Reflections on dementia

With the increasing aging population worldwide, its not a surprise dementia cases are increasing as well. Eventually, all of us will end up being a caregiver at some point in our lives. 

The hardest hit would be on the 'Sandwich generation', a generation that takes care of their elderly parents while also trying to raise their younger generation. I would say the responsibilities are twice as heavy. 

I would also highlight that most of the caregivers are leaning towards the older age, its not uncommon these days to see a 60year old taking care of a 80 year old.. 

Hence, my highlight that caregiver themselves should be supported and evaluated throughout their caregiving journey. In all honesty, how often do we focus on caregivers?

As clinicians, once we diagnose dementia, we tend to focus on our patient as our whole entire universe. What can we do for a change to make our care extend towards caregivers?

-care giver assessment (screen for their physical and mental suitability). This includes screening caregivers for mental health issues and cognitive impairment. 

-educating care givers on the challenging journey ahead, preparing them on their role transitions and educating them on the basics of dementia

-mobilising their supports (genogram to understand family dynamics, atlas caremaps). 

-educating about burnout (ways to seek external help, community supports that are available)

-psychotherapies including family therapies. 

-grief work (ways to cope with deterioration due to progression of dementia and ultimately loss)

-addressing ethical dilemmas (autonomy vs safety, justice)

Having said all of the above, the most important intervention is having community support. As we can see the level of care for dementia highlights community involvement from level 1-3. Only level 4 is specialised care.

Without community cohesion, we will not be able to deliver dementia care which is comprehensive, hollistic and inclusive. Afterall dementia not only affects the person but it changes everyone. 

For more indepth information, kindly refer to the textbook titled family caregiver distress by dollores gallagher-thompson et al. 

My reflection on mental health crisis

Is mental health issues on the rise?

YES..

Is it tiring to work in a mental health setting?

YES

Ever wonder why mental health issues are rising?

YES.. all the time

How did this reflection of mine started? 

Well, it began because my boss mentioned about the decline of the fabrics of our society, the moving of collective communities into a single nuclear family.. and now, everyone is for himself mentality. Which leave the responsibilities of caring for the unfortunate to goverments and the state. 

Will goverments be able to take care of every mental health sufferer?

Hopeful is an optimistic word..

in the long run, i think its quite pessimistic

I had the joy of reading a book called 'Has medicine lost its mind?', written by Robert C Smith.. 

It was an illuminating discovery..

The issues highlighted were

1. We have been taught to seperate physical and mental health as seperate entities

-kindly read the book for a lengthy history of this. it puts things into perspective

2. The stigma exist even in the medical fraternity

-true, i've experienced first hand how other departments undermine by skills just because i'm in psych. Those insinuating comments that i can 'read the mind', 'cure people just by talking'

3. Dr's themselves have poor understanding on mental health issues

-true. i spent my medical school training with just 6 weeks of psychiatry out of 2.5 years in clinical years. i was trained in a traditional training system.

-i was lucky to get a psych case in my final year, i guess i was kind of interested..

-as medical student, psychiatry was facinating. however, there was  no continuity when i began entering housemanship.

-i had a steep curve when i was studying for my post grad exams as medical officer.. i had no clue about psych medications, let alone the topics out of depression, bipolar and schizophrenia

4. The overpowering emphasis on neurosciences

-medicine without science is quackery

-psych is a bridge between the mind and brain, over emphasizing on the brain alone kind of tip the scales.. 

-the drive away from psychoanalysis meant that talk therapies are declining, we resorted to a magic pill to solve our mental health issues..

5. Talk therapy is damn blood expensive

-trust me, therapy is time consuming. the billing is done per hour.. which leaves therapy only affordable for the rich.

-why is it so expensive? because its really draining for therapist.. please do not picture a couch and a patient laying on it. there's alot of analysis to be done by listening and selecting what to say to acheive the therapeutic effect. 

The way forward?

Mental health is everyone's business.

Holistic treatment is key.. there goes the rationale for biopsychosocial model

It's not going to be treated by magic bullets, fancy retreats or any fancy products 

My takeaway, it takes small steps, sometimes 2 steps forward and 1 step backwards, humility and constant drive to be a better human to acheive the perfect mental health. And that formula varies from each one of us. 

Reflections part 2

 Ive always had a background thought that children are a screamy whiny spoilt bunch. In pediatrics, ive seen how everything needs to be precise and accurate. I foresee that life would not be much fun in the pediatric section. I entered my posting with 0 expectation, i just wanted to get it done and dusted.

Imagine my surprise when my supervisor posed the golden question to me, what did i want to achieve in the span of 4 months? Of all my encounters never had any of my supervisor ever asked me this. Wow i thought, what a great first impression made. I was truly in awe, finally someone wanted to engage me in my learning journey. This was how it got my curiosity started. To be honest, i dont think i gave much thought about my answer until after that. 

Neurodevelopmental disorders are the bread and butter of this department. The parental shock and despair upon receiving news that their child had a neurodevelopmemtal disorder, compounded by the anxiety if their child would ever lead a normal life, the sacrifices that has to be made to help their child fit into society were witnessed too often. Who could answer the question 'Dr, did i do something wrong during my pregnancy that might have caused it?' and look into the eyes of the crushed parents. The south part of the country fare slightly better than borneo partners, there was more awareness, more therapy options, more special school facilities. I was envious seeing how many people had more awareness and were more willing to bring their children to be screened. Socioeconomic standing also plays a role in the outcome, whichever parents that could afford to go for private therapy did have the upper hand. It dawned to be at times to think if free universal healthcare is still sustainable in the long run. 

Adolescence were the harder subcategory of patients. No wonder this period of growth was termed growing pains. Adolescence now had more challenges compared to the previous centuries, especially during the covid years. Self harm was rising as well as increased child abuse. 

Here, i learnt that it really takes a whole community to raise a child. The most effective interventions were done via a team. Each team member played an important role, contrary to the popular believe that doctors were in the highest hierachy. I had alot opportunities to take part in awareness programme which i truly appreciated. Colleagues and bosses were accomodating, giving me a pleasant working experience. 

-to be continued

Reflections

 The medical world can be a vortex which keeps churning you deeper until you lost all sense of control. I had so much things i love to do in my younger days, but one by one it was put off the shelve or postponed. The breaks were all replaced by more time working, more time spent on training activities or escapism through netflix. This was what i see when i look back now, the endless packing and moving with short getaways to attend important events but never truly able to stay for long. For some it might be described as part and parcel of training. To me now, i think this is how burnout was born. I wasnt even aware of burnout that time, thanks to covid, ive gained alot insight and i finally can see clearly.

I spent half of my 20s in Borneo. Starting off as a young aspiring doctor, ready to take off to serve the underprivilege citizens of our country, i arrived with alot of hopes of changing things for the better. Retrospectively now, i think i was abit too naiive. To think of it now, it might be similar to the 'white supremacy'. Even before i knew it, i found a home in Borneo, touched by their kindness and hospitality. Heck, it even manage to convinced me on cultural assimilation and diversity. Honestly, it became my comfort zone. 

When i finally decided what i want to do for life, the news about training outside Borneo gave me alot anxiety, multiple nights thinking about the what-ifs, the inferiority complex of maybe im not up to practise city medicine and the heart break of saying goodbyes to the friends ive made. I cried bucket loads, the grief came in pangs and waves. My comfy world that i had build felt like it was crashing down. 

I landed at the south part of the country, with loads of help from my parents who helped with my moving. I met a mutual friend and we hit it off together for our 1st posting. I was lucky to meet another human who knows how things in this state works. I started making friends from many introductions. This posting was the best place to get orientated to places, our job was mainly going for house visits. I could finally see on my own how rehabilitation and community care was being done for my patients. I was happy i wasnt confined by the walls of the hospitals. Here, being tactful and thinking out of the box were important. I was also seeing firsthand the stigma of mental illness from our community. When i described my experience to my friends, the response were alittle shocking. To them, they felt that i wasnt doing a doctors job. To me, it felt like i was contributing a small drop into an ocean, small but vital. I still believe that we had to be role models to empower the community and key decision makers to safeguard our patients. The idea of isolating people with mental illness by hospitalization or instuitionalising them is obsolete now. Mental health is everyones business and community plays a big part in sustaining their wellbeing. 

-to be continued

Lets start somewhere

When i was young, i dreamt often.. 

I dream of a path i would trot on.. 

How many hiatus ive taken, how many self doubt moments i had wasted,

And yet here i am, 

I chose exactly what i dreamt of.. 

Yet i still wonder about the purity of my intentions. 

Whatever it was, its one full circle completed. 

So what did i encounter on my hiatus journey?

Many, many things that made me perhaps better and stronger..

The system has a way of beating the crap of ones individuality, 

Silencing the thoughts and voices, 

Yet its always there and it was not lost.

It just needs some time and courage to let it out. 

Am i a little wiser? 

Perhaps.. but im also alittle naiive

Yet here i am today, thankful for where ive been and what ive seen.

Truly, our subconcious minds are a powerful place. 

Updates

Fastforward from where i left off it seems like time hasnt been moving so fast afterall. 

2 years plus with alot speedbumps,ive finally earned myself the permanent registration number. From that point onwards, i stalled awhile uncertain of the many roads i couldve undertaken.. a reflection of the past, a kind soul and a buddy was all it took for me to end up here. I was quite certain my life events were leading me to where i am now. After all these years, with depersonalisation i managed to move on yet at times i still go back wishing i couldve fix what still felt like a heavy unfinished business. 

What ive learnt from all these years is that the journey is the most important instead of the destination. 

Funny isnt it that after all these years my writing voice hasnt come back. Seems that what ive been repressing for so long has affected the writing part of me. 

Adieu. 

DIL DNR whats really going on

what ive learnt in medicine is at some point we all have to let it go.

the first time i knew what DIL DNR meant i was overcome with a tremendous helplessness.
to me DIL DNR simply means theres nothing to be done and all we can do is stand and watch.

my first encounter with DIL DNR was a jaundiced patient with hepatitis b and massive distended abdomen. the prognostic score was childs C. it was the first time i found out that someone could be scored as C. she was there in the ward, in one corner tucked away for 1 week. everyday i passed over her and i noticed that the tinge of yellow got yellower. her condition deteriorated as each day passes. foams would appear from her mouth, it got more in quantity and frequency. she was already in a coma when i met her. hepatic encephalopathy i was told. it meant there were too much ammonia inside her brain making her lose conciousness.

DIL means death in line. it meant the condition was a life threatening one. it also meant that there was no cure nor recovery. the condition would be a downhill one. what attempts we could do was to prolong time. perhaps buy some time so that family members could gather and bid goodbye. whenever DIL was issued, i would soon realise that there will be many visitors coming in. prayers were done often. sometimes hopeful visitors would stop me and ask if there was a slight chance of recovery. i could sense their desperation and a tiny twinge of hope from their eyes as if willing me to say yes. i wouldve given false promises that land me in trouble if i has given any signs of compromise to their pleads. initially i would shy away and inform them that its best to consult the specialist. few days would pass and the same question would be asked to me. by then ive observed enough words specialists would use to reply. my statements were usually im afraid the condition doesnt look good. or i would explain to them what are we treating for and show them tests that things are indeed getting worse. it was tempting for me to say eventually they will die but its too crude. its almost inhumane to utter such atrocities. most of the time the family members wouldve understood. i can see the sadness in their eyes. the limp nodding of the head, the silent sigh and sometimes tiny drops of tears forming in their eyes. usually i would silently exit myself or a gentle pat on their shoulder.
i soon also realise the reason why they keep asking me the same question. they needed confirmation. they believed that by reasoning it out they could accept the outcome. sometimes i could sense their frustrations. the same frustrations that i felt when medicine has nothing more to offer. i would suggest ways of easing the suffering of their love ones. gentle massaging, hourly turning or prayers. anything to make sure their love ones doesnt feel alone in their passage towards the end. im not sure how all of this helped them to face the fact that their loved one was indeed dying. but i feel no one should face death alone. i wouldnt want to be alone with death.

DNR meant do not resuscitate. no cpr. no medications to revive patients.
the reason why DNR is issued was if the doctor felt cpr would bring more harm than good. why prolong the suffering? why not let the patient die in peace. unnecessary intubation and admission to icu was not going to help. if anyone did aggressive resuscitation despite DNR issued its going to be a medicolegal issue. the fact is not many survive after cpr. mostly died after a few rounds of cpr. the ones who made it were a symbol of miracle. ive met a few who developed brain damage after cpr. it was the most cruelest outcome. i saw how much suffering the event caused. an incapacitated human being, bed bound,developing tons of complications like bed sores, pneumonia,etc. it was like a start of a very painful ending.
DNR was hard in the sense that families often feel that we doctors refuse to do anything to save their loved ones. its hard on the clinician where in their whole life theyre trained to save lives. good communication will help ease the shock to the family receiving the news but still emotions are hard to control.

i wouldnt lie that i didnt tell myself that i explained to myself that DIL DNR was the best for the patient. to be able to die peacefully and with dignity is a basic human right. these moments highlight the fine line that doctors are not god. the limitations of medicine is fairly clear here. whenever the nurse inform me that the bp pulse or oxygen saturation is dropping in a DIL DNR patient, i still go and attend. there are no crash cart following me. no cpr performed. i went and observe my patient, quietly asking god to ease their suffering and give them a smooth transition from the living realm to the realm of death.
as the breathing ceases, the heart slows down and the eyes becomes fixed, i pronounce the time of death and update the family. one live has just ended. soon the mortuary will come and transport the body away from the ward. i stamp the papers and the death reporting. case closed.