Friday, December 15, 2017

Books for Xmas?


Design & Text ©Bee Zhang 2011            Photos ©Am Ang Zhang 2011

Inspired by our 2-yr old grandson's enthusiasm about aquatic creatures after a recent visit to the aquarium, we have just published a unique children's photo book called "Looking for Sting Ray", which has 20 beautiful 9x7 in. full bleed photos of: corals, turtles, anhinga, blue tang, file fish, butterfly fish, pompano, cleaner shrimp, pompano, barracuda, flounder, star fish, and sting ray. It is a cool introduction to nature for a pre-school kid and our grandson loves it! Guess who took all the photos? 



Design & Text ©Bee Zhang 2011                  Photos ©Am Ang Zhang 2011


Antelopes and Friends

Hardcover, 21 Pages 
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Antelopes and Friends


A coffee table quality photobook for a special child, introducing wild life in Africa. Photos of the animals (impala, nyala, kudu, wildebeest, warthog, gruffalo, zebra, rhinoceros, waterbuck, hippopotamus, giraffe, buffalo, elephant, saddlebilled stock) were taken by the author himself during safari trips in Africa.



Nature Posts:

Thursday, December 14, 2017

Christmas & Bach: Kandel & Dementia!


Christmas Anemone 

© Am Ang Zhang 2014 


As I listen to Bach's Christmas Oratorio I am reminded of the work of Kandel on memory. Why is it that listening to the same piece of music as rarely as once a year evoke such pleasing brain syntonic response.

There is now a fair bit of research on the use of music for dementia patients. This is encouraging. 

However, the work of Kandel showed that it would have been more beneficial if the memory of the music were imputed at an early age only for the brain to be stimulated at a much later age for maximum beneficial effect.

The Cockroach Catcher was very pleased to be at  La Traviata as it was one of those operas that you do know inside out. The scenes might be different but the music essentially stimulates the re-programming of Kandel's memory proteins. 

I am reminded of the grand father of one of my daughter's good friend who at the age of 102 was still playing Chopin Preludes a few days before he passed away. He had full command of his mental capacity until his death.

Could taking away much of classical music education have a devastating effect on the memory health of the nation as a whole? If so, should we not bring it back to give most of us a fighting chance?

Britain might then be able to supply the next generation of musicians as a result.


Think about it, SoS and Mr. Simon Stevens.

Eric Kandel, M.D.:
"We are what we are through what we have experienced and what we have remembered."          

In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel was giving his lecture. I was fortunate enough to be able to secure a seat.


"What learning does is to change the strength of the synaptic connections in the brain," Kandel explained, "and this has held true for every form of learning so far analyzed. So, what genetic and developmental processes do is specify the cells that connect to each other, but what they do not specify is the exact strength of those connections. Environmental contingencies, such as learning, play a significant part in the strength of those connections.""Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes."


In his book In Search Of Memory, he remembered his arrival in New York in 1939 after a year under the Nazi in Vienna:

“My grandfather and I liked each other a great deal, and he readily convinced me that he should tutor me in Hebrew during the summer of 1939 so that I might be eligible for a scholarship at the Yeshiva of Flatbush, an excellent Hebrew parochial school that offered both secular and religious studies at a very high level. With his tutelage I entered the Yeshiva in the fall of 1939. By the time I graduated in 1944 I spoke Hebrew almost as well as English, had read through the five books of Moses, the books of Kings, the Prophets and the Judges in Hebrew, and also learned a smattering of the Talmud.”

Eric Kandel/Amazon


“It gave me both pleasure and pride to learn later that Baruch S. Blumberg, who won the Nobel Prize in Physiology or Medicine in 1976, had also benefited from the extraordinary educational experience provided by the Yeshivah of Flatbush.”

In Hebrew and English!!! That did not seem to have done him and Blumberg much harm. Right now some governments seem hell bent in doing away with rote learning and that includes some medical schools.


Vienna was, as recently as 1939, the year he and his family fled the city for the United States, the most important cultural center in the German-speaking world. "The city's great tradition of scholarship provided a foundation for experiments in literature, science, music, architecture, philosophy and art, experiments from which many modern ideas were derived," he writes. "Vienna's culture was one of extraordinary power, and it had been created and nourished in good part by Jews." The Nazis drove out those Jews they did not murder, and with their departure a city of verve and excitement — a city of intense intellectualism and the acme of cultural attainment — became a prosaic place.

If there is another book that does a better job of demonstrating how biological research is done, or of telling the story of a brilliant scientist's career, I don't know it. Nor do I know one that better conveys the unique excitement that drives the success of research and permeates the thinking of its most able practitioners, or that gives a better descriptive narrative of the historical evolution of our understanding of mind. True, in places the detail is so minute and technical that certain parts of it will prove to be nearly inscrutable to any but the most diligent reader, or to those with a background in molecular science. But it hardly makes a difference if some passages are judiciously skimmed. Like the good teacher he no doubt is, Kandel has sprinkled his more abstruse sections with an occasional summary sentence that clarifies entire previous pages. His is an important and marvelous book. Sigmund Freud and the illustrious cavalcade of pioneering neuroscientists, psychologists and philosophers who have contributed so much to our understanding of the human mind during the past century would look with pleasure on it.
La Traviata

Apparently the prima, the week before (I attended the second performance, on December 16th), was thrown into disarray when tenor Stephen Costello cancelled just an hour before the performance. There were no problems with Mr Decker’s tricky staging or ensembles on the 16th. Musically and dramatically well-prepared, soloists, chorus and orchestra were on top form. Marina Rebeka, whose only previous Met performances were as an unimpressive Donna Anna in Michael Grandage’s tedious Don Giovanni four years ago, was a superb Violetta.

Attractive, comfortable on stage (and standing on the minimalist furniture), and with a shining soprano, she negotiated the coloratura difficulties of the first act with ease, even touching on an interpolated high E flat at the close of “Sempre libera”. She has several degrees of pianissimo as well; the spun lines of “Dite alle giovane” and “Addio del passato” were lovely and touching. She uses no chest voice at all and it was occasionally missed late in the opera, but the voice opens up to a grand size when needed, and she did well with “Amami, Alfredo” and her death scene. She should be a valuable asset to New York’s opera lovers.





Other Opera Posts:

NHS: Learning From Boris


The Cockroach Catcher: NHS Reform: Choice?

The Cockroach Catcher: Empress' New Clothes





Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
                                                                                                                  The Way We Were                        

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Wednesday, December 13, 2017

NHS: The Last Cook.



It has been a few years since The Cockroach Catcher retired and in that time, the landscape of Child & Adolescent Psychiatry has changed. Can CAMHS survive the storm like the pelican?


Without much public notice, much of this sub-specialty has shifted into private hands. Just around half the last time I looked. Now there is talk of looking at CAMHS with the offer of money! Wow! Or was the outcome going to be: lets sell the profitable parts of CAMHS such as Anorexia Nervosa and leave the rest! i think I know what it would be. Just look at Dermatology!!!

And it may indeed be true that more money is pumped into CAMHS as outsourcing ignore one big factor: privateers are there to make money and NHS cannot get out of the contracts and ended up paying more. Look at outsourcing social services.

Dermatology shows how NHS being decimated

By Dr David Eedy, President of the British Association of Dermatologists - 15th December 2014 11:24 am
The news that a third of NHS contracts in England have been awarded to private sector providers since the service was reorganised in 2013 is a fact that dermatologists and their patients are all too aware of.
In fact, some estimates put the figure at 70% of NHS contracts going to private providers in just the first year.
Dermatology is a prime example of how government meddling is decimating the NHS, despite the fact that each year, 54%of the population is affected by skin disease, and 23 to 33%of the population at any one time has a skin disease that would benefit from medical care.

I have personally dealt with "gaming" by private insurers. Now, it looks like the gaming is over as the payer is the NHS. You only need to look at the papers to realise that Anorexia Nervosa in particular is a growth industry. They are difficult to treat, recovery is not guaranteed and when the payer is the NHS: WOW!

 As the sun sets on our beloved NHS:
                                                           ©Am Ang Zhang 2012

Perhaps it is not that well known that the dismantling of our beloved NHS started long before the present government and the future does not bode well for those of us that likes to keep NHS in the public domain.

Child Psychiatric in-patient units across the country were closed some time after many adult hospitals were closed or down-sized.

To me, the government is too concern with short term results that they impose various changes across the board in Health Care & Education without regard to the long term consequences or costs.

After all, I have made good use of in-patient facilities to un-diagnose ADHD and that would in turn save children from unnecessary medication and the country from unjustified benefit claims.

Such units were also great training grounds for the future generation of psychiatrists and nurses. Instead, most rely on chemicals to deal with a range of childhood psychological problems.

Indeed it was a sad day when the unit closed.

From The Cockroach Catcher:

Chapter 48        The Last Cook



O
ne of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.
         I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K. and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.
         The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes.  Instead a cook was employed to cater for the needs of the children and nursing staff.  We doctors were not supposed to eat there. But we did.  Mainly for lunch.
         If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
         All very homely.
         I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.
         You never know as people do not really research these things.
        
         ……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.
         She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note.  You never know.
        
        
         Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.

         Sheena was petite, worn and a chain smoker.
         But she had two lovely looking girls.
         We knew from the start there were handling issues and most likely diet ones too.
         One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.  
         It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on.  Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.
         Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.
         With a simple routine the girls were clean in no time.   At least during the week as they all went home week-ends, when the unit was closed.
         We were at a loss as to what was going on.
         The girls would get worse over the week-end and soil. This went on for quite a while.
         Then one day the cook talked to me.
         “Sheena never stays Mondays,” she told me.
         I listened.
         “Have you noticed she is always in dark glasses on Mondays?”
         How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.
         Sheena was not a movie star.
         I arranged to see Sheena.
         She said, “You knew.”
         I nodded.


         “But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”
         I suggested that I should speak to him but she looked terrified.
         She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.
         She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in.  We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next?  Another violent man most likely.
         Was it such a cop-out on my part?
         Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far.  That was before Maria Colwell. 
         The unit had long since been closed.
         The last cook in the NHS retired .
The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Friday, December 8, 2017

Anorexia Nervosa: Let Her Die!



A reprint:



©Am Ang Zhang 2014

Can a patient be allowed to die? 
Can a seventeen year old patient be allowed to die?
Can a seventeen year old Anorexia Nervosa patient be allowed to die?

Are we not supposed to save lives?

Could doctors be held to ransom? By?

Here is a Play: Let Her Die!

The Players:

The parents:
Father used to run a business security agency specialising in industrial counter espionage. Or was it espionage? I cannot be sure.

Too often there is this bizarre desire by some parents to make sure that if they cannot do it, no one else should either. We need to recognise it early enough. We are doomed otherwise, and so is the patient.

The patient: Nicola
It was really quite painful to sit there and talk to someone who looked worse than the worst they showed from Auswitz. Why could Nicola not realise that if she wanted any man to like her she would need to look a lot better, which involved doubling her weight for starters.

The Doctors:
Dr Hillman:

This was a family given up even by Dr Hillman, my most fervent supporter of family therapy. Father used to run a business security agency specialising in industrial counter espionage. Or was it espionage? I cannot be sure.

The Consultant:
        I did not go round looking like a hippie or pretending that I liked the music the teenagers listened to. I told them to me it was trash. I did not pierce my ear or have a tattoo. I certainly did not wear trainers to work.
       
        In short, you do not have to gain respect by becoming like them or worse, by pretending that you are like them.

The Experts:
I spent one session with them and agreed with Dr Hillman. They were good. We looked like a bunch of amateurs dealing with professionals. None of the family therapy tricks work, Minuchin or Haley.
        Impenetrable!

The NHS Trust & GMC

To me, suspension on full pay is a risk every doctor takes nowadays, as the basis is no longer limited to bad practice. It is no longer a reflection on whether you are good or bad clinically. Many psychiatrists are no longer prepared to use techniques that might upset their patients or parents of their patients.

The Main Action:

A family meeting was called and it lasted only a few minutes.
          I was in top form.

          “Nicola has been eating but after two months has not put on any weight. I cannot see any reason for her to continue to stay here. She might as well do the eating at home. She can then sort out for herself why she is not gaining weight without the pressure from us.”
          I tried to put it in the calmest way possible.
          “You mean you will let her die?” Father sounded a bit annoyed.

        With that father got up and left the room without saying another word.

          “What do I do now? You have upset him!” said mother.
          Good, something got to him at last, but I did not say it.
         
Nicola gave a wry smile to me as if to say, “You found me out.”
          She turned to mum, “Let’s pack and leave this dump.”
          We all kept still.
         
Six months later, one of the nurses bumped into Nicola in a nearby town. She was kicked out by father and moved in with another ex-anorectic. She was with a boy friend. More importantly she was wearing a very sexy dress to show off her then very good figure.
          She did not die.

                                           Based on an extract from my book The Cockroach Catcher

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2 comments:

Dr No said...
CC - Dr No rather suspected that if you didn't turn up and comment on badmed, then you were probably doing a post of your own!

Dr No reads the moral of your post as less is more, ie the more doctors try to control patients (admission, section, forced feeding), the more the patient resists. Do the opposite (patient can go home, even die if the want to) and the patient still resists - in Nicola's case by gaining weight...even if she did do so rather rapidly...and, of course, having a spook for a dad is enough to put anyone on edge...

E's case (the one recently in the news) is very different. She was almost twice N's age, very different family by the sound of things, significant co-morbdities and a long history of failed forced feeding attempts (albeit with one early success). She was, if such a concept is meaningful, in end-stage anorexia nervosa.

Can a patient be allowed to die? Yes - we do it all the time.

Can a seventeen year old patient be allowed to die? Yes - we reluctantly and with great sadness do it from time to time.

Can a seventeen year old Anorexia Nervosa patient be allowed to die? Not if we can possibly help it. But anorexia nervosa is truly pernicious illness, and sometimes it defeats us all - although usually a bit later in the patient's life.

Would Dr No have discharged Nicola as you did? Almost certainly, and probably for the same reasons! 
Cockroach Catcher said...
It is perhaps The Cockroach Catcher's own experience with young Anorexia Nervosa Patients that has coloured his views. There is in him a genuine feeling that doctors should be allowed to doctor pure and simple and in that sense he feels that psychiatrists should be doctors too, real doctors.

Remember the early days of treating phobia when bus loads of phobic patient from none other than the Maudsley were taken to Piccadilly Circus and dumped there. It was known as implosion therapy. then later suicidal patients were given the sharpest razor blades so that they can get on with it.

In Psychiatry, the best treatment is without doubt Placebos. But placebos only works if neither the patient nor the parents knew.

In reading DN's blog I reposted my patient where I let her die.

Well, did I or was that part of Haley/Minuchin treatment? You can decide.

No the early day psychiatrists did not mean harm to come to the Picadilly or Razor patients, but when non-doctors are involved, good luck to the said patients.

Perhaps DN;s patients was of Millennium Trilogy quality and ooops, what was the state doing?

Please let the real doctors or better still the real psychiatrist get on with their real work, if only they are allowed to remember how to give all the guidelines floating around.

The Cockroach Catcher retired partly because he sensed he would not be allowed to carry on his own doctoring ways.