Healing The Maladies Of The Mind.

Old couples who had warmth and love despite the illness of the other,

Newly weds who looked at each other with fresh excitement but had deep seated issues,

Middle aged men and women who came alone in awareness of their condition,

Little ones who buzzed around with abnormal activity,

Young men who had fallen prey to addictions or who had been betrayed by relationships,

Women who survived the torment in their families but were victims of an innate sorrow,

Old men who had spent their twilight years in a liquid trance and were now facing the consequences,

People of all ages from a 11 year old boy bullied at school to a middle aged mother tormented by obsessions beyond her control, who had taken the extreme step to end their miseries as a lasting solution.

They were all patients in the Department of Psychiatry where I have been posted for 15 days.

I didn't have a lot of expectations since this was a busy government set up with limited facilities but as the days progressed by views were altered to some extent. We had admissions in the Male and Female Psychiatry Ward, follow up of references from the new hospital wing, OPD duties and also ECTs given twice or thrice a week while there are EEG facilities at a low cost, a small vocational activities centre and programs held in view of Mental Health Awareness.

We had a program in view on suicide prevention where we had a few cultural events, poetry and paintings were on display and we were given saplings to mark the event. during the past fortnight there was much to be learnt from Dr. P who was known for giving time to patients and counseling them and also looking into other comorbidities, Dr. B who has been in the hospital for almost a decade now and hence has an established rapport with her patients and Dr. S who always made it a point to explain the scientific basis of the illness to the patient and the attenders and also tried to implement aspects of cognitive behaviour therapy along with medication.

There were patients being seen by the Prof for since 6-7 years, patients who had shown tremendous improvement with medication and those who remained in the same level of (dys)function inspite of regular medication. Commonly, there were cases of Alcohol Withdrawal Syndrome, Generalized Anxiety Disorder, Major Depressive Disorder, Bipolar Affective Disorder (Mania), Catatonia, Obsessive Compulsive Disorder and undifferentiated Schizophrenia among others in the wards. The patients were monitored with respect to their medication and many left the premises close to their premorbid personality while some, like Y had to be discharged against medical advice (DAMA) since his religious inclinations had increased and he began to demand to go home. L was a typical case of schizophrenia with bizzare delusions, thematic perseverence and formal thought disorder even as he was oriented to time, place and person. During my ward duties for 5-6 days, the patients became somewhat more cheerful during the evening, some would even joke and manage a smile during my post dinner rounds while for some, the dreaded night only spelt restlessness and craving for liqour.

The OPD sees quite a consistent turnout of patients everyday with a minimum of 20-30 new cases and another 30-40 coming for medications or follow up. Commonly the cases were of dysthymia and MDD in middle aged women, adjustment disorder or sometimes bipolar affective disorder in younger women, generalized anxiety disorder in middle aged males, social anxiety in younger males, alcohol dependence syndrome in males (and even nicotine dependence syndrome) of all ages,
Attention Deficit Hyperactivity Disorder in children and cases of dementia in the older age group.

During my interaction with the patients (we were to take the patient history, vitals and present before the Professor who would then look into the treatment and counselling aspect), I realized that it requires some effort to dissociate the family conflicts, financial crisis or relationship failures (i.e the psychosocial stressor) from the actually illness of the patient. I felt that to a large extent, the individual's symptoms can be improved with treatment but when the stressors persist, it is nearly impossible to guarantee a significant change in the quality of their life. However, while we cannot instruct them on how to lead their life, we can always give our suggestions or better yet, help them to cope with their circumstances with courage and endurance.

The most important skill in this department is listening. While in most other departments, a preliminary examination and relevant history elicited to establish the timeline guarantees a probable diagnosis and treatment, in this case it is more of gently unearthing the relevant facts from the mound of unnecessary detail from not so forthcoming patients until they are ready to share the persecutory thoughts plaguing their mind. Only then can you consider a diagnosis or a sometimes a mixed episode after which you look at other comorbidities and decide on the suitable drugs.

Another indispensable quality is that of empathy. You cannot help your patient of you cannot try and understand how they are feeling. True, you and I know that the voices they are hearing in their head are not real but you need to make your patient feel that they are not alone in their suffering. You will need to educate them that they are not ill fated to feel such strong obsessions or deep seated feeling of sorrow, it is after all an imbalance of neurochemicals like seratonin and dopamine which can be controlled with timely and appropriate medication, support from their family and regular follow up.

Lead Kindly Light.

From mounting debts that pushed them off the edge

Through affairs that drove an irreparable wedge,

To the grieving for whom relief was a far fetch,

They chose the untrodden path of no return.

While somewhere a wife grieved for her beloved

Elsewhere a lover regretted hasty words unapproved.

And yet another father repented over love unshowered,

For they had lost a loved one to a preventable illness.

Tender care and concern was what they needed

To nudge the fallen spirits that could be reignited

A warm kindling fire of support was all they pleaded,

To awaken the sanguine Phoenix from their ashes.

To save one from the clutches of despair,

Is akin to saving a drowning man at sea.

By giving wings to a wounded man's dream,

Be that social pillar that shall heal and repair.

Suicide is not the answer.

Written in view of Suicide Prevention Awareness.

Keep your eyes and ears open!

Here we are at the end of August with 2 months of Medicine looming large. The past month has been spent in the Ophthalmology department and presently in the Department of ENT.

Ophthalmology department worked very systematically and since there were PGs here, there were specific tasks allocated to the interns. We did a LOT of IOP measuring, VT measuring, Lacrimal syringing, conjunctival washes and seeing the OPD cases upto one extent following which the PGs would take over. We even had a seminar assigned to us on a specific topic and thankfully that went without a hiccup. 

The Department is extremely productive; there are OTs almost thrice a week with one of them being a 'Camp OT' where more than a dozen patients would come for the cataract surgery. Apart from the regular cataract surgeries, Pterygium excisions, dacryocystectomy and Trabeculectomy procedures, there was the speciality clinic where they did laser procedures for Posterior Capsule Opacities (PCO: a common post op complication), Testing of Visual Field by the Automated Perimeter, B Scan (when the fundus was not well visualized on Direct Ophthalmoscope) and Fundus Fluorescein Angiography in cases of Diabetic Retinopathy and CRVO and so on.

While some days were interesting with something new presenting in the OPD like a Corneal Ulcer or Nystagmus or perhaps a foreign body, other days were spent in the mundane reality of testing the IOP of patients who simply refused to follow my instructions in spite of the simplest of explanation in the most controlled calm voice possible. Ophthalm duty did not actually involve frequent casualty calls and even when they did, there would be a first year PG to help you with it. The PGs were friendly and the kind you could approach for all the questions that pop into your head.

Following 13 days in Ophthalm (I took two days off and headed home for the weekend. Ah, bliss.), It was time for ENT. The ENT OPD was definitely busy and there were regular admissions for the surgical procedures like Tonsillectomy, Septoplasty under FESS, hemithyroidectomy, Excision of swellings, Tympanoplasty with Mastoidectomy and sometimes even emergency tracheostomies.

 The OT is twice a week so more often than not, due to the heavy load of cases, a patient ended up having his surgery after it had been postponed ATLEAST once. After a 'shakeup' of things regarding the casualty duties, it appeared that we would not have to do duties but of course that was not meant to be so the duties are back on and we keep the PGs in the loop.

While ENT does bring you in close contact with infections, it also brought out the effect of people's habits. Oral submucosal fibrosis was a common presentation after years of tobacco chewing as was a carcinoma of pyriform fossa or a tonsillar malignancy in chronic smokers. One patient came to us with a very obvious swelling in the neck that ulcerated in few days, change in voice, inability to swallow and in stridor requiring a tracheostomy within a few days. While some of the early stage cancers are given RT/CT, the others are given more of palliative care since they would not be eligible for radical neck dissection and RT due to the  widespread growth of the tumour.

Another patient I followed up was Eshwaraiyya who came to us with uncontrolled epistaxis. He had earlier undergone ligation of the sphenopalatine artery at St. John's as well but the problem had reared its ugly head again. He had a history of cerebrovascular accident few years ago and was on ecosprin since then. He was also a known case of hypertension and had been passing blood in stools for some time now which had caused his Hb to drop to alarming levels of 5gm/dL. After transfusion of 3 pints of blood his Hb improved but that didn't solve the root of the problem so we referred him to the surgery department where they scheduled him for a colonoscopy to find out what could be causing the bleeding.

ENT was a memorable posting thanks to the interaction we had. Some of the professors were friendly and explained more on the procedure and the case at hand, the PGs were approachable and I was excited to find a fellow bibliophile in Sana ma'am and also, it was good to have more interns join us making the work load lighter, fun times more frequent and many light hearted moments during the course of these 15 days!

The next 6 months are the 3 big majors starting up with General Medicine which includes 15 days of psychiatry. I have a lot of trepidation about the coming days but hopefully they will be eased once I get into the thick of action. Here's hoping I can do my best, deliver to the best of the facilities available and assimilate as much as possible from my experiences. :)