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.


.........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.”

  A  reprint:

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 and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in 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 based): Tell tale tooth: Teratoma.
     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 for Nervous Diseases), 
             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.

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 UKAmazon Kindle US           

Sunday, July 12, 2020

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.

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!

Thursday, July 9, 2020

Eric Kandel: From Memory to Memory!


Eric Kandel, M.D., who was awarded the Nobel Prize in 2000 for discovering molecular mechanisms of memory storage, told the crowd at last week’s Flexner Discovery Lecture that he has recently become interested in memory in the aging brain. “We’ve been studying age-related memory loss, and not a moment too soon,” quipped the 87-year-old Kandel, University Professor and Fred Kavli Professor in the Department of Neuroscience at Columbia University.
“There are many people in the field…who think that the Aplysia rather than the investigator should have won the Nobel Prize,” Kandel said.
In more recent work, Kandel and his colleagues have turned their attention to age-related memory loss. The researchers wondered, Kandel said, if memory loss during normal aging is a distinct process or an early phase of Alzheimer’s disease.
They determined that mice, which do not experience spontaneous Alzheimer’s disease, also experience age-related memory loss, suggesting that the two processes are distinct, he said. Other studies showed that brain regions involved in age-related memory loss and Alzheimer’s disease are different.


©2015 Am Ang Zhang

No I did not do any diving in Patagonia!


We were having dinner at our Ecocamp in Patagonia with a very interesting couple.
The husband is aiming to climb the Matterhorn and somehow in the conversation we talked about their other adventures that included Diving. I show them some of my underwater pictures. Somehow Nudibranch was mentioned and as it turned out we exchange email addresses and became good friends.

Nudibranch reminded me of Aplysia and Kandel:






Nudibranch © 2009 Irene Man


Nudibranch is so named because of its naked gills.
Here is a description in The National Geographic:

Nudibranchs crawl through life as slick and naked as a newborn. Snail kin whose ancestors shrugged off the shell millions of years ago, they are just skin, muscle, and organs sliding on trails of slime across ocean floors and coral heads the world over.

Found from sandy shallows and reefs to the murky seabed nearly a mile down, nudibranchs thrive in waters both warm and cold and even around billowing deep-sea vents. 


So why, in habitats swirling with voracious eaters, aren't nudibranchs picked off like shrimp at a barbecue? The 3,000-plus known nudibranch species, it turns out, are well equipped to defend themselves. Not only can they be tough-skinned, bumpy, and abrasive, but they've also traded the family shell for less burdensome weaponry: toxic secretions and stinging cells. A few make their own poisons, but most pilfer from the foods they eat. Species that dine on toxic sponges, for example, alter and store the irritating compounds in their bodies and secrete them from skin cells or glands when disturbed. Other nudibranchs hoard capsules of tightly coiled stingers, called nematocysts, ingested from fire corals, anemones, and hydroids. Immune to the sting, the slugs deploy the stolen artillery along their own extremities.


Memory & Knowledge: Talmud & Taxi

In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel was giving his lecture. I was fortunate enough to be able to secure a seat.

"Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes." Eric Kandel.

In his book In Search Of Memory, he remembered his arrival in New York in 1939 after a year under the Nazi in Vienna:

“My grandfather and I liked each other a great deal, and he readily convinced me that he should tutor me in Hebrew during the summer of 1939 so that I might be eligible for a scholarship at the Yeshiva of Flatbush, an excellent Hebrew parochial school that offered both secular and religious studies at a very high level. With his tutelage I entered the Yeshiva in the fall of 1939. By the time I graduated in 1944 I spoke Hebrew almost as well as English, had read through the five books of Moses, the books of Kings, the Prophets and the Judges in Hebrew, and also learned a smattering of the Talmud.”

Eric Kandel/Amazon


“It gave me both pleasure and pride to learn later that Baruch S. Blumberg, who won the Nobel Prize in Physiology or Medicine in 1976, had also benefited from the extraordinary educational experience provided by the Yeshivah of Flatbush.”

In Hebrew and English!!! That did not seem to have done him and Blumberg much harm. Right now some governments seem hell bent in doing away with rote learning and that includes some medical schools.

Lord Brain:
When I was training in London in the 70s, I spent some time at Queen Square. Those in the know will recognize it as the place for neurology this side of the Atlantic. It was drilled into us then that sadly we were given a number of brain cells when we were born and it was all downhill from then on or something to that effect. It was well known that neurologists were great diagnosticians but for most neurological conditions, not much could be done. How depressing indeed. Even as recently as four weeks ago, I heard a young doctor told his father that there was nothing he could do with his brain cells. One is given so many at birth and no more can be expected. Lord Brain (1895-1966) would have been so proud.


Knowledge:

Yet it was also London that shook the world with new discoveries about the brain, and the study was on the most unlikely group of people: Taxi drivers. Their “KNOWLEDGE” was the basis of our knowledge on brain plasticity today. The “KNOWLEDGE” is a term officially used to describe the test the Taxi Drivers had to take to get the license to drive Taxis in London. Streets in London have evolved over time and are not on any grid system at all. Early postmortem examinations led some pathologists to note the small size of the Taxi drivers’ frontal lobes. Yet actual weight measurement showed that size was all relative. It was the enlarged hippocampal region that created that impression. Later work using modern scanning techniques confirmed the early impressions.


Kandel & Doidge: Neuroplasticity & Memory.