Thoughts from John Elder Robison's "Switched On" Book re: his rTMS (repetitive Transcranial Magnetic Stimulation) Experiences

John Elder Robison (prominent adult ASD Advocate) wrote a Book earlier this Year called "Switched On" (www.amazon.com/Switched-Memoir-Change-Emotional-Awakening/dp/0812996895) regarding his Experiences from the rTMS Trials @ the Beth Israel Deaconess Medical Centre (Boston, Massachusetts) in 2008.

I was very privileged to take Part in the initial ASD rTMS Trial @ Monash Alfred Psychiatry Research Centre (MAPRC) in November 2010, and was therefore very interested to read a more detailed Account from John.

My old Blog Posts about my rTMS Experiences are below:
http://aamsio.blogspot.com.au/2011/07/my-experience-from-repetitive.html
http://aamsio.blogspot.com.au/2011/07/my-experience-from-repetitive_30.html

Recent ABC Coverage on rTMS:
http://www.abc.net.au/radionational/programs/lifematters/john-elder-robison:-switched-on/7322548
www.abc.net.au/radionational/programs/lifematters/transcranial-magnetic-stimulation-explained/7330468

I'm very grateful that Dr. Peter Enticott (of MAPRC) notified me about the Book, and I emailed him my initial Thoughts after reading John's Book, as attached below in raw un-edited (and "binge-typed") Form. I'm sure there are some other Thoughts / Opinions missing, but I might add them on into a future Blog Entry after reading it for the second Time during Annual Leave later on.
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I ordered a Copy of "Switched On" and read it about a Month ago, and very glad I read it. but didn't have Time to reply. I'll send you another Email after reading it the second Time during my Annual Leave later on, if there's Points that I forgot to include below.

I found it very painful (emotionally) to read @ Times, coz some of it reminisced with my Sentiments and Experiences.

I think his Account of his TMS Experiences were very well-written, and will provide much Discussion re: future Treatments for ASD Adults.

I feel like John Elder Robison gained a Lot more distinct Changes following the TMS, and he was able to present the Advantages and Disadvantages of becoming more emotionally labile and intuitive to other People's Feelings. It's like a Blindfold was temporarily removed from him, but since the Release, he won't be able to forget it. His Awareness has increased and provided more Stress, but also more Opportunities/Options to respond in Order to achieve a Resolution.
- I briefly felt very embarrassed when I read about his previous "social Faux Pas" coz I have done plenty prior to becoming more Aware post-Diagnosis.

And I could understand his Thoughts where he flips between seeing his AS as a Gift or a Curse. I did find it upsetting/painful when @ some Point he saw himself as "defective", probably coz it's Something I think about on a daily Basis @ Work. I feel like I have to use my Strengths (eg Attention to Detail and Hyperfocus) to (over)-compensate for my other Deficits in clinical Medicine. It's worked so far, but @ great mental Expense, which is why I'm trying to get into the Pathology Training Program ASAP (with minimal Patient Contact etc).

I can relate to John's "Release" by being able to tolerate Eye Contact after TMS, coz it always felt uncomfortable prior. So now, I know what it's like to look @ People in the Eye without flinching, and this has improved my "Ability" to "appropriately" communicate with Patients, other Hospital Staff, and People outside of Work.

The other Things that John Discusses re: understanding People's Feelings and reading facial Expressions is Something that I learnt manually from rote-Memorization and Experiences. I still have flat Affect most of the Time (not depressed), and I only naturally change facial Expression when I'm euphoric / very upset / very angry.

I think what makes Part of it painful is how both me and him are in the Minority of ASD Adults who have been privileged to receive some Form of Assistance / "Treatment", and even afterwards we are still having to work hard to maintain our Livelihoods coz we're in the statistical Minority, and Adult Society is currently unlikely to provide much Accommodations. There's so many other ASD Adults (diagnosed and undiagnosed) who are struggling with Employment / Bullying etc.

Another Thing which I found painful was as John Recounts his Experiences, I also looked back and saw how many wasted Opportunities I had, and all the Mistakes I made pre-Diagnosis. But Past is Past, you can only learn from those Experiences and move forward.

I still make Mistakes post-Diagnosis, but I'm very self-critical, and I think it contributes to my low self-Esteem post-Diagnosis, coz I know how vulnerable I am, and how Others (in and outside Medicine) could easily exploit me if they knew my Weaknesses. I don't feel Shame coz this was how I was born, and sometimes I wonder whether Life is worth Living, but I look @ how many Hurdles I've jumped over so far, and even if I "fall down" later on, I can still act as a Source of Inspiration for some ASD People.

A Point of Interest would be whether John's Experiences will influence the Direction that ASD Research takes as he is on the Autism Speaks Panel, eg towards Something more socially-oriented, rather than Something to improve short-Term / Working Memory or Verbal Fluency etc. Certainly the frontal Lobes are implicated in ASD / ADHD, so these Functions are inter-related, but I feel there's a Risk of Bias.

I think for John, his TMS Experience seems so intense, like "getting thrown into the deep End of the Pool", mystical and profound, almost psychadelic, but it came @ the Expense of making his "Ego" more prominent. Not in the "arrogant" Sense, but the improved Awareness of himself and other People seemed very difficult to take in @ the Time, but he was able to cope eventually.
- A Bit like how in the Bible, Adam and Eve ate the "Fruit of Knowledge" and suddenly realized they were naked.

- Once you see it, you can't "un-see" it.

Whereas for me, I was like "dipping my Feet into the Wading Pool". Concretely / Directly, I only benefited from improved Eye Contact, but it served as a Catalyst for understanding other Neurotypicals in general coz I can spend more Time looking @ their facial Expressions, processing their Speech and direct / implied Meanings, and less Time thinking about how I'm uncomfortable with their Eye Contact. I'm still very flat and "Swiss" although there have been Occasions where I'm close to breaking down emotionally.

I also resonate with John about the constant Anxiety about whether TMS or becoming more "socially aware" will impair one our special Interests and ASD-related Strengths.

For me, even after reading his Book, I wonder if the Reason why I have my Ambitions, Strengths and Special Interests (Mahjong, Accordion) is coz of my Deficits. For me, interacting with NTs in general costs more than it benefits, and while there are general Rules of Behaviour, there's still significant Heterogeneity. Whereas with a Board Game or learning a musical Instrument, the Rules are much stricter and clear-cut, and the Gains are easier achieve and therefore more rapidly gratifying.

- Temple Grandin's Comment @ the Back of the Book totally hit how I felt:

"Switched On is a mind-blowing book that will force you to ask deep questions about what is important in life. Would normalizing the brains of those who think differently reduce their motivation for great achievement?"

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In short, I've enjoyed reading John's TMS Account (as demonstrated by finishing the Book within 2 Days) to see how his Experiences and Opinions were similar / different to mine.

I think TMS has much Potential to help ASD Adults / Children, but it must be done in a Way to avoid totally converting them to NTs (not that it's possible with the current Technology anyway), and hopefully there'll be a Way to help preserve their Strengths whilst reducing their Weaknesses. I don't think it's a Zero-Sum Issue, but unfortunately I suspect this won't be 100% possible.

I think for ASD People, the possible Goals of TMS are very variable depending on Level of Function.

I do think that for non-verbal ASD Children / Adults, the core Goal of TMS should be to facilitate Speech Development coz that's crucial for independent Living, regardless of whether you have Friends or not.

Also, what I think can be done now is to help educate ASD Adults on how to "respond appropriately" if they happen to recognize a facial Expression or Feeling in another Person. So that Way, an ASD Adult who becomes more self-aware of others (via TMS or gradual Knowledge Acquisition) can feel less anxious / awkward about how to react, and just say what "needs to be said".

Passed Internship

I passed Internship!!!!!!!!!!

I can't believe the Year has gone by so quickly. There have been LOTS of Ups and Downs physically and mentally, I feel like I just finished a long Roller-Coaster Ride.

It was almost exactly 1 Year ago, in which I was having Internship Orientation, and completely panicking over what my first Day of my very first "proper full-Time Job" would be like.

I'm so happy that I've completed this Hurdle, but am so exhausted. It didn't help that I spent the past 2 Days packing up my Luggage, driving back to Melbourne, and then unpacking my Stuff again.

I feel I'm having a Comedown from all the Busy-ness on the Ward, yet from speaking to Others I apparently had it very "soft", given that I did most of my Rotations at a rather small rural Hospital with fewer Patients.

I got my new Badge which has the same Photo but now says "Hospital Medical Officer" instead of "Intern". To be honest, whilst I passed Internship, I think I'll still feel like an Intern for quite some Time. I'll have to force myself to not refer to myself as an "Intern" on the Phone. I met a few of the new Interns at the Valedictory Dinner, and they'll also have a steep learning Curve as they learn to navigate the Wards. I can totally empathize with any Anxieties they have.

I'm so grateful for all the Support and Supervision that I've received from various inspirational Drs, in Addition to the overall positive Camaraderie from other Interns that I've met so far. So many People have helped me throughout the Year (including my Family), I just can't thank or repay everyone enough, and I don't think I could've made it without them. There'll be many People that I miss.

I dunno if it's a Fluke that I passed Internship, but I do know that the HMO-2 Year will likely be a Lot more challenging, given that the first 2 (of my 4) Rotations will have no Intern or Registrar, ie it'll just be me and the Consultant. So I'll have to figure out Ways to be more efficient without compromising Patient Care, or my own Physical & Mental State. I normally like to be very thorough in Documentation (especially Discharge Summaries) but it's relatively Time-consuming, so will have to learn to be comfortable including less Details. I might be in for a rude Shock...

I don't think Clinical Medicine is for me in the long-Term, as I predict I'll utterly burnout (unless I happen to work Part-Time or Locum casually). However, I've learned so much by communicating and working with other Staff and Patients, that these Things have assisted me with understanding other People (especially NTs) better as an Aspie / ADHD-er. And I can translate these Skills to Pathology (providing I manage to break into the Training Program) or even non-Medical Stuff (if for whatever Reason I end up quitting Medicine entirely).

Additionally I'm so glad I took a Gap Year to start learning the Accordion (amongst several other Things). It has provided me much positive Distraction / Relief after Work when I get tired from talking to People. And even if I procrastinate from playing the Accordion for Days, the Music is so refreshing once I get back into it. I dunno how the Hell I went through Med School without an Accordion???!!! Oh well, better late than never...

I've also had a net Weight Loss of 2 kg during Internship, bringing me down to 58kg, which is a bit scary considering I already dropped from 66 to 60kg during my East Timor Medical Elective in my Gap Year.

It's now Annual Leave Time for 3 Weeks, and then I'm back to Work again!

"Fingers crossed" that I'll go back to Work refreshed and a bit heavier...

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...

Starting Internship Tomorrow

My time is up, and I'm back in Australia.

Oh how my Gap Year went by so quickly. I'm so happy and grateful for the experiences that I've gained (medical and non-medical) during this period, even though I haven't documented it fully on this blog. I need to finish off the remaining East Timor Medical Elective entries when I have spare time.

Medicine in Australia is excellent for a first career, and I'm not ashamed to be a doctor anymore. At the end of the day it's just a job, and whilst the Medical Profession continues to be devalued/degraded by the powers that be, I still have many skills and experiences to gain from working as a doctor for a few years, before potentially moving on to whatever I find more intellectually stimulating and/or higher paying. For now, Medicine is my back-up job. I will try to cherish any positive moments that occur with my "heart".

I've finished the internship orientation, but tomorrow will be my 1st day of work.

Here's to hoping things will go well, I have to bite the bullet and start full-time work for real. Need to take things one day at a time and learn things by osmosis.

Fingers crossed...

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?!).