Friday, July 20, 2012

NHS: A Closer Look!

A closer look as it may not be there:

©Am Ang Zhang 2005

I wrote a while back about: ?A National Car Service.
NCS (National Car Service)?

Imagine a society where you take your beloved car to a Private Garage for some repair work and it turns out that the Private Garage did a very bad job and did serious damage to the engine, transmission and other unknown bits. Now imagine that there is a State run National Car Service that will put right everything and at no cost to you and no charge to the Private Garage that did the damage in the first place.

Would it not be wonderful?

Doctors continued operating on Kelly McLure, 31, after she suffered her cardiac arrest at the private Belvedere Hospital, in Kent, it was claimed.

Southwark Coroner’s Court was told paramedics were kept waiting for 45 minutes despite insisting on taking her straight to A&E.

Instead Dr Edward Latimer-Sayer, her surgeon and Dr Ahmed el Sayed Moustafa, the anaesthetist, continued with the routine nose and chin procedure after stabilising her.

Mrs McLure, known as Kat, suffered brain damage during the operation on November 22, 2005. She died six months later.

In 2002, Denise checked into a private clinic for what should have been a straightforward procedure to remove fat from her stomach. Afterwards she spent six weeks in intensive care (in NHS hospital), the surgeon having repeatedly punctured her bowel.

In the next seven years (again under the NHS) she endured more than 20 operations to repair the damage before succumbing to meningitis in 2009. She was 43.                             
Read all about it here>>>>

The surgery was performed by Dr Gustaf Aniansson (from Sweden), at the private Broughton ParkHospital near Preston, Lancashire. Dr Gustaf Aniansson took himself off the GMC register so that he could not be struck off and it was believed he continues to practice in Sweden.

In the new world order of our NHS, private provider (AQW)for commercial reasons need not let the public have access to information about their activities etc, and even the doctors they provide. As they say, be very afraid.

Dr Phil Yerboot is very direct:
In  Boob Jobs and One Night Stands
The PIP breast implant scandal rumbles on with a seeming stand-off between the Minister of Health and the principal users of these implants, Transform and The Harley Medical Group.

Transform has nothing on its website (that I could find) to inform patients about the PIP implant issue. The Harley Medical Group does so here, but feels that this is a problem that it wishes to lay on the MRHA for licensing the PIP implants. Both are interesting organisations, with peripheral clinics where early consultations with Nurse specialists are followed by surgery at a few central hospitals. The Transform group lists its Surgical staff here. I could not find similar information on the Harley Group website, though they do state that their surgeons are on the UK Specialist Register as Plastic Surgeons, this may well be because of recognition in another EU state. Several on the Transform website seem to have only Specialist Training as General Surgeons.  The Transform Surgeons have mostly trained overseas and are not rooted in the UK medical culture in the same way as most BAAPS members, most of whom have past or present substantive NHS Consultant posts.               

It is my understanding that if there is just one fully registered surgeon prepared to be clinically responsible, ANYTHING GOES.  For all we know, it could be someone from Sweden and that someone could at short notice resign from the GMC.

Perhaps SoS will have to set up an NBS, National Breast Service soon.

Right now, we still have the NHS, the National Health Service. It is free even if the damage was done by a private doctor and treatment will be for as long as it takes. The private doctor will not be charged any fee and some even continues to practice here or in other countries.

Soon, such a National Health Service may not be there! That is how the government is going to save money.

First appeared in Jan 13 2012.

Wednesday, July 18, 2012

Biodiversity: Abalone & Nanotechnology

Recent medical blog posts by Dr No and The Witch Doctor coupled with the banking scandals would mean that aspiring Bright Young Things may indeed need to take The Cockroach Catcher’s advice and take up opera singing or biodiversity as alternatives. There is of course always archeology and anthropology. Looking at my friend’s children the last two were strictly for the Bright Young Things with super rich parents.

The Cockroach Catcher will now try to convince you that if you do not have the voice, then perhaps Biodiversity is for you.

Those that know what these shells are will know that they housed one of the most sought after sea food in the Far East.
 ©2012 Am Ang Zhang
Yes: Abalone.

But I am not going to give you a recipe but talk about the colour especially of the inside of the shell.

It has been widely known that colour on the whole is produced by the light it absorbs. That remained true for leaves, flowers and dyes etc., etc.

No so with Abalone.

No, instead there is a 2-3 layered nanoparticle/nanocrystal network that would affect the passage of light and the energy of light will be changed when it emits from the surface of the crystals.

Butterflies too use the same nanocrystals.

These indeed form the basis of modern day Nanotechnology.

Mother Nature should be ecstatic

Tuesday, July 17, 2012

Family & Healing: School Phobia & Post Natal Depression

In an age when it has become more or less impossible to gear your intervention or non-intervention in the practice of Medicine, I remember this family fondly.

From The Cockroach Catcher: Chapter 19   Who Is The Real Patient? Part 1

he early seventies was a very exciting time in London as the first ever course in Family Therapy in the U.K.was just launched.  Gregory Bateson just published Steps to an Ecology of Mind, which to this day still manages to be exciting for anyone interested in family systems – a term coined to describe the interaction within a family or extended family.   Of course years before that, Ibsen neatly observed family interactions in Ghosts and Wild Duck. 

©2006 Am Ang Zhang

         Catherine, aged fourteen, had not attended school for some time and all attempts by the school authority and educational psychologist failed to get her back to school. This was a pity as Catherine was really university material.
         She had eleven older brothers and sisters. Two older sisters were married.  One of them had a little baby of ten months. The other had two children at school. The youngest of the brothers attended a public school (i.e. an English private school) on a scholarship, and with financial assistance from the older siblings.
         After an initial visit by the social worker, the team decided to approach the case in a family therapy sort of way – big family therapy in every sense of the word.
         At that time, family therapy was a relatively new development and had probably grown out of some group therapy principles. One of the first courses was established at the Group Therapy Institute in London when I was still at the Tavistock. Little did I know then that it was history in the making. Of the people I was with then, either teachers or co-trainees, many have become prominent practitioners in the field.
         Even the rather adventurous social worker was feeling a bit dubious.  “Do you belong to the school that insists on everybody in the family attending?”  She asked, hoping I would be a bit eclectic about it.
         “Let’s try and get everybody at least for the first session.”
         “I will do my best,” she promised.
         Good old Miss Kimble. She always got things done.
         As some of the family were working, the session had to be organised for the evening.   There is so much mystique attached to our kind of work that families often oblige without asking too many questions, at least at the early stage.
         One of the older unmarried sisters took it upon herself to organise the meeting. The main one that caused some problem was the oldest brother who was a long distance lorry driver going all over Europe.  The meeting needed to be on one of those nights when he was back from his delivery tour. The brother at the public school had a cricket match and he was apparently one of their best bowlers. One of the other brothers agreed to go to the match and bring him to the meeting as soon as the match was over.  The sister with the baby would have to bring the little one but the older children would look after her at the meeting.
         I told them that they could all join in.
         Luckily with so many children the family had a reasonable sized council house and the family room was fairly long.  They moved the dining chairs through to provide seating for everybody.
         The scene was set. We just had to deliver the goods.
         “We have come this far.  We just have to do it,” I told Miss Kimble.  She probably had more faith in me than I had in myself.
         Father looked after the parks and gardens for the council and had been with them since leaving school. Mother had not worked outside of home since the first child was born. She used to work in the Council Offices and that was where she met her husband.
         All the unmarried children who had left school had jobs except for the one who organised the meeting. She was in fact the eldest sister. All hope was on the boy and Catherine, except now Catherine was not going to school and had not been for nearly a year.  Two of the sisters worked in an insurance company, which was a very important local employer. Three boys worked for the Parks and Gardens department. One girl was a life guard at the local public Sports Complex that just opened and one boy looked after the gymnasium. The parents had done well and you could see that it was a very close knit and caring family.
         Only the truck driver was absent. We chatted and waited. The baby in the meantime was crawling in the middle with the two older children fussing over her. Catherine sat close to mother and now and again would hold her hand. I was not too sure who was comforting whom but then family therapy was about observing the family interactions.
         Cricket boy was busy devouring a plate of food mum left for him as he missed his school dinner.
         Others were exchanging various gossips about boyfriends and girlfriends.
         I thought that this was fun but there was also a lot to take in. The traditional approach would have allowed one to be more focused but it would probably have taken a long time to get to where we wanted to get to quickly.
         When I heard air brakes, I knew that big brother had arrived. Everybody else knew as well. Swiftly Catherine let go of mum’s hand and went to the door.  One of the other sisters had the plate that had been kept warm in the oven set in a tray complete with a big can of beer.  I declined the offer of beer as I was working.
         Big brother was quite a big fellow but was friendly enough as he shook hands with me. After a few bites and some gulps of beer he turned to me and said:

 “We are all here now. What is this about?”
         To this challenge, I explained in a very simple fashion why I wanted to see the whole family. I went on to use what I had since described to my juniors as a journalistic approach to history taking, as distinct from the traditional topic-by-topic approach. With the journalistic mantra – Who?  What?  When? Where?  Why? How? – the patient or the family would just enter the conversation barely aware that you were taking a history. To keep focused, you do need to have clearly in your own mind the information you are seeking.
         If you are not experienced, you can follow a printed questionnaire and take three hours of history but you will just end up with loads of seemingly unrelated information.
         With my favoured journalistic approach you follow leads.  The whole session becomes more integrated and it is easier for patients and families as you are not likely to appear to be jumping from one thing to another. It also comes across as more professional.
         One thing led to another and my break came when one of the boys let slip that he remembered mother going into hospital after Catherine was born and big sister gave up a good job at the insurance company to stay home to look after the rest of them.
         Mother was in the local mental hospital and had electrical shock treatment.
         Mother started crying and big brother was rather upset and asked me what relevance this had except to upset mum.
         At this point, the little baby who had been crawling around stopped in her track and crawled to Grandma and started touching one of her slippers. She started crying too.
         I have my own theory that even before acquiring language, babies are able to retain emotional memory of early experiences. Later on in life it becomes difficult to grasp the source of the upset as there are no words to describe such emotional experiences. Traumas in early life have diffused effects; those happening later on in life are more focused and perhaps easier to deal with.
         One famous psychiatrist once talked about his own experience of his mother’s depression. He talked about having images of a wooden arm and it was through years of psychoanalysis that he reconstructed the whole image of his very depressed mother who had a rather catatonic posture in the deepest depth of her depression. He could remember himself as a toddler running into the house after play to be met with the wooden arm, sharply quietening down and then backing off. It was a rather moving seminar he gave at one of the conferences and a rare occasion when a British psychiatrist talked about psychoanalysis.
         Back with the big family – all went rather quiet. A couple of the girls were sobbing. Catherine tried to comfort mum who said she knew it was all her fault. The eldest brother thanked me for making things clear for him.
         All were relieved to hear that I would not be forcing Catherine back to school and that mother would not be prosecuted.
         All agreed that Catherine would be wasting her brains if she did not have some form of education and I explained that I would be looking into alternatives.
         Miss Kimble told me later that I was lucky to have that break and that it was a good job the baby was there.
         It was uncanny that in my thirty plus years of experience, over half of the children who had problems attending school in a big way had mothers who had serious puerperal (post-natal) depression.  Was the school refusal (school phobia) a clinical manifestation of genetically transmitted depression, or was it the psychological effect of living with a depressed mother? I really do not know.
         Catherine never managed to return to “proper” school but with a fair bit of individual therapy we managed to get her to attend a tutorial unit. This we achieved by getting mother to find some part time work. Big sister too started working part time.
         It was daunting for me to think that a single family session brought about so much change, but then I was reminded that the strength was with the family – we just tried to tap it.
         Catherine had good exam results on the limited subjects she could sit but was immediately offered a trainee post at the insurance company.
         Years later I bumped into one of the older sisters at the Sports Centre.  She thanked me again for what I did for the family and told me that everybody was fine.
         I told her I was scared by the lot of them especially her big brother. She told me I did all right. Catherine was his favourite sister.
         I cannot remember seeing another big family since and with the disintegration of families it became increasingly difficult to do that type of family work.

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Saturday, July 14, 2012

Friday, July 13, 2012

Mind & Ecology: Family & OCD

The mind is fascinating and more fascinating in Child Psychiatry if you can afford the time to try and understand it.

There is little doubt in my mind after spending 30 years trying to think like a child (un-ashamedly borrowed from Picasso), I have come to realised that our creator has provided our mind the facilities to heal and recover. It is perhaps important that we should not jump in and use medication Willy Nilly. Unfortunately nowadays they might be used for the personal gain of the psychiatrist!

From The Cockroach Catcher: Chapter 19   Who Is The Real Patient? Part 2

he early seventies was a very exciting time in London as the first ever course in Family Therapy in the U.K. was just launched.  Gregory Bateson just published Steps to an Ecology of Mind, which to this day still manages to be exciting for anyone interested in family systems – a term coined to describe the interaction within a family or extended family.   Of course years before that, Ibsen neatly observed family interactions in Ghosts and Wild Duck. 

©2006 Am Ang Zhang

Both plays vividly captured family interaction that has hardly been bettered by any other modern writings.
         Wayne must have been about thirteen when he was referred to me. As with many similar cases he had not attended school for the better part of a year. I thought that this was another case of some degree of maternal depression rubbing off on the boy.
         Wayne’s father was a Sea Captain for years but for some years now he preferred to stay with Wayne’s grand parents. “Who could blame him?” Wayne would remind me and himself. There was never a question of divorce and he did not want to involve the psychiatrists either.  He preferred to just stay quiet about it.
         Wayne had a very impressive crop of hair very much like that of Art Garfunkel. He was also very good looking, which immediately made him number one target for bullying. His favourite subject was English. He liked poetry and Shakespeare best – further cause for bullying.  He enjoyed classical music as his father had a vast collection of records. But he kept this secret hobby to himself as the bullies already had too many reasons to pick on him. It was a rather sad reflection of our society.
         The crisis came when his English teacher went on maternity leave. Before then, he was teased as the teacher’s pet. His attendance at school was erratic at the best of times and when she went on leave he stopped going entirely. Then when he realised she was not coming back Wayne decided that school was finished as far as he was concerned.
         To me Wayne had managed to find a good excuse to relieve himself of some rather petty and chronic bullying which could sometimes be worse than being severely beaten up. I condone neither, but both kinds occur with serious regularity in our schools although generally denied by school authorities. The side effect of this is that it is often a relief for all concerned when a request is made that the child should not attend school. It is when you start asking for other educational provision that troubles generally begin.
         Wayne, once you got to know him, was the most pleasant boy you could wish to meet. He was not only courteous and well spoken, but also very knowledgeable about his subjects of poetry, Shakespeare and music. I do prefer to see more of the Wayne type than some other types I do not care to mention. It might be unprofessional but I know a few of my colleagues felt the same way too.
         Some patients kept us interested.
         Despite his age, Wayne was always brought to the clinic by his mother. They both cycled in. The reason was quite simple: Wayne needed protection, not from anyone in the clinic but from the possibility of bumping into someone on the journey to the clinic and back.  When I realised this, we shifted the appointments to school hours and Wayne managed to turn up now and again without his mother.
         His mother was always well turned out, always soft spoken and always waited in the waiting room through the whole session except when she saw our social worker. But those appointments were spaced out as nothing much came out of them. 
         After nine months, Wayne finally opened up to me.
         Mother never threw away anything. Nothing at all!
         Except wet waste, which was a relief.
         This was a serious case of OCD (Obsessional Compulsive Disorder). It was still a great shock to have the full extent of the things that were kept detailed to you. Even a five bedroom house soon ran out of space.
         Wayne told me that as far as he knew, mother had always been reluctant to throw away anything but it seemed to get out of control about five years ago when she discovered that father kept a woman in a port in the Far East. She moved out of the master bed-room and the rubbish moved in. Everything was neatly put in big rubbish bags and properly tied up. Some were in apple or other supermarket boxes. Even vacuum cleaner bags were kept.
         Mother did a good job of it so that there was no bad smell at all, Wayne would reassure me. Just no space.
         All these months, I had been thinking that the bullying was the cause of Wayne’s problem. Did I get it wrong? All the time I spent trying to improve his self esteem, was it time wasted? Was there something I could have done earlier? Why did he take nine months?
         Perhaps he needed that time to find out if I was going to send his mother to an asylum. Perhaps he needed all that time to trust me enough to talk about the sickest person in the family. Perhaps he never had any plan but the secret just came out.
         Perhaps these were all valid explanations, but what could we as a clinic do?
         It would be great if I were able to tell you that we carried out some wonderful therapeutic intervention. Mother was able to get rid of her “collection” and Wayne went back to school and eventually went to university and became a Professor in English or the Classics or something like that.
         It would have been nice, but that would only have been a fairy tale.
         We tried to arrange a couple of mother/son meetings but we really got nowhere. Wayne made vague promises in front of his mother that he would get back to school if this and that happened but I think he knew that neither he nor his mother could really initiate any change.
         Could a mother or son in such a relationship make a bold move to get the other going? I fear not. It was a kind of symbiotic relationship that had gone too wrong for too long.  By making a move to get “better”, one party would be putting enormous pressure on the other to do likewise. Often either party would be afraid to become better in case the other one might become even sicker.  It was just too risky to get better.
         It is not uncommon for young and enthusiastic juniors to be attempting the bolder approach to force a change. I have come to realise and respect that many forms of mental illness are a kind of defence and in the end the mind or the gene that is the engine driving it knows best.
         Similarly with drug addicts, alcoholics and many with sexual deviancy and perversion, our belief that they may change is perhaps misguided at the best of times and at worst, dangerous to others in society.
         I was young then and a plan was soon hatched to somehow persuade mother that we would arrange for her “luggage” to be cleared. She indicated that she would find it difficult to watch. We managed to persuade her to go on a short break in her favourite seaside resort so that she would be away.
         To our great surprise she agreed.
         On the day, we had a phone call from the car that we had arranged to pick her up.
         “She did not answer her door.”
         Our social worker rushed there. Wayne’s mother refused to let her in but talked to her at the door. She had changed her mind. She did not want to go ahead with the plan. By then the firm we engaged to remove the rubbish had turned up too but she was adamant that she did not want it done. After an hour of hard negotiation everybody left.
         She turned up for her next appointment to say that she could not sleep the night before thinking about what we offered to do for her (or perhaps to her). She felt it was such an imposition. She would need to dispose of those things herself when she was ready. When she was ready! I have a great admiration for the English way of understating things.
         Wayne I never managed to get back to school. He never sat any examinations.
         On the official school leaving day he asked me what he should do next. I told him that perhaps on leaving my clinic that day he should go to the local Job Centre to find a job.
         To my great surprise he did. He was immediately offered a job at the local Water Works department as a receptionist/secretary. There they had problems keeping any female secretaries and Wayne fitted the bill. He had been typing since eleven and his English was good.
         As far as I know, he is still with them. I do not think mother ever threw her things away.
         Some cases you remember because of good dramatic changes. Others you just remember.

From Wild Duck:

"Deprive the average human being of his life-lie, and you rob him of his happiness."

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Waste Not: OCD & MOMA

Wednesday, July 11, 2012

Bright Young Thing: Medicine or Opera!

As many “Bright Young Things” were struggling to find an alternative to medicine if they do not want to go into finance, the Cockroach Catcher may now have another answer apart from “Biodiversity”.

The Cockroach Catcher and his wife were fortunate enough to attend a performance of Verdi’s Ernani at the Met earlier this year.

“She was amazing” my wife said, ‘What  a voice and so effortless!”

She is the new rising star: Angela Meade

"I didn’t grow up listening to opera," she recalls of her childhood in Washington State. "My parents still don’t listen to it unless I drag them to one! But I was participating in a community college choir and the director suggested I take some lessons. My teacher gave me a couple of arias, and I found out that it was a really natural thing for me."

It wasn’t long before Meade dropped the pre-med classes she was taking to become a voice major at Pacific Lutheran University. She got into the Academy of Vocal Arts in Philadelphia, and while a student there she competed in the Met’s National Council Auditions—and won. (Her experience in the final rounds of the Auditions was captured in Susan Froemke’s acclaimed documentary The Audition.) Less than a year later came Ernani.

The critics, for their part, are already enraptured with Meade’s abilities. The New York Times recently declared of her performance at the Richard Tucker Music Foundation’s gala, "Her sound was enormous, rich and unforced; her coloratura runs and passagework were dispatched with aplomb and precision." And even Meade’s parents have given up their hope of their daughter becoming a doctor. "My father loves it now—now that he knows I can support myself," Meade jokes. "He had really wanted me to finish my doctorate, but I told him, ‘This is an amazing opportunity and I need to see if it works. If it doesn’t, I’ll go back and get my doctorate.’ But it panned out!" 

Angela Meade as Elvira and Roberto De Biasio as the title character in
 Verdi's "Ernani" at the Metropolitan Opera. Photo: Marty Sohl.

Much interest centered on the evening’s Elvira, the soprano Angela Meade. A recent winner of the Beverly Sills Artist Award for young singers, Meade in recent years has attracted notice with second-cast and cover performances of Verdi and Donizetti at the Met and the fearsome title role of Bellini’s Norma at the Caramoor Festival. She has a sumptuous voice—lush, blooming, bright and majestic as sunlight—and her proud stage presence is that of a diva to the manner born. She negotiated the peaks and valleys of Ernani, involami with ease and commendable agility, and her cadenza was a thing of heart-stopping beauty, a buoyant, shimmering pianissimo that recalled Montserrat CaballĂ©.