The old couples

The eighty-three-year-old granny is the only person taking care of her husband, the eighty-six years. He is down with myelodysplasia syndrome and requires monthly blood transfusion. They speak only Hakka, but acquired sentences of broken bahasa due to the frequent hospital visits.

This time around, he suffered from pneumonia. It has been day 2 of hospitalization, she remained by his side. Her care never cease to amaze me. From feeding, dressing, clearing up phlegm, tepid sponging to each tender touch that reflects true actions of love.

"For better, for worse, for richer, for poorer, in sickness, and in health, till death do us part."

How many of us do mean it I wonder.

Getting along is a rough ride. Selflessness would ease sailing through. I am a tad envious of the old couple actually.

Dear God, let our relationship mounts more of You and less of ourselves.

The little artist

I am in Paediatrics Surgery, a posting which I am entertained more by the kids than the subject itself. Rather slacked and lazy nowadays as things move in a slower pace compared to that of in General Surgery. Having to relax once in a while is good.

Recently discovered a talented artist, who draws unceasingly without an eraser. A 6-year-old's copyright masterpiece:

Impressively creative isn't it?

A solved mystery: Surgeon Vs Physician

He was in his late fifties, a known case of vitiligo for the past 12 years who was admitted to surgical ward for dysphagia for 10 days. More difficult on swallowing solid than fluid. It wasn't preceded by abdominal pain and there was no constitutional symptom. No family history of cancer. Neither does he smoke nor drink.

It was unlikely oesophageal carcinoma in such acute presentation. Reflux oesophagitis or ulceration causing stricture is possible but there was no symptom pointed towards it. So oesophageagastroduodenoscope was indicated to look for the direct cause of dysphagia. Barium swallow was arranged too but patient would have problem in swallowing.

Here's how the story starts...

He refused to lie down in scope room claimed to have shortness of breath in supine position. Oh well, he had been sit sleeping for the past 4 days. Medical referral made but work out elicited no cardiac or pulmonary related dyspnea. He appeared comfortable and oxygen saturation was always perfect under room air. His big bunch of family members were around everyday and they take turn to massage him. So I, evil enough, put him a PSY label - feigning and attention seeking.

One fine day, another medical referral was made. This time around, a physician came to review instead. He solved the mystery just by a sentence:

"Pakcik, tengok saya!"

Slowly, the patient lifted up head with much struggle, and dropped down again shortly. He had droopy eyelids and proximal myopathy on examination.

Yes, he was in head-nodding position most of the time, which I didn't bother to find out why.

"So what's the diagnosis?" We were asked.

"Myasthenia gravis..." We stared dumfoundedly. It never even cross my mind.

Further history was elicited that his muscle weakness started months ago, worst towards evening. And his son is diagnosed myasternia gravis too on treatment!

Thinking about it, everything seems to be co-related:

Vitiligo
Head-nodding position
Massage
Dysphagia
Shortness of breath

I feel a bit dumb.

Lesson of the day:
1) Think wide! Surgery posting doesn't mean diagnosing only surgical related problem.
2) Do not judge!

Twenty five minutes

It was my last labour ward call. It wasn't as peaceful as I thought it could.

At almost 3am, a primigravida was brought in as active phase labour with hyperstimulation in her 35 weeks gestation. She was induced with one Prostin 3mg for preterm prelabour rupture of membrane (PPROM) >24 hours. Tocolytic was given. There was no sign and symptom of chorioamniotis then and CTG was reactive.

The labour progressed well till the midwife shouted:

"Baby flat!"

With immediate attention, I gloved up to aid in resuscitation before the Paediatrics team arrived. MO oncall was alert. The case was summarized to MO with the emphasis of reactive CTG, clear liquor and second stage took merely 11 minutes.

True enough, the CTG showed reactive trace throughout the whole second stage. MO went on further and noticed the change of baseline heart rate from 150bpm to 120bpm for the last 25 minutes. There was otherwise good beat to beat variation and acceleration with no deceleration. Venous cord pH was 7.12 with base excess of -22mmol/L.

The last 25 minutes...

I felt bad as MO just rested for barely less than an hour and there came a bad outcome. As a soon-to-be posting leaver who should be well entrusted, I failed to ensure things checked and reported for appropriate intervention. In this case, a change of baseline was not picked up earlier.

But of course, the reason for a flat baby is often uncertain. The patient herself exerted multiple risk factors such as preterm labour, PPROM, induction of labour as well as hyperstimulation. This baby was intubated but subsequently discharged well.

Obstetrics is a field of litigation. People move on with good outcome but once there is a bad outcome, every single step will be traced backward for error picking. Every small matter needs to be dealt with extra caution.

Lesson learnt.

Her last word

It was an ordinary oncall day running all over to get the hand-overs done and attended to patients' complains till a staff nurse yelled:

"Dr. Ng, tengok SPO2-nya..."

She was a 53-year-old lady bedded right at the acute cubicle, critically ill with striking features of bilateral gangrenous lower limbs as well as the tip of nose. Her SPO2 dropped to 88% under room air. With immediate attention, I questioned her for symptom of difficult breathing.

"No." She replied softly with a little head shake.

She desaturated further despite the propping up position and the change from nasal prong to ventimask. Gradually, her eyelid drooped and she became unresponsive. Her short while of gasping was typical of Cheyne-Stokes respiration. Auscultation revealed bilateral reduced air entry. Copious frothy discharge started to bubble from her oral and nasal cavities. Carotid pulse was fading.

Cardiopulmonary resuscitation commenced immediately with suction in between aided by two staff nurses. MOs oncall arrived 10 minutes later and certified fixed dilated pupils, asystole with no spontaneous breathing.

Death had occurred. It occurred faster than I could respond. She was just talking to me seconds ago. Vital signs monitor showed a final SPO2 of 45% with undetectable pulse rate.

Residue cardiac activities...

Frankly speaking, my mind went blank through out the 10 minutes of resuscitation. I knew not what else to do or what to tell her husband and son who were behind the curtain. The feeling was totally different from how I used to practice on dummy or how I used to practice breaking bad news to my friend.

Perhaps I am experience lacking. This event had added to my first failed resuscitation.

May you rest in peace.

Dying process begins well before death occurs.
The last sense to go is hearing.
So, do talk to the dying ones.
-The journey towards death, Angela Morrow-

The angel smiles

He smiles, so wide and sun-shinny. A 9-year-old boy came tightly held by his mother in his broad based gait. I attempted rapport building. He spurted me saliva all over. He has Angelman syndrome with most of the following features:

Consistent (100%)

• Developmental delay, functionally severe
• Speech impairment, none or minimal use of words; receptive and non-verbal communication skills higher than verbal ones
• Movement or balance disorder, usually ataxia of gait and/or tremulous movement of limbs
• Behavioral uniqueness: any combination of frequent laughter/smiling; apparent happy demeanor; easily excitable personality, often with hand flapping movements; hypermotoric behavior; short attention span

Frequent (more than 80%)

• Delayed, disproportionate growth in head circumference, usually resulting in microcephaly (absolute or relative) by age 2
• Seizures, onset usually less than 3 years of age
  
• Abnormal EEG, characteristic pattern with large amplitude slow-spike waves

Associated (20 - 80%)

• Strabismus
  
• Hypopigmented skin and eyes
• Tongue thrusting; suck/swallowing disorders
• Hyperactive tendon reflexes
• Feeding problems during infancy
• Uplifted, flexed arms during walking
• Prominent mandible
• Increased sensitivity to heat
• Wide mouth, wide-spaced teeth
• Sleep disturbance
• Frequent drooling, protruding tongue
• Attraction to/fascination with water
• Excessive chewing/mouthing behaviors
• Flat back of head

Half way through history taking, again he spurted me saliva.

"Don't play with saliva." I said, not knowing earlier that impaired swallowing mechanism and saliva drooling are the features. Mother warned him by a gentle slap on his lips. He was still smiling. Happily and contented.

He is the only child. The diagnosis was certainly life changing to the family. To expect a child is joyous, but who would anticipate a needful kid? I saw his mother teaching him patiently. I noticed the mother's cross pendant. I saw motherly love.

They stepped out the clinic meeting his father. The touch his dad offered was tender. The whole family walked away with much laughter. Staring at their shadows, I am glad for such loving and supportive family. He remains the angel of the family despite being a little extraordinary.

His smile will stay with me vividly. It is indeed the happiest disease I have ever seen. Hope my ignorance was forgiven.

So smile back if somebody is smiling at you. It may be the only way he communicates.

The cause of pain

Noted the bed ticket of a patient. The first two lines:

Pt. c/o pain (Patient complained of pain)
- was being examined by medical students

We did cause pain to patients, be it knowing or unknowingly...

The tag says:

"Not for medical student to examine patient."

Medical students are purely annoying sometimes...

Accident and Emergency

In my 2 weeks rotation of a brief exposure to Accident and Emergency, there's this patient I'll not able to forget.

A 43-year-old single mother who was brought in unconscious sustained from skull fracture with visualized brain matter crushed into pieces by axe, multiple strikes. Pupil was dilated unilaterally, non-reactive with a Glascow coma scale of 3. She was massively stained with blood. A few of us approached and did the basic life supports as we could.

By turns, I was bagging the resuscitation mask and cleaning off the blood stain on the patient. She had got a slash on her face too. And what shocked me was, the flesh of her tip of nose could flap open upon a wipe. Gosh, how to treat her? Is there any way the brain matter can be patched back? Pressing on her nose, I could only say a prayer.

Unfortunately, miracle did not take place. She passed away on the same day of admission after an 18 hours strive. I felt sad. Not solely on her decease, but for her daughter who is not able to experience mother's love again. Sad for the action of human being which was so cruel and irrational. It's a human's head, not a pumpkin! How could one able to lay an axe on it without giving a second thought! And the murderer who robbed was her very own lover!

For the news article, click here.

Another young chap, brought in unconscious. I gave few taps on his arm routinely, calling "Encik, encik". He was unresponsive. Without safety precaution of wearing gloove, I removed his jacket by which I found my hand was blood stained before I ran to get gloove. All tools to set line were ready. The cardiac monitor showed a flat line. Yes he was pulseless, his chest wasn't expanding. Unknowingly, I was actually dealing with a dead body.

Accident and Emergency department isn't as dramatic as those seen in the television, but everything done needs to be fast and precise! The rate of patients wheeling in and out is fast too. Same goes to the speed of one's heart stop beating.

I see how fragile life is.

Very Important Person

As usual, I was tagging along a doctor for clinic session.

Medical assistant (MA): The Timbalan Menteri, Dr. XXX's daughter is here.

Doctor: Ok, ask him to come in after this patient.

MA went out to call the Timbalan Menteri and his daughter. Back into the room a minute later...

MA: He is still registering...

And I saw the VIP soon after he registered bypassing waiting time.

Ever wonder why is life so unfair? Not only a small matter like this but as whole. Well, if there are things to complain about it would be an endless list.

On the bright side, aren't all the unfairness makes us work towards something more aggressively? It's a training process building up our characters. There are things that we need to live with anyway. As what the Chinese says, "close one eye" and just be contented with what we have.

Life is unfair but God is just.

Geriatric psychiatry

I have special fond towards senior citizens compares to kids. Conversing to them needs extra effort to hear or comprehend but I enjoy listening to their life experiences and thoughts sharing. Geriatric is a study of elderly ages 65 and above. Studies show 20% of them suffer from mild to severe dementia by which 15% of them developing depression there after. My very limited exposure to geriatric psychiatry was like an arm chair strategy where we picked cases and discussed about the plan of management but unfortunately not many of them were being treated in reality. People perceive it as a normal aging process and many a times they are being neglected. Having lost memory and ability to take care of themselves, they are helpless and feel very much a burden to their family members. The few persons I encountered have lost hope to carry on life. They pass time purposelessly and do not wish to live any longer. “家有一老，如有一宝” (Having an elderly at home is a treasure of a family). How far are we still practicing this? How much are they being treasured as somebody significant in our society nowadays? Have we given our best concern to our dear ones at home? An ex-drugs addict in his 60s, bachelor, homeless, was tearful talking about how much guilt he has looking back his life. He feels worthless. The clerking stopped as I reminded him of his bad experiences. How I wish I could share with him the peace I own, the hope that carries me through. When everything else fails, life is still worth living for my hope is set on You. Thank You Lord, for being my greatest strength to move on.

Sense of respect

Had a case presentation session with a doctor. There were a few interruptions of the medical officers (MO) since he had just come back from a long leave and needed to make things clear. MOs were supposed to report to him regarding patients' conditions and problems.

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Heard of a rumour that this doctor is way too "strict" to MOs and HOs (house officers) until I saw it with my own eyes and confirmed it. The poor MOs were standing in the midst of us, medical students, being yelled and commanded at. The doctor was too, cracking sarcastic joke there after which to me, was not funny at all. I would say, with words that hurt, with his expression that insulted. The MOs could do nothing but stood and nodded helplessly.

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Was thinking to myself, what if that happens to me in the future? I guess I will hold back tears, take deep breath, obey and nod too. Is it not the way responding to superior? It hurts. Even if one's work done is not satisfying, I wonder if there is a more constructing way to correct or request.

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I did not enjoy the learning session. Perhaps I had prejudice towards that particular doctor. I apologize for being too jugdemental at times. Okay, had enough ranting. Last word, treat people as the way you want to be treated.

Training in progress

Orthorpaedics has been busy! The past few days had achieved record breaking for 2 things, three scheduled case presention sessions to 3 different doctors in a day, and the longest standing hours from 8am to 6pm for 2 days continuously, including the pathetic short lunch and driving time.

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As a result, I had bilateral knee pain, heels pain and muscle ache. Can't imagine how a houseman's life going to be like since a few days for me are enough to prove my aging process. To make matter worse, a sudden squad at the end of the day brought about multiple crepitus all over the circled joints below. Luckily I sustained no strain or sprain.

Stress started to pile up, not because exam is around the corner. Having known my own flaws each day, my knowledge and skills are below the par of what is expected. The limited things that I know has slowly slipped away. Huh, stressed! I need to work harder, on my discipline and time management too. Training is in progress, I must get through!

The first line treament

Dragged myself through the first week of Family Medicine posting after the long, sweet 9 weeks holidays. Showed up with my somnolence most of the days, I admit I haven't discovered the fun of this posting yet. It was rather dull for me, till I was awaken slightly by Dr. S, for the last case presented on the last day of the week.

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Young Malay lady, a known case of hypertension who claimed to be compliant to medications. Her blood pressure measured on the spot shooting 170/100mmHg. She brought her youngest son aged 2-year-old with her who was noted to be fretful on her lap. And her husband was asking the consulting doctor to hurry as he needed to get back to work.

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Mind was set to think whether to increase the medication dosage or to monitor her blood pressure for a persistently high. Had totally ignored an important area till Dr. S identified it.

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She was shown with a non-smiling face with a few stressors which would probably be the reason contributing to her high blood pressure:

- She is busy as nasi lemak vendor cum house wife taking care, currently breast feeding her kid.

- Her husband works and back home late often, he was rushing her for work at that moment.

- A thought that she might be worrying about her husband getting another spouse.

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We didn't elicit further. It was a thought bringing out the word "holistic" again to me. Well being comprises of not only of physical aspect but also mental, social and spiritual. Many a times the first line prescription can be as simple as a word of encouragement, prayer or even a pat on the shoulder. How often has it been ignored due to carelessness or time constrained?

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Stress is what everyone has. It is too a common trigger of people falling sick. One may not able to lighten the stress level of another, but at least the word of encouragement keeps him/her going.

Mission completed

Time flies. I have completed my 3 weeks attachment in IJN (National Heart Institute) in a blink of eye. Two weeks was spent in cardiology while another week in cardiothoracic surgery. It was a good experience indeed as this attachment has changed my perception towards Malaysia’s health care system a little.

Attitude
Hospital staffs like doctors, nurses, guards or even cleaners are there with servants' hearts. They smile to greet the passer by daily. I hardly see any sour face or screaming at patients which is a common scene seen in general hospitals. Things are explained clearly to the patients to ensure compliance and patient's needs are met as much as possible. Supportive hospital staffs play a role in aiding patient's disease progress. The effective patient-staff relationships can be shown by loads of thank you cards on the notice boards and tokens of appreciation on the wall along the corridors.

Efficiency
Patients who are for further investigations are scheduled as early as possible. Tests like stress ECG and echocardiography are performed immediately if necessary and the results are interpreted on the day of consultation itself. Invasive investigations such as angiogram or biopsy are done within few days without delay. Besides that, doctors are divided into teams of 3 or 4 and each team has their own allocated patients. Team work makes things easier as they lighten one another’s burden by working together to see patients for ward round or clinic.

Social welfare
To my amazement, the funding of IJN is good. All patients who can’t afford the cost of admission or treatments get subsidized either completely or partially. For prescription wise, the best drugs with the least side effects are prescribed to the patients without having considered the cost of the drugs.

I am grateful to Dr. Kevin who supervised me through out my attachment. He is a dedicated and cheerful doctor who had inspired me by the way he treats people. I enjoyed following his clinic, ward round or emergency cases. Cardiology is now my considered specializing field after gynaecology. I don't mind working in IJN in the future though the food there seriously needs some improvements. By the way, he walks extremely fast! I am pretty much trained up for brisk walking now :p

Thanks for treating me as a part of the team. It’s truly a blessing to the people having you as doctor. All the best for your future undertaking!

Decisions that kill

It was stressful. The second day of cardiology attachment started with ward round in Coronary Care Unit with 2 doctors and 1 nurse. I reached before the specialist and introduced myself to the doctor-in-charge.
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“Good morning, I’m Ching Mun from IMU. May I join your ward round, doctor?”
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So the first patient was seen without the specialist. Half way talking to the patient, the doctor turned to me and asked again for my name. He looked at my name tag and scribbled on the bed ticket:
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“S/W Dr. Ng Ching Mun” (S/W: Seen with)
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Oh my… Perhaps I didn’t introduce myself as Medical student from IMU. Felt so uneasy and didn’t know how to correct him that I’m not a doctor yet! The specialist came there after and his name was written in the subsequent patients’ bed tickets instead of mine *allayed*.
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This was not the major stressors. Being the only Medical student there (Deva started with cardiothoracic surgery first) means I have to answer all questions directed to me. There were only 2 questions for me today and I answered 1 wrongly and couldn’t answer the other one at all. It simply means I need to read and practice more.
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Going into the main point, many think doctor is a noble occupation. Well maybe it is. A quote from the Spiderman remains vividly in my mind:
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“The greater the power, the greater the responsibility.”
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I testified that verse again.
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Patient A, a known case of heart disease on warfarin with INR of 4+ who was last seen well and active. A doctor tried to correct his INR by giving Vitamin K to prevent bleeding tendencies. However, a thrombus formed as a result of the attempt. He complained of sudden abdominal pain. Laparotomy showed bowel infarction due to blockage of vessel by the thrombus and resection was done. He passed away of sepsis lastly.

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Patient B, a dentist who complained of pain and numbness on her left upper limb. She was diagnosed with subclavian artery stenosis and had a stent done. A rare complication of broken stent occured. The vessel leaked to develope aneurysm which compressed her laryngeal nerve affecting her voice quality and ability to speak. She was treated with antibiotic for 2 weeks due to infection. To prevent the aneurysm from getting bigger, another stent was inserted to block the blood flow from aorta and thus the blood flow to her left upper limb was impaired further. The pain progressed from bad to worst. She was depressed.

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There is no absolute right or wrong in Medicine. Patient A might be at risk of massive bleeding if INR was not corrected. And nobody expected patient B would get worst after treatment. One can suggest a treatment plan with his points going for while the other can say no with valid reasons.

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Patient C, an elderly in her 80s with a previous coronary artery bypass graft presented with chest pain. She was subjected to either bypass again or treated medically. The doctor chose the latter, and secretly told me that the chances of her dying of heart attack is high based on his experience. She might leave anytime. It is still better than to die in an operation theater.

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It striked me the most when one patient submissively said:

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"Doctor, it's all up to you. You decide what is best for me."

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Medical students can make mistakes and fail exam, but medical doctors can't afford to decide wrongly and loss life.

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Greater power comes greater responsibility.

Salute the women

Been through 2 weeks of obstetric posting. I am supposed to study real hard. Somehow feel that my blog is calling me.
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Came across with pregnancy and its beauty. Wonder how God has such creativity, making everything so perfectly compensated for two cells to merge and grow. All mechanisms take place in a woman's body to wonderfully accomodate the developement of a new life. From a heart beat, to every move, and eventually a cry and to every breath. I'm marvelled.
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Came across with labour and its dreadfulness too. Seeing mothers suffered from excruciating pain. Long hours straining with the risks of many complications. Menstrual pain for me is unbearable. Just can't imagine how delivery pain is going to be like.

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Encountered a shoulder dystocia during my first on call on new year day. It was the third new year baby I welcomed, by just observing. This baby's shoulders were stucked with her head jutted out from the vagina. The doctor-in-charged was applying traction and screamed for help after repeated tries. I was panic looking at the little head turned blue. Moving to the mother's side, I held her hip flexed, and gave her moral support. A staff nurse was at the other side, holding the other leg and pressed onto her abdomen.

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"Kuat lagi! Sikit lagi..."

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And thank God the baby was delivered after nearly a minute. Relieved. All the distress and frown on the mother's face ultimately turned to smile and rejoice with her newborn on her chest. The pain and unstitched torn perineum or vagina did not matter at the moment of time.

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It was an adventure. Women bear so much risks and pain to deliver. But it was encouraging to see some of their husbands were by their sides, saying prayers, holding their hands and giving them support. It did make a big difference!

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Some wonder why girls are better treated than guys many a times. Girls give birth, guys don't. Girls are generally more dedicated to the life of others and their hearts are more tender to the surrounding things. I think they deserve it, don't they?

The mother and son

Overheard a conversation between a 4-year-old son and mother in the ward while I was reading bed ticket.

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Son was admitted for fits and mother was taking care of him. Mother poured water into a cup and handed over to him. Spoken in Mandarin:

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"Mummy, you drink..." The son lifted the cup to his mother.

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"Mummy doesn't want to share with you, I cough seriously." *Aww... how sweet!*

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Son took a sip, gurgled and threw it back into the cup.

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"Eh, you do it again! I beat you ah..." Mother warned.

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She just sounded exactly like my mother, with a similar tone and expression. I miss her.

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Paediatrics has just over. Next comes obstetric posting. I am exciting :)

Route of communication

Dear Dr. XXX / XXX,

Thank you so much for your suggestion which you had written in such HUMONGOUS alphabets. We shall take over this gentleman as you had so kindly suggested. By the way, I DO NOT have any visual impairement so there is no necessity to take so much trouble and effort to use gigantic alphabets. I see it as absolutely unnecessary. Thank you!

P/S, My MOs do not have any visual impairement either.
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.................................................. --

Found it in a patient's bed ticket when I was doing ward work. A bed ticket is what medical staffs use to communicate with one other. Never thought that it is a place to express feeling too.

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To be a good doc, communicate well (write well)!