International Daughter's Day: Stubborn Mother 2.

Rachel

Rachel could not get to school. She was having such bad back pain. Her family doctor wrote an urgent referral. As she would not see the psychologist at school, school was considering taking mother to court.

          There was a change in managing school refusal. Education Authorities suddenly turned trigger happy and all over the country parents were taken to court. I did wonder if this was due to a shortage of Educational Psychologists who were now too busy dealing with Formal Assessments as a result of the new Education Act, or whether it was due to years of public criticism of the inadequacy of the softly softly approach to the problem. There is some truth that there is a hard core of children whom no teacher really wants to see at school and the authorities are quite happy they are absent. These are children who are entitled to free meals and the hidden saving of them not attending school adds up to a pretty substantial sum. To assess them would take up precious Psychologist time and also may generate expenses in terms of ferrying these children by taxi to special tutorial units or schools.

          But Rachel came from a professional family. Mother was a lawyer and father an insurance executive commuting to London. Yes, Rachel had some problems a year earlier because of her height. She did stop attending school for a while, claiming she had pain in her back. She was way over the 98^th percentile for height. Some strong pain killer prescribed by her doctor seemed to have done the trick and she had not been absent until the present attack of pain.

          Clinical judgment is indeed a kind of “profiling”. We judge our patients from a variety of information and we “profile” them. It may not be correct but we do.

          I had my suspicion that the Educational Psychologist never got to see her record to realise that she was not really the type anyone should ever dream of prosecuting.

          The family doctor thought that I should be given a shot before anyone should have a go. Mother was told in no uncertain term that she needed to get Rachel to see me.

          “But she was in such pain!” mother said.  She did protest but in the end succumbed. With the help of a neighbour, they managed to get her to the clinic and she was lying down in our waiting area.

          I had one look at Rachel, perhaps 6 ft tall, lying flat in the waiting area and asked my secretary to call an ambulance whilst I talked to the Radiology Consultant. An X-ray examination was ordered and if necessary an MRI scan.

          How could I come to such a decision without even spending half a minute with mother or the patient? Was I being over dramatic? Or was it what we have been trained for? Was it why psychiatrists are trained as doctors first?

          I could of course have been entirely wrong and the girl might really have been school phobic. Would I have subjected her to an unnecessary X-ray examination? Would my reputation suffer as a result?

          The ambulance came. The paramedics were excellent. They treated it as potential spinal injury and transported her that way. I accompanied her onto the ambulance. You had to see her face to know you were right. She was grateful someone believed her. For me it was worth all the drama. My only wish was we were not too late that she might not be able to walk.

          Mother too shook my hand as the ambulance got ready to go. I always told my juniors. “Trust them, most of the time.”

          I left a message for the radiologist to call me.

          The call came back from the radiologist. She had two collapsed vertebrae, a common condition among very tall children who have just had a growth spurt. The Orthopaedic Surgeon was preparing for an emergency operation.

          “Good work.” The radiologist said.

          I knew. He meant: “Good work for a psychiatrist, and a child psychiatrist at that.”

          Some time later mother arranged to see me to tell me in detail what was done.

          “She wants to thank you for believing her.”

         

          I was just doing my job.

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The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

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.

Golf, Cholera and Tiger Woods

From The Advances in Physiology Education:

“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)....

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Loquat, Winter Melon & Sapote

This Child Psychiatrist also uses the Stethoscope

 This was from 2008!

In his NHS Doctor Blog, Dr Crippen commented on The Shrink behind Lake Cocytus: "I have never seen a psychiatrist with a stethoscope but fortunately this one has one."

I totally agree. If we do not use the Stethoscope, who will? Between The Shrink and myself, we cover both ends of the age spectrum. When I was Consultant Child Psychiatrist, I managed to “un-diagnose” a few psychiatric cases made by non-psychiatric colleagues, and not just by GPs, I hasten to add. One girl’s family was on the brink of facing prosecution because of her failure to attend school. It was left to me to discover that she had two collapsed vertebrae.

I noted in my book The Cockroach Catcher:

“…. I have often wondered if it would be such a disservice to mankind if doctors were not so understanding of the psychological side of things. The possibility of a serious illness being missed is of course a major concern when a patient seeks help for one reason or another. To put psychological conditions at the top of the list of possible diagnosis is dangerous. Given the concern over cost in most health care systems, the need to restrict the use of expensive investigation is understandable. However, with clinical reliance on sophisticated investigations especially in modern medical training, the art of physical examination is perhaps lost to this generation of newly qualified doctors…..”

It was refreshing to visit Lake Cocytus. If the truth be told, Lake Cocytus is a sort of childhood haunt of mine. I have a cousin quite a few years older and she was reading a Chinese Translation at the time. The same drawing was on the cover (Gustave Doré 1832-1883) and it fascinated me. I read it and was thankful that I did not become crazy. The few that knew me well might disagree!

N95 Masks: Medical Heresy from Plague to SARS-CoV-2

• March 10, 2021

  Dr. Wu Lien-teh's 142nd Birthday

Google Doodle celebrates the 142nd birthday of Chinese-Malaysian epidemiologist Dr. Wu Lien-teh, who invented a surgical face covering that is widely considered the precursor to the N95 mask.

Google honoured Dr Wu Lien-teh, a Chinese Malaysian epidemiologist who discovered the N95 mask over a hundred years ago, with a personal artwork on their search graffiti. 

Portrait of Dr. Wu Lien-teh, circa 1910-1915. (Courtesy of the Library of Congress PPOC.)

Link: https://www.google.com/doodles/dr-wu-lien-tehs-142nd-birthday

It was the 2002-3 SARS epidemic that led to the massive adoption of face masks as personal anti-viral protection in China and elsewhere in East Asia: More than 90% of Hong Kong residents reportedly wore them during the SARS epidemic. 

Anti-epidemic masks as we know them today were invented in China more than a century ago, during the Chinese state’s first effort to contain an epidemic by biomedical means. When the plague struck the northeastern provinces of the China in the autumn of 1910, the Chinese authorities broke with their longstanding opposition to Western medicine: They appointed Wu Lien-teh (also known as Wu Liande), a young and brilliant Cambridge-educated Chinese doctor from British Malaya, to oversee efforts to stem the outbreak. The plague that was killing at least 1 in 3 was about to meet its match.

Soon after arriving in the field, Wu asserted that this plague wasn’t being spread by rats, as had been assumed, but was airborne. The statement was heresy, and turned out to be correct. Wu proved his point by adapting existing surgeons’ masks — which were made of a cotton wad encased in gauze — into easy-to-wear protective devices and ordered Chinese doctors, nurses and sanitary staff to use them. He also made sure that the masks were worn by patients and their immediate contacts, and he distributed some among the general public.

The ultimate price of foolish arrogance

One very arrogant French doctor by the name of Mesny arrived a week later than Dr Wu at Harbin. Dr Wu paid him a courtesy call and briefed him of the results of his own initial investigation of the disease and the importance of wearing special protective face mask. This is the extract from Dr Wu’s own writing,

The Frenchman was excited, and kept on walking to and fro in the heated room. Suddenly, unable to contain himself any longer, he faced Dr Wu, raised both his arms in a threatening manner, and with bulging eyes cried out “You, you Chinaman, how dare you laugh at me and contradict your superior?”

Dr Wu replied, “I am sorry, Dr Mesny, that our talk intended by me to be a friendly one, should lead to such unpleasantness.”] (Page 19 of Dr Wu's Autobiography)

Dr Wu then left the place.

Dr Mesny later visited another hospital operated by the Russians. He examined a few infected patients without wearing a mask against the advice of Dr Wu. A few days later, he was infected with the pneumonic plague and died 6 days after he examined the infected patients without wearing a protective mask. The ultimate price of blind and foolish arrogance.

The personal protection equipment worn during the 1911 plague epidemic in Manchuria.Credit...Institut Pasteur/Archives Henri Mollaret

Wu’s colleagues on the ground were skeptical until the death of the French doctor who wouldn’t cover up even while attending patients. Gauze masks were soon adopted, extensively. Some wearers would first stamp them with a seal from a temple — more than simply medical devices, the masks became talismans.

Dr Wu’s Philosophy

“I have emphasized the need of faith, perseverance and originality: the first, because without it during troublous times we would simply have to throw up one’s hands and despair: the second, because no great scientific or medical benefit has yet been achieved without thorough attention to accuracy and details; the third, because with a conservative education handed down for 4000 years like ours, it is most essential for our minds to branch out in new directions so as to cope successfully with the progressive tendencies of the times.”

“But in order to achieve the quickest and most permanent results in the most economical way, her leaders should absorb the best that the West can offer, such as, seriousness of purpose, service to others as well as self, a scientific temperament, rigid scrupulousness in management of business undertakings, attention to detail and a willingness to learn from outsiders even at the height of success. On the other hand, they should eschew the weaker points of western civilization, such as, undue worship of material success at the expense of the soul, over-indulgence in the ordinary comforts of life and luxuries, and lack of discipline in the family.” 

Link: https://discover.hubpages.com/education/The-Pioneer-Plague-Fighter-Dr-Wu-Lien-Teh

Underclass: The Old Beggar

Hasselblad/150mm lens.

Available light


Film: Kodax TMax 100

Printed on Record Rapid paper/ Selenium Toned

Selenium Toning is for archiving prints and imparts a lovely tone depending on concentration.

The Old Beggar in Loule Portugal©Am Ang Zhang 2005






Link: Silverprint

Photography:

Vacation: Bird Photography

Fun with Photoshop

House M.D. : Canon 5D Mk II

WPPI Las Vegas: Digital Photography & Art

Photography: Old & New
Photography: Best lens for portrait & landscape!

Photography: The Vatican

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:

Being Mortal: Medicine and What Matters in the End

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  

Complications: A Surgeon’s Notes on an Imperfect Science

 (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.

Quotes

- ‘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.’