Not in gainful employment

Wednesday, December 17, 2008

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

Tuesday, December 16, 2008

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 gro
w 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

Saturday, December 13, 2008

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

Tuesday, December 9, 2008

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

Tuesday, December 2, 2008

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

Friday, November 28, 2008

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.


Wednesday, November 26, 2008

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

Monday, November 24, 2008

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

Friday, November 21, 2008

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

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.


Kindly click on the link above.


Tuesday, November 18, 2008

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.
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

Monday, November 17, 2008

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

Sunday, November 16, 2008

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

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.


Thursday, November 13, 2008

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

Monday, November 10, 2008

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


Thursday, November 6, 2008

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.

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.

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

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

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

Thursday, October 2, 2008

(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

Selamat Hari Raya to all my muslim friends
Maaf Zahir Batin

Best wishes from me during this wonderful festive season.

Retinoblastoma: Ugly like hell

Thursday, September 25, 2008

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."

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,

My first post- Surgery and Me

Saturday, September 20, 2008

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.