Captain Atopic : Degranulated

Lockers

2010-03-12T05:20:00.005+10:00

It's exam week here, and those of us at The Coast have trekked to the Big Tertiary Hospital for clinical exams. There's a swish new building for students there, complete with a swanky common room and this wall of space-aged combination lockers. You can use them for five minutes or five months, if you want. Look at them, all patterned green and shiny and new.

Up at The Coast there's a single bay of ratty old lockers, maybe thirty in total. We even have to bring our own padlocks. At the Coast, the Clinical Coordinator puts your name on your locker.

That really speaks volumes about both Hospitals, and it's the reason I chose The Coast.

Cut Short

2010-03-04T19:07:00.004+10:00

Saturday night, half an hour before closing up a hectically busy evening. We'd nearly sold out of Sharpz Kits and it seemed every asthmatic on The Coast was heading out clubbing for the number of inhalers being let loose.

Self-harm chills me. Ignoring the blood and flesh. The diminishing sensation of each nerve's tingling throb, fading to the feel of cotton sheet across shaven leg. It chills me.

In a quiet moment, the doors whirred and two girls came in, about eighteen. Both wore black cut-off t-shirts, plaid red mini-skirts, fishnets and raccoon eyes. The one with the large dressing on her arm begins to inspect the wound-dressing displays, and the other heads in my direction.

"Hey, um, we wanna get something to take out stitches and dress a cut. What can we use?"

I wandered over to the display, and casually asked a few questions. The 'cut' was about half a foot long, running down her arm elbow to wrist. It was bullet-pointed at each end by fine, linear scars running perpendicular to the newest laceration. The ragged edges, she perkily informed me, were because the knife had been blunter than expected. The on-duty Doc in the ED had stitched her up quite nicely and dressed the laceration.

There were already some finger-sized holes between the stitches; the iodine smeared in distinct, gloveless finger-prints. She and her friend wanted something to prevent infection. And remove the stitches.

"So," I asked, "why are you so keen to whip these stitches out?"

"It hurts. Maybe get some more from my other doctor. I just don't want it to get infected, 'cos that's gross."

We calmly chatted about removing her own hour-old stitches being a very bad idea and that the longer she left the cut open, not only the greater chance of infection but some other nastiness could happen. She was adamant, emotionally blunted as the knife she'd used.

We don't sell stitch cutters; they're almost never appropriate for use in the community. I further counseled regarding antiseptics and signs of infection and dressings. 'Stitches in' was the best option, I stressed.

I impressed the importance of visiting her GP the next day, and provided them with the 24-hour Psychiatry Hotline number. I felt that I was losing their audience. The girl with arms intact had begun wandering around the store, disengaged.

We moved to the till, where I slowly put the sale through; iodine, two dressings, some tape. The friend strolled over to the till to join in the sale. She had in her hand, the largest pair of scissors from the shelf. She triumphantly dropped them on the counter.

And they both stare disbelieving as I say "I'm not selling you those."

Why I'm Against Pharmacist Prescribing

2010-02-24T22:06:00.000+10:00

Every year or so, some Pharmacy organisation rears its head and suggests Pharmacists be able to prescribe medications. Schedule 4 medications are the realm of the doctors. Pharmacists can't prescribe them now, and nor should they.

Of course, pharmacists are already entrusted with the responsibility of monitoring access and assessing suitability of certain medications; the "Schedule 3s". As a cohort, we can give out appropriate thrush creams, morning-after-pills and asthma relievers, and we're generally pretty good at it. Often our ability to assess the need for pain medication or sedating antihistamines is overwhelmed by apathy or the desire for profit.

Whilst I'll deal with profits opposing ethical prescribing later, the key point is that pharmacists are limited in their diagnostic powers. We don't take long, effusive, thorough histories. Not only is there not enough time in a community pharmacy, but pharmacists are simply not trained in the process. It takes several years of medical school just to refine this strength, let alone remember all the pharmacology, indications and interactions. As the Dean said on my first day of Pharmacy School "Where doctors are the doyens of diagnosis, we are the masters of medicine"; a philosophy I'm still well agreed with.

There is a suggestion that an increased knowledge base and Continuing Professional Education (CPE) strengthens the case for pharmacist prescribing. Rather than establish a new-found ability to select and initiate medicines, CPE strives to further inform pharmacists about options for treatment without establishing which medicine is prefereable for each individual patient. That decision requires a full history and physical exam.

Even in hospitals, where the most book-smart pharmacists hang out, there are rarely opportunities to initiate therapy. Specialist physicians are substantially better equipped to make these decisions, and not necessarily through their qualification. Hospital pharmacists play an essential role on the wards; checking charts and modifying therapies. I've not seen a pharmacist saunter up to a physician and say, "You know what, Mrs. Jones has been hypertensive and tachycardic for a while, I think you should give her some atenolol." It's just too much of a leap of faith, without acres of physiology, pathology and pathophysiology.

Don't get me wrong, both physiology and pathology are taught in Pharmacy school, but not, I believe, at a level even close to what's required to diagnose or initiate medication.

In recent years, some Pharmacists have undergone further training and assessment to become accredited to perform additional roles; rural and remote Pharmacists have an extended scope of practice compared with their metropolitan colleagues. Usually there's also a close relationship with a local doctor and as seems to be the way out bush, there's a strong emphasis on health outcomes, not profits or convenience.

Comparatively, Home Medication Reviews (HMRs) are a good way of reviewing patients on thirty or more medications, streamlining their dosing regimen and spying on exactly how much a patient or couple push the SafetyNet 20 Day rule. Most of the reports that have wandered across my path are blowing smoke, often created from preconceived templates and noting obvious interactions that would have flashed up on the prescriber's software at the moment of prescription. Sure, they can point out the odd interaction and help educate the patient about which over-the-counter products to avoid. But that remains the community pharmacist's job; they don't claim $140 a pop for each batch of suggestions.

The Pharmaceutical Benefits Scheme (PBS), through regular reviews, has also begun the establishment of 11 month repeat 'scripts for some medications. This means that the prescriber doesn't have to be writing 'scripts every five seconds for a medication that's unlikely to change in dose, frequency and is well tolerated. But, they still need to review it yearly and the medicine is still doctor-initiated. This aspect is most likely to garner public support; "I always have to see the Doc for my sleepers", "I can never get in to see Dr Bob." The PBS appropriately limits the number of repeats based on clinical indications and recommended treatment courses, with an eye to reducing medication wastage.

In a recent report in The Australian, the Pharmaceutical Society of Australia (PSA) campaigns for pharmacist prescribing. The article also notes that the PSA represents 75% of pharmacists in Australia. I'm not one, having resigned my membership in 2007. I have, however, done some polling - enough for a half-decent binomial distribution - and there's no way the vast majority of pharmacists would initiate medications for chronic diseases. At present they're not comfortable writing "sick day" certificates; you can't even cause much harm with those.

Thankfully, most pharmacists appear well aware of their limitations. This most recent push again appears cast from the ivory-tower of pharmacy advocacy without a mind to the majority of the workforce in everyday community pharmacy practice.

The article continues, "PSA national president Warwick Plunkett said a basic requirement would be that the pharmacist dispensing the drugs could not also have prescribed them, to remove the danger that some might seek to profit from their own scripts."

Thanks Captain Obvious. Unfortunately, Mr Plunkett neglects to mention the marked benefits of running a larger pharmacy with two pharmacists on duty; they would be able fill their own store's prescriptions whilst the one-pharmacist strip-mall stores would not. The comment is intended to give the appearance of balance and ethics, when in fact it panders to large banner groups and shuns smaller, independent pharmacists.

The PSA is clearly biting the hand that feeds; it seems a corresponding retort was issued by the Australian Medical Association (AMA) just a few days later, suggesting it should be Doctors running the Pharmacy show. Everyone just needs to calm down.

Although pharmacists know about medicines and some common minor ailments, we're not qualified to diagnose illness nor initiate medications that fall beyond our scope of practice. Most diseases, particularly chronic illnesses, fall beyond the pharmacist's scope of practice. Moreover, allowing pharmacists to prescribe removes a key ethical and quality-control barrier; there's no way the notion could lead to better health outcomes. Pharmacists shouldn't prescribe schedule 4 medications. Most of us are well aware of our clinical limitations; the folks making national media press releases are an exception.

Nouvelle-Zélande, sur des photographies. Partie 3

2010-02-24T07:32:00.000+10:00

In which the inlets of Banks Peninsula lead onwards...

Akaroa Harbour

Pier, Governers Bay

Lyttleton Harbour from Governors Bay

0545am, Mooloolaba, Sunshine Coast

Nouvelle-Zélande, sur des photographies. Partie 2

2010-02-19T19:12:00.000+10:00

In which the West Coast's great green walls and grey ocean reveal themselves...

Pancake Rocks, Punakaiki

Waterfall, Franz Josef Glacier

Valley wall, Franz Josef Glacier

triumvirate acqua, Franz Josef Glacier

Raining

2010-02-16T17:15:00.001+10:00

It's raining today. Big, fat tears from the grey swollen sky.

This morning when I left the house, the sun was just peaking over the ocean. It was dazzlingly beautiful, even the green dew in the trees sparkled. I'm on birth-suite, and as I left the house and drove off, I thought to myself "Someone's going to have a baby today. I bet they're on the way to the hospital right now, all excited and nervous and filled with joy." A good day to be alive, to see new life. I sang along with the radio, full voice.

Hospitals, in the early morning, always seem dark. A concrete giant wakening from a fitful sleep. I changed into blues and headed to birth-suite, bounding along as the corridors wiped the sleep from their windows.

Several babies had been born over night. Other women had come in labouring. The midwives looked exhausted, the doctors bleary eyed. A baby had died. The grief was palpable; handover came and went on autopilot. It was the third death in a week. This was the worst.

Outside the skies opened. Rain so thick you could taste it indoors. The hills behind the hospital disappeared in the fog of wet. Black looming wet. I found some space alone. I sat and cried.

Nouvelle-Zélande, sur des photographies. Partie 1

2010-02-14T18:39:00.004+10:00

In which a mountain is summitted and waterfalls and blow-holes discovered.

Down into the Clarence Valley from Mt Isobel, Hanmer Springs

View to the East, Summit of Mt Isobel, Hanmer Springs

Dog Stream Waterfall, Hanmer Springs

Batman 1000, Puzzle nil.

Blowhole action, Punakaiki

Eyes

2010-02-08T10:37:00.002+10:00

Sitting in the corner of the meeting room, an off-call consultant's eyelids fall. The night registrar talks animatedly and the day team joke. The consultant's patients have been discussed and his coffee hasn't kicked in. The bounce of his chin rouses him

The round passes through a medical ward; eyes look up, eyes dart around. The octogenerian's glassed, cloudy eyes search for focus, and find wanting. The narc'd lady next door sleeps soundly, eyes rolling in an opiate fog.

In clinic, eyes have fear. Why can't my GP handle this. Or eyes of frustration, "You made me wait an hour to tell me you can't work out what's wrong

In corridors, more tired eyes. Interns, fresh faced aside from the bags, snake some biscuits from the tea-trolley between patients. Jaded admin look daggers through bloodshot Monday-itis

On the kids' ward, the eyes are bright, glossy, new. Eyes working hard to focus for the first time. Others closed tight in sleep.

The labouring mother, too, has tired eyes. Drunk on birth and hormones, sapped of energy. She battles not her lids between contractions; her sweated brow furrows for another wave. Eyes roll as she dozes.

"Anxious", say the father's eyes. He sees and feels pain; and pain is seen in him

His eyes change, her eyes change too. They see new eyes, bright, lustrous, screaming eyes. They see love.

Through tired, happy eyes.

Kicked

2010-02-04T09:49:00.002+10:00

Yesterday, I had my butt kicked by a consultant. In front of three junior doctors, it was explained curtly, ruthlessly that the way I'd charted a history from a clinic patient was woeful and inadequate.

The intern had quietly copped a similar treatment not five minutes earlier, at the same time as presenting his case; the experience was cringe-inducing, despite the intern's grace.

The consultant is quite forthright and particular; each patient's history must be documented just so in certain and exact language. I'd managed to take sufficient history given the presenting complaint, but my written order of information was, well, not up to scratch.

Ironically, my thinking and subsequent questioning were much more clear than in similar settings last year; I know why I'm asking what I'm asking as lists of differentials begin to form on my mind's slate. The last step, communicating in clearly to the consultant via written form, is not a foreign language; I just seem to smudge some of the punctuation marks.

According to at least one professor, shame and fear are the cornerstones of medical education. Neither of these emotions were particularly strong during my semi-public ass-kicking. The experience made me more determined.

I'm not in love with gynaecology, nor am I particularly enamoured with this consultant. Sure as anything, I'll go back to their next clinic. I'll take a history, write it up, and probably get whipped again. I'll do it because it will make me better.

Hydrozole: Another Poor OTC Combination Product

2010-01-31T10:18:00.000+10:00

Today I was again reminded how nonsensical some OTC combination products are. The thought was sparked by a prescription I received for Hydrozole(R). It's a non-PBS item and can be Pharmacist prescribed. Hydrozole is one of those annoying combination products; hydrocortisone 1% w/w and clotrimazole 1% w/w. According to television advertisements, of which there are many, it's apparently good for sensitive, inflamed skin conditions. I think it's crap, and most texts agree.

You see, if indeed the problem is a fungal infection then treatment, with an azole antifungal is required for 14 days after the lesion resolves (AMH, 2010). Moreover, if the 'rash' is eczematous and a steroid indicated, then a "5 days on, 2 days off" regimen is the usual treatment. Now, it's quite likely that an inflamed fungal infection occurs. And here's the kicker; at every pharmacy I work at, you can get both a steroid cream and an antifungal cream together for less than you pay for hydrozole.

What I suspect happens is that a prescriber is asked about a 'rash', and odds are, it's one of the two. Instead of suggesting the patient purchase one or t'other, they cover their bases and bow to he pressures of 6-minute medicine by writing a 'script; the prescriber's seen the TV adverts, too. I'd be impressed if most prescribers knew the cost of antifungals or steroid creams; I suspect most would pick the combination cream as less expensive. This presents an interesting challenge for those patients who "Just want what's on the prescription."

In short, hydrozole is a medicine that survives on its media profile. It's not appropriate for a simple fungal infection, excessive for an eczematous-type rash and cannot be used to treat anything for the appropriate time. Pretty much, there's no good reason to use Hydrozole(r) and even less reason to prescribe it.

Healthy Baby

2010-01-28T16:34:00.003+10:00

So, it's now the end of my second week of O&G. Despite a holiday on Australia Day, I'm exhausted. One overriding impression I've gained so far, is that there's a great mix of ways to have baby.

I'm not talking about positions, methods or even situations; I'm talking about philosophies. For some, having a baby is about walking a certain path, with or without certain inputs or stimuli. Others simply want a healthy baby at the end, no matter the methods.

As with any philosophy, there are extremists; mothers-to-be with training in hypnobirthing and aromatics who refuse interventions or medical assistance even with triplets on board, or expectant mothers who at the twelve-week mark, plot out a date for an elective caesarian. In fact, I was getting a little frazzled by all the demands and requirements of O&G patients.

Then, as a patient was being admitted, I saw the most sensible thing I've seen all rotation. An answer to a question on the birthing plan;

"I want whatever is best for my baby, to make sure they're safe and healthy."

It was right there, in the mum's handwriting; a raw, honest, pragmatic look at birthing. I think for many people, exerting such enormous amounts of control over the journey is to compensate for the uncertainties about the destination, both for first-time mums and multips. A healthy baby is indeed a wonderful thing.

Puzzled Cubes

2010-01-23T23:23:00.000+10:00

For Christmas, Batman gave me a Rubix cube. In Dunedin my flatmate Sandy taught me how to do one, and I could remember a few of the steps, but solving it outright took some practice. After memorising the solving algorithm, I've been able to do it pretty quickly since early January. This week, I taught someone else how to do it; he's down to under 4 minutes.

Rubix cubes are one of those beautiful enigma puzzles. The average Joe suspects that the first step is to make one whole side and then loses their way. The cube when mixed up appears horrifyingly complex, yet once the method, the system, are locked away in the memory bank, it becomes a case of applying several steps of an algorithm.

Sometimes, it feels like this is the way medicine could be done. First, orientate the ~~patient~~ cube in the correct manner. Find the white side and ensure it faces up, and the yellow side faces down.

Step One; make the cross. Ensure you know what it is you're moving. Where you're moving it from and to, and in which order. Make a plan. After you think you've done the steps, check your work. Do the next step, the corners. Gather information, make a plan, action it, check the results.

This routine continues whilst all the steps are performed. And, in most cases, it'll work. The challenge comes in picking the cube that's had the stickers pulled off and put on in the wrong place, or the cube that can't turn in certain ways.

So, it's not really how medicine can be done at all. It's a good safe way for students to learn, to apply a system, to check results. It may not always be the quickest, but for most cubes, they'll face up just right.

But down the track, you don't want to be twisting for hours some poor cube whose stickers are just on wrong.

Cowboys, Indians and Cricket; Racially motivated attacks vs Australian culture.

2010-01-14T09:06:00.000+10:00

Last week, Vijay (@Scanman) tweeted;

To my Aussie friends: A genuine doubt: Is there a racial motive in the attacks on Indian students? A blog post would be appreciated.

I've had a good long think about it. I'm not sure exactly where the recent acrimony between Australians and Indians started, but I've a strong inking that it began around cricket. The 2007 series in India, where Andrew Symonds was called a monkey, raised the sporting relationship to boiling point at which it simmered through the Australian summer. The kettle blew at the Sydney test and the resultant ill-feeling was splashed across the news media in both countries.

I attended the Gabba ODI in early January, and was disgusted by the behavior of the Australian fans. Within seconds of Harbajhan Singh arriving at fine leg, the drunk twenty-something Ocker lads behind us started shouting "Who's the monkey?!" When the call was repeated I told the bloke to 'can it'. He continued, louder, more obnoxious and more puerile in his language. After an hour or so, even one of his mates told him to 'put a sock in it'.

After the match, I vowed I'd not be returning to a one-day game at the Gabba. The drunken Cowboy who sat behind me had no reason to lambaste the Indian team. Something in his psyche thought it necessary to play 'an eye for an eye' with racial slurs. Whether it was a fear of foreign culture, a need to point out the difference between people, or jealousy of the Indian Cricket teams obvious talents, I don't know.

I believe there is a sectors of Australian society do indeed fear people from the sub-continent. In the same manner as Australian gold miners spoke of the Chinese 'Yellow Peril' during the Gold Rushes of the 1850's, immigrants from whatever background are isolated and begrudged their part in society.

In the 2005 Cronulla riots, racial tension was at the fore; one group branding themselves as 'true Australians', the other comprising predominately first-generation Australians of Middle-Eastern, particularly Lebanese, descent. Several were injured during the riots, which brought Australia's seething race issues to the fore of both local and international media.

Let me be clear; this is not every man, woman and child in Australia. This is a group of narrow-minded, fearful hypocrites. Australia is a country with multiculturalism at its core; Sydney and Melbourne without it would be a shadow of themselves. In the last decade, the majority of immigrants to Australia have been from China and India, the two most populous nations on the planet. Many immigrants have tertiary education and are deemed to be high-functioning members of society. In short, the Australian government has attempted to ensure that permanent migrants can 'pull their weight'. To neglect Australia's multicultural identity is to misrepresent the nation entirely; we are not a nation of blonde-haired surf-bogans with big knives, Akubras, eureka flags and southern cross tattoos.

Vijay has asked if the current attacks on Indian students are racially motivated; I would contest that they are. Perhaps there is a perception that 'International Students' are not full and functioning members of society; disliked for their mercenary learning styles. But I don't buy that; the argument is too high-brow to gel with the people committing the attacks. I believe the problem is driven by a few ignorant, narrow minded, violent tools wanting to pick on someone who looks different to them.

That Indian students have been injured is shameful. That someone has died, abhorrent. I cannot express enough sorrow at these events, the families loss, the student's trauma. It genuinely upsets me.

Australia, both government and citizens, condemns the attacks. Societal change will happen. Violence is not tolerated; the attackers labeled cowards by all. Australia, like all countries, is not perfect. With time, outrage and solid social education, racially motivated attacks will cease. It defies logic to entirely avoid a country because a fraction of a small group of ignoramuses have, in the past, taken the step from untoward thoughts to opportunistic attacks.

No society is flawless; each year Australian tourists are kidnapped or killed in foreign countries, developed, developing and undeveloped. It would be ridiculous to think that any travel is risk-free. This is a less than ideal way for the world to be, but a fair summary; there are bad people in the world. Some of them live in Australia, others live elsewhere. Australia does not have a culture of violence, corruption or crime against guests.

I urge international students to continue or start a course of study here; the education is world class and the lifestyle phenomenal. We are not Cowboys, hicks and red-necks, although there are some here, as in most countries. Australia is a safe, tolerant, multicultural society, where international students are welcome.

Five Things...

2010-01-13T15:03:00.003+10:00

Five new things I've learned in the last twelve months;

Pharmacy isn't really at a crossroads. It just thinks it is, and has done for a good quarter of a century. In truth, the profession often struggles to define its true purpose, torn between finance, health, community and hospital. Within the profession, the best we can do is to pick our path and cop the flak that comes our way.
Failure is not fun. Although, it's a good learning experience, but certainly not something I'd want to experience too often.
Rural doctors are the true all rounders of medicine. The basics of General Practice, surgery, medicine, obstetrics and psychiatry are standards in their armoury. They are, in my experience, well rounded humans and excellent teachers. Best of all, they know when to ask for help.
The joy of 'returning' to competitive sport. I haven't played Grade Cricket since I was fifteen, and the feeling of standing in the field, appreciating a fine day in the fresh air, clouds wandering across the sky and physical exercise in healthy amounts is something I've gained new respect and appreciation for. The art of mastering orthodox spin bowling has provided an extra challenge.
Fabien Cancellara is awesome; this guy is one of the strongest cyclists on the planet, and boy, can he time trial. He's the Contre la Montre monster. In fact, this whole road cycling gig is a helluva lot of fun; you'll doubtless hear more about my cycling escapades into 2010; I even have an encore to the Razorback Challenge lined up.

Of course there are many more; it's back to Uni next week, whereupon medical anecdotes and insights will continue; first up, Obstetrics and Gynaecology.

PureGolf2010

2010-01-04T08:01:00.000+10:00

Golf isn't for everyone. In fact, I'm the worst handicapper in my family by about twenty shots.

A strong sense of adventure, however, has inspired my brother and his mate to play golf every single day for a calendar year. They kicked off at Kauri Cliffs in New Zealand on New Years' Day and will travel around New Zealand, Australia, Singapore, the United States, the UK, Europe and parts Asia, playing every day.

It's not purely self-indulgent, either. The pair are raising money for The First Tee New Zealand charity; a crew that's about developing strong morals and ethics in young 'uns through golf.

The guys have, by themselves, mobilised their skills to create a wonderful marketing machine, and they're having a great time doing it. They're on facebook and at @puregolfchap, although I strongly suggest you check them out at puregolf2010.com

Black Fingernails

2010-01-03T15:42:00.001+10:00

I'm in New Zealand, visiting family and friends and truly enjoying a holiday in the area I grew up. I even managed a drive past my old schools.

A friend from said school had an aversion to fingernails, or the inappropriate disposal thereof. His grandmother, as grandmothers do, had chastised him for cutting his nails onto the floor and kicking them away. She told him that if you didn't put your fingernail cuttings into the rubbish that upon your death, you would become a ghost, stuck in limbo, forced to wander the earth until you had found and disposed of your offcuts.

I loved this story. Not because I believe in ghosts or that I have a fanatical concern for my fingernails. Quite the opposite, in fact.

What better way to ensure one's return to a place than flicking blackened fingernail offcuts into the ether; a guaranteed second look at that beautiful beach, serene bushland or windswept mountain. Now, where did I leave those clippers?

Insomnia notes

2009-12-28T21:33:00.001+10:00

Can't sleep? Do some reading...

Conquering the Razorback Challenge

2009-12-22T21:09:00.003+10:00

Despite my best intentions, I'd been avoiding the Razorback. I was beginning to push my luck a little; Christmas to New Year always provides plenty of work for unmarried locums far from family, and I was beginning to have visions of an attempts on Christmas morning at 5am or on the night of 29th December at 11pm between work and flying overseas. I'd gone so far as to dig out my lights and make sure the batteries worked.

I hadn't scheduled this morning as an attempt. I had planned to join the group up Palmwoods-Montville, as per a typical Tuesday. Last night, a change of plan required I be home and fully functioning before 8am, ruling out the somewhat longer group trip. Still keen to work the legs, and with the challenge looming, I decided that I'd have a go at The Razorback.

So, on three hours sleep and a handful of leftover chocolate, I found myself rolling steadily to the base of the climb. It was 5:45am, windless with the clean sun steaming away the morning dew.

I decided that, if I wasn't to outthink myself, that not looking at my bike computer would be important. I would ride on feel. I stood up on a few of the earlier sections, breathing deep. A few walkers were on their way down, more than the number of tradies in utes whistling up. I passed the NEVER TIRE sign. The road felt good.

At the start of the main climb, just prior to the shop, I got jittery and slowed. My heart was beating hard enough to take my pulse by listening. From about four feet away. I turned the pedals more slowly, sitting and looking around.

I started to overthink things, "I only have three more chances; work's chaotic from here on...", "How will I write about failing from here?", "What if I get a flat?" It was a little paranoid, for sure. I shook my head out and rolled on up, past the turnoff.

At the shop, I reverted to stake-based goals. There were twelve before Hell corner, I think. Things got heavy, and by things, I mean legs, bike, body and breathing. I stubbornly grunted and ground Rosie up the road, standing and pushing hard. I stopped looking up. I watched the white line roll under the front tyre and strained against gravity.

I looked across the road at the arrow signs. They seemed too short. I was past them. I was through Hell corner! The road met me, and I breathed deeply. I expected to pop with every pedal push. I hurt. I stayed positive. I just focused on turning the cranks.

The next few minutes were achingly slow. I briefly spun up to a comfortable cadence and sat, before The Razorback reared its head and stood me back up, sucking at the air. I rode along the ridgeline, the sun pouring across my left shoulder, casting an exhausted, wobbly shadow across Razorback Rd. I looked back down; my computer said 8km/h, and I wondered how I was still upright.

At this point, my vision went a little foggy. I felt awful, sure, but I didn't think I'd pushed too hard. I couldn't work out why I couldn't see. I mean, the white line was there, rolling under my tyres, the air was fresh and tasty. I wibbled and wobbled on the tarmac. I felt bloody feral. In retrospect, the setting was picturesque, but I was in far too much physiological distress to contemplate appreciating it.

Then, after a period of numbness, I clicked. I was riding so slowly that my glasses had fogged, and hence couldn't see a thing. I felt steady enough to take one hand off the bars, just briefly. I saw a corner, saw my chance and snatched them away into my pocket. Unfortunately, my vision remained little blurry and I was stupendously nauseous. I thought, "I'm too far through to quit now. Suck it up. Keep going!"

Then, around the corner, I saw a building. It heralded the chute up to the summit. Just five hundred metres more.

The road narrowed and the trees crossed overhead. I spied the bridge across the road. The nausea evaporated, and I felt stronger, accelerating both against the flattening gradient and the likelihood of success.

A couple beginning the descent, breaking hard, flew past and called encourangement. I knucled down and rolled over the final road mark, battered. I had finished the Razorback.

I struggled to a picinic table and lay down, drenched, dyspnoeic and delighted. After recovering with the help of a full bottle of water, I took a few snaps, twittered and hopped back on the bike.

I rode down the Palmwoods-Montville Rd, revelling in the cool fresh air, dry roads. I passed several riders, "Good Mornings!!" aplenty. I drove home with plenty of fresh goals whirling around my self-satisfied brain, and wolfed down breakfast. The Razorback was Conquered.

Just for one more look, here's the profile;

Short short stories

2009-12-17T02:23:00.000+10:00

Some moments just seem to grab at the eyes and mind. The personality or passion on show, or the loud atmosphere aurrounding makes an imprint on both retina and hippocampus. Here are a few such moments;

It's July in Melbourne and a cold, damp night. The Italian restaurant blasts heat onto the street like a wood-fired oven. Inside, it's dark and relatively empty. The woman sits in the corner, alone, pushing her pasta around in small circles. One hand massages her temple. Her makeup is smudged and her bottom lip trembles as she quietly cries.

The beach is alive. Surfers, walkers, dogs. A couple, late 50's, lean back on the strings of a fabulous red and gold kite. Their faces beam broad toothy smiles at each other. My friend comments on the beautiful kite. They thank him and say they've been doing this once a month for many years. The kite was a wedding present.

She's young and a bit scared. It's Sunday afternoon and she wants the Morning After Pill. The bloke with her is in his forties, temples greying and fit looking. They're both in running gear and joggers. As she starts to answer questions, her voice trembles and she cries, overwhelmed. He quietly says, "I'll leave you to it" and wanders into the store. She's terrified, but okay and calms down; it was her first time. He pays for the medication and buys a dozen condoms too. "Make sure you use these next time, Daughter", he says caringly. "Thanks Dad," she blushes.

Razorback Challenge : Tactics, Signs and Fish

2009-12-15T20:33:00.001+10:00

As promised, this week saw an attempt on the Razorback. Certainly not my best effort, however, and consequently not enough to break through the Corner of Doom.

I'd be lying if I said I felt fresh on Monday, thanks to a weekend of Cricket and work. Probably not the best state of body or mind to being trying the Razorback, but nonetheless, I had a crack.

I took the opportunity to refine some tactics and get my head in the right place. I nursed myself softly, softly to the shop at the Hunchy Rd turnoff. That's the point when the road climbs up and up at 12%, and the hurt really begins.

Meantime, I noticed two property names on the ascent. The first was an apt description of the scenario "Summer Hills", the second was an inspiration to look out for each time; "NEVERTIRE"

At the shop, I figured that taking it easy had slightly paid off; I felt better than expected, expecially considering I'd ridden a flat fifty earlier in the day. So, in a more positive state of mind,
I divided my goals into micro and macro and pushed the pedals from road-stake to road-stake, setting miniscule 30 metre goals to each corner. Not over-extending myself before the shop is a definite must for a successful attempt.

At the corner of doom, I again fizzled into an anaerobic mess. I'd clawed the last hundred metres to that point and the effort was more than enough to tip me into lactic-land. It felt like being slapped with a cold fish. One positive was the speed of recovery, which was substantially quicker than previous digs.

Last update, I was unsure if the deficit was psychological or physiological, and yesterday's attempt answered the question. Psychologically, I'm all over it. I can push myself until I pop. I can do tactics, and I'm pretty sure I ride smart. Physiologically, my endurance is improving, my hill climbing is much better than a few weeks ago. Today, I smashed my best time on the Palmwoods-Montville climb by two minutes. Unfortunately, when it comes to the sheer gradient of the Razorback I'm not quite strong enough, yet.

Part of me wants to run and hide from this bloody steep hill, to train on 'flatter' rides. I don't think that's going to work. So, I'll give it another crack. Again and again; I'll practice like I play, and hey, if that gets me up, then the challenge will be complete!

The Plan:
1. Keep trying!
2. Start easy, save energy.
3. Get stronger.
4. Be bloody minded.

Two weeks to go.

Telling

2009-12-10T20:31:00.000+10:00

I know that medicine has hardened me, just a little. It struck me this week during a group ride. The bloke I was chatting with as we hummed through the suburban coast at 35km/h recalled a friend of a friend who'd recently died. She's had a heart attack in her early forties.

Three years ago, it would have really rocked me. I would have thought long and hard, empathy welling inside me, wanting to know the how and why. Thinking how awful, how unfair.

The first thought that jumped into my mind was, "I wonder what the likelihood of an MI is for a 40-something woman?" and visualized a distribution curve. Then, I considered possible risk factors. Then, I thought about the woman's family.

This all happened in a second. Three years ago, I would have thought "Gosh, how tragic!".

It's not that I don't care. It's not that I don't feel. It's just that sometimes, the things that rock a lay-person aren't as raw, as world-changing as they used to be. Evidently, I'm still thinking about this woman. I listened to my riding partner, he talked about the unfolding of events, the death itself, the funeral. Of course I didn't ask anything about risk factors or other medical things; he wasn't telling me the story because he was interested in all that.

He was just telling me; I asked how her kids were coping. I hope they're okay.

Coins

2009-12-07T07:16:00.000+10:00

I've been thinking about this post for a while; in fact, the idea was sparked one day in June as I strolled down a grey and wind-whipped beach.

On the surf's edge, a pale bronze light flicked the edge of my vision; it was some way up the shore. As I moved closer, I saw it was a tarnished dollar coin, and dusting it off, I pocketed it.

My memory travelled back a few decades to my second year at school. I was a new school, again. I liked this school very much; the teachers were cool. The Principal struck me as old - I'm not sure that he was - wise, genial, but to be feared by a cheeky six-year old.

One lunch hour, a pale bronze light flicked the edge of my vision. I trotted across to where the sparkle had appeared; the base of a tall tree, and saw that there were two coins. A one dollar coin and a two dollar coin, making three dollars. New Zealand had only that year swopped notes for these coins, making the treasure all the newer and more exciting.

I picked them up and looked around for their owner, who was not to be found. I went to the duty teacher and she suggested I give the coins to The Principal, which I dutifully did.

Around the time I finished secondary school, the Principal retired. He'd been in charge of the school for most of its existence, and it was a big send off. At the farwell, the Principal quietly passed an envelope to my Mum. It contained three dollars. And a faded post-it note;

"Capt. Atopic $3 handed in" and the date. I kept the coins at the bottom of my drawer. I was again reminded of the coins when I finished Pharm School and packed up to move out. They stayed with my other primary school treasures. The beach dollar sat on the window sill for months. The idea crawled to a dark corner of my memory, hibernating.

This week, I've moved house again. Everything boxed, schlepped and revealed. Meanwhile, The Principal's coins are stored across the Tasman. Unpacking my desk, I rediscovered the beach coin; and I remembered remembering.

Razorback Challenge: Week 2

2009-12-01T23:36:00.003+10:00

Exams finished Friday, since which time my liver and sleep-cycle has copped an absolute pounding, thanks both to the end of year Cocktails and catching up with a good group of guys to watch the Windies v Australia at the Gabba.

Since exams I've been more than time-poor; I've played Club Cricket, moved house and driven some 600+ kilometres. I was planning on a jaunt up Palmwoods this morning, but even that failed to materialise.

So, a plan - roadmap, if you will - for the next fortnight; Palmwoods once, a long flat ride and a Triathlon on Sunday. Not exactly hill specific riding, thus far. Next week will be almost entirely off the bike, in Sydney. Running some hills each day will be on the cards and some good recovery time, too. Monday 14th will see a fresh attempt at the Razorback.

This is going to be a good, hard graft; 28 days remaining to ride!

Razorback Challenge: Week 1

2009-11-24T21:44:00.000+10:00

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

Admittedly, I haven't been back to The Razorback yet. I'm prioritising exams this week, so time with books and computers wins out over spewing up hills.

That being said, I'm not completely sitting around at home; I've been ridden the longer, 'flatter' Palmwoods-Montville Rd a few times weekly for the month. It has slightly different properties to Razorback, and finishes just down the road;

Today I rode a new personal best, at 20mins 40sec, a full minute faster than my previous fastest time. So, my climbing has improved and exams start tomorrow.

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

Otherside; the NSAID/Codeine addict

2009-11-23T01:18:00.000+10:00

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

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

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

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

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

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

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