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.

Monster Change

Now I'm posted to Hematology ward. My HO leader wants me in ID, but my MO doesn't want to let me go. She wants me to stay. I'll just have to wait, CM to see how it goes. I'm quite comfortable in Hematology ward already...

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After going through halfway through housemanship, I do notice changes. I think it's for the worse in some aspect.

I have become the monster that I despise most when I see the monsters (some of my MOs or specialists) that I dislike and hope not to be. In my struggle to perform for others, I have succeeded in slowly chipping away some of my past existence, revealing the ugly caterpillar one so much wished to hide. A reverse transformation of nature, that may only come with stress and power and greed and desire to self-preserve.

Wings that sprout to fly are made of leather and bones instead of soft, feathers. I may soar high but less than grace. My breath becomes fire all of a sudden that singes hearts if not burn outright.

Is this how the course of things go? Where one forgets the very being he once was and strive to improve or at least maintains?

I loath when my superiors act on impulse and emotions. Disregarding the feelings of others. Breeding only contempt and a vicious cycle of loathing. I today have succeeded in succumbing to anger from that irrational emotion. My mild, growing wrath licking like fire the hearts of my dear colleague, my co-working staff nurses.

For becoming a monster, I apologize.

I long for humanity once more. For humility that I should be.

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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.

Housemanship and Birding

Both are of the same age of about 1 year plus. While both are similar in age, there is a difference between the two.

Sabah has provided me the opportunity for me to travel and bird widely, gaining experience and skills in bird identification. Along the way I have met new people with similar interest. The 'sports' is already becoming an obsession. Every free time in the early morning or late evening is spent to bird. With the shift system applied to house officers, birding opportunities have become even more abundant. My lifer list is now nearly at 250.

What about being a doctor, my true 'career', the job where I should put my dedication in making myself a better doctor? This is my 4th posting. I will be moving to my 5th if my department lets me. After 1 year plus, working as a doctor, I must admit that my skills and knowledge are not on par or to the level which I am satisfied. Sure, during the months of work I have gained experience and knowledge but honestly it is still inadequate in my humble opinion. Sure the shift system has given me a lot of free time for myself and sleep, but in the long run, it has made me more calculative and pampered. Within weeks after the implementation of the shift system I have forgotten the lethargy accompanying a busy oncall and to work the next day til end of office hours. I am honestly ashamed with my MOs whom are still obligated and dedicated to continue their work even being post-call.

Shift system is not all that bad or for birding. Perhaps I should capitalize with the extra free hours. Some of the things possible now are:
- Study for MRCP, MRCS or other exams
- Attend OTs or minor OTs to gain more hands-on experience
- Attach to pediatric surgery activities, my supposedly main interest in medicine.
- Read more on my spiritual aspects of life and other non-medical (and birding) aspects.


So where is my direction in my life career? Birds or Human lives?

Failure to change now would only lead to the detriment of my future patients. Islam demands the best in our work. To be the best requires realization and hard work as well as tawakal. Not solely the latter.

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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Death on Table and Trauma Alert

Retrospective entry, 24 September 2011.

Final peds surgery oncall today:

1. Death on table

- Day 5, term kid had a bowel perf. He was unstable from the go. Peds medical team insisted the surgical team went in despite not optimally stabilized. So we went in. BP crashed despite on full blast inotropes. CPR initiated. We all knew the baby won't leave the table alive. We closed him up. poor boy expired. Blame game begins.

2. 3 Neurosurgical admissions

- All 3 kids had some sort of fall and bang on the head. Admitted for observation. On admission all were normal active kiddies. Too bad the last one came in at 3 am.

3. Trauma alert

- Before that 3 am admission, I was on my way to sleep at ~12am. Then came the unusual trauma alert which I have never heard before. I ignored it and shut my eyes. The trauma alert was called the second time summoning my MO oncall that night. Shit, I said. It means there's a dying kid in casualty. I went down pronto and attended to a pale looking kid with a distended abdomen. He had a tractor backhoe fell on his tummy. Intra-ab injury. He needs blood. I went up - down for the blood. Scan later showed Liver and splenic laceration. Can't go in for this case as opening the kid up might distrupt the clots causing a tamponade effect on the injured liver. Opening him would cause him to bleed more...

4. Intestinal obstruction and excuse to not go too work :)

- Another admission at 6am. My perfect excuse to not go to work at SMC side :D Kid had an intestinal obstruction. History of gastrostomy for a stomach volvolus. Fortunately he was stable enough. Then followed peds surgery rounds.

Damn, I really wanna do peds surgery...

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Kuli

Our system in the medical field in Malaysia is of total hierarchical dominance. HOD's words are final, and housemen are dogs.

Nope. You can't question what you are asked to do. You must do it. It must be done. Specialist orders the MO to get it done, MO orders HO to get it done. Not getting things done will get the MO screwed and will get the HO screwed by the MO.

Some things that are requested are so absurd that the houseman's job is practically suicidal ie. requesting an URGENT MRI that is NOT INDICATED. The houseman will definitely get screwed by the radiologist.

That's the houseman situation: lose - lose. He gets screwed up and down, front and back.

Sure you can speak up and speak up your mind. But unfortunately we live in a system where questioning your superiors might be disrespectful and outright RUDE.

What you say doesn't matter.

In meetings, houseman gets screwed left and right and asked to pay for fines (denda saman) they don't deserve, "Apa boley buat? Bayar sajalah"

Then an angel (a special specialist) speaks up on behalf of houseman saying that we don't deserve this shit. We should stand up for ourselves.

"You guys are doctors for God's sake! Leaders!"

I smell the wind of change.

I'm not going to start rebelling. But perhaps the next generation of MOs and Specialist can change the system where we really do work as a team. Where opinions of team members matters! Where working might actually be fun and motivating!

Because this life of kuli is certainly demotivating. I hate my job for this reason. But I am not giving up on it yet. Hopefully I'll be a part of the tide of change that will be sweeping the old ways.

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