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?!).

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

“ENRICO” (?CANCER METASTASES)

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

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

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

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

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

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

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

OHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Week 4 (22/9/14 – 26/9/14)

DR DAN'S 70TH BIRTHDAY

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

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

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

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

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

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

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

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

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

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

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

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

 

That was it, no more, no less.

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

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

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

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

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

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

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

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

 

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

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

BUYING CHICKEN

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

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

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

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

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

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

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

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

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

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

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

East Timorese Patients (Observations so far)

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

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

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

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

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

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

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

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

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