Homework - hyponatraemia

"My country, my dream"

Part 1 of several.. Tidying room up and came across various essays - this being one of the earliest I held on to.

It's coming up to ten years since I penned that piece of writing - and unfortunately things don't seem to have progressed at all.

Sobering isn't it?

Journey of Life and Hope

In this essay I will cover my personal experience with mental illness, and my understanding both as a patient and as a clinician around mood and anxiety disorders. More specifically, on what it is and who is affected, ways to spot the problem, how it is treated and dealt with, and what will happen afterwards.

Who is affected

For the purposes of writing this, I have simply defined "mental illness" as any illness affecting brain function - amongst other thing, this includes memory, planning and problem solving, emotions and emotional regulation; whereas "mood disorders" point to the subgroup of mental disorders that significantly impact a persons emotional being and mood. I have taken the liberty to add the caveat that the illness must be causing either distress or affecting someone's daily functioning.

The crux of mental illness is that these are illnesses - meaning there are processes involved in the brain and body that causes it and that it is not made up or less real than any other illness (e.g. diabetes). Like most other illnesses, there are complex factors leading to them, but more importantly, noone chooses to have a mental illness - the same way that noone chooses to have any other illness. In that regard, assigning blame, either to a person with the illness, or to anyone else, is not only wrong but also counterproductive as it does not help with finding a treatment or solution and will likely increase guilt/shame/embarrassment leading to a lower chance that the illness will be admitted (by the patient or anyone else) and treated appropriately.

The chance of someone getting diagnosed with a mental disorder is high, with over a third of people in most countries reporting sufficient criteria to be diagnosed at some point in their life. In practice this means that noone is "immune" from having one - there are protective factors but no "vaccine". It can happen to anyone, including you, and chances are you personally know someone who has a mental illness or has had it in the past. I have it and am recovering from it.

Spotting the Problem

The DSM IV criteria for depression and anxiety is listed elsewhere, and is the criteria that is applied by clinicians worldwide - but in practice it can be difficult to recognize in yourself and in other people.

Some signs to look out for include

- Loss of hope, loss of faith in mankind/self/world/others

- Pessimism and cynicism, the tendency to catastrophize

- Withdrawing from activities and/or interaction with others

- Moodiness, irritability, increased fluctuations in mood - and then just apathy

- Lack of self care - including not eating or not sleeping

It can not be emphasized enough that thoughts of suicide should always be explored.

My experience with depression and anxiety was a slow build up of unease, tension and nervousness which in hindsight probably occurred over at least months, if not years (essentially throughout medical school and into the first year of work), culminating in not being able to function mentally one day - when I needed to take time off work as I was unable to process or do anything useful. The process happened so slowly that it was only until things came to a head that I actually realized and accepted something was not right in my thinking and emotional regulation mechanisms.

Over medical school, despite having little difficulty with the subject matter - i.e. I knew that I had the memory and problem solving/processing skills to learn about medicine and do it well, damnit, and I did pass - there was an increasing sense of inadequacy and of being a fraud. Which I dealt with by pretending that I could not have done better (the slide into "passes were good enough") together with finding the obstacles to doing well ("the system was flawed"), an unhealthy dose of self-recrimination - ("I can't adjust, I couldn't find friends, I just didn't fit in") and becoming isolated from my family, peers, friends, and the wider world ("so what's wrong with staying in my room the whole day?").

Somewhere along the way I lost my joy in doing medicine, the enjoyment of learning and gathering knowledge, skills, the capacity to truly care about myself and others, and the trust in my own judgement. Things were about me, but I was never allowing myself to just "be me".

The feelings and thinking patterns only intensified when I started work. Added to that was the jolt when I realized that I was now a "proper doctor" and the abrupt changing of responsibility. And the (self)expectation that things would be difficult so I took it as a matter of fact that this happens to everyone and I should just "deal with" the emotions and "get on with the job". It was a weakness to need help and I was quietly and then openly terrified of both having responsibility and admitting that I could not responsibly manage certain situations on my own. The more I soldiered on the more cynical I got, and the less efficient, but I was grasping at the gain I made (getting better at organizing, and presenting, and the technical aspects of doctoring) and did not see or believe that there was anything wrong.

Work became a slog - a list of tasks to mechanically get through, a series of never ending duties. Getting up was a chore. Eventually I was working and thinking through a fog. Added to this was the growing panic that I was not doing my job well, but it was hard if not impossible to clarify in what sense to my colleague and my seniors, and the suspision and guilt that I was putting other people's lives at risk but froze, procrastinated, justified against doing it when I needed to ask for help. One day my brain quit working altogether. At that point I left work on sick leave, and sick leave continued for weeks and months.

Journey to Recovery

In medical school they teach the standard way to answer questions relating to psychiatry is the "bio-psycho-social" model - in short, the causes and solutions to mental (or any) illness are in the realm of biology and physiology, psychology (thinking, emotions, reactions), and social (family, friends, society).

An important step however, is acknowledging and accepting that the mental disorder or the problem exists, and that it will not easily disappear without changes in all three domains. And that it is an illness, that noone is at fault for causing it. This journey is extremely personal but at the same time impossible without help and support from other people. Human beings, after all, are social animals.

The time off work for me was a time to reassess and reevaluate - during the initial stages of it on some days even getting out of bed was a major undertaking. I had pills to dampen and diminish the effects of spectacularly bad moods (hopelessness, anxiety, a pervasive feeling of doom), but the bulk of treatment was working together with my psychologist to equip myself with a set of tools and a way of thinking and managing my emotions, feelings and reactions.

The process I underwent had elements of cognitive behavior therapy (changing thoughts will change emotions and reactions to situations will change behavior) as well as the acceptance and commitment therapy getting to know unpleasant feelings, then learning not to act upon them, and to not avoid situations where they are invoked). It was and is hard. The rewards from it - the sense of peace, the sense of self - more than justify the efforts.

The first steps involved being more aware of my emotions by labeling how I was feeling using descriptive terms and getting to know the nuances of it without trying to change it. I spent time expanding my emotional vocabulary and recognizing how I was feeling - being as specific as possibly with adjective words (sad, happy, satisfied, anxious, jittery, gloomy, scared, uneasy, uncertain, worried). Not trying to fix anything, just learning to sit with the emotions.

With help, I then moved to tracing the source or roots of the emotion - what circumstances and thoughts I had to trigger the emotion - again, in as specific a manner as possible, down to recreating the tone of voice that my mentalspeak was using to myself. Being able to recognize which thoughts led to which emotions and evaluate how rational or helpful the thoughts were. There was times where the process would trigger more unhelpful thoughts ("why did you ever think like that you idiot") but I needed to be able to unravel the train of situation, thoughts and emotions before I could sensibly and incrementally change.

Changing involved a few things - relearning my problem solving skills and applying it to self and not trying to solve situations that were unsolvable or out of my control/responsibility and learning to ask for help, recognising and celebrating each skill learnt, congratulating myself with what progress I made, modifying my internal commentary, and realising, truly believing in shared humanity - that everyone is flawed, including me, and truly believing in myself, measuring it against the yardstick of what I valued ethically (honesty, joy, learning, peace, growth).

I could not have done it without the help and support from numerous people – family, friends, colleagues. I was exceedingly fortunate to be already embedded in a few community activities in Auckland and have the chance to get involved in more pursuits throughout the process – including the symphonic band, the badminton group, tai chi, and my newest obsession, Ingress.

What happens next

For me? Life is on the mend and it is a wonderful adventure once more. I'm still working on improving my mindset and my abilities but at the same time I am balancing the duality of continuous self improvement and progress with the enjoyment of the journey. I am where I need to be at the moment, but I am also moving towards being more true to myself and my values.

I am still on a return to work program (unpaid sick leave) but now the difference it that I am enjoying being at work. Yes there are hard days and tiring days - but even on the off days there is something that I appreciate, that I value. I am continueing to take my medication and this will be reassessed after I am on it for 6 months to a year.

Conclusion

If nothing else, this is the message I would like to share.

1) Mental illnesses or disorders exists, just the same as physical illness.

2) Recognizing the problem is tricky, but watch for changes in behavior, mood and outlook and never ignore any suicidal or "not worth living life" thoughts

3) It is treatable.

4) The journey is difficult, but extremely rewarding and joyous.

The Hump

One of the most memorable lines for me of Starship Troopers (Robert A. Heinlein) was the description of "the hump", as below - in a letter from an old trooper to a recruit in boot camp :

You are now going through the hardest part of your service -- not the hardest physically (though physical hardship will never trouble you again; you now have its measure), but the hardest spiritually . . . the deep, soul-turning readjustments and re-evaluations necessary to metamorphize a potential citizen into one in being.

 and then later on,

The noblest fate that a man can endure is to place his own mortal body between his loved home and the war's desolation

Starting to come into my own as a house officer, feeling more comfortable in my role - I've been pondering this metaphorical hump.

Do I think this hump exists in the trial-by-fire that is internship?
Yes. Well, probably.

... deep, soul-turning readjustments and re-evaluations neccessary ....

Far more valuable to me than the medical knowledge and practical experiences that I've gained, is the attitudes and ethos of being a house officer, and by extension, being a medical professional - a "real doctor". I've being fortunate enough to be in a team where strong role models abound, and can watch, and think through what it means, to me, for me, to be a (dare I say it?) good doctor.

"Do not dump on your colleagues" - get your patients sorted - make sure that everything in the plan has been arranged, tie off all loose ends as much as possible so that the after hours/night doctor does not have to pick up the care of your patient.

"Own your patients" Know them, talk to them, track their progress, chase all the results and follow them through... this is the most rewarding thing about medicine, being able to see improvement with what your team have put in place

"If in doubt, ask" and ask the appropriate person in the right manner and right time. This is perhaps the most difficult thing for me to do - I'm still reluctant to call anyone, no matter how simple, or urgent... but I am improving (if only due to the fact that I have to refer/get opinions/consults every day) through practice.

"Help each other" Doctoring is hard, long, sometimes thankless - but the support you get from and give to your colleagues is priceless. Be it teaching a junior, or sharing drinks, or just offering to do jobs, offering a shoulder to cry on... So many little things. And its not just doctors, it is the whole team, including the ward clerk, the nurses, physio, OT, social worker, dietician, pharmacist, etc etc etc.



... to metamorphize a potential citizen into one in being.

Or a potential doctor into an actual doctor.
Some of my seniors vouch for the time where things just "click" - where being a house officer goes from new, hard, different - into something almost routine; getting into the groove of knowing what to do, and knowing who to call when you don't know what to do.

I personally feel that this metamorphisis will probably take years; and the learning curve will level off at times and be almost ninety degrees at times. And its just part of life, and the job.


"The noblest fate that a man can endure is to place his own mortal body between his loved home and the war's desolation"

Time, sweat, tears, fatigue... combating illness, fright, sadness, grief - and sometimes, false hope.
We ain't magicians - but we can sure do our darnest.

I passed

!!!

:D

Why Medicine?

Why Medicine?

"Because I got in" doesn't quite seem to be a good enough answer. Especially now that I'm facing the Final Finals (of DOOM). Rite of passages indeed - despite every. single. consultant. telling us that we will be fine.

Because there's so much choice, the infinite variety of paths to follow after placing the elusive initials before our name? Or thats what I used to tell myself. Because I'll get bored doing other courses. From this side of the fence, right now I'm starting.. I'm definitely regretting the sheer amount of knowledge we need to cover. I'll never get bored doing medicine? Perhaps. But sometimes I wonder - if you've done a hundred, a thousand hip replacements, if you've charted paracetemol-and-codeine a million times, if you need to intepret yet another chest x-ray, if you need to replace another venflon at too-late o'clock... do you really not get sick of it?

I suppose some do, and possibly I may do in the future. On the other hand, every patient, every interaction is different. Take a "standard" history - presenting complaint, history of presenting complaint, past medical history, medications, allergies, smoking-alcohol, social history, review of systems. Same process for everyone, sort of a long open ended form to fill in. But the story of a elderly lady with a broken hip is vastly different from the story of a young man with asthma. The emphasis is different. Ultimately the goal is the same, help people to get well.

Such a simple phrase "helping people"

Its the one angle I have consistently brushed aside when I'm asked, why medicine? Its a good reason, sure, but I'm not convinced its the right one for me. Or perhaps it is - its the satisfaction of "changing lives".

That seems eerily like playing God.

To be honest, it scares me. Its the curse of medicine - the constant "what-ifs". What if I'm not good enough - what if I miss the blindingly obvious ectopic pregancy. What if I administer the wrong drug. What if I don't proritize things right, neglecting the guy thats actually dying in order to, say, complete a discharge summary so someone else can go home. What if I'm just not competent?

Maybe I'm not. Good enough, that is.

On the other hand, saying that seems to be an insult in some ways to the many people teaching us. The patients that allow us to fumble multiple times at taking histories, doing examinations, taking blood, putting lines in. The nurses that roll their eyes at our ineptness yet still take the time to instruct us on putting on sterile gloves the right way. The TIs and housemen who spend their precious downtime quizzing us on various scenarios, the registrars that look at their schedule and go, yeah, I can squeeze in a tutorial at lunchtime. The consultants that insist it has always being the students that present cases during ward rounds, and that teach at every opportunity.

Maybe I have to trust that they taught me well, and that I've actually learnt.

Perhaps.

And I guess that, is why I still do medicine - the fact that everyone is determined to see you succeed instead of fail. And the chance in turn, to be the teacher.

Halfway thru' Surgery

And loving it :D.

(If you don't include the times where I feel like there's not enough hours in the day to finish up assignments - not that there are many, but when hospital time is such that by the time I'm home im tired... its hard to get the motivation to read stuff up - or do assignments. Solution : stay in hospital a bit longer to finish up those ..........)

But seriously, surgery - as an attachment - is fun. I've never felt this much as part of the healthcare team in any other run -

Lots of stuff :
1) clerking patients in - students' admission forms (history and physical examination) are used as part and parcel of hospital records - and taken seriously! My houseman countersigns the respi/cardio/abdo examination findings and annotates some bits on the history, but doesn't rewrite .... its much more involved than say, medicine where they seem to be, oh, nice, you've done an admission - now let me write up what I found, and you just keep that for your own learning.

Was a bit unnerving the first time i discovered that they do trust us, somewhat - where I wrote in the PC : 5 day hx of acute abdo pain .... the consultant quoted that during handover. (unnerving because on the reg note it was 3 day... was a matter of interpretation of the story, the first pain started 5 days ago, but 3 days ago was the start of unremitting pain)

2) Discharge summaries .... has to be done, and i know ill get utterly sick of these - but first time i do them is here (and not in acute med or psych, which most ppl seem to do)

3) Procedures! Taking bloods (well, once. ><), ABI, assisting in theater - this is especially so after hours where its the surgeon, the scrub nurse, and you... even if it is just holding retractors, pressing the cautery button, cutting stuture ends etc there's a heck a lot of attention involved in helping and not getting into the surgeon's way - but they let you know quick enough if you arent doing anything right.

4) Presenting patients - Well, to be honest I'm still not competent at this. At all. Beginning to dread the moments where the reg would be like "Pretend I'm on the phone...." because i'm still not used to using the correct terms and i handwave alot of stuff. The difference? "Uh, the wound looks really bad." vs "The wound is inflammed and there seems to be a pus-filled abcess, which is hot and tender to the touch"

5) Teaching and Learning. Lots and Lots and LOTS of this. Quizzes about everything. And from pretty much everyone. Was like this in acute med, too - but it seems to be more... pressured? here (or maybe there i actually remembered more stuff, because here i feel like im guessing the answers alllllll the time)

--

Surgeons seem to spend a LOT of time in the hospital. Even when they aren't on call/acutes.

Its fun. I dont know if its for me, though - I'm still not sure if i have the commitment to work as hard as everyone in surgery seems to be working...

The Obligatory Airport Post

So, I'm at Sydney Airport .. which doesn't free WiFi, but does have free internet kiosks.

And I'm working my way through the list of things I do at every airport where I have to spend 3 to 6 hours at...

1. Find the boarding gate
2. Recheck boarding time
3. Find food
4. Find a place to take a shower (preferbably hot water, soap and paper napkins provided)
5. Find something to kill time.. like
6. Find free internet (bonus points if its WiFi, but if it is, find a plug point)
7. If 6 unavailable, find a bookstore (with a comfortable nook to settle in)
8. If 6 and 7 unavailable, find a plug point for offline laptop entertainment

For more than 6 hours transit, the option to take a nap is very tempting ... with this, the order of preference is

Padded couch > carpeted floor > unpadded chairs > tile floor ... but for all these option a wall/corner is essential.

---

And on other news : Exams Are Over. 

(I don't think I failed.)

I definately passed 1/5 of the exam (OSCE - didn't get called in for the friday re-evaluation =D)

For the rest of it... Well, I took a stab at answering all questions; and I know i answered some questions fairly well, with the rest going by the examstrategies... like 

1) Write the bleedin' obvious ("The man has acute kidney injury due to a prerenal insult)

2) Describe, describe, describe - especially for histology/ pathology questions.. even if you have no idea what it is ("There are numerous black lesions on this coronal section of the brain..")

3) Write anything at all related to the question =D

....

But overall (fingers crossed) its a pass. Not a spectacular pass, but I believe i wrote enough sense to get by. I hope. But what's done is done .... and results are in like, 3 weeks anyhow.

...

Which means my next blog post will be in 3 weeks.

...

And I shall just leave you with this comment.... the most memorable single occasion in Med 3 was the anatomy/dissection lab that began with "First, bisect the pelvis".

Ending of 3rd Year

And its 3 days to our last lecture, 14 days to our exams ... and a week and a half after that - preclinical years (oops, i mean, Early Learning in Medicine) will come to a close.

We said thank you and farewell to "our" cadaver today - whom we spent hours learning from (by taking it to bits, really...)

Of course - this preexam period is ... scary.

I don't think I know half of what I really need to know in half of the areas that we're covering.
(As for the other half, I know zilch.)

The semi-comforting line is "We want 90% of the students to know the essential 10% of the knowledge we're giving you, not vice versa" - but... as always, Which is the essential 10% (and then actually learning it) is the million dollar question.

I'm losing it - and i need to sit down and STUDY - but all i want to do sometimes is cry, really.


Year 4 will be a blast....... if i pass year3.

Back to Secondary School?

Hm.

My schedule feels strangely like secondary school again.

Badminton : starting up in a week or so, i think - 3-4 times/week. If i get into the team...

Band : ... yes, i've started up again. hehehehe. Symphonic band (again).

Classes : okay, fewer classes (4hours/day every weekday), but more preparation/homework to do.

but with the important addition of chores : i'm flatting this year, so cook/clean/laundry/shopping needs to be all taken care of. Not that i'm complaining, its fun to be "independent" so to say, (except that i'm getting financed by parents).

So... yeah. band.

(Badminton is more routine now, i suppose, but we'll see this year's team makeup - and we'll see if im still joining =D)

And of course, the joys of trying(and failing) to sight-read. And pretending to play when actually im hopelessly lost.

But this is uni... so, instead of like 4-6 alto saxes playing, I'm one of three(!!!!) altos. Playing 2nd (but i did have a choice and 2nd is easier). The point is... Its much harder to "wayang". And the pieces are harder (duh!) - including one which has what seems like an insane number of running notes played at an insane speed (okay, only dottedcrochet=120, even then...)

On the other hand.. the clarinets *still* have it harder (snicker).

A bit surprised to know my tone + skills haven't completely gone... but i supposed thats normal.

First performance on 20th march (next next saturday). =D

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