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".

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

Week 5 (29/9/14 – 3/10/14)

“ANITA” (Not Pregnant and Intellectual Disability)

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

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

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

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

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

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

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

Better luck next time...

Semester 12 - General Practice (RETROSPECTIVE POST)

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

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

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

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

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

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

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

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

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

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

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

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

Semester 12 - Surgery (RETROSPECTIVE POST)

My Surgery Rotation was done at another Hospital. I had the privilege of shadowing a senior General Surgeon, and was allowed to scrub into a few of his Surgeries.

On the Surgical Wards, the majority of patients on the Unit I was attached to, were admitted for Cholecystectomies (Gallbladder Removal), Thyroidectomies (Thyroid Removal), Hernia Repairs, Skin Cancer Excisions and Mastectomies. I didn’t get to do many Venepunctures, as the Pathology Nurse was strictly supposed to do the morning Orders. I also didn’t like how Butterfly Needles for taking blood (easier to maneuver IMHO) were scarce, with only Straight Needles being available. I really liked the Ward Rounds coz they felt very quick. As Inpatient Stay was much shorter than Medical, the Patient Histories were very abbreviated, as was the History and Physical Exam. It all seemed more succinct. The Intern and Registrar got into the Rhythm of asking about Abdo Pain, Flatus, Bowel Movements, inspecting the Sutures, and palpating the surgically operated area (typically Abdomen). Ward Rounds probably took about half the time for the same number of Patients in Med.

Scrubbing into Theatre was exciting. Perhaps it was coz I’ve never scrubbed in before (apart from 2 Operations in O&G, of which I didn’t really assist). For some reason, the senior Surgeon performed a lot of Mastectomies and Skin Cancer Excisions but no Thyroidectomies (I had to shadow another Surgeon to observe that). In the Mastectomies, I initially assisted by massaging the (unconscious) Patients’ breasts in a circular Manner to help distribute the injected Radioactive Dye (which eventually gets concentrated in lymph nodes, making it easier to identify for Biopsy), which was a surprisingly enjoyable experience. The Surgeon also suggested I palpate the Breast Cancer, which I felt to be lumpier than the regular Breast Tissue. In the actual Operation, I later got to hold the Retractors which lifted the Skin Flaps so the underlying Tissue could be excised off. The Surgeon used this Tool which created small Electrical Sparks when a Button was pushed, which burned off whatever it got into Contact with. I felt REALLY awkward when I actually enjoyed the smell of burnt Human Tissue, reminiscent of a smoky BBQ. I also had the opportunity to use this Tool, in which I zapped his Forceps that were in direct Contact with the Tissue. Thankfully both of us were wearing sterile Gloves so we didn’t get electrocuted. It was actually an enjoyable process coz every time I zapped it, the affected Tissue would fizzle and turn black. I was internally very pleased to eventually see that mass of fatty Breast Tissue get excised and “released”, revealing the Pectoral Muscles underneath.

I experienced a similar Pleasure watching the Left Thyroid get “released”, but due to my lack of any Involvement, found the Surgery more tedious to observe. I found that I had difficulty standing in one Spot for long periods of time, and was impatiently alternating between left and right of the Operating Table every 15 - 20 Minutes. I’m not sure if the other Surgeon got annoyed by that Frequency, but perhaps they tolerated it coz I wanted to change Positions to alter my View. It took about 3 Hours for the Left Thyroid to be carefully excised, revealing a large red fleshy Gland. We were allowed to Palpate it, and my, it felt warm and fleshy, but nearly the same Texture than the Placenta. It fit into my Palms, I could squeeze it like a Stress Ball!

Ironically (or not Ironically), my most stressful bits in this Rotation was the Mini-CEX. We had to pass 2 Mini-CEX’es for each of the Semester 12 Rotations. Though granted we were with a seemingly lenient Surgeon, I still felt Pressure to perform at an appropriate Level. My first Mini-CEX involved performing an Abdo Exam on a Patient and describing the Findings, in which I did so-so. The second Mini-CEX was taking a History from a Patient, followed by presenting the Information with a basic Management Plan. The second Mini-CEX felt very much like an OSCE, but in full View of my Classmates. I recall being very Algorithmic / “Robotic” when taking the History, but fortunately the Patient didn’t find it weird or offensive, and answered all my Questions. Our Conversation felt very much like a Table-Tennis Session, with responses rapidly bouncing between us. I was so mentally exhausted when the 10 Minutes was up, but the Patient and her Partner were very impressed by my History Taking. When articulating the Management Plan, I talked a lot slower coz I haven’t adequately prepared this before (verbally) + I was exhausted, but the Surgeon didn’t seem fazed. Thankfully I passed this.

I wonder that if I get drained just from just 10 Minutes of Clerking, how will I cope with Internship? Perhaps it was the Context in which I was being observed by multiple People which added to my Nervousness. It’ll probably become easier with more Experience. I realized a few more of my Weaknesses, which was in explaining Procedures and some Medical Concepts. I’ll have to work on this, or at least memorize the Explanations that are comprehensible to Laymen. The Surgeon also said that it also helps to draw Diagrams (particularly Anatomical) to aid Patient Comprehension and to get them engaged, so I’ll look into that too.

I think Surgery (along with O&G) is one of those Specialties that most People love or hate, particularly due to the long Hours. I conceptually love the Notion of Surgery, in that you’re making a Physical Difference from the Operations (removing or repairing something), which appealed to my Concrete / Black & White - Thinking Traits. However I just didn’t think I’d have the Patience to deal with the Duration of each Operation. Too much Standing, and whilst I have a strong Eye for Detail, I didn’t think the latter (along with the shorter Ward Rounds) was enough to tolerate the Former. 3 Hours just to remove the Left Thyroid. If I waited to observe the Right Thyroid being excised too, that’d be another 3 Hours in which case I’ll miss Dinner!!!

In the Past, I was even more Black & White, in that whilst I intellectually knew that an Operation wasn’t an instant Process like “Order Thyroidectomy --> BOOM --> Voila it’s gone!”, I academically treated it as such, and was unable to adequately appreciate how Rigorous and Time-Consuming Surgery was until this Rotation. I suppose if you’re the Surgeon, and if you’re very engaged and interested in the Surgery, the time may “Fly by” or be more tolerable. I can see how Surgery would appeal to a Person with Concrete Thinking, and anecdotally a lot of Surgeons in the Past (particularly Neurosurgeons) had Aspie Traits. I respect the Surgeons’ Efforts to work in this Specialty, but for me, no thanks. I want to have a Life outside Medicine. Somebody else can pursue Surgery instead, and good on them for their Ambitions. Besides, I’m currently more interested in the Diagnostics Process of Medicine of which Pathology (and perhaps even GP) is more encompassing of that.

Geriatrics (Part 2/3, RETROSPECTIVE POST)

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

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

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

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

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

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

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

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

Psychiatry (RETROSPECTIVE POST)

Psych (6 Weeks)

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

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

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

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

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

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

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

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

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

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