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ramblings of an unknown psychiatrist

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Archive for the ‘medicine’ Category

Important Content: a story

Posted by Dheeraj Kattula on June 12, 2011

“Don’t irritate me, even a bit more mama”, Shravan Iyer said rushing into his room. He closed the door behind his back and muttered to himself “I am sick of these females”. He lay in his bed, pillows covering his ears. The soft Carnatic music that his mother was playing in the dining room could not be heard in his room.

About a hundred kilometres away was the Azad family, a high class business family which was English speaking but had retained its traditions. They had been having trouble controlling Salma, since her teen years. Her behavioural problems never ceased even after visits to many dargas. Many holy men tried to get the ‘Jinn effect’ out of her, but all was in vain.

Sandeep went to Shravan’s room to get his ipod as he prepared to go for his evening jog. When he went in he smiled at his brother, who was in no mood for any humour. Shravan was pacing in his room, running his hand through his hair, turning to and fro, clenching his teeth and kept muttering to himself. Sandeep asked if he needed something. Shravan denied wanting anything. Just as Sandeep left the room, there was a loud noise. There was a shout “Stop it, you bitch”. Shravan had broken the desktop computer in his room with his Cricket bat.

After a lot of shopping for a magical remedy Azad’s wanted to try out medical help, after a cousin told them that Salma could be mentally ill. “I AM NOT MAD.YOU ALL ARE….”,Salma shrieked. Her neighbourhood knew her shriek. It was because the Azads had done a lot of philanthropy in the neighbourhood for two generations that people put up with the drama of their home. Otherwise it was a pain to be woken up by Salma’s shouts.

Sandeep and his mother came running into Shravan’s room. It was not acceptable to destroy a computer. It was OK if he punched or threw pillows at the wall to let his frustration. They had been thinking that he probably had a ‘love failure’. They had been very tolerant of him to get over it, but things had only been getting worse. He stopped going to work for the past two months and had been increasingly preoccupied. They had been encouraging him all the while fearing that he might harm himself, but that day’s aggression was clearly beyond the limits.

Salma was taken to a psychiatric facility. The doctors could not conclude about her illness. They wanted to clarify her diagnosis by observing her in the ward. After all her only behavioural problems were a bit of adamancy and problematic shouting to get her way through.

Shravan was evaluated in the same hospital. It was found that he had been having auditory hallucinations. The psychiatrist just asked him if the voices spoke to him or spoke among themselves regarding him or gave a running commentary on his actions. He replied that the voice abused him. The psychiatrist moved on to assess other areas in his mental status. He recorded second person auditory hallucinations in the medical records. He was admitted into the facility due to risk for property.

Salma was admitted in the same facility in room no 3. Her family had requested for room no 10, which was the last room in the corridor. It would give them some more privacy and that Salma would not be a disturbance either. The doctor insisted that treatment in all rooms would be the same and did not change her room. He wanted to avoid few extra steps he might have to make during rounds.

Salma shrieked that night in the corridor. Shravan realized that the one who had been tormenting him was near. He had been hearing a similar voice shouting at him and abusing him all this while. Salma looked at him and was shocked. His thin built, fair complexion and brown eyes reminded her of the school teacher, who abused her when she was 12 years old. She shouted even more.

Shravan could hold himself no longer. He charged towards her and caught her neck with his hands. She fell backwards and opened her room door and fell on the table. In her agitation she got a knife which was on the fruit tray. She picked it and drove it into her assaulter’s abdomen. He bent on himself. There was a gush of blood. Salma fainted.

Shravan was operated upon and he survived. The knife had nicked the spleen. It had to be removed to save his life. Iyer family did not want to pursue the legal case. Azads paid a good amount to the police and saw that FIR was not filed.

The psychiatrist was clueless about what had happened. Was he wrong in where he placed them as inpatients? He was convinced that he was following the diagnostic manuals. He had picked the phenomenology right. He was right in the diagnosis. He was following treatment guidelines and he was right in the drug treatment.

What he did not realize is that diagnosis depends on the ‘form’ of psychopathology but risks are due to the ‘content’ of the psychopathology. In his management, he should consider content as seriously as form.

Shravan and Salma continued their treatment in the facility and did well.

Dargas- A Sufi shrine built over a grave of religious figure usually frequented by Muslims.

Jinn effect- Effect of Demons

Posted in Diagnosis, fiction, medicine, psychiatry, schizophrenia | 4 Comments »

“He will get bed sores and die in about three months. Take care of him. Feed him with what he likes.”: Medical Model VS Family Practice Model

Posted by Dheeraj Kattula on June 29, 2010

He was discussing about his experiences after he came down from the mountains. He was doctor doing medical work in the communities based in nearby hills. He was posted there by our hospital for a couple of months. Of the many things he told that day, I remember this story clearly.

He had seen a 74 year old man with a fracture in his femur in a hilly village. He asked me what he would have done. It was a simple answer for me. I said, “You would have told them to bring him down to the hospital. We could give some charity, even if they cannot pay fully. The bones can be fixed.” There were five competent orthopaedic surgeons in our hospital at that time. He smiled sarcastically. He wanted to make a point, but what he said shocked me.

He had said, “I told them, that he might not live very long. He cannot move here and there because of his broken hip. He will get bed sores and die in about three months. Take care of him. Feed him with what he likes. Let him enjoy the time he has.”

I was filled with malaise. What?!!! How can a doctor say this kind of stuff? I couldn’t control myself. I asked him, “Wasn’t it inhuman? Fractures are treatable. Isn’t it? Then why not offer it. How can we give a death sentence for a treatable condition?”

He laughed at me as if I was talking rubbish. I heard his argument keenly. Probably, it was to rubbish his argument to boost my egoistic ethical pride. He said, “Listen, this old man has a son who is the only bread winner. His daughter-in-law is a house wife. His grandson is now in standard 10. His grand-daughter is in standard 8. It costs about Rs 5000/- to bring him down from the hills in a vehicle. The cost of treatment in the hospital would at least be Rs 30,000/-. They do not have that much of money. If I do send them down, they will have to bring him back after a discussion with a orthopaedic surgeon. In the bargain they would have spent off large amount of money. Just in case they go ahead and treat him, they will have to sell off their house. If they sell it off, then they will have to live in the street.”

I was listening. He went on, “If they spend all that they have, the grandson may not pursue education beyond high school. The grand-daughter would have to discontinue school to add to family income. All this might add one or two more years to a 74 year old man. Is adding a couple of years to such a man worth losing the future of a whole generation?”

It was a tough call. I was a new graduate then. I was trained in the medical model. I was supposed to tell the best medical treatment available to the patients and let them decide what they wanted. I realized this model absolves me of any feeling of guilt. The truth is I do have in my mind what is better, but still I would have done what is ‘right’. My friend’s argument did not convince me.

After about 6 years of that incident I am wondering if that ‘right’ that I would have done is really right?  What would I do if I were in that old man’s position? I am absolutely sure I would rather wish a better future for my grandchild than live a few extra years. I have heard grandparents in India bless their grand children, “Let my years be added to you.” Of course that does not mean that one can assume this sentiment in every case?

The point is that my friend is a family physician. His expertise is not only in managing health problems at a primary level but also in understanding clinical problems and treatment options in the light of socio-economic conditions and the values of the family. His model makes people happier and fulfilled more than the medical model which has the appearance of being more scientific. May be it is time the specialists learn to use the broader model. This can be done when; in addition to eliciting clinical histories clinicians spend some more time with patients in understanding their and their family context and expectations.

PS: This event happened about 6 years ago. Today, thanks to Chief Minister’s insurance scheme and 108 ambulance services, patients like the one described can get free treatment in our hospital.

Posted in challenge, children, Diagnosis, distress, economics, education, ethics, indian society, medicine, philosophy, social | Tagged: , , , , , , , , | 3 Comments »

Being a Woman, Leper and a Brahmin

Posted by Dheeraj Kattula on January 9, 2010

Apologies: To all the pundits on ethics of confidentiality. This post might not be acceptable to the people that I have written about. Insistently, I write this. Consider the fact that no bad news is acceptable to the ones who make that news, be it rapists or racists. This story is real. Read it if you want to or chuck it if you don’t care. Stories that must to be told should be told.

Note: I respect confidentiality. I am a doctor, not a journalist or policeman. Therefore there is no need for me to tell the real names. The name I have used is fictitious. Also, the persons in the story are aware of my feelings towards their attitude. I hope to understand them and change their attitude for the better in my future interactions. I continue to treat this family.

Post: Being a Woman, Leper and a Brahmin

Her name is Madhusmitha Panda. She is about 50 years old. She is unmarried. Of course, who would marry her, for she had Leprosy. She had the stigmata of having had leprosy. She walked with a limp. Her toes were shrunk and her foot was deformed.

Her father retired from Government Service and receives a pension. He is about 80 years now. He is hard of hearing, but quite independent. Her mother was in her 70s and she had uncontrolled diabetes. She had no other siblings. She had few cousins, who were all married and well settled economically. The women who were married to her cousins do not take good care of them. So the three live independently in a small house. They have no other social supports.

She was an old patient of our institution. She had received MDT (multidrug therapy) and was cured of Leprosy few years ago. Our nurses have treated her of a foot ulcer a couple of months ago. She used to come on an out patient basis for dressing of the ulcer in her foot.It had healed well.

I saw her few weeks ago with a bad ulcer in her foot. Considering her situations, I felt that it would be difficult for her to come all the way from her home on a regular basis. Remember that travel costs money. I advised her to stay in Leprosy Home, a place where she could get free accommodation, food and ulcer care.Her father was not interested .He said that he would bring her regularly for dressings.

Madhusmitha came daily for dressings. Her father brought her everyday in an auto rickshaw. Over few days we realized that the ulcer is not getting better. At the same time she is developing changes in her sole indicating that there is possibility of new ulcer developing. This was because she was not giving adequate rest to her foot. Being the more able of the three, she had to do all the house hold work. Her dressings were not maintained as they had to be. We pressed them for an admission. It can be assumed that once a patient gets admitted, he/she could get some rest.

We also had asked her father to buy her MCR (Micro Cellular Rubber) footwear from the shoe maker in Leprosy Home. We told him of the costs etc.He wanted to find out, if it was available elsewhere. Even after a while, her foot did not improve. We realized he has not purchased the footwear for her. We felt irritated. He was not even willing to go to the Leprosy Home! We knew we could help her if she were admitted. When we insisted on admission, he blurted out, “How can I leave my daughter? What if someone does something?” . The nurses told me that he did not trust his own daughter. That is why he accompanied her everyday, even into the dressing room.

We had a word with her mother. We thought she could think more rationally. It made sense to admit her daughter to get treatment for free! She asked, “Do good people stay there?” I began to reason with her that most people living there are nice people. They too were suffering like her daughter. I also told her that there will be people to take care of her daughter. As I was explaining this, our nurse told me, “Sir, the meaning of her ‘good people’ is not nice people as you imagine. She refers to people of higher caste. She is a Brahmin. So, she does not want her daughter to live in a Home with lower caste people.”

I was shocked. I thought “What? Mother of a Leprosy patient was discriminating other oppressed people!!!”.Madhusmitha is not suffering with Leprosy problems alone. She was suffering for being a woman. She was suffering for being a Brahmin. Her parents think that they are being helpful and protective but they are the biggest stumbling blocks to her care. They being old cannot care for themselves. They want Madhusmitha to do all the household work. After all, she was born a woman. It is her responsibility to do the household chores. Adequate rest is therefore not possible. On the top of it, they deny her benefits of admission into a Home because of being Brahmins. Sadly again, because of associated stigma they do not want to go to the Home to buy MCR footwear.

I asked her mother, “Mousi, you said you have problems with wives of your nephews. Isn’t it?” She nodded with an expression anticipating sympathy. “Are they not Brahmins like you?” I asked. She agreed though her expression changed. I asked her, “Tell me who is better? The wives of your nephews, who being high caste Brahmins do not care for you or the tribal people and health workers in the Home, who would dress your daughter’s ulcers and take care of her, even in your absence?” There was a pause. She answered in a low tone, “Tribals”.I am glad that she could see the obvious truth.

Frankly, I felt that if that old couple die then Madhusmitha might get a better deal. Till then she would remain a Brahmin woman, who would do all the household chores, limping with ulcerated feet. She should have been born into a Tribe. She would have had a better deal.

I still cannot understand how they could discriminate against persons from tribal background when they themselves get discriminated for having leprosy. I wonder how they try to hide the identity of having had leprosy, but flaunt the identity of high caste origin.

Posted in distress, indian society, leprosy, medicine, stigma, women's issues | Tagged: , , , , , , | 13 Comments »

Battle with Malaria: a personal sickness story

Posted by Dheeraj Kattula on July 23, 2009

Background

Towards the end of June 2009 I went to Kandamaal district, an interior hilly area in Orissa endemic for Malaria. This was as a part of a medical team conducting medical camps in different parts of the district. I was there for five days. My experiences there deserve to be a separate post in my blog. I would write that later.

On my way back, in the train it felt a bit cold. I got up from my upper berth to switch of all the fans, thinking I was helping others in a cold night. A couple of hours later I found the fans switched on! Only then I realized that probably it was MY problem and not for others. I also had a bad migraine. I reasoned it to be due to sleep deprivation and physical exhaustion. But as soon as I landed back in home/hospital, I got my blood tested. It was positive for Malaria parasite Plasmodium falciparum. Out of 1000 red blood cells about 3 were infested with the bugs. Probably, during the time spent in Kandamaal, I was bitten by one of the female Anopheles fluviatilis mosquitos carrying the Malaria bug Plasmodium falciparum.

Treatment:

I started taking medicines immediately. I respect Falciparum bug. It could do ANYTHING. I also had a board meeting to attend. I took Tab Sulphadiazine + Pyrimethamine, Chloroquine and also Artesenuate. It was surely an over-kill but I wanted to be safe.

Three days passed. Fever did not come down. I also began to vomit and could not hold anything in my tummy. I was admitted in the hospital and was given intravenous fluids. A physician friend visiting us started me on intravenous antibiotics, ‘just to be safe’. I complied in good faith. This was carpet bombing in my system. Tab Artesenuate became Injection Artesenuate.

dheeraj on sickbed

on sickbed

7 days passed. My last dose of Artesenuate was given. I still had fever. As fate would have it, I became deeply jaundiced. It was not the typical hemolytic jaundice seen in Malaria but was deeper one seen in Liver injury. I stopped all injections and i.v fluids as I began to tolerate oral foods. I started Cap Doxycyline the fourth antimalarial. Fever came down after 2 more days. Jaundice was persisting. We knew we cannot do anything about it. Malaria Hepatopathy was the diagnosis. I was supposed to have some dietary restrictions and that is all. My staff insisted that I took some liver tonic. They forced me to buy some ayurvedic stuff Syp. Amlicure DS. I take it, to please them.

Milestones:

It was the first time that I got admitted in a hospital, first time got an IV canula, first time received ‘saline’, first time IV antibiotics etc. Of course I was living in my own room but my room was made into a special ward with IV stand coming in etc!

It was the first time I did not shout ‘mummy’ when I was getting pricked with needles. I could stomach the fact that situation is grave and that killed the fear of needles and pricks.

Reflection:

It was not easy for my friend Siva to take care of me. We had physicians, gastroenterologists, malaria experts as our friends but did not have facilities to do few of the tests that could be easily done elsewhere.

Siva had to allay anxiety of my parents, who called regularly to enquire about my status. He had to balance the risks of keeping me here and risk of transporting me in a very weak state.

He and I, both of us learnt to be cool when we knew we have to wait and watch, as we do not know what was happening. I learnt that in desperation people don’t look at evidence but act in faith. Eg: my friend giving Injection Ceftriaxone and me taking Ayurvedic medicines!

My staffs were like a family. They took care of me just I would have been cared at home by my family. They made fruit juices of different kinds apple, lime, mousambi, grape, dalimbo ( a local fruit), mango, pomegranate etc and supplied at periodic intervals. They tried to give injections as painlessly as they could. They kept a watch as needed. Of course they were always praying for my recovery.

My family stood strong. They felt bad that they could not come to take care of me. I tell them that their trouble was not needed. They had faith that nothing bad will happen.

I lost 2 inches of my waist and 6.5 kgs of weight in a week’s time. I loved it. At last the ‘all round development’ that I hated has come down. Many of my old clothes have got a new lease of life. Few days ago, I comfortably fit into a pant that I had last fit into more than a year ago. I hope I do not put on weight as my appetite is slowing improving. I watched a couple of Bruce Lee movies day before yesterday. I am now waiting to get out and exercise. I started to walk today with a little extra jump in my gait.

My jaundice is not yet gone. I look as yellow as I looked a week ago. I started feeling much better though. At one point I took four breaks to send a 5 sentence email, today I could sit in the OPD and see patients. In fact I had a 1 hour psych session with a patient today.

Jaundiced eyes

Jaundiced eyes:for clarity compare the eye colour with the colour of the teeth 🙂

Thank God, I am not entering into ‘half pay leave’ zone.

Ops I almost forgot to mention…I had never purchased ‘Real- fruit juice’ till now. Rs 75/- for food products never enters my budget, but this time I bought myself many liters of such juice lichee, pineapple, apple, orange, mixed fruit etc. I also bought oats and chocos for the first time. Sickness had made me enter new markets!

I have probably treated more than 1000 patients with malaria last year. Whenever someone came with side effects, I used to tell them without even listening fully, “I know…You will feel….etc. Don’t worry. Just do…”. I do not think I would be the same now. I might listen more and then say “I understand…Why don’t you try…You might not like to do it, but it is good for you to…If you are unable, do come back. We will help you.”

I feel I have matured through the sickness experience. Felt like this after many milestone experiences, but I am not sure if I really did mature !

Posted in Diagnosis, distress, medicine | 4 Comments »

“Normal”, “Abnormal” and “Label”

Posted by Dheeraj Kattula on June 26, 2009

Warning:

The post might have a lot of jargon,which you might not enjoy. It might be written in a fashion, which may make you feel that author and his thinking is complicated. Don’t worry. He is ‘normal’ only. If you want to stop reading the post mid-way, It might be absolutely ‘normal’. So, no problems with that too. If you call this post bad, I would say you are a ‘label-er’ but not ‘abnormal’. If you say this is written splendidly in Sanskrit, it is only then I could consider you abnormal. Assuming normalcy of some sort I invite you to read the post:

“Normal”, “Abnormal” and “Label”

There would always be debates on defining, what is ‘normal’. There are many models to define what is abnormal.

‘Statistical infrequency’ is one of the models to define what is abnormal. If some thing is rare then it is abnormal. If that be the case gifted people are abnormal as they are rare!

‘Failure to function adequately’ is another model to help not labeling gifted individuals as abnormal. But, who defines what is adequate and what is functioning? Is there a consensus?

‘Deviation from social norms’ is another such model. Social norms vary with culture, context, situation, age, gender, development and historical context (time).

Identifying parameters that are abnormal, considering the possible causes and treating them is a part of routine medical practice. In psychiatry, the parameters are more behavioral in nature.

Is “normal” a dichotomous construct (yes/no), a continuous construct (0-fully dysfunctional, 100-Mahatma Gandhi), or a dimensional construct (Einstein- professionally a genius, politically eccentric, interpersonally deficient)?

If we observe, we might find ourselves in different areas of the normal curve in different aspects. For example when I dance (as I sometimes do), people don’t see me in awe but rather laugh in amusement :-/ ( not so sadly :-)) Dancing Dheeraj

Or when I play cricket, I know the timing of my shots is awful. I might discuss the physics behind ‘reverse swing’ but would never be able to read its trajectory and time a ‘square-cut’ to the boundary. This just shows that I probably am low in Body Kinesthetic Intelligence. A not so sophisticated ‘labeler’ might call me ‘Kinesthetically Retarded’! (Ops! I labeled him a ‘labeler’ :-)) .The more specialized psychiatrists have even a diagnosis for it ‘Developmental Coordination Disorder’. “Diagnoses for all by 2025” seems to be the motto of some psychiatrists.

It is interesting that though we draw clear lines and cut across the parameters as normal and abnormal, most parameters are distributed normally. There are individuals very close to the line drawn but on different sides of it. They end up with different labels/ diagnosis and probably different treatments. Is this not quite terrifying?

Not just that, if the line is drawn somewhere close to the mean, then we have more problems. Take for example Complicated grief, Atypical PTSD (Post Traumatic Stress Disorder), High-functioning Asperger’s syndrome, Developmental Coordination Disorder etc. Besides, some conditions that are abnormal in a majority of settings become desirable in very narrow contexts. For example Anti-Social Personality Disorder in politicians and businessmen, Histrionic Personality in actresses and performers, Schizoid Personality in mathematicians and physicists and so on.

Good news is that most medical researchers consider these statistical issues before formulating guidelines and are not keen on labeling everything and everyone as abnormal. Most Clinicians go by patterns of symptoms, signs, laboratory results and diagnostics not isolated laboratory findings. Clinicians are not bothered, so thankfully not confused about statistical issues!

A good doctor picks up most of the abnormal parameters in his history taking, clinical examination and diagnostic work up, logically thinks through and explains these with the most judicious explanation, considers rarer possibilities and tries to rule them out or in and treats appropriately covering for most possible causes and always tries to relieve symptoms and is less bothered about the ‘label’ he gives to his patients.

Posted in Diagnosis, grief, medicine, personality, psychiatry, statistics | 4 Comments »