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Wednesday, January 3rd, 2007
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11:31 pm - Welcome to 2007!
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I have been missing for a long time and not been blogging for sometime now...
I have decided to go missing for a while...
Been busy with studies and work...juggling family life at the same time
Creating bigger goals...
I have decided to convert my blog to talk about my experiences as a medical doctor...as if I haven't been doing that all this while...
Thanks to those who still look at it...I know, its not been updated for more than 6 months. Hope to write more stuffs as the days go by
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| Wednesday, May 17th, 2006
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12:17 am - It's been a long long time...
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Just back from my MRCP exams...yeap, been busy for the past few months preparing this examintion...it's like I'm going for the examination of my life. There were lots of people siting for this exam this time round...more than 100 people, some who were known to me, some my seniors, and some on my juniors from IMU. The exam centre is at University Malay (UM) in KL and its an advantage for me that I don't need to travel far to take this exam.
Sigh, the outcome of the exam is somewhat debatable...a lot of ambuiguity, but I have to aconclude that more time is needed to prepare for this exam, a few months is just not enough, unless its really an intensive few months! Topics are very broad, but I'm glad they asked a lot of nephro questions...some which I could not even answer! My gosh, all of us were sweating inside the hall...we had 2 papers, 100 questions each, best choice answer (A, B, C, D, E). 3 hours each paper...can you imagine, I was at UM from 1pm until 9.30pm! It's was all dark and scary by the time we finished and got out of the examination hall!
Well, going back to work tomorrow...long day ahead...now have to start praying and find out the results in 3 weeks time...
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| Saturday, April 15th, 2006
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1:28 am - Time flies...going back to school...
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It's been almost a month since I posted anything...
Going back to school, going back to my books, I have registered myself for the part 1 MRCP paper in May 2006. Stress is building up, and I'm have to divide my time very well for work, studies and Choon Yan...
I've been more involved with clinic work lately, taking care of the CAPD and haemodialysis units...and expanding my knowledge in this area. How much you want to gain in a department pretty much depends on how much you want to learn. Spending more time doing 'PR' work and making sure everything is fine while trying to grab as much knowledge as possible from my seniors, specialists, and consultants. Some patients are really irritating in the clinic, asking you from A to Z, when they themselves are not compliant to medications and diet controls...but I had a patient who was VERY compliant to his medications. He showed me his pill box, with comes attached with a self activating ALARM! (yes, its all in one set!) I have never seen anything like it before...now he will never forget taking his medications...
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| Thursday, March 23rd, 2006
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12:41 am - Still in nephro...
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Started to do clinics today, what a change of emphasis...patients are more stable compared to the wards....but you still see many patients in denial of they kidney disease; well, I guess who wouldn't, just because the doctors do some blood tests, ultrasound my kidneys, then say that I am having kidney failure because the tests came back positive...not to mention that I am feeling so well now! (the patient). But they don't know 'well' for how long...
Enjoying nephrology, though work here can be quite 'routine' at times, but the exposure if definately helpful, especially if I've considered taking up a career in medicine.
I have already lost count how many IJC's, femoral's and Stab PD's I have done...
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| Sunday, February 12th, 2006
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4:07 pm - What a week it has been...
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Total count: 20 stab PDs, 4 IJCs, 6 femoral lines...
It's been another interesting week at the nephrology unit...so many issue to discuss over...
Making the right/best decisions...I guess that is something that will still be difficult to do even after being a consultant...I had a patient who passed away during my call...we had noted that she had a unilateral calf swelling on the morning before the passed away...our most likely diagnosis then was DVT, not to mention that she had ESRF due to long standing diabetes mellitus and was in the ward for regular tenckoff Peritoneal dialysis until she was started on her CAPD program. She started having low BP in the afternoon, just before the ultrasound scan, and the swelling was not getting any better. We had already started treatment for DVT and now we are suspecting that she might have pulmonary embolism...She deteriorated so fast that we didn't have time to do much to help her...before long, she was already on triple ionotrops...
I wonder if we had done enough...i guess nothing is enough when the patient is only 44 years old... its more difficult to handle the family than the patient itself...
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| Thursday, February 2nd, 2006
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11:10 pm - What a holiday...and it's back to work...
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Not something I was looking forward to, but all good things have to come to an end...
My holidays was well spent with family and friends...not to mention that Choon Yan was there with me...
I was very pleased to see that I had only a few patients to see in the morning...However, when I left the ward at 8pm (yeah, 8PM!), the ward is full! Both nephrology wards had been pilling up with patients througout the day...it was worst that a warzone when i got out of it...
Did 3 stab PDs, one femoral line and a CVP...first i tried a short line via the internal jugular...failed, then used the ultrasound to help me out, also failed...the best part was I finally go it via a peripheral vein! I should have gone there straight in the begining...for some reason, that guys peripheral veins are larger than his central veins...or perhaps my skills just needs more polishing up!
Total of 18 stab PDs, 4 IJCs, 4 femoral lines...
I had a patient who came in today, on regular haemodialysis, not having dialysed for 1 week! When my consultant saw him, he almost fainted...he came in septic looking, tired, febrile...Some patients' level of education really needs to be strenghtened...the best part was the nurse told her that she didn't need dialysis; so now i'm wondering whether its the patients or the medical staffs are at fault!
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| Monday, January 30th, 2006
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12:13 am - Gong Xi Fa Chai!
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Happy CNY all readers of my blog...
Another year goes by...better things to look forward this year....hopefully, better pay, better work enviromenet, advancement in career, thinking about settling down, passing exams, lots of things in my mind...
Spent time at home during CNY...eating, eating and eating...The same things happen every year...but I felt very homely this year, and Choon Yan was with me...
Have a nice day people...
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| Saturday, January 21st, 2006
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10:30 pm - Nephro's been busy...
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busy as it is...but there has been much more learning for me...
its quite pityful to get end-stage-renal disease...and requiring dialysis...not many people can afford it...it can go up to rm2000-2500 a month. Some get financial support...some don't...and their disease get worse...they come in every week not looking any better...what can we do for such people?
Even kidney transplant patients are not without problems...with the amount of immunosuppresion that they are taking, all sort of bugs can make them ill...
My calls have been pretty allright so fat...not to mention that I have already done 2 this week, and my third for the week tomorrow. Hope it stays the same...no half day off for post call people...we are pretty short on MO's anyway...so, everyone is just helping each other out with ward work and procedures...
Hope tomorrow goes well...
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| Tuesday, January 17th, 2006
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11:22 pm - Post-call
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My first nephro call...I had difficulty getting back used to calls when I had to do everything...coming from surgery, where I didn't have to do much, and could ask someone to do it...now I need to do everything back again myself...that's gives me full control of the situation...which makes me a pretty tired person also...
Glad that admissions were kept to a minimal...I got a couple of hours sleep. Got 2 more calls to go this week...
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| Friday, January 13th, 2006
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11:53 pm - A new Begining...
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I guess today is one of the best days of my life...an opportunity to move on in my carreer. Never had I dream about having a day like this...an opportunity comes with many obligations...some which I am about to take which is going to change the rest of my life and the people around me...what am I talking about? I shall keep it to myself until everything has been finalised...
My life has always been an uphill climb from the day I completed my SPM...it comes in waves, when I finished SPM, I thought the worst was over, but within a month, I enrolled myself into a college in KL, then completed my matriculation, and within another month of completion, I enrolled myself to IMU. After 1 year 8 months, I got myself involved with studying again...this wave is going to be another challenge in my life. It's back to the books, and to proceed on with my career path, to be a better doctor, to give back what has been given to me, to aquire more so that I can give it back to the people later.
I had made a promise in the past, and I shall not forget that promise...it'll make me stronger everyday. Without Choon Yan by my side, my challenges would not have gone smoothly. Her presence and support drives me to work harder eveyday...she makes me understands the better things in life....
2006 is going to be interesting...looking forward to a lot of exams...
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| Thursday, January 12th, 2006
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8:45 pm - Whooooopieee....
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I finally got my full registration...ended my months of frustration trying to get the MMC to get my name on the list!!!! Had to make loads of phone calls and sepak to the right people before all this was done...
Enjoying nephrology...to date, already done 8 Stab PDs, 2 internal jugular catheters, 1 femoral cath...i guess that's the only three procedures i will do around here...really making up the time i missed during my housemanship years...also spending time leaning about basic nephrology...
Taking leave tomorrow for an important interview...hope it goes well...
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| Sunday, January 8th, 2006
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12:38 am - The new Begining...nephrology...
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I have finally ended surgery and had already spend 2 days at nephrology...
so far so good...I am very happy to be back in a medical based posting...since I've never had any exposure in nephrology while as a houseman, this is a good time for me to fill up the empty gaps...I guess this is one of the problems when you are attached to a hospital that is too specialised...we had exposure in hepatology and cardiology, but not nephrology...i wonder why also...
I had already done 2 stab PD on my second day at nephrology....really cool, finally get my hands on it...though I must say that it can be a rather dangerous procedure...since you're going in blind, there is always the risk of bowel perforation or viscus injury...have to keep praying that you dont drain out blood or faeculent material...I have already seen all these complications while I was in general surgery.
My first Femoral catheter was done in nephro...cool man...the catheter itself already costs rm 200 ++, failure is not an option...now he can do dialysis...
The team is smaller in nephrology (as compared to surgery)....but the HOD is one great person...he spends a lot of time doing clinical work...my respect for him...I have great MO's to work with...hope that I can keep up the standards around here...not feeling as depressed as I should (I have this tendency to feel depressed when I join new postings, cause I'm like a dumo there...), though there are so many things that I still don't understand in nephro...my consultant said, "its okay, you're going to be blur this week, but don't worry, you'll learn".
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| Monday, January 2nd, 2006
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1:47 am - Happy new year 2006
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Another year goes by...how did everyone celebrate it? I was at home...sleeping
Choon Yan was working on the 31st.
Been resting a lot in the past week...exploring the other side of myself (besides medicine)
Finally got my new car...
Off an on, we need to think back about things that has happend in the past...year 2005 for me has been an unforgetable experience...starting as a blurcase houseman. and ending as a medical officer..I started the year off in O&G department...before heading the Paediatrics and the Surgery...I saw myself acquaring more skills in the diciplines that I have been rotated too...most of the times it feels that the event just took place yesterday. I only hope that I have caused less suffering and brought more hope to my patients in my everyday work. Now is the time to look ahead...
Since my 5 rotations have been almost completed...I will be heading to nephrology next. May the force be with me...
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1:45 am - Happy new year 2006
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Another year goes by...how did everyone celebrate it? I was at home...sleeping
Choon Yan was working on the 31st.
Been resting a lot in the past week...exploring the other side of myself (besides medicine)
Finally got my new car...
Off an on, we need to think back about things that has happend in the past...year 2005 for me has been an unforgetable experience...starting as a blurcase houseman. and ending as a medical officer..I started the year off in O&G department...before heading the Paediatrics and the Surgery...I saw myself acquaring more skills in the diciplines that I have been rotated too...most of the times it feels that the event just took place yesterday. I only hope that I have caused less suffering and brought more hope to my patients in my everyday work. Now is the time to look ahead...
Since my 5 rotations have been almost completed...I will be heading to nephrology next. May the force be with me...
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| Monday, December 19th, 2005
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8:07 pm - Surgery coming to an end...
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You can feel that the end is getting closer...I think I'm going to miss it (I seem to say this for all my postings).
Post call today. Yesterday's call was a terrible one...it was not the admissions that were killing me, but it was a burnt patient who came in a day earlier that was driving me nuts...trying to keep him alive...
He sustained 70% 2-3rd degree burns all over the body...his toes were already like charcoal...he had inhalation iunjuries...ventilation and maintaining BP was the greatest challenge...They teach you parkland formula at med school...but you find yourself infusing like 30 litres of fluids in 48 hours! I was begining to wonder where all the fluids are going to...The best part was, this is the second time he got burnt injuries of such magnitude! He might not be soo lucky this time...After infusing so much fluids, he started having electrolyte imbalance, then later developed SVT in the early morning...thanks to my surgeon words of wisdom, which probably pissed the patient off and he started throwing his tantrums and giving us the SVT! It took us quite a while to get it back to sinu rhythm, not responding to traditional anti-arrythmic drugs...my surgeon and I were almost begging on our knees that he make it through the night...in the end, he did...but for how long more, I won't know...
The other day I mentioned about the IJN team coming to selayang for an organ salvage...for those who read the papers recently, you guys would probably know which child who was given a new lease of life after going of the mechanical heart machine and getting a new one from somebody else. Hope he does well...
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| Friday, December 16th, 2005
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11:46 pm - The first time i even saw an organ salvage...
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Today was an interesting day...we had a patient who was pronouned braindead and planned for organ salvage after discussing the issue with his family. The family agreed and it was not long before the 'teams' arrived with great speed to salvage the organs. IJN's team was probably the most impressive...the rest of the other teams were available in the hospital itself...IJN brought along every member of their team, from the attendent up to the cardiothoracic surgeon...they even brought their own anaesthetist, scrub nurses and sister! I suddenly felt that the OT was dominated by IJN people...
I arrived a little late...and had already seen a midline incision made from the thorax up to the lower abdomen...it really remimded me of how autopsies were done, except that this one, the heart is still beating! I can visualize it so clearly from about 3 metres away from the OT table. The IJN team was very happy with what they saw of the heart, and could certainly make good use for someone who really needs a heart transplant. Multiple organs were salvaged, liver (not to mention, the child was already on the next table, being prepared to be the reciepient of the transplanted organ.), kidneys and lungs. I wasn't too sure about the pancreas, skin, cornea (which are also salvagable) as they did not mention about it.
IN the end, it was something interesting to watch...even the pathologist was there...i think more for a medico-legal reason...not so much as in participating in the surgery. It makes me begin to wonder, once you're brain dead and your family/yourself agress for organ donation...that's what happens to u...
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| Friday, December 2nd, 2005
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6:04 pm - Waking up to find out that everything is not okay...
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My first call of the month...and it's been a busy one (like always)...I only managed to get out of ED around 2.30am...after setting to resusitation cases in the red zone...both of them had to be admited and observed for head injury. Then I had to attend to a first class patient on the 9th floor.
That was not the most troubling part of my call. I had woken up around 7.30am in the morning to prepare myself for the day...As soon as I walked out of my call room, I was encountered with a very interesting, not unusual scenario in the hospital...
As I was walking through the ward, I started seeing an elderly lady weeping away in the corner. She called for me, but was speechless to explain to be what is going on. Then she pointed at her husband, and to my surprise, he was lying there, motionless, pale, almost lifeless. This is not the way I want to wake up to...you don't feel that bad when it's your houseman or nurse who calls you for an unconcious patient, but when you find it yourself...you began to wonder what is going on in the ward...
I had to scream to the top of my lungs before someone took notice of what is going on...nurses were busy changing sheets, ward HO's were doing their own rounds, medical students were just looking. I had to wait 10 minutes before the cardiac monitor came. We had already started resusitation before that and all of us were taking turns to CPR him, and later intubated him. We had called the anaesthetic team for help, but u can't always wait for them since we don't really know how long this patient has been out...All sorts of drugs went in, adrenaline, atropine, sodium bicarbonate...When the cardiac monitor came, he was really in asystole...we continue resusitating for around 25 minutes and suddenly, he went back to sinus rhythm! It's the first time in my life that I have seen something like this happen...(a miracle perhaps?). We manage to get a BP then, and his stats stabilized until we manage to transfer him to ICU...
I was begining to wonder the cause of the event...he was post op 12 hours - a total colectomy was done. Hypovolemia i suppose? I'll let the primary team find out...
A reminder to all the medical students and HO's...resusitation! resusitation! resusitation! know what to do...at least then you will have a chance to save a person's life...This is one of the better days, most of the time, the asystole will remain...though I cannot be certain, how much brain damage may have accored while he was in asystole...
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5:42 pm - Another Sad Story...
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One of the sad things you get to see in the ICU all the time is trauma cases...and the one I am going to tell you is not going to be any different.
4am in the morning, someone drives on the road, heading back home after a party, gets himself involved in a car accident. Arrived in the emergency department via ambulance, he is drowsy, low GCS score and is electively intubated. Prior to intubation, you smell this strong breath of alcohol, you ask yourself, " Shit, why did this fellow drunk himself, drove and endangered the lives of others for his own satisfaction and gradification"
Most of the time, many of us wound be wondering that this fellow decided to disturb us in the middle of the night. Disturb applies to the paramedics who brought him here, the nurses who took care for him, and doctors who attended to him. Not to mention, the lady at the registration counter has to look for his IC and register him as a patient in the hospital. Was all these necessary if a person decided to be resposible about his own actions?
Of course, he ended up in the surgical team and I saw him the next morning in the ICU. He had already suffered a head concussion, a liver laceration, splenic injury and possibality a lung contusion. We were all concerned about the patient in ICU, but no one else more more concerned that anyone of us...the mother. I can still remember how she gazed at me, asking how his son was, and begging down to her news to our team to save his son. There was only so much we could do. We have already done 3 laparotomies for the past few days, spleenectomy, packed the liver, arrested bleeding arising from the abdomen, antibiotics, and increased ventilator settings etc. Then he had a severe lung infection and going towards sepsis...and started having acute renal failure. We had to finally break the silence to the family after almost a week. The prognosis was not very encouraging...We always give hope to the family, and preparing them for the worst. That is a great challenge for many of us in the Surgical and Anaesthetic team.
When I had finally broken the news to the family, everyone was sad, but no one was as sad as the mother...All she only cared was for the safety of his son...She was so heartbroken, but we offered hope to her, since he was still young. It is probably better for the family to know the truth early rather than a sudden collapse and death. Though there is always a possibality of a miracle, but in actualy fact, it does not come everyday...anyhow, we still continue to battle with his lung infection and renal failure. He is still in ICU...
Perhaps one should wonder...would any of this have happend if he decided to go home earlier and not booze away until the early hours of morning. Who sufferes the most? The patient? or the mother?
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| Monday, November 21st, 2005
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11:32 pm - Lesson to learn...
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Everyday is a learning day...and today was not different...
I was given the responsibality to take care of the periphery patient today...not something I would like to do all the time, since its pretty stressful...my surgeon, senior MO's were not in...and I had to consult a few other specialists regarding management of some of the cases, especially at ICU. It's always important to call for help even though you think you know what is best. Knowing what you think is the best does not always apply the same for other people, some people have more experience and I don't considered myself very experienced in the field of surgery...I've just been here for 2 months!
Another very sad incident happend in the ward today...pt came in very bad, had massive UGIB, requiring ventilation, scope done, bleed stopped...but then rebleed suddenly and crashed in the ward. Since she was ventilated, not many people took much attention to the Low BP, until it was really low...tachycardic...resusitation really started when my surgeon dropped by to notice that her vitals are not stable...fluids went in..., slowly manage to get blood and bloods went in...she was already on ionotrops...(that was the mistake), we later proceeded to manual bagging was saturation did not picked up, BP was fluctuating like crazy, IV lines were bad...we had to go into femoral, next lines...evetually...she passed away...we barely had much time to explain to the family...and she crashed so badly...probably another massive GI bleed...
1) When BP is low, don't start ionotrops first, see if her fluids is adequate, accertain her cause of low BP...ie low intravascular volume, sepsis...or heart failure.
2) When resusitation, never forget the ABC's...airway, though intubated, if saturation if not picking up, check ET tube, suction to clear airway, bag manually. Circulation, get IV access fast before the patient collapse fully...the larger the canula, the better it is...
3) Dont' just stand there...do something...no point have 5 doctors around, when no one is not leading the pack...one person must take charge, the senior most should do that...waiting for the surgeon to come and take responsibality is a big mistake, you have to take charge first.
It's hard to say in the end of the day if we could have or not saved that patient, not to mention she is 84, premorbid having a hip fracture which was just repaired 11 days ago... did we try our best? did we detect the earlier signs...there is room for much debate...
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| Thursday, November 17th, 2005
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7:53 am - More stupid referrals...
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I virtually use the word stupid as some of my colleagues in other hospitals just don't know how to make referrals...you can't just simply pack someone and send it to somewhere else and hope that they can do something magical that wound save the patient.
On another one of my on-call nights, I had an urgent page at 1am in the morning. When I returned the call, I heard a vietnamese doctor (who could barely speak good english) on the line (bear in mind, he was working in a government hospital). He had an elderly lady who presented with UGIB scope has been done 2 times already and transfused 12 units of blood. I asked him nicely why are referring to me for at this hour when the patient is probably still bleeding. He said " For further management". I gave him back, "What further management you want me to do? You have a surgeon there who can do scopes but he can't do a laparotomy to secure the bleeding? " It was like he didn't even know what he was doing. I had consulted my surgeon and he was pretty pissed about it too. When I had finally resorted to ask him to discuss with his surgeon again, then he only told me about the reason for referral. They had wanted to ask if there was any other possible intervention by scope method to stop the bleeding before surgery. I was very frank with him, it 1 something in the morning for goodness sake, and your patient is barely stable for a transfer (the patient is currently admited in Temerloh, Pahang), inview that she had very high risk of bleeding/rebleeding which can happen anytime while in the ambulance. In the end, the MO never paged me back...not sure what happend to the patient, but I know she definately needed a laparotomy.
Lesson to learn - when you refer a case, besides stating the history, please have your purpose of referral, and not just say 'for further management; cause that really pisses me off. At the same time, please choose the nearest hospital, not always a preference hospital (as it might be too ill or dangerous for the patient to travel 3-4 hours with no proper/full medical equipment). Making a good referral will not only do good for the patient, but it will keep us expected of what is coming in...etc, we might need ICU support, ultrasound, CT scans and we can get them ready prehand before the arrival of the patient.
There are more scenarios which I would like to share...but I'll save them for later.
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