Tuesday, June 20, 2017

Oporto & Hippocratic Past: Do No Harm!


We were in Oporto last summer and in this beautiful place famous for its Port, I stumbled upon a museum that reminded me of our Hippocratic Past. 



It was the medical museum right in the middle of Oporto. 



The following is extracted from The Cockroach CatcherChapter 30  Religious Fanaticism



I
n our work we have some unusual referrals now and again and sometimes they require unusual handling.
         I had an urgent call to deal with a serious suicide attempt at a well known local boarding school.
         No, the child was not admitted to hospital as would be the usual practice, but was kept at the infirmary at the school instead. I arranged to make an immediate visit to see her there.  She was only twelve.
         This was one of the few Church Schools that catered for able children who could not afford expensive private schools. Part of the intake were bright children of church personnel from all over the country. It still had rather medieval costumes for uniform and you could spot the school children a mile away with their long dark blue gowns. Boys and girls had the same outer costumes, but different belts and buckles according to the pupil's year group.
         The school had the feel of a monastery and was quite overpowering as you entered. Individual boarding houses lined up neatly. It read: “We mean business. You are here to learn.”
         The infirmary was even more imposing. It was part of the main block. The main door as you could imagine was at least 15 ft tall and weighed a ton.  The old wrought iron handle had seen a few centuries of use and yet its hinges were well oiled so that when the matron greeted me, she had no problem opening it and it did not produce the squeak I expected.
         The dark double height ceiling made darker by a few centuries of candle and oil smoke would make you think twice before falling ill.  I was led through a couple of archways before I reached the infirmary. There were glass cabinets with all kinds of ancient medical equipments. I was once fortunate enough to archive by photo the small museum at our psychiatric hospital and had since been interested in ancient medical tools. This place seemed to have more and one wondered what they used those tools for. Then I realised that this was a hospital before it became a school, and during the war it was a military hospital.
         At least I am in good company today, I thought, and I had better not let down my colleagues from the Hippocratic past.
         It was early March and spring had not quite arrived in southern England that year. There was not much light coming through the small oval windows. Matron seemed to have read my mind.
         “This was not in fact a proper hospital ward as the main hospital buildings are now the dormitory. This was the staff chapel, but as we all now use the main chapel, it seems such a good idea to turn this into an infirmary. Very good for migraines and headaches and that is normally what we deal with.” Matron said.
         I thought - mmmmm, neither condition can be confirmed by any medical investigation.
         Still it was quite a big room and with the neatly made beds and their white sheets, was speaking loudly – this is an infirmary; you are here to be ill and hopefully to recover.
         Ruth was sitting in one of the middle beds and with her nurse.
         “We have kept a nurse with her since last night, doctor.” Matron assured me.
         There we were, a rather petite looking girl in her hospital outfit sitting on the rather high bed trying to read.  She had a small face and as I approached, slipped off the bed and stood to attention. That said a lot about what kind of school this was. She was reading a French novel but I could not really tell which one it was. She looked cheerful, certainly too cheerful for someone who had tried to get to the other side less than twelve hours ago.
         It was a job to persuade matron to let me speak to Ruth on my own. When she realised that I meant what I said she sent the nurse to sit outside the door just in case and still hoped that I would let her keep it ajar an inch or so. She eventually agreed to have it closed but the nurse would just be outside.
         Ruth herself was not too bothered and I suspected that when you lived in a big dormitory, privacy was not a big concern.
         It was not my style to jump straight to what happened. This disappointed her a bit.
         “Don’t you want to know what happened?” she asked.
         But she agreed to do it my way and in fact it was a better idea, she later agreed.  She thought I was going to ask about the night before and then send her to a mental institution.
         Matron had informed the parents of my visit and mother, who was a social worker, was driving up from the coast and hoped to meet me within the hour.
         There is a very simple rule when we assess attempted suicide. We have to decide if this is the usual or the unusual.
         The usual – probably late teenage, made up to look twenty one, argument with boyfriend, got drunk and took eighteen Paracetamol or whatever was handy including the rest of the month’s pill. Most survived but now and again they were unlucky, were found too late and died a rather painful death. I was lucky – I never had to deal with those. I heard of one though, but she was dead when found. She left mum a note but mum was out with her boyfriend all night and the next day she came home to find a dead girl. Luckily these cases were rare and for that we had to thank our lucky stars. The virtual disappearance of barbiturates and tricyclic antidepressants meant that we had to deal with fewer accidental deaths, though Paracetamol remained the most potent killing agent.
         This girl was not like the usual. She tried to hang herself with the very belt with which she was meant to tie her cloak. Luckily for her the light to which she tied the belt did not hold her weight and she fell to her bed and tripped out the mains. Most of the other girls were asleep but her best friend saw her. She was too scared to say anything at first but now she could not stop crying and had been kept in her own dorm away from my patient’s influence.
         She was one of the star pupils of her year. Her father was the chaplain at a church near the coast. She was the only child. She was also a very good swimmer and represented the school in competitions. She was very talkative and despite what happened was quite at ease telling me about herself and her views of life.
         For three nights before going to sleep she heard a voice telling her to hang herself.  The previous night she actually saw a shadow telling her she must do it to keep her parents from harm. She thought it would not matter as her parents were more important.
         I did not think she was making it up. She did try to hang herself.
         What should I do?  Was this the start of a psychotic illness? Did she have a fast growing brain tumour?  If I made the wrong decision, she might end up dead one way or another.
         No, there was no other sign of either a depressive illness or psychosis. Why were the parents not here for something so serious? Why was mother still at work? Why was father not on his way here? Perhaps they did not take this seriously and maybe I should not either.
         This was an otherwise well put together girl, clever, good looking and had a good prospect of achieving well.
         Would this be someone you put on an antidepressant or antipsychotic?  Would I need to send her to a mental institution?
         One of the most important things we learned in medicine is: when in doubt, do nothing.
         To be more precise, do not do anything that is not reversible. What was the rush?
         I had for years an arrangement to admit my patients, if necessary, to our paediatric ward which normally took in tonsils and dental patients. The hot cases were appendicitis, and then there were my patients who did not require psychiatric inpatient treatment; they had mostly been anorectic patients who, incidentally, had done well over the years. They were often there without other anorectics and that was perhaps one of the reasons they did well.
         A number of O/Ds (overdoses) used to go through the paediatricians, and I would be consulted before any of them could be discharged – a sort of safety valve approach. There were no seriously ill patients. The nurses were a fairly stable group.  It was an ideal place for mothers returning to a nursing career. Over the years, they had got to like my special group of patients, including infants with a sleep problem.
         That would be the ideal place for Ruth. It was a modern hospital. And we could observe her. Like they say, something is going to give.
         Mother turned up. She did look like a social worker. She explained that if this was a hysterical gesture she did not want the girl to think that she could do something like this and get her attention.
         But that was not how I saw it. No, this was no textbook case.
         It was very interesting talking to mother. Half the time I was talking to a colleague and the other half to a very frustrated modern woman married to a very strictly religious man.
         She and her husband were at college together. They were idealists. They were CND members. They marched against this war and that and eventually he studied theology and she, social work. Ruth was a perfect baby, bright and cheerful. She was their only child. She obeyed all rules and she was diligent.  She was every mother’s dream. She was cute, charming, clever and full of life, never demanding in any way and had always been the top achiever in everything she did, academic or sport. She had quite a following in school and what happened came as a shock, and a serious shock to a boarding school.
         A religious boarding school.
         Such behaviour could be infectious and more so when a natural leader did it.
         This is particularly true of psychiatric patients and more so adolescents in an institution. Some years ago a colleague’s two daughters sadly committed suicide one after another in a boarding school.
         I had to come up with a solution.
         A friend once said to me, “You often have to do certain things when a patient is referred to you, not because it is necessary for the patient, but because it is important for the referrer, the parents or the people around the patient.”
         I could not leave Ruth in the boarding school. I could not send her to a mental institution. So I had to admit her to the paediatric ward.
         Mother agreed. Matron was most relieved. Ruth of course would not object. I felt happier getting her out of that rather imposing place.
         An MRI did not reveal any lurking growth and you would be surprised how many parents would have been disappointed with that. Luckily not this mother.
         Ruth became extremely helpful on the ward assisting with the younger kids distressed by their ops and she would be patiently reading them stories. Schoolwork was sent in regularly and I did not think she suffered much from being absent.
         Visiting was rather restricted, not by the hospital but by the school for obvious fear of contamination, contamination of the minds of the innocent ones.
         She soon revealed the figure she saw was that of her father. She said she was afraid to tell me before.
         Now I understood the reasons I never once saw father. 
         She told me that over an extended period of time she would be shut in with him in an under-stairway cupboard when he would recount biblical passages of hell and damnation. The idea was to give her a real taste of hell. 
         “Why was it necessary?” I wondered to myself, “Why do this to a girl who by all standards is perfect?”
         I wish I knew and I wish I had made up the story. But real life could be very strange indeed.
         With her permission, I brought mother in and she started crying when Ruth said, “I told him.”
         Mother assured me later that she did not think there was any sex abuse but it did cross her mind that all the dramatic teaching of Revelation might have something to do with her daughter’s hearing voices and especially those of her father.
         At that time I had just come back from Peru, with images of Juanita[1] still fresh in my mind.  The tribal rituals of virgin sacrifice in the Andes, visions and religious fanaticism suddenly took on a new meaning.
         She respected her father and what he said had to be done, even if it was hallucination.  Sacrifice would be nothing and if she was to go to heaven anyway, she would have avoided the torture of hell.
         I continued to see her and her mother. We seldom talked about religious matters, but more about studies, literature, sport and current affairs. Father never came to any of the appointments.  I did not force him to come to see me. I believe it was sometimes more revealing to let things unfold. Often things that did not happen told a story too.
         There were two more sightings of the devil but she was not distressed.
         I never pronounced any judgment on the origin of her symptoms and school soon gave up asking me. There was an unspoken understanding with Ruth and mother and I preferred to leave it that way. I felt that my job was not to destroy but to help recovery.
         Was it ethical? Could I have missed what is called Satanic Abuse? We do know what happened to some of those who were so sure of their views of abuse. How much harm was caused? How many children were wrongfully taken away never to return to their parents?
         Of course doctors could be wrong and of course my views might change in time but for now things were working out. 
         Bad parents are generally easier to deal with. It is easier for children to know from early on that they are better off not taking any notice of them and they will, at least the resilient ones will, survive. Many children of psychotic parents become independent and tough from an early age. “Good parents”, on the other hand, are more difficult to handle and if they already have a position in society, what are the poor children supposed to do?
         Ruth had been sheltered in her upbringing. She was not streetwise and staying in a highly religious institution, she did not have the chance to mix with any rebellious children.
         As a first born, she followed rules and orders.
         I continued to see them.  Later, without any direct instruction by me, mother worked out that it would be better to move her from her current school to another church school. This one was less austere and the focus was more on education than on religion. She blossomed and now as she was not boarding, she began to go out and meet boys. Soon enough she was dating a boy. With mother’s help they kept this from father whom I still had not met. She achieved some exceptional GCSE results, moved on to a state sixth form college which her now boyfriend also attended. He wanted to be an engineer and she was aiming for languages.
         She went on the pill and father still had no idea she had this boyfriend.
         Her A Level results were straight A's and she got her place at a top university. She came to see me during the Christmas break.  She settled in very well and was enjoying her course.  I did not ask her about her hallucinations. Sometimes we need to know what not to say.
         Mother left father as soon as Ruth got to university and continued to work as a social worker. Father was transferred to the north.
        
         Perhaps I should have raised alarms about father.
         Perhaps.
         I was lucky she came to no harm.
         Sometimes one may not be so lucky.





[1] Juanita (also known as "The Ice Maiden") was discovered on the top of Mount Ampato near Arequipa, Peru, on September 8, 1995 by Johan Reinhard. She was 12 to 14 years old when she was sacrificed and is believed to have died about 500 years ago.
    Although she was frozen in the frigid temperatures on Mount Ampato, her body was discovered because a nearby volcano had caused Ampato's snowcap to melt. The undisturbed site of her burial included many items left as offerings to the gods. Two other children's bodies were discovered near her.

May 30, 2016 ... In The Cockroach Catcher, in the opening chapter I recalled an Anorexia Nervosa patient that has been “dumped” by her Private Health Insurer.

Jun 14, 2016 ... ... of childhood psychological problems. Indeed it was a sad day when the unit closed. From The Cockroach Catcher: Chapter 48 The Last Cook ...


Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ...
Apr 25, 2014 ... ... then the Tate also rejected Picasso………” The Tate now of course has several Mondrian works. Now you can read the whole chapter here: ...

Jun 29, 2011 ... In The Cockroach Catcher I got my Anorectic patient to play the cello that was banned by the “weight gain contract”: Jane got on well with me.

Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ...


Jul 20, 2016 ... The following is an extract from The Cockroach Catcher: “Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he ...

Monday, June 19, 2017

Over Hydration!!!

It is HOT! HOT! HOT!


©2017 Am Ang Zhang 

But please do not overdo the hydration. It is more dangerous than you think!


It is amazing that after over 40 years they are just beginning to realise that. Research on Marathon runners showed that many had low sodium, a sure sign of over-hydration. 


Ancient Remedy: Modern Outlook



Chinese farm workers have always worked in the heat of the fields but heat stroke seems to be rather uncommon. I wonder if our dried preserved plum has something to do with this. 

The Chinese preserved plum is said to quench thirst, and as a child I could never really understand the rationale. Now I know. It is preserved with salt, sugar and herbs such as licorice by a complex process. If you suck one of these plums and then drink water, you have the combination of sugar and salt that carries the salt back into the system. Why plums? Like a lot of fruits, plums contain potassium. This is oral rehydration therapy (ORT) the ancient Chinese way, before the science of modern ORT.


It has to be said that the diet of many such Chinese workers was generally higher in sodium, from dried salted fish and vegetables. It is likely that the serum sodium of many such workers would have been at the high end of the normal range. Modern advice on cutting down sodium often does not take account of sweating in hot countries. A friend of mine with hypertension had an epileptic seizure when he went to work in Singapore. Luckily the medical services there were alert to the problem and he survived. He was on a low sodium diet and on diuretics amongst other medications.

I also remember one very hot August day when we hiked down Grand Canyon to Angel Point. There were warnings everywhere of the risks and even fatalities on such walks. The National Park did have clean drinking water taps along the way and one particular girl overdid the drinking. She had a narrow escape, as the Ranger fortunately knew a thing or two about rehydration. He put some salt in a can of Sprite and reverted a potentially serious situation.

When the first public golf course was opened on the beautiful island of Kau Sai Chau in Hong Kong, drinking water was provided along the course. One player drank so much that he nearly died of water intoxication (result of drinking excessive amounts of plain water which causes a low concentration of sodium in the blood leading to amongst other problems: ‘brain’ swelling---cerebral oedema). Marathon runners are at greater risk than most as reported by the New England Medical Journal. There have been other notable cases of water intoxication elsewhere. I remember one of my professors telling us: the body survives dehydration much better than drowning. How right he was, as water intoxication is in a sense a kind of drowning.

The first time we went to Thailand the most amazing dip was simply a bowl of sugar that has been mixed with salt and some chopped chilies for good measure. This dip was used for serving unripe mangoes, papayas, guavas and other local fruits, and gave me a taste sensation that was unforgettable. Same principle as ORT.

In Thailand, workers in rice fields, fruit orchards and vegetable patches manage to survive temperatures of over 100°F.

On the other hand, Chinese dried plums are such neat, little, easy to carry things. Perhaps we should try to popularize this ancient remedy for the benefit of all. Be warned, only those made with sugar and salt work, not the ones with artificial sweeteners.

“Few afflictions have attracted as much attention and impacted on as many societal and biomedical areas as cholera…….The finding that cholera was due to the ingestion of contaminated water lent to the demise of the prevalent ‘miasmatic theory of contagion, set the platform for the ‘germ theory of disease,’ and promoted the growth of public health concerns for water purification and sanitation. More recent attention to this disease led to the notion of ‘secretory diarrhea’ and the translation of basic principles to the development of oral rehydration therapy and its ‘spin-offs’ (Gatorade and Pedilyte).
Stanley G. Schultz University of Texas Medical School
Cholera is caused by the organism Vibrio cholerae. Alert readers will note that Vibrio has caused much excitement because of the phenomenon of Quorum Sensing.

I well remember Hong Kong’s cholera epidemic in 1961 and the major cause of death was the rapid loss of fluid due to a specific secretive action of the cholera germ. Patients could die in a matter of hours. The medical profession has long been of the strong belief that Intravenous Fluid (IV Fluid) is the only answer. In that situation, the patient is in shock and to find a vein means a cut-down: literally cutting through the skin to find one. It is a messy business as the patient is violently pumping out fluid in the most horrendous fashion.

Johns Hopkins established a centre in Calcutta in the 1960s to study precisely a better way to replenish the fluid. IV fluids were expensive to manufacture and required medical personnel to administer. Their Clinicians sought help from basic physiology and carried out the first carefully controlled study which showed that intestinal perfusion of cholera patients with saline solutions containing glucose strikingly reduced fluid loss. Put simply, the patients could just drink a glucose and salt solution and the glucose would allow the salt to be piggy backed and absorbed, thus sparing the need to use IV fluids.

“……These compelling findings, however, did not convince the medical establishment, who remained skeptical that such a simple therapy could substitute for traditional intravenous fluid replacement in severely stricken patients under epidemic conditions in the field.”
The World had to wait for a war, this time in Pakistan, when Bangladesh fought for its independence in 1971 and 9 millionrefugees poured into India and with them cholera. When IV saline treatment was exhausted, Dr Mahalanabis, who had worked at the Johns Hopkins Centre in Calcutta, took the gamble and decided to prescribe a simple solution of glucose and salt in the right proportion for the friends and relatives of the cholera patients, thus saving at least 3.5 million people. Since that time it was estimated that such a simple and cheap remedy saved at least 40 million more lives.
No wonder The Lancet hailed the development of oral re-hydration therapy (ORT) as "the most important medical discovery of the 20th century".
NEJM: Marathon Runners:


Of 766 runners enrolled, 488 runners (64 percent) provided a usable blood sample at the finish line. Thirteen percent had hyponatremia (a serum sodium concentration of 135 mmol per liter or less); 0.6 percent had critical hyponatremia (120 mmol per liter or less). On univariate analyses, hyponatremia was associated with substantial weight gain, consumption of more than 3 liters of fluids during the race, consumption of fluids every mile, a racing time of >4:00 hours, female sex, and low body-mass index. On multivariate analysis, hyponatremia was associated with weight gain (odds ratio, 4.2; 95 percent confidence interval, 2.2 to 8.2)....

Latest:

Loquat, Winter Melon & Sapote

Germany: Health Care & Smoking!





Germans contributes 7% of salary before tax and employers match that amount.

In return, patients get access to care which is so rapid that national waiting data is not collected.

Germany's spending on health care is relatively high, just over 11% of its wealth, compared to 9.8% in the UK and it has more doctors and hospital beds per patient than the UK.

The Caesarean rate is higher, so is the use of MRI for diagnosis and the length of hospital stay.

Many doctors in Germany set up in practice on their own, as GPs or out-of-hospital specialists, but as cities are more popular that leaves rural areas with a shortage.

Most patients feel they can see a doctor easily, so for example the number of visits to the equivalent of A&E is very low compared to the UK.

While out of hours care has been reorganised, GPs and other out of hospital doctors are often still involved in helping provide cover on a rotation.

All Photos: 

©2017 Am Ang Zhang 


Apart from Greece, they have the highest % of smokers in the First World and they are between 20 to 24. Patriotic?? 

Wednesday, June 14, 2017

Prickly Politics and Ping Pong!



©2016 Am Ang Zhang 

The Cockroach Catcher remembers his Adolescent days fondly, I mean my Adolescent In-patient days fondly. There was much politics to deal with and this time he used Ping Pong!

The Cockroach Catcher:  Chapter 24  Ping Pong


I
t is the nature of life that now and again you have to do people favours. Sometimes you do it in case you need favours back. More often than not it is about doing the right thing.
         One of my outpatient colleagues was female and ethnic. When she realised that I became in charge of the adolescent unit, she said to me, good, now I can get some of my patients admitted.
         It was very difficult to decide if there was racism or sexism. It was true that many of her referrals did not get to be admitted and most of the time the nurses had justifiable reasons. One nurse in particular warned me from day one that I should not touch any of her cases.
         Nurses are very powerful in an adolescent unit. They have front-end dealings with patients from pre-admission to admission to discharge. For someone new like me it would have been foolish not to take notice of such a clear cut warning. But anyone who knows me well enough would not expect me to be easily intimidated.  I would not have an all out fight but I have my ways.
         However, this consultant did not help herself in matters. Before my arrival she had been writing to the Health Authorities about her difficulties in getting patients admitted. Luckily for the nurses all the blame was laid on the previous consultant who was eventually suspended and dismissed.
         By then, the nurses felt that they were in some position of authority and my emergence was not exactly met with fanfare, although there was for some a sense of relief as my success at the Children’s Unit in the last ten months was beyond anybody’s expectation except mine. The nurses working in the Children’s Unit, including the wife of the charge nurse at the adolescent unit, warned me that adolescents were different.
         It was also difficult to turn up at a place that had been running on auto-pilot for some time. The staff began to feel that doctors might not indeed be necessary except for this silly rule that they alone could prescribe.
         The consultant in question was known to have an “over-understanding” approach to cases and she felt sorry for a number of patients where there was a strong social element to the problem. Due to shortage of beds, we did try to limit admission to genuine psychiatric cases.
         However when I was asked by the Health Authorities handling her complaints to look at one of her cases again what choice did the nurses think I had? Quite simply, admit or else.
         But the decision was always mine!
         One of the boy’s problems was that he lived with mum and had not been to school for nearly a year.  As the consultant requested an assessment at a psychiatric unit, Education Department refused even to look at him until that had happened.
         A stalemate.
         In the meantime, Education Department had saved the better part of thirty thousand pounds and they had a legitimate reason.  He was first kicked out of school because he used threatening language with a female teacher when asked to read his story. 
         Mother also reported how threatening he was to her at times.
         From this bit of history he was definitely no good for our unit. The last time the unit had to be closed in the middle of the night was precisely because of violence to female staff.
         We too had a legitimate reason not to admit him.
         I took the charge nurse Martin on one side and asked him to tell me what he would think if we were dealing with a brand new referral.
         I discovered months later that he found me genuine and really wanted to give me a chance to make a go of it. As such he had to tell me the problem. 



©2016 Am Ang Zhang 


         The problem of anarchy.
         There was amongst some staff a strong anti-authority feeling.  There was no doubt they were let down by the previous consultant and some of the nurses could have been hurt.  Following the incident, an outside consultant was employed to provide a report at great expense to the NHS Trust.  I could have told them the problem free of charge.
         Such is management nowadays that the dirty work has to be done by an outsider.  We were still in the investigation period and no doubt everything I did would be under scrutiny.  The survival of the unit would depend on the outside consultant’s report. I had lunch with him on many occasions and luckily his NHS views were in fact very close to mine. Six weeks he had to be with the unit and six weeks was a long time.
         So I was lucky in that there had to be a truce.  We could not let personal prejudices override clinical decisions.
         In the end and some thousands of pounds later we managed to keep our unit running and in some little way I changed my view about outside consultants. The good ones are good and this one was a practising inpatient child psychiatrist so there was no need really to say too much about politics and anarchism. He understood because he experienced it himself, and he found a way to deal with it.
         So running an adolescent unit is like running a mini-country. In our democratic age, the wisest thing to do is to bring about the changes you want when you are riding high, and then leave.  Do not wait to be kicked out.
         As psychiatrists, we do have certain power conferred by the Mental Health Act and that is often a sore reminder of the difference between us and the other staff – more so as we still had two Sectioned patients in the unit at the time: one anorectic on tube feeding and one psychotic.
         Martin the charge nurse said he would visit the boy Leroy at home to assess him and if I could agree to a time-limited admission we might have a “goer”. He thought that Leroy was probably “all barks” only.  His father was from the West Indies and the one time Martin met Leroy he was just loud and boastful and not as threatening as mother always made him out to be.
         In the two years I lived on a Caribbean island, I discovered that many of the children there were in fact very gentle and timid, and they were never rude to their parents. I know not all the islands are the same and generalisation can be very dangerous.
         “But you may have to speak with Kevin.  He visited the last time.”
         Kevin was the one who warned me not to even think about it. There were many ways to deal with violence in our kind of unit.  More often than not if the adolescent patients sensed that there was no leadership they ran wild.
         I decided on a direct approach. 
         “I am going to be frank with you, Kevin. I want you to go out with Martin and see this boy again and I want him in a.s.a.p. unless you can convince me that there is a good reason why he should not have the benefit of a six week assessment. I know you think I am doing a favour and I can tell you now, I am. Sometimes in life you have to because not doing it is going to hurt a lot more people, including ourselves.” 
         “Six weeks then.”


©2016 Am Ang Zhang 



         My new junior, who was a very timid girl, decided to go out on the visit too when she realised that there would be protection. Leroy had just turned thirteen and she told me that she thought he might well have the King’s disease.
         “You mean what they claim King George VI had?”  I thought it was very clever of the drug firms wanting to push the new drug for Social Phobia to involve the King.  “Don’t forget King George VI had lung cancer and metastasis could do strange things.”
         No problem.  Leroy agreed to come in when he learned that we had two ping pong tables and that Martin played County Championship League.  My junior said she was glad she went and she really did not understand what the fuss before was about. I told her that even in adult psychiatry, reports on patients could often paint an unreal picture and the mildest people could be made to appear like big monsters.
         It was suggested that the only time there might be trouble would be when the boy came to be admitted, and therefore he should not come in his mother’s car but in a hospital bus instead, accompanied by some of the big male nurses. I might have given in to the idea but my junior came to my rescue. She would go with the charge nurse and bring him in her car. Mum could drive down on her own.
         “It is a hospital lease car anyway.”
         “The last time a male nurse offered to take a female patient home he was accused of touching her and he was suspended.”
         “Was he guilty?”
         “No, but he died of a heart attack. We shall send our bus but you can be the medical escort.”
         I remember once escorting a Manic Depressive (Bipolar 1) from Hong Kong to London and I had to inject him en route, sitting right at the back of a BOAC[1] 707. That was an experience. So I reminded my junior, “Don’t forget the rapid sedation pack – just kidding.”
         Why should all the fun be left to the nurses, I thought to myself but I was never going to let her drive, Crown Car or otherwise.
         Leroy looked as if he was going to camp, with his new white trainers and sports outfit that father presented over the weekend together with the latest sunglasses.
         Martin told me sometime later that father called him wanting to know if I was “Cool, man. You know what I mean, man.”
         “I told him you were actually Chinese. He said he did not want no white doctor putting no funny thing into his boy.  I also told him the consultant would be happy to see him any time he liked.”
         Martin reckoned he was doped up heavy with something from the way he was slurring his speech. He was all right as long as I was not white.
         “Good, no more racism. Not from us.”
         Father also gave Leroy a new sports-bag to carry all his stuff. It was really too big for him and my junior reported to me the verbal duel between mother and son. 
         “You are blocking the way with that stupid bag.”
         “Dad gave it to me.”
         “He is stupid.”
         “He is not.”
         “Why didn’t you go live with him?”
         “You took his house.”
         “He shouldn’t hit me and you are copying him. Stupid bag, you are not going to Jamaica, you know, stupid sunglasses.”
         “Tag Heuer, they are the best.”
         “Move your stupid bag. Stupid Nike bag.”
         She turned to my junior, “He does not really want to go in, and that is why he is so slow.”
         With that he moved.
         “Have you read Jay Haley[2]?”  Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's.
         “I have read Bateson.”  Gregory Bateson was the well known social scientist who wrote Steps to an Ecology of Mind, and Mind & Nature.
         I am beginning to like her. She is going to be a good psychiatrist.
         So Leroy arrived and was at a bit of a loss standing outside the Nurses’ Office.
         It was time for mother to leave.  We tended not to let mothers stay too long for admission for obvious reasons.
         “Aren’t you going to give me a kiss then?  Why aren’t you crying? I thought you did not want to come in.”
         Did she not realise that maybe the boy was not that stupid? After a year shut up in the house with a mother like that, he would take up any chance to be away for six weeks!
         He did kiss her and started to cry.


©2016 Am Ang Zhang 



         My junior cried too. I thought she did because she felt sorry for the boy.
         “Leroy is a lamb, isn’t he?” Martin said to me later.
         “So we shall be fine then.”
         He smiled.                                             
         For the first weekend inpatients were normally not granted home leave to allow for settling in and from then on the weekend leaves would be dependent on their performance at community meetings and on how they were assessed by their fellow patients. They had to ask for a grade and if the grade was not good enough they were not allowed home. This system had been running for years and I really did not want to rock the boat at such an early stage.
         It was all stage-managed by the teaching staff, who unfortunately found this the only way whereby they could have any control over the children’s behaviour.
         The first weekend Leroy was fine except when mother visited. There was some silly argument and he took himself to the toilet and did not come out until he was assured mum was gone.
         Then he said he missed his dad, who did not have a car and mum refused to drive him down as the last time she drove him somewhere he hit her after some argument.
         “He wanted a new game from dad and dad promised he would get him one if he could get home leave,” Kevin told me the real reason he wanted to be home.
         That is very much the modern way a parent relates to a child. They do not know any other way.
         “Psychology, you see,” he told Kevin over the phone. “I want to help the China Man.”
         “I need everybody’s help!”
         “Do you agree that Leroy has Social Phobia[3]? Everything fitted in with the criteria in DSM IV.” My junior plucked up courage to ask me during supervision.
         It was good to keep oneself on one’s toes with juniors who had just arrived from London and who read up on everything.
         “What’s wrong with shyness?” I joked, “Do you want me to put him on SSRI (Selective serotonin reuptake inhibitors)?”
         “It is supposed to work.”
         “If he starts taking SSRI at thirteen, what is he going to do for the rest of his life?!”
         “The newer short acting ones are supposed to be better.”
         “Take one advice from me; think the opposite, the opposite to what the big Pharmas tell you. In pharmacology, shorter acting drugs are more addictive. That was what I learned in Medical School and is still true if you think carefully about it.”
         By Community Meeting time nobody had a hard word to say about Leroy, but they all noticed he did not socialise much. He had to ask for his grade as per time-honoured ritual. He could not. Everybody tried to urge him. My junior sat next to him and tried to hold his hand. He rushed off to the toilet and locked himself in again.
         “To lock yourself in a toilet is a down-gradable offence and to do it twice in a week is just not on. And, Doctor, we have to be very strict with these rules.  Otherwise we shall start having problems again,” said a teacher.
         So, I was warned. My junior got rather emotional and said that was just too much for her. It was her first case and why couldn’t they be more understanding?
         Martin interjected and said that of course if there were psychological reasons the consultant could grant a special home visit like half a day so that everybody could save face.
         I liked that. Saving face. But then how popular would I be with the teachers? 
         What about Leroy’s face?
         I knew whose face I wanted to save.
         So I arranged to see Leroy straight away.  No, I did not ask him why he could not speak up for himself. I knew already.
         “I hear you are a very good ping pong player.”
         “Table Tennis, you mean.”  He was speaking to me.
         “O.K. Table Tennis. You know he is good.”  I said, pointing to Martin.
         “Yeah, that is why I am not playing him.  I played with Gerry.”  Gerry was his nurse.
         “The fat one.”
         He smiled a little, thinking I was rude.
         “He was a bit slow.”
         “You must have given him a good run.”
         Smile again.
         “I hear you did not play with the kids though.”
         “How did you know? They are no good.”
         “Well, how about this? Have you ever played a Chinese?”
         “No.”
         “We hold the bat differently, you know.”
         “Weird.”
         “We’ll play three games and if you win you can go home for half a day and if you don’t, you stay.”
         The look on my junior’s face was something to be seen. Martin put on a look to pretend that he knew I would come up with something, although he admitted later that what I suggested was the last thing on his mind. 
         The scene was set for a three game match between the consultant and his patient to decide if his patient could go for a short week-end leave.                        
         Even the headmaster came out to watch, shaking his head in disbelief.
         It was spring, still cold but sunny. The sun was streaming in. I lost the first game. I had not played for fifteen years. I took off my jacket.  I barely managed the second.  That brought some cheers.
         From certain quarters.
         He beat me bad on the last one. I did not get past 9 and that was bad for ping pong – sorry, Table Tennis.
         I thought everybody forgave me. I did not give the game to him. He beat me fair and square. The situation was too surreal for anyone to remember to get cross.
         The girls clapped as they all loved him and wanted to mother him, especially the older ones, even when many of them did not have a chance of home leave as their weight was not good.
         I became their hero.  Nobody reported me to the General Medical Council.   Not that time, anyway.
         Mother was horrified but thought that if he had been good and had not attacked any female he would be fine. She would just take him to his father, who would buy him his game.
         On Saturday I was there for a new admission. My junior rushed in saying there was a disaster.  Leroy would not go with mum because she did not want to buy him a Diet Coke from the Petrol Station next door.  She said there was a pack from Tesco sitting at home and the Coke from the Petrol Station was too expensive.
         “After all that!” I exclaimed to myself.
         He just sat near the door. I went out, waved my arm in a table tennis move and asked him to follow me to the car.
         “Cool wheels,” he said, “but it’s for old people though.”
         I ignored him, opened the car boot and gave him a can of drink – still cool from the overnight frost.
         I knew where his problem was.


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[1] BOAC – British Overseas Airways Corporation, now British Airways
[2] Jay Haley - A brilliant strategist and devastating critic, Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's. 


[3] Social Phobia (now renamed Social Anxiety Disorder): Everyone feels nervous from time to time. Going on a first date or giving a speech often causes that butterflies-in-your-stomach feeling, for example. Or maybe you feel shy at a party among a group of strangers, but then slowly warm up to them and have a great time.