The second trimester ends.

It has been an interesting journey so far.

If you recall, dear reader, the first thing I did after we received our diagnosis was to download a book called “Five Fingers Ten Toes” on Amazon and read it overnight. It has a few reviews, all five star, as is common in books about differences. It’s a simple, honest book, written by a mother who raised a limb different child in a time and place where few resources were available. She survived on faith, humor and a strong community. When the kids grew up, she took a creative writing course and wrote the book. It gave me tremendous hope when I needed it.

The founder of the Lucky Fin Project later connected me to the author, who was just as open and sweet on Facebook Messenger, offering support and advice.

I quickly realized the limb difference community is different from most communities I’m used to- people are helpful and positive, and almost aggressively so. They seem to realize what you need even if you are hesitant asking for it.

Molly Stapleman from LFP also connected me with a few mothers in our region who are raising limb different children. Again, these ladies were incredibly proactive in reaching out and offering support and advice.

I read more. I read blogs, mostly. Living One Handed, written by a funny guy/pastor. Born Just Right, written by a very resourceful mother of an almost teen with a limb difference. Stream of Caitlinness, written by a one handed young woman/teacher. When I ran out of blogs about people with limb differences, I branched out. I read blogs written by people with skin conditions that make them stand out, people with dwarfism, people with autism, people who are wheelchair bound. I was particularly impressed by Don’t Hide it Flaunt It, an organization and website run by a NY based lawyer with a genetic limb difference who, as she says, “gave birth to her difference”, i.e. has children with same anomalies as herself.

I read “Double Take”, a brilliant memoir written by Kevin Connolly, a 23 year old champion skier and photographer who was born without both his legs. He didn’t shy away from describing the brutal realities of his life. I hope he writes more.

I spoke with a psychologist who has a limb difference. I met with one of the local mothers. I signed up for and missed a meeting of the Helping Hands Foundation, a group made up of parents raising limb different children. That was the day we had our only heavy snow of the season. Instead of driving to MA, I spent the day reading “When Breath Becomes Air”, a memoir written by a 36 year old neurosurgery resident as he dealt with a diagnosis of terminal lung cancer while finishing his residency. He and his wife decided to have a child after he received his diagnosis. His wife asked him if he really wanted to have a child, given that it would make his death more painful. His response? “Wouldn’t that be wonderful?” His contention, “We agreed that life was not about avoiding suffering, but about meaning.” hit home. So I re-read “Man’s Search for Meaning.”

Someone connected me to a (HUGE) group of physician mothers on Facebook. From there I was directed to two subgroups, one of desi women physicians, from one of whom I procured a fresh yogurt starter when mine went bad. The other was physician mothers’ of special needs children. More connections forged, more insights gained.

At the recommendation of someone in this last group, I am now reading “Far From The Tree”, a beautiful book about raising children who are different. I’m also planning to meet some of the local Helping Hands mothers on a playdate. I went for another ultrasound today, with the same doctor as the first one. He had a medical student with him. Today we laughed and joked, about a materno-fetal medicine fellow who was going to join them but didn’t, about the baby and the fibroids and who shall prevail, about pregnancy induced dementia.

In the meantime I’ve taken to calling the baby Luke. I saw a onesie which had a one handed pirate monkey on it and almost bought it. As my toddler obsesses over fingers and paws and mittens, I wonder what she, an exceptionally perceptive child, will make of her baby brother. For now she is content to occasionally kiss (or kick) my belly and I’m content leaving it that way.

 

Posted in limb difference, pregnancy, parenting, Uncategorized | 5 Comments

Hello! I’m blogging again..

..and here’s why.

Back in 2013 I stopped blogging- food was no longer all that interesting, and psychiatry was getting harder to write about. Offline life was getting more and more hectic- new job, new house, new child, and so on. I did not think the world needed to hear from me anymore.

Its 2016. I now have a child, a precocious two year old who lights up our life. I have a wonderful job, a wonderful husband and a home I love. We have a second baby on the way, and I have been feeling pretty smug with the way things have worked out.

Until a few weeks ago. I went for my 18 week anatomy ultrasound scan after work. I had been feeling well, with the first trimester fatigue subsiding. My OB had been joking with me, telling me how “boring” my pregnancy was. I used to tell him, “I like boring.”

That was about to change. The ultrasound tech told me she was having trouble seeing the baby’s left hand. Maybe he wasn’t cooperating. She had me pee, and then called in the doc. He was able to get the baby to move, but still could not see the left hand. He started to sweat as he told me the hand was “most likely missing.” He apologized. I heard myself say, “Hey, it’s only the left hand.” He said something about the left hand not knowing what the right did, and then start apologizing again. All I wanted was for him to leave the room so I could start crying.

Back in the car, I called my husband and my sister. Both physicians who deal with ultrasounds, they told me how unreliable ultrasounds were and we would wait for the repeat scan scheduled two days out. We all clung on to that little ray of hope through the tears and the bewilderment.

I did a few things anyway. I went to my birth board, and was quickly referred to the Lucky Fin project, an organization created by the mother of a young girl with a limb difference. I downloaded a book written by the mother of another young man with a limb difference and read it overnight. I read every website I could find about limb differences. By the time of the second scan, I had a fair idea of what we were dealing with. My husband accompanied me this time, and we both saw the missing left hand clearly. The doctor was different this time, a calm woman who told me, “I’ll cry if you will.” So we both did. She then gently told us that termination was an option.

An option? I consider myself fiercely pro-choice, but this wasn’t a choice. We saw a baby on the scan, a yawning, penis flaunting, playing-with-toes baby. A baby without a hand. If I lost my hand today, would I kill myself? And thus the decision was made. Did I revisit that decision in moments of darkness? Yes. But I always reached the same decision, again and again over the next few weeks. The husband never doubted the decision at all. In his line of work, it’s always “life over limb.” His friends said, “But this is your child.” He said, “that’s precisely why it’s even more true.”

What can I say, I married an idealist and a romantic.

So here we are. Six weeks out, and freshly back from a trip to the homeland. We shared the news with close friends and family. Everyone has been supportive, though the topic obviously makes some people uncomfortable. We’ve reached out to physicians in the field, to families, to friends and strangers. The limb difference community has been incredibly supportive. I still occasionally battle with “why my child?” Was I too smug? Did I consider myself too lucky? Did I not drink enough water? Did I squat too much? Why, oh why, did I watch that bloody lunar eclipse?

And then the baby kicks. I see pictures of other adorable kids and successful, happy adults with various kinds of limb deficits. And I know things are going to be okay.

This is why I’m blogging again. Because we’ve started another journey, one I that I believe will be worth sharing.

 

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Of guns

Newtown is half an hour away from here. When the shooting at Sandy Hook happened, I was at work. I could hear the clinicians talking about it in the hallway, and I started to Google for news. The details kept coming in. When it became overwhelming, I got off the internet, because I had patients to see. A lot of them, especially the parents, came in tears. I had to listen to them, stay with them in that moment, and be honest about my inability to offer much more than support.

It kept eating at me, though. The news on the local radio. The way the classic rock channel that I like (owned by a conservative corporation) went from saying “It’s too soon to talk about guns” to calling the President Loser of the Week for wanting to enact gun safety reform. When the opportunity to volunteer in Newtown came, I jumped at it. It gave me a chance to feel like I was doing something, even if most of it was sitting around in a school, chatting with middle aged counselors from nearby towns, more mental health professionals and therapy dogs than people who needed them in the cold evening hours.

I have an alien’s perspective on guns. India is not a hunting society. I grew up vegetarian, in a religion where any form of violence, even a mental “I want to strangle him!” is a sin. A significant part of my childhood was spent “rescuing” pests- ants, cockroaches, wasps- and releasing them outside rather than killing them. I never saw a gun until I was 13.

That’s when it changed. My father, a well-to-do businessman in a small town in a state that is considered The Wild West of India, was kidnapped. This wasn’t unheard of in election times. It was business as usual. They wanted money. The policemen came. There were long meetings that I wasn’t a part of. Policemen with guns sat around our house and the maid took them tea and biscuits. Four days later, my father came back.

The next day, a senior police officer told my father to buy a gun. He smiled at this, but applied for a license just the same. A month or so later, I saw my first double barreled musket up close. I could never imagine my father shooting at someone. Neither could he, and in a few days, the gun disappeared somewhere in my mother’s pantry. We never saw any bullets.

The next time I thought about a gun was when I took this job. One day a week, I was working in a substance abuse residential facility, the patient population mostly made up of felons under court mandated treatment. Some of them were sociopaths. They tried to charm me into giving them a diagnosis that would lead to secure housing. When that didn’t work, they would try aggression. There would be pointed questions, about my car that was parked outside, my family, where I lived. They would talk about violence, about what they might do if they didn’t get the help they needed.

There were days I got scared. There were days I frantically looked up scales that would tell me the likelihood that they would attack me, what I could do to make sure they didn’t. I didn’t find much beyond what I already knew. I thought about buying a gun. Another few minutes of research told me that that was stupid, that I was more likely to be killed by my own gun than to be able to defend myself with it. So I didn’t.

Instead, I turned to my father and his faith. The good old hota swayam jagat parinaam– The World Takes Care of Itself. I will die some day, and I don’t control how/when. I will not be stupid. I will not own weapons that are likely to kill me/my loved ones/or even complete strangers. Children. Innocents. I will volunteer at all the Newtowns where I can. Because I know there will be others. As long as there will be guns.

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Election 2012

I read two articles in the newspapers today, one about Governor Romney’s 2011 tax returns and the other about a welfare mother. (Remaining cognizant of the fact that this is the NYT, a newspaper with a liberal bent.)

It made me think about my role in this society. I am a legal alien. I came to this country as a student and went through specialized psychiatric training. I invested a huge amount of my own money to start the process and was then paid a salary by my training programs, in return for the patient care I provided as a trainee. By general consensus, medical trainees provide a lot more skilled labor than they are paid for. While training as a specialist, I worked 80 hours a week, took overnight calls taking care of extremely sick patients, and made anywhere between 30,000-50,000 dollars a year throughout my 5 year training.

At the end of this training period, my agreement with both US and Indian governments was to return to my country. But like most skilled immigrants, I wanted to stay. The US government allows me to do that if I promise to serve in an under-served area with a health professional shortage, for a minimum of three years. Before hiring me, a health organization has to prove that they advertized for an American citizen to take the job for at least 6 months, and no one did. I took one such job.

I now work for a Federally Qualified Health Center in an inner city area. All my patients are poor, most of them have Medicaid, with a small proportion being on Medicare and private insurances. I also see patients who do not qualify for Medicaid yet can’t afford private insurance- the center puts them on a sliding fee scale, and they are able to see me and their other doctors at about $20/visit. This adds up when you add the cost of paying for medication out of pocket, but thankfully, the 4 dollar drug programs from companies like WalMart allows me to make sure they have the bare bones medications they need.

What does this mean for me? Most days, my practice feels like trying to plug a hole in a dam with my finger. A vast majority of my patients have been too sick to work for years. This includes those with schizophrenia, those with severe bipolar, crippling depression, dementia, traumatic brain injuries, moderate-severe mental retardation.

Some people who come to see me have milder symptoms. Often, they bring in disability papers for me to sign. Sometimes, I have to tell them that, in my opinion, their mental health diagnosis is not enough to keep them from working. A lot of these people drop out of treatment when I tell them that. Some don’t.

Most of my patients live in a continual state of crisis. They don’t have transportation, or housing, or food, or money for their children’s school supplies, money to take their family to doctors who don’t accept Medicaid. I try to see them often, because every month brings a new crisis. “I lost my visiting nurse because the insurance said I no longer qualify.” “I can’t afford physical therapy.””I went to interviews, but no one will hire me because I’m old/have a prison record/have visible tremors/am overqualified.”

I work as hard as I can. The clinicians I work with often double as social workers for these patients, helping them finding crisis housing when they lose their apartment, filling out paperwork for them to be brought to the doctor’s office when their clunker dies, finding vocational opportunities that allow them to find work, even if a few hours a week.

For this work that I do, the government pays me a salary that puts me squarely in the top 10 percentile of the income distribution. This salary is considerably lower than what other specialists make, and considerably lower than what I would make if I were in private practice, or employed by a for profit hospital or university. It is more than enough for what I consider a very comfortable life.

And I’m grateful for this. I’m grateful for the opportunity to remain in this diverse, open country, grateful for the opportunity to do what I do best, grateful that my 30-35% taxes pay for this health center, the roads, the traffic lights, the police, the EMS, urgent care centers, housing shelters, and yes, various forms of government assistance.

Because I come from a country where there is no government assistance. Every day, I’m aware of the fact that most of my patients, had they been in India, would either die, or resort to begging on the street in order to survive. This nation allows them not to do that. And for that, I’m grateful.

*Disclosure- I am neither a Democrat or a Republican. Being on a visa, I cannot vote. Like most Americans, I try to see beyond the smoke screens both parties put out. I don’t completely support either side, but have a clear bias towards one.

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The shocking facts about shock treatment.

Have you ever heard a medical war story?
I died on the table, and they brought me back twice. Broke two of my left ribs. The doc said it was a miracle.

You probably have. How about a psychiatric war story?
I was so depressed I wanted to kill myself; they gave me shock treatments and I got all better. Look at me now.

You probably haven’t. The reason is not that stories about ECT, electro-convulsive therapy, don’t exist*; it is because there is still a huge amount of stigma about mental illness in general and about ECT in particular. It is not something you talk about when you run into an old friend at the grocery store.

We’re all familiar with the horror stories, though, the images burned into our minds from years of TV and cinema. A feisty, likeable young man strapped down on the gurney, shocked with naked wires till his hair singes, turned into a zombie staring into space.  Our hearts turn with indignation. How dare they?

I ran into some of that recently, on Twitter. A simple comment about the effectiveness of ECT brought on the wrath of the antipsychiatry folks.

You’re mixing electricity with water!
Doctors just love to strap people down and shock them don’t they?
Have you had ECT yourself? You seem to have very strong feelings about it.

The wrath has persisted – even when I and two other psychiatrists clearly stated that yes, if severely depressed, we would choose ECT as a treatment for ourselves. It’s no surprise; there is little knowledge and plenty of misinformation about ECT amongst both patients and doctors.
Let’s talk about ECT, then.

What is ECT?
During ECT, a small electric current, smaller than a Taser or a cardiac defibrillator, is applied to the person’s temple to induce a generalized seizure, lasting 15-45 seconds.

How does it work?
*Edited. There is no definitive answer to exactly how ECT works, but there are several well documented changes in the brain. The small seizure releases several neuro-chemicals in the brain. It also modulates the activity of several brain centers, such as the frontal cortex, prefrontal cortex, and cingulate cortex.

What is it used for?
The main use of ECT is in people who are severely depressed, often with strong suicidal thoughts, psychosis, catatonia, or severe malnutrition due to refusal of food.

ECT is not a first line treatment. It is usually considered in patients who have failed multiple treatments with several different medications and psychotherapies.

Is it better than other therapies?
Meta-analyses (collecting and analyzing multiple studies done over years) show that ECT is more effective than any other treatment used for severe major depression**. Significant improvement occurs in 70 to 90 percent of patients who receive ECT, compared with approximately 30 percent for medication.

In 2011, the FDA conducted its own systematic review and meta-analyses** with the following findings:
– An analysis of 5 randomized trials estimated that improvement on the depression rating scale was about 7.1 points greater in patients who received ECT compared with sham ECT.
– A review of 3 randomized trials found that ECT was more effective than placebo.
– An analysis of 8 randomized trials estimated that improvement on the depression rating scale was about 5.0 points greater in patients who received ECT compared with antidepressant medication.

Is it painful?
No. ECT is performed under anesthesia. Along with anesthetic, a muscle relaxant is usually administered so that the body does not shake, unlike a regular generalized seizure. This prevents accidental injuries during the convulsion.

There are two movements commonly seen during ECT- the initial facial grimace, which happens because electrodes directly placed on the temples cause the facial muscles to contract- it is often scary to students watching the procedure, but the patient does not feel a thing.
Second, a blood pressure cuff is placed on one ankle to prevent the muscle relaxant from reaching one foot. This allows the doctors to observe the seizure in the toes of one foot, to corroborate with the EEG.

What EEG?
An EEG- brain wave monitoring – is done during ECT. This allows the doctors to ensure an adequate seizure time, 15-45 seconds. This also allows them to use medication to terminate the seizure if it goes on longer than intended. An EKG-cardiac monitoring- is also commonly done.

What are the side effects? Can it kill the patient?
The death rate of ECT is 2 to 4 deaths per 100,000 treatments, making it one of the safest procedures performed under anesthesia. Death is mostly related to heart-related side effects. All patients must undergo a medical evaluation for clearance prior to receiving ECT, and a cardiac consultation is indicated for those with heart problems. Other side effects include aspiration pneumonia, fractures, injuries to the tongue or teeth, headache, and nausea.

What about the brain damage?
ECT causes three types of brain side effects:
– Acute confusion- this is a result of the seizure and anesthesia. It resolves in half an hour.
– Anterograde amnesia- decreased ability to retain new information. This usually resolves in 1-2 weeks after treatment.
– Retrograde amnesia- forgetting recent memories, for events that occur during the course of ECT and a few weeks- months prior to that. The deficits are greatest for knowledge about public events, rather than personal information. Some of the lost memories may return, while others may not. In one systematic review, 30-55% of patients reported persistent memory loss.***

The typical ECT patient is severely depressed and accepts some degree of memory loss as a reasonable tradeoff for improvement in depression.

Can someone be given ECT against their will?
ECT should be done with informed consent- a discussion of risks and benefits with the patient. It often involves patients watching videos of the procedure to assuage their anxiety, and they are given plenty of time to ask questions and decide if they want to proceed with treatment. Under rare circumstances, if a patient is too sick to give an adequate informed consent, the doctor may petition the court for a treatment order. ****

The trope of a poor, mentally ill person being given ECT against their will is just that, a trope. The typical ECT patient today is relatively affluent and receives ECT in a private center. State hospitals rarely offer the treatment.

For further information, please visit:
The National Institute of Mental Health. http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml
JAMA. http://jama.jamanetwork.com/article.aspx?articleid=193642
UpToDate basics. http://www.uptodate.com/contents/electroconvulsive-therapy-ect-the-basics?source=see_link
UpToDate beyond the basics. http://www.uptodate.com/contents/electroconvulsive-therapy-ect-beyond-the-basics?source=see_link

* Surgeon/writer Sherwin Nuland gave this wonderful TED talk about the history of ECT and his own experience as an ECT patient. Please watch this video for a patient perspective. http://www.youtube.com/watch?v=oEZrAGdZ1i8

** FDA Executive Summary: Prepared for the January 27-28, 2011 meeting of the Neurological Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT). http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/UCM240933.pdf

**UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799.

*** Rose D, Fleischmann P, Wykes T, et al. Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003; 326:1363.

****The only time I saw a court ordered ECT in 6 years of training was an elderly patient, depressed to the point of zero communication. He was completely immobile, could not eat, could not use the restroom. He stayed so still for such a long time that contractures developed in all 4 limbs. Since he could not communicate his wishes, the doctors petitioned the court. After 6 ECT treatments, he started communicating enough to be able to work with physical therapy, and eventually became mobile enough to walk short distances with a walker. I will never forget the first day he smiled at me.

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How it all went down. (V)

The 15 minute ride to  the community mental health center is over soon. It’s a beautiful building, nestled between well manicured lawns. The clinic where I work looks nothing like this. Still, it’s a community mental health center. This is where I have been working for the past 6 months- I know this population. It makes me feel confident.

We meet our team leader, go through a smaller orientation, and are asked to wait in what appears to be a group room. There is a smaller room off to one side with food and drinks, labeled For Candidates! I make myself my third cup of coffee of the day. We all gather around the table, making small talk. Someone leaves for a walk, someone else catches a nap. There is no cellphone reception. An hour passes by.

Our team leader is back. He leads us down the hallway to meet the examiners. I am introduced to my examiners, one a generic handsome doctor type and the other an older swarthy looking gentleman with an inverted U shaped mouth. I follow the examiners into a clinic room.

The patient is already seated as we walk in. I take my seat at the desk. The examiners sit to one side, poker faces on. My patient is a middle aged woman, pleasant and eager to cooperate. I launch into my standard introduction, amended to include a brief line about the examiners. While talking, I draw lines on the writing pad, dividing it neatly into 8 blocks. I have done this thousands of times. This is easy.

History of Present Illness.

Past Psychiatric History.

Medical History.

Substance Abuse.

Family History.

Social History.

Mental Status Exam.

Assessment and Plan.

I let her talk freely for the first five minutes, barely interrupting, scribbling notes in the columns where they fit, sifting words into data now since there will be no time later. Never actually looking at the paper. She has the rhythm of someone who’s been in the system for a while, and knows what to say. So far so good.

Next, I start probing, leading with open ended questions, then following with more concise ones. At some point, I make a comment, trying to clarify her thoughts during a period of sickness. She turns to the examiners and says words that are pure exam joy- “She’s Good!” The examiners don’t blink. We carry on.

One of the examiners calls out the five minute warning. My patient, bless her, has given me enough information to fill in all my little boxes. We do a quick mental status exam and I thank her for her time. She smiles, wishes me good luck, and leaves.

My examiners don’t give me the usual couple of minutes to gather my thoughts. Dr. Inverted U hangs back while Dr. Handsome starts questioning me. I answer the questions as I would while discussing a case with colleagues- my case summary, differential diagnosis, plan. As we dig deeper, I realize I don’t have enough information on her current family situation. The examiners know this- Dr. Handsome asks me to hazard a guess. I do- he maintains his poker face, while Dr. U nods in the background. For the rest of the Q&A, I make sure to look at Dr. U- he keeps nodding.

And just like that, it’s over. We spill out of our clinic rooms, visibly more relaxed, grinning, suddenly hungry as we walk back to the bus. It turns out that the examiners are taking the same bus back to the hotel as the examinees. This dissuades most people from exam talk, and we spend the rest of the ride swapping restaurant reviews.

Once back in the car, I text my friend. We meet soon after, going out for dinner, treating ourselves to ice cream. Talking about our cases. Both of us agree that we might pass, but the three week wait is going to be hard.

As it happens, the results comes out in less than two weeks. I pass. So do my friends, new and old. Now we can get back to the actual practice of medicine as opposed to the stylized performance of the Oral board exam.

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