The 3 things that made my day

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



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

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

Polio

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

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

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

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

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

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

Enjoy

All the things that aspirin does

Kindly click on the link above.

Improvisation-Surgery-Euphoria

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

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

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

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

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

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

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

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

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

Incision was made using a 15 blade.

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

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

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

Extracting the cyst.

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

Irrigation with normal saline.

Suturing using nylon. Interrupted suture.

Done.

Patient was given antibiotic in case the wound is infected.

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

This is a take home message from Dr Kama.

I was satisfied spiritually.

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

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

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

Hostility-Part 2

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

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

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

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

Questions are raised, but not answered.

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

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

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

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

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

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

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

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