Thursday, September 17, 2020

Ecclesiastes & NHS: Tannhäuser & Vanguard!

 


The thing that hath been,
it is that which shall be; and that which is done is that which shall be done:
and there is no new thing under the sun.

Ecclesiastes 1:9
Last summer’s entertainment has been that of the alleged ritualistic sexual activity of some well known politician.

Why should so much media time be wasted on such matter or was it a deliberate distraction from something more important?

No it was not even about the Junior doctor’s contract but more of that later as Tannhäuser is opening at Covent Garden in the spring.

Tannhäuser in the kingdom of the goddess Venus, by Henri Fantin-Latour. Photograph: akg-images

The sexual exploits of the elite Parisians were no different to that of modern day politicians:

Wagner's decision to place the obligatory ballet in the opening scene also offended the influential Jockey Club, whose members were in the habit of arriving at the interval to see their mistresses dance before going backstage for sex. By the third night, dog whistles could be bought in the streets outside the Opéra for the express purpose of interrupting the performance.


But what is most important is the new NHS Vanguard:

Without new legislation or public debate a new NHS is happening or so we thought. The Cockroach Catcher wrote on September 7 2015:

Simon Stevens spent some years in the US. Is Vanguard a re-working of Kaiser Permanente?


I have always admired Simon Stevens and his ability to quickly picked some of the best loved people in the NHS to promote Vanguard. The like of which has not been seen in any State run change since Bevan. But Vanguard is going to mean a good deal more than we were led to believe. I suspect that the people working for him are either not aware or they were told not to divulge it. Like Steve Jobs, the smartest people keep their main aim to themselves. He has picked the people that were very savvy with Social Media and that part of the NHS is exploding with little reference to the plight of Junior Doctors or the bribery of GPs. Nothing should distract now! But is everything about Vanguard new inventions of Simon Stevens?

Remember:
The thing that hath been,
it is that which shall be; and that which is done is that which shall be done:
and there is no new thing under the sun.

Ecclesiastes 1:9

Lets see what Bloomberg say:
BRITISH EXPERIENCE

UnitedHealth followed up on June 30 with another report for lawmakers pinpointing $332 billion in savings through better use of technology and administrative simplification. If enacted, those changes would potentially benefit UnitedHealth's Ingenix data-crunching unit. Ingenix, with annual revenue of $1.6 billion, is poised to establish a national digital clearinghouse to ensure the accuracy of medical payments and provide a centralized service for checking the credentials of physicians.

Stevens, an Oxford-educated executive vice-president at UnitedHealth, once served as an adviser to former British Prime Minister Tony Blair. In that capacity, Stevens tried to fine-tune the U.K.'s nationally run health system. Today he tells lawmakers that theU.S. need not follow Britain's example. Concessions already offered by the U.S. insurance industry—such as accepting all applicants, regardless of age or medical history—make a government-run competitor unnecessary, he argues. "We don't think reform should come crashing down because of [resistance to] a public plan," Stevens says. Many congressional Democrats have come to the same conclusion.

UnitedHealth has traveled an unlikely path to becoming a Washington powerhouse. Its last chairman and chief executive, William W. McGuire, cultivated a corporate profile as an industry insurgent little concerned with goings-on in the capital. From its Minnetonka(Minn.) headquarters, the company grew swiftly by acquisition. McGuire absorbed both rival carriers and companies that analyze data and write software. Diversification turned UnitedHealth into the largest U.S. health insurer in terms of revenue. In 2008 it reported operating profit of $5.3 billion on revenue of $81.2 billion. It employs more than 75,000 people. 

Stevens argues that while UnitedHealth will likely benefit financially from health reform, the company will also aid the cause of reducing costs. He cites what he says is its record of "bending the cost curve" for major employers. 

During a media presentation in May in Washington, Stevens said medical costs incurred by UnitedHealth's corporate clients were rising only 4% annually, less than the industry average of 6% to 8%. But that claim seemed to conflict with statements company executives made just a month earlier during a conference call with investors. On that quarterly earnings call, UnitedHealth CEO Hemsley conceded that medical costs on commercial plans would increase 8% this year. 

Asked about the discrepancy, Stevens says the lower figure he is using in Washington represents the experience of a subset of employer clients who fully deployed UnitedHealth's cost-saving techniques, including oversight of the chronically ill. "These employers stuck at it for several years," he says. "We are putting forward positive ideas based on our experience of what works."

Now 4 days later Steven Carne in Open Democracy:

And Stevens' PACS (part of Vanguard) are explicitly modelled on San Francisco's Kaiser Permanante’s Accountable Care Organisation model (a latter development of the American HMO model)- despite US concerns about restrictions on which patients can be treated where, long wait times, and still high costs.

I asked a friend in California recently what Kaiser were like. She smiled, “Oh they're great! ‘Til you get sick”. Their focus on prevention and health resilience belies a reluctance to provide full health care that might cost shareholders their profit. Only a top-up payment plan will see you in the real hospital.

SNAP.

England has never seen anything quite like this:
Steven Carne again:

This dishonest vocabulary aims to fool the public into supporting a host of dubious changes. It relies on a counterpoint image of a desperately archaic NHS, crumbling in an inevitable apocalypse of overweight aging diabetic bed blockers who really should know better and die in their own beds – “Care Closer to Home”.
It glosses over the fact that public funding is being withheld (and wasted on market bureaucracy).
The manipulative buzzword bingo tries to persuade us that when we take part in their endless focus groups, petitions and surveys, we are helping the ‘struggling’, ‘failing’ NHS to meet the ‘challenges of the 21st century’.
It hides the fact that private corporations are moving in and setting the agendas. It hides the fact that behind the trusted blue square of the NHS logo, private health and insurance firms are already operating, mostly unseen by the public.
At a recent event we were given another buzz phrase. “Be the Change You Want to Be...”
We are learning as quickly as we can. But the actions and spin of NHS England and the corporate health, insurance, technology and pharma companies are bewildering and confusing to those of us trying to keep up. Just as we’d begun to get our heads around 2012’s Clinical Commissioning Groups (CCGs) and Commissioning Support Units (CSUs), new NHS boss Simon Stevens’s Five Year Plan ushered in a new layer of jargon and organisational spaghetti – Primary & Acute Care Systems (PACS) and Multidisciplinary or Multispecialty Health Teams (MHTs).

If you read it thinking it made any sort of reasonable sense - then we need to worry.

One of the key weapons being used against the NHS, public and campaigners is the growing misuse of socially minded vocabulary and community development buzzwords.

You’ll all have come across them. Engaged, participatory, resilient, empowering, co-produced, personalised, sustainable….

You’ll find these buzzwords all over the NHS, mixed with a dash of new age personal therapy speak borrowed from the West Coast of America (as we’ll see shortly, there are other imports from the West Coast, too).

……. This dishonest vocabulary aims to fool the public into supporting a host of dubious changes. It relies on a counterpoint image of a desperately archaic NHS, crumbling in an inevitable apocalypse of overweight aging diabetic bed blockers who really should know better and die in their own beds – “Care Closer to Home”.

It glosses over the fact that public funding is being withheld (and wasted on market bureaucracy).



The thing that hath been,
it is that which shall be; and that which is done is that which shall be done:
and there is no new thing under the sun.

Ecclesiastes 1:9

NHS-Kaiser Permanente: Integration or Fragmentation?

Wednesday, September 9, 2020

Pandemic and Mahler: Nature and Hope

On September 12, 

Joyce DiDonato in Bochum, Germany is going to sing 

“Ich bin der Welt abhanden gekommen” by Gustav Mahler.
                                   

 

Ich bin der Welt abhanden gekommen,

Mit der ich sonst viele Zeit verdorben;

Sie hat so lange nichts von mir vernommen,

Sie mag wohl glauben, ich sei gestorben!

 

Es ist mir auch gar nichts daran gelegen,

Ob sie mich fuer gestorben haelt,

Ich kann auch gar nichts sagen dagegen,

Denn wirklich bin ich gestorben der Welt.

 

Ich bin gestorben dem Weltgetuemmel!

Und ruh' in einem stillen Gebiet!

Ich leb' allein in meinem Himmel,

In meinem Lieben, in meinem Lied!

Yosemite ©2007 Am Ang Zhang

I am lost to the world
with which I used to waste so much time,
It has heard nothing from me for so long
that it may very well believe that I am dead!
 
It is of no consequence to me
Whether it thinks me dead;
I cannot deny it,
for I really am dead to the world.
 
I am dead to the world's tumult,
And I rest in a quiet realm!
I live alone in my heaven,
In my love and in my song.

Janet Baker: https://thelistenersclub.com/2019/01/07/i-am-lost-to-the-world-mahlers-song-of-the-solitary-artist/


I do not know Mahler. No, not when I started at the Tavistcock in 1972.

One day at our referral meeting, a very interesting referral turned up from none other than the much revered paediatrician at the Royal Free up the road from us. In the early 70s referrals are specific to the individual teams and I have a suspicion that she likes to refer to my consultant as much of her cases landed into our team. I suspect that Dr Collingwood’s solid paediatric base having worked with Winnicott may have something to do with it. She is a very flamboyant character as I have met her at a couple of child protectopm conferences where she is much revered or indeed feared. I must admit I prefer her kind of consultant that knows her specialty and show great respect for similarly capable colleagues. Her flamboyance command much respect.

Dr Collingwood does not routinely put patients on psychotherapy as very often the management is through good practical advice. This is more so with this paediatrician and so when we got this referral where she specifically asked if the 14 year old could have psychotherapy and preferably with someone that knows a bit about music, we all gasped but nobody said much. 

Looking back now, it is amazing that I joined Tavistock not knowing what to expect and after nearly three years of training there, it has never occurred to me that one should use any medication on children. I have never once written a prescription. I know of a friend in California where the son was diagnosed with ADHD and was on Ritalin until well into late teens. Her youngest sister was diagnose Schizophrenic because she had such a vivid imaginary friend and was put on one of the newer antipsychotics. Yes, you guess right she is now a balloon. Not to be outdone, the middle sister who is quite a charmer was diagnosed, you guess right, bipolar but was not put on Lithium but the other mood stabiliser and a novel antipsychotic.

My prime years of child psychiatric training in a drug free environment was fantastic in ways that I only realised years later.

Miss Frys spoke up for me, “Dr Zhang is very fond of music and he is forever carrying boxes of discs from the Swiss Cottage library!”

Well, that settles it then. But this will be my first adolescent. The small kids I can cope by playing with them. This is real talking therapy now. I put on a brave face as they are all looking at me now at the meeting.

So I told them that from an early age, I sat in on my cousin’s piano lessons, then I was introduced to classical music at primary school by my village friend. My first record he lent me was Beethoven’s 5th Symphony. I have built my own sound system at high school as it was the cheapest way to get good sound and I even ran the school music club playing classical music at lunch times. Moving to England meant that my music playing equipments were left behind but I did purchase a reasonable disc playing set up and on Miss Frys’ tip, use our Swiss Cottage library extensively.

“Your favourite composer?”

“I now pick up some unusual works. At Swiss Cottage Library, I tend to go for new records and often box sets so that they are often complete segments of works. Older records are rather scatchy so I tend to look out for brand new arrivals and sometimes they can be some rarer music.”

“Like Mazart’s Quintets!”

So one does not escape the eyes of Miss Frys who is also a keen music lover and often goes to the Royal Festival Hall as she lives virtually next door to it.

“And Peter Grimes, which of course is Dr Collingwood’s territory!”

I love the way the referral meeting turned into a cultural one. Looking back now, it has as much significance to the likes of Nobel Laureate Kandel as it did in my humble early child psychotherapy training.

Dr Collingwood has a nice bungalow in Aldeburgh which is of course the home of Benjamin Britten and Peter Pears. The opera, I have never heard of until one day the librarian was placing new discs onto the shelves and hinted to me that it was a great one to listen to. Dr Collingwood is one of the volunteer ushers at The Maltings and some years later when our family spent a week at Aldeburgh and we pay pilgrimage to The Maltings for a Peter Pears recital. We met Imogen Holst, daughter of the composer at the sea front.

It took over 30 years for us to see a performance of Peter Grimes at the Royal Opera House[1].

I have by now seen quite a few children in therapy and I have on the whole been quite relaxed about using the toys and drawings throwing in Winnicott’s squiggle game[2] now and again for the children who are a bit too old for the set toys we have. It is interesting that most other junior doctors are more at ease with the older adolescents where they often come round to our case presentations to hear about the younger kids. It was only when I became a consultant that I realise it was unusual to have a preference for the very young children whereas many of my colleagues somehow avoided them.

Jonas

Now what do I do with this adolescent that our paediatrician thought needs some fairly deep therapy as he seem to be struggling with everything and most serious of all with his mother.

Unlike working as a consultant, I did not get to see the parents at all. Most of the time it would have been Miss Frys or her Social Worker trainee. The Psychologist only access a child if referred by the Consultant.
Some other time, Dr Collingwood would see the parents.

As it turn out, Jonas’ father is a Surgeon at the Hospital where the paediatrician works and his mother teaches piano at his school, one of the best known state school in the area. It is so good that many of the professional class living in Hampstead send their children there. Do we still wonder why good areas have good schools! Of course it is only natural that good areas with intelligent pupils attract good teachers. It goes on.

I have at least learned from Winnicott’s squiggle game the importance of the therapist’s quick response and spontaneity and why should talking to the older child be any different.

Traditional psychotherapist will probably throw up in horroe but at least those I am learning from do not have or suffer from that kind of rigidity.
Much later as a consultant I have adapted this approach well as it helps to establish rapport very quickly especially with parents.

But my supervisor wants to throw me into the deep end and I have no idea what to do.

Jonas first noticed the Mondrian on the wall.

“Did some kid do that? Very neat!”

Perhaps he is right. Picasso wanted to draw like a kid too.

Then he noticed the records I was about to return to the library: Mozart Quintets.

“Mozart’s best as he wrote for himself!”

That was how we started. Some might think I plotted it by putting the records on my desk. I wish I could have claimed to have planned it. I think sometimes spontaneity may be best.

But this boy knows his music and yet I am not quite prepared for what he gave me as the sessions progress.

Many thought the therapist is suppose to be a mirror and be there to let the patient see more clearly about their own psyche. Others are more assertive and felt compelled to make interpretations not realising that often one is limited by ones own psyche or understanding of it. Hence the need for some personal analysis to deal with that aspect.

There is of course a world of difference between reflection and interpretation. My personal feeling is that there needs to be a balance between the two.

Psychotherapy is thus quite far removed from medical history taking. In a severe medical episode, there is a need to get a clear view of the events leading to the episode in order that appropriate investigation is carried out to be followed by the right course of treatment.

Psychotherapy afforded us with the luxury of a deeper understanding of the patient without having to ask probing questions. It goes without saying that with the more frequent sessions of therapy the therapist gains a very deep understanding of the patient without the need to go through an intensive and compact history taking. We also tend to remember these patients literally for ever.

Jonas hardly sees his father as he is busy his patients. His mother would have been a concert pianist but she had to make a choice between bringing up Jonas and looking after a rather nice house on the Heath. But she has high hopes for Jonas, her only child.

Yes, to be something she could only dream of, a concert pianist. Jonas has been a good piano player but once he turned nine told mother he would like to learn the violin.

He picked that up in no time and is now on to Grade 8 exam for violin. He left his Piano at Grade 5.

As I progressed with Jonas, it became clear the very strange role I am playing. I am his mother that he can talk to and argue with. And perhaps practice with. In truth it was easier as I am not his mother and on the other hand I am. But I am the one who could provide some answer his mother would not give him.

One day I have a complete set of Brahms Symphonies on my desk, from the library of course, and he casually asked if Brahms was my favourite composer or not.

Brahms 1st Symphony was a present given to me by one of my uncles when I made my amplifier. He worked for Abbotts in Hong Kong and when I got to medical school, he gave me my Littmann Stethoscope.

“I love the 1st especially the solo violin part in the last movement.”

“Well, you should listen to Mahler as he used various bits of singing unlike Beethoven’s Choral Symphony. And my best Mahler is his Third Symphony, though everybody else I know prefer the 2nd.”

The truth is I have two commuting friends that are fond of music and Mahler has not been one they talk about.
Yosemite ©2007 Am Ang Zhang
I tried that day to secure any Mahler and could only find one: Das Lied von der Erde.

It was a shock to my commuting friends especially when they read the details: Chinese poems translated by a German?

During the next session, I have not seen Jonas more enthused and energetic. He could not wait to tell me more about Mahler[3]. The 3rd Symphony[4]s all about nature and is so positive and energising.
I have to say now that I have probable gained more from this one patient than I have from any other. To be introduced to Mahler at the time when London was just waking up to it and wake up it did.

We were able to talk about the struggle of Mahler and of the sadness of the death of his daughter and eventually him dying of Rheumatic Heart Disease[5].

One day he was able to declare that his struggles were nothing compare to Mahler’s.

It is interesting that he never really talked about his own sadness as Mahler’s overshadow his and yet in true traditional psychotherapy style he has gain his own insight.

His time with me, or was it my time with him was coming to an end. Dr Collingwood is highly intuitive and on the recommendation of my psychotherapy supervisor helped me to terminate the therapy. It was perhaps a credit for a state funded system like the NHS that one does not need to hang on to therapy for ensuring adequate income. The main danger for privately funded psychotherapy is the unnecessarily prolonged therapy periods with the result that the patient is addicted to the therapist or the other way round.

On his last session, he told me he has got his distinction in Grade 8 Violin but he did not want to be a violinist.

He wants to be a conductor.

As I wrote this, I Googled and found that he is now a conductor for a German Opera Company.

No, Jonas is not his real name.

In 2009, Das Lied von der Erde was performed in Hong Kong and The Mahler 3rd in December of 2016[6], a sort of home coming. Thank you Jonas for introducing me to Mahler.




Nature & Mahler: Royal Festival Hall!


Related:








[1] http://cockroachcatcher.blogspot.com/2011/06/peter-grimes-individual-against-mass.html
[3] http://cockroachcatcher.blogspot.com/2010/08/proms-mahler-nature.html
[4] https://www.youtube.com/watch?v=9Yr720ftjaA
[5] http://cockroachcatcher.blogspot.com/2009/11/sadness-songs-superstition-mahler_29.html
[6] http://www.hkphil.org/eng/concerts_and_ticket/concerts/concertdetail.jsp?id=554

Friday, August 21, 2020

National suicide awareness: Antidepressants may cause sucides!



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.

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.

Perhaps it is in the British History:
 Maudsley and Lithium
First, why a small group from the Maudsley Hospital in the 1960s could, in an almost malicious manner, have sown scholarly confusion about the true effectiveness of lithium. Aubrey Lewis, professor of psychiatry and head of the Maudsley, considered lithium treatment “dangerous nonsense” (). Lewis’s colleague at the Maudsley, Michael Shepherd, one of the pioneers of British psychopharmacology, agreed that lithium was a dubious choice. In his 1968 monograph, Clinical Psychopharmacology, Shepherd said that lithium was toxic in mania and that claims of efficacy for it in preventing depression rested on “dubious scientific methodology” (). Shepherd also scorned “prophylactic lithium” in an article with Barry Blackwell (). Moreover, Shepherd was publicly contemptuous of Schou. He told interviewer David Healy that Schou had put his own brother on it, and that Schou was such a “believer” in lithium that he seemed to think “really there ought to be a national policy in which everybody could get lithium”

 


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

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.

Could Lithium be the Aspirin of Psychiatry? Only time will tell!

Wednesday, August 5, 2020

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:
         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 if not in the world and the doctor would stay with her in the ambulance. She would be fine.
  
Faith & Prayer      
         When I got into work later that day, my secretary asked how my patient was as she heard from her friend that the church was going to hold a 24-hour vigil for her.
         Trust my secretary. She knew someone from the same church and she always had the knack of extracting information first hand.
         “They say this may be the work of the devil as the doctors and surgeons all did the right things and removed this big tumour but the devil must have got to her.”
         I did have a vague fear that there might have been some anaesthetic accident but quickly told myself off for thinking along that line. I knew all the anaesthetists and such a thing could never have happened.
         I was back at the hospital to deal with an overdose case. The junior was there and we had a chat in Sister’s office.
         They had to ventilate her. That was the first thing she told me. I thanked her for going up there and she said it was scary but she felt important and the mother who was in the ambulance could not thank her enough.
        
         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.”'
        “Well. My view is this. We are here. We live. We help others to live and maybe we do not ask too many questions and we might or might not in the end know the answer.”
Back to the patient:
   
         “But do you think this girl is going to live though? I do not want this girl to be my first death. It would be so awful.”
         “Neither do I. I keep saying to myself that it is now over seventy two hours and she is still alive and I do know that some cases of viral encephalitis can be very dramatic in presentation and recovery.”
         “But which virus?”
         “The nearest I have is Herpes.”
         “Mother’s cold sore.”
         “You have noticed that too.”
         “I was with her for a long time.”
         We had our own prayer for her too. Let it be Herpes encephalitis and all would be well.
         I left the hospital feeling slightly strange. I just had a philosophical encounter with a young doctor. How strange it is that threats of death always get one thinking about these things.
         The girl remained unconscious although the word was that the EEG was more hopeful than was first thought.  GOS decided to transfer her next door to Queen Square - National Hospital for Nervous Diseases. A lumber puncture[6] was done and the initial findings were in keeping with viral encephalitis. They were now trying to grow the virus. They also wanted Queen Square to decide on assisted ventilation.
         There was now a candlelight vigil at the church and it was hoped that there would always be a lit candle until she came home. The story was in the local paper and radio. Faith was now on field test if not on trial. The doctors were not. They had done their best.
         On the 10th day the ventilator came off, and she was able to breathe without support.
         They then started a vigil in the girl’s home.
         By the 23rd day, as my optimism was about to give in, word came from the hospital that she became conscious. It became big news in the papers.
         When mother came home from London, she came to see my secretary to give her the details. She told my secretary that she always knew that her daughter would live.
         No virus was ever isolated and her diagnosis on discharge was that she had a variant of Encephalitis Lethargica[7].
         “Did you agree with the diagnosis?” The junior asked me when I saw her next.
         “Why should I be arguing with the best neurological centre in the world? It is harder to argue with a variant of Lethargica. However the next few months or years will be important. If she is well then Herpes fits in better and often it is an allergic type of reaction on first exposure. But if she is like those in Awakenings[8], then Encephalitis Lethargica.”
         I saw her at the local hospital rehab a couple of times. Initially there were a good deal of residual symptoms including awkward gait and dis-inhibition. She became better and was moved to a specialised centre and that was the last I heard of her.

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.

I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often.”



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?










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

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