Thursday, December 24, 2020

Amanda: A Christmas Story!

Finland ©2012 Am Ang Zhang

Christmas reminds me of one Christmas Day when I had to see a patient at the hospital. I had to be with our friends in London so the children and my wife had to wait in the car for me. Just as well the children never asked me why my patient could not go home.

 .........At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either.  It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.


Amanda
         My old secretary Karen went to work for a plastic surgeon in the local hospital specializing in burns. Out of the blue she gave me a call. 

         “It is about Amanda. You should see her. She has all these scars on her.”

         It had been over two years since I last saw Amanda. It was rather sad as she had a real talent in art and I managed to secure the last ever support from the Education Authorities for accommodation for her at the Art College. But she dropped out after a year.  Nevertheless she still managed to make appointments to see me a couple of times before disappearing.  

         “Why don’t you ask her to arrange to see me next time she has a follow up at the clinic.”

         “That should not be a problem.”
         “But only if she wants to.”
         “I think you may still be of some help.”

         Well, Karen actually drove Amanda to my clinic late that afternoon and I stayed on to see her. Luckily Karen was still in the room with me when Amanda simply decided to lift her T-shirt. She was not wearing anything else underneath and what she revealed was a body covered in a number of three to four inches long keloidal scars. Some were actually over her breasts.

         Karen stayed as chaperone and Amanda did not seem to mind. In our work there are certain risks when you see young people on their own and more so when you see someone like Amanda. I sometimes felt rather unsafe with some of the mothers too.

         Amanda was first presented to me as a severe anorectic who more or less required immediate hospital admission. I put her in the paediatric ward rather than referred her to the hospital as at that time we were having some trouble with the quality of care there.

         At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either.  It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.

         Her body weight gradually picked up and it was time for some trial home leave. She pleaded with me not to let her go home even for half a day.

         I did not want her to become dependent on us and there was every sign that she had now settled in on the ward.

         She came back from home leave and decided not to follow our agreed contract. It was popular in those days to have a weight gain contract and we had one too. Of course now I realise how rigidity with a contract can have drawbacks. In fact in child psychiatry too rigid an approach often causes problems one way or another and it is one of the few medical disciplines with which strict guidelines are not a good idea.

         At the time, another patient was on the ward after a serious suicide attempt. She had been abused by her step-father and step-brother over the years. She had had enough and decided to end it all.  I was trying to sort out where she could go as there were all the child protection issues.  She became very friendly with Amanda.

         One day when I arrived on the ward, the Sister-in-charge handed me an envelope and said that Amanda would like me to read it first.

         I have since used the same two pages she wrote as teaching material. Most female junior doctors could not go through with reading it aloud. It is nice to think that years of medical training do not really harden someone. Or was it something too horrible to be faced with?  It was particularly upsetting when the abuser was Amanda’s father.

         Amanda was by then fourteen but her father had been abusing her since she was about eleven. Her mother worked night shifts and father would come to her bed room to tuck her in. This had been going on for as long as she could remember. She started to have budding breasts and her father would at first accidentally brush them and Amanda would be quite annoyed with that. Then one night he started fondling with her breasts and also outside her pants. She was so scared she froze and did not say anything. He went further and further until he penetrated her. She was bleeding quite badly and told her mother, who told her that was what happened to girls when they grew up. She knew what menstrual period was but she said this was different; but mum did not want to know and gave her a box of sanitary pads. Then her period started and she started to worry about becoming pregnant. Her father said it was not a problem and asked her to suck him instead. She recorded that she was sick every time. Then one day her father decided to try her “back-side”. It caused so much bleeding it stained her school skirt and when she told her mother she was bleeding from her “back side” she just said, “Don’t be silly.  It is only a heavy period.”

         It is disturbing even for me to give you the details now. But this is what is happening to many children and is happening all around the world. If anything, I probably have toned down the content of that letter. What has gone wrong with mankind?  I cannot say I know any better since my early cockroach catching days. 

         Then on the day I “forced” her to go home he picked her up and made her go down on him in the car on the way home when he parked on a lay-by.

         In the end it was the other girl in the ward who encouraged her to write to me. She told her that she suffered the same for a long time and was stupid enough to try and hurt herself before she could tell anyone.

         There was no time to waste to report this to Social Services. However, Amanda’s father, who worked at the local mental hospital, had a “breakdown” and was admitted under the Mental Health Act the night before all of this came out. Amanda was not aware of this.  When I showed mother what Amanda wrote, she just said to me, “He is in a mental hospital,” and walked out.

         It has taken me years to grasp that maternal failure plays a major role in family sexual abuse. This mother’s action says it all. Can’t you see he is mad?

         It was a most peculiar case. His psychiatrist refused to even let me know of his problem, citing patient doctor confidentiality. He obviously had not worked with child abuse. Mother denied all knowledge of the bleeding incidents and claimed that it was all in Amanda’s imagination and it became very hard trying to place Amanda because her mother would not acknowledge that there was a problem. At this time West[2] was arrested and it helped me at least to understand the unfathomable.



Art Institute of Chicago’s new special exhibition, “Magritte: The Mystery of the Ordinary, 1926-1938.”Magritte:
         One of the nurses who got on well with Amanda told me that I should look at her examination portfolio for art. Every picture was morbid.  One struck me with the RenĂ© Magritte[3] style of surrealism. A body of a girl with a penis floating over what looked like a classical stone grave. The head was covered in cloth and separated from the body. There were many daggers on the upper body of this half-man half-woman. There was a sort of school in the distance with small figures of school children. The sky was normal blue with white clouds which contrasted dramatically with the central theme. There was no question that the sky was a Magritte sky, and so was the cloth covered head. The rest was original Amanda.

         I knew then from what I remembered of Erickson that the picture was not just about the past with which one naturally associated but also about the future. Yet it took me a few years to realise that it was about the cutting.

         She said she was now working as a waitress. Her teacher at college did not want her to do all the morbid paintings, so she quit. She had been sleeping with virtually any man she came across and every time she would cut herself afterwards. She wanted to feel something, she told me. What was worst was that whenever she was with a man she saw her father.

         What an outcome. I had spent so much time with this girl and this was in the end what happened. She said one day she would be in a mental hospital like her father, but she hoped to kill herself before then.

         I no longer remember Amanda as a severe anorectic but rather a very talented artist who suffered serious abuse. Yet in a society which prides itself in social care, she did not become a famous artist with a high income, telling all about her history of abuse in front of a famous chat show host. Nor did she become a movie star telling all after drug and alcohol rehab.

         Instead she was on benefits and I am struggling hard to find something uplifting to end this story.

It has taught me one thing: Anorexia Nervosa may be just a manifestation.


Art Institute of Chicago’s new special exhibition, “Magritte: The Mystery of the Ordinary, 1926-1938.”

 “Magritte was an amazing artist who has much to offer us today,” said Stephanie D’Alessandro, the Gary C. and Frances Comer Curator of Modern Art at the Art Institute, who was instrumental in assembling this exhibition of nearly 80 paintings, plus collages, objects, photographs, periodicals and examples of the artist’s work in advertising.
“I think that living in an age of mobile phones, in which we are so used to acquiring all sorts of information with great speed — and assuming it is ‘correct’ — has resulted in a loss of the ability to let a picture really take us into its own world, with all its unique habits and customs. So working with installation designer, Robert Carson, I’ve tried to create a series of small, initially quite dark spaces that should help make the experience of each art work more intense and intimate, and will let your imagination tell you where you want to go.”
The Magritte show, awash in images at once grotesque and erotic, mundane and mysterious, unspools in more or less chronological order. It begins with the crucial body of work, both paintings and paper collages, that he created in 1926 and exhibited the following year in his first one-man show at the elegant Galerie Le Centaure in Brussels — a show greeted by mostly negative reviews. It moves on to his subsequent time in Paris, where he lived for three years, becoming part of the Surrealist circle led by the French poet and theorist, Andre Breton, and such artists as Salvador Dali and Joan Miro.






The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Wednesday, December 2, 2020

Kindle & Vacation: The Cockroach Catcher @$0.99 on Kindle!

Today is the 7th day of the Year of the Rooster, Everyone's Birthday according to Chinese Tradition. I am offering the Cockroach Catcher for free for three days on Amazon after midnight Pacific Time. Afterwards it will only be $0.99!


Click Here: Amazon Kindle       Please review at Amazon!


Patagonia ©2015 Am Ang Zhang
It is always nice to be somewhere remote to see different landscapes and stimulate the brain, but there is one drawback: you do not have luggage to carry lots of books to read.!

This is where Kindle comes in handy. Yes a 3rd generation gadget that allows you to store and read books and other printed material.   You can pack with you many books on this device that weighs less than a paperback.


This has inspired me to launch a Kindle edition of The Cockroach Catcher (yes, the book).   More importantly, the Kindle edition costs a fraction of the physical copy.  If you do not yet own a Kindle, you can simply download the free Kindle software and read Kindle books on your iPhone, iPad , iPod touch & your Personal Computer. You can read the book within seconds from ordering.        US Verson

Here are some reviews:
on August 10, 2014
Format: Paperback|Verified Purchase


From a doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

My 80 year old Mum has a long-standing habit of collecting old newspaper and gossip magazines. Stacks of paper garbage filled every room of her apartment, which became a fire hazard. My siblings tricked her into a prolonged holiday, emptied the flat and refurbished the whole place ten years ago. ……My eldest son was very pretty as a child and experienced severe OCD symptoms, necessitating consultations with a psychiatrist at an age of 7 years. The doctor shocked us by advising an abrupt change of school or we would "lose" him, so he opined. He was described as being aloft and detached as a child. He seldom smiled after arrival of a younger brother. He was good at numbers and got a First in Maths from a top college later on. My wife and I always have the diagnosis of autism in the back of our mind. Fortunately, he developed good social skills and did well at his college. He is a good leader and co-ordinator at the workplace. We feel relieved now and the years of sacrifice (including me giving up private practice and my wife giving up a promising administrative career ) paid off.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.


Most recent one from Chez Sam’s:

And CC, your book is amazing! I am only on page 44 but so far, so wonderful. I think how you turned this anorexia patient around just goes to show what human interaction rather than tick box protocols can do in a short period of time and at low cost too. This is an exemplary illustration on perhaps one of the reasons why a good health system like the one in Singapore can not be fully implemented in Britain. it's the change of perceptions and methodology to suit that's difficult.

And, as a city girl, I found your early life in villages fascinating and very enriching for a bright child like yourself, I suppose, had I been your mother, I too would have not asked you any questions when you were told to leave that school ... but the school supplier of cockroaches! [shiver]Dearime! I run a mile when I see one, let alone catch them and dissect them! boys will be boys after all, now that I know that you weren't joking. you are a cockroach catcher, not only of the soul, but for real! @@

The book is a must read doc, I am really enjoying it :-)”

More here>>>>>>


Zhang laments the dawning of the age of red tape in psychiatry, which is the same all over the world. The emphasis on "guidelines", also known as "evidence based medicine", and artificial restraints on access to services, have changed the landscapes of our practice. If everyone practices cookie cutter type of medicine, where will we find new thinking and new treatments? 
This book is a "must read" for all professionals in the mental health field, and for all interested individuals. It is a kaleidoscope of life seen from the eyes of the therapist who genuinely cares about his patients as people. Zhang provides an in-depth understanding of the human condition. 
In my view, this book gives us a glimpse into the soul of psychiatry, into holistic medicine at its best.


Sleeping on Duty: Bed 1 & The Moon!


Recent Junior Doctor discussions on sleeping on duty brought back memories for this retired Child Psychiatrist. When I did my first House Job (residency) in Internal Medicine I was on for two nights out of three and three weekends out of four as it is busier weekends and more of us would be needed. 

We have three Internal Medicine Units and I am in Medical C for want of a creative name or a rich donor. We need to be on after acute take as these were our patients. It provided for continuity and training. Then we are off for one night when, if we do go to the cinema, it would be a waste of money as we fell asleep within minutes. We have 36 beds and bed 1 is with bed 36 behind the nurse station. Nurses tried not to use bed 36 so that the Houseman could catch some sleep. I once fell asleep on one of the those rare nights when everything went quiet at about 2 am. I was catching up with history from a wife at the nurse station. The wife stood across the highish station and the next I knew was that an hour or so went by. I fell asleep holding my pen. 

The wife of the patient just said: You must be tired, doctor. 

No complaints and she did not walk off either. I was so grateful. Medicine the way it should be. In Hong Kong.




©2013 Am Ang Zhang

Then I remember my Bed 1 patient: 


The Cockroach Catcher  Chapter 47  Going To The Moon



 Time and again I have been asked why I decided to pursue child psychiatry as my career. This question was often posed by my juniors who were at the point of their life when they had to choose their career path. It would have been dishonest of me to tell them that I knew exactly why. In life certain events seem to just happen and hopefully they gel together well enough so that one does not have to say at the end of one’s working life that a wrong decision was made.
         After passing my finals, I did my internship in Internal Medicine and Obstetrics and Gynaecology.
         In our final year the first reports came through of cures in Leukaemia.  People’s hopes were rekindled and Medicine moved into a new era.
         Needless to say cancer touches every family in more ways than one can imagine and especially when it hits at one’s prime in life it is a highly emotive thing. In other words, no one is immune, not even if you are a doctor. At the time of my internship we had to deal with all those over the age of twelve and a number of inpatients were young Oncology cases. One of the boys I can remember was having the full VAMP treatment. Someone had a dry sense of humour to borrow from the word Vampire and with good reasons. Blood samples had to be drawn often and it was years later that I appreciated the work of some psychiatrists who recommend the limiting of daily blood drawing to before 10 A.M. every morning. This simple enforceable rule greatly reduced the emotional stress of the children involved. Patients were by and large compliant and they knew that the blood drawing was important.  When they were able to work out that it would not happen after 10 A.M. they had at least a good ten hours of relative peace.
         I had this highly intelligent boy on the ward with Leukaemia on treatment. He was barely thirteen and looked nine-ish. He was my most helpful assistant and would follow me on the lab trolley when I was doing my blood sample rounds. He would fill in the forms and match the numbers on the sample bottles. He never made a single mistake as far as I can remember.  Most of my contemporaries had some pet patient like that. How else could we have got through the day’s work? Most sisters and matrons turned a blind eye and the consultants and professors had been there so they did not mind either. Considering that we were then spending the major part of our waking life on the ward, we got closer to these patients than to anyone else in our life at that point.
         This boy was beginning to show the effect of VAMP and he had some of the most frightening nightmares when he would scream in the middle of the night and nothing much would comfort him. He would sit up and say something about going to the moon and that was probably the only thing of which anyone could make some sense. The regular night nurse who had children of his age was most fond of him and would give me detailed reports of the timing of such occurrences. At other times I could see her playing her mother rather than nurse role and just holding him while he sobbed.
         He had the Number 1 bed which was right by the nurse’s station and it was a rather cosy one as the bed opposite was generally the last one to be used. If I had not been on call, he would give me a quick run down on who was new and who was unconscious and who had insecticide poisoning from suicidal ingestion. In any case, one could smell the insecticide as one walked in as these survivors breathed it out.
         We all so hoped that the cure would extend to him and he would certainly make a good doctor or a good nurse.
         One day when I returned from weekend leave – the one in four weekend that we got to catch up with our sleep, our romance and our family – I could smell something but it was not Malathion[1]. Something was wrong. All his things were gone and the bed was now stripped bare. Night nurse was still around, waiting for me to turn up.
         “He has gone to the moon,” she said.
         Oh no. He had a massive bleed in the brain and passed away during the weekend. His last words were: I am going to the moon.
         I more or less decided at that moment that although we were brought up on the first day of Medical School to confront death, this just might be too much for me. Dealing with the death of a good friend’s father following a cerebral haemorrhage was hard enough but the passing of a young thirteen year old was going to leave its mark and I did not want too many of those.



The Cockroach Catcher
Review on Amazon



The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
                                                                      The Way We Were


     

A Chapter on Anorexia Nervosa,  


Anne of Green Gables