East Timor Medical Elective - Week 5 (Part 1 / X)

Week 5 (29/9/14 – 3/10/14)

“ANITA” (Not Pregnant and Intellectual Disability)

Anita was a (slightly overweight) teenage girl who was admitted to BPC as she had (IIRC) Amenorrhoea for a few Months. Maria initially tried to clerk her, but gave up partway through as she (Anita) was a seemingly very poor Historian, and was apparently unable to give straight Answers. I decided to give Anita another Chance and spoke to her that Afternoon.

Anita was with her sister (and her sister's boyfriend). I asked her questions but like with Maria, she was unable to confidently say “Yes” or “No”. I thought she might've been delirious, and asked her about location and time, but she initially couldn't answer it. Other people giggled during the History-taking, and another Guy whispered her the answers but I told them not to coz I was assessing her Cognition. Her sister ended up offering a collateral History, but I didn't think it was an accurate Account, coz I had a gut Feeling she was trying to manipulate the Story to suit her personal Agenda.

An Abdominal Ultrasound was done which showed an empty Uterus. A Urine Beta-HCG test was also ordered which was negative. I told Anita and the rest that she wasn't pregnant. What really surprised me was that Anita's sister looked really disappointed, that she wasn't pregnant.

I couldn't understand why Anita's sister wanted her to be pregnant, especially when it looked like she had an undiagnosed (Intellectual) Disability. I mentioned that she may have an (Intellectual) Disability, using the word “Aleijadu” (disabled) but she (Anita's sister) got really defensive and said it was because she only had Schooling up to Grade 3. I then asked Anita really simple questions, like the colour of objects I pointed (Red, Yellow, Black, Green), but she guessed those wrongly too. I briefly discussed Anita's case with Maria who said that even if she had that little schooling, she should be able to recognize “basic” colours. I passed on Maria's Opinion to Anita's sister but she immediately became silent and seemed upset. I reiterated that she wasn't pregnant, and that if she was, there would be something seen on the Abdominal Ultrasound by now.

I discussed the Disability issue with the other Timorese BPC Staff, and they said that the term “Aleijadu” is mostly in reference to physical Disabilities. They actually have a term for stupid/slow-minded which is “Bilaan”, but it's sometimes used perjoratively, like “Retard” in English. They all agreed that a Grade 3 student would usually recognize those Colours. Even though I didn't say “Bilaan”, they said that Anita's sister could probably tell that I was implying it.

In the following morning's Ward Round, Anita's Bed was found to be empty. Usually the Patients wait for Dr. Dan's “official” approval to be discharged even if the issue got sorted out in the afternoon, but this time they left prematurely.

I felt a bit bad inside, like I was too blunt when talking to them. The possibility of your relative not being “normal” can be shocking. Also, Psychiatry and Neurological Conditions are also overall very poorly understood in East Timor by the public. The Shock may also be even worse if you were building up a massive Lie/Inaccurate Justification the entire Time. Although Anita wasn't pregnant, I was concerned about her in the long-term, especially when she is vulnerable to getting raped, but we didn't bring the Discussion that far.

Better luck next time...

Semester 12 - General Practice (RETROSPECTIVE POST)

My GP (General Practice) Rotation was at a Bulk-Billing Clinic in a rural Victorian Town with 2 other Medical Students. Initially I thought it’d be an isolating Experience not being in Melbourne, but in some ways it was actually nice to have GP as our final Rotation as we’d be away from the “Chaos” of the Public Hospital and the “Hysteria” of other Medical Students prior to our Final Exams, plus I could have a short Break away from my Parents who at Times aggravate me (especially when I’m stressed).

Very interestingly, all bar 1 of the GPs at that Clinic were from the UK, which in some sense made me a bit less self-conscious as I could attribute more of my Idiosyncrasies to “Cultural Differences”. Nevertheless, I told them about my AS, and they were polite and accommodating without being patronizing. In fact I swore one of the GPs was an Aspie based on his Physical Appearance and Behaviour, which really surprised me given that I’d thought he’d made the wrong Specialty Choice and burnout rapidly, but he didn’t recall so.

Communications-wise, the “Aspie” Doctor was very methodical but also displayed some Flexibility depending on the Patients’ initial “opening Speech”. He said that one should aim to give the “Golden Minute” to the Patient’s “opening Speech” because it helped Identify what their Concerns were so you could subsequently direct the Conversation in the right Direction. He introduced to me a very useful Acronym called “ICE” (Ideas, Concerns and Expectations). He told me that as long as I clarified all 3 of those Issues, the Patient would be more likely to be satisfied with the Consultation coz it gave them the Impression of being listened to, even if you have insufficient Medical Knowledge. It was one of the “Soft Skills” that would enable Doctors to sound more caring, fostering the Doctor-Patient Relationship.

The GP Environment struck me to be a lot cleaner and calmer than on the Wards. I loved that the Day started without any Ward Rounds, and I could sit comfortably, focusing on 1 Patient at a Time in a Room which created a stronger Sense of Privacy (as opposed to Curtains by the Bedside). I initially had Issues with Time-Management coz I was going into too much Detail (History or Examination - wise) out of Ignorance and Academic Interest, but became a bit more efficient towards the End of the Rotation by narrowing down the Patient’s Main Concerns from the start and then targeting that, ala ICE. It was excellent Practice for OSCEs coz of the numerous Opportunities to take Histories and Examine Patients (both Differentiated and Undifferentiated) under Time Pressure. I frequently felt like I was asking a List of Questions for Specific Issues, but had to figure out how to make it not sound so Robotic. I usually faced them and took the History in one go and gave little Responses here and there, before typing the Notes on the Computer, to facilitate the listening Impression. I was fortunate that for Clinical Depression in particular, asking about the Symptoms in itself (sleep, appetite, hobbies) indirectly demonstrated to the Patient that you truly cared about them.

The Cost of independently clerking the Patients, however meant that I had to present the Cases to my supervising GP, which was verbally Challenging. I invariably stuck to a Structure when presenting a Patient, but had to look away from the GP when concentrating hard coz the Eye Contact would actually distract me from my Train of Thought (but not painful like my pre-rTMS days).  

I think about halfway through the Rotation, I started feeling like a Waiter, asking the Patients “What would you like today? How can I help you? Is there anything else you’d like to talk about?”, and filling in Scripts and typing Referral Letters, letting the Patient comment whilst I was editing it. Whilst the Referral Letters initially seemed challenging, I actually experienced a sense of Pride in typing them, like I was the Patient’s “Advocate”. I could see myself improving over Time just by repeating various Structures. I was ecstatic that GPs could be paid for Consultations that were purely for Scripts or Referrals, it looked like easy Money, although I’m sure that the Reality is somewhat different!

I did have Gripes in that there seemed to be a significant Proportion of Patients who had chronic Medical Issues, particularly secondary to their Western Lifestyles or dangerous behaviour (Smoking, Junky Diets, Heavy Drinking, non-cautious IV drug use). According to their Medical Histories, it seemed like there was little progress by Way of actual Patient Effort to adjust their Lifestyles in Spite of repeated Appointments and Medical Advice. To be Frank at the Time I was actually very annoyed by a lot of such Patients, who invariably were on Disability Pensions (funded by the Taxpayers) for Complications of seemingly self-inflicted Conditions but didn’t complain about this openly. If these People were in Countries with less generous Welfare or Healthcare Systems, they might be dead by now. It was almost like they were being “rewarded” for chronically bad Behaviour. I wasn’t sure if there were underlying Psychological Issues that weren’t adequately addressed that may have impeded on their Compliance.

I and the other Med Students were frustrated by such “loser” chronically non-Compliant Patients. We actually brought up this Issue in a Tute with the GP Lecturer, but she then quoted from the GP Textbook “John Murtagh’s General Practice”, which VERY SURPRISINGLY stated that we SHOULD NOT TRY TO HELP THEM (!!!), but instead simplify Management Goals (as the Patient wouldn’t comply with complex ones), and maintain respectful Communication. She said that we weren’t the only Med Students to be frustrated, and that the MD Students of the ERC (Extended Rural Cohort) who have far more GP Exposure than us were already “Jaded”. She stated that not all Patients can be helped, and that you’ll eventually have to give up on some of them to minimize Burnout / Frustration, contrary to what other Politically-Correct GPs say. On the bright Side, these Patients still made regular Appointments to see the GP and Nurses, but it was Compliance with Treatment that was poor. Maybe their GPs still have the Chance to use a different Approach to positively influence them before they die, though I seriously doubt it given the Years that have already elapsed and all the Communication that’s been already documented.

In GP, you act as a “Jack-of-all-trades”, which appealed to me due to my relative enjoyment of Paediatrics and Geriatrics. As the first Point of Contact in the Community, the GP also plays a practical Role in Coordinating the Patient’s regular Care. It’s also by far the most flexible Specialty to offer Part-Time Work (including in Training), hence its Popularity with working Mothers. The average full-time Earnings seems to be much less than Hospital Specialists, but for some, the lower Pay is a Compromise for avoiding the Politics and Bureaucracy within a Public Hospital.

I was concerned whether I could handle all the Talking though, coz I was already mentally drained after 4 morning Consultations, having go back to my Student Accommodation for a Nap or sitting in Silence during Lunch-Time. I could always try to work Part-Time instead.

I was also worried that being at the “Frontline” in Community Healthcare, I could get sued by non-compliant Patients’ despite my Efforts to help them, as demonstrated by the ABSOLUTELY RIDICULOUS Lawsuit last year by a morbidly obese Patient against a GP (which eventually got overturned) who eventually developed Liver Cancer (likely as a Complication of chronic morbid Obesity). Cases like these make me pissed off, coz it gives the Impression of absolving the ***Legally-Competent*** Patient with no Physical Disabilities, any personal Responsibility in looking after themselves, penalizing the Doctors instead. IMHO it also disempowers them from taking Control of their own Lives. Had that Case not been overturned (and set a Precedent), who the Hell would want to look after Obese Patients and/or chronic Smokers then? Smokers could potentially sue GPs for developing COPD and having an impaired Quality of Life!!! Ie tons of Lifestyle-related ticking “Lawsuit-Timebombs”.

It really seems that none of the Medical Specialties are a 100% Fit for me, and that I’ll have to aim for one that best suits my Strengths, Weaknesses and Interests. Given the current Dearth of Pathology Trainee Positions, perhaps I could initially train in GP for the Job Security, and then work on the Weekends for the purpose of having a bit of Patient Contact, if I got into the former later on?! I’m not sure how feasible this is. Too bad I’m not interested in Haematology which has both Clinical and Laboratory Aspects…

Geriatrics (Part 2/3, RETROSPECTIVE POST)

There were weekly Radiology Meetings where Doctors presented Geriatric Cases prior to having their (Patient) Radiology Results shown on the Projector Screen. Some of the CT and MRI Scans were really eye-opening with regards to the amount of Brain Atrophy that has occurred. Even though I didn’t get to see the Patient, I felt really upset inside, a “Gut” Feeling of Sadness for how much Neurodegeneration has occurred and how miserable he must be, to lose so much of the Knowledge and Skills that he painstakingly acquire throughout his Life. What is his Quality of Life like? Is it really worth it for him to keep living? Would his children (if any) consider him to be a Burden? What is the Trigger for Neurodegeneration, and why is there such Variation amongst elderly Patients of the same Age, even in those that didn’t have Strokes or other Cardiovascular Risk Factors?

Interestingly, they also discussing an “Official” Statement from the FDA or some American Health Organization that Statins don’t accelerate Dementia, even though there have been numerous Anecdotes about this, and the Fact that a lot of Brain Matter consists and requires Cholesterol to function. I was worried that there may be a Cover-up by the Drug Companies, especially as Statins are a HUGE source of Income to them, and wouldn’t want to be complicit in prescribing it if that was the Case, but I don’t have the Evidence to prove either way. Maybe we’ll just have to wait and see in the coming Decade…

I managed to witness my first Code Grey during this Elective, which involved a Patient with Dementia wanting to go Home to see her Children and Pet Dog, trying to escape and screaming and being violent when being restrained by Nurses as she was attempting to abscond in her Walking Frame. When Security came, she stopped resisting and started crying. I felt so sorry for her, that she was so frail with reduced Mental Faculties. She had Children to look forward to upon going Home, but I wonder what about those that are Single like me? What will happen to me if I (Goodness Forbid) get some form of Dementia in the future? How would I cope and what resources will be available by then? The Resident actually walked up to her and acted Calm, wanting to ask her what her concerns were and trying to reassure her that her Children and Pet Dog were fine, and that it was important for her to rest and comply with Treatment to facilitate Recovery in Order to be discharged. I was really impressed by this Resident’s Actions in light of this Commotion as it helped calm her down, so she didn’t need to take so much sedating Medication.

 With regards to the Patient Case Mix, it was quite impressive. Although there were a lot of Bread-and-Butter Issues like Diabetes, Pneumonia and Fractures, I also saw quite a few Rare Conditions like POEM Syndrome and Multiple Myeloma. The Neurogeriatrics Ward was a good Area to practice Neurological Exams to help isolate the different Brain Areas affected by Strokes, which was also tragic in my Mind coz I saw several Dysphasic and Dysarthric Patients again.

MMSEs (Mini-Mental State Exam, a screen for Cognitive Impairment) was the most common Assessment I did on the Geriatric Patients. I was similarly impressed by the Variety of Responses and Scores. Although on the Surface there was a fixed List of Questions and Tasks to attend to, there was actually more Flexibility required than I thought, when phrasing the Questions and providing Accommodations without overtly distorting the Assessment Process. Hence the preconceived Monotony was non-existent.

For Patients who were visually impaired, I had to write “CLOSE YOUR EYES” really big on a Sheet of Paper. A Patient with severe Hearing Impairment required me to speak VERY loudly and slowly into her Ears for a few of the Memory Tasks (which weren’t allowed to be written). I came up with the Strategy that if she couldn’t hear what I was saying, she could squeeze my Hand in which she did. She was really happy that she could understand what I was saying and my Efforts to Accommodate her, because a lot of Nursing and Medical Staff in the past thought she was Demented or Delirious (!!!) when in Fact she just couldn’t hear what they were saying, and thus comprehend their Requests. She said that I helped her “Interact with Young People, and feel part of the Community”. It felt really good that I was able to correct a common Misconception about her, so she’d be less likely to be treated along the wrong “Medical Route”, especially for misdiagnosed Delirium.

I felt like crying when I did an MMSE on a Dysphasic Patient who had a lot of difficulty answering my Questions in the MMSE, like he was being locked from expressing himself.  I felt really guilty for doing the Assessment on him, like I was forcing him to be reminded of his Inadequacies, although from an objective Point of View, I shouldn’t feel guilty at all, as everybody needs to be assessed at some Point so they can have a Management Plan more specific to their Circumstances.

On the other hand, there was a Female Patient who recently had a Stroke and was Dysphasic, but was very Cooperative and “level-headed” when trying to do the MMSE, which somewhat inspired me, that she was willing to try things out even if she had a recent physical Insult, and may not have been good at it.

Geriatrics (Part 1/3, RETROSPECTIVE POST)

I did my 8 Weeks’ Geriatrics Elective in the massive 11 Weeks’ Break between Semesters 11 and 12. Interestingly, the Senior Geriatrician who approved my Elective WAS 1 of the 2 Examiners in my Long Case Exam (!!!), but he actually delegated my Supervision to another Geriatrician, so I didn’t see him much apart from the weekly Radiology Meetings. The Elective was held at the Geriatrics Department away from the main Hospital Campus, and although I was given Opportunities to follow the Geriatricians onto the (Main) General Medicine Wards to see Referrals, I didn’t pursue that coz I felt I was much more attracted to staying at the Former Location. Likewise, there were Opportunities to attend Outpatient Clinics for “Memory”, “Falls”, “Incontinence” and “Wounds”, but I only attended a few Sessions of each before getting drawn away to the “Main Stage”.

Geriatrics Outpatient Clinics were well Organized. Incontinence Clinic was probably the least interesting to me coz the Majority were Female Patients (despite the fact that Men can have enlarged Prostates --> Overflow Incontinence) and they had Stress or Urge Incontinence. I was able to witness and take a few Histories, but wasn’t allowed to examine their Pelvic Region or operate the Machine which detected their PVR (Post-Void Residual, ie urine remaining in Bladder after Urination), so I felt rather left out of the Diagnostics Process.

Falls Clinic was very good coz I got to see how the Geriatrician use a systematic Approach to exclude numerous causes of Falls (Medical and Environmental Causes), along with observing how he did Physical Exams, not just Upper and Lower Limb, but also Falls-Specific ones such as “Timed Up-And-Go”, ie more Action and engaging.

Wounds Clinic was fascinating visually, plus the Fact that there was a Multidisciplinary Team working at the time (Doctors, Nurses, Podiatrists, Pharmacists), it felt like a “Medical Party” : P . There was a very passionate Wounds Specialist whom I initially thought was a Dermatologist (Skin Doctor), but was actually a Pharmacist. He made the Effort to explain the Pathophysiology of Venous and Arterial Ulcers, what he was doing in each Step with his Creams / Ointments / Special Bandages and how it would help the Skin, whilst I furiously wrote Notes. I walked into another Room and was awed by the Podiatrist as he skillfully shaved off Slivers of dead Skin from Diabetic Patients’ Calluses on their Foot. I think he might’ve thought I was overly eager coz I was peeping close to observe the Slivers curl off. That Podiatrist could perhaps be a Sculptor as an alternative Career : ) . Whilst the Callus was being shaved, I was also took a partial Medical History of the Patient. It was disturbing yet intriguing how some of the massive Venous Ulcers were slow to heal in the Elderly Patients. The Venous Ulcers were typically superficial up to ~10 cm in Diameter, but all that “Raw” red, shiny dermis looked REEEEAAALLLLY PAINFUL even though our Textbook said it’s not supposed to hurt much. I was shocked at the Fragility of their Skin, when I saw a Nurse accidentally tore a bit of the Patient’s skin with a Scissor while cutting the Wound Bandages, so delicate like Tissue Paper. Whilst the Patients were being treated, I was able to take casual Medical Histories from them, focusing on Risk Factors for Ulcers and Falls (which lead to Skin tearing off). The Visual Details and the Patients’ Information was very stimulating.

In the Memory Clinic, I played a more passive role in observing the Geriatricians do Memory and Cognitive Assessments, although I was amused by the Variety of responses given. I “LOL’ed” in my Mind when an elderly male Patient was asked to point at the Picture that was Nautical, and responded “Hmmm this is difficult. I can see the Boat over here, but a Crocodile is technically Nautical as well…”. There was 1 male Patient aged ~70, who I suspect is an undiagnosed Aspie who has an ASD Daughter, presenting for his Radiology Results, that most likely ruled out Neurodegeneration. I was curious to see if he exhibited signs of Dementia, but the Geriatrician said that Clinically and Radiology-wise he looked fine, although there were concerns by his (NT) Wife that he has some sort of Cognitive Impairment due to his supposedly poor Relationship / Interpersonal skills during their entire Marriage. He had that round Macrocephalic (large head) Appearance and Flat Affect common in Aspies, and the same Special Interest his whole Life. I felt like bursting out and saying that he may have AS, but knew that it was technically unprofessional to do so, so left him alone. I know it was just 1 person, but it was a relief to know that he wasn’t diagnosed with Parkinson’s Disease or Fronto-Temporal Lobe Dementia (yet?) because my personal research suggests that ASD / ADHD people are apparently at higher risk of these 2 Dementias, very sadly : ( It was also very emotional when the Geriatrician had to inform another Patient their Diagnosis of Alzheimer’s Disease, its Implications and Initial Management. She tried to put a lighter spin on the Diagnosis, in that he just had to do Things differently, like using Public Transport instead of Driving, but his Family Members were shedding Tears and hugging him, likely knowing that these were Attempts to Soft-Pedal his Diagnosis, which is typically terminal within ~7 years IIRC…

Psychiatry (RETROSPECTIVE POST)

Psych (6 Weeks)

Our Psychiatry Rotation was done at the APU (Acute Psych Unit), which was in a separate building from the main Hospital. However our first Week included Lectures at another Hospital from an eminent Psychiatric Consultant. We also got to hear a Speech from a Schizophrenia Advocate about his Experiences with Schizophrenia and the Healthcare System which was a bit touching. I was internally amused that he also had Flat Affect, and I was able to detect the Parallel about how his Condition came to control his Life, and his ways to cope with it. Like ASD, Schizophrenia also comes as a Spectrum, although it’s typically much later onset, however at least they (along with ADHD) have the Convenience of official Medications to control any acute Symptoms. Even with Asperger Syndrome, you don’t stop thinking about it every day. You don’t want to define yourself by your Condition, but it affects the way you process Information and analyze Things that frequently you feel like an Alien or an Amateur Anthropologist on a foreign Planet.

I wonder if De-Institutionalization is the best thing for certain Psych Patients. Understandably there were significant Abuses in the massive Psychiatric Institutions in the past, which I think was also secondary to the Paternalistic Culture of Medicine, however I do see some Merit in that System. Currently, there apparently isn’t enough Funding to get all of the De-Institutionalized Psych Patients to adequately integrate into the Community, which to some Degree poses more harm to both the Patients and possibly the Public.

On a note, the recent and tragic Stabbing of Dr. Michael Wong (Neurosurgeon) at Western Hospital in Melbourne, by a Patient who was supposedly Psychotic and was a poor English-Speaker seemingly demonstrate Gaps in the Welfare of such Patients, who really should’ve been stabilized prior to being released.

Psychiatry was considered a “scary” Rotation by a lot of the Students, so very few from my knowledge went to the APU to clerk Patients, with the exception of supervised Clerking in Tutes by the Psych Registrars. I was warned that a lot of the Psych Patients in the APU were potentially aggressive or manipulative due to comorbid Personality Disorders (predominantly Cluster B), so I had to wear a Security Alarm when speaking to them. I ended up going through a lot of Patient Files to read their Medical Histories and learn how their Psychiatric Conditions have evolved, and how it was managed. I must say I found this very engaging, almost like reading an exciting Novel or Biography.

I did manage to speak to 2 Patients - a Woman with Bipolar Disorder and an Aspie Guy who was around my Age. 

I’m not allowed to disclose the presenting History due to Confidentiality Issues, but it was so fascinating / surreal to see a person display the Textbook Symptoms of a Medical Condition, especially a Psychiatric one. The Woman was still in a Hypomanic Phase, and looked elated and chatty. She stated that she hasn’t had much Sleep or Food to eat (due to low Appetite) recently, and told me a lot about her Personal Life, which whilst I didn’t mind at all due to the Open-ness, was apparently inappropriate to NTs as it was being “Overfamiliar”. She spoke rapidly but I was still able to follow her Train of Thoughts. In some ways it was actually easier for us to engage in Conversation as there were lots of different Topics to talk about. My perception was that it was easy to develop Rapport with her, to the Point where I actually gave her a small Present for her Birthday during her Admission. In Retrospect, I realized this was “Unprofessional” and was told by my Psychiatrist that such behaviour could distort the Professional Relationship, particularly as people in Hypomanic or Manic Phase are vulnerable to being exploited, plus the fact that she was only being “Overfriendly” coz she hasn’t been adequately medicated yet, and that the “Stabilized” her would have a higher Guard on par with most NTs. 

The Woman was fearful of the Aspie Guy coz he was being very noisy, which I presume was making sounds as a Stimming Activity. I found this amusing and sad as Aspies are usually quite “Soft” and “Innocent” if unprovoked (into Meltdowns) and would make very weak Enemies due to their intuitively reduced Theory of Mind and likely Executive Dysfunction to execute any malicious Plans whilst getting away with it very difficult if not impossible. I suppose she doesn’t know about his Diagnosis, and I wasn’t sure if I was allowed to tell her due to breaking Confidentiality, but I told her that he’s also experiencing Discomfort of another sort.

The Aspie Guy was actually a lot harder for me to talk to, which surprised me. I told him that I read his Personal History and was trying to explain that he’s not Alone, and that I have similar Symptoms and Experiences to him but have various Coping Mechanisms, and would be happy to teach him what I knew, but he seemed to be in Denial about his Diagnosis, sadly. It was actually quite frustrating for me at the time trying to reason with him coz I felt like I was looking into a Mirror of myself when I’m extremely grumpy, although I suppose in super-Meltdown mode as a Child, I couldn’t be reasoned with either.

I felt that I let him down coz as an Aspie, I was supposed to be empathetic towards his Experiences, and that I didn’t do “well” enough, in contrast to the Woman with Bipolar Disorder. In Retrospect however, I think he had overlapping Issues of Sleep Deprivation and Agitation over being in a new Environment filled with “Strangers” (other Psych Patients) that wouldn’t be conducive to Mental and Physical Rest. Certainly from my Sleep Problems in the past, I’ve done things that I never would’ve done if I was well-rested, plus I had impaired Cognition. I briefly discussed his Case with his Case Worker who actually agreed that the APU was NOT the appropriate Place for him to be managed, but there was a HUGE shortage of appropriate Facilities for ASD Adults in Strife to be referred to, which is why he was here for now. I hope his situation has improved by now...

It made me wonder how much I could decompensate in the future to the Point of needing a Psychiatric Admission myself... : S