Thursday, April 19, 2018

Osthmanthus & Guava: An older and more sedate time!

Guava fruit and the beautiful trunk.

                                        Osthmanthus fragrans©Am Ang Zhang 2011

In The Cockroach Catcher:

The examinations were finally over and I was back home in the village that I had more or less abandoned for the most of the last five years.  I could not remember skies as bright and temperature as high, but it was a nice interlude from the mad preparations and the nerve-wracking examinations.
         We had an unusually dry May. The worst of the 1966 rains seemed like a distant memory and the crisp blue skies somehow made the heat tolerable. Even back then we seemed to be complaining of the ever rising temperatures in Hong Kong. The way we had been complaining about the rise every year, the temperature should really have reached 110 or more by now. The air-conditioning of offices, followed by that of private homes, necessarily led to the feeling of higher ambient temperatures in the streets.
         The garden was filled with the fragrance of the white tropical jasmines.  That fragrance is only second to that of the Osmanthus (Gui Hua)[1], the flowers of which are tiny and appear more towards winter. We used to collect the Osmanthus flowers, dry them and use them to flavour our best teas.  Jasmine is more a late spring and summer flower and we had a big bush. By nightfall the cooling hill breeze brought with it occasional whiffs that made you want summer to last forever.
         It was a peculiar time for those of us who had lived in or around the university for the past five years.  We left home as school children and now we were back, and with any luck the majority of us would in a few weeks become fully fledged doctors ready to apply our skills.
         We had changed and the rest of the family probably not as much; and yet it was a time to savour – the last of the old before embarking on the new and brave.
         It was good to be reminded of the fine cooking back home, of an older and more sedate time when shopping was done twice a day for fresh ingredients.  This practice of course still continues in some parts of the world.

.........The guavas were not quite ready but our own giant papaya tree seemed capable of fruiting through the year. These were yellow fleshed and delicious though without the special fragrance associated with the red variety. Bananas too grew wild and bunches were cut when ready and suspended from a tripod for indoor ripening. It was too risky to let them ripe on the tree as various animals and birds would have had first claim.

[1] Osmanthus (Gui Hua) - Osmanthus fragrans is a flower native to China that is valued for its delicate fruity-floral apricot aroma. It is especially valued as an additive for tea and other beverages in the Far East.

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Tuesday, April 10, 2018

Tioman Island vs The Great Barrier Reef!

The Great Barrier Reef at 18.2871° S is hitting the news with much bleaching. 

Tioman Island: 2.8167°N Not Bleached.

Ideas without precedent are generally looked upon with disfavour
and men are shocked if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.

We have always been led to believe that bleaching of the world's coral reefs is final proof of global warming. Not quite according to the NOAA:

When corals are stressed by changes in conditions such as temperature, light, or nutrients, they expel the symbiotic algae living in their tissues, causing them to turn completely white.

Warmer water temperatures can result in coral bleaching. When water is too warm, corals will expel the algae (zooxanthellae) living in their tissues causing the coral to turn completely white. This is called coral bleaching. When a coral bleaches, it is not dead. Corals can survive a bleaching event, but they are under more stress and are subject to mortality.

In 2005, the U.S. lost half of its coral reefs in the Caribbean in one year due to a massive bleaching event. The warm waters centered around the northern Antilles near the Virgin Islands and Puerto Rico expanded southward. Comparison of satellite data from the previous 20 years confirmed that thermal stress from the 2005 event was greater than the previous 20 years combined.

Not all bleaching events are due to warm water.

In January 2010, cold water temperatures in the Florida Keys caused a coral bleaching event that resulted in some coral death. Water temperatures dropped 12.06 degrees Fahrenheit lower than the typical temperatures observed at this time of year. Researchers will evaluate if this cold-stress event will make corals more susceptible to disease in the same way that warmer waters impact corals.

The Great Barrier Reef at 18.2871° S is hitting the news with much bleaching. 

These are doing fine at Tioman Island,  2.8167°N

All photos©2014 Am Ang Zhang

Medicine and Snorkelling: Think outside the box!

The first modern snorkel was invented by none other than Leonardo da Vinci, apparently at the request of the Venetian senate. It consisted of a hollow breathing tube attached to a diver's helmet of leather.

You may wonder why I wrote about snorkels in my book The Cockroach Catcher. The evolution of the snorkel tube makes me think about progress in medicine.

“... In those days we had snorkels that had a Ping Pong ball at the top end – a sort of umbrella handle at the top with the Ping PongBall inside a little cage so that it floated up to stop water coming in. ….

Imagine the shock when we went to the Great Barrier Reef and were given snorkels that bore no resemblance to the ones I used in my childhood. There was no Ping Pong ball in a cage and there was a drain at the bottom. The top was slightly curved with a clever design so that water from waves could not get in. Any water that managed to get in was drained away at the bottom. I looked at it and smiled. One must always question traditional beliefs. We can be blinded by what looks like a most sensible and reasonable approach – Ping Pong ball in a cage. ...

Medical Schools should remember to teach future doctors that without breaking rules and old dogma, no progress would ever be made in medicine....”
My Point is that doctors sometimes need to “think outside the box”.

Snorkelling is one of my favourite hobbies. I find it so relaxing and therapeutic. Slow breathing, say for 15 minutes a day, is now proven to help reduce blood pressure by a clinically significant amount. What better way to do it than in the sea, surrounded by fish and corals?                                                                                                                                                                       

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US       

NHS & Gawande: Morbidity and Mortality Conference M+M

The GMC warned that the safety of hospital patients is being put at risk because inexperienced young doctors are too often being left in charge of A&E and other units. We need to look at the way medical liability is covered in Hospitals where indeed all juniors must be covered by a consultant in one way or another. The responsibility would indeed be that of the hospital management and not on the poor Junior Doctor.  The difficulty is the choice between NO doctor or a less experienced one. Should the patient be told or should the A&E just be closed? Will management do that or just continue to abuse the poor juniors and blame them when things go wrong. No wonder my friends' children prefer to become lawyers. 

I read Gawande when I was touring Peggy's Cove and posted about his book Complications! Honestly, I did not know Gawande was giving the Reith Lectures. 

Latest Gawande Book:

In one of the most moving passages in the book, Gawande’s father, in hospice, rises from his wheelchair to hear his son lecture at their hometown university. “I was almost overcome just witnessing it,” Gawande writes.

........Gawande offers no manifesto, no checklist, for a better end of life. Rather, he profiles professionals who have challenged the status quo, including Bill Thomas and other geriatricians, palliative-care specialists, and hospice workers. Particularly inspiring are the stories of patients who made hard decisions about balancing their desire to live longer with their desire to live better. These include Gawande’s daughter’s piano teacher, who gave lessons until the last month of her life, and Gawande’s father, also a surgeon, who continued work on a school he founded in India while dying of a spinal tumor.
He’s awed not only by his father’s strength, but by the hospice care that helped the dying man articulate what mattered most to him, and to do it. Gawande thinks, as he watches his proud father climb the bleachers, “Here is what a different kind of care — a different kind of medicine — makes possible.”

What would lawyers say about M + M:

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 

            >>>See also Dr No: We Have No Black Boxes
                                               Abetternhs's Blog  What are we afraid of?

August 27 2014:

What a charming place: Peggy's Cove of Halifax.

The Cockroach Catcher was finishing reading the book Complications and such charming old landscape reminds him of the old traditional medical training he received and how some doctors still do. Like the author of this book.

The book reads more like a collection of blog posts and in fact it was. Yet it was real and touching. Sometimes it was brunt and brutal. and after all doctors are as human as anyone. Complications includes those doctors themselves may suffer: mental illness and alcoholism as well as the serious cardiac condition of the author's young son.

We, doctors make mistakes and please we must be allowed to sort them out without affecting career or worst, future medical behaviour.

A great book for doctors in particular and when on holiday in a charming place.

All photos©2014 Am Ang Zhang  

 (Metropolitan Books, 288 pages, $24), a collection of 14 pieces, some of which were originally published in The New Yorker and Slate magazines, Gawande uses real-life scenarios – a burned-out doctor who refuses to quit; a terminal patient who opts for risky surgery, with fatal results – to explore the larger ethical issues that underlie medicine. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes?
While “Complications” is full of tragic errors and near misses, the book is not intended to be an expose. Rather, Gawande asserts, it is meant to deepen our understanding of the intricacies of medicine. “In most medical writing, the doctor is either a hero or a villain,” he says, with an edge in his voice. “What I am trying to do is push beyond that and show how ordinary doctors are – and at the same time show that what they can do is extraordinary.”
John Freeman, Copyright (c) 2002 The Denver Post.


- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’

- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’ 

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 

Monday, April 9, 2018

Hamlet: Forgiveness

The Cockroach Catcher
Chapter 26  Forgiveness

….My fault is past. But, O, what form of prayer
Can serve my turn? 'Forgive me my foul murder'?...

Now might I do it pat, now he is praying;
And now I'll do't. And so he goes to heaven;

Hamlet Act 3, Scene 3.
William Shakespeare

ometimes we are reminded of our patients in the most unusual way.  One summer we had the opportunity to go on a Baltic Cruise which started and finished in Copenhagen. It is unavoidable on such tours to come across tragic stories in history.  The different Baltic countries had their fair share of wars, sieges, slaughters and some of the most macabre murders in the history of mankind.

© Am Ang Zhang 2006

         Our last stop was outside Elsinore and those of us who were interested were tendered to visit Kronborg Castle, the setting for Shakespeare’s Hamlet.
            Hamlet reminded me of Anita.    

She refused to attend school because of Hamlet.  In my work I have come across many unusual patients but it has never occurred to me that someone would refuse school because of Hamlet.
         I can still remember being called to see her on a Domiciliary Visit as she had refused to come to the clinic.  The parents were not very forthcoming and felt that at seventeen, she should be able to talk to me herself.
         She reluctantly agreed. We then had a most interesting discussion about Hamlet. She was upset because her English teacher did not like what she wrote about Hamlet. The essay was about Hamlet and forgiveness. She felt that Hamlet indeed should have been more “forgiving” and killed his uncle when he was praying.
         “So what if the uncle goes to Heaven?  Big deal!”
         “Instead,” she added, “he got himself killed as well.”
         Our sweet prince was no hero to her and that upset her teacher. He really wanted the class to write about Hamlet and Laertes exchanging forgiveness.

           Exchange forgiveness with me, noble Hamlet:
           Mine and my father's death come not upon thee,
           Nor thine on me.
        Hamlet, Act 5, Scene 2
         She then refused to return to school. At least that was what appeared to be the problem.
         I eventually got her back to school and persuaded her to see me at the clinic regularly for the next eight months or so. She wrote a good deal and told me that she kept a diary that was kept under lock and key. She said whatever happened she would never let anyone see it, not even her psychiatrist, as she would probably have to kill that person afterwards. I did not ask to see it and told her that I had no intention of asking to see it in future.
         Teenagers have their secrets and I certainly want to respect that, I thought. She did show me some other writings and she had some very interesting and unusual things to say.
         Looking back, I often wondered about the challenges we faced, having to base our diagnosis and treatment on some of the most subjective things related to us by our often very disturbed patients.  We could hardly expect to get any “truth” from them, and yet various psychiatric professional bodies seem to accept psychiatric diagnosis made in this way as infallible.  She probably did give me a clue but unfortunately I missed it.
         One day she was very distressed, saying she thought she might have caught something from a Spanish Waiter that she slept with. I was a bit puzzled as she did not appear to be the promiscuous type and certainly not the type who would sleep with someone she hardly knew.
         We had some discussion and I advised her to go to the Special STD Clinic to have it seen to.
         She never turned up again despite several reminders.
         Then she came to the notice of the adult psychiatric department following a serious overdose. This was on the day of her father’s death. She saw a lady psychiatrist and disclosed to her that her father had been abusing her since she was eleven. She never kept any follow-up appointments though and there had not been any further episodes of self harm.
         Nearly a quarter of a century later we had four boys referred because of serious sleep disturbance.  One of my colleagues at the clinic made an initial home visit and afterwards asked to see me in a distressed state.
         She said it was one of the worst cases she had ever come across and asked me to see the mother, who happened to be my patient twenty some years prior.
         It was Anita.
         She, who should be in her early 40s then, appeared worn and exhausted, and looked much older than her age.
         When her father died it was all too much for her. She said she was very confused by what happened to her. She admitted that there never was a Spanish Waiter but she was hoping that I would inquire further.  She was desperate to understand what was going on then.
         “The overdose woke me up,” she recalled, “I felt I had to forgive what my father did to me.”
         She decided to go into journalism. One of her assignments was to do an article on a notorious murderer.  For that, she had to interview that murderer in prison.
         “That was the start of all my troubles.”
         Fascinated by her first case experience, she became a voluntary prison visitor for those prisoners who did not have any visitor of their own.
         “We live in a very forgiving society.”
         Then she met this man that was to become her husband. He was serving time for murder.
         “He killed his father who abused him for as long as he knew,” Anita recalled, “I could identify with him and I felt so sorry for him.”
         Was it the process of reparation?  I too struggled to understand her.
         She found herself falling in love with him.
         Prisons allowed conjugal visits and before long she had two boys by him. Because of her and the children the parole board soon granted him day release passes.
         A murderer granted day release!  Not long after he was out on license.
         We indeed do have a rather forgiving penal system.
         “But he never even knew his father, let alone killed him!”
         By age nineteen he was doing time in a borstal and soon after his release he killed the landlord who took pity on him and gave him board and lodging. The landlord was unfortunate enough to catch him trying to steal from him.
         “I did not know until the trial.”
         It is amazing how protective we are of convicted criminals. I could never understand why the probation service did not warn her.
         No wonder the public has little faith in our rather liberal judicial and parole system.  People sitting on parole boards seem to continue to fail to see into the darker side of the human psyche. Often those trained to understand the human mind also appear not to understand, or are they so driven by performance targets and results that they just want another successful treatment to add to their credit?
         This man had “anger management” therapy when he was doing time. The truth is a psychopathic personality is capable of adapting to suit his ulterior motive. We do have too many psychiatric casualties from such unfortunate releases from maximum security mental hospitals and I am not even referring to psychotic patients.
         He could not hold his job as a security guard and started to do break-ins. He was open to his wife and she said she did not understand why she never informed his probation officer.
         “Perhaps I was afraid of him but he convinced me that these people would get their money back from insurance and he was never going to hurt anyone as he loved her and the children and did not want to be locked up again.”
         One cannot help wondering how much the wives of “famous” serial killers actually knew and to what extent they were convinced by the arguments put forward by their spouses.
         She had two more boys.
         One day he decided that they could make more money if he set her up as a prostitute. He would stop the house break-ins as it was getting more dangerous with the alarms set up by people.
         Surprisingly she went along.
         “I had to do something to stop his burglary activities.  I did not want to lose him.”
         “I was sick over the first client.  As it reminded me so much of what my father did, I told him I could not do it.”
         The next day he said he was resuming his break-in business.
         “The rest is in the papers.”
         He came home when the children were having tea. He was covered in blood.
         “The idiots tried to stop me!” he told her.
         The children were screaming.  Suddenly she felt a strong repulsion and called the police.
         Even the most forgiving philanthropist had her limits.
         “I was thinking more of my children. I was not going to be like my mother. I was sure she knew all along.”
         I had to agree.
         How could this ever have been allowed to happen? What did her forgiveness do to her? Could I have done anything?
         He was tried for murder and sentenced to life imprisonment without parole. What he did was much worse than what he told her on the day he came home covered in blood, but that was by and by. Hopefully no one will think it unkind to lock him away forever. You never know.
         Anita had to pick up the pieces of her life again, having had her long held belief in good human nature and forgiveness totally demolished.
         It was probably destroyed a long time ago by someone she should have been able to trust.

Read more:

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.


Email: cockroachcatcher (at) gmail (dot) com.