We Need Guidance, Please

What we don't need are insults. We just need guidance. One of my favourite teacher was Pang Chee Hoong, physician whom took care of male medical acute and HDU 1 during my time there. And that was when I learned how to put in the central lines.

I was in my 5th posting and I still haven't done any central lines yet! But Dr Pang showed me the way and now I'm more confident. I came out of medical with almost 10 central lines and quite a few on my own with assistance from nurses.

Coming to anesthesiology, CVL are mostly done by MOs in the OT. I assume that even they want that bit of practice.

Last night though I had my chance of putting in 2 on my own. But shit did I panic when I realized that I haven't pulled out the guide-wire when I inserted the triple lumen! My heart pounded like hell and I thought I would end up in IJN instead of the poor patient with the thyroid storm.

Fortunately the wire was still there when I pulled out the triple lumen. Booyah! Still a good flow!

Setting up central lines is one of my favourite procedures as a houseman. Haven't tried it on peds yet but would like the experience. Hell I still need the practice to set up regular lines in peds. Still suck at it. Learning from them experienced nurses is not a bad thing. I still have much to learn. As always.

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Tips to CVL insertion:

- Success is assured when patient and your position is correct. Failure is guaranteed when positioning and exposure is sub-optimal.

- Always have help around.

- The hardest part is getting the needle in the vein. Once that's done, the rest is a breeze.

- Know the potential complications.

- I know consent is important in the event of complications, but most of our folks, if we explain to them in details regarding the possible complications of CVLs, they would consult the whole kampung before agreeing. From Dr Pang: Do first, ask later. Save life first. (Up to you which you want to believe).

- Always pull out the guidewire first!!! Having a guidewire in the heart is equivalent to putting in wrong group match to a patient.

Have fun!

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The Assessment

Started HDU today. Patient's are quite stable for now and not much movement. Things will be busier this Monday... Had a patient whom was tachycardic the whole day. Didn't think of it much till I noticed she had a temperature and BP was starting to drop. All after the relatives noticed.

I should have acted sooner. Fluid challenge and antibiotics stat. Because in sepsis, everything can change when you act just one few moments sooner...

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I passed my assessment with a 70% mark. For the more academic and curious I'll share the topics:

• ECG: Pulseless ventricular tachycardia
• ECG: Complete heart block
• CT brain: Hemorrhagic stroke
• CXR: Pneumothorax
• Gen Med: Diabetes mellitus
• Clinical: Organophosphate poisoning
• Resuscitation: Hyponatremia and hypokalemia
• Resuscitation: Neutropenic sepsis

I don't think I did great. What the assessment showed me was how weak I was in medicine and management and how unsystematic I am. I think that's what assessments are about. To assess what you don't know rather thank what you know. Identifying your weak points helps you realize your weakness so you can work on it and take it to the next level. The questions are all med school stuff. Yet I still fumbled with answering.

And this is on paper.

Real life is different. More factors are equated in. Staff, teamwork, patient's character, your own character, the ward environment, the hospital system, your superiors, and of course your cases. Some people manage well in-situ, under pressure. I am not one of those people. But repetition and practice helps. The more you experience the better you get. You don't turn super overnight. Heck, you don't become great after months of practice.

I shouldn't therefore be too happy that I'm already a few more steps to leaving medical. I might be leaving but still lacking in the necessary skills and knowledge. This could be dangerous. longer stay however may just provide that extra push to develop.

After all that said... No way I'm staying in medical more than I have to :p I'm stressed with the work, but enjoy it at times. It's one of the only postings where opportunity to learn and practice independently is abundant.

I hope I've learned something and continue to learn.

Sudden Death

Again I haven't blogged here in awhile. Updates: I'm currently in Medical posting, it's already been about 2 months. So far I'm enjoying the posting quite a bit but the amount of death I'm seeing weekly. Today was another except that this was an unexpected one...

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A patient was admitted into female medical extension for acute flare of rheumatoid arthritis. In casualty she was given PCM, tramadol, morphine and fentanyl but none seem to have helped. She was still in severe pain on admission.

We brought my MO to see the patient first when she came in to start her rounds. We thought we'd get back to her later to solve her pain issues at the end.

"She won't die from the pain."

Whether she died from the pain or not I'm not too sure, but she did die today.

Halfway through the ward rounds, the staff nurse informed me that the patient was not breathing. She was right. I called my MO and we initiated resuscitation. Oh how there were so many inadequacies at the moment when every second counts.

1. No crash cart in the ward
2. Patient's only IV line was blue and not functioning
3. Oxygen thank was not by the bedside
4. We couldn't open the patient's jaw for intubation; temporomandibular RA

We couldn't manage to revive her after 30 minutes of trying. She passed away.

Our impression was drug overdose from the amount of opioids given to treat her pain. I'm more inclined to believe it was hypoglycemia as her DXT showed LO value. Later we found out that someone from the A&E sent her blood for dengue serology IgM which turned out to be positive. Did dengue kill her?

Whatever her cause of death, it came swiftly, unexpectedly. We were caught unaware and unprepared. Death is like that. It comes when nobody expects it. But we can still prepare. We all know how. It's only a matter of implementation.

Shift System in Surgery

The government calls it Flexi-schedule or some shit.

But it's still the shift system.

We've started today.

In theory surgical department shifts sounds pretty good.

Work like usual:
Weekdays: 7am to 5pm (am shift), 4pm to 8am (night shift), then day off for night shift to return to work the next day.
Weekends: 7 am to 12 pm (am shift), 11 am to 8am (night shift), then day off again.


The way the number of HOs are arranged is such that everyone will work in the morning except for those in the night shift. So its basically the same as before only that night shift or 'oncalls' don't have to come in the morning and they get a day off the next day. Quite neat ;)

Only that now weekends we'd havta stay til 12 pm and not leave earlier when our jobs done. But that's no biggie.

I'm looking forward to the shift system, at least in Surgery as it frees up a lot of free time though not much change where birding is concerned but we'll see :)

I'll be doing night shift tomorrow. Am will be birding time nyehehe

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New World

Retrospective Entry:

I felt like an immigrant the first few days I was here.

When I first arrived I had mom and a hotel room. When mom left, I still had the hotel room but we just had to find a more permanent place to stay.

I was lucky that I had Nadhir, Jazmi and later Nurliyana. (poor unfortunate souls, unlike me, was thrown to KK, Sabah for their housemanship [Liyana didn't stay with us ok, she managed on her own:p]) around which made life less lonely. We stayed at the hotel a few days longer depending on Pak Tri (our cab driver remember?) to drive us around town, back and forth to the hospital to settle first few days of orientation.

We were also lucky we had Jai, our senior by a year who also happen to be in A&E rotation where their shift rotation makes it easier for him to help us out by showing places and lending his car.

KK didn't provide any permanent quarters for their houseman. Even their hospital looks like something out of Silent Hill. The only quarters at a nearby flat which they provided for a few days looked like something out of a Japanese ghost story where Toshio can just suddenly come out. We spent only one night.


All the while we have been looking through newpapers, mudah.com.my, advertisements on boards for any place to stay.

Again thank God Jai was around.

Food here is more expensive, and the local cabbies slit your throat (fares are minimum RM 20 per ride regardless of how near it is to your destination).

We couldn't move freely and food supplies were short as we didn't have places yet to place our groceries if we bought any.

In the end, I contacted a landlady and rented a fully furnished apartment located right in between all the three hospitals we were destined to rotate. Besides the furniture, the place also had a swimming pool and was surrounded by a few nearby churches. The nearest mosque was a bit to far to walk on foot. Oh yeah, no elevators and our apartment is on the 4th floor. Moving in was tiring but at least we had a roof. All we need now are wheels... My car is being shipped and is due to arrive in 2 weeks time...

In the meantime we still depended on Jai and Pak Tri.

Orientation week was heaven. Well not really but it sure beats working life. We still get paid while filling in tons of forms and listening to orientation presentations (I slept through most of it as usual).

Then we knew our postings.

Me, Nadhir and Jaz - O&G
Liyana - Pediatrics (though she had Trevors coming along, another fellow colleague from Manipal whom came along with us).

Reputed to be the toughest postings in KK. We were warned on day 1 that extension rates for both postings were high.

We started work on day 4 of the weekdays.

That was the start of everything new...

I remembered...

Depression.

Tips:

- Mentally prepare yourself for things to come even if you don’t know what. Me being mentally prepped to come work here helped a lot.

- Bring cash. You're like a UR over here. You don't belong. Not yet.

- Shelter, food, car, contacts. Contacts. Contacts. Fast. I can't stress how important.

- Bring lotsa pen and passport sized photos (like 30) cuz you'll need them during registration time.

Sorry you're not in the pic Liyana, tula sampai lambat. Meant to take a pic of us 4 before starting work but dunno why I didn't do it.

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Virgin Posting: O&G

Exhausting
Intense
Frustrating

Some of the various emotions one (I) experienced during my O&G posting here in KK, Sabah.

I knew it would be hard but never really knew how hard it would be.

First few days during tagging, I was depressed, tired and severely demotivated. Tagging puts us to work from 6.30am - 11 pm / 9pm. And during those times without transportations of our own, we were stuck in the hospital going back later than we meant to hithcing rides from Jai (MANY THANKS, UNREPAYABLE), and pirates (drebar keta).

How we suffered then.

Learning curve was steep. You were meant to learn to present cases well, refer early from PAC, post case for emergency caesarian, refer cases to pediatricians, collect information for statistics presentations, work fast enough. HORDES of mothers burst through the doors, and more offsprings burst through their *ahem* with some ending up not so favourably. And I was almost constantly screwed left right by my superiors. I was in constant fear. Of screwing up somewhere. Leaving a baby dead or ill, not acting fast enough to prevent a threatening maternal condition, not documenting enough, not presenting well enough in morning prayers missing information. I screwed up a lot.

Sometimes I felt like quitting. Alot of times I felt like quitting.

But I didn't. Not like I could.

So I held my head up high, because my pride demands me so, and do my best in whatever I could do. Which I believed later resulted in trust, respect and friendship among my superiors.

The posting also required teamwork and this put a tight bond among us, at least during work which forged new friendships. A lot of the people I met were of variable races, ages and in the midst of work, they matter not. Helping each other out was rewarding a lot of times whenever I can.

Despite what others say about O&G, I found it ironic that deep inside, I sort of enjoyed the posting. I built me up, toughened me somehow, and provided with a lot of experience I needed even though personally I did not think i learned enough.

If I could go back in time, I would like to spend more time doing a lot more Caesarian sections, cuz my current skill sucks. I'd like to perform more ERPOC on my own, and perform pipelle samplings and deliver more twins and breech. Not just for the fun of it, but because the skill is essential later on in the course of my work whether I'll end up in O&G or not.

My personal thanks to everyone I met. Nurses, fellow housemen, medical officers, specialists, consultants, patients, never ever forget the patients I've met. Without them, I would not come this far although I haven't actually gone anywhere far at all.

The last few days were fun, with O&G charity and O&G night.

My prayers that O&G dept, SWACH will continue to prosper and improve.

PICS

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Polyhydramnios - Spectrums

I've decided to write on interesting cases here. In the future I'll decide if they would be included in the travelogue.

Polyhydramnios - Spectrums

Case 1

22yo Primid @ 26W + 3D

Late booker

Referred for further management of fetal anomaly seen in TA scan and reduced fetal movement.

Patient was aysmptomatic, not in labour. V/S were normal. Per abdomen SFH was 30W size, with difficulty to papate the fetal parts and positive fluid thrill. There were no contractions.

TAS revealed:

- Dilated fetal heart. Still beating.

- Fetal ascites.

- Empty mother's Morrison's pouch.

What are other TAS features to look for?

What is the probable diagnosis?

What are the investigations to be performed in this case?

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Case 2

28yo, G4P3 @ 38W+1D

Antenatal problems: Anemia in pregnancy, AFI normal throughout pregnancy, no GDM, fetal anomaly scan not done.

Came in active phase of labour.

V/S stable

PA: Ut size: 38W, singleton, cephalic, head 5/5 floating, difficult to plapate the fetal parts/

Admitted to labour room for controlled ARM. CTG was reactive prior to admission.

On rupturing the membrane, 1.5 L of liquor was drained with fresh blood stains. CTG worsened showing unprovoked decelerations.

Impression was placenta abruption secondary to ARM.

Posted for EMLSCS.

Intraoperatively uneventful.

Baby boy delivered with BW 2.1kg. Admitted to NICU for TTN. Later discovered to have tracheoesophageal fistula, imperforated anus. Planned for thoracotomy, TOF repair and colostomy my the peds surgery team.

Mother was well post-op.

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Maybe I'll write a bit on polyhydramnios when I'm a bit in the mood. I find both cases interesting. There was another with hydrops fetalis but I didn't note the case.

Other cases of polyhydramnios I'm on the lookout for are:

- diabetic causes

- Twin-twin transfusion

- Other fetal anomalies (ie. Spinal disorders due to problems swallowing)

The Backbone of the Wards - Nurses

Hada request from a friend to write about nurses in Sabah (she's a nursing student) and compare them to Peninsular Malaysia nurses. She hears them grudgingly back talk about doctors almost everyday and would like to hear from me if there's any difference.

I think its human nature to back talk whether they mean it or realize it. I'm not encouraging it but just acknowledging its existence. Yes it exist here. Not just among nurses, but among doctors as well. Nurses back talk that arrogant houseman, houseman backtalks that malignant specialist, patients backtalks that nurse. Sometimes you don't hear it, you just sense it. Makes you wonder what people talk or think of you behind you back.

But so far I enjoy working with the nurses here. Its too early to make a general overall conclusion but the nurses I've met are really helpful and most are fun to work with. The labour room staff are a cheerful bunch. They offer food and invite us to Raya at their place. They are the ones who cover our asses and remind us of jobs. They tell us the correct dose for medications and help teach us stitch. The nurses I've met taught me Caesarian section. I have a feeling they'd be able to perform a better C-sec than most new MOs if only they had the license to do so. Most importantly they keep the wards organized and in-check. I believe them to be more professional than most doctors regardless of rank.

Prof Nasa was right. You should treat your nurses you work with with RESPECT. They are not down the food chain. We work together to achieve a common goal. This would be much easier if everyone did not talk behind each others back and be suspicious of each other.

I love my nurses. Make them love you too.

Oh, nurses in KK I've met a lot are pretty and cute too =D

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