Tuesday, September 11, 2018
Trauma and Human Resilience: II
Part 1:
View from World Trade Center © Am Ang Zhang 1994
Then came September 11. I remembered I was on holiday in Spain when it happened. I had just finished golf. I put my clubs away and went to the club house for a drink with my playing partners. As I approached their table, I sensed that something was wrong. There were no drinks.
Then one of them said, “One of the World Trade Centre Towers
I was trying to see if I heard right.
“In New York
“New York
Then moments later, the Spanish waitress came out and said to us, the second tower was down too.
I rushed back to our villa and shouted to my wife to turn on CNN and tried to contact our children, one of whom worked in Manhattan
Lines were dead.
Luckily, an Email came through our other daughter who was in England 55th Street Brooklyn .
What a shock. Unlike my parents’ generation we have had a long period of peace and prosperity but now everything was shattered.
The following day my office put a call through and I talked to my Associate Specialist.
The clinic just had an urgent referral. A local girl was referred. Very disturbed by what happened as one of her father’s good friends was one of the pilots whose plane went down. The family spent many holidays with them in their Florida
“Whatever you do, by all means talk to the parents but not to the girl. No one should see her. They should not turn on the TV and avoid any reminder of what happened.”
I then nearly said, “Give her Vodka, Gin or similar,” but I did not.
I gave the next best thing.
“Put her on a short course of Benzodiazepine to let her sleep for a few days.”
It shocked my Associate Specialist. It was not a drug I normally used, if at all, and why now?
Well, whatever happened, all I could say was that the family was in total agreement and months later my Associate Specialist told me that it was brave of me but it seemed to have worked for this girl.
In July last year I met a young couple at the swimming pool of our holiday condo. I thought they were Chinese but it turned out they were Vietnamese Chinese.
We started chatting. He said he left Nam (Vietnam
Jokingly, I said, you mean you were on the Helicopter?
“Yeah, how did you know?”
“You looked too young to be working for the Embassy.”
“My mum worked there. But my story was nothing, you should hear hers.”
His wife, an elegant looking petite Chinese swam closer.
“So, tell me.”
Well, she came out later. Her mother put her and four sisters on a junk (a Chinese fishing boat), one of those that took refugees out of Nam Hong Kong but they swam ashore. She spent the next three years in one of the Hong Kong camps.
“Yes, I remember those.”
“I know - the stench. We got used to it.”
Those camps were run under the auspices of the United Nations but the UN never really paid Hong Kong a single dollar. However that is beside the point. Conditions were very poor and one could hardly decide if it was Hong Kong ’s or UN’s fault. Every time we drove past it was like passing a local authority rubbish tip. We had to wind up the windows. Yet there were politicians who felt they needed to keep it bad to deter people. They continued to flow in right up to the handover. As it was still under British rule, Britain tried its best to keep people from going to Britain U.S.
I said something that sounded like an apology, an apology for Hong Kong , and for mankind.
“No. It’s fine. I am not bitter. We waited and we got to the U.S.
She told me someone suggested that she should have some therapy. She never did.
“Some things you can never change. If it happened it happened.”
But she managed to get most of her family out of camps and settled in the US
What a story of human resilience and triumph over adversities.
And I can still remember that lunch time meeting and the learning from King’s Cross.
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
From another doctor friend:
The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.
My 80 year old Mum has a long-standing habit of collecting old newspaper and gossip magazines. Stacks of paper garbage filled every room of her apartment, which became a fire hazard. My siblings tricked her into a prolonged holiday, emptied the flat and refurbished the whole place ten years ago. ……My eldest son was very pretty as a child and experienced severe OCD symptoms, necessitating consultations with a psychiatrist at an age of 7 years. The doctor shocked us by advising an abrupt change of school or we would "lose" him, so he opined. He was described as being aloft and detached as a child. He seldom smiled after arrival of a younger brother. He was good at numbers and got a First in Maths from a top college later on. My wife and I always have the diagnosis of autism in the back of our mind. Fortunately, he developed good social skills and did well at his college. He is a good leader and co-ordinator at the workplace. We feel relieved now and the years of sacrifice (including me giving up private practice and my wife giving up a promising administrative career ) paid off.
Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.
Objectively, a reader outside of the UK UK
Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.
From Australia
I have finished reading The Cockroach Catcher and thoroughly enjoyed it.
Zhang, I particularly liked the juxtaposition and paralleling of your travel stories and observations with your case studies, Of course, I could appreciate it even more, knowing the author and hearing your voice in the text. Because I’m dealing with anorexia, ADD and ADHD students I was very interested in your experiences with patients and parents and your treatment. Amazing how many parents are the underlying causes of their offspring’s angst. It was an eminently readable text for the medically uninitiated like me. Keep writing, Zhang
The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US
Monday, September 10, 2018
World Suicide Prevention Day:Un-Awareness of Lithium for Preventing Suicides.
Is it really Un-Awareness? Was there a specific reluctance? Was there a belief that the new antidepressants will do?
Antidepressants or Lithium! Side Effects but you will live to experience it!
One of my ex-juniors, now retired, called to ask if I have read about another celebrity suicide. How very sad!
Dr. Baldessarini of Harvard:
“Lithium is far from being an ideal medicine, but it’s the best agent we have for reducing the risk of suicide in bipolar disorder,” Dr. Baldessarini says, “and it is our best-established mood-stabilizing treatment.” If patients find they can’t tolerate lithium, the safest option is to reduce the dose as gradually as possible, to give the brain time to adjust. The approach could be lifesaving.
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.
"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. After all it is less than one eighth the price of a preferred mood stabilizer that has a serious side effect: liver failure.
Thank goodness: someone is talking about it.
Atacama where Lithium is extracted © Am Ang Zhang 2015
Lithium: The Gift That Keeps on Giving in Psychiatry
At the recent American Psychiatric Association annual meeting in San Diego Harvard Medical School
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 $
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.
Latest: British Journal of Psychiatry
Saturday, September 1, 2018
Best to Imitate Nature: Lotus.
Since the introduction of the ‘Lotus concept’ in 1992, Lotus leaves have become an icon for superhydrophobicity and self-cleaning surfaces, and have led to the concept of the ‘Lotus effect’. Although many other plants have superhydrophobic surfaces with almost similar contact angles, the lotus shows better stability and perfection of its water repellency. The upper epidermis of the lotus leaf has developed some unrivaled optimizations. The extraordinary shape and the density of the papillae are the basis for the extremely reduced contact area between surface and water drops.
All Photos© 2018 Am Ang Zhang
Often they grow in murky waters and yet they always look so pristine? Have you ever wondered why? Well, this lotus phenomenon has inspired a German scientist to invent a self cleaning paint.
“……STAY CLEAN LIKE A LOTUS PLANT. A University of Bonn
It is human nature to be critical. It is now a habit of most, especially intellectuals, to be critical of big corporations. You give them credit at your own peril. So the Cockroach Catcher is risking his reputation by quoting from this unlikely source yet again. This magazine is available free online so that you do not even have to be on the plane to read it. But, my goodness, it is full of gems!
This article said:
“They say that imitation is the sincerest form of flattery. If so, Mother Nature should be ecstatic, because scientists around the world are patterning industrial processes and all kinds of everyday products after her designs. Welcome to the field of biologically inspired design….
……Some might claim that mimicking nature isn’t exactly new, though. Orville and Wilbur Wright studied birds while designing the first airplane. Velcro resulted when a Swiss engineer began to wonder how the seeds of the burdock plant stuck so stubbornly to his woolen socks. Engineers modeled the nose cone of the Japanese Shinkansen bullet train on the beak of a kingfisher. In the medical field’s search for therapies and cures, physicians have studied nature for millennia. (One of the common arguments made by conservationists is that pharmaceutical companies often find new drugs hidden in the biology of plants that grow in threatened places, like rain forests.) And in recent decades, medical companies have grown increasingly sophisticated at manufacturing joints, bones, artificial skin, and even cells that copy their natural counterparts……”
In the book The Cockroach Catcher, Dr Am Ang Zhang muses over Artemesinin:
“……This reminds me of the story of Artemesinin, now reckoned to be the most powerful anti-malaria drug. It was recorded in the Chinese book of Herbal Medicine, which is over a thousand years old, as treatment for swamp fever. Its rediscovery by China was met with scepticism until it was noted that during the Sino-Indian conflict Chinese soldiers were not dying from the malaria that was rampant in that part of the world. For a long time, the Chinese did not share the findings with the rest of the world. By chance along the banks of Potomac River , specimens of the plant were found. It took some years before the drug was developed. By now it is the standard treatment of choice……”
Ancient Medicine & Nobel.
Other Nobel Posts:
Fremantle: Medical Heresy & Nobel
Medicine & Nobel: Morality & H.P.V.
Curiosity & Nobel
Kandel & Doidge: Neuroplasticity & Memory.
Nobel: Kandel and Lohengrin
Chinese Shared Nobel Prize in Chemistry
Nature Posts:
ECOLOGY: First Bees, Now Bats.
Paraguay: Technology Meets Ecology
Hong Kong: Humpback Whale
Tasmania: Whales & Dolphins-Mother & Baby
ECOLOGY: First Bees, Now Bats.
Paraguay: Technology Meets Ecology
Hong Kong: Humpback Whale
Tasmania: Whales & Dolphins-Mother & Baby
Friday, August 24, 2018
Brain Tumour & Unusual Treatment.: GBM & Pork.
© Am Ang Zhang 2015
A short while back I blogged about GBM and how an innovative treatment may have helped. Being a doctor Dr Anderson noted this:
My wife, Carmen Alicia, called a local friend, also a cardiologist, who sent us to a nearby hospital; there, an MRI exam revealed a small spot on my brain. The neurologist felt it needed to be biopsied to obtain a tissue diagnosis. I immediately returned to Virginia and went to several specialists, who suggested further testing before I decided to have an invasive brain biopsy. I also had a blood test for cysticercosis, an infection that results from eating undercooked pork contaminated with Tenia solium. This common parasite produces cysts all over the body, including the brain. It is the most common reason for seizures in many countries, particularly in India, where children with seizures are first treated for this disease even before other studies are done. My blood test was strongly positive. I started a course of oral medicine to treat it. The test reassured me.
My later research showed that there may indeed be some association of Tenia and GBM.
Neurocysticercosis (NC) is the most frequent and widespread human parasitic infection of the central nervous system (CNS). Glioblastoma multiforme (GBM) is a neoplasm of CNS in elderly population and may have a similar clinical and radiologic presentation as of NC. The coexistence of NC and neoplastic intracranial lesion in an individual is a very rare entity. The incidence of NC among intracranial space occupying lesions is reported to be 1.2-2.5%.[1–4] Though cerebral cysticercosis may be associated with glioma,[5] but this rare coexistence of NC and brain tumors puts into question a causal relationship between the 2 diseases. Here we report a case in which glioma and cysticercosis appeared concomitantly, with continuing progression of low grade Glioma to high grade Glioma (GBM, WHO grade IV).
So some religious dogma might actually be good for ones health.
But watch out, even if you do not eat pork:
Neurocysticercosis in an Orthodox Jewish Community in New York City
All the patients and their families adhered to Orthodox Jewish dietary laws, which forbid the eating of pork. Moreover, T. solium taeniasis due to the ingestion of contaminated pork is extremely unlikely in the United States. Cysticerci were detected in only 3 of more than 83 million hogs examined after slaughter under federal inspection in 1990.
The most likely sources of infection in the patients described in this report were women living and working in the patients' homes who had recently emigrated from Latin American countries where T. solium infection is endemic.
In 2003 the world was in the grip of a new plague that challenged our knowledge of medicine to its limit.
For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease. The alarm was first raised by its first victim, Carlo Urbani. He was an Italian physician employed by the World Health Organisation (WHO) and based in Hanoi , Vietnam
Doctors often thought that they would be immune, a God given right I suppose. Not so this time! The virus obviously knew what it was doing.
A doctor friend had just been diagnosed with GBM (glioblastoma multiforme) grade IV. My hospital librarian had the same tumour and told me that the hospital neurosurgeon got it too. Another close friend who is an ENT surgeon has just been diagnosed with NPC (Nasopharyngeal Carcinoma).
Looks like doctors are no longer as immune as we like to believe and that goes for those that worked closely with doctors like our beloved librarian. .
More about the DOCTOR I mentioned earlier:
He is a cardiologist for thirty five years, (so not a neurosurgeon then) but with the diagnosis his research unravelled one of the possible reasons for "catching" GBM.
Why?
Why did this tumor happen to me? I never smoked and had had no brain injuries, and there is no history of such tumors in my family. As a cardiologist, I had implanted close to 400 pacemakers in my life and during the procedure was exposed to ionizing radiation (X-rays). In the early days we used portable X-ray machines and gave ourselves some protection by using thin lead gowns. Nowadays, heavy lead gowns are worn, and doctors and technicians protect their thyroid and eyes with shields and glasses. We also use heavy sheets of radiation-protective glass that hang from the ceiling.
At some point in my research, I was surprised by an article by a Johns Hopkins-trained cardiologist who now practices in Israel
GBM
" I had a glioblastoma multiforme (commonly called a GBM) grade IV. This is the most malignant brain tumor; no grade II or III exist. A glioblastoma is what killed Sen. Edward M. Kennedy (D-Mass.) in 2009. While rare, it is the most common of the brain tumors. The prognosis is dismal; on average, patients survive only 14 months after diagnosis even with chemotherapy and radiation. After five years, only 5 percent of patients are still alive."
So depressing.
But wait: The Zapping!
" The Preston Robert Tisch Brain Cancer Center at Duke University
As doctors there examined me, it was obvious that my tumor had already grown again; in fact, it had quadrupled in size since my initial chemo and radiation. I was offered several treatments and experimental protocols, one of which involved implanting a modified polio virus into my brain. (This had been very successful in treating GBMs in mice.) Duke researchers had been working on this for 10 years and had just received permission from the FDA to treat 10 patients, but for only one a month."
The procedure:
"I was given the Salk polio vaccine to prevent a systemic polio infection.
At Duke, my skull was opened under local anesthesia and I had the viral infusion dripped through a small catheter directly into the tumor in my brain for six hours."
The result:
"I returned to Duke a month after the infusion, and though an MRI showed some expected swelling, the more significant fact was that the tumor had stopped growing. I have gone back to Duke every two months since then, and the tumor, initially the size of a grape, is now a scar, the size of a small pea. It’s been two years since the initial biopsy and radiation, and one year since the experimental polio viral treatment, and I have no evidence of recurrence nor tumor regrowth.
According to a presentation about the research that the Duke doctors gave last May, the results so far are promising: “The first patient enrolled in our study (treated in May 2012) had her symptoms improve rapidly upon virus infusion (she is now symptom-free), had a response in MRI scans, is in excellent health, and continues in school 9 months after the return of her brain tumor was diagnosed. Four patients enrolled in our trial remain alive, and we have observed similarly encouraging responses in other patients. One patient died six months following . . . infusion, due to tumor regrowth.” They added: “Remarkably, there have been no toxic side effects . . . whatsoever, even at the highest possible dose.”
That has been true for me. I feel as fit as I was three years ago, before the first symptoms of the glioblastoma made their appearance. I remain only on an anti-seizure medication."
Laoshan China
© Am Ang Zhang 2011
Thirty years ago, I saw mountains as mountains, and waters as waters.
When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains,
and waters are not waters.
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.
Friday, August 17, 2018
Food Labeling: They just print what you want to hear!
Looks like it is not only my patients that fake!
18 September 2015
German carmaker Volkswagen has been ordered by US regulators to recall half a million cars because of a device that disguises pollution levels.
The "defeat device" allows cars to pass lab testing even though they actually emit 40 times the emissions standard.
The illegal system allowed cars to detect when they were undergoing smog emission test and lowered the rate of pollution. Those emission controls were then turned off during ordinary use.
Now how many would take up the recall as it has nothing to do with safety and if you remove the devise you are going to use more diesel.
Forbes thought the same too: read it here!
It was a device to mislead regulators and not consumers. It benefits consumers.
Not quite, just like faked Kona Coffee, it is still caviar but a cheaper species.
Looks like the big boys are moving in as the pickings are better with the rich and famous who can’t tell their burgundies, coffees or now caviar.
I think I like to get my hand on those cheap stuff that could be passed off as fakes.
The Guardian:
Is fine dining having its Apollo 13 moment? I know it's not on the same scale as "Houston
King is the founder and co-owner of the eponymous King's Fine Foods, the UK 's largest supplier of caviar with a client list that includes Buckingham Palace
Random DNA tests taken back in October at King's premises in Richmond
The Cockroach Catcher has always been amazed that in a short time under pressure from consumer groups and the government, food manufacturers and supermarkets managed to produce detail analysis of the product they sell so that consumers can be clear what they are “consuming”!
What he was amazed was how healthy most foods were: sugar free, trans-fat free, cholesterol free. Even when the product has cheese.
Wow! Modern food processing technology! Or was it modern labelling technology!
Then he remembered Ribena. You can read about it here>>>>>
Vancouver ©2012 Am Ang Zhang
I happened to be in one of the world’s most livable city and imagine my surprise when I read this in:
Calgary Herald:
Tests unveil misleading food labels
Bad nutrients understated, good ones overstated
By Sarah Schmidt, Postmedia News
Some of the world's biggest food brands and leading organic labels have understated the amount of bad nutrients — such as fat, sugar and sodium — in their products, or overstated the good ones, internal government tests show.
Kraft, Frito Lay, Unilever and Heinz are among the big names with a product that flunked Canadian Food Inspection Agency (CFIA) testing, conducted to see if nutrition claims on labels live up to their billing.
Loblaw's popular President's Choice brand had multiple "unsatisfactory" tests on products ranging from cereal to spaghetti.
Premium brands like Amy's Kitchen, Eden Organic, Natur-a, Kashi and Yves Veggie Cuisine also fell short on composition claims, as did Canadian food-makers like B.C.-based Sun-Rype Products Ltd. and Quebec-based Aliments Fontaine Sante.
No Sugar:
Among the breads and baked goods tested, Fenwicks "no sugar added" cookies (too much sugar)
Iron:
In the snacks category, Krispy Kernels Inc.'s Island mixed nuts claimed to contain 90 per cent of the recommended daily intake of iron per serving. Samples tested by CFIA found contained a fraction of that: 10.5 per cent.
A sampling of other findings shows the huge discrepancies that can exist between labels and ingredients.
Cholesterol:
Some snacks boasting a "No cholesterol" message on their label showed levels ranging from 4.3 milligrams (Lays Smart Selections chips) to 10.5 mg (Barbara's Cheesepuff Bakes) per portion, according to CFIA tests.
(PepsiCo says its own tests on Lays chips, conducted after CFIA informed the company of the agency's eight unsatisfactory tests involving samples of three Smart Selections chip products, showed the claim was accurate.)
Kraft made the same no-cholesterol claim for its Ritz "Real Cheddar Cheese" crackers, but CFIA testing showed the crackers contained 3.2 mg per portion. Dare's cinnamon snap biscuits contained 4.9 mg, CFIA testing showed.
These discrepancies pale in comparison to the findings of two canned snail products picked up from Dollarama stores in Regina Indonesia
Vitamins:
Canned foods from Unico (pizza sauce), Primo (vegetable soup), Stokely (pumpkin) and Amy's (refried beans, butternut soup) all fell short of their vitamin claims. So did Eden Organic's vegetable spirals, President's Choice organic pasta sauce, Fontaine Sante spinach dip and Island Farms yogurt.
Of the 40 products found to be overstating the amount of vitamins in their products, Yves Veggie Cuisine Ground Round (Mexican flavour) and a prepared pasta dinner by Olivieri Creations stood out for being wildly inaccurate.
The label on Yves Veggie Cuisine Ground Round, a product of the Hain Celestial Group, said each serving contained 80 per cent of the daily value of vitamin A, but CFIA testing showed 3 per cent. And a pre-packaged tortelloni and chicken dinner by Olivieri Creations claimed to contain 110 per cent of the daily value of vitamin C per serving, but CFIA found a serving contained only 1.1 per cent.
Sun-Rype, Oasis and Bolthouse Farms were among the juice brands that overstated — by about double — the amount of a vitamin.
Two juices from Dewlands fared worse; each boasted 35 per cent of the daily value of vitamin A, butnone was detected in either.
Omega acids:
Big-brand products that failed to live up to their omega-3 or omega-6 fatty acid claims included President's Choice Angus burgers, Kraft House Italian dressing and Country Harvest tortillas. Hellmann's mayonnaise under-delivered on the amount of polyunsaturated fatty acids, as did Kashi's honey almond flax cereal.
Specialty products that overstated one these so-called "good fats" include Natur-a soy beverages, So Good fortified soy beverage, Ruth's cereal, and Mom's Healthy Secrets cereal.
GoldSeal canned salmon, Ocean's canned salmon, Our Compliments salmon burgers and High Liner salmon were among the fish products that overstated the amount of omega-3 or omega-6 fatty acids.
Salt:
Some products pitched as reduced in sodium didn't live up to their billing, including Heinz "25 per cent less sodium" Dora the Explorer vegetable and pasta soup, Eden Organic "low salt" canned green lentils, rice and beans, R.W. Knudsen Family "low sodium" vegetable cocktail, "50 per cent less sodium" President Choice crackers, and "low sodium" President's Choice tomato and roasted red pepper soup.
There were also "unsatisfactory" discrepancies in three different Bread Works Bakery "low in sodium" cracker products, with one containing 277.8 mg of sodium, not 70 mg, according to CFIA tests.
Two different cans of Unico artichokes, picked up four months apart, were found to be saltier than claimed on the Nutrition Facts Table.
Calories:
"Light tasting" Nutriwhip testing showed 68 calories per portion, not 20 as claimed on the label. A green tea beverage from Tempest Tea claimed to contain just 5 calories, but testing showed 106 calories per portion.
If it could happen in Canada
Twitter:
Canadian Food Inspection Agency cuts cause Vancouver food inspectors unit to disband straight.com/food/630636/ca… via @georgiastraight
First Posted as
Food Labels: Real or Really? April 21, 2012.
Thursday, August 16, 2018
Anorexia Nervosa : Enmeshment & Failure!
©2013Am Ang Zhang
Alert readers would have noted a number of Anorexia Nervosa cases on this blog and in my book, The Cockroach Catcher and that Minuchin’s name has indeed been mentioned.
Regardless of what present day psychiatrists (and that includes those dealing with Anorexia Nervosa, Minuchin have in one way or another inspired us in our dealings with Anorexia Nervosa and of course families in general.
He has inspired me the most in my work with families and with Anorexia Nervosa in particular.
He was born in Argentina and soon served in the Israeli army before continuing his training including that of psychoanalysis in New York US
Minuchin above all helped me in my understanding of family dynamics and in turn in my personal dealings with problem families and Anorexia Nervosa.
Minuchin has recognized a group of family system characteristics that reflect the family dynamics of patients with anorexia nervosa:
Enmeshment:
This is a transactional style where family members are highly involved with one another. There is excessive togetherness, intrusion on other's thoughts, feelings and actions, lack of privacy, and weak family boundaries. Members often speak for one another, and perception of the self and other family members is poorly differentiated. A child growing up in this type of family learns that family loyalty is of primary importance. This pattern of interaction hinders separation and individuation later in life.
Overprotectiveness:
This refers to the excessive nurturing and protective responses commonly observed. How can the psychiatrist begin to argue against such a good trait! Pacifying behaviors and somatization are prevalent.
Rigidity:These families are heavily committed to maintaining the status quo. The need for change is denied, thereby preserving accustomed patterns of interaction and behavioral mechanisms. Rigidity is commonly observed in the family cycle during periods of natural change where accommodation is necessary for proper growth and development. You must have seen families where for every single day of the week they eat the same meal year in year out.
Avoidance of conflict/ conflict resolution:
Family members have a low tolerance for overt conflict, and discussions involving differences of opinion are avoided at all costs. Problems are often left unresolved and are prolonged by avoidance maneuvers. Everyone would come up with a highly believable excuse. After all everyone is very clever!
Apart from classical Autism, parents of many sufferers of Anorexia Nervosa are amongst the most successful in their own profession. Many are CEOs of major corporations including Hospital Trusts and PCTs. Minuchin’s powerful understanding of the family dynamics has allowed me to navigate the very difficult terrain. More so than trying to learn Tango!
Minuchin
It is not easy to admit to failures and harder still for doctors to do so especially if they did everything right and according to protocol.
Doing the “right” thing is not an indication of success.
Hardly.
Yes. I am coming back to Anorexia Nervosa again and I do not apologise for it. I am apologising for our failures though
When I took over the adolescent unit as its consultant in charge there were six Anorexia Nervosa patients in varying stages of emaciation or weight gain depending on from which side you want to look at it. It is not always wise to have so many anorectic patients together as they do share tricks with each other and it is often more difficult to customise treatment.
What needed my urgent attention was of course Sammy. Sammy had a very feminine name but preferred the nickname Sammy. Sammy’s Section was due to expire in less than 14 days and I had to compile a report for the Tribunal which would be sitting to decide on her fate.
It was perhaps a sign of our failure as psychiatrists to effectively treat Anorexia Nervosa that eventually case law was established to regard food in Anorexia Nervosa as medicine. Therefore food may be used forcibly to treat Anorexia Nervosa when the condition becomes life threatening.
The usual test of mental capacity no longer applies. Instead the law is used forcibly to feed a generally bright and intelligent person “over-doing” what most consider to be “good”. They try to eat less and eat healthily by avoiding fat and the like and wham we have the law on them.
I have to admit that I have not liked this aspect of Sectioning. Unfortunately it is used often, judging by the high numbers of tube fed patients.
On the other hand not everybody is able to treat Anorexia Nervosa patients or, in reality, do battle with them. It requires experience, energy, time, wit, charisma and often impeccable timing. However, sometimes I do wonder if we are indeed doing a disservice when we take things out of parents’ hands by agreeing to take over.
With hindsight and upon reflecting on a number of cases I have dealt with, I often wonder: if hospitalisation had not been an option at all, would improvement rate and, more importantly, mortality rate have been any different.
We do not section people for smoking, drinking, or doing drugs, which all endanger life. Nor do we stop people running the Marathon or eating raw oysters when these activities regularly lead to mortalities.
Society is coming round to do something about over-eating in children but it will take some time before they apply the Mental Health Acts.
To me, the moment a psychiatrist turns to the law he is admitting that he has failed.
At least that is my view and if I perpetuated the Compulsory Order with Sammy, I too would be part of that failure.
There had been no weight gain in Sammy despite the tube feeding and the debate was: shall we increase the feed or shall we wait? Everybody just assumed that she would stay on as a compulsory patient.
Despite bed rests and even more embarrassingly the use of bedpans, many Anorexia Nervosa patients managed not to gain weight whatever we pumped into them. The balanced feeds were in fact quite expensive. There was no secret that they were aware of the exercises they could perform even on bed rest and the determination not to put on weight had to be seen to be believed. If such determination was applied elsewhere I was sure these young girls could be very successful.
I had to find an answer, an answer for Sammy and an answer for myself.
Being forced to eat by the State remained the treatment of choice for everybody except for one stubborn consultant.
“At least we did all we could,” my staff constantly reminded me.
“And she is the most determined of all the Anorectics we have right now.”
More reason to show the others that this new psychiatrist had some other means than brute force, I thought to myself.
Yes, I could be as determined as they were.
The hours of family therapy only brought about accusations and counter accusations with hardly any resolution. Middle class families have certain ways of dealing with things where some branches of family therapy are not particularly good at all.
The modern trend is certainly moving away from blaming families. Or that is the rhetoric of most who write publicly about it.
Whatever the official line, families cannot help feeling blamed.
“If we are not to blame, why do we need family therapy?”
“There are so many other families like ours. Why do they not have the same problem?”
We may reassure them that there are and that is the truth, but the truth is that there are also Anorexia-free families.
Yes, it might help if they do find a gene like they did with obesity. Yet that cannot explain why there are more extremely obese people in say the U.S. which collects gene pools from across the globe.
So Sammy’s family had the full benefit of eight sessions of family therapy by two very experienced therapists. In the end, there was just a lot of recrimination between all parties including the therapists and all agreed it would not be the way forward. That was when tube-feeding started.
Minuchin[3] dealt with over-involvement, over-protectiveness and conflict avoidance in these families with no special apology on whether he blamed the family or not. He used to start with a meal session with the family. His success, like many such methods, probably had more to do with his charisma than his method and is thus difficult to replicate.
For Sammy and her family the message was simple and clear enough, no matter how hard we lied.
The family had failed and the hospital had to take over.
That was the blunt truth.
But the hospital had failed too and we had to resort to the Mental Health Act on one of society’s most sensible and decent and safest citizens.
I decided enough was enough. I could no longer perpetuate the no-blame approach. I could no longer continue to hide behind the power conferred onto me by the law.
In short, I had to reverse just about everything that had gone on before, and more.
Just two weeks before the tribunal sat we had the big review meeting. To most at the unit, the review was fairly routine as there was hardly any choice – a full Section for Hospital Treatment primarily intended for difficult to treat Schizophrenics and difficult to control Bipolars in the acute manic phase. Sammy would be “detained at Her Majesty’s pleasure”, and classed with the likes of the few psychotics who had committed the most heinous murders. To save Sammy’s life, it would be natural to continue with the Mental Health Act.
Yes there would be weeks of tube feeding and bed rest, but the State had to take over the complete care of this bright young thing for her own sake.
I could not see any other way either.
Unless …….I could reverse everything that had gone on before.
If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative. Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.
I had a plan.
These meetings were attended by just about everybody who had anything to do with the patient. They were held at school times so that most of the teaching staff could be present as well. These meetings also had a tendency to drag on as everybody seemed to have a lot to say about very little, a trait not just limited to psychiatrists but also seen in social workers, therapists, nurses, junior grade doctors, teachers and visiting professionals. People always seemed to have a lot to say on cases where there was the least progress.
My personal view is that this was a sure sign of anarchy which had unfortunately drifted into our Health Service, encouraged in part by the numerous re-organisations that had gradually eroded the authority of the doctor.
Saul Wurman[4], an architect by training but also an author of business and tour books, famously wrote that meetings really do not always need to be an hour long. Why can it not be ten or twenty minutes?
Could I achieve that?
After briefly explaining to all the purpose of the meeting, I turned to Sammy, who still had the nasal feeding tube “Micropore’d[5]” securely and said, “What do you think?”
“It is so unfair. Now I shall not be able to go to Harvard.”
It is generally perceived as a given that a U.K. citizen who has been Sectioned will not be able to use the Visa Waiver to visit the U.S. If that person then has to apply for a Visa, having been detained under the Mental Health Act must be a major hindrance, although I have never seen this applied in practice. One of my patients did have to cancel a horse trial trip to Kentucky because she was sectioned at the height of a manic episode.
I did not know she had aspirations to get to Harvard but I was not surprised given what I already knew about mother.
“Before I say anything else, can I ask you a few things?”
“What? Sure!”
“Do you smoke, drink, take Ecstasy or go out clubbing?”
“No. Why?”
“Do you have piercings and tattoos on you?”
“Tattoos—yuk! Yes, I having my ears pierced. That is all.”
“Do you like Pop music?”
“No way. I play the violin and I like Bach and Bartok!”
Everybody was attentive now.
“Do you shoot heroin or smoke Cannabis?”
“No way!”
She was getting annoyed.
“What about boys and sex?” I felt bad even to ask especially in front of her mother, who I thought would faint if we knew something she did not.
“How can you even ask and in front of my parents? You know I don’t do things like that!”
I can remember my own adolescence. I did not do any of those things either and I did not even have pierced ears.
I then turned to the parents. Mother was a history teacher at a famous private school in one of England’s most middle class town. She also spent a year at Harvard, hence Sammy’s ambition to follow her. Father was a prominent city lawyer.
“You have always provided well for her, a good education, European and U.S. holidays, a comfortable home and expensive music lessons.”
“We are fortunate enough to be able to do that. She is our only child.” Mother replied in a tone implying, “what’s wrong with that?”
“And she has always been a bright child, strong willed and single minded. She passed her Grade 8 violin with distinction at 14 and could have become a musician. But she wanted to do International Studies.” Mother added.
“So she always had her way.”
“She has always got on with everything, studying and practising the violin. And she keeps a tidy bedroom!”
A tidy bedroom! My goodness, everything was falling into place.
“Sammy……”
“Yes……”
“You know what? You are the first adolescent I know that keeps a tidy bedroom, do not do drugs, do not drink, do not smoke and you do not do a load of other things I asked you about. You are by modern standards a FAILED adolescent!”
Then I turned to the parents.
“And you, FAILED parents!”
“And we FAILED you. We failed you because we had to hide behind the law and force feed you.”
Sammy said, “I can’t do all those things even if you make me.”
Ah, the turning point.
“No, don’t get me wrong. I don’t want you to either.”
I then told her that I would like to take the tube off her despite lack of progress, or because of it.
It simply had not worked.
I wanted her to take over, do what she needed to do and I would decide in about ten days if I had to extend the Treatment Order.
Forty five minutes. The meeting took forty five minutes as people had to present summaries of different reports, the details of which were irrelevant here.
The battle was over. Sammy looked relaxed. Nobody was fighting her now. She was back in control.
I took her off the Section as she started to put on weight and before long she was discharged.
We forget how easy it is to entrench. To entrench is a sure way to perpetuate a problem.
Wednesday, August 15, 2018
Sepsis & Quorum Sensing!
For the past three hundred years……we’ve been completely wrong……we don’t know anything about bacteria until about a decade ago….”
Bonnie Bassler
Bassler group finds an alternative mode of bacterial quorum sensing
Whether they are growing in a puddle of dirty water or inside the human body, large groups of bacteria have to interact with each other and coordinate their behavior in order to perform essential tasks that they would not be able to carry out on their own. Bacteria achieve this coordination through a process called quorum sensing, in which the microorganisms produce and secrete small molecules, called autoinducers, that can be detected by neighboring bacterial cells. Only when a large number of bacteria are present can the levels of secreted autoinducer build up to the point where the community can detect it and, in response, alter their behavior as a coordinated group.
In a paper published last month in PLoS Pathogens, a team of researchers led by Sampriti Mukherjee and Bonnie Bassler from the Department of Molecular Biology revealed the existence of a new quorum sensing molecule that increases the virulence of the pathogenic bacterium Pseudomonas aeruginosa. The finding could help researchers develop new antimicrobial drugs to treat the serious infections caused by this bacterium.
P. aeruginosa is an incredibly adaptable organism that can grow in diverse environments, from soil and freshwater to the tissues of plants and animals. It thrives on the surfaces of medical equipment and is therefore a major cause of hospital-acquired infections, causing life-threatening conditions, such as pneumonia and sepsis, in vulnerable patients. The bacterium has become resistant to most commonly used antibiotics, making the development of new antimicrobial treatments a priority for both the Centers for Disease Control and Prevention and the World Health Organization.
Hospital Infection: Quorum Sensing
This is the story of a much respected retired professor. As he celebrated his 82nd birthday, we have to be thankful that he must have some strong genes to have survived the last eight months. An unfortunate slip at home fractured one of his ankles, and as a pin was needed a surgical procedure was performed in a local hospital by the Orthopaedic surgeon. For the following eight months an otherwise independent and healthy eighty one year old had to suffer the indignity of many more hospital procedures because of a lingering infection.
“I don’t know” was his answer when we visited him and asked if it was the dreaded MRSA.
He was never tested!
Nearly 15 years since the discovery of Quorum Sensing by Nottingham University the topic seemed to be shrouded in some mystery. The Cockroach Catcher read about it by chance in an airline magazine and his own survey of some recent medical school graduates from Cambridge and Southampton indicated that this was not in their curriculum and they had never heard of it.
There is of course a Nottingham Quorum Sensing website and certainly Cambridge produced some research papers.
Why?
Bonnie Bassler said that all we knew about bacteriology in the last 300 years is all wrong. Strong words indeed. So are we still teaching medical students all the wrong stuff?
Is professional jealousy at work here? Surely not. But Quorum Sensing will itself lead to other exciting findings about the world of the microbe that has so far got the upper hand on the ever so clever Homo sapiens.
Think MRSA and C.difficile and I am sure you will agree.
I know that it is a new field and much of it theoretical and conjectural but I was a medical student once and the greatest buzz for me then was Heart Transplant, and VAMP treatment for some kind of leukaemia. So could we not let the future doctors have some excitement other than the 3G iPhone?
Surely we need to inspire some great brains to go where no men have gone before.
It is now well established that in France and Holland where hospitals do not run to capacity, they do not have the level of MRSA and C. difficile problem that we have here.
I do not think that is the result of them using some of the methods we have been known to use here, i.e. not testing the patients. Their standard of care is probably different and their wards are not as crowded.
We do seem to have lots of “good” lateral thinkers working in the NHS. In the meantime, our well loved professor has decided to move to sheltered housing. Months of struggling with his immobility and inability to go walking, swimming, shopping and getting on with his daily chores robbed him of his desire to be independent. But at least he survived.
What about his hospital manager? Did he or she get the bonus? 
SARS and Quorum Sensing
There is a chapter in The Cockroach Catcher called “SARS, Freedom and Knowledge”. I wrote about the SARS virus:
“For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease. ……
Our knowledge base was in total chaos. What we knew was obviously not good enough. Nor were the most up to date antiviral drugs……”
I am not a bacteriologist nor virologist but that did not stop me writing about these little creatures.
When I picked up the in-flight magazine on a recent flight, an article titled “Genius at Work” caught my eye. Bonnie Bassler is the bacteriologist at Princeton who discovered and pioneered the work on what she now called quorum sensing in microbes. To be more precise her initial work was with Vibrio harveyi. Vibrio is in the family of bacteria that causes Cholera. Vibrio vulnificus is carried by oysters and was most likely responsible for the serious illness of Michael Winner, film producer and now food writer of the London Sunday Times.
On following this up back home, I found an article on the website of Howard Hughes Medical Institute – she is one of the HHMI Investigators. From this article, I learned that:
“Virulent bacteria do not want to begin secreting toxins too soon, or the host's immune system will quickly eliminate the nascent infection. Instead, Bassler explained, using quorum sensing, the bacteria count themselves and when they reach a sufficiently high number, they all launch their attack simultaneously. This way, the bacteria are more likely to overpower the immune system….
For the past three hundred years……we’ve been completely wrong……we don’t know anything about bacteria until about a decade ago….”
Wow! Just as we thought we knew everything there is to know about microbes.
Bonnie Bassler will one day get the Nobel prize for medicine. You read it here first.
Fascinated, I wanted to find out more about this genius. I would like to share with you her answers to some of questions that children were invited to ask about her life and work:
“You all asked me essentially the same question: how and when did I get interested in science. As a kid, I loved doing puzzles, solving riddles, and reading mystery books. I also loved animals and always had pets. Around high school, those interests (puzzle solving and animals) convinced me that I should be a veterinarian so I could work on mysterious illnesses in animals and cure them. In college, I realized I did not like big-bloody stuff. It became clear to me that I probably wouldn't enjoy being a vet, but I did not know what I'd do instead.
Fortunately, the vet curriculum required me to take biochemistry, genetics, and lab courses. Once I got into those classes, I fell in love with doing puzzles about little things (DNA and RNA and proteins and how they all fit together in cells). I also adored doing lab experiments and puzzling over my results. I realized that lab research was the perfect path for me. It allowed me to spend every day figuring out mysteries/puzzles that have to do with what make us alive. What could be a bigger mystery or puzzle? I changed my major in my junior year, and I have not left the lab since. (I still love animals and have a pet—Spark my cat—and I often go hiking hoping to see animals in the wild.)
I think being open-minded about what Nature is trying to tell you is the key to being creative and successful.”
Now in England , only a couple of Medical Schools require biology. In my book, I puzzled over this fact:
“The ability to dissect out a full set of cockroach salivary glands was a prerequisite requirement for medical school entrance in Hong Kong in our days. It is almost a 180 degree turn around nowadays when many young doctors have no idea about the biological world we live in. Nearly all Medical Schools in England no longer specify biology as a prerequisite subject for anybody who wishes to embark on the study of the human body. As we are so intertwined with the rest of the living biological world I find this policy quite extraordinary.”
Book I am reading:
As the Nazi regime slaughtered millions across Europe during WWII, it sorted people according to race, religion, behavior, and physical condition for either treatment or elimination. Nazi psychiatrists targeted children with different kinds of minds―especially those thought to lack social skills―claiming the Reich had no place for them. Asperger and his colleagues endeavored to mold certain “autistic” children into productive citizens, while transferring others they deemed untreatable to Spiegelgrund, one of the Reich’s deadliest child-killing centers.
SARS ACCOUNTS: Dr Yannie Soo, Tom Buckley.
Other Posts:
Learning From History: 1918 Flu Pandemic, Hong Kong SARS, Swine Flu & Influenza A(H1N1)
Swine Flu: WHO Level 5 & The 1976 Vaccine Disaster.
Swine Flu: WHO Level 5 & The 1976 Vaccine Disaster.
Monday, August 13, 2018
NHS & Gawande: Morbidity and Mortality Conference M+M
It seem timely to bring back an old Blog!
We need to look at the way medical liability is covered in Hospitals where indeed all juniors must be covered by a consultant in one way or another. The responsibility would indeed be that of the hospital management and not on the poor Junior Doctor. The difficulty is the choice between NO doctor or a less experienced one. Should the patient be told or should the A&E just be closed? Will management do that or just continue to abuse the poor juniors and blame them when things go wrong. No wonder my friends' children prefer to become lawyers.
I read Gawande when I was touring Peggy's Cove and posted about his book Complications! Honestly, I did not know Gawande was giving the Reith Lectures.
Latest Gawande Book:
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
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.’
>>>See also Dr No: We Have No Black Boxes
>>>See also Dr No: We Have No Black Boxes
Abetternhs's Blog What are we afraid of?
August 27 2014:
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.
All photos©2014 Am Ang Zhang
(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
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.’
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.’
Read more:
NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
Wednesday, August 1, 2018
Junior Doctors & Sunset: 1st day & Tears?
No, it was not the sunset that brought tears:
From Avatar Land© 2015 Am Ang Zhang
This is extracted from another post that is about not just the strange medical condition that I have to wait 30 plus years for an answer but to the Junior Doctor that I fondly remembered. This brought tears to my eyes as it was NHS at its best.
Now are we seeing the end game. Well only 54,000 pawns left on the Chess Board.
.........Perhaps we should catheterise her. She had not been seen to use the toilet for hours although she was not drinking much. She was still going round in her room – we gave her the side room and a nurse – and we put on an input output chart so we knew. The new junior doctor’s car broke down so she was late in examining her.
Bother, I forgot it was changeover time, when new doctors came in for their new six-month rotation. This is one of the days of the year not to be ill.
“Good work Sister. What do we do without you?”
Sister did the catheterisation but only got about 150ml. The mass was still there.
I phoned Ob-Gyn. The consultant had left for home, but I got her Senior Registrar.
He came over. Yes, it was possible that she was pregnant but unlikely as there were no breast changes. He would hate to do an X-ray but that seemed justified in the case of an undiagnosed abdominal mass.
My mind was racing now. Sometimes you do have to believe what you see. Sometimes you have to believe the parents. She was not one of those girls. She could not be pregnant. So now we had to go through the differential diagnosis for abdominal mass in a young girl of thirteen.
Ovarian cyst was the obvious one.
This big?
Possible.
No. It cannot be.
The x-ray came back. The tell tale tooth was there and yes – a Teratoma, the distinctive type of tumour that can include teeth, hair, sometimes, even a jaw and tongue. I guessed just a split second before the results came back. How annoying.
Working diagnosis: Teratoma with possible toxic psychosis.
Emergency operation was arranged. Yes, she would be fine a little while after the operation, I reassured the parents.
Junior Doctor arrived:
Junior Doctor arrived:
The junior arrived and took some history and did a quick physical before she was prepared for the theatre. This petite doctor with a very babyish face told me that on her first day in her last job she had to do an emergency tracheotomy. This time she had been on call for the last three nights and the battery in her old Mini could not cope with the heavy frost so she had to wait for AA before coming. She was most apologetic for not having got in earlier.
She asked if I had seen many toxic psychosis cases and I asked if she had come across any in her psychiatric placement. As with all good psychiatrists answering a question with another is in our blood and here it worked well.
Neither of us knew what was to hit us next.
At 2 A.M. I had a call from her.
“Your patient – I mean our patient could not be aroused after the operation. Yes they removed the teratoma, complete and intact. It is bigger than any specimen I have seen but she could not be aroused. Any ideas?”
“Call the paediatrician on call in the regional paediatric unit and I will be in.”
What happened? I asked myself as I drove to the hospital.
What had we done? This was fast becoming a nightmare situation.
What was I going to say to the parents?
Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.
Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.
A good doctor is one who is not afraid to ask for help but he must also know where to ask.
“Get me Great Ormond Street
“I already did.”
She is going to be a good doctor.
“Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
Who needs consultants when juniors have that kind of network? This girl will do well.
“Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
“Yes, you do and thanks a lot.”
I told mother that we were transferring her daughter to the best children’s hospital in England
.........She was impressed with mother’s faith and trust in God.
She said mother was near to tears. It was bad enough to have such a large Teratoma and then to have the patient unconscious with no one knowing what was going on was very frightening.
“I have seen some deaths as a medical student but never since I was registered. I do not want this to be my first.”
I knew the feeling well but what could I say? A doctor has to face it some time.
“Do you believe there is God?” She asked
“Do you really think I can answer that one?”
“Well, you have more experience.”
“To me it is like reading a good book. You would not know until the end.”
“So you mean I am not going to know until then.”
“Interpret whichever way you like. I remember Jung in his Memoir gave quite an account on the Holy Trinity. There were seventeen bishops in Jung’s family including his own father. Jung had always been puzzled by deity and the bible and most of all by the concept of the Holy Trinity. I know many religious philosophers struggle with that too. By some accident he had access to his father’s inner library. He saw this folder clearly marked Holy Trinity. The relief was phenomenal. He could now have the answer. He hesitated before opening the folder.”
“What did the folder contain?”
“See, you want the last chapter. I wanted to know as well. The folder contained pieces of blank paper.”
“That was it?”
“That was it.”
NHS & Ham: World Class Medicine without trying!
Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US Hong Kong or the rest of the commonwealth.
Why?
We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.
Dr No said...
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?
What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.
Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals.
Can we continue to practise World Class Medicine even if we wanted to?
Back to the patient:
Would my patient be dealt with in the same way in 2015?
GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
Paediatrician to me: ? Psychosis or even Catatonia.
Seen same day and admitted to Paediatric Ward, DGH.
Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.
Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
Radiologist (Hospital & no India
Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.
Patient unconscious and transferred to GOS on same day. Seen by various Professors.
Patient later transferred to Queen’s Square (National Hospital
Seen by more Professors.
Regained consciousness after 23 days.
Eventually transferred back to local Hospital.
None of the Doctor to Doctor decisions need to be referred to managers.
We did not have Admission Avoidance then.
How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.
The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.
Not to mention the operation etc. and the transfer to the Centres of excellence.
Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.
Related paper:
Post Script:
“Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.
“Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.
I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often.”
King’s Fund: Million £ GP.
See also:
NHS Reform: Dr House & Integrated Service.
Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
The Way We Were
The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US
Thursday, July 26, 2018
NHS; The Last Cook & The Last Sunset!
As the sun sets on our beloved NHS:
©Am Ang Zhang 2012
Perhaps it is not that well known that the dismantling of our beloved NHS started long before the present government and the future does not bode well for those of us that likes to keep NHS in the public domain.
Child Psychiatric in-patient units across the country were closed some time after many adult hospitals were closed or down-sized.
To me, the government is too concern with short term results that they impose various changes across the board in Health Care & Education without regard to the long term consequences or costs.
After all, I have made good use of in-patient facilities to un-diagnose ADHD and that would in turn save children from unnecessary medication and the country from unjustified benefit claims.
Such units were also great training grounds for the future generation of psychiatrists and nurses. Instead, most rely on chemicals to deal with a range of childhood psychological problems.
Indeed it was a sad day when the unit closed.
From The Cockroach Catcher:
Chapter 48 The Last Cook
O |
ne of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.
I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K. and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.
The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes. Instead a cook was employed to cater for the needs of the children and nursing staff. We doctors were not supposed to eat there. But we did. Mainly for lunch.
If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
All very homely.
I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.
You never know as people do not really research these things.
……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.
She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note. You never know.
Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.
Sheena was petite, worn and a chain smoker.
But she had two lovely looking girls.
We knew from the start there were handling issues and most likely diet ones too.
One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.
It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on. Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.
Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.
With a simple routine the girls were clean in no time. At least during the week as they all went home week-ends, when the unit was closed.
We were at a loss as to what was going on.
The girls would get worse over the week-end and soil. This went on for quite a while.
Then one day the cook talked to me.
“Sheena never stays Mondays,” she told me.
I listened.
“Have you noticed she is always in dark glasses on Mondays?”
How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.
Sheena was not a movie star.
I arranged to see Sheena.
She said, “You knew.”
I nodded.
“But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”
I suggested that I should speak to him but she looked terrified.
She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.
She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in. We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next? Another violent man most likely.
Was it such a cop-out on my part?
Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far. That was before Maria Colwell.
The unit had long since been closed.
The last cook in the NHS retired .
The Cockroach Catcher at: Amazon Kindle US; Amazon Kindle UK ;Lulu.com
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