Psych and thoughts

It's finally the "holidays" (with an EOPT and pros both coming within the next 6 weeks) after 1 month in psychiatry.

My initial thoughts before entering psych was: Great. Psych. That was probably my differential for every presenting complain that didn't make sense to me.

Upon entering psych: This place is a madhouse. I'm probably going to go mad if I stay here long enough!

Well, 1 month has past. Admittedly, I still have my bias against these specialty - probably a major reason is because I simply cannot understand the plight they are going through (and there the doctors are saying that empathy is a very important part of the communication process).

How am I to empathise with them when I fail to understand what they are going through? Do I imagine the same voices that they hear, or imagine the torment they go through when they are infested with thoughts of germs and diseases? Or am I supposed to fake my empathy right in front of them while keeping that straight face?

Yes, I can understand some of the depressed patients, maybe the anxious ones too - surely all of us have went through periods of depression or anxiety, it's just how severe it was. But how am I to understand the delusional people? "There is somebody after me. They are spying on me. I don't know who but I'm very sure they are doing it" And they say it with such conviction that you would think they are telling the truth - if not for the fact that they are right there in the psychiatry ward.

Struggles with patients aside, the psych content itself has given me much insight about.. well, life. Life in general. It can get quite funny how we start diagnosing ourselves and others during lectures as we spot the uncanny similarities between psychiatric disorders and ourselves or people around us. And of course, the usual occupational hazard where everything around us is somehow related to hallucinations and delusions just because this is the psych posting.

Truth is, everything around us IS related to psychology - just that psychiatry focuses more on diagnoses and medication rather than psychology per se. There is always this concept of a spectrum between normal and pathological. Pathological could be defined by the standard DSM-IV criteria or ICD-10 that is being thrown around the wards, lectures etc. But what actually is normal? How is normal defined? If being normal just means not abnormal, then it is simply contained by the definition of pathological that in the first place, has been defined by other humans/psychiatrists themselves.

Going back to how we tend to relate school content to ourselves, it can sometimes be quite scary if we think about situations we are going through in life - could I be going through a major depressive disorder? Could I have a personality disorder rather than just the traits? The list of questions goes on. It even extends to people around us - are they suffering from a disorder, should I recommend them to seek treatment?

Or put it another way, again at the original question: how can I be certain that this current phase of my life can be considered normal? Am I over-reacting to the stimuli around me or is this actually deemed to be a normal response?

On a related, or perhaps rather unrelated note, I did think about something: How does all this fit together when you bring God into the picture? There are patients saying: Mary and Joseph told me to jump; they pushed me off the building. Others are saying: The voices tell me to jump, but the voice of Jesus tells me that these voices are evil - do not listen to them!

It can be quite confounding (for lack of a better word) when we try to delineate what makes a hallucination versus the true voice of God Himself. It makes a world of difference - one guy has schizophrenia which needs to be treated, while the other may very well be receiving visions from God or words of Knowledge and Wisdom. How then, are we able to differentiate these two? A fleeting thought comes to me: If I do hear the voice of God, I may actually be going mad. Or more optimistically speaking, I'm starting to hear God's voice for real.

Perhaps these thoughts are churned out by my mind which tends to go into a whirlpool of questions whenever left idle - which means all I ever do with my life is play and think about these questions. Not very productive indeed.

But sometimes, I find these questions can help to understand ourselves better, it can sometimes help to understand others better. Though I may not necessarily find answers to all these questions, I suppose it is good enough if it helps me to perceive things better in various situations. Whether it is myself, my loved ones, my patients, or even people unrelated to me.

~Just another Sunday night rambling just because I feel like penning out my thoughts~

Death

Prior to the A&E posting, I already knew that I would see the first deaths happening to patients right before my eyes. At that point, I didn't really know how I would feel, or how I would react.

Just 1 week ago, I stepped into the resuscitation room only to see CPR being carried out on a patient - she came in with a cardiovascular collapse, ECG showed asystole and VF at different times. In the midst of the chaos, I found myself rooted to the ground, not knowing what to do or what I could do. So all I did must utter a prayer to God: Father, be with her... be with her...

Minutes later, I heard someone say, "Game over. Stop CPR." My heart sank. I didn't know what to feel or how I felt at that point. Not that I had time to think - the next patient arrived at the opposite bed. Instinctively, I turned to that patient to catch up on what was happening.

She was a middle aged lady who came in for shortness of breath. She looked terrible, what medical people like to call "toxic looking". After a while, it was determined that only dialysis would help her, relieve her and possibly save her. When conveyed to her, her only reply was no, I do not want dialysis. She seemed to ignore us when we tried to persuade her and explore her reasons for rejecting treatment. Yes, we were taught that patients have every right to reject treatment, even life saving treatment as long as they are competent. Even so, something whelmed up in me - I started becoming annoyed, or should I say, angry that she would not even accept something that would help her. I couldn't see how somebody would always literally throw their life away when a life saving alternative was offered to them!

Upon reflecting on this incident, I couldn't find the reason why I would react so strongly when usually I would try to persuade the patient or perhaps, accept her decision because she probably knew what was best for her. I couldn't sleep that night till it was really late, thinking long and hard about the day's happenings... Turned out that fatigue got the better of me before I could put any pieces together.

Just yesterday, another collapse came in, with the CPR machine already on. Assessed rhythm was asystole at first, followed by PEA. Again, I said a short prayer to God, hoping that He would bring life back to this patient... After giving shots of adrenaline and more CPR, there seemed to have hope. His heart started beating on its own, his pulse returned. Just as the consultant was about to take his bloods, again, his pulse disappeared, returning to PEA. To my surprise, the consultant gave the signal to halt resuscitation attempts, stating how adrenaline can give such a phenomenon and that further attempts would not be useful given the history and since he was already brain dead.

Once again, there was this struggle within me. One part of me accepted what was given to me, the other part of me just wanted to continue trying... Medically speaking, further attempts would only be futile, and even if successful, would lead to a poor quality of life, if any at all, for the patient. But somehow, I couldn't rationalise these things on the spot. I could only stand at one spot, watching while the staff wrapped up his body, waiting for a completely flat strip on the ECG to officially document his death...

Many thoughts raced through my mind. Could we have saved him? Did we stop too early? Could other interventions be done? How much should be or shouldn't be done? How many lives can we actually save? Why did God give that shimmer of hope, only to take it away? And alone the same lines... are we actually trying to play God when we resuscitate a person with a collapsed heart?

Later on, upon thinking slightly more... I looked back at the other collapsed patient and wondered what is it in me that makes me so affected by such happenings in the hospital, which are not uncommon especially in the A&E?

Retrospectively, perhaps the past events in my life have really shaped me and affected me more than I thought it would have. I recalled incidents that happened years back and concluded that maybe, it has impacted my life so much, just that I failed to realize it back then.

Then, yet more unanswered questions remain. It ultimately boils down to: What is it that God has in store for me when He has called me and brought me in to this path down the medical field? I don't know the answer really, but I believe that in future, how much I can do will only be limited by how much He is willing to do through me.

Unless the LORD builds the house, its builders labor in vain. Unless the LORD watches over the city, the watchmen stand guard in vain.

What drives you?

M4 has started for a few months now. Currently in O&G which really makes me (or the guys for that matter) feel like a fish out of water. Somehow, I began to dislike this posting - the content, the interaction.... I don't know, it just feels like I'm dragging myself through each day hoping that the weekend would come soon enough. I totally could not find any passion in this area of Medicine. This posting was more of a necessity than actually a learning experience to me.

Incidentally, this HK drama started showing - a medical show "on call 36 hours". Yes, a drama will always be a drama. Scenarios are painted out with the aim of evoking emotions from the audience - some pretty far fetched. But on retrospect, these issues (though spiced up) are actually really real in our daily ward lives... Take for instance this doctor (in the show) who didn't take his work seriously. He just wanted to have fun and was always having problems with this particular patient. But the relationship improved overtime and he realised that he himself could make such a huge impact on the patient who promised to stop smoking if he stopped drinking soda. Unthinkable really but applied to our lives now.... patients have so much trust in doctors, they see them as people who will save their lives, change them for the better and ultimately, return them into the community in the healthy state they once were in... It is things like these which really bring out the rewards in being part of the healthcare profession.

One day over lunch, a casual question was brought up: has there been any patient now (O&G) that has inspired you? I can't remember my answer but I know for sure that yes, there were. In fact, more so here than in other postings. I've met so many patients, highly optimistic about life (maybe not so much their condition) regardless of how dismal it may have been. I can confidently say that the most inspiring patients I have met were over here in this posting.

Perhaps what makes this profession enjoyable and rewarding is really the people you meet, more so than what you can actually offer them - which can be very limited. In fact, what they offer you can sometimes be much more than you could imagine - their outlook of life, how they deal with challenges and the courage that they bring with them. It simply inspires us and gives us that nudge to keep us going.

Ups and downs in life

Just attended Charles' and Li Feng's wedding last Saturday. Part of the sermon went something like: our life is full of ups and downs. What matters is regardless of where we are, it doesn't really matter as long as we have God with us.

I've lately been in the valleys of my life for another mixture of factors and one predominant trigger. Not the first time it has happened and I know that, by the grace of God, it will come to pass. The most dreaded part about these downs is that, while I know God is a gracious God, it somehow happens that these downs in my life always seem to be the times when I'm furthest from Him - and it's when I'm furthest from Him that things in my life start to break into pieces, leaving me all disgruntled and exasperated...

But every cloud has a silver lining; I know that once this period passes, I will only come out stronger and it's by these trials where I learn to depend on God more, knowing that His will reigns above all.

On a brighter note, I'm reminded by Charles and Li Feng that the purest love that can be found between two people is only achieved by seeking Him first and letting Him point you to each other.

Another encouraging thing in my life now is that a good friend of mine is turning to Christ. How infinitely thankful can I be that yet one more person is accepting Christ into his life...

Father, though I walk in darkness now, thank You for showing me the light around me, and things that I can give thanks for. May You be glorified forever more, amen.

M4

So the past 1-2 months have been spent enjoying the absence of school in my life and just getting my brain wasted away while meeting up with friends in between.

The sad reality that school's starting again tomorrow dawned upon me once again. As I try to anticipate what's coming up, google and wiki do give me a rough idea - but it only served as a reminder that my brain has to start working again to understand the intricacies of the human body - which incidentally reminded me of how I was awed before at how God could make the human body function so amazingly that, while so much is known about it, so much more isn't.

Sigh. School. Random rambling...

Let me never lose sight of why You have placed me where I am

Happiness

True happiness can only be found when others around you are happy. The best way to make yourself happy is to make someone else happy.

A simple way to put happiness - this has been preached before, probably multiple times in different places by various people. It holds much truth but few are able to practise it fully...

Are we able to be a mirror that depicts fully the reflection of God in our lives?

1 day

Exhausted but yet motivated for I am blessed beyond measure

9 days

I don't really believe in myself... but I believe in You

Just another random thought

It's been a while since my last post - perhaps because of struggles here and there, both emotionally and spiritually. The past 2 months of my life were terrible - devoid of God; that feeling where I know I need to seek Him but at the same time, feeling... just so distant. Thank You God that I have now reconciled myself with You...

Perhaps I'm one who thinks about things, thinks too much at times or maybe most of the time. A particular happening may be small, but I can think it through until it starts becoming huge to me, regardless of how small it really is. Not just once, but on many occasions. I'm thinking, is it human nature to analyse things so thoroughly? We are stuck at where we are, we project an infinite number of possibilities and fear the consequences of each if we carry out a particular action. We think about what happens tomorrow and fear the endless possibilities of disasters. What if things don't go as we wish? What if we don't do what we ought to, and something terrible happens? - The word 'if' can be said to appear an insensible number of times in our thoughts

Then after thinking things through and rationalizing with ourselves, our heart comes in and says, hey everything is just wrong. Logic may say this, but somehow, I just feel it should be the other way... As if the brain doesn't have enough conflict with itself, the heart comes in and makes things more complicated than they are.

Logic may lead us in a very sensible direction but we at times, we end up following our heart because it just seems to be 'the right thing' to do. Or we can think things through and come to a conclusion that things aren't working out right - then it just takes a simple message from another that speaks to the heart and our judgement is altered: things seem to be going perfect.

Sometimes it's really amusing how our heart can dominate over logic. It can be a nudge from God, a simple gut feeling or even a message from a person that completely changes our day.

Maybe, just maybe... Maybe God gave us a heart for the purpose of ruling over the brain at special times.

It's funny too, that I wanted to write about how my days in the past month have been bogged down with various thoughts and how different events or encounters made it worst - and now I'm here writing about how the heart can change everything... simply because my heart told me to

Palliative Care

Just finished a whole week in the palliative side of medical practice. The posting lasted 4 days, some theory, some practical and exposure to different fields of it. Though it was short, there's just a whole load of things to reflect upon.

The typical ward round and documentation of patients' condition has this format (or close to) SOAP. (S)ubjective - Ask the patient how he feels today. (O)bjective - check his vitals. (A)ssessment - what are the current issues? (P)lan - Can he go home? All seems well and good. You cover the medical side of things, and hey, you talked to the patient and asked about his opinion. On the surface it seems to be a good framework, but going deeper down, all these is so... superficial.

Contrast this to pallative medicine - the team moves around in 2s or 3s. Every patient gets seen for more than just his medical condition. His well-being is asked about, his ideas, concerns, expectations. How he's coping with his illness, his prognosis. Psychosocial issues are probed into. Financial status, home-care, family support, future plans. Spending an hour just to find out about all these is not uncommon - it can even be considered little.

Entering medical school requires you to write an essay on why you want to enter, why they should choose you. The model essay go something like - I want to save the world. I want to treat every patient like they're my parents. I want to spend as much time as needed with them. I want to give them the best care that I can. I want to explore and address every issue they can possibly have. I want to give my all for every patient in the ward.

Idealistic? Yes. But in retrospect, palliative medicine is definitely closer to this idealistic world that has been preached during lectures, during the theoratical part of medical school. It just seems like all these ideal practices have become a specialty named Palliative Medicine rather than one that is incorporated in all fields.

Definition of palliative medicine - The care of patients with advanced/terminal life-threatening illnesses.

Is it right to only focus on the non-medical issues that patients may have only after their illness has progressed to that terminal stage? Are they not entitled to the same amount of care even before their cancer becomes incurable or before their lung diseases have progressed to the untreatable stage?

As usual there comes the debate between idealism and reality. The ideal world is always... well, ideal. But the cost of it in this context is time. Reality doesn't allow for that much time when there's a few more cubicles of patients waiting to be reviewed and another hundred more in the clinics. That's the harsh reality that is present. The question is, if palliative physicians can do it, why can't the others?