- Email: [email protected]
“Of course haloes are out of fashion”*
DISSECTING ROOM
The sound of sirens Bringing out the dead A Martin Scorsese Picture starring Nicolas Cage. Directed by Martin Scorsese. Script writer Paul Schrader. On general release in the UK and USA. s it ironic coincidence that the British release of Bringing out the dead should have occurred in the same month in which the BBC’s Panorama television programme questioned the quality of care delivered by UK paramedic teams? Panorama focused principally on regional discrepancies in services, underlining shortfalls in drug administration, diagnostic skills, and airway management. The public reaction on learning that these emergency skills are based on a maximum of only 8-weeks of practical training has been predictably one of horror. Remarkably, Scorsese seems to have captured the mood of the moment through different eyes, with a film
I
whose central character is a New York paramedic, haunted by his inadequate airway skills that resulted in a patient’s death. The film is set in the early 1990s, a time before Mayor Giuliani’s zero-tolerance regime and of internecine drug wars in the intense environment of New York’s Hell’s Kitchen. Based on the novel by ex-paramedic Joe Connelly, the emergency medical services we observe are still under the jurisdiction of the Fire Department. Internal audit, continuous training, and regulation are not feasible concepts, and many of the staff have taken sick leave. The film’s opening sequence shows an ambulance turning sharply into the
“Of course haloes are out of fashion”* For Nigel so you wear your hair shirt under the skin, discipline that muscle bulge with endless exercise, vomit what we persuade you to eat, scour away the ooze and flab of femaleness. You sculpt your body with the purity of no food, float above our weight stuck to the earth. The heaviness of your heart, your thighs drags at you so much you carve it away hack at the sin of being alive of being you, and keep guard against the devil who mocks if you sleep or dream. It feels safer up there high on fasting. Out of reach.
Gillie Bolton Institute of General Practice, Sheffield University, Community Sciences Centre, Northern General Hospital, Sheffield S5 7AU, UK *Dannie Abse. Selected poems. London: Penguin, 1977: 78.
THE LANCET • Vol 355 • April 1, 2000
camera’s path. A Van Morrison harmonica riff from the soundtrack substitutes for the note of the siren and the pulse from the roof-mounted flashing lights illuminates the driver’s cab. Frank Pierce, played by Nicolas Cage, is a product of the old Catholic community in New York’s West Side who works in the neighbourhood that raised him. Dealing with an increasing barrage of mutilated humanity on a nightly basis, he is now on the edge. He hasn’t “saved” anyone in weeks and his hands that “once moved with . . . speed and skill” now only bring in corpses. A 56-h shift kicks off with a cardiac arrest, and the victim is taken to the Emergency Room at Our Lady of Perpetual Mercy, the local public hospital known locally as the Lady of Misery. Here a policeman with permanently affixed sunglasses brutally maintains security, a school-matronly triage nurse berates new patients, and a cynical ER resident tells Pierce about “Red death”, the cocktail of heroin and aminoacids currently hitting the streets. And here in this place of perpetual misery, Pierce also befriends Mary (Patricia Arquette), the reformed junkie daughter of the cardiac-arrest patient. She shares a common childhood background with Pierce, and the hours that follow are punctuated by meetings with her as she awaits news of her father. Increasingly unable to deal with the reality of his job, Pierce anxiously avoids the responsibility of caring for patients “in the back of the bus”, using cocktails of glucose, adrenaline, and alcohol to get through the night. He refuses to answer calls from the dispatcher (wittily played by Scorsese himself), and is haunted by the face of Rose, the asthmatic homeless Hispanic girl whom he fatally failed to intubate. Pierce suffers for everyone around him: he has become a “grief mop”.What is a normal human reaction to pain and suffering has grown into a sense of personal culpability for every death he sees. His colleagues provide a stark emotional contrast. Their defence mechanisms are robust, if inappropriate, varying from John Goodman’s food-obsessed materialist, through Ving Rhames’ hypocritical born-again Christian, to Tom Sizemore’s frank sociopath who is intent on meting out his own violent interpretation of American Justice by beating up his patients and his own ambulance. Each character is dysfunctional but has deliberately reduced personal involvement with their cases to a minimum, avoiding the emotional penalty that Pierce is paying. Long-time collaborators Scorsese and Schrader, whose work spans Taxi Driver and The Last Temptation of Christ, blur
1193
DISSECTING ROOM
distinctions between madness and spirituality. Superficially we know Pierce is mentally unstable. In a scene reminiscent of Yossarian’s dilemma in Catch 22, or Klinger’s similar predicament in MASH, Pierce begs unsuccessfully for sick leave from his unit Captain. A chemically induced dream sequence shows him pulling lost patients from the ground (a clever although not entirely convincing digital effect). The dead girl’s face projected onto every passerby may be interpreted as an obsession or a true haunting. The conversations Pierce has with the now sedated and ventilated cardiac-arrest patient may be auditory hallucinations or may be a real ability to communicate with the dying and the dead. But much of his anguish comes from a loss of faith, not in God but in his acquired creed of modern medicine. He mourns the loss of the elation he felt when he could save lives, the feeling “that God has passed through you, that God was you”. Destructive gods feel no such euphoria, but then again neither do they burn out or require sick leave and psychotherapy. Despite the subject, Bringing out the dead is a far from grim-faced movie.The same bleak comedy recognisable to all who work in medicine pervades the film, reproducing proficiently the shield of locker-room humour used by acute medical staff worldwide. The juxtaposition of hectic soundtrack with blurred double-speed photography gives a popvideo feel to the street scenes—the sight of Nic Cage’s manic eyes as he drives to the sound of “Bored with the USA” by the Clash is not to be missed. Many critics have pointed to the lack of a classic dénouement in this latest addition to Scorsese’s catalogue of New York. True, the psychotic blood-bath beloved of certain Scorsese fans is lacking, yet there is ultimately resolution of conflict, albeit with heavy religious symbolism in the final scenes: the closing still-life tableau bears an uncanny resemblance to a 16th-century pietà. Where Scorsese hits the target again is in posing the larger questions behind situations of life and death. Questions of how we as individuals in close proximity to death and injury continue to cope with our own lives and why our culture still largely denies, and often perpetuates, the impact of trauma on the carer. Although these questions remain unanswered, perhaps now is the time to start asking them. After all, how do we maintain sanity and perspective when faced with daily reflections of our own mortality? Jaydeep Sarma [email protected]
1194
Paediatric concern for the abused child Child abuse and neglect: a clinician’s handbook Christopher J Hobbs, Helga G I Hanks, Jane M Wynne. New York: Churchill Livingstone, 1999. Pp 504. $95·00. ISBN 0443058962. s a practicing child psychiatrist, I was delighted to have the opportunity to review Child abuse and neglect: a clinician’s handbook which is written from a paediatric perspective. Psychiatrists and paediatricians do not usually share the same texts, nor do they share the same knowledge base. This book, however, is an exceptional basic text for clinicians of differing disciplines. Its scope is broad enough that it provides a basic fund of knowledge, upon which the different disciplines can build a separate expertise. I was particularly impressed by how well this book filled in the gaps in my knowledge and provided me with practical information. The book starts with a theoretical and historical perspective. Child abuse is a long-standing human problem. There are no parallels in the animal kingdom for this behaviour. There is no evident survival value for human beings. It has not had such public attention until recently. Indeed, Americans had a Society for the Prevention of Cruelty to Animals before we had such a society for children. The authors comment on the appalling history of abuse of children including chimney sweeps who were kept small and thin so they could clamber up the soot clogged flues, quoting William Blake “Little black things among the snow crying weep weep in notes of woe”. The next five chapters cover: “Failure to thrive”, “Physical abuse”, “Burns and scalds”, “Neglect”, and “Emotional maltreatment”. These chapters include data on abuse that we all should know. Beyond the data is a clinical wisdom. Neglect, which is often the neglected area in the abuse literature, is well covered here. Reading the chapter, I realised that the success of the Head Start Preschool Programs was seen later on, in adolescence when children, stimulated and interactively educated early on, are able to maintain some initiative in their own education and stay in school. There are four chapters on sexual abuse which cover the clinical symptoms and physical findings very well. The colour plate section is 32 pages long and has excellent photographs and radiographs. The discussion helps those of us who have often tried to differentiate normal peer sexuality from sexual abuse. The chapter on sexual abuse of children with special needs was exceptional. The authors note that children
A
with hearing impairment appear to be one of the most victimised groups. Presumably this stems from the extreme vulnerability caused by a limited ability to communicate. They also put us on the alert for sexual abuse when a child presents with encopresis or with secondary enuresis that does not respond to the usual treatments. The final chapters include such topics as “Fetal problems”, “Poisonings”, “Suffocation”, and “Munchausen by proxy”, as well as “Other forms of child abuse”, “Management and treatment of abuse”, and “Fatal abuse”. The discussion of fetal alcohol syndrome is excellent; it even includes the amount of alcohol (8 units per day) considered to produce the syndrome. The discussion of factitious illness includes an exceptional understanding of the dynamics of the doctors who get involved in over-investigating children with Munchausen syndrome by proxy. We are usually informed only about the dynamics of the mother. In the chapter on treatment I was glad to see a description of the abuse case with a good prognosis. This type of case usually involves only physical abuse, where parents can learn different ways to parent and to discipline their children. We see so many poor-prognosis cases that it is important to be able to recognise the families for which treatment can give good results. The discussion of cultural issues relating to abuse was also useful. In our clinic, we have found that some of our cases with the best prognosis have been children who have been physically abused by families with prominent cultural issues as well. In summary, this book is an excellent text for any professional being trained in the child abuse area. As a suggestion for the next edition I would like to have a better description and understanding of the psychological disorders of the children who are discussed. Vulnerable children are often described as just “learning disabled” and are not given complex psychiatric diagnosis. Moreover, although there is a discussion of the psychological consequences of abuse there is little mention of posttraumatic stress disorder. This disorder is one of the most clinically significant problems that psychiatrists treat. Roxy Szeftel [email protected]
THE LANCET • Vol 355 • April 1, 2000
The sound of sirens Bringing out the dead A Martin Scorsese Picture starring Nicolas Cage. Directed by Martin Scorsese. Script writer Paul Schrader. On general release in the UK and USA. s it ironic coincidence that the British release of Bringing out the dead should have occurred in the same month in which the BBC’s Panorama television programme questioned the quality of care delivered by UK paramedic teams? Panorama focused principally on regional discrepancies in services, underlining shortfalls in drug administration, diagnostic skills, and airway management. The public reaction on learning that these emergency skills are based on a maximum of only 8-weeks of practical training has been predictably one of horror. Remarkably, Scorsese seems to have captured the mood of the moment through different eyes, with a film
I
whose central character is a New York paramedic, haunted by his inadequate airway skills that resulted in a patient’s death. The film is set in the early 1990s, a time before Mayor Giuliani’s zero-tolerance regime and of internecine drug wars in the intense environment of New York’s Hell’s Kitchen. Based on the novel by ex-paramedic Joe Connelly, the emergency medical services we observe are still under the jurisdiction of the Fire Department. Internal audit, continuous training, and regulation are not feasible concepts, and many of the staff have taken sick leave. The film’s opening sequence shows an ambulance turning sharply into the
“Of course haloes are out of fashion”* For Nigel so you wear your hair shirt under the skin, discipline that muscle bulge with endless exercise, vomit what we persuade you to eat, scour away the ooze and flab of femaleness. You sculpt your body with the purity of no food, float above our weight stuck to the earth. The heaviness of your heart, your thighs drags at you so much you carve it away hack at the sin of being alive of being you, and keep guard against the devil who mocks if you sleep or dream. It feels safer up there high on fasting. Out of reach.
Gillie Bolton Institute of General Practice, Sheffield University, Community Sciences Centre, Northern General Hospital, Sheffield S5 7AU, UK *Dannie Abse. Selected poems. London: Penguin, 1977: 78.
THE LANCET • Vol 355 • April 1, 2000
camera’s path. A Van Morrison harmonica riff from the soundtrack substitutes for the note of the siren and the pulse from the roof-mounted flashing lights illuminates the driver’s cab. Frank Pierce, played by Nicolas Cage, is a product of the old Catholic community in New York’s West Side who works in the neighbourhood that raised him. Dealing with an increasing barrage of mutilated humanity on a nightly basis, he is now on the edge. He hasn’t “saved” anyone in weeks and his hands that “once moved with . . . speed and skill” now only bring in corpses. A 56-h shift kicks off with a cardiac arrest, and the victim is taken to the Emergency Room at Our Lady of Perpetual Mercy, the local public hospital known locally as the Lady of Misery. Here a policeman with permanently affixed sunglasses brutally maintains security, a school-matronly triage nurse berates new patients, and a cynical ER resident tells Pierce about “Red death”, the cocktail of heroin and aminoacids currently hitting the streets. And here in this place of perpetual misery, Pierce also befriends Mary (Patricia Arquette), the reformed junkie daughter of the cardiac-arrest patient. She shares a common childhood background with Pierce, and the hours that follow are punctuated by meetings with her as she awaits news of her father. Increasingly unable to deal with the reality of his job, Pierce anxiously avoids the responsibility of caring for patients “in the back of the bus”, using cocktails of glucose, adrenaline, and alcohol to get through the night. He refuses to answer calls from the dispatcher (wittily played by Scorsese himself), and is haunted by the face of Rose, the asthmatic homeless Hispanic girl whom he fatally failed to intubate. Pierce suffers for everyone around him: he has become a “grief mop”.What is a normal human reaction to pain and suffering has grown into a sense of personal culpability for every death he sees. His colleagues provide a stark emotional contrast. Their defence mechanisms are robust, if inappropriate, varying from John Goodman’s food-obsessed materialist, through Ving Rhames’ hypocritical born-again Christian, to Tom Sizemore’s frank sociopath who is intent on meting out his own violent interpretation of American Justice by beating up his patients and his own ambulance. Each character is dysfunctional but has deliberately reduced personal involvement with their cases to a minimum, avoiding the emotional penalty that Pierce is paying. Long-time collaborators Scorsese and Schrader, whose work spans Taxi Driver and The Last Temptation of Christ, blur
1193
DISSECTING ROOM
distinctions between madness and spirituality. Superficially we know Pierce is mentally unstable. In a scene reminiscent of Yossarian’s dilemma in Catch 22, or Klinger’s similar predicament in MASH, Pierce begs unsuccessfully for sick leave from his unit Captain. A chemically induced dream sequence shows him pulling lost patients from the ground (a clever although not entirely convincing digital effect). The dead girl’s face projected onto every passerby may be interpreted as an obsession or a true haunting. The conversations Pierce has with the now sedated and ventilated cardiac-arrest patient may be auditory hallucinations or may be a real ability to communicate with the dying and the dead. But much of his anguish comes from a loss of faith, not in God but in his acquired creed of modern medicine. He mourns the loss of the elation he felt when he could save lives, the feeling “that God has passed through you, that God was you”. Destructive gods feel no such euphoria, but then again neither do they burn out or require sick leave and psychotherapy. Despite the subject, Bringing out the dead is a far from grim-faced movie.The same bleak comedy recognisable to all who work in medicine pervades the film, reproducing proficiently the shield of locker-room humour used by acute medical staff worldwide. The juxtaposition of hectic soundtrack with blurred double-speed photography gives a popvideo feel to the street scenes—the sight of Nic Cage’s manic eyes as he drives to the sound of “Bored with the USA” by the Clash is not to be missed. Many critics have pointed to the lack of a classic dénouement in this latest addition to Scorsese’s catalogue of New York. True, the psychotic blood-bath beloved of certain Scorsese fans is lacking, yet there is ultimately resolution of conflict, albeit with heavy religious symbolism in the final scenes: the closing still-life tableau bears an uncanny resemblance to a 16th-century pietà. Where Scorsese hits the target again is in posing the larger questions behind situations of life and death. Questions of how we as individuals in close proximity to death and injury continue to cope with our own lives and why our culture still largely denies, and often perpetuates, the impact of trauma on the carer. Although these questions remain unanswered, perhaps now is the time to start asking them. After all, how do we maintain sanity and perspective when faced with daily reflections of our own mortality? Jaydeep Sarma [email protected]
1194
Paediatric concern for the abused child Child abuse and neglect: a clinician’s handbook Christopher J Hobbs, Helga G I Hanks, Jane M Wynne. New York: Churchill Livingstone, 1999. Pp 504. $95·00. ISBN 0443058962. s a practicing child psychiatrist, I was delighted to have the opportunity to review Child abuse and neglect: a clinician’s handbook which is written from a paediatric perspective. Psychiatrists and paediatricians do not usually share the same texts, nor do they share the same knowledge base. This book, however, is an exceptional basic text for clinicians of differing disciplines. Its scope is broad enough that it provides a basic fund of knowledge, upon which the different disciplines can build a separate expertise. I was particularly impressed by how well this book filled in the gaps in my knowledge and provided me with practical information. The book starts with a theoretical and historical perspective. Child abuse is a long-standing human problem. There are no parallels in the animal kingdom for this behaviour. There is no evident survival value for human beings. It has not had such public attention until recently. Indeed, Americans had a Society for the Prevention of Cruelty to Animals before we had such a society for children. The authors comment on the appalling history of abuse of children including chimney sweeps who were kept small and thin so they could clamber up the soot clogged flues, quoting William Blake “Little black things among the snow crying weep weep in notes of woe”. The next five chapters cover: “Failure to thrive”, “Physical abuse”, “Burns and scalds”, “Neglect”, and “Emotional maltreatment”. These chapters include data on abuse that we all should know. Beyond the data is a clinical wisdom. Neglect, which is often the neglected area in the abuse literature, is well covered here. Reading the chapter, I realised that the success of the Head Start Preschool Programs was seen later on, in adolescence when children, stimulated and interactively educated early on, are able to maintain some initiative in their own education and stay in school. There are four chapters on sexual abuse which cover the clinical symptoms and physical findings very well. The colour plate section is 32 pages long and has excellent photographs and radiographs. The discussion helps those of us who have often tried to differentiate normal peer sexuality from sexual abuse. The chapter on sexual abuse of children with special needs was exceptional. The authors note that children
A
with hearing impairment appear to be one of the most victimised groups. Presumably this stems from the extreme vulnerability caused by a limited ability to communicate. They also put us on the alert for sexual abuse when a child presents with encopresis or with secondary enuresis that does not respond to the usual treatments. The final chapters include such topics as “Fetal problems”, “Poisonings”, “Suffocation”, and “Munchausen by proxy”, as well as “Other forms of child abuse”, “Management and treatment of abuse”, and “Fatal abuse”. The discussion of fetal alcohol syndrome is excellent; it even includes the amount of alcohol (8 units per day) considered to produce the syndrome. The discussion of factitious illness includes an exceptional understanding of the dynamics of the doctors who get involved in over-investigating children with Munchausen syndrome by proxy. We are usually informed only about the dynamics of the mother. In the chapter on treatment I was glad to see a description of the abuse case with a good prognosis. This type of case usually involves only physical abuse, where parents can learn different ways to parent and to discipline their children. We see so many poor-prognosis cases that it is important to be able to recognise the families for which treatment can give good results. The discussion of cultural issues relating to abuse was also useful. In our clinic, we have found that some of our cases with the best prognosis have been children who have been physically abused by families with prominent cultural issues as well. In summary, this book is an excellent text for any professional being trained in the child abuse area. As a suggestion for the next edition I would like to have a better description and understanding of the psychological disorders of the children who are discussed. Vulnerable children are often described as just “learning disabled” and are not given complex psychiatric diagnosis. Moreover, although there is a discussion of the psychological consequences of abuse there is little mention of posttraumatic stress disorder. This disorder is one of the most clinically significant problems that psychiatrists treat. Roxy Szeftel [email protected]
THE LANCET • Vol 355 • April 1, 2000