East Timor Medical Elective - Week 4 (Part 6 / 6)

“HORACIO” (PARKINSON'S DISEASE)

After Dr. Dan did his gratitude speech thanking the Patients etc (followed by loud applause), it was meal-time. After eating a bit, I was told that a Patient arrived (very late) to see Dr. Dan. I was curious to see the Patient and find out why he came so late.

Sitting on the bench, where the ceremony was held less than an hour ago, was a frail old man called “Horacio”, hunched forward, with a resting tremor in both of his hands. His son accompanied him.

Spot Diagnosis: Parkinson's Disease.

I asked Horacio's son what has happened, and he said that his Father has been walking weak and shaking like this for nearly a year now. “Why are his arms and legs weak?” he asked.

I told him that I suspected it was a Neurological Condition called Parkinson's Disease, that affects your movement, but he was confused, saying “The sickness is with his limbs and not his brain.” I explained that some Brain Conditions can impair movement, and asked if I could examine Horacio.

Horacio's arms were having a tremor. I shook his hand and moved his arms about. They were stiff with Cogwheel Rigidity, which further supported my thoughts. He also had the same Flat Affect as me, and I asked his son whether he smiles these days, in which he said no.

Dr. Dan came to meet him and also gave the same spot diagnosis, and arranged for him to have a script for Levodopa / Carbidopa. Unfortunately the Pharmacy ran out of this, and I became desperate. “What about Pramipexole or Ropinirole?” I asked the Pharmacist. Nope, they didn't have those either.

I felt sorry for Horacio, and wished that if I were in his position in the future, that somebody would try to get the medication for me. Being at a higher hypothetical risk of Parkinson's Disease (or Fronto-Temporal Lobe Dementia) later on in life, this patient triggered a “soft part” in my heart. I wanted him to start the medication and experience its benefits.

I wanted to demonstrate the degree of concern that I'd wish for someone to have towards me if I had it. I didn't want to perpetuate or feel abandoned. So I offered Dr. Dan to go to a Pharmacy and buy the medication using my own money if it was available. I told the Patient and his son to wait for 30 minutes whilst I ran out with my bag huffing and puffing.

A few hundred metres down the road from the Clinic, a man in a motorcycle came up to me, and asked if I wanted a lift. I asked him who he was, in which he claimed he was Horacio's son's friend “Vincent”, who was observing me the entire time.

Having only ridden a motorcycle once before as a child, I was quite reticent to accept his offer, but due to my perceived “urgency” of the issue at the time (being in “Adrenaline Mode”), agreed to do so. The helmet barely fit my head, and I couldn't fasten the helmet belt under my chin, but I thought “Whatever” and let it be.

I made sure my backpack was fully zipped up, but my other handbag couldn't be closed, so I quickly tucked the items to the bottom lest it fall out during the ride. As I sat on the motorcycle, Vincent told me to grab onto his shoulders tightly.

I grabbed onto him for “dear life”, and as the motorcycle started going ahead, I gripped him even harder. The breeze/wind was sweeping past my arms, and my heart was beating fast. I was freaking out inside due to the state of Dili's traffic and the fact that I wasn't wearing any other protective gear, but strangely was able to look flat on the outside, and to some extent even exhilarated. He could tell that I had very little experience riding motorcycles, in which I soon admitted to him. I was simultaneously horrified yet excited at this “motorcycle adventure”.

He dropped me off at each of the 4 nearby pharmacies. As I entered each pharmacy, I quickly rattled out my spiel in Tetum to the staff about needing Levodopa/Carbidopa for Horacio, hoping that I'd “hit the jackpot”. I started feeling doubtful inside when the pharmacy assistants had puzzled looks on their faces, claiming to have never heard of these medications before, or even Parkinson's Disease. I initially thought they were stupid, but gave them the benefit of the doubt and mentioned that it was a neurological condition that makes the patient have difficulty walking and moving their arms etc, and one of them thought I was thinking of Stroke. When I mentioned “neurological condition”, or more specificially “brain disease” (moras kakutak), one of them thought I was referring to a Psychiatric Condition instead. Another assistant offered to sell me Methyldopa because it had the same suffix (-dopa), but I rejected that, explaining that it was a completely different drug for a completely different condition (Hypertension).

Each rejection from a pharmacy made me more disappointed, and as it came close to 7 PM, I knew it was time to give up. The Adrenaline and hopeful suspense from the motorcycle rides between the pharmacies ended, and I felt very disillusioned, having turned out empty handed from these attempts. I wanted Horacio to have the medication so badly, so I would hate to tell him in his face that the pharmacies didn't offer it.

As I returned to the Clinic, it surprised me that Horacio and his son weren't there anymore, although to be honest I was a bit relieved coz I was spared having to break the bad news to them. Vincent said that he'd inform them instead that I couldn't find the medication. I thanked him very much for the rides.

I told Dr. Dan about my failure, and started walking home in the dark feeling quite upset and frustrated about this fruitless venture. I started pondering why the Pharmacy staff were seemingly ignorant, but it became clearer to me. Pharmacies, like with nearly all other private healthcare facilities, function as businesses. They will sell the medications that are profitable and are in higher demand. Because East Timor's population is very young with the mean life expectancy at ~65 years, the prevalence of Neurodegenerative Conditions such as Parkinson's and Alzheimer's Disease etc would be much lower than in Australia. Low demand for a low-prevalence condition would mean that the Pharmacies are much less likely to stock it. Out of principle, this is fair from a financial point of view (“Capitalism”, “Supply and Demand”), but I felt really sorry for Horacio and all other East Timorese patients with low-prevalence conditions who wouldn't be catered for when the time called for it. The Public Healthcare System may provide medications for these people, but unfortunately are also unreliable and have frequent shortages due to incredibly meagre budgets.

After this realization, I stopped feeling guilty because I knew I tried my best at the time and wouldn't be able to rectify the situation any other way in that short time period.

My sadness toned down as I internally gloated on this intense experience. In Australia, had a patient been diagnosed with Parkinson's Disease, they'd simply receive a script and obtain it from any bread-and-butter pharmacy, try the medication and see a GP/Specialist for follow-up, end-of-story.

But the healthcare situation in East Timor allowed me to take a much more “colourful” route.

My desire to obtain the medication temporarily overrided my fear of riding motorcycles, especially in a city with very dangerous traffic like Dili. I was told to avoid riding Microlets because they were dangerous, yet I managed to ride a motorcycle here, and from a stranger!!!

I couldn't believe that the encounter with Horacio, the motorcycle rides to the pharmacies, and the return trip, all occurred in ~ 30 minutes. I checked my handbag and nothing fell out thankfully.

Most importantly, I felt so grateful and lucky that I was physically unscathed.

Omg what an adventurous end to the week...

East Timor Medical Elective - Week 4 (Part 5 / 6)

BPC'S 15TH ANNIVERSARY

Friday afternoon was BPC's 15^th Anniversary. It was amusing that Dr. Dan's Birthday was quite close to BPC's “Birthday”, and I asked a staff member if both have ever been celebrated together, in which she said “Yes, in fact most of the time!”

Cake for BPC's 15th Anniversary. The icing design is based on BPC's logo. Middle symbol is supposed to be a Crocodile, from the traditional East Timorese Legend of "La Faek".

The front door to the main building was covered with cloth / curtains, and a clothed table set up for the ceremony. The arrangement was simple yet pretty. I sat at the side of the main waiting benches. I felt like something big was going to happen.

A girl lights up the Candles before the Sermon starts.

The crowds gathered, and eventually the Padre/Priest showed up in his gown, starting his sermon. I was unable to understand all of it, but clearly he was quoting from the Bible and at some point discussing the “Catholic values” of love etc, and linking it with Dr. Dan's charity work. There was a bit I disagreed with however, when he followed the discussion of medical work by stating “La iha sakrifisiu, la iha hadomi.” ( “[If] there's no sacrifice, there's no love.”)

***WARNING – RANT, NOT DIRECTLY RELATED TO THE ANNIVERSARY***

For about a minute, I got really annoyed when he said that, because he somehow implied that Medicine as a Career was a “Calling”, that one must give it their all-in to their work as a Dr. At the time it felt extremely “traditional”. My observations are that as the Medical Profession in Australia (and several other Western countries, especially the Anglophone ones) has become significantly devalued and disrespected compared to the “good old days” (30+ years ago). It's gotten to the point that the notion of introducing a $7 co-payment for visiting a GP (in spite of the 9+ years of study/training to be an independent GP) is seen by the voting majority as so “unaffordable” (in spite of the copious social welfare relative to other countries), even though they happily fork out (much) more for Hairdressers and Restaurant Meals.

These days in Australia at least, being a Dr is for the most part just a job rather than some “G-dly pursuit/passion” that “should” take over your entire life for the sake of saving humanity, irregardless of the pay. Even in the face of increasingly onerous (and possibly unjust) Medico-Legal Pressure/Stress, Public Hospital salaries for Drs continue to decline in real terms every few years through an apparently fractured Dr' Union, in addition to exploitation by State Governments. This is in contrast to the Nurses who in practice hold more clout despite their graduate and junior nurse oversupply being far far worse.

We're human as well, and have our own personal, financial needs etc. I resent it when a lot of people (Australian or not) think that just because we're working as Doctors, that money should never be an issue. They expect Doctors to work and behave like Saints/Monks, yet for the most part in Australia they're not treated as such (as opposed to Developing Countries). Interestingly, a lot of these people have far more sympathetic views towards Nurses. Medicine is a highly trained profession, with a lot of responsibilities, impacting on Patient's lives every day. One mistake can kill a Patient. My opinion is that the remuneration should reflect that, otherwise at the very least the working conditions should be conducive for focusing on Clinical Work. 

Drs in Developing Countries have much lower pay, but at least they don't have to worry about getting sued or notified regularly. They can just focus on Clinical Work and try their best to treat Patients with the limited resources available, ie “Classical Medicine”. With Medico-Legal repercussions being so strong in Australia (closely following America), I think it's gotten to the point where if Drs' real pay continues to fall, retention within the Public System will decrease as more Drs feel the pay isn't worth the responsibilities and stress of covering their “Professional Asses” for half the day, lest they miss something and get penalized over some dubious technicality by some judge who happens to have negligible Clinical Insight by comparison (and just follows the fine print created by other similarly clueless politicians/senior bureaucrats etc). 

Some people try to dismiss the issue of (Public) Drs' pay, purely attributing it as a product of Supply vs Demand, but the fact that the vast majority of Junior Doctors and (Non-GP) Registrars are stuck within the Public System means that State Governments can exploit their Monopsony (as much as possible) on such highly-skilled labour, undermining these Drs' true value compared to a genuinely free market (hypothetical). How else could you make an Intern “only” earn ~$32/hr after studying for 5-7+ years at Uni, when a School-Leaver can already earn ~$24/hr as a Waitress in a suburban Cafe, even though for the latter job the entry requirements are vastly lower, and labour supply vastly greater?

These Nay-Sayers can try to dismiss the issue of Australian Drs' pay/conditions in light of the current climate, but at the end of the day, Drs can and will vote with their feet if needed (as demonstrated by the Queensland Health debacle earlier this year)...

***RANT OVER***

After the sermon, the choir started singing songs. Again I only understood part of it, but I started feeling a lump in my throat. Some of the choir people, and audience started shedding tears and sniffled during the singing. 

Choir singing in the Mass with Keyboard Accompaniment.

I started feeling strange. Initially I felt a tingling sensation in my skin, with my “hairs standing straight”, as I absorbed the magnanimous blend of melody and harmonies. By the time they reached the Portuguese Hymn “Ao Amor que te Arrasta”, my throat became tight, and I felt like I was about to cry, and had to restrain myself from doing so. I stopped looking at the Choir singing, and just stared at the lyrics, and intermittently closing my eyes, but it didn't help much.

I couldn't understand why I started having such a strong automatic reaction, like I was being possessed by an unknown being. I felt like I was subconsciously being commanded to remove my Flat Affect, and cry. It was only a few minutes after I got annoyed at that specific sentence from the Padre/Priest, and I was surprised at how quickly my feelings changed. I didn't like how my body was being pushed to do something that I intellectually thought was irrational, and didn't want to give into “Emotional Conformity”, yet another part of me felt that to cry was the correct emotion to display during this period. I previously never entered into my “Social Database” to cry during Hymn singing, especially when we sang Hymns routinely at Assembly in High School. Back then, we had Assemblies 3 times / week, so it would've been ridiculous for me to cry that frequently. I felt like I was being overwhelmed emotionally, to the point of being nauseous.

I wanted to leave the place coz I felt overloaded, but thought it would be rude if I left early on such a large occasion. I just sat and decided to let the music “penetrate” me, hoping that my body would quickly down-regulate the seemingly visceral response. Eventually it did, but only near the end.

I didn't cry at the end, but as the nausea disappeared, I could “observe” the warmth and passion shown by the Choir, in fact the East Timorese people at the ceremony. I personally hated conformity in its own right, but I could now see how pleasing it was to have people gathered at a place for celebration. Some of the piety was visible; Patients with TB or suspected TB sat in the audience and took off their face-masks as a sign of respect. Everybody's presence at the time just felt “beautiful”, but I was unable to quantify it. Some of the Patients who complained of Pain earlier in the day, looked much livelier and in less visible pain as well. The arrangement just “felt right”.

Priest/Padre is feeding round wafers to a long line of people.

As my emotions were under better control, I was pondering again as the ceremony progressed to the audience lining up to eat the circular Wafers representing the Body of Christ, followed by Dr. Dan giving a gratitude speech. The singing, it's part of the Catholic Culture, but also the East Timorese Culture. The Unison of people doing the same thing together looked wonderful but was an example of conformity. I lamented about how Australia lacked an obvious “Culture” (not including Property Investment/Speculation, “Tall Poppy Syndrome”, Political Correctness, and AFL), but realized that in order to have a “Culture”, there has to be conformity. If everybody does something different, then you're statistically much less likely to have a Culture, let alone a prominent one like that of the East Timorese, whose population is superficially more homogenous. 

Ever since migrating to Australia, I had an “inside feeling” that in spite of its relative wealth, there was something missing that other poorer countries (or even America) had. I had access to food, clean tap water, and a home connected to electricity, adequate sanitation, in addition to my direct Family. Yet when I went out in Melbourne, I frequently felt the outer environment was rather “Bland” and “Soul-less”, especially the suburbs. I thought that there was something “off” or “Artificial”. I thought I was being spoiled or ungrateful for having such sentiments in a Developed Country. Yet in Dili, a City of ~200,000 people (as opposed to Melbourne's ~4 Million), with far less public amenities, I felt much more stimulated outside of home, and not in the anxious sense.

It must be the people and their collective behaviour, I thought. Their population is less Multicultural (in spite of the other Tribal languages in the Districts) than Australia, and the people have far less opportunities Education and Vocation-wise. The weather is becoming hotter, but the people on the whole behave quite “warmly” in spite of the Language Barrier. I don't feel Euphoric here, but have been appreciating the more “visible” homogeneity in behaviour from the locals – their responses, questions, opinions, gratitude (is gratitude more from being poor, or Catholic influence?), “warmth”. Nearly all the locals I speak to are eager to learn new things and/or help develop the country, even if they are unable to think of specific solutions. National development is an obvious goal that unites people. Their word for development, “Dezenvolvimentu” is used copiously in TV and Newspapers. Many people are poor, and Youth Unemployment is high, but they just keep moving on, day by day.

The conformity was easier for me to process thanks to my fondness for repetition, and I felt great joy at being able to understand East Timorese people as a whole a lot quicker than Australians, without being considered “superficial”, “naive”, or “lacking insight”. It pleased me to be able to rapidly understand the psyche of NT people from another country despite my initial deficits secondary to the AS. The paradoxical stimulation from the East Timorese people's superficial simplicity/purity still baffled me (at the time of this writing).

However at the very end of the day I wouldn't want “Mass” conformity to happen in Australia. I think I was in the position to be able to be fussy over the presence of an obvious “Culture” or not. In the long-term, I value my freedom to be un-chained to an overarching Religion (Catholicism), or Collectivistic Society (as per traditional East Timorese Culture) where there is pressure to get married and have children, along with much more influence from relatives (non-parents) in various issues. The taxes are much higher in Australia and there are a lot more lazy/ungrateful Bogans and Politicians, but in spite of the over-regulation and bureaucracy, I still have many more opportunities to pursue what I want vocationally and academically here than in East Timor, in addition to access to a far more robust Healthcare System (Public and Private).

It's probably unfair to compare with a Developing Country, but many things aren't set in stone. In the future, if my values change, and if I manage to save up enough money, I always have the option to explore/move to other countries (even East Timor?!) if I get fed up with life in Australia later on. Australia seems to lack an overarching “Culture” and is geographically isolated, but the price for this relative Individualism (along with wealth) is that you have to put in much more effort to find others with similar interests, beliefs and goals, eg Subcultures or Hobby Groups. Otherwise you can just resort to the internet. You can't have your cake and eat it. 1^st World Problems indeed. At least I don't have to truly worry about starving to death, or despair at a hospital being short of a common Antibiotic, any time of the year.

East Timor Medical Elective - Week 4 (Part 4 / 6)

“MATEUS” (APPENDICITIS)

I clerked “Mateus” in another afternoon (this time on medication) with Natalya and another student watching me, but apparently he was waiting for nearly ~6 hours since being admitted this morning. I didn't recall seeing him in the morning Ward Rounds, so he probably arrived just after we left the Baixa (Gen Med) ward. 

I looked at Dr. Dan's mini-notes: “RLQ pain - ?Appendicitis ?Ascaris”.

Oooooh, a potential Appendicitis case, I thought.

I asked Mateus what his problem was, and he said that he's been having pain that started in the RLQ last night, and later spread towards his RUQ and Epigastric area.

It sounded strange. I recalled the textbooks stating that Appendicitis initially starts in the centre of the Abdomen (around the belly button), and then migrates towards the RLQ, and then causes diffuse Peritonitis if not treated fast enough. Mateus' abdominal pain didn't sound like the textbook, but I was still worried.

 After asking enough questions about his Abdo pain and gross (basic) Systems Review, I decided to “jump” to the Physical Exam.

His bowel sounds were still present. I lightly palpated his Abdomen, and he winced as I examined his RUQ and RLQ. I then percussed, and was internally pleased when he felt pain from this. Omg, Percussion Tenderness is present! He could really have Appendicitis.

I then gently pressed on the left half of his Abdomen, which wasn't painful, but I let go after a few seconds, and he winced again, saying it hurts the right side of his Abdomen.

OMG he has Rovsing's Sign! I was so delighted upon seeing this for the first time, but didn't smile about this in front of the others. I became very excited and concerned.

“I think he has Appendicitis, I need to tell Karl immediately,” I said.

Karl soon came and I presented the case, with Appendicitis being my most likely differential, in which he agreed, and continued him on the empirical antibiotics.

I felt so proud of myself on having “diagnosed” Appendicitis within 15 minutes, but knew that I had a hint from Dr. Dan's mini-notes, so could take a targeted history and physical exam much more easily. If I had no hints to begin with, my clerking would be more time-consuming, and that will only improve with practice and feedback. But I was also happy to see in person, how a patient doesn't necessarily present themselves perfectly as per the textbook descriptions.

He was monitored overnight and was to be transferred to the ED of GVNH, for admission to have an Appendicectomy.

I knew that the overall standards of Healthcare in Developing countries were lower than in Developed countries, but it was still shocking to see the differences in person.

I spoke in my slow, “formal” English accent to one of the ED Drs, who wrote notes based on what I said, including Physical Exam findings, including the Rovsing's Sign. I was surprised. Isn't the ED Dr supposed to examine the Pt himself?!

For some reason, it was another ED Dr that ended up physically examining Mateus. Ok, at least he's been examined by someone now. Bloods were to be taken next.

Next was the jaw-dropping moment. The Dr used a glove to tie around Mateus' arm as the “tourniquet”, and with his bare hands (unwashed), started inserting the needle into Mateus' vein. Mateus' arm wasn't even swabbed with Alcohol!!! Internally, I was gasping and horrified, but still maintained my Flat Affect on the outside. Oh how I dearly wished to have taken a photo of the Dr taking Mateus' blood, and get away with it!!! I'd be very interested in seeing the infection rates from Venepunctures and Cannulas in East Timorese patients secondary to poorer hygiene practices.

"The Scream", by Edvard Munch.

I left after the bloods were taken, as he then had to wait until 2 PM (it was now ~12:30 PM) to have an Abdo Ultrasound done as the radiographers were still on their lunch break. In fact, the majority of the hospital staff (doctors, nurses, lab staff) have a lunch break from 12 – 2 PM. Things go to a halt. 

It baffled me as to why GVNH doesn't roster their staff in a way, so there's at least 1 person working at any time of the day, or that staff take turns working during lunchtime. I suspect a strong factor was the near absence of Litigation. Then again, on their relatively “peanut” wages (apparently ~$US 700 / month for Interns at GVNH), if the Medico-Legal pressure was present akin to Australia, I bet 90+% (if not 100%) of the Drs would try to jump ship to another Country, or another Career altogether. Anyhow I'd hate to be an acutely ill patient arriving at the ED at 12:05 PM... : S

Note: I visited Mateus a few days later and it turned out he eventually had an Appendicectomy done, and was recovering with no post-op complications (yet?!).

East Timor Medical Elective - Week 4 (Part 3 / 6)

“ENRICO” (?CANCER METASTASES)

I knew I had a “short fuse”, but forgot to take my afternoon medication one day. I was trying to clerk a newly admitted patient called “Enrico”, who Dr. Dan noted had “Abdominal Pain” as his main complaint.

I think when I'm more tired or sleep-deprived (especially un-medicated), my mind seems to be more concrete, inflexible, and absent-minded, augmenting my desire to be very methodical.

I greeted Enrico and starting asking him about the Abdominal Pain, trying to cover “SOCRATES” (Site, Onset, Character, Radiation, Alleviating Factors, Time Course, Exacerbating Factors, Severity) before moving on to other questions.

I asked him if his Abdominal Pain spread to other parts of his body, he started talking about his headache and shoulder pain, and how it's so bad. Without realizing that his headache was important, I thought he was just going off on a tangent, or not understanding my question. I thought his shoulder pain was just a plain old Arthritis from his old age, and that his headache was the bread-and-butter variety. At the time, I thought that if Dr. Dan didn't write “Headache” or some other medical complaint in the mini-notes, then it couldn't be serious or worth focusing on.

I repeated again slowly in Tetum and gave examples of pain radiation, but then he kept talking about his headache, how it's so bad. I was still focusing on the Abdominal Pain and got increasingly annoyed at his diversion from my history taking. I think I actually asked the same question in various forms up to 5 times (in grammatically correct Tetum), but to little avail. In my spaced-out, disinhibited state, I thought he was trying to fool around with me and got a bit angry. The patient opposite Enrico's bed giggled from my visible frustration, and said I needed more patience.

It was a futile effort trying to get him to talk any more about the Abdominal Pain, so I just gave up on the history taking and physically examined him. He had Epigastric tenderness, so my differentials included Peptic Ulcer Disease and Pancreatitis (although that was unlikely).

Soon after, I presented my “incomplete” case to Karl, and he said that another differential diagnosis would be Stomach Cancer which has metastasized to his brain, causing a headache. He needed a CT-Brain at GVNH to rule out any CNS lesions.

OHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH.

I felt really guilty, that I got angry/annoyed at someone who didn't deserve it. It made sense now. Yes, his headache could very well be a sign of something much more sinister. I realized that there will be times where being too methodical is actually bad, and you need to know when to change your strategy. I also realized that Dr. Dan is also human and at times will miss things too, so I couldn't just depend on his mini-notes as the core stimuli for history taking. You need to focus on what the patient says themselves, expand on that, and attempt to fit the puzzle pieces together to formulate the relevant differentials. 

By dismissing what the patient says based on what other Drs say, it can sometimes impair your ability to find the right answer. At the very least, in Australia I'll be documenting to the best of my ability all of the patient complaints for Medico-Legal reasons, even if I secretly don't believe them.

Since this episode, I decided to take my afternoon medication routinely again to improve my alertness and cognition. I thought that I didn't need it coz I've “crashed” (sleep attacks etc) in the afternoon a lot less often than in Australia, but my cognitive impairments (especially after lunch) were still present even if I didn't fall asleep. I now also take Dr. Dan's mini-notes as a “partial hint”, but not a definitive summary of the patient's problems. At the end of the day, you need to know how to take a History and do a Physical Exam yourself, for the benefit/convenience of both you and the patient.

East Timor Medical Elective - Week 4 (Part 2 / 6)

“JOAO” (GLOBAL HEART FAILURE, and PLACEBO EFFECT?)

Monday evening was very sombre by comparison. I was about to go home at 6 PM, but as per Murphy's Law, was informed by a nurse that a new patient just arrived to the Emergency Room.

“Joao” was a boy who came with his parents, feeling quite short of breath. Karl and Maria were still busy in their afternoon ward rounds but would soon check him out. His legs were both swollen with pitting oedema, abdomen and JVP distended, all from Right Heart Failure. There were crackles in the bases of his lungs, suggesting Left Heart Failure too. His heart was already beating very fast. Unfortunately, he had Mitral Stenosis which was untreated for years, and now we were looking at the end complications. Dr. Dan already commenced him on a very low dose of Beta-Blockers to slow down his heart rate, in addition to taking Frusemide (a diuretic Rx). I was really anxious for him to get rid of his “excess” fluid as much as possible.

He was already on medication, I thought. This is a medical emergency, so ABC, ABC. I quickly looked at his palms and the inside of his mouth. He wasn't cyanosed yet, but clearly had increased work of breathing. I ran out of the room to get a pulse oximeter, returned and clipped it to his finger. 94% saturation, so still ok-ish. Joao and his parents didn't understand what the pulse oximeter did, so I basically said it shows how much oxygen is in the blood, and that anything above 90% is still acceptable. Joao and his parents then became very focused on the displayed number. But inside, I felt uncomfortable because I wasn't sure if that number was correct though. It also displayed his pulse which was completely inaccurate. I was hoping that by focusing on a number, that it would help quantify his status and calm him down.

I was confident he needed Oxygen for comfort and asked Joao if he wanted to try it. He immediately said yes.

I ran to the nurses' room, and brought back the oxygen tank with a mask. He looked relieved when it arrived, and I started putting it on him. I tried to switch on the Oxygen Tank and turned the delivery rate to 6 Litres / minute, but there was a leak in the delivery device connecting to it, releasing a small “air stream”. Barely any of the Oxygen was going through the tube.

I felt devastated. Was Murphy's Law cursing me again? What should I say to him?

I dramatically increased the delivery rate, and a bit of the Oxygen was now flowing through the tube, with the “air stream” producing a prominent hiss. Oh dear, lots of wastage. I asked Joao if he could feel it coming through, and he said yes, but only a bit. 

He looked much calmer now, but inside I felt guilty. A lot of Oxygen was leaking out and being wasted, which could've gone to other future patients in Cardio-Respiratory distress. How far should one go when there are limited resources? His Oximetry sats was hovering at around 94 or 95%. But how much Oxygen is he really receiving? I couldn't quantify it, and was wondering how much of his calmness was from actually receiving significant Oxygen, or from the placebo effect of looking like he's receiving a treatment. Calming his parents down would also have influence on him.

I holding his hands for a few minutes, and the room was silent apart from the hiss. Karl and Maria soon arrived, and ceased the Oxygen delivery as it would be unsustainable at the current delivery rate, rapidly depleting the Oxygen tank. I offered to lower it to the original 6 Litres / minute, but this was also considered a bad idea: If Joao wasn't actually receiving the Oxygen, then wearing the mask would only result in him breathing back in more Carbon Dioxide, worsening the situation. His Oximetry sats was still acceptable in room air, but Joao clearly looked more distressed / upset.

Karl and Maria were medically correct, but in my mind, I was still anxious. I was using the Oxygen Tank as a psychological crutch, and obsessed about giving Joao Oxygen. I called a BPC assistant who also did some device repair, but he was unable to repair the leak. 

There was one more Oxygen tank, but much heavier. Joao got admitted to the main ward, with that Oxygen tank placed next to his bed for “comfort”, even though the attached device also leaked. I felt really sorry for him. No working Oxygen tanks at BPC tonight.

Please don't die, please don't die, please don't die.

It was getting dark and I had to return home. I said bye bye to Joao and his family. That was the last I saw of him.

At home that night, I realized how obsessive I was about the Oxygen, and how emotionally “soft” I was. I felt so bad/sad to see him suffer, and wanted to give the Oxygen not only to comfort him psychologically, but myself as well. I wanted to give them the impression that I was doing something, even though clinically it wasn't doing much, and resources-wise, unviable. There was an element of selfishness and I felt guilty. I was being empathetic, but I had the wrong application.

When there are limited medical resources, you have to be prudent as much as possible. It's always a challenge to help many people in such a setting, where there's only so much you can do. There'll be many times where you just have to be brutal and ration things out (eg opioid analgesia), when in a developed country, everyone would have far more access to it. You're not being intentionally mean or cruel, but trying to use resources wisely based on priority.

In fact, it could be argued that in the process of “overtreating” 1 Patient, you'd be impairing the outcomes of many others, which some would consider as even more selfish. I suppose in Australia, where rationing of this degree has yet to take place, Drs have far more breadth to order investigations and prescribe medications to please Patients (demanding or not), in addition to covering their asses Medico-Legally. At the end of the day, you are working as a Dr, and not as a “People-Pleaser” (even if it attracts more referrals and repeat appointments). For the sake of good Clinical Practice, there'll eventually come a point where you need to set boundaries and say “No”.

Note: Joao was transferred to GVNH the next morning, but died several days later. I couldn't get any further details from the Ward Clerk at GVNH. RIP... : (

East Timor Medical Elective - Week 4 (Part 1 / 6)

Week 4 (22/9/14 – 26/9/14)

DR DAN'S 70TH BIRTHDAY

Monday this week was Dr. Dan's 70^th Birthday. The morning ward rounds proceeded as usual, but when we arrived at the Malnutrition Ward, there was a surprise! Luisa and “Livia” (another assistant) started playing a Happy Birthday song from their radio. There were balloons, and large colourful letters saying “HAPPY 70TH BIRTHDAY DR DAN” hung across the wall. A table with the birthday cake and several beers was in the middle of the room, surrounded by much of the BPC staff.

The ward rounds took a pause. I thought that Dr. Dan would cry or be very emotional, given that he's reached a new decade in life, but he smiled and shook hands with everyone who congratulated him, one by one. It was so cute to see the little children smiling and reaching up to shake his hand too.

“Amy” (a volunteer Dr) then presented Dr. Dan her handmade Birthday Card that we all signed. This was then followed by the cutting of the birthday cake and distributing of the beers. The room was small, but at that moment felt cozy, so very “Gemutlichkeit (sp?)/ Gezellig”.

It was a very pleasant start to the day, and I (selfishly) felt lucky to have my medical elective coincide with this occasion, along with the BPC 15^th Anniversary on Friday.

East Timor Medical Elective - Week 3 (Part 6 / 6)

TEMPORARILY GETTING RID OF AUSTRALIAN MINDSET (TOXIC “TALL POPPY SYNDROME”)?

At night after giving Chicken for the first time, I was worried about how I'd be perceived.

My normal Aspie self would see this in a concrete, objective manner as an act of spending money to buy a Chicken and giving it to people who otherwise would have difficulty buying it.

However, my past experiences with NTs (Neurotypicals) was that they had a statistically much higher chance of putting a skew on events, particularly with stronger emotional biases, even to the point of discrediting the person who had “neutral” or “altruistic” intentions to begin with. Ie, I already knew that acts of charity aren't necessarily viewed as good by everyone. 

I pondered, is buying things for other people considered [ patronizing / showing off / egotistical / arrogant / trying to please everyone / insecure and wanting to be liked by “buying friends” / an attempt by a potential “Paedophile” to lure innocent children ]?

I asked another assistant (“Martinho“) whether buying things for East Timorese people was at any times considered patronizing, offensive, or ignited criticism and cynicism from others. He said,

“In East Timor, people appreciate the gift, no matter how much it's worth, even if it's just 5 cents. We won't get angry or think it's patronizing.”

 

That was it, no more, no less.

I was very relieved to hear this, but then confused. How could the response of East Timorese people be so simple/pure and positive? Aren't they predominantly NT as well? How could they be so different in mentality? Are they still “human” for having such a straightforward, “bestial” response?

My mind was racing, trying to think of the underlying “Physiology” behind this mentality. Could it be that East Timorese think like this coz of their poverty, so “beggars can't be choosers”?

I realized that the cumulative negative reactions of NT Australians in the past (towards me, and others) have made me feel like EVERY F***ING-THING I said, did, or achieve, would somehow be offensive, unacceptable or Politically Incorrect to somebody, for some G-d-damn reason that was initially beyond my “simple” AS mind. My constant attempts to update my “social skills” database as a means of facilitating my function within a predominantly NT-environment actually worked against me here. But in reality, it wasn't just the NT-environment that I was attempting to adapt to, but an Australian one. I underestimated the influence of Australian “culture” on the environment.

There are Australians who deny the existence of “Tall Poppy Syndrome”, but my observations in the media, along with my personal experiences, suggest to me that it's alive and well. The person being “cut down” doesn't even have to be rich or intelligent, it seems to be as long as they attempt or do something that other people don't do, that it frequently attracts criticism or derision, even if others had zero intention of doing that task in the first place.

I thanked Martinho for the explanation, but felt really upset, and really nauseated inside.

I wasn't sad at the gratitude of the East Timorese people, but sad that “Australian cynicism/jealousy” and “Tall Poppy Syndrome” had “poisoned” my mindset, even outside of a social environment, and OUTSIDE of Australia. My worries in the Chicken incident were for nothing.

I was unable to purely accept a charitable act for what it was, and in the grueling process of understanding people, paradoxically lost my ability to appreciate goodwill without triggering negativity.

The East Timorese are much poorer than Australians, and have access to far less amenities, medical and non-medical. The children seem so innocent and easily entertained, whilst the youth are disillusioned re: unemployment. Yet in spite of all of this, emotionally and spiritually they seem “purer” and more “elemental”. Despite 3rd-World conditions, in some ways, they are “freer” than Australians. Their “freedom” from cultural cynicism and Political Correctness is exquisitely liberating and luxurious for foreigners who've “walked on egg-shells” for years. What is the price to experience such Mental Clarity in one's country, to regain a part of one's “Inner-Child”? 

 

I'll miss East Timor very, very much when I come back to Australia... : (

East Timor Medical Elective - Week 3 (Part 5 / 6)

BUYING CHICKEN

This week, I asked one of the clinic assistants, “Luisa”, if there was anything I could do to help them or the children on the Malnutrition Ward. One of them told me that the children like eating meat, especially chicken. Unfortunately, their (very meagre) budget only allows for THREE chickens / month, split amongst the SIX children.

I decided to start buying a roast chicken every Saturday for the children as a treat. (This would be completely illegal in Australia, as under the litigious climate, would be seen as a potential health hazard, and as a “conflict of interest” towards to children as a staff/volunteer!!!)

On Saturday, I approached the Rotisserie on the way to BPC, to buy a roast chicken (chopped up) for $5. It was eye-opening to see the presentation of the meats. They were all stored on trays in the glass cabinet at room temperature. There was a risk that it may be spoiled, but I was told that it's actually a popular place. I hypothesized that if the place was popular, then it was unlikely that it'd sell spoiled meats, especially when the prices are expensive by local standards. I asked for the chicken, and the woman chopped it up, placed it in a paper-folded “container”, added a little bag of soy sauce, and placed the container in another plastic bag. Primitive, but workable and memorable.

I slowly walked to the clinic under the hot sun, wondering how they would respond, and if everything would turn out fine. I was too “shy” / anxious to present the chicken to the parents myself, and asked Luisa to distribute it evenly amongst the children. I nervously waited in the office, before preparing to walk home. 

Luisa bumped into me and said, “Ken, the children are eating the chicken, go have a look!”

I followed her into the Malnutrition room, and it looked like a “Kodak moment”: it was quiet apart from the ceiling fans and the chewing noises of the children. The parents were quietly focusing on them eating the chicken with the porridge. No complaints at all.

Inside I felt very “touched” but couldn't figure out why, and had to leave the room after a few seconds, coz I thought I was going to break into tears. They weren't openly worshipping me, but I suspected they were happy.

It seemed way easier to please people in developing countries. $5 was what it took to brighten the day of 6 families. I can see why working in a developing country could be attractive, with the poverty and reduced resources (medical and non-medical). The people seem much more grateful, and are less inclined to take things for granted.

But I had to remind myself, that if I wanted to work in a developing country in the far future, to truly consider how much of this would out of genuine altruism and/or job satisfaction, vs the desire to feed one's Ego and be “worshipped” by the patients etc.

I've decided to continue buying a roast chicken for the remaining Saturdays I'm in East Timor, but leave the Malnutrition Ward ASAP after I have distributed it out. At least that way, there is minimal potential time for me to “gloat” about this deed and “thrive” in their live gratitude.

East Timor Medical Elective - Week 3 (Part 4 / 6)

East Timorese Patients (Observations so far)

It's now clear to me that the East Timorese patients are most amused by the Neurological Exams, by far. When I used the tendon hammer to do knee jerks on a patient, the other patients and relatives were looking on in amazement. Natalya was with me and she said that after I left, some of the patients were hitting their knees with their hands, trying to elicit the jerk (so cute)! A few patients were quite strong for knee flexion, and when I was trying to stop them from pulling their feet towards their bottom, stumbled over to others' laughter. Then there was the grandmother, who when asked to touch her nose, ended up putting her index finger up her nostril (lol), with her children “cracking up”!!!

We got to debride the dead/macerated skin from the Leprosy Pt's feet. It looked quite gross, and I pulled off his toe nails, but he didn't feel pain. I was very worried about causing pain if cutting too deeply, and “jumped” when his foot suddenly shifted for easier viewing by another student. It almost felt as if I was having more pain than him, and he was laughing so much the entire time.

It made me happy that the patients etc took joy in taking part in physical exams. I couldn't tell if it's because of their “Un-Medicalized” state, or coz they take humour in little things, perhaps because they'd otherwise have little to be laughing about (in light of poverty and hardship). In fact I think their threshold for humour is very low by Australian standards, to the point of finding “slapstick” content hilarious. I imagine they'd love the classical Charlie Chaplin movies. Even outside the clinic, I've seen children laugh at me when taking big bites out of an ice-cream cone, or when my head hit a low-lying branch whilst walking. Adult strangers have laughed just coz I was walking fast / running from one place to another in a hurry. It seemed Aspie-ish, in that they perceived these little details with more value, and don't overlook it automatically. But I strongly suspect that this “Humoural Sensitivity” will gradually fade away if they become wealthier, and progressively de-sensitized by the deluge of Western media and culture.

(In fact, maybe I could make a list of things that have amused the East Timorese patients, or amusing responses by them...)

It was touching for me to see a Heart Surgery Pt return from Australia, and donate his remaining Oxycodone to the Clinic's Pharmacy for other patients in severe pain coz he didn't need it anymore. I've never seen such “medication” generosity in Australia, where Oxycodone and Morphine have a reputation for being overprescribed and abused or diverted for money.

Unfortunately, part of the “Medical Innocence” manifests in a lot of patients as being rather “poor” historians (even taking communication barriers into consideration). It's not uncommon for a patient to say one thing, and then say the opposite several sentences later. I thought they were lying, but seemingly according to my Tetum Language Book, it states that East Timorese people will state something as the truth even if they're not sure that's the case – the usage of modifiers such as “perhaps”, “maybe”, “if I recall correctly” is less prevalent than in English. If they've had a certain issue for several years, they often just say “kleur ona” (a long time), without specifying the years. I have to “prod” them to state how many years. And then there are a handful of patients who misunderstand Asthma, thinking that it means shortness of breath (from any cause).

It doesn't help that Tetum has several deficiencies in facilitating history-taking. Despite the inclusion heaps of Portuguese loans for scientific/technical terms, the core Tetum actually misses several grammatical points that would've facilitated history taking. For example, you can't ask “How long have you had this pain for?” Instead, you have guess the units of time, ie “How many days/weeks/months/years have you had this pain for?” There were others but I can't think of it for now.

My observations so far are that they're most accurate when it comes to discussing medical issues that are very recent onset (eg abdominal pain startig last night), with progressively less accuracy for more chronic issues.

The “Medical Innocence” is quite interesting at times, especially the heterogeneity in medical knowledge amongst the East Timorese patients. There was a village girl who had Pneumonia, and I told her mother that she'd be receiving “antibiotika” (antibiotics). She didn't know what antibiotics were. I then said it was a medication that helped eliminate certain “bakteria” (bacteria), but then she didn't know that word either. Then there was another patient who knew what bacteria was, but never heard of a “virus” (virus). I had to get the interpreter to explain to her that a virus was a bit like a bacteria in that it can cause infections, but it's even smaller, and you can't kill it with antibiotics.

East Timor Medical Elective - Week 3 (Part 3 / 6)

“FRACTURE GIRL”

On Wednesday evening, I was about to leave BPC, but then got called into Dr. Dan's office.

I thought he was going to show me a patient with a heart murmur, so was surprised when he showed me a girl with a Greenstick Fracture. I looked at her arm, and she looked up to me with her big eyes. My heart “jolted” when he told me to put a temporary splint in the emergency room, and ride the ambulance with her and her Dad to GVNH's ED for an X-Ray and proper cast. Initially I got annoyed coz I wanted to go home and rest, but it quickly subsided as I felt really sorry for her and wanted to help, plus I was having another Adrenaline rush (which masked my fatigue), so said Yes to him.

A new “quest”. I forgot to take my medication that afternoon so was a bit scatter-minded. I needed to think things through methodically otherwise it'd be hard to get things done properly. 

Step 1, I had to bring them to the Emergency Room. I asked them to follow me to it. I walked a few steps, and they were behind me, stopping as I stopped (as I didn't want them to lose track of me). I felt like the Villager in Age of Empires who had to guide the Sheep back to the Town Centre. She entered the room, and I pushed the main bed away to make space for the chair for her to sit on.

After entering the Emergency Room was Step 2, finding a splint. I've never put on a splint before, but was aware that you needed a long solid object, wrapped in bandages to help immobilize the limb. I immediately visualized the “perfect” long plank of wood classically shown in First Aid Textbooks, and scanned the room up-down, left-right for it, triple-checking. Nope, it wasn't available. I then brainstormed of alternatives – long thin pieces of metal / plastic, cardboard. Nope, not available either. Time was ticking and I felt frustrated. Both the girl and her Dad were staring at me quietly.

I realized that I hadn't checked my bag yet, and as I opened it, realized I could use the cover of my note book as a (mediocre) splint. I ripped out the cover, rolling it into a cylinder and placed it around her arm, forgetting that it was only supposed to be on one side. I told her Dad to hold the cylinder up at her elbow level.

Step 3, find a bandage. This was much easier. There were bandages on the shelf, but I couldn't find the perfect textbook one, but didn't want to waste more time being indecisive, so took a guess and opened up the closest package to me, which was a thick, puffy one. I wrapped it around the cylinder, but couldn't let ago otherwise the bandage will go loose again.

Step 4, I needed string to secure it. Tetum time, I said “Hau presiza...” (I need...) whilst nodding at the bandage, but temporarily forgot the word for “tying”, in which case he said “kesi” (typing), and I said Yes! Then I had to obtain the word “string” in Tetum from my memory. I remembered “talin” being a unit of items being held by a string, and said it, and he understood.

He scanned, and then took out one that was hanging out of a folder. He brought it over, holding the bandage firm whilst I tied a few knots around it.

Step 5, find an ambulance driver to take us to GVNH. We walked out, and I couldn't see one. Dr. Dan was outside and I told him, in which case he asked another person to contact the driver to pick us up. He said that the driver will arrive in a few minutes, but those 5 minutes felt much longer. I looked at the “splint” I made, and felt rather embarrassed but proud of this “improvization”.

The ambulance driver arrived but I wasn't allowed to sit in the back with them. On the way to GVNH, I was constantly worried about her, wondering if the bumps on the road may have caused further trauma.

We arrived at GVNH, and I entered the ED. The first time I entered this place, it looked very “drab”, and even “greyer” by Australian standards. Step 6 was registration. The “Boss Level”. From my previous experience with the Cuban Radiologist, thought that I had to behave in a very meek manner without showing any signs of aggression or anger, as the Drs here have the potential to avoid helping patients with virtually ***NO*** medico-legal penalties compared to Australia. The extremely frightening reminder of this risk, was a furious-looking mother and her crying daughter of similar age to the “fracture girl”, screaming in Tetum to the Triage man. I suspected that they've been waiting for a while and haven't been seen by a Dr, despite the presence of empty beds, and Drs chatting at the counter. “Don't let them push your buttons, hide your feelings, censor yourself, don't get angry, don't get angry, don't get angry”, I repeated in my mind. 

I walked up to the Triage man, and in my most “formal” accent, slowly greeted him in English and introduced the girl's medical issue. He took further details from her Dad and pointed us to the main ED counter. The furious-looking mother immediately became even more outraged, which disturbingly confirmed my hypothesis. 

Step 7, the actual “Boss Battle”, or advocating for the Patient. The girl and her Dad followed me, as I walked slowly towards the ED counter. The Drs stopped chatting as they looked in our direction. I greeted them with the same accent again, and described her needs. I tried to add “weight” to my sentences by beginning them with “Dr. Dan Murphy”(needs / thinks / wants etc), hoping they'd be obliging to help secondary to my name-dropping.

As soon as I mentioned “X-Ray”, one of the Drs immediately said “The X-Ray machine is broken. She will need to come tomorrow to have the X-Ray done.”, followed by another Dr saying “Does she only need an X-Ray?”, seemingly ignoring my mentioning of the need for a cast.

I paused. The clincher: my answer to this question would determine if they would help us or kick us out. Say the wrong thing and I'd lose the level and prolong the girl's suffering. The answer was obviously “No”, but in the past (when un-medicated) I had a higher risk of saying the wrong answer, or forgetting to say important things at high points of stress. Surely the Drs knew that she needed a cast? It almost felt as if they didn't want to help in the evening, whether out of laziness or fatigue.

I worried that they'd give more excuses even if I said “No”, so formulated a sentence in my mind and quickly analyzed its truthfulness and influencing potential, coming up with:

“Dr. Dan Murphy needs her to have a cast put on her arm to stabilize her fracture, even if she doesn't receive an X-Ray today. It is important to have a cast, to prevent the greenstick fracture from potentially getting any worse.”

If the Drs disagreed, then it'd make them look really bad, even if they couldn't get sued. I wasn't aware of a way to argue out of delaying putting on a cast for a greenstick fracture in a haemodynamically stable patient. 

Thank Heavens the "Rivers Parted", and the Drs “agreed” to help us. They told us to go to another room, where a Dr started undoing my “splint”, and began preparing a cast. Unfortunately I wasn't able to watch the entire process, as the ambulance driver called me out to drop me off at home. On the way back, I was relieved but even more exhausted after that ordeal. 

Mission accomplished for the cast. What a diversion, I felt so “battered” by the time he dropped me home. I think this task was the one that so far (by end of Week 3) demanded the most of my improvization/flexibility and communication skills. I thought that advocating was a simple task, but in retrospect realized you needed to demonstrate the medical knowledge to justify your demands and facilitate delivery of treatment. G-d help the non-critical patients who come on their own without a Dr or medical student to escort them, especially when the public here are much less “medically literate”. 

Whilst I personally found their “Medical Innocence” endearing last week, I now understand how this can work against them in a potentially very dangerous sense. I'll never forget this episode...

East Timor Medical Elective - Week 3 (Part 2 / 6)

EAST TIMORESE PEOPLE AND FORGIVENESS

I couldn't understand why the East Timorese people forgive so easily. Especially with regards to the Indonesian massacre of the East Timorese in 1991 and 1999 (apparently up to ~1/4 of the population died), why they have still have little problem with Indonesian culture or Indonesian people. It's a complete contrast to a significant portion of Chinese and Koreans who hate Japan coz of WW2, and the Australian Aboriginals who still complain about injustice even though they've already received an official apology, and copious social welfare (unlike the East Timorese who receive virtually NONE) and academic scholarships despite the statistical majority not making the most of what they've been given.

I got told that it's because East Timorese people need to look forward and not dwell on the past. Their economy is also still largely independent on Indonesian products, so it's important to have amicable relationships to avoid an embargo that would destroy their economy even further. But I wondered how much of their external humility is due to their poverty. If East Timor was in an economically superior position, could they then be less forgiving and get away with it? Do they genuinely forgive Indonesians (eg as a Catholic notion, eg “turning the right cheek”), or is this a strategic move to not “rock the boat” any further lest they suffer from a hypothetical Indonesian embargo?

An Aspie (before I came to East Timor) told me that she never burns bridges with other people, “you never know when you need them”. Maybe East Timor is in a similar situation.

Nevertheless I find their attitude very inspiring, and it helps to put into perspective the significance of some of my previous problems, of which I've now moved on from.

MINI-CLINICAL NOTES

- I saw a patient whose respiratory symptoms were milder than before. I thought that it couldn't be TB, if he wasn't diagnosed with it after the first time (that was more severe), but I was proven wrong. He was still given a provisional diagnosis.

- There was a dyspnoeic patient who had suspected TB. He didn't officially have Asthma, and never used “Ventolin” (salbutamol) before. He had digital clubbing for a long time. I was puzzled as to what condition he had. Maria came to listen to me present the patient, and soon commenced him on nebulized salbutamol + budesonide. 

I felt dumb; it was obvious but it just didn't occur to me at the time. Just because a patient has never been diagnosed with the condition, doesn't mean they can't have it. You might as well give the treatment a try.