Kings Cross View

True Unbelievers

2011-02-13T14:56:00.000+11:00

At a time in history when science has expanded human medicine and technology like no other, I am appalled and the unbelieving devotees of pseudo science. Perhaps it is the lack of science education or just a shutting down of critical faculties that leads people to trust shonky well marketed anti scientific ideas. Not to vaccinate children in 2011 should be classified a criminal offence . Those who believe in alternative therapies could be forced to use them in life threatening situations. Can you imagine getting homeopathy for a heart attack?

Alan has left the Cross for Byron Bay this week

2011-02-06T21:09:00.000+11:00

A MENTAL health nurse seemed like an like an impossibility for me. I have realised for some time that many of my patients had serious mental health issues and that the public system was failing them systemically.
Kings Cross is a magnet to the homeless and the mad. They feel comfortable here; there has always been a tolerance of outrageous behaviour on the streets. Many of my patients lived rough in parks or cars or couch surfing in other people’s flats.When the mental health nurse initiative was announced, I searched far and wide to employ somebody to assist me.

Alan was in charge of community mental health triage at a local teaching hospital. He was disillusioned and looking for something different, having worked on the streets in Liverpool and London in the UK. The fit was seamless from the first patient.

I would invite him into the consultation with the patient’s approval, and then he would lead them to his cubbyhole in my tiny practice and work miracles. Alan would liaise with the housing department, getting homeless schizophrenics a place to live much faster than I ever imagined.

He would facilitate care plans and personally escort broken-toothed dental disasters 200 metres to the local dentist to make sure the first appointment was firmly in place.
He would ride his motor scooter on home visits to Woolloomooloo, where children at risk were subsisting with benzodiazepine-dependent mothers.
Now we case manage several hard-end mentally unwell patients who had fallen through the cracks of the underresourced public system. They trust Alan implicitly, and with his assistance their management has become much easier.

To give you a taste of some of our new patients, one is a highly deluded man who believes he was a boy soldier. He performs the most amazing impromptu bird impressions in the middle of a consultation and claims to have fought in the Vietnam war, Bosnian conflict, first Gulf war and even the cold war. ASIO is very concerned about him as he keeps ringing the organisation for the money it owes him for his heroic undercover operations.

Alan has performed miracles for him, applying for and succeeding in getting him priority housing and a pension he should have had years ago; getting his teeth sorted out; even getting in touch with his family to reassure them he’s okay. They had not heard from him for years and imagined he had died.

On occasions Alan will walk a dishevelled unwashed patient to the Wayside Chapel for a shower and a change of clothing. They return smiling and clean for a consultation.
In the last few months, we have been deluged with referrals from Mission Australia and the Salvation Army. Word has passed around that the homeless receive a timely and efficient service. We now have a waiting list.
These patients are the most thankful and compliant group. To see them emerge from hopelessness has been an uplifting experience for all of us in the practice.

One such patient is a deluded homeless Korean man sent to us by the Salvation Army who lives off scraps in Chinatown, sleeps outside churches in the city, and tells me about “Hella Sharon”, an imaginary woman who visits him in a car every night and uses him for sex.We are attempting to repatriate him with the assistance of his sister in Seoul. It has been a slow process to get him to trust Alan, but he is making headway.
I had never realised how much mental illness was a part of general practice until Alan came to work with me. Now I cannot imagine working without a full-time mental health nurse. My practice has become much more fulfilling since he joined me.

Cage Fighting: Sydney Entertainment Centre

2011-02-06T20:16:00.001+11:00

IT came out of the blue: a request to be the doctor at a cage fighting competition at the Sydney Entertainment Centre.

My knowledge of this extreme sport was fairly limited, apart from the hysteria I’d seen on TV.

Mixed martial arts permits all sorts of disciplines to be used together. It involves striking and grappling techniques, so it looks like kick boxing, regular boxing and many other fighting traditions rolled into one.

These amazing pugilists have been around since the time of the ancient Greek Olympics: Pankration was introduced in 648 BC.

What was known then as the most extreme combat sport is now one of the fastest-growing spectator sports in the world.

The program in Sydney was to be broadcast live on pay TV in the United States.Men from the US, Brazil, the UK, Australia and Samoa were matched against each other in 10 separate bouts.NSW combat sports coordinator Craig Waller brought me rapidly up to speed at the weigh-in held the day before the bouts were to begin.

These were big men. They all had an entourage of coaches, attractive women and hangers-on. Most were heavily tattooed, with many of the Brazilians having religious motifs across their backs. They had been fighting since they were in their early teens in poverty-stricken favelas, where an aptitude for fighting was a meal ticket out of squalor.

Luckily I brought a large cuff for checking blood pressure, since most had biceps the size of my thighs. All 20 fighters had to be checked for HIV and other blood-borne infections before being weighed. On examination, all were extremely fit. Nobody swore or spat on the floor. I expected exponents of the martial arts to be wild men, but somewhat surprisingly, they were charming, well mannered professionals.

When I cheated and watched a short bout of cage fighting on YouTube, I thought it was a free for all, no holds barred competition, something like human cockfighting. I soon discovered that it is a strictly regulated and controlled sport. Up to a point.

Assisted by my practice nurse Matt and medical student Nici, we entered the waiting rooms of the Entertainment Centre armed with a hefty medical kit that contained sutures, local anaesthetic and skin glue. We wandered through the waiting areas observing the fighters prepare themselves for the combat ahead.

A number of them were meditating, others shadowboxing and some dancing to Brazilian music. Hooded tracksuits were the fashion order of the day.

Young female dancers in skimpy outfits completed the picture. They were, apparently, employed solely to entertain the punters between rounds and encourage the innumerate audience to count to five.

A cage fighter enters the ring with no boots and half-gloves. Each fight consisted of three five-minute rounds, with a minute in between where the seconds patch up their battered charges.

The brutality of these bouts at ringside was mesmerising. Four paramedics and two ambulances were in attendance, and the screams of the crowd soon had my pulse racing.

Fighters can use their fists and feet and entire body weight to either knock down their opponent or force him to submit.

Ringside doctors must observe the fight closely and have the authority to shut it down any time, should a combatant be badly injured or unable to continue.

At the beginning of each fight, the referee looks to the doctor for the thumbs-up sign to indicate that proceedings can begin.

The star attraction was Ken Shamrock who aged 46, still managed to trade blows with a younger opponent. He had a considerable fan club in the audience. His nose had been pulverised a number of times and looked like it could use the services of a reconstructive ear nose and throat surgeon. I figured that his flattened proboscis was not a major issue under the circumstances.

After each fight I would return to the change rooms with Matt and Nici to check for damage and my medical student in her final year became wide-eyed when she entered the backstage area that had been turned into the post-fight lounge.

There was a palpable odour of spent testosterone. The fighters slumped on chairs, their entourages of up to 10 people applying ice packs to swollen soft tissues and massaging tortured muscles.

I treated minor emergencies, such as reducing a dislocated finger. I wasn’t keen to apply traction but the Brazilian fighter looked at it with a pained expression and said with a strong Portuguese accent: “Just do it, Doctor... when I was growing up in the favela we did it all the time.”

Advocates of cage fighting reckon it channels young men's aggressive impulses and the training provides them with a tough discipline. Others suggest it is barbaric and risks serious head injury.

Certainly, the broken noses and cauliflower ears testify to sheer tenacity of the bouts. For me it was one of the most exciting experiences of my medical career, but not one I could repeat on a regular basis without ulcer medication and tranquillizers.

My Christmas presentations: A funny wrap-up

2011-02-06T19:05:00.000+11:00

My Christmas presentations: A funny wrap-up

Dr Raymond Seidler more by this author

31st Jan 2011

To say that I was looking forward to a break over Christmas and into January is an understatement, but fate had other plans for me.

On the eve of our trip overseas, my son had a spontaneous pneumothorax requiring surgery which quickly threw our holiday into disarray.

He was on the mend and with the hospital up the road, I decided I might as well work through the holiday period.

Now, Kings Cross is always an edgy place, but it takes on a new frisson of excitement over Christmas.

Mine was the only practice open here and, with no receptionist, I fully expected a challenge opening up for four hours a day over all the public holidays.

Nothing prepared me for the strange and unusual presentations I engaged.

Backpackers were stuck in Sydney unable to head to Queensland due to the floods and a few meandered into my waiting room on Christmas Day.

A young woman from London was obviously suffering a fever and a deep resonant cough. She had slept on the floor in Heathrow for four days in freezing conditions and proceeded to develop fulminant pneumonia on her flight to Sydney. She was now headed for the emergency department at St Vincent’s for a holiday detour.

Trans-sexuality is common in my bailiwick but a middle-aged woman I had not seen for four years presented me with a special festive season challenge.

On Christmas Day she decided that I should complete the documentation to change her gender legally to a woman.

The paperwork was complicated and required that I visually check to ensure she no longer just dressed like a woman but in fact had undergone a surgical procedure that was irrevocable. It was.

We needed a justice of the peace to countersign her gender reassignment. None was available. She left in an agitated state muttering to herself.

Sexual activity was soon firmly on the agenda. Two young men describe their Christmas Eve in glowing terms but confided sheepishly that in their inebriated state, sex had occurred without protection.

Seeming to need each other for support, they told me they could not remember the women they had been with. Could I check for a barrage of sexually transmitted infections?

Of course, the pathology lab was closed and all I could do was suggest they return on Boxing Day.

They, too, became restive.

By now I was pondering the wisdom of opening my practice doors. An assortment of middle-aged tourists then plagued me with requests for scripts of medication they had left at home. Antihypertensives, sleeping tablets and thyroid hormones were the orders of the day.

My last patient was a drug user who wanted to be straight for the new year and requested that I facilitate his detox over the next six days. He was heading up the coast to his parents and had to be straight or they would lock him out of the house again. A painful negotiation ensued with fruitless calls to detox centres. He left crestfallen.

As I organised myself to leave and cycle home through the by now quiet streets of Kings Cross, street people that I had seen over the last year wished me a happy Christmas and seemed amazed that a GP would be about.

“Go home, Doctor,” they yelled, holding aloft a 4 L cask of cheap plonk. One even offered to share some of his wine with me.

Working over these holidays was singularly entertaining, but even so, I reckon I’ll take Christmas 2011 off.

Article in the Australian

2011-02-06T19:01:00.000+11:00

ALMOST every GP in Australia has been threatened, assaulted or verbally abused as drug addiction, long queues and disputes over medical bills push unstable patients over the edge.

The first national survey of violence against GPs suggests 88 per cent have been subjected to verbal aggression and one in six have been physically attacked by patients or their relatives.
One in five had been sexually harassed, 8 per cent said they had been stalked and 2 per cent reported being sexually assaulted.
The taxpayer-funded survey suggests 6 per cent of Australia's 23,000 GPs have been physically assaulted in the past 12 months alone -- twice the assault rate for the general community.
It found receptionists were frequent targets of aggression, with one in five saying they were verbally abused on a weekly basis.
The Australian Primary Health Care Research Institute study found drug-affected and drug-seeking men were the most common perpetrators.

"Triggers to patient-initiated aggression included procedural issues such as long waiting times to see a doctor, unavailability of the doctor of choice and refusal of specific patient-requested medication or treatment," the institute found in the yet-to-be-published study. "Other triggers of aggression included issues of payment and refusal of bulk-billing."
Difficulties with overseas-trained doctors and discrimination against female GPs were also reported as possible triggers.
The aggression often had a lasting affect on victims, with 38 per cent reporting an impact on their emotional wellbeing, and 14 per cent suffering physical injury.
Violence was more common in metropolitan clinics, particularly towards closing time.
The study found most GPs believed their professional associations had not done enough to address the dangers facing them.
Sydney GP Raymond Seidler, who now gives talks to doctors about how to reduce the risk of practice violence, is one who has suffered such an attack.
"I have been knocked down by a drunk patient -- he took a swipe at me because I refused to see him because he was intoxicated," Dr Seidler said.
Sydney GP Theodore Rothonis was stabbed in the back in April 2009 as he wrote out a prescription by a patient he already knew to be schizophrenic.
The knife was driven in so hard it bent, chipping his spine and puncturing both lungs.
"You never turn your back on people again, whether they are women or children or whatever," he said.

Aged Care Dilemma

2011-01-26T18:08:00.003+11:00

Ross Gittins clearly elucidates the problem with aged care in Australia. His solution is fraught with difficulty.

I worked as a general practitioner in an aged care institution on Australia Day. It was hot and the rooms were not air-conditioned and some of my patients were suffering near heatstroke. Many people there had little in the way of assets but a few have had their assets stripped by their avaricious children who sold the family home and invest the money after obtaining a power-of-attorney. They render their elderly parents impecunious by liquidating the family home thereby throwing them on to the taxpayer for care in aged care institutions and maximising their take when the inheritance comes around.

There needs to be a plan where everybody contributes to their eventual placement in aged care facilities so that standards are maintained and the true cost is borne by the whole community.

Mafia dressed down

2011-01-22T09:10:00.001+11:00

In arresting 127 mafia linchpins in New York, New Jersey and New England, the FBI has had an impressive win against organised crime. It was a shame, however, that the mobsters arrested looked so shabby in poorly fitting jeans, trainers and tee shirts on TV. Time was, no self respecting Mafia Don would be arrested without the full sartorial elegance of the best Italian tailors and an equally well dressed brief at his side.

SMH Letter

2010-12-30T12:10:00.002+11:00

Kings Cross has always had a unorthodox rough edge but lately as Elizabeth Farrelly points out the convergence of alcohol and huge numbers of young people make the environment downright dangerous. Police fearing to go to work in such an environment is perfectly reasonable. Just observe the heady mix of testosterone booze and try to reason with intoxicated aggressive people who resent police doing their duty. Have a look at the streets at 6 am before the cleaners have been through and see a beautiful suburb desecrated. We need to restore the Cross before it is lost to mindless hoons.

SMH Letter

2010-12-27T20:10:00.003+11:00

Fernando Henrique Cardoso is not alone in recommending that the war on drugs should end. What he fails to realise is that the insatiable demand for drugs by cashed up Western nations looking to alter their collective state of consciousness is so great that to acknowledge its extent is political poison. Add to this the burgeoning industries that have sprung up to counter the criminalisation of drugs. These would cease to make a nice living were illicit drugs off the banned list.

force-fed at the front

2010-12-22T09:55:00.000+11:00

An army it is said marches on it’s stomach, but the military meals shown in your article would not tempt me after a day fighting insurgents in hostile territory. Freeze dried pork ribs and skittles don’t seem all that enticing. What happened to world war 2 ration packs with spam and tins of beans? Now that would get a soldier moving.

holiday time

2010-12-22T09:43:00.000+11:00

Dear editor,

Pleasant Activity Training as recommended by Ross Gittins in his article sounds like a good idea. Reality however is somewhat different. We often don't take our accrued annual leave and the result is stress-related illness or physical problems. More problematic still is going on leave and staying connected to work by e-mail or other electronic umbilical cords. Never entirely disconnecting seems to be the norm these days. A real holiday is pulling the plug, rediscovering yourself and your friends.

Yippies again

2010-11-25T17:07:00.002+11:00

Phillip Adams’ evocative piece on the Yippies and their antics in the 1970’s reminds me of a kinder gentler period of history. We have become much less fun loving and more shrill in the 40 years since their last hurrah. Maybe mass hallucinations should be entertained again as suggested when the yippies planned to augment the water supplies of American cities with Lysergic acid Diethylamide and turn the whole nation on

Building before Xmas

2010-11-25T16:17:00.001+11:00

I am in the process of setting up a miniscule super clinic in Kings cross with the aid of the federal government. I can use the infrastructure money to fit out the second flat I have rented next to my existing practice. It will be fantastic if I can find some fellows to paint, plumb and create a stud wall but I did not factor in the silly season and tradies lassitude

Don’t try to have any building work done between now and Christmas. There is an unspoken rule about the last weeks of the year being unobtainable at any price. Every contractor and tradesmen worth his salt is flat out hammering drilling and plumbing. This frenzied time occurs every year and Sydney closes down for the languorous period from Christmas to Australia Day. The building trades pack up their tools and rightly disappear up or down the coast to attend to their own tumbledown piles which require maintenance not provided in the year of the School stimulus building program that seized everybody who could wield a tool like dengue fever on a hot night in Bali.

Add to this torpor the sheer obstinacy and bureaucratic minefield of the local council who will not feel the same sense of urgency to provide Development applications or Construction Certificates in a timely fashion. The paperwork is mind boggling: the copies the plans the CDs the pdfs all in quadruplicate before the bureaucrats wuill look at it. Woe betide anyone who leaves paperwork unfinished. The council stamp of authority will be withheld. And what’s worse is the crappy old block of flats I work in is heritage listed. Frankly I cannot see the architectural worth for the life of me but there you are. A heritage impact statement is the next thing

Any pressure applied to councils seems to have a strangely inverse effect on the passage of paperwork though the system. It is full of twists and turns that resemble a blocked lower colon without sufficient innervation to produce any result in the time allotted. Complaints fall on cloth ears: Irritability and rising blood pressure are seen as seasonal affectations which must be borne in the spirit of the Christmas.

“Mate I’d love to help you but I have three jobs on the go before Christmas and I am flat out. I could get one of my mates to help you out though. He doesn’t have a building ticket and lost his drivers licence last week for drink driving but he is a great bloke and will fix the stud wall quickly. That is if he doesn’t get nicked on his outstanding warrant between now and New year. Want his number? I’ll SMS it to you. But don’t spread his name around. Know what I mean? He is the last card in my deck.” So goes the inevitable refrain.

And if by chance you are lucky to get somebody to work for you, they do it in fits and starts because they are doing seventeen other jobs at the same time. Multi tasking gone mad. So bad is the situation that your builder may forget that he started the job at your address and never return til the next downturn in the building industry. This may be in two years time. Suddenly he will arrive on the doorstep with a forlorn expression asking how the job is going. His apprentice will have jumped ship and his ute unrepaired after a serious smash. He will have a lumbar crush fracture and be working in a brace.

So you start again only to discover the construction certificate is no longer valid and a bit more hair falls out while that nasty twitch in your left eye makes you look a bit crazy. The concretor looks up and asks poignantly….

“Are you okay, Doc?”

Season’s greetings to all builders labourers, gyprockers and council employees. Now get to work!

Roid Rage amongst US Soldiers in Afghanistan

2010-11-25T12:43:00.000+11:00

Megarrhexia is a new body image disorder where men try to increase their muscle bulk disproportionately, often using illicit anabolic steroids. The fact that an increasing number of US servicemen are employing steroids to bulk up should not be surprising considering the world wide trend to increase muscle mass. What is disturbing is that these soldiers may behave irrationally under the influence of such drugs expressing ‘roid rage’ or even frank psychosis. In the presence of weapons of mass destruction in Afghanistan this may well represent an increased risk to civilian and military populations alike.

The contrast with Taliban soldiers could not be more stark. Skinny undernourished and poorly provisioned men are fighting coaltion forces with extraordinary ferocity.

NBN catastrophe looming

2010-11-18T08:43:00.000+11:00

In the light of the gathering clouds of economic doom in Europe, surely Australia should rethink the rollout of the NBN, To spend $43 billion at this time is folly, especially since Ms Gillard is sitting on the 400 page business case until after parliament rises and the silly season begins.

Letter to SMH

2010-11-16T08:33:00.001+11:00

What an inspiration Aung San Suu Kyi is to the rest of the world. No wonder Barack Obama considers her a hero. Her quiet dignity, poise and elegance stand in cointradistinction to the brutish regime with whom she has sought to peacefully reconcile.

SMH Letter

2010-11-03T08:05:00.001+11:00

Dear Editor

If it is true, as Mr Berlusconi’s ex wife suggests, that he suffers from an obsession for young attractive women, the voters of Italy should respond. Trouble is, most Italian men suffer from the same obsession. A backlash against this behaviour seems unlikely.

Organic thieving

2010-11-03T08:02:00.002+11:00

Ripe for the picking is an apt title. The poor organic customer is being fleeced. The photograph showing oranges at $4.75 in the Double Bay market means each orange costs around a dollar. Only an organic zealot could part with that kind of money when ordinary oranges that look more appetising, sell at Flemington retail markets for one dollar per kilo.

Zimbabwe love affairs

2010-10-28T09:24:00.002+11:00

Dear Editor

The alleged affair between Grace Mugabe and Gideon Gono in Zimbabwe would be entertaining if it did not have sinister undertones. Even in his eighties, Mugabe wields a big stick and the protagonists in this soap opera should realize that there is nowhere they can hide from the Zimbabwean secret service and Mugabe’s wrath. At least Grace is living in comfort in their Hong Kong mansion, while the rest of Zimbabwe is reduced to penury.

Letter to SMH re Shore School and closing the mouths of babes

2010-10-24T09:27:00.002+11:00

Dear Editor

The taping closed of naughty boys mouths, who would not stop speaking, at the Shore school, is completely understandable. Duct tape should be part of every teacher’s kit.

Paperless lawyers

2010-10-21T08:36:00.002+11:00

Dear editor
Your series on the problems with the judiciary has been illuminating. Patently these isolated men and women have a culture that needs change urgently. But no less so than their lawyer colleagues who have remained mired in paper based obfuscation which is designed in part to confuse clients. In 2010 all legal practice should be paperless. Then perhaps we would not see boxes of ring bound folders entering courts and the whole impenetrable process of the law sped up immeasurably,

Madut

2010-10-18T16:48:00.000+11:00

My taxi driver to hobart airport was Madut a tall stauesque Kenyan who had grown up in Nairobi and then migrated to Tasmania on a scholarship to study commerce. He was keen to return home to marry his high school sweetheart and bring her to Australia. he mentioned that Hobart was too quiet for him after the 24/7 life of Nairobi.

We discussed the dangers of east Africa and he admitted that street kiuds high on Khat, a drug they chew will often assualt tourists they believ are making unecessary displays of wealth. He told me that an Indian lady with gold bangles had her arm chopped off on Haile Selassi Avenue by a gang boy who wanted her jewellery. The crime was witnessed by local police who gave chase and then stopped as theperp threw a gold bangle from the amputated arm distracting the police officer and then made his getaway.
Madut mentioned his father had five wives and over 30 kids. Polygamy is legal in Kenya
He reckons that if he goes back to Nairobi there will be a queue of girls who will want to marry him and come to Australia.

Enrolled Nurse Conference

2010-10-18T14:52:00.000+11:00

Just about to leave Hobart with some Salmon I have purchased. Hope it doesn't thaw out in the plane.
Fantastic conference full of dedicated nurses for whom my talk on Kings Cross resonated. They came up afterwards and were so enthusiastic. A couple asked if they could work with me in the future. All I did was explain my patient load and the exotic people I see with some stories that seemed to resonate with nurses at the coal face. They are extraordinary people who devote themselves to the toughest job of all for very little recognition and even less pay.
Mental health nurses from Bundaberg described the awful conditions they work under in regional Australia with little support form the medical profession. I am convinced that these women do better without the interference of hapless doctors.
Hobart is rainy and wet again.
Home tonight

The bus in mid life!

2010-10-14T08:36:00.003+11:00

Amazingly, the RTA did what the threatened and I have been banned from driving for six months. Embarrassment at having to catch public transport has it's upside though. I have lost weight from all the extra walking I now do.

The gross unfairness of my disqualification still rankles. Despite letters of complaint to the CEO of the RTA about me being a working doctor and needing a car to visit elderly patients in their homes, I was told that the decision was final and that was that.

Dinner parties and nights out with friends and colleagues confirms that many of my cohort are in imminent danger of losing their licences too. so the thought crossed my mind during a feverish night of insomnia that I should start the Anti RTA party for the next state election. I reckon I would have thousands of members all appalled at the unfettered power of this statutory body to wreck the lives of otherwise law abiding citizens.

As the magistrate so poignantly put it before me and the assembled multitude in court, "If you had been low range drink driving I have the discretion restore your licence at my discretion but I cannot affect points accrued by fines from the constabulary. The law is an ass.
Bad luck doctor."

Australlia: the 'dumb blonde' of the world

2010-10-14T07:45:00.000+11:00

Editor

How could anyone describe Australia as “the dumb blonde” of the world, attractive but unintelligent?
Fact is we encourage this view by our anti intellectual, she’ll be right obsession with mediocrity in all things except sport. If fewer young women decided to leave their hair natural rather than peroxiding themselves and improved their minds rather than their bodies, the world might have a better opinion of us.

HSC, Mark three

2010-10-10T22:34:00.002+11:00

The Higherr School Certificate is fast approaching. After two sons have been through the trials and tribulations, I thought I had a plan to deal with the oncoming stress of son number three. Previous pandemonic outbursts of the older two examination candidates were just a distant memory and I was convinced that with my increasing maturity and the passage of time, I could handle anything son number three would throw at me. Alas, I was wrong. I now realise that each child behaves differently and that rather than diminish, the level of conflict has risen to fever pitch.
You see, Z is idiosyncratic. He does weird things and now as the pressure is on, he has become more demanding. For example, today he told his brothers and I not to walk on the kitchen floor as it disturbs him while he is studying below. Woebetide anyone who fails to take the hint. He will scream from the room down below using expletives about how we don't care about his ongoing stress. So we have begun wrapping rags around our feet to minimise our foot fall lest he turn on yet another tirade.

He seems to take particular pleasure in torturing me. I am the brunt of his invective which knows no bounds. I am told by my appeasing partner that we have to understand that the young thing under extraordinary stress that his regular wanderings around the house wearing his hoodie tightly over his cranium, in a new version of learning. Apparently it is now the case that whole essays must be committed to memory and therefore in order to focus his attention he shuts out all extraneous sound or light, in his relentless pursuit of excellence.
We have tried telling him to relax, to go for a walk or have a massage, but he responds with a grunt explaining that there are only 216 hours left until the big day and that he cannot waste even 20 minutes on frivolity.

My wife has begun feeding him at his desk so that he is not wasting time joining us at the dinner table. She searches for delectable morsels far and wide, that will entice his jaded taste buds and turns on anybody who inadvertently eats what she has prepared for him.

To be sure, the house has become almost uninhabitable. Z moves from room to room like an invading marauder, usurping desks, floorspace and computers as he searches for new and untouched areas to spread his notes and textbooks. Soon tiring of one room, he will annexe another. Last week he moved out of the house altogether to his grandmother's and we were relieved. But now he has returned and the clock is ticking. I plan to move to his grandmother's in the vain hope that I can avoid any more confrontations with the wildebeest that has become my previously charming son.
My fondest hope is that by mid-November when all of this madness is over he will recover its previously adorable personality and we will be able to talk again without my blood pressure and pulse rate rising.

Please please, spare me any more final high school examinations. Set me free from the pain, the ignominy and the nagging fear that he may be right. The final examinations in 2010 are infinitely more complicated than they were in 1969 and I am a stupid loser, like he says.

Bill Clinton's Vegan Diet

2010-09-26T18:08:00.000+10:00

There has been much discussion of ex-president Bill Clinton's extraordinary weight loss over the last few weeks. It appears that the once corpulent aficionado of McDonald's and other fast foods has become enamoured of all things natural. He now eats a truly restrictive vegan diet eschewing dairy products meat and fish. Since daughter Chelsea's wedding in April this year, Bill has managed to lose 12 kg in weight. But it's not just the wedding that caused this profound change in his lifestyle. In 2004 he underwent quadruple coronary artery bypass, but due to his intemperate eating habits, the cardiologists this year have had to insert stents into his grafted arteries.

Mr Clinton is no slouch academically. He has researched the subject of longevity with heart disease extensively and in a recent quote to CNN he said "I did all this research, and I saw that 82 percent of the people since 1986 who have gone on a plant-base, no dairy, no meat of any kind, no chicken, no turkey—I eat very little fish, once in a while I'll have a little fish—If you can do it, 82 percent of people have begun to heal themselves."

Perhaps if we look at Bill Clinton as an archetypal baby boomer, some clear explanation for his behaviour will emerge. Like most men of his age, by the time symptoms arrive it is too late for primary prevention and his doctors moved to medical or surgical treatment. It is not as though Mr Clinton did not have access to the best and brightest medical treatment in the world. His six monthly medical checkups as president, would have involved extensive cardiological investigations.

We may conclude then, that he was warned about lifestyle issues and encouraged to take medication long before his coronary artery surgery in 2004.

How did he fail to heed the constant exhortations of his medical attendants? Was he so addicted to salt and fat that even armed with the best possible medical information, he failed to significantly effect change that would keep him away from the interventional cardiologists?.
Sometimes an addiction can overwhelm even the most intelligent and erudite person and it certainly appears that despite all the warnings Bill continued to eat junk. His biography in Wikipedia gives us an inkling into the dysfunctional family life Bill was exposed to early on.

"Clinton says he remembers his stepfather as a gambler and an alcoholic who regularly abused his mother and half-brother Roger Clinton, Jr., to the point where he intervened multiple times with the threat of violence in order to protect them." He shares this problematic violence with many other people who suffer addiction and seem powerless to change their life course.

In 2010 Clinton has fallen under the spell of two charismatic diet and lifestyle doctors: Dean Ornish and Caldwell Esselstyne. Ornish practices in Sausalito California and has been influenced by Swami Satchidananda in his quest for holistic health, while Esselstyn has written 'Prevent and Reverse Heart Disease' and his website quotes:

"A groundbreaking program backed by the irrefutable results from Dr. Esselstyn’s 20-year study proving changes in diet and nutrition can actually cure heart disease"

Bill Clinton's profound metamorphosis into this fit man has captured the popular imagination. Many commentators are concerned that Bill now has a gaunt look that makes him appear unhealthy.

It will not be too long before patients in Australia present to their GPs asking to go on to the Bill Clinton regime. Be aware however that the use of almond milk as suggested online is expensive and probably not environmentally sustainable.
•

Top of the class

2010-09-14T07:22:00.001+10:00

If Anglo Australians are falling behind their migrant counterparts in academic excellence, we should be looking at the study techniques of the high achievers. Alas many Aussie kids think that being clever at school is geekish and that sport is the only way to popularity. Our educational culture needs an overhaul and the positive parental influence of clever students should be emulated.

Miranda Devine and Ben Cousins TV show

2010-08-28T08:53:00.001+10:00

Miranda Divine is correct in her critique of the Ben Cousins story. The expose is a
tawdry romp through Ben's self absorbed life. His child like naiveté and lack of
remorse are palpable. Far from dissuading drug use this program glamourised his self
indulgent lifestyle. His justification for his bad behaviour do little to reclaim his
battered reputation. AS for the claim by Seven that this was a pivotal program in drug
education for the country, nothing could be further from the truth.

Cage Fighting Doctor

2010-08-27T06:13:00.001+10:00

It came out of the blue -a request to be the doctor in a cage fighting competition At the Sydney Entertainment Centre. My knowledge of this extreme sport was fairly limited, apart from the hysteria I'd seen on TV. Mixed martial arts is a full contact combat sport that permits all sorts of martial arts to be used together. It involves striking and grappling techniques, so it looks like kick boxing, regular boxing and many other fighting traditions rolled into one.

These amazing pugilists have been around since the time of the ancient Greeks; ‘PanKration’ was introduced in 648 BC. What was known then as the most extreme combat sport and now is one of the fastest-growing spectator sports in the world. The program in Sydney was to be broadcast live on pay-TV in the United States. This meant the fighters had travelled from all parts of the world to beat each other up here under my watchful gaze. Men from America, Brazil, UK Australia and Samoa were matched against each other in 10 separate bouts

New South Wales combat sports coordinator Craig Waller brought me rapidly up to speed at the weigh-in held the day before the bouts were to begin. These were big men. They all had an entourage of coaches, attractive women and hangers on. Most were heavily tattooed and many of the Brazilians had religious motifs across their backs and they had been fighting since they were in their early teens in favelas.

Luckily I brought a large cuff for checking blood pressure as most of the men had biceps this size of my thighs All 20 fighters had to be checked for HIV and other blood-borne infections before being were weighed. Some had spent hours in the sauna trying to shed weight. On examination, they were all extremely fit men. Nobody swore and no one spat on the floor. I expected exponents of the martial arts to be wild men, but somewhat surprisingly, they were charming, well mannered professionals.

When I cheated and watched a short bout of cage fighting on YouTube, I thought it was a free for all, no holds barred competition, something like human cockfighting. I soon discovered that it is a strictly regulated and controlled sport.
Assisted by my practice nurse Matt and medical student Nici, we entered the waiting rooms of the Entertainment centre armed with a hefty medical kit that contained sutures, local anaesthetic and skin glue. We wandered through the waiting areas observing the fighters prepare themselves for the combat ahead. A number of them were meditating, others shadowboxing and some dancing to Brazilian music. Hooded tracksuits were the fashion order of the day. Young female dancers in skimpy outfits completed the picture. They were, apparently, employed solely to entertain the punters between rounds and encourage the innumerate audience to count to five.

A cage fighter enters the ring with no boots and only half gloves. Each fight consisted of three five-minute rounds with a minute in between where the seconds patch up their battered protégés.
The frenzied brutal nature of these bouts up close at ringside was mesmerising. Four paramedics and two ambulances were in attendance and the screams of the crowd soon had my pulse rate racing. Ringside doctors must observe the fight closely and have the capacity to shut it down anytime, should a combatant be seriously injured or unable to continue. Fighters can use their fists and feet and entire body weight because their opponent to either be knocked down or submit. At the beginning of each fight, the judges and referee look to the doctor for the thumbs up sign to indicate that proceedings can begin.
The star attraction was Ken Shamrock who aged 46, still managed to trade blows with a younger opponent. He had a considerable fan club in the audience.
After each fight I would return to the change rooms with my nurse and med student to check for damage. We reduced a dislocated finger and glued a number of facial wounds after applying local adrenaline on a swab. There was a palpable exhaustion with dazed men and their support teams hovering around.

Advocates of cage fighting reckon it channels young men's aggressive impulses and the training provides them with a tough discipline. Others suggest it is barbaric and risks serious head injury. Certainly, the broken noses and cauliflower ears testify to sheer tenacity of the bouts. For me it was one of the most exciting experiences of my medical career, but not one I could repeat on a regular basis without ulcer medication and tranquillizers.

Water water everywhere

2010-08-26T09:47:00.001+10:00

The flood in Moore Park is just another example of the parlous infrastucture neglect that has been going on in NSW for more than a decade. Not as bad as Bellevue Hill says Sydney Water.
expect more failure from our utilities as the pipes of Sydney give up and our precious water floods the streets.
Watch for a pothole near you

Entertainment Centre Sydney Fight Doctor Impact FC July 10

2010-08-25T12:44:00.001+10:00

2010-08-25T12:43:00.000+10:00

2010-08-25T12:42:00.000+10:00

2010-08-25T12:41:00.000+10:00

Indecumbent heaven

2010-08-24T06:50:00.001+10:00

The four smiling indecumbent members of parliament head for Canberra today to negotiate the nation's future.

Considering the extraordinary power that they will wield, perhaps it is time to leave Sydney and move to one of their regional electorates where I could be guaranteed that the infrastructure and quality of life will improve dramatically.

e consults

2010-08-23T21:30:00.002+10:00

I have used e-mail now for many years and proudly add my e-mail address to all correspondence with patients and to my business card. My real concern is the fear that doctors seem to have about allowing their patients e-mail access. Surely it is far better to have a patient e-mail their GP and have an endless list of telephone calls to return at the end of the day. At least with e-mail, I can deal with them at a time that suits me. There is nothing worse than playing telephone tag with a patient.

In 2010 we need to step up to the mark and acknowledge that e-mail has become the most common and effective communication tool that we have.

I long to embrace e consultations. They are often funny, diverting them require patients to formulate reasonably meaningful communications with doctors. This makes the patient more likely to be involved in their own care. The Ubiquity and banality of mobile phone consultations bores me stupid. I refuse to give out my mobile phone number except to patients over 75 who can not remember more than six digits in a row, I will gladly provide my e-mail address to any and all of my patients. Surprisingly they do not abuse my inbox and life has become infinitely more manageable.

Brisbane, 21 August 2010

2010-08-21T17:16:00.003+10:00

What a liveable city. Today I rode a bike that I hired in the Botanical Gardens along the river and acrioss the bridge to the Art Gallery where I enjoyed the Valentino exhibition. This Milanese coutourier changed the world of women's fashion form 1959 to the present day. The largely female audience were captivated by his timeless creations. And Brisbane shone in the Spring sunshine. From the red Poinsettias in the gardens to the family groups around the 'beach' - an extraordinary municipal pool that has a sandy beach on the edge of the river

Mr Cousins hangs up his boots:AAP report

2010-08-18T12:57:00.002+10:00

Aug 16, 2010

Ben Cousins' imminent retirement will see him exit the supportive environment of an AFL club with little to fall back on "except his drug history", a doctor has warned.

Dr Ray Seidler, an addiction specialist and GP based in Sydney's Kings Cross, said the end of Cousins' playing career later this month could trigger a tumultuous time for the 32-year-old.

Cousins' family, and broader support group, would need to rally around him to reduce the risk of a relapse into drug abuse, Dr Seidler said.

"His whole existence is bound up in football and to announce his retirement, at age 32, means he will have to make some major adjustments in his life," Dr Seidler told AAP on Tuesday.

"These sorts of life changes lead to destabilisation of people who have addiction, and very often it can lead to them going off the rails unless there is somebody watching them fairly closely.

"It may be an opportunity for him, but on the other hand it may be a crisis."

Dr Seidler said Cousins, like many professional athletes who retired at an age when most people were establishing their careers, would need to find a "new way to rationalise his existence - his raison d'etre".

His retirement from football would feel like "losing your job ... an extremely well paid job where you're in the public eye, to then suddenly slip from view into obscurity".

Dr Seidler said the transition was not easy, particularly so in the case of a retiring athlete who had battled with drug addiction.

"Ben, it seems to me, doesn't have much to fall back on except his drug history .... I think he needs a lot of support and redirection."

Upon returning to the sport with Richmond in 2009, Cousins agreed to a strict regime imposed by the AFL whereby he was required to undergo drug-detecting urine tests up to three times weekly and hair tests four times per year.

Cousins confirmed his impending retirement on Tuesday morning and said he would now pursue business interests in Melbourne.

He wants to maintain close ties with his current club Richmond and said he would like to undertake a mentoring role with young people "down the track".

Cousins made his AFL debut as an 18-year-old at West Coast, where he won the 2005 Brownlow Medal and played a key role in their 2006 premiership in a decorated career.

But his on-field brilliance masked off-field drug abuse, a problem that came to a head in 2007 and prompted a year-long ban from the game.

Cousins' past two seasons with Richmond also included a hospital admission following an accidental overdose of sleeping pills.

Dr Seidler also said it was too early for Cousins to take on a role in drug education, or warning of the dangers of addiction.

"I don't know that he could be a poster boy ... he has just had a recent admission to hospital and I don't think he can brush that aside," Dr Seidler said.

"He is too close to the fire still."

Cousins' final game will be against Port Adelaide, in Melbourne, on August 29.

"I'm no tech head. I am no Bill Gates" Abbott

2010-08-11T07:44:00.000+10:00

Tony Abbott wants to reduce the cost of the national Broadband network by slowing it to 12 mbps. When asked for detail he told reporters he was no tech head and no Bill Gates. Surely in 2010 the leader of a political party should understand the internet and it's ramifications. Julia Gillard is no better. She does not get how the NBN will transform Australian lives. One does not have to be a tech head to be across the policy.

world sauna titles

2010-08-08T21:49:00.001+10:00

Today in Finland north of Helsinki, two finalists in the world sauna title were taken to hospital after they competed in a Sauna set at 110°centigrade.One of the contestants died, the other suffered burns as they attempted to outstay each other in the excessive heat.

letter to Good Weekend

2010-08-08T21:42:00.001+10:00

After reading ‘Muscles Bound for Glory’ article and observing the grotesque images of female body sculpting, I am appalled that you could run a story glorifying the obsessive compulsive desire of some women to compete in this parallel universe.
Carbohydrate and, fluid depletion together with sleep deprivation plus some of the wackiest dietary regimes that I have ever heard of turned me off my breakfast cereal. These poor women need psychological help and the Good Weekend could do better than to glamorise their tawdry sport.

The end is nigh

2010-08-06T07:42:00.001+10:00

Dear editor

As a climate change skeptic, I'm starting to worry that I may be wrong. The torrential monsoonal downpour in Pakistan which has left 4 million people displaced and 1600 dead could possibly tip me over. Add to this the explosion of wildfires and drought in Russia that has lead to a cessation of all wheat deliveries for the rest of the year with an increase in wheat prices internationally of 70%. And the weather forecast for Moscow shows a maximum temperature of 38 degrees. Perhaps the climate doomsayers are right.

Kevin Rudd's Bile

2010-07-31T18:24:00.001+10:00

interesting that of all the organs that Kevin Rudd could have had removed in this election campaign, it was his gall bladder that came out yesterday. The small pouch that concentrates and stores bile.

Leglaised Marijuana in California

2010-07-30T06:22:00.001+10:00

It appears that legislators may choose to legalise pot in California as the near bankrupt state looks for innovative ways of taxing the population. A pot tax would recoup millions of dollars that end up in the black economy.

Acute Psychiatric Care

2010-07-29T18:57:00.002+10:00

It was my receptionist, who alerted me to the fact that James was in my waiting room. She called me on the intercom and explained that she thought he was a drug seeking patient. Walking out to greet him, I was taken by his agitated appearance. Quietly, I whispered that I was not prepared to prescribe tranquillisers or opioids under any circumstances. He acknowledged my message and walked into my consulting room. Across my desk, I noticed that his pupils were pinned consistent with recent opioid use. As his story unfolded I discovered that he had been referred to me by someone in the street who knew me and that he had spent a total of 19 years of his 45 year life in jail. He acknowledged he was now dependent on heroin again and that his life was spiralling out of control. I was alarmed when he said that he had been communicating with his long dead sister, but that now he felt she was slipping away and he could no longer talk to her. The impetus to see somebody had come when he tried to introduce his friend to his dead sister. She was so taken aback by this that she had advised him to seek medical help. When I asked James if he had received any mental health treatment in the past, especially in jail, he said no that he was too embarrassed to talk about it with anybody.

It transpired that James sister had died in a motor vehicle accident when James was 11 and his sister was 7. The car had been driven by their alcohol dependent father. James acknowledged that he was not sleeping and had suicidal ideas but no active plan.

Reaching for a sample of an antipsychotic medication, I explained to James that I thought he needed to be assessed by a crisis team but in the meantime the medication would help him sleep. I then phoned the local acute care team and then my day proceeded to deteriorate. First, I was told, that no one was available to speak to me and my name would be placed on board. Somebody would call me back in the afternoon. When I explained that James lived a few kilometres away in a different area I was told I would have to phone another acute care team, as he was out of area. My irritation was evident to the triage nurse on the phone when I explained that the patient was in front of me and a call later in the afternoon was not a satisfactory response. She commiserated but said that all of the mental health team personnel were at a meeting and nobody could speak to me now. Armed with a number of adjacent team I rang them immediately and discovered that again my patient was not in their catchment area. Another number was provided and I rang that one. By now James was pacing up and down in my office. Again, the team was unavailable but a nurse would call me back.

Forty five minutes had gone by and I was no closer to a resolution of James's acute problem. Finally the call came in the nurse asked me if I thought James was suicidal. Yes I said he had had suicidal ideation. Then she asked if he had an active plan with intent. No, I responded. " Are there are drug and alcohol issues associated with this patient?"

“Yes, he uses heroin. Perhaps you'd be better off calling the drug and alcohol service at your local hospital.”
“He doesn't like hospitals and refuses to attend. He has spent a long period incarcerated and this is major issue I countered.

“Well then” she said exasperated “perhaps you'd better call the police as I don't think our team would attend under these circumstances.”

By now, my hallucinating patient had had enough. James headed for the door. I encouraged him to return the next day and to take the medication I'd provided him. He has returned daily and with medication, has become more stable. But my experience with acute care teams has been illuminating. I have discovered a systemic desire to exclude patients that fall into the ‘too hard basket’ and staff that is adversarial and largely unhelpful. Perhaps this is due to the poor funding of this vital service or to the fact that psychiatric hospitals are full to overflowing.

The reality in 2010 is that GPs have no central phone number which is dedicated to them and so we must traverse an impenetrable thicket of bureaucracy. No wonder GPs have decided to leave the difficult end of psychiatry to the public system and have opted out.

We are still the best placed to deal with such patients. They trust us and only have to tell their story once.

Waverley Court - Criminal justice at it's shining best

2010-07-29T11:49:00.002+10:00

Tuesday morning dawned with apprehension. At 8:50 AM I lined up with a group of poor unfortunates in the foyer of Waverley courthouse. Many hapless victims of the criminal justice system did not speak English and were asked by a female court appointee if they were pleading guilty or not guilty. Some look blankly into space as this question is posed. A court official then says "well did you do it or not?"
more blank looks as she shepherds them downstairs to court one.

I am told I must attend court to as I am pleading guilty with mitigation, to my speeding offence outside a closed school. Anticipating at least half a day to wait to be heard I try to pull rank explaining that I am a GP on call. Soon after my name is called the lady magistrate looks over her glasses at me standing sheepishly in the dock.
"I'm afraid there is nothing I can do . The Roads and Traffic Authority have absolute discretion to cancel your licence.

"It is", she observes, "a travesty that somebody with 40 years driving experience should lose their licence but in future you will no doubt be mindful of the consequences your actions"
"Yes your honour" I blurt out, "I am just one of the 600 people every week in New South Wales who loses their licence."
Her honour dismisses me with a parting gift.

"And make sure you don't drive unlicensed or you'll be seeing me again in less pleasant circumstances"
Leaving the court, I resolve to have my bicycle serviced.

Mad Mel

2010-07-22T08:18:00.001+10:00

Dear Editor

Miranda Devine’s assertion that Mel Gibson’s tirades are the result of his alcohoism and bipolar disorder does a disservice to bipolar sufferers. His rants are well documented but rather indicate that he is more likely to suffer from a narcissistic personality disorder. This condition is common in Hollywood and among the upper echelons of society, generally.

A book Mr Keating, a book

2010-07-17T11:58:00.001+10:00

Mike Carlton is right in suggesting that Paul Keating should write his autobiography to set the record straight. Alas he prefers taking potshots from behind his desk. It would be illumminating to find out if Bob Hawe was as Keating asserts, missing in action for 4 years while suffering a depressive illness. The political record remains incomplete if this episode of Australian history was covered up..

The election 2010

2010-07-17T11:53:00.001+10:00

Editor

Why would Julia Gillard show her hand and provide policies that may be painful or impossible to implement? Doubtless her handlers have told her not to put her head above the parapet. There are too many cracks in Labor policy from the past two years to risk announcing anything new in the next few weeks. We have yet to hear the full cost of the insulation and school renovation debacles. Roll out the brown paper to hide the cracks.
I am not looking forward to another interminable campaign.

2010-07-15T18:23:00.002+10:00

In an insightful article in today's Australian, Ivan Briscoe elucidates the disastrous results of a decade of war on drugs. Murders associated with narco trafficking in Mexico since 2006 have reached 22,000. This extraordinary figure is far worse than the toll to the war in Afghanistan.
Inequitable distribution of wealth in countries like Mexico, Peru and Bolivia means there will always be a ready market for corruption and cocaine transportation. The insatiable desire of Americans for this drug leads tons of cocaine spilling over the border and create mayhem in towns like Juarez.
Knocking off the kingpins does little to stem the tide has thousands of young men battling poverty see cocaine as a passport to the consumer society they can only dream about or watch on television.
And so hard currency from America flows across the border in exchange lines of cocaine that would reach around the world.
The profits from the drug trade splashed around in poor countries south of the Rio Grande create the illusion that the heads of the drug cartels are benefactors for the poverty stricken population. Recent riots in Kingston Jamaicaclearly illuminated disconnection when the poor tried to protect an infamous drug dealer from the Army because of his benevolence in their community.
So at last in 2010 there is a glimmer on the horizon to indicate that this endless wasteful and unproductive war will solve nothing but create more suffering than has ever been imagined. In Europe governments have begun to relax drug laws and to treat addicts as though they have a medical problem rather than with punitive criminal justice sanctions.
Imagine a world in which illicit drugs were controlled, sold at a reasonable price and had maintained pharmaceutical purity. The many headed monster of the war on drugs has created could be slain with enlightened legislative alternatives.
Demand for cocaine and heroin will not diminish in the foreseeable future. We had better find a sustainable alternative to the patently ineffective campaign we wage now.

Ben Cousins and the real world of pills

2010-07-08T21:30:00.002+10:00

Ben Cousins recent hospitalization after what appears to have been an overdose of caffeine tablets together with alcohol and prescribed sleeping medication should be a wake-up call to the AFL and the rest of Australia. Addiction to prescribed medications in this country has escalated dramatically over the last decade and Cousin's admission that he took more of his prescribed sleeping tablets that was suggested is common in a small but significant population who live unsustainable lifestyles. It is not new. Australia has a long and tortuous tradition of abusing prescription medications from over-the-counter tonics containing stimulants and sedatives at the turn of the last century to APC powders which contained caffeine aspirin and phenacetin from the 1940s to the 1960s.. These caused a whole generation of women to develop end-stage kidney disease. The toll of these easily obtained medications, mostly without prescription, is well recorded in the history of pharmacopoeia abuse in this country.

An escalation of dose is one of the cardinal signs of addiction to hypnotic medication. There is no doubt that taking a large dose of caffeine in the form of tablets and then drinking alcohol after the game would precipitate an edgy, sleepless state where a standard dose of sleeping medication would not work. It is in this situation, amongst people like Ben cousins who have had problems with addiction before, that the provision of an open box of sleeping tablets becomes an invitation to overdose. The World Anti-Doping Association WADA removed caffeine from its banned list because its excessive use could not be distinguished from the social use in caffeinated drinks. It was also discovered that high doses of caffeine worked to diminish performance rather than enhance it.

Perhaps, in the light of what has happened in Melbourne, pressure should be applied to coaches not to provide caffeine tablets to players before and during games. Maybe if they understood that by giving their young players excessive doses of caffeine they were potentially impairing their performance on the football field they would become more circumspect in handing around and open bucket of pills at half-time. This is the primary reason that caffeine was removed from the elite sports banned list in 2005.

The wider abuse of prescription medication including sleeping tablets and painkillers does not stop with first grade footballers. Potent opioid drugs available on prescription have become black-market favourites amongst first-time drug users who prefer the certainty of pharmaceutical grade drugs compared to illicit street drugs. These strong medicines percolate from experienced drug users into the general community and vice versa as their street price creates a nice little earner for those receiving a Centrelink pharmaceutical benefits card. They can visit a couple of general practitioners per day and turn a five dollar prescription into nearly $1000 on the street if they provide a credible story of chronic pain. Alarmingly to health authorities, this particular medication generates around $40 million worth of annual sales in Australia.

Similarly, sleeping medication leaks from the general population onto the streets where Valium sells for a dollar a tablet and the popular tranquilliser, Xanax sells for up to 8 dollars per tablet. Overdoses are common when these prescription medications are mixed by unsuspecting naive users and emergency department beds are disproportionately taken up on Friday and Saturday nights with young people who experimented with medications that they have procured either from unsuspecting doctors or from the family medicine cabinet.

It would be easy to call full-time for all this inappropriate leakage of seriously dangerous medications. This country is well overdue for an integrated real-time online program that allows every GP and pharmacist to trace prescriptions that have been written for a particular patient on a particular day. This would reduce the harm dramatically and deter many of the thousands of doctor shoppers who stalk medical practices on a daily basis seeking millions of prescriptions per year.
A chastened Ben Cousins will no doubt resist the temptation to reach for the No Doz caffeine tablets and then take sleeping medication to come down. Cazaly was able to get up there with sheer unrefined unadulterated talent.

Ben Cousins

2010-07-06T07:40:00.001+10:00

Dear editor,

Prescription drug abuse is reaching epidemic levels in Australia. There is no reliable way of tracking patients’ prescription history when they attend a number of practitioners. Perhaps if the doctors who prescribed sleeping tablets for Ben cousins knew that he had received prescriptions elsewhere, they would have been more circumspect in their actions. Ben is not alone. Every day countless Australians overdose on prescription medication.
There is a solution. We need real-time online prescribing information which tracks patients as they move from doctor to doctor. This occurs in Canada. We are well overdue for such technology

Kevin Rudd departs

2010-07-03T16:31:00.002+10:00

Rudd undone by the enemy within.
It is telling that in your incisive article on the failings of Kevin Rudd, your correspondent, Phillip Adams failed to detect any problems with his behavior describing him as “ funny and engaging”.
The fact that a prime minister would ring a journalist 12 times in a day urging him to leave his employment with a newspaper is neither funny nor engaging. Perhaps Phillip Adams suffers from the same fatal flaw of hubris and fervently believes that this level of contact with the elected head of government a right and proper thing

Cairns FNQ

2010-07-03T11:46:00.002+10:00

Here for an opthalmological conference where I am speaking to practice staff about their lives. It transpires that many work 12 hour days without a break. Driven by the machine that creates endless patients wanting surgery for cataracts and life without glasses.
Tomorrow I talk to the doctors about work life balance.
Cairns is a strange place with a multicultural feel to it. A strong Asian and aboriginal presence. Tourism is suffering in the wake of the GFC and we bounce around in the huge Cairns Conference centre which can house twice as many delegates.

My audience is receptive and charming. An hour and a half goes rapidly and they mob me afterwards asking for slides on how to deal with difficult patients. Their clients sound utterly charming in comparison with my daily fare of alcohol and drug dependent people. Only one lady admits to an altercation with a patient that has come to blows.And he was intellectually disabled. Luxury.

Hing's Cross

2010-06-17T14:07:00.001+10:00

At 92, Dr Norman Hing still practices as a GP two days a week in Sydney's King's Cross. He will retire shortly after 63 years continuous general practice in the same suburb. I'm sure he has to be amongst the oldest working GPs in the country. He cuts a dashing figure in a crisp white clinical jacket, joking with his adoring patients in the waiting room he shares with his much younger brother, Mervyn.

The waiting room is adorned with signed photographs of a generation of stars of stage and screen and cabaret. Amongst them: Billy Joel, Carmen MacRae, Sarah Vaughan, Peter Allen, Shirley Bassey, Neil Sedaka and Frank Sinatra. Norman was certainly the first to GP in Australia to develop a celebrity practice. He was the doctor for Lee Gordon -- an extraordinary entrepreneur who brought the first international acts to Sydney in the 1950s.
" For many years, I was the only GP in King's Cross. It was an amazing place especially when the Yanks were here at all the clubs were jumping. In the 40s it the Roosevelt and Joe Taylor's club. Later came the Chevron and the Sebel townhouse. This is where the stars chose to live in Sydney, and I was their doctor" observes Norman. "The Sydney Stadium was where everybody performed and so I was the appointed Doctor for any star who came to town"

At one stage, people called this place 'Hing's Cross'. My brother Albert was a dentist around the corner and another brother Stan was a pahrmacist. We knew everybody. It was a real village"
Norman smiles at the memory. "Now I'm treating the grandchildren of many of the patients I brought into the world. Obstetrics was part of the GPs workload in those days"

The Hing family came to Australia in 1905. Norman's father opened stores in Guyra and Inverell, importing napery from China and business flourished despite the White Australia policy. As a young man Norman studied engineering with a view to returning to Canton in China and rebuilding villages. But after two years, he decided medicine would suit him better and it has since become a family profession." There are eight doctors in my immediate family now", Norman observes proudly.

Graduating in 1942 from Sydney University, Norman was a part of a small group of residents who lived in at Sydney Hospital. "My bedroom looked out over Macquarie Street and there were only 20 of us working in the hospital" It was an intimate group who lived and breathed medicine.

With war raging in the Pacific Norman decided to enlist as a captain. He wanted to fight the Japanese in New Guinea but was told that because of his Chinese features and small stature, " you might be mistaken for a Nip and shot." There were many other examples of prejudice encountered by the young doctor Hing as he pursued his practice but he remained resilient and focused.

When asked what he thought were the important advances in medicine made in his lifetime, he mentioned cardiac surgery and the extraordinary technology and techniques available to patients." Who could imagine lithotripsy in my day?" he reflected.
And of the joys of general practice he observed the wonderful relationships that he established with people from all walks of life. "They became a part of my life and almost a part of my family"

Out in the waiting room, some of his old patients are wondering where they will go when Norman and Mervyn retire. He points them in my direction. They take one look at me and decide that I am far too young and lacking in experience

injection centre, a success

2010-06-17T13:18:00.001+10:00

Dear editor,

Paul Haege's letter misses the point of the medically supervised injection centre in King's Cross. It could never hope to accommodate all of the drug users in the area during the hours of its operation and so there will always be discarded needles in the street, but there has been a huge reduction. The success can be measured more in direct referrals of injecting drug users to treatment programs from the centre. My practice is 400 m away and I treat a number of people who have been referred.
Perhaps Paul does not remember the bad old days in the 1990s when the overdose deaths occurred on the street or in dingy hotel rooms. Drug users would inject in parks and on the street. A fleet of ambulances would convey users to hospital. This no longer happens.

Her majesty's new clothes

2010-05-26T07:52:00.001+10:00

The extraordinary pomp and ceremony exhibited in the opening of Parliament in London by her Majesty Queen Elizabeth and Prince Philip, leaves nothing to the imagination.
I wonder how many court attendants it took to install the royal couple into their ceremonial outfits. Will the new austerity in the UK lead to a less spectacular opening in future.

Lohan's Bracelet

2010-05-26T07:51:00.001+10:00

Dear editor

Lindsay Lohan’s high-tech alcohol detecting bracelet adds a new dimension to crime and punishment. Detecting alcohol abuse has been a complicated procedure of the past with expensive blood tests and randomly applied breathalysers. This new technology sounds promising to those who have to maintain abstinence.

Diabetes in the underclass

2010-05-23T20:09:00.001+10:00

Diabetes in the underclass.

Despite all the advances we have made in the treatment of both type I and type II diabetes there are still some people who fall between the cracks of appropriate management. They are the underclass in Australia. Many GPs do not encounter these patients but they are certainly overrepresented in hospital emergency departments and charitable institutions. My practice sees homeless men from the Salvation Army, Mission Australia and the Matthew Talbot hostel. They are more seriously disadvantaged when diabetes is added to their load of problems. In the presence of homeless alcohol dependence or psychiatric disorder, any diabetes becomes a major management issue.
Just testing blood glucose becomes a challenge. Such men are often unwilling or unable to regularly test their blood glucose. glucometers given away or loaned are lost or broken. Food becomes a priority and especially with the free charity vans that supply often high-fat and high-carbohydrate comfort meals around the city, men fill up on the wrong sort of nutrition. The young volunteers who enthusiastically ladle out these meals have no conception of what the diabetics are serving require.
Many emergency departments prefer to treat such men with long acting metformin and diet rather than insulin even though they may well qualify for insulin treatment. They are wary of the inherent risks of an unstable lifestyle. Diabetes Education is often difficult and patchy in this population. They are by nature, itinerant and failed to keep appointments.
At the Matthew Talbot hostel for homeless men in Woolloomooloo nurse Sally Cantwell is sanguine about her role in maintaining good health among such men. She explains that they often walk long distances each day in inappropriate footwear. They sleep in institutional dormitories or rough and as a result there is an epidemic of serious chronic tinea pedis amongst them. This becomes ulcerated, requires antibiotic treatment for secondary infection and may never resolve. Sally says much of her time is spent dressing such men's feet only to find they return in worse condition after a long hike around in the city. She says probably the most important thing that government or charitable institutions could provide would be free good quality footwear for this population. When asked about the all pervading smell of tinea infected feet, Sally responded that she seemed to have lost her sense of smell over the years and that dressing grossly infected feet did not bother her.
By comparison, says Sally, homeless women's refuges with diabetic patients have much better compliance. She puts this down to an enthusiasm for female patients to attend GPs and a better grasp of the disease with all of its ramifications.
When I suggested a diabetes van should be parked right next to the food vans in the inner city servicing the homeless with nurses and diabetes educators instructing men how to inject long acting insulin and what to select for dinner, Sally replied that this could slowly change the disastrous outcomes for these men.
The scenario for diabetics with comorbid psychiatric illness or drug and alcohol issues on the bottom rung of society, are worse still. Many antipsychotic drugs can cause weight gain and so worsen diabetes. Drug seeking behaviour or binging on alcohol also make the outlook catastrophic as they can contribute to cognitive impairment with associated severe diabetic complications.
So as we congratulate ourselves the diagnosing and managing patients with diabetes better in general practice, spare a thought for those at the bottom. Much of what we assume is common knowledge these days about chronic disease management is light-years away from this population. And it is not just the homeless. There are under resourced communities that live in stable housing who through ignorance or poor management end up with random blood glucose levels in the mid 20’s. They are significantly undertreated, poorly managed and become frequent fliers to the major teaching hospitals of our large cities and regional areas.

2010-05-23T20:06:00.001+10:00

Malcolm in the middle

2010-05-01T11:25:00.001+10:00

Malcolm Turnbull's return to the seat of Wentworth after his epiphany at Gallipoli over the last 2 weeks must be viewed with a degree of cynicism. Surely his heart is not in politics after the shellacking he underwent when the party ditched him for tony Abbott . Perhaps it is the imminent election of the young Tory toff David Cameron that is giving Malcolm a rush of blood to the head? Does he not remember the fateful words of PeterCostello,
'the souffle does not rise twice"

The Jails Are Growing

2010-04-28T08:19:00.001+10:00

Dear editor,

Ross Gittins is correct in his assessment of the rate of growth of jails. Stopping recidivism and seems to be a low priority. It has been clear for a number of years now that one dollar spent in treatment of drug individuals who are likely to be imprisoned says seven dollars further down the track, yet there seems to be no political will to increase drug treatment. This means that low-level drug users end up incarcerated where they learn to be career criminals. Similarly, with the chronic mentally ill, the lack preventative outreach to maintain treatment of the community leads to men and women with mental illness becoming dissembling wrecks on the street. This leads to low-level crime and the inevitable collision with the criminal justice system. Unfortunately, drug users and the mentally ill do not have much political voice and so the jails will continue to expand filled with the mad and drug dependent.

Doubledemerits

2010-04-24T18:31:00.001+10:00

Who would have thought that double demerit blitz does nothing to lower the road toll? It is clear that all it achieves over hiolidays is to raise revenue. And yet successive governments repeat the mantra that is provides safety to the community. The irrefutable drop in the Victorian road toll with no double demerits but undisclosed speed cameras should be a saluitory lesson for NSW. Paying police double and triple time to prey on motorists merely boosts the state’s flagging coffers, irritates drivers, and keeps cops away from their families at holiday time.
.

No thanks Mike Carlton

2010-04-24T18:23:00.001+10:00

What a shame that ‘Michael’ Mike Carlton will not take up the offer to sit on the ABC or SBS boards. How much more exciting would things be for viewers with the Carlton influence pervading our TV screens. Out with the hopeless English cop shows and in with documentaries on military and naval battles over the centuries – all of course with more than a dash of left of centre bias. Boy’s own stuff. Michael could have his own version of Friday News Review and he could play every character.

Dark side of the tobacco industry

2010-04-24T18:22:00.001+10:00

Governments have tried to rein in the tobacco industry for years now. They are mistaken if they think that big tobacco will fold up it’s tent and move on. The product is immensely profitable and highly addictive. With the Australian population of smokers diminishing to 18 per cent, companies will try anything to retain their strangle hold on existing smokers and encourage a new generation to take up this pernicious habit

Kindle

2010-04-08T21:27:00.001+10:00

Moya Ward is right about the Kindle. I have ordered one from United States and am waiting with bated breath till it arrives. Many people are affronted by the cost of books and environmental destruction that occurs to produce hard copy. The future will be a seamless transition to electronic books. We are witnessing a transformation of monumental proportions. Luddites like Louise Adler are standing in front of a powerful locomotive of change. The digital world of publishing is upon us.

The nose as a medical instrument

2010-04-05T17:37:00.001+10:00

Accreditation of my practice for the third time has become a reality. All the bean counting, checking and manual preparation keeps me awake at night. And it's no wonder. The process has become much more complicated than I recall. My practice and procedures manual has become a monster document with over 230 pages of text. Medical equipment needs to be calibrated and checked for performance.

Recently, over coffee, a colleague of mine who refuses to accredit his practice, suggested that the most important equipment that a doctor uses on a daily basis is never checked for performance. I puzzled over his meaning. He then told me it was our eyes ears and noses that provided us with far more information than any piece of technical equipment that we purchase for our practice. On reflection, he is right. Just recently I had an encounter with a homeless man in my practice. He was wearing rubber soled trainers and had been out in the rain. His wet socks and shoes had begun reeking that characteristic odour of bacterial overgrowth which had begun in his perfect incubator. About 30 seconds into the consultation I registered my discomfort with my usual question. " Have you been out in the rain in those shoes? Yes Doc I've been sleeping rough for a few days", he answered sheepishly. Knowing from personal experience that running shoes impregnated with that particular odour are unsalvageable, I suggested he turf them and procure a new pair from the local op shop. After he left, I turned my medical student -- an impressionable third year from Sydney University and asked if he could register the smell that now pervaded my entire consulting room. He looked at me blankly and asked "what smell?"
It transpired his sense of smell was severely limited as a result of childhood rhinitis and that he had no idea what I was talking about.
Spraying the room liberally with an air freshener, I began thinking how important the sense of smell is to a doctor.

All those diagnoses then are made so much easier with the assistance of an intact, calibrated, olfactory system. There is the tell-tale odour of suppurating tonsils when a patient opens their mouth to be examined and that terrible lingering smell of a fungating tumour which has burst through the skin and is secondarily infected. The mousy, ammoniacal odour of liver failure always associated with jaundice and a swollen ascites filled belly. The sweet fruity acetone smell of a diabetic's breath in ketoacidosis once smelt is never forgotten. There is a foetid taint to patients with lung abscess and a rotten apple smell of gas gangrene. A patient in renal failure will have an ammoniacal or fishy breath smell from the breakdown of urea to ammonia by saliva. And finally, there is the faecal smelling breath of a patient with intestinal obstruction.

It is said that some palliative care nurses can smell death in patients who are in imminent danger of passing on. Certainly there is well reported evidence of cats sensing impending death. In July 2007, a fascinating story emerged in the New England Journal of Medicine about a cat that could predict the deaths of patients in a nursing home several hours before they died. Oscar, was a cat that the staff of a nursing home in Rhode Island adopted. He is said to have predicted 25 deaths by moving onto the beds of moribund patients before the medical staff realised they were going to the mortuary.

Research showing that dogs can discriminate odours associated with urine from patients with bladder cancer has been validated.

So perhaps before my accreditation process is complete, somebody should check and validate my olfactory system and place a barcode on the bridge of my nose to prove it's been done.

Heavy loss of points

2010-04-02T13:26:00.003+11:00

It is hard to believe that somebody as law-abiding as me would be in the invidious position of having his drivers license cancelled. However, alas, here I am exposing myself the full blast of public scrutiny on my blog. All two of my followers will understand my despair. Yesterday, I was booked driving past a private school which was closed at 52 km/h. There was a police radar trap at the side of the road outside a prominent Catholic girls school. There were no students inside and no activity was visible. I assumed that the Draconian rules did not apply on Easter Thursday. How wrong I was. Double demerits plus the excruciating reality that sitting on 12 points means an automatic loss of my license. I plunged into a pit of despair envisaging myself pushing a bicycle up New South head Road, much to the entertainment of my friends in their cars. The reality is terrifying. Public transport, trains and buses and bicycles my only hope for six months of enforced car lessness.
The Chinese always say that a crisis leads to an opportunity. Perhaps here is my chance to make motorised bicycling into a national sport. I see clubs forming middle-aged drivers have lost their licences and are forced to use the tiny 49cc engined two stroke alternative.

But I'm not going down without a fight. This battle will require all my tenacity and application. I will take the matter to court and explained that a man in full, such as me can ill afford the ignominy of being seen on public transport or worse still pushing a bicycle through the dangerous streets of Sydney. I will throw myself on the mercy of the court and plead with the judge to give me one more chance. I will make outlandish promises of good behaviour and lawfulness. And even promise not to listen to Radio National while driving so I lose concentration.

No doubt, my pleas to the judge will fall on deaf ears.

"Think of all my poor patients your honour, stuck in their houses without me able to visit them and minister to their illnesses. They can call my practice for a home consulatation but nobody will come.They will die sick and alone unable to obtain the succour and commanding presence of their usual GP coordinating their care and providing hope when none is available. The hospitals around my practice will feel increased load as I am pushed off the main track of life into an unused trunk line replete with weeds and rusty carriages, and my patients are forced to call ambulances for trivial illnesses which I could have dealt with so easily with a car.

I throw myself on the mercy of the court and beg for an extension of my good behaviour bond.My top speed will be 29 km/h for the rest of my life. Please, your honour ... if not for me, then for my crumbling ancient patients"

aged care blues

2010-03-24T11:29:00.001+11:00

it seems like whenever I go to visit an elderly patient in the local aged care facility, they are hiding from me. On three occasions yesterday I failed to connect with a patient who wanted to see me. You see, the problem is, that she is ambulant and manages to scoot around the building evading me every time. This is already well, and great fun -- however like most GPs we don't have time to engage in such shenanigans. What we really need is a radio frequency device to track our patients no matter where they are. The dining room, the games room, their bedroom anywhere at all.

letter to Sydney Morning Herald published

2010-03-11T18:37:00.000+11:00

Dear editor,

The thoughtful opinion page editorials by Lindsay Tanner betray a side of the finance minister that we are seldom able to see in the media. For the most part he is the aggressive forceful government finance spokesman. In this role there is little space for his obvious humanity to be displayed. I for one enjoy reading his opeds and wish that more of his gentle side could be seen by the public at large.

Fast Medicine

2010-02-28T17:19:00.003+11:00

In an age when instant gratification is the norm, it is hard to make a case for slow medicine. Increasingly people are looking for the McDonald's model of rapid diagnosis, a quick fix using modern technology and then back out into the fast lane. After 32 years of full-time general practice and over 210,000 consultations, I reckon I've seen and heard most things at least once. Now I acknowledge this does not make me an expert on everything nor does my memory always serve me well, but it certainly gives me an edge over some of my part-time colleagues and helps me work faster.

I can fill out those awful treating doctor reports from Centrelink so fast now that I feel guilty entering the amount of time spent at the bottom of the document. Prescription printing, thanks to technology takes a fraction of the time I recall from the old days of hand written scripts using my fountain pen and a flourish.
And voice recognition software, allows me to enter patient's history details, type referral letters and generally appear to have magical powers as their history seemingly types itself across my LCD screen. This often causes my patients to forget why they have come to see me.

If I had to imagine the worst possible general practice nightmare, it would be to have closed my books to new patients. How awful practice would become, stuck with the same old faces and the endless complaints for which I have been unable to find a solution. No, for me it has to be a constant rush of new blood. Challenging new patients to supplant those for whom I can do no more. Those fateful words ringing clear “ As we have come to the end of our therapeutic relationship, here is a list of other general practitioners you might care to consult.”
Out with the old, in with the new. How else can you challenge your diagnostic capacity? The more diagnoses you make the faster you become. I often challenge medical students in my practice to come up with a provisional diagnosis before the patient sits down. For this they must use every sense critically.
There is an anecdotal story of a famous now retired oncologist who would see 70 patients in the course of the session. He did this by banning chairs from the consulting room. By all accounts he was well loved by his patients who affectionately called him Speedy Gonzales.

Perhaps, in order to practice true fast medicine we dispense with much of the unnecessary banter that clogs the consultation. “Things like how are you? How can I help you today? What seems to be the problem?” We need to cut to the chase and belt out those streamlined prescriptions. Leave slow medicine to the semi retired GPs practising in central coastal villages.

The mental health story

2010-02-04T09:15:00.001+11:00

A mental health nurse story

A mental health nurse story

A mental health nurse seemed like an impossibility for me. I have realised for some time that many of my patients had serious mental health issues and that the public system was failing them systemically. Kings Cross is a magnet to the homeless and the mad. They feel comfortable here there has always been a tolerance of outrageous behaviour on the streets. Many of my patients lived rough in parks or cars or couch surfing in other people's flats.

When the mental health nurse initiative was announced I searched far and wide to employ somebody to assist me. Alan was in charge of community mental health triage at a local teaching hospital. He was disillusioned and looking for something different, having worked on the streets in Liverpool and London in the UK. The fit was seamless from the first patient.
I would invite him into the consultation with the patient's approval and then he would lead them to his cubbyhole in my tiny practice and work miracles. Alan would liaise with housing department getting homeless schizophrenics a place to live much faster than I ever imagined. He would facilitate care plans and personally escort broken toothed dental disasters 200 m to the local dentist to make sure the first appointment was firmly in place.
He would write his motorscooter on home visits to Woolloomooloo where children at risk were subsisting with benzodiazepine dependent mothers.

Now we case manage several hard end mentally unwell patients who had fallen through the cracks of the under resourced public system. They trust Alan implicitly and with his assistance their management has become much easier. To give you a taste of some of our new patients: One is the highly deluded man who belives e was a boy soldier. He performs the most amazing impromptu bird impressions in the middle of a consultation and claims to have fought in the vietnam war, bosnian conflict, first gulf war.even the cold war. ASIO are very concerned about him as he keeps ringing them for the money they owe him for his heroic undercover operations. Alan has performed miracles for him: applied and succeeded getting him priority housing and a a pension that he should have had years ago, getting his teeth sorted out, as well as getting in touch with his family to reassure them he's okay. They had not heard from him for years and imagined he had died.

On occasions he will walk a dishevelled unwashed patient the Wayside Chapel for a shower and a change of clothing. They return smiling and clean for a consultation.

In the last few months we have been deluged with referrals from Mission Australia and the Salvation Army. Word has passed around that the homeless receive a timely and efficient service. We now have a waiting list. These patients are the most thankful and compliant group. To see them emerge from hopelessness has been an uplifting experience for all of us in the practice.

One such patient, is a deluded homeless Korean man sent to us by the Salvation Army who lives off scraps in Chinatown, sleeps outside church in city tells us about an imaginary woman who visits him in a car every night . We are attempting to repatriate him with the assistance of his sister in Seoul. It has been a slow process to get him to trust Alan, but gradually is making headway.

I had never realised how much mental illness was a part of general practice until Alan came to work with me. Now I cannot imagine working without a full-time mental health nurse. My practice has become much more fulfilling and interesting place since he joined me.

Kerala India

2010-01-17T12:50:00.003+11:00

Sitting on a beach facing a brilliant orange sunset over the Arabian sea in Kerala, I am seriously chilled out. After 2 weeks in this idyllic south Indian state it is hard to concentrate on anything apart from the next delicious meal or what to read.

But for the fishermen on the beach this is an unforgiving environment. They toil dragging their nets, only to find after hours of work that their catch is meagre. Dynamite fishing still occurs here with sporadic explosions at night frightening the tourists and catching even fewer fish.
Almost every hotel offers Ayurvedic treatments and has doctors on site. This ancient form of Indian medicine dates back 5000 years. Ayurvedic doctors were extracting catarcts and doing rhinoplasties long before western medicine had dreamed of such procedures. Many Europeans arrive for two week treatments involving detoxification, diet, massage, yoga and meditation. My kids were intrigued by the sight of poeple walking around our hotel wearing banana leaves on their heads for most of the day after massage with coconut oil.

Our hotel has an orphanage started by the owner in the days after the tsunami which devestated this area in 2004. Mmany dazed children who lost their parents would be brought in, and today the Bethsaida orphanage has 500 boys and a separate facility for girls. We brought games that my children had grown out of from Australia to give to the orphans and also some pharma company pens. When we visited we caused a near riot. The boys huddled around my sons and daughter asking cricket questions about Ricky Ponting and Michael Hussey. The boys sleep on concrete floors in large dormitories and they can attend their relatives every three months in local villages. Some go on to work in the hotel or study at local colleges. Two boys exchanged e mail addresses with my sons and now correspond regularly. This was a highlight of our visit and the pictures of exhuberant children are inspiring considering they have so little of the material goods we take for granted Australia.

I was intruiged by the enthusiastic uptake of many of the more unusal aspects of ayurvedic medicine by travellers from around the world and asked casually around the pool, what seemed to be the benefits.

A thirty something Englishman - a banker from the city of London, who had been out regularly for the previous six years at this time, began raving about the positive effects of Ayurveda. "It is extraordinary," he intoned "At the end of my two weeks here, I feel like I am 14 again. I remain a vegetarian till at least March and last year I stayed off the booze til April."

And to be sure he had a spring is his step as he left me to bound off for another treatment, leaving me pondering whether I wanted to feel like I was 14 again. I rolled over decided not and asked the waiter for a cold Kingfisher beer.

Psychosurgery 2009

2009-11-29T12:19:00.004+11:00

Neurosurgery for psychiatric illnesses seems to be making a comeback in the US. I vividly remember as a medical student seeing flattened patients who had undergone these procedures in the early 1970’s. They were fairly primitive but did extinguish some of the most repetitive obsessive compulsive disordered behaviours. Perhaps now with vastly improved imaging modalities of the brain and better surgical techniques, operations will be more precise and relieve sufferers of long term burden that can wreck their lives.

Thailand travel

2009-11-08T13:15:00.004+11:00

Travelling in Thailand to Hua Hin, some 200 km south of bangkok to a beach side resort ton that has grown dramatically since i was here seven years ago. There is now a six lane highway through the town. The market is a pleasant clean place with much less of the hassle of Bangkok. The weather is hot and steamy. One forgets how oppressive tropical heat can get and how lethargic it makes you feel. Still the compensations are fantastic massage and a laid back lifestyle with a smiling local population. The Asara Spa is beautifully designed. The service impeccable and we leave tomorrow for a day in Bangkok before flying to the cradle of civilization Athens...

VIP medicine

2009-11-01T12:13:00.000+11:00

VIP medicine
There are some patients in every practice who feel entitled. They demand extra services and they are often wealthy or connected. Such people do not like to wait for the doctor. They will often use modern technology to attract your attention demanding your mobile phone number or your e-mail address to provide them with extra access to your service.
They will insist on paying you the highest level of remuneration for your work often plying you with flattery and perhaps small gifts or favours. But very soon you begin to develop a strange codependence that leaves you with an uneasy feeling.
Celebrities are notorious for such behaviour with doctors but lately the VIP medicine has spread to the general community. It is often difficult to say no to requests from such patients who may demand all sorts of favours from excessive prescription drugs for imagined physical or psychological pain to disabled parking permits and even certificates to exclude them from attending jury duty or court. Alas, most GPs have great difficulty in not complying with patient requests. This is not taught at university and is probably the most important skill that young medical students and doctors need in their everyday armamentarium. There is not a clinical day that goes by when the word ‘no’ needs to be articulated and oft repeated. For such patients have selective hearing loss, they believe through experience that all their wishes will be fulfilled and anybody who thwarts them will suffer their slings and arrows. VIP treatment is hazardous. The line between patient and doctor is often blurred with coercion sometimes subtly exerted on an unsuspecting practitioner. Rich and famous patients are different and a doctor treating them needs to be mindful of these potential difficulties. The film, music and professional sport industries are notorious for applying pressure to doctors so that the show which must go on, can go on.

I remember vividly escorting a movie star through the emergency department of a large Sydney teaching hospital after he had fallen from his motorcycle during a shoot at nearby film studios. There was an entourage of nurses, first-aid attendants, film company executives and personal assistants thronging around the patient's bed. The blowtorch was applied to me when I was told that every 24 hours that this star could not appear was costing hundreds of thousands of dollars in downtime for the entire crew. I was expected to work miracles.
Famous rock singers with viral upper respiratory tract infections set to appear before 20,000 screaming fans demand immediate and ongoing treatment. Pressure will often be applied to prescribe unnecessary antibiotics or even corticosteroids in an attempt to return the star to full health as fast as possible. Doctors who do not comply are rapidly dispensed with and a new practitioner is sought through the grapevine.

Demanding patients will monopolise your time and tie you up in knots unless you set up clear and effective boundaries.
Here is an example of such an interaction
“ Look doctor, I know what I want, I've had it before. It works every time my schedule is so packed today. Can't you just send a script down the pharmacy and my assistant will pick up later this afternoon? I promise to make it worth your while. Hang on Doctor, the director wants me on the set. I have to go now. Thanks for everything. I’ll make sure there are two tickets for you at the premiere.”
So begins the slippery slope, the ethical compromise and the clear sensation that medical protocols have gone by the wayside in the presence of overwhelming force.
It is easy to understand how both GPs and even specialists can be seduced by such unrelenting pressure exerted by the most manipulative people on earth. The smell of the greasepaint, the roar of the crowd and a wad of notes are potent forces in turning one's head.
The secret though remains clear in the words of the old Shakespearean adage ‘ above all, to thine own self be true’
Ask yourself would you do this for any other patient? If not, just say no. Say ‘no’ again and walk away from the bright lights. It is far more comfortable in the shade.

2009-10-31T13:56:00.000+11:00

To hear that Andre Agassi hates the game of tennis and many other sports stars feel the same about their games, is to be expected
Many such high achievers have aggressive parents pushing them to excel from an early age. They train and train, often with doting parents urging them on to greater heights, abandoning a real childhood for the gruelling circuit of junior sport and endless competition. It is no wonder they burn out in their mid twenties and seek solace in alcohol drugs or dysfunctional relationships. The balance in their lives has been grotesquely distorted and all the money from the tour does not compensate for the loss of meaningful life. We should think twice before consigning succeeding generations to the horrors of professional sport. It is a destructive addiction. If only intellectual pursuits were as well paid there might be a chance of changing the prevailing culture

the cost of the war on drugs

2009-10-03T18:54:00.001+10:00

Dear editor

It has long been clear that the cost of the war on drugs has become uneconomical. Michael Duffy's article quotes a figure of $4.7 billion a year as an estimate of how much the Australian government spends.I believe this figure is a gross underestimate. The knock-on effect of the illicit drug trade reaches into every corner of Australian life. Despite 40 years of huge effort, there is little to be happy about. We should seriously consider decriminalising, controlling and taxing illicit drugs in this country.
Duffy fails to mention the human cost which is almost incalculable. Some 5000 Mexicans have lost their lives this year -- more than the toll of Afghanistan's war.
Thousands of Australians suffer the effects of adulterated drugs of unknown potency, ending up in our emergency departments. Do we abandon another generation of young Australians to drugs provided by criminal gangs or do we make a calculated economic and humanitarian decision to stop the damage.

Body contact sports and injury

2009-10-01T08:32:00.000+10:00

It is not just the brain that suffers in body contact sports..Knees, spines shoulders, ribs and hips all sustain a perennial hiding. The bodies of old body contact warriors leave a lot to be desired physically and psycholgically. You will spot them in shopping centres prematurely limping with vacant stares into supermarket shelves. Their once proud bodies have long gone to fat and their weight bearing joints have been replaced or reconstructed at least twice. The young fit men who enlist for punishing contact sport should view images of the end game and sign a disclaimer.

Letter to Medical Observer

2009-09-13T11:18:00.000+10:00

Dear ed,

The fraught relationship between mainstream medicine and complementary treatment continues. Dr Michelle Woodhouse's assertion "that you cannot get bogged down in rigid randomised trials is precisely the point. We must have scientific rigour not mumbo jumbo and wild unsubstantiated claims.
Let's face it complementary medicine is expensive, unproven and time consuming. it is all very well to advocate for 1 hour consultations but this is not feasible in the real world of general practice and few patients can afford such luxury. add to this the extravagant claims made by complementary practitioners about the medications that they on sell within their practices for a tidy profit. muddying the water further are the shonks doing IV 'chelation therapy' the weird vitamin C infusers, the orthomollecular psychiatrists, anti aging clinic with testosterone supplementation for all men over 50 and human growth hormone injections. And of course the homeopathic vaccinators for serious childhood diseases. Spare me if this dog's breakfast of snake oil sales people do not inspire confidence amongst mainstream doctors. Hang on, my next one hour consult has walked into my waiting room!

Stressed Doctors and patients- a ray of hope

2009-08-22T11:05:00.003+10:00

Time out for stressed GPs and patients

Reading Dr Herbert Benson's book the Relaxation Response a few years ago, I sensed he was on the right track. So many patients had anxiety and stress related illnesses that teaching them to relax had beneficial effects on their general health. Now in elegant research from Harvard where Benson runs the Mind Body Institute, he has shown that relaxation can produce disease fighting genes which protect for a variety of disorders from hypertension to arthritis. Benson has long advocated the 'relaxation effect' and is obviously a man who regularly practices this technique.
But how to introduce the positive effects of relaxation to time poor doctors and their digitally enhanced patients?. Back in 1991, i produced an audio cassette for patients with a guided muscle relaxation, which I gave to anxious or stressed people. Many reported using the tape till it fell to pieces.
Now, I have discovered to my relief, an easier solution with the internet and mp3 players. On my computer desktop I have saved a number of free internet sites that allow people to download as podcasts or use online. With this ease and portability there is much greater chance that they will use the techniques to advantage. With some less tech savvy patients I will send them an e mail with the appropriate website embedded or even produce a cd that they can play at home. Better connected people will download the podcast to their mp3 players and use them whenever time permits

Physiological markers have been measured by Benson showing an increase in the feel good hormone Serotonin after relaxation together with a reduced heart rate and blood pressure. Growth hormone levels increase facilitating tisuue repair.

The opposite occurs during stress. Blood pressure and heart rates rise. There is evidence of reduced immunity and fertility.

Time pressured GPs seldom have the opportunity to teach patients such techniques and they are mostly the preserve of psychologists and mental health nurses, but I have found a way to incorporate relaxation into a consultation. It takes only six minutes and it uses a web podcast easily accessed for free. After hearing a long and upsetting history I will explain to a patient that we are going to spend some time relaxing together. No more talk. i click on the six minute meditation website. It seems that even a short introduction is a powerful motivator for patients to continue at home and provides me with a six minute hiatus of peace in an otherwise fraught day. Sometimes I will click on after a particularly stressful encounter relaying to reception that I need some down time between appointments. This gives me a chance to refresh, regroup and face the continuing onslaught with equanimity.

A short intervention like this by a GP works in all sorts of clinical situations from counselling on alcohol consumption to cigarette smoking, so why not with the all pervasive epidemic of our time - anxiety, stress and insomnia.

Many people have not actually paused to relax in a long time and after even six minutes they report feeing better. I encourage them to build on this base by twice daily practice.

We GPs are perfectly positioned to encourage patients to become more mindful and slow down. These techniques are now evidence based and can be mastered with little effort. The upside is that patients are grateful, there are no side effects and you will feel better after a busy day of consulting

The final trip to Zurich

2009-07-18T11:13:00.000+10:00

Assisted suicide

Dignitas is a Swiss-based clinic which assists people who have decided to end their lives with assisted suicide. Recently, a number of people in the UK have elected to end their lives in Zürich despite not having life-threatening illnesses. Evidence from the Journal of medical ethics in the UK has indicated that 21% of people being assisted to suicide with Dignitas had a non-fatal disease process. Perhaps the most poignant of these is the case of Daniel James, a 23-year-old Briton who became a quadriplegic after a spinal fracture while playing rugby. In England, this case and others have sparked a debate about the legitimacy of suicides for those who may have productive lives ahead of them.
Since 2002, 115 Britons have chosen to end their lives at Dignitas by downing a glass of Phenobarbital in the company of a relative or carer. Among the conditions which were treated in this period with assisted suicide have been 17 patients with Crohn's disease, 27 with multiple sclerosis and three with renal failure. One patient had rheumatoid arthritis. None of these patients was in the terminal phase of their illness.
Prof Stephen Field, chairman of the Royal College of General practitioners said recently “ I am horrified by this list”. The ethics committee of the British Medical Association commented, “This list raises considerable concern. To go off and commit suicide on the basis of these conditions would be premature and unreasonable.” The British Medical Association voted overwhelmingly at their meeting this month to oppose assisted suicide
Despite these concerns, there is a list of some 800 Britons who have signed up for Dignitas's version of euthanasia. Many of them join after the diagnosis of a life-threatening illness as an insurance policy for the future.

Ludwig Minnelli, the founder of Dignitas recently told the BBC that suicide was “a marvellous opportunity”. As a human rights lawyer, he exhorted people not to be paternalistic and to allow anyone with mental capacity to have the right to choose their future.
Negotiations with Dignitas by the Zürich government have led to changes which will govern the practice of assisted suicide in the future. These new rules include the regulation that assisted suicide is only allowed to those in serious suffering due to health problems, accident or disability. All other options must be exhausted and only a deadly dose of sodium Pentobarbital can be used. Those who assist may charge of $ US 461. No patient may be below 25 years of age.

A number of Australians have used Dignitas to end their lives. Amongst them, is a retired doctor JE who died in January 2007 and his experience of the process is set out in the New South Wales voluntary euthanasia website, where Australians over the age of 18 may join the Swiss association, where details of the procedure are provided.
.

. 'You must first take an anti-emetic solution (pleasant taste), followed 30 minutes later by the bitter tasting lethal barbiturate preparation - both about an average sherry glassful in volume. The volunteer is kind and thoughtful, and everything is done at the pace you wish. For example, if you wish to spend time with the people who have come with you, the volunteer will wait outside.
When you are ready you can sit on a chair or lie on the bed. The barbiturate should be drunk quickly but, even if you do not drain the glass, the dose will be fatal. You may have help holding the glass or the straw, but you must swallow it unaided. For those who cannot swallow arrangements are made so that you can trigger the self-administration of the drug by injection. You go to sleep within 1-2 minutes and die 20-30 minutes later. There is a video camera at the end of the bed to provide proof that you were not helped. Two witnesses are required, one of whom must be the volunteer.'

It seems now that international ‘death tourism’ as it has been labeled, beats a well worn path to Zurich and though many in the medical profession have misgivings, those in terminal distress avail themselves of the service in increasing numbers.
_____________________________________________________________________

The mystery contuinues about Michael

2009-07-12T18:13:00.001+10:00

Michael Jackson and his doctors

The memorial service is over and though Michael Jackson's body has not been buried, theories swirl about in relation to his pharmaceutical drug abuse.
Clearly the doctors attending him found it difficult to deny the star tranquillisers, opioid painkillers or even anaesthetic drugs like Propofol. It was said by a biographer as late as 2005 that “no doctor was in a position to say no to Mr Jackson”. Recent evidence obtained by CNN, shows he was dependent on Xanax or Alprazolam -- a rapidly acting and highly addictive tranquillizer that is the favourite of the world's fast set. Police documents obtained by CNN indicate that Jackson was taking up to 40 pills of Xanax per night in 2004. Documents obtained by the LAPD indicate that he received prescriptions from doctors in California, New York and Florida. Amongst these physicians, were a cardiologist and a dermatologist? His cardiologist, Dr Conrad was there at the time of Jackson’s death performing CPR and it has been reported that the star received injections of Demerol or pethidine daily. The question arises as to why a cardiologist would treat pain and insomnia. In Australia this addictive opioid is no longer used for analgesia. Such unfettered access to tranquillisers and other drugs by the rich and famous is not new. Marilyn Monroe was evidently prescribed huge amounts of Nembutal -- a drug implicated in her demise by her psychiatrist Dr Ralph Greenson. He is the first one on the scene and discovers Monroe's lifeless body as he peers through the French windows of her house in California. Dr Greenson also treated Tony Curtis, Vivien Leigh and Frank Sinatra.

Even that late president John F Kennedy had his own private physician who is reported to have provided him with amphetamines, testosterone, barbiturates and pain killers for his wartime back injury – a veritable cocktail of dangerous drugs. Kennedy was once quoted colourfully saying to an aide, about his regular injections “I don’t care if it’s horse piss, it works” His doctor was struck off in 1975 for inappropriate prescription of controlled substances

Elvis Presley was treated by Dr George Nichopoulos known as ‘Doctor Nick’. This man wrote thousands of prescriptions for addictive medications to keep Elvis going . Nichopoulos was charged in 1982 on 14 counts for abusing his licence to prescribe. In 1995 he became the road manager for Jerry Lee Lewis. Our own Heath Ledger accidentally overdosed on prescription drugs amassed from different prescribers across the world. Xanax was amongst his preferred list, found at autopsy.

Jackson's friend, Uri Geller described the difficulty people had denying him his drugs of choice. “When Michael asked for something, he got it”
How complicit were doctors in the downward slide resulting in the death of Michael Jackson? The old edict of Hippocrates still resonates today. ‘Primum, non nocere’. First do no harm. Yet it is clear that those facilitating Jackson's access to phenomenal quantities of prescription drugs should be guilty of unethical behaviour, if not criminal negligence. Patently, Michael Jackson was damaged emotionally by his early life and the relentless pressure placed on him by his father. The last few years left him battered by media criticism. Such people are primed for addiction to prescription medication and a capacity to pay a physician up to $150,000 per month retainer just adds to the risk.

The medical profession is easily seduced by celebrity. The smell of the greasepaint and the roar of the crowd, act as potent stimuli to doctor’s egos. They receive recognition, fame and excessive remuneration. Persuasive arguments for the high level of prescribing to Jackson will no doubt be found in defence of irresponsible medical practice, should this affair hit the courts in the US. Perhaps it is time to shine a light in the shadowy world of stars and their physicians before too many more die uncertain deaths.

Michael Jackson and his doctors

2009-06-29T21:21:00.002+10:00

A View from the Cross
Dr Raymond Seidler

The recent death of Michael Jackson has some echoes to the passing of the previous king of rock, Elvis Presley. Both rock music megastars had physicians at their personal beck and call.
Cardiologist, Dr Conrad Murray was with Jackson in the moments before he died having allegedly injected the star with Demerol, known in Australia as Pethidine, a highly addictive opioid pain reliever. Tapes from the 911 call indicate Dr Murray was performing CPR on Jackson prior to his transfer to hospital.
It is clear that Jackson had a chronic pain syndrome, and had become addicted to potent painkillers. His pain was associated with previous injuries sustained in falls and misadventure in his extraordinary musical career. Over time with unrestricted access to prescription medication, Jackson certainly became dependent. He received one injection per day and always had a doctor to give it to him. “No doctor was in a position to say no to Mr Jackson.” Published: June 27, 2009

The injectable narcotic Demerol had been a concern for a long time. This drug is no longer recommended for pain relief in Australia as a result of its potent addiction potential.
The concept of having one's own private physician is not new. Many celebrities travel with a full-time doctor. It is unusual to have a cardiologist on call, however. The maintenance of an ethical relationship between physician and star remains problematic. Dependence on strong painkillers seems to be a common thread through many tortured lives lived large on the public stage. And it is clear that the responsibility for maintaining this addiction can be laid at the feet of the personal physician. These doctors are extraordinarily well-paid and are often in the thrall of their star patients whose constant demands must be almost impossible to manage in an ethical and sustainable way. Thus the doctor becomes co-dependent on his patient, by virtue of the financial imperative and the desire to keep the patient happy and working.
Michael Jackson was not a well man and had been struggling to improve his health prior to a gruelling planned tour of the world. This pressure would have been manifest in the treatment provided by Dr Murray and may well have reflected a departure from what would be considered acceptable by the vast majority of medical practitioners.
Dr George Nichopoulos was Elvis Presley's private physician. He was known as ‘Dr Nick’. He wrote thousands of prescriptions for addictive medication for Elvis and then tried to detoxify him from his drugs of choice. This process was largely unsuccessful. Nichopoulos injected Elvis with placebo medication and always was present at every consultation with any other medical practitioner. In 1980 Nichopoulos was formally charged on 14 counts of abusing his licence to prescribe. He was finally struck off in 1990 and became a road manager for Jerry Lee Lewis.
Beguiling as the smell of the greasepaint and the roar of the crowd, is for many otherwise circumspect practitioners who become seduced by their extraordinarily talented patients and their impossible demands

.The list of tainted doctors goes on for decades..President John F. Kennedy had a number of doctors attending him whilst in office but one in particular was known as "Dr Feelgood". Doctor Max Jacobson provided the President with injections allegedly containing amphetamines and other controlled substances, including testosterone. Kennedy remarked colourfully "I don't care if it is horse piss. It works." Doctor Jacobson's medical licence was revoked in 1975 for inappropriate prescription of controlled substances.
Modern history is littered with celebrities whose lives are tragically cut short and are closely connected to private physicians. Marilyn Monroe, whose doctor prescribed excessive amounts of Nembutal for anxiety and insomnia and with which she took her life. Heath Ledger, whose cocktail of prescription drugs, led to his recent demise.
It may be timely to have more professional oversight of those doctors who self select to treat stars. Medical ethics are easily corrupted in the rarefied atmosphere of the megastar.

More from Miranda off centre

2009-05-24T12:02:00.001+10:00

Miranda Devine is wrong. Abstinence is the preserve of only a few drug dependent users. The majority need help to abstain and are at constant risk of relapser. What they don't need is a columnist advancing an argument for a failed expensive treatment modality which has seduced users into believing that a naltrexone implant is a quick fix. This expensive unresearched and faulty
technology exploited a loophole in the Therapeutic goods Administration rules to import devices from China and implant them at huge cost into heroin users. The techniques used by the purveyors were more akin to used car salesmen than medical practitioners and psychologists.

Documented case histories abound of people selling off family property to purchase the naltrexone implant only to find it did not work after a few weeks and relapse into heroin use with thousands of dollars in debt. Worse still may have overdosed when they relapse assuming the implant will protect them. I have seen a number of users who have sustained catastrophic medical outcomes as a result of failed implants. Operations to retrieve such implants are costly and scarring physically and psychologically. every drug treatment service in Sydney will corroborate these cases of meltdown after insertion of the devices.

methadone and buprenorphine do not drug users into an addicted haze. Most get their lives back on these scientifically validated treatments that are not sold like snake oil. Methadone in particular has created more successful outcomes than any other scientifically validated treatment. Journalists, doctors and lawyers take it every day and are undetectable form the normal population. Miranda Devine has set treatment back by supporting naltrexone when the entire treatment world has forsaken it. She needs to research the worldwide literature before shooting from the hip.

Irish Malaise - a letter to SMH

2009-05-21T15:19:00.000+10:00

Dear Editor,

Your abbreviated two column report into terror perpetrated on up to 30,000 children in Ireland's workhouse styled schools by the church needs more discussion. Australia's connection cannot be denied as a number of disgraced priests and brothers found their way here to establish similar institutions in this country. It appears that generations of systemic abuse took place under the watchful gaze of educational authorities who did little to protect the most vulnerable in the community. That young children were woken with beatings every morning in a ritualised brutal dehumanising system that masqueraded as schools is terrifying enough, but add to this systemic paedophilia with perpetrators shielded from prosecution by their holy orders is criminal. Perhaps this explains why so many young Irish people have left home never to return.

More Miranda Madness

2009-05-21T15:16:00.000+10:00

Dear Editor,

Miranda Devine's extraordinary defence of rugby league and those men within it who perpetrate violence beggars the imagination. the diatribe goes on to excuse urination in public places and violent behaviour because' men have to express 'what it feels like to be male and to have testosterone surging through young bodies'. Her excuse for clubland rape is that women are responsible in some way for the actions of predatory men. To extrapolate further that decades of androgynous feminism have destroyed chivalry is just arrant nonsense. she needs to take a long hard look at how boof headed musclebound overpaid football players have become the new aristocracy.

Naltrexone 2009

2009-04-13T20:35:00.001+10:00

For many heroin users, and their desperate families, the prospect of a quick fix for addiction to this all consuming drug has been a tantalising reality. Naltrexone implants have been inserted into thousands of Australian heroin users over the past decade despite serious concerns about their safety raised by drug treatment agencies around the country. These implants are not registered with the therapeutic goods administration and are either produced here or imported from China. Clinics around the country have been inserting these devices, utilising a loophole under the special Access Scheme, by claiming that heroin dependent patients are critically ill and at risk of death.

These implants do not come cheap. Each one costs the user or their family $5000. More than 3050 implants have been inserted in Australia over the past five years. Dr George O'Neil, a retired obstetrician and gynaecologist has been manufacturing and implanting these devices in Western Australia for the past 10 years. He has received $1.7 million from the Medical Research Council, $3.8 million in Federal government grants for industry and $8 million from the West Australian government. His website claims to be successful in 85% of cases and he has the ideological fervour of a man who believes absolutely, that he produces the panacea for opioid dependence.

In The Medical Journal of Australia a recent editorial has called for an independent review, of naltrexone implants in Australia. Emergency department doctors at two Sydney teaching hospitals have reported major morbidity in 12 patients after implants. There is further evidence from Prof Louisa Degenhardt in the same journal in 2007, that between 2000 - 2004 there were five deaths associated with naltrexone implants.

I have reported my concerns to the TGA on two occasions only to be told that because naltrexone implants were used under the special Access scheme, that they were under the radar. Having seen young patients, whose parents have cobbled together the huge amount required to such an implant, desperately unwell within weeks of insertion and begging to have the implant removed as a matter of urgency has caused great consternation. I have referred for such patients to a local teaching hospital in the last year. None of them seem to have had the procedure clearly explained, nor was there adequate follow-up by the clinics involved.

The Pharmaceutical Services Branch of New South Wales Health says it does not have the jurisdiction to control Special Access Scheme medications. Here we have playing out, the inevitable bureaucratic buck passing that ends when broadsheet newspapers produce a deluge of evidence by investigative journalists that leave government departments looking embarrassed. Perhaps most telling of all is the fact that the TGA will not release its records of adverse events surrounding naltrexone implants under freedom of information laws.

In the last two weeks I have contacted the Health Care Complaints Commission regarding serious adverse outcomes in two of my patients, whose families were seduced by the prospect of the easy solution to a difficult problem. and fell for the slick advertising of the Naltrexone implant clinic.

Desperate drug users and their families will reach out for any potential solution that is marketed as a way out of a life of hopelessness. We as the medical profession must scrutinize such claims for clear unequivocal evidence of efficacy before giving tacit support.

The Therapeutic goods administration needs to shut down this loophole in the Special Access Scheme and announce all adverse reactions for naltrexone implants as a matter of urgency by instituting a full investigation into it’s failure to protect the most vulnerable Australians.

2009-04-10T19:42:00.003+10:00

Miranda Devine has revealed tragic consequences of uncontrolled home births. The alarming figures for death and disability should make women think twice before embarking on home birthing, particularly in outlying areas.

The ideological bias against hospitals is reminiscent of the anti-vaccine lobby. So now we have the madness of isolative home birth practice followed by an unvaccinated baby and all the attendant problems that can arise. It is time for some regulation from legislators to prevent such catastrophic outcomes.

Dr Raymond Seidler Kings Cross

2009-04-10T19:42:00.001+10:00

Assault on the profession

2009-04-03T07:13:00.001+11:00

In a week when the AMA sends out a survival kit for GPs containing information on how to deal with difficult or violent patients. A rural New South Wales GP Dr Hamish Steiner, appears on the New Inventors with a small illuminated panic button that sends out a silent duress alarm to all other computers on a network in the practice, we have the awful reality of one of our colleagues GP Theo Rothonis being stabbed in his Waterloo practice by a 65-year-old psychotic patient. Most pyschotics are victims of assault rather than perpetrators. However many chronic schizophrenics are now managed by GPs with little assistance from an over stretched public mental health system and psychiatrists who would rather treat depression and anxiety than the sharp end of psychosis. Emptying out psychiatric hospitals has not been a successful move.

For those of you who believe in synchronicity, perhaps these events are linked in some perverse way. They should provide us with an opportunity to become serious about our own protection.

It is certainly true that GPs have slipped from their pedestal as the most esteemed members of society. Patients regularly verbally abuse doctors, to the extent that many GPs now see this as part of their daily grind. These days it doesn't take much for a patient to lose control. A delayed consultation, a failure to provide a script on demand, or refusal to issue medical certificate for Centrelink benefits. Any of these can light the short fuse that sets a patient off.Equally, associates of a disturbed patient may perpetrate violence especially if drugs or alcohol are added to the mix.

To shrug your shoulders and say that verbal abuse is just part of the job is I believe setting a dangerous precedent. There is certainly a hierarchy of behaviour elicited by patients or even associates of patients which can predict most violent outbursts. Yet we GPs are given very little formal training in how to assess patient behaviour before the inevitable explosion. Worse still, many of us do not report such incidents, when they occur. It has been suggested that a national database of assaults against GPs should be maintained. Professor Leanne Rowe wrote extensively on the topic after the tragic death of Melbourne GP Dr Maarouf- Hassan in 2006. Much more training should be provided to us all to cope with unexpected critical incidents

Intuitive practice staff will often know before the GP, which patients are likely to lose it. Pacing in the waiting room, excessive perspiration, a loud voice and excessive complaints to the practice receptionist, should all be seen as red flags. Duress alarms and CCTVs may need to become commonplace in general practice should assaultive behaviour continue at it's present rate. Female doctors will need to be escorted to their cars at night and providers of medical after hour services will have to be more aware of the dangers that lurk in suburban houses where a doctor is called to render assistance at night.

I know Dr Theo Rothonis. He is a committed 40 year old GP who in the course of his working day in a seriously socioeconomically deprived area of Sydney, laid his life on the line. Luckily a colleague heard his screams and came to his assistance. It could have ended differently. We should all be alert and alarmed.

Michael Phelps and his misdemeanour

2009-02-22T20:13:00.000+11:00

Male US athlete of the year, Michael Phelps is in trouble in 2009. Publication of a photograph of him using a marijuana bong in a British tabloid this week will place in jeopardy his $100 million of endorsement contracts. Not to mention his squeaky clean reputation as arecord breaking olympic swimmer adored by young people around the globe.

What if the Richland county sherrif in South Carolina decides to go ahead and charge Phelps with possession of marijuana? He will join the 800,000 Americans charged each year for this misdemeanour. Of this huge number, 82% are latino or African American because they are more likely to be stopped and searched by police.

Michael may not be as clen as his handlers would like. In 2004 he was charged with a drink driving offence. At the time his long time coach Bill Bowman reflected “ When you see him swimming, he just seems superhuman, you forget he is 19 and he is just trying to grow up”
And a superhuman effort has been effected to transform Michael from a 7 year old boy whose parents divorced and whowas unable to sit still or concentrate. Diagnosed with ADHD ghe was treate with Ritalin for a couple of years and then he discovered swimming- something he could focus on and his life beagan to settle, as he churned up and down the lanes of a pool. His particular body build which makes him so phenomenally successful with a long torso and relatively short legs caused him to be cruelly taunted. Now he is a hot property with girls holding up placards to him saying “ Can we hang out?”

In his statement about the bong incident,Michael has acknowledged that he” engaged in regrettable behaviour and bad judgment” But since marijuana is only banned by the world anti doping agency during competeition and he has never failed a drug test before, he is likely to avoid official censure. In fact he stepped up to have more than the mandatory drug testing to dispel rumours that his super performances had to be the result of performance enhancing drugs.

Imagine the furore if michael phelps had not apologised officially but decided to stand up and be counted as many of his peers have done citing recreational pot as just another way to relax and chill out after a gruelling 10 months by any one’s standard. It has been recorded that phelps has to ingest 12000 calories per day to keep pace with his prodigious physical output. He is known to have eaten 23 hambugers in a day. The say no to drugs lobby paints all marijuana users as couch - bound amotivational zombies sitting in front of TV, staring into space.
Reality means that many successful people take cannabis recreationally and suffer few if any side effects. Amongst the success stories who are coincidentally pot smokers include; Nobel laureates, at least three US presidents and Pulitzer prizewinners.

It is possible that like many adult sufferers of ADHD, Michael was self medicating with cannabis to reduce his problematic hyperactivity symptoms which had returned in the off season when he had stopped his furious training schedule. He just wanted to be one of the ordinary guys having fun at a party. An intrusive photo snapper has changed all that turning Michael from star to pariah overnight. He deserves to be cut a little slack.

A New Year medical tale

2009-01-09T13:37:00.003+11:00

A backpacker from Ireland came in this week with infected sores on his
face, arms and legs. I was at a loss to understand how these perfectly
round wounds occurred, until the history unfolded in his lilting Dublin
brogue. "I was asleep on Bondi Beach dead drunk on Christmas Day and
some people put their cigarettes out on my face and body,'' he said.
``They are very sore, doctor. Do you think they will scar?''

Quite possibly, I thought, proffering him a script for antibiotics and
some burn cream. Asked if he had learned anything from this experience,
he replied: ``Yes, I decided to give away the booze until after New
Year. But what should I tell my mum?''

Alcohol in excess means not only assaults and violence, but also
sexually transmitted infections from indiscriminate conjugal liaisons.
Asking patients when their recent sexual activity took place, and with
whom, is fraught. The alcoholic, amnesic fog descends, and the forlorn
young person suggests it could have been any time in the last week, with
persons or persons unknown.

To this mix of unbridled festive behaviour, add the relentless
Australian sun burning down on intoxicated bodies. A parade of burning
flesh, blisters and heatstroke is never far away from doctors'
surgeries. Despite the warnings about the dangers of exposure to the
sun, despite the shocking television images of melanoma, young people
still see themselves as bullet-proof and invincible.

Today, in emergency departments all over Sydney, a string of fractures
will begin arriving around 11am. People who have broken bones sometime
in the previous 24 hours first attend hospital, not realising that the
nagging wrist pain is serious or a swollen, tender joint is deformed and
misshapen, until the anaesthetic effects of alcohol or other drugs begin
to subside.

Piecing together the story, a phalanx of tireless triage nurses attempt
to produce a coherent history of the present illness, so the medical
record does not look like a fairytale.
Unwanted new year pregnancies may take a few weeks to manifest, but
early opening pharmacies do a brisk trade in morning-after pills for
those who recall a tryst the night before, where the best laid plans for
safe sex are laid waste in the heat of the moment.

No wonder so many people resolve to improve their health and lifestyle.
The previous month has been one of excess. Food, alcohol and late nights
all take their toll. Dyspepsia heartburn and digestive upsets means that
belts need to be loosened and antacid preparations swallowed by the
handful.
Mental health issues too, previously suppressed, surface at this time of
the year. Unresolved conflicts flare up, especially at parties when
exhaustion and overindulgence collide.

Depression is higher now than other times of the year. Everybody is
supposed to be enjoying themselves, but some find just getting out of
bed a major hurdle, and the prospect of a social outing an anathema.
Suicidal thoughts are more prevalent at Christmas and New Year,
especially for those whose capacity for enjoyment has been curtailed by
illness or serious psychological distress.

It is a dangerous time to get sick at the end of the festive season.
Most doctors are away. Hospitals are operating skeleton staff, and
surgery has stopped for all but the most urgent emergencies.
But for a general practitioner in Kings Cross, it's a time to see
patients from all over the world, with maladies only prevalent at this
time of the year.

Dr Raymond Seidler works as a general practitioner in Kings Cross.

The long lunch and Bob Ellis

2008-11-23T19:07:00.002+11:00

Dear editor,

Curmudgeonly old Bob Ellis rues the loss of long lunches. He invokes the
period before Paul Keating made tax-deductible luncheons a thing of the
past, as a time when business was done over a four hour debauched
bacchanalian orgy of excess.

Poor Bob, he is still living in the dark ages when people could turn up
after an alcohol infused lunch at 4 p.m. and proceed to snore through the
rest of the working day. Then they would drive home over the
limit. Australia then, did no work after 1 p.m.

His conclusion is correct, however. 'The morrow may prove a bummer'. At
least you'll be able to cope without a hangover and the nagging fear that you have mortally insulted a business partner.

Death of John O' Connor - 'Pal' a homeless guy of the Cross

2008-10-07T21:35:00.007+11:00

Dear Editor

John O' Connor, the homeless man from Kings Cross known as Pal, who died this week aged 45, was a victim of a fractured health system which failed to deal with his special needs. And there are many more still alive to take his place in the queue for treatment in our over burdened inner city health services.

I saw him everyday rifling through garbage, often in Kellett Street, leaving piles of discarded refuse on the street, and plunging needles into his wasted arms in full view of passersby. He was often inappropriately clad in winter and frequently draped in a St Vincent's gown and blanket, from a recent admission to the emergency department. He had a total of 800 admissions to St Vincents Hospital.

Suffering a deadly combination of drug dependence and mental illness which caused his chaotic and destructive behaviour, he was frequently begging around the Cross. In a better system he would have been involuntarily held in a secure residential facility where he could be treated and kept safe at a fraction of the cost of his multiple admissions.

In NSW this means only incarceration. Since we have emptied our psychiatric hospitals, there is little hope for people like John to live a dignified existence in safety. He was frequently bashed, injured and mistreated by other street people and miscreants. I took his photograph in Kellett Street near the rear of the Safe injecting Centre where he regularly sought discareded drugs in garbage and when I showed him his image on the screen, he was shocked. So was I.

His frequent flyer status into the ED is St Vincent’s has cost the taxpayer a fortune. Figures of between $500,000 and $1 million for hospital treatment in the last few years and at the end of he day all the short, well meaning interventions have come to nothing.

John's legacy should be a more proactive system that addresses needs of our longterm homeless with dual diagnoses like mental illness and drug dependence. They the most vulnerable in our society and are frequent attendees in our hospitals.

As the economy goes to hell in a handbasket, and once comfortable Australians are jettisoned from their societal anchors, you can bet there will be many more like John admitted and rapidly discharged from our public emergency departments to live rough in unforgiving inner city streets.

letter in response to Miranda Devine's op ed

2008-08-23T18:04:00.000+10:00

Miranda Devine's solution to the ADHD epidemic is for all mothers of such kids to be like Debbie Phelps and encourage their children to focus down on swimmimg and leave stimulant medication` like Ritalin in their wake. Real life is not so easy.As anybody who has come into contact with sufferers of the disease, it is draining and debilitating both for the child and his parents.

Stimulant medication works paradoxically but can salvage relationships both at home and at school. Doctors do not pathologise normal exhuberent behaviour of boys, but rather treat the extreme end, which disrupts families and classrooms alike. They are not drugged into docility. Such emotive description is unhelpful when describing an illness. It may be news to Miranda but teachers have always been involved in identifying behavioural problems in their classes and are often consulted by parents and psychologists for their opinion.
I see the result of not treating such children. When they become adults they suffer worse psychiatric problems and have the additional weight of substance abuse as a comorbidity. Would that all such children find their flow in swimming and become a Michael Phelps. Alas, he is an exception rather than the rule.

Submission to Australian Senate Committee on Alcopops

2008-08-21T20:53:00.002+10:00

I am a specialist in addiction medicine practising in Kings Cross NSW. In addition, I am also the secretary of the Eastern Sydney Division of General Practice and regularly present on drug and alcohol issues to medical and lay audiences.

Recently, our division of general practice hosted a youth Forum for all the high schools in our area. Attendees included a 75 students from variety of private and public schools. My presentation was on intoxication and the subject of premixed alcopops came up in discussion. The consensus of opinion amongst the young people was that raising the excise on premixed drinks would do nothing to reduce the level of binge drinking amongst their cohort. Many of the young women said they would just resort to cheap drinks or buy their own spirits, and at the same time purchase a bottle of soft drink to mix with either vodka, bourbon or whisky. They also explained to me and to their teachers that they would seek out cheaper alcohol alternatives like wine in casks which they explain could be procured for around $10 for 4 Litres

It is my contention that increasing the price of such premixed drinks will reduce their availability and desirability but do little to reduce the level of binge drinking in young people. Traditionally, punitive techniques on the supply side of the equation have been spectacularly unsuccessful while there are cheaper alternatives available. If heroin is taken as an example, since 2002 it has become much more expensive for users as a result of reduced supply. Many users have resorted to alternative, cheaper drugs like crystal methamphetamine, with devastating effects.

Alcohol has pervaded Australian society completely, with approximately 10% of the adult population drinking hazardously. Treatment programs are at best uncoordinated and unresponsive to community needs with poor funding and a focus on abstinence-based regimes.

The issue of hazardous binge drinking amongst young people has yet to be addressed in a coordinated national programme. If we take Newcastle New South Wales as an example, the inner city environment has become a no-go area for older residents on three nights of the week as a result of extraordinary indiscriminate violence perpetrated by young alcohol fuelled population that descends on the area over the weekend.

In my own area of Kings Cross, there is clear evidence of mayhem on the streets every Friday and Saturday night with older people holed up in their flats unable to sleep and terrified to go down to street level where antisocial behaviour has reached epidemic levels.

Today in Australia, young people can earn more money than before and have more leisure time. This combined with a propensity to drink at hazardous levels has fuelled unprecedented disintegration in the places where they choose to meet and socialise.

Raising the price of alcopops seems to have the hallmarks of knee-jerk reaction. It has all the appeal of a simple answer to a complex question. Until we address the underlying issues of alcohol dependence in Australia generally and in young people in particular, we are doomed to repeat our mistakes. And to say that this is an Australian phenomenon only is to fly in the face of international reality. We have it seems, an epidemic worldwide of binge drinking in young people. Even countries which previously have controlled their drinking through cultural mores which demand better behaviour, seem to have been swept up in this tsunami.

I believe that even if we banned alcohol altogether for sale to people under the age of 21, we would still have a problem. The issue cannot be addressed on the supply side only. A concerted national campaign with zero tolerance of alcohol fuelled misbehaviour combined with a national treatment programme funded by the liquor industry and government seemed to me the only viable solution to a difficult and seemingly insurmountable problem that defies punitive legislative changes the way bootleggers defied prohibition in the United States during the 1920s.

E mail consultations

2008-08-21T17:27:00.000+10:00

It is not just young people who want e mail consultations. In the centre of Sydney, where I work, many tech savvy patients will send me digital photographs of rashes and even videos of their injuries in mpeg to forego a consultation face to face. Time strapped patients and cyberchondriacs will outline their symptoms and give the GP a web based differential diagnosis that they attach to the e mail.
Way back in 1998 a tech savvy patient sent me a digital photo of his groin rash while he was travelling in London. He said it was easier to e mail me, with a picture, than see some cloth eared NHS doctor in the UK who would take five days at least to obtain an appointment. Privacy is not an issue for these patients. They are not concerned with encryption and are willing to run any risk to get a quick effective answer to a vexing problem by e mail. Meanwhile most Australian GPs hide their e mail addresses from their patients, preferring instead to use a steam driven fax machine in 2008!

Australia and the world's biggest ecstasy bust

2008-08-10T20:13:00.005+10:00

World record hauls of ecstasy have occurred in Australia since 2004 but
nothing approaches the 4.4 tonnes detected in tomato cans last June, in
Melbourne, with a street value of $440 million. It indicates that despite
extensive education and interdiction, Australia's youth have embraced this
drug like no other. The market remains buoyant.

Ecstasy or MDMA an hallucinogenic stimulant was first formulated by a
mainstream pharmaceutical company in 1912. Merck Co could find little use
for the preparation and it was an intermediary drug for the manufacture of a
styptic Then languished til the 1960's when it was discovered by
psychologists in America and gradually found it's way into the illicit
market first in the gay scene and then more generally into mainstream
society.

As a GP in Kings Cross, I have seen hundreds of ecstasy users over the last
decade and despite horror stories in the press, most take this drug with
impunity. The phenomenon of "Eckie Monday' meaning that the weekend come
down from a binge requires a medical certificate for work absence, is
common. So too is the weight loss and lack of vitality in habitual users who
dance themselves into exhaustion and grind their teeth in clubs all over
Sydney.

Early mornings in the Cross provide a cavalcade of burned out E
users heading home after an all nighter. But for the most part, they do not
suffer any serious medical problems. A few may develop over heating or
hyperthermia and require short admission for hydration with a litre of
fluid or two intravenously in an emergency department. Seizures and drug
induced psychosis do happen, but at a very low rate. Even this outcome does
little to dissuade users to quit their drug of choice.

Sure there are horror stories of PMA [para methoxy amphetamine]a cheaper,
dangerous substitute for Ecstasy causing sudden death, but this is so rare
as to not affect demand at all. ecstasy testing kits are now available over
the internet. A user scrapes off a small amount of tablet and combines it
with a reagent to detect the active MDMA. These testing kits are common in
Europe outside clubs and should be encouraged here.

Young people are educated on the risks and dangers of all illicit drugs.
Most schools now have excellent drug education programs covering all illicit
drugs in Australia. Kids use the internet to plug holes in their knowledge
Despite this, successive government programs portraying ecstasy as a danger
have done little reduce ecstasy use in Australia. Most young users have
observed their friends taking E without adverse effects. Combine this with
the boundless optimism of youth and an unshakeable belief that they are
bulletproof and you have a recipe for an explosion in demand.

Drugs use follows fashion cycles and in many ways government demonisation,
with horrific video footage, entrenches the inevitable warfare
between the young and their parent's generation. It is unusual,in my
experience, for a young person to request treatment for ecstasy abuse unless
they are dragged kicking and screaming by a concerned parent. They do not
want treatment if their recreational use is limited to weekend diversion
and will show a therapist bored disinterest.

Price is a keen indicator of availability and none of my patients ever
complain of difficulty obtaining ecstasy. So we can conclude, that despite
these huge hauls by Federal police and the National Crime Authority,
significant stockpiling must occur around the country.

Drug trafficking will go on as long as there is demand. Australia has always
been at the forefront of illicit drug use world wide. In 1936 we had the
highest use per capita in the western world of cocaine and heroin. And now
we appear to have won a gold medal for ecstasy.Very little has changed.

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