Monday 30 June 2014

Nuts or Normal??

The DSM5 Revisited.
          The Diagnostic and Statistical Manual of Mental Disorders updated in 2013 and published by the American Psychiatric Association serves as the American authority on  mental diagnosis.  It has a frightening influence on the lives of individuals with the  potential of labeling them for life, on the basis of clinical observations that often are subjectively interpreted and sometimes seem to have great difficulty in distinguishing between normal reactions to the stresses of life and actual mental illness. There seems to  be particular difficulty in dealing with what is to be considered a normal response to bereavement and in distinguishing it from a depressive disorder.  In the DSM4 psychiatrists are advised  not to  make a diagnosis of depression for at least two months after the death and then only in the  presence of some of the  more serious signs of depression.     The new edition removes this qualifier, thereby medicalising grief and making treatment with antidepressant or other drugs  more likely.  This in  itself  may not impair the grieving process. The suggestion  that avoiding  the diagnosis of depression in this situation, as a general rule may result in people who are profoundly depressed not receiving treatment, would imply that the physicians treating these persons are lacking any capacity to diverge from the cookbook recommendations that the DSM5 has become, in  favour of appropriate individual treatment.  Experience, knowledge of the patient and understanding seem  to be totally disregarded, with treatment recommendations increasingly veering to early introduction of drug therapy.  Unfortunately, insurance company coverage, government pensions and fee schedules appear to have an unseemly connection to diagnostic codes. Unlike the rest of medicine, in psychiatry, there are  no  diagnostic tests to confirm  or refute diagnosis.  There is a trend towards early (perhaps too early) diagnosis and drug treatment.  Perhaps the  'Choosing Wisely' Program needs to be applied in psychiatry as urgently as anywhere else.

Friday 27 June 2014

Denial, is it always bad?

     When I  was at home recovering from stent placement and my son was away, he had a close friend drop by to see how I was doing.  He arrived with two bowls of an exotic Oriental soup, that he had told me about at a barbeque in the summer. I thanked him for the soup and when  he asked me how I  was I told him I was doing just fine.
     " Well, I was told you would say that anyway, that you minimize these things.  How are you really?"
      When I challenged my son  about branding me as a minimizer, his response was, "well, you are."
       I resisted the temptation to say "no, I'm not," followed by "well, that's better than being a maximizer,"  and decided to give the whole denial topic some thought.
        Denial is defined by Freud as a psychological defence mechanism in which a person is faced with a fact that is too uncomfortable to accept and rejects it instead, insisting it is not true  despite what may be overwhelming evidence.
         Now this can be a very bad thing and result in  people not seeking needed investigation and attention, but take out 'overwhelming' and the whole denial concept may serve a valuable service.This is particularly so for folks in the Health Care Professions who are dealing with depressing diseases and disabilities much of the time..  As a medical student, healthy doses of denial kept me going, because when I saw and  looked after people with horrible diseases and even shared some of their symptoms  I knew it really couldn't happen to me.  THAT's denial and that's what enables most of us to carry on without becoming hypochondriacs.  Without denial, it would have been harder to carry on and may have resulted in unnecessary investigation and worry.
           When I  got older and became a victim of the ravages of time I continued to benefit from that defense mechanism and knew the various vague symptoms I experienced from time to time were just the normal consequences of aging.  I was not so stupid as to continue the denial when  it became difficult to carry on  my normal activities and it was at such a time that I  would involve my family doctor.  Then it became her problem, and I (for the most part) would do what I  was told.   I think that this approach has served me well and never felt that the denial  phase resulted  in any  adverse  outcome.  To put it another way it enabled me to minimize the situation until it went away or until it became apparent that I ought to do something about it.  This saved me much investigation during an era when investigation was often excessive and the results were not always without harm.  Attitudes regarding investigation are changing and initiatives are already under way to rationalize investigations and avoid fishing expeditions as in the 'Choosing Wisely' program, where the risk of too early and too extensive investigation is currently being examined. The risk of denial is that it may go on too long, resulting in delay in diagnosis and treatment.
         There are forms of denial not related to personal health that people use as a temporary defence that allows them to deal with a situation while they are developing the strength and skills to deal with a catastrophic situation.  I have seen many patients over the years who used this mechanism to their advantage.I have also seen many over the years who have been more disabled by being 'maximizers' than by being 'minimizers'.

Tuesday 24 June 2014

Emergency!! A true Story of the Olden Days!

(This is a story of the days when there was no doctor in the Emergency except  the poor frightened Junior Intern!! Only the names of the guilty have been changed)
          It was my first night on call in the Emergency Room, all by myself.  Me, the brand new intern, alone, terrified.  It was a small but busy hospital in Ashford, Kent.  I had just come over from Ireland and I knew no one yet.  At half past eleven I had finally seen all the patients and the waiting area was empty.  I was relieved that the most serious thing I had to deal with was a patient or two with pneumonia and a few sick kids, and none of those horrific injuries that I so dreaded having to deal with had turned up.    It was December 31st  1961  and it looked as though I was going to get to the midnight 'Ring in the New Year' party on West One after all. 
            "Ready for a nice cuppa yet, doctor?" asked Nurse Mary Hand.
            "No thank you.  Have to leave room for beer or two at midnight." 
            "Yes, I'll go down with you for a few minutes and we'll leave Jane to mind the shop.  Then, I'll come back and she'll go down for a while."
            Another patient trickled in with a bad backache that she had had for four years, but seemed a bit worse tonight, New Years eve.  As she was on her way home after the late shift and passing by the hospital she thought she*d drop in and have it looked at.  I had no sooner packed her off than the dedicated line to the ambulance service began to ring. Jane came running down to the Cubicle where I was still completing my notes.
                 "I just had a call from the Ambulance driver.  They’re bringing in a man who has just been hit by a train.  Real bad they say he is.  They’ll be arriving in a few minutes."
            I felt a wave of panic pass over me.  Until now, I’d always been in a large teaching hospital, with its hierarchy of students and physicians of increasing experience, capabilities and specialization.  This meant that there was fierce competition when the 'big stuff' came in.  The sharks from the specialty services were constantly cruising the water to see that their trainees and not some insignificant intern were getting exposure to enough clinical material.  Consequently, junior interns were pushed aside, and although present, often didn't get much hands-on experience. 
            The sirens screamed as the ambulance pulled up to emergency bay.  The nurses had prepared the acute trauma room and directed the ambulance men pushing their gurney into it.  I rushed in, suppressing the overwhelming desire to run away.  The sight that greeted my eyes justified my fears.  On the gurney lay a man of about forty-five, motionless and then my eyes came up to his head.  The scalp and underlying skull were avulsed from just above his eyebrows carrying with it a fair chunk of brain all hanging on a hinge formed  by a delicate flap of skin.  It was an injury that no-one could possibly have survived.  That much was immediately obvious as I attempted to suppress the gasp of horror that came to my lips.  The two nurses, who had rushed to the bedside with IV fluids and other emergency equipment, also gazed at the corpse, in horror.  I didn't know what to do.  Medical care for the patient ends at the moment of death.  But wait a minute; everyone knows that the first thing a physician has to do is certify the patient as dead.  There are three clinical signs of death, dilation of the pupils, absence of heart beat and absence of breath sounds.  As I learned so well in later years, when you don't know what to do, you do what you know how to do.  
            "I called the Senior Surgery Resident.  He'll be right down." Mary said.
            'Don't just stand there, doctor, do something.'  The prevailing philosophy might often better have been 'don't do something, doctor, just stand there'.  But it wasn't, and I felt compelled to take action.  I took my pen flashlight out of my white coat pocket, retracted the blood-encrusted eyelid of the unfortunate dead man and shone the light into the dilated pupil, knowing full-well that he was dead. 
            Just then, a tall well built, blond man, in a white coat, strolled into the room, with an easy stride.
            "I'm Rhys-Jones, the surgical resident," he introduced himself, with an Oxbridge drawl.        “May I ask what the hell you’re doing?  The man's brain is lying beside him on the bed and you're looking for pupillary reflexes.  You're not going to find any, he's dead!"
             I felt stupid, not for the first time and certainly not for the last.  Even then, I knew it doesn't last long.

            "Come on, lad, there’s nothing you can do here.  We better give the coroner a call, this will require an autopsy.    Only, of course,” he added with a grim smile, "if you didn't get a pupillary reflex. You must be the new intern from Ireland, Lord save us," he said, with a mock Irish accent.   And since you have cleared the waiting room, you might just want to stop at my flat on your way home for a quick glass of Kentish cider."

            Heffan Rhys-Jones turned out to be a helpful colleague and a good friend, apart from the fact that he never allowed me to forget the circumstances of our first meeting. He never hesitated, after a couple of drinks to regale our friends with the story  (lapsing into a mock Irish accent), 'of himself checking for reflexes in a poor old soul, who's brain was sitting on the gurney beside him'. 
            Hef, as he was nicknamed was married and had a little girl about a year older than my own daughter.  
            One of the most useful things he introduced me to was the illegal Kentish Apple-Jack that the farmers in those parts illegally distilled from fermented Cider.  This was a brandy that was at least 40 proof and I suspect a good deal more.
            “I can get us a good big crock of it for about ten shillings. One of the ambulance drivers has contacts. Why don’t you ante up five bob and we’ll buy one between us” he said.  “It’ll probably last us the whole year.”  
            The prospect of having enough to drink was enough to make two impecunious interns think they’d died and gone to heaven.
             “Okay,” I said, forking over my five shillings.
            Three days later I got an urgent call from Hef.  We both lived in flats owned by the hospital in houses that were just across the plum orchard that opened onto the hospital back door across from ours.
            “Can you drop over here, Dear Boy, on your way home and help me to move this damn Crock that that the ambulance drivers dumped in the middle of our kitchen?   A bloody great ambulance pulled up at our door and three ambulance drivers only just managed to get this huge earthen wear crock into our house and dumped it in the middle of the kitchen, took the ten bob and took off as fast as they could.”
            No wonder, I thought.  They could go to jail for illicit spirits dealing.  “I’ll be right there,” I said, “We can sample some.”
           “We can try,” he said.  I didn’t know what he meant. 
            Twenty minutes later I arrived at their door.
            “Thank goodness you’re here,” said Megan, “I can’t do a thing in the kitchen with this great big thing in the middle of the floor.”
            I walked into the kitchen and there it stood.  A large three foot high stone jar, light brown upper half and dark brown in its lower portion.  We barely managed to waltz it into a corner between us.
            “We’re never going to get a drink out of that,” I said, despondently.  “How can we tip that?”
            “There’s more than one way to skin a cat,” said Hef, in a way that I knew we would be getting a drink out of it very soon!   And we did, for an entire year!

Friday 20 June 2014

What the heck is DSM5 and why should I care?

DSM5 stands for "Diagnosis and Statistical Manual of Mental  Disorders 5".
             You should care about it because whether you are deemed to be normal or a nut case may depend on what it has to say. 
             "So who authorizes this?" you may ask.
              The American Psychiatric  Association.
             Well, who would use this catalog that was last updated by  the APA in 2013  and has 947 pages and over 300 psychiatric diagnoses?
              Your Lawyer, your Insurance Company, Your Doctor for instance, not to mention your psychiatrist.
               First published in 1952 (DSM1), it was 130 pages long and listed 106 mental  disorders, so as you can see, we are a lot crazier in 2013, even though a number of the diagnoses in DSM4 have been removed!
               The DSM was originally published as a text to help physicians diagnose the myriad presumed pyschiatric  signs and symptoms but has now become the basic criterion for decision making in the insurance, legal  and governmental  arenas.   It was supposed to help define that fine line between  normal life reactions and mental disease, like when does normal grief at losing a loved one become a psychiatric illness.  It has become increasingly difficult to determine where normalcy ends and disease begins.  When  should  we put a very active child into the abnormal group and put him/her on medications that themselves may effect their delicate brains.  Experts in  the field cannot resolve this dilemma but it is sufficiently critical  for the criticism of the most recent DSM to have resulted in a petition by 13000 mental  health care workers sponsored by mental health organizations which called for an independent outside review of the document.
              Follow my blog for further discussion in  the coming weeks and post your comments.

Tuesday 17 June 2014

Make me Manly!

              Big Pharma is working really hard to create life-long medication requiring 'diseases' that it blithely advertises to the public.  The latest of these 'diseases' is Low T.  The real name for Low T  is hypogonadism which is not a very catchy title, so one can see why a  catchier title  was  desirable.   The ad usually start with a big handsome 45+ guy who is feeling a little down, golf swing not what it used to be and obviously no hot shot  in the sac anymore.  Next, the 'wonder drug' schtick and while you watch the post treatment cheerful man now smiling happily while his sweetie sidles up to him, the narrator cheerfully runs  through the myriad side-effects so rapidly that I  can't keep up with  them, even though I already have a pretty good idea of what they are.  Some are serious.
             "Low T," is an advertisement that Big Pharma is pushing these days that  would make it appear that low testosterone is an almost universal disorder and that any male over 45 years old  better get in and see their doctor They are meeting with considerable success in promoting the various preparations of testosterone as some sort of wonder drug, although the condition of low testosterone is actually quite rare (about 2%, I believe though I'm too lazy to look  it up!) . A lot of men, who don't need it are taking it by one route or another - you can even get it as an underarm roll-on.  It's about a 2 billion dollar a year industry and growing.

Friday 13 June 2014

Ode to a Lifelong Friend!

Photo: I lay you, faithful stethoscope to rest,
Against how many hearts have you been pressed?
Oh mighty stethoscope you told me much,
And confidence exuded from your touch

The secrets of the airways all laid bare,
As you measured sounds of heart and air,
No MRI or CAT scan will astound,
The way you did just listening to the sound. 

Now relegated to a lowly role. 
I still think you head the Honour Roll!

I lay you, faithful stethoscope to rest,
Against how many hearts have you been pressed?
 The secrets of the airways all laid bare,
As you measured sounds of heart and air,
No MRI or CAT scan will astound,
The way you did just listening to the sound.

Oh mighty stethoscope you told me much,
And confidence exuded from your touch.
Now relegated to a lowly role.
I still think that you head the Honour Roll!

Tuesday 10 June 2014

Time to consider the victims!

           Three RCMP officers were killed and two wounded by a worse than worthless piece of humanity who set out to "bag himself some cops". I really think we need to re-institute the death penalty.
           In my young days, I was a physician to the RCMP and for years looked after Regina RCMP establishment, one of the two major training centres in Canada.   One of my responsibilities was doing physicals on prospective recruits and then looking after them during their tough training period. ( I have written an amusing piece about that elsewhere). During many years of association with the Force, I was almost always impressed with the quality and dedication of these young men.
          Many of them had wanted to be RCMP officers since they were in school. Most of these men (and now women) know they may be putting their lives on the line.
           So, when I read about Justin Bourque coming out of his hole, unarmed, with his hands up and saying "I am done", I knew it was time to bring back the death penalty.
           Three young police officers have been deprived of their lives, two more seriously injured, family and children deprived of father and husband, and I grieve for them, while this monster will lead a rather comfortable life in the relative luxury of a modern Canadian prison.

Sunday 8 June 2014

Whose tissue is it, anyway?

Landmark case.
      If you think your tissue is your own once it is separated from you, think again.  In a precedent setting landmark case in Ontario the court ruled that excised human tissue belongs not to the person from whom it came but to the institution that holds it. Its hard to imagine why anyone would care and I think it's appropriate that it should belong to  the institution because there is a greater likelihood that this would be of  research or teaching value.  It would also be available for a retrospective review where subsequent diagnostic doubt may arise.  I can't imagine many patients saving the tissue for future reference. There are not many reasons I can think of that a patient would want such tissue, or control of it, other than in some rare medico legal issue and that is precisely how this case arose.  In order to verify his diagnosis a physician petitioned the court to examine a small block of liver tissue taken in 2009.  Because it was not clear to whom the tissue belonged the doctor had to seek permission. In this case the court made a rational  and for Ontario, precedent setting decision and determined the tissue belonged to the institution and not to the patient.
       The other reason is a financial one.  If your tissue is used for research and this leads to a new drug or test, that turns out to be a big money maker, if you own the tissue strain that is being used, then you are in a position to profit mightily. 

Wednesday 4 June 2014

Brain Games

                      I'm not going  to bore you with the physiology of  neuroplasticity, you can google or Youtube that , if you feel so  inclined.    I just want to get on the trail of the means by which we can protect, enrich, fortify and increase the capacity of the three pounds of gelatinous genius that resides in its bony crypt in our  heads, before its too late.   So I took the usual route and found my way to POSIT, which  listed a number of programs, thence to which looked like the best of  the  bunch.
                      As soon  as I  went to the site Brain HQ informed me that if I  registered I would be eligible to work on some free exercises that would "sharpen your visual precision and expand your field of  view".  I noted that there were specific groups of  exercises  directed at different  aspects of  brain function.  For instance, I could direct my efforts at any or all of the  following: attention, brain speed, memory, people skills, intelligence and navigation.  All of the above are available for $14 for  a month or $8 a month if you  sign  up for a year ($96).  The free exercises I took consisted of remembering the position in the sky of one of a group of birds flashed on a screen.  This became increasingly complex as one progressed through the tests and if  one stuck with it, one certainly became more proficient.  Whether that proves anything other than practice makes perfect,  is impossible to say, nor would it be fair to expect it to with just a demonstration program.
                       It would probably be worthwhile looking around at a few other such programs before deciding which is  best to enroll in to give it a real trial.  So I am going to do that and try to decide which  is the  best program  to save my  brain and who knows, turn me into a genius!

Monday 2 June 2014

The Plastic Brain.

   When I was a medical student, we were taught (and there was no doubt about it) that fairly early in childhood the brain was cemented into shape and incapable of further development or repair, even when diseased or damaged. That belief dramatically effected the concept of what could be achieved in the treatment or management of diseases of the nervous system and greatly limited the horizons.  So when I started reading occasional articles about neuroplasticity in the early twenty first century, I found it very promising.   There is now an irrefutable body of evidence that the nervous system possesses a plasticity we never suspected.  That given favorable circumstances it could repair or remodel itself. That supports the thesis that new synaptic pathways can be developed that  bypass damaged areas of the brain and that structural  remodeling can take place. Even the aging brain can be trained to protect old pathways and develop new ones. The implications of that alone may be enormous.  It is not clear whether  various training activities that have been designed to protect the aging brain or help repair brain damage are effective, although some comments I have read would suggest they are not.  I would like to hear from anyone who has had any experience of such programs before I decide whether to register myself  for one and assess its efficiency in improving memory and general brain agility. In the meantime I intend to look further into the specifics of neuroplasticity, a promising and encouraging phenomenon.