Monthly Archives: November 2009

Twilight years

I did not realize how disturbed i was until i got home, and found myself still reminiscing about the dogs i have seen in the dog pound. I found myself analyzing and rationalizing their circumstances, and all i could do was feel pangs of sadness for them.

The last row of the dog kennel has special significance. I knew that aggressive dogs were kept there, dogs who could only be managed by teams of experienced staff brandishing a pole to literally keep the snapping dogs at arm’s length; neglected dogs who were at risk of being broken out by their incorrigible owners and pets of staff members who were away. Then i discovered another type of dog kept in that area – dogs awaiting euthanasia.

There was a senior dog in the last pen. His age showed on his face. His facial hair was turning white. A Ridgeback cross i reckon. He laid sadly on a dog bed. His sadness was evident. How do i know that? I can’t explain, but you could feel the vibes emanating from him. He barely looked up when i stood in front of his pen; just remained quietly curled up, as though he knew what his fate was, and he was resigned to it. I would normally have called out to the dog, or entered the pen to pat them or play with them, but this dog, i couldn’t. I felt hypocritical, and so i walked away without a backward glance.

As i was cleaning out the pens in the other rows, i met an eight year old arthritic Labrador. She could barely walk, yet she dragged herself to the gate with her usual albeit dampened down Labrador exuberance. I entered the pen to scoop up her poop and the stench hit me. God, the odour. What on earth happened to this dog? This sort of smell, i have come to appreciate, is the smell associated with neglect in animals, and poverty in patients. The Lab wagged her tail weakly as i bustled around her pen to tidy up her bedding so i could hose the pen clean. I left her pen to work on the others.

Minutes later i heard a loud bang. I froze, listening intently, waiting and hoping i will not hear the sharp shriek of pain. I didn’t. The dog beds are flip-opens. You put the beds down for the dogs to lie on, and you flip them up onto the wall if you want to hose the floor. Some dogs have a tendency of bashing the beds when they are up so they come crashing down. If the dogs are not agile enough, they get crushed underneath. I am not so worried for the larger dogs, but more for the puppies and smaller dogs because the consequences will be catastrophic.

I took a leisurely walk down the row of pens, curious dogs glancing at me as i strolled past. And i discovered it was the old lab who flipped her bed. She managed to dismantle the bed, and was standing on top of the rocking platform quivering and wondering what on earth to do. She gave me an apologetic look. I felt sick. This old dog wanted a bed to rest; she tried her best. And i wonder whether her former owner knew about her plight, and whether they would take her back in a jiffy, because i know a true dog owner’s heart will break if they see their pet in such a state. I have learnt that not all people who give up their dogs are heartless, and that cruel circumstances can sometimes force the cold hand of fate. Maybe that’s why dog pounds have a clause that all owners who give up their dogs must sign – that they waive all rights to inquire about the fate of their dogs.

I entered the pen and tried to coax the dog off the rocking platform. She could not and dared not. The unstable platform was straining her arthritic joints, and she was frightened. I walked up and attempted to re-hinge the bed with the dog still on. She leaped off once the bed stabilized and gave me a grateful look. I patted her on the head, and left to do the remainder of my chores.

I am perturbed. I think it really is a shame to treat a lifelong companion in such a shabby way when they hit their senior years. To subject them to the chaos of a dog pound, and confine them to a small enclosure is just…unthinkable. And these dogs still find it in their hearts to accept and forgive. It honestly makes me sick.

 

Advertisements

Thinness

Anorexia. Never thought i would personally know someone with it. The first day i laid my eyes on her i jolted visibly. When we made eye contact a few seconds later, i felt my heart skipped a beat. I am not one for melodramatics, but this time the true horror seethed through me. I always had a hunch, but i really did not want to be proven right. Now that my doubts have been put to rest, i did not feel any better.

We were never in the same clique. Personality clash, you could say. But by a strange turn of events, we happened to dine on the same table through mutual friends. She was seated across me; and i seemed to be in the front row seat, treated to a blistering show of anatomy in its purest form. Like a true spectator, i cowered under the might of the impact.

I smiled at her. The first in many years. She nodded. Funny how all animosity seemed to melt away without a trace when someone is in desperate need of help. Perhaps it is the most basic of human instinct. We made conversation. Actually she spoke to me, and i replied when spoken to. The power balance had changed. I knew it and she knew it. I did not pursue the matter because what is the point? Challenging an opponent when she’s down on the ground is ignoble. Yet on the other hand, i wondered whether i was encouraging her self-destructive behaviour by finally giving her the attention she so badly craved.

I wanted to reach out and apologize. The times when i acted so cold and indifferent. Wanted to let her know that it is ok; she did not need to resort to this to gain control. But who am i to be so egoistic anyway? I was never a close friend, but yet i still feel guilty. See how this plays out? Our conscience never lets us go, even over the most minute of things.

She’s not getting better. She has refused all treatment. I know she ain’t going to last. I am still perplexed as to how i feel over someone who is clearly withering away in front of me. So this is what it is like to see someone die in front of your eyes and you can do nothing. How simple but how abstract. Where is the stark sense of helplessness? I feel only horror.

And what will patients say when they see this medical student? What happens when she goes on her psychiatric rotation? Will she be banned from the eating disorder unit? Will the starving girls in the inpatient unit see her and treat her as a role model, as one of their own?

God, this is confusing. This dilemma.

Family support

There is a patient in the wards. She has major depression, recurrent it seems. She is, or was a student. When you are held involuntarily under the Mental Health Act, you have got to put everything else on hold, don’t you?

She is not from here. She speaks minimal English. She has a few extended family members in this foreign place. Her immediate family is back home.

This patient is not doing too well. Her depression is not lifting and she is actively suicidal. She’s classified high risk and has been placed in the most secure wing of the mental health ward. She has been here for a few months already. Within the first few weeks of her admission, her extended family has abandoned and disowned her. So much for family huh?

Her parents have been notified but for some inexplicable reason, they are unable to come down to at least visit their youngest child. Now this young woman is in limbo. Surrounded by strange faces, far removed from her familiar environment, and forced to take medications by people who speak a different tongue; i really am not surprised she is not feeling a little better.

From a medical standpoint of view, even if we are able to release this patient back into the community, where is she going to go? She cannot fend for herself. As it is, she has been bullied and assaulted by the other more domineering patients. So we keep her in hospital where at least there’s someone to keep an eye on her 24/7. But she is not a citizen. Her visa is expiring. Maybe it has already expired. Who knows?

Patients like her really need strong family support. That her extended family has ditched her without a bat of an eyelid is horrifying. How can you ditch your brother’s or sister’s children when they are in need of serious help? How do you account for your behaviour to your sibling? You are related by blood, and by virtue of that, there are some familial obligations and responsibilities that you cannot shirk. This is astounding. I am shocked beyond words. I understand how difficult it is to care for someone with a mental illness, but right now, no one is compelling you to be a carer. All you have to do is visit your relative once a day, or hell at least once a week. They just need some reassurance, and trust me, they will get better. Slowly yes, but surely.

And the patient’s parents. I don’t know what difficulties you are in, but i think your child should be highest priority. Always. I for one, know you are not in financial difficulty, so i am not exactly sure what is holding you back. The shame and stigma of a mental disorder? Shame on you. And if you are truly finding it hard to come visit your child due to some dire circumstances please liase with your daughter’s doctors. We can help. We are here to help. We know your anguish as a parent to be kept away from your child who so desperately needs you.

Sometimes the solution is plain to see. But i am not sure why everyone does not take to it.

Nothing beats the pain of having your own family give up on you.

Ego

This patient re-presented with an infection of her wound. Five days ago she came to the hospital because of a large carbuncle on her leg. It was surgically drained. She was warded, so that proper daily care of her wound could be carried out by the nursing and surgical staff. She discharged herself in two days, against medical advice. She came back after the weekend. The wound looking decidedly worse for wear, the pus copious, the stench mind-numbing. She was admitted into theatre for a thorough clean of her wound. The wound was left open, so that granulation tissue could form, and it would be easier to suture it shut.

A few days later, we were in the operating theatre to sew the wound shut. A new surgical trainee was tasked with the job. With limited resources anyone who could help was allowed to assist. That would be the medical student – me. I have witnessed and assisted in several carbuncle surgeries before, and although i do not profess to have an in depth knowledge of the procedure, i was at least familiar with some aspects. And i did some pre-reading beforehand. I saw the trainee struggled with the procedure. He selected the thickest sutures available (which looked like ropes to me, metophorically speaking, when i compared them to the finer sutures used by the more experienced surgeons), and started working on the wound.

The wound was gaping big. This trainee hooked the sutures around the edges and started pulling them shut. When i say pull, i really mean it in the literal sense. He was tugging at the sutures trying to get the wound to close. I stared in silent horror. Anyone could see that the wound ain’t gonna close, and even if it did by some miracle, it ain’t going to stay shut for long, and you are going to be in some serious shit when the wound explodes up on the wards. I kept my mouth shut. My place as a medical student is low on the totem pole. And i do not profess to be fantastic at this, so maybe perhaps, this trainee knew what he was doing. I was rationalizing. I knew that. Surgery is an elegant graceful art. If you have to resort to pure barbaric brute force, you are doing something wrong.

The trainee was sweating now. The head surgical nurse was popping her head in one too many times asking us when we would be done. The surgeon schedule for the surgery after us was here, and we were holding things up. The trainee then made a decision to excise some of the granulation tissue, the very tissue that we had waited patiently for to grow, before we attempted to close the wound. The precious tissue that grew to help cover part of the wound, was now being taken out because the trainee could figure no other way out to close the wound. I looked on, not quite understanding, yet grasping the seriousness of the situation. The trainee started suturing the wound shut. Still it was too big. This time when the trainee heaved the sutures shut, the suture actually broke with a loud snap. There was silence in the room. I could feel the tension. I heard the operating nurses stopped their conversation, and i felt eyes on us. I was at a loss. This trainee was obviously clueless. We were toying with a patient here; i did not like that.

And then in strode the more experienced surgeon, the one who had been introducing me to the techniques of surgery. I felt relieved. He looked at the wound.

“I think we have to do something about that, don’t you think?” he said pleasantly to the trainee.

“I have it under control,” the trainee said stiffly.

I could not believe my ears. The need to pander up to one’s ego, the irrational decision to argue when time is tight, and the fact that someone more experienced was trying to hint that something is not right, and you still did not concede, was bewildering.

The chief operating nurse came into the theatre once more, this time seriously irritated. What was taking a minor surgery so long?

“We are going to have to do skin flap and mobilize the skin to help close the wound,” the surgeon stated with no further room for arguments.

With that, he expertly made the cut, moved the skin flap and had the whole situation under control in minutes. He also selected a finer suture, to suture a more manageable wound shut. The trainee did not say anything.

Ego. I have been prey to it. But as we mature and develop, shouldn’t we get our priorities right? I hope i never embarrass myself like that in future.

Out of touch

I have noticed how out of touch with family life i have become. It was Halloween two days ago. Hell, i did not even know that. I never celebrated Halloween, was never in my culture. Never seen anyone here celebrate it either, but then of course, i have no friends the age of kiddies, or i will be quite paedophilic. And then just before i was about to leave for a friend’s birthday party, i heard the doorbell rang. I saw two kids dressed as witches at my door. They stared expectantly and eagerly at me. But took a tentative step back when my dog growled. My dog ain’t used to kids either.

Instantly, i felt a sense of impending doom.

“Is it Halloween?” i stammered, in a feeble bid to make conversation with these children. God, i have not spoken to children in ages.

“Yes!” one of the girls answered excitedly. Her sister nodded solemnly.

“Erm, ok, give me a minute.”

I walked slowly towards my kitchen, knowing full well i had no secret stash of chocolate, and neither did my housemate. It was also at this point in time did it occur to me how excruciatinly healthy both of us are, with not a single junk food in the house. And for once, i wondered whether that was normal. I made a show of rumaging around, and finally i knew i could stall no more. I sighed inwardly, took two muesli bars, plastered a weak smile on my face and went to the door.

The kids looked confused. Their dad looked horrified. I was appalled. I guess that made us quits?

After they left, i made a quick escape to my friend’s party. I saw more kids walking up my street and i felt even more nauseated. That was a close shave. I gave my housemate a heads up, but she got lucky. It started raining by the time she got home, so she got off. Damn.

On hindsight, i think perhaps it was better to have dropped a dollar or two in their buckets and tell them to get their own candy. Might have been better. Oh well, there’s always next year. And i will be sure to have a supply of chocolates ready, though i think i have probably earned myself an infamous reputation with the neighbourhood kids (and parents). How i managed to evade them the last two years still beats me. I must have been busy at work to even realize…

Tha lack of insight was just amazing

Psychiatrist sat beside bipolar patient in ward. Med students stood quietly in one corner.

Psychiatrist started the conversation.

“Can you tell me what happened?”

“Nothing…i felt down, so i stabbed myself.”

Silence.

Patient continues.

“But i am feeling pretty shitty about it right now. Shouldn’t have done that. that’s why i walked to Emergency with my bloodied arm.”

Psychiatrist nodded, a deep look of concern on his face.

“You need someone to turn to, in between your crisis. You understand what i am saying?”

“Like a friend? I do not want to burden my friends. They are shocked by my moods anyway.”

“Is there no one else at all?” the psychiatrist gently probed.

A long pause as the patient thought hard.

“I guess i could visit a brothel…those girls over there are pretty good, they agree with everything i say.”

I nearly keeled over mentally, aghast at what i had just heard. It was completely off the mark, the exact opposite of what we (the medical team) wanted. We were trying to get the patient to understand his situation, to come up with his own solution, by gently leading him to it. But this?? THIS?!

“And i don’t think my girlfirend will be too happy about it.”

OF COURSE! I wanted to yell out, but i kept my mouth shut.

This is no place for judgement. I keep my opinions in my own head. People have difficulties in their lives; they think differently. The psychiatrist was cool as a cucumber. I was astounded. How disrespectful to the women in the room.

I wonder what the patient’s girlfriend’s reaction would have been had she been present for the consultation.

#1 reason why i will never go into psychiatry. I cannot empathize with the mentalities of some patients. If i can’t hold back my judgement, i can’t provide optimal medical treatment. So thanks, but no thanks.