Where is your local GP?

Have you noticed? Your GP has gone. Yes, just not there any more! A community icon for generations, this Australian institution is now in its death throes.

To find the reason, we need go no further than the dentist who charges $50 for you to walk in the door and, more often than not, another $50 to do whatever needs doing in the 15 or 30 minutes you might be there.

A plumber, vet, electrician or builder will charge about the same. The appliance repair person charges even more.

So where do doctors fit into all this? Australians were told over 20 years ago that 'Medicare' would finance doctor's fees and it would be funded out of taxation. Doctors were told that bad debts would be a thing of the past and that they would be paid promptly for their services at 85% of an agreed or 'common' fee. Successive governments of both persuasions have supported Medicare and actively encouraged bulk-billing. To this day the 'phone information line will only give information if you state that you are bulk-billing the patient. There was no arbitrated mechanism for annual fee adjustments and only on government largesse were rebates increased, at ever decreasing increments. Anyone who expected otherwise was foolish indeed.

Differential fees were introduced for doctors who jumped onto the Vocational Register. It offered a temporary relief from financial ruin by paying an extra $2.50 per consultation for bulk billed customers and refunded the extra money to those privately billed.

Doctors' practices were examined more closely than any other worker in the land. How long we spent with individuals of certain ages and sexes ... what tests we ordered ... what drugs we prescribed. All this without our consent ... even those who never bulk billed were drawn in. Now we have ludicrous committees trying to assess our 'work values'. Practice incentives have been thought up by bureaucrats with no detailed knowledge of the supposed deficiencies of general practice. As an example, it was felt that all doctors should do house calls and, along with after hours care, this is written into the agreement to be on the Vocational Register. Are patients not the best arbiters of who is a good doctor? We do it for vets and dentists, knowing little about those fields, but knowing what we want as consumers.

GPs used to work on the same street corner for 40 years and more for two reasons: There was demand for their services ... and they earned a decent income in the process.

Now traditional general practice has become unviable. This has not happened because of the supermarket revolution elsewhere. People are not demanding big medical clinics ... but they are there and they can survive better in a cut-price atmosphere. Alternative pursuits, some very valid additions to practice, can help pay the bills. These are many and varied ... acupuncture, hypnotherapy, laser treatments, drug group counselling sessions and other pursuits.

Who do we have to blame for all this? Ourselves, or our immediate predecessors to be more accurate. Any group which accepts government money must be prepared to die. Like soldiers. That is what happened to nursing homes. A perfectly viable, profitable and expanding industry for an aging population has been stifled to death thanks to government interference. Restricted subsidies and uniform regulations for nursing homes have turned a varied and free environment for our old folk into a uniform, regimented and unfriendly set of small, safe bunkers. Only the seriously rich can expect adequate retirement care.

So to the solution ... if it is not too late. I suggest that GPs do not do anything relating to a new matter for less than about $50. This is comparable with the minimum fee for many other professionals such as plumbers, vets, dentists, decorators, etcetera.

Even if an old patient just wants 'a certificate', they need to be told that they are also expecting the service which backs up that certificate, such as a history, physical and record in the medical notes. They may need their blood pressure measured. It is now widely recognised that visits to the GP for unrelated causes are important points of intervention, including blood pressure, smoking, drinking and diet just to name the most obvious. With the history known there could be Pap tests, thyroid, work related illnesses, chest X rays and a myriad of other areas which may need attention.

If the patient only gets $21 back from Medicare that is not the doctor's business. Most patients assume that doctors make lots of money and that they pay dearly in their taxes to ensure this is the case. They may not know that GPs mostly earn very modest incomes. Most specialists and employed doctors have kept their income parity, having had strong lobbies to look after their interests. GPs lobby groups have consistently acted against the interests of their constituency and continue to do so to this day. The AMA and GPs College have both failed dismally while the latter has facilitated much of the erosion to doctors' independence.

Most workers in the position doctors find themselves today would use strong-arm industrial tactics with no holes barred. Do Australian GPs have the will to take on this fight? If not, it means that the Australian public can bid farewell to the old family doctor forever. What is your strategy?

Written by Andrew Byrne ..

What can you do to reduce the alarming drug overdose death toll?

by Andrew Byrne ..

The press has been full of the disastrous toll from heroin overdoses in recent weeks, especially from Victoria. As doctors, we must face our responsibility to the community to address these matters in any way possible.

The overdose death rate in Australia rose gradually from 30 to 40 per million over a number of years in the mid 1990's. Although official figures are not available, this rate appears to have gone up from 4 deaths per week to almost 14 as reported from Victoria this year. One newspaper described it as "the overdose epidemic Australia had to have". Mostly in metropolitan Melbourne, 2 deaths per day are causing great tragedy to the families who are both ill-prepared and perplexed.

It is clear that every one of these heroin overdoses is preventable.

The means of prevention are a number of well known proven strategies as well as some proposed innovations which have shown promise in trials here and overseas. It is accepted that preventive education of addicts, availability of needles and syringes as well as methadone treatment are all effective in stemming some of the potentially lethal complications of drug use. 'Safe injecting rooms', heroin prescription, rapid detoxification, oral morphine, long acting methadone and buprenorphine are among other strategies which deserve further examination.

Improvements to our emergency services are unlikely to reduce the toll much since, in most areas, they are prompt and effective at saving lives when they are called in time.

Educating drug users about the means to save lives is important. 'Do not inject while alone'. 'Use small quantities initially'. 'Call emergency services immediately if overdose is suspected'. 'Use clean syringes'. 'Do not mix drugs and alcohol'. These are all simple but life-saving messages.

Increasing the accessibility of good quality methadone treatment will certainly reduce the death rates. It is well established that once in treatment, the mortality diminishes significantly. Methadone treatment should be available to all who require it, like any other effective pharmacotherapy. The indications are simple: chronic compulsive opiate use with proven inability to withdraw. For historical reasons this is still restricted in some states and has been banned altogether in the Northern Territory. A recent review in the Journal of the American Medical Association stated that "All persons dependent on opiates should have access to methadone hydrochloride maintenance therapy under legal supervision" [ref 1].

It is likely that bringing addicts out of secluded locations and into 'safe houses' will also spare some lives. Supervision is available and help can be summoned if overdose occurs. Most importantly, these marginalised folk can come into contact with treatment services.

Switzerland and Holland both have official death rates of less than 5 per million compared to our rates of over 40. If we could copy their examples, over 500 young Australian lives could be saved each year. These countries must be 'doing something right'. Injecting is far less common among the young in Holland where the average age of heroin injectors is around 40 years of age. The Swiss introduced 'safe injecting rooms' over 6 years ago. Switzerland has had heroin prescribed for certain groups of resistant addicts for over 5 years. Cannabis is decriminalised in Holland.

Whatever the reasons for our high overdose death rates, we desperately need to investigate all these means for reducing it. The prime reason for NOT having a heroin trial, 'sending the wrong message,' is now out of date. The second reason sometime proffered is that it 'has not worked' overseas. This is intriguing as the reported outcomes of the London, Zurich and Geneva based trials all showed benefits to addicts and society generally and a referendum in Switzerland endorsed the practice of heroin prescription to seriously addicted patients under strict supervision.

Politics, personal prejudice and international pressure must be put aside since Australian lives are too important. We need to approach this epidemic from a scientific standpoint as we did with HIV. If we can match our successes there is very much to gain.

Ref 1: Effective Medical Treatment of Opiate Addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA 1998 280:1936-1943

Gradual detoxification to 0.5mg buprenorphine 'effective' over 10 days

Diamant K, Fischer G, Schneider C, Lenzinger E, Pezawas L, Shindler S, Eder H. Outpatient Opiate Detoxification Treatment with Buprenorphine. European Addiction Research 1998 4:198-202

There are impressive outcomes reported in this Vienna study of well-motivated heroin addicts doing a structured 10 day out-patient graduated detoxification using buprenorphine sub-lingual tablets.

The authors of the study chose 50 motivated heroin or opium addicts and administered up to 10 days out-patient treatment with reducing doses of buprenorphine. Doses were titrated daily depending on the degree of withdrawal symptoms. The maximum dose was on day 2 at 2.6mg. Doses averaged 2mg daily for the first 5 days, then reducing to 1.5mg for 2 days, 1.0mg for 2 days and 0.5mg on the tenth day. For only 20% of cases was it the first formal attempt at withdrawal. Withdrawal symptoms were measured on the WANG scale and were most severe initially but waned substantially despite buprenorphine dose decreases.

Patients were also routinely given an antacid preparation (famotidine or 'Pepcidine') and night time sedation if required (prothipendyl - an antihistaminic sedative).

With 15 patients dropping out, this treatment was acceptable to 35 of the 50 patients (31 male, mean age 27) yielding an overall 70% 'success' rate. Even if only a half of these remained abstinent for the medium term, it could still be considered better outcome than traditional drug free treatment.

Buprenorphine is a semi-synthetic narcotic derived from thebaine. It is long acting (>36 hours) and has opioid agonist as well as antagonist effects, rather like pentazocine (Fortral). It has been available in Australia since 1992 as an injected or sublingual analgesic but it is not yet licensed for maintenance addiction treatment. Such maintenance treatment may require much higher doses, up to 32mg daily, so 0.2mg SL tablets are not suitable. In addition, this drug, as a Schedule 8 can only be used in addicts with prior permission from the health authorities in most Australian states.

A large multi-centre trial of the sub-lingual version has reported preliminary results which apparently confirm overseas experience showing safety and efficacy when compared with methadone maintenance. Buprenorphine also has a number of important advantages over methadone such as a longer duration of action, allowing second daily attendance, a lower potential for acute toxicity as well as a possible antidepressant effect. The researchers pointed out that this drug will not be a replacement for methadone, but may be a useful alternative for those in whom methadone is not suitable.

This drug's wider availability in Australia will greatly enhance our repertoire in dealing with drug addiction. In France it has been available on normal doctors prescription for over 3 years with apparently good results in up to 50,000 patients. In the meantime, less satisfactory drugs such as codeine compounds, propoxyphene, quinine, clonidine and metoclopramide may be used to mitigate some of the symptoms of withdrawal. It is to be hoped that this drug can be marketed in a suitable preparation for addiction as soon as possible.

comments by Andrew Byrne ..

A decade of caring for drug users

[Letter in Br J Gen Pract. 1999 Feb;49(439):146.]
Sir,

Martin et al�s report on treating drug dependent patients in general practice is heartening (October Journal).1 It is a shame that the authorities do not reward such innovative and successful interventions with appropriate payment, encouragement, and replication elsewhere. Oral supervised methadone is well established as an effective management for heroin addiction.

Although it was obviously successful in numerous cases, the research evidence for injected methadone is still rudimentary. Like heroin prescription, it should probably be reserved for patients who have failed at standard treatments such as oral methadone or supported detoxification.

After 14 years of prescribing and dispensing methadone in our general practice in Sydney, we have found that oral methadone suits up to 90% of heroin injectors who present for treatment. There should be no arbitrary limits on daily doses (we use up to 350 mg daily; mean = 85 mg). It is normal practice in most jurisdictions for at least two doses per week (up to 7 in new or unstable patients) to be consumed under supervision. The use of non-supervised methadone may be effective in certain cases but this has not been demonstrated generally in the research literature. It omits a fundamental safeguard for compulsive drug users and also increases the possibility of drug diversion.

Oral methadone �failures� should be candidates for studies of alternatives such as injected methadone, prescribed heroin, rapid detoxification, oral long-acting morphine, or other approaches. There is no reason for this to happen only in specialist units. A general practice with sufficient experience in dependency, as in this case, is perfectly capable of doing the same as, or even better than, existing dependency units.

Andrew Byrne

Reference

1. Martin E, Canavan A, Butler R. A decade of caring for drug users entirely within general practice. Br J Gen Pract 1998; 48: 1679-1682.

Doctor shopping: dependency and a consistent approach to drug policy issues

The Health Insurance Commission's (HIC) approach to 'doctor shopping' may not be the most effective strategy. The HIC is driven by finances, public opinion and, to some extent, by government policy.

Claims that 'doctor shopping' has decreased in the time of the HIC's efforts in this area do not prove that these are necessarily causal. We know that historically all drug and alcohol use fluctuates in response to influences from many quarters. I understand that 'doctor shoppers' are currently defined as those who can be identified as attending more than 15 doctors in a year.

The medical profession should only support measures which are medically and scientifically sound. For example, we now have strong support for the provision of clean needles for drug users, correct labelling of alcoholic beverages, tobacco warnings, nicotine patches, methadone and the like.

The consumption of benzodiazepines is a major problem for a small minority of the Australian population. Dr Andrew Parkes of the HIC invited participants to have an input into this matter, but before any consultations, the momentum was already strongly in favour of the current 'voluntary' reporting arrangements. The scientific approach was rejected over a politically saleable scheme with no clear rationale. There is little reason to think that the current measures address any fundamental problem although they could be part of an overall strategy to counter the harms occurring from the use of tranquillizers in our society. The current measures are an invitation to use false Medicare cards, to use black market sources and generally avoid addressing the underlying problem. I am not aware of the involvement of dependency specialists, urine testing, psychiatric intervention or other more logical and medical approaches.

We know that around 700 young Australians died from heroin overdose last year alone and about a third may have been on benzodiazepines which may have contributed to the deaths. These drugs have been shown to be associated with risk-taking behaviour and it is clear that they can affect judgement, memory, balance and sleep patters, even in modest doses. In older patients, it is now proven from numerous studies that therapeutic doses are associated with more than doubling of the rates of falls and hip fractures.

While banning benzodiazepines outright is no solution, the continued NHS subsidy is equally inappropriate. But for political sensitivity, these drugs would be dropped from the 'free-list' immediately. Government funding of sedative use by young people who have no clinical indications for the drugs seems bizarre. Indeed, the easy availability of the drugs due to the NHS scheme has undoubtedly contributed to the current overuse of benzodiazepines. It also gives some ill-founded legitimacy to a treatment for which there is little clinical justification under the current prescribing instructions.

We need to look at why people take these drugs. Surveys on the reasons for episodes of drug use have commonly come up with the reply "because it was there". Some users are undoubtedly recreational drug takers. Some become truly dependent on the drugs, others are binge users and a small number are arguably on therapeutic doses for clinical indications.

When I spoke to the HIC officials about this matter, the department had done virtually no research on the subject, although they have access to an enormous amount of relevant statistical information. I suggested that the department look at the number of 'doctor shoppers' who had ever had a urine drug screen ordered. This simple step defined a group of patients who had mostly volunteered for methadone treatment in the past who were currently attending large numbers of doctors for sedatives. Hence, they could be identified as patients who were already in contact with D&A treatment services, albeit with sub-optimal results.

Although there is no proven treatment for benzodiazepine addiction, doctors should still be involved in the treatment of a dependence for which the profession is at least partly responsible. The principles of 'primum non nocere' apply here as elsewhere in practice. 'Harm reduction' is a closely related concept which has been used to let the general public know what doctors have always done where short-term 'cure' is not feasible.

Public health policies have ensured that in the case of tobacco, alcohol and even opiates that there is a clean source of a safe form of the drug. Tobacco is easily the most dangerous of these although it is probably subject to the least controls. These controlled drugs are only available to adults in safe quantities from certain licences premises at restricted hours. Benzodiazepines should be no different than other drugs on doctor's prescription. A safe supply should be accompanied by an appropriate degree of medical supervision, advice and psychosocial supports.

While there are still many unknowns in addiction studies, it is quite clear from the research that when there is increased availability, longer hours of operation or reduction in price, there is generally an increase in overall consumption. This 'availability theory' is supported by many research studies as well as being based on sound fundamental principles. Serious arguments against it still come from such parties as the tobacco and alcohol industry. Some tobacco industry officials still claim that nicotine is not addictive and that tobacco does not cause lung cancer.

We should press for a more logical approach to drug policy as it impinges on our practices, the health budget and the lives of our patients.

Comments by Andrew Byrne ..

Dose-Related Efficacy of Levomethadyl Acetate

Eissenberg T, Biglow GE, Strain EC, Walsh SL, Brooner RK, Stizer ML, Johnson RE. Dose-Related Efficacy of Levomethadyl Acetate for Treatement of Opioid Dependence. JAMA 1997 277;24:1945-51

This study confirms the place of LAAM (levomethadyl acetate) in the treatment of opioid dependence. For over 20 years in the US it has proven safe and effective in a variety of situations. As well as being a useful alternative to methadone, this drug has a sufficiently long half life to allow three times weekly dosing, thus doing away with daily attendance.

Volunteer heroin addicts were randomised to low, medium and higher dose regimens. Predictably, there was significantly less illicit heroin used at higher doses (2.5 days per month reported heroin use vs. 6.3 in the low dose group). Retention in treatment at 17 weeks was not particularly high at 55% - 65% but there was no significant difference between the three groups.

This is the first time that a positive dose response has been demonstrated with LAAM, and in a representative group including women (39%). Patients had used heroin for an average of 8 years and most reported a previous treatment episode.

This study adds crucial pieces to the drug treatment jigsaw. Recent research also allows us to discern the position of other developments like buprenorphine, naltrexone, heroin prescription and ultra-rapid detoxification.

With numerous patients who are unsuccessful with methadone, LAAM should be made available in Australia without further delay.

Written by Andrew Byrne

Australian naltrexone trial performed in Newcastle, Mater Hospital 1994-6

Foy A, Sadler C, Taylor A. An open trial of naltrexone for opiate dependence. Drug Alcohol Rev 1998 17:167-174

This pilot study was performed on heroin addict volunteers in order to determine the safety and acceptability of naltrexone treatment in preparation for a larger controlled trial. The drug is still unregistered in Australia but is likely to come on the market later this year.

There were 43 patients (29 male, 14 female) prescribed naltrexone 50mg daily for six months following detoxification lasting from 5 to 10 days using clonidine. Of 32 who could be contacted at one year, 8 had ceased heroin use for virtually the whole period. A further 2 patients had patterns of remission and relapse which were confirmed by clear urine tests specific for morphine (heroin metabolite) for at least one full month.

Only two patients (5%) took naltrexone for the full six months yet retention was reported at 34%. By ten weeks, more than half the patients had stopped taking naltrexone and had dropped out of treatment.

Three patients ceased the drug due to side effects in the first two weeks. One had a seizure and two had symptoms associated with depression. There were 20 patients (47%) who developed headache in the first 3 days, but only one, with associated depression, had to stop the treatment.

There were weekly visits to the clinic with dosing apparently unsupervised.

Comment: This study results are consistent with the literature on the subject which shows little if any benefit in unselected addicts prescribed oral naltrexone. Rather than justifying a larger trial in such patients, more might be gained by examining groups which have already shown promising results such as professionals, prisoners and 'probationers' (not to mention alcoholics).

Compliance in methadone, buprenorphine and prescribed heroin trials is much higher than in this report. Twelve month retention is of the order of 50 to 80% and continued illicit drug use is consistently low. All of these treatments need better matching to appropriately diagnosed patients especially so as to determine who may be suitable for general practice management. Buprenorphine, a long acting opioid, has been prescribed widely in France recently by GPs with no regulatory framework in place and results have been gratifying thus far.

Comments by Andrew Byrne ..

BMJ letter on New South Wales prison methadone treatment.

BMJ 1998;316:1744 (6 June)

Letters

Methadone treatment is widely accepted in prisons in New South Wales

EDITOR: The study by Seaman et al provides the first confirmation of what many have observed for years that there is strong evidence that appropriate treatment for drug misuse should be made available to all prisoners, especially before release.1 It is normal practice (and a requirement under international treaties) to provide medical treatment for prisoners that is similar to that which they would receive in the community. Methadone and other treatments for drug dependence should be no different. We know that there are illicit drugs in most prisons. Additionally, the prevalence of infection with HIV and hepatitis B and C is higher in prisoners than in the general population, and risk taking behaviour is widespread.

Methadone treatment was introduced into prisons in New South Wales in 1987 as a pre-release measure. Treatment has since been expanded to become more widely available for voluntary maintenance. Despite some initial misgivings, there has been almost universal acceptance of this treatment by prisoners, staff, and medical authorities. It has been associated with reduced injecting in prisons,2 and is currently being studied in relation to the transmission of blood borne viral infections.

Andrew Byrne, General practitioner.
75 Redfern St, Redfern, 2016 NSW, Australia

Kate Dolan, Senior research fellow.
National Drug and Alcohol Research Centre, University of New South Wales, Sydney, 2033 NSW, Australia
--------------------------------------------------------------------------------
Seaman SR, Brettle RP, Gore SM. Mortality from overdose among injecting drug users recently released from prison: database linkage study. BMJ 1998; 316: 426-428[Abstract/Full Text]. (7 February.)
Dolan K, Hall W, Wodak A. Methadone maintenance reduces injecting in prison. BMJ 1996; 312: 1162.

It's all in the gram stain: endocarditis in drug user

"Skin rash and joint pains occurring in a heroin addict who has recently commenced treatment should be taken seriously."

by Andrew Byrne

The patient presented with a 24 hour history of acutely tender, swollen left ankle and right elbow. Subsequent lack of response to treatment and florid rash led to a life-threatening diagnosis.

Background:

A month earlier, my 25 year old patient had started methadone for a six month heroin habit. 'Toong' had first used opium at the age of 12 back in his home village in Thailand. He became dependent in his early teenage with regular daily use of poppy tea and then smoked opium. His father who was a religious man and tried to stop his son from using drugs. An amputee, he died when Toong was 18 years old. His mother brought the rest of the family to Australia when Toong was aged 20. He worked in a restaurant for a living and used no illicit drugs for his first four years in his new country. After running into a friend from Bangkok, he began dabbling again, working his habit up to $50 per day. He also began injecting.

Toong had tried cocaine, amphetamine and ecstasy but had never used these drugs on a regular basis. When he could not obtain supplies of heroin he took tranquillizers so he could sleep. He bought these on the street for a dollar a tablet. He smoked cannabis about three times daily, using a bong, but did not use tobacco which gave him asthma. He never drank alcohol. He had no other previous past ill-health.

He was injecting four times daily and was supporting his habit by dealing in drugs. Toong had spectacular evidence of venipuncture sites up and down both arms. The pupils were very large as he was in withdrawal, having not used narcotics for 2 days. There were six previous episodes of detoxification, including one in a Buddhist compound where he was given foul green liquid to make him vomit. Each time he had returned to heroin use.

His blood count was normal. Liver function tests showed low grade hepatitis with enzymes about double the normal upper limit. Bilirubin and creatinine were normal. Antibodies for HCV and HBV were positive and he was HIV negative.

Commenced on 30mg of methadone daily, his dose was gradually increased to 55mg. He ceased all heroin use and went back to his English studies and worked part time in a Thai restaurant. After three weeks, his estranged girlfriend came for a discussion about his treatment. She commented on how well he looked and suggested that he cut out the methadone as soon as possible.

With good initial progress as documented by voluntary urine testing, he requested dose reductions to 25mg over a number of weeks. He ran into some old friends and relapsed to heroin use. His previous dose was restored and he stopped illicit drug use.

Presentation:

After a month in treatment he presented with a day's history of pain in the left ankle and right elbow. There was no previous history of arthritis. Both joints were acutely inflamed with tenderness and limitation of movement. He was hot and sweaty with normal mental state. He had constipation which was thought to be due to the methadone. His temperature was 38.4, pulse 110 and regular. He had lost 4kg after having gained about the same amount since his original presentation.

A presumptive diagnosis of gout was made, blood tests ordered and naproxen prescribed at a dosage of 500mg three times daily. The pains were worse two days later and he was booked in to see a rheumatologist the following day. By this time, he had a florid erythematous rash over the entire body. Blood tests were unremarkable apart from an ESR of 60. Uric acid was 0.39, white count 5,900 with normal electrolytes and creatinine. Rheumaton test for rheumatoid arthritis was negative. He was HLA B52 negative.

Post viral arthritis was diagnosed but as the patient was so unwell, he was admitted to hospital. There was noted to be a soft systolic murmur. Fluid aspirated from the ankle was turbid but had no significant growth on overnight media. Blood cultures, however, were positive for staphylococcus aureus.

Infective endocarditis was confirmed by echocardiogram which showed vegetations on the tricuspid valve. Chest X ray showed multiple areas of subsegmental collapse indicating a probable embolic process.

Progress:

The patient was immediately commenced on high dose intravenous antibiotics and serial examinations were ordered. These showed an ongoing process in the heart with poor ventricular function and pericardial effusion.

The oral daily methadone dose was kept constant throughout and he stated that he had no desire to use heroin or other illicit drugs. He asked to come off the methadone after three weeks in hospital and gradual reductions were ordered.

His stormy hospital course included complications both from the disease as well as the treatment. Nine weeks later his condition had settled to the point where he was discharged on oral antibiotics, inotropic agents and diuretics. Surgery had been contemplated, but was not needed. Though they were extensive, the vegetations had not damaged the valve irretrievably.

While in hospital Toong had met up with a Buddhist monk who spoke his language. He had become quite religious following his serious illness. His decision was to withdraw from all drugs and lead a 'pure' life. He took advice of the D&A specialist at the hospital and over 5 months reduced his methadone dose to zero. He moved to the country to attend a Buddhist temple retreat with like minded souls to rebuild his shattered life.

Dr Andrew Byrne is a Sydney GP who specialises in drug and alcohol medicine.

Sick in the Air!

Despite the stress of air travel, do not expect any sympathy from others on the ground. Empathy is found only from fellow travellers, equally debased and thrust, sardine-like into modern silver flying tubes.

"If there is a doctor on board, would you please contact the cabin staff". I owned up and found myself taking the pulse of a large American lady called Valerie. She was sweaty and dizzy four hours into a cross pacific flight. The other volunteer was a retired psychiatrist from Melbourne who was a great moral support.

There had been no chest pain or shortness of breath. My aero-patient was on lipid lowering agents (Zocor) but had no cardiac history. There were no recent operations and she had no symptoms related to the gastrointestinal tract. She was a non-smoker. Although normally a teetotaller, Valerie did have a glass of Australian wine with a meal an hour earlier.

She was pale as a ghost. It was impossible to hear the heart or the brachial artery in the air, despite the Qantas aircraft being equipped with an excellent medical kit including stethoscope and sphygmomanometer. The constant drone of the engines is all that could be heard. In her propped up position, Valerie's blood pressure was under 100 systolic and the pulse 110 per minute and quite thready. She was in a lather of perspiration to the point that it was dripping off her. She was conscious but drowsy when I got to her.

After some generous fellow travellers gave up their seats, she was able to lie down for a while. With the addition of some piped oxygen, the blood pressure rose to 150 systolic with a stronger and more regular pulse at around 70.

On closer questioning, the poor woman had taken a motion sickness tablet before leaving Ohio that morning and, feeling quite queasy on reaching Los Angeles, took another before the long flight to Australia. Perhaps this led to the drop in blood pressure and her 'attempted faint'. With the lack of room in economy class it is physically impossible to faint, so the poor soul was drifting in and out of consciousness until we arranged some oxygen and the opportunity to lie horizontal (if only we had been in first class!).

I was summoned to the flight deck. Did we need to put down in Hawaii or could we proceed straight to Oz without danger to the lady's condition? The crew related some cases where airlines had been sued for not taking the appropriate action. My credentials were sought. Working in casualty for ten years sounds like a cruel and unusual punishment ... but it impressed our captain. There were no signs of cardiac instability and a general check-up could wait until morning.

Even if a traveller does have a myocardial infarct, there are all the necessities of a mini-intensive care ward on board Qantas. Intravenous drips, anti-arrhythmic drugs and even a portable defibrillator with ECG monitor. I was told that Qantas plans to introduce a cardiograph transmission service so that a cardiologist on the ground could be asked for an urgent opinion within minutes.

With a lot of time to kill (like 14 hours), the pilot engaged in some chit chat. I was engrossed in the cloud formations over the Pacific Ocean. We had to skirt around several massive mushrooms during the 40 minutes I was there. All the time, he was engrossed in telling me all about how doctors mostly know nothing about alcoholics and addiction. I was therefore not alone in my ignorance. 'The 12 step programs were confused with the 12 traditions of Alcoholics Anonymous which most doctors also misunderstood', I was told.

The pilot and his wife had been in the US for three weeks during which they visited the grave of 'Doctor Bob', co-founder of Alcoholics Anonymous. I was told further that there was no need to be Christian or even god-fearing. Moslems, Jews and even Atheists can partake fully in 'the fellowship'. I was getting very uneasy by this stage, but disengaging without offending could be difficult. I decided to invoke my patient's condition and excused myself, having already pronounced we should fly on direct to Australia.

I was thanked for my assistance and offered my choice of the duty free cart. I took a French neck tie and returned to my economy seat way below. The patient was fine. She had resumed her seat and the fluids, oxygen and passage of time had worked wonders.

The head steward explained that to touch down in Honolulu would have cost $90,000 in fuel alone, not to mention the delays, landing fees, missed connections etcetera. 'The designer neck tie is a little nothing in comparison', he said.

There was a cute sequel to my story. Next morning, I went into my favourite haunt in Victoria Street, near St Vincent's Hospital for a real coffee, a species hard to find in America. The waitress welcomed me back and offered a strong brew for my jet lag. While waiting, a large woman with an American accent walked in ... and ... yes, it was my patient, Valerie! She was speechless at first, but walked up to the waitress and told her that I was the 'most wonderful man in the whole wide world'. It was not a complete coincidence as I had advised her to attend St Vincent's Hospital for a check up on arrival. It made Oz seem like a 'small town' place indeed ... but it was nice to get some reliable follow up without doing exhaustive research!

Andrew Byrne is a GP in Redfern, NSW. He has a special interest in drug and alcohol medicine.