Nightmare

I just woke up from a vivid Dream (or rather a Nightmare).

I was in a Room gathering Notes for 2 other Medical Students until the Tutor came in and passed me a Note, which happened to be a Notification on me to the Medical Board.

The Complaint was from a male Patient who stated that whilst I was scrubbing in Theatre for his "Buttock Surgery" (I suspect this is for non-cosmetic Purposes, therefore General Surgery albeit unusual), I injured him too much with whatever Tools were used in the Operation (presumably Scalpels), and he has been permanently scarred and in pain. His Wife "Norm" was very distressed ever since. For some reason the Notification stated he was taking "Irmlodipine" (which I presume should be Amlodipine, spelling error in my dream!) but nothing else.
The male Patient said in the Notification that he was ready to contact the Medical Authorities and was willing hunt me down ASAP.

It was soon after that in which I woke up.

Holy shit, thank goodness that was just a Dream!!!

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I'm trying to reduce the stress of this Nightmare by openly discussing it via this Blog Entry.

As ridiculous as this Nightmare sounds, it particularly striked me as it mimicked my very real Experience of being notified to the Australian Medical Board (part of AHPRA) for unfair reasons during Med School. Whilst I got away with it in this instance, I recall being extremely stressed / anxious for 4+ months as I was worried that I'd be deregistered, wasting my (incompleted) Medical Education.

I wonder if this Nightmare was a reflection of my ongoing or subconscious Fear of being Sued or Notified by a Patient?

I wonder if I will have this constant fear while doing the actual Internship in 2015? Will I be able to sleep without having to resort to Benzodiazepines or Antihistamines?

I know classmates and Doctors who in the past think that maybe I shouldn't do Medicine due to the high-Stress Nature of the Profession, but I'm still willing to give it a go, just to see how I fare out. I may have Asperger Syndrome, but historically there were plenty of Aspies in Medicine with successful Careers due to very strong compensation mechanisms. Let's see if I can become one of them...

Paediatrics (Part 5/5, RETROSPECTIVE POST)

I enjoyed Paediatric Outpatients a lot. I remember where there were a few days where I forgot to take my Medication, yet I was still fully alert and engaging with the Children and Parents without any major Issues.

I had to ask myself why I loved Paediatric Outpatients so much at the time? Being honest with myself, I came up with the following 3 reasons:

1. I was socially isolated and talking to People in Outpatients filled a void in my Social Life (as pathetic as it may sound).

2. I found it easier (less cognitively exhausting) to relate to and communicate with Children than Adults, and the Adults (Parents) seemed easier to please indirectly by me interacting positively with the Children.

3. I felt like a productive Member of the Medical Team, Clerking Patients for the Paediatricians in advance whilst they were busy seeing other Patients (but then again, this could apply to any Medical Specialty if given the opportunity to work at Outpatients).

After finishing the Paediatrics Rotation, I had a weird feeling. Could I possibly be more suited to training in Paediatrics than Pathology (if I stay in Medicine)???

Really, an Aspie working in Clinical Medicine for the long-term? Surely that would burn me out eventually?!

I liked that Children were easier to talk to and were less likely to have complications from lifestyle-related / self-inflicted issues, and that they were more amenable to positive changes. However sometimes, Children's Medical outcomes were impaired from poor Parental Care or Chaotic Environments outside of their own will, which made me really frustrated inside.

Paediatrics is also saturated in Melbourne, so apparently it's hard to collect referrals, but if you're really good at your job, I suppose that may be a non-issue.

Medically, I could see myself having trouble with Procedural Skills on Children, particularly Cannulation and Venepuncture. Their veins are just so small! Physiologically, due to Children's atypical Presentations of various Medical Conditions, especially Infections (like Bacterial Meningitis), I was worried that the high prevalence of Undifferentiated Presentations will increase my Risk of missing something dangerous, or that I want to treat it as something dangerous, but am unable to do so due to restraints in resources (eg limited ED Beds in Emergency, “Not everyone can be given Antibiotics”). The Swiss-Cheese model means that something's got to give eventually, which has lead to cases of Children dying from Bacterial Meningitis in the past → Litigation. I was also told that Parents in Paediatrics are actually very annoying, but they seemed tolerable to me during my Rotation. As a Single Male, along with reasons 1 & 2, I was worried that my Enthusiasm may eventually make me susceptible to being falsely accused of Paedophilia, as is already the case with numerous Male Primary School Teachers in Australia and the UK, hence the current under-representation of Males in that Field.

I suppose Reason 1 could be abolished by having a Social Life outside of Medicine, it's just that I need to put an active effort into it and not let Medicine take over my life like it has in the past. I would like to think that I could be a positive role model for ASD Children, but I might be able to achieve that as a GP instead (shorter Training Path) and still have Patient Contact.

Hmm decisions decisions...

Paediatrics (Part 4/5, RETROSPECTIVE POST)

Strangely I didn't meet any ASD Children by myself which was a real shame, although I witnessed a few when sitting with other Paediatricians in the Epilepsy and Developmental Paediatrics Outpatients (at RCH), several who were very low-functioning supposedly secondary to documented Genetic Mutations, non-verbal and had Bowel + Bladder Incontinence (severe Frontal Lobe impairment). According to my Developmental Charts, none of their domains (Gross Motor, Fine Motor & Vision, Speech & Language, Social & Emotional) reached that expected of a “normal” 3 year old. One of them couldn't tolerate Eye Contact at all and had to use a Mirror in order to look at other people. 

They would most likely required expensive 1-on-1 support for the rest of their life (given the current technology), being a massive financial and/or emotional “burden” on the Carers and Taxpayers. It made me wonder how productive it is for me and other Aspies to be placed in the same Diagnostic Category (ASD) in the DSM-5, although it's true that we're both on the Autistic Spectrum. The purpose of the Spectrum is to acknowledge there is significant variation in functioning and abilities, but I worry that people would just stereotype me to be totally impaired or incompetent when actually I have my sharp sets of strengths and weaknesses. Maybe the only Solution is for more Aspies to “Come out of the Closet”, to help promote awareness of the condition, and that not all ASD people are “Retarded” or “Savants” like “Rainman” (Kim Peek, who supposedly had FG Syndrome in fact, and not ASD).

For a fleeting moment, I wondered if low-functioning ASD Children (at least, the ones who will still be low-functioning as Adults) were better off being aborted instead of being born as they wouldn't have the Executive Function or Cognitive Abilities to lead any semblance of a “Productive Life”, but I was horrified and disgusted at myself for possibly supporting Eugenics (beyond Terminal conditions). I really wasn't sure what to think.  The Cognitive Dissonance seriously made me very uncomfortable.

I've for the most part thought it was sad but acceptable for pregnant Women to terminate Foetuses diagnosed with Trisomy 21 (Down Syndrome) given the Severity of the Disability, but to support the Termination of innocent Autistic Children?

How could I be a Supporter of ASD Individuals, yet go against some of my kind???!!!

Am I a Hypocrite???!!!

Does one have to be productive member of Society to justify their Existence or Differences (Medical Condition, Disability, Sexual Orientation, Lifestyle etc)???

Where does one draw the line for Therapeutic Termination???

This is all so complicated to me, and I'm unable to neatly categorize it using typical “Black & White” Thinking because of the Emotions and Politics involved. I still dunno what the correct Answers to the above Questions are...

Paediatrics (Part 3/5, RETROSPECTIVE POST)

"Max" (ADHD): My most favourite interaction in Paediatrics was with an ADHD Child called “Max” (not his real Name).  When I opened the door, the first thing Max said to me was “Are you Somalian?” in which I said that I wasn't, without getting offended at all. Whilst the Paediatrician was talking to the Mother about Max's Medication regime, I tried to engage with him by asking him about school and his interests which included video games. I tried to ask questions about his favourite video games but soon exhausted my “Repertoire”. He quickly got bored and proceeded to play with a few styrofoam Cups.

I tried to engage him again by making up a little game where he had to stack the cups in various configurations of progressively increasing difficulty. Every time he successfully made a cup tower, I said “Well Done!”, and he called for his Mother's Attention for similar Praise. Eventually he reached a ceiling point of his ability, so to prevent him from feeling really bored again, I decided to show him how to make “Cup Wheels” by connecting two smaller Cup Ends together with Cellophane Tape, so they can roll on a flat surface smoothly. He got really excited about this novel invention and kept rolling the Cup Wheels down a slanted surface, and then decided that he could make a Cup Tower, so the Cup Wheels could smash into it, with the Cups spreading across the table. The stimulation was enough to sustain him for a few more minutes but soon he got bored again.

I tried asking about his interests, but surprisingly he remembered our conversation and said “You already asked that.” He then ran outside of the room and I went after him. He wanted to urinate but didn't want to use the normal Toilets, preferring to urinate outside. I asked if he wanted to wash his hands, but he didn't, saying that it's “yucky”, which I suspected was a sensory issue relating to water. He then wanted to race me back to the Outpatients room, and I agreed. I outpaced him and reached the room first, but he falsely accused me of having a Headstart.

I really didn't want his hands to contaminate anything else in the room, so I tried to get him to clean his hands with the Debug (an Alcohol / Chlorhexidine Hand Rub) by cleaning my hands with it to set an example. I asked Max if wanted to try catching the Debug while I squirted it like a game, and he said “Yes!”, so I kept on squirting it until he “scored” and was happy. But this happiness was shortlived, for the cut in his hand started to burn from the Alcohol, and he was moaning (LOL). By then the Paediatrician was done with the appointment and he had to go.

It turned out that Max didn't get an increase in his Medication as he desired. As the Paediatrician and Max's Mother exited the room, the lights were switched off, and Max was staring at the computer screen, totally silent. I looked at his face and it looked like a mixture of blankness and disappointment. I suspected that it was due to him ruminating over the Medication issue.

I said to him, 
“I know you are thinking about [ Medication ], and that you want more of it, right?” 

Max slowly said,

 “Yes.”

                         
“You didn't get what you want and that can make you sad or angry. Dr. X is the one who gives you the [ Medication ]. If you want a higher dose of [ Medication ], you have to tell him next time, and say why.” 
                          
"Ok."

            I wrote on a scrap piece of paper the Medication, the desired dose, and his reason as a memo for him to use in his next Appointment before leaving the Room and waving Bye Bye.

I was very pleased but drained that I was able to adequately distract Max during the entire appointment so he wouldn't disrupt the Paediatrician's consultation as usual. The Paediatrician said, 

“You did well, but this is one of his good days.” 

“Thanks”, I said. But I wonder how Max would've behaved if I wasn't there to distract him??? : P

Paediatrics (Part 2/5, RETROSPECTIVE POST)

Paediatrics Outpatients was where I became very enthusiastic for the first time in Clinical Medicine. The awesome thing about Outpatients was that we had the opportunity to see Patients on our own, and then present the information to the Paediatricians afterward for further input. The children always came with at least 1 Parent / Guardian. The majority were for Respiratory or GIT complaints (eg Abdo Pain, Constipation), with some presenting for follow-up following Inpatient management several weeks ago.

To be honest, whilst my Clerking wasn't particularly good at the time as I didn't use any shortcuts and was being too methodical in both History and Physical Exam, and writing all the details down (and thus taking too long), I really enjoyed the Consultations. For some reason I found it quite easy at the time to engage both the the child and the parent, something which a senior Paediatrician said was a challenging aspect of the Specialty. I was hypothesizing that it was because I am overly sensitive, and also get distracted easily, it enabled me to “bounce” back and forth between the 2 individuals with little effort. What also facilitated this was that if I had difficulty figuring out what to say next to a parent, I could reduce the “awkwardness” by focusing on the child, and vice versa. Switching to the child was sometimes useful when the parent was being too chatty (which happened frequently).

The best thing was the children (without trying to sound like a Paedophile), I felt I could relate to a lot of them better than the adults. It felt easy for me to talk to the ones who were verbal. The younger ones (especially Pre-Teens) had more concrete thinking which I could relate to (Frontal Lobe underdevelopment). I found it very endearing when one of them asked how they managed to put the Test Tubes (containing Blood) into the computer I was using (in the Outpatient room) in order to obtain the blood results. My basic explanation was that the Test Tubes were being analyzed by a big machine in a lab somewhere else in the hospital, and that the results are recorded by a computer program, which then sends the data electronically to other computers for view. It reminded me of when I was younger and didn't understand how a Fax Machine worked – I used to think that the same piece of paper that got put into a Fax Machine would physically be transported through the thin telephone wires and pop out, to be printed at the receiving end!!!

I could use simpler English (cognitively easier for me) and shorter sentences when speaking to the children without being seen as patronizing. I relished in the fact that I could ask simple questions without pretense like “What is your favourite colour?”, “How old are you?”, “What do you like to play?”, and get straight answers from the Children without being seen as a “loser”, “dickhead”, or “pervert”. The parents also seem pleased that I was engaging with the children and communicating at the same level. Neurologically, I knew that they were less developed than an Adult NT, so I found them much less threatening on the whole, as I perceived them to be cognitively less able of being manipulative and chronically dishonest. This probably increased my confidence which permeated into my behaviour, seemingly despite my poor medical knowledge. I liked how a lot of the NT Children seemed more inquisitive and disinhibited, before they become fully conditioned into their stereotypical, conformist Adult forms. In short, I felt I had more potential to make a positive difference to the Children.

Paediatrics (Part 1/5, RETROSPECTIVE POST)

Following O&G was CAH (Child and Adolescent Health, ie Paediatrics). Of the 9 weeks, I spent about 6 weeks in total at the Paediatrics Department of my Clinical Hospital, and the 3 other weeks at RCH (Royal Children's Hospital) for lectures and a mini-attachment. Paediatrics was the first Clinical Rotation that I REALLY enjoyed and was enthusiastic about, of which there were multiple factors. I temporarily felt “ALIVE” and “SWITCHED ON” which was a huge contrast to my very low state the previous Semester. Another thing that made this Rotation memorable was that all the supervising Paediatricians knew about my AS and were amused by it given its relevance to Paediatrics. None of them were patronizing or treated me like a child. I didn't experience any repercussions in disclosure and knew in advance that it would be taken well.

The Paediatrics Department of my Clinical Hospital was very small compared to RCH, there were about 18 beds, and about 1/3 of them were for Eating Disorders. Being male and not a Paediatrician involved in their care, I was advised to avoid speaking to patients with Eating Disorders (all teenage girls). Most of the rare and complex cases would've been transferred to RCH, so the remaining Case-Mix at the Peripheral Hospitals (including this one) were very “Bread-and-Butter” - Pneumonia, Bronchiolitis, Gastroenteritis, Dehydration, with a bit of Epilepsy. Because there were so few Inpatient beds, I actually spent more time at the Paediatric ED which although had even fewer beds, but had much higher turnover, and hence more opportunities to practice Clerking and Physical Exams.

Like with Women's Health, we had a PBL (Problem-Based Learning) Tute each week at the Clinical Hospital and opportunities to attend Outpatients, along with morning Ward Rounds (including on the Weekends if we'd like).

PBLs were mostly on “Bread-and-Butter” cases. However there were two Tutes that stuck out in my mind, the first one regarding a fictional 4 year old boy who was being assessed for ASD / Fragile X Syndrome. Somewhere in the text it said that the boy had frequent “Tantrums”, particularly coz he wasn't able to communicate his ideas owing to his Speech Delay. I wasn't happy at the term “Tantrum” being used coz it brought the connotations of being naughty, rebellious, and/or manipulative (in reference to NT children, eg at the supermarket wanting something but not getting it), when he was anything but. 

In the Tute, I said I found the term offensive and misleading and that the more appropriate term for such an ASD child would be a “Meltdown” due to his current neurological deficits being unable to meet his personal needs, leading to massive frustration and vulnerability. And that the approach to his “Meltdown” (Education, Accommodations, minimize Sensory Overloads) would be completely different to that of a “Tantrum”, which we were taught to just “ignore the child until they stop whining, to give them the message that their Tantrum isn't working or acceptable”. I feared that parents would treat ASD children having Meltdowns inappropriately, which would just exacerbate the situation and cause more mental scarring. However the Tutor insisted that it was still a “Tantrum” in the literal sense, and was thus appropriate. This incident was very frustrating and ironic to me, given that ASD people like me supposedly take things more literally (relative Frontal Lobe deficits), and have an impaired ability to comprehend language pragmatics (including subtle connotations), and yet it was the Tutor (NT) who took it literally.

The second memorable Tute was about a Teenage girl who had several psychosocial issues to be addressed in conjunction with Epilepsy management, including Smoking, drinking Alcohol, teenage Sex and possible Depression. IIRC, in the passage regarding her Past History, that she “Tried Sexual Intercourse a few times last year but didn't enjoy it, so hasn't had it since.” This phrase was particularly interesting to me, coz it was only then I realized that sometimes, in order to dislike an activity, you have to give it a try first. I literally told the Tutor that “In order to know that she doesn't like Sex, she has to try it first,” in which he concurred. 

It may sound really obvious to others, but it helped influence my approach in life, that part of personal growth involves getting out of one's comfort zone (or narrow interests / repetitive activities) and experiencing new things temporarily, which would assist with developing one's perspective too instead of relying on preconceived notions or fear. I now see it as collecting more data to analyze. Sometimes there are strangers who I'm interested in speaking to, and whilst I used to be too anxious about approaching them at all, now I'm more forthcoming and curious, thinking it's “It's either I speak to them now, or never and continue to wonder what it's like if I had spoken to them”.