©2016 Am Ang Zhang
The Cockroach Catcher remembers his Adolescent days fondly, I mean my Adolescent In-patient days fondly. There was much politics to deal with and this time he used Ping Pong!
t is the nature of life that now and again you have to do people favours. Sometimes you do it in case you need favours back. More often than not it is about doing the right thing.
One of my outpatient colleagues was female and ethnic. When she realised that I became in charge of the adolescent unit, she said to me, good, now I can get some of my patients admitted.
It was very difficult to decide if there was racism or sexism. It was true that many of her referrals did not get to be admitted and most of the time the nurses had justifiable reasons. One nurse in particular warned me from day one that I should not touch any of her cases.
Nurses are very powerful in an adolescent unit. They have front-end dealings with patients from pre-admission to admission to discharge. For someone new like me it would have been foolish not to take notice of such a clear cut warning. But anyone who knows me well enough would not expect me to be easily intimidated. I would not have an all out fight but I have my ways.
However, this consultant did not help herself in matters. Before my arrival she had been writing to the Health Authorities about her difficulties in getting patients admitted. Luckily for the nurses all the blame was laid on the previous consultant who was eventually suspended and dismissed.
By then, the nurses felt that they were in some position of authority and my emergence was not exactly met with fanfare, although there was for some a sense of relief as my success at the Children’s Unit in the last ten months was beyond anybody’s expectation except mine. The nurses working in the Children’s Unit, including the wife of the charge nurse at the adolescent unit, warned me that adolescents were different.
It was also difficult to turn up at a place that had been running on auto-pilot for some time. The staff began to feel that doctors might not indeed be necessary except for this silly rule that they alone could prescribe.
The consultant in question was known to have an “over-understanding” approach to cases and she felt sorry for a number of patients where there was a strong social element to the problem. Due to shortage of beds, we did try to limit admission to genuine psychiatric cases.
However when I was asked by the Health Authorities handling her complaints to look at one of her cases again what choice did the nurses think I had? Quite simply, admit or else.
But the decision was always mine!
One of the boy’s problems was that he lived with mum and had not been to school for nearly a year. As the consultant requested an assessment at a psychiatric unit, Education Department refused even to look at him until that had happened.
A stalemate.
In the meantime, Education Department had saved the better part of thirty thousand pounds and they had a legitimate reason. He was first kicked out of school because he used threatening language with a female teacher when asked to read his story.
Mother also reported how threatening he was to her at times.
From this bit of history he was definitely no good for our unit. The last time the unit had to be closed in the middle of the night was precisely because of violence to female staff.
We too had a legitimate reason not to admit him.
I took the charge nurse Martin on one side and asked him to tell me what he would think if we were dealing with a brand new referral.
I discovered months later that he found me genuine and really wanted to give me a chance to make a go of it. As such he had to tell me the problem.
©2016 Am Ang Zhang
The problem of anarchy.
There was amongst some staff a strong anti-authority feeling. There was no doubt they were let down by the previous consultant and some of the nurses could have been hurt. Following the incident, an outside consultant was employed to provide a report at great expense to the NHS Trust. I could have told them the problem free of charge.
Such is management nowadays that the dirty work has to be done by an outsider. We were still in the investigation period and no doubt everything I did would be under scrutiny. The survival of the unit would depend on the outside consultant’s report. I had lunch with him on many occasions and luckily his NHS views were in fact very close to mine. Six weeks he had to be with the unit and six weeks was a long time.
So I was lucky in that there had to be a truce. We could not let personal prejudices override clinical decisions.
In the end and some thousands of pounds later we managed to keep our unit running and in some little way I changed my view about outside consultants. The good ones are good and this one was a practising inpatient child psychiatrist so there was no need really to say too much about politics and anarchism. He understood because he experienced it himself, and he found a way to deal with it.
So running an adolescent unit is like running a mini-country. In our democratic age, the wisest thing to do is to bring about the changes you want when you are riding high, and then leave. Do not wait to be kicked out.
As psychiatrists, we do have certain power conferred by the Mental Health Act and that is often a sore reminder of the difference between us and the other staff – more so as we still had two Sectioned patients in the unit at the time: one anorectic on tube feeding and one psychotic.
Martin the charge nurse said he would visit the boy Leroy at home to assess him and if I could agree to a time-limited admission we might have a “goer”. He thought that Leroy was probably “all barks” only. His father was from the West Indies and the one time Martin met Leroy he was just loud and boastful and not as threatening as mother always made him out to be.
In the two years I lived on a Caribbean island, I discovered that many of the children there were in fact very gentle and timid, and they were never rude to their parents. I know not all the islands are the same and generalisation can be very dangerous.
“But you may have to speak with Kevin. He visited the last time.”
Kevin was the one who warned me not to even think about it. There were many ways to deal with violence in our kind of unit. More often than not if the adolescent patients sensed that there was no leadership they ran wild.
I decided on a direct approach.
“I am going to be frank with you, Kevin. I want you to go out with Martin and see this boy again and I want him in a.s.a.p. unless you can convince me that there is a good reason why he should not have the benefit of a six week assessment. I know you think I am doing a favour and I can tell you now, I am. Sometimes in life you have to because not doing it is going to hurt a lot more people, including ourselves.”
“Six weeks then.”
©2016 Am Ang Zhang
My new junior, who was a very timid girl, decided to go out on the visit too when she realised that there would be protection. Leroy had just turned thirteen and she told me that she thought he might well have the King’s disease.
“You mean what they claim King George VI had?” I thought it was very clever of the drug firms wanting to push the new drug for Social Phobia to involve the King. “Don’t forget King George VI had lung cancer and metastasis could do strange things.”
No problem. Leroy agreed to come in when he learned that we had two ping pong tables and that Martin played County Championship League. My junior said she was glad she went and she really did not understand what the fuss before was about. I told her that even in adult psychiatry, reports on patients could often paint an unreal picture and the mildest people could be made to appear like big monsters.
It was suggested that the only time there might be trouble would be when the boy came to be admitted, and therefore he should not come in his mother’s car but in a hospital bus instead, accompanied by some of the big male nurses. I might have given in to the idea but my junior came to my rescue. She would go with the charge nurse and bring him in her car. Mum could drive down on her own.
“It is a hospital lease car anyway.”
“The last time a male nurse offered to take a female patient home he was accused of touching her and he was suspended.”
“Was he guilty?”
“No, but he died of a heart attack. We shall send our bus but you can be the medical escort.”
I remember once escorting a Manic Depressive (Bipolar 1) from Hong Kong to London and I had to inject him en route, sitting right at the back of a BOAC 707. That was an experience. So I reminded my junior, “Don’t forget the rapid sedation pack – just kidding.” Why should all the fun be left to the nurses, I thought to myself but I was never going to let her drive, Crown Car or otherwise.
Leroy looked as if he was going to camp, with his new white trainers and sports outfit that father presented over the weekend together with the latest sunglasses.
Martin told me sometime later that father called him wanting to know if I was “Cool, man. You know what I mean, man.”
“I told him you were actually Chinese. He said he did not want no white doctor putting no funny thing into his boy. I also told him the consultant would be happy to see him any time he liked.”
Martin reckoned he was doped up heavy with something from the way he was slurring his speech. He was all right as long as I was not white.
“Good, no more racism. Not from us.”
Father also gave Leroy a new sports-bag to carry all his stuff. It was really too big for him and my junior reported to me the verbal duel between mother and son.
“You are blocking the way with that stupid bag.”
“Dad gave it to me.”
“He is stupid.”
“He is not.”
“Why didn’t you go live with him?”
“You took his house.”
“He shouldn’t hit me and you are copying him. Stupid bag, you are not going to Jamaica, you know, stupid sunglasses.”
“Tag Heuer, they are the best.”
“Move your stupid bag. Stupid Nike bag.”
She turned to my junior, “He does not really want to go in, and that is why he is so slow.”
With that he moved.
“Have you read Jay Haley?” Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's. “I have read Bateson.” Gregory Bateson was the well known social scientist who wrote Steps to an Ecology of Mind, and Mind & Nature.
I am beginning to like her. She is going to be a good psychiatrist.
So Leroy arrived and was at a bit of a loss standing outside the Nurses’ Office.
It was time for mother to leave. We tended not to let mothers stay too long for admission for obvious reasons.
“Aren’t you going to give me a kiss then? Why aren’t you crying? I thought you did not want to come in.”
Did she not realise that maybe the boy was not that stupid? After a year shut up in the house with a mother like that, he would take up any chance to be away for six weeks!
He did kiss her and started to cry.
©2016 Am Ang Zhang
My junior cried too. I thought she did because she felt sorry for the boy.
“Leroy is a lamb, isn’t he?” Martin said to me later.
“So we shall be fine then.”
He smiled.
For the first weekend inpatients were normally not granted home leave to allow for settling in and from then on the weekend leaves would be dependent on their performance at community meetings and on how they were assessed by their fellow patients. They had to ask for a grade and if the grade was not good enough they were not allowed home. This system had been running for years and I really did not want to rock the boat at such an early stage.
It was all stage-managed by the teaching staff, who unfortunately found this the only way whereby they could have any control over the children’s behaviour.
The first weekend Leroy was fine except when mother visited. There was some silly argument and he took himself to the toilet and did not come out until he was assured mum was gone.
Then he said he missed his dad, who did not have a car and mum refused to drive him down as the last time she drove him somewhere he hit her after some argument.
“He wanted a new game from dad and dad promised he would get him one if he could get home leave,” Kevin told me the real reason he wanted to be home.
That is very much the modern way a parent relates to a child. They do not know any other way.
“Psychology, you see,” he told Kevin over the phone. “I want to help the China Man.”
“I need everybody’s help!”
“Do you agree that Leroy has Social Phobia? Everything fitted in with the criteria in DSM IV.” My junior plucked up courage to ask me during supervision. It was good to keep oneself on one’s toes with juniors who had just arrived from London and who read up on everything.
“What’s wrong with shyness?” I joked, “Do you want me to put him on SSRI (Selective serotonin reuptake inhibitors)?”
“It is supposed to work.”
“If he starts taking SSRI at thirteen, what is he going to do for the rest of his life?!”
“The newer short acting ones are supposed to be better.”
“Take one advice from me; think the opposite, the opposite to what the big Pharmas tell you. In pharmacology, shorter acting drugs are more addictive. That was what I learned in Medical School and is still true if you think carefully about it.”
By Community Meeting time nobody had a hard word to say about Leroy, but they all noticed he did not socialise much. He had to ask for his grade as per time-honoured ritual. He could not. Everybody tried to urge him. My junior sat next to him and tried to hold his hand. He rushed off to the toilet and locked himself in again.
“To lock yourself in a toilet is a down-gradable offence and to do it twice in a week is just not on. And, Doctor, we have to be very strict with these rules. Otherwise we shall start having problems again,” said a teacher.
So, I was warned. My junior got rather emotional and said that was just too much for her. It was her first case and why couldn’t they be more understanding?
Martin interjected and said that of course if there were psychological reasons the consultant could grant a special home visit like half a day so that everybody could save face.
I liked that. Saving face. But then how popular would I be with the teachers?
What about Leroy’s face?
I knew whose face I wanted to save.
So I arranged to see Leroy straight away. No, I did not ask him why he could not speak up for himself. I knew already.
“I hear you are a very good ping pong player.”
“Table Tennis, you mean.” He was speaking to me.
“O.K. Table Tennis. You know he is good.” I said, pointing to Martin.
“Yeah, that is why I am not playing him. I played with Gerry.” Gerry was his nurse.
“The fat one.”
He smiled a little, thinking I was rude.
“He was a bit slow.”
“You must have given him a good run.”
Smile again.
“I hear you did not play with the kids though.”
“How did you know? They are no good.”
“Well, how about this? Have you ever played a Chinese?”
“No.”
“We hold the bat differently, you know.”
“Weird.”
“We’ll play three games and if you win you can go home for half a day and if you don’t, you stay.”
The look on my junior’s face was something to be seen. Martin put on a look to pretend that he knew I would come up with something, although he admitted later that what I suggested was the last thing on his mind.
The scene was set for a three game match between the consultant and his patient to decide if his patient could go for a short week-end leave.
Even the headmaster came out to watch, shaking his head in disbelief.
It was spring, still cold but sunny. The sun was streaming in. I lost the first game. I had not played for fifteen years. I took off my jacket. I barely managed the second. That brought some cheers.
From certain quarters.
He beat me bad on the last one. I did not get past 9 and that was bad for ping pong – sorry, Table Tennis.
I thought everybody forgave me. I did not give the game to him. He beat me fair and square. The situation was too surreal for anyone to remember to get cross.
The girls clapped as they all loved him and wanted to mother him, especially the older ones, even when many of them did not have a chance of home leave as their weight was not good.
I became their hero. Nobody reported me to the General Medical Council. Not that time, anyway.
Mother was horrified but thought that if he had been good and had not attacked any female he would be fine. She would just take him to his father, who would buy him his game.
On Saturday I was there for a new admission. My junior rushed in saying there was a disaster. Leroy would not go with mum because she did not want to buy him a Diet Coke from the Petrol Station next door. She said there was a pack from Tesco sitting at home and the Coke from the Petrol Station was too expensive.
“After all that!” I exclaimed to myself.
He just sat near the door. I went out, waved my arm in a table tennis move and asked him to follow me to the car.
“Cool wheels,” he said, “but it’s for old people though.”
I ignored him, opened the car boot and gave him a can of drink – still cool from the overnight frost.
I knew where his problem was.
| May 30, 2016 ... In The Cockroach Catcher, in the opening chapter I recalled an Anorexia Nervosa patient that has been “dumped” by her Private Health Insurer. |
| Jun 14, 2016 ... ... of childhood psychological problems. Indeed it was a sad day when the unit closed. From The Cockroach Catcher: Chapter 48 The Last Cook ... |
Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ... |
| Apr 25, 2014 ... ... then the Tate also rejected Picasso………” The Tate now of course has several Mondrian works. Now you can read the whole chapter here: ... |
| Jun 29, 2011 ... In The Cockroach Catcher I got my Anorectic patient to play the cello that was banned by the “weight gain contract”: Jane got on well with me. |
| Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ... |
| Jul 20, 2016 ... The following is an extract from The Cockroach Catcher: “Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he ... |
Jay Haley - A brilliant strategist and devastating critic, Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's.
Social Phobia (now renamed Social Anxiety Disorder): Everyone feels nervous from time to time. Going on a first date or giving a speech often causes that butterflies-in-your-stomach feeling, for example. Or maybe you feel shy at a party among a group of strangers, but then slowly warm up to them and have a great time.
After decades of decreasing scarlet fever incidence, a dramatic increase was seen in England beginning in 2014. Investigations were launched to assess clinical and epidemiological patterns and identify potential causes. Lancet.
The strangest finding is that there is no evidence of any genetic mutation of the bacteria concerned nor resistance to antibiotic treatment. Perhaps we need to look closely at Ed Yong’s masterful new book, I Contain Multitudes, which tells the stories of the microbes that swarm within and around us.
Are we too clean? Do we use too much "Antibacterial" laced cleaning things? Or is the new near religious fervour in not using antibiotics to blame? We simply do not know.
But Scarlet Fever reminds me of Mahler.
©2013 Am Ang Zhang
Mahler wrote Kindertotenlieder to five poems written by Rückert. Rückert wrote 428 poems following the death of his two children from Scarlet Fever.
Mahler lived in an age when bacteriology was very much in its infancy. There was still little understanding of the role Streptococcus played in a range of illnesses from Scarlet Fever to Rheumatic Heart Disease and Radium was often used to treat Streptococcal related conditions.
Mahler’s own daughter tragically died from Scarlet Fever four years after writing Kindertotenlieder and Mahler himself contracted Rheumatic heart disease. When there was still little understanding of the etiology of diseases, superstition came into play so much so that Mahler did not want to write a ninth symphony. It was the start of the Curse of the Ninth Symphony.
Das Lied von der Erde was indeed the result as it was composed after his Eighth Symphony and he did not want to name it his Ninth.
Mahler conceived the work in 1908 when he was already unwell with his heart condition. A volume of ancient Chinese poetry under the title of The Chinese Flute (Chinesische Flöte) repoetized by Hans Bethge was published in German and Mahler was very much taken by the vision of earthly beauty expressed in these verses. Fate he felt has been unkind to him but he felt able to accept it in his own fashion.
Mahler died on May 18th 1911 in Vienna.
"I think it is probably the most personal composition I have created thus far." Gustav Mahler
Bruno Walter described it as: "the most personal utterance among Mahler's creations, and perhaps in all music."
My first encounter was in the early 70s with the recording by Janet Baker and Waldemar Kmentt (with Kubelik conducting the Bavarian Radio Symphony Orchestra). I still think it is one of the very best performances of Das Lied von der Erde.
© Am Ang Zhang 2018
I had a most enjoyable time on a Viking Ocean Cruise to return to the sad case of a Doctor being struck off. Reminds me of the book I read by Gawande:
In one of the most moving passages in the book, Gawande’s father, in hospice, rises from his wheelchair to hear his son lecture at their hometown university. “I was almost overcome just witnessing it,” Gawande writes.
........Gawande offers no manifesto, no checklist, for a better end of life. Rather, he profiles professionals who have challenged the status quo, including Bill Thomas and other geriatricians, palliative-care specialists, and hospice workers. Particularly inspiring are the stories of patients who made hard decisions about balancing their desire to live longer with their desire to live better. These include Gawande’s daughter’s piano teacher, who gave lessons until the last month of her life, and Gawande’s father, also a surgeon, who continued work on a school he founded in India while dying of a spinal tumor.
He’s awed not only by his father’s strength, but by the hospice care that helped the dying man articulate what mattered most to him, and to do it. Gawande thinks, as he watches his proud father climb the bleachers, “Here is what a different kind of care — a different kind of medicine — makes possible.”
What would lawyers say about M + M:
- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’
I read Gawande when in Peggy's Cove and posted about his book Complications! Honestly, I did not know Gawande was giving the Reith Lectures.
What a charming place: Peggy's Cove of Halifax.
The Cockroach Catcher was finishing reading the book Complications and such charming old landscape reminds him of the old traditional medical training he received and how some doctors still do. Like the author of this book.
The book reads more like a collection of blog posts and in fact it was. Yet it was real and touching. Sometimes it was brunt and brutal. and after all doctors are as human as anyone. Complications includes those doctors themselves may suffer: mental illness and alcoholism as well as the serious cardiac condition of the author's young son.
We, doctors make mistakes and please we must be allowed to sort them out without affecting career or worst, future medical behaviour.
A great book for doctors in particular and when on holiday in a charming place.
(Metropolitan Books, 288 pages, $24), a collection of 14 pieces, some of which were originally published in The New Yorker and Slate magazines, Gawande uses real-life scenarios – a burned-out doctor who refuses to quit; a terminal patient who opts for risky surgery, with fatal results – to explore the larger ethical issues that underlie medicine. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes?
While “Complications” is full of tragic errors and near misses, the book is not intended to be an expose. Rather, Gawande asserts, it is meant to deepen our understanding of the intricacies of medicine. “In most medical writing, the doctor is either a hero or a villain,” he says, with an edge in his voice. “What I am trying to do is push beyond that and show how ordinary doctors are – and at the same time show that what they can do is extraordinary.”
John Freeman, Copyright (c) 2002 The Denver Post.
Quotes
- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’
- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’
- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’
In recent write ups about antidepressants, there is no mention of Lithium. The Cockroach Catcher first worked with one Australian Psychiatrist that worked with Cade and I was, so to speak, very biased towards Lithium. Yes, Lithium has side effects that might be serious. But hang on, you get to live to experience it. Think about it.
Thank goodness: someone is talking about it.
Atacama where Lithium is extracted © Am Ang Zhang 2015
Nassir Ghaemi, MD, MPH
June 16, 2017
At the recent American Psychiatric Association annual meeting in San Diego, an update symposium was presented on the topic of "Lithium: Key Issues for Practice." In a session chaired by Dr David Osser, associate professor of psychiatry at Harvard Medical School, presenters reviewed various aspects of the utility of lithium in psychiatry.
Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.
These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).
Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless.
Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?
APA Nassir Ghaemi, MD MPH
- In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)
- We haven’t developed a drug that’s more effective than any other drug since the 1970’s
- All we have developed is safer drugs (less side effects), but not more effective
- Dose lithium only once a day, at night
- For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium (Originally by Dr. Frederick K. Goodwin)
Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.
In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.
And many lives too!
I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here. It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.
The following is an extract from The Cockroach Catcher:“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”
“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”
Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.
“Get him admitted and I shall talk to the doctor there.”
He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.
He had one of the worst encephalitis they had seen in recent times and they were surprised he survived.
Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.
Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.
I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.
Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows. Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.
Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.
Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.
Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.
Could Lithium be the Aspirin of Psychiatry? Only time will tell!
Related Posts:
Abstract: Lithium has been used as a mood-stabilizing drug in people with mood disorders. Previous studies have shown that highest levels of suicide mortality rate in Japan. Lithium levels in the tap water supplies of each municipality were measured using natural levels of lithium in drinking water may protect against suicide. This study evaluated the association between lithium levels in tap water and the suicide standardized mortality ratio (SMR) in 40 municipalities of Aomori prefecture, which has the inductively coupled plasma-mass spectrometry. After adjusting for confounders, a statistical trend toward significance was found for the relationship between lithium levels and the average SMR among females. These findings indicate that natural levels of lithium in drinking water might have a protective effect on the risk of suicide among females. Future research is warranted to confirm this association.
"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."
One might ask why there has been such a shift from Lithium.
Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?
Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.
Some felt it has to do with how little money is to be made from Lithium.
Another Baby Murdered:
“A mother stole a baby from a wealthy family. She proceeded to throw her own baby into a fire and bring up the baby from the wealthy family as her own.”
That was not another major Social Services blunder.
That was at the Metropolitan Opera on Sept. 25th 2015.
Verdi’s Il Trovatore is probably well known to most for its Anvil Chorus. For me it is about The Dark Side, the dark side of human nature.
The Dark Side:
“My hunch is that despite media coverage many of us still fail to grasp the dark side – the dark side of human nature. Until we do, we shall continue to read about child abuse, abductions and murders of the worst kind.”From The Cockroach Catcher.
Much has been written about training others to do the doctor’s work in an attempt to save health cost. What is not covered is the fact that there is training and there is a broader aspect of education. The ability to transmit culture external to genetic coding is what distinguishes Homo sapiens from other animal species on Planet Earth. Many bloggers are well educated in this cultural respect either by design, by choice or by accident. There is now an uncomfortable feeling of de-education in the Brave New World. Will the next generation of doctors, nurses and bloggers be as cultured? I do wonder!
In the mean time unnecessary deaths continued since Dennis O’Neill & Maria Colwell with millions spent on QCs holding public enquiries. A Chronology of selected inquiries Darker side:
Doctor suspended for blowing the whistle:
Dr Kim Holt was suspended from Great Ormond Street Hospital.
SOMEONE took a decision at the famous Great Ormond Street Hospital (GOSH), in Bloomsbury, to suspend a senior pediatrician, Dr Kim Holt, from her post.
We know why the good doctor was suspended on full pay.
These are the facts: Dr Holt, a specialist of 25 years experience, started working in Haringey in a children’s department run by GOSH
in 2004.
Two years later she started writing to her superiors complaining about the loss of staff, and the risk of a possible “disaster” at the child protection service in Haringey if more doctors were not attached to the department. This was a matter of “public interest” and should be “investigated”, argued Dr Holt.
As readers will know, such a “disaster” occurred when a locum pediatrician was called in to see Baby P and made a mess of her examination. Two days after the examination Baby P died.
Was Dr Kim Holt patted on the back for her whistle-blowing?
No, someone, or a committee at GOSH, felt offended by Dr Holt’s interference – and suspended her.
Dark Side of The Opera:In Il Trovatore, Azucena is the mother who killed her own baby and Manrico was brought up by her. Manrico is the brother of Count Di Luna that burnt Azucena’s mother for being a witch. Azucena had to avenge her mother’s death. How much hate can you hold. She had to throw her own child in the fire, bring up Manrico so that he would one day be killed by his own brother! Unbelievable! The full synopsis here.
Most people were looking forward to seeing the Russian superstars take the stage for very different reasons. One hand there was Anna Netrebko, singing her first Leonora at the Met, a character that she has dominated in Europe. And on the other side of the bracket was the return of baritone Dmitri Hvorostovsky to the stage after months of battling a brain tumor. Safe to say that both stars were at very high levels, delivering nuanced and deeply poignant performances.
Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."
Julius Caesar (I, ii, 140-141)
Looks as though the following might be surplus to requirements by the new NHS, as it was decreed that clients or service users do not really need hospitals.
The Background:
Historically, London Medical Schools were established in the hospitals in the poorer areas in order that medical students could have enough cases to practice on and in return the poor patients had the advantages of free treatment. There is nothing like volume for medical training.
For a very long time, doctors trained in London were one of the most valued. A Senior Registrar (yes, in those days) can easily get a Consultant job anywhere else in the Commonwealth and often a Professorship (British styled ones). In other words London trained doctors are a highly exportable commodity.
“The shape of the London hospital system has also been affected by developments in medical science and medical education. In many ways it has been the activities of doctors which have determined the pattern of the hospitals. The increasing ability to treat disease and improved standards of care shortened the time patients spent in hospital, raised the demand for services and led to an escalation of cost. The development of specialisation led first to the development of the special hospitals and later to special departments within the general hospitals. Advances in bacteriology, biochemistry, physiology and radiology created the need for laboratory accommodation and service departments, so that hospitals no longer consisted merely of an operating theatre and a series of wards. Sub-specialisation ultimately meant that services had to be organised on a regional basis and the very reputation of the capital’s doctors affected the number of patients to be seen. The hospitals of central London have long served a population much larger than their local residents.
It is against this complex background of population movement, poor social conditions, disease, wealth and poverty, professional expertise, critical comment and publicity that the London hospitals developed. A complex institutional pattern emerged. Voluntary hospitals grew up beside the ancient royal and endowed hospitals. A local government service providing institutional care for sick paupers developed alongside the hospitals. A network of fever hospitals, scientifically planned from the outset, was established. Physically near to each other, staffed by doctors who had trained in the same hospitals, and often serving the same people, the different objectives and status of the institutions led them to work in virtual isolation from each other. Each hospital had its own traditions and nobody standing in the middle of a ward could have doubted for a moment the type of hospital he was in. Countless details gave each an atmosphere of its own, and the different methods of administration and levels of staffing set them apart.” Geoffrey Rivett
Most of my Medical School Orthopaedic Surgeons were trained here.
The hospital treats almost 10,000 patients a year.
Although most patients would not consider travelling too far for a routine hip replacement, which can probably be done as well in their local district general hospital, the specialist clinics at the Royal National Orthopaedic may provide a reason to make the journey.
Specialist clinics deal with bone tumours, scoliosis (curvature of the spine), rheumatology, spinal injuries, specialist hand and shoulder conditions and sports injuries.
One word of warning – the RNOH's trust did not do well in the Healthcare Commission annual health check.
Strange that. So it may be the next to go.
If you have a head injury, stroke or condition affecting the brain, such as Alzheimer's, epilepsy or multiple sclerosis, this is the place to go. Along with the nearby Institute of Neurology, it is major international centre for treatment, research and training. The National Hospital for Neurology and Neurosurgery has 200 beds at its central London site near Euston station, and treated more than 4,500 in-patients and 54,000 outpatients last year.
Healthcare Commission quality of services rating: Good
Perhaps not for sale so soon. Or saving it for the needy MPs?
Neurologists wear bow ties in my days.
The largest specialist heart and lung centre in the UK, the Royal Brompton and Harefield acquired its reputation through the work of Sir Magdi Yacoub, the internationally renowned surgeon who pioneered heart transplants in the UK the 1980s.
The trust attracts staff and patients from across the country and around the globe, and is a centre for research with between 500 and 600 papers published in scientific journals each year. Its 10 research programmes each received the highest rating in 2006.
Each year, surgeons perform 2,400 coronary angioplasties (where a balloon is threaded through an incision in the groin to the heart and expanded to widen a blocked artery), 1,200 coronary bypasses and 2,000 treatments for respiratory failure – so they do not lack for experience.
Other specialist heart units with strong reputations are Papworth Hospital, Huntingdon, where Britain's first successful heart transplant was carried out in 1979; and the Cardiothoracic Centre, Liverpool, formed in 1991.
Healthcare Commission quality of services rating: Good
It could not be anything else.
The first dedicated cancer hospital in the world, founded in 1851, is still the best. With the Institute of Cancer Research, the Royal Marsden is the largest comprehensive cancer centre in Europe, seeing more than 40,000 patients from the UK and abroad each year.
It has the highest income from private patients of any hospital in Britain, testifying to its international reputation.
Very ready for Medical Tourism!!!
Healthcare Commission quality of services rating: Excellent
The country's largest ear, nose and throat hospital is also Europe's centre for audiological research, with an international reputation for its expertise and range of specialties, all on one site on London's Gray's Inn Road.
Its services range from minor procedures such as inserting grommets (tiny valves placed in the eardrum of a child to drain fluid from the middle ear) to major head and neck surgery. A quarter of its 60,000 patients were referred from other parts of the UK and abroad last year. The hospital has a cochlear implant programme, a snoring and sleep disorder clinic, and a voice clinic, the oldest and largest in the UK. One in 25 people develops voice problems such as hoarseness, but it rises to one in five among, for example, teachers, actors and barristers.
A measure of the Royal National's success is the fact that one third of patients referred from other clinics or hospitals with voice problems has their diagnosis changed on investigation there. Although there are many other centres where throat, nose and ear problems can be treated, none are pre-eminent enough to be included in this guide.
Wow!
Healthcare Commission quality of services rating: Good
Britain's leading national and international referral centre for diseases of the bowel is the only hospital in the UK and one of only 14 worldwide to be recognised as a centre of excellence by the World Organisation of Digestive Endoscopy.
It is a chosen site for the NHS bowel-cancer screening programme being rolled out across the country, which seeks to detect and treat changes in the bowel before cancer develops. Bowel cancer is the second most common cause of cancer in the UK but often goes undetected because sufferers can fail to report important symptoms, such as blood in the faeces, often out of embarrassment.
Bowel cancer can be treated via colonoscopy, to find and remove polyps – growths on the wall of the bowel. The hospital's education programme attracts clinicians from across the UK and overseas with the aim of spreading good practice elsewhere.
The hospital is part of the North West London Hospitals Trust.
The liver unit at King's is the largest in the world. It is one of 31 specialist liver units in the UK, but none can match it for expertise, facilities or state of the art equipment. It offers investigation and treatment for all types of acute and chronic liver disease, which is increasing in the UK.
The unit performs 200 liver transplants a year, and more than 200 patients with liver failure are admitted to its intensive care unit each year.
King's carried out the first successful transplantation of islet cells – part of the pancreas involved in producing insulin – in a Type 1 diabetic, greatly reducing his need for injected insulin. Last month, the Department of Health announced plans to establish six new islet transplantation centres round the country, based on the research at King's.
Healthcare Commission quality of services rating: Excellent
No bargain price, I am afraid.
The Maudsley Hospital
The Cockroach Catcher was there too.
One of Britain's oldest hospitals, the Maudsley's contribution to mental-health care stretches back at least 760 years.
Today it is a centre of excellence for the delivery mental-health care. Its addictions centre offers new treatments for drug abuse, alcoholism, eating disorders and smoking, it provides innovative care for disturbed children and adolescents and is the largest mental-health training institute in the country.
It has pioneered new approaches to the treatment of heroin addiction and its specialists have raised concerns over the link between cannabis and schizophrenia which have led the Government to review changes to the law.
Healthcare Commission quality of services rating: Good
If you have a child with a rare or complicated disorder, this is the place to come.
And they do and many are from the Middle East.
So the bad press would not matter, good for the Medical Tourist trade.
It is the largest centre for research into childhood illness outside the US, the largest centre for children's cancer in Europe and delivers the widest range of specialist care of any children's hospital in the UK.
Great Ormond Street won't treat just any patient, though: it only accepts specialist referrals from other hospitals and community services – in order to ensure it receives the rare and complex cases and not the routine.
Paediatrics is one of the most rewarding areas of medicine for doctors because it has seen some of the most spectacular advances over the past 30 years, especially in cancer, where survival has improved dramatically.
Many of those cared for at GOSH still have life-threatening conditions but they are promised the best care both because of the expertise of its medical staff and because of the trust's extraordinary success in attracting charitable donations, which have made it among the best-funded medical institutions in the country.
Healthcare Commission quality of services rating: Excellent.
Baby P or no Baby P.
My eyes still well up when Moorfields is mentioned. Honest.
The largest specialist eye hospital in the country and one of the largest in the world, Moorfields was founded in 1805. It treats more patients than any other eye hospital or clinic in the UK and more than half the ophthalmologists practising in the UK have received specialist training at Moorfields.
However, in recent years the hospital has relied too heavily on its reputation and grown complacent. Though standards of academic excellence are still high, it has neglected the services it offers to patients, which were rated weak on quality by the Healthcare Commission in its annual health check last year.
The hospital carried out 23,000 ophthalmic operations last year, providing surgeons with extensive experience on which to hone their skills. The reputation of the trust is such that it has started to run clinics in distant hospitals, capitalising on its brand. The hospital employs 1,300 staff who work on 13 sites.
Perhaps it is not so good to be following on commercial branding. Stick to medicine!!!
Despite its recent problems, Moorfields remains Britain's most highly-regarded eye treatment centre. No alternative hospitals have a comparable reputation.
Healthcare Commission quality of services rating: Weak
For bargain hunters then.
So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.
What about medical training? If these hospitals are sold, who pays?
And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day.
Say something now.
Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."
Julius Caesar (I, ii, 140-141)
If you think you have read this before: you have indeed. As NHS reform is just re-cycling of earlier political dogma, the Cockroach Catcher can re-cycle his blog posts!!!