short-lived episode of chest discomfort earlier in the day. He was well and painfree on presentation to the emergency department. A cardiograph was performed and it seemed normal to me. The medical registrar, who was off duty, was in the resident's quarters on the hospital grounds so I sent the cardiograph over for her to look at. She agreed that the cardiograph was normal. I sent the patient home after a period of observation confident that the pain was not his heart, but uncertain of the diagnosis. Just before the end of my shift that morning, the ambulance arrived for a "certification" of a body - you see, people aren't actually dead until a doctor pronounces them dead, so given the emergency department doctor was the only accessible doctor in town overnight, the ambulance relied on us to pronounce death before a dead patient could be transported to the morgue.

That morning the body was that of the patient I had seen the previous evening. I felt ill. I was exonerated after an investigation however until this occurred, I suffered the unpleasantness of rumour and innuendo floating around the hospital that a "young doctor had sent an unwell patient home to die". That day I learned that despite doing one's best given the circumstances it is sometimes not good enough. I also learned that ruminating was not a healthy past-time.

Others of my colleagues had their own unpleasant visions brought in the back of the ambulance. One night when my wife was in the emergency department, it was her job to pronounce death. This body was bagged up in pieces (having been, when alive, laid down across the rail tracks just outside town - this means of suicide was not that uncommon in that town) and there was no earthly reason why it should take the "skills" of a doctor to diagnose the deceased. It was just for the "paperwork" ... as if the bits would somehow join up, reanimate and sue the mortuary for "false imprisonment"! Life's regulations are strange sometimes.

Other memories that jump out of the blur? Many ... but how many pages do I devote to them? Maybe this journal will be expanded into a tome at some stage in the future.Boat races, cocktail happy hour, bush bands and pub meals (loved the pepper steaks and salty chips), weekend resident's parties, weekend's off with my wife, working with a devout Jew who could not work on the Sabbath, defensive driving courses, holidays by myself, sleeping in different rooms to conserve my and my wife's precious sleep, food poisoning at a staff function, end-of-year "revues" ... all spring to mind if I let it wander.Black and white ... mostly grey with splashes of light and colour. Not as satisfying as a good pepper steak.