This no-brainer came out of the conjunction of three things: the offer of writing a chapter for a book on PTSD, the requirement to write an essay for my intermediate training in Family and Systemic Therapy, and the recollection of a clinical vignette.

Well, and a fourth thing – a friend returning from the borders of Rwanda where she had been working with Medecins Sans Frontiers. She and a couple of colleagues had been overwhelmed by refugees, and then an outbreak of Cholera in the refugee camp. She described squeezing through the first bag of IV fluid, putting up the second (with no drip-stands) and moving on to the next patient, knowing she was unlikely to see the person again. Her trauma was palpable, as well as her need to disseminate it, diluting it in doing so – the clearest illustration of the “ripples of trauma” I have ever seen – or felt.

It seemed perfectly clear that trauma does not only exist in individuals, but is communicated and therefore exists between them. I found some literature that supported the idea, and the essay was well-received. I have no idea if anyone read the book. Perhaps this is an indication – I have had none of the over-solicitous emails inviting me as an “expert” in PTSD, in the way that I have, so many times, in relation to a single co-authored paper on constipation.

This was an interesting project! I was working as a senior trainee in paediatric liaison psychiatry and was gripped by the problem of demonstrating that our interventions worked. The scenario is frequently one of a young person repeatedly presenting with a somatic concern which the medical team fails to assuage. It is often possible to enable this concern to reduce and even vanish through a series of conversations or activities broadly informed by a “mental health” mindset (but who will establish causality to general and scientific satisfaction?).

I thought that a time series might help in this task of demonstrating benefit, though I did not have any training in the use of time series. I found a young person who was admitted astonishingly frequently and obtained the admission and discharge dates for a period of about three years, during which time he enrolled in the local CAMHS day programme where he played pool a couple of times with a nurse and maybe chatted about seemingly inconsequential things.

Whether or not there was a drop in his admissions (which I think there was) became lost in my fascination with the numbers. In order to overcome the problem of seasonal variation, known to affect admission in his condition, I calculated moving annual totals (of days spent in hospital) on monthly basis. There still appeared to be a rhythmical cycle in the figures, so I repeated the exercise but using random figures, generated by Excel, setting the range between 0 and 30 days in per month. There was still a cycle visible!

I decided that there was something going on that I couldn’t understand and, under the circumstances, I should go back to being a trainee psychiatrist. I did ask around for some ideas. Someone said that some random number generators don’t generate very random series of numbers. My own idea was that an outlier (let’s say 28 days in one month – but see post below!) might dominate the total as it passed through from being a newby, to a has-been, causing a wave.

If anyone wants to take this up and explain it to me, go for it! There is a “leave a reply” box below, or go to HOME and leave a reply there.

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Wanting to challenge the received “wisdom” that fathers are “hard to reach” I invited a bunch of guys to an early evening group. Four came consistently. Another four (if I remember rightly) expressed interest for another time. They “formed, stormed, normed, and performed” but mainly formed and normed. Without knowing it I had basically created a focus group and, as there was little likelyhood of repeating the exercise, this was more like qualitative research than a pilot. I felt that they were not “hard to reach” at all – not if you were prepared to put in a tiny bit of effort.

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Someone said that they doubted it was possible, so we did it and it was fine.

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Karey and I wrote this after sharing a registrar post on the acute inpatient ward in Wellington Hospital. There had been some scepticism as to our ability to do this effectively. We took half a day each. Karey expressed milk for our firstborn. In the middle of the day we handed our son in one direction and a list of patients and jobs in the other. “He has had x to eat and slept for about an hour at eleven” in exchange for “Mr Y is newly admitted with depression and hallucinations, so-and-so needs bloods…” Etc. It worked. Not just from our perspective, but according to  the team as well – at least that is what they said. There was one key person whose perspective we never obtained until it had faded from his memory…..

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This piece was written during House Jobs. I had been on call for three days with almost no sleep. I still remember my tears when, as I dared to sink onto the bed on the third night, my bleep sounded. I sedated an elderly confused woman instead of finding out the cause of her confusion and helping her. I still feel shame, though do not blame myself. I suppose that I would call this self-compassion now. I was shocked at how easy it is, with sleep deprivation, to alter someone’s priorities.

West A. (1986) Personal View. British Medical Journal 293, 754.

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Link to paper on nih

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This piece, described by one of my tutors when he saw it as a cris de coeur, was a frustrated response to the fact that a) I saw an attitude developing around me at clinical school that we should not question what was happening until we had more “authority” and, b) that there was a very poor response to questionnaires we sent out to fellow students and an even worse response to invitations to attend meetings to discuss the medical school curriculum. I was already pleading the authority of the subjective.

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A good friend decided to drop out of medical school. Even that vocabulary is suspect! He decided to do something else. Maybe he floated out of med school, or jumped, cruised, wandered, ran. I can’t remember now whether his leaving was audibly commented on along the lines of “dropped” or with visible smugness on the part of those left behind, but I felt at the time that the med school – teachers, students and all – should have responded with greater self-doubt: could we have done better and might we have retained him for medicine? Medicine is such a broad school. With the danger of a narrow ethos. I am in little doubt that he would have found a niche and the profession would have been better with him in than out.

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