A couple of years ago I went out camping in the woods with a few of my friends. It was a dark and stormy night, and we felt very alone in our little tent, so we started telling scary stories.

I described how these hills used to be coal mining country, and the coal mines were dark and dangerous. If you didn’t die from coal lung you’d die from cave-ins, and if you didn’t die from either of those, you’d starve to death on the miniscule wages they paid you. The mine just up the hill from us was the worst. The manager had an extortion racket that he was keeping hidden from the owners - he would demand a “tribute” of 50% of the day’s wages from each of his miners, or he would think up a reason to get them fired. Pay was starvation level even without giving the manager his cut, and so after a few months of this tribute the miners became pale, sickly, and emaciated. Paradoxically, they started working harder and harder, hoping they would strike it rich enough to get a bonus that they could use to get out of that awful place.

One of the miners worked even harder than the others. He just kept digging and digging, and when he looked back, he’d gone too far, left everyone else behind, and couldn’t find his way back. Life out there was so bad he found he barely cared. He just kept digging and digging and digging, figuring that working himself to death was as good a way to go as any other.

Finally he came to a vein of rock darker than any he’d ever seen before, and when he broke through it - wham! - he had dug all the way to Hell. Satan came over to meet him, and told the miner that they had a problem. He couldn’t stay in Hell, because he wasn’t a sinner. But he couldn’t go back either, because the rules say no mortal may leave Hell alive. So Satan offered him a deal - he would transform the man into a vengeful ghost, who could spend eternity possessing mortals and driving them to madness.

The miner thought a bit, but he wasn’t convinced. The only guy he wanted to possess and drive to madness was his evil manager who had stolen a tribute from every one of his paychecks. After getting revenge on him, he wasn’t sure he wanted an eternity of possessing random other people. Satan suggested that maybe he could spend eternity possessing people and talking about how evil his manager was, so as to make his name forever dishonored. The man thought that was a good idea, and so with a word Satan transformed him into a spirit. He spent a while haunting his evil manager, then after that possessed random other people in the area to give monologues on how exploitative his manager’s labor practices were.

And so (I finished) sometimes, on nights much like tonight, with groups of campers much like our own…

“Hold on,” interrupted my friend. “Is this going to end with you saying that you’re possessed right now, and that’s why you’re telling us this story?”

“Um,” I said…“I guess that…”

Just then the police burst into our tent. “Stop right there!” said one of the officers. “You’re under arrest!”

“For what?” I asked.

“Possession by a miner within tent to diss tribute.”

Lots of people seem to agree with me about making FDA approval easier, but every so often I flirt with a much crazier position - I think we need to overhaul the prescription system, with less of an emphasis on making people get constant prescriptions from doctors every time they want to take drugs. Let me give an example.

Yesterday I was called in to evaluate a patient who had attempted suicide. He’d attempted suicide because his pain was so bad. His pain was so bad because he “couldn’t afford” the one medication that could control his pain.

(I’m being deliberately vague for confidentiality reasons, sorry)

I looked up the medication that could control his pain on GoodRx.com. It costs $5 per month in our area. This guy was poor, but not so poor he couldn’t pay $5/month to prevent pain so bad it made him want to die.

Turned out the problem was: he’d been receiving the medication happily for a couple of years, getting new prescriptions from his doctor each month. Then he lost his house. Somehow his Medicare (Medicaid? I can’t remember) was tied to his home address, such that by missing some stuff they sent to his home address he lost the insurance and had to re-apply for it. This took however long it takes to re-apply for things with government agencies. During the interim, he had no insurance. When he had no insurance, he couldn’t afford to see a doctor. Without a doctor, he couldn’t get his monthly refill on the prescription that he’d been receiving without any problem for years. So he couldn’t get the $5 medication he needed to control his pain. So he decided to commit suicide.

This is an interesting case because it cuts through a lot of the pat solutions that people have for these kinds of things. “Oh, just regulate the price of everything!” Wouldn’t help. I guess making applying for government insurance less bureaucratic would help, but good luck with that.

I know this isn’t the most consequentialist way to think about things, but imagining that I’m in terrible pain, and there’s a medication which I *know* works, and which I’ve used safely for years, and which only costs $5, but nobody will let me buy it because I don’t have an Official Piece Of Paper from a suitably credentialled rich person, would make me…well, it’d make me want to kill myself.

There’s a new report out of CERN that a team of scientists has unraveled the structure of the photon. Apparently this started years ago when some equations showed that photons acted like tiny “hands” - structures with a “palm” and radiating “fingers” - which “crawl” across time/space and “grab” the solid particles they interact with. This explained most of the properties of light but wasn’t an exact match for the data. The latest result is that single photons are actually made up of hundreds of these shapes, all joined together into a single particle.

Moral of the story: many hands make light work.

“Although at first glance the single character sentence 子子子子子子子子子子子子 does not seem to make sense, when this sentence is read using the right readings of the kanji 子, it means ‘the young of cat, kitten, and the young of lion, cub’. It is told in the work Ujishūi Monogatari that the Japanese poet Ono no Takamura used this reading to escape death.”

“I will make a public pledge to eat every single day. All of them.“
– source

@sinesalvatorem confirmed as the Egyptian chaos serpent Apep.

I testified in court for the first time today. I was an expert witness. A patient at my hospital had drunk bleach and then tried to kill a bunch of people, and I was supposed to testify that, based on my expertise and years of training as a psychiatrist, that sounded pretty crazy.

The courthouse was a skyscraper downtown. The fashion theme of the court-goers was “poor underclass people trying to cargo-cult formal dress”; for some reason they ended up looking like ‘40s gangsters.

The courtroom itself was a beautiful chamber made of white marble and very expensive-looking wood. On the wall was written in big metal letters WHEN LAW ENDS, TYRANNY BEGINS. There were flagpoles obscuring the A and the Y, so the visible letters said WHEN LW ENDS, TRANNY BEGINS, which I interpreted as a kabbalistic prophecy of Rationalist Tumblr.

I sat through a couple of really pitiful cases where people who realistically will probably never leave long-term state psychiatric hospitals got to have their yearly hearing, pled to the judge to please let them out of their long-term state psychiatric hospital, and were uniformly told they would have to stay for another year. Then my turn came. My hospital’s lawyer asked me to describe the facts of the case, which I did. I started hoping maybe this would all be easy

Then the patient’s lawyer got to cross-examine me. He decided to die on the rock of “the patient never really drank the bleach”. He pointed out that the patient had been admitted directly to the psychiatric hospital without spending any time in a medical hospital, and asked me if it was realistic that someone could drink bleach and not have to spend time in the hospital.

I got really freaked out because I hadn’t wanted this job, and I had hoped that I could just say that, as an expert psychiatrist, drinking bleach and trying to kill people sounded pretty crazy to me, and then sneak off the witness stand without having to deal with the whole “hostile cross-examination” thing. And I always feel bad about not knowing enough about non-psychiatric medicine, and I really didn’t know whether bleach-drinking always required a hospital stay, and I wasn’t sure whether it was supposed to be common knowledge to everyone except me that drinking bleach was super deadly, and I was tempted to just BS something, but I was on the witness stand and under oath, so I just said this was outside my expertise as a psychiatrist.

The defense attorney got really angry and asked “Well, have YOU ever drunk bleach, Dr. Alexander?” My hospital’s lawyer objected, and the defense lawyer said some legal stuff, and the two of them argued about it for a second, and finally the judge indicated that she would allow the question and I had to tell the court whether I had ever drunk bleach.

I said I hadn’t.

(I kind of wondered what my parents would think if they knew that right now I was on a witness stand, testifying under oath that I had never drunk bleach.)

The defense attorney asked, still pretty condescendingly, whether this was because, without any medical expertise, using my total layman common sense, I thought that drinking bleach was probably really bad.

I was kind of panicking, and I didn’t know what to do, and I worried I had just destroyed all my credibility as a doctor by not being able to emphatically say that drinking bleach required immediate hospitalization, and now I didn’t know whether I was going to look like I was walking back on my previous statement or what, so I just answered that yes, it seemed reasonable to say that drinking bleach was probably worse than not doing that.

The defense attorney got very excited, like I had just conceded the whole case. Then he asked me some very confused questions about bipolar disorder, and I think I did an okay job explaining why he was very confused, and then he rested.

Despite my bungling the bleach questions, the whole “trying to kill people” thing still sounded pretty bad, so my hospital won the case and the patient was found to be in need of continued care.

I just got home and looked it up, and according to science.howstuffworks.com:

Should you worry about drinking a mouthful of bleach? You’ll probably be fine. Most household bleaches contain fairly low concentrations of sodium hypochlorite – about 3 to 6 percent. That’s not an endorsement for trying it, but for the average adult, you shouldn’t expect anything worse than an upset stomach.

I FEEL SO VINDICATED RIGHT NOW.

I’ve talked before about why it’s so important to learn how to take a medical history (answer: because patients are worse at explaining themselves than you would have believed possible).

Today’s example: interviewing an immigrant man who said he had suffered trauma in “my country’s equivalent of the Boy Scouts”.

A couple of questions later, I finally figure out that he’s talking about Hezbollah.

Once upon a time there was an ugly duckling. All of the other ducklings had grown their beautiful white soft downy feathers, but this duckling had no down feathers at all and was bald and ugly and all the other ducklings teased him.

He went to the mysterious crow who lived in the woods and asked for help. The crow said to repeat the magic words “HOCUS POCUS” at midnight with a full moon, and then he would grow his down feathers. The duckling tried that, but the moon just laughed at him and said the magic had no power here.

So he went to the creepy raven who lived in the swamp and asked for help. The raven said to repeat the magic words “ABRA CADABRA” at high noon on a sunny day, and then he would grow his down feathers. The duckling tried that, but the sun just laughed at him and said he wasn’t bound by the magic.

So he went to the wise old owl who lived in the tallest tree and asked for help. The owl explained that the duckling should just ignore the mockery of the other birds and accept that he was okay just the way he was, because there were no magic spells to make ducklings grow feathers.

Moral of the story: You are beautiful, no matter what they say. Words can’t bring you down.

I give my ER patients a cognitive exam to assess for dementia. One of the questions is “Who’s the President?” Many people voluntarily add who they’re supporting for President in November.

So far the pattern is that the depressed people are voting for Hillary and the alcoholics are voting for Trump. This is probably a metaphor for something.

1. Have a nightmare about suddenly realizing I’m on call and forgot to turn on my pager.

2. Wake up, laugh a bit about how I’m finally adult enough that I’m having “forgot to do my job at work” nightmares instead of “forgot about an exam at school” nightmares.

3. As soon as I think “forgot about an exam at school”, realize that today is the day I scheduled months ago to do my big yearly training exam, and that I’m actually off from work today, and I totally forgot about this until this second

4. Run to car, rush to hospital just in time to make the exam and avert disaster.