Education of a Knife

Sleeping a little too much?

2011-09-15T02:59:00.000-07:00

One of the patients that I encounter this morning during the Psychiatric Liaison round. 41 year old gentleman was referred to the PSY team for methadone replacement therapy. He is an ex heroin addict presented with 2 days history of altered consciousness and excessive drowsiness. The wife claimed that he was unusually sleepy and tired over the few days prior to admission. There were no documented fever, seizures, limb weakness. Systemic reviews of the cardio, respi, genitourinary system were unremarkable. FBC was normal with total WCC of 6x10^9. Comment on the CECT findings and I will post up what was reported by the radiologist.

Causes of 3 figure ESR

2011-07-08T20:54:00.000-07:00

I was taught by my prof that there are 5 common causes of a 3 figure ESR:

1) Multiple Myeloma

2) Polymyalgia Rheumatica/Temporal Arteritis

3) SLE

4) TB

5) Advance Malignancy

Though these are common causes, they are not definite or exhaustive. I have actually came across a lady with rhrumatoid arthritis having an ESR of 120mm/hr.

This gentleman presented with 1 year history of chronic back pain that worsened over the past 4 months. His condition deteriorated 2 weeks prior to admission and he was unable to ambulate independently without the aid of crutches due to the pain. Multiple X-rays were taken and showed

His ESR was 114mm/hr. What's the diagnosis?

Rash?

2011-04-26T05:35:00.001-07:00

8 year old boy presented with arthralgia, abdominal pain, maculopapular rashes and renal impairment.

Myelomeningocele

2011-04-15T20:15:00.000-07:00

亲爱的宝贝，再撑一下

Acromegaly

2011-02-21T22:30:00.000-08:00

Courtesy of Dr Fadzli, Endocrine MO

1)Spend a few seconds in general inspection

2)Start off by examining the patient's hand, you notice that he has spade-like, sweaty hand, the skin is thickened and doughy.

3)Check for carpal tunnel syndrome(Phalen and Tinel Test)

4)Look at the face-check for prognathism(causing malocclusion of jaw), prominent supra-orbital ridges, wide inter-dental spaces and macroglossia

5)Offer to look for skin tag(molluscum fibrosum) at axilla

6)Look at lower limbs for pitting edema to suggest cardiac failure, look for evidences to suggest osteoarthritis of the knee, thicken heel pad

9)Check for proximal myopathy by asking patient to squat down

10)Assess the visual field to look for bitemporal hemianopia(acromegaly tends to be due to macroadenoma)

After eliciting all the positive signs, suggest to examiners you would like to complete your physical examination by

1)Check the blood pressure which is an indicator for active disease process

2)Check urine for glycosuria

3)Check fundus for DM/HPT changes

4)Examine the cardiovascular system for heart failure, neck for goitre and abdomen for hepatosplenomegaly

Questions

1)How do you confirm the diagnosis?

2)What are the modalities of treatment available?

3)How do you monitor treatment response?

4)Any endocrine syndrome which is associated with acromegaly?

Liver Atlas and Casebook

2011-01-05T21:18:00.000-08:00

Was browsing through the book collection in the HDOK library and came across this book titled “Liver Atlas and Casebook” edited by our very Malaysian Director General of health, Dr Ismail Merican himself. I highly recommend this book for students like me out there as it highlights important concepts pertaining to the diagnosis and management of common diseases that affect one of the largest organs in our human body- the liver. On the other hand, this book compiles a number of complex cases, which were managed by the highly specialised team in our very own hepato-biliary excellence centre- Selayang hospital. Overall rating of 8/10 with high resolution pictures of specimens for an in depth understanding of the pathology of most liver diseases. Some of the important facts that I’ve gathered after finishing ¾ of the book.

The text book triphasic CT characterisation of HCC

Arterial enhancement as HCC derives its blood supply from the hepatic arterial circulation

Complete venous washout

HCC usually causes thrombosis of the portal vein and its branches. Jaundice is not a common presenting feature of HCC.
Diagnosis of HCC rarely depends on liver biopsy due to potential tumour dissemination that may convert a resectable lesion into a non resectable disease.
Among the common presentations of HCC is abdominal pain/discomfort usually felt as a dull sensation, awareness of abdominal mass/constitutional symptoms of appetite and weight loss. Jaundice and ascites develop in later stages of the disease, when present contraindicates surgery.
Serum AFP may be normal in up to a third of patients with HCC
Text book CT characterisation of FNH(Focal Nodular Hyperplasia)

Hyperdense vascular enhancement with central hypodensity (stellate scar)

FNH usually does not require intervention unless patient is symptomatic/ uncertain and suspicious for malignancy
The most common benign liver lesion-hepatic haemangioma that is usually picked up incidentally.
Leptospirosis is caused by “Leptospira Icterohaemorrhagiae”. Rats are common source of human infection. It can also infect cattle shoes and swine. Incubation period takes about 10 days (average)
Adolf Weil was the first person to document this disease and thus severe form of leptospirosis is also called Weil Syndrome.
Jaundice and haemorrhagic manifestation are not uncommon, hence the name “Icterohaemorrhagiae”
The leptospires, directly/through immune mechanism damage blood vessels, cause centrilobular necrosis of the liver, renal tubular dysfunction by causing interstitial nephritis and acute tubular necrosis. Diagnosis is based on serology with 1:800 being diagnostic.
Liver abscess usually shows up as a hypoechoic area with some debris within it. ( On ultrasonography)
K.Pneumonia has emerged as one of the most common pathogen responsible for liver absvess
Metastatic infections are commonly seen in patients with K.Pneumoniae liver abscess. They are

Enopthalmitis

Septic Pulmonary embolism

Pulmonary abscesses

Cerebral abscesses

Purulent meningitis

Otitis media

Osteomyelitis

Prostate abscess

Psoas muscle abscess

In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause
Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass
Occasionally an infected cyst would present with pain and fever
In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause
Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass
Occasionally an infected cyst would present with pain and fever

The land below the wind

2010-12-29T23:28:00.000-08:00

I will be flying off to Sandakan in less than 24 hours to do my month long elective attachment with the boys in Duchess of Kent Hospital, department of Internal Medicine. I am feeling quite excited as I've never been to that part of the world yet. 4 of us will be doing some travelling around Borneo as well so do wait up for pictures of proboscis monkeys, sea turtles and orang utans.

The SUN, SEA and SICK PEOPLE. The 3S of a successful elective posting. SANDAKAN here I come!

Wonderful Tonight

2010-12-25T21:16:00.000-08:00

Classical love songs by 方大同

好听

TB

2010-12-15T19:17:00.000-08:00

This is the chest X-ray I saw in the general medicine ward of a 30 year-old man who presented with the following complaints:

1) Chronic productive cough x 6/12 associated with

-Exertional dyspnoea

-Multiple episodes of hemoptysis worsened over the past one month

-Greenish sputum

2) On and off low grade fever associated with night sweats chills and rigors x1/12

3) Significant weight loss with decreased oral intake due to poor appetite

Physical examination revealed decreased chest expansion over the upper chest. Percussion over the chest revealed dullness over the right upper lobe with apical crepitation on auscultation. Several enlarged cervical lymph nodes were present as well.

Chest X-Ray of another patient with active PTB. Note the cavitation. consolidation and deviated trachea(mediastinum) due to scarring.

Yes, you are right, he was having active pulmonary tuberculosis.

Tuberculosis is one of the common topics that can be tested in an undergraduate exam (obviously not in Monash) and questions are commonly asked about the treatment and its side effects. The first line medications for TB and their associated adverse drug effects are as follow:

R.I.P.E.S

Rifampicin-cholestatic jaundice, orange urine, thrombocytopenia, enzyme inducer( OCP less effective)

Isoniazid-Peripheral neuropathy, hepatitis, pyridoxine deficiency, drug induced lupus!

Pyrazinamide-hepatitis, hyperuricemia (Gout)

Ethambutol-Optic neuritis

Streptomycin-ototoxicity and nephrotixicity

Zap those female anopheles!!

2010-12-06T06:10:00.000-08:00

A few days ago, a close friend of mine who is also a final year engineering student approached me and asked: “I’m currently trying to come out with an idea for my final year project and I am thinking of integrating engineering into medicine. What do you think? Any ideas?”

Well, since it’s the end of year holidays now and I barely have anything intellectually stimulating to do, I decided to help him with some information gathering. Below are some interesting video clips that I have come across.

Nathan Myhrvold and team's latest inventions -- as brilliant as they are bold -- remind us that the world needs wild creativity to tackle big problems like malaria. And just as that idea sinks in, he rolls out a live demo of a new, mosquito-zapping gizmo you have to see to believe.

From designing a device that could prevent breaking the cold chain of vaccines to diagnosing malaria infection by just looking into your eyes/nail beds, if only more geeks would put their skills to use like this, the bright future that we long for is definitely not far away. Who needs to learn how to do a BFMP(Blood Film for Malaria parasite)? Diagnosing malaria is going to be a no brainer! And since this gadget could specifically exterminate the mosquitoes other than some other harmless insects with wings, I believe Dengue fever/DSS all can be put to a stop.

Next, how about using an I pad during a surgery to view high resolution CT/MRI scans? A team of surgeons in Kobe University Japan actually put this device into good use. The touch screen seems to be working fine although it is covered by a sheath of sterile plastic film and the surgeon has donned on his gloves.

kobe surgery [japanprobe]
Uploaded by jdx459. - See video of the biggest web video personalities.

Not a big fan of these products(I-phone/I-Pad) tho, just another over-rated, highly glorified mobile phones around. One of my housemates once told me:" The sole reason of me getting an I-phone 4 is just to impress the chicks, nothing else".

Anyhow, we all have to admit that advancement in the field of medical technology has certainly improved our quality of life and revolutionized how medicine is being practiced today.

Holiday

2010-11-24T01:51:00.000-08:00

Exam has finally ended. Time to rejuvenate and reward myself back at home-the pearl of orient. I would like to extend my sincerest thanks and appreciation to all the people who made this year a memorable one.

1) The patients. Without them, I wouldn't have acquired any of the skills and knowledge that I have thus far. And most importantly -the art of medicine.

2) My outstandingly dedicated tutors!

3) Specialists and consultants from both the surgical and medical department

4) MOs and all the HOs that I've had the pleasure working with! Gratitude is extended to Dr Fadzli for being so accommodating and for all the feedback, direction and assistance when I needed them. Not forgetting the house officers from D2, PP1, W4 who have indeed enriched my learning experiences.

5) Ward sisters and staff nurses!- Thanks for showing me that nursing has a very special place in the health care system. And you guys are indeed indispensable!

Take care and hopefully we will meet each other again next year in my subsequent postings.

Running out of water

2010-11-15T02:05:00.000-08:00

It is incomprehensible that while our beloved country is planning on building a 5 billion ringgit 100-story sky scrapper.On the home front, HSA has run out of normal saline infusion solution. All the patients are now on either dextrose solution or half saline regardless whether they are diabetic or the fluid replacement therapy is apparently inadequate!

Spot Diagnosis?

2010-11-04T19:24:00.001-07:00

Courtesy of C.S.Lee

Thoughts for the day

2010-11-04T03:58:00.000-07:00

1) You're in deep shit if you have a pneumonia caused by staphylococcus aureus. A knowledge on how heroin is taken could possibly lead you to the diagnosis!

2) A drug addict taught me that heroin can be used in 4 ways

I) Injecting it

II)Smoking it

III)Snorting it through the nose

IV)Inhaling it-Chase the dragon

Smoking and chasing is safer as compared to the rest as it reduces the risk of OD.

3) Commonest cynotic congenital heart disease is still Eisenmenger's syndrome

4)You need 2 medical students, 2 house officers, one ward sister and another staff nurse to insert a branulla in an emotionally unstable patient.

5) The chicken and egg story in a 28 y.o hypertensive patient. Hypertension causes the CKD or the CKD causes the hypertension? A thorough search for secondary causes of hypertension warranted?

6) You need extreme patience to be an infectious disease physician. Day in day out, you deal with resistant bugs, patients who defaulted their treatment and among others.

7) Met a few patients with haematological disorders. APLS, thalassemia and AIHA. Heamatology is quite a fascinating field I think.

8) Observed a bone marrow aspiration and trephine biopsy. The doctor that obtained the consent must be very persuasive!

9) A pericardial rub sounds like a systolic murmur

10) Saw Dr Liu today in the ward. He asked: Why are you still here. You like this place so much? What's wrong with you? I winked at him. He tapped on my shoulder and said: Better come back and serve.

Reflections..

2010-10-31T02:01:00.001-07:00

Another year has zoomed past and we are almost at the end of third year medical training. Time flies as they say. The end of another year is always the time when one looks back and reviews our achievements, what we did well, what we did not do so well and then look forward to set goals to rectify them.

Year 3 has been uneventful to me so far in the sense that life practically revolves around texts and patients. With the end of year exam approaching soon, I am starting to spend more time hitting the books instead of roaming around the wards acting like a house officer. Now don’t get me wrong, it’s not that I am better or comparable to them, it’s just the method of learning that I have adopted since the beginning of the year. Osler once said: To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.

A few things that I’ve learnt to appreciate over 12 months being posted in different departments:

Respect patients

All students should ask yourself, “Who taught me medicine?”

“Prof A is really good, he taught me this and that. He even printed notes for us!” one of my colleagues answered. At the end of the year, most students will be going around, knocking the doors of their lecturers to thank them for making them a better doctor. But how many actually pondered whether these individuals really taught us the art of medicine? Did they develop heart failure to teach us what an elevated JVP looks like? Did they suffer from cyanotic congenital heart disease just to show us clubbing of the fingers?

Then who taught us medicine? Obviously the patients.

Patient came in with wheezing to show us the signs of asthma.

Patient came in with a myocardial infarct taught us what are the ECG changes that you could pick up in an acute coronary syndrome. Without these patients we would never have learnt. Yet there are students who are capable of performing examination without even obtaining consent just to satisfy their hunger for good physical signs. They come, they strip, they auscultate and they leave.

Our parents taught us to always respect our teachers. That’s the reason why we should have utmost respect for our patients-Our great teachers. And not treating them like dummies for you to practise on.

To wish

Make it a habit to wish the patients and their family members when you clerk them. You’ll be surprised to see how cooperative and pleasant the patients become when you wish them. Always be polite to patients irrespective of their socioeconomic status, education level, ethnicity, language, culture and religion. I’ve learnt tremendously from drug abusers, inmates, people from the lower socioeconomic background throughout the year. They never fail to make me realise that I am indeed so lucky and blessed to be living in such a comfortable life and to pursue what I like in life.

"Healing occurs when you let another human being know that his suffering and fears matter to you"-Anonymous

Choose your friends by their character. Choose your socks by their colour. Choosing your socks by their character makes no sense and choosing your friends by their colour is unthinkable-Anonymous

Be less intimidating

Always stand or sit at the same level with patients when you clerk a new patient. If you are standing and patients are lying down, it can be very intimidating for them. Pull up a chair and sit beside the bed if necessary. Try to calm them down especially during bedside teaching sessions. I learnt to routinely shake/hold their hands while introducing them to my colleagues and teacher before each session starts. Trust me, this will ease their nervousness tremendously. Thank them before you leave, not because they have been cooperative but for the fact that they have imparted some knowledge in you.

Refer to them by their names, and not “cases”. They are not experimental subjects and don’t you think it’s rather dehumanizing to be referred as such?

Duties

Never do things half heartedly. What you do now will definitely reflect who you are going to be next time. Clerking without examination is unacceptable and it just shows that you are not interested in learning. It sucks to be the group leader in the sense that you are directly responsible for the group’s learning progress. Inevitably you will meet people who clerk a patient 15 minutes before bedside and expect the tutor to show them the clinical signs and to finish up all the remnants. Excuses like “The patient was eating when I wanted to examine” or “ Patient was not in bed when I wanted to examine” are commonly given as they fail to step up to their responsibilities. Be responsible when you carry out your duties. If you don’t know or haven’t done it, just admit it and remember to do it properly next time. You must be responsible towards yourself and your colleagues.

However, I’ve learnt to accept and adapt. Confucius once said: If I am walking with two other men, each of them will serve as my teacher. I will pick out the good points of the one and imitate them, and the bad points of the other and correct them in myself.

And finally Attitude

“Attitude , not aptitude determines altitude”. It is the attitude in learning that makes all the difference. Although you can argue that why take things so seriously? You'll get the same degree anyway, since you still call the person who ended up last in medical school -Doctor. It is up to us to decide whether or not to be a 99% doctor or a 50% doctor.

Spot Diagnosis?

2010-10-20T02:00:00.000-07:00

A few of the patients that I've seen over the week..

The mad house

2010-10-15T05:39:00.000-07:00

Just some random thoughts for the day

1) The medical ward in hospital Sultanah Aminah is indeed a mad house. You'll have patients screaming, yelling, crying even swearing from time to time. It's stressful to work in such environment, the workload is unreasonable with tonnes of blood to take, lab investigations to review, cannulae to be inserted. Worse still when you have a 10 year old dengue patient who is afraid of needle being admitted...tds FBC..argh...

2) I entered the ward when the sun has not yet risen and I went back home when the day has gone dark. Extremely exhausted to the extend that I lost my appetite for dinner.

3)I poked an elderly man 3 times, one for an ABG, inserted a branula and withdrew blood and lastly a blood CNS under strict aseptic technique. I'm sorry.

4)I love the ECG machine in D2, it is printed in A4 size, no more long messy ECG strips laying around.

5)The hospital is so poor that they ran out of reagents for TROP T, creatinine and serum calcium. This is a tertiary referral center and I believe the patients should receive tertiary specialist care.

6)My fasting blood sugar after morning round is about 3.2 mmol/L. This is the value after going around looking at 40 patients without taking a single sip of water or breakfast.

7)Lung cancer and PTB is so prevalent in this region.

8)Ascultated my first carotid bruit, and realized that clinical examination is way more superior as compared to sophisticated imaging investigations.

9)Every complaint from the patient is genuine.

10) And in medicine, what ever that happens after 5 actually makes you better.

Clinic Cafe

2010-09-13T02:57:00.000-07:00

If you are feeling sick and not well, you need to visit a clinic to get some medication. How about if you are feeling hungry and thirsty, can you visit a clinic? The answer is YES-Clinic Cafe.

Cool huh? Overall, it would be quite a nice place to chill out, decent atmosphere, service was good. However, food was just average.

Yellow discolouration

2010-08-21T08:00:00.001-07:00

The pathologist reported

Sections show fragments of gastric mucosa with sheets and nests and occasional glands of malignant epithelial cells invading the stroma. The tumour cells are pleomorphic, have increased N/C ratio, vesiculer nuclei and eosinophilic cytoplasm. Abundant mitotic figures are seen.

Impression: Adenocarcinoma, poorly differentiated, infiltrating

This is an elderly woman in her seventies, who was warded 4 months ago with the chief compliant of yellow discoloration of her eyes and skin. I remember this particular patient vividly as she gave the medical team a hard time figuring out what is wrong with her.

When she was admitted, she was grossly jaundice. It wouldn't be difficult to spot her in a sea of people. The semester one student nurses were pretty curious with her presentation and some of them asked me what's wrong with her.

It's pretty simple when you have a patient presenting to you with jaundice which is actually yellow discolouration of the mucous membrane and skin due to excessive bilirubin deposition. In our Malaysian setting, an underlying liver pathology/gall stone disease is usually the culprit.

However, upon detailed history taking, we couldn't elicit anything related to an underlying chronic liver disease. No weight loss, appetite was fine either. Crepitations at both lung bases were picked up and the legs were minimally edematous as well. She has no risk factors of viral hepatitis infection but of course a full jaundice workup was done including hepatitis serology.

An ultrasound was subsequently ordered to look for evidence of liver cirrhosis that could explain her presentation. I scratched my head when the report came back, everything was fine other than the enlarged lymph nodes compressing the porta hepatis. Liver was homogenous in terms of echogenicity, no evidence of cirrhosis.

To cut the long story short, a full battery of investigations were performed and we finally hit the jackpot when an OGDS found a fungating mass at the body of the stomach. A biopsy was taken and the result as mentioned above. Bile flow was obstructed due to external compression by the enlarged lymph nodes. Prognosis was not good. Management was then to relieve the obstruction by stenting, the rest are just palliative.

I followed her up for almost two and a half weeks, trying to understand the disease progression. Every afternoon before lunch time, she'll definitely ask me whether I've had my lunch. And if I say no or later, she will start lecturing me on how I should take care of my own health, and how eating late is bad for health. She was a very cheerful lady and even the student nurses enjoyed chit-chatting with her. They call her "po po"(grandma). After the stent was put in, she was allowed to be discharged

Today while I was doing my groceries in Giant, I bumped into her daughter. We started talking and I asked about po po. "She passed away 2 weeks ago, in peace, without any pain" her daughter said. " Thanks for asking doc" she added.

I can't remember her exact full name. But other than that, I can remember every single thing she told me before she passed away. I spent quite some time telling stories, listening to stories, laughing with a woman who would not survive the year.

I do hope she's doing fine up there, surrounded by lovely people!

A good cry

2010-08-07T03:46:00.000-07:00

She looked outside the window and started crying. Her tears welled up in her eyes, rolled down her chicks and then subsequently she broke into a full out sob. She tried to suppress the urge to cry, wiping away the tears with her tudung.

I excused myself from the team of doctors doing round, went over and gave her a gentle tap at her back and said:" I'm sorry Mak Cik, is there anything else we could do for you?". I knew she had no choice, your mind overrides any effort to suppress the need to cry, I told her it's fine to let it all out, because i know when you hold your tears back, you are only amplifying the emotions your body is trying to release through crying. She took a deep breath and said: Thanks for the pineapple cake young doc, and asked me how I became a doctor at such young age.

Her husband is a 65 year old malay gentleman with a known history of type 2 diabetes mellitus under the follow up of one of the district clinic. He presented with the chief complaint of dysphagia(difficulty swallowing) that was progressively getting worse. It started off with solid food especially bolus of rice and subsequently followed by fluid. Prior to admission this time, he could only tolerate 3 spoons of whatever food before regurgitating. Vomitus was free from billous substances and the fact that he could pin point the level of obstruction above the nipple line strongly suggest a mechanical obstruction at the distal oesophagus. With the significant weight loss of 20kgs in one month with anorexia, any sound reasonable competent doctor will give the the provisional diagnosis of a malignant space occupying lesion anywhere along the oesophagus causing the above symptoms. And yes, the was the provisional diagnosis of adenocarcinoma of the lower oesophagus was agreed by the specialists and the rest of the MOs and HOs. The plan of management at that time was to get an urgent OGDS for diagnosis and probably a tissue biopsy of histopathological evaluation.

Looking at him, he was lying on his bed, propped up with the wife and a wheel chair beside him. He has not been ambulating well according to the wife, and probably it is due to his poor oral intake i said to myself. A quick glance at him reveals a man in his 60s, emanciated with temporal wasting looking quite pale probably with a haemoglobin level of 8 or 9. He's not in pain, comfortable under room air without any oxygen supplementation. Did a quick examination on him and found nail bed, conjunctival pallor, distended abdomen with positive fluid thrill and bilateral pedal edema up to the mid shin. From auscultation, there was reduced air entry bilaterally with bronchial breathing just above it suggesting some degree of pleural effusion. After palpating the abdomen quickly, I concluded that his physical findings were consistent with the provisional and probably there is liver metastasis to the liver causing a hypoproteinemic state.

When I went back to the ward after class that day, I was confused as the OGDS did not show any intraluminal obstruction, but instead 4 large oesophageal varices occupying more than 1/3 of the oesophageal lumen with red cherry spots indicating stigmata of recent hemorrhage. Something was not right, from the history itself, there was nothing to suggest an underlying liver disease. No previous history of jaundice, distension, tea coloured urine and pruritus. Stool was normal as well. I traced his liver function test and found myself even more confused with the LFT being relatively normal. Serum albumin was on the lowish side, serum bilirubin and the other liver enzymes were normal. Nothing at all that suggest a primary liver pathology. Coagulation profile was not prolonged as well. I doubted my skills in history taking at that point, did I make a mistake? But I am very sure that the patient's complaint upon admission was "Susah nak telan".

During the A.M round the next day, an abdominal ultrasound was done and serological investigations to detect Hep B/Hep C infection were dispatched. The report from the radiologist came back stunning all of us- a large heterogenous hypoechoic lesion over the left lobe of the liver suggesting hepatocellular carcinoma! The liver was mildly cirrhotic and there is no clear fat plane between the mass between the body of pancreas, suggesting local infiltration. This is not a good news at all, his wife asked me about the radiological report, I said I am not in a position to give any comments and the consultant will be a better person to talk to. To cut the long story short, a 3 phase liver CECT was done and subsequently found multicentric lesions over the liver with invasion into the main and right hepatic veins and distortion of the IVC. Everything make sense now, the portal hypertension was not due to cirrhosis of the liver, but instead thrombosis in the main hepatic veins with anatomical distortion of the IVC. Budd-Chiari syndrome.

I put the CT films down and rush to the patient, I asked for permission to examine him. By then, the abdomen is grossly distended with the umbilicus everted. Shifting dullness cannot be any more clear, even with such an amount of fluid in the abdomen, when I laid my hands over the epigastrium, I noted a firm mass with an irregular boarder, covering half of the epigastrium. HOW CAN I MISS THAT from the initial physical examination? I flipped open the case file and found out that it was missed by the HO who first examined him as well. This is a retrospective finding, nothing to be proud, but definitely something to be ashamed off. All my tutors were right, even the consultant was right, medicine is still an art that cannot be replaced even by the advent of sophisticated imaging technology.

She looked outside the window and started crying. I asked whether I could do more although I do know that as a student, I can do nothing. The wife and the family members decided to bring him back. There's nothing that can be done here in HSAJB for him, only palliative management. I spent some time talking about a few things that could possibly go wrong after discharge, asking him to come back if ever he finds himself passing black stool or experiencing any symptoms of anemia from UGIB. The ascites will only get worse, and I reminded him to come back for a peritoneal tap if he finds himself having difficulty breathing from all the fluids in his lungs and the restrictive effect imposed on the lungs by the large abdomen. I thanked both of them for all the teachings and bid goodbye.

HCC without the background of cirrhosis, alcohol binging and chronic hepatitis infections. Something different from the pathology that I've learnt previously. Looked up the patho textbook that night itself, and found that a variant of HCC can occur without cirrhosis/ hepatotrophic viral infection- Fibrolamelar carcinoma of the liver. I hope that the mass could be a benign one like an adenoma or focal nodular hyperplasia. But from the aggressiveness of the mass as reported, and the fact that is has infiltrated the major hepatic vessels and distorted the IVC, its unlikely that it is benign, a tissue biopsy is still mandatory for confirmation.

Too bad, I've lost all the notes that I've taken for this patient. Must have misplaced it. From the history, daily reviews and even investigations, all gone. Ahh, what a waste, but he taught me so much throughout his stay in the hospital that I can still remember that his serum bilirubin level-it was only 29.

Necessity is the mother of invention

2010-07-30T20:17:00.000-07:00

I had an interesting encounter with a 75 y.o gentleman who was admitted with the chief complaint of passing black stools for the past 2 days. Upon clerking him, I found out that he has a number of pretty nasty co-morbids that require him to be on a long list of medication. When I requested for the medications that he is on, he showed me this:

A mini pharmacy. And he's such a good patient that he can tell you what is medication for, the dosage just off his head. I like the fact that he's such an organised person, obtaining the drug history can never be easier.

He's on Casodex, an androgen receptor antagonist that give rise to gynaecomastia.

Upon physical examination, I found this device attached to a part of his body. Upon questioning, this device is in fact his own creation. Speaking about the latest medical invention, this man could probably win himself an award or something!

Give it a guess, I'll buy you a drink if you manage to guess it right.

What's Surgery Like

2010-07-01T22:02:00.000-07:00

5 months in the Department of Medicine, Hospital Sultanah Aminah JB, was undoubtedly the best experience I've had so far in my medical schooling life. I owe it to the fantastic team of people in the ward I was assigned to. Because of their teaching and guidance, I am actually quite functional and versatile in terms of ward duties. I've done most of the procedures so far including a pleural tap, assisted in several peritoneal dialysis and peritoneal tapping. Venepuctures and IV cannulations were so frequently done that they call me a vampire.

But now, everybody is everywhere. The MO has been posted to some other ward, some of the HOs are doing their minor posting either in haemato/chest/ ID department. I miss those days where I was so gung-ho spending more than 12 hours in the ward, studying while waiting for the staff nurses to call me if there is any blood to be taken or any branullas to be inserted. I would wake up early just to join the morning rounds with the MO, caused that is the time I will get grilling for not knowing stuffs.

"Chee, kepala u kosongkah?", the MO will say when I fail to examine the hands properly. "Can't you see, the joints are swollen!". "Now tell me 5 syndromes that are associated with Rheumatoid arthritis". " Sorry Dr F, I know only 2". " Tell me 5 reasons why patients with RA develops anemia" "Tell me about all the organisms that cause atypical pneumonia, which one causes haemolytic anemia?". LOL. Then he will walked away feeling pissed, but I know he is not, he was just trying to act stern.

Patients, although they are sick will try to console me by saying its ok, and offered to let me examine them again after I've read. Having said that, I tried to recall the syndromes associated with RA and yet i am still missing 1 of them.

1) Nephrotic syndrome

2) Felty's syndrome

3) Kaplan's syndrome

4) Carpal Tunnel syndrome

5) ?? Ish..

Anyway, I will be spending my last weekend her before I head back to JB. Surgical posting is next and I wonder what is in store.

When you hear about surgery, do you think of TV dramas like "Grey's Anatomy?" But in reality surgery is not always so glamorous or so dramatic. I was told by some of the surgeons back in Sunway that surgery is challenging, exciting, varied and very rewarding.

I think what attracts me to surgery over a lot of other specialities is the hands-on approach. The directness of treatment is something very lacking in other areas of medicine. And Yes, the feeling of actively "fixing" someone is hard to resist when that could mean the difference between life and death.

But at the same time, surgery for me lacks alot of the cerebral diagnostic element that I love so much about internal medicine. In the medical ward, knowledge is the only thing that sets you apart from the others. In surgery, its more to skills and technique. As long as you can be a good assistant in the OT, you are considered to be a good surgical HO. Besides that, I find that the medical consultants are more gentle, in the way they approach their patients. Surgeons on the other hand are always called the butchers.

Anyway, I do keep an open mind. I'll need to have adequate knowledge in both the field of surgery and medicine before I can proceed any further. I remembered how I miss a gastric outlet obstruction secondary to post op adhesions in a pt with chronic renal failure who just underwent an exploratory laparotomy because of bacterial peritonitis. From the abdominal X-ray, the stomach was obviously distended and yet I could miss it. And the best part is, when she asked me what's wrong with her tummy I said everything is fine. See! It's dangerous to talk without knowledge.

I'm all hyped up for the coming posting. Besides, I've heard that I've got pretty good tutors. 5 Essential Features of a top surgeon

1) Fingers of a Lady

2) Eyes of an Eagle

3) Heart of a lion

4) Stomach of a Camel

5) Legs of a horse

I'll see whether I could acquire any of the above at the end of the posting, HAHA!

Career Choice: Ambition Vs Family by Lucia Li, Medscape Student

2010-06-30T21:01:00.000-07:00

People take different roads seeking fulfillment and happiness. Just because they're not on your road doesn't mean they've gotten lost.
I am ashamed to admit that there used to be a time when, if a colleague told me he/she wanted to be a GP, my first thought would be "you're only doing it because you want to have a family." I was harsher on my female colleagues because I somehow felt that the only proper execution of modern-day feminism was to work hard. I would feel a little sense of masochistic pride that my own ambitions were a little more time-consuming. Now I look back and think how foolish, patronising and downright idiotic those thoughts were.
The concept that medicine, to many others of my colleagues, was simply an interesting and satisfying way to make a profitable living was alien to me. The concept of medicine being a way to pay the bills hadn't even featured on my radar. I guess, somewhat naively, I had looked upon medicine as a calling. I hoped, and still hope, to contribute in a big way to our knowledge about disease and treatment. In the specialty I hope to pursue, I have found a real passion. To me, medicine will never just be a job.
But the whole point is we live in a free society in which we can choose our mode of happiness. No-one should be criticised for wanting to spend more time with family or even for wanting to give up a career to raise one. Least of all, women should not criticise other women for that choice.
The specialty I wish to pursue is not what anyone would call family-friendly. It's a long, hard slog. It's a competitive arena. Because of this, people seem to respect this decision. However, those people wanting to do family-friendly specialties, even if their decision is motivated by genuine interest, may come across derision from people who see it as ‘slacking off' or a ‘cop-out'. I can't help but wonder if this sort of attitude is borne of the need to justify their own sacrifices; they have sacrificed their own family lives for their career and, in moments of self-doubt over whether these sacrifices were worth it, their frustration manifests in ridicule of others.
I confess to being a little bit daunted by how much I may potentially have to sacrifice of my personal and family life in order to be successful in my chosen specialty. Nevertheless, I have my heart set on it, I genuinely believe it will make me happy. And that choice, the choice of what will make you happy, is what is worth celebrating, irrespective of why you chose it. ‘Ambition' is not a dirty word. And neither is ‘family'.

Even as a medical student, I often contemplate on the family vs career dilemma. And yes I'll have to admit that at this stage, career is still prevailing. However by saying that, it's easy to be young and say " I will work my ass off, providing the best for my patients, and I shall put my family planning on hold." But when you are no longer a gung-ho 20 year old medical student or a 25 year old senior medical officer, seeing your colleagues going into a less competitive field, living comfortable lives, will make you think twice about the decision you have previously made. I had a conversation with my dad recently in the car:

Me: I'll be graduating in another 2 and a half years. After completing my housemanship in Malaysia I'll try to further my studies as soon as possible. And perhaps after that join one of the university's medical center for practice and academic teaching.

Dad: Ok, but if you see any good candidates(girls) along the way, just approach them and be friends.

Me: Haiya, no time la. Besides, it's hard for me to settle down. I might get posted to some rural areas in the inner Sabah/Sarawak. Who knows? And I can't afford to be distracted. The amount of money you are paying for my degree should produce an outstanding doctor, not mediocrity.

Dad: Ya la, I know, but don't wait too long.

Me: Don't worry la, some of my tutors get married pretty late as well. Dr Y completed his MRCP at the age of 35 and when he returns to Malaysia, he's still single. Dr K too, he just got married last year. I even know of a professor who dedicated his life to medicine, now still single(trying to scare him)

Dad: That's not success, no matter what, don't put it on hold for too long!

I'm not blaming my dad, I guess he's just a little worried that I will become too career minded. Medicine can be like a jealous mistress- These words were spoken to me by a few wise tutors. I listened to them but still could not fully appreciate the gravity of my chosen career. I'll just let maturity and experience change my views on things.

I don't think its impossible to achieve a great career and family, because at the end of the day, you make your own time. And I believe, one will never be too busy for his/her love ones.

Everybody has their own interest and it's important to respect them. "Ambition" as what the author mentioned is not a dirty word. I admire people who dedicate their life to medicine, serving the Rakyat who really need them. Afterall it is an honor and privilege to be called doctor. This is why I want to have a MBBS after my name. That is why we are allowed to handle life and death situations. That's why we don't mind staying up late in an operation theater for our patients. It's a life, a calling, not a business. And I seriously couldn't imagine how hard it is to do that all, if you do not possess the heart and passion.

Be the best doctor you can be, make time for what you love, the rest are just excuses.

Abstract for Endocrine Society of Australia annual meeting.

2010-06-19T04:23:00.000-07:00

Expression and cellular activation of peroxisome proliferator-activated receptor γ in granulosa cell tumours.

Simon Chu, Chee Yong Chuan, Maria Alexiadis and Peter J Fuller

Prince Henry's Institute

Granulosa cell tumours (GCT) of the ovary are rare, hormonally-active neoplasms characterised by endocrine manifestations, an indolent course, and late relapse. Chemotherapy and hormonal therapy have proved to be of limited efficacy. Nuclear receptors (NR) are well defined targets which have a central pathogenic role in endocrine malignancy. They are potential targets for therapeutic intervention. NR have established roles in granulosa cell biology but their roles in GCT remain largely unexplored. In order to more systematically examine the NR family in GCT, we used ABI Low Density Array microfluidic cards to analyse 14 GCT and two GCT-derived cell lines for expression of the 48 NR. The levels of expression were remarkably consistent across the GCT. We found that peroxisome proliferator-activated receptor gamma (PPARg) had greater than 10 fold absolute expression when compared with either the NCBI tumour or brain reference RNA pools. PPARg agonists are regarded as potential therapeutics in the treatment of inflammatory diseases and certain cancers. Given the high expression levels of PPARg in GCT, we investigated whether the use of PPARg and/or retinoid X receptor (RXR) agonists or antagonists have an effect on GCT-derived cell lines. We observed that the PPARg/RXR agonists and antagonists had no affect on cell proliferation, cell viability or apoptosis. Although the use of PPARg agonists is unlikely to be of use in treating GCT, a combination of therapies involving knockdown of NF-kB signalling may be of benefit. We have previously observed that several other members of the steroid receptor family are transrepressed due to constitutive activation of the NF-kB signalling pathway. We are currently investigating whether PPARg is transcriptionally active in these cells using a reporter construct specific for PPARg and whether the non-responsivness to PPARg agonists or antagonists in vitro is due to NF-kB transrepression.

When the HOs are desperate

2010-04-10T20:40:00.000-07:00

A fancy way of doctors saying that they have absolutely no idea what is causing the fever is PUO- Pyrexia of unknown origin or more commonly termed FUO, Fever of unknown origin.

When doctors come across patients who were admitted for evaluation of PUO, they were forced to put on their thinking cap, generating differentials that could suggest a cause for the patient's on going chronic fever. In reality, they know just as much as the patient at that point of time and I do admit, it takes hell of a gut for a doctor to admit that he doesn't know what is wrong with you or what is causing the fever.

This 24 y.o female patient was referred from the OPD for evaluation for her 2 week history of unsettling fever. The HO is indeed stressed out to find out the exact cause by looking at all the tests he/she ordered

Pleural Effusion

2010-04-10T20:28:00.002-07:00

Just this week, I've come across 2 patients with massive pleural effusion. Thought of sharing with my fellow colleagues since this is indeed a popular topic for bedside discussion or even exam.

This 80 y.o patient presented to the A&E with 2/7 progressive SOB and subsequently an AP CXR was taken

A 55 y.o patient with a known history of DM and HPT presented with generalized edema, ascites, peripheral upper and lower limb swelling and facial puffiness.

Pleural effusion can be divided into unilateral or bilateral.

1) What are the common causes for pleural effusion

2)What is the difference between transudation and exudation. What is the Light's criteria?

3)What are the clinical signs of pleural effusion

4)What are the investigations that you would order for the above patients to find out the underlying aetiology.

Bendera

2010-03-13T06:21:00.001-08:00

Patient came in c/o light-headedness , provisional diagnosis of uncontrolled DM was made.

MO to HO: Ask the patient whether he has erectile dysfunction

HO to Me: You ask then

Me to pt: Uncle, nak tanya sikit, jangan rasa terhina k, soalan routine saje ok? Bendera boleh naik ar uncle?

Pt to me : Walaupun sudah 66 tahun, bendera masih boleh naik, no problem!

Me to HO: No erectile dysfunction

My patient died

2010-03-03T04:44:00.000-08:00

When I saw him going into cardiac arrest, and subsequently his death announced, I had a sense of futility, then sadness. I was just talking to him yesterday, asking him whether he felt better, eating well and ect. It was as though he just disappeared.

I had seen somebody die. Some willing, others were not. Some were expected to die and some not. Some died of natural causes and other deaths were iatrogenic. It does not get easier for me. On the other hand, if death became easier for me, I would lack empathy. I want to be the sort of doctor that, 20 years down the line, when any of my patients die, I will still feel sad, and sorry for them.

This type of learning, with the rare opportunities for open dialogue abt death and dying is unique. In the hidden curriculum of medicine, where learning about death comes from seeing it on the wards, there is little time and often doctors are unwilling to discuss death and emotions relating to it. A personal education from a willing and honest patient is invalueble.

I am still clueless about the process of dying, my role in it and my response to it.

Cardiomegaly

2010-02-27T19:58:00.001-08:00

No doubt this is the biggest I've seen.

C/O: Penile Swelling, unable to pass out urine, bilateral pedal edema

Dx:

CCF secondary to non compliance to fluid restriction, with MR+MS secondary to rheumatic heart disease complicated by AF.

Smoking

2010-02-27T02:38:00.001-08:00

The reason why I make it a point to drop by my designated ward everyday(at least for the morning) is not only to clerk patients for my learning, learn new procedures and etc, but also to experience bizarre incidents that could really baffle and puzzle my mind as a medical student. I often walked out from the ward smiling, telling myself I've enjoyed my day.

While I was doing my routine tasks in the ward this morning, I get a whiff of something burning. The cubicle was quiet as the visiting session has just ended. At first I thought I was having some problem with my olfactory bulbs and thus having some "smell hallucinations". But when it got stronger, I turned around and saw the bed of a patient burning in flame. Relax, it was just a small one at the side of the bed, not to the extend of burning the patient alive.

I alerted the nurse and she passed me a jug of water, I then splashed it on the bed to put it out. The climax is when the HO came to interrogate to find out who was the culprit. The nurses found a cigarette box underneath the pillow of the neighboring patient. But he denied. The nurses got upset and asked me to give his shirt a smell, LOL!

One of the housemen then came and threatened that they are gonna collect saliva samples from the cigarette butt found on the floor and determine whose DNA it belongs to. But still, her effort was futile as both the patient and his neighbor denied all the way.

Thank god he didn't smoke near the oxygen supply, I might not come out from the ward alive.

Respectful

2010-02-12T03:30:00.000-08:00

My clinical training started officially and I will have to admit that this week has been the best week throughout my medical training so far. Had the opportunity to auscultate 2 pan systolic murmurs in a 15 year old kid with VSD and another 70 year old uncle with a mitral valve prolapse complicated by infective endocarditis. Although it is physically and mentally exhausting at the end of the day, i know that the more patients i see, the more i learn.

Clerked a 65 year old man who was referred for evaluation of his shortness of breath and chest pain. He is known to have hypertension diagnosed 3 years ago with previous history of ischemic heart disease. He was unable to ambulate himself due to the shortness of breath(NYHA class III) and was then put on oxygen therapy. Spoke to his son and managed to obtain a comprehensive history.

This is a classic example of textbook heart failure in which the heart is unable to pump out enough blood to sustain the body's demand. I thought this was an interesting learning opportunity for the group and hence decided to present to Dr W during bedside. However, throughout the session, the patient seemed rather uncomfortable with 12 of us surrounding him, talking in some odd jargons that he himself could not comprehend. The son and son in law weren't that happy with our presence as well. While presenting the case to my tutor and my fellow colleagues, i feel very bad for disturbing him, making him a subject of study for the 12 of us. Throughout the session, I was not paying full attention to what Dr W was saying, I was instead concerned about how the patient is feeling. Periodically, I will take a peep at him, or ask the son whether everything is ok. I adjusted the window beside the bed so that more fresh air could ventilate the already stuffy ward. The session ended in an hour and i thanked him before i leave.

Medical students should ask themselves a pertinent question, " Who taught me medicine?" Many would respond " My professor, my consultant, MO, lecturers" and so on. When they graduate, they will go knocking on the doors of their profs and lecturers to thank them personally for making them a good doctor.

If you come to think about that,

Did the professors really teach us the art of medicine? Did any of them developed heart failure and atrial fibrillation so that i could palpate an irregularly irregular pulse for the first time? Did they suffer severe shortness of breath to show us the cardinal sign of heart failure?

The ans is so obviously no. No doubt that they did facilitate our learning, guiding us along the way. They teach us the correct technique of physical examination not forgetting sharpen our skills in critical thinking which is utmost important in reaching a definite diagnosis. Mind you, they were heavily paid to teach us(in monash at least), but did the patients receive any monetary gain by teaching us? NO!

Parents taught us to respect our teachers, that's the reason why we should have utmost respect for the patients. They are our TEACHERS, and will continue to be one, throughout our career, until the day we decide to stop practicing medicine. Without them, we would never become doctors.

So now as students, and future doctors, what we could do is to at least respect them. They are not "cases". Quoting Dr W, a pencil case? or a brief case?

Show sincere care

2010-02-12T00:21:00.001-08:00

A wise physician said to me, " I have been practicing medicine for 30 years and I have prescribed many things. But in the long run I have learned that for most of what ails the human creature, the best medicine is CARE."

"What if it doesn't work" I asked

"Double the dose" he replied.

Anonymous

Attitude not aptitude, determines altitude =)

SurgeXperiences 315

2010-01-23T02:25:00.000-08:00

Thanks for dropping by. Welcome to the 15^th edition of SurgeXperiences, the only Surgical Grand Rounds that is devoted to the best surgical related posts!

Without further ado,

Dr DJ, a surgeon from Mumbai, India who blogs at “Dr DJ’s Surgical Adventures” brings us two great posts. First he chronicles about a difficult situation where things are not in their expected places.

“The doctor doing the CT suddenly yells, “Where is the doctor that managed to do this”. The intern accompanying the patient almost had a fit”

Read on to believe it for yourself!

Medical practice is not universal, medical customs and indications differ widely between countries and indeed patients’ expectations differ even more. The second piece of literary from Dr DJ sheds some light on how cultural differences between doctors and their patients are common and may have important clinical implications for clinical encounter.

“I would love to have a middle ground and say it is our duty to inform the patient that a complete medical examination is required, but how many would agree to strip down completely just for a fever?”

Next up, ER Doc over at “Tales from the Serenity Now Hospital” shares a story of complete lack of common sense.

“I try to educate my patients as much as possible on things. I don’t always do a good job when its really busy. But this time I was sure to explain what milking the prostate really is”

Over at “Two weeks on a trolley” is a post titled Dr Ima Toilet that explores the worst things that could happen to you on the wards. Read on to discover how he was peed directly into his eyeballs during a delivery, drenched in liquid poo after inserting a tablet into a child’s bottom, not forgetting an encounter where a patient approached him from behind and urinated on the back of his legs. Poor guy!

There is also a mention about a med student who gulped a piece of cadaver adipose tissue and eventually became a surgeon. Read on for a good laugh!

Romana, a plastic surgeon in Little Rock, AR reviews a journal article about “Histologic Relationship of Pre-auricular sinuses to Auricular Cartilage”. [Read Here]

With the number of injured casualties continues to escalate, MSF’s surgical units in Haiti continue to work around the clock, providing relief and treatment despite having limited staffs and resources. However as the death toll in Haiti continues to climb, frustration appears to be overwhelming as relief efforts are seemed to be slow and disorganized. [Read Here]

Over at the “Forensic Scientist Blog” that covers the life, times and interests of a real life forensic science technician, he explores how forensic scientists use body parts to identify and perform criminal examinations of the deceased. He highlighted the role of prosthetics implanted by surgeons as well as scars from routinely performed operation such as appendectomies are indeed handy in aiding the process of identification.[Read Here]

Though I strongly believe that everyone should have access to a good defense, even I wondered how some lawyers can help defend people who have done horrendous things. When lawyers help killers and child molesters off the hooks my finding some legal loopholes, you got to ponder if they’re really upholding the legal system or merely just thinking about monetary gain and their ego.

Bongi a south African surgeon who blogs at “Other Things Amanzi”(my all time favourite) mourns over the death of his patient and rants about why he hates lawyers.

And that’s it for this edition of SurgeXperiences, please send submissions for the next edition via this form. Also , for anyone who wishes to join the ever growing family of SurgeXperiences, do not hesitate to contact Jeffrey who runs the show.

SurgeXperiences 315-Call for submissions

2010-01-14T22:04:00.001-08:00

Thank you for paying a brief visit. SurgeXperiences is the one and only blog carnival that assorts the best surgery related posts in the medical blog sphere today. It was pioneered by one of my esteemed counterpart, Jeffrey Leow of Monash Medical Student who is adventurous enough to open up new areas of thoughts and bringing something new to the surgical blogging community.

SurgeXperiences was first started on 1st July 2007 and it is hosted by various hosts ranging from surgeons, anaesthetists, radiologists, students and even to patients. It is published fortnightly and each season lasts approximately a year.

The current edition, SurgeXperiences(314) is up at Suture for a Living. Yours truly will be hosting the upcoming edition (SurgeXperiences 315) on the 24th of January for the first time.

Being a fresh 3rd year medical student with minimal surgical experience, knowledge and background, it is my fervent hope to still be able to contribute to this carnival by attempting to produce a succinct post that will hopefully satisfy readers' likes.

It is an uneasy but apprehensive experience for me since this is my first post and I certainly do not want to disappoint the readers, so please bear with me while I accustom myself to how to system works.

Submissions can be done here.

Dateline : 22th of January, Friday

Here are all the previous issues of SurgeXperiences for your reading pleasure and do not hesitate to contact Jeffrey who masterminded this remarkable blog carnival-SurgeXperiences-Where we share our surgical experiences!

Tremendous experience, Summer Vacation Research Scholarship

2010-01-13T13:48:00.000-08:00

Even as the academic year winds down, I was preparing to meet a new challenge: 8 weeks in a laboratory that will hone my scientific skills and prepare me for a possible career in research. I was fortunate enough to work in the Steroid Receptor Biology lab in Prince Henry’s Institute of Medical Research as part of the initiative supported by the Cancer Council of Victoria.

Such programs give students a chance to immerse themselves in cutting edge medical research in tertiary research institutions. For an international student like me, it is a pivotal experience that helped me decided whether to pursue a career in research, and to consider a possible career of being a physician-scientist.

Throughout my placement here, I realized researchers/clinicians who bridge the gap between clinical medicine and basic science are in a unique position to exploit the expanding knowledge of human genome and other recent advances to make remarkable discoveries that will benefit the human health.

The range of possible research areas that I was exposed to is immense. Emerging areas include identification and use of markers to allow early detection of ovarian cancer, gaining an in depth understanding about the exact pathophysiology and discovery of new molecular targets for possible therapeutic agents spearheaded by the steroid biology receptor group over in PHI.

Upon completion of this program, I truly recognize the increasing importance of science and research for practicing physician. I probably didn’t have any idea that I am going to do research before this experience. This journey down under really does build up the excitement, but even if I decided not to pursue research somewhere down the line, I am undoubtedly better prepared for 21^st century medicine after working in the lab.

By immersing myself in the project looking into the “Pathogenesis of Granulosa Cell Tumour”, I am proud to say that I have mastered a few key techniques in laboratory research. Among the techniques are cell culture, plasmid purification, bacterial cell transformation, mammalian cell transfection, PCR, Western Blotting and many more.

Personally, I have the impression that research is more tedious and meticulous compared to clinical medicine. Moment to moment awareness is crucial to avoid to avoid making mistakes that could jeopardize the whole experiment. Techniques such as cell culture are indeed demanding requiring strict adherence to sterile practices to prevent unwanted contamination.

Besides learning core techniques, one of the most valuable lesson I have gained from the people here is to be analytical in science. I was taught by my supervisor to think critically when things go wrong in science. Critical skills in investigate thinking do provide a basis for better medical practice, better assessments of evidence for that practice that will change rapidly in my generation of physicians and a better foundation for new biology of medicine. Spending time to search for answers as well as fixing problems that arise truly intrigues my inquisitive mind.

Although the results for my experiments are not conclusive, I have indeed benefited tremendously as in PHI there has been a great focus on understanding the aspects of translational research, a valuable experience for medical students beginning their careers, By having done an independent study project, I have gained insights in how things move from the lab bench to patient bedside.

2010

2009-12-30T17:07:00.000-08:00

I personally think that making resolutions for the upcoming new year is ambitious as there is a fair chance that I might not be able to live up to them. With the end of the year 2009 and the arrival of the brand new year, I take this as an opportunity to reflect upon myself and think about ways to further improve myself.

Whether you are a college student, a high school student or a working adult, there are plenty of resolutions that you could make to further enhance your study/working experience and to put yourself right on track for a successful future.

Anyway, in light of the potential for a change, I have come up with my own list of things that I want to do or continue doing.

1)Put on a significant amount of weight. Being underweight prevents me from donating a full pine of blood. Besides, I need to start impressing the girls.

2)Step up to be a better human. As a son and a brother particularly. They have been awfully neglected. I shall try my best, despite the heavy schedule that I am expecting to have.

3)Strengthen Relationships

4)To mold the character of a helping doctor to those who are really in need. To treat every patient with utmost respect as if they are my loved ones. But prior to doing that, I shall equip myself with as much knowledge as possible so that I know, I know so clearly that, the patient will not be in anyway being disadvantaged by my incompetency, and this patient is safe under my care.

5)To be the best student I can be, an active learner, a team player as well as a leader.

This is the last post for the year and I look forward to the new one.

A Doctor's Delights Discoveries from the Richard Travers Collection

2009-12-09T22:29:00.000-08:00

Work in the lab ended early today. Majority of the people in Prince Henry's Institute are already in Christmas mood, conversation topics often revolve around the celebration of this upcoming festive season.

Since I have half of the afternoon free, I attended an exhibition on medical history, " A Doctor's Delights: Discoveries from the Richard Travers Collection" held in Sir Louis Matheson Library.

Have you ever pondered how the word "medicine" came about? The word medicine is actually derived from the Latin "Medicina", meaning the art of healing(Wikipedia). Early records on medicine have been discovered from early Ayurvedic medicine in the Indian continents not forgetting to mention about ancient Egyptian medicine, traditional Chinese medicine and Greek medicine that uses animals,plants and even bodily fluid as therapeutic agents.

Since then, medicine has improved by leaps and bounds as what we can observe today owing mainly to the invaluable field of modern scientific biomedical research. Some of the medical books and artifacts displayed there were from the 16th centuries, indeed intriguingly arousing. 20 mins of my life was spent walking down the memory lane of medicine.

Looking at the history of medicine shows how ideas have developed over the centuries. Medical barbers were the fore-runners of today's skilled surgeons; Leonardo Da Vinci was amongst the first to dissect the human body, trying to figure out the anatomy of the mysterious human body as well as to learn how it works. Till today, medical students still learn about anatomy in the same way.

Below are some pictures that I've managed to capture with my mobile, not the best of quality. I apologize for that. Will be paying a second visit within these few days for more pictures of the collection, stay tuned.

The Anatomy of the Brain with a Description of the Nerves and their Function (1664) by the British physician Thomas Willis (1621-1675) is one of the older items in the collection. A book from the founder of the circle of Willis! How fascinating!

Bernard, Claude, 1813-1878, Illustrated manual of operative surgery and surgical anatomy. This book basically talks about surgical techniques involved in different procedures. Picture depicts surgical amputation of the upper limb(fingers).

Insulin: Its use in diabetes/ Commonwealth Serum Laboratories, Department of Health, 1925. The therapeutic potential of insulin in maintaining glycemia in diabetic patients has been recognised since 1925!

Cole's atlas of anatomy and physiology of the human body.(Melbourne : E.W. Cole Book Arcade, [191-?]). Early atas of human anatomy!

Early prescription record in a local drug store.

The anatomy of gravid uterus by William Hunter(Not the one who discovered the adductor canal)! Quite a renown anatomist 1718-1783.

Intracranial Tunours: Notes upon a series of two thousand verified cases with surgical mortality percentages pertaining thereto/ by Harvey Cushing. A book by the same neurosurgeon who discovered Cushing's Disease!

Double Medal Honours

2009-12-05T20:37:00.000-08:00

Two scientists from PHI in Victoria are to receive medal honours from the UK Society for Endocrinology. The awards recognise their major personal contributions to international hormone research.

Professor Peter Fuller, Associate Director and Head of the Steroid Receptor Biology Laboratory at PHI, is to be awarded the 2011 Hoffenberg International Medal. The award, which is made to an endocrinologist judged to have made outstanding contributions to hormone research, also promotes international collaboration between researchers.
The award highlights Professor Peter Fuller’s international reputation as both a clinician and a scientist. Peter’s research interests lie in understanding the molecular mechanisms of steroid hormone action. He has led studies that focus on the adrenal steroid hormone aldosterone and its role in hypertension and cardiovascular disease. His laboratory also studies the molecular pathogenesis of granulosa cell tumours of the ovary. Both Evan and Peter will travel to the UK in March 2011 where they will give their medal lectures at the Society for Endocrinology annual meeting

More info at PHI's Official Website

I reckon another cake day is on the way to celebrate Prof Fuller's achievements. A knowledgeable clinician with an absolutely humble character. Still cant believe I'm going on ward rounds with him tomorrow.

On another note, I just realised that I haven't been doing what I am supposed to do since I landed in Melbourne. - My virgin visit to the club! Who is up for it?

Of Medicine and Life long learning

2009-12-04T02:00:00.001-08:00

It is Friday once again and today concluded my second week of studentship in Prince Henry's Institute. Life as a student here is never mundane as everyday is different. You learn different things/techniques, you make different mistakes, you meet different people, you hear different codes(code blue/code red) and you attend different seminars. Quite variable. There is an explosion of knowledge in Prince Henry's itself and It makes it hard for me to digest and catch up.

I reckon it is fundamentally crucial for doctors or even medical students to keep themselves(or at least try to) updated with what is happening in the medical field from time to time. One of the best resources that I think is absolutely useful is Medscape. Just subscribe to their newsletters in various fields and you could get heaps and heaps of updates/advancements and even clinical trials that are currently being carried out in different parts of the world. There are videos on panel discussion on every single topic you can find not forgetting the chance to earn some CME points at the same time.

At this stage, year 2 medical students from Monash should probably be quite familiar with the drug Thiazolidinedione(TZD) which is used as one of the agent to control glycemia in T2DM patients. When I learnt about it last year, I was quite fascinated as this drug actually acts as an agonist to the nuclear receptor PPAR gamma to initiate transcription of insulin sensitizing genes. Interestingly, this is the same receptor that Simon and I are looking at right now in terms of tumorigenesis of granulosa cell tumor of the ovaries. However from a recent conversation with Jun, an endocrine fellow in MMC who is currently pursuing her Phd in PHI, I was told that one of the TZD, rosiglitazone was found to cause heart failure in patients by inducing water retention while messing up sodium balance. I then searched for this particular drug in Medscape and found an article written in 2001 claiming that Rosiglitazone could reduce cardiovascular mortality and morbidity in T2DM. I was confused for a while, wanting to know the real story behind this wonder drug. I then googled "Rosiglitazone FDA Heart Failure" and then a second article written in the year 2007 from Medscape appeared. Guess what? Roziglitazone really has an adverse effect and could precipitate heart failure, warned by the FDA. Pioglitazone which is widely used is currently being reviewed as well. I doubled checked, and It was valid. In a short duration of time, a drug can be known to cause harm, treatment strategies could be modified, guidelines are then being reviewed as frequent as possible. Frustrating huh?

In medicine, things are constantly changing. Thus, this serves as a good reason for us to instill the habit of keeping ourselves updated even at this stage itself. Even in undergraduate, why not? Many still could not accept that fact that medicine is really a life long learning process. It is not a course, it is not a job, it is not a career either. It is a life.

On another note, I attended a talk 2 days ago and was amused by the debate between the endocrinologists, diabetologist and the researchers. They were arguing about the use of insulin secretagogues in the management of T2DM. The researchers claim that insulin secretagogues like Sulphonylureas causes pancreatic beta cells exhaustion and on other hand, the endocrinologists softened their comments by saying that choices of medication is indeed limited. Was reading through Nature's Endocrinology review and there was an article saying that the current stereotyping of DM is oversimplified owing to the fact that the prevalence of "Double Diabetes" or better known as "Type 1.5 diabetes" has dramatically increased in both developed and developing countries. They argue that there is a need to review the current dichotomous classification of DM. Interesting isn't it, its never ending. New things come up every single day.

Managed to catch up with Prof Fuller this afternoon when all the staffs of the steroid biology receptor lab celebrated over the acceptance of Amanda's thesis on the role of mineralocorticoid receptors in the context of cardiac fibrosis and heart failure. She is now officially a post-doc research fellow in PHI, nicely done!

I expressed my intention of doing a BMedSc to Prof Fuller and we had a good chat about it. That concludes the day and I shall look forward to the endocrine ward rounds and journal club with Prof Fuller on Monday. A teaching session with the Endocrine Director of Southern Health without the presence of other medical students, how lucky. Hopefully the presence of inspiring figures like him will keep my passion for medicine burning.

Home sick

2009-11-27T22:34:00.000-08:00

I'll have to admit that I am not a "family" guy. After 2 years studying in KL, I have never missed home. Perhaps this is due to the fact that Penang is just approximately 365km away from KL and I know that I am able to board a bus back whenever I want. As a son, I do call back home everyday, making sure everything and everbody is doing fine at home. Although it is just a short call, but It was sufficient, at least I know I am playing my role, as an integral part of the family, as well as the eldest son of the family. I am not sure whether It is really enough, but perhaps It is true that the time we spend with our family is never truly enough.

I have been in the land of down under for nearly a week. Strangely during this period of time, I felt terribly home sick, exaggerated particularly when I come back home from work. The house is awfully quiet with all the housemates in their respective rooms. I felt truly isolated, detached from human touch. This is the reason why I look forward to work everyday, at least I could talk to somebody in the lab. Facing the four walls in my room, I started to look for people to chat online, I become so emotional that I requested for my brother and parents to come online more frequently.

Why is this happening? I've never been so home sick before. There are moments that I ponder, why the heck I am doing here when I could have instead spend 2 months of quality time with my family. Perhaps it is true, this is a trade off, losing one quality of something for gaining another aspect. I am not entirely sure whether I"ve comprehended fully the upside and downside of this decision that I've made. But I know, no matter what, I need to complete what I've started with.

In the school of medicine, there are lecturers, clinicians, surgens who got married very late in their life due to overwhelming commitments towards their career. Some even remain single until now. Dinner session with Wei Men and Rachel yesterday gave me a big slap on my face, forcing me to realise that there are so much more to life than academics. Relationsip, family and friendship for example. Dude, I'll have to admit that I am so envious of you two.

I looked at my surrounding when both of them went to grab some food. I saw a few couples and families few tables away happily enjoying their meal, spending precious family time toghether. I was alone at the table, waiting for both of them to come back. I opened my backpack to get my bottle of water and heck what I saw is my edition of "Nature's review of Endocrinology and Metabolism", one of the journal that has the highest impact factor in the scientific world. I stopped for a while, so disgusted by myself.

Strolling along Yarra River at night with both of them made the feeling more overwhelming. The night scenery was exeptionally breathtaking. Couples are sitting beside the river, looking at the high rise building of Melbourne city, spending romantic time together. I tried to maintain my composure when both of them are around. Again, I would like to thank them for the scrumptious dinner and also for being such an accomodationg host.

Just like in Diabetes Mellitus where glycemia is a balance between insulin secretion and action. I guess my life is placed on a balance between career and human relationship. Is it terrible to come to a realisation now that somehow there are flaws in my life? After 2 years of struggle through medical school.

Of Medicine & Scientific Research

2009-11-24T23:29:00.000-08:00

It has been 3 days in Prince Henry's and I have come to an awful conclusion that I am an complete idiot in molecular biology. Due to the fact that I have a very limited knowledge and experience in lab techniques and molecular work, It makes it even harder to comprehend the stuffs and materials that were delivered to me. Even a simple task like handling micropipettes poses some difficulties for me. Things like handling the biohazard hood for tissue culture and the required fundamental sterile techniques are so unfamiliar to me. Sometimes, things that we perceived to be useless and waste of time in the past could come in useful and handy in the near future. So I reckon a good student is like a sponge, constantly absorbing all the knowledge and materials that are delivered to him without doing any selective studying. So I guess, its time for me to revisit some of the epidemiology and the public health topics covered in these 2 years.

Within 3 days, I've experienced an explosion of knowledge and has been able to witness with my own eyes how science and medical research could have such a big impact factor in our daily life, especially in health care. All the researchers and students in PHI are incredibly passionate about the work that they're working on. Some of them even discuss and talk about it over lunch breaks, reading journals, trying to keep themselves up to date with the latest research in the scientific field. It really does give you the feeling that you are currently in a tertiary research hub. This does not only apply to PHI, It also applies to the people from MIMR, the doctors involved with research work, basically the whole scientific community of Southern Health. This is the main reason why Monash is at the forefront of medical research-excellent environment for scientific work as well as a bunch of dedicated people.

In PHI, there are seminars and forums being held once in a while. All the staffs and students are required to attend the talk no matter who the speaker is, to show respect to the invited external speaker ( It could be internal speakers at times). When talks are being scheduled, Dr Simon or other people in the lab will not hesitate to update me about it, making me feel like I am really part of the group.

I've been fortunate enough to be able to attend two of the seminars held recently. The first one was on "Novel medical therapies to cure ectopics" by a researcher from Centre for Cancer Research, MIMR discussing about the potential use of Epidermal Growth Factor Inhibition in conjunction with Methotrexate(MTX) which also serves as an anti-neoplastic drug to cure ectopics. The second one actually revolved around the role of apoptosis/apoptotic cell death in folliculogenesis. Will blog about them soon, more reading to catch up with before I am able to write about that.

The steroid biology group meeting was held yesterday morning chaired by Prof Fuller. This is a venue for each member of the group to evaluate their own progress and also to get updated with what others have been doing over the week. In that meeting, James was presenting on his work which deals with glucocorticoid and mineralocorticoid receptors. Have you guys ever wondered why mineralocorticoid receptor has glucocorticoid activity (i.e cortisol can bind to mineralocorticoid receptor) but on the other hand glucocorticoid receptor has high affinity and specificity only towards cortisol and not other mineralocorticoids.

Extensive studies are being carried out in PHI itself, looking into the structures, genes and functions of these receptors, they've managed to narrow down to a few amino acids that are responsible for the difference between the 2 receptors. Not far from now, perhaps in Guyton or Ganong, there will be a section that explains why this happens.

I truly believe, clinicians who are active in research are at the forefront of medicine. As clinicians, they are familiar with the clinical aspect of their work, but I guess It is still due to their inquisitive nature of their character and their hunger for knowledge that got them into research. Isn't it fun to know how things work even if It requires you to look into the molecular aspects of it? One of the perks of research I would say!

PHI

2009-11-23T00:31:00.000-08:00

Today marks the first day of me working in Prince Henry Institute of Medical Research as a vacation scholar. I was fortunate enough to be awarded the Summer Vacation Research Scholarship by the Cancer Council of Victoria @ $250 per week and will be spending 10 weeks working on the molecular pathogenesis of Granulosa Cell Tumour(GCT), which is a rare form of ovarian cancer under the steroid receptor biology group spearheaded by Prof. Peter Fuller.

I woke up early this morning feeling extremely ecstatic. Took my breakfast (Milk+Cereal, cant afford other than this), and then had a slow walk to the hospital which is situated only 15-20 minutes from my place. Prince Henry's Institute is a non-profit medical research institute situated in Monash Medical Centre(Central Clinical School) together with some other renown tertiary centers such as the MIMR(Monash Institute of Medical Research).

Prince Henry's Institute is renowned for its research in reproductive medicine as well as endocrinology, the study of hormones and it's signalling pathway. The main reason I chose to work under Prof Fuller is because he is one of the few clinicians who are extremely active in research, who will probably be the best person to provide me with valuable insights regarding the future career prospects in academic medicine. I love clinical work a lot that I am certain and definite that I would not dedicate my medical career into pure research, instead I aimed to contribute as much as I can to the advancement and development of medical knowledge by indulging myself in some sort of clinical research somewhere down the line. Instead of being just a consumer, where I am only confined to gaining and leeching knowledge from some other's work, I would want to be acclaimed for my contribution in the medical arena.

Ask any students in Australia who is pursuing a biomedical related degree and they will be happy to name you a few research organisation which have been well established over the years. Names like Burnet, Peter Mac, MIMR, PHI, Baker are well known among the local students. Indeed, I am very fortunate to be part of this leading research institute, no doubt it enables me to have a sneak preview of what research is going to be like.

Throughout this 10 weeks, I will be particularly looking into the role of PPAR (Peroxisome Proliferator-Activator Receptor) in the pathogenesis of GCT. Lots of reading up to be done before the research group meeting that is going to be held tomorrow morning.

This Ligand that Ligand, this kinase that Kinase, P53, BCL-2, Transfection- Had a hard time comprehending all the jargons introduced, but I guess it's still part of learing =)

p/s : As a vacation scholar, you get your own office like the honours and PHD students, you get your own locker ,you get to see what's 2 dimensional gel electrophoresis and also a DNA sequencing machine!

The Ovarian Cancer Felllow.

Dr Simon Chu, on the right end corner who is going to be my main supervisor has returned to PHI as the Loreal Paris Research Fellow after 2 years studying overseas. In his projects, he will be exploring the origins of some of the most serious form of ovarian cancer.

The silver ribbon that they're wearing was introduced by the OCRF(Ovarian Cancer Research Foundation) and the main objective is to raise awareness about Ovarian cancer and also to raise much needed funding support towards finding an early detection test for ovarian cancer.

A journey down under

2009-11-19T18:49:00.000-08:00

Mom cried while she was sending me off at the airport. "It's just for 2 months" I said, patting her at the back, thinking that she is making a big fuss out of this. To me, I failed miserably as a son. Haven't been spending sufficient time with them and my siblings, the sense of guilt is overwhelming.

I boarded the plane at 12.40 pm with Amanda who is visiting her friend over in Clayton. I looked at the map and realised that Australia is not really far from Malaysia, yet the whole journey took 8 hours. Looking at the sky in the plane, I managed to put my worries, burden at the back of my head for a while. It was beautiful. I can see ice forming outside the window due to the low temperature and Amanda started taking shots at it using her new DSLR.

The night scenery of Melbourne City from the sky is truly breath-taking. Just by looking at the lights from above, I can tell that this city is well arranged. Amanda met up with her friends after that and that left me alone in the airport.

Had to sleep over in the airport yesterday as I arrived at 12 midnight. Took me quite a moment to get used to the currency. Bought a vanila shake from MacD and found a good spot at one corner to sleep over. It was cold in the airport and even with both my jackets on, soon I noticed that my fingers and nail beds were turning blue. Thanks to the body's homeostasis, I managed to conserve some heat via peripheral vasoconstiction. It was a rough night, but It was thrilling.

I managed to get a few hours of poor quality sleep. The fear of loosing my luggage kept me awake every now and then. I checked whether my passport and wallet are still with me constantly, just in case.

It was 5am in the morning, I bought myself a cup of steaming hot coffee that costs me 3 dollar and headed towards the bus station to wait for the shuttle bus that is scheduled to bring me straight to Monash Clayton Campus. While waiting, I enjoyed observing the people around me with a cup of coffee in my hand. The morning breeze was exceptionally fresh, I took a deep breath in and told myself, "you're a lucky man cyc, this is gonna be a hell of an experience".

Dandenong Airport Shuttle bus ( Melbourne Airport-> Monash Clayton 25 dollars)

Conclusion of Year 2

2009-11-13T18:26:00.000-08:00

The VIA(Vertically Integrated Assessment) paper that I sat for yesterday morning marks the conclusion of year 2 of the MBBS program. Instead of feeling relieved, I felt lost as soon as I step out from the exam hall, and I sighed.

It was a sunny afternoon and my colleagues were either either expressing their congratulations to each other or busy indulging themselves in the discussion of the questions that came out. Some of them were jumping in joy, indirectly implying that it went smoothly while some of them just looked emofied and stoned. I did well I would say, mistakes here and there but generally It was a good paper, so comprehensively structured that It could really reflect our clinical competency( not including Theme 1 and Theme 2, I've never considered them as a subject =P )

It felt weird for not having any particular tasks to accomplish after the daunting exam. I guess I am still better adapted to the busy, fast pace, mundane kind of lifestyle. Goals and tasks keep me occupied and focus, almost all the time.

Year 2 indeed has been a roller coaster ride with its ups and down. I'll have to admit that It has been the toughest academic year for me so far, to the extend that I am just too tired to do anything else except to get sufficient sleep once I reach home at almost 12 midnight everyday. The study load is just enormous and the level of stress increases exponentially due to the back to back assignments that might at some point perceived to be unreasonable and a total waste of time.

However, I'm glad that its over. Deep down there, I know I will be roaming around the wards next year, engaging myself with patients. The "real" medicine finally begins.

Here comes the end of the year and I shall summarize some of the highlights that I reckon to be significant in my journey as a medical student.

1)Attended a public forum by Sir Matin Evans, nobel prize winner for medicine in the Academy of Sains Malaysia. Took a few shots with him and managed to obtain his signatures together with a few words of wisdom.
"Knowledge and Understanding", those are the 3 words he wrote on my writting pad.

2) Donated blood for the second time in the interval of just 6 months. Donated 350 mL instead of 450 due to the fact that I am underweight!

3)Finally turned bald after god knows how many years. A bald head + severely cachexic figure = people tend to mistaken you as an intravenous drug user. It was fun for a short period of time as people tend to pay more attention on me and of course, the girls like to touch and play with your head.

4)Represented Monash in the 7th interuniversity physiology quiz held in UM. I am so proud of the team's acheivement for emerging as Malaysia's top university after NUS and Chulalongkorn University beating UM and a few good local universities despite the minimal contribution I've poured in.

5)Celebrated my 20th birthday in the Uni. My colleagues and juniors were awesome people. Thanks for making it a memorable experience. The number "2" is somewhat intimidating to me.

6) Awarded a summer research scholarship by the CCV(Cancer Council of Victoria) to spend 10 weeks in Prince Henry;s Institute if Medical Research/ Monash Medical Centre to work on granulosa cell tumour of the ovaries.

7) Met a few really inspiring figures that serve as a motivation for me to strive harder.

My flight has been scheduled on the 19th, its just merely 6 days after my last paper. I feel so sorry for my parents, for not being able to see their son often throughout these 2 years. I am always somewhere out there, exploring opportunities, hardly even spend time at home. Its a mixed feeling. But well, I guess I'll just have to try harder in juggling my time between studies and family.

Could not afford to lose the warmth of family/relationship for the coldness of a scalpel couldn't I?

Not in gainful employment

2008-12-17T17:38:00.000-08:00

Click here for the full article.
It is not shocking. I indeed predicted it.

Every year, thousands of top scorers throughout the nation are vying for a career in medicine. But do they really has what it takes to become a good doctor? I still believe there are flaws that need to be addressed and look into promptly in the process of selection in order to select only the ones with the passion.

By the year 2015, the amount of doctors is going to be one-fold of the amount of doctors today. By then, we would be begging to get hired. It might sound ridiculous, but we might ended up fighting with the nurses just to draw a patient's blood.

For those who are interested to have medicine as their life long career:

If you are a money seeker, fortune hunger kind of person. I would suggest you to leave this journey immediately before you realize that you have made the biggest mistake in your life once you reach the age of 40. This is because there are no doctors who became a millionaire by juggling his time between on calls, assisting deliveries during the wee hours of the morning, struggling to open his eyes after a continuous 36 hours of duty.

If you are looking for job security and employment upon graduation. I suggest that you join the uniform forces for eg the military or the police forces. They need you badly. Based on the news report above, medicine is no longer a prestigious or a profitable career.

Even in the first year itself I realized that if you want to excel in medicine, you need to be grounded. Long hours of mugging, memorizing is inevitable. Trust me, it is sometimes frustrating and totally unrewarding.

Since the competition is so immense right now, I have no choice but to agree with the fact that: Only the fittest survive.

A mentor

2008-12-16T01:31:00.000-08:00

I've got my white coat, Now what do I need?

Professionalism is utmost important to me. Because I know, the first impression that I will portray in front of the patient or during any medically related occasion is crucial in reflecting my competency as a future medical practitioner. I will usually spend significant amount of time in front of the mirror, looking at myself, looking for any flaws that could not be seen public for example my nostril hair that seems to grow ridiculously fast. Not to say that I fertilize them. Well this post is not about my narcissism or my self absorption, instead it is about the need to have a mentor, especially in the medical field.

I put on my tie, adjusting the length so that it is proportional to my height and of course making sure that the knot is not too big ( personal preference). Finally, I put on my tie pin and there you have it. A young, not so good looking but decent doctor to be in the making. Thinking of that, I reminisce all the rigorous training I've had, telling myself that I did well, above average I presume. In the process of congratulating myself, I never bother to stop and think about all the people that made it possible.

There are people like my parents, teachers and doctors that I've spoke to. They are the ones that make me try and try even harder. I've passed year 1 with my sanity intact. I think that's my biggest achievement so far. Forget about UPSR,PMR and SPM or even college. Living as a SPM or college top student is never close to live a life as a medical student and the worst news is. Living as a medical student itself is still far fetched from being a house officer or a practicing physician. All these mentors have made a difference in my life. From now on, whenever I put on my white coat proudly, I promise I will think of them. They will be symbolically there, adjusting my white coat, making sure that it fits and I look good in it.

If you are lucky, you'll have multiple mentors. But for me in this medical arena. I have one.

Life is complicated and good mentors usually have some battle scars. They like to advice and more importantly they know how to listen and bring out the best of you.

I hereby introduce you to my mentor, Associate Prof Dr Kelvin Lim. Well, I don't really think that he is aware that I admire him so much as we did not go through the ritual ceremony that is required when a disciple finally found a long awaited master as portrayed in most chinese movies.

His qualification:
MBBS (Newcastle) FRCS (Edinburgh) BDS (London) LDSRCS (England) AMM Consultant Maxillofacial and Facial Reconstructive Surgeon,Gleneagles Intan Medical Centre

I would have to admit that it was his awesome qualifications that impressed me initially. However, as time passes by, I found out that he is not merely a doctor to me. He is somebody that provides advice and counsel hoping that you could make good choices in life. He is undoubtedly good at what he did and is interested in passing it down to the next generation. The passion in medicine and teaching that he possesses is overwhelming, he is generous and terrifically smart. He was once a dental surgeon before he decided that medicine is truly his calling and thus making a bold decision in venturing into medicine hence find himself in agony for another 5 years. I know, the best doctors are those who are keen on the vocation, not those who are in it for reason that they do not seem to understand. Only with the right attitude and mindset, you will come out as a respectable healer. Those who does not have it will still eventually make it through. However, they will cause heartache for themselves as well as their beloved ones.

He was the one who made me realize that at my stage, a little bit of humility would be appropriate. He was the one who exposed me to the hostile world of medicine, telling me that life has more to offer other than taking care of sick people. He was the one who proved to me, in order to be successful, it is sheer hard work and sometimes it is unrewarding. He was indeed the one that instill the drive to be successful in me. " I want to be like him, a renown surgeon" this is the thing that kept me going all these while.

Mentoring is part and parcel of medicine. It is about passing the knowledge to the next generation. Yes, you can see it in the hippocratic oath itself, reiterating the importance of making the next generation as competent as you, if not better.

That just as I have learned from those who preceded me,
so will I instruct those who follow me in the science and the art of medicine.

Isn't it good to have some one that you look up to? Telling yourself that you want to be like him/her someday? Cultivate this relationship, and you will find yourself going the extra miles although you never thought you could do it.

Of Success and Celebrations

2008-12-13T22:29:00.000-08:00

I realised that success is not merely being able to tick off all the resolutions that you've made at the beginning of the year. It is about touching lives and making changes for the better. Christmas is coming. This festival is not merely about commercialised Santa and Christmas trees, It is about the celebration of love. Let's take a moment to remember those who are alone out there. Merry Christmas and a Happy New Year.

Best Wishes from me.

Of Medicine

2008-12-09T02:02:00.001-08:00

In medicine, as in life, there are ordinary relationships as well as extraordinary ones. Extraordinary ones teach us about ourselves, and connect us deeply to other people, providing ample space for us to grow and to mature. They make a difference as they remind us of each other's humanity. It seems to me that the relationship between Salai , me and the fellow refugees was extraordinary.

Salai was the leader of the student activists back in Myanmar. He was the one who believes that he, as the young generation of Myanmar could make a change by participating in direct actions to make changes in the government and the social conditions of his country. Unfortunately, his activities were tracked down by the Myanmar military, forcing him to make a drastic decision- to leave his country and to abandon his family.

Student activists were hunted by the government officials. They were captured, tortured. Salai, a law student managed to crossed the boarder, and eventually ended up in Kuala Lumpur, a city that is different from his hometown, living in despair, hopes and dreams were vanished. Deep down in his heart, he know he could not fulfil his dream of becoming a lawyer. What he can do now is to survive.

I had lunch with him the other day. We went to a not-so-fancy restaurant near the clinic to dine in. We were chatting about the political predicaments in Myanmar most of the time. Through his eyes, I can see the hardships that he is facing. A salary of 500 per month is just sufficient to keep him alive. The fear of being captured by RELA officers haunts him. The refugees deal with human traffickers at the boarder very often. Senior citizens were killed, girls were either raped or forced into prostitution, men were beaten up brutally. They begged for their undervalued life. They begged for survival.

The chances of getting an UN card is extremely difficult. The standards and the application process that one has to go through in order to be registered as a legal refugee is stringent and rigorous. Once they are registered, they are entitled for a 50% discount for health care in Malaysia.

In Malaysia, If you are well established and rich, girls will come to you.
In the refugee community, If you have a UNHCR card ( United Nation Refugee Agency), girls will come to you.

Irony isn't it?

"Calvin, you are very lucky to be able to stay with your family" he uttered.
"Yes I know, I count my blessings everyday." I winked at him.

When these kind of words hit me. I was too lost for words. In life, you need people to wake you up and make you realise of the facts and truths of life. Words from Salai were truly an eye opening. It made me realise that a little bit of humility and appreciation is appropriate in life. My goal in life is to become a world renown surgeon and his, is apparantly to survive. The incongruity is obvious.

Not everybody can go to university like Salai back in Myanmar. Not everybody has the chance and opportunity to be literated. Even for people in Myanmar, they know that education is the only way they could lead a better life in the future. Due to the lack of education among the people, deadly diseases like AIDS/HIV is common among the refugees. It is very hard to pin point the prevalence of AIDS /HIV among the community, but It seems that It is on the rise.

I am always struck by how much is medical condition is also a social condition. For those on anti-retro viral treatment, daily rituals include punctuating each day with pill taking and of course appointments with the doctor monthly.

For those who are not aware that they are infected with the virus, they contribute to the spread of the epidemic in such a way that they are not aware of. This is where the health care providers come into picture. Contact tracings are done extensively, counsellings are done, to salvage as much as they could. Yet, we could not ignore the fact that people are dying everywhere, especially in the rural areas where accessibility to health care remains a problem. People like the refugees are isolated from information that might have could save them. Even when they have to information, are they able to convert those valuable information into treatment or prevention?

I don't know.

I spoke to a man who had a wonderful homogeneous relationship for 10 years. He was diagnosed to have HIV. And yet, he doesn't seems to be worried. Denial? I suppose so.

One advantage of being in medicine is that you realise It is indeed a crazy crazy world out there. You see more than others. Medicine is not a course, It is a calling. And deciding to become a doctor means devoting your life in helping the sick and underprivileged ones. As a doctor, you are determining the fate of your patient. I do believe, because I've seen it in my own life, when love and compassion is shared with a patient, the patient can see a world bigger than the disease itself. And thus they can summon the will to live in the world that they see.

Salai wrote a poem that seems to reflect the inner turmoil he and most persons in his situation feel on an almost daily basis. Enjoy my friends, this is not something that you read everyday, appreciate it and put yourself in their shoes.

*****************

Salai ZT Lian is an ethnic Chin from Burma who seeks justice and freedom for his people. The Chin are 90% Christian and they suffer persecution in the hands of the Burma army.

There will be enemies:

Those who force my loved ones to go the wrong way,

Those who treat my loved ones carelessly,

Those who cause my loved ones to cry with anger

Those who insult my loved ones' dignity, and

Those who destroy my loved ones' dreams.

There will be friends:

Those who take care of my loved ones kindly,

Those who help my loved ones in sad and unhappy times,

Those who make my loved ones smile after crying

Those who uplift my loved ones' dignity, andThose who encourage my loved ones to dream sweetly.

There will be my loved ones:

Those who live selflessly,

Those who sacrifice life for right and justice,

Those who sympathize with the poor and disabled,

Those ready to help the troubled, and

Those who create an environment for people to dream sweetly.

On Vacation

2008-12-02T05:51:00.000-08:00

Will be on a short hiatus since I am off to Hong Kong for a holiday. Lazing around and doing nothing at home is certainly not my type of tea. I miss the patients, I miss the refugees. Well, I guess spending time with my family is the least I could do as an obedient son.

That's all for now, will be back 5 days later for more updates. Till then, happy holidays and best wishes from me.

The 3 things that made my day

2008-11-28T20:15:00.000-08:00

1) This is something that has definitely elevated my mood. Read about It before, nothing could exaggerate my emotional well being out of proportion other than having a close look at It with my bare eyes.

2) Attended Shan's New Year Celebration at the Chinese Assembly Hall. Witnessed an undivided and unbroken unity among the refugees which no longer exist among Malaysians. The tight spots and predicaments that they have suffered when they are trying to earn a living in this country truly bring to the consideration and notice to me that, I am truly truly blessed in every way that I could think of.

3) Back in Penang for good. Took a 2 weeks off and I declare myself officially on holiday. Looking forward to the trip to Hong Kong next week and of course the chance to share my experience in the arena of medicine with my juniors during alumni night.

Polio

2008-11-26T00:17:00.000-08:00

Polio was never a big killer, but the evil of this disease was its ability to disappear and reappear every summer and autumn. It predominately affected children, hence the name "infantile paralysis," and although seldom fatal, the condition often caused paralysis and disability.

Pub Med

Met a patient with a previous history of polio infection when he was still in his childhood. You can hardly see polio patients nowadays in Malaysia due to the effectiveness of the Ministry of Health in eradicating this notorious disease that was once an epidemic throughout the world.

Poliovirus (an enterovirus), once invades your body, It multiples in your throat and intestinal tract and then travels to your central nervous system through blood and lymph. As It multiplies, the virus destroys the anterior horn cells of the spinal cord (that Is why It is regarded as a lower motor neuron disease). The muscles of the lower limb are affected more often than the upper limb. The limb becomes floppy and lifeless. In the most severe cases (bulbar polio), poliovirus attacks the motor neurons of the brain stem, patient might suffer from breathing difficulty, dysarthria (difficulty speaking) and dysphagia (difficulty swallowing).

Apparent muscle wasting was observed on the left leg due to the lesion on the lower motor neuron supplying that region. Due to the unopposed muscle action during childhood development, the structure of the foot is compromised.

This is a normal wound infection. He was given antibiotics and was sent home.

This is total coolness I would say. How hardly can you see patients with post polio infection walking around like this ( except for Dr Robert ). At that moment, I truly appreciate the miraculous advancement of medicine in providing us with potent vaccines that shielded us from this ill-famed disease.

For more interesting stories about Polio, BMJ has lots to offer.

I felt pain

2008-11-24T01:34:00.000-08:00

The least favorable feeling in the world, and the one I get so often is seeing somebody agonising in pain, yet what you could do is just stare at him as helplessly as a baby.

I stumbled across a patient who presented with lower back pain that persisted for 4 months today in the clinic itself. He was in his twenties and apparently what came to my mind was muscle strain as there was no history of fall or trauma. He was pale, the face was obviously lacking of intensity and brightness. One of his hand was on his back, telling the doctor about the wrenching pain that diminished his quality of life. He complained of weakness and numbness and pain radiating down on both of his legs.

"Could it be a PID ( Prolapse Intervertebral Disc) since the patient presented with sciatica" I whispered.

To have a closer look at him, Dr Kama ordered him to take off his shirt.

"What can you see Calvin, this is an interesting one"

" Scoliosis, but he is only 28, no history of trauma or fall, no mechanical stress exerted along the spine either.Scoliosis?"

The whole thing is like a puzzle, waiting for me to put all the pieces together so that I can at least figure out what is wrong with him. I was indeed puzzled. Scoliosis is a medical condition where the spine is curved from side to side, forming an S shape.

What causes the spine to curve? Did he lift up heavy things?

I recall that scoliosis is usually associated with loss of density of the vertebrae, sometimes found in osteoporotic patients in which the micro architecture of the bone is impaired.

"Don't tell me he has osteoporosis at the age of 28" I laughed, not knowing what is coming ahead of me.

"If there is no history of fall and trauma, the only thing that I can think of is actually infiltration" uttered Dr Kama.

"Infiltration? You mean malignancies? Cancer?" I said dubiously.

"I'm afraid so" said the doctor while laying his hands on the patient's spine.

In medicine, doctors are the detectives. We observe, we make our hypothesis and then we rule in or rule out the possible causes. Every decision is dealt with professionalism, a wrong move and you put the patient's well being at stake.

I scrutinised his body, looking for any abnormalities. What I found was that his shoulders are uneven, probably due to the fact that he has to compensate for his posture to keep himself balanced with the curved spine.

He was skinny, pale as a corpse, and the muscles above his cheek bone as well as the first dorsal interossei was wasted. I compared it with my hand. It was obvious.

It all fits.Vertebral compression occur either due to mineral loss of the bone in osteoporosis, or due to vertebral destruction in benign or malignant tumors. He smokes, and it all points to lung cancer. The curved spine impinged on his lumbar nerve roots causing him immense pain, forcing him to stop working. Every step he takes hurt, every move, everything he does causes emotional distress.

I am pretty sure It was lung cancer. He was scheduled for an X-ray and is supposed to come back tomorrow. At this point, I somehow felt his pain. Watching him take every step at one time, groaning in pain hurts me. I know NSAID ( Non Steroidal Anti-Inflammatory Drugs ) and simple analgesics would not have any therapeutic effects on this kind of pain. When you cannot do anything but to wait. It hurts.

He walked out of the door, looking at his back and his abnormal posture, I prayed. Yes, I prayed.

All the things that aspirin does

2008-11-21T06:30:00.000-08:00

Was surfing the net and I came across this very interesting article regarding the therapeutic effects aspirin posseses and the future it holds.

Ask any medical student and he or she will tell you that aspirin reduces fever, pain, and inflammation but may cause ulcers. If prompted, students may also recollect that it prolongs bleeding and may prevent strokes and heart attacks, but they are unlikely to know of aspirin’s use in treating cancer or Alzheimer’s
disease.

A very interesting artical where it explores the therapeutic usage of aspirin besides serving as an analgesic, anti-pyretic and anti-inflammatory. I reckon every medical student should know how aspirin inhibit the cyclo-oxygenase pathway, interupting the synthesis of prostaglandins (eg PGE2/PGI2) and how low doses of aspirin serves as a selective COX-1 inhibitor used in treating ischemic heart problem.

Many does not know It is also used in treating Alzheimer and cancer by inhibiting the same cyclo-oxygenanse pathway.

Enjoy

All the things that aspirin does

Kindly click on the link above.

Improvisation-Surgery-Euphoria

2008-11-18T04:30:00.000-08:00

In Gleaneagles Intan hospital, you have top notch health care facilities equipped with cutting edge surgical equipments, machine, well trained surgical nurses, well design OT and of course world class well renown, esteemed surgeons.

In ACTS clinic, you are short of everything. Even the basic surgical equipments. No retractors, no proper lighting, no proper table to ensure patient's comfortability during any kind of procedures. Doctors are pushed to the limit, they have to improvise, make their way through the procedure without proper equipments, testing their skills to the limit.

I managed to witness a sebaceous cyst removal today with Dr Kamarudin. It was an experience that swear I wont forget for the rest of my life.

Patient presented with a growth at the posterior aspect of the thigh. After inspection, It was diagnosed to be a sebaceous cyst. It is harmless but It causes discomfort and pain to patient and thus Dr Kama decided to excise it. I palpated the cyst. It was hard, boarders were regular and It is movable. Laying my hands for the first time on a cyst is truly breath taking. I certainly do not know how to describe it here, Its a mixed feeling indeed.

Sebaceous cyst- A sac with a fatty white, semi-solid material called sebum. Sebum is produced by sebaceous gland in the epidermis.

Preparation was carried out. As you can see, the table is not an operating table. It is just some old couch that were found inside the store room. Sigh..saline, povidon, 15 blade, gauze, forceps were prepared and placed inside the kidney dish.

Dr put on his gloves while I put on my surgical mask. Holding my camera in one of my hand, I try to recall the basic steps that have to be done prior to any kind of surgery. Local anaesthesia, disinfect the site of incision...Its like a string of pictures, flashing chronologically in my mind.

Local was given subcutaneously. Lignocaine was used. Injected subcutaneously around the cyst.

Povidon was applied around the cyst to disinfect the incision site.

Incision was made using a 15 blade.

The lighting was bad. The room was quite dark so thats why we need a torch light. No OT lamp unfortunately.

I watched each and every process meticulously, jotting down notes and taking pictures. Surgery has always been so interesting for me.

See the whitish thing over there, that's the cyst. Filled with sebum. Due to the improper use of instrument, Dr Kama punctured the cyst and sebum started squirting out. It was grayish in colour, indicating infection. According to Dr Kama, sebum is a perfect reservoir for microorganism to grow.

Extracting the cyst.

Extracted. It took 40 minutes to take out this thing. Patient was relieved.

Irrigation with normal saline.

Suturing using nylon. Interrupted suture.

Done.

Patient was given antibiotic in case the wound is infected.

" Medicine is all about anticipation. And anticipation comes with knowledge"

This is a take home message from Dr Kama.

I was satisfied spiritually.

I am having a pretty bad running nose right now. Probably due to the weather and the exposure to patients with common cold and cough. Took ceterizine, a second generation of anti-histamine which I took from the clinic just now. Desperately need some rest.

I auscultated a patient's lung today. The wheezing sound of a patient with asthma is truly amazing. Its still on my mind right now, the feeling of satisfaction, euphoria is uncontainable.

I don't need sex, medicine is truly truly my orgasm.

Hostility-Part 2

2008-11-17T04:12:00.000-08:00

Picture courtesy of Pauline W. Chen MD

Second day of attachment, exhilarated. Woke up at 7 in the morning, It took me quite some time to open up my eyes. Obviously I was deprived of sleep, I was in a state of inactiveness, sluggishness, and fatigue. Forced myself to get up as I do not want to be late, rushed into the bathroom.

I unclothed myself, switch on the water heater and I let the water run down my skin, enjoying each and every moment of that. Brushed my teeth and I was set to go, grabbed my backpack with my anatomy text book and my handbook of clinical examination, I headed to the bus stop.

I was emotionally aroused during these 2 days. I could hardly conceal my feelings of lively and cheerful joy when I get the chance to participate in the discussions led my the doctors, give my opinions regarding the underlying pathology, serving as the co-investigator in the clinic, and of course banging on differential diagnosis. I enjoyed the session where the doctors would ask me questions, forcing and encouraging me at the same time to put on my thinking cap.

" Calvin ( the name I use there), what is the differentials for this patient since he presented with palpitations, pulse 120, sweating and of course you can see that he is so skinny?" asked Dr Caroline who is holding the lab results of the patient.

"Umm..Umm..I don't know doctor", frustrated.

" Its thyrotoxicosis ( Grave disease )"

"Oh, that's why he is having palpitations and excessive sweating" I blurted out.

Darn it, I learnt about Grave disease during my lecture on harmful tissue reactions some time ago. It basically refers to the hypermetabolic clinical syndrome resulting from serum elevations in thyroid hormone levels. The expectations that I put on myself was defeated. I think I should at least be able to recognise the syndrome. The feelings associated with not achieving a particular goal or the belief that a goal has been prematurely interrupted is truly devastating.

As a first year meddie, I am very thankful as I have been given all the wonderful opportunities to see patients, examine them and of course put myself in their shoes, appreciating and understanding the socio-economic status of the refugees. No doubt, the barriers face by the doctors are language, culture, knowledge and of course financial. The clinic is indeed running over budget, staffs are trying their best to cut down the cost in each and every way that they can.

I wanted to document down all the interesting stuffs that I encountered. Not to mention about common cough and colds, diabetes, TB, hypertention and HIV, I managed to witness a few bizarre diseases like thyrotoxicosis, leukemia, chronic otitis media, prolapsed intervertebral disc and many more. Just to highlight a few of the cases that I find interesting, the story of a 16 year old girl being forced into prostitution caught my attention, hence prompted me to name this post "hostility".

Case 1
16 year old teenage girl from myanmar was forced and sold against her will into prostitution and was diagnosed as HIV+ after the first ELISA test was shown positive, comfirmatory test is pending. She was repeatedly abused sexually in Thailand. Serving as a sex slave, she was exposed to a never ending list of STD(sexually transmitted disease). You name it, syphilis, herpes, genital warts. Although she said most of her client was wearing condoms during the intercourse, I doubted it. Hostility is a form of angry internal rejection or denial in psychology. This is what I was experiencing that time. She is just 16, her future is ruined. If the test is still positive for the second time, she would need anti-retroviral treatment. Can she afford it? Counselling session was scheduled for her, counsellors had a hard time breaking the bad news to her.

" Is she mature enough to actually comprehend the whole situation?" I was worried, and at the same time curious about how she will react towards the news.

What is wrong with our society, I kept asking myself. 16 year old into prostitution? That's unacceptable. I was disgusted, stoned for words. When I know that she was not paid for her services, instead she was given new clothes after sleeping with a few strangers, I was utterly disgusted, angry, furious, but at the same time trying to be emotionally detached.

A hostile nation I would say. Sigh...

*****
Case 2

I then met a patient presented with leg pain, swelling at the ankle joint, no history of Fx (fracture) or fall. I laid my hands on the joint and I can feel the warmth around the joint. The temperature is significantly elevated.

"Calvin, common, what do you think" said Dr Kamarudin.

"The swelling and pain might probably due to increased intracompartmental pressure. I think its compartment syndrome." I answered, did not give a second thought about it.

" No history of fall or Fx, so its not" he said in a cynical way.

"Oh rite..I cant think of any of the moment sir"
I hated myself so much at that moment. I did the anatomy of the lower limb together with its clinical applications quite extensively I reckon. My confidence dropped below 0, I think I am not competent at all.

“What is it Sir?”

“Its gouty arthritis, its quite distinct you know”

Pain is elicited upon dorxiflexion.

I sucked. What is the point of knowing all the drugs involved in the treatment and management of gout if you cant even recognise and diagnose it. What is the point of know that allopurinol interrupts the formation of uric acid by inhibiting the action of xanthine oxidase if you do not even have the chance to prescribe it?

I sucked

Actually I have more to blog. Met one patient with no ear drums bilaterally. Another one presented with nystagmus due to who knows what reason. Will blog about it perhaps tomorrow. My brain is too tired to function. Its time to get some rest.

*Lights off*

Hostility- Part one

2008-11-16T03:55:00.000-08:00

After finishing the dreadful exam, bidding farewell to each and every one, for once in my life, I woke up in the morning without a slightest clue on what am I going to do for the rest of the day. Some people might find It enjoyable and relaxing, but for me, It irritates me. Sedentary lifestyle is definitely not my cup of tea. I gaze towards the ceiling, looking at It blankly, enjoying the moment of silence. A list of my favourite tunes were playing repeatedly in my mind, trying to welcome the start of a new day.

I did not sleep well the night before. I was tossing myself restlessly on the bed trying to convince myself that I need to have adequate amount of sleep to function the next day. I was curious. Thoughts were exerted into my mind continuously just like how sodium ions get diffused into the cell due to the difference in the concentration gradient.

" What kind of patients will I see tomorrow?"
" I haven't got my Hep immunisation, would it be dangerous for me?"
" How could I possibly communicate with them as I don't even speak their language?"

Questions are raised, but not answered.

Few weeks before the exam, I was planning on how I could fully utilise my holidays. I contacted Dr Kelvin and asked for an attachment with him but unfortunately I was rejected due to the strict policies adhered by the private health care sector in which they do not encourage medical students to wander around the hallways of the hospital as we, medical students are considered as a legal liability. I put myself in his shoe and thanked him for his attention.

My wish to make full use of my 3 months break was fulfilled when I contacted Dr Caroline, the doctor in charge of ACTS( A call to serve) and she was glad that I would actually volunteer my service to them, a non profitable organisation that provides health care to the refugees that are currently residing around KL.

Dear Calvin, thank you for interest in our work. We treat all refugees at this clinic, mainly they are from Myanmar, some from Somalia, Sri Lanka Nepal etc. So you can see that language is a big problem. But you will be very welcome to come, see & satay a while if it suits you. We are very informal here, you won't have to register, just let us know when you want to be here. We have an average of 40 - 60 patients a day, from common colds to great big wounds, some HIV +ve & TB. You can talk to the patients, do some clerking, even examine them, except treat of course. They will be happy to share their stories with you. Your stay can be as long as you want or as short.So feel free to come on board. We also run mobile clinics in Cameron Highlands some weekends, this is where they stay in the rough & the cold.Hope this is of some help to you.
kind regards
caroline

When I knew that I could examine and clerk patients, I was in cloud nine. As a first year, we are not given privileges to examine real patients. I was honoured. I knew this is an excellent chance for me to widen my horizon. I replied her with a big warm thank you.

I stopped my thoughts from wandering by forcing myself out of bed. As usual, I will spend a few minutes looking out the window, admiring how beautiful the sky is. To me, the sky is like a cold vast expanse which envelopes the earth like a blanket. Utterly beautiful.

I reached the clinic way before the appointed time. Around 9. I stroll along the sideways around the vicinity of the clinic to make myself familiar with that area. Bricksfield is like a mini version of India, the buildings are old, traffic is hectic, people rushing here and there running their errands. The concrete floor is still wet as It rained during the wee hours of the morning. A group of women carrying their babies were gathering just below the clinic which is located at the second floor of an old shop house. One of them was breastfeeding. Yes, she pulled up her shirt and started feeding her baby, just like that, sitting on the sideway, ignoring the people that walk pass them. I overheard their conversation and I am fairly sure that they are not locals. " Guess they are waiting to see the doctor" I supposed.

After getting myself familiarised with the surroundings, I decided to meet Dr Carol up. I walked up the stairs, disgusted by the rubbish that ware scattered along the staircase. It was fairly dark and It sends a chill down my spine. I walked up the stairs and reached the clinic. The clinic acked. Like what you normally see when you open a can of sardin. More than 40 patients consist of the young as well as the old was sitting on the bench, waiting patiently for the doctor to arrive, hoping to get rid of whatever disease that is bothering them. I was greeted by one of the staff there, his name is Allen, a citizen of myanmar currently working with ACTS. He talks humbly and introduced me to the rest of the staffs. The one thing that I observed from these refugees is that they are very modest. They way they talk and address you makes you feel that you belong there. They were more than happy to find out that I will be spending my holidays with them as they are obviously understaffed.

I was then greeted by peter who told me that Dr Carol could not make It today but still he introduced me to the another doctor in charged, Dr John Loh, a graduate from Taiwan. I sat into the consult room and started building rapport with him hoping that he will somehow teach me something that I wouldnt get to learn in text books.

Departure

2008-11-13T21:32:00.001-08:00

It is the time of the year again where we have to bid goodbye to our fellow colleagues. " This is the last dinner that we are going to have I suppose" I said indistinctly, in a low voice. We held our glasses together and wish each of us all the best in our endeavours. Inevitable sense of sadness filled the air, string of images and thoughts were forced into my mind. Strings of nostalgic feelings overwhelmed me when I thought about the good times we had together. Studying our ass off for examination together, having dinner together practically everyday, arguing over stuffs that do not make any sense. It is indeed a great year with you guys around me. Year 1 is never going to be enjoyable without you guys.

The MuMeds dinner is one of the highlights of the MuMeds's social events. I would say It is the biggest event ever organised by the society and certainly the most glamorous but then again, I was kinda disappointed on how disorganised the plannings of the event can be.

The dinner is for all the year 1 and year 2 but I took it as an opportunity for 5 of us to gather together for the one last time. It is a brilliant excuse for me to dress up nicely and to prove that the blazer that I bought 1 year ago was a good investment albeit I only wore it twice since last year.

The dinner was held in Bread & Olive, a local restaurant up the hill that offers a bird's eye view of KL city. The scenery was truly captivating. Looking down from the top, we took pictures with one another. Dinner was then served, accompanied by the music, we had our last dinner together, chit chatting as usual. While talking about the plans that we have for the coming holidays, we were amazed by how fast time flies. We promised to keep in touch and headed down to the balcony to have our last photo session before the bus departed.

It was indeed a great night with breath taking scenery. Looking forward to see you guys next year and I am sure year 2 is gonna be extraordinary for all of us.

Farewell to year 1

2008-11-10T17:38:00.000-08:00

It was nerve wrecking, but I am relieved as it is over. I woke up early that morning, looking out the window, the sky is still ill-lighted. Finally, the long awaited day has come. Axienty consumed me. The feeling of uncertainty is truly unbarable. " What kind of questions will the examiner ask me" I pondered. Switching on my laptop, I decided to go through all the steps and procedures again, trying hard to make sure that they remain etched in my mind.

There are 3 types of learners
1) Superficial learners
- They study for the sake of passing exams. They feel stressed whenever exams are drawing near.

2) Deep learners
-They study for the sake of their interest. Would not feel much stress when exams are approaching. They read widely to satisfy their hunger for more knowledge.

3) Achievers
- This is the group of people that study for the sake of their egoism. They want to be good in everything and percieve exam as an arena for competition. They strive very hard to be a "role model" student so that other students will look up on them.

I think I am somewhere between 2 and 3. No doubt that I have burning passion for medicine and in one of my previous post I did mention that medicine is my orgasm =), however, I still care
a lot on how people look at me. What do they think about me. I want people to know that I am competent, not just ordinary. And this is why, I feel stressed before OSCE. I guess the bench mark that I have set for myself is too high afterall. Yes, I did aim for perfection.

Looking at myself in the stained mirror, I put on my tie. Adjusting it so that It is proportional to my height. After making sure that the triangular knot of my tie is small enough, I put on my tie pin, reached for my white coat and put it on. I told myself I was ready, took a few deep breaths and I left.

The first sation was peripheral neurological examination. Dr Kelvin was the examiner. When you are facing your idol in the medical arena, I could feel the immense preassure pressing on myself. I was gasping for air. This is the only station that I think I screw up in the examination. It was unorganised as a lot of the steps are not required to be carried out for eg vibration, gait. I was interupted repeatedly, my mind went blank at some point but i still managed to keep cool. The patient was asked to put on a poker face. With no facial expression at all, I find it difficult to establish an rapport with him. When a doctor, fail to establish a rapport with a patient, I consider myself a failure.

" Candidate, any other tests that you would like to perform?" Dr Kelvin asked.
I was stunned. I thought I have finished everything, although it was unorganised. I stood there for 10 seconds looking at him.

" In a real situation, I would perform a SLR (Straight Leg Raising) test to comfirm the correct segment of lesion sir" I answered.

" Can you perform it to the patient?"

" But this is a neurological examination, SLR is actually under musculo-skeletal" I was confused. Nevertheless, I performed the test.

" Its ok, I will explain to you later why" Dr Kelvin tried to reassure me that everything is ok.

When you are the 3rd type of leaner and you somehow screw up in front of somebody you admire the most. This feeling is truly undoubtedly devastataing. I feel embarrased. Due to my
ego, I could not accept the fact that i performed ordinarily in front of him. I was disappointed.

But I guess the rest of the stations went pretty smoothly. I always tell myself that I should strive to be the best. On the other hand, should I accept the fact that I am always vulnerable to fallibility and uncertainties?

Anyway I do not wish to be like this doctor below. As I've said, It was nerve wrecking, but thank god it is over. Passed year 1 with my sanity intact =)

Guess I'll have to bid farewell to year 1, Its certainly hell of a year.

Cyc, signing off

20%

2008-11-06T16:42:00.000-08:00

The final Med1022 written examination is over. Attended the exam debrief yesterday and thank god everything went smoothly as I expected. Now, all I have to do is just stay focus and strive for excellence in the upcoming OSCE (Objective Simulated Clinical Examination).

Enjoyed a cup of freshly brewed hot cafe latte in starbucks right after the written exam. I was glad. At least my hard work paid off. Was sipping on the coffe while talking about random stuffs with my collegues. I was amazed how fast time flies. One more exam and I will be officially an 20% doctor. After all the time and effort that I have put in, making sacrifices along the journey, studying throughout the night, It arouses me whenever I know that I am one step closer in achieving my dreams.

Looking at the stems for OSCE in this wonderful Saturday morning with lots of thoughts in my mind. I wonder whether I am competent to call myself a 20% doctor. Well, I make sure that I am fairly good with my anatomy, pharmacology, physiology that would probably come in handy in the future. But am I competent mentally? In terms of facing uncertainties? Facing grief? Somehow deep inside me I want to be a doctor that can be entrusted when you just look at him. The way he talks, indirectly tell you that everything is gonna be fine. But with the 20% knowledge I am having right now, I know the journey is still long.

Medicine is practically an art of science. You deal with people. You need to improvise. You need to know what you are doing. Memorising the steps of clinical examination blindly just merely to pass the exam is shallow. For me, I need to know all the basis of doing all those examination. The 6 steps of: Ask Look Feel Move Specific Tests should not be something that restrict what you can do. Modify it, do those that suits the patient the most. After all, what doctors do is to find out what is wrong and at the mean time please the patient.

I am pretty sure I am gonna do just allright on Monday. Fingers crossed and hopefully I can show the examiners how competent I am in dealing with patients. Dr Kelvin once told me although I am an undergraduate, never restrict yourself on what you can learn. Being a year one doesnt mean what I know should only be for year 1. I want to achieve more than 20% perhaps.

Below are the scenarios that I might be having on monday.

Truck Driver’s Pain
Time allowed: 8 mins
Mr. Christopher Ram, a 42 year old truck driver, has come to the GP complaining of lower back pain after loading his truck with a consignment of computers for a new college. He had felt a sharp pain in his lower back which had gradually become much worse and spread to his right buttock. He also had a burning/tingling sensation down the outer side of his right leg which extended to the top of his right foot. A diagnosis of a prolapsed intervertebral disc affecting the L5 spinal segment was made.

Task: Neurological Examination In response to the L5 spinal segment

Life Style
You are a doctor in a GP clinic. Arif Asri, a 36 year old sales manager, has come to your clinic because he is very concerned about his health and wants to know what he can do to improve it. He has recently been diagnosed as having diabetes mellitus. Apart from this, he has gained a lot of weight in the past two years, and also smokes about 20 cigarettes a day. On examination his BP is 130/90 mm Hg and his BMI is 30.

Task: Assess his understandings on his current condition and see whether I could talk him into changing his life style.

CPR
Time allowed: 8 mins
You have entered the room to find Jennifer is unconscious on the floor.

Task: Save Jennifer, save the world.

Examination of Shoulder
Time allowed: 8 mins
Joe Peters, aged 23, comes to see the doctor because he is worried about his left shoulder.
Joe has noticed that sometimes throwing a baseball is painful. There has been no recent injury. He plays baseball every weekend and has recently increased his training. You are a medical student at your General Practice placement, you have been sitting in with the GP. The GP has asked you to examine Joe’s shoulder.

Task: Examine the shoulder and look for abnormalities.

Headache
Time allowed: 8 mins
You are a medical student attached to a GP’s surgery (clinic).You have been asked by the GP to take a history from patient Jane Henry. You have never met her, and she is coming for a new problem which is a headache.

Task: I am gonna play detective here. Where does headache leads me to?

Eye Examination
Time allowed: 8 mins
Patient Name: Joey Binder
Age: 25
Occupation: Teacher
Joey, aged twenty five, has come into the GP to get his/her eyes checked. You are a medical student on a site visit, and the GP asks you to examine Joey’s eyes while he/she supervises you.

Task: Look into her eyes

Injecting
Time allowed: 8 mins
Jess is a 22-year-old student who has come to see you, her/his GP, because (s)he is quite unwell and has a productive cough. You diagnose pneumonia, and decide that the most appropriate treatment would be procaine penicillin injected intramuscularly. This is a very thick suspension, which causes pain on injecting.

Task: POKE!

Guess It will be fun afterall with all the adrenaline rushing inside you. Trying your @ss off just to impress the examiners. Wish me luck folks. Till then.

Best wishes
Cyc

Radiograph of London Teen Stabbed..I repeat..STABBED!

2008-10-02T07:38:00.000-07:00

(Image Credit)
Courtesy of Scan Man's notes

"LONDON (Reuters) - Police have released shocking X-ray images of a 16-year-old with a knife lodged in his head after a stabbing in London to serve as a warning about the dangers of knife crime.

The teenager was taken to hospital with the blade still stuck just above his eye after the attack outside a Tesco supermarket in Southwark last November.

The Metropolitan Police said the boy, who has not been named, has since recovered, although he still needs close hospital supervision.

The images show how the knife entered the boy's forehead just above his eye and the tip reached to just above his ear. Two of his friends were also stabbed during the attempted robbery outside the shop.

A wave of shootings and stabbings in London in recent months has prompted a police crackdown on young people carrying knives and guns.

Detective Constable Scott Albert said: "Anyone thinking of carrying a knife should be warned by this case. Don't be a statistic. Life is precious."

A 17-year-old, who can't be named, was found guilty of attempted murder and grievous bodily harm at Inner London Crown Court last week. He will be sentenced on October 23.

(Reporting by Peter Griffiths; editing by Steve Addison)"
Frankly, I do not know how the hell the boy actually survived. A direct stab into the frontal lobe like this would probably cause instance death, if not permanent paralysis.

I am so curious about his prognosis, blind? deaf? neck down paralysis? death after months of mechanical life support? comatose? Vegetative state?

Anyway, wish him best of luck, count my blessings. I appreciate the police's effort to release these images into the mass media, it actually serves as reminders to the public, creating awareness.

I am sure the neurosurgeon had a great time removing the knife.

Ps: According to Scan Man's notes, this is actually a CT scanogram and not an X-rays. However, I could not differentiate between both of them as my knowledge in radiology is apparently zero. Guess I'll need to do some reading up on this.

Take home message: Life is precious

Selamat Hari Raya

2008-10-02T07:19:00.000-07:00

Selamat Hari Raya to all my muslim friends
Maaf Zahir Batin

Best wishes from me during this wonderful festive season.

Retinoblastoma: Ugly like hell

2008-09-25T07:59:00.000-07:00

Neoplasm/cancer or an abnormal growth of cells is longer unfamiliar in this society. It instills fear in anyone who knows how deadly it is, crushing every of your hopes that you have left for this hostile world. Some people would rather have a radical double mastectomy after knowing that they have a high risk of developing breast cancer due to the inheritance of the mutated BRCA1 and BRCA 2 genes, giving up their sex life, begging for survival as helpless as a baby. Have anyone of you all actually thought about how cancer cells look like? For me, if you are speaking in terms of microscopic views, it is gorgeous, captivating. Somehow I find that abnormal cell growth either benign or malignant represents a parasite that has long been residing inside your body, waiting for the right chance and the right time to be released from the surveillance of the body's immune system, and thus ending a life by proliferating out of control.

It all happens in chronological order. First the patient will present to you with an emanciated condition, loosing weight, fatigue, reduced physiological function and etc. Then, as the cells starts to proliferate by having a shorter cell cycles, it denotes the start of a loosing battle. The body's effort to kill off the cells seems futile, day by day, the expansion occurs. Practically till the last breath you could probably gasp.

Yes, cancer cells, you are undoubtedly beautiful and attrative to me. For those that does not catch what I mean, below is a histological cross section of an adenocarcinoma at 10x taken from one of the slide from the histopathology lab.
The irregular architecture of the cells, with features of dysplasia,enlarged/darker nuclei and bizzare rate of mitosis together with a high N-C ratio is bringing out the message that : the battle has just began. Look at it..Isnt it wonderful? Microscopicly i mean, ugly like hell if you consider the consequences of its presence.

Recently, I have the opportunity to meet a patient who is diagnosed with retinablastoma in one of the private hospital in KL. Jason* a 27 year old male presented with distorted facial features is diagnosed with retinoblastoma when he was at the age of 2 ( if i am not mistaken ). Asymmetry of the face was noted with prominent atrophy of the muscles on the left side of his face due to the fact that he undergone a series of chemotheraphy and radiation treatment to kill that cells that apparantly had destroyed one of his eyes causing complete loss of vision on the right eye. Series of chemotheraphy and radiotheraphy have severely damaged the vascularization of the left side of the face resulting in asymmetry and delayed facial bone development. Back at that time, the surgeon removed the eye and arranged plans for him that include a few different modalities of treatment. From then, his life has been totally different from the normal children.

Name of the patient has been de-identified to protect confidentiality.

"Retinoblastoma - (Reh-tin-oh-blast-oma) is a cancer of one or both eyes which occurs in young children. There are approximately 350 new diagnosed cases per year in the United States. Retinoblastoma affects one in every 15,000 to 30,000 live babies that are born in the United States. Retinoblastoma affects children of all races and both boys and girls.

The retinoblastoma tumor(s) originate in the retina, the light sensitive layer of the eye which enables the eye to see. When the tumors are present in one eye, it is referred to as unilateral retinoblastoma, and when it occurs in both eyes it is referred to as bilateral retinoblastoma."

retinoblastoma.com

I am here not to talk about the pathophysiology of retinoblastoma but instead to tell you how I feel after i met and talked to him personally. Well, to give a clearer picture, shown below is the actual CT scan of the patient. The scan denotes the deformity suffered by the patient well.

Being a retinoblastoma patient, he did not have the chance to further his education to the tertiary level. From the way he talks, I probably think that he is in denial as he did not even know that he suffered from retinoblastoma after years of theraphies and treatment. The mother who was the one who is doing the talking all the time. From the mother's look, I could understand the feelings that she is going through. Although I did not go through what she has gone through, being placed in a situation like this is unbearable for me. The uncertainty of his future would be the matter that worries her the most I guess.

As a parent, the fact that your child has cancer is one of the worst situations you can be faced with. You may have many different emotions, such as fear, guilt, sadness, anger and uncertainty. These are all normal reactions, and are part of the process that many parents go through at such a difficult time.

(Retinoblastoma, white color in the center circle of the eye (pupil) when light is shined in the eye, such as when taking a flash photograph)

As a first year meddie, this case do really widen my horizons. Being a doctor or a surgeon does not involve only slicing and cutting. They deal with the quality of life of the patients as well. Jason is completely cured I would say. What he needs is a facial reconstruction to help him regain his self esteem.

When the surgeon asked him what are his current wishes, he said:

"I just want to put on a spec, thats all"

Simple thing like this do touched me. Right till the bottom of my heart I would say. Looking at the doctor and then at the patient. Even as an observer, I am satisfied. Satisfied spiritually. Now I know, medicine is really satisfying. As a doctor, you have a pair of hand that is capable of healing, putting things back into their order. Isnt that a noble thing to do?

Anyway, I am looking forward to the reconstructive surgery that will be held maybe next week. Hope to see him regaining his self esteem after being given a new "face".

Well, this post is getting kinda long and boring. So i think I better put an end to it.

Anyway, I saw a patient with footdrop when I was on my way to uni yesterday morning. He was waddling as he was trying his best to make his foot clear the ground. I suspected it was due to a common peroneal nerve injury. Went to the old folks home today, did a neurological examination on a patient with parkinson. Saw what is pill rolling and shuffling gait all about.

It is so satisfying to tie what you have learnt with what you see.

Seriously, "What you dont know, your eyes wont see", thats rule number one in the world of medicine.

Signing off,
Cyc

My first post- Surgery and Me

2008-09-20T03:08:00.000-07:00

It has been a while since I blog. The last post was 5 months ago if I am not mistaken. Life has been very rewarding for me during this transition period, practically living with medicine from day to night while trying to clear up all the mess in my life and to find a new direction and meaning in life.

I don't need sex, medicine is my orgasm. When I turn around and look at all time that passed by me without even me noticing, I know that I missed out a lot of interesting stuffs in my life due to the fact that I spend most of the time with books, atlases, notes, somehow trying to stuff the vast amount of knowledge into my tiny little brain. I have a limited social circle. I no longer hold 3 presidentships like I used to be in high school. I am no longer the president of SOSAM, like i used to be in Inti College. I am just an ordinary emanciated guy here in the university trying his best, with his utmost ability just to make sure that he is competent and is ready to be in the first line of health care one day.

Life has been too routine for me, hmmm, I guess.

I was told by Dr Kelvin that " There are a lot of interesting stuffs in life other than medicine. Get a life". I start to ponder whether all the sacrifices that I have made is worthwhile. From the moment that I am keen that I would want to devote my life to serve the humanity, I know that my life is going to be different from others. Yet, I am rambling and ranting, complaining about my life. Frankly speaking, I do not know what I want.

Been really into surgery since the first semester and I managed to attend a few surgeries involving MVA ( Motor Vehicle Accident) such as mandibular fractures in Gleneagles Intan under the supervision of Dr Kelvin. Somehow in the OT, I can feel my the adrenaline pumping, the scent of the operating theater seems to stimulate my olfactory receptors. Looking at the surgeons working meticulously, surgical nurses assisting, I somehow feel that I belong to the group. I truly feel that this is my calling.

"10 blade scalpel, retractor, suction", looking at how the surgeon works amazes me. From the first incision to the last suture, every movement is done with the highest level of confidence. Even as first year medical student, I know that there is no room for errors. Even the slightest mistake the surgeon makes could jeopardise the patient's health. Every nerves should be avoided. Every incision should be precise. Somehow the surgeons have this quality that attracts me.

"Sometimes wrong, but never in doubt". This shows how confident they are when they are holding the scalpel and lives are at stake. However, fallibility is unevitable and medicolegal issues are common.

You can say that as a first year medical student, it is rather ambitious and not down to earth to be so sure that you are going to end up in a particular field. However, I see it as a motivation, for me to strive for exellence. I am truly blessed as I am given a chance to study medicine. Although the journey is long and I could not see the end of it. I can assure you that this is a journey with a lot to lose, life time learning, commitments and devotion.

Passing medical school is easy. But making yourself a competent medical practitioner requires more than just academic qualifications. Year 1 is coming to an end soon, and I am going to be officially a 20% doctor. Hopefully, I am able to note down all the interesting events that I go through along the journey, provided I am not suffocated by the never ending work load.

As what i said in my previous blog,

This is my story and I promise I wont leave anything out.