Mentor

A wise man once said that a great teacher does not teach but to inspire others. This is exactly how I feel toward this man who has inspired many generations of doctors in this hospital.

He is an internationally renowned physician who has dedicated his life to mankind through his clinical work and research.

Although I didn't have a direct opportunity to be his student, but many of my teachers were once thought by him. So one way or another I feel indebted to him.

The bad news is he is currently unwell, the old enemy that he fought and defeated has returned and want a rematch, which I believe he will not give in or give up that easily. With Aidilfitri is around the corner, things would be even more challenging for him and the family.

Be strong now Prof, now more than ever.

We are with all the way.

alone@aidilfitri.com

Happydoc is a newbie in our hospital, having just joined the masters programme last June, he was considered a junior. His stylish hair, boyish look and nice taste in the clothing department reminds me of the once locally famous 4u2C group.

But oh boy! I was totally wrong about him, after knowing him later did only I realised that he has strong experience in internal medicine having gone through all the major postings in GHKL.

So superdoc has helped me a lot during my rough period in these last few months. Perhaps he's one of the few good soul out there whom willingly want to befriend a crooked chap like me.




On another note, I must say this would be a lonely Aidilfitri for yours truly. I thought I could be happy again this Raya... but i guess that my wish would just have to wait this time... which may be forever. I finally realised that in life.. it's not what we want that matters. And above all the ironies in this world one thing stays true -- sometimes we can't always get what we want.

I have to live with that now.

Lastly but surely not the least Selamat Hari Raya to all my readers
... may all your wishes come true.

Listen to your heart

Once upon a saturday morning...

A 70 year old man presented with neck pain which aggravated by movement. Which of coz is your typical 'atok tua dengan sakit tengkuk' scenario. A young doc at the A&E however noted something is amiss. His pulse rate only register at 26 per minute!



An ECG revealed a second degree heart block - Mobitz type II which could progress rapidly to 3rd degree or complete heart block which is your Grim Reaper's recipe for dinner.

The heart is likened to a pumping machine which in a normal mortal pumps out about 5 litre / minute of blood into the circulation. It however needs an electrical supply to coordinate its pumping activity. Right now his heart's electrical wiring is fucked up big time.

The A&E doc paged the cardiology unit MO on call aka 'me in sleepy mode' to further manage this case. On further questioning he admitted to been having giddiness for the past 2 days. After consultation with the registrar & cardiologist on call, we decided to perform an urgent transvenous temporary pacemaker (TPM).

Under local anaesthesia we pierced the right internal jugular vein (a big vein at the neck) and push the pacing wire into the heart.

One hour later with the TPM on board we set the heart rate at 60 beats/minute. This should buy some time until the 'fellowship of the heart' reconvene on Monday morning to decide the next best course of action.



My only concern that night was what if the old man suddenly 'mengigau' at 2am in the morning and pulled out the pacing wire that hanging down from his neck !

Thank you for smoking

Malaysian public and mass media have forever blasted our public hospital/clinic/A & E waiting hour. Accusing doctors for incompetency and what not. Even though it's true that long consultation takes place. However they are unavoidable since communication breakdown happen not just between 2 lovers but also between patient and doctor.

For me mostly the challenge stems out from the difficulties in taking medical history. As the old medical axiom says: "99% of diagnosis comes from accurate history".

What I could easily achieved in 10 mins in overseas, takes twice as long in Malaysia. Here is some of my personal favourite.

Q: Pakcik dah bape lama ade darah tinggi?

A: Dah lamaa, sejak anak pakcik yang sulung tu lahir.
- Yup, great as if i know his eldest son personally, please be more specific uncle.

****

Q: Makcik bawak tak ubat, boleh saya tengok?

A: Nah (She emptied an old expired multivitamin bottle onto the bed - at least 5 different types of drug mixed together came out)

- Those unlabelled medications really speed up our consultation time.
****

Q: Okay, saya rase masalah jantung ni okay, kite jumpe 6 bulan lagi.

A: Hmm okay, tapi boleh tak tengok telinga pakcik jap.. macam ade lendir keluar, dah 6 bulan.

- The habit of showing 10 different types of medical problems in one clinic visit

****
Q: Your heart attack is related to your smoking habit.

A: But doc I have quit.

Q: Oh okay.. Since when?

A: Yesterday.

- Buddy that doesn't count

****
Q: So you had an abdominal surgery done it Selayang Hospital a year ago , exactly what did they do?

A: Hmm i dunno, they never told me... Hmm why don't you check your record?

- If someone cuts open your tummy, please pay attention on things he/she removes.

****
Q: You'd been admitted 5 times into Ampang Hospital before, why did you come here this time?

A: I like to try new hospital, it might be better here.

- Argghh 'doctor shopping' isn't a good idea. Your '2 volume' medical record is not here.

****
Q: Asoo, kenapa datang hospital, apa sakit?

A: Aaa.. sebab... aaa tatau cakap melayu.

Q: Anak mana, biar saya cakap dengan die.

A: Dia balik rumah.


****
Q: So how can i help you?

A: I got breast lump here - since 2 years ago.

Q: Great! you've come to the right place. Here in A & E, we give priority to chronic breast lump.

The hunter became the hunted

First came the abdominal pain.. then the purging! The man laid with eyes wide open the whole night literally restless on his queen size bed. Every single joints and bones within him felt twisted and burned to ashes. Not to mention the hourly visit of chills & rigor which clamp down his muscles while making his mind seem cease to exist.

Thinking it was just a viral food poisoning he stayed at home the morning after, tried to shake it off with oral hydration salts and lot of water. Which was an error in judgement because by afternoon his condition deteriorated which left him with no choice but to drag himself out and drive all the way to the hospital.

Upon arrival at the emergency dept, a newbie triage medical assistant made a 'diagnosis of probable dengue fever' hence advised him to go someplace else for blood checking. He proceeded by ticking the 'normal' checklist box without examining the patient. However the triage machine detected a rapid pulse rate of 120/min with a low BP of 100/60 whereas it should be 120/80.

The patient was then put in an observation ward with 1.5 litres IV drip went in over 5 hours, however the repeat BP later was even lower at 80/40. Then the man started adjusting the IV drips himself made it running faster.

At 9pm the senior doctor 'on call' came down to the A & E and started 1 pint gelafundin fast and having assessed it lack of response he finally said...

"Frapp, we gotta admit you upstairs".

So there i was, admitted into my own ward.. and put in the very bed where I did resuscitation on another patient about a month ago. Things started to feel different after I got my first dose of IV antibiotics called rocephin. The recurrent chills & rigor decided to shy away for good. Six days later , I was discharged home...with a different perspective on life in ward as a patient.

To all staffs & my friends, thank you for everything.

***
The CSI folks in the lab finally found the culprit from my sample... an uncommon 'Gram -ve bacilli' from the vibrionacea family named called P. shigelloides. I hope they burned in my gut.

The enemy within

One fine day, your GP tells you that your persistent cough with blood may indicate you have lung cancer. And a second opinion from Dr Dunhill Marlboro concurred with it. So your GP refers you to the most respected respiratory unit in the Klang Valley (which I happen to work with currently ehem ehem).

The task is now how do we look for it? Let's assume your respiratory physician works for the CIA, and your cancer's name is Osama.

Chest xray:

The CIA can use satellites to take aerial photograph of Afghanistan (your lungs) hoping to see some shadows that resemble Osama. With some luck they may see some suspicious looking shadows wearing turban holding machine guns (lung nodules/lesion). Which may be Osama (harmful malignant nodule) or it could be just innocent small kids with toy gun (harmless benign nodule). To confirm it we need to extract that bugger out for confirmation. We need to biopsy it!


Biopsy via bronchoscope:

What they need now is to grab some of the lesion. Imagine your airways is like a network of caves. Now, if the lesion sits near the big airways a favourite option is to do insert a fexible endoscope via your nostrils/mouth into the airways and biopsy that lesion (send some agents into the caves and grab Osama to be sent to Guantanamo Bay for interogation. Trust me - doing the bronchoscope is really look like one is exploring a cave network.




CT scan-guided biopsy:

Boy! The CIA didn't realise that Osama doesn't play hoola hoop near the cave opening to be captured. He is hiding deep underneath the ground. So forget the caves onslaught. The CIA now has to drill the ground and send a covert team to kidnap Osama guided by special satellite image (CT scan).



Pleuroscopy:

Or if there is pleural effusion AKA 'abnormal fluid collection in the pleural cavity'. We can puncture the side of your chest and insert a flexible scope into the pleural cavity and suck the fluid out and biospy your pleural wall from inside... hmm something like the CIA can examine a river next to the cave plus some take some soil sample, hoping to find Osama's waste in the river which means he's there all along.

Oh all right that is a crap anology! So i'm gonna skip it and you guys just have to wait for Discovery channel.

Disclaimer:

The above anology is just for fun. If the CIA happen to read my blog. I'm neither working for Osama nor that I know where he is.

PS: Btw the CIA/Bush and Co. are bunch of moron who wouldn't know it even if Osama sleep in the White house over Thanksgiving.

Let's nuke the bastard

There is no certainty in life, you make plans and hope for the best.

At 40 years old, you could either be married or stay single... with a bit of luck you might live long and dance the funky chicken at your 70th birthday party.

Or you could also be diagnosed with cancer at the tender age 30 years old. I've seen lot of fatalities to these malady. It knows neither mercy nor boundary. Any of the human organs is a potential target, from prostate to ovaries... from brain to bone marrow. In most cases you can't cure them.


Sure we can kill the sonoffa with chemo or radiotherapy but not without caveat emptor. Take chemo for instant we have reliable cocktail on our shelf. But the side effect can be nasty to the other healthy living cells. Not to mention the nausea and puking your guts out. In the end the cancer cells might return and haunt us back like Stallone in Rambo 4 (he should know when to quit).

Performing pleural biopsy on a patient with pleural effusion, suspected to have lung cancer.

This unlucky pakcik smoked 1 pack per day for 15
years.

Cut that sucker out you say. Sure if it is Stage 1 NSCLC (non-small cell lung cancer)... why not? But what if we diagnosed Ahmad's cancer a bit too late. Think of it like PS2 game - Stage 4 is a more difficult level where surgical resection is rendered useless because your Damansara cancer has taken the LRT to Port Klang and married a second wife there. What did you say?? That LRT route doesn't exist? Oh sue me then and later take it to Ong Tee Keat.

Not to mention the issue of 'no-fly zone' or no man's land where if Muthu's cancer cells have an office on the 52nd floor of Petronas tower. The surgeon surely can't take it out without chopping away the first 50 floors. Hint: Most brainstem gliomas are deemed inoperable due to its close proximity with certain vital part of the brain required by Muthu to breath, shit or copulate.

I would not be far wrong in that to own your own cancer cells are likened to the top 3 real estate pearls:

1. Location


2. Location
   
3. Location.